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WOMEN AND NUTRITION: REFLECTIONS FROM INDIA AND PAKISTAN


Introduction
Women's Nutritional Status
Synergistic Effects on Nutritional Status of Gender and Poverty
Some Consequences of Female Nutritional Deprivation
Women's Nutritional Roles
Prospects for Intervention
Appendix A: Women and Nutrition - Matrix for Policy Planning
Summary
References

By Meera Chatterjee and Julian Lambert1

1 Dr Chatterjee is consultant health and nutrition scientist. Dr Lambert is Chief of Nutrition and Child Disability Section, UNICEF India Country Office, New Delhi.

Introduction

In 1987 India and Pakistan had a total population of 913.1 million, which is considerably greater than that of all 49 countries of Africa (587.9 million). Of these, 440 million were female, 200 million being women of childbearing age. Uttar Pradesh, India's most populous state, alone had a population of 128.5 million, which is significantly greater than that of Africa's largest country, Nigeria, with a total population of 101.9 million (1987).

India and Pakistan have both made rapid gains in food production in the last two decades as a result of the green revolution, although these gains have been offset by rapid rates of population growth. In India, per capita food availability has been sustained, while in Pakistan the number of calories available per person per day increased from 2200 to 2348 between 1970 and 1986. However, these increases in overall food supplies have not been accompanied by any significant reduction in the amount of malnutrition among either women or children.

Besides high general death rates and infant and child mortality rates, both India and Pakistan have high maternal mortality rates. The number of pregnancy-related deaths every year in these two countries is estimated to be 166,000, or 450 per day. Accounting for 45% of all maternity deaths in the world, the maternal mortality rates of India and Pakistan (500 and 600 per 100,000 live births, respectively) are 250 to 300 times those of developed countries such as Canada (2 per 100,000) (UNICEF, 1989). These differences are far greater than those observed between these countries' infant and child mortality rates.

Malnutrition plays a key role in maternal mortality, just as in infant and child deaths. In 1965, a WHO Expert Committee on Nutrition in Pregnancy and Lactation wrote, "Next to young children, pregnant and lactating women are nutritionally the most vulnerable group, especially in the developing regions of the world, and yet comparatively little is known of their special nutritional needs." (WHO, 1965). Regrettably, little has changed since then and maternal malnutrition remains a major problem in India and Pakistan, where the majority of women are in a constant state of nutritional stress, beginning in childhood, then adolescence, and continuing through the childbearing period which often commences before growth has ceased, and consists of a continuous cycle of pregnancy and lactation, all too often resulting in premature death. Chronic protein-energy malnutrition, iron-deficiency anaemia, and deficiencies of iodine and vitamin A are among the common nutritional deficiencies that affect women in the two countries.

In this paper, we take the liberty of discussing the nutritional situations of women in India and Pakistan together, as the similarities appear to outweigh the differences. Occasional inferences are also drawn from Bangladesh. The paper is concerned with both the nutritional status of women and their nutrition-related roles, as these two aspects of "Women and Nutrition" are clearly inter-related. Through their diverse "nutrition-related roles" women influence the nutritional status of individual household members (for example, through child care) and of the household as a unit (eg. by earning). As women are members of the households in which they acquire, cook, serve, consume and store food, their own nutritional status is the effect of the exercise of these roles and of the ensuing 'household nutritional status.' While a woman's nutritional status is part and parcel of her household's nutritional profile, it is also a cause of the household's nutritional status, as a woman's performance of her "nutrition-related roles" depends, for example, on her 'energy level.' Socio-economic and socio-cultural factors (such as income, literacy or traditional beliefs) simultaneously influence both women's nutritional status and their nutrition-related roles. In the Indian subcontinent, the apparent contradiction between women's primary responsibility for household nutrition (eg. food preparation, health care), and their own serious malnutrition renders a simultaneous examination of these two aspects particularly interesting.

Women's Nutritional Status


Nutritional Levels
Gender Differentials
Micro-Nutrient Deficiencies

A discussion of women's nutritional status can encompass both absolute levels of nutrition among women, and their nutritional status relative to men, i.e. issues of discrimination between males and females in nutrition-related matters (such as feeding and health care) and consequent gender differentials in nutritional status. These aspects are, of course, intimately related.

Nutritional Levels

In India, the National Nutrition Monitoring Bureau (NNMB) collected data on household and individual food consumption, and individual nutritional status (judged by anthropometric and clinical indicators) during the late 1970s and early 80s in ten major states of the country on a sample basis. In a representative year (1979; there are no discernible secular trends in these data), 41% of households were "calorie inadequate" in the national aggregate, and 19% were short of both calories and protein (NNMB, 1980). In the different states, calorie inadequacy varied from 23% of households in Andhra Pradesh in the south, to over 65% in Uttar Pradesh in the north. The percentages of individuals who were "calorie inadequate" were consistently higher at the national (46%) and state levels (range: 28 to 70%), suggesting that in a proportion of households (variable across states), whereas the total food availability was adequate for all members combined, there was inappropriate distribution so that some individuals bore a disproportionate burden of deficit.2 This is likely to be true also of those households where food (calorie) availability is inadequate in the aggregate.3 From other evidence we know that the burden falls on children, and possibly on women.

2 A single exception to this is Uttar Pradesh which had 65% calorie-inadequacy at the household level (the highest among all the states), but 54% at the individual level (fourth highest of ten states surveyed). Although the deficit of inadequate households is not discernible from the published NNMB data, U.P. had the lowest average calorie consumption per consumer unit (1983 Kcals per CU per day, compared with the Indian recommended intake of 2400 Kcals). Thus, a tenable explanation that emerges is that, in the face of high household food deficits, greater 'equity' is achieved between individuals because survival is at issue (see later in this paper).

3 Another possible explanation for the higher percentage of calorie inadequacy among individuals than households could be that the households that are calorie inadequate account for a larger proportion of individuals, i.e. that their size is significantly larger than that of calorie-adequate households. However, there is no evidence of this from these data, nor any suggestion of it in other data known to us. The 'deviance' of U.P. from the other states' pattern would also lead one to discount a household-size explanation, as U.P. is known to have larger households than many other areas covered by this survey.

The NNMB data (pooled over 1975-78) establish the poor nutrition levels in the Indian population (NNMB, 1980). As one would expect, calorie inadequacy is consistently greater among children than among adults. In children below 13 years, at least 80% have intakes less than levels recommended for their respective ages. (Unfortunately, gender-specific data are not available under 13.) Among 13-18 year old girls, over 80% consume less than the recommended calories; among women over 18 years, 60% of those engaged in "sedentary" activity and almost 70% of those engaged in "moderate" activity have intakes below the relevant RDAs. Over 75% of pregnant and 80% of lactating women engaged in "sedentary" activity consume less than recommended, while 100% of "moderately" active women in both physiological categories fail to achieve recommended levels.

Table I. Distribution of Population (Pakistan) in Different Sub-Groups according to Percent of Calorie RDA Consumed: percent of population group in cells

Percent of RDA

Adult Males

Adult Females

Pregnant

Lactating

Less than 70%

27.3

25.6

22.0

19.9

70-79%

12.9

8.9

18.5

12.1

80-89%

12.6

13.3

10.2

14.7

90-99%

10.4

12.8

8.5

13.7

100-109%

8.1

4.4

11.9

9.5

110-119%

6.1

7.9

3.4

6.9

Above 120%

22.7

27.1

25.5

23.2

Source: Planning Commission (Pakistan), 1979
Table I shows the average daily intake of calories among adults in Pakistan. Approximately 60% of the adult population consume less than the recommended daily allowance, and around 40% consume less than 80% of the RDA.

Gender Differentials

The Indian NNMB data reveal a mixed picture of male-female differences in mean caloric (and protein) intakes. In 1982, girls in the 13-16 year age-group consumed much less than boys, and only two-thirds of their recommended calorie intakes (in all states surveyed except Karnataka) (NNMB, 1984). While 16-18 year-olds fared slightly better than boys, they were still consuming below their requirement. Earlier data (1979) showed no significant differences in the "calorie adequacy" of males and (non-pregnant/non-lactating) females over 18 years old (NNMB, 1980). While no data are given in this year for pregnant women, lactating women are more calorie inadequate than their non-pregnant/non-lactating counterparts.

