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Judith McGuire and Barry M. Popkin
Part 1 of this paper (Food and Nutrition Bulletin, vol. 11, no. 4, pp. 38-63) presented some of the background on the real constraints in time, productive opportunity, and health and nutrition that poor women face in their daily lives. It showed that the cultural, economic, and biological limitations placed on such women preclude their being as healthy and as productive both economically and socially as they might be if they had access to adequate resources. Four particular classes of interventions are likely to reduce the constraints against women's improving their nutritional situation: (1) increasing women's income and control of income and productive resources, (2) reducing their child-care burden, (3) increasing their productivity in household production, and (4) improving their own health and nutrition directly.
The logic is as follows: Women's income generation leads to greater control over income, which in turn leads to expenditure patterns favouring nutrition. On the other hand, women's income-generating work diverts time from child care and other household production to the money-making activities. The net impact of increased income and decreased maternal child-care time is a function of the quality of substitute child care. Hence, adequate child care is an important intermediary between women's economic participation and child welfare. Women's home production activities require large amounts of time that might be better spent on economic opportunities, child care, or rest.
Poor maternal health and nutrition diminish women's strength and efficiency in market, household, and child-care spheres and adversely affect reproductive outcomes. Improving women's nutritional status should improve their health and increase their productivity in household as well as market activities.
What follows is a review of programmes and policies shown to create a positive-sum game by addressing these four issues.
Increasing women's income and control of income
Inadequate productive resources and too few basic consumption goods are major determinants of undernutrition in developing countries. At any given level of poverty, however, the nutritional efficiency of resources within the household depends on income control, time allocation, intrahousehold food distribution, and the abilities and skills of those who provide nutrition-enhancing services (cooking, breastfeeding, health care and hygiene, child care).
One way of increasing women's economic influence within the poor household is through increasing their participation in income-producing activities . This tactic has been the focus of most "women in development" efforts. However, economic activities can compete with production of goods and services for home use. The net effect of greater income and control of expenditures and reduced home-production time will depend on the returns to women's labour and the quality and affordability of available mother substitutes.
To increase productivity, women farmers need access to agricultural extension, credit. land and livestock, labour, and technology. The benefit from increased agricultural productivity derives from sales and consumption of goods produced. To assure that women benefit requires a careful gender analysis as part of problem identification and programme decision. While men can appropriate women's labour for their crops, women cannot necessarily do the opposite. Since men's responsibilities may not include supplying the household with food, increasing household income can increase women's workload, reduce their control of income, and adversely affect household food supply [2-6].
At present, agriculture extension is far more likely to reach men than women [7; 8] and to be concentrated on men's crops and tasks. Making extension available to women involves more than training and motivating extension agents to address women farmers' problems and their problems on the farm. It may involve adding women extension agents on equal footing with male ones. It also involves rethinking many of the means of communication used in extension: scheduling public meetings at times convenient to women, providing separate accommodations for women and child care at residential training programmes, disseminating information through channels accessible to women, and assessing women's problems accurately and providing demonstrations for them .
Credit is less available to women, in part because it is often channeled through extension agents and in part because women have neither cash income nor collateral to put up as loan insurance. Where loans to women have been made, their repayment rates are usually better than men's . Women's savings groups or co-operatives are a promising means for women to qualify for credit as long as they obtain the management skills and autonomy required to maintain control of such organizations.
Usufruct rights to land are usually contingent on inheritance or the continued goodwill of a man (household head, chief, father, brother, husband, son), and, where agricultural modernization and land value appreciation are rapid, usufruct rights may be withdrawn or transferred to lower-quality or more distant fields. Men's control of land extends to control of cropping patterns. Henn  notes that in Cameroon and Tanzania, men can prohibit women from growing cash crops on 'women's" fields. The punishment a woman receives for disobeying her husband can be divorce, physical abuse, or alienation from land.
Assuring women's secure access to clan or community land is not easy to accomplish. Legal means often fail, and there is no sure way to force households to increase women's land rights. It is possible in resettlement schemes and through land-distribution programmes to increase women's access to land, but the track record there is abysmal.
Technology is also less available to women. On one hand, the plough - the most widespread technical advance - is used primarily by men and applicable to their tasks of clearing the land and tilling. In fact, the plough can exacerbate women's workload by allowing men to clear a larger parcel of land, which women then have to cultivate without technological advances. Agricultural research on women's crops, their farming methods, and women's tasks (particularly weeding, transplanting, and post-harvest processing) is also lacking . Finally, women usually lack the cash or credit to acquire the technology. Moreover, when women's work is mechanized and monetized, it is often taken over by men .
