Introduction
Background
Nutritional Status
Policy Implications
References
By Satinder Bajaj1
1 Satinder Bajaj is a professor of nutrition at the Punjab Agricultural University, Ludhiana, India.
The household nutrition security is the assurance that the family will be adequately provisioned to receive food and health care that is commensurate with the requirements of its individual members. When the problem is focussed on the vulnerable section of the population who are below the poverty line (38.7% in India), the women can be observed to play a central role in child care and food processing even when their economic roles require extensive time and physical energy. Any new effort at women’s development must divert their time and energy from other activities. The policy implications of nutrition security to families have at their core the empowerment of women to enable them to break the vicious cycle of what has been termed the zero sum game. The limiting resources of rime, energy and income within the frame of cultural and economic conflicts have rendered women’s development programmes ineffective in a number of countries, including India (1).
The background, intervention programmes and the nutritional status of the Indian women are examined with a view to suggest a policy strategy that can enable women to participate in the national development programmes intended to secure the family’s health and nutrition.
Education
Economic Contribution and Support
Interventions for Growth and Development
Nutrition Intervention Programmes
Supportive Interventions
The reports on amniocentesis and female infanticide in India depict the low value given to the life of a female. Sex specific death rates are higher for female children in both rural and urban areas of India (Table I).
Table I. Sex and Age Specific Death Rates in India (0-4 years), 1971-1983
|
Year |
Deaths per 1000 population per year |
|||
|
Rural |
Urban |
|||
|
Female |
Male |
Female |
Male |
|
|
1971 |
59.3 |
53.2 |
33.3 |
31.1 |
|
1976 |
55.9 |
54.2 |
30.1 |
29.0 |
|
1978 |
57.9 |
48.9 |
27.2 |
25.6 |
|
1980 |
48.1 |
44.2 |
23.0 |
21.4 |
|
1983 |
43.1 |
40.6 |
21.7 |
21.1 |
Source: Office of the Registrar General of India
The female infants, toddlers and preschoolers tend to be more malnourished than the males (Table II).
The sexwise morbidity patterns likewise show that more females suffer from deficiency as well as infectious diseases (Figure 1).
A wide gap exists between male/female literacy (Figure 2).
This may be seen in conjunction with enrollment at primary and middle school level (Figure 3), indicating that literacy differences would continue during the life span of these girls.
The relevance of the syllabus and the requirement for the girls to stay at home to take care of the siblings and share household chores are considered to be some of the reasons for low school admission and higher drop out amongst girls. An educational policy that aims at a socially relevant syllabus and teaching that provides self-confidence and psychological uplift to girls are desirable as are well-targeted programmes (2).
Table II. Malnutrition in Children in Punjab
|
|
|
Male % |
Female % |
|
Severe malnutrition
|
Infants |
2.4 |
18.4 |
|
Toddlers |
8.0 |
14.7 |
|
|
Pre-schoolers |
4.3 |
6.7 |
|
|
Moderate malnutrition
|
Infants |
15.3 |
30.4 |
|
Toddlers |
21.0 |
35.3 |
|
|
Pre-schoolers |
21.6 |
38.2 |
|
|
Mild malnutrition
|
Infants |
25.6 |
30.5 |
|
Toddlers |
34.4 |
35.7 |
|
|
Pre-schoolers |
39.5 |
37.2 |
|
|
Normal
|
Infants |
56.7 |
20.8 |
|
Toddlers |
36.6 |
14.3 |
|
|
Pre-schoolers |
34.7 |
27.9 |
Source: Shanti Ghosh: “Discrimination begins at Birth”. Conference on the Girl Child, UNICEF, 1985.
Most (94%) of the women work force in India operates within a highly exploited sector characterized by long working hours, lack of skills, low productivity and lack of job security (National Commission of Self-Employed Women). There is very little organization in the form of trade unions to enable women to bargain for better conditions. An important reason for women acquiring low-skill jobs is lack of training which could improve their employment status. The major systems which employ rural women in India and enjoy government support (Table III) show that most of the effort is focussed on male workers. The women are viewed as indirect beneficiaries through male members of their families. Construction sites are another place where women are highly exploited through loan bondage, credit tying and succumb to deprivation through frequent mobilization into alien, unhealthy surroundings which disturb the physical and social security of the family. Domestic work (the data for which is not available in the National Data System) frequently employs young girls under the age of ten to act as mother’s help. A figure of 1.68 million female domestic workers as against 0.62 million males has been reported (3). While young unmarried girl children acting as domestic help might find themselves better fed than they might be at home, the married domestic help has often to neglect her own family.
