Executive Summary:

The Role of Grandmothers

and other household actors

in maternal and child health

A qualitative community study:

Navoi, Uzbekistan

Judi Aubel, Consultant

Project Hope Team:

Nigora Muratova, MD, Maternal Health Specialist

Nasiba Bosorova, midwife

Lilya Djelilova, MD, IEC Specialist

Delya Allabergenova, MD, IMCI Specialist

Nuriddin Shaymanov, MD, HIS Spesialist

Abdunabi Kuchimov, MD, Program Manager

Project Hope Child Survival Project

Navoi, Uzbekistan

July 2003

Executive Summary

Since late 1999, Project Hope has been working with health and local authorities in Navoi Oblast in eastern Uzbekistan to help strengthen maternal and child health services. One component of the project focuses on strengthening maternal and child health (MCH) services in formal health facilities, while the second, community component aims to strengthen household strategies and practices related both to promoting the health of women and children and to appropriately managing childhood illnesses. In order to develop the second component, a community study was undertaken as a basis for identifying strategies that would be more likely to have an impact on household MCH practices.

The goals of the community study were:

1) to understand the roles and influence of family and community members, especially GMs, on maternal and child health practices

2) to understand the knowledge, advice and practices of household members, especially GMs, related to: breastfeeding; care of the sick child; women’s nutrition during pregnancy and breastfeeding; and nutrition of the young child.

The methodology used in the study was quite different from that typically used in such MCH studies. Most community studies on MCH topics focus on understanding individual behaviors, specifically the behaviors of women-of reproductive age (WRA). In this study a holistic, or systems framework was adopted, and the aim was to identify and understand: the different categories of actors involved at the household and family levels in MCH; their respective roles both in promoting the health of women and children and in dealing with illnesses; and the influences and decision-making within the household related to different aspects of MCH.

Given the objectives of the study, a qualitative methodology was adopted in order to collect in depth information on household and community processes related to promoting MCH. For this purpose focus group interviews were conducted with a total of 244 interviewees including: grandmothers; grandfathers; women with young children; men with young children; several traditional healers; and few Mahalla officials. The team of interviewers consisted of the 5 Project HOPE field staff and two of their close collaborators from the MOH.

Key findings of the study:

All families have their own strategies both for promoting the health of their women and children and for dealing with sicknesses when they are ill. In all cases, these strategies are based in part on modern health promotion and treatment ideas and in part on traditional Uzbek concepts of how to promote health and treat illnesses. Household strategies and practices related to maternal and child health (MCH) are primarily determined by senior women, or grandmothers, also by younger women themselves, and to a lesser extent by fathers and grandfathers. All of these various household actors have an influence on the health/nutrition of women and children both when they are well and when they are sick. Although younger women have periodic contact with health providers, on a day-to-day basis, most of the advice and supervision they receive comes from GMs, and secondly, from other household members.

Within the family, GMs play a multi-faceted role related to the day-to-day functioning of the household and family members view them as “the general managers in the family.” Their role includes: management of human resources; financial resources; food resources; and all health-related situations.

Their expertise in all of these critical aspects of family life underpins the respect accorded to them and their wide-ranging influence within the family context. Their influence in MCH matters is only one dimension of the broader scope of their authority at the household level.

One of the core values in Uzbek society is respect for the experience, knowledge and advice of elders. The importance of “respecting the advice of the elders” applies to MCH promotion insofar as the younger generation is expected to acknowledge the experience of senior women in this field. Women and their husbands are expected to respect the experience and advice of their mothers-in-law regarding all MCH matters.

In the extended family setting, the MCH knowledge and practices acquired by WRA are strongly influenced by the teaching and expectations of the experienced and authoritative GMs. In this context, they have a relatively limited degree of autonomy to adopt MCH practices which are not approved of by these senior women.

Families in rural Navoi have access to three sources of health care provided in the modern, traditional and family sectors. Modern health facilities are readily accessible and frequently used. In addition, traditional health providers, or “traditional healers,” operate in virtually all communities. However, in all cases, efforts to promote health and to manage illnesses take place primarily in the “family sector” wherein the senior women provide expertise and leadership.

GMs give advice to younger women when they are pregnant and when they are breastfeeding. GMs both advise and directly intervene in the care for newborns and for young children. When children are well they advise on what should be done to keep them healthy and when they are sick they diagnose and propose the appropriate treatment both within the household and outside. Many of the practices proposed and used by the GMs are beneficial to women and children. However, in light of current MOH priorities for MCH, some of their practices related both to women and children’s health are not optimal.

Particularly related to nutrition, their knowledge of the nutritional needs of women and children and the nutritional values of local foods and of is somewhat limited.

In all rural Navoi communities, GMs have frequent contact with one another and GM networks constitute indigenous communication and support mechanisms that contribute to family and community well-being. Both the GM networks and GM leaders are already actively involved in MCH promotion. And all GMs expressed their interest in learning more about the “new ideas about MCH.” Project Hope should explore possibilities of developing GM-focused activities working through the GM networks and leadership. Such activities should be developed in collaboration with the community women’s organization in each mahalla (municipality) to establish local ownership and increase the prospects that such activities will be sustained over time.

Given the status and experience of GMs in Uzbek communities, any activities to strengthen their current knowledge and practices should be carefully chosen in order to encourage them to participate. Teaching methods used with them should be based on adult education principles of respect and dialogue, rather than on traditional, one-way “school teaching” in which people are told what to do. In Uzbekistan, stories are a popular traditional form of communication and teaching, and it is suggested that this technique be tried with GM groups in MCH-promotion activities. Project HOPE staff and their MOH partners could develop stories addressing priority MCH project topics and GM leaders could be taught how to use these stories to stimulate discussion in GM networks.