133f Public Disclosure Authorized f Child and Maternal Healthl Services in Rural India The Narangwal Experiment 7 0 N~~~~~~oiiirneI Inttgrated Nutrition and Health Care Arnfred A4rKwh Inarnn (and Assoiates- Public Disclosure Authorized I.eX Public Disclosure Authorized I8~~~~H0 Public Disclosure Authorized Childand Maternal Health Services in Rural India The NarangwalExperiment Volume 1 Integrated Nutrition and Health Care ArnfriedA. Kielmann CarlE. Taylor CecileDeSweemer Robert L. Parker Dov Chernichovsky William A. Reinke Inder S. Uberoi D. N. Kakar Norah Masih R. S. S. Sarma Published for The World Bank The Johns Hopkins UniversityPress Baltirnore and London Copyright © 1983 by the International Bank for Reconstruction and Development / The World Bank 1818 H Street, N.W., Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America The Johns Hopkins University Press Baltimore, Maryland 21218, U.S.A. The views and interpretations in this book are the authors' and should not be attributed to the World Bank, to its affili- ated organizations, or to any individual acting in their behalf. The map appearing in chapter 1 was prepared exclu- sively for readers of this book; the denominations used and the boundaries shown do not imply, on the part of the World Bank, any judgment on the legal status of any territory or any endorsement or acceptance of such boundaries. Editor James E. McEuen Production Virginia deHaven Hitchcock Figures Pensri Kimpitak Book design Brian J. Svikhart Cover design Joyce C. Eisen First printing December 1983 Library of Congress Cataloging in Publication Data Main entry under title: Child and maternal health services in rural India. (A World Bank research publication) Contents: v.1. Integrated nutrition and health care / Arnfried A. Kielmann ... [et al.] 1. Child health services--India--Narangwal. 2. Maternal health services--India--Narangwal. 3. Birth control--India--Narangwal. I. Kielmann, Arnfried A., 1935- . II. Series. [DNLM: 1. Rural health--India. 2. Child health services-- India. 3. Maternal health services--India. WA 310 C5341 RJ103.I4C43 1983 362.1'9892'00954 82-23915 ISBN 0-8018-3064-8 Child and Maternal Health Services in Rural India The NarangwalExperiment CarlE. Taylorand Rashid Faruqee Research Coordinators A WORLD BANK RESEARCH PUBLICATION Foreword The two volumes of this study are books I have long been wait- ing for: waiting to find corroboration or refutation of what initially may have been no more than hunches or surmises, born of valid observation but not subjected to any rigorous statis- tical analysis. My generation was brought up in an age when quantitative analysis had not yet developed into the modern technology of intervention that it is today. It is true, of course, that this technology may often lead one astray by forcing upon one what will be no more than spurious refine- ments that the multitude of individual responses, which depend so much on exogenous factors, will bear. Nevertheless, one feels fortified when one's subjective hunches are supported by objective statistical analysis. When they are not, one is still loth to shed one's hunches but gives more serious thought to doubts. And doubts are far more important than certitudes. In the late 1950s through the early 1970s, the certitudes of many national policies to improve the well-being of people in the developing countries were almost exclusively the estab- lishment of family planning services, the development of con- traceptives, and the extension of family planning communica- tion. Reduction of fertility, it was argued, was a straight- forward function of these services: they alone would deliver the goods. International advice and aid bore down on national doubts, and anyone who pleaded that mortality (especially in- fant and child mortality), or the state of nutrition, or the v vi FOREWORD low levels of literacy and women's participation in economi- cally productive activity was a far more obdurate enemy than high fertility was shunned like a pariah. Policy prescriptions and action programs that relied almost exclusively on these assumptions--in whose aid, again, many statistical correlations were invoked--did not, however, work the way they were expected to. Already in the 1950s the United Nations had convened a distinguished interdisciplinary group of scholars who foretold why they would not [(United Nations, The Determinants and Consequences of Population Trends, Report no. ST/SOA/Ser. A/17 (New York, 1953, revised 1973)]. C. Chandrasekharan also had produced the Mysore study, which identified many determinants and imponderables and the cunning ways in which they interact to affect fertility behav- ior [C. Chandrasekharan, "The Mysore Population Study: A Coop- erative Project of the