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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!


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