Examples of successful efforts to increase women's agricultural productivity have been rare until recently because ideology and reality have led more to criticism of existing projects than to success stories. Some recent work [5; 9; 10], however, has provided useful guidelines for successful programmes.
Women agricultural labourers
The demand for paid agricultural labourers (often landless women) has increased with the dissemination of high-yielding crop varieties. In India, where over a third of the agricultural labour force is female, women have not experienced a surge in demand for their labour equivalent to that for men's labour in the wake of the green revolution. In fact, women's wage rates have fallen . To have equal access to agricultural employment, women must have access to new technology and training: Agricultural research must take cognizance of the demand for female labour by developing alternative cropping systems and new plant varieties. Appropriate action should be taken during testing and reproduction of new crops and technologies to include women affirmatively.
Another opportunity for increasing female agricultural labour productivity is through improving women's nutritional status, as shown for tea pickers in Sri Lanka and Indonesia [16; 17].
Women's non-agricultural labour productivity
For women who earn income from non-agricultural activities, increased returns for their labour are also possible. Many women are involved in informal-sector activities, particularly market sales, where margins are low and women have low returns for labour [13; 18]. They are forced into the informal sector by conflicts between formal-sector hours and household responsibilities, by lack of education, and by frank sexism on the part of employers .
While regulating change and upgrading market structures are likely to facilitate better working conditions and profitability, training and credit are likely to contribute more to productivity. A recent US Agency for International Development (USAID) evaluation found, in the Dominican Republic, that loans to poor street vendors were successful because they are quickly disbursed, did not require collateral, and were appropriately small . Women employed in the formal labour force are likely to be better off than those in the informal sector and are more likely to be young and unmarried; `'comparable-wage" legislation is less likely to increase women's wages than to exclude women from formal employment opportunities . Educating women and enforcing anti-discrimination laws are more likely to increase women's access to better paid and more productive formal-sector employment over the longer term.
The exogenous introduction of women's income-generating enterprises - often handicrafts or small livestock - has been unsuccessful from an economic as well as a participation point of view .
Reducing women's child-care burden
Mothers are the primary caretakers of children only in early infancy . Older siblings, grandparents, and members of the extended household regularly care for preschool children even when the mother is not employed outside the home. Children's nutrition is often worse with non-maternal (particularly sibling) caretakers [21; 22]. The quality of child care and the employment conditions matter a great deal.
Several reviews of child-care programmes [23-26] show that formal child care is available only to a minute proportion of families. Instead, women rely on family or neighbourhood sources of care. Myers and Indriso  point out that existing child-care arrangements are usually good for either the child or the mother but rarely for both. An optimal arrangement is responsive to both generations' needs. Kin-based care is likely to be convenient and affordable (the cost of sibling care in terms of lost educational opportunities seems to be less salient than its low out-of-pocket costs) but may be suboptimal for children. Siblings provide certain kinds of mental stimulation for children but often fail to provide reasonable-quality health and nutrition care and infant-directed stimulation [22; 27]. New child-to-child programmes are training children in health, nutrition, and mental stimulation, but the participants are not supposed to become full-time care givers .
Child-centred care consists largely of nursery schools providing systematic mental stimulation, but often not for the whole workday. Child-centred nutrition and health interventions are usually of short duration and provide no psycho-social stimulation or custodial care. Such programmes are not geared to the hours or labour demands of working women because they end in the middle of the workday or require the mother to attend with her child. Optimal child care provides health and nutrition services plus mental stimulation in a culturally acceptable, convenient, and affordable way.
Myers and Indriso  provide several illustrations of such child-care programmes:
- In India mobile crèches have been created at the work site for women in casual construction labour. Care is provided by lower-middle-class women from the location who are specially trained by the umbrella private voluntary organization project. The programme, which covers infants through 12-year-olds, includes nutritious meals, health surveillance, and mental stimulation or schooling, depending on the child's age .
- In Salvador, Brazil, a non-traditional training programme for women spun off a child-care programme as a required adjunct to its primary activities. This programme enrolled community women in a care givers' training course to teach them about children's health, nutrition, and development and gave them practical skills (e.g. making toys from local materials) needed to run a day-care centre. The community built a centre; the day-care trainees staffed it; and the centre is heavily subscribed not only by the training-programme participants but by the rest of the community as well .
