WOMEN AND NUTRITION: TANZANIA FOOD AND NUTRITION CENTRE’S EFFORTS IN IMPROVING THE NUTRITION OF WOMEN IN TANZANIA

Introduction
Nutritional Status of Women in Tanzania
A Summary of Tanzania Food and Nutrition Centre’s Work and its Contribution towards Alleviating Nutrition Problems of Women in Tanzania
References

By Pauline Kisanga¹

¹ Pauline Kisanga is the principal nutritionist at the Tanzania Food and Nutrition Centre, Dar es-Salaam, Tanzania.

Introduction

Research during the UN Decade for Women showed the situation of women in many parts of the world to be deteriorating. Changes in the agricultural systems and patterns of development adversely affect women. The nutrition situation of women cannot be divorced from the socio-economic situations in which they live and especially from the traditional norms and customs that dictate women’s behaviour in relevant societies. In Tanzania, women are the major agricultural producers, responsible for about 70% of food crop production and supplying about 80% of their working time. The major part of this food feeds the family due to the women’s traditional responsibility for food subsistence. She therefore cultivates, weeds, harvests, processes and stores, and also takes part in tending to the cash crops.

Despite their major input to agricultural production, women face a host of problems which interfere with their efforts. In many areas women do not get easy access to suitable agricultural land. For example, in a cash crop intensive area like Kilimanjaro, women are normally forced to look for food plots many miles away from home. Technology in the food crop area is normally of a low level, with women still using the traditional hand hoe for both cultivation and weeding. The labour burden on women is a major constraint to productivity. Another drawback is that women are excluded from the decision-making process. They have no control over the way resources are allocated for different functions of the family or society, e.g., use of cash income, sale of produce, etc.

The extension workers’ services also often concentrate on cash crops while women’s crops and small livestock are left to more or less tend for themselves. Another constraint is that of obtaining credit without which she cannot purchase fertilizer, hire a tractor or even an ox-plough. The present structure and policy of cooperative societies, the major credit organs in the rural areas, do not appreciate the women’s credit constraints, focussing more on cash crops.

Then comes the biological reproduction process - pregnancy, child bearing and nursing; and the social reproduction process - caring for children, husband, the sick, the old, entertaining guests and performing all the household chores which include washing, collecting water and firewood and preparing food. All this is always termed service and is not accounted for as labour even though it is so crucial for the economic health of the nation.

In our present society traditional customs are now dying out - the good customs are not being passed down the generations. Knowledge of contraception and family planning is often limited to those married women whose husbands allow them to practice family planning. The good habits about care of a pregnant woman and the extended family support that was there to reduce her workload are now non-existent. The rural woman has no say over the number of children she and her husband are going to have, nor sometimes the choice of a husband, nor the socialization of boys in the dudes of a father.

Lack of an adequate health care system, especially in the rural areas, leads to high maternal death rates. Inadequate maternity care is still the major cause of female deaths in Tanzania. It has been established that half the child deaths in Tanzania occur during the first year of life, especially in the first four weeks. These statistics point to poor maternal nutrition and health care as well as the workload for pregnant women being major reasons for infant mortality.

In summary, the key problem of women in the rural areas centre on workload, unequal ownership, access and allocation of resources and the secondary status of women in the decision-making process. The repercussions of these aspects are felt in all areas of life, not excluding nutrition.

If the health, nutrition and socio-economic status of women is to be improved, together with that of their children, action is necessary in all areas of development, including health and nutrition. Table I gives certain indicators of the public health and socio-economic situation in Tanzania (1987).

Nutritional Status of Women in Tanzania

Underweight
Anaemia
Iodine Deficiency Disorders (IDD)

In Tanzania malnutrition among mothers, especially in rural areas, is a common phenomenon. The commonest types are underweight, anaemia due to malaria and nutritional deficiencies; and iodine deficiency disorders. Most of these deficiency disorders are aggravated by infection and energy drain due to heavy workload.

