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Meera Chatterjee
The major challenge facing third-world women today is to overcome the resource constraints that consign them to low levels of productivity and well-being. While women's role in the food chain is essential to produce that all-important resource, food, it paradoxically does not guarantee women even minimum levels of nutrition. Malnutrition adversely affects women's participation in the economic system and their productivity. To break this vicious downward spiral, it is important to focus simultaneously on women's nutrition-related roles and their nutritional status.
Nutritional stress on women is the outcome of low dietary intake on account of economic and social backwardness, and their high energy output for work and child-bearing. That third-world women work more than men when economic and domestic labour are combined seems now to be widely accepted. Their reproductive responsibility is inescapable. Among the consequences of this triple burden of market production, home production, and reproduction are high levels of protein-energy malnutrition and anaemia among women.
These nutritional problems have received attention in the context of pregnancy and lactation. The consequences of inadequate body reserves, deficient dietary intakes, and the resultant low pregnancy weight gains for birth outcomes, birth weights, and infant survival are established. Maternal depletion on account of high fertility among third-world women has been well recognized, and the consequent high maternal mortality rates of less-developed countries are the subject of great concern. However, less attention has been accorded to these same nutritional problems in the context of women's general wellbeing and their participation in economic and social development. The papers in this issue of the Food and Nutrition Bulletin focus attention on this critical area.
Aspects of the challenge
Women's life cycle
Two papers (by Bajaj and by Chatterjee and Lambert) underscore the life cycle of women's nutritional problems and roles. On the Indian subcontinent' female nutritional stress begins in childhood and continues through adolescence into adulthood. Tradition imposes systematic patterns of discrimination against females, and biological, social, and economic forces are sometimes inseparable. Nutritional attention is therefore called for throughout the life cycle.
The consequences for nutritional needs of conception close to menarche, while the young girl is still growing, and the opportunity to renew maternal resources between reproductive cycles are reflected upon also in the paper by Rasmussen and Habicht. Adolescence affords a second chance to boost female health and growth in order to enhance women's productive and reproductive capabilities. Post-menopausal women also deserve greater nutritional protection as they continue to participate in the labour force, and because appropriate measures could prevent debility due to chronic diseases.
The nutritional handicap accumulated in the life of a woman is passed on to the next generation through low birth weight, which considerably reduces survival and jeopardizes growth. In essence, small mothers give birth to small babies, who grow into small mothers. The cycle turns with the realization that the plight of young girls is inseparable from that of their mothers.
Gender, poverty, and structural adjustments
The synergistic effects of gender and poverty on nutrition are discussed in the papers by McGuire and Popkin and by Chatterjee and Lambert. Women are over-represented among the poor. Poverty is associated with higher female employment but lower income, with greater drudgery in domestic work but lower access to support services, and with high fertility. All these contribute to poorer nutrition and health status of families.
However, even among the poor, different groups of women are affected differently by macro development policies, such as the commercialization of agriculture or family planning. They have different survival/ coping mechanisms, including traditional/local resources, and hence require different support strategies. Women in urban areas may be more disadvantaged than rural women because of the lack of traditional support systems.
However, despite their poverty, women have strengths and have shown resourcefulness in the face of difficulty, and innovation in coping (as, for example, with the firewood crisis). Programmes must harness these strengths and build upon them, reaching women through organization, mobilization, and communication.
Multiple roles
In adulthood, the multiple roles of women exacerbate nutritional stress, as McGuire and Popkin discuss. Women are important participants in the labour force and contribute significant proportions of family income. In addition, they have a central role in food-chain activities such as production, marketing, processing, preparation, and intra-household distribution. However, these contributions are not recognized in terms of women's status, and therefore family and state investments in women's education, nutrition, health, and skill-training, in service support for women, and in drudgery-reducing technologies are low.
As a result, women are caught in a nutritional "zero-sum game." To participate in the processes of economic development and avail themselves of new technologies, market opportunities, or even social services, women must invest time, energy, and income which are already in short supply. These can only be diverted at the expense of their own nutrition and health status, or of the health and economic security of their families. The ultimate constraint of time affects the extent to which women can acquire nutritional goods and services and allocate them to improving their own well-being or that of their families. Women's own energy can be drained into a negative-balance situation resulting in illness and death. In sum, there is a limit to what can be expected of women by way of participation in development programmes, unless these efforts concentrate specifically on "enlarging the size of the pie" of benefits that accrue to women. For any programme, therefore, a cost-benefit analysis from the point of view of women is essential.
Health care
The conflict between women's (economic) earning role and (biological and social) mothering role results to some degree in a squeeze on child care, with consequences for child health and nutrition. Within the household, women play an important part in health care. They are responsible for water supply, environmental hygiene, food preparation, and preventive health activities. However, paradoxically, they have limited access to health services outside the household because of social, economic, and supply constraints, labelled a lack of "permission," "ability," and "availability" by Chatterjee and Lambert. Thus, an absolute shortage of health care in the developing world is transformed into acute scarcity for women. Increasing the number of female basic health workers is advocated to rectify this situation, as they have greater access to women at the household level and can focus on women's and children's health. However, as health and other development programmes place greater emphasis on women volunteer workers, women assume a fourth role - overload? - as community organizers.