- Organized child care is not just an urban solution. Seasonal and year-round child-care programmes in rural areas have been successfully implemented in many countries. In Senegal, seasonal agricultural demands had relegated small children to inadequate care until a community day-care programme was initiated. The programme includes feeding (the food deriving in part from a community garden attached to the centre and in part from in-kind fees) and custodial care. Mothers rotate responsibility for the gardening and child care. The programme is so successful it has been replicated elsewhere in Senegal, and its scope has been expanded to include other community development activities . - An Ethiopian fruit-growing co-operative instituted day care as a co-operative venture to facilitate women's participation in co-operative activities. Not only does the programme provide custodial care, health care, and nutrition surveillance, but women are given work credit for breast-feeding their infants .
These and other examples provide consistent guidelines for setting up day-care programmes: (1) they must be convenient for women; (2) adequate training and supervision of day-care providers are required to provide good quality care; and (3) community fund-raising and participation, as well as outside funding sources, are probably required, because costs of such programmes - in facilities, equipment, training, and personnel - often put them beyond the reach of the individual families that need them most.
Increasing women's efficiency in home production
The third area in which there is potential for increasing women's ability to carry out their nutritional responsibilities is that of home production. Tasks in this category include post-harvest agricultural processing, water and fuel-wood supply, cooking, and cleaning; making soap, textiles, and pottery for use by the household; and health and nutrition activities. If women can save time or their own energy through increased efficiency in this area, they can use the released resources to generate more income, to rest, or to take better care of their children.
"Appropriate technology" has often been proposed as a solution to certain household production problems, but it has rarely met expectations. The most prevalent target of appropriate technology has been the time- and energy-intensive cleaning and pounding of grain. In West Africa, grain milling, cassava processing, and palm-oil extraction are all energy- and time-consuming processes under women's control.
Efforts to introduce improved technologies in these areas must be responsive to women's needs and technological control [30-32].
- In South Asia, activities such as winnowing, pounding, and parboiling rice were traditionally carried out by women. Although pounding grain is very time- and energy-intensive and pure drudgery, it is a major source of income to the poorest women in South Asia. Small mechanical mills run by men have made great inroads into the grain-pounding business. The new mills are far less expensive than human pounding, but the social cost of the loss of income to poor women is high [33; 34].
- In Upper Volta (now Burkina Faso) in the mid-1970s a programme introduced grain mills, carts, and local wells, which were supposed to alleviate the greatest time and energy burdens on women - pounding grain and gathering fuel, wood, and water [35; 36]. Yet about half the women did not use the grain mills because of cost (even though a women's group had established the price and had control of the millers). It was suggested that women used the mills only when they were forced to by illness or seasonally high work loads - when their opportunity cost was higher. The carts intended to be used for firewood gathering and water hauling were used by only half the women, once again largely because of cost. The wells were popular, but they went dry just at the point when alternative sources of water were least accessible: hence their time saving was minimal. Analysis of time use before and after the introduction of these technologies showed, however, that women did indeed gain time and that they devoted it primarily to spinning cotton or (less frequently) to rest.
- In Cameroon a corn mill which could be hand-operated by women and significantly reduced the labour required for milling proved successful. Loans, to be repaid by charging a small fee for use, were made available for women's groups to purchase the mills. The women were also trained in the use and maintenance of the mills . With the time released, women attended classes in soap-making, cooking, and child health.
- Soap production in Ghana has been greatly improved by a private voluntary organization's commercial production of ash. Women no longer need to burn large quantities of wood; they just mix and cook the soap ingredients .
Home-based technologies need to be appropriate (solar cookers should not require women to cook in the hot sun at midday, for instance) and should not require large cash outlays; and women should be provided with the training to maintain and repair them . Women, likely users of water pumps, are rarely trained in their operation, maintenance, or repair. Moreover, poor women may even lose income from the introduction of pumps: in Tanzania women water carriers lost employment when water pumps were introduced. In Kenya, on the other hand, women's self-help labour was found to be more successful than paid male labour in the construction and maintenance of dams and catchments; this success was attributed to women's being the chief users of water and thus having the knowledge and skills to maintain the water system .
Overall, technological solutions to women's household production problems are likely to be more successful if women are involved from project conception to execution, if they have access to credit to procure the technology, and if they maintain or gain control of the technology and resources transformed.
