International Center for Research on Women ICRW/OMNI Research Program Charlotte Johnson-WelchCharlotte and KurzKathleenM. ResourcesApproach Women’sa for Case The Results: Nutrition Enhancing March 2000 Copyright© 2000 International Center for Research on Women 1

Enhancing Nutrition Results: The Case for a Women’s Resources Approach

Kathleen M. Kurz Charlotte Johnson-Welch

Contents

Acknowledgments 2

Introduction 3

A Conceptual Framework 5

Women’s Contributions to Family Nutrition 8

Resources that Support Women 13

Conclusions and Recommendations 20

References 22 2

Acknowledgments

We would like to thank the following people for their contributions to this document:

■ The ICRW/OMNI research partners and their colleagues at Mahidol University (Thailand), CEPREN (Peru), FARM Africa (Ethiopia), Tanzania Food and Nutrition Centre (Tanzania) and the National Potato Research Centre, the Kenya Agriculture Research Institute and the International Potato Centre (Kenya), whose research showed us how this approach worked in the field;

■ Barry Popkin, University of North Carolina; Sonya Rabeneck, ACC/SCN; Chessa Lutter, Pan American Health Organization; Susan Burger, Helen Keller International; Eleonore Seumo, CARE International; and Katherine Dickin, Cornell University, whose technical review contributed significantly to strengthening how we stated our case;

■ Our ICRW colleagues, especially Sarah Gammage, Ana Pieczanski, Annelies Drost-Maasry, and Miriam Escobar, who were important members of our research team and who provided support, encour- agement, and substantive input through the life of the ICRW/OMNI Research Program; and Rekha Mehra, who provided intellectual guidance, clarity of thought, and a sense of vision that kept us on track and fixed on our objective; and

■ Dr. Frances Davidson and Dr. Tim Quick, Office of Health and Nutrition, U.S. Agency for Interna- tional Development; Dr. Suzanne Harris, International Life Sciences Institute; and Dr. Paula Trumbo, formerly at ILSI, who were willing to invest in our idea and, through us, the research teams and women in developing countries.

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Introduction

ver the last two decades, the nutrition of who are the most vulnerable . . . future reductions young children and mothers around the world (McGuire and Popkin 1989, O in the high rates of has been improved, thanks to research, policy 1990; Holmboe-Ottesen et al. changes, and programmatic investments (ACC/ 1989; MacCormack 1988; malnutrition world- SCN 1997a,b,c; ACC/SCN 1992; Gillespie and Huffman 1987). A key aspect of wide will be limited Mason 1991). Worldwide prevalence of under- women’s diverse roles is their unless those who weight (low weight-for-age) in children 0-5 years, participation in economic an indicator of short-term nutritional changes, activities. In fact, in poor design, test, and dropped from 38 percent in 1980 to 34 percent in families women work out of implement nutrition 1990. Similarly, rates of childhood stunting (low economic necessity; it is programs adopt a new height-for-age), an indicator of nutritional status in essential that they earn income generation of ap- the longer term, have dropped from 49 percent in to be able to adequately care for 1980 to 40 percent in 1995 (ACC/SCN 1997c). their families (Mehra and proaches to reduce it. Gammage 1999). This is Despite these gains, the rates remain unaccept- particularly the case in households ably high, and progress is uneven between and that are female-headed or female-maintained.2 within countries. High rates of stunting remain in And so women’s productive and reproductive South Asia, Southeast Asia, and sub-Saharan roles are inextricably linked. The types of care Africa (54, 38, and 39 percent, respectively). This women provide their families, combined with the is of particular concern to development practitio- conditions of the economic activity in which they ners and policymakers because stunting captures participate, determine whether family nutrition the cumulative effect of poor nutritional status, and welfare ultimately benefit. and serves as a proxy for the effects of social and economic development on child well being. The central question of this paper is: If women are the primary caregivers in their families, how It is the premise of this paper that, although some can their ability to carry out their roles be additional improvement could occur through the strengthened so they can improve and sustain the full implementation of existing approaches, future nutritional status of their family members? This reductions in the high rates of malnutrition paper will attempt to show that the key to worldwide will be limited unless those who design, achieving better family nutrition is through test, and implement nutrition programs adopt a ensuring that women have the set of resources new generation of approaches to reduce it. New they need to carry out their primary caretaker approaches should focus on sustainable strategies role, including the decision-making authority to that families can use to promote the nutritional use those resources to the family’s optimal benefit status of their own members. One approach that (Mehra 1994; Desai 1993, McGuire and Popkin deserves concerted attention is strengthening 1990; Leslie and Paolisso 1989; Rogers and women’s roles in promoting their families’ nutrition. Youssef 1988; Piwoz and Viteri 1987; Jolly 1985).

Women have large, important roles in taking care In the last few years, other voices have also called of their families, especially the youngest children for a focus on the situation of women if the