An examination of percentile values of calorie intakes expressed as percentages of recommended levels among 13-16,16-18, and over 18 year-olds (in pooled 1975-78 data) reveals no major differences between males and females (NNMB, 1980). Only among pregnant and lactating women were these values lower than males, as well as lower than non-pregnant and non-lactating women. On the other hand, the data from the Pakistani Planning Commission do not reveal any consistent differences in the distribution of adult males and females in different calorie consumption categories, nor between pregnant, lactating and "other" adult females (Table I).

Micro-Nutrient Deficiencies

IRON Pooled 1975-78 data on food consumption from the Indian NNMB (1980) show that girls between 13 and 18 years of age obtain lower percentages of the recommended levels of iron than do boys in the same age groups (Table II). With the onset of menarche, young girls are highly susceptible to anaemia in the absence of adequate dietary iron. The prevalence of anemia among women in India is extremely high, as shown by a study conducted by the Indian Council of Medical Research (ICMR) in four areas of the country (ICMR, 1982). It was found that over 95 percent of 6-14 year-old girls in the Calcutta area were anaemic, around 70 percent in the Hyderabad and Delhi areas, and around 20 percent in the Madras area.

Table II. Percent of Recommended Levels of Iron Consumed by Different Age-Sex Groups in Different States



Percent of Recommended Levels of Iron

13-16 Years

16-18 Years

State

Male

Female

Male

Female

Andhra Pradesh

68

56

87

77

Gujarat

85

63

95

59

Karnataka

150

93

156

98

Kerala

54

45

72

43

Madhya Pradesh

80

63

93

70

Maharashtra

108

70

130

76

Tamil Nadu

96

63

99

67

Uttar Pradesh

110

53

130

69

West Bengal

103

58

119

55

Source: NNMB (1980)
Anaemia is also common in pregnancy, frequently caused by a combination of low iron intakes and poor absorption, exacerbated by malaria and hookworm infections. In some poor communities in India, 80-90% of pregnant women may be anaemic, while nationally more than 50% of women may be affected. A national survey in Pakistan in 1976 found over 54% of pregnant women to be anaemic (Planning Commission, 1987). Between 40-50% of maternal deaths may be associated with anaemia or the resultant increased dangers of hemorrhage. Agarwal et al., (1988) in Varanasi treated 119 pregnant women with 60 mg iron and 500 mg folic acid daily for 100 days and improved their hemoglobin levels by 1.6 gm % (compared with a fall of 0.3 gm % in a non-treated group). They found that birth weights increased significantly between the supplemented group (mean = 2.91 kg) and the placebo-treated control group (mean = 2.59 kg).

IODINE. An estimated 200 million people in India and Pakistan are at risk of iodine deficiency disorders. Of all micro-nutrient deficiencies, a shortage of iodine in pregnancy has the most far-reaching consequences. In some seriously affected areas in the Himalayas, 80% of the population suffer from goitre and up to 10% of newborns may be cretinous.

Iodine deficiency disorders also have a significant impact on rates of spontaneous abortion, still-births, and infant and neonatal deaths. The dramatic effects on perinatal and infant mortality, and on birth weights and the development quotients of the children, of a single iodized oil injection given at the start of pregnancy were demonstrated by Thilly (1983) in Zaire (Table III). If administered early in pregnancy or preferably prior to conception, iodized oil gives guaranteed results. Given that cretinism is irreversible, and that an iodized oil injection is low cost (35 cents) and has an effective span of 5 years, the eradication of iodine deficiency disorders can be high on a list of priorities.

Table III. Effect of Injection of Iodized Oil Given to Women During Pregnancy (Zaire)


Not Treated

Treated

Birth Weight (grams)

2634
(SD = 552)

(98)

2837
(SD = 542)

(112)

Perinatal Mortality per 1000

188

(123)

98

(129)

Infant Mortality per 1000

255

(263)

167

(252)

Development Quotient

104
(SD = 24)

(66)

115
(SD = 16)

(72)

Number of subjects is in brackets
All differences between treated and non-treated were significant

Source: Thilly (1983)

Synergistic Effects on Nutritional Status of Gender and Poverty


Regional Variations
Socio-Economic Differentials
Dietary Intake vs. Energy Expenditure
Economic Crises
Some Demographic Influences on Gender Discrimination
Effects of "Development" and the "Demographic Transition"

The effects of gender and poverty on nutritional status may be synergistic. In an economic analysis of malnutrition among young children in Punjab, Levinson (1974) found that, while gender was the most statistically significant determinant of nutritional status, male-female differentials in nutritional status were especially great among the lower socio-economic/caste group. Nutritional status among the higher, land-owning caste was better on the whole, and the gender differential was also smaller.

In Levinson's study, gender had a highly significant effect on caloric intake among the study population as a whole, and on diarrhoeal disease rates among the economically better-off, with females having lower intakes and exhibiting higher rates of infection. Although both high and low socio-economic groups discriminated against females in breastfeeding practices, girls in the better-off households consumed as many calories and more protein, iron and "supplementary food" as boys because food resources were not scarce among these families. Among the poor, however, discrimination against female children, coupled with inadequate purchasing power meant their young girls had lower caloric intakes, consumed less supplementary food, and less solid food compared with boys. This resulted in considerably higher mortality levels among low-caste female infants (IMR = 196 per 1000 live births) compared with males (125 per 1000), documented in a contiguous study area (Kielmann et al., 1983). Levinson ascribes the greater vulnerability of girls to differentials in the care and upbringing of sons and daughters: "These differences reflect an economic as well as a cultural premium placed on living sons...(while) daughters are considered unproductive and an expensive economic drain, particularly the cost of dowry when they marry." This socio-cultural attitude considerably influences household nutritional care of girls in their natal homes, and is carried to varying degrees into marital - daughter-in-law, wife and mother - situations.

A few studies (eg. Ghosh et al., 1982) have documented deterioration in nutritional status (cross-sectionally) as females grow older, the combined result of socio-cultural, economic and biologic processes. Gender differences in adult nutritional status also appear to be exacerbated by poverty, as McNeill (1984) demonstrated in Tamil Nadu.

Regional Variations

In addition to the national surveys cited above, a number of smaller household dietary intake studies in different parts of the Subcontinent provide information on differentials between males and females by age, socio-economic status, region and season. A 'mapping' of these studies shows that nutritional 'equity' between males and females is lower in north India and improves towards the South. While in Rajasthan, a northern state, all children under 12 and adult women were deprived of their fair nutritional "shares" relative to adult males as well as to the applicable RDAs, the gender differential disappeared among adults in the western states of Gujarat (except for lactating women) and Maharashtra, and the southern states of Andhra Pradesh and Tamil Nadu (Harriss, 1986). However, even in the latter areas, preschool girls tended to be worse off than boys, and some gender differentials occurred seasonally. In most instances, adolescent girls appeared to be as well - or sometimes even better-off than their male counterparts. In the East (including Bangladesh), the situation was similar to that found in Rajasthan, but the nutritional deprivation of women appears to be economically rather than culturally mediated, as "work" plays a significant role in female undernutrition (see below). Regional variations are also seen in Pakistan, with higher rates of malnutrition among women in Baluchistan and Sind compared to Punjab and the North-West Frontier Province. In essence, the social and economic value of women underlie regional variations in their nutritional status and in male-female differences in nutrition.

Socio-Economic Differentials

While not permitting an examination of gender differentials within each socio-economic category, the NNMB's dietary intake surveys document lower food consumption in households without land, compared with landowning households; among those who possessed land but did not grow crops in the reference year, compared with those who did grow crops; among labourers and "others" (village artisans and petty businessmen), compared with cultivators; and among Scheduled Castes and Tribes, compared with non-scheduled groups (NNMB, 1980). Thus, women in these groups are likely to be at the greatest risk of malnutrition.

Dietary Intake vs. Energy Expenditure

There is some evidence that while women get a 'disproportionately' small share of household food, they may expend a larger proportion of 'household energy'. A few studies (Jain and Chand, 1979; Batliwala, 1982; Khan et al., 1982) suggest that women work longer hours and expend more energy than men. Batliwala (1982) estimated that women had a shortfall of 100 calories a day on an average if their physical activity in paid and unpaid domestic work were considered altogether, while men had a surplus of 800 calories (in 560 households in six Karnataka villages).

