BACKGROUND AND INTRODUCTION1

¹ Prepared by Rosemary Kevany, Mahshid Lotfi, and John Mason.

Background to Symposium on Women and Nutrition

Recognition that women's position in society and their well-being were disadvantaged gathered momentum particularly in the developed world in the post-war years and led to considerable changes in their position. This recognition was pushed by certain crucial underlying social and technological changes, as well as a liberalized political environment. Women were part of a rapid increase in the extent and quality of education during this time. In the United States the civil rights movement, affirmative action, and consciousness-raising resulted in a political renaissance for both black people and women. Access to higher education and training, as one direct result, improved the bargaining position of black and white women in the job market. Technical advances and their acceptance, notably birth control, but also technological means of freeing them from drudgery thus providing time for self-development, coincided in time and were essential parts of the changes. This emancipation led to, and was supported by, important changes in societies' attitudes, and was underpinned by legislation.

These major changes provided women particularly in the wealthiest societies with almost similar social, political and economic rights to those of men in these countries. Although further progress is still to be made, by the 1980's women were increasingly seen as nearly equal partners in the workforce at all levels of developed society. This liberation movement, evolving at different rates in various countries, was an important factor in the global concern for issues affecting women, with a leading role coming to be played by the United Nations. With advances in industrialized societies under way, the position of women in developing countries, and the equally compelling case for concern for their position, came increasingly to the fore. Acceptance of civil rights had helped bring in support for women; human rights was now seen as a worldwide issue, and lent weight to concerns for women's position in developing countries.

The United Nations Declaration of Human Rights of 1948 and the UN Committee on the Status of Women at that time codified the ideal of equal rights for men and women; during the subsequent four decades attitudes, customs and laws in favour of women were gradually modified. The International Women's Year, the UN Conferences on Women in Mexico in 1975 and in Copenhagen in 1980 were some of the important events in the calendar. The year 1975 was International Women's Year "to be devoted to intensified action to promote equality between men and women, to ensure the full integration of women in the total development effort and to increase women's contribution to the strengthening of world peace" (UN, 1985). The period 1976-85 was designated the United Nations Decade for Women: Equality, Development and Peace.

The changes in developed societies in favour of women's status were seen almost universally as signs of progress in society, beneficial not only to women, but to communities as a whole. The driving forces for these changes were partly feasibility, and partly moral. The status of women in a society was seen as "a significant reflection of the level of social justice in that society" (WHO, 1984). Official statements about the equality of the sexes, however, could become controversial and uncomfortable when the substantive intent was to change the accepted structures of society. Changing concepts of women's rights collide with religious and cultural norms in many societies. Nevertheless, it has become more and more widely accepted that many concepts of women's rights are universal, and should reach all women whose lives are blighted and foreshortened by discrimination inherent in cultural attitudes and economic practices.

Transforming these concerns into a global issue led directly to the movement for women in development. This was seen both as a means of improving the lot of women worldwide, but also soon justified by the view that any reasonable assessment of development objectives must include all of society; and further than that, that successful development would have to involve women, and indeed would be more successful the more women were involved. Although the processes required much working out, the objective of improving women's conditions was given increasing prominence on development agendas.

These ideas are articulated in the Report of the World Conference to Review and Appraise the Achievements of the UN Decade for Women: Equality, Development and Peace, presented at the Nairobi Conference in 1985 as proposals for 10 years follow-up. Here, eight thousand women from diverse nations and backgrounds came together on common ground, motivated by their shared inequality of opportunity. The Report contained many proposals for radical changes in women's access to education and health services. It specifically endorsed women's right to control fertility. Roles played by women in different sectors of the economy were analyzed and ways of improving and strengthening women's contribution in each sector were discussed.

