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The impact of maternal work status on the nutrition and health status of children

Rita Abbi, Parul Christian, Sunder Gujral, and Tara Gopaldas

Abstract

The effect of mothers' work status on their children's nutrition and health was determined from data from 1,990 rural children, one to six years of age, from Chandrapur District, Maharashtra, India. The relative risk of a child of a working versus a non-working mother being malnourished was 1.7 by weighs for age and 1.8 by height for age. The relative risks of developing anaemia and vitamin-A deficiency were 1.4 and 1.5 respectively for the children of working mothers. The relative risks for younger children of getting measles, severe diarrhoea, and worm infestation were significantly higher in those whose mothers worked. Family income and child's age were significant intervening factors in the ad verse effects of maternal work status on all nutrition- and health-status variables except pneumonia and vitamin-A deficiency. Poor income appeared to be the major detrimental factor, with the mother's working status being an aggravator.

Introduction

It is widely accepted that the work status of the mother plays an important role in determining the health and nutrition status of her child [1; 2]. Two separate mechanisms for this effect have been postulated [3, 4]: first. the mother's increased income associated with her employment. and, second, the time taken away from child care when she goes to work. While one of the effects is direct and positive. the other is inverse and negative. It is quite common for women in low-income groups to contribute a considerable amount to the total family income by working outside the home. Evidence suggests. however, that the nutrition status of their children is negatively affected [5]. It would be of interest to find out whether the well-being of children is affected more by the time constraints of women who perform the dual role of mother and earner, or by the increased income generated by the mother's working. If the two phenomena co-exist, it is likely that the beneficial effect of maternal employment may be nullified.

We explored the impact of mothers' work status on the nutrition and health status of children. Since toddlers are expected to depend more on their mother for their needs than pre-schoolers, the effects were studied separately for children under and over the age of three years.

Materials and methods

Data were collected as part of the USAID-assisted Integrated Child Development Services (ICDS) impact-evaluation project in Chandrapur District of Maharashtra, India. The survey was carried out in five of the eight blocks of the district in 1987-1988.

Data were collected by pairs of trained investigators consisting of one medical intern and one nutrition/social scientist. In all, 1.990 rural children one to six years old were measured, using standard procedures for weight and height [6]. Weights were taken on a Salter spring balance to the nearest 0.1 kg; infantometers and height meters were used to measure the length and height of infants and children respectively to the nearest 0.1 cm. Children's ages were established by the mothers' recall with the help of a local events calendar.

The children were examined for signs of pallor, using the anaemia recognition card [7]. Clinical examination for ocular signs of vitamin-A deficiency. conjunctival xerosis with Bitot's spots, corneal xerosis (with and without ulcers), and keratomalacia was carried out by medical interns. A history of night blindness was also obtained. Mothers were asked whether their children had suffered from pneumonia, severe diarrhoea (defined as four or more loose stools per day lasting more than three days), measles, or worm infestation in past year.

Mothers were questioned directly about their work status. A woman was considered to be working outside if she remained away from the house for at least five to six hours, whether or not she was involved in an income-generating activity; for example, she might have gone out to help her spouse in her own field. This, in fact. is the most common activity that takes mothers away from home and children among the poorest rural and tribal families.

Statistical analysis

The data were cleaned and processed on an IBM-compatible PC/XT using DBase III plus [8]. The weights and heights of children were converted to sex-specific Z scores of weight for age and height for age based on growth reference curves of the US National Center for Health Statistics (NCHS)/Centers for Disease Control (CDC) and using the CDC Anthropometric Software Package [9; 10,. The weight and height of the children were categorized into various grades of malnutrition as defined by the Indian Academy of Pediatrics [1]) and Waterlow [12] classifications. Children's ages in months were squared to transform the curvilinear relationship between nutrition status and age into a linear one. The income distribution was skewed toward the right. Therefore a natural logarithm was derived to normalize the shape of the income distribution curve.

