3

Nutritional Status

As in most developing countries, the nutritional status of girls and women in Sub-Saharan Africa is compromised by the cumulative and synergistic effects of many risk factors, including limited availability of, or access to, food resources because of natural and human-made disasters; lack of control over inputs and resource allocations at the household level; traditional feeding practices and other customs that limit women's consumption of certain energy- and nutrient-rich foods; the energy demands of heavy physical labor; the nutritional demands of frequent cycles of pregnancy and lactation; a high burden of infections; and limited access to preventive or curative care.

Available data on nutrition in Sub-Saharan Africa emphasize preschool children and women of reproductive age. Thus, our analysis, despite its emphasis on a life span perspective, is limited by the scarcity of reliable data on the female population outside these age groups. In addition, only rarely are the available data nationally representative or comparable over time. The hope in this chapter, as in other chapters of this volume, is that a first attempt to assemble much of what is known about the nutritional situation of women and girls in Sub-Saharan Africa will lead to interim recommendations that may be useful to policymakers and program planners. Even more important, it is hoped that this review will suggest hypotheses and stimulate interest in conducting multidisciplinary, applied research concerning the extent, causes, and consequences of nutrition-related problems among Sub-Saharan African females throughout their life span. The committee also hopes that such research will provide a stronger foundation for the design of appropriate, cost-effective interventions to improve the nutrition and health situation of women and girls in the region.

This chapter begins with an analysis of some of the major determinants of the nutritional status of females in Sub-Saharan Africa, focusing particularly on household and individual factors that determine energy intake and expenditure. The reader is also referred to Chapter 2 for a discussion of macro-level factors that affect nutrition. The chapter then summarizes available data on the extent and types of malnutrition that affect females in Sub-Saharan Africa, including a section assessing the extent of gender differences. The chapter pays particular attention to conditions that burden females disproportionately; these are listed in Table 3-1. Protein-energy malnutrition (PEM) is discussed in light of the increased nutritional demands of pregnancy and the increased risks that pregnancy and childbirth impose on a woman who is stunted as a result of PEM. The chapter also gives careful consideration to two deficiency disorders—iron-deficiency anemia and iodine deficiency disorders—that occur more commonly in females than in males. The third section of the chapter uses a life span perspective to examine the functional consequences of malnutrition among Sub-Saharan African females. The chapter concludes with some preliminary research recommendations.



