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FOOD AND NUTRITION BULLETIN
Published by the United Nations University, Tokyo. Japan.
Food and Nutrition Bulletin
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The Food and Nutrition Bulletin incorporates and continues the PAG Bulletin of the former Protein-Calorie Advisory Group of the United Nations system and is published quarterly by the United Nations University in collaboration with the United Nations ACC Sub-committee on Nutrition. The views expressed are those of the authors and not necessarily those of the United Nations University or the ACC Sub-committee on Nutrition.
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This issue of the Food and Nutrition Bulletin carries a series of articles concerned with the health and nutritional status of women and of their children, which can be classified according to three different focuses: (1) research reviews and recommendations, (2) programmatic recommendations, and (3) descriptions or analyses.
Leslie, Pelto, and Rasmussen identify key research questions concerning the nutrition of women in developing countries. Holmboe-Ottesen, Mascarenhas, and Wandel review the literature concerning women's work along the food chain and how it may affect their nutritional status and other aspects of their lives. Bennett presents a theoretical framework for answering the question of whether women's income-producing work results in an improvement or a deterioration in the health and nutritional status of their children. McGuire and Popkin emphasize the time and energy constraints of women who are targets of programmes and are expected to participate in them; they recommend that there be more symposia to explore the issues involved in making programmes more effective for women.
In contrast, the article by Rogers and Youssef emphasizes programmes that address the origin of nutrition and health problems in social and economic systems. They stress that, because government funds for social services in developing countries are dwindling, programmes that address women's concerns must help women to develop their own resources to better their nutritional and health status. They also discuss measures that would be necessary to avoid the pitfalls McGuire and Popkin point out concerning women's lack of time and energy to participate in programmes, stressing, for example, the necessity of providing programmatic support for women to form groups such as unions, which would give them more economic power, and child-care co-operatives, which would help them to devote time and energy to activities other than child-care.
Three articles provide descriptions or analyses of women's work, income status, education, and/or living conditions and also make observations or policy recommendations that go beyond these descriptions and analyses. Katona-Apte describes the desperate plight of destitute women in Bangladesh and their coping strategies. She observes, as do Rogers and Youssef, that lending to such women, as the Grameen Bank experience in Bangladesh attests' would be a good credit risk. Tin-May-Than analyses the energy input and output of women weavers in Burma and observes that, despite their very long work days, their sedentary labour does not provide them with sufficient muscular or cardiovascular development to permit them to work at more strenuous jobs. Abbi et al. attempt to analyse the effects on children's nutritional status of their mothers' knowledge of nutrition while controlling for the effects of the socio-economic characteristics of the family. This study, which was conducted with 2,618 mothers in ten rural and tribal areas in India, emphasizes that, unless mothers' "economic status improves simultaneously, they may not be able to put into practice all that they know."
Additional articles in this series addressing women's nutritional and health issues in developing countries will appear in the next issue of the Bulletin. We would appreciate any responses readers have to these articles. Comments may be addressed to: The Editor, Food and Nutrition Bulletin, Massachusetts Institute of Technology, E38-256, Cambridge, MA 02139, USA.
We gratefully acknowledge the preliminary organizing work of Monica Brana in soliciting materials for this special issue.
Joanne Leslie, Gretel H. Pelto, and Kathleen M. Rasmussen
The purpose of this paper is to highlight a series of important questions concerning the nutrition of women in developing countries. The aspects that will be addressed fall into three subject areas: economic perspectives on the nutrition of women, the maternal depletion syndrome, and cultural perspectives on the nutrition of women.
The following are some key questions concerning the nutrition of women in developing countries today.
To address these questions, a number of issues must be considered concerning the relationships among social and biological factors as they relate to the nutritional status of women.
Women in the workforce
The heavy work load of women in developing countries has recently been receiving more attention from nutrition and health researchers. In the past two decades a large body of data has been accumulated that documents the multiplicity of work activities typically required of women throughout the world, including domestic activities, home food production, agricultural labour, and, increasingly, participation in the paid labour force. These data have come from a variety of disciplines and include time-allocation studies, income and related economic research studies, and, to a more limited extent, energy-expenditure studies.
The average work day of women in developing countries is 10 hours or longer . Recent International Labour Organisation statistics show that approximately one-third of the paid labour force, internationally, was composed of women, and in most countries the proportion of women in the workforce is growing. For many women, pregnancy and lactation provide little relief from the demand to engage in income-producing activities. For example, research by Leslie and colleagues in Jamaica showed that 11% of women were working at six weeks postpartum, a proportion that steadily increased to 62% by 12 months .