Apart from the fact that women have the right to be healthy and enjoy all the benefits that life offers, the health and nutrition of a woman is very important because of her role in social and reproductive processes. The outcome of pregnancy is better in women brought up in good nutritional health; who have consumed nutritious food from birth to maturity, received adequate medical care, sufficient rest, and who continue to have these advantages during pregnancy, than in those from poorer socio-economic backgrounds.

Table I. Indicators of Public Health and Socio-Economic Situation in Tanzania (1987)

Area of Tanzania (km2)	945,000
Total Population in 1987 (million)	22.5
Population Density (persons/Km2)	25.3
Population Growth Rate (%)	3.5
Rural Population (%)	85
Urban Population (%)	15
Infant Mortality Rate (IMR) (1988)	107/1000
Adult Literacy Rate (%)	85
Life Expectancy at Birth (years)	55
Income per capita per annum (US $)	300
Population within 5 km walking distance from Health Facility (%)	73
Antenatal Care Coverage (%)	95? (50)
Growth Monitoring Coverage (%)	76
Full Immunization Coverage (1987) (%)	54
Estimated number of Households with any type of Latrine (%)	67
Estimated Population served with Tap Water (%)	38

Children born to healthy mothers normally have higher birth weights. Stunting can result from impaired growth in utero when the foetus is deprived of essential substances. Mothers with higher parity are often more affected as too close and too many pregnancies deplete the mother’s nutritional status and this results in low birth weight for babies. Low birth weight babies experience higher morbidity and mortality rates especially in the first year of life and hence higher chance of dying leading to a vicious cycle of another pregnancy - malnutrition in mother - malnutrition in baby - death. A poorly fed mother often fails to breastfeed successfully and hence a higher chance for a child becoming malnourished due to implied early introduction to other supplements.

Underweight

Nutritional status surveys on adult populations in Tanzania are few and these show women to be grossly underweight in most rural communities. Table II shows the results of some of these studies.

The low BMI’s are due to too much energy expenditure and high nutritional depletion due to constant infections as well as low dietary intakes.

Table II. Nutritional status of women from selected studies

Place, Time	Number	% BMI <20
Iringa, 1985	420	29.8
Arusha, 1987, lean season	47	36.2
Arusha, 1988, lean season	57	33.3
Kilimanjaro, 1988, lean season	57	49.0

Anaemia

The laboratory definition of anaemia is usually based on a haemoglobin value of below 11 g/dl reference range for age and sex, although in certain circumstances the lower cut-off point of 10 g/dl is used.

The causes of anaemia are many. For example, malaria infection shortens the life span of the red blood cells by its direct haemolytic attack. In the presence of underlying iron deficiency the iron produced from the destroyed blood cell is not sufficiently reutilized and this will lead to increased iron deficiency. On the other hand, hookworm infestation can cause negative iron balance especially in Tanzania where the total iron absorbed is low due to low iron bioavailability.

In Tanzania’s (1987) hospital-based study in Dar es-Salaam, Kilimanjaro, Mwanza and Mbeya, maternal death rates were reported by Justensen (1987) as 378 as against 270/100,000 as stated by UNICEF (1985). 12% of deaths in Justensen’s study were due to anaemia, most of which is iron deficiency anaemia.

Table III gives prevalence of anaemia in some community nutrition surveys carried out by TFNC from 1972.

In 1971, 1974 and 1977, anaemia was reported as the third commonest fatal complication of pregnancy, out-ranked only by difficult labour and haemorrhage. This is the same to date according to Justensen (1987) and Kavishe (1981). According to these figures, therefore, anaemia is of great public health significance in women in Tanzania.

Iodine Deficiency Disorders (IDD)

In Tanzania endemic goitre ranks third in the list of nutritional disorders. The others, in order of their importance, are protein energy malnutrition and anaemia.

