|Child malnutrition: Myths and solutions 2|
A.K. Shiva Kumar
Where does one then begin looking for explanations for child malnutrition? There is much we can learn from our own experiences. Within India, for instance, Sikkim reports the lowest rates of child malnutrition, Madhya Pradesh the highest. What explains the differentials in child malnutrition between Sikkim and Madhya Pradesh?
First, start with low birth weight. Birth weights of less than 2,500 grams are very closely associated with poor growth not just in infancy but throughout childhood. Estimates for India reveal that 20-30 per cent of all babies are born with low birth weight, suggesting that children begin to get malnourished in the womb –– and indeed suffer from an inter-generational transfer of malnutrition.
Only 13 per cent of children born in Sikkim are of low birth weight. The proportion is 24 per cent in Madhya Pradesh.
Second, a major factor adversely affecting the birth of healthy babies is the poor nutritional status of women. Nutritional deficiency among women and mothers is high. Data from the National Family Health Survey-2 for 1998-99 suggests that more than one-third (36 per cent) of Indian women have a Body Mass Index (BMI) of less than 18.5 kg/m2. Added to this, given the heavy burden of work on most women and the persistent anti-female biases in society, pregnant mothers rarely get adequate attention, care, diet and rest.
Only 11 per cent of ever-married women in Sikkim suffer from ‘chronic energy deficiency’ (with a BMI of less than 18.5 kg/m2). The proportion is 38 per cent in Madhya Pradesh.
Third, child malnutrition outcomes tend to be better where women enjoy greater freedoms and more autonomy.
Women in Sikkim enjoy far greater freedoms and autonomy than women in Madhya Pradesh. Women in Sikkim have better access to money, greater exposure to the media, and freedoms to go out of the house than women in Madhya Pradesh.
Here are some comparative indicators:
8 The female-to-male ratio of population 0-6 years in Sikkim is 986; it is 929 in Madhya Pradesh.
8 The average age at marriage for women in Sikkim is 22 years; it is 19 in Madhya Pradesh.
8 In Sikkim, 42 per cent of women do not need permission to visit friends or relatives; in Madhya Pradesh, only 20 per cent of women enjoy this freedom.
8 Close to 79 per cent of women in Sikkim have access to money; in Madhya Pradesh, only 49 per cent do.
D In Sikkim, 22 per cent of women are not exposed regularly to any media; in Madhya Pradesh, the proportion is 45 per cent.
Fourth, another factor closely related to child malnutrition is care of the child. Failure to introduce supplementary foods at the end of 6-9 months is a major factor accounting for child malnutrition. Breast milk provides vital nutrients throughout the first year of life; but breast milk alone is not sufficient. The energy and calories needed for healthy growth can come only from additional food. Beyond four to six months, infants must be given solid foods to supplement breast milk. Data from the National Family Health Survey-2 suggests that only around a third (34 per cent) of children, 6-9 months old, receive solid and mushy foods to supplement breast feeding. It is, therefore, not surprising that a child typically becomes malnourished between six months and 18 months of age, and remains so thereafter. In most cases, nutritional rehabilitation is difficult.
Close to 87 per cent of children, 6-9 months old, receive breast milk and solid or mushy foods in Sikkim. Only 27 per cent of such infants do so in Madhya Pradesh.
Fifth, education is another important factor explaining the prevalence of child malnutrition. Two linkages are striking:
1. Chronic energy deficiency drops significantly with improvements in the levels of education. And we know the that higher the levels of chronic energy deficiency, the higher will be the levels of child malnutrition.
Chronic energy deficiency among illiterate women is 43 per cent whereas it is only 18 per cent among women who have finished high school.
2. The lower the level of mothers’ education, the higher is the level of child malnutrition.
Malnutrition among Indian children below three years born to illiterate mothers (55 per cent) is more than twice the levels reported among mothers who have completed high school (27 per cent).
The importance of literacy and schooling becomes even more evident when we compare educational attainments in Sikkim and Madhya Pradesh.
8 Sikkim reports a female literacy rate of 62 per cent, Madhya Pradesh of 50 per cent.
8 In Sikkim, 49 per cent of ever-married women, 15-49 years, are illiterate. In Madhya Pradesh, the proportion is 69 per cent.
8 In Sikkim, 89 per cent of girls, 6-17 years, attend school; in Madhya Pradesh, the figure is only 71 per cent.
The pathways of influence between women’s education and nutritional well-being could be many. More educated women tend to be better informed, enjoy better opportunities for employment, tend to be less superstitious and seek out modern healthcare and advice much more readily than less educated women. Educated women also tend to have a greater say in decision-making within the household, enjoy greater self-esteem and are treated more equally within the household and by society. Along with basic education, the socialising processes of schooling expose young girls to several aspects of human life, including an opportunity to make friends, interact, broaden perspectives, consult and discuss many matters. In the event of illness or any problem, women who have been to school are in a more advantageous position to find out what is in the best interest of children through a broader process of dialogue and consultations than women who have been denied the freedom to even go to school.
To Sum Up…
India’s children face a severe crisis. Bangladesh (56 per cent) is the only country in the world that reports rates of child malnutrition higher than Bihar, Orissa and Madhya Pradesh.
In understanding child malnutrition, the focus has to shift from incomes and food availability to an appreciation of how families establish command over food and healthcare, acquire and apply knowledge on child-caring and rearing practices, allocate time to look after children and protect the cleanliness and safety of the environment. We also need to look at women’s freedoms, gender equality and elimination of discrimination against girls and women. Ultimately, nutrition and healthy growth are the outcome of three essential factors: accessibility to food within the household, healthcare, and child-caring practices. Few would argue over food. It is true that if children do not get food to eat, they will be malnourished. Similarly, with health. But it is the absence of care — care of the mother and care of the child — that explains a lot of child malnutrition in India.
1 The measure for child malnutrition used is underweight for age. Data for India and Indian states relate to children below the age of three years and are from National Family Health Survey-2, 1998-99. For other countries, data on child malnutrition relate to children below the age of five years. In general, malnutrition rates among children below five years are marginally higher than the rates reported among children below three years of age. To that extent, in the cross-country comparisons, India’s figure is an under-estimate.
2 The gini index measures the extent of equity in the distribution of income (or consumption) among individuals or households within a country. A value of 0 represents perfect equality, a value of 100 perfect inequality.
A.K. Shiva Kumar, a development economist, is a consultant with UNICEF. He lives in Delhi