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The impact of maternal workload on child nutrition in rural Iran
Fatimeh Rabiee and Catherine Geissler
This paper and the following one both demonstrate an adverse impact of mothers' work outside the home on the health and development of their infants and preschool children and explore the reasons for it. Although both are local studies, they have been accepted for publication because of their wider implications.
The first paper, based on work in rural Iran, concludes that the mechanisms for this effect are not primarily financial. Because it would be very difficult to change the pattern of women's economic activities in such a society, it is suggested that seasonal day-care centres are the most feasible means of alleviating the problem. The lack of funds for foods with an adequate density of protein and calories, plus the tendency to offer such foods only in over-diluted form, is wide-spread.
The following paper, by Wandel and Holmboe Ottesen, based on work in rural Tanzania, comes to quite different conclusions. The authors find that "the amount of mothers' field work did not seem to have any profound or conclusive relationship to children's nutrition stands" because of buffering or compensating circumstances. In this society, unlike many others, women's time constraints do not appear to be important in explaining the variation in children's nutrition status. However, because three meals per day was seen as an absolute maximum that could be provided to young children, advice about more frequent feeding or more time-consuming food preparation is not likely to be accepted.
The Bulletin always tries to judge the usefulness of a local study in a country to policy makers, programme planners, and researchers in other countries. It usually rejects descriptive studies that do not either have applicability to some other situations or introduce new methodological considerations. The publication of these two contrasting works concurrently is warning once again that the conclusions from studies in one population may or may not be applicable to other populations. This can be determined only by investigation of their local appropriateness.
Several studies have shown that the nutrition status of the children of mothers working outside the home is poorer than that of children of non-working women [1-3]. Such findings could be due either to the quality of the alternative child care or to a relationship between poverty and the consequent necessity of working outside the home. To investigate this issue, the role of maternal workloads on child nutrition was analysed from data collected in a larger study on the determinants of nutrition status in women and children in rural Gilan, Iran, which was undertaken in 1982 [4, 5].
Gilan is one of the richest provinces in Iran, with the highest rural energy intake and the highest mean income level . It is a rich agricultural area, where 55% of the total Iranian rice, 90% of the tea, 100% of the olives, and 50% of the peanuts are produced (Ministry of Agriculture, unpublished data, 1981). Thus, there is no question of inadequate overall food availability. However, parasite infestation is a major health problem in the area because of water pollution, improper sewage disposal, and the subtropical climate (Iranian Department of Health and Welfare, unpublished data, 1978).
The few nutrition studies that have been conducted in the area have shown a considerable extent of malnutrition in the form of impaired child growth. anaemia, and deficiencies of specific nutrients such as vitamin A, riboflavin, vitamin C, and iron, but none have attempted to determine the causes [7-14]. The one survey on infant feeding  found that mothers, in all age groups, in rural Gilan were able to breast-feed less and for a shorter time than their counterparts in urban areas, indicating an impact of agricultural work on lactation. Women play a more important role in the economy of the household in this area than in most other parts of Iran by participating in agricultural production.
At the time of the study, Iran had recently undergone a revolution and had become involved in war, so that a rationing system was in force for scarce foods, including chicken, cheese, vegetable oil, sugar, powdered milk, and baby food. All these items were also available on the open market but at three to four times the price, and therefore were inaccessible to many in reasonable quantities .
The study was conducted in Tagengokeh, a village in the Astaneh district of north-west Gilan, which was chosen as being representative of the area in that it had the most common size of land holding, proportion of different socioeconomic groups, and mix of crops. A list of households obtained from the Malaria Eradication Office showed that 7% of the households were non-agricultural, 80% farmers, and 13% labourers. From this list a total of 148 families, comprising 935 individuals (approximately half the population), were selected by stratified sampling so that almost equal numbers fell into each of five socio-economic groups according to the principal occupation of the head of household: (1) non-agricultural (builders, drivers, shop keepers, government employees), (2) upper agricultural with more than 0.8 hectares, (3) middle agricultural with 0.4 to 0.8 hectares, (4) lower agricultural with less than 0.4 hectares, and (5) landless agricultural and non-agricultural labourers.
