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The Nexus of Gender Discrimination with Malnutrition: An Introduction

There is a complex relationship between gender discrimination and malnutrition, mediated by women's empowerment and social status, that needs to be more fully understood in south Asia, a region where progress in raising the nutrition levels has slowed in recent years. The collection of papers in this special issue is based on studies in three sites in India and Bangladesh that sought to find ways in which the health and nutrition status of girls and women could be improved.

REVIEW OF WOMEN’S STUDIESEconomic & Political Weekly november 3, 200749The Nexus of Gender Discrimination with Malnutrition: An IntroductionKavita Sethuraman, Nata DuvvuryMalnutrition and gender discrimination, both of which remain widespread in south Asia, are inextricably linked. Across the region, there is a consistent pattern – where rates of malnutrition are high, gender discrimination is prevalent. However, the interaction is not simply one whereby girls are more likely than boys to be malnourished. In fact, in most instances, particularly among young children, a consistent gender disparity in nutritional status is hard to find. Indeed, the relationship between malnutrition and gender is more complex and is linked to women’s empowerment and social status and their implications for nutrition outcomes in women, children and adolescents [Osmani and Sen 2003].Understanding the relationship between nutrition and gender is increasingly important because malnutrition continues to affect nearly 50 per cent of women and children in this region, despite the existence of extensive nutrition programmes aimed at reducing the prevalence of this condition [SCo 2004, NIPORT2005 andIIPs 2007]. Perhaps it is more worrisome that the downward trend in the prevalence of malnutrition has slowed significantly in the last decade, with the rate falling at less than 1 percentage point per year [SCo 2004]. The consequences of malnutrition in infancy and child-hood in terms of mortality, morbidity, and child development are well established [Allen et al 2001]. More importantly, malnutritionis inter-generational in nature. Malnourished girls become mal-nourished adolescents who marry early and have children during adolescence. Their children in turn become malnourished,and so the cycle continues. Gender inequality plays a significant role, particularly at the adolescent stage of the life cycle of malnutrition. Gender BiasGender bias is a constant feature of the life cycle of women in this region that undermines their own and their children’s nutritional outcomes and development. The bias is particularly acute for girls beyond early childhood, who often receive less care, healthcare and inadequate nutrition. This, however, is only one of the myriad problems they face throughout their lives. In this region alone, a staggering 45-55 per cent of adolescent girls are married at that age [NIPORT 2005 andIIPS 2007]. This life-changing event is quickly followed by early childbearing which in itself carries high risks. Maternal mortality is estimated to be two to five times higher amongadolescentgirlscompared to adult women; in addition early childbearing carries the increased risks of infant, perinatal, and neonatal mortality [IPAS 2002 and Mathur et al 2003]. In terms of nutrition, adolescent mothers are morelikelytohave lowbirthweightinfantswho are more likely to remain mal-nourished in childhood [Allen etal2001]. We gratefully acknowledge the support of the World Bank, the govern-ment of the Netherlands, and the Ford Foundation for making this re-search possible. We are also deeply indebted to Pertti Pelto for his advice and guidance over the course of this research.There is a complex relationship between gender discrimination and malnutrition, mediated by women’s empowerment and social status, that needs to be more fully understood in south Asia, a region where progress in raising the nutrition levels has slowed in recent years. The collection of papers in this special issue is based on studies in three sites in India and Bangladesh that sought to find ways in which the health and nutrition status of girls and women could be improved.
