A crisis has been hiding in plain sight for many decades: Pakistani women suffer immense micro-nutrient deficiencies, which in turn, are adversely affecting their visibility and contribution to society. This goes beyond traditional notions of healthy mothers; it is equally about healthy working women, whose nourishment is critical to any national development project.
Medical studies have been pointing to this alarming situation for long: a study carried out in 2000 reports that the health of the population is adversely affected by inequities, with women and children worst affected. More than half our children lack the all important protein energy component. Such a magnitude of malnutrition points to stark inequities within the country.
When it comes to statistics, there isn’t much in the way of up-to-date numbers and analyses. The last official survey, National Nutrition Survey (NNS), was conducted in 2011. Its findings were released in 2013, and as expected, the situation had taken a turn for the worse.
As per the NNS-2011, 51 per cent pregnant women were anaemic, 46pc suffered from vitamin A deficiency, 47.6pc from zinc deficiency and 68.9pc from vitamin D deficiency. Malnutrition was only slightly lower among non-pregnant women — 50.4pc of whom were anaemic, 41.3pc had vitamin A deficiency, and 66.8pc had vitamin D deficiency. A remarkable 58.1pc of households are food insecure and only 3pc of children receive a diet that meets the minimum standards of dietary diversity.
Where does this leave Pakistan in global standings for gender empowerment? Lodged at the bottom, ranked 144 out of 145 countries.
This begs the question: are Pakistani women deliberately being deprived of food?
The NNS-2011 found that nutrient deficiencies affected over 35-39pc of adolescent married women, while the problems only increased with age. Major reasons for high maternal mortality are malnutrition, severe anaemia, poor access to prenatal care (28pc) and dearth of trained attendants at birth (20pc).
As per the NNS-2011, 51 per cent pregnant women were anaemic, 46pc suffered from vitamin A deficiency, 47.6pc from zinc deficiency and 68.9pc from vitamin D deficiency. Malnutrition was only slightly lower among non-pregnant women — 50.4pc of whom were anaemic, 41.3pc had vitamin A deficiency, and 66.8pc had vitamin D deficiency.
Gender discrimination, gender roles, and social norms affect women more: they can lead to early marriage and childbearing, close birth spacing, and under-nutrition, all of which contribute to malnourished mothers.
This in turn affects children: even though the proportion of underweight children has declined during the last one-and-a-half decades, approximately one-third of young children are still underweight. Stunting and wasting have actually increased: among children under the age of five years, stunting has increased from 41.6pc in 2001 to 43.7pc in 2011, and wasting has increased from 14.3pc in 2001 to 15.1pc in 2011. There has been no change in the percentage of underweight children since 2001, which is 31.5pc.
“If you notice, people do not allow housemaids to bring their babies along. As a result, their children are often not well fed,” argues Dr Zulfiqar A. Bhutta, the founding director of the Centre of Excellence in Women and Child Health at Karachi’s Aga Khan University (AKU).
“Unfortunately, society does not encourage breastfeeding, and daycare centres for working women’s children are absent,” he adds, while emphasising the need to encourage breastfeeding, as this decreases the risk of death in the first two years of a child’s life.
While it is convenient to assume that malnutrition is merely a problem borne of poverty, it is in fact a problem that cuts through class and income backgrounds, and is not restricted to women of a certain class. Poor income is not the only predictor of malnutrition; gender, urban-rural differences in access, utilisation and quality of healthcare also influence health. Then there are underlying factors such as illiteracy, unawareness of the mother about healthy behaviour, lack of decision-making power of women, and deep-rooted cultural values of a patriarchal system that hinder women’s nourishment.
It is a ‘culturally’ accepted norm, particularly among the unlettered, that women can survive easily on minimal food without encountering any ill effects. Gender biases exist within households in patterns of food allocation, with women often receiving a lower share of food requirements than men. Even expectant mothers are given no additional food portions.
Traditions and superstition are plentiful too: for instance, it is believed that adolescent girls shouldn’t eat ‘hot’ foods, i.e. foods that are nutritious and energy giving, such as eggs, meat or fish.
Because of such customs, not only are their lives endangered but the continued malnutrition may lead to further dire consequences: it weakens women’s ability to survive childbirth, makes them more susceptible to infections, and leaves them with fewer reserves to recover from illness.