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 3 Nutritional Status As in most developing countries, the nutritional status of girls and women in Sub-Saharan Africa is compromised by the cumulative and synergistic effects of many risk factors, including limited availability of, or access to, food resources because of natural and human-made disasters; lack of control over inputs and resource allocations at the household level; traditional feeding practices and other customs that limit women's consumption of certain energy- and nutrient-rich foods; the energy demands of heavy physical labor; the nutritional demands of frequent cycles of pregnancy and lactation; a high burden of infections; and limited access to preventive or curative care. Available data on nutrition in Sub-Saharan Africa emphasize preschool children and women of reproductive age. Thus, our analysis, despite its emphasis on a life span perspective, is limited by the scarcity of reliable data on the female population outside these age groups. In addition, only rarely are the available data nationally representative or comparable over time. The hope in this chapter, as in other chapters of this volume, is that a first attempt to assemble much of what is known about the nutritional situation of women and girls in Sub-Saharan Africa will lead to interim recommendations that may be useful to policymakers and program planners. Even more important, it is hoped that this review will suggest hypotheses and stimulate interest in conducting multidisciplinary, applied research concerning the extent, causes, and consequences of nutrition-related problems among Sub-Saharan African females throughout their life span. The committee also hopes that such research will provide a stronger foundation for the design of appropriate, cost-effective interventions to improve the nutrition and health situation of women and girls in the region. This chapter begins with an analysis of some of the major determinants of the nutritional status of females in Sub-Saharan Africa, focusing particularly on household and individual factors that determine energy intake and expenditure. The reader is also referred to Chapter 2 for a discussion of macro-level factors that affect nutrition. The chapter then summarizes available data on the extent and types of malnutrition that affect females in Sub-Saharan Africa, including a section assessing the extent of gender differences. The chapter pays particular attention to conditions that burden females disproportionately; these are listed in Table 3-1. Protein-energy malnutrition (PEM) is discussed in light of the increased nutritional demands of pregnancy and the increased risks that pregnancy and childbirth impose on a woman who is stunted as a result of PEM. The chapter also gives careful consideration to two deficiency disorders—iron-deficiency anemia and iodine deficiency disorders—that occur more commonly in females than in males. The third section of the chapter uses a life span perspective to examine the functional consequences of malnutrition among Sub-Saharan African females. The chapter concludes with some preliminary research recommendations.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 3-1 Nutritional Disorders Adversely Influencing Health in Sub-Saharan Africa: Gender-Related Burden Disorder Exclusive to Females Greater for Females than for Males Burden for Females and Males Comparable, but of Particular Significance for Females Iodine deficiency (goiter)   X   Iron-deficiency anemia   X   Protein-energy malnutrition   X   NOTE: Significance defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males. WOMEN'S ROLES AND FEMALE NUTRITIONAL STATUS IN SUB-SAHARAN AFRICA Crucial conflicts face poor women in low-income countries as they try to fulfill their economic, biological and social roles at each stage in the life cycle, particularly during the childbearing years. Changes in behavior that enhance their contribution to one area can have crucial negative effects on their other roles and activities. This role conflict relates to the tremendous time, energy, and money-resource constraints facing these women.… Conflicts between the economic, reproductive, and cultural roles of women can have detrimental effects on their nutrition and/or that of their families. (McGuire and Popkin, 1989, p. 53) Standard models of determinants of the nutritional status of both children and women include quality and quantity of dietary intake, presence of infection, and energy expenditure as proximate determinants, which are themselves seen to be determined by a range of household, community, national, and global variables related to wealth, food production, education, and availability of health services, among other matters (see Kennedy et al., 1992; Leslie, 1991; Merchant and Kurz, 1993). In this first section, we focus on the implications of three interrelated variables that are particularly significant determinants of the nutritional status of Sub-Saharan African women and, indirectly, of the nutritional status of their children. These include women's central role as food producers, their high fertility, and their high level of energy expenditure, which is, in part, a consequence of the first two variables. Effects of Household Food Production and Acquisition Strategies on the Nutritional Status of Women and Children Women's agricultural labor in Sub-Saharan Africa is extremely important, both as a percentage of total agricultural labor and as a percentage of women's total labor force participation. Almost 80 percent of economically active women in Sub-Saharan Africa are working in agriculture (UN, 1991). Throughout most of the region, not only do women put in longer workdays overall than men (Juster and Stafford, 1991; Leslie, 1989), but women also spend more hours a week in agricultural work (McGuire and Popkin, 1989; UN, 1991). Women's responsibility is at least equal to that of men in determining the quantity of food available at the household level, and it is significantly greater in determining the variety and palatability of the household diet (Holmboe-Ottesen et al., 1989). Findings from a study in Malawi of the gender division in agricultural decision making are reasonably representative for the region as a whole (Lamba and Tucker, 1990). The study found that husbands make most of the decisions regarding major farm inputs and have almost complete control over decisions concerning cash-crop production. Women have significant input into decisions regarding the production of food crops and full responsibility for decisions about the cultivation of selected vegetables—such as pumpkins and beans—that are used in

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa food preparation. With respect to the use of income, men appeared to have control over formal, more regular sources of income (for example, income from the sale of cash crops or from employment), while women tended to manage the income from the sale of beer, fruits, or cooked food items. In Sub-Saharan Africa, women's dominant role in both subsistence food production and food preparation may give them more control over their own and their children's dietary consumption than women in some other regions of the world, but this control comes at the cost of extremely long and energy-demanding workdays (Bleiberg et al., 1980; Holmboe-Ottesen et al., 1989). Subsistence agriculture remains the basis of food consumption patterns throughout most of rural Africa, which leaves the populations vulnerable to famine when crop failures caused by natural disasters are compounded by inadequate government response (see Chapter 2). At the same time, however, traditional food production and security strategies are rapidly evolving in the region because of population increases, deteriorating environmental conditions, and changing market circumstances, alterations that have led to significant urban migration and increased linkages between rural communities and major urban centers. This adaptation process has brought significant changes in food production patterns, the distribution and acquisition of food, and household food consumption. There is some evidence that gender asymmetries in access to productive resources have meant that women are less able to take advantage of agricultural intensification strategies (Dey, 1992). Effects of Commercial Agriculture Concerns have also been raised about the effects of agricultural intensification strategies on the health and nutritional well-being of women and children (Ferguson, 1986; Lado, 1992; Raikes, 1989). Some studies have suggested that expansion and intensification of commercial agriculture in Sub-Saharan Africa have contributed to gradual declines in food production levels and reductions in the amount of food available for household consumption. It has also been argued that women and children may be adversely affected by a shift to cash-cropping because of increased demands on women's labor for agricultural activities and reductions in women's individually earned income, and that children, in particular, may be adversely affected by earlier weaning and a reduced frequency of meals during the peak of the agricultural season. Conversely, it has been theorized that