Nutritional issues were discussed under the headings of food, agriculture and health to which 15 paragraphs were devoted. While women contribute significantly to agricultural development as key food producers in many regions of the world, substantial increases in poverty and landlessness among rural women were projected by the year 2000. This was specially true for Africa. The Nairobi Forward-looking Strategies for the Advancement of Women gave a set of recommendations in order to stem this trend. These were basically concentrated on promoting productive capacity of rural poor women in agricultural production, creating employment opportunities, improving access to health care and education and reducing their work-load, by means including the establishment of adequate child-care facilities, improving traditional knowledge, and introducing modern technology (UN, 1985).

The inter-agency mechanisms in the UN system asked that co-ordinating bodies such as the ACC/SCN ensure that issues described in the Nairobi report be regularly on their agendas. This led to the SCN exploring the question of "women and nutrition", and to some of the ideas put forward at the SCN's symposium. Here we continue with some of the thinking involved in defining issues for the meeting.

Women's Status in Developing Countries

In many developing countries, the majority of women have inferior social status to men, occupying the lowest paid and most insecure positions requiring the least skill. Women are given less educational opportunities than men in the same society, reflected in lower literacy rates for adult female populations compared to male: for example globally it is estimated that 32% of women are literate, vs. 52% for men (UNESCO, 1987). The gap is much wider for some parts of Africa and Asia. Female children may receive less nutritional and health care, with consequent higher mortality rates (WHO, 1987) - although in some societies, in Africa for example, female children may be favoured. Cultural preference for boys in many such countries further reduces the social prestige of mothers of only female children (Simpson-Hebert, 1982). Large numbers of women remain children in the eyes of the law throughout their lives. They are guided legally always by a male member of the family, depriving them of control over the most basic matters. Such historical cultural, social and political norms have resulted in a lack of self-confidence and self-respect in women. This is particularly ironic since illiteracy and poverty do not imply lack of intelligence - on the contrary, intelligence may be sharpened by threats to survival.

Ample evidence documents that in societies with preference for boys, female children receive less nutrition both quantitatively and qualitatively and have inferior nutritional status. A review of this subject concludes that "sex discrimination in nutrition and health care appears to increase girls' vulnerability to infectious diseases" (Waldron, 1987). This increased vulnerability to infections affects and is affected by the severity of malnutrition (Tomkins and Watson, 1989).

Attitudes within households are responsible for pan of the situation. At an extreme, the husband may see his wife as virtually "disposable" after the early years of marriage. If she falls ill, less, if any, resources are spent on health care to ensure her prompt recovery. If she dies, she can be replaced by another spouse often accompanied by a second dowry. The second spouse, like the first, comes with the same inherent cultural and social disadvantages. She is traded as a piece of property between families; she had no rights as a dependent child and will have none as a spouse. Her neglected health during childhood and adolescence leaves her short of stature and malnourished at the outset of reproduction - reproduction that may be initiated before she has completed her own growth. Her domestic training has taught her to be subservient and to expect no role in decisions about how income will be spent - this despite the fact that she is a major contributor. Her low status leaves her little opportunity to demand participation in decisions on family resource allocations. When she does have control of resources, as in female-headed households, evidence suggests that she copes more efficiently, with less resources, for the nutrition and health maintenance of her children, and possibly herself.

The conditions of the world's 2.5 billion women are far from homogeneous. The fact that women in many developing countries have to face social and cultural disadvantages in a much broader sense than that experienced by women in developed countries is clearly reflected in their largely inferior health, nutrition, education, and economic status compared to women in wealthy countries, as well as vis-a-vis men in their own societies. The life expectancy of women in northern countries - such as Iceland, Japan or Scandinavia - is thirty years more than that of their sisters in Ethiopia, Afghanistan or Nepal. Half a million women die annually of causes related to delivery, and most of these deaths are preventable (Wallace, 1987). Thus for example maternal mortality rates are estimated as 8.74 per 1000 live births in rural Andhra Pradesh, India compared to 0.02 in Sweden (Royston and Lopez, 1987); according to these authors, there are "more deaths in India (from causes related to pregnancy and childbirth) in one week than there are in the whole of Europe in one year". Hundreds of millions women mainly in developing countries experience extreme stress resulting from their children's death, disabilities and various diseases.