2 A female-headed household is one in which a woman has the day-to-day responsibility for maintaining that household, whether an adult male resides fulltime, partially or not at all in the household. A female-maintained household is one in which the woman contributes greater than 50 percent of the household income whether an adult male resides fulltime, partially or not at all in the household.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 4

nutritional status of the family is to be improved. Whatever the impetus for these recent calls, this Recently articulated as the “South Asian enigma,” paper demonstrates that an approach focused on Ramalingaswami, Jonsson, and Rohde (1996) women is feasible, in addition to necessary. To have asked, “Why are child malnutrition rates explain how to achieve the improvements for higher in South Asia than in sub-Saharan Africa women that will allow them stronger roles in even though each has similar poverty rates and improving their families’ nutrition and well-being, public expenditures in health, and South Asia has a framework is presented in which these concepts more food availability?” Their analysis is that the can be shown in their component parts, followed answer lies in the low social status of women in by examples showing that interventions in this South Asia, specifically that undereducated direction can improve nutritional status, and women with only limited economic opportunities finally, by recommendations for action. are unable to fully protect their families’ nutrition. Furthermore, a UN committee on nutrition has This paper does not describe in detail the con- called for action, saying that malnutrition is: straints women face in meeting their multiple responsibilities, because this has been done …not simply the result of inadequate before (McGuire and Popkin 1989, 1990; food availability or inadequate access to Holmboe-Ottesen et al. 1989; MacCormack 1988; health services and a clean environment. Huffman 1987). It aims to show, instead, how The quality of care and feeding offered to investments in women—as income earners and children, which is critically dependent agricultural producers, as food processors and on women’s education, social status and preparers, and as caregivers and health promot- workload, is now seen as a significant ers—can be made and how those investments contributing factor. Special efforts can yield nutritional results.3 It also attempts to should include the improvement of the dispel the myth that making investments in situation of women (ACC/SCN 1997b). resources women need is an indirect and, therefore, inefficient path for improving nutri- This call for a focus on the situation of women tional status. The ultimate goal of this paper is to may, in fact, be a response to a broad demand for convince program officers, researchers, and research that is more program- and policy- policymakers in the nutrition arena that making oriented so that greater strides can be made in these investments is fundamentally feasible and figuring out how to reduce rates of malnutrition effective. (Berg 1992), as well as to the charge that nutri- tionists need to develop a “public nutrition” approach (Beaudry 1999; Mason et al. 1996).

3 In a few studies reported here, the effect of men’s income or resources on child nutritional status was contrasted with women’s, but in most cases the focus was on women’s income and resources.

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A Conceptual Framework

he conceptual framework presented here technologies or business practices. Other Tillustrates the flow from what women need to resource needs are institutional in nature: finan- perform tasks to how those tasks contribute to cial services, water and sanitation services, and nutrition (see figure 1 on pp.6-7). The framework health delivery systems. Also, social networks— was developed based on research conducted in whether extended family networks or acquired five countries that explored how to achieve community networks based on common needs— micronutrient outcomes through a woman- are resources because they provide women with centered approach (Johnson-Welch 1999). It access to labor and other productive resources begins with a UNICEF model (see area on p.7) such as credit. Finally, and most fundamentally, showing the factors needed for good nutrition of women need education, good health, and good people of all ages, including the most vulnerable nutritional status—as it is their human capital that children 0-5 years of age (UNICEF 1998). The drives and maximizes the utility of the other most immediate factors contributing to good types of resources.4 nutritional status are dietary intake and health. Good dietary intake and good health of individuals This critical part of the framework (labeled as are in turn influenced by their access to food, the “basic factors”) indicates that because women care they receive, and the health care services acquire food, take care of family members, and they are able to access. Many elements and prevent or treat family health conditions, ensuring details of the relationships among these three women’s access to necessary resources is a levels are well understood (Engle, Menon, and central issue.5 Unlike the preceding three levels of Haddad 1997), and many of the programs and variables, however, the relationship between the policies necessary to promote the relationships extent of resources women have (resources which have been considered or are already occurring allow them to access food, care for their family, within programs. and promote their family’s health) and the actual dietary intake, health, and, ultimately, the nutri- The model also indicates that adequate access to tional status of their family has received relatively food, to care, and to health services is dependent little attention. on a further set of basic contributing factors. Within a family, women who procure food, take It is the purpose of this paper to describe the care of its members, and promote family health resources women need to enhance their contribu- need resources to be able to do so. Resources tions to nutrition and to show the subsequent include economic inputs (such as improved seeds effect on nutritional status. The elaboration of or fertilizer) to increase production, or equipment these resource issues is guided by the left side of (such as seed presses or grain mills) to reduce the framework (see p.6). Women acquire or use time and labor demands while increasing produc- nutrition-related resources according to three sets tion. Women also need skill training in the use of of activities: economic activities, including wage

4 In some frameworks time is listed as an important resource (Leslie and Paolisso 1989; Saito et al. 1994). Women make choices among activities in their caretaker and income-earning roles when they feel they do not have enough time to perform all of them well. That some activities are not performed may have negative consequences on the family’s nutrition and well being, for example, a sick child not being taken to clinic. In this paper, we do not list time as a resource because time itself cannot be created. Instead, we discuss labor-saving technology and other resources that save women time by increasing their efficiency or productivity. Time, then, becomes a cross-cutting issue and examples of resources that save women’s time are described in many of the sections that follow.

5 While the political and ideological superstructure, the economic structure, and political resources in turn influence the resources, and therefore nutrition, as shown in Figure 1, this paper places its focus on resource allocation within the family, especially to the women.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 6

labor, self employment, and agricultural produc- critical is that women have adequate resources to tion; food management activities, including effectively carry out these three sets of activities, processing and preparing food; and care giving thereby enabling them to provide for the nutri- activities, including feeding practices, health tional needs of their families. In the framework promotion, and health seeking behavior. What is below, economic activities are divided to show

Figure 1. Linking women’s access to resources and nutrition

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that women are likely to earn cash from some economic activities like wage labor and self employment, enabling them to buy food, as well as get food itself when their economic activity is agricultural production.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 8