Health and nutrition activities
Another way to help women become more efficient in their household production is through reducing the unnecessary burden of sickness by teaching improved preventive health care, hygiene practices, and food preparation. The development of "instant" weaning foods is an excellent example. In Nepal, a dry instant weaning food called sarbottam pitho can be made in the home and reconstituted at the time of feeding to avoid bacterial growth. It is superior nutritionally to the usual "bacterial broth" and reportedly requires little extra maternal time to make .
Reducing the time costs of food procurement and preparation is important for the public and private food sectors. Bread is probably the most widespread time-saving convenience food. It requires no further processing, stores well, and can be eaten throughout the day. Many developing countries artificially keep the price of bread low because it has become a staple of the urban poor. A study in Sri Lanka  found that, as women's wage rates rose, the household consumed more bread and less rice. Dried soups and pasta products are also very popular convenience foods because they require very little preparation time and fit in well with traditional foods and eating styles. Since convenience foods are generally highly refined, they may lack important nutrients found in more traditional foods. Whether the benefits of convenience foods outweigh the costs is virtually unknown. Street foods - often sold by women - are other convenience foods that can save women time. These are precooked, ready-to-eat foods sold in rural and urban areas, on streets as well as house-to-house .
Improving women's health and nutrition
Historically, interest has focused on women's health and nutrition largely because of their child-bearing and child-rearing role and because women are at nutritional risk because of reproduction. There is no question that improved maternal health and nutrition directly improve foetal and neonatal health. Much less is known about the impact of improved maternal health and nutrition on women's successful fulfilment of their other productive roles (though there have been some studies - e.g. on Indonesian tea pickers  and Indian factory workers ).
In addition to lacking information on women's productivity, we are still very much in the dark on how to reach women with health and nutrition programmes for their own good . Women's nutrition supplementation studies in Guatemala  and the Gambia  have obtained good participation rates with measurable improvements in anthropometric results for women and children. (The Gambian women reported having more energy as a result of these nutritional status improvements.)
- A CARE feeding programme in India found women more likely to participate if the food ration was ready to eat and women could pick it up on their way to the fields .
- A World Bank project in Indonesia induced women to eat better diets through a nutrition education programme. Behavioural trials determined that pregnant women were willing to increase their total food intake slightly and to eat more greens, but were unwilling to eat extra protein or a great deal of additional food. Compliance with iron supplements was good, and the negative side effects (of which the women were forewarned) did not reduce compliance . This Indonesian work demonstrates that women can be motivated to improve their nutrition so long as it does not conflict with firmly held beliefs.
- Efforts to increase the food intake of lactating women in Indonesia met with success also, and several practices (increased liquid intake and increased food) apparently increased women's breast-milk supply as well. As a result, some of them had to nurse their infants more frequently, but they did not mind the extra work because their infants were more content.
- The ICDS programme in India found that it obtained better participation of lactating women and young infants if mother and child were admitted as a unit (perhaps allowing the mother to justify her attendance) and if both participants were given food rations .
- Improving prenatal care by training traditional birth attendants in the Philippines has improved care participation rates .
- Use of supplementary feeding was associated with greater tetanus toxoid coverage (and antenatal clinic attendance) in India's Project Poshak .
- In the Philippines, Wong et al.  found that accessibility (travel time) to prenatal care and availability of health insurance strongly affected participation in antenatal clinics, as did women's education.
Sustained participation of pregnant women in supplementary feeding programmes is based on addressing the actual or perceived risk of cephalopelvic disproportion that may cause women to restrict food intake in late pregnancy [42; 50].
The consistent finding of these studies is that, to persuade women to use health and nutrition services for themselves, services must be made as cost-free as possible by making them convenient geographically, minimizing the out-of-pocket and opportunity costs of using them, and making them harmonious with current beliefs and practices. In addition, women need the authority or permission to seek help for themselves.
To optimize the nutritional effectiveness of these programmes, a combination of the elements discussed above is necessary. Women cannot procure the benefits of household technologies or child care without paying for them, but they are constrained from increasing their income by the time demands of home production. If women were healthier and nutritionally better off, they might be more productive economically, but they have neither the time nor the permission (possibly a function of their contribution to household income) to eat more food or obtain health care for themselves. Thus, complementary interventions are needed to break the deadlock on women's resources for nutrition.
Throughout the two parts of this article we have noted information gaps and research needs. We summarize here the most urgent issues requiring further research.