The role of work activities in explaining the nutritional status of women, including patterns of energy expenditure, the extent to which tasks are obligatory or discretionary, and the extent to which adjustments can occur in relation to illness, pregnancy, lactation, or food availability is as yet very poorly explicated. Women's economic activities also have an important effect on their nutritional status (as well as that of other members of the household) through income generation and/or food produced. Work patterns, economic activities, and energy expenditure as critical mediators between social conditions, food availability, and women's nutritional status should be given primary attention.
Family composition, migration, and social change
Women's work patterns, economic activities, and food intake are all influenced by family structure. The number of female-headed households is increasing in almost all countries. The proportion of female-headed households ranges from an estimated low of 10% in Middle Eastern countries to nearly 50% in parts of the Caribbean and southern Africa . In addition, worldwide there is a very large number of rural households in which the adult male is regularly absent for much of the time, working in wage labour in urban centres or even engaging in cross-national migration in search of work.
The international economic crisis and national policy responses to it, rapid urbanization, explosion of access to mass media, and broad changes in traditional culture all act in concert to change family structure and organization. Cultural mechanisms that protected girls from pregnancy prior to marriage and that spared the new mother from usual activities (up to six months postpartum) are falling away under the pressures of modern life. For example, many rural women in a highland Mexican valley reported they could no longer observe the traditional 40-day postpartum rest because there was no one to take over their domestic activities. Similar developments have been reported for other parts of the world as well.
Urbanization has been, and continues to be, a major factor undermining traditional social ties and labour exchange that supported "peri-partum" women. In all contexts, urban and rural, analyses of the relationships of the family structure to the nutrition of women (and other family members) would be an important route through which to understand how social processes are linked to nutritional outcomes.
Cultural beliefs and practices
Many years ago Jelliffe advised nutritionists in public health to reinforce cultural beliefs and practices that were positive for nutrition, to leave neutral practices alone, and to change only those beliefs and practices that are negative. Although this approach seems to be reasonable, following this advice is more difficult than it first appears.
One major problem is to distinguish between cultural beliefs that are made as normative statements and the behaviours in which people actually engage. For example, cultural beliefs that restrict specific foods during pregnancy and lactation appear to be widespread. However, there is little empirical data documenting their impact on intake, and in a few studies there is some evidence that "food taboos" are more often breached than followed.
A second problem concerns the function of cultural beliefs; while some culturally defined pregnancy food restrictions are couched in terms of sympathetic magic (certain foods must be avoided or the baby will be born with a special defect), others are intended to restrict foetal size to make delivery easier. In environments where there is no access to obstetric surgery, and where childhood malnutrition leads to small maternal pelvic size, such "taboos" may have a positive function in reducing the incidence of cephalopelvic disproportion and other delivery complications.
This is not to suggest that all cultural beliefs have a positive function, for this is clearly not the case. Longstanding beliefs and practices, however, represent attempts to adapt to environmental conditions, so that changing only the "negative practices" without also changing the environmental conditions may bring about other negative outcomes. Moreover, the basis for judging a practice to be "maladaptive" is relative to the knowledge and values at a given time and place. It was not so many years ago that biomedical advice in the United States recommended restricting pregnancy weight gain to less than 20 pounds and withholding food from children with diarrhoea. Today we would regard these as "negative practices."
Perceptions of nutrient needs and a "culturally appropriate" female body image
One aspect of culture that has been given very little attention is the matter of perceived nutrient needs and cultural perceptions of appropriate or attractive body size and shape. In part, the purpose of growth monitoring of small children is to sensitize caretakers to concepts of normal growth and development and to the relationships of growth to food intake. To date
there has been little, if any, systematic analysis of cultural views of growth, and what little we have in the way of ethnographic reporting is highly anecdotal. Similarly, there has been very little analysis of cultural views of the nutritional (food) needs of girls and women or the relationship of these to the needs of males.
Just as young child feeding practices reflect, to some extent, culturally derived views of what a "healthy" or "normal" child should be like, so too is the food intake of girls and women affected by cultural norms of attractiveness. The impact on adolescents' and women's health of the "thin is beautiful" norm in Western cultures is beginning to attract serious research attention, especially as it relates to eating disorders. The role of cultural perceptions in affecting the food intake of women in developing countries is almost entirely unknown. While food availability and work patterns undoubtedly have a more primary causal force, the potential for such influences should also be considered, particularly in urban areas.