Such discrepancies can be attributed to a range of social, cultural and biological factors; however deprivation of formal economic status is probably the single most important influence in determining variation in health and well-being of both women and their dependent children. The significance of this economic disenfranchisement is rarely identified in analyses of women's status, yet it has direct and serious consequences for all aspects of their lives and those of their family.

That women produce much of the food in many regions of the world, that they rear most of the children and provide for the eating of their families, has been known for a long time, but only relatively recently has the significance been fully understood. Women are responsible for a large proportion of the world's food production. Women's economic importance in terms of their contribution to global food production was only officially recognized in 1974 during the World Food Conference. Women are central in determining levels of living - and nutrition - for the child, the adult, the household, and the community. Why then has women's economic contribution been so little recognized either by the husband or the economic planner?

Women's work in the developing world is almost exclusively classified as "informal" by current procedures of national accounting. This practice persists despite universal evidence that women contribute substantially to national economic output, as entrepreneurs, consumers, underpaid and unpaid workers. This contribution is particularly evident in small-scale production and service provision which form a major part of economic activity in low-income countries. They are the major service providers of health and child care, informal education, household management and routine procurement of food and fuel. Nevertheless this work is not categorized as "formal" economic activity, and consequently is not identified specifically in estimates of gross domestic product, for instance. The situation needs to better quantified, as a basis for policy.

Not specifying these major contributions by women to economic performance and development has important consequences. At household level the failure by the male heads of household to recognize the economic value of these functions results in the low social status of the mother and the neglect of her health, nutrition and social well-being. This effect is institutionalized and has been incorporated in the traditional gender role of women.

At the national level, economic planners perceive no immediate advantage in recognizing the contribution of women to economic growth. Women's production is principally subsumed under that of men and thus does not merit any specific attention nor the allocation of scarce resources for investment. International procedures for national accounting do not demand that production be identified by gender. One reason may be that specific identification could mean that resources would have to be diverted from short term growth and applied to longer term investments including women's education, better training facilities, equal employment opportunities and conditions, facilities such as day care centres, maternity leave, etc. None of these yield benefits in the short term. It follows that, at the national planning level, women's health, education, training and employment are not perceived as important components of economic development and they are consequently assigned a low priority for capital investment. As a result, the establishment of legislation, institutions, services and facilities that would assist in developing women's potential and status are neglected.

Relations between Women's Issues and Nutritional Issues

Enhanced women's status benefits nutrition

Programmes intended to improve nutritional conditions for women and their families can be more successfully designed and implemented if there is a greater understanding and awareness of the specific roles that women play. This is because women's status and their health (and nutrition) are intricately entwined (Lyons, 1985) so that for any meaningful improvement one must first deal with those ways in which health and nutrition of a woman are affected adversely by the existing social, cultural and economical systems. "A sound nutrition programme needs to go beyond the provision of health and nutrition services and to recognize that nutritional problems often have their origins in social and economic systems, and that these problems can be solved only by bringing about changes in these systems, particularly at household level" (Rogers and Youssef, 1988).

Many women in poor societies are overworked by too many calls on their time and have too few resources to adequately cope with their circumstances. Women's fatigue is now recognized as a social disease - hidden behind the barriers of traditional norms - affecting not only their own health and well-being, but also their ability to care for the nutrition of their families (Ahooja-Patel, 1980). Nutritional objectives may often best be achieved through measures that enable such women to more effectively cope and better fulfil the roles that they identify for themselves - provided that the necessary resources are also available.

Women's access to productive resources affects food availability at the household level. Increased access to productive resources itself can be an outcome of many complex interrelated factors such as: increased income and more importantly increased control over it (both women's income and total household income); enhanced educational opportunities, social knowledge and decision-making power; increased time available and devoted to productive tasks as well as enhanced efficiency of production. In other words social, cultural and political empowerment of women must be regarded as prerequisites to solving any nutritional problems.