Economic Crises

In times of extreme food scarcity, female access to food is more circumscribed than that of males. A survey of some flood-hit West Bengal villages in 1978 showed that females of all ages up to 72 years had higher rates of malnutrition than males (Kynch and Sen, 1983). The female/male ratio of malnourished 0-5 year olds was 1.07. If only moderate and severe malnutrition were considered, the ratio rose to 1.40; and it was 1.59 among severely malnourished children alone. These data suggest that females were both more at risk of malnutrition and more severely affected by it. They also point, as before, to the synergistic effect of impoverishment and gender bias, which has been documented in Bangladesh as well (Bairagi, 1986).

Some Demographic Influences on Gender Discrimination

Discrimination against female children appears especially acute in the case of girls born into families who already have a surviving child, particularly among low socio-economic groups (Das et al., 1982), a finding that is supported by the observation of higher mortality risk among girls of high birth order (Das Gupta, 1987). The shorter period of breastfeeding of girl children in turn increases the likelihood of ovulation and subsequent conception by their mothers. Shorter birth intervals after female births compared with male births have been documented by Haldar and Bhattacharya (1969). The increased risk of malnutrition and mortality to these female children is accompanied by further nutritional depletion of their mothers.

Effects of "Development" and the "Demographic Transition"

A comparison of data from studies in the Punjab in the 1970s and '80s reveals that the social discrimination against young girls in matters of nutrition has persisted despite the agricultural growth and economic development experienced in the area. Das et al., (1982) found that 24% of female children among "privileged" families were malnourished, while 74% among the "underprivileged" suffered from malnutrition. Among male children, the percentages were: 14 among the privileged and 67 among the underprivileged. Das Gupta's finding (1987) that the gender differential in food consumption among 0-4 year olds was higher among landed than among landless families is instructive. Furthermore, the selective discrimination practised against second or higher birth order daughters particularly among the better-off who aspire to smaller families suggests that the "demographic transition" that has occurred in the region may have worsened the status of the female child, as mothers continue to be under severe pressure to bear and nurture sons.

Even development at the "micro-level" may have negative repercussions. An in-depth study of two villages in West Bengal (Sen and Sengupta, 1983) demonstrated that the 'inequitable' distribution of "development benefits" exacerbated a priori differentials between males and females. Following land reforms in one of the study villages, the proportion of people owning land increased, and undernourishment among 0-5 year olds decreased. However, despite better overall nutritional levels, this village showed sharper gender differentials in anthropometric status, as only boys' nutrition improved, while girls' nutrition in this village remained on par with that of girls in the "underdeveloped" village. In sum, the economic benefits accrued selectively to boys. The finding of this study that a supplementary feeding programme helped to partially overcome the sex bias in nutrition is significant for policy and programmes.

Some Consequences of Female Nutritional Deprivation


Physical Underdevelopment
High Maternal Mortality
Low Birth Weights and High Infant Mortality
Skewed Sex Ratio

Physical Underdevelopment

A major consequence of girls' nutritional deprivation in early childhood and adolescence is their failure to achieve full growth potential. A majority of girls from low income families reach adolescence about 12-15 cms shorter than their well-to-do peers in the same society (Rohde, 1987). The National Nutrition Monitoring Bureau's data on Indian women's heights and weights show that between 12 and 23 percent of 20-24 year-old women in the different states surveyed had heights below 145 cms; and between 15 and 29 percent had weights below 38 kg (NNMB, 1980). The percentages were even higher among younger girls - eg. 49 percent under-height and 67 percent under-weight among 15 year olds in Kerala - who have not yet completed their adolescent growth spurt, but who may yet marry and bear children at this early age. Girls who bear a child before the close of the adolescent growth spurt may remain physically underdeveloped and hence are at greater risk of obstetric complications, obstructed labour or maternal death, as well as of bearing low birth weight infants. During pregnancy, women's access to food is often restricted through the taboos and rituals observed in traditional Indian and Pakistani households. Besides low maternal pre-pregnancy weights and inadequate weight gains during pregnancy, low birth weights are also related to low hemoglobin levels, so that the high prevalence of anaemia adds to the negative outcomes of childbearing.

High Maternal Mortality

In developing countries overall, maternal mortality accounts for some 25% of deaths in women of childbearing age, compared with 1% in the U.S. Worldwide, WHO has estimated that 250 women die every four hours due to problems associated with childbirth. In India, deaths due to pregnancy and childbirth accounted for around 12.5% of deaths among rural females aged between 15 and 45 years in 1986 (Office of the Registrar General, 1988). While the aggregate national maternal mortality rates are estimated to be around 500 and 600 per 100,000 live births in India and Pakistan, respectively, rates over 1000 have been recorded in certain parts of these countries. These rates contrast with the range of 1 to 15 maternal deaths per 100,000 live births in developed countries. In comparison with this up to 1000-fold difference, the difference between the lowest and highest recorded national infant mortality rates in the world is around 25-fold.

High maternal mortality in India and Pakistan is a reflection of women's undernutrition, poor health status and high fertility. Poverty, low rates of female literacy, and poor access to or utilisation of health services are some of the underlying factors. Several common causes of maternal deaths are related to malnutrition, particularly to anaemia, while other serious causes, such as toxemia and septicaemia, reflect the inadequate health care available to women in the ante-natal, intranatal, and post-natal periods (see below). Some research in India found that for each maternal death there were 16.5 cases of illness related to pregnancy and childbirth, most of which would go unattended.

Low Birth Weights and High Infant Mortality

In both India and Pakistan, an estimated 25-30% of babies are under 2500 grams at birth, and low birth weight is a significant factor underlying their high infant mortality rates (eg. 105 in rural areas of India in 1986). From a retrospective study of over 10,000 perinatal deaths, Mehta (1980) found that 75% were associated with weights of less than 2500 grams.

Poverty exacerbates the problem of low birth weight for poor women have both a 'nutritional handicap' and inadequate access to food during pregnancy. For example, Ghosh et al., (1982) found a 35.5 percent incidence of low birth weight among babies born to poor, short women, compared with 24 percent among those born to poor women over 145 cms in height, and 15 percent among babies of better-off, taller women. A detailed study of 5914 live borns in Pelotas, Brazil found that although low birth weight infants were more common among low income mothers, low birth weight was a much more important determinant of infant mortality than income per se (Victoria et al., 1986).

In India and Pakistan, low food intake during pregnancy is a major problem. Numerous studies have found that women consume little or no extra food during pregnancy, and may even consciously limit their intake in the fear of developing large fetuses which would make labour more difficult, given small pelvic sizes. Food taboos often deprive women of protein and iron sources, as well as reduce calorie availability. Fetal growth in India is similar to that among Caucasians until the last 5 to 6 weeks of pregnancy, when fetal weight gain significantly slows (Table IV). In addition, the average gestational age for Indian infants is 38.5 weeks.

Table IV. Mean Birthweights of Newborns

Gestation in weeks

Grams

Baltimore

New Delhi

Varanasi

28

1050

922

1005

29

1200

1177

1128

30

1280

1326

1255

31

1560

1499

1405

32

1750

1608

1575

33

1950

1941

1755

34

2170

2052

1955

35

2390

2250

2145

36

2610

2421

2345

37

2830

2691

2528

38

3050

2760

2690

39

3210

2843

2805

40

3280

2985

2865

41

3350

2911

2860

42

3400

2027

2830

43

3410

3000

2790

Source: Greenwald (1966)

Skewed Sex Ratio

The summary outcome of the higher mortality of females are the sex ratios found in both India and Pakistan - 904 women per 1000 men in Pakistan, and 933 in India, in 1981. In India, women have higher mortality rates than men up to the age of 35 years, the most significant differential occuring in the 0-5 year age-group. Because of the large number of deaths in this age group, they account for most of the skewedness in the sex ratio, and malnutrition is a significant underlying factor in many of these deaths.

