Delivering for Nutrition in India: Insights from Implementation Research - 24 September 2019

1. Rajpusht
Evidence based and actionable
dietary advice for pregnant and
lactating women in Rajasthan
An initiative funded by
© Koshy | Source: Flickr
Dr. Goutam Sadhu , Professor and Dean(admin),
IIHMR University, Jaipur
and
Ms. Namita Wadhwa , Associate Director,
IPE Global Limited

2. What aggravates the problem?
Gender Norms– women eat the last and least
• PLW in Rajasthan consume 30% less than ICMR’s recommendation
for calories and protein in third trimester of pregnancy and during
lactation.
• Social norms around ‘food’ during pregnancy and lactation: eating
papaya causes miscarriage
• Food taboos propagated by mothers-in-laws: eating more food
during lunch and dinner by a pregnant could cause lethargy and
dissuade her from doing her domestic chores
• Low levels of motivation among front line workers hampers
downward accountability: poor service delivery, operational leakages
RajPusht: Evidence-based Interventions in Rajasthan
Make local food affordable during pregnancy
and lactation : Conditional Cash Transfers to
PLW to purchase local food as per nutritional
requirements
Make eating food legitimate during pregnancy and
lactation: Create enabling environment (household
and community) to support PLW consume local food
as per nutritional requirements

3. Behavior Change: Insights and Implications
Lesson:
• Create social and
physical window for
food access by PLW
• Motivate women and
her influencer groups
(MiL, Husband)
• Capability to act and
decide when physical
and social access to
food is created
Credits: Sight and Life
Improving food intake is feasible through
non-main-meal occasions
Women need permission to eat more
during pregnancy and lactation
Actionable dietary advice is advice
that is relevant, specific, and desirable
FLWs are not motivated enough and belong to
the same ecosystem
• No need to cook, so no permission needed
• Small portions, doesn’t meddle with belief
that it could cause lethargy
• Direct dietary advice to women will have low
impact on changes in dietary intake
• Engaging with MIL for sanctions and
Husbands for emotional support is important
• Local food, easily available at home that
reduces burden of being ‘selfish’
• Unborn child being the emotional hook – not
for self, but for the one in womb
• Invest in their capacity enhancement
• Incentives – monetary and social
Insights Implications

4. 4
Key messages, takeaways
Local Solutions Local food
KYC: Know your Community
Leadership at all levels in
Government

5. A quantitative optifood study in 2017 to study dietary pattern and identify dietary gaps of pregnant and
lactating women in Rajasthan
The specific objectives of the study were: 1)To examine the dietary patterns of pregnant &
lactating women by occasions, portion of meals etc and to understand the difference from their
normal dieting behaviour, 2) To identify the gaps based upon recommendations by Indian Council
of Medical Research (ICMR) and 3) To Identify a pragmatic dieting chart to address nutrient gaps
using local food habits and available food products that are acceptable and affordable to women
and their family members.
Study Objectives
• Quantitative household surveys across two rounds
• Three districts – Udaipur, Baran and Barmer to understand variability in food consumption and
availability
• Sought information on food frequency and 24-hours food recall, cultural practices and barriers,
and a market price survey to capture the cost of food items
Methodology
• Multi-stage sampling method using Population Proportionate to sample (PPS)
• 600 pregnant and lactating women + 120 non-pregnant, non-lactating women in each district
• Total sample of 2160 women
Sample
”
”
”
Analysis
• Standardization: Food Consumed in 24-hour are standardized into raw food
• Conversion into Nutrients: The raw food were converted to food energy, protein and other micro-
nutrients
• Socio-Economic Differentials: MS Excel and IBM SPSS 21
• Food based recommendations: Optifood & MS Access
• Statistical techniques: Bivariate Cross Tabulation, Central Tendency, Linear Optimization (Optifood)

6. ₹5,000
median
monthly
expenditure
of a
household
5.3
average
family size
Above
Class 5
Illiterate or
below Class 5
56% 44%
90%
Hindus
Respondent Profile
55%
joint families
Education
88%
Socially
backward
classes
1 in 3
have
BPL card
25 yrs:
median
age
BPL: Below Poverty Line
Married at
16-20
years of
age
68% women
watch TV
regularly.
Only 5% listen to
the radio.
.
Total sample of 2160 women
(600 pregnant and lactating women + 120 non-
pregnant, non-lactating women in each district)

7. 0% 20% 40% 60% 80% 100%
Food
preperation
Groceries
Assets
Healthcare
for children
Healthcare
for self
Joint families 57%
30%
60%
58%
28%
Nuclear families94%
82%
80%
88%
84%
0% 20% 40% 60% 80% 100%
Food
preperation
Groceries
Assets
Healthcare
for children
Healthcare
for self
PLWs participation in household decision making becomes prominent when their
husbands are involved (>80% in nuclear families and ~ 50% in joint families)
Decisions taken by Wife Wife and husband Only husband Mother-in-law Others
+ > 80%
+ ~50%

