Previous - Next
This is the old United Nations University website. Visit the new site at http://unu.edu
Impact of caregivers' health and nutrition status on caregiving capacity
Only a few studies have been identified that directly examine the effect of caregivers' health and nutrition status on caregiving capacity. Most research on maternal factors in relation to the quality or quantity of child care focus either on women's time allocation or on women's social situation, e.g., socioeconomic status, education, self-confidence, or prestige. The neglect of women's health in this context is yet another example of the low priority given to women's own concerns.
More research exists that evaluates the effect of health and nutrition status of the child on caregiver-child relations. For some of these studies, it is unclear whether the identified associations are due to the health and nutrition status of the child, the caregiver, or both. For example, in a study in Mexico [47], pregnant women received a nutritional supplement from the 45th day of gestation until delivery. Between the 12th and the 16th weeks of age, the infants also received milk and prepared baby food. In comparison with unsupplemented mother-infant pairs, significant differences were found in infant sleeping patterns, mobility, behaviour, and stimuli received from both mother and father. On the one hand, supplemented infants early on initiated different contact patterns in the family; on the other hand, supplemented mothers were also more active in the postpartum period than were unsupplemented mothers. Obviously, caregiving capacity must be evaluated within caregiver-child relations, thus being affected by child characteristics that also influence these relations. In most situations, unfavourable conditions simultaneously exist for both caregiver and child, thereby making it difficult to distinguish between contributions from the two actors.
Studies in Kenya and Egypt [48] attempted to distinguish between the effects of the nutritional status of the mother and the child on mother-child relations. For the two countries, mothers were the primary caregivers 60% and 75% of the time, respectively. The mothers' and the toddlers' food intake was assessed between 18 to 30 months postpartum, using oral recall and food weighing. Observation periods of 120 minutes every second month (Kenya) and 30 minutes per month (Egypt) were used to estimate caregiver-child relations as captured by verbal and nonverbal responses, vocalization, speed of response to distress, and physical contact. The mothers' and the children's intake, adjusted for each other in separate analyses, as well as their interaction, were evaluated in their ability to predict caregiver-child relations. The toddlers' food intake explained more of the variation in caregiver-child relations than did the mothers' food intake. In the Kenyan sample, higher maternal intake was associated with more physical contact, whereas in the Egyptian sample, it was associated with fewer nonverbal responses and more vocalizations towards the toddler, but lower speed of response to distress. In the Egyptian sample, an interaction between mothers' and toddlers' intake through physical contact was found, and in general all associations were stronger for female than for male toddlers. In Egypt, total energy intake and carbohydrates were the most consistent predictors of caregiver-child relations, whereas in Kenya carbohydrates and protein were the important parameters. The authors concluded that simultaneous consideration of both caregivers' and children's health and nutrition status are critical in evaluations of caregiver-child relations. Also, the association between nutrition and caregiving may be mediated by cultural factors, sex of child, and type of nutritional parameter.
Further evaluations of the Egyptian data also have been performed [49-51]. In these, maternal food intake during pregnancy and postpartum as well as weight and haemoglobin and vitamin B6 status postpartum were used as indicators of maternal nutrition and health. Lower maternal energy intake zero to six months postpartum was significantly associated with less vocalization to infants, and lower maternal postpartum haemoglobin levels were significantly associated with less response to infant vocalizations. Overall, anaemic women spent substantially less time taking care of their infants. Finally, significant correlations were found between poor maternal vitamin B6 status and non-response to child's vocalization, non-effective response to infant's distress, and greater utilization of older siblings as caregivers. A possible mechanism suggested by the authors was maternal clinical depression as a result of poor vitamin B6 status.
In addition, indirect evidence for an effect of women's health and nutrition status on caregiving capacity can be inferred from the review above of global health concerns in the light of the physical and mental demands of adequate caregiving.
Breastfeeding is one of the most important examples of care, as it represents food security, caring, and a healthy environment. Both breastmilk quantity and quality are adversely affected among malnourished women. Breast soreness and white vaginal discharge are reasons for discontinuing breastfeeding for some women, and women who have experienced sexual abuse may be unwilling to expose their breasts. Thus, these health problems negatively impact breastfeeding.
Childhood (and maybe current) PEM, anaemia, blindness due to vitamin A deficiency, diarrhoea, reproductive tract infections, and AIDS are associated with decreased adult work capacity and increased fatigue. Many women experience nausea during the first trimester of pregnancy. These ailments likely reduce the mothers' ability to carry out energy demanding tasks such as bringing children to health clinics, providing frequent meals, and playing (i.e., compensatory care).
Morbidities such as stress, headache, backache, cretinism, reproductive tract infections, menstrual disturbances, and violence likely undermine women's mental vitality, thereby affecting their ability to provide enhancement care (e.g., showing affection, preventing illness, and stimulating the child).
Finally, certain morbidities such as stress incontinence, vesicovaginal fistula, sexually transmitted diseases, and AIDS, may lead to social ostracism, causing great difficulties for the mother to find needed support. In addition, ill health in general may lead to less prestige in the family and less access to support for these women. The resulting apathy and depression may also reduce the ability of these mothers to provide enhancement care.