Women's Nutritional Roles


Care of Female Children
Women's Roles as "Providers"
Women's Social Status
Early Marriage and High Fertility
Fertility and Mortality
Effects of Women's Status on Female Child Survival
Women's Education, Fertility and Mortality
Women's Economic Status
Effects of Women's Employment through Income
Women's Decision-Making Power
Other Characteristics of Female Employment
Employment and Child Care
Women’s Access to Health Care

Care of Female Children

Gender differences in nutritional status in childhood initiate women's 'nutritional handicap,' and are also evidence of the problems experienced by women (mothers) in the exercise of their "nutrition-related roles," specifically their child care and feeding responsibilities. Although child nutritional status is clearly the outcome of a host of factors, starting with the nutritional status of pregnant women, gender differentials are established during the breastfeeding and supplementation stages. Several micro-studies have observed anthropometric differences in infancy (eg. Gopalan, 1985), which persist through childhood (eg. CARE, 1974). Girl infants are breastfed less frequently, for shorter durations, and over shorter periods than are boys (Das et al., 1982; Ghosh, 1985; Khan et al., 1983), a situation that may be exacerbated among the poor for social and economic reasons. A study in Tamil Nadu found that while male children were breastfed for five months longer than female children on the average, male children in landed families were breastfed almost ten months more than female children in agricultural labour households (McNeill, 1984). Weaned earlier, young girls may not get the required quantities of supplementary food, as described by Levinson (1974). Discrimination against female children in the quality of food given has also been shown - in cultures as diverse as those of Tamil Nadu (Devadas and Kamalanathan, 1985) and Punjab (Das Gupta, 1987). Male children receive larger quantities of cereals, fats, milk, and sugar than females. Higher caloric and protein intakes by males of all ages have also been documented in Bangladesh (Chen et al., 1981). The differential feeding of girls is accompanied by lower levels of health care (discussed below), so that they are simultaneously exposed to higher rates of malnutrition and longer periods or more severe morbidity, ultimately resulting in their significantly higher mortality.

Women's Roles as "Providers"

Women also exercise nutritional effects on the household by the acquisition of food through work, and by the preparation of food for consumption. Thus, women's employment, income and "decision-making power" vis a vis the disposal of their income, on the one hand, and their ability to cook and serve appropriate quantities of food to individual household members (based on nutritional knowledge and "autonomy" in 'kitchen' decision-making), on the other, are important determinants of women's nutrition-related roles. Therefore, the performance of these roles is related to women's social and economic status.

Women's Social Status

Women's inadequate dietary intakes and poor nutritional status are founded in the anthropological observation that women and girls eat "last and least," a reflection of the inferior social status they are accorded in Indian society throughout their life cycles. We shall explore their social status through two important manifestations: marriage and childbearing patterns, and educational levels.

Early Marriage and High Fertility

Marriage and childbearing affect women's nutritional status directly, as well as indirectly through associated socio-cultural norms and practices. They also affect women's education and employment, which exert considerable influence on household nutrition. Indian women have one of the lowest mean ages of marriage in the world - 18.3 years (1981) (Office of the Registrar General, 1983), with lower averages obtaining in rural areas and in some states (particularly in the north). These low ages are reflected in the proportions of girls married among younger age groups: almost 8% of 10-14 year olds, and 44% of 15-19 year olds. "Universal" marriage almost obtains by the age of 24 years among women in most states of the country. In Pakistan, the mean age at marriage was 20.4 years in 1981.

Among the correlates of age at marriage, female literacy is paramount, while other factors such as 'general' literacy, per capita income, level of urbanisation, non-agricultural employment and mass media, are also important (Srivastav, 1986). At the state-level, women's participation in agriculture has a negative correlation with female age at marriage because higher participation rates are indicative of more "traditional" communities. Thus, where women are married early, they are not only deprived of schooling and the benefits this may bring to nutritional awareness, but they are exposed to the 'double energy demands' of grueling agricultural work and of early, frequent and prolonged childbearing.

Early marriage is tantamount to early childbearing because young married women are under considerable societal and familial pressure to "prove" their fertility. This is demonstrated by prevailing age-specific marital fertility rates. In 1978, 17.5% of rural and 19.7% of urban 15-19 year old females bore a child (Office of the Registrar General, 1982). The 15-19 year age group accounted for 8% of births in rural areas; over one-third of all births occurred to women under 24 years of age and two-thirds to women under 29 years (Office of the Registrar General, 1983). Of a 30-year reproductive span, an Indian woman spends 16 years in pregnancy and lactation on an average.

Fertility and Mortality

Early, frequent and prolonged childbearing are associated with higher risks of malnourishment and mortality to both mothers and infants, as discussed above. First births and those over four are particularly problematic, the former also being related to low maternal age and age at marriage. Many first births occur under the age of 20; girls who are married young are more likely to have high order births. Infants born to women married under the age of 18 have almost twice the risk of death compared with infants of women married after age 21 (Office of the Registrar General, 1981). According to the nation-wide 1979 Survey of Infant and Child Mortality (Office of the Registrar General, 1981), the high rural infant mortality rate reflected the high proportion of births (20-25 percent) which had a birth order of five or more. Maternal depletion and anaemia are among the factors explaining these relationships.

Another known correlate of high infant mortality is "rapid" childbearing, or closely spaced births. In India, Das (1975) found that the mortality rate among children born between 1.5 and 2.5 years of a previous birth was almost half that of children born within a 1.5 year birth interval. With longer intervals the mortality rate decreased further. A survey by the WHO of 6000 women showed that the mortality of infants born within a year of a previous birth was twice as high as that of infants born after two years of a previous birth (the infant mortality rates in these groups were 200 and 100, respectively) (cited by Ghosh, 1987). A spacing of between 1 and 2 years resulted in an infant mortality rate of 145, while a spacing of 3-4 years reduced the rate even further to 80. A two-year spacing between births could reduce India's aggregate infant mortality rate by 10 percent and child mortality by 16 percent. It would also reduce maternal deaths by lowering maternal "nutritional depletion" and susceptibility to disease. Similar observations have been made in Pakistan, where the IMR was found to be 179 for a birth interval of less than 2 years, compared with an IMR of 92 for an interval of more than two years (World Fertility Survey).

The studies cited above also pointed to another factor important to the survival of infants - mothers' previous child loss experience. Mortality was considerably higher among infants whose mothers had lost a previous child. Child loss shortened the interval between births, and thus most likely aggravated the nutritional status of the mother. It is also related to "maternal competence," an 'intermediate variable' through which socio-cultural and socio-economic factors such as education and employment exert additional influence on women's nutritional status, morbidity and mortality (see below). The compound effects of women's low education, low employment and early marriage are a larger number of births, closely spaced, more nutritionally-depleted women, and a larger number of maternal and child deaths.

Effects of Women's Status on Female Child Survival

There are some discernible relationships between the survival of female children and mothers' characteristics. The sex ratio of children 'ostensibly born' and surviving varies by the age of their mothers, being particularly low among mothers under 15 years (Office of the Registrar General, 1983). The female child of the young mother is at particular risk of death because young women are under the greatest pressure to produce sons. The extent of this pressure is also related to women's economic status. Bardhan (1987) has shown that son preference in India correlates inversely with female earnings across the states. Where women's economic status is low, their social status is enhanced by mothering sons. As mentioned above, Das Gupta (1987) found that second or higher birth order daughters are particularly at risk of death where women's status is low. In her study, the sex differential in mortality was more influenced by birth order than by economic or education levels per se.

Women's Education, Fertility and Mortality

Numerous factors, including rural/urban residence, religion, caste, occupation, educational level, household per capita expenditure, and age at marriage, influence fertility, with the effects of the last three being particularly profound. Illiterate women have considerably higher fertility than do literates - more than twice as high among 15-19 year olds and 30% to 50% higher among other age groups in rural areas, with as much variation among urban groups (Office of the Registrar General, 1982). While their higher fertility is in part due to a lower mean age at marriage, other factors, such as higher desired family size, and higher child mortality rates are also important. Literacy results in fewer higher order births, with considerable differences between women having below primary level education and those with five or more years of schooling (Office of the Registrar General, 1982).