The relative risk of children becoming morbid or malnourished based on mothers' working status was calculated using a prevalence odds ratio [13] with a 95% confidence interval. Analysis of covariance was done to study the effect of maternal employment on child nutrition and health status, controlling for the effect of income and child's age. Data analysis was done using the Statistical Package for the Social Sciences (SPSS/PC + ) [ 14].

Results

The socio-economic backgrounds of the working and non-working mothers were comparable. All the families lived in rural areas with simile, environmental sanitary conditions and used a common drinking-water supply. Only 25% of the total mothers had four to seven years of schooling. Nearly 50% of the literate and 70% of the illiterate mothers worked outside the home. The average family size of both working and non-working mothers was seven. The average per capita monthly income of the families of working mothers was significantly lower than that of the families of non-working mothers - Rs 65 versus Rs 103 (US$3.95 versus US$6.25).

Table 1 and table 2 show by age group the relative risk for children of working mothers of being malnourished by weight for age and height for age respectively. The risk was calculated using normal versus malnourished categories of children. The risk of having a low weight for age was significantly higher (1.7 times) for children under three years old and higher but not significantly ( 1.4 times) for older children of working mothers. On the other hand, the relative risk for the children of working mothers of having low height for age was significant for both those under and those above the age of three - 1.8 and 1.6 respectively.

TABLE 1. Relative risk of low weight for age in children of working mothers compared with those of non-working mothers

a. Indian Academy of Pediatrics classification for weight for age.
b. The nsk for each age and maternal-working-status group is calculated from the total number of malnourished children versus normal children within the group.
* P<.01.

Table 2. Relative risk of low height for age in children of working mothers

a. Waterlow classification for height for age
b. The riskfor each age and maternal-working-statusgroupis calculated from thetotal number ofmalnourished children versus normal children within the group
* P<.01.
** P<.001.

Table 3 shows that the relative risks of having vitamin-A deficiency and anaemia were 1.4 and 1.5 respectively for the children of both age groups with working mothers. The effect, however, was significant only in the case of anaemia.

TABLE 3. Relative risk of vitamin-A deficiency (by ocular signs) and anaemia (by pallor) in children of working mothers

* P<.01.

The relative risk of measles was almost double, and that of severe diarrhoea was 1.5 in children with working mothers. The reason for this is not known. Although the negative effect of the mother's work status was independent of age for the occurrence of those two conditions' in the case of worm infestation it was significant in the younger group A significantly lower percentage of children of working mothers were immunized against measles than those of non-working mothers (15% versus 20%). The risk of suffering from worm infestation for children under three years old with working mothers was double that for children of non-working mothers.

TABLE 4. Relative risk of morbidity in past year in children of working mothers

*P< .01.
**P< .001.
***P< .0001.

Since the mean per capita monthly income of the families of working women was significantly lower than that of the families of non-working women, and since age is a significant determinant of the effect of maternal employment on child nutrition and health status. the relationship between these variables was examined, controlling for the effect of income and age of the child. Maternal work status exerted a significant effect on both the nutrition and the health status of children, the only exceptions being in the cases of vitamin-A deficiency and pneumonia.

TABLE 5. Analysis of covariance: effect of maternal work status on children's nutrition and health status (F values)

*P=.05.
**P<.01.
***P<.001.

Discussion

Numerous studies have found that children of working mothers have a lower nutrition status than do those whose mothers remain at home [1; 15-18]. Others, however, have found maternal employment outside the home to have a positive impact on children's nutrition status [ 19]. It is also believed that economically independent women are more likely to be able to use their knowledge to maintain good nutrition and health for their children than economically dependent women. In the present study, however, the working status of the mothers appeared to have a deteriorating effect on both features of their children's lives. It should be stressed that most of the working mothers we surveyed had little or no access to the income they generated.