8. Cooking oil Sugar Wheat flour Buffalo milk
Onions Tomatoes
Potatoes
Buttermilk
Garlic
Cow milk
Green gram Ghee
Their energy requirements are mostly from cereals, oils, milk and milk products
Top 10 foods consumed across all respondent groups
1 in 4 women are non vegetarian:
chicken, mutton and egg are the most
commonly preferred animal source
foods
However cultural taboos exist;
consumption of meat, fish and poultry
is restricted during pregnancy
Exposure to media among women is
high; most are aware of nutrition
related messages delivered through
these channels

9. Very high macro and micronutrient gaps among women: especially fat, calcium,
zinc, vitamins A and C

10. • A pregnant woman’s diet does not change much from what it was
before her pregnancy shaped by belief that pregnancy is a normal
state
• Mostly about excluding some items that may be detrimental to
delivery (‘sticky’ starchy items, papaya, banana, fish, meat and
poultry) are hot foods and consumption of these food item during
pregnancy causes abdominal pain and uterine contractions.
Potatoes, Bengal gram roasted, black gram, tea and coffee are
also avoided during pregnancy.
• emphasis on consuming green vegetables, fruits and milk, though
frequency is an issue
– Fruits are aspirational, they are expensive and
recommended by doctor/ FLW to increase blood count
(apples, pomegranate). But most are not able to regularly
consume, a factor of affordability.
– Green vegetables are seasonally available and consumed as
per affordability.
– Milk is considered good for health, buttermilk is cooling and
good for the ‘hot’ state of pregnancy, but for some dairy
consumption impacted by non-availability of milk cow at home.
• Some complain of not feeling hungry, nauseous and wanting a
greater change of taste in diet
Findings and Insights

11. CURRENT CONSUMPTION
1
serving
a day
4
serving
s a day
1/2
everyday
1
serving
a day
0.3
serving a
day
5
servings
a day
seasonal
fruits
Vegetables (also
green leaves)
EggPulses and products
Groundnuts
Curd, milk &
buttermilk
Food taboos, myths and family beliefs were assessed before making any
recommendations
In addition to current
consumption, we
recommend six other
common foods

12. • The dietary intake of pregnant and lactating women were poor and very less than the recommended levels. Majority of women depend upon cereals and other
elastic foods such as oils, milk, and milk products to fulfil their energy and nutrients demand. The median intake of fruits, meat, fish and poultry products were
almost zero in both the groups.
• The study also highlights that the intake of energy, protein, iron, calcium, vitamin C and folic acid were low among pregnant, lactating, and non-pregnant
women compared to Recommended Daily Allowance (RDA). The gap were higher in fat, calcium, vitamin A, and C across all categories. Iron and zinc intake
were also less among all target group.
• Due to food taboos family beliefs the situation among pregnant and lactating women gets complicated, leading to negative balance of nutrients. Further, the
concept of hot & cold food adds woes to their dietary charts.
• Women respondents participation in household decision was more among the higher educated women, women belonging to nuclear family, other backward
classes (OBCs), general caste and women with expenditure capacity of more than INR 10,000/- per month, compared to the counterpart groups.
• There is a significant association of the working status of mothers with insufficient nutrient intake compared to non-working mothers. Non-working mothers
were at higher risk of insufficient Vitamin C, Riboflavin, Folate, Vitamin B12, and Vitamin A RAE. Uneducated mothers were at higher risk of Vitamin A RAE
insufficiency compared to educated mothers. In addition to this, family type, drinking water source, poor handwashing practices, and poor sanitation found
significantly associated with mothers’ nutritional status.
Conclusion
Cost of the lowest-cost diet: that meets or comes as close as possible to meeting nutrient needs, lowest-cost diets ranged from INR 63/day (about 1 US$ /day) for pregnant women while INR 69/day (about 1
US$ /day) for lactating women.
Considering that average household size among the study population was 5.47 people, that 41% of the population living in the Rajasthan expenditure less than 30 per persons /day, it appears that a
nutritionally adequate diet for pregnant and lactating women is not affordable for many households in Rajasthan. Even with recommended food, a nutritionally adequate diet may not be affordable for some
households in Rajasthan who earn more than Rs 10000 per month (18 per cent). Multiple constraints may prevent families from implementing the FBRs. Other constraints, such as time required to prepare
food and fuel needed, should be further explored to develop effective strategies for supporting a nutritionally adequate diet for the most vulnerable groups.