Information was collected over three seasons, when factors likely to affect nutrition status were expected to vary: winter, when the workload was low; late spring-early summer, when the workload was high; and autumn, when the workload was moderate. The data collected included family food supply, individual food intake of women and of children under 5 years old, anthropometry, deficiency signs, haemoglobin levels, and the results of bacterial and parasite examination of faeces, weaning food, and drinking water, as well as beliefs and practices related to food and health.
Findings and discussion
The study village consisted of 400 households, with 2,000 inhabitants. It had one health centre, with three village health workers, who provided primary health care and environmental health services such as chlorination of drinking wells and malarial treatment. The village had electricity, and two primary and two secondary schools. The drinking water supply was from individual household wells ranging in depth from 2 to 12 metres, chlorinated once a month. River and span" water was used for washing clothes and carpets. The nearest public bath was 8 km away. All houses had pit latrines, usually uncovered, at an average distance of 20 metres from the well, but defecation in the bushes was common. Most of the houses were built of sun-dried bricks and mud, had wooden floors, ceilings, steps, and porch, and were thatched with grass. The majority of houses in all socioeconomic groups had no windows and were not painted, and so were dark, damp, and full of insects. Houses had only one to three rooms and so were crowded. Furnishings were simple, consisting of straw mats, and mattresses and blankets. There was very little difference in the environmental conditions between socio-economic groups except in the quantity of possessions; housing and sanitation facilities were similar.
Some characteristics of the five groups are shown in table 1. Apart from differences in the amount of income and land holdings, there was a socio-economic gradient in the possession of prestige household goods (such as a radio, tape recorder, television, refrigerator, or gas cooker), four-wheeled vehicles (car or van), which were owned only by members of groups l and 2, two-wheeled vehicles (bicycle or motorbike), and modern agricultural equipment. The majority of families in all groups owned and had built their own home. In addition, 19% in group 4 and 10'% in group 5 were poor enough to be eligible to be given a free one-room house after the Islamic revolution.
TABLE 1. Characteristics of the five socio-economic groups
|Group (no.)||Household (no.)||Family size||Income (tomans per month)||Land (ha)||Possessions (%)||Literacy (%)|
|Household goods||Car, van||Bicycle, motor-bike||House||Farm equipment||Adult||Child >6.5 years|
None of the women from the households studied had a regular job throughout the year. However, 54% in group 1, 100%, in groups 2 through 4, and 63% in group 5 were economically employed during spring and summer. The principal occupation of women of all the groups was agricultural, either on their own land or labouring. Most of the women were occupied from March to October doing rice and tea farm work. This kept them away from home and children, particularly during the summer, when the weeding and harvesting were most intense, as shown in the agricultural calendar in table 2.
TABLE 2. Work intensity by month (March-November)
|March||Ploughing and fertilizing tea land||Moderate||Preparing vegetable and pulse land||Light|
|April-May||Ploughing rice land||High||Planting rice||Light|
|May-June||Cleaning canals, irrigating rice land||High||Transplanting rice, weeding tea||High|
|July||Fertilizing rice land||Light||Harvesting tea, weeding rice||Moderate|
|August||||||Weeding and harvesting tea, weeding rice||Moderate|
|September||Harvesting rice||High||Weeding and harvesting tea||Moderate|
|October||Harvesting rice||High||Harvesting tea||Moderate|
Energy intake and growth
It was in this summer season that acute malnutrition or thinness (wasting, <90% of standard weight for height) in young children was greatest and energy intake was particularly low. The delayed effects on growth are seen in the increased prevalence of shortness (stunting, <95% of standard height for age) in autumn. Seasonal differences were particularly marked for the youngest age group (table 3).
TABLE 3. Seasonal differences in children's energy intake and growth
|Age (years) and season||Intakea||Nutrition status|
a. For energy intake, only children over one year of age and
there fore no longer breast-feeding arc included.
b. Wasted, <90%, of standard weight for height
c. Stunted, <95% of standard height for age.