Improved nutrition benefits women's issues

Much of the information available on nutrition of women relates to their nutritional status during pregnancy and lactation and its effects on delivery and child bearing functions. Malnourished women are particularly vulnerable to pregnancy and childbirth complications which can end in loss of their lives. Low weight and/or immature and malnourished infants born to such women are themselves vulnerable to life-threatening disease and nutritional problems. Deficiency of energy, protein and micronutrients like vitamin A, iron and iodine have well-recognized health consequences. It is thus obvious that by concentrating on proper nutrition throughout the life-cycle of a woman, she would have a much healthier life to pursue her multiple responsibilities for production, reproduction and care of family more efficiently, thereby in turn enhancing her social and economic status. Better success in performing such functions - especially in child rearing - brings about self-confidence, an issue of much significance for tackling many problems women have to face.

Improvement in health and well-being of women and their families through better nutrition contributes to reducing their burdens, emotionally and financially, and alleviating time constraints. Gained time and resources which become available in this way can be used for income-generating and productive activities or participating in educational, health or social engagements, from which women and their families can benefit. Further, use of labour-saving technology for food production, processing and preparation would decrease women's workload. When time is of a less constraint, women may use it for self-building and constructive social contacts.

Increased resources are needed for nutrition programmes for women, their children and families, to increase their nutritional knowledge, to give better and more secure access to foods (e.g. through supplementary feeding, using food aid for food for work projects, food subsidies etc), and to ensure better preparation, preservation, handling and distribution of foods.

National food and nutrition policies, plans and regulations focusing attention on nutritional problems of those socio-economically deprived and vulnerable, would directly or indirectly be beneficial to addressing women's issues. In other words, improving women's nutritional status and well-being would, perhaps, be one of the most effective way to physical empowerment and health promotion through which women may find better opportunities to enhance their status socially and politically.

Possible interventions

Clearly women in poor countries have many circumstances that are very different from those in the industrialized world, and which may only change with economic development: they are poorer, after all. Yet there are many parallels, and the ways in which women's status could improve in poor countries are not always so far different. The over-riding need has been called empowerment: equality of status in society and in the family; an equal role in making decisions. This would more than anything enable women to realize their potential to do those things that they decide to do - and this will usually include care of family, children, and themselves. Such empowerment does involve often major changes in attitudes, institutions, and possibly legislation. It may take time and be hard to achieve. But any consideration of women and nutrition issues is at best partial without this recognition.

In viewing the changes in women's position in industrialized countries at the start of this introduction, several factors were noted which both helped bring about these changes, and were themselves part of the improvement. A number of these changes have direct relevance to the present situation in developing countries - for example education, fertility control, and labour-saving technology. In some very basic needs women in poor societies to this day lag far behind, notably in this context in their food security and access to health services.

Emphasis on education for women is so clearly correct that we can only reinforce this priority. It is well established that children of better educated women have better nutritional status, usually even allowing for income and other similar effects. Education here, rightly, means broad education, and is not just specific to health, nutrition, and child-rearing practices, essential as these are. A nutrition perspective would give major priority to women's education, for its direct effects and its role in changing society for the better.

Women's ability to decide on the timing of their reproduction is similarly seen by many as fundamental human right. Here again, a nutritional view may help to reinforce this position, pointing out the convincing case that too-frequent pregnancies, to too young mothers, lead to malnutrition and increased maternal and child mortality; and that the reasons - although intuitive - are well understood. They concern breast-feeding, birth weight, maternal nutrition, child care, and so on. Many agencies are dedicated to promoting access to family planning; those concerned with women and nutrition should lend weight.

