Dr Neha Sareen, Nutrition Scientist, Vitamin Angels, India, talks about the current nutritional status of women in India, the gaps in policy implementation, linkages with gender based inequality, and effective measures that need to be adopted
Each year, 30 million women in India enter pregnancy, with hopes and dreams to bear nourished offspring. They dream a journey of hope not only for themselves but for their children who they have to provide physically, emotionally, and mentally.
Mother’s nutritional health is critical for her baby. However, data still reflects the poor nutritional status of mothers across the country. In India, many women enter pregnancy with one or more nutritional risks. The recent National Family Health Survey (NFHS-5, 2019-21) shows that 19 per cent of women aged 15-49 years are underweight, while 24 per cent are overweight or obese, and 57 per cent of women are anaemic (NFHS-5, 2019-21). Being too thin, obese, and anaemic increases the women’s risk of poor pregnancy outcomes, difficult deliveries, and also mortality. Maternal mortality ratio (MMR) is still high at 113 (Sample Registration System, 2016-18) deaths per 100,000 live births. Latest data trends also show that while thinness is reducing (23 to 19 per cent) the new-age problem of overweight and obesity (21 to 24 per cent) is on the rise (NFHS-4 vs. 5).
The Indian policy intent for maternal nutrition is visibly clear. While Mission Poshan 2.0 mentions ‘maternal nutrition’ as one of the interventions in 2022, the Extended Pradhan Mantri Surakshit Matritva Abhiyan, includes ‘nutrition counselling’ as one of the interventions. Recently, the Ministry of Women and Child Development also released the Body Mass Index – specific counselling cards.
However, policy intent does not translate into tangible actions on the ground to respond to all forms of maternal malnutrition. This is due to various reasons.
- Priority is still accorded to reduce MMR and not morbidity, hence focus remains on maternal severe anaemia and not on thinness and obesity.
- There is a lack of operational know-how on time-effective workflow to deliver all constituents of nutrition services at various antenatal care (ANC) contact points.
- The standard and simplified job aids tailored to gestational month as well as the type of nutrition risk is missing. This creates constraints for the health workers on what to ask, how to classify nutritional risk women and what to do when a risk is identified.
- A lot of focus is given to weighing of children, but gestational weight gain monitoring and gestational month specific counselling is not accorded priority.
- While nurses and health providers are given training, the nutrition component is weak or missing. A cadre of trainers who understand nutrition and dietetics to support the nutrition component in medical training is also missing.
- Women who are thin, short, anaemic, obese, and with mental illness require “extra care”. This extra care is often missing not because of intent but lack of clarity on their systematic screening and management.
- At the planning level, all nutrition items (supplies, training, human resources, etc.) are inadequately budgeted in the annual health budget plans.
- At the reporting and review level, a consensus on critical nutrition indicators is either not available or often missing, as a result this is never reviewed.
The burden of thinness, overweight and obesity, and micronutrient deficiencies, in women is also driven by low household food security, inadequate care, poor access to health and nutrition services, and unhealthy household environments. These underlying causes are shaped by context-specific social, economic, political, and environmental conditions. The poor nutrition of women is also deeply rooted in gender inequities. It results in low levels of education and household decision-making among women, affecting them at the young age at which they get married and first become pregnant.
A recently published data on maternal diets in India shows that dietary intakes amongst pregnant women were sub-optimal with low energy, inadequate protein, and fat intake. Intakes of essential micronutrients such as iron, vitamin A, riboflavin, vitamin C, and folic acid were less than 50 per cent of recommended levels for most pregnant women. Data also reflected that strong gendered social norms affect many aspects of women’s health and well-being, including nutrition behaviour and practices. From childhood to adulthood, women’s health and nutrition are given lower priority as compared to men. Women are usually the last to eat in the household and eat the least amount of food. In many households, men are responsible for the procurement of food from the market, often themselves deciding what food items to buy while women have limited access to markets and minimal ability in exercising their choices for food items.
In order to improve nutrition and health outcomes for women, there is a need to protect, promote and support diets, practices, and nutrition services across the lifecycle – spanning preconception, pregnancy, and postpartum, including the lactation period. The health system provides a critical role in delivering nutrition interventions to women, which includes promoting nutritious diets and optimal nutrition practices. However, other systems are also needed to improve women’s access to nutritious, safe and affordable diets, provide effective and sustainable delivery of nutrition services through non-health platforms and strengthen women’s care practices. This requires coordinated actions by different government bodies. Furthermore, to effectively impact women’s nutrition and health outcomes, gender considerations and women’s empowerment should be considered in the design of all programmes.
The World Health Organization (WHO) guidelines on ANC recommend nutrition-specific interventions during pregnancy, including nutrition assessment, counselling on dietary intake, and micronutrient and balanced protein energy supplementation. Thus, for positive pregnancy outcome, India should also aim to adopt WHO’s global guidance and provide maternal nutrition interventions using integrated health service packages across a continuum of care. On the occasion of this International Women’s Day, it is critical that we renew our vigour to fight the malice of malnutrition among women and protect it as a basic human right. Effective measures are necessary to make the next 25 years of our development journey truly women-led.