‘Not All Women’s Health Is About Maternal Health’

Poor nutrition, which directly causes malnutrition, has many underlying causes--poverty, of course, but also lack of education, poor sanitation, low quality of health services and ineffective nutrition programmes, IndiaSpend reported in July 2018.

Women also face several health problems that have nothing to do with their reproductive health that require attention from policymakers. In addition, they continue to face disparities in terms of access and treatment, spending less time in a hospital for all kinds of diseases and also less money on treatment compared to men.

About 13.5% of Indian women aged 15 and above are diabetic, while 21.3% of them have hypertension, as per the fifth National Family Health Survey, 2019-20 (NFHS-5). In addition, about 57% of them are anaemic, an increase from 53% in 2015-16.

To improve women’s health, we need to focus on these social determinants of health including providing access to adequate nutrition, sanitation, as well as by providing employment and education to women, according to Dipa Sinha, assistant professor at the School of Liberal Studies, Ambedkar University, Delhi. Sinha is a member of the core group on Right to Food under the National Human Rights Commission.

As India elects the 18th Lok Sabha, we spoke with Sinha to evaluate the performance of various schemes, including nutrition schemes, over the past few years.

Edited excerpts:

According to the NFHS-5, 16% of Indian men and 19% women have low body mass indices, in addition to 32% children under five years having low weight for age, despite the country being self-sufficient in cereal production . How much has the system of disbursing food entitlements improved and what do we need to do to improve it further?

Malnutrition is an outcome of multiple factors. Food is very important, but there are a number of other factors like sanitation, care for the child, feeding practices, etc. that influence the nutrition status. In India, there are gaps in all of these, according to the data.

At present, the food programmes meet very basic food security requirements of the beneficiary households. The role of food as a determinant (of nutritional status) goes beyond satiating hunger. It is meant to provide adequate nutrition. For this, you need a diverse diet. Whatever little data we have on dietary diversity, the Indian cereal-based diets lack in several food groups. There is very little protein in Indian diets. Good quality protein, which is animal protein, is unaffordable, so a lot of people don't consume them on a regular basis. Fruits, vegetables, oils, etc. are not given through the public programmes. Their consumption depends on people's capacity to buy them from the market.

In addition, there are a number of issues like unemployment, livelihood security, etc. that affect food access. We look at food security not just from the point of view of rice and wheat--or roti and chawal--but actually appropriate diets that would improve nutrition. The public programme does not meet these requirements.

To a certain extent, the mid-day meal and Integrated Child Development Services (ICDS) do give foods like vegetables and proteins, but when the cost of providing them increases, these schemes also end up giving mainly cereals.

The way the PDS can be improved is by including dal and edible oil. School and anganwadi meals can be improved by including eggs.

Nutrient deficiencies affect all sections of the population, so what is the rationale behind targeting women and children under the ICDS for nutrition?

If you look at undernutrition, there are certain age groups where it is very critical to make interventions. For instance, pregnant women need additional good quality food. If they don't put on weight during pregnancy or have a healthy pregnancy, then the likelihood of the child being born underweight is higher.

Similarly, nutrition programmes for the young child from birth to about five to six years of age is essential because that is the age when the most growth happens. A lot of times, malnutrition that sets in in that period is irreversible later. Children in that age group can eat home-cooked food, they do not need some special food or packaged food. However, they need adult supervision and care for appropriate feeding. For example, because they're young children, they have small stomachs, they cannot eat a large quantity, so you have to feed them more frequently. So that small quantity of food has to be nutrient-dense. In our home, that might be a khichdi with an added spoon of ghee or chicken broth or something like that.

Similarly adolescence is another period, especially for girls and for boys, when there are periods of growth spurt. We focus more on girls because that is the period during which, in some ways, the woman's body is preparing for pregnancy. A lot of studies show that it is not enough to intervene only during pregnancy, it doesn't help very much. You have to start earlier. This means, in the woman’s life cycle, early childhood, adolescence and pregnancy are periods during which if you intervene, that has a long lasting intergenerational effect on malnutrition. That is why we focus on these age groups.

Additionally, there are gender issues, issues of intra-household distribution, etc. Children can't eat on their own, so care has to be provided along with feeding. That's why something like the anganwadi and creches become very important.

All of this is quite well understood and evidence-based. We do need a household-level intervention to improve everybody's diet, but these specific groups need some additional support. That is why all countries usually have early childhood programmes for maternal and child health, which include a nutrition component because these are phases in life where you need additional nutrition and care.