Marriage and childbirth brings greater predisposition to illness and even death; further, the babies born to them are at higher risk of malnutrition. Adolescents and young married women become even more affected, because their access to services is curtailed by their low decision-making power in the household, limited mobility, and strict veiling norms.
The well-being of a population is based on prevailing economic factors, particularly income and consumption patterns; however, it doesn’t depend solely on these; social indicators such as life expectancy, health, education and nutrition are also important dimensions. Given the nutrition status quo, it is no surprise that Pakistan has the highest maternal mortality in the South Asian region, and among the world’s worst maternal mortality ratios, and prominent nutrition-deficiency diseases.
Financial crises and scarcity of food are described by the NNS survey as the prime culprits. But an assessment of the proportion of boys and girls (ages 13-18) consuming below 70pc of recommended nutrients indicated many gender discrepancies, including in consumption of high-protein foods such as meat, fish and eggs. This may be because boys are given preference within the family in the consumption of more costly high-protein foods, while girls rely more on high-calorie staple foods, and remain undernourished.
The status quo points to Pakistan’s failure to address malnutrition among women despite the Constitution emphasising the right to food in Article 38: “The State shall provide basic necessities of life, such as food, clothing, housing, education and medical relief.”
Pakistan has keenly signed and even ratified various covenants, treaties and conference recommendations. The human right to adequate food has been recognised in different international instruments, most notably the Universal Declaration of Human Rights (UDHR); the International Covenant on Economic, Social and Cultural Rights (ICESCR); the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW); and the Convention on the Rights of the Child (CRC).
It’s a depressing picture, but to look ahead at future promise — Pakistan’s adolescent promise — it’s critically important to safeguard and improve their nutrition, step up their calorie intake, and to enable them to become healthy, productive members of society.
To begin with, successive governments need to do away with their short-sighted and reliance on donor agencies to fill the nutrition gap. There needs to be adequate allocation of funds from the national exchequer for human resource development, with well-planned policies and programmes, and targeted, time-bound solutions.
It is equally important for Pakistan’s new nationalist project to ensure gender justice and gender equality by removing discriminatory laws, customs, policy decisions that relegate women to subservience. Malnutrition in women leads to economic losses for families, communities, and countries; it reduces women’s ability to work and can create ripple effects that stretch through generations.
Adolescent girls are especially vulnerable to malnutrition because they are growing faster than at any time after their first year of life. They need protein, iron, and other micronutrients to sustain the adolescent growth spurt and meet the body’s increased demand for iron during menstruation. But usually they suffer from iron deficiency anaemia, and protein energy malnutrition, iodine deficiency; they have low serum calcium, vitamin D and vitamin A levels.
It makes sense therefore to further step-up girls’ and women’s nutrition, health and education — much more than the steps being currently undertaken. Fortification of staples with iron, iodine, vitamin A, and other micronutrients; fortifying sugar with vitamin A and salt with iodine and wheat flour with iron are all relatively simple steps to take forward. Adolescent girls and pregnant women are especially in need of iron and folic acid supplementation. Cheaper sources of high biological value protein, legumes and soya beans are also good alternatives for the purpose.
Malnutrition can be addressed by long-term initiatives including food security, child protection, empowerment of women, targeted agriculture safety nets and early childhood development programmes. Improving female education, enabling women to become economically self-sufficient, and motivating them to utilise health facilities, emphasis on balanced diets for mothers, sensitising caregivers and health personnel to gender issues will help enhance their health status.
The writer is a development worker and women’s rights activist
Early marriages and nutritional deprivation
by Zofeen T. Ebrahim and Madiha Latif
Marrying girls off robs them of more than just their innocence
To best understand malnutrition in women, one has to look at the issue more holistically, as malnutrition does not just suddenly occur in women. The “nutrition deprivation” in the life cycle of women, where they are in a constant state of nutritional stress from childhood to adolescence to childbearing period, is the central issue.
Public health expert Dr Inayat Thaver explains the “inter-generational cycle” thus: “A female baby of low birth weight (LBW) is born, fed inadequately; reaches puberty, is married off early, delivers a number of babies who may also be of LBW.”