Elaborate conceptual frameworks have been developed to answer the question of whether a woman's income-producing work results in an improvement or deterioration in the nutrition and health status of her children [5]. Our analysis showed that the children of working mothers fared significantly worse than those whose mothers stayed at home. The negative effect was more pronounced among children under the age of three than in those older than three. The mother's lack of time for child-care activities perhaps aggravated the already poor nutrition status of economically deprived children. Childcare activities are time intensive [1], particularly for younger children. Consequently, a decrease in child-care activities during this vulnerable age is hound to affect the children's nutrition and health status negatively.

Such a negative effect has also been shown to relate to a decline in breast-feeding [I] and to use of surrogate parents in the absence of mothers [2]. In the present population, 31)% of the children of working mothers were looked after by siblings and 57% by grandparents. No differences were observed in the nutrition and health status of these children. This would mean that maternal working status was a true differential of child nutrition and health status.

Furthermore, analysis controlling for family income and the age of the child clearly demonstrated that the working status of women had a significant adverse effect, lending support to the view that maternal child-care time may be an important factor in determining the growth and well-being of the child. Working mothers probably are unable to perform their child-care responsibilities ably and efficiently. It may be stated that, while the economic status of the family plays a significant role in determining child welfare 20], maternal child care is even more important.

There are two principal ways in which mothers' involvement in work outside the house has a negative effect on their children's nutrition and health status. First, the work load can affect the woman's own nutrition and health and consequently decrease her capacity to attend to other activities such as child care [21] or to produce an optimum quantity of breast milk. Second, time constraints imposed by her involvement in work outside may prevent her from attending to the needs of her children [22]. It is regrettable that it was not possible to measure women's time allocation. It is possible that working mothers spend less time than assumed in child care. Moreover, for non-working mothers, others may be sharing in child care.

It is reasonable to assume, on the basis of the well-established relationship between the economic status of families and child nutrition and health, that children of poorer families would have a poorer nutrition and health status than their better-off counterparts. Since in most cases, particularly in rural areas. it is low income that forces women to take part in earning money, it is likely that the poor nutrition status of children in these families is due mainly to the lack of money. Their poor health and nutrition status are exacerbated further by inadequate care as a result of their mothers' working.

In conclusion, we can say that, since the working rural women in this study belonged primarily to low-income families, their children were at a double disadvantage. Not only did low economic status have a deteriorating effect on the children's nutrition and health but, even more, the greatly decreased childcare time available to working mothers had an additional negative effect.

Policy recommendations that might emanate from this study would be to provide (a) crèches for children under the age of three of poor rural working women, (b) some training in simple child care for siblings and grandparents who care for these children, and (c) income-generating activities for women within the home that would economically more than offset their free labour on the farm.