Goitre is found everywhere in Mainland Tanzania with low prevalence along the coast of 0-10% and 80-90% in high prevalence areas (mostly in mountainous areas). Surveys conducted during the early 60s (e.g. Gottlieb M, 1973) give prevalence rates of between 9%-67%. The most recent studies of 1980-81 show similar trends with an average prevalence of 47% (Kavishe, 1983). The high rates of endemic goitre also suggest high risk of cretinism. Although more information is still required on the distribution of cretinism and its relationship to endemic goitre and other nutrition, medical or genetic factors, it has been shown that cretinism occurs with increased frequency in mothers with goitre. In Tanzania, IDD prevalence in women of child bearing age is three times higher than that in men.

Table III. Anaemia by Area and Population Group

Date	Area	Population	Sample Size	Mean Hb (g/dl)
1972	Dar-es-Salaam	Pregnant women	1317	9.3
1973	Kilosa	Adult Women	1702	11.2
1973	Bagamoyo	All ages	1467	10.4
1974	Tabora	Adults	328	12.8
1979	Rufiji	Under 5’s	288	7.9
1979/80	Iringa	Under 5’s	1143	11.2
1984 (April-May)	Iringa	Under 5’s	979	11.8

Source: TFNC Reports - Maletnlema et al 1974; Kavishe 1981

A Summary of Tanzania Food and Nutrition Centre’s Work and its Contribution towards Alleviating Nutrition Problems of Women in Tanzania

The Ilula Study
Women’s Workload
The Kikwawila study on women’s workload
Recommendations

The major focus of Tanzania Food and Nutrition Centre between 1973 at the time of its inception and 1983 was on clinical research aimed at defining causal relationships between malnutrition and health factors as they appeared in Tanzania; and creation of awareness in the general public on matters relating to nutrition. Emphasis was more on infant and young child nutrition than on women or other adult groups.

From 1984, more practical action oriented research began to emerge and the Women’s Decade brought the issues of women into the open. That helped because the government began taking really positive actions towards improving the situation of women, and TFNC also started placing more emphasis on improving the situation of women.

The Ilula Study

Among the most important studies by Tanzania Food and Nutrition Centre in the area of Women and Nutrition is the Ilula (Iringa) study. This study, which was funded by SAREC, was a collaborative effort between TFNC and the Institute of Nutrition and Department of Paediatrics, University of Uppsala, Sweden. The study was aimed at identifying risk factors that contribute to the high maternal and infant morbidity and mortality, leading to developing strategies for the control of these problems through early detection. The choice of Iringa was well suited because positive results from the study could immediately be injected into JNSP programme areas.

The study covered two villages with a total population of 5,657 (1978 census). The villages are about 45 km from Iringa municipality. The sample was selected through enrollment of all mothers immediately recognized as pregnant. Altogether 300 mothers were covered. The study was designed into 3 parts. The first part, the obstetric study covering 703 cases, identified factors influencing maternal health and the health delivery system. The questionnaire used was based on WHO’S questionnaire by a task force on Hypertension Disorders in Pregnancy. Within 48 hours after delivery, every woman within the area was interviewed and measured. Secondary information was derived from antenatal cards and other hospital records.

The second part was a maternal and child health study whose components included a rapid nutrition baseline survey on factors influencing maternal, neonatal, perinatal and infant morbidity and mortality and how they relate to socio-economic and cultural factors. Basic information on income, household work patterns, prevalence of major diseases etc., was also included. Other relevant biological tests were also done. The three hundred mothers were then followed up at weeks 12-16, 22-24 and 32-36 of pregnancy and measures taken by a midwife for fundal height, weight. Samples of urine for albumin, and blood for Hb were analyzed. Mothers were also interviewed on 24 hour dietary recall and work patterns. Dietary records were filled in and the length of gestation, birth weight, height and head circumference of baby and cord blood serum were collected at birth. Quarterly home visits were continued by a midwife after birth.