Activities to improve the health of the caregivers
The underlying causes of women's health problems are of course manifold. However, one characteristic is common to many of them: the low status of women in most societies. This results in poor access to health care and delivery care, lower food intake, higher work load, repeated closely-spaced pregnancies, gender-based abuse, and spread of sexually transmitted diseases. Thus, these aspects of women's health will only change substantially when women's situation in society improves.
As pointed out earlier, there is a lack of data on women's health problems globally, and effective health interventions are only possible when a more complete picture of the situation of women has emerged. However, encouraging developments include the Safe Motherhood Initiative, the large US Agency for International Development-funded breastfeeding and Mother Care initiatives, and the Women's Health Initiative by the US National Institutes of Health. The calls for innovative frameworks, indicators, and measurement techniques are being heard. Similarly, further qualitative studies in additional settings on women's own perceptions of health and health concerns are urgently needed.
In the short term, the following activities may improve caregiver health and help optimize caregiving capacity:
Reduce maternal mortality through programmes like the Safe Motherhood Initiative;
Reduce malnutrition among women through food supplementation, food fortification, reduced work load, increased child spacing, parasite control, and nutrition education. Best timing of interventions during the reproductive cycle needs to be identified. Interventions should probably start with the adolescent girl or the girl child;
-Improve women's access to health care. Encourage women to seek treatment for reproductive tract infections and help when experiencing violence;
-Improve women's ability to be in charge of their health through access to education, family planning, decision-making, and financial credits;
-Minimize negative effects of existing poor maternal health on caregiving capability through food supplementation during lactation and encouragement for the mother to utilize resources around her when ill.
However, there is one lesson that we should already have learned. Women's health did not improve substantially as long as it was justified only in terms of its link to pregnancy outcome. It probably will not do so either if seen only through its link to caring capacity. The underlying causes of poor health among women are too complex to be solved solely by means of limited projects. If we really want women to provide optimal care for their children, we have to make sure that they are healthy- for their own sake!
References
1. WHO. Official Records of the World Health Organization, no. 2, p. 100. Geneva: United Nations, World Health Organization, Geneva Interim Commission, 1948.
2. Engle P. Care and child nutrition. Theme paper for the International Nutrition Conference. New York: UNICEF, 1992.
3. Longhurst R. Nutrition and care of young children during emergencies. Food Nutr Bull 1995;16:407-12.
4. Engle P. Ricciuti H. Psychosocial aspects of care and nutrition. Food Nutr Bull 1995;16:356-77.
5. AbouZhar C, Roystone E. Maternal mortality: a global factbook. Geneva: WHO, Division of Family Health, 1991.
6. Herz B. Measham AR. The safe motherhood initiative: proposals for action. World Bank Discussion Paper no. 9. Washington, DC: World Bank, 1987.
7. Koblinsky MA, Campbell OMR, Harlow SD. Mother and more: a broader perspective on women's health. In: Koblinsky M, Timyan J. Gay J. eds. The health of women. A global perspective. Boulder, Col, USA: Westview Press, 1993:33-62.
8. Graham WJ, Campbell OMR. Maternal health and the measurement trap. Soc Sci Med 1992;35:967-77.
9. van der Kwaak A, van den Engel M, Richters A, Bartels K, Haaijer I, Mama A, Veenhoff A, Engelkes E, Keysors L, Smith I. Women and health. Vena Journal 1991 ;3:2-33.
10. Kurz KM, Poplinsky NL, Johnson-Welch C. Investing in the future: six principles for promoting the nutritional science of adolescent girls in developing countries. Washington, DC: International Center for Research on Women, 1994:1-23.
11. DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q 1985;38: 302-16.
12. Hetzel BS. The prevention and control of iodine deficiency disorders. ACC/SCN State-of-the-Art Series Nutrition Policy Discussion Paper no 3. Rome: Food and Agriculture Organization, 1988.
13. Levin HM, Pollitt E, Galloway R. McGuire J. Micronutrient deficiency disorders. In: Jamison DT, Mosley WH, eds. Evolving health priorities in developing countries. Washington, DC: World Bank, Population, Health and Nutrition Division, 1990:421-54.
14. Leslie J. Women's nutrition: the key to improving family health in developing countries? Health Pol Plan 1991;6:1-19.
15. Royston E. The prevalence of nutritional anaemia in women in developing countries: a critical review of available information. World Health Stat Q 1982;35: 52-91.
16. McGuire J, Popkin B. Beating the zero-sum game: women and nutrition in the third world. Food Nutr Bull 1989;11(4):38-63.
17. ICRW. Strengthening women: health research priorities for women in developing countries. Washington, DC: International Center for Research on Women, 1989.
18. Behrman JR. Intrahousehold allocation of nutrients in rural India: Are boys favored? Do parents exhibit inequality aversion? Oxford Economic Papers 1988;40: 32-54.
19. Martorell R, Arroyave G. Malnutrition, work output and energy needs. In: Collins KJ, Roberts DB, eds. Ca pacify for work in the tropics. Cambridge: Cambridge University Press, 1988:57-75.
