Experience has taught that even when there is adequate food in the house and a family lives in a safe and healthful environment and has access to health services, children can still become malnourished.
Inadequate care for children and women, the third element of malnutrition's underlying causes, has only recently been recognized and understood in all its harmful ramifications.
Care is manifested in the ways a child is fed, nurtured, taught and guided. It is the expression by individuals and families of the domestic and cultural values that guide them.
Photo: Exclusive breastfeeding for the first six months of a child's life not only provides the best nourishment and protection from infection, but also enables mothers and their infants to develop close emotional bonds. A woman breastfeeds her three-month-old baby in the Federal Republic of Yugoslavia.
Nutritionally, care encompasses all measures and behaviours that translate available food and health resources into good child growth and development. This complex of caring behaviours is often mistakenly assumed to be the exclusive domain of mothers. It is, in fact, the responsibility and domain of the entire family and the community, and both mothers and children require the care of their families and communities.
In communities where mothers are supported and cared for, they are, in turn, better able to care for young children.
Among the range of caring behaviours that affects child nutrition and health, the following are most critical:
Feeding: As we have seen, exclusive breastfeeding for about six months, and then continued breastfeeding with the addition of safe, high--quality complementary foods into the second year of life, provides the best nourishment and protects children from infection.
The introduction of complementary foods is a critical stage. A child will be put at increased risk of malnutrition and illness if these foods are introduced much before the age of six months, or if the preparation and storage of food in the home is not hygienic.
On the other hand, a child must have complementary foods at the six-month point, since breastmilk no longer meets all nutritional needs. Delaying the switch-over much beyond six months of age can cause a child's growth to falter.
From about 6 months to 18 months of age, the period of complementary feeding, a child needs frequent feeding -- at least four times daily, depending on the number of times a child is breastfed and other factors -- and requires meals that are both dense in energy and nutrients and easy to digest.
The foods a family normally eats will have to be adapted to the needs of small children, and time must be made available for preparing the meals and feeding children.
Good caring practices need to be grounded in good information and knowledge and free of cultural biases and misperceptions. In many cultures, for instance, food and liquids are withheld during episodes of diarrhoea in the mistaken belief that doing so will end the diarrhoea. The practice is dangerous because it denies the child the nutrients and water vital for recovery.
Other behaviours that affect nutrition include whether children are fed first or last among family members, and whether boys are fed preferentially over girls. In a number of cultures and countries, men, adult guests and male children eat before women and girls.
The level of knowledge about hygiene and disease transmission is another important element of care. It involves food preparation and storage, and whether both those who prepare the food and those who eat it wash their hands properly before handling it.
Ideas concerning appropriate child behaviour are also important. If, for instance, it is considered disrespectful for a child to ask for food, feeding problems can occur.
Protecting children's health: Similarly rooted in good knowledge and information is the caring act of seeing that children receive essential health care at the right time. Early treatment can prevent a disease from becoming severe.
Immunizations, for example, have to be carried out according to a specific schedule. Sound health information needs to be available to communities, and families and those caring for children need to be supported in seek ing appropriate and timely health care.
Therapeutic treatment for a severely malnourished child in the hospital is far more expensive than preventive care. According to a 1990 US Department of Agriculture study, nutrition investments for pregnant women were very cost-effective: Every $1 spent on prenatal nutrition care yielded an average savings of about $3 in reduced medical costs for the children during the first two months after birth.29
A study in Ghana has also found savings in health care costs: Children receiving vitamin A supplements made fewer clinic visits and had lower hospital admission rates than children not receiving the supplement.
Support and cognitive stimulation for children: For optimal development, children require emotional support and cognitive stimulation, and parents and other caregivers have a crucial role in recognizing and responding to the actions and needs of infants.
The link between caring stimulation and malnourished children is also important: Several studies have found that malnourished children who were given verbal and cognitive stimulation had higher growth rates than those who were not.30
Breastfeeding affords the best early occasion to provide support and stimulation. It enables mothers and their infants to develop a close emotional bond that benefits both. All children need -- and delight in -- the kind of play and stimulation that is essential for their cognitive, motor and social development.
Verbal stimulation by caregivers is particularly important for a child's linguistic development. Ill or malnourished children who are in pain and have lost their appetite need special attention to encourage them to feed and take a renewed interest in their surroundings during recovery.
