Photos by Saikat Mojumder

Discovering JiVitAland

The day is already hot in Bangladesh’s Rajshahi Division.The muezzins have long since announced the dawn prayer, and the blue sky frustrates the villagers’ hopes for the monsoon rains. A farmer drives a pair of white oxen along a road that bisects fields of rice and jute. A shirtless man strains to pedal a rickshaw van. A woman in an orange sari hangs laundry on a rope strung between palm trees.

As farmers and housewives begin daily routines that have remained constant for generations, 652 local women are starting a day’s work that is novel for Bangladeshi villagers: collecting public health data. Setting out on foot and by bicycle, they are instrumental in conducting one of the world’s largest community trials of the role of nutrition in maternal and infant survival. By the trial’s conclusion in 2011, these JiVitA Project workers will have recruited nearly 100,000 pregnant women and their babies.

The decade-long JiVitA Project comprises three main studies that have shared a common purpose: testing whether micronutrients will save the lives of mothers and babies in northwestern Bangladesh—and by extension, in other rural regions of South Asia. JiVitA (pronounced “jee-veetuh”) is a play on the Bangla word jibheetoh, or “alive.”

“Women die in childbirth at a much higher rate in South Asia than they do in developed countries,” says Parul Christian, DrPH ’96, MSc, MPH ’92, an investigator for all three trials and an associate professor of International Health at the Bloomberg School.

The project in Bangladesh grew out of a groundbreaking nutrition trial in Nepal that concluded in 1997. That trial, also led by School faculty, showed that giving vitamin A to pregnant women reduced maternal deaths by 44 percent overall. These remarkable results prompted researchers to wonder: Could vitamin A also improve survival in other parts of South Asia where malnutrition was widespread?

In the 11 years since the JiVitA Project started in Bangladesh, researchers have investigated the effect of vitamin A on maternal health (JiVitA-1) and infant health (JiVitA-2). The study now under way (JiVitA-3) is examining whether infants are more likely to survive if their mothers are given a daily multi-micronutrient supplement during pregnancy.

“We see great opportunities for public health approaches to improve health and reduce infant mortality in these vast rural settings of South Asia,” says JiVitA Project director Keith P. West, DrPH ’87, MPH ’79, RD, the George G. Graham Professor of Infant and Child Nutrition, who also led the earlier Nepal study.

Habib-ara, one of JiVitA’s 14 staff coordinators, thinks of generations to come as she supervises 60 field staff. (Like many women in Bangladesh, Habib-ara uses only one name.) “A healthy mother will give birth to a healthy child,” she says. “Today’s child will be a mother in the future.”

On this July morning, in week 448 of the JiVitA Project, field distributor Nur Banu is visiting a new baby. This “JiVitA baby” was born the previous afternoon in the village of Kamar Pachgachi, where Banu herself lives.

As one of the 596 field distributors—all of them female—Banu is assigned to find local women as soon as they become pregnant, recruit them to the study and then give them prenatal supplements. In addition, whenever a child is born, the field distributor doses the new baby with vitamin A. That task brings Banu here today.

She finds the newborn asleep in the family’s kitchen shed, lying on a bed of rags and straw. The child’s mother, Shahinoor, sits on a low stool beside the chubby-cheeked baby girl. The baby is Shahinoor’s fourth child, and she is not yet named. Shahinoor looks frail, her red cotton sari draped over her head.

Like 95 percent of JiVitA babies, this one was born at home. In keeping with village customs that regard childbirth as polluting, Shahinoor did not give birth in the family house, however. The combination kitchen shed and cow stall next to the house served as an atur ghar, or labor room. The shed has grass walls, a mud floor and a corrugated iron roof. Mother and daughter will remain there for three days. On the third day, a barber or someone else chosen by the family will shave the baby’s hair, which is considered unclean. Then Shahinoor will return to her house, and her newborn daughter will enter it for the first time.

Banu greets the new mother and unpacks her supplies just inside the shed door. She has been here dozens of times. She began visiting JiVitA household #0049 even before Shahinoor became pregnant with this child; as a married woman of childbearing age, Shahinoor was a candidate for the study and has been among the local women Banu regularly visits in her search for pregnant women.

In December, Shahinoor told Banu that she’d missed her period. Banu tested her urine to confirm the pregnancy and invited Shahinoor to take part in JiVitA-3. Like 98 percent of women asked to participate, Shahinoor consented. Since then Banu has visited Shahinoor twice a week to remind her to take the daily supplements, to record how often she has done so, and to refill her supply. By the trial’s end, Banu and her co-workers will have followed 36,000 pregnant women to measure the effects of multiple micronutrients on infant mortality and morbidity.