Health and the Links to Nutrition: Maternal Health is Key
22 March 2004
22 March 2004
Statement by Thoraya Ahmed Obaid, Executive Director
Good afternoon, ladies and gentlemen.
Today, at this second, a baby girl is being born somewhere in the world. She is being born to a mother who is undernourished. The mother herself is young, 18 years old. It is likely that the baby is stunted in height and low in weight, even though she was born at full term. If she survives, her growth will be more likely to falter. Her ability to learn will be irreversibly damaged, as will her ability to develop other skills needed for the labour market, home and community. She will also be more susceptible to infectious diseases.
Later in life, she will be more likely to suffer from the so-called diseases of affluence such as diabetes, coronary heart disease and diet-related cancer. Throughout her life, her options—and her power to make choices about those options—will be as stunted as her growth will be. During her childbearing years, she will bear low birth weight babies of her own, continuing the cycle of poverty and ill-health from one generation to the next. And society will be worse off, both socially and economically.
Ladies and gentlemen, the scenario I have just painted for you is lived by one in three infants in the developing world. The food security and nutrition status of an infant reveals much about her history to date and tells us much about her forward trajectory through life. And this status is determined in large part by the health and nutrition status of her mother. And the health and nutrition status of the mother is determined in part by the status of women in society.
Today, in my talk, I would like to stress three major points:
I will also stress a fourth point—that better nutrition is needed to combat HIV/AIDS and malaria.
Ladies and gentlemen,
Nutrition is a fundamental human right and it plays a key role in health. Eradication of hunger ranks high among international goals because good nutrition is essential for the health and human capacity needed to achieve so many of the other Millennium Development Goals. Freedom from hunger is a sound foundation for economic growth in the world’s most impoverished nations. Well-nourished people learn better, produce more, and can more effectively fight off disease, and provide better care for their children and the environment.
Yet, malnutrition and low weight in children and mothers persist, and are leading causes of disease worldwide. In the poorest regions of the world, they are also the major contributors to loss of healthy life. The effects extend beyond the individual and the family to the society at large because malnourished people are unlikely to be able to fully participate in whatever economic opportunities may be available.
Today, the majority of the developing world’s 846 million hungry people reside in Asia. However, sub-Saharan Africa is the region of the world that is witnessing the largest increases in the numbers of the hungry. And it is the region that is farthest from progress in achieving the international goal to reduce extreme hunger by 2015.
Today, the high economic costs of hunger and the economic benefits of good nutrition are increasingly understood. We also have greater understanding of the causes of hunger. We know that the main causes of malnutrition include inadequate access to food and nutrients, inadequate care of mothers and children, inadequate health services and unhealthy environments. We also know that hunger and poverty are perpetuated by lack of access to assets, lack of access to institutions that give voice and provide opportunities, and by vulnerability.
The fact is that grossly unequal social conditions and exclusionary practices frequently prevent access to food, health, sanitation and education. And this inequality and discrimination hit hardest on women, girls, infants, ethnic minorities and other vulnerable groups. It is this exclusion and discrimination that is a major cause of poor nutrition and poor health of women and girls, which leads to malnutrition in infants and across generations.
Promote gender equality and empower women
That is why the empowerment of women and girls is so essential. They need education, better nutrition, and better treatment, including access to reproductive health services, so they can take better care of themselves and their children.
It is well documented that women’s low status in the household and within society is an important cause of poor nutrition. Women’s low social status, lack of decision-making power, and lack of control over income have a significant adverse effect on health-seeking behaviours and child health and nutrition outcomes.
According to Joan Holmes, President of the Hunger Project, chronic hunger occurs: “when people lack the opportunity or are systematically denied the opportunity to earn enough money, to produce enough food, to be educated, to learn the skills to meet their basic needs, and to have voice in the decisions that affect their lives”.
There is growing international recognition that discrimination against women is a major cause of hunger and malnutrition. For when we speak of hungry people, we are most likely talking about women and children.