In addition to improved nutrient intake, optimal cognitive development also requires stimulation of, and regular interaction with, young children. The quality of these actions can be enhanced through education of parents and other caregivers. Child-to-child programmes, for example, can provide simple resources to older children to improve the care, development and nutritional well-being of their younger siblings.
Policy makers need to recognize the significance of such measures and actions and take them into account when devising policy and programmes.
But the timing must be carefully planned: Many early child development activities concentrate on children who are age three and older when the focus should be on children up to the age of three and should link care, good feeding and psychosocial activities.
Care and support for mothers: As long as the unequal division of labour and resources in families and communities continues to favour men, and as long as girls and women face discrimination in education and employment, the caring practices vital to the nutritional well-being of children will suffer.
Women, on average, put nearly twice the hours of men into family and household maintenance. In Bangl adesh, India and Nepal, for example, girls and women spend three to five hours more a week than boys and men in tasks such as carrying fuel and growing and processing food.31
They then spend an additional 20 to 30 hours a week performing other unpaid household work. If the burdens they carry are not better and more equitably distributed, both they and their caring role will suffer.
The elements of care most critical for women during pregnancy and lactation include extra quantities of good--quality food, release from onerous la bour, adequate time for rest, and skilled and sensitive pre- and post-natal health care from trained practitioners.
The AIDS pandemic has introduced new and volatile considerations and aspects of care into already sensitive areas of human behaviour and interaction. High priority should be given to improving access to services that help minimize the risk of HIV transmission to women before, during and after pregnancy, as well as to their partners (Panel 6).
Cultural norms and misconceptions affect the care women receive during pregnancy. In some culturally conservative communities in parts of Asia, for example, fish, meat, eggs and fat are not part of the diets of pregnant women because it is feared they will make a baby too large and difficult to deliver. Research shows, however, that better maternal diet can improve the birthweight of children in many cases without causing significantly increased head circumference of the newborn, which is the factor most likely to put small women at risk (Panel 7).
The adjustment of workload is another aspect of the care accorded women during pregnancy -- and one with powerful ramifications.
A survey in one village in the Gambia, for example, found that even during periods of relatively low seasonal agricultural activity, women gained on average just 5.5 kilograms during pregnancy -- only about half of the recommended weight gain that women need to sustain their developing foetus.32
Reductions in a woman's workload during pregnancy, combined with more food of good quality, improve the nutritional status of a woman and her unborn child and reduce the risk that the child will have a low birthweight.
In Viet Nam, when men assumed some of their pregnant wives' responsibilities during the third trimester of pregnancy, women rested more, and their infants weighed more at birth. In Indonesia, infants born to women who received a food supplement did not weigh more at birth, but they developed better during the first year of life.
The fact that women are usually the primary caregivers does not mean that men, families and communities are exempt from care-giving responsibilities.
The often oppressive and demanding patriarchal environment in which millions of women live must give way to an equal partnership in which women enjoy autonomy and the sense of accomplishment that comes from building skills and capacities.
At the same time, girls need to be free from pressures to marry early. A study in West Africa, for example, found that nearly 20 per cent of girls in rural areas of the Gambia and Senegal and 45 per cent of girls in Niger marry before the age of 15.
Figures such as these underscore the great need for girls and women to be involved in major personal decisions, including not only their marrying age but also how closely the births of their children will be spaced.
Photo: How women are valued and treated in society, including their level of education, affects their ability to feed and care for their children. A first-grader in Colombia takes lunch before class begins.
Adolescent pregnancy is a major risk factor for both mother and infant, as the girl may not have finished growing before her first pregnancy, making childbirth dangerous.
The infant of a very young mother may have a low birthweight (Fig. 7). Higher risks of toxaemia, haemorrhage, anaemia, infection, obstructed labour and perinatal mortality are all associated with childbearing in adolescence.
A number of measures are essential, therefore, to enable women and girls to develop their skills and abilities. These include ensuring their access to family and community resources, such as credit, and to education and information.
It is often said that poverty at the family level is the principal cause of child malnutrition. While it is true that a lack of resources and malnutrition often go hand in hand, this statement tells only part of the story.
Many poor families do in fact receive adequate nutrition, and malnutri tion is found in many better-off families.