Female education is also related strongly and inversely to infant mortality. Using data from the 1979 Survey of Infant and Child Mortality, Jain (1984) established that female education and household economic status were important "household-level" factors explaining mortality variations. In India as a whole, illiterate mothers experienced 145 infant deaths per 1000 live births, while those with some education had an infant mortality rate of 101, and those with primary education had 71 deaths per 1000 infants born. In rural areas, infants of illiterate women had a mortality rate more than double that of infants whose mothers had a primary school education (132 and 64, respectively), while in urban areas the difference was reduced to two-thirds higher among illiterate women (81) compared with primary-schooled women (49). This suggests that other 'urban factors,' such as the availability of health services (see below) can partially offset the detrimental effects of female illiteracy on infant mortality. However, poverty may be an over-riding negative factor, as analysis of the infant mortality rates of different states shows that while the IMR decreases with increasing female education, the relationship does not hold in some poor states such as Assam and Andhra Pradesh. The relationship between female literacy and infant mortality has been found to hold good in Pakistan as well.

The mechanisms whereby women's education results in lower child mortality have been the subject of some speculation. As child health and survival are enhanced by better hygiene, improved nutrition and feeding practices (of the child as well as of the mother) and timely medical intervention, education may improve women's practice of any of these. Schooling may enable women to take independent decisions and act on them. Educated women may have greater roles in household decision-making, and be permitted by other household members to pursue appropriate strategies. In Bangladesh, D'Souza and Bhuiya (1982) showed that household decision-making does indeed change with the education of women, with greater shares of household resources becoming available to women and children. Clearly, the effects of women's education on their own nutritional status and on that of their children is exerted through their roles as providers of household health and nutrition care.

In fact, when it comes to child nutrition, mothers' knowledge may be more important than income. Bairagi (1980) studied the relationship between child nutrition and factors such as family income, maternal education and birth order. He found that income was not the only constraint on nutritional status, even in the lowest income group. Maternal education had a significant influence on nutritional status, as did the child's sex and birth order. A literate mother used scarce resources better for her child's welfare than did an illiterate mother with higher income. Sen and Sengupta's (1983) study of two villages in West Bengal showed that children with literate mothers fared better than those with illiterate mothers in terms of nourishment. However, these authors suggested that "literacy and prosperity" went hand in hand as the beneficial effect of mothers' education was greater in the village where there was a higher degree of "urban integration". In Das Gupta's (1987) study of Punjabi villages, women's education was associated with reduced child mortality, but she found that education increased the discrimination against girls of higher birth order, perhaps because with education women desire smaller families with only one daughter. In the Punjab, education may also increase rather than decrease the quantum of dowry required to marry off daughters because it does not clearly enhance the "economic value" of women.

Women's Economic Status

That women's nutritional status and health are related to their "economic status" is demonstrated both by macro- or regional-level analyses as well as micro- (household) level data (Chatterjee, 1988b). The North-South dichotomy in nutritional levels and differentials discussed above suggests that where females have high economic "value," they receive larger shares of food and health resources; where their economic value is lower, they remain at considerable disadvantage. Regional analyses of health indices other than nutritional status, such as mortality rates or sex ratios, further substantiate this relationship. Two particular aspects of women's economic value have been related to health status - labour force participation and inheritance of property, including payment of dowry. Bardhan (1974) first hypothesized that greater demand for female labour in the rice-growing Southern region of the country supports higher female survival rates, compared with wheat cultivation in the North. Analysing sex ratios in different regions, Miller (1981) found a clear relationship between high labour force participation rates among 15-34 year old women and young girls' survival. However, in some areas where female work participation was low, such as West Bengal, Assam, Orissa and Kerala, the sex ratios were not unfavourable to females, as "culture" protected females, despite economic backwardness.

Rosenzweig and Schultz (1982) provided further evidence of a relationship between women's work and survival through a two-stage regression analysis of an all-India sample of rural households, first demonstrating a correlation between rainfall and female employment, and then a negative correlation between female employment and the male-female survival differential. Higher female employment in wetland cultivation decreased the difference in the survival rates of males and females. Female employment was more significant than present wealth or parents' educational status in explaining variations in sex-specific survival rates. Significantly, a rise in male employment exacerbated the difference between boys and girls' survival in favour of boys.

Regional differences in female survival are also related to the payment of dowry, a practice which is more prevalent in the North than in the South. Miller (1981) noted that high dowry and marriage expenses were associated with adverse sex ratios. There is also an inverse correspondence between female work participation and dowry - the lower the former, the higher the latter. Thus, in areas where female work participation is low, a daughter's value is considered to be below the cost to parents of her upbringing and marriage, including dowry payments. (The value of domestic labour is not considered as it is perceived to accrue to marital and not to natal families.) The low value attached to young girls underlies lower investment in their education in areas where female work participation and survival are low, marriage costs high, and early marriage and early childbearing the norms.

Effects of Women's Employment through Income

There is some evidence that women's employment has the potential to benefit household nutrition through increasing household income. Gulati (1978) found that daily nutritional adequacy in agricultural labourer households in Kerala was related more to women's employment than to men's employment. She estimated that on days when both the male head of household and his wife were employed, their shortfalls in terms of calories were 11 and 20 percent, respectively, while on days on which the woman was unemployed, the shortfalls increased to 26 and 50 percent Kumar (1978) found a strong association between child nutrition and mother's income in low-income households, but no significant association with father's income. Female children were particularly dependent on their mother's wages.

Women's Decision-Making Power

Women's employment may also exert influences on household nutritional status through increased women's "status," "power," "autonomy" or "decision-making ability." There is some evidence that women's earnings are spent preferentially on goods and services which improve the health of children, implying an increase in women's decision-making power. For example, a study of women participants in Maharashtra's Employment Guarantee Scheme reported that the nutritional status of children was better when women received the cash or grain payments directly (ILO, 1979). Mencher and Sardamoni (1982) have also reported that where women exercised control over their wages, these were spent on food and other basic needs.

However, women's participation in wage work alone may not guarantee them greater decision-making power. Harriss (1986) found that men made market decisions relating to food in 60 percent of households in three Tamilian villages she studied, and made joint decisions with their wives in another 15 percent of cases, leaving women primarily responsible only in 25 percent of households. In the majority of households women had some say in the "qualitative" issues (eg. the "choice of ingredients"), but did not have much say regarding quantities, regardless of whether or not they participated in wage work.

Other Characteristics of Female Employment

Some characteristics of women's employment, such as seasonality, have important implications for household nutrition. For example, Palmer (1981) reported that pregnant/lactating women often lost weight during peak work (low food) seasons, and infants were summarily weaned at such times. As women's agricultural work tends to be seasonal because of its task-specificity, households that are dependent on women's work for their nutritional adequacy would be especially vulnerable. Seasonal variations in food availability often exaggerate differentials in food intake between men and women. When more food is available, it appears to be preferentially allocated to males, thus increasing the gap. However, in households with low average food availability, women and children are especially at risk during lean periods and may fall below the survival line, as the shortfalls in caloric intake would be exceedingly drastic. Even among slightly better-off households, discrimination against females in the allocation of food renders them more susceptible to malnutrition. The availability of off-season employment and food-for-work schemes may mitigate these detrimental effects of agricultural seasonality on nutritional status to some extent.

Employment and Child Care

Other employment-related factors such as the location of work-sites relative to homes, the time spent in work and in travel, the energy cost and ergonomic nature of the work, or the provision of child care facilities at work places may also greatly affect women's nutritional status and roles. These factors may, in fact, determine the extent and nature of the "tradeoffs" between women's productive and domestic roles. In their detailed study of an Andhra village, Bidinger et al., (1986) found that employment in the household in general but also of female members specifically, was a major factor affecting the energy intakes of children under 6 years of age, and the equitable allocation of food resources. Female employment was a more significant determinant than income or landholding size. Female labour participation contributed significantly to the dietary intakes of children. The authors hypothesized that working women had more say in food distribution within the family "as male members saw them as more competent." On the other hand, they also suggested that while malnutrition in poor households was due to the lack of food, among medium and big farm families, women who hired and supervised labour had little time for child care, which precipitated some of the severe malnutrition the researchers observed among children in such households in their study. In this context, the contention by Mencher and Sardamoni (1982) that in landless and small farm families women must work because men cannot meet household expenses entirely is significant because of the consequent lack of choice afforded the poor family. Among the poor in particular, the additions to household nutrition made possible by women’s employment may not totally offset the detrimental effects on child feeding and care of women’s absence from the home.