Have India’s current programmes for nutrition and health of women and children, such as the ICDS, Pradhan Mantri Matru Vandana Yojana (PMMVY) and Janani Suraksha Yojana (JSY), improved over earlier interventions? If yes, how?

The ICDS has been around since 1978. It started off mainly as a supplementary nutrition programme. Over time, pregnant and lactating women and then adolescent girls got added to the ICDS. It provides supplementary nutrition by providing take-home rations for young children, pregnant and lactating women, ideally a protein-dense food like sattu (roasted bengal gram) powder or panjeeri (a sweet made from nuts and seeds), growth monitoring, preschool and a number of other services. But it was implemented on a project basis till 2006, when the Supreme Court said that it should be universalised.

The ICDS also does growth monitoring by checking the weight of pregnant women and children. It also provides iron and folic acid supplementation and supplementary nutrition for children as well.

JSY and PMMVY are more recent. The JSY is now almost 20 years old. It began in 2005 as an incentive for women to deliver in hospitals because the home delivery rate was very high, as skilled attendance during delivery could reduce infant and maternal mortality.. If there is an emergency during delivery, for example, the woman is bleeding too much or if there is some issue with the baby, then also you need skilled attendance. Providing such attendance becomes difficult in the home environment. So the policy goal was to encourage people to go to a hospital or health centre to deliver. JSY is basically a cash incentive to make people deliver in a facility that can handle complications.

The PMMVY was announced in 2017 and launched in 2018. It is a nutrition-related programme that is part of the National Food Security Act. It is a cash transfer but it is still part of the FSA. The idea there is that for the first six months, the only food for a child is breast milk. And to breastfeed, the mother has to be with the child. Since most women in our country work in the informal sector, they don't get leave or maternity benefits. So this was supposed to be a wage compensation which would allow women to be at home and enable them to feed the child, get some rest and get better nutrition while they are breastfeeding.

The issue here is that the amount is very low and it comes very late. It is provided only for the woman’s first child. Only from last year, they began providing it for the second child if the second child is a girl. One reason behind this restriction, I think, is budgetary. The other is related to population control, although that does not make much sense. There is some feeling that if you give it to subsequent children, then for that Rs 5,000, which comes almost a year after the child is born--although it’s supposed to come immediately--people will be incentivised to have more children.

About 88.6% of all deliveries are conducted in an institution, as per the NFHS-5. Can we attribute this to the success of the JSY?

Yes, the JSY has contributed to increasing institutional births. In addition, there is an increase in antenatal care also. Those are the things that have contributed to the decline in maternal mortality.

There were 103 maternal deaths for every 100,000 births in India in 2020, a decrease from 179 in 2010, which suggests that the improvement in maternal mortality ratio has not kept pace with the increase in safe births, institutional deliveries, etc.

There have been studies (here and here) saying that the JSY was very effective in bringing people to health centres to deliver, but that it was not as effective in reducing the mortality and morbidity. There can be multiple reasons for that, the first of them being that although they did come to the hospitals to deliver, there are many cases we know of in which the hospitals were not equipped. Then, there were instances of women delivering in the corridors or outside the hospitals and so on. The whole point of the hospital is that there is a sterile environment with a skilled attendant present. Overall, the quality of the hospital or health centre, availability of blood and medicines at the centre, availability of emergency transport, etc. make a difference.

MMR has a lot to do with care provided at the time of birth, but the health of the woman during pregnancy also matters. This brings us back to the issue of nutrition. Anaemia is one underlying cause that has not been addressed.

Anaemia affects 57% of the women in India and 25% of the men, a number that has increased since the 1990s, despite the existence of food security programmes and supplementary nutrition programmes. What do we need to do differently to move the needle on this?

That is a difficult question. A lot of people are grappling with this, but one important determinant is the issue with which we began: dietary diversity and good quality diets.

Anaemia has a lot to do with diet diversity. We know there are five broad food groups that we are supposed to eat from: fruit and vegetables, some healthy fat, and protein--both plant-based like dal and animal-based like milk, egg, etc., in addition to cereals, but there are gaps in the consumption of all these food groups. Surveys show that starvation has decreased, the number of people sleeping on an empty stomach has come down, which is true. But at the same time, what they're eating is not enough to meet all the nutrient requirements.