Women’s Contributions to Family Nutrition

omen contribute to their families’ nutrition Women also earn income through their own Wthrough earning and expending income, enterprises and by selling products in markets through producing and processing foods, and (Draper 1996; Moreno-Black and Leimar Price through seeking and providing care for their 1993). These income-earning opportunities rest family members. within the control and management of women and, therefore, put income directly into women’s Earning and Expending Income hands (Sebstad and Chen 1996). In addition, Women are economically active in a broad range their expenditure-replacement activities, such as of sectors, and spend a higher proportion of the hauling water, caring for basic health needs, and income they earn on food and other basic needs cleaning their homes and surrounding areas, frees than men do. up household income that might have been used to purchase similar services. This unspent Women’s income may be used to buy food, income can then be used for other purposes, vitamin supplements, immunizations, medica- including buying food or health care services. tions, or to pay fees for health services. They work in the formal, semiformal, and informal Since women tend to spend income directly on labor markets, and earn income as wage laborers the purchase of goods and services that promote or as salaried employees in different economic the nutrition, health, and general well being of sectors including agriculture, manufacturing, retail their families, increasing women’s income can and commerce, and services (see table 1). have a greater effect on those outcomes than (Women’s agricultural work and food production increasing men’s income. For example, data from are discussed more fully in the next section.) Brazil suggested that income managed by women

Table 1. Sectoral distribution of women in the labor force (percentages) Region 1970 1980 1990 Agric. Manuf. Services Agric. Manuf. Services Agric. Manuf. Services Sub-Saharan 30 18 28 36 28 30 37 28 36 Africa North Africa 5 11 9 10 25 15 20 23 17 South Asia 17 12 9 20 18 11 32 41 15 East & Southeast 34 41 33 37 42 35 34 44 41 Asia China N/A N/A N/A 46 44 35 47 43 38 Latin Am 12 29 43 15 29 44 16 36 48 & Carib. Middle East 12 12 12 14 12 16 12 10 17 Newly Indepen. 50 38 47 49 43 53 45 43 56 States OECD 25 27 40 31 28 45 33 29 48 (Source: Mehra and Gammage 1999)

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Table 2. Effects of income earned by men and women on household welfare indicators

Effect of Effect of Ratio of effect: income Country Effect on women’s income men’s income earned by women/men Kenya Household Positive Negative — calorie level Guatemala Food expenditures Positive Positive 2.0 Brazil Child weight Positive Positive 4.2 for height Brazil Child survival Positive Positive 18.2 (Adapted from Quisumbing et al. 1995) was associated with about a three percent mothers earned more than half of the family’s increase in food expenditures as opposed to only income and had greater control of decision- 0.6 percent in the hands of men, and the differ- making power over family resources (Buvinic et ence was statistically significant (Thomas 1997). al. 1992). Thomas showed that women also tended to invest in foods that were associated with better health of Comparing studies in East and southern Africa, their family members, and the gender difference Kennedy and Peters (1992) also found that in income expenditures on food and health were women spent a higher proportion of their income reflected in child nutritional status. Indeed, on food than men. Income controlled by women according to the study, child weight-for-height had a positive impact on household caloric intake increased eight times faster if income was in the in addition to the overall positive effect of total hands of women than in the hands of men, a income on caloric intake. Similar findings were statistically significant difference. found in a study in the Indian states of Kerala and Tamil Nadu: “...regardless of how much a woman Similarly, a study in Kenya showed that children earns, she gives a fairly high percentage to her from female-headed households had significantly household [maintenance costs], always a much better nutritional status (both height-for-age and higher percentage than that given by her husband weight-for-age) than children in male-headed or other male household members” (Mencher households (Kennedy and Cogill 1987). These 1988). See table 2 for an overview of effects of female-headed households were also poorer on income earned by women versus men in a variety average than male-headed households; thus, the of settings. higher nutritional status was being mediated by factors other than income. The authors hypoth- The effect of women’s income is also beneficial to esized that these women made more decisions women’s own dietary intake (Bisgrove and Popkin about allocation of resources within their house- 1996). In a study of 28,000 households in holds than did women from male-headed house- metropolitan Cebu, in the Philippines, data on holds. Data from Malawi also show that “...al- women’s occupations, income, and dietary intake though their per capita expenditures are only 74 were collected for 3,327 women who gave birth percent of those of male-headed households, de between May 1983 and April 1984. Analysis of facto6 female-headed households provide a level this data for 938 women at 14 months post- of household caloric adequacy that is 95 percent partum found that women’s work significantly of the male-headed households” (Kennedy and improved their dietary intakes of energy, protein, Peters 1992). Similarly in Chile, child height-for- fat, calcium and iron, notably as a result of age was significantly greater in households where consuming commercially prepared foods. Further-

6 De facto is used in the same manner that “female-headed” is used earlier in this paragraph.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 10

more, women with low incomes and women who consumption and sale, while the propor- worked in the informal sector benefited more tion of women involved in the economi- from this income effect than did women with cally active agricultural labour force higher incomes and those who worked in the ranges from 48 percent in Burkina Faso formal sector. to 73 percent in the Congo… Asian women account for 50 percent of food Food Production and Processing production and their participation in the Women also contribute to family nutrition by agriculture labour force ranges from 35 bringing food into the household. They do this percent in Malaysia to 60 percent in through agricultural work in subsistence crops and Thailand. In Latin America and the in cash crops, by gathering wild foods and Caribbean, women represent a smaller producing minor crops such as sweet potatoes, part of the agriculture labour force but and by acquiring donations or in-kind services. continue to play significant roles in Once the food enters the household, women subsistence farming, poultry and small process and prepare it for consumption. animal production for domestic con- sumption (United Nations 1997). Women’s significant contribution to the agricul- tural production of subsistence crops is high- Table 3 illustrates women’s significant role in lighted in a UN report: agricultural work by country, especially in sub- Saharan Africa. Rural women are responsible for more than 55 percent of the food grown In addition to subsistence production, women also [worldwide]; in Africa, they produce 70 contribute to cash crop production. This contrib- percent of the food. Moreover, women utes to household nutrition in two ways. Women comprise 67 percent of the agricultural may work as wage laborers (in someone else’s labour force in developing countries. fields) thereby earning income that may be used [Further] women in sub-Saharan Africa to purchase foods and meet other household contribute 60 to 80 percent of labour in consumption needs. They may also work in food production for both household family fields, and contribute labor directly to the