Women’s employment in the organised sector, in the context of inadequate protective legislation or lack of enforcement of existing legislation, has been considered inimical to breast-feeding because of mothers’ time away from home (eg. Ghosh, 1987). Only among certain occupational groups, and for very limited numbers, are there viable arrangements which permit women to take care of the nutritional needs of their infants and young children. In India, “Mobile Creches” are available for women in the construction industry in a few metropolitan areas, and legislation calls for creches/day care centres to be provided to women in the plantation sector, in factories and mines, but these remain inadequate. The large majority of women workers in agriculture are not served by such facilities, although in areas where the Integrated Child Development Services Scheme (ICDS) has been established, a part-time alternative exists. However, the attendance of infants and toddlers at ICDS anganwadis is low on account of structural and social constraints. The situation of urban, self-employed women - vendors, petty traders, domestic servants, etc. - is difficult as they lack access to institutionalised child care as well as the traditional joint family system. Unfortunately, there is little or no information on the effects of different female occupations on the nutritional status of children, of the women themselves, or of other household members; nor on the effects of the support services provided for the few occupational groups mentioned or of different child care situations on overall ‘home nutrition management.’

In sum, while there are indications that women’s work can bring about improvements in household nutrition, particularly if women have control over their wages, there are numerous unanswered questions on the issue of women’s employment and nutrition. Does women’s employment enhance nutrition and health, and if so, under what conditions? Who benefits, and how, and what is the process by which improvements are brought about? Are women’s wages preferentially allocated to nutrition and health care, so that one could argue that women’s wage employment improves family well-being more than men’s wages? Are working women more knowledgeable about nutritional needs, food values, etc.? Do they make more or better decisions in favour of nutrition? What are the disbenefits? The answers to these questions have relevance to actions such as the promotion of appropriate employment options for women, legislation of women’s wages for different types of work, provision of support services for productive and domestic work, including creche and child care facilities, development of “drudgery-reducing technologies” and services such as fuel and fodder, water supply, and so on. An understanding of household decision-making processes may strengthen policy-making and action in vital social arenas such as education.

Women’s Access to Health Care

Women’s access to health care affects their nutritional status and roles. As the first-level health care provider within the household, a woman’s knowledge of good health and nutrition practices is crucial. Although such knowledge may be gleaned elsewhere, eg. in school, from older family members or other informal networks, as formal health systems become increasingly concerned with health “promotion,” they are important conduits of health knowledge. Health services offer the next level of support to the household when treatment is required, or in the arena of preventive health action. Household health and nutrition profiles subsume the health of women, which in turn determines the extent to which they can effectively carry out their multiple roles as producers, mothers, child-minders, etc., all of which affect household health. Antenatal, intranatal and postnatal care affect the viability of infants and the survival of mothers; nutritional care protects growth and development and ensures better health for work and during pregnancy and lactation; family planning services address issues of birth spacing, family size limitation, which we have seen affect women’s health status and roles. Experience in both India and Pakistan has shown that health care and health education are best delivered to women by women, preferably from a similar socio-economic background.

Assessment of women’s access to health care is complicated because it is not only a determinant of women’s/household nutrition and health status but also the outcome of women’s status in society. Thus, both health status and access may be simultaneously affected by (macro and micro) socio-economic and socio-cultural factors. Access implies both the physical availability of services and a social and economic situation for women which permit and enable them to use health services when in need (Chatterjee, 1983; 1984). Unfortunately, there are few investigations of women’s health needs in India linked with assessments of available health services and with information on health “knowledge, attitudes and practices” at the household level. Available studies focus on differential access of males and females to health services, particularly among children, sometimes relating this to nutritional levels or morbidity rates. For example, Gopalan and Naidu (1972) showed that while females outnumbered males four to three among children suffering from kwashiorkor, more than half of hospital admissions were of boys. Similarly, Dandekar’s (1975) survey of 37,000 people in rural Maharashtra revealed that although higher percentages of girls were ill than boys, lower percentages received medical treatment in the group under 15 years of age. Girls may be taken to less qualified doctors than boys (Das et al., 1982), and expenditure on medicines may be higher for boys than girls, particularly among better-off families (Das Gupta, 1987). In fact, better and more timely medical care for boys may be the most important factor explaining high survival among males compared with females, as early studies showed (Singh et al., 1962; Kielmann et al., 1983). These and other studies imply that households discriminate against female children in terms of health care, in a vein similar to the nutritional discrimination discussed above.

There is differential use of health services among adults as well. In Dandekar’s (1975) study, a greater proportion of ailing women than men received no treatment, and those women who were treated received mostly home remedies or traditional medical care, while men received institution-based care. Hospital and clinic attendance records in both India and Pakistan invariably show a preponderance of males receiving treatment. A comparison of studies of hospital admissions in different parts of India shows considerably higher ratios of male to female admissions in northern hospitals (eg. 2.1:1) compared with southern hospitals (1.3:1), although males were clearly favoured in all areas (Miller, 1981). The proportion of treatment provided to women in general is lower whether one considers out-patient attendance or indoor admissions. For example, in one study of admissions to a major hospital in Delhi, only 35 percent were female (Ghosh, 1985). Similarly, larger numbers of males are treated at Primary Health Centres in Utter Pradesh (U.P.), Gujarat and Rajasthan (Khan et al., 1983) - as much as five times as many men as women (Murthy, 1982). The observation that women seek medical help only at advanced stages of illness is corroborated by hospital-based data showing higher case-fatality among female patients (eg. Kynch and Sen, 1983).

These findings are even more significant in the light of reports that illness is reportedly higher among women than men, even though female morbidity is likely to be underestimated because women are “shy” to reveal illness, or purposely downplay them to avoid seeking medical care. The few studies that compare the health of women and men in the same household generally report a higher prevalence of illness among women (eg. Khan et al., 1982; Jesudason and Chatterjee, 1979). One study followed 110 families over a two-year period and found a significant difference in the number of illnesses suffered by adult women and men (10.8 episodes per year compared with 6.0) (Kamath et al., 1969). However, failing to find a gender difference in the incidence of disease, some researchers in Bangladesh have suggested that higher female morbidity is largely the result of the lack of treatment of female illness (Chen et al., 1981).

Only in a few percent of female illnesses is treatment sought from government health facilities such as Primary Health Centres in rural areas (Jesudason and Chatterjee, 1979; Khan et al., 1982). The vast majority of women simply use traditional remedies, and a few approach private (traditional or allopathic) medical practitioners. Women’s attendance at subcentres or PHCs for ‘preventive’ and ‘promotive’ health services (eg. antenatal care) is similarly low (Jesudason and Chatterjee, 1980; Khan et al., 1982). While official statistics maintain that three-fourths of deliveries in rural areas are conducted within homes with the help of female relatives, friends or dais, micro-studies report proportions closer to 90-95 percent (eg. Jeffery et al., 1984; Khan et al., 1983). The persistence of low treatment rates despite the availability of free government health services in India suggests that social strictures and/or the economic costs of seeking health care (either opportunity costs or direct costs on transport, medicines, etc.) are daunting to women.

“Quality of service” issues are also important. In a household health survey in Madhya Pradesh, many of the respondents who had visited government facilities complained of lengthy waiting times, lack of adequate personnel or medical supplies, or “rude behaviour” on the part of staff (Jesudason and Chatterjee, 1979). Such complaints in turn discouraged other potential users, although consumers’ poor knowledge of services available was also a serious constraint to use. Only one-third of respondents knew the location of the nearest sub-centre, and about 40% the location of the nearest Primary Health Centre; even fewer knew the working timings of these facilities. Only a quarter of the women had actually ever visited the sub-centre, and less than 20 percent the PHC. Clearly, to encourage use, the health system has to improve ‘consumer education’ as well as management of services.

There are significant regional differences in the availability of health services in India, which may partially explain variations in male-female differentials in health and nutrition. Mortality levels in different states have been related to health care variables, such as per capita health expenditure, trained birth attendance, numbers of hospital beds, etc. (eg. Bardhan, 1984). Trained birth attendance is lowest in the north and northwestern regions, and highest in the south, a pattern that roughly coincides with the status of women and is inversely related to mortality (Dyson and Moore, 1983). Analysis of the nation-wide Survey of Infant and Child Mortality data shows that trained birth attendance strongly supports infant survival (Jain, 1984). While the availability of health services was important in explaining child mortality reduction (among other factors, such as clean water supply), both female literacy and household economic status were important mediators in this process.