In order to improve the employability of women, a purposeful human resource policy aimed at improving training facilities for women is urgently called for. There is also a need to have clear definition in the labour policy to enable women to receive direct benefits and secure their families.
Figure 1. Sexwise Morbidity Patterns among Children - 1985
Source: The Girl Child in India - Data Sheet on Health. National Medical Centre and UNICEF (1985).
The government schemes (45 schemes in 17 ministries and departments) for women do not represent a holistic approach. The schemes range from relief-oriented (short stay homes) to supportive (working women’s hostels), to mixed (such as TRYSEM). Most of these are not as effective as visualized because they do not reach the maximum number of most deprived women in the unorganized sector.
Since time is a major constraint in the participation of women in programmes, cognisance has to be taken of all work performed by women including domestic work. There is a clear need for evolving a strategy that improves women’s working conditions and generates free time.
Figure 2. Literacy Rates
Source: Census of India, 1981
Two periods of growth make children vulnerable. Infancy characterized by total dependence, is more important for formation of self-concepts and later self-worth. A total educational programme for the family and the community is required to strengthen this period. Unless the whole family participates in a practical exercise of giving the child (both boys and girls) a sense of worth, any intervention will remain at a superficial level. A girl has to fight against her family and community if they do not share her sense of self-worth.
Physical growth monitoring during infancy provides a powerful tool to control malnutrition. It can prove to be a very important platform for providing community education for growth and development of children (4).
The second crucial period for growth is adolescence. During this time the girl gets ready for her adult role to carry the burden of early marriage, dowry and teenage pregnancy. An estimate of 10-15% (approximately 25 million) of annual births in India are attributed to teenage mothers. The malnourished state of the teenage girl compounded (5) with her own growth spurt and pregnancy to which is added the pressure of shift to the in-law’s house, dowry problems and the possible birth of a girl child, are some problems requiring intervention. Clear policy and targeted programmes for adolescent girls that aim at nutritional improvement (6, 7) and confidence-building are required to empower this woman to secure the nutrition and health of her family.
Figure 3. Enrollment Rates at Primary and Middle Levels of Education
Source: Dept. of Education, Govt. of India, 1983, 1984, 1985.
An important and direct intervention for pregnant and nursing women in India is the Integrated Child Development Services (ICDS) scheme which provides supplementary food, tetanus immunization, iron and folic acid supplements as well as health and nutrition education. The nutritional basis for food supplements are dietary surveys revealing energy deficiency in the diets of low income pregnant and nursing women. Studies (8) on actual measurements of energy intake and expenditure of pregnant and nursing women showed a deficit in the energy balance of lower and middle income groups during the third trimester of pregnancy (Figure 4). The deciding factor in determining energy balance is the energy expenditure. Since the lower income groups expend most of their energy in earning their livelihood they have no relief from expending the extra energy. Clearly rest and extra energy intake are indicated for these women.
Maternal weight gain relates positively to the birth weight of infants. Women engaged in hard physical labour during pregnancy do not gain adequate weight and deliver low birth weight babies (9). Maternal mortality accounts for the largest proportion of deaths among women in their reproductive life period. Maternal mortality in India is 400 - 500 per 100,000 live births (this figure in rural India is as high as 1000 - 1200 in some areas). Anaemia, haemorrhage, toxemia, sepsis and abortion are the reported causes (3).
Table III. Number Employed in the Large employment Systems (Lakhs)
|
|
Women |
Men |
|
Agriculture |
19 |
756 |
|
Dairying |
750 |
50 |
|
Fisheries |
10 |
18 |
|
Small Animal Husbandry |
150 |
20 |
|
Khadi & Village Crafts |
17 |
20 |
|
Handicrafts |
5 |
22 |
|
Sericulture |
8 |
12 |
|
Handlooms |
30 |
45 |
Source: Shanti Ghosh (1985). Discrimination begins at Birth. Presented in the Conference on the Girl Child, UNICEF, 1985.