Over-commitment of women's time is emphasized as a serious deprivation, and the specific relation to nutrition is gone into in some detail later. It is worth remembering that the rapid expansion of household technology in the past few decades in higher-, and now beginning in middle-income countries, has been a major factor in freeing up women's time. Although washing-machines and refrigerators will be quite some time in coming to poor households in developing countries - but they will be consequential - technology can be extremely important for such matters as water supply and fuel for cooking and heating the home. When many hours of a woman's day are spent in fetching water and carting wood, piped water and bottled gas or kerosene for cooking can be literally life-saving. Investment in water supplies may have as much effect through time-sparing as through hygiene. Modern access to energy, eventually by electrification, is needed for environmental reasons: it is hard to think of a more wasteful process than walking miles to cut down scarce trees to carry home to burn, let alone to turn into charcoal and then burn. Better technology here would have multiple benefits, including time-saving for women.

Interventions to improve household food security, health and nutrition can be specifically directed to women, and may often be more effective as a result. Support for women's productive work, in agriculture and otherwise, is likely to have better effects for herself and the household where it ensures more control over more resources. The objective of improving household food security importantly includes enhancing the role of women.

Serious deficiencies in health services for women contribute to the high mortality risk of child-bearing, and their overall health problems. This not only has direct effects on women's health, but contributes to the cycle of poverty. Moreover, children and the next generation are disadvantaged by low birth weight, malnutrition, and compromised caring capacity. A nutrition perspective would strongly support greater emphasis on access to health services for women.

Symposium on Women and Nutrition

The ACC/SCN's annual symposium held in February 1989 at UNICEF headquarters, New York, was entitled "Women and Nutrition", and tried to specify this relationship clearly and to identify topics of concern. Two closely related issues were considered as increasingly urgent: the role of women in determining nutrition of households and societies, and the nutrition of women - throughout their lives - in its own right. The several background papers commissioned for the symposium were intended to deal with the kaleidoscopic nature of women's overlapping commitments.

An analysis of women's time and energy expenditure is essential for any quantification of unpaid domestic and agricultural labour. The concept of the "zero sum game" which is emphasized in the main background paper by J. McGuire and B. Popkin is meant to encapsulate the conflicts and trade-offs most poor women have to face as part of their daily lifestyle. And many hardly so cope: as the symposium heard, many women are on the edge of being burnt-out while a large number are constantly at risk. One criterion for an effective intervention was stressed to be precisely that it increases women's ability to better cope. Through such measures nutritional objectives could perhaps be best reached. Complementary points on this background paper were provided by A. Steel and D. Benbouzid. The need to find ways to reach women effectively and to deliver what they need is discussed by A. Steel.

The paper by M. Chatterjee and J. Lambert aimed at giving some reflections from India and Pakistan on the subject of women and nutrition in these settings. Among other issues discussed they raised the point that nutritional deprivation resulting from gender discrimination appears to be economically rather than culturally mediated. Thus women's nutritional status may only improve significantly if employment and health care situations are altered substantially to compensate for the disadvantages women have been facing.

P. Kisanga introduced the Tanzania Food and Nutrition Centre's efforts in improving the nutrition of women in Tanzania. Based on these observations rural women should be included more in nutrition and health studies in order to find specific solutions to their particular problems.

Nutrition security systems at household level were discussed by S. Bajaj. In order to achieve nutrition security at family level, some imaginative food distribution systems are required through which vulnerable families can improve their entitlement. Plans have to reach down to the people through a system of linkages in a large country like India. While area planning will help to focus efforts, the rural planning process should play a significant part in programming at the state level.

If there were ways to circumvent women's legal and economic powerlessness, by providing better access to resources for poor women, would they work? A promising example was provided by J. Quanine, on the experience of the Grameen Bank in Bangladesh. Initiated in 1976, the idea has proved to be a successful intervention for empowering women economically. Women form more than 70% of the bank's members and repay more than 90% of their loans on time. Income generation support of this kind provides an original and workable solution which enables women to market a portion of their food resources and control a measure of income.

Women's nutritional status is discussed by H. Ghassemi as an overview of this aspect. Based on limited available data on women's food intake and nutritional status there are indications of higher risk of food deprivation in women and young children among households with chronically low level of food intake.

