Anaemia and Food Taboos in Pregnancy
Sunita, 24, is 26 weeks pregnant and attends the antenatal clinic at a block PHC in Barpeta. Her haemoglobin is 8.2 g/dL. She has two children under five and works in the household. She says she feels tired and dizzy. Her mother-in-law believes green leafy vegetables and eggs are 'hot' foods that will cause a big baby and a difficult delivery, so the family gives her mostly rice, dal, and two cups of tea with meals. The family earns about ₹9,000 a month and has no refrigerator. The PHC has iron-folic acid tablets in stock but no nutritionist. Sunita is willing to change but does not want to quarrel with her mother-in-law. She has no bleeding, no fever, and her blood pressure is 110/70 mmHg.
1. Identify the three most important nutrition-related problems in this case and explain why each matters for Sunita and her baby.
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First, iron-deficiency anaemia: Hb 8.2 g/dL in the third trimester increases the risk of fatigue, preterm birth, low birth weight, and poor tolerance of blood loss at delivery. Second, low diet diversity and protein intake: the family avoids eggs and green leafy vegetables, so Sunita may lack protein, iron, folate, and vitamin A; rice and dal alone are not enough for pregnancy. Third, tea with meals: tannins in tea reduce iron absorption from food and from iron tablets. The family's budget and lack of refrigeration are real constraints, but they do not justify removing eggs and greens. The mother-in-law's 'hot food' belief is a barrier, not a personal failing; the plan must work with it. These three problems interact, so fixing only the tablet supply will not be enough.
2. Give a practical one-day meal plan using local, affordable foods, and explain how you would introduce it without confronting the mother-in-law.
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Use foods the family already buys and can store without a fridge.
- On waking: water; tea only between meals, not with meals.
- Breakfast: chira (rice flakes) with milk or curd and a little jaggery, or roti with a boiled egg if the family accepts eggs.
- Lunch: rice, dal, a seasonal xaak (green leafy vegetable) such as lai or spinach, and small fish if affordable.
- Snack: roasted chana or groundnuts, banana, lemon water.
- Dinner: rice, dal, pumpkin or gourd, and greens.
- Iron-folic acid tablet at night with water or lemon water, not tea. To introduce it, ask the mother-in-law which greens the family already uses and ask her to teach Sunita how she cooks them. Explain that iron gives strength and helps the baby grow, rather than saying the family is wrong. Offer small, low-cost changes first, such as adding one green and moving tea away from meals.
3. What follow-up and referral would you plan, and which findings would make you escalate the same day?
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Plan a repeat Hb after four weeks or as per protocol, check tablet compliance and side effects, and ask about dark stools or constipation. Give deworming only as per the facility protocol and stage of pregnancy. Ask the ASHA to follow up at home and involve the mother-in-law in counselling. Escalate the same day if Sunita has breathlessness at rest, palpitations, chest pain, swelling of the face or legs, fever, bleeding, severe headache, blurred vision, reduced fetal movement, or if Hb falls below 7 g/dL. Also escalate if she cannot keep tablets down or has severe vomiting. These signs suggest severe anaemia, pre-eclampsia, infection, or another emergency that cannot be managed at the sub-centre.