The relationship between availability and women’s use of health facilities, and female literacy, and their combined effects on mortality have been well established (eg. Krishnan, 1975). Certain areas of India such as Kerala and Goa bear further witness to the strength of the relationships. Infant mortality in Kerala was found to be lowest where access to health facilities was easiest (Krishnan, 1976; Nair, 1980). Mothers’ education is a highly significant explanatory factor (Zachariah and Patel, 1983). In sum, the state’s well-developed health services and high levels of female education together explain Kerala’s impressive mortality and fertility declines, the crux being that public health activities have been made effective by prevailing high literacy levels which stimulate demand, peoples’ participation and government responsiveness (for a detailed discussion see Chatterjee, 1988a).

Prospects for Intervention


Focus on Nutrition for ‘Women as Women’
Nutrition in Adolescence
Improving Female Literacy, Education and Health-related Knowledge
Increasing Numbers of Female Health Workers
Detection and Care of Mothers “At Risk”
Increasing Female Employment and Income

As has been shown, the nutritional status of women in both India and Pakistan is all-too-often unsatisfactory, a process that begins at birth and often ends in early death. Numerous ‘causative factors’ and correlates have been identified. The potential interventions to address the problem of female malnutrition are similarly numerous. The range of options available to planners in various sectors is laid out in Appendix A. (Although the options apply primarily to India, the matrix could easily be modified to suit other countries.) Here, discussion will be limited to a few key issues.

Focus on Nutrition for ‘Women as Women’

The concept of improving women’s nutrition for their own sakes, rather than just as mothers, needs to be fostered. There is little doubt that a woman whose basic nutritional and health needs are met will be in a better position to meet the needs of her family. Specific nutritional deficiencies such as those of iron and iodine must be tackled (and they can be, at low cost) with all women forming the target group. Better targetting of supplementary feeding at those most at risk of malnutrition, and job-creation and literacy programmes will help to address the more intractable problem of protein-energy malnutrition.

Nutrition in Adolescence

The nutritional status of women can be considerably influenced by attention during adolescence, with ‘spin-off’ benefits also to the children they bear later. Even children who are stunted and malnourished throughout childhood can experience catch up growth if fed adequately during their adolescent growth spurt, and achieve an adult size almost as great as children who were better nourished in their early years. For example, one African study demonstrated complete catch up during adolescence of a cohort of girls who at 10 years of age were 20 cms shorter than a normally-nourished cohort (Rohde, 1987). Thus, mid-day meal programmes for adolescent girls could have very long lasting benefits.

Improving Female Literacy, Education and Health-related Knowledge

The critical role of female literacy in improving women’s overall health and nutritional status should be well recognised. The coincidence of girls’ adolescence and dropping out from school signals the need for education systems to focus on keeping girls in schools. This may be done through the provision of special incentives, public education and offering alternative forms of education. It is important to provide basic vocational skills, enhancing girls’ employability, and delaying marriage until they are physically prepared for child-bearing.

While these are longer-term goals, in the short term efforts to specifically improve women’s knowledge of health, nutrition and hygiene must be increased. The communication of basic nutrition information, based on a proper understanding of existing knowledge, attitudes and practices, and involving health workers, primary school teachers, women extension officers, and other frontline workers, reinforced by appropriate use of the mass media, can help empower women to successfully address malnutrition.

Increasing Numbers of Female Health Workers

The provision of basic services to women in rural areas of India and Pakistan is a huge undertaking, given the numbers of women involved. Furthermore, in addition to size, the delivery system must be appropriate in ‘quality’ in order to address women’s nutritional and health problems. Experience has shown that to provide effective services to women, the frontline workers must in turn be women. Under these circumstances, shortages of female health workers are a serious constraint to improving women’s nutrition and health status. While this is widely recognised, many countries are still a long way from meeting their ‘womanpower’ requirements in health systems (or, for that matter, in education or other key sectors). International aid agencies can play a key role in this area. For example, in Pakistan during the early drafting stages of the Eighth Five Year Plan, the Government announced plans to recruit and train one community-level worker for each of the country’s 50,000 villages. The Plan further stated that all these CHWs would be men educated to high school level. Following considerable pressure from a number of donors and UNICEF, the Government revised its plans stating that at least 50% of the workers would be females for whom they would relax the educational qualifications.

Another key female health worker is the trained birth attendant. In the subcontinent traditional birth attendants ‘cover’ 50% or more of all deliveries, and in some places they may visit mothers in the post-partum period for varying periods of time. They can be useful resources not only to conduct safe deliveries but also in antenatal and postnatal care of women.

Detection and Care of Mothers “At Risk”

In the arena of Maternal and Child Health services, simple indicators of maternal malnutrition and predictors of risk of low birth weight can be usefully employed. These can be derived from Table V, which lists factors associated with low birth weight from a number of case-controlled studies reviewed by Walsh (1987). Among the most significant are severe anaemia, poor obstetric history, current obstetrical problems, and TB which increase the chances of a woman having a low birth weight baby four-fold or more. All these problems can be diagnosed and managed at the primary health centre level, where skilled attention and limited resources should be focussed on the most needy.

Food supplements during pregnancy, particularly if given during the last trimester, have been shown to have a positive impact on birth weights. For example, food supplements given to pregnant women through the Indian ICDS programme resulted in a mean increase in birth weights of 150 grams (Bhatnagar and Tandon, 1981). A review of a number of studies by Sai (1986) concluded that the mean increase in birth weight resulting from a daily supplement of 500 kcals was 300 grams. Research in the Gambia by Prentice (1983) showed that supplementation is particularly effective when given during times of food shortage, such as that caused by seasonal fluctuations in food supply.

Table V. Predictors of Low Birth Weight Risk

Problem

Odds Ratio

Percent of Women Affected

Anaemia 7-9 grams

1.5 - 2

20 - 70

Anaemia <7 grams

3 - 5.3

6

Current obstetrical problems (toxaemia, haemorrhage, twins)

5 - 6

15

Bad obstetric history

8

1 - 2

Maternal weight <35 kgs

3.2 - 3.8

10 +

Syphilis

2.7

0.5 - 5

Diabetes mellitus

3

0.2

Hypertension (diastolic >90)

2

5 - 10

Urinary tract infection

2

10

Heart disease

2.7

5

Active tuberculosis

4

5

Parity >5

2.1

5 - 8

Previous stillbirth

2.6

1 - 6

Rural

1 - 1.6

30 - 70

Income <200 rupees

1.4 - 2.7

4 - 40

No education/illiterate

1.4

40 - 45

Manual/farm labour

1.3 - 3

2 - 10 +

Age >30 years

1 - 1.6

10 - 20

Height <140 cms

1 - 3

1 - 10

Gestational age <37 weeks

2 - 4

10 - 20

Source: Walsh (1987)

Increasing Female Employment and Income

Increasing numbers of female health workers would also increase female employment, albeit on a very small scale. While we shall not discuss the issue of female employment at any length here, this strategy could clearly do more to improve women’s nutrition and health status than many others. Ensuring ‘fair’ wages for work done so that women can purchase adequate food for themselves and their families, improving working conditions so that these are not nutritionally-draining or hazardous to health, and providing access to services such as day care, health care, and those to lighten domestic work, are all important ingredients of female employment strategies.

Both India and Pakistan share the rare distinction in the developing world of having elected women leaders. It is hoped that this elevation of women to the highest elected positions in these countries will be translated steadily into improvements in the position of women within the household.

Appendix A: Women and Nutrition - Matrix for Policy Planning

Cause of Malnutrition

Possible Interventions by Sector

Primary Health Care

Agriculture & Rural Dev. Sector

Labour Sector

Social Welfare Sector

Legal Systems

Education Sector

Social Communications

Housing and Urban Dev. Sector

Social mores: girl children not welcome at birth

TBA’s delivering girl children given special recognition



Special recognition to women with surviving girl child of 1 - 2 years

Severe legal systems to punish female infanticide foeticide; law against amniocentesis

Curriculum change to promote status of girls and children

Massive social communication


Women giving birth to girl children not cared for adequately




Special care of mothers, particularly girl children. Special feeding





Low enrolment of girls in schools - illiterate, low level of skills



Organized Sector - priority to worker families for training of girls

Feeding programmes for girls?


