A new research study finds that average maternal nutrition in India is not only much worse than what national data suggest but significantly worse than in sub-Saharan Africa, where women are, on average, poorer, less educated and have higher fertility rates.
According to the study, 42.2 per cent of Indian women are underweight when they begin pregnancy, nearly seven percentage points higher than the figure of 35.5 per cent cited in the National Family Health Survey (NFHS)-3 and 25 percentage points more than the figure for sub-Saharan African women.
The study was published on March 2 in the prestigious Proceedings of the National Academy of Sciences (PNAS), highlighting another significant aspect of discrimination against women in India.
"These findings should be a wake-up call about maternal nutrition in India. The health of children is one of the most important measures of the well-being of society and that starts during pregnancy," said Diane Coffey, who conducted the study. Coffey is a researcher with Princeton University's Office of Population Research and co-founder of r.i.c.e, an institute that researches human development of Indian children.
"Infants whose mothers do not weigh enough when they are born are more likely to die in the first month of life. Infants born to undernourished mothers are also more likely to have low birth weight, which is associated with height and health in childhood and adulthood, as well as cognition and economic productivity," she added.
Her study applies a variety of econometric statistics to explain the problem with maternal nutrition in India. Although NFHS-3 puts the percentage of women between 15 and 49 years of age at 35.5, this is the average for all adult women. "It will be an incorrect estimate of pre-pregnancy underweight if women who become pregnant have different body mass index scores than women who do not become pregnant," Coffey says.
In India, pregnancy is concentrated between the ages of 18 and 25, which are also ages at which women are most likely to be underweight. Coffey's analysis found that only 16.5 per cent of women in the sub-Saharan African sample are underweight before pregnancy and the average prepregnancy Body Mass Index or BMI among African women is 21.5, which is 2 BMI points higher than among women in India at 19.5.
Weight gain during pregnancy is considered another significant indicator of maternal nutrition and establishes whether it is possible for Indian women to compensate for prepregnancy deficits. The US Institute of Medicine recommends that women who begin pregnancy underweight gain between 12.5 and 18 kg during pregnancy, and that women who begin pregnancy at a normal weight gain between 11.5 and 16 kg. Coffey's research finds that women in both regions gain only about seven kg on average. But severe pre-pregnancy deficits in India mean that Indian women end pregnancy weighing even less, on average, than women in sub-Saharan Africa do when they begin pregnancy.
Coffey says there are two big reasons that explain big differences in maternal health in India and sub-Saharan Africa.
"The first is the status of women in Indian society. In India, young women who become mothers are severely discriminated against - they have to work hard, and are expected to be self-sacrificing, even to the extent of not eating enough in pregnancy. The status of young women in sub-Saharan Africa is much better," she says.
The second likely reason is diseases. "Diseases caused by open defecation (parasites, cholera, diarrhoeal diseases, typhoid) affect adults as well as kids. Adults who are sick with intestinal diseases are skinnier than they would be if they were not sick - women in India would almost certainly weigh more during pregnancy if we could reduce open defecation. Open defecation in rural Africa is far less than in rural India, and population density is much lower," she added.
The fourth edition of the NFHS is underway but Coffey says her observations from field research in Uttar Pradesh suggest that the state of maternal nutrition might improve but not enough to make a significant difference to the overall picture. "The statistics for open defecation and calorie intake are not improving so maternal health and nutrition are unlikely to change either," she says.
India's maternal mortality ratio (MMR), though considerably improved from 1990, was 178 per 100,000 live births in 2010-12 compared with the Millennium Development Goal (MDG) of 140 MMR per 100,000 live births. According to the Economic Survey, India expects to achieve 141 MMR per 100,000 live births by 2015, the final year of the MDG but the PNAS study suggests that this could be an optimistic target.