In their own right
The overwhelming consensus emerging from the papers in this issue is that women must be viewed first and foremost as women. While women will be mothers too, motherhood is just one part of the inexorable life cycle. Women must perceive the inconsistencies and conflicts inherent in society - for example, the fact that their work may not improve their own nutrition. This calls for intervention programmes to be bolstered by efforts to increase women's awareness, self-confidence, and motivation to act.
Much of women's status in traditional societies is derived from mothering. They fail to meet their nutritional requirements, consciously limiting their food intake during pregnancy to facilitate childbirth. In the face of high pregnancy-associated mortality risk and an absence of adequate obstetric care, this is viewed as a rational response on the part of women, despite concomitant low birth weight. Clearly, one programme implication is that the nutritional supplementation of pregnant women must be accompanied by better facilities to diagnose and deal with obstetric difficulties.
Literacy, training, and communications
The profound effects of women's literacy and schooling are discussed by Chatterjee and Lambert. An impact is found on women's productivity and earning capacity; on fertility, reducing their reproductive burden; on their household decision-making power and resource management; on their self-confidence and on direct action for the health and nutrition of their children, or on their own health, resulting in better child survival; and on their participation in programmes and innovation for change. Both increases in income and improvements in status and power are mechanisms through which education brings about better nutritional status.
Education improves self-confidence, increases knowledge of available resources, and improves their use, resulting in increased well-being. Bajaj stresses the need for improved training systems and for confidence-building among women through formal or informal channels. The role of communications is a key one. Simple messages conveyed in locally understood script or pictorials, and participatory methods of communication that pay attention to local attitudes, practices, and constraints are important in enhancing women's nutritional status and roles. "Negative traditionalism" must be fought early. Specific health and nutrition education can be aimed at effecting behavioural change.
The role of men
Efforts to enhance the position of women take place in the context of family and community. While women are often accused of perpetuating discrimination against themselves through mistreatment of daughters and daughters-in-law, in most traditional societies the patriarchal construct leaves them little option. This calls for attention to men, to soften the opposition, as it were. Men must be educated about the cost to society of neglecting women and the need for affirmative action for women, which arises both from the fact of their greater work burden and their unique reproductive roles.
Action and research
Although there is considerable evidence already for the need to act in favour of women's nutritional status and roles, there is a continued need for nutrition research, information sharing, and documentation of efforts aimed at improving women's nutrition. The papers by Rasmussen and Habicht and by McGuire and Popkin highlight this. Rasmussen and Habicht point out that data on the consequences of malnutrition for the performance and survival of women throughout their life cycles are almost completely lacking. The consequences to families and to society at large are also inadequately quantified. Other questions include: What are the effects of women's income on the nutritional status of the household and of the women themselves? What are the effects of child care or support services on women's productivity, income, reproduction, and child nutrition?
However, there is considerable agreement that research should be combined with or emanate from programmes. There is already a substantial knowledge base on which greater efforts to empower women to act in favour of better nutrition can be built, and there is an urgency for such action. The issue of women's nutrition status and roles is crucial to the proposal for nutrition as a basic right for all in the 1990s, in which human development goals are paramount over economic goals.
Recommendations
Greater efforts are required to increase women's access to productive resources in the agricultural and non-agricultural sectors that directly or indirectly enhance food availability at the household level. This includes access to land, water, agricultural technology and extension, training, credit, employment, and markets. Efforts to increase women's income must be accompanied by social programmes that support women's control over the income they earn. Simultaneously, efforts are needed to improve the effectiveness and reduce the time and energy costs of women's domestic production, notably in the areas of food preparation and water, fuel, and fodder collection.
The provision of adequate child-care facilities is needed to reduce women's child-rearing burden. Health-care services must be made more accessible to women and children to prevent illness and facilitate treatment. In this context, direct nutrition interventions at the household level could alleviate the chronic protein-energy malnutrition and widespread anaemia suffered by women throughout their life cycle. Programming for women's health must extend beyond their role as mothers to encompass their non-reproductive and work-related energy and health needs. Besides ensuring supply, programmes should generate demand for maternal and child health care and trained birth attendance, through health and nutrition education.
The need for a holistic approach to women's programming across economic and social sectors clearly emerges. Social interventions should involve more consciousness of women's nutrition, as in the example of the Grameen Bank in Bangladesh, and interventions may be usefully combined. Most compelling is the evidence that women's education can be an effective means of improving their economic status as well as family nutritional status. Incorporating health and nutrition education into formal school curricula for girls and adult functional literacy programmes could greatly improve women's health and nutrition, as well as their control over fertility and social development.