Table 3. Women in agricultural labor force as percent of women in labor force Regions and Countries Percent Regions and Countries Percent Sub-Saharan Africa (1990) Asia Cote d’Ivoire 70 India 24 Guinea-Bissau 90 Indonesia 35 Malawi 91 Thailand 50 Senegal 88 Uganda 83

Near East & North Africa (1988) Latin America & the Caribbean Morocco 32 Brazil 10 Jordan 30 Costa Rica 2 Turkey 54 Mexico 12 (Source: FAO 1998; Mehra 1994; Flynn & Oldham 1999)

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household production of cash crops. While sale of it. Food processing can often . . . women’s roles these crops means more income for the house- improve the nutritional quality of in food processing hold, it may not translate into nutritional benefits foods and increase dietary diversifi- offer yet another as the disbursement of that income may not rest cation. Women process oilseeds, with women. In this case, women’s contributions such as sunflower or sesame seeds, entry point for to nutrition may be indirect, that is, increased to produce cooking oil; transform interventions that 7 production that may translate into more food in cassava into gari ; smoke and dry can enhance the market. fish and meat; and process and preserve fruits and vegetables family nutrition. Yet another way that women produce food for (Mehra 1996; ECART 1994; their families is by gathering wild foods and by McSweeney 1979). Thus, women’s roles in food cultivating minor crops, including sweet potatoes, processing offer yet another entry point for vegetables, fruits or secondary grains (Moreno- interventions that can enhance family nutrition. Black and Leimar Price 1993; Longhurst 1986; Fleuret 1979). The importance of these foods is In central Tanzania with only one rainy season, particularly great during the pre-harvest period of drying vegetables is an important food processing major food crops and when crops fail. technique for trying to maintain a year-round supply of vitamin A-rich foods. In a recent study In Kenya, new varieties of sweet potatoes rich in there, new solar dryers were developed to beta-carotene were introduced to women farmers respond to women’s preferences for small, with an end goal of improving vitamin A intake of household-sized units, and to their desire to have young children, thereby preventing vitamin A choices about costs and construction (cheaper deficiency. The Kenyan study showed a signifi- mudbrick or more expensive wooden). An cant increase in the intake of vitamin A-rich foods intervention combining health and nutrition (38 percent, p=0.0015), according to the food education with improved solar dryers enabled frequency methodology developed by Helen women to increase children’s vitamin A intake Keller International (Rosen et al. 1993), among and year-round availability of dark green leafy children whose mothers received both the vegetables (Mulokozi et al. 2000). The frequency production-focused intervention of planting of consuming vitamin A-rich foods (HKI scores) materials and access to agricultural extension increased between baseline and the post-interven- services, and the consumption-focused interven- tion period 18 months later significantly more in tion of nutrition education and training in food the intervention communities than in the controls processing and preparation. This compared to a (p<0.01), especially among those who adopted decrease in vitamin A food intake (30 percent, but the new technology. This suggests that the not statistically significant) for children whose availability of dried dark green leafy vegetables mothers received only the production-focused and their consumption by young children 0-5 inputs (Hagenimana et al. 1999). This example years old could contribute to reducing vitamin A suggests that: (a) women’s farm production offers deficiency in this age group. an entry point for interventions that can improve nutrition; and (b) interventions that increase Care- and Health-Promoting Practices women’s agricultural productivity and increase A third way in which women contribute to their health and nutrition knowledge may yield nutrition is by taking care of their families’ health more benefits than ones that target only produc- and development needs. These include use of tivity or only knowledge. health services for prevention, including immuni- zations, vitamin A and iron supplements, and Once food is produced and enters the household, growth monitoring; treatment and remedial care; women are principally responsible for processing breastfeeding and other feeding practices; and

7 Gari is a staple food product derived from cassava, a plant of tropical America and Africa cultivated for its tuberous roots.

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engaging children in activities that stimulate their are being made in women’s access to resources intellectual and emotional growth and develop- and human capital, immediate gains can be ment (Engle, Menon, and Haddad 1997; Food and achieved by improving women’s childcare prac- Nutrition Bulletin 1999; Range, Naved and tices. Bhattarai 1997; Leslie and Paolisso 1989). Although there is a recently burgeoning literature In Bangladesh, children (6-18 months) who were on care practices, the following examples are some growing well were fed at or before mealtimes; of the few that illustrate the important contributions had greatest dietary diversity of all children in the these practices make to family nutrition. sample; had foods prepared specially for them; and had breastfeeding mothers with the fewest Ruel and colleagues (1999) found in Ghana that dietary restrictions (Range, Naved and Bhattarai receiving good caring practices—defined in this 1997). It was interesting to note in this study study as child feeding and use of health services for that although income explained some of the growth monitoring and immunizations—were variation in nutritional status in the entire strong determinants of children’s height-for-age. sample, only the care variables were significant They suggest that, even as long-term investments predictors of improved growth.