Recognizing that the two issues - the role of women in determining nutrition of households and societies and the nutritional status of women - are intricately linked, and that women simultaneously exercise roles in economic production, home production and reproduction, often with damaging consequences for their own nutritional status, the symposium recommended actions for direct nutrition interventions for women as well as for the strengthening of their roles as an important route towards improving nutrition for all. In the summing-up of the symposium and related discussion, the following recommendations, among many possibilities, were given priority (ACC/SCN, 1989).

· Greater efforts should be made to increase specifically women's access to productive resources which directly or indirectly affect food availability at the household level. These include access to land, water, agricultural technology and extension, training, credit, employment and markets. Efforts to increase women's income must be accompanied by measures to ensure women's control over income, which may lie in the arena of social development. It was stressed that frequently poor women had not benefitted from production breakthroughs (e.g., in agriculture); they remained among the poorest in society. Women's entitlement is a priority yet to be widely recognized.

· More programmes should be directed at improving the effectiveness and reducing the time and energy cost of women's home activities, notably in the areas of food preparation, water supply and fuel collection. An intervention that saves (or frees) women's time would be an efficient intervention, with linkages to other factors. Importantly, reduction of women's child-care burden should be ensured through provision of adequate child-care facilities and health services for women and children. Programmes should aim to increase demand for such services. At the same time, direct nutrition interventions should be aimed at alleviating the protein-energy malnutrition and widespread anaemia suffered by women at all stages of life.

· Ensuring the schooling of young girls and increasing young women's functional literacy could be the most important and effective means of improving women's nutritional status in the long term because of the associated effects on health and nutrition awareness, fertility and social development. It was pointed out that a "second chance" for improving women's growth and hence reducing low birth weight due to small maternal size occurred just prior to puberty; increased attention to nutrition at this age, often through schools, would be well justified. The meeting recognized the key role played by men in societies throughout the world in accommodating women's social and economic advancement. It is frequently crucial to address men in order to enhance the effectiveness of women's programmes.

References

ACC/SCN (1989). Report of the Fifteenth Session of the Sub-Committee on Nutrition and its Advisory Group on Nutrition. New York, 27 February to 3 March 1989.

Ahooja-Patel, K. (1980). Fatigue. World Health, June 1980.

Lyons, C. (1985). More than a Medical Issue. Women's World, 6, 30-32

Rogers, B. L. and N. Youssef (1988). The Importance of Women's Involvement in Economic Activities in the Improvement of Child Nutritional Status. Food and Nutrition Bulletin, 10(3), 33-41.

Royston and Lopez (1987). On the Assessment of Maternal Mortality. World Health Statistics Quarterly, 40, 214-224.

Simpson-Hebert, M. (1982). Food and Family Prestige in Iranian Household. Paper prepared for the Conference on Women and Food - Feminist Perspectives. University of New South Wales. February 25-27, 1982.

Tomkins, A. and F. Watson (1989). Malnutrition and Infection, A Review. ACC/SCN State-of-the-Art Series. Nutrition Policy Discussion Paper No. 5. October 1989.

UN (1985). The Nairobi Forward-looking Strategies for the Advancement of Women. In Report of the World Conference to Review and Appraise the Achievements of the United Nations Decade for Women: Equality, Development and Peace. 15-26 July 1985. Nairobi, Kenya.

UNESCO (1987). The Current Literacy Situation in the World. United Nations Education Scientific and Cultural Organization, Paris.

Waldron, I. (1987). Patterns and Causes of Excess Female Mortality Among Children in Developing Countries. World Health Statistics Quarterly, 40, 194-210.

Wallace, H.M. (1987). The Health Status of Women in Developing Countries of the World. J. Trop. Pediatrics, 33, 239-242.

WHO (1984). Women, Health and Development. Report by the Director General. Executive Board Seventy-fifth Session, 30 November 1984. World Health Organization, Geneva.