United Nations and the Government of India," Population Studies, no. 34 (1961); also United Nations report no. ST/SOA/Ser. A/34 (1961)]. Some of these determinants had been spelled out by critics of Malthus as early as the second quarter of the nine- teenth century when, as a result of social, cultural, and eco- nomic factors, natural fertility in Europe had already declined to levels lower than in developing countries a century later. Socialist thought in the last quarter of that century hinted that education, health (particularly reduction of infant, child, and maternal mortality), women's liberation and work outside the home, equity, and income were the chief determi- nants of a woman's right and decision to have the number of children she desired. The development of contraceptives and family planning communication came more or less after the other determinants had begun to work in Europe. But these interrelations and historical paths were ignored for the developing countries in the haste to achieve quick results that kept eluding their sponsors despite the pressures already mentioned. FOREWORD vii Against this faith in the primacy of contraceptive supply and services together with family planning communication that prevailed throughout the 1960s and well into the 1970s, small groups of men and women persisted in investigating more com- prehensive approaches to the complex problem of child and maternal health in the developing world. For India, the Khanna study [J. B. Wyon and J. E. Gordon, The Khanna Study-- Population Problems in the Rural Punjab (Cambridge, Mass.: Harvard University Press, 1971)] yielded important and complex relationships, as did Project Poshak [T. Gopaldas, Project Poshak, 2 vols. (New Delhi: CARE-India, 1975)] and several of the evaluation exercises conducted by the Planning Commission of India, which ultimately led to substantial attitudinal and policy changes from the period of the Fifth Five Year Plan onward. A series of interim research conclusions emerging from the Narangwal Project, which had its origin as early as 1955 in the Narangwal Rural Health Teaching Centre (it became the Narangwal Rural Health Research Centre in 1961), have whetted the appetite for the full account these volumes provide. The chief value of these books to me lies in their sta- tistical rigor, complexity, and rectitude bordering on wel- come understatement and a disinclination to attempt blanket answers. The conclusions they contain cannot, of course, be the last word on policy issues or on the understanding of subtle interrelationships. Rather, the principal virtue of the books rests in the way the authors have questioned assump- tions that need investigation because they are so firmly embedded in faith and honest endeavor. There were difficulties in the way of continuing the Narangwal Experiment, but these were quite unconnected with the objectives, content, and worth of the Experiment. The way in which the Experiment was conducted and analyzed must not suffer obloquy, and surely not for the wrong reasons. I did viii FOREWORD in which the Experiment was conducted and analyzed must not suffer obloquy, and surely not for the wrong reasons. I did not have then, nor do I have now, any misgivings about the solid worth of the Experiment and the messages it had begun to convey as long ago as 1968-69, to which the books bear ample testimony. And for this I must compliment the authors for their devotion, persistence, and rectitude. These volumes are indispensable to those who, like them, hustle while they wait, work with faith yet are visited by doubt, and look for rigor and comprehensivenessin research design and methodology. ASOK MITRA Professor of Population Studies Jawaharlal Nehru University New Delhi December 1983 Contents Foreword by Asok Mitra v Preface xvii The Narangwal Nutrition Project Team xxi Definitions xxiii PART ONE. THE NARANGWALNUTRITION EXPERIMENT CHAPTER 1. BACKGROUNDAND SUMMARYOF FINDINGS 3 Carl E. Taylor, Arnfried A. Kielmann, Cecile DeSweemer and Dov Chernichovsky The Social Burden of Malnutrition and Infection 3 Background Information on Synergism between Malnutrition and Infection 5 Prior Field Trials 8 Purposes Underlying the Research 11 The Narangwal Setting 12 The Punjabi Setting 15 Planning the Experiment 19 Summary of Narangwal Results 26 Growth and Development 26 Morbidity 27 Mortality 28 Input Services, Costs, and Cost Effectiveness 30 Synergism between Nutrition and Health Care Programs 31 CHAPTER 2. RESEARCH OBJECTIVES, DESIGN, AND METHODOLOGY 35 Cecile DeSweemer, Arnfried A. Kielmann, Robert L. Parker, and Carl E. Taylor Goals and Objectives 35 Research Design 37 Characteristics of Experimental Groups 39 ix x CONTENTS Methods of Data Collection 42 Longitudinal