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Resources that Support Women

hile the activities in which women engage ries of production-focused inputs, labor-saving Wcan contribute to their families’ nutrition, technology, microfinance for women, social the degree to which their families can benefit networks and support, and women’s own human from these activities depends on the number and capital. amount of resources women have available. This section focuses on the resources needed to Production-focused Inputs improve women’s efficiency and productivity, and Production-focused inputs are defined here as the makes the argument that an investment in these physical factors that would improve the efficiency resources would lead to a new generation of or productivity of an economic activity, such as improvements in nutrition worldwide. improved seeds and fertilizer in agricultural work. Land is also an important input, and it is expected There are two caveats about the information in that when women own or control land, their this section. First, although it is divided into families’ nutrition would benefit, but specific specific resources, the interventions featured are evidence on its nutritional impact was not found. often designed as a package of several resources. Labor-saving technologies and financial services There are few examples of single-component are considered to be other important resources, interventions offered to communities, which and are discussed separately below. usually have multiple needs. This means any improvement in nutritional status is to be attrib- In general, if women had as much access as men uted to the resource package and not to any one to resources such as land and agricultural inputs, component of it (Johnson-Welch 1999). Second, as well as education, training, and credit, their the literature on the impact of resources in productivity would increase, as shown through women’s control is much larger than is reviewed data from Kenya (see table 4). here. The cases included here are those that have been evaluated for nutritional improvements or Similarly, in Thailand and Korea, researchers are likely to improve nutrition. found women farmers to be as efficient as men after controlling for education, age, and produc- The key resources that women need to become tion-focused inputs (Quisumbing et al. 1998). more efficient and productive fall in the catego- And in Ethiopia, when female-headed households

Table 4. Returns to increasing human and physical capital of women farmers Study site When Women Have: Yield Increases: Maize farmers, Age, education, input levels 9.0 percent Kenya (1976) of male farmers Primary schooling 24.0 percent Food crops farmers, Age, education, input levels 22.0 percent Kenya (1990) of male farmers Same land area as 10.5 percent male farmers [Same] fertilizer level as 1.6 percent male farmers (Adapted from Fong and Bhushan 1996)

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 14

had access to the average values of inputs that to a motorized and physically larger press; how- male-headed households had, the gross value of ever, these presses were less reliable and were outputs was 1.3 percent higher for the female- dependent on fuel and replacement parts, which headed households (Addis et al. 1999). Increasing were not always available. The new ram press women’s access to these inputs, therefore, would technology enabled women to produce sufficient improve overall agricultural productivity and amounts of cooking oil for home consumption and increase food available to their families. sale, and reduced their time constraints.

In Bangladesh, longitudinal data collected by Data were collected at three points in the year to Helen Keller International suggest that improving capture seasonal variations in activities and food women’s access to production-focused inputs availability, including before, during and after the contributed to increases in vegetable production intervention. Dietary intake was measured using and household income, as well as improved two non-consecutive 24-hour dietary recalls and children’s nutritional status (Marsh et al. 1995). food frequency consumption. Children in house- Women received seeds and seedlings, training in holds with the new press had significantly larger production and storage techniques, and health increases in caloric intakes and significantly and nutrition information to encourage production improved nutritional status in the lean season of backyard gardens for home consumption and than did children in control households, most commercial sale. Household income rose by 12 likely due to an increased consumption of percent through the sale of vegetables. Further, weaning foods and other table foods containing because they were producing vegetables for their sesame seed oil. own consumption, household expenditures for these foods fell by ten percent, yielding a net In Burkina Faso, a multi-year, multi-sectoral increase of 22 percent in household income. project supported by the United Nations Educa- Increases in food consumption and income were tional, Scientific, and Cultural Organization associated with a larger decrease in percentage of (UNESCO) and the United Nations Development intervention households with severely under- Program (UNDP) led to more meals served to weight children (25 to 18 percent) than in control families following introduction of a mechanical households (22 to 19 percent). Rates of night grain mill (McSweeney1979). In this case, women blindness fell from 2.3 percent to 1.2 percent over took advantage of the time saved by using the two years in the intervention households.8 mill to prepare extra meals and different menus, and the result was dietary improvements. Simi- Labor-saving Technology larly, an intervention study in Ghana that in- Another way to increase efficiency and productiv- creased women’s access to a labor-saving pro- ity is to improve women’s access to labor-saving cessing technology for production of gari yielded technologies. For example, women in The Gambia improvements in women’s and children’s nutri- were introduced to an improved manually oper- tional status (Kennedy et al. 1994). ated ram press to extract oil from sesame seeds and the effect on women and children’s nutritional Microfinance security was significant (Silva-Barbeau et al. 1997). Women’s access to microfinance services helps The study compared mother-child dyads in two them meet immediate needs as well as future ones sets of communities—80 living in five communi- through savings. Access to loans also enables ties that received the ram press and participated in women to invest in productivity enhancing tools monitoring women’s adoption of the press and equipment and other assets. For instance, (intervention group) and 40 living in five matched access to credit permits women to purchase control communities. This latter group had access agricultural inputs, such as fertilizer and improved

8 Although statistical significance was not reported, the difference in the change from before to after the intervention period for the intervention and control groups was likely sufficient to be statistically significant, given the large sample size (980 intervention households and 194 control).

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seeds, which can enhance their efficiency and with input delivery and health education, were productivity; or to purchase medicines that demonstrated in a program in Ghana (MkNelly promote family members’ health. Credit also 1997). Freedom from Hunger designed the Credit enables women to accumulate assets, such as with Education Program to address two gaps that livestock or poultry, and these contribute either impacted negatively on the nutritional status of directly to household nutrition through production children—women’s lack of access to financial of milk and other food products or indirectly services (including loans) and their lack of through income generated through market sales. knowledge about how to care for and feed their Having an accumulation of assets also provides children. Village banking services and business women with an informal insurance mechanism; in training for rural women were combined with other words, they can sell assets when they need education in appropriate breastfeeding, child cash; or they can trade them to obtain other goods nutrition, diarrhea treatment and prevention, or services. They can also use assets for collateral. immunization, and family planning practices.