Special vocational training for girls. Special incentives for girl students. Classes for girls at appropriate time



Inadequate food in adolescence



Employment opportunities for adolescent girls

Food preparation for programmes


School feeding programmes focussing on girls



Early marriage - teenage pregnancy

Better family planning practices. Concept of family welfare pushed vigorously


Education in organized sector re. importance of girls’ education, development


Better enforcement of minimum age of marriage. Incentive to parents to postpone marriage


Communication for postponement of first pregnancy


Frequent pregnancy - large families, unhygienic birth practices

Good antenatal care through well trained TBAs. Provision of sterile kits to TBAs. TT Iron Folifer, I-oil. Child survival, particularly immunization, vitamins CDD/ARI. Incentives for small families


Maternity leave and benefits in organized sector. Supplementation with nutrients




Promotion of small family concept and proper child spacing


Lack of adequate child care services



Creche facilities in organized sector

Extended ICDS. Creche facilities in ICDS



Communication for utilization of services


Low value added jobs in organized sector



Training of women for better jobs. Certain minimum proportion of jobs for women


Legislation for equal wages for women

Increased proportion of women teachers



Low wages, irregular employment, low knowledge due to being in unorganized sector

All women community health guides

Agricultural extension by women for women. Credit for women. Women’s co-ops in dairy, land development


Maternity leave and benefits to women in unorganized sector





Crowded unhygienic living conditions in urban areas



Creche facilities in cities. Working girls hostels





Low cost housing schemes for women. Slum improvement schemes

Inadequate fuel/fodder/water facilities



Social forestry. Village wood lots and more efficient stoves. Fodder programmes attached to women’s co-ops.






Source: Developed by Mrs Geeta Athreya, Health and Nutrition Section, UNICEF, New Delhi.

Summary4


Gender and Nutrition
Employment and Nutrition
Health Status and Nutrition
Interventions and Options

4 This summary was prepared for the ACC/SCN by Rosemary Kevany.
India and Pakistan account for 45% of all maternal deaths in the world. This paper examines the nutritional status of women from childhood through adolescence, pregnancy and lactation in biological terms, with reference to protein energy malnutrition, iron-deficiency anaemia and deficiencies in iodine and vitamin A (looking at causes) and more specifically, in socio-economic and socio-cultural terms (looking at effects) to women’s household nutritional roles. Correlates identified in this paper are gender, employment and health care services.

Gender and Nutrition

Although Indian National Nutrition Monitoring Bureau (NNMB, 1980) data find no major differences in percentile values of calorie intake for males and females, in the context of gender differentials, pregnant and lactating women suffer a disproportionate burden of food deficit due to inappropriate distribution of food within households. In addition to suffering a calorie shortfall, women also work longer hours and expend more energy than men. Gender is a statistically significant determinant of nutritional status, and male-female differentials are especially evident in the lower socio-economic/caste groups, which indicates that the effect of gender and poverty on women’s nutritional status may be synergistic. A mapping of differentials of nutritional equity between males and females according to age, socio-economic status, region and season, indicates that nutritional deprivation of women appears to be economically, rather than culturally, mediated and that the variable social and economic value of a women is a crucial factor in her access to food. Where females have high economic value, they receive larger shares of food and health resources; where their value is low, they are disadvantaged. In times of extreme poverty and food scarcity, female consumption of food is substantially less than males.

Other demographic influences on gender discrimination include a shorter period of breastfeeding for female children which may lead to shorter birth intervals between females, with consequent risk of malnutrition and mortality. Social discrimination against young females persists as mothers continue to be under pressure to bear sons and to nurture them more carefully than daughters. Son preference correlates inversely with low economic status and second female children are particularly at risk of death. A consequence of the sex bias is that the nutrition and health deprivation of females in childhood and early adolescence exposes them, via pregnancy, to the subsequent cycle of low birth weight infants and high infant and maternal mortality rates. Low food intake during pregnancy is correlated with low birth weight infants; food taboos deprive women of protein and iron sources and in many cases women make a conscious decision to limit intake for fear of a large fetus resulting in obstructed labour and obstetric complications.

Gender differentials are established and perpetuated by women themselves at the breastfeeding and supplementation stages; female children are weaned earlier than males, and are given less supplementary food and health care, resulting in significantly higher mortality rates for female children from 1-5 years. Inadequate dietary intakes for female infants and children are precursors of the inferior social status they enjoy throughout their life cycle. Early marriage means early childbearing which adversely affects not only women’s nutritional status but also her education and employment opportunities. Correlates of age at marriage include literacy, per capita income, urbanization and non-agricultural work; agricultural work has a negative correlation with age at marriage in the sense that early marriage and agricultural work carry a double indemnity of high energy expenditure and frequent childbearing. Rapid childbearing is a known correlate of high infant mortality and child loss itself shortens the intervals between pregnancies, which in turn depletes the nutritional status of the mother. The compound effects of inferior education and employment added to early marriage, are increased by closely spaced births and elevated maternal and infant mortality.

Female education is inversely related to infant mortality. Health services can partially offset the detrimental effects of illiteracy, except where poverty is a predominant negative factor. Conversely, education improves the role of women in household decision-making and control of resources, and permits them to choose healthier feeding and hygiene practices.

Employment and Nutrition

Such economic factors as participation in the labour force, inheritance of land and dowry payment have particular relevance to women’s health status and survival. Women’s employment increases household income, with consequent benefit to household nutrition. Employment may increase women’s status and power, and may bolster her preference to spend her earnings on the health and nutrition of her children, but does not always guarantee her decision-making ability when contested by the husband. Agricultural work is affected by season, and women often lose weight during peak work (low food) seasons. Seasonal variations in food availability exacerbate food differentials between males and females. Off-season employment and food-for-work schemes could remedy this problem. Although female labour participation contributes to the dietary intake of children, the gain may be offset by diminished breastfeeding and child care due to the absence of the mother; trade-offs between the domestic and productive role are inevitable. Facilities such as mobile creches and day care centres are scare in poor communities.

There is a dearth of information available on the interaction of female occupation and child nutrition; this needs to be addressed as it is relevant to women’s employment options, wage scales and support services. In addition, domestic constraints and drudgeries need to be measured and appropriate technologies directed to minimize the effort of fuel and water collection.

Health Status and Nutrition

Women’s knowledge of nutrition and access to health care services has a crucial bearing on their own health and that of their children; infant mortality is lowest where access is easiest. Access means both physical availability of services, (convenient times, suitable personnel and medicines, trained birth attendants) and a cultural environment which allows women to use health services for themselves, in distinction to, or together with, their children. In both India and Pakistan a preponderance of males receive hospital treatment, while women tend to rely on traditional remedies. This tallies with social devaluation of women and women’s deliberate self-neglect associated with her lesser status. Health services must be consumer-friendly in order to encourage women to use them. In this regard, health education is best delivered to women by women from a similar socio-economic background. “Womanpower” requirements need to be met by training female health workers. (Pakistan has recently substituted 50% females for males in a proposed community health workers (CHW) scheme covering 50,000 villages due to pressure from UNICEF and other donors.)

Interventions and Options

The concept of “women as women”, responsible for their own health and welfare, needs to be advertised within nutrition programmes with particular emphasis on improving female literacy; high levels of female education are related to mortality and fertility declines. Particular attention must be paid to adolescent girls in view of the catch-up potential during their growth spurt. Strategies should be designed to circumvent culture and norms and to allow adolescent girls to remain in school longer, to train for a job and to delay marriage. “At risk” mothers should be diagnosed at primary health care clinics, and screened for anaemia, obstetrical problems and TB, as well as offered food supplements during the final trimester of pregnancy (taking into account “eating down” resistance).

Women’s nutritional status will not change substantially unless gender, employment and health care correlates are altered. The biological solutions are fairly straightforward, and appear to be a matter of organization and finance by government and donor bodies to provide clinics, personnel, supplies and information. There is no question however that the socio-cultural aspects of women’s position in society militate against their health and welfare and that changes must be made in the very fabric and organization of society to reinstate/establish women in a position of equity.

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