The focus of our food policy has always been only on cereals. Even for iron-deficiency anaemia, the absorption of iron depends on your overall diet containing sufficient protein, micronutrients, vitamin C, etc. On these, the data reflects very poorly on the Indian diet. This definitely strikes as one of the obvious reasons behind such a high prevalence of anaemia. The solutions offered for anaemia, like rice fortification, etc. don’t take care of the overall diet. So they are not very effective in addressing the problem.

What are the ramifications of having such a high percentage of the population weakened with anaemia?

The health ramifications are wide, for the women themselves and also for their children. It has an impact on maternal mortality, the health of her child, etc. It increases her chances of having a low birth-weight child, who is more likely to be malnourished. There is a whole intergenerational effect.

Anaemia has an effect on the productivity of the workforce. To be clear, the prevalence of anaemia is very high even among Indian men. It makes you weak, so you are not able to work as much. That is a direct economic consequence: you fall ill more often and you cannot work to your potential.

Since the ‘Scheme for Adolescent Girls’ was subsumed under the Saksham Anganwadi and Mission Poshan 2.0, girls in the age group of 10-14 were no longer covered by it. Since the NFHS tracks children’s health from the ages 0-5 and women’s health in the 15-49 age-group, what do we know about the nutrition status of girls in the age group of 5-14? Has there been an improvement there?

We don't have a lot of data looking at the health of adolescent girls particularly. The NFHS looks at data for women but mostly the focus is on women as mothers. The population that is sampled is in the age group of 15-45 years of age. Adolescent girls would be 10-19 years old, so the sample of 15-19 is not enough. The comprehensive national nutrition survey (CNNS) which surveys these age groups, shows that a quarter of girls in this age group have low BMI, and a large proportion of them are anaemic.

However, because a lot of pregnancies happen amongst adolescent girls, from the data collected about them, we know that their health is not great.

Further, the component of supplementary feeding for adolescent girls, although a part of anganwadi, is not included in the National Food Security Act. While supplementary nutrition for young children and pregnant and lactating women is a universal programme, it is not the case with adolescent girls. With the merger of schemes and unavailability of data in the public domain it is also not clear what the coverage of adolescents is in these schemes targeted towards them. The school meals also are only up to class 8, and therefore adolescent girls in class 9 to 12 are not covered.

What are the biggest challenges, according to you, before the reproductive and child health programme in India for the next decade?

Everything that we've been talking about so far. First of all, we need to look at it in a more comprehensive manner. Nutrition, women’s status, sanitation, and diet are underlying determinants of the reproductive health outcome. So it's not just about the service availability, which we have improved. But there is a lot of scope for improving the quality of antenatal care, neonatal care and so on.

The programme needs to look at its outcomes in a more comprehensive manner and take account of the social determinants of health, which include nutrition and other things, only then can we truly address it.

What do we know about the health needs of women older than 45 years of age from surveys?

The whole attention of the NFHS has been on reproductive and child health. It is not a general health survey, so we don't have data on women from that age group. Elderly women do have a unique set of problems; also women live longer. With all these nutritional deficiencies, things like knee aches, arthritis, calcium deficiencies, back aches, are common but we don't know or do anything about them. All that is also health.

This is usually the context in which women's health is talked about, you know, the reproductive health, maternal health services, nutrition, etc. What else do we need to do to improve women’s access to health?

First, we need to move towards understanding that women's health is not equal to only reproductive health. Women also get TB, cancer, hypertension, and all the illnesses possible, and then they also give birth and have other sexual/reproductive health issues. The way women's health has been looked at has been very instrumental. In fact, not all women’s health is about maternal health.

Other than for reproductive health, there are no programmes for women’s health. There is a lot of effort spent in universalising antenatal care, for instance. That will happen through ASHA workers, in anganwadis, or through workers going to women’s houses to make sure she comes to the centre, etc. We have a method there, even though there are gaps in this also, which is absent in the case of other health problems.

Micro studies show that for similar kinds of complaints, women are less likely to go to seek treatment compared to men. They would delay it for longer, or not visit the doctor as frequently, not spend as much as required, or disrupt treatment. These require not just direct interventions, but also an overall improvement in women's status. This requires providing them with an education, employment opportunities, etc.

In the health system, even things like having female doctors can improve women’s access. Also training for male doctors to deal with women. There are a lot of things which can be done to make the health system more gender sensitive. The point is we are not thinking about it.

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