References

1. Popkin BM. Solon E. Income. time, the working mother and child nutriture. Environ Child Health 1976: 22(4): 156-66.
2. Choudhary M. Jain S, Saint V Nutritional status of children of working mothers. Ind J Pediatr 1986:23:263-66.
3. Mosley WH, Chen LC. An analytical framework for the study of child survival in developing countries. In Mosley WH, Chen LC, eds. Child survival: strategies for research. Cambridge. UK: Cambridge University Press. 1984:25-28.
4. A. Zimicki S. D'Souza S. Socioeconomic differentials in child nutrition and morbidity in a rural area of Bangladesh. J Trop Pediatr 1986;32:17-23.
5. Bennett L. The role of women in income production and intra-household allocation of resources as a determinant of child nutrition and health. Food Nutr Bull 1988: 10(3): 16-26.
6. Jelliffe DB. The assessment of the nutritional status of the community. WHO Monograph Series. no. 53. Geneva: World Health Organization. 1966.
7. Anaemia recognition card. New Delhi: Voluntary Health Association of India.
8. Learning and using dBase III PLUS Torrance Calif. USA: Ashton-Tate. 1987.
9. National Center for Health Statistics. NCHS growth curves for children. birth-18 years. DHEW Publication no. 78. Washington, DC': US Department of Health, Education, and Welfare, 1977.
10. Jordan MD. The CDC anthropometric software package for disease control. version 3.0: tutorial guide and handbook. Atlanta, Ga. USA: Centers for Disease Control. 1986.
11. Indian Academy of Pediatrics. Classification suggested by the nutrition subcommittee. 1971-71. Indian Pediatr 1972;6:360.
12. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J 1972;3:566-69.
13. Miettenin O. Estimability and estimation in case-referent studies. Am J Epidemiol 1976:103:226-35.
14. Norusis MJ. SPSS/PC+ for the IBM (PC). Chicago: SPSS Inc., 1986.
15. Blau DM. Investment in child nutrition and women's allocation of time in developing countries. Discussion Paper no. 371. New Haven. Conn. USA: Economic Growth Center, Yale University, 1980.
16. Hart G. Women's participation in the labor force: implications for employment and health nutrition programs. Ithaca. NY, USA: Cornell University Press. 1975.
17. Popkin BM, Bisgrove EZ. Urbanization and nutrition in low-income countries. Food Nutr Bull 1988;10(1):3-23.
18. Gopaldas T, Patel P, Bakshi M. Selected socioeconomic, environmental, maternal, and child factors associated with the nutritional status of infants and toddlers. Food Nutr Bull 1988;10(4):29-34.
19. Rogers BL, Youssef N. The importance of women's involvement in economic activities in the improvement of child nutrition and health. Food Nutr Bull 1988; 10(3):33-41.
20. Abbi R, Christian P, Gujral S. Gopaldas T. Mothers' nutrition knowledge and child nutritional status in India. Food Nutr Bull 1988;10(3):51-54.
21. Holmboe-Ottesen G, Mascarenhas O. Wandel M. Women's role in food production and nutrition: implications for their quality of life. Food Nutr Bull 1988; 10(3):8-15.
22. Aguillon DB, Caedo MM, Arnold JC. Engel RW. The relationship of family characteristics to the nutritional status of pre-school children. Food Nutr Bull 1982; 4(4) :5- 1 2.

Food security

Food security issues associated with development in Thailand

Yongyout Kachondham

Abstract

Thailand has sustained economic growth and generated an increase in national/ and per capita income, but income distribution and poverty profiles remain major concerns. The prevalence of protein-energy malnutrition (PEM) in children under five years of age was 53% between 1979 and 1982 and 23.5% in 1987. Although there has been a marked improvement as a result of the nationwide growth-monitoring and community-based nutrition programmes of the Ministry of Public Health, PEM and micro-nutrient deficiencies still undermine the quality of Thailand's future human resources in vulnerable groups. Moreover, Thailand is facing new nutrition-related health threats, including heart disease, hypertension, and certain types of cancer. Meeting the food security and dietary needs of people depends on improvement in every link of the food chain, including research, training, and technology development in food production, food storage and distribution, nutrition and public health, income distribution, education, and food and nutrition policy.

Among the most difficult problems confronting the world community during the history of humankind have been those of food shortages and diet deficits. There seems to be little dispute, however, that remarkable increases in food production have been achieved over the past decades by many developing and developed countries alike, helping to provide for the nutrition needs of all human beings. Yet the number of hungry people has increased because of rapid population growth and. more importantly, the lack of effective food distribution and political will to solve the problem. Moreover, food chains and food webs, which are the process of transferring energy from sun-light to life on earth, are more and more vulnerable to disruption when human beings try to manipulate the ecosystem of this biosphere as never before.

Interventions are usually confined within disciplinary boundaries and are not always in the best interests of the communities targeted. A major challenge in the next decade and century will be to overcome unequal purchasing power and rapid environmental deterioration as hindrances to the achievement of food security.