* Difference between summer and autumn, p < .001.
The energy intakes are expressed in terms of the WHO/FAO recommended dietary intakes (RDI) based on age  and are extremely low. When expressed in terms of body weight, they are higher but still under 90% of RDI. These low intakes of the young children were not related to family food availability or to maternal intakes, as both of these were adequate in all socio-economic groups and at all seasons, except for groups 4 and 5 in the summer .
The general low level of intake may be accounted for by the fact that children up to 2.5 years old were fed a diet of low energy density. This was because of rationing and the high prices of energy-dense foods as well as maternal food beliefs. Ninety-six per cent of the babies were breast-fed immediately after birth, 65"/o Up to three months, 40% to six months, and only 25% for more than a year. The majority of women related cessation of breast-feeding to their high work load in spring and summer.
Sugar solution was the first supplementary food to be given when the milk flow became inadequate. Eighty per cent of the children over three months old were bottle fed either solely or in addition to receiving breast milk. Even in this agricultural area, 65% of the bottle-fed children were given powdered milk because of the short and unreliable supply of fresh cow's milk, which was more expensive than powdered milk even on the open market (1.9 versus 1.7 tomans per 100 kcal [T 144= US$1]). Because of rationing and high open-market prices, most children received very diluted milk. No other foods were given until six months of age, as mothers believed infants are unable to digest solid foods before that age. At six months only 50% were introduced to other supplementary food: biscuits, bread, mashed cooked rice with yoghurt, or gravy from stew. Even at 12 months only 72% of the children were offered supplementary foods other than sugar. By 18 months biscuits were the main source of energy (28%) after milk (33%). Sugar provided 21% of the energy, and the remaining 18% came from very small amounts of yoghurt, meat. chicken, and fish.
The small quantities were partly due to food scarcity. Eggs and cheese were not given to children under 18 months old as they were believed to cause stammering and delayed speech and to impair intellect respectively. Mothers often realized the problem of low intake, which they usually attributed to the high price of milk. Their main reason for not giving more of the foods available to the family was that young children cannot digest beans, the dish most frequently prepared. Milk, biscuits, and rice were the only "good" foods they mentioned. Mothers were more conscious of foods that were bad rather than good during the weaning period.
The mothers were classified as having light or heavy workloads according to the number of hours spent away from home. Most of the mothers of young children (108) had heavy work loads in summer, leaving home around 7 a.m. to walk up to three kilometres to the fields and returning to prepare and eat lunch at 11:30. They left home again at 1:30, coming back at 6 in the evening. A few worked in the fields only in the morning or the afternoon, but most worked all day. In addition, they prepared the family food, washed clothes, and did other housework. When the women were away from home, the young children were looked after usually by siblings between the ages of 8 and 13, as older children also worked in the fields.
A few of the women (N = 18) had a light workload and were therefore free to take care of their young children. Seven of these were from group 1 and had a higher income than the rest of the families studied (mean income 5,380 tomans), and this was their reason for not going out to work. Eleven were from the lowest socio-economic group, group 5; although their total mean income (T 1,951) was not as high as that of others in the same group with a heavy workload (T 2,370, N= 17), their per capita income was higher (T 650 versus T 504). However, in group 5 income was not a determinant for not working outside the home: the main reason was that these were young mothers in small nuclear families with no one to look after a young child.
The nutrition status and related factors of young children (under 2.5 years old) of mothers with light and heavy workloads (defined as being away from home less than or more than three hours a day respectively) in summer are compared in table 4. A trend is evident for the children of mothers with a heavy workload, despite a greater family income, to have lower energy intake and a higher prevalence of diarrhoea, to be given sedative drugs, and to be thinner at this season although not more stunted. In the following autumn the relative situation was similar, although the prevalence of thinness was reduced (from 26% to 11%) and of shortness increased (from 51% to 57%).