More than a third of the live births are of the fourth order or more. It is obvious that respite from pregnancy, rest and care are important needs of the women. The ICDS programme addresses itself to these problems, yet the awareness of the programme and its full utilization leave scope for improvement (10, 11).
Apart from the ICDS, a number of programmes endeavour to support the nutrition of the family. These include the National Anaemia Prophylaxis Programme (12); National Goitre Control Programme (13, 14); National Programme for Prevention of Nutritional Blindness due to Vitamin A Deficiency (15); Mid-day Meal Programme (16,17); Special Nutrition Programme (18); Applied Nutrition Programme (19); and Chief Minister’s Noon Meal Programme (20). These direct nutrition interventions differ in their immediate direct impact and their indirect outcomes. Some are more sharply focussed than others. While the poor households have been reported to benefit most from these nutrition interventions, better area and population focus is required.
Antipoverty and employment programmes offer support to vulnerable households. In India, interventions designed during the last two decades aim at meeting regular trend level shortfalls in food arising from income gaps, shortages in poor crop years and off seasons when physical access reinforces income shortage to render the hard core poor to maximum vulnerability. These interventions which include public distribution systems (PDS) and public employment programmes do not always contribute to raising the nutritional status of at-risk families. The contribution of PDS to raising the per capita calorie intake was estimated to be 46-138 Kcal for the highest and lowest income groups as revealed by elimination of the rationing system (21).
An evaluation of the Employment Guarantee Scheme (22) shows an appreciable impact on the employment situation of female workers and consequently on child nutrition. Other employment schemes such as the National Rural Employment Scheme (NREP) and Rural Landless Employment Guarantee Scheme have not shown improvements in nutrition of poor households.
Figure 4. Energy expenditure (E) and Energy Intake (I) in Pregnant Women by Income Group (UMIG = upper middle; LMIG = lower middle; LIG = lower)
Source: see reference 8
Studies on the energy balance of 300 female subjects (23) which included manual workers (MW), educated working women (WW) such as teachers and researchers, as well as housewives (HW) showed that manual workers had shorter heights and lower weights (Table IV), and obtained most of their nutrient requirements from cereals. The working women and upper class housewives consumed more fats, milk and milk products as well as vegetables. The manual workers expended most of their energy and time in earning their livelihood, and spent least time in household activities (including child care). The educated working women spent more rime in household activities in comparison to housewives whose main job was housekeeping (Figure 5). An important step in assuring nutrition security is time freeing and improving wage earning. As a policy it is possible to attach such interventions to child spacing and family planning as incentives and educational strategies.
Table IV. Distribution (%) of Subjects According to Various Factors
|
Sr. No. |
Factor |
MW |
WW |
HW |
|
1
|
Type of family: |
|||
|
Nuclear
|
81 |
77 |
61 |
|
|
Joint
|
19 |
23 |
39 |
|
|
2
|
Size of family: |
|||
|
3-5
|
67 |
86 |
55 |
|
|
6-8
|
31 |
12 |
18 |
|
|
9-11
|
2 |
1 |
7 |
|
|
12-14
|
- |
1 |
13 |
|
|
15-17
|
- |
- |
7 |
|
|
3
|
Age (Yrs): |
|||
|
20-25
|
37 |
15 |
14 |
|
|
26-30
|
25 |
30 |
31 |
|
|
31-35
|
20 |
35 |
36 |
|
|
36-40
|
18 |
20 |
19 |
|
|
4
|
Height (Cms): |
|||
|
Below 140
|
2 |
0 |
0 |
|
|
140-145
|
11 |
0 |
0 |
|
|
146-150
|
13 |
0 |
1 |
|
|
150-155
|
28 |
22 |
25 |
|
|
156-160
|
37 |
39 |
54 |
|
|
161-165
|
9 |
31 |
16 |
|
|
- |
8 |
4 |
|
|
5
|
Weight (Kg): |
|
|
|
|
Below 35
|
13 |
0 |
0 |
|
|
36-40
|
15 |
3 |
0 |
|
|
41-45
|
32 |
3 |
4 |
|
|
46-50
|
28 |
12 |
7 |
|
|
51-55
|
12 |
20 |
20 |
|
|
56-60
|
- |
24 |
25 |
|
|
61-65
|
- |
30 |
26 |
|
|
66-70
|
- |
4 |
9 |
|
|
Above 70
|
- |
4 |
9 |
|
|
Key: |
MW = Manual Working Women |
|
|
WW = Education Working Women |
|
|
HW = Housewives |
Source: Gupta, S. (1985)
Figure 5. Expenditure of Time and Energy during Different Routine Activities
MW = manual work; WW = educated; HW = housewife
Education
Conclusions and Prospects
In devising a functional nutrition policy, the subject of targeting comes up with great frequency (24). To recognize target households, evidence and information are needed to determine the conditions under which the families require intervention and the extent to which the malnutrition in such households is due to insecure food availability, disease or social discrimination. An important step for the government is to set up a policy research unit for developing continuous information flow to establish such a system.