Thailand is primarily an agrarian society, with approximately three-fourths of its population residing in rural areas. Although rice farming is still the cultural and economic foundation of the nation. it is estimated that the manufacturing sector will contribute as much as 25% of the GDP in 1990. compared to 15% contributed by agriculture. Due to an industrial and export-oriented agricultural development policy, the economy has undergone rapid and sustainable growth. Over the past two decades Thailand has been cited as one of the success countries of the developing world. During the four National Economic and Social Development Plans from 1961 to 1981, Thailand had an enviable long run of a sustained economic growth rate averaging over 7%, which generated a fourteen-fold increase in the national income and an average eightfold increase in the per capita income [1].

At present, according to every economic indicator, it appears very likely that Thailand will enjoy a third consecutive year of an exceptional double-digit growth rate. Nevertheless, Thailand's income distribution and poverty profile are of major concern.

Although household income increased steadily in real terms in the past two decades, the Gini coefficient widened from 0.43 in 1976 to 0.50 in 1986, and the percentage of the population below the poverty level showed no sign of improvement during this period [2]. The expeditious introduction of predominantly capital-intensive, large-scale technology has failed to create sufficient jobs and income to eliminate absolute poverty in rural areas. especially for those who engage in the agricultural sector.

Future economic progress will more likely benefit those who have non-agricultural occupations because it is due to the inflow of foreign capital, which largely finances development in non-agricultural activities. On the other hand, since world agricultural production is expected to increase, lower international prices and demand will limit Thailand's export of agricultural products [3] and thus negatively affect agricultural households, which are more numerous and worse off. Furthermore, Thailand is an oil-importing country, and, since oil prices may rise. it could face greater difficulty in reducing trade deficits, taming inflation, and sustaining economic expansion in the decade to come.

In terms of food production, Thailand consistently exceeds the annual domestic requirement and not only is self-reliant in rice, the country's main staple. but in 1986 was the world's largest exporter of rice and cassava (34.6% and 89.2% of the world market respectively) along with several other agriculture and livestock commodities [4]. Year in and year out, the cash value of Thailand's exports of agricultural commodities and food products far exceeds that of food imports. In 1981 Thailand earned 74,161 million baht, 48.6% of which was from food exports. while food imports amounted to only 5,963 million baht, or 2.7% of the total [5]. On the other hand, amid such overall economic thriving conditions and bounty of food, there is still considerable poverty and undernutrition.

The prevalence of protein-energy malnutrition (PEM) by weight for age in children under five years old, reflecting macro-nutrient deficiency, was 53% between 1979 and 1982 and 23.5% in 1987. Although that shows a marked improvement as a result of the nationwide growth monitoring and community-based nutrition programmes of the Ministry of Public Health [6], the present PEM magnitude still undermines the quality of Thailand's future human resources and the prospect of a better quality of life.

Micro-nutrient deficiencies are also common in certain vulnerable groups. Iron-deficiency anaemia was widespread among pregnant women in 1986, being highest in the eastern region (35.9%) and lowest in the north (20.4%) [7], and also among children 0-5 years old (29.2%) in the 1988 national nutrition survey [8]. The northern region and some provinces in the north-east are also categorized for endemic goitre. The goitre prevalence among schoolchildren is 10% or more in 31 of the districts in those areas [7]. At present, although tremendous commitment and effort is being given to the goitre problem, intervention strategies, activities, and resources to alleviate nutritional anaemia are far from adequate.

In addition, because of uneven prosperity in the society, inadequate consumer protection and unmitigated environmental dangers. Thailand is now facing a new chapter of nutrition-related health threats. Heart disease, the number-one killer in recent mortality statistics (30 deaths per 100,000 persons per year) [9], and hypertension are known to be associated with over-nutrition, which is common among the more affluent. In addition, certain kinds of cancer are now believed to be related to over-consumption of fat as well as to the contamination of toxic substances in the food chain as a price of uncontrolled environmental hazards associated with rapid industrial development.