More information is needed on women's nutrition, food consumption, and nutritional risks, especially changes in nutritional status occurring over their reproductive lives . In particular, the maternal depletion syndrome needs to be investigated and the incidence of cephalopelvic disproportion resulting from improved diet documented . Better information on the effect of improved nutrition on women's productivity in the market and home is also needed.
The impact of increases in women's income on the level of allocation of food expenditures and on their own and other household members' nutritional status needs further exploration.
The impact of formal and informal child care on women's productivity, income, and reproductive behaviour, on children's health and mental development, and on community child-care norms and behaviours needs elaboration. Cost-effective and culturally appropriate child-care mechanisms should be investigated in pilot studies.
The effect of increased water and fuel-wood supply, reduced food-processing time, and increased efficiency in post-harvest food processing on women's income and nutrition, household food security, and children's nutrition needs careful study. All too little is known at present about household management skills and productivity. Quantitative models of labour allocation and household production need to be complemented with observational studies to determine what women and their families need to know and have to become more productive.
Knowing what women need is one thing; delivering it to them and even convincing them that they need it is quite another. Research is needed along with service-delivery programmes in agriculture, education, health, and nutrition to raise demand, increase sustained participation, and enhance effectiveness. In particular, we need new ways of creating the self-confidence mothers need to adopt new behaviours and participate actively in maternal-child health programmes.
Women play a major role in producing food, in generating household income, in bearing and rearing children, and in overall household production. Throughout their life cycles, poor women experience role stress because of conflicting time, energy, and economic demands made on them. The biological roles of pregnancy and lactation often compete with physical labour for women's nutrient intake and reserves. Women's economic activities compete for their time with child care, home production, and other social roles. Women may also find conflicts between their biological needs and the ideal woman defined by culture. Their nutrient needs may be belittled, their need for rest derided, their desire that children should be widely spaced overridden.
Because poor women lack resources, these conflicts engender a zero-sum game: any extra effort a woman devotes to one of her roles (economic, biological, or social) detracts from her fulfilment of other roles. Nowhere is this compromise more apparent than in nutrition: women grow food, women's income buys food, women prepare food and breast-feed, women's bodies nourish the foetus and the suckling child, women use their physical energy for work, and women are responsible for prevention and treatment of most illness. To make a positive-sum game in nutrition, women need to be able to increase their access to food, reduce the nutritional costs of their role conflicts, and enhance their control over nutrition-related resources.
The programmatic and policy implications of this situation are that, to overcome these constraints, women need access to income enhancement simultaneously with access to burden-reducing services and technology. The existence of time lags before income gains are realized implies that women need subsidies, credit, or direct resource transfers during the transition in their income potential. This transition period can be long (in the case of education or institution building) or short (in the case of credit). The most successful projects cited above minimized the conflicts in women's financial responsibilities and time commitments between family and market; provided child care along with occupational training; provided health and child care along with agricultural development efforts; provided for cost recovery and credit along with grain mills. The most successful programmes, in other words, respond simultaneously to women's dual constraints - time and money.
A few key interventions stand out as central:
- promoting good child care through a combination of regulation, training and technical assistance, institutional development, and public subsidies to provide substitute child care in rural and urban areas that will meet women's economic needs and family responsibilities and children's need for health care, nutrition, mental development, and socialization;
- facilitating women's access to credit through institutional development, supporting savings societies, changing banking practices if necessary, and making loan size and procedures appropriate for women;
- creating demand for women's health, nutrition, and family-planning programmes and harmonizing delivery systems and logistics with women's constraints;
- ensuring women's access to and control over technology and other productive resources through research and development, targeting, training, marketing, and credit.
Child-survival technology can be a powerful tool enabling women to meet productive and family responsibilities better, but the costs of participation must be appropriate to the resources available to women.
Interventions in these areas promise to help women break out of their time, money, and energy constraints. They create opportunities for a positive increase in available time and energy resources that can improve the nutritional status of women.
We thank the Advisory Group on Nutrition of the ACC/SCN, Dr. Abraham Horwitz, and Dr. John Mason for their encouragement and advice in all phases of the development of this overview article. We thank the ACC/SCN for providing financial support for its preparation. We thank Martha Burdick, Samya Burney, Patricia Dargent, Lionel Deang, and Anna Viggh for research assistance. We also thank Linda Adair, Corazon Barba, and Chloe O'Gara for comments on earlier drafts. We thank Lynn Moody Igoe, Frances Dancy, Catheryn Brandon, Mary Ann Daly, and Ealise Crumb for editorial and secretarial assistance. None of these persons is responsible for the final views presented here.
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