In the third part, 50 out of 300 mothers were followed up for more indepth observation on women’s workload and dietary intake by recording all food purchases for three days for each quarter. The results of the study were very useful indeed for designing future interventions. The following are some of the results (Kavishe et al, 1985).

i) 29.5% had a BMI of <20 showing underweight

ii) 30% of mothers actually lost weight during pregnancy

iii) 50% of pregnant mothers only increased weight from second trimester.

iv) Dietary intakes, especially of energy source, were very low averaging 1,695 kcal or 60% RDA

v) Energy intakes were highly correlated with weight increases

vi) There were negative correlations between energy intake and expenditure. It shows that those who work hard to survive are the ones who do not have enough food to eat. These are those who lost weight.

vii) Excessive workload negatively affected weight increases.

Women’s Workload

Heavy workload has a direct effect of causing loss of energy leading to body weakness under conditions of poor food supply but also has an indirect effect on children causing malnutrition due to inadequate time for child care and feeding by nursing mothers. A TFNC study carried out in Arusha periurban area, Kisanga et al (1984), shows that nutritional status of children under five years old improved with increased time for child care.

Efforts by TFNC in the area of reducing women’s workload were prompted by the results of the Ilula study, in 1986. As a first step, a national overview of the women’s work situation was made. This was done through a number of methods.

1. Designed questionnaires were sent to women’s organization leaders in the 20 regions and 53 districts of Mainland Tanzania.

2. Visits were made to institutions researching on or producing implements that reduced women’s workload.

3. The data was analyzed to give indications of time spent on different activities, types of traditional tools used and of appliances produced by the different institutions.

It was noted that distance, heaviness of the load and the time spent on queuing contribute to the workload. The use of poor traditional tools as shown in the appendix IA are very laborious and energy consuming, Rutahakana and Kisanga (1987). Visits to institutions revealed that a lot of effort is being made to produce appropriate implements to reduce the workload of women. However, there was little in the area of simple agricultural technology for clearing land, cultivating, planting, weeding, harvesting, etc. Improved tools are a prerequisite if the women’s workload is to be reduced. Another observation was that institutions producing workload-reducing tools do not carry out much promotional training, but rather sell their items through customer demand. Thus there was a great need both to increase production and encourage purposeful promotion of these appliances.

The study concluded by saying that women spend long hours on simple non-productive activities because of lack of appropriate tools, distance and inadequate facilities. Educational, research and production institutions and private individuals are making efforts in designing some of these technologies but meet with little support from the government. Rutahakana and Kisanga (1987). Lack of coordination of these efforts at the national level was also a major setback.

This study was followed up by a national seminar for extension workers, Home Economics teachers, institutions and private individuals researching and producing appliances. From the recommendation of the workshop, TFNC efforts continue both in research to further define the problem and to identify solutions as well as carry out area-specific promotion of appropriate appliances. Such area-specific actions are always preceded by a rapid rural appraisal (RRA) to identify area-specific problems, available resources, inherent customs etc. and assist the local communities to design and implement projects suitable to them. Such efforts have begun in (Kitefu) Arusha, (Ongoma) Kilimanjaro and (Kikwawilla) Morogoro. In Kitefu and Ongoma a quick 24-hour recall method of mothers’ activities and participant observation were used, while in Kikwawilla a more sophisticated method is being used as is discussed below.

The Kikwawila study on women’s workload

This study has been phased into two parts; phase one: the slack time and phase two: the agricultural labour intensive period. It has the objective of establishing accuracy by use of a stop watch and close observation over the recall method usually used for time budget in relation to different women’s activities. It also aims at correlating time allocation to different activities, to mothers’ and children’s nutritional states. A comparison between time spent on productive, reproductive and social activities will also be made.

The study covers 50 households (HH) selected from among 100 households in which previous nutritional and agricultural studies had been carried out. The sample was selected to include 25 households with malnourished children, and 25 with normal children. All children were matched for certain basic characteristics such as the number of parents, family size, composition of the household, number of children under five, etc.