A woman-centred policy for improving the nutritional status of the vulnerable families is evident in most health and nutrition schemes in India. Evaluation of these schemes show that desired impact can be produced only if modifications are made, particularly at the operational level. Yet if the delivery systems are examined, many conceptual ambiguities are evident. One ambiguity is that women and children are the target groups for intervention. Missing within the framework of the schemes at the policy planning level is the built-in component to enable women to actually participate. The community participation component of most schemes appears to be appended as an afterthought. In the ICDS Scheme, for instance, referral service is one component for health; yet missing at the operational level is the infrastructure for referral to operate (25).
Policy literature focusses on production, purchasing power and poverty aspects (26, 27). It is rare to come across fresh research on education which could transform behaviour. If women have to be empowered to secure their family’s nutrition, the community needs to undergo revolutionary action for change, in which the educators are involved in a two-way flow of knowledge towards problem solving (28, 29).
The education system in general, and nutrition education in particular, assumes that the target audience is ignorant and the resources are not adequately utilized. Such one way transfer of knowledge even when sophisticated social advertizing methods are used does not create the desired change in behaviour. Education which encompasses all aspects of training and brings about attitudinal changes is most essential if women are to play a key role in the household nutrition security. Although educational materials are expensive to produce, very little research goes into the methodology of communication. We must find and train people who are able to popularize technical information and knit it together with the indigenous knowledge and present it to the target audience so that it results in a two-way flow.
In order to illustrate the importance of a people-centred method of communication, Rana (personal communication) during her consultancy for DANIDA Drinking Water Project in Orissa, India, drew attention to pictorial language. It is commonly believed that pictures are universally comprehended, therefore, funding agencies spend vast sums of money on them while communicating with illiterate audiences. In her experiment, Rana asked four women of varied educational background (from Class 3 to BA) to draw their version of six messages on water and sanitation. It is interesting to note2 that the women drew from their knowledge of reality, they drew serial time perspective in the same frame (as is done in folk art in many countries), their pictures had their own stylization code (such as flowers represented cleanliness and squiggles represent dirt). They did not draw the vanishing point perspective but drew from the broadest aspect (again as is done in folk art in many countries). The emotional ambience and community relationships were an important and integral part of their drawing. If existing pictorial (posters and charts) are reviewed against this information, the inadequacy of communication materials becomes evident.
2 Unfortunately the posters could not be reproduced here - details may be obtained from Dr Bajaj at the address in footnote 1.
Access to indigenous knowledge and people-centred educational strategy would appear to be time consuming and cumbersome, yet that need not be the case. It is possible to draw generalizations across cultures and time from a wide range of information. Proper classification and adaptation can form the basis for dialoguing. A fresh look is also required at the training to make it more participatory and meaningful within the context of the peoples’ lives.
The woman, despite her low socio-economic status, is the central figure for participating in development programmes meant to elevate the nutritional status of families. Empowerment of women through a two-way flow education and direct focus of economic programmes can enable the woman to participate actively in establishing and maintaining the nutrition security at household level. Without economic power and self-confidence, the household nutrition security through the aegis of women remains at a superficial level.
The government has to expend money, technical expertise and time to plan economic programmes intended to benefit women directly. A continuous flow of information on the community’s needs and indigenous knowledge are required to establish a system which would feed into the participatory training and exchange of knowledge.
Acknowledgements
The work of my doctoral students which is presented here is acknowledged, and appropriately referred.
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