REVIEW OF WOMEN’S STUDIESnovember 3, 2007 Economic & Political Weekly50
REVIEW OF WOMEN’S STUDIESEconomic & Political Weekly november 3, 200751In the south Asian region, adolescence is the period in which gender and nutrition become inextricably linked. During this pe-riod, adolescent girls (often malnourished) make the transition from their natal home as unmarried girls to their marital home as newlyweds. In this new environment, they must assume and master the new gender roles of daughter-in-law, wife, and moth-er quickly, often in less than one year. At this critical stage of life, as new and young members they have the least power and voice, in their marital family, and the least ability to negotiate for their own and their children’s health and nutrition. As a result, they are often unable to make or even influence decisions that could improve their own and their children’s well-being. It is this real-ity that magnifies the nutrition-gender interaction in the region. Gender and DevelopmentDespite this reality, the field of gender and development and the field of nutrition are seldom connected. The former is based on hu-man rights and social development models that follow an empower-ment paradigm, whereas the latter is predominantly based on a bio-medical model that follows a welfare paradigm – yet the two are complementary, and both are needed for healthy human develop-ment. Women’s empowerment programmes do not always address nutrition or food security per se, but they promote sustainable livelihoods – by empowering women through knowledge and awareness of and access to key resources that can facilitate their livelihood activities – thus giving women an opportunity to meet their basic needs. However, many of these programmes give in-adequate attention to young adolescents, married or unmarried. Nutrition programmes, on the other hand, tend to focus on provid-ing services to improve nutrition, but often overlook the socio-cultural context. In fact, nutrition programmes are rarely equipped to address the socio-cultural dimensions that affect women and children and that are in fact related to improving nutrition.One strategy for breaking the cycle of malnutrition that affects one generation to the next would be to prevent low birth weight. Low birth weight is a consequence of low pre-pregnancy weight, young maternal age, and inadequate weight gain during pregnancy. The prevalence of low birth weight in this region is estimated to be about 25-50 per cent, and the majority of affected infants re-main malnourished in childhood; evidence further suggests that there are long-term consequences as well [Allen et al 2001 and WHO 2004]. However, in the prevailing context of early marriage and childbirth during adolescence in south Asia, preventing low birth weight would require that adolescent girls are well nourished when they marry, are older when they marry, or can delay their first pregnancy until their bodies are mature enough and their nutri-tional status is adequate to sustain a healthy pregnancy. Inter-ventions that could achieve these outcomes are not solely nutri-tional ones, but nonetheless carry significant potential to improve future nutrition outcomes and break the cycle of malnutrition. Changes such as delaying the age at marriage and first pregnancy require a shift in social norms around marriage and childbearing. At the aggregate level, long-standing socio-cultural practices seem immutable, but at the community level, social change is palpa-bleand provides windows for intervention. Within individual communities, social norms, beliefs, and practices are constantly being evaluated, negotiated, and challenged. Given the contin-ued high prevalence of malnutrition in south Asia, the limited impact of nutrition programmes, and the prevailing gender in-equality, there is a need to alter existing social and public health programmes to increase their reach, impact, and effectiveness. To this end, the Nutrition and Gender Initiative at the Inter-national Center for Research on Women(ICRW) undertook a qualitative study in three study sites, two in India (Maharashtra and Rajasthan) and one in Bangladesh. The primary objectives were to understand: “(1) The perceptions, attitudes, and practices related to the health and nutrition of girls and young women aged 10-25 years and the perceived linkages of these factors to low birth weight. (2) The perceptions, attitudes, and practices related to the social status of girls and young women, as well as theirempowerment, and gender roles, and the perceived linkages of these factors to low birth weight. (3) The perceived ways in which the health and nutrition of girls and young women could improve, especially through women’s empowerment and improved social status.” The partners in India were the Institute for Health Management in Pachod(IHMP), Maharashtra, and the Foundation for Research in Health Systems(FRHS), Ahmedabad, Gujarat. In Bangladesh, the research partner was the International Centre for Diarrhoeal Disease Research, Bangladesh(ICDDRB). A key focus of this study was to explore changes in the lives of adolescent girls and young women in the period around marriage. The main participants in this study across the sites were unmarried adolescent girls and newly married adolescent girls and women. This study design is unique in that the common methodology and tools were devel-oped collaboratively by the research partners. From the start of the study, research partners collaborated to determine the con-ceptual framework, research questions, scope of the study, meth-ods to be used, data management and coding, and analysis. Three-Site StudyThis collection contains four papers describing a broad set of findings from this three-site qualitative study. Two of the papers present findings on unmarried adolescent girls, and two present findings on the experiences of newly married adolescent girls. Together, they provide insights into issues that are critical for adapting or changing existing health and nutrition interventions, with the aim of improving nutrition in the long-term, by examin-ing certain key questions: “Are there opportunities to improve the care, health, and nutri-tion of unmarried adolescent girls? Are parents willing to in-vest in their daughter’s health and nutrition for the sake of their daughter’s well-being?”“Are unmarried adolescent girls able to exercise some degree of agency and autonomy in terms of mobility, in a social context that is otherwise stringent? How does the level of mobility affect their op-portunities in terms of health, education, and social development?”“What is the experience of domestic violence among newly married adolescent women? Are there mitigating or mediating EPW is grateful to Kavita Sethuraman and Nata Duvvury for help in putting together this issue of the Review of Women’s Studies.