20. Rasmussen KM. Maternal nutritional status and lactational performance. Clin Nutr 1988;7:147-55.
21. Winikoff B. The maternal depletion syndrome: clinical diagnosis or eco-demographic condition? Biol Soc 1988;5:163-70.
22. Merchant K, Martorell R. Frequent reproductive cycling: Does it lead to nutritional depletion among mothers? Prog Food Nutr 1988;12:339-69.
23. Merchant K, Martorell R. Haas J. Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals. Am J Clin Nutr 1990;52:280-8.
24. Adair is, Popkin BM. Prolonged lactation contributes to depletion of maternal energy reserves in Filipino women. J Nutr 1992;122:1643-55.
25. Winkvist A, Rasmussen KM, Habicht J-P. A new definition of maternal depletion syndrome. Am J Publ Health 1992;82:6914.
26. Winkvist A. Maternal depletion among Pakistani and Guatemalan women. Doctoral thesis, Cornell University, Ithaca, NY, USA, 1992.
27. Rasmussen KM, Fischbeck KL. Effect of repeated reproductive cycles on pregnancy outcome in ad-libitum fed and chronically restricted rats. J Nutr 1987;117: 1959-66.
28. Wasserheit JN. The significance and scope of reproductive tract infections among third world women. Int J Gynecol Obstet Suppl 1989;3:145-68.
29. Chin J. Current and future dimensions of the HIV/ AIDS pandemic in women and children. Lancet 1990; 336:221 -4.
30. De Bruyn M. Women and AIDS in developing countries. Soc Sci Med 1992;34:249-62.
31. Paolisso M, Leslie J. Meeting the changing health needs of women in developing countries. Soc Sci Med 1995;40:55-65.
32. Paltiel FL. Women's mental health: a global perspective. In: Koblinsky M, Timyan J. Gay J. eds. The health of women. A global perspective. Boulder, Col, USA: Westview Press, 1993:197-216.
33. Carrillo R. Battered dreams: violence against women as an obstacle to development. New York: UNIFEM, 1992.
34. United Nations. Report of the working group on violence against women. Economic and Social Council. Vienna: United Nations, E/CN.6/WG.2/1992/L.3, 1992.
35. Heise L. Violence against women: the hidden health burden. World Health Stat Q 1993;46:78-85.
36. Sorenson SB, Stein JA, Siegel JM, Golding JM, Bur man MA. Prevalence of adult sexual assault: Los Angeles epidemiological catchment area study. Am J Epidemiol 1987;126:1154-64.
37. Foster GM, Anderson BG. Medical anthropology. New York: Alfred A. Knopf, 1978.
38. Barsky AJ, Cleary PD, Klerman GL. Determinants of perceived health status of medical outpatients. Soc Sci Med 1992;34:1147-54.
39. Anson O. Paran E, Neumann L, Chernichovsky D. Gender differences in health perceptions and their predictors. Soc Sci Med 1993;36:419-27.
40. Winkvist A, Akhtar HZ. The ability to stay healthy: needs, priorities and images of health among low-income women in Punjab, Pakistan. Int J Anthropol 1994;9:250.
41. Hunte P. Sultana P. Health-seeking behavior and the meaning of medications in Balochistan, Pakistan. Soc Sci Med 1992;34:1385-97.
42. Del Vecchio Good, M-J. Of blood and babies: the relationship of popular Islamic physiology to fertility. Soc Sci Med 1980;14B:147-56.
43. Mull DS. Mother's milk and pseudoscientific breast milk testing in Pakistan. Soc Sci Med 1992;34:1277-90.
44. Nichter M. Negotiation of the illness experience. Culture Med Psychiat 1981;5:5-24.
45. Gittelsohn J. Pelto PI, Bentley ME, Russ J. Nag M. A protocol for using ethnographic methods to investigate women's health. Baltimore, Md, USA: Johns Hopkins University Press, 1992.
46. Gittelsohn J. ed. Listening to women talk about their health. New Delhi: Har-Anand Publications, 1994.
47. Chavez A, Martinez C, Yaschine T. Nutrition, behavioral development, and mother-child interaction in young rural children. Fed Proc 1975;34:1574-82.
48. Wachs TD, Sigman M, Bishry Z. Moussa W. Jerome N. Neumann C, Bwibo N. McDonald MA. Caregiver child interaction patterns in two cultures in relation to nutritional intake. Int J Behav Dev 1992;15:1-18.
49. Rahmanifar A, Kirksey A, Wachs TD, McCabe GP, Bishry Z. Gala OH, Harrison GO, Jerome NW. Diet during lactation associated with infant behavior and caregiver-infant interaction in a semirural Egyptian village. J Nutr 1993;123:164-75.
50. Allen LH. The nutrition CRSP: What is marginal malnutrition, and does it affect human functioning? Nutr Rev 1993;51:25567.
51. McCullough AL, Kirksey A, Wachs TD, McCabe GP, Bassily NS, Bishty Z. Galal OM, Harrison GO, Jerome NW. Vitamin B6 status of Egyptian mothers: relation to infant behavior and maternal-infant interactions. Am J Clin Nutr 1990;51:106774.