The study methods include interviews covering basic characteristics like reproductive history, morbidity, mortality, family size, education level of mother, meal patterns and a 24-hour recall of mothers’ activities including distance to crucial services like health care, water collection sources or firewood sources. The second method is participant observation plus use of stop watches and filling of record sheets to cover the period of time from mother’s waking up until retiring to bed.

In the second phase, similar techniques will be used including improvements on observed errors and elimination of double recording in situations where the mother carried out two activities simultaneously such as cooking and feeding the baby as has been shown by the first stage.

The study will utilize the results of previous studies in the village (agricultural, food production, and consumption studies) to facilitate adequate description of selected parameters, e.g. food production/consumption in relation to mother’s workload and/or nutritional status of mother and/or child, etc. From the first phase of the study some methodological shortcomings have been observed, but some useful preliminary observations were made, for example:

1. There were some observed significant differences between time recorded by stop watch and 24 hour recall.

2. During the slack period women spent more time socializing and doing social activities like beer brewing, drinking and mat making.

3. Children 11 years old and over and not attending school, had significant input in the day’s activities.

4. Men also contributed by chopping firewood and with household work when the wife was ill and there was no relative around.

1. Health care was the most time-consuming single item due mostly to time spent queuing rather than distance to health service which was often 2-3 hours.

2. Washing was often limited to 2-3 times/week due to soap limitation.

3. Water demanded over 3 trips a day, but most often children participated.

4. A 3-hour walk was on average demanded to a firewood source and it has been observed that supplies dwindled yearly.

5. Young children were observed to be with their mothers up to two years after which they were left at home with grandmothers or older siblings.

Among the observations made and lessons learned by TFNC were the following:

1. Women have serious nutritional problems which must be attended to immediately.

2. Different government ministries and research and production institutions are involved in the question of women’s workload, but no impact is felt in the rural areas.

3. Workload, lack of time-management skills and tangible alternative ways of raising income, were identified as problems.

4. There is need for more accurate research on the nutrition situation of women in rural areas.

5. Rural women are not sufficiently aware of their limitations and poor socio-economic and nutritional status.

Recommendations

1. Rural women should be more reflected in nutrition and health studies in order to find solutions to their problems.

2. Activities designed to improve the situation of women should be better coordinated at both national and grassroot levels.

3. Education and training emphasizing the nutritional needs and conditions of women should be targeted to families rather than women alone.

4. Women should be given skills on how to manage time within the existing circumstances.

5. Government must take more realistic actions to change the socio-economic situation of women.

References

Gottlieb M (1973). The Problem of Goitre in Tanzania. A Programme for Prevention by Salt Iodization and for Improved Salt Marketing in Tanzania. Economic Research Bureau Paper 73.6.

Justensen A (1987). How can Maternal Mortality be Reduced? Paper presented at Public Health Association Workshop.

Kavishe F P and N Mlingi (1985). Towards the Eradication of Endemic Goitre Cretinism and Iodine Deficiency in Tanzania.

Kavishe F P (1983). Results of Goitre Prevalence in Tanzania.

Kavishe F P (1981). Nutrition in Pregnancy in Tanzania: A Review. TFNC Report No. 649.

Kavishe F P, A Ballart, M Ngonyani, B Ljyngqvist, T N Maletnlema and G B Medhin (1985). Determinants of Reproductive Performance and Child Survival in an African Rural Community. A baseline study of Ilula Village, Iringa.

Kisanga P (1983). Nutritional Requirements of Pregnant Mothers (A Swahili version). TFNC Report No. 696.

Kisanga P, M Ngonyani and V Lyamuya (1984). An indepth study on Child Feeding Practices in two Arusha locations: Ngarenaro and Tindiga.

Ministry of Education, Tanzania and SIDA (1987). A Report on the Evaluation of the new adult Education Curriculum from the point of view of its relevance to and impact on Women.

Rutahakana R and P Kisanga (1987). A Review of Women’s Workload and Institutional Efforts to Promote Appropriate Technology in Tanzania.

UNICEF (1985). Analysis of the Situation of Children and Women.