It is also true that women have significant productive roles in developing countries. Rural women are responsible for half of the world’s food production and produce 60 to 80 per cent of the food in most developing countries. This is particularly true in South Asia and in Africa. Women food farmers produce 80 per cent of Africa’s food, and do the vast majority of the work to process, transport and market this food. Yet, they own only one per cent of the land, and receive less than 10 per cent of the credit given to small-scale farmers.
Sub-Saharan Africa is the only region in the world where average food production per person has been declining during the past 40 years. In much of rural sub-Saharan Africa, women are subsistence farmers. Yet, they are often given small and marginalized plots of land. They have less access to credit, extension services and technological inputs than do men, which puts them at a disadvantage in terms of food production.
There is a great deal of research showing that the greater the per cent of household income earned by women, the greater the food security of the household. Studies show that women put more of the money they earn into the health and welfare of the family and the children, compared to men. Yet, low wages and poor work conditions leave women with few adequate child care options, and studies show that malnutrition is significantly more likely among young children when their mothers have to work under such conditions. So, we see here a vicious circle. On the one hand, the mother is working and contributing her earnings to her family, yet she is barely able to survive and her children stand a high chance of suffering from malnutrition.
The poor nutritional status of infants and women has implications for overall development in terms of productivity losses throughout the life cycle of both boys and girls. Hence, not only are improvements in the status of women needed to improve nutrition, but better nutrition for girls and women can also help to identify policies and interventions that can reduce gender inequality. This can be done by both promoting level playing fields and by promoting catch-up in terms of women’s status. These policies will benefit women, their children, and overall economic development.
This has been shown to be the case in the African nation of Burkina Faso. It was found that women had less access than men to food, information, assets, institutional services, and rights. They also had less access to agricultural inputs, which resulted in a loss of agricultural output and productivity. But when they gained equal access, their productivity increased and so did the yield of crops.
It is clear that greater efforts are needed to empower women and increase their equal access to food and other vital assets, resources and services to reduce hunger and malnutrition.
As I stated at the beginning of my statement, malnutrition often begins at conception. When a pregnant woman consumes an inadequate diet, has an excessive workload, or is frequently ill, she will give birth to smaller babies with a variety of health problems. Children born to malnourished mothers are more likely to die as infants. If they survive, by the second year of life, they may have permanent damage, including brain damage, which cannot be reversed. For this reason, pregnant and breastfeeding women, and children under 2 years of age should be priority target groups for nutrition interventions. Other critical groups include pre-adolescents and adolescents, particularly girls. Let’s face it: healthy mothers have healthy infants.
Ladies and gentlemen,
The images of hunger that fill television screens tend to be of infants and children that are acutely malnourished – victims of famine. But famines account for less than 10 per cent of hunger-related deaths. The remaining 90 per cent are the result of chronic, persistent hunger—the silent, day-by-day killer that takes the lives of some 20,000 people each day.
Research has shown that even moderate and mild forms of malnutrition in children are important predisposing factors to child death. All degrees of malnutrition – severe, moderate and mild – are linked with the deaths of over 6 million children, over one half of all child deaths each year.
All over the world, child malnutrition is linked to poverty, low levels of education, and poor access to health services, including reproductive health services and family planning. It is widely known, for instance, that having babies too closely together increases the chance of poor nutrition in both the mother and child. Studies show that waiting at least two to three years between births allows the mother to replenish nutritional reserves. We must also remember that health services during pregnancy and childbirth provide vital entry points for nutrition interventions. It also true that adequate health services, especially emergency obstetric care, are needed during childbirth to ensure a healthy outcome for both mother and child. Studies show that the death of a mother reduces the chances of a healthy life for children who are left orphaned. So, clearly all of these interventions are mutually reinforcing.
This is important because malnourishment in infants and children, even moderate, increases their risk of death, inhibits their cognitive development and affects health status later in life. Studies show that the under-nutrition of a foetus is linked to chronic disease in adulthood. It is also known that the effect of malnutrition during the first two years of life is mostly irreversible, and actions thereafter have little or no impact on underweight rates and physical and mental problems. Undernourished infants tend to enter primary school later and drop out earlier. When they are in school, they tend to be less able to learn as compared to better-nourished individuals.