Nutrition in childhood and adolescence
The nutritional status of women, particularly as it is affected by childbearing, is, in part, a function of experiences of childhood and adolescence. In the past, the nearly exclusive focus on nutrition and reproduction led researchers to ignore nutritional issues of girls in the age range of 6 to 15 years. Although the data on intra-household food distribution are far from adequate to address this issue, there is some scattered evidence to suggest that adolescent and pre-adolescent girls may fare least well in conditions of food scarcity.
Although some aspects of adolescent nutrition have been systematically examined (e.g. the relationship of menarche and body composition), multi-sectoral studies linking social and cultural factors to nutrition and health in girls and young women are few and far between.
The maternal depletion syndrome
The concept of a "maternal depletion syndrome" was first proposed in the 1960s to refer to the interaction of several social and biological factors that collectively produce a clinical syndrome of physical depletion. Over the years. the emphasis in discussions of the concept has focused on the deleterious effects of closely spaced cycles of pregnancy and lactation, with little attention given to the interrelationships between reproductive experiences and the social-biological context in which these experiences take place.
A serious weakness of some studies that might be relevant for assessing the "maternal depletion syndrome" is the failure to distinguish age and parity. The relationship of age and parity to maternal mortality has been shown to be U-shaped. For example, in Bangladesh, more than half of the maternal deaths in the sample were among women of high age and high parity . One would expect to find a similar U-shaped relationship with birth weight (using the latter variable as an indicator of maternal depletion), but this has not been systematically examined.
The effect of parity on lactation performance (another variable that could be used to assess maternal depletion) has received more attention. For example, studies in Kenya suggest there is an interaction between nutritional status and parity on lactation performance . There was progressively lower lactational performance with increasing parity for women of greater weight for height, while no such effect appeared among the low weight-for-height group in a cross-sectional sample. This suggests that the low weight-for-height women were not well off even in their first pregnancy, whereas evidence of the increased cost of lactation with high parity occurs among those who are somewhat better off. Studies in Gambia also provide evidence of reduced lactational performance and reduced energy density of milk with increasing parity .
Parity and age also relate to family composition and energy expenditure patterns. The availability of older children to help with domestic and other economic activities and the relationship of household composition (including the presence of in-laws and adolescent daughters) to reproductive outcome and energy expenditure in adult women should prove to be a fruitful area for future research. Comparing the results using animal models of age, parity, and nutrition interactions with the situations of women in various socio-cultural situations will help to elucidate the conditions that exacerbate or buffer the biological relationships.
Current status of the key questions
The questions listed at the beginning of this paper represent some fundamental issues that need to be addressed if we want to improve our understanding of the situations of women in developing countries. Given the limited purpose of the paper, evidence with respect to these questions has not been reviewed. It is important to note, however, that there is a serious dearth of data relevant to these matters. Our current understanding is piecemeal at best, and the results of the studies that do exist are often difficult to interpret because of methodological weaknesses in the study design and measurements and, perhaps more importantly, the lack of a solid theoretical foundation as a basis for framing research hypotheses.
Although a maternal depletion syndrome may exist, convincing data are not available at present, and clearly it is not a universal phenomenon. Techniques curently available could be used to measure the maternal depletion syndrome, but what is required are appropriate study designs that capture the "natural history" of the syndrome with longitudinal observations. Descriptive epidemiological studies are also needed but should be designed to provide information about the relationships of particular nutritional conditions to age, parity, poverty, and maternal working conditions. Experimental studies are needed to establish the direction of causality, especially concerning associations between parity and nutritional status.
These methodological suggestions apply not only to the analysis of the "maternal depletion syndrome" but also to other issues concerning nutrition and women. Previous studies have generally failed to utilize complex models of the determinants of nutritional status, including dietary quality and micronutrients. Research models that include social as well as biological determinants are also essential. More careful specification of theoretical models, together with better measurement of the primary data by multidisciplinary research teams, could begin to explicate the processes that compromise or protect the nutrition and health of women in developing countries.
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2. Leslie J, Powell D, Jackson J, Searle K. Infant feeding, women s work. and social support in Jamaica. Working paper. Washington, DC: International Center for Research on Women, 1988.
3. Youssef N, Hetler CB. Rural households headed by women: a priority concern for development. Working paper. Rural Employment Programme. Geneva: International Labour Organisation, 1984.
4. Fortney J. The importance of family planning in reducing maternal mortality. Studies in Family Planning 1987; 18:109-14.
5. van Steenbergen W, Kusin JA, de With C, et al Lactation performance of mothers with contrasting nutritional status in rural Kenya. Acta Paediatr Scand 1983;72:80510.
6. Prentice A. The influence of maternal parity on breast-milk composition. In Schaub J, ed. Composition and physiological properties of human milk. Amsterdam: Elsevier, 1985:309-19.
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