Women typically do not hold bank loans, however, The nutritional status and health of one-year-old because they lack the collateral to acquire them. children of participating mothers was significantly They often prefer to take loans that are smaller better after three years of the program compared than banks issue. A UN report states that “... to one-year-old children of mothers from a group women farmers receive…less than 10 percent of in the intervention communities who did not the credit allocated to small-scale farmers. In five participate and also compared to those from east and central African countries, it is only one control communities. Height-for-age Z-scores9 percent of the total credit available for agriculture” improved 0.3 points among participant children, (United Nations 1997). whereas they fell among children with mothers who did not participate and with mothers from Recently, a number of microfinance programs the control areas (-0.13 and –0.11, respectively, have sprung up to fill this important gap, making p=0.01). Weight-for-age Z-scores of children of small loans available to women (about US $100), participating mothers were also significantly without requiring physical or financial collateral. higher. More participating mothers gave colos- A microcredit loan is generally made to a group of trum to their newborns rather than discarding it; women, which then monitors the repayment rates more exclusively breastfed for longer; and fewer of its members. As many as 98 percent of these reported ever using a feeding bottle, a source of loans are repaid regularly. Recent experience fecal-oral contamination. Participants’ children also suggests that providing women with access also were found to have solid food diets of higher to complementary inputs such as general busi- nutritional quality. The children were more likely ness advice and planning, technical assistance to meet caloric intake requirements, and mothers and training, information on equipment and new were more likely to know how to prevent and technologies, markets, and rules and regulations treat diarrhea. The interest earned from loans improves the efficiency of financial inputs enabled Freedom from Hunger to fund 80 percent (Malhotra 1992). Through packages such as of the operating costs of the program. these, women’s businesses are more likely to expand, become more sustainable, and yield Use of credit to enhance access to livestock was greater benefits, both in terms of income and how demonstrated in a recent study in Ethiopia to it is used. yield nutritional benefits when combined with other inputs and information. A program to The child health and nutrition benefits of improv- provide women access to crossbred dairy goats ing women’s access to microfinance, combined was supplemented by agricultural inputs and

9 Z-scores, which are two standard deviation units from the mean of NCHS reference data, are used to measure nutritional status.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 16

health and nutrition information to improve characteristics, including the number of members dietary diversification (Ayalew et al. 1999). and their relationships, and primary residence Assessments were made before and after the (urban or rural; in Malawi or abroad) and their intervention period. Results showed that young contributions (food or non-food items) to the children were at lower risk of being vitamin A sample households were used to construct indices deficient, assessed by dietary intake and clinical that represented inter-household exchange signs, if they lived in families that owned livestock networks for women and for men. Results and had participated in the intervention program indicated that family members based in urban (see table 5). Access to resources enabled women areas or abroad contributed more to child to change their care and feeding practices to the nutritional status (height-for-age Z-scores) than did benefit of children. rural networks, and women’s relatives had a stronger influence on child nutritional status than Social Networks and Support did men’s. Low suggests that the exchange In addition to increasing women’s efficiencies and network variables are “reasonably strong proxies productivity, another method to reduce women’s for access to income, particularly the ratio of time and labor demands is to draw on others’ reciprocity and urban/abroad variables...” espe- labor. This is often done through a network of cially for women. This implies that reciprocity friends and family, civic participation, and group networks may cushion women and children from membership (Pinstrup-Andersen 1999). These external shocks that are beyond the immediate networks provide women direct access to labor, control of an individual or household. financial assistance, food, childcare, information, and contacts, or assist women in an intermediary Studies in Guatemala, India, and Peru also demon- capacity to access those resources. Moreover, strated the important contribution that social women’s social networks permit them to share networks make to improved nutritional outcomes. risks, practice new behaviors, try new food crops, A Guatemala study found that when children (one and supplement their labor when food shortages to two years of age) of working mothers were cared and other external pressures constrain their ability for by an adult rather than by a sibling the health of to meet their family’s nutrition needs alone. children and height-for-age (at four years) were significantly improved (Engle 1989). And social The contributions of family networks to child networks through women’s clubs in Hyderabad, nutrition were shown in rural Malawi (Low 1995). India, and community kitchens in Peru, in which Data were collected over 18 months to explore members make a large number of luncheon meals factors related to food and nutritional security in that they use themselves in payment for their three agri-ecological zones. Information on family volunteer time and also sell to others, also led to

Table 5. Impact of participation in the intervention on nutritional outcomes in Ethiopiaa

Participated in Didn’t participate Impact of trial intervention in intervention intervention b Child in the top quintile 0.49 0.37 20 % of the HKI scores Household had a 0.38 0.13 25% vegetable garden Child consumed milk 0.76 0.51 22% more than 4 times a week a These results are adjusted for other determinants of the expected outcomes. b Differences are significant at p<0.01.