Yet, despite this knowledge, malnutrition continues to affect millions of poor infants and young children:
Ladies and gentlemen,
This does not have to be the reality at the beginning of the 21st century. This sad scenario can be changed. These deaths are preventable. The world possesses the know-how and the resources to turn this crisis situation around.
An investment in preventing foetal under-nutrition is a highly effective investment because it not only improves maternal and infant nutrition, but it may also slow down or prevent the onset of chronic disease later in life.
Improving maternal health and nutrition is key.
Improve maternal and infant health
Maternal malnutrition is not only associated with malnutrition in a developing foetus, it is also directly associated with the ill-health, and possible death, of the mother. Poor nutritional status may affect the chances of maternal mortality in various ways. For one thing, if the mother is malnourished, she may have experienced stunted growth, resulting in a small pelvis, which can result in obstructed labour, one of the main causes of maternal mortality.
Other causes of death during childbirth are associated with micronutrient deficiencies.
Over 100,000 pregnant women die each year from severe iron-deficiency anaemia. This equals one fifth of all annual maternal deaths. Iron deficiency during pregnancy is also associated with multiple adverse outcomes for both mother and infant, including an increased risk of haemorrhage, sepsis, low birth weight and increased overall infant mortality. Serious iodine deficiency during pregnancy may result in stillbirths, miscarriages and congenital abnormalities. Iodine deficiency disorders jeopardize children’s mental health and often their very lives.
Childhood anaemia can begin when mothers have the ailment before or during pregnancy, and the infant is born with low iron stores. The health consequences of iron deficiency for children include premature birth, low birth weight, infections and elevated risk of death. Later physical and cognitive development is impaired, resulting in lowered school performance.
Deficiency in vitamin A is also a major threat to health. In pregnant women, vitamin A deficiency increases maternal mortality and causes night blindness. Infants born to women who consume too little vitamin A have low stores at birth. The breast milk of those women is also low in vitamin A.
Although severe vitamin A deficiency is declining, sub-clinical deficiency still affects up to 250 million pre-school children, contributing significantly to raised morbidity and mortality in high-risk populations.
Vitamin A deficiency is the leading cause of preventable blindness in children and raises the risk of disease and death from severe infections. Between 100 million and 140 million children are vitamin A-deficient and an estimated 250,000 to 500,000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight.
Since breast milk is a natural source of vitamin A, promoting breastfeeding is the best way to protect babies from vitamin A deficiency. However, if the mother is deficient, supplements are needed for both mother and child. In a recent trial in Nepal, low-dose vitamin A supplementation reduced maternal mortality by 44 per cent. For deficient children, the periodic supply of high-dose vitamin A in swift, simple, low-cost, high-benefit interventions has produced remarkable results, reducing mortality by 23 per cent overall and by up to 50 per cent for acute measles sufferers.
Zinc deficiency presents another threat to pregnant women and babies. It is associated with long labour, which increases the risk of maternal and infant death, especially in areas where there is limited access to health services.
Another deficiency that threatens pregnant women is folate deficiency, which is associated with a high risk of pre-term delivery and low birth weight. Folate deficiency also contributes to anaemia, especially in pregnant and lactating women, and may be associated with increased risk of maternal morbidity.
Overall, malnutrition lowers the body’s ability to resist infection and leads to longer, more severe and more frequent episodes of illness – thus increasing mortality risk. The publication, Nutrition Essentials (BASICS/WHO/UNICEF, 2000), highlights six key nutrition interventions: exclusive breastfeeding for about six months; appropriate complementary feeding with continued breastfeeding for two years; adequate nutritional care during illness and severe malnutrition; adequate vitamin A intake for women, infants, and young children; adequate iron intake; and adequate iodine intake.