The broader explanation lies with in a fuller understanding of the different types of resources necessary for good nutrition, and of the factors that affect families' ability to access and control these resources.
The three components of nutri tion -- food, health and care -- interact closely in their influence on family life. Often efforts to fulfil one precondition for good nutrition compete for the same resources required to fulfil another condition.
For example, if a woman has to spend excessive time in producing food to achieve household food security, her ability to provide adequate child care can be compromised. The re sult may be malnutrition in her young child.
Political, legal and cultural factors at the national and regional levels may defeat the best efforts of households to attain good nutrition for all members.
These include the degree to which the rights of women and girls are protected by law and custom; the political and economic system that deter mines how income and assets are distributed; and the ideologies and poli cies that govern the social sectors.
Photo: Increased awareness and education about the causes of malnutrition are essential if the problem is to be successfully addressed. A health card in her hand, a woman holds her baby at a UNICEF-assisted health centre in Syria.
For example, where it is known and appreciated by everyone in society -- men and boys, women and girls, teachers and religious leaders, doctors and nurses -- that women in the late stages of pregnancy need rest and protection from overwork, families are more apt to receive the social support they need to ensure this protection.
In places where there is a tradition of non-discrimination against women in law and custom, women are more likely to have good access to resources, including credit, and to the decision-making power that can enable them to make the best use of services for themselves and their children.
There is no doubt that while economic poverty is not the only kind of poverty that eventually affects nutrition, it is still an important factor.
Overcoming entrenched poverty and underdevelopment requires resources and inputs that few developing countries, particularly the poorest, can muster, either on their own, through existing levels of private external investment and loans, or through current patterns of official assistance and loans.
In 1995, for example, aggregate resource flows to the developing world from all sources totalled $232 billion, including $59 billion in official development loans and grants and $156 billion in private resources. Middle-income countries were the biggest recipients of the private investments and loans: Two thirds went to them and one third to low-income countries. The two regions of the world with the highest rates of childhood malnutrition -- sub-Saharan Africa and South Asia -- received only $1.6 billion and $5.2 billion respectively.
And although bright spots exist in terms of investment and trade in sub-Saharan Africa, the problems of the continent's economies remain stark, including relatively low levels of internal demand and the import quotas industrialized countries impose on African manufactured goods.
At the same time, developing countries overall owed more than $2 trillion in external debt in 1995. Sub-Saharan Africa, for example, paid $13.6 billion in debt servicing in 1995 - nearly double what it spent on health services. And developing countries bear by far the greatest proportion of the global burden of disease, which drains their human and economic resources.
One potentially optimistic note in this dismal picture of declining aid flows and increasing debt is the new 'Heavily Indebted Poor Countries (HIPC) Debt Initiative' launched by the World Bank and the International Monetary Fund in 1996. This initiative is designed to assist poor countries to achieve sustainable levels of debt based on an established track record of implementing social and economic reform and on the condition additional resources are channelled to basic social services. Bolivia, Burkina Faso and Uganda will benefit from the initiative only in April 1998 or later. More generous and timely debt-relief would enable these counties and others that will hopefully soon qualify to release resources to reduce malnutrition.
If the basic causes of malnutrition are to be addressed, greater and better targeted resources and improved collaboration, participation and dialogue are needed. Awareness and information must be generated: between sections of national governments; between governments; with all development partners, donors, UN agencies, non-governmental organizations (NGOs) and investors; and above all with those whose circumstances are rarely under stood or noticed, the poor themselves.
Action against malnutrition is both imperative and possible. The world, as the next part of this report explains, has already accumulated a wealth of experience and insights on which progress can be built.
The cycle of poor nutrition perpetuates itself across generations. Young girls who grow poorly become stunted woman and are more likely to give birth to low--birthweight children. If those infants are girls, they are likely to continue the cycle by being stunted in adulthood., if something isn't done to break the cycle. Adolescent pregnancy heightens the risk of low birthweight and the difficulty of breaking the cycle. Support is needed for good nutrition at all these stages-- infancy, childhood, adolescence, and adulthood -- especially for girls and women.
Source: ACC/SCN Second report on the World Nutrition Situation: Vol.1: Global and Regional Results, ACC/SCN Geneva, 1992
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