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improved nutritional outcomes (Carrasco Sanez et Identifying the support systems that women use in al. 1998; Huffman 1987). caring for and feeding their families and in earning income and producing food is an important first An underutilized source of social support for step in intervening to ensure these critical mecha- women’s contributions to nutrition is men. nisms are responsive to women’s needs. Although role differentiation occurs at the house- hold level, men play several critical roles in Women’s Human Capital supporting their families’ nutrition. First, they are Another resource women need to improve their often both the gatekeepers of income and assets ability to earn income and care for their families in the household and have strong influence over is to be strong themselves in mind and body, i.e. the allocation of the benefits that accrue from to improve their own human capital. And those within the household. Second, men’s women’s human capital is strengthened by opinions may influence how women choose to eat investments in their leadership capabilities, or not eat. Research from Mexico suggested that education, nutrition, and health (Baker et al. 1996; women limited their food consumption during Merchant and Kurz 1992; Parker et al. 1990). pregnancy because their husbands did not want them to gain much weight (Parker et al. 1990). A These investments enable women to better similar pattern was found in a Thai refugee camp process information, to adopt new practices and of Khmer and Vietnamese refugees. In this case, technologies, to use health services, and interact the nutrition education was redirected to the effectively with health care professionals. Also, husbands to encourage greater food consumption their newborns are less likely to have low birth among their wives who were pregnant. The weight and more likely to be healthier (Smith and intervention group had significantly higher Haddad 1999). The converse is that if women’s knowledge scores about dietary intake during human capital is compromised, they are less able pregnancy than the control group. Moreover, to meet their income earning and caring roles. In women in the intervention group also had fact, the illness or death of a mother severely significantly higher average weekly weight gains limits the survival of her children (Save the (Parker et al. 1990). Children 1999).

In a pilot study to improve children’s nutritional Leadership capabilities. A critical element of status and that of pregnant and lactating women, women’s human capital is women’s leadership CARE/Cameroon targeted men as a key interven- capabilities. In Thailand, women were trained in tion group. Field workers met with men and problem-solving methodologies and community discussed the importance of improving women mobilization techniques (Smitasiri and and children’s nutrition, and their potential role Dhanamitta 1999). They applied what they had toward that improvement. Nearly all the men in learned to work with their communities to the intervention began to support their wives’ identify solutions to reducing vitamin A, iron and efforts to try new care and feeding practices. iodine status. The interventions included school- Further, the women reported that they were more based distribution of iron supplements to adoles- willing to try the new practices because of their cent girls; improvements in nutritional quality of husbands’ support (Seumo, personal communica- school and home-based meals by including oil, tion). This proactive effort is a good example of vitamin A- and other nutrient-rich foods; health how recognizing men’s influence on family and nutrition education in the schools and decisions and behaviors, and actively engaging community; and local production of iodized salt. them in the process of designing and implement- Baseline and post-intervention data from interven- ing interventions to improve family nutrition, can tion and control communities were compared, enhance the outcomes of those interventions. and the findings included significant differences

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 18

in vitamin A intakes among young children 2-5 Nutrition. Improving women’s general nutritional years old, young adolescents 10-13 years old, and status is another investment in their human pregnant and lactating women; and vitamin A, capital, and can be accomplished through several iron, and iodine status among the young adoles- means — by decreasing their energy expenditures, cent girls in the intervention communities as and by increasing their nutrient intake. Labor- compared to those in the control communities saving technologies, which are described in an and in comparison to baseline. earlier section, help decrease energy expenditures. By improving women’s productivity and work Another example of how an investment in efficiency, these technologies also contribute to women’s leadership can yield nutrition benefits is women’s nutritional status by reducing their provided by a recent study in seven community workload and energy expenditure. For instance, kitchens (comedores) in Peru. Over an 11-month the gari processing technology was an improve- period of time, kitchen members participated in a ment over traditional gari processing methods that series of training and problem solving workshops were heavily labor intensive, thereby reducing that aimed to strengthen their decisionmaking and women’s energy expenditure while increasing leadership skills. They received health and production of the food (Kennedy et al. 1994). nutrition information; developed and tested Other technologies that have this dual benefit recipes that included locally available iron-rich include wells or piped water systems that are close foods; and learned how to adapt preparation and to women’s homes, and fuel-efficient stoves that serving methods used at home to those more reduce the need for fetching firewood (Leslie 1991). appropriate to a larger scale production. Women also were trained as quality assurance supervisors Reducing micronutrient deficiencies in women, in to ensure the new standards and procedures were addition to in their children, is yet another implemented in consistent fashion. As a result of investment in their human capital. Recent their efforts, there were significant improvements intervention trials found that vitamin A or beta- in women’s iron status and reduced rates of carotene supplementation in Nepal reduced anemia (Carrasco Sanez et al. 1998). Heme iron, maternal mortality and severe morbidity (West et bioavailable iron and vitamin C intake improved al. 1999; Christian et al. 1998). significantly among members and anemic women, but not among non-members. Prevalence of Regarding iron status, a review of data on the anemia dropped significantly (from 49 percent to economic consequences of iron deficiency (Ross 41 percent, p<0.05) in the intervention group. and Horton 1998) indicates that reducing iron deficiency among children yields improvements Education. The benefits of investing in women’s in their cognitive development and, if projected education to build human capital are well estab- into adulthood, these improvements can affect lished (Summers 1992). Educated women “...have hourly earnings and wages. Iron deficiency their first child later, make greater use of health anemia causes tiredness, lethargy, and fatigue, services, and are involved in work that generates and it impairs work capacity (CDC 1998). In fact, more income for themselves and their families” when women adult tea plantation workers (Merchant and Kurz 1992). A recent study in received a daily iron supplement, their daily Ghana found that maternal education was the activity was 80 percent greater than among most important predictor of good caring practices matched pairs of controls. (Ruel et al. 1999). Further, women who are educated are more likely to adopt agricultural and Health investments. And finally, improving other technologies that increase productivity and women’s health is an investment in women’s efficiency (Quisumbing et al. 1998). human capital that furthers their ability to earn