Adolescent nutrition: a neglected dimension
I have just described interventions needed for pregnant and breastfeeding women, and for infants up to 2 years of age. Now, I would like to talk about a group that is often ignored, and that is adolescents.
Today, there are about 1.2 billion adolescents in the world, comprising one in five persons on earth. These 10- to 19-year-olds face a series of serious nutritional challenges, which affect not only their growth and development, but also their livelihood as adults. Yet, adolescents remain a largely neglected, difficult-to-measure and hard-to-reach population, with the needs of adolescent girls, particularly, ignored.
Adolescence is a unique period in life because it is a time of intense physical, psychosocial and cognitive development. Caloric and protein requirements are maximal. Increased physical activity, combined with poor eating habits and other considerations, such as the onset of menstruation and pregnancy, contribute to the potential risk for adolescents of poor nutrition.
Studies show that community-based approaches are needed for the sustained strengthening of household food security with emphasis on nutritional adequacy for adolescent girls. Mass information and awareness programmes are needed to alert governments and communities to the importance of health and nutrition for adolescent girls. In particular, there is an urgent need to ensure a sustainable adequate intake of iodine by all adolescent girls and women of childbearing age prior to conception – in the long term through iodized salt and, if necessary, in the short term through distribution of iodized oil capsules.
Combat HIV/AIDS, malaria and other diseases
I would now like to talk about nutrition, HIV/AIDS and malaria.
The magnitude and depth of HIV/AIDS impacts in sub-Saharan Africa are staggering. Livelihoods are being devastated and the food and nutrition security of millions of households seriously undermined. In fact, inadequate access to food is one of the first signs of distress in a HIV/AIDS-impacted household. Malnutrition, in turn, increases both the susceptibility to HIV infection and the vulnerability to its various impacts. Malnutrition also has a strong negative impact on those suffering from malaria. Nearly 57 per cent of malaria deaths are attributable to malnutrition.
Nutrition, therefore, plays a critical role in all four of the main strategies for combating HIV/AIDS: prevention, care, treatment and mitigation, and in combating malaria.
At an individual level, HIV infection essentially accelerates the vicious circle of inadequate dietary intake and disease that leads to malnutrition, while malnutrition increases the risk of HIV transmission from mothers to babies and the progression of HIV infection.
Mother-to-child transmission (MTCT) of HIV has nutritional implications. In a recent study, exclusive breastfeeding has been seen to confer a significantly lower risk of HIV transmission than partial breastfeeding. Infants of mothers who have an adequate vitamin A status might have a reduced risk of vertical transmission. More studies on these issues are still needed.
The nutritional status of those infected and affected plays a large part in determining the individuals’ current welfare and their ability to further develop their livelihoods towards activities that help to mitigate the impacts of AIDS and prevent the spread of HIV.
With regard to nutrition, HIV/AIDS significantly impacts individuals and households, by accelerating the vicious circle of inadequate dietary intake and disease, and by diminishing the capacity to ensure the essential food, health and care preconditions of good nutrition. It is also clear that when farmers fall sick, they cannot tend the crops.
The losses caused by HIV/AIDS affect every determinant of food security, including health status, income, capacity to care for children, ability to participate in governance, ability to work on farms and other productive activities, as well as to participate in social networks.
The good news is that nutritional support has the potential to significantly postpone HIV/AIDS-related illness and prolong life. Food aid has significant potential for improving the situation of HIV/AIDS-impacted households and communities, and reducing early death from malaria.
I would like to conclude by charting a way forward.
The International Conference on Nutrition (ICN) framework for nutrition identifies household food security, health services and a healthy environment, as well as care for women and young children as the three underlying determinants of malnutrition. It is necessary to address all three to improve nutrition outcomes. Therefore, one of the key policy priorities is to empower women and invest in girls.
The Hunger Task Force, in its recommendations, also says that the empowerment of women is a key part of an overall strategy to achieve the hunger MDG. It also emphasizes that increased investments are needed to raise agricultural productivity, improve the market functioning for poor producers and consumers and increase the nutrition status of adolescent girls and women.