Furthermore. infectious disease is still a major factor in precipitating malnutrition [10]. Particularly for pre-school children, the high morbidity from diarrhoeal and respiratory diseases has multiple adverse effects on nutrition. The issue is also complicated by the fact that even relatively mild degrees of specific nutritional deficiencies reduce resistance to most infections and increase their incidence and severity. For this reason, medical and public health measures to reduce infection and its consequences may result in improved food use and reduce malnutrition.

Other elements, both economic and social, can also indirectly influence nutritional status. Agriculture production, food prices, purchasing power, marketing systems, and food habits are examples of important socio-economic factors [11]. Rapid changes in dietary, food-acquisition, and food-expenditure patterns have created concern among scholars and policy makers alike. In the rural areas, because of pressure on the land and its resources due to population growth and rapid rural development, household food acquisition and food security rely more and more on money and market systems rather than on domestic cultivation and hunting and gathering. These rather primitive means of securing food provided a diet in which the food varieties were nutritionally balanced but which might be insufficient intermittently in some periods of the "hunger season." In some cases, development in electrification, communications, and transportation is also conducive to poor nutrition, especially among the poor and under-educated.

Commercial advertising and the promotion of processed food in rural areas may result in an adverse situation when people sell more nutritious food in favour of buying less nutritious, but more prestigious, food. In the urban areas, there is an accelerated shift from home-based food preparation to processed or pre-cooked food. National and international agribusiness will also certainly have an increasing influence on people's daily lives. Consumer behaviour is being modified as never before by intensive advertising and, quite often, by unfounded claims for the health benefits of special foods. Some hazardous food habits that may lead to parasitic infestation and other medical problems have also been difficult to modify.

In these circumstances, although nutrition education may contribute to improved food choice and better use of available food supplies' good communication strategies are needed to change people's values and perceptions. It is quite clear that the food-security challenge for the world in the 1990s and the twenty-first century - arising from inadequate purchasing power and environmental degradation - will be to ensure economic and ecological access to food [12]. The effect and impact of the transition in consumption and food expenditure on the nutrition situation are inevitable. Nevertheless, it is quite uncertain whether this is a blessing and propitious change.

No single body of knowledge or field of discipline alone is sufficient to provide the direction and means to overcome hunger or lack of food security and malnutrition. A growing body of knowledge of nutrient requirements and a healthy diet may exist, but the interventions to ensure adequate food entitlement and consumption, at both the community and household levels, are complex and variable. Meeting the food-security and dietary needs of people depends on improvement in every link along the food chain - research, training, and technology development in food production, food storage and distribution, nutrition and public health, income distribution, education, and food and nutrition policy. Identifying the elements and the specific links in the chain that are weak in the context of Thailand's rapid societal transition is a challenging agenda for nutrition research. Countries that are entering the development transition without policies that ensure sound equity will be facing the same needs.

References

1. Thailand: managing public resources for structural adjustment. World Bank country study. Washington, DC: World Bank, 1984
2. Hutaserani S, Jitsuchon S. Thailand's income distribution and poverty profile and their current situations. Bangkok: Thailand Development Research Institute. 1988.
3. Macroeconomic Policy Program. The outlook for the Thai economy. TDRI year-end conference, "Thailand in the International Economic Community." Bangkok: Thailand Development Research Institute, 1989.
4. FAO production yearbook. Rome: Food and Agriculture Organization, 1986.
5. Department of Business Economics. International trade and important economic information, B.E. 2524. Bangkok: Ministry of Commerce, 1981.
6. Annual report. Bangkok: Nutrition Division, Department of Health, Ministry of Public Health, 1987.
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8. Nutritional survey report, B.E. 2259. Bangkok: Nutrition Division, Department of Health, Ministry of Public Health, 1987.
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11. Rabidhadana A. The role of social science in nutrition research. Proceedings of the workshop on Integration of Food Crops, Fisheries, and Nutrition Research in Northeast Thailand. Bangkok: Institute of Nutrition. 1988.
12. Swaminathan MS. Global agriculture at the crossroads. earth '88: changing geographic perspectives. Washington, DC: National Geographic Society, 1988.

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