REVIEW OF WOMEN’S STUDIESnovember 3, 2007 Economic & Political Weekly52factors for this physical violence? How is such violence linked to theirs and their children’s well-being?”“Are there opportunities to delay the first pregnancy among newly-wed couples, for improved maternal and child outcomes in the future? What interventions are needed?”The collection also has one article by Maithreyi Krishnaraj that offers a conceptual understanding of the issues.The first of the four papers presents findings from Rajasthan on parental care and support for unmarried adolescent girls. In a state that is often considered one of the most backward in India, the researchers present some surprising findings. Key among them is that the majority of adolescent girls receive a medium or high level of care and support from their parents, both overall and in terms of three individual dimensions (psycho-social support, healthcare, nutrition care, and total care and support). Not sur-prisingly, perhaps, better educated girls receive more care than their less educated counterparts, suggesting that families who choose to educate their daughters may value them differently than other families. Although this is a small study, the findings suggest that even in a setting where gender discrimination is rife, how girls are valued appears to be changing, and that parents are in-creasingly willing to care for and invest in their daughters. These findings challenge the view that all girls in such settings experi-ence some form of neglect and illustrate how changes at the com-munity level can benefit girls. In addition, the levels of care and support observed highlight opportunities for change. Specifically, the findings suggest that health and nutrition interventions that support the efforts of parents to care for unmarried adolescent girls would be welcomed by many even in more remote settings. The second paper presents findings from Bangladesh on the mobility of unmarried adolescent girls. Understanding the mobil-ity of girls is important because it determines their access to edu-cation, exposure to the wider world, and acquisition of life-skills. Greater mobility can confer greater autonomy for their future well-being. As widely noted in the literature, in south Asia, the mobility of girls is usually severely restricted after menarche. But this study’s findings show a range in the mobility of adolescent girls: some families do not allow girls to venture far from home, whereas other families impose few restrictions. The researchers note that most girls still need both an acceptable reason and ex-press permission to go out. Also, not surprisingly, most girls usu-ally have to be accompanied if they move anywhere outside their ‘bari’. Among the girls with few restrictions, some had a wider network of relatives they could meet on their own. Interestingly, several girls developed conscious strategies to negotiate for and obtain permission to go to various places. The findings of this study suggest that the variation in the mobility of girls is linked to their household environment and family interactions; some families adhere more strictly to social practices and restrictions on mobility, whereas others are more lenient. Importantly, this variation suggests that there are opportunities for change. It fur-ther suggests that targeted interventions for adolescent girls are likely to be used, and in some instances, girls themselves may also negotiate for access to such services and interventions. The third paper presents findings from Maharashtra on the ex-perience of newly married adolescent girls of physical violence in their marital home. Several key elements emerge from this study’s data that sheds light on the circumstances that undermine women’s and children’s well-being. First, the researchers clearly identify two time periods for the onset of violence – within six months of marriage and after the birth of the first child. Second, the various data sources clearly show that violence against women is perceived as an acceptable means of conflict resolution within households, and in many instances is justified through the social contruct of ‘chukle’ or mistakes. But the extent to which women actually experience violence within households varies. Third, it is clear from an examination of the early experiences in marriage that some adolescent girls enter households that have stringent standards in terms of gender role expectations, whereas others enter households with flexible standards. In the stringent house-holds, when families perceive that women have failed to fulfil their gender role expectations, physical violence is more common. In contrast, flexible households are more likely to support and mentor women into their new roles in the early stages of marriage. These findings clearly illustrate that the extent to which women are able to ensure their own and their children’s well-being is closely linked to their marital household environment. This suggests that interventions that target young mothers and children in these settings need to consider the impact of violence on access to services, programme participation, and the ability to follow the advice of health providers; furthermore, it suggests that other family members also need to be involved. More importantly, the findings suggest that interventions need to be designed to ad-dress values and beliefs within families, by promoting models of more equitable relationships that draw on the practices of flexible households and that exist within their own community context. Ability to Delay PregnancyThe fourth paper presents a comparison of findings across the three study sites on the ability of young newlywed couples to de-lay their first pregnancy. This analysis finds that the extent to which couples communicate about delaying their first pregnancy varies by site. In addition, the social acceptability of delaying the first pregnancy and using contraception to do so varies across the three sites as well. In the Maharashtra site, couple communica-tion is minimal, and the majority of couples conceive within a year of marriage. In the Rajasthan site, there is more couple com-munication, but very limited use of contraception. In the Bangla-desh site, however, many couples discuss when they would like to have their first pregnancy and mutually agree to use contraception. Nonetheless, in all three sites, it is clear that there are competing interests because the families of couples generally want a first grandchild soon after a marriage in the family. Of interest is the finding that in Bangladesh, where oral contraceptives are widely accepted, available, and used, young couples have begun a seem-ingly new trend of using contraception to delay the birth of their first child, although this is not the main thrust of the family plan-ning programme and services. Taken together, the findings suggest that there is variation across sites in the extent to which couples can delay a first pregnancy. Social acceptability of both temporary contraceptives and couple communication on contraception are key factors in creating an environment that enables couples to

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