TABLE 4. Nutrition status and related factors of young children in relation m mothers' workloads
|Workload||Family incomea||Diarrhoea (%)||Drug (%)||Thin (%)||Short (%)||Energy (% RDI)b|
|Light (N= 18)||3,285||7||0||17||45||69|
|Heavy (N = 108)||3,690||16||30||35||39||65c|
a. Tomans per month
b. Only non-breast-fed children over one year old are included.
Factors related to nutrition status
The older siblings who cared for the young children while the mothers were away from home were probably minimally competent in feeding and related child-care tasks. This may have been one of the factors accounting for the even lower intakes of these children. There were no obvious differences in the type of food given to each group.
Diarrhoea was more prevalent in the children of mothers with high workloads. A number of possible underlying causes may be seen. Although no obvious difference was seen between the formal educational backgrounds of women doing heavy and light work, the hygiene practices in the two groups were quite different, as indicated by the percentages of women not washing their hands after defecation (57% versus 17%), using mud to clean plates and pans (11% versus 6%), washing feeding bottles with water, salt, and rice (81% versus 55%), and not boiling water for milk preparation (59% versus 50%). The last practice is likely to be due to the lack of time available, as was mentioned by the women with high workloads. The other practices could only be explained by lack of knowledge regarding personal hygiene.
The majority of women with heavy workloads belonged to socio-economic groups 2-4 (71%) and were older (mean age 38 + 4 years) than those with light loads (24 + 2 years). Other factors contributing to the higher frequency of diarrhoea may have been poor supervision of the children in an environment highly contaminated with parasites. the use of contaminated drinking water, and the growth of bacteria in foods kept for long periods of time while the mothers were working. Eighty-four per cent of children in that age group had intestinal parasites; 70% of drinking water had unacceptable levels of coliforms by WHO standards; 52% of drinking water samples were contaminated with intestinal parasites; and 46% of food samples had unacceptable levels of coliforms and total aerobic viable counts. Liquid baby foods such as milk and commercial formulations were more frequently contaminated than rice preparations.
The use of drugs (opium and promethazine [Phenergan]) is another explanatory factor for the nutrition differences between children of mothers with low and high workloads. These drugs were used particularly at night to keep children quiet and allow the mothers to rest. Children given sedatives had significantly lower energy intakes (p<.05) than those not sedated and showed a trend toward a higher prevalence of thinness and shortness. as seen in table 5. Sedation possibly resulted in reduced frequency of feeding, as the children were asleep for a larger proportion of time.
TABLE 5. Energy intake and nutrition status in relation to use of sedatives
|N||Energy (cal)||N||Thin (%)||Short (%)|
|Sedated||22||748 ± 292||37||35||45|
|Nor sedated||72||890 ± 190||89||30||38|
These data indicate that maternal work can have a negative effect on the nutrition status of young children through mechanisms affecting food consumption and health that are not directly financial. Although the number of women with a low workload was small (the data come from a study not specifically designed to test the workload hypothesis), the results consistently indicate a detrimental effect of working on children's health in this environment. Solutions to the problem could theoretically include a reduction of women's workload by mechanization or redistribution of tasks, removal of sources of ill health that are exacerbated by inadequate care, particularly water contamination, and provision of improved child care. However, agricultural mechanization has far-reaching implications for landholding and rural employment, and redistribution of tasks based on sex would be a slow process at best, even though men have little work during the critical months of July and August. Weeding and planting rice are not considered to be men's work any more than food preparation and housework are. As most of the rest of the family is involved in agriculture during the heavy work seasons, there are few means to organize better child care at the family level. Seasonal crèches organized at the community level could possibly counteract the detrimental effects of women's high workloads at this time, as could improved sanitation.
We are grateful to Mr. Sattar Nikdel, Director of the Health and Welfare Organization of Astaneh district, for the provision of research facilities, to Samira Dehganshoar and Tahmineh Rabiee for field assistance, and to Mr. Gholizadeh and other staff members of the Parasitology Department of Astaneh district for invaluable assistance.
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