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income and care for their families (Tinker et al. infections, HIV/AIDS and other sexually transmit- 1994; Koblinsky et al. 1993). While recognizing ted diseases, post-abortion and obstetric compli- that the consequences of poor health during cations such as hemorrhage, and obstructed labor infancy and childhood impact on adult women’s also impact on their ability to be economically health, this paper focuses on their health as youth active and provide for their families (Huntington and adults. Women’s productivity is negatively and Piet-Pelon 1999; Vernon and Foreit 1998; impacted when they suffer from parasitic, skin, Population Council 1995; Germain et al. 1992). and infectious diseases (McDermott et al. in The range of health problems that women face Koblinsky 1993). Episodes of malaria negatively and the factors, including gender, poverty, and affect women and, if these occur during preg- social status, that influence women’s health nancy, can contribute to low birth weight suggest the need for broad investments through a (Wijeyaratne et al. 1992). Women’s reproductive comprehensive approach. health problems such as reproductive tract

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 20

Conclusions and Recommendations

o repeat the central question of this paper: If Thus, it is critical that a new generation of Twomen are the primary caregivers in their approaches explicitly address women’s resource families, how can their ability to carry out their constraints if families are to be provided with roles be strengthened so they can improve and sustainable ways to promote the nutritional status sustain the nutritional status of their family of their own members. This recommendation is members? A review of a number of studies has not revolutionary in content. What is new is shown that substantial reductions in rates of demonstrating different and additional avenues malnutrition, especially among infants and young for accomplishing it. Success will require drawing children who are most vulnerable, can be accom- from different disciplines, including community plished through interventions designed to in- development, economics, agriculture, crease women’s access to resources that support microfinance, as well as child survival, health, and their income earning and care giving roles—a nutrition. To make the process work partnerships women’s resources approach. will have to be formed among institutions. It would be a mistake for institutions to stretch their This approach enables women to carry out these skills across disciplines and across expertise areas dual roles more comprehensively. Typically, of programs and research. This paper proposes nutrition interventions tend to focus on the some very specific recommendations that need to immediate contributing factors shown in Figure 1. be considered by researchers, by program For instance, health and nutrition education and planners, and by policymakers if the process is skill training activities may aim to change feeding going to work: practices as a means to improve energy intake and, therefore, weight and height. Programs may ■ Researchers should investigate and rigor- distribute vitamin and mineral supplements to ously evaluate a variety of ways to increase increase micronutrient intake and status or women’s access to resources that will better support water well and latrine construction to enable them to promote nutrition in their improve environmental sanitation. They may families. train community health workers or traditional birth attendants to provide health services that The strong research and evaluation skills of are of acceptable quality. nutrition researchers are needed to investigate the interventions that most positively impact nutri- To achieve future reductions in the high rates of tional status, and to determine in which combina- malnutrition that exist in developing countries, it is tions, under which circumstances, and in what necessary to focus on the big picture of how doses the interventions work best. Rigorous malnutrition can be reduced most effectively and evaluation includes collecting reliable data to to look beyond the immediate contributing factors. inform the design of the intervention, and This would involve reducing women’s time conducting assessments before, during and after constraints so they can attend education and the intervention, with an intervention period of training sessions; increasing women’s income so sufficient duration to enable measurement of they can purchase these dietary supplements; or impact. During the assessment, researchers improving women’s access to land, fertilizers, and should pay careful attention to process indicators other production technologies so they can increase to determine if the intervention is going well and production of food crops to feed their children. to the use of appropriate impact indicators, such

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as weight, height, hemoglobin or serum vitamin Their close connections to communities and their A, depending on the goal of the study. Research- innovative spirit can lead to a new generation of ers should work with program practitioners and approaches to make future improvements in community members to interpret the data and nutritional status in developing countries. draw conclusions and recommendations for programs and policies. Program practitioners should join with nutrition researchers and with communities in designing Once the intervention research has been con- and implementing effective approaches to ducted, the researchers should join with the addressing women’s resource constraints, as well program practitioners to disseminate the results as in monitoring and evaluating the process, widely, especially to policymakers in the national outcome, and impact results. This partnership and international arenas so they can be per- will enable program practitioners to document, suaded to support efforts using a women’s analyze, and evaluate their results, so that, resources approach. together with the researchers, they can make a strong argument to policymakers and other ■ Program planners should use a women’s program practitioners and researchers. resources approach, and join with researchers to evaluate and document its impact on improving ■ In order to promote the women’s resources nutritional status. approach, policymakers should insist on partnerships between program practitioners and Some interventions, typically those implemented researchers from a variety of disciplines. by NGOs, already “go outside the box” by using a variety of approaches to improve nutrition. These National and international policymakers can institutions are apt to be flexible and responsive promote this new approach by ensuring that to community needs in their programming supportive policies are in place, such as easing the because they work closely with communities and way for women to have access to credit or land use a broad development approach integrating tenure, or by encouraging input from communi- numerous perspectives and expertise (Shah et al. ties, NGOs, and others in resource allocation 1999). Thus, they often realize and act upon the decisions. In addition, donors and policymakers need to address fundamental constraints, includ- can encourage this resource-focused, partner- ing women’s access to resources. supported approach by allocating their resources contingent on assessments of women’s resource Program practitioners should continue to draw on needs; by demanding reliable data; and by their strong community development and inter- assuring that program planners and researchers vention skills to focus attention on many aspects are active members of the design, implementa- of the big picture of community nutrition and to tion, and evaluation effort; and by encouraging identify constraints that contribute to malnutrition. communities to participate.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach 22

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This publication was made possible through support provided by the OMNI Research Project managed by the International Life Sciences Institute with funds from the Office of Health and Nutrition, the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-5122-A-00-3046-00. The opinions expressed herein do not necessarily reflect the views of USAID.

Enhancing Nutrition Results: The Case for a Women’s Resources Approach