Given the rise in world wealth, increases in international inequality and the widespread application of human rights principles to development, the case for making these investments has never been stronger.
The common denominator in the many failures to achieve the global promise of hunger reduction can be branded as a lack of political will. The world can achieve the hunger MDG if it chooses to do so. Such a choice is political, and political choices can be influenced by targeted and sustained advocacy.
One needs to stress the contributions of improved nutrition status to the attainment of the MDGs. In terms of the poverty goal, for example, improvements in nutrition status are urgently needed during pregnancy and the crucial first two years of life to boost the lifetime well-being of an individual and help break the intergenerational cycle of poverty.
For the actions in improving nutrition of mothers and children and empowering women to be most effective, or perhaps effective at all, they need to operate in a supportive policy context. In essence, this means a political class that is supportive of improving the status of women. Women who cannot access the information, education, assets and time necessary to improve their nutrition and that of their children will be unable to influence decisions that affect their lives. The inability to make these claims and to engage with men in jointly delivering them will diminish the chances of any nutrition action from being successful.
We must also realize that, in improving the nutrition of mothers and children and empowering women, the role of men is crucial. If these actions are to be framed solely as actions for women, lobbied for by women, and enacted by women, they will be doomed to failure. Without the buy-in of men – as to the need for these interventions and for their active participation in creating the choices for women and time to act on those choices – the responsibility on women will become a counterproductive burden.
Providing immediate assistance through woman-centred and life-cycle-oriented nutrition programmes will address chronic and acute hunger and ensure that the most vulnerable groups can benefit from hunger-reduction strategies that are based on income generation and increasing agricultural productivity
I would also like to stress, as does the Hunger Task Force, that the private sector has to be a part of the solution. The nutrition community has historically avoided partnership with the private sector, largely due to the negative experiences relating to the undermining of exclusive breastfeeding. However, there may be some roles, responsibilities and situations in which the private sector has a comparative advantage. For example, private industry has been a key player in the fortification of food with micronutrients. One fortification success story, still unfolding, is the massive reduction in iodine deficiency through salt iodization.
An important step is for health sector planners to work with nutritionists to identify the most critical nutrition interventions, how they will be provided, and how to sustain them through capacity development, quality assurance and supervision. Although all of this has cost implications, planners should recognize that neglecting nutrition costs more.
Finally, I would like to endorse the findings of the Standing Committee on Nutrition, which earlier today released its 5th Report on the World Nutrition Situation. In the report, the Committee stresses that nutrition status – both the attainment of it and how it is attained – has much to offer those who seek to strengthen governance, reduce poverty and make trade liberalization and health-sector reform work for the poor.
For health-sector reform, the huge and largely unappreciated role that malnutrition plays in the global burden of disease, together with the existence of a range of cost-effective health-sector interventions to improve nutrition, makes nutrition activities among the best ways to improve the efficiency and quality of health services. And, since malnutrition affects the poor and most vulnerable (women and children) most, addressing malnutrition also addresses inequities in health.
In addition, a focus on malnutrition inevitably involves a focus on individuals who are socially disadvantaged and, hence, especially vulnerable to risk. Recently, nutrition components have been successfully incorporated into anti-poverty and safety net programmes on a large scale in Mexico and Central America (for example, transferring cash or food in return for school attendance and the attendance of pre-schoolers at health clinics with a focus on growth-promoting activities). These programmes have combined to reduce poverty today, while safeguarding human capital accumulation for the next generation.
The potential of the nutrition community to accelerate broader development goals is clear. The potential of the broader development community to mobilize resources for malnutrition reduction is equally apparent. For this “win-win” situation to materialize, the nutrition community needs to recast itself. It must see itself as the part of the development community that is concerned with nutrition. It must forge new connections across unfamiliar divides. If it does not, nutrition status might be relegated to simply being an indicator of the attainment of the Millennium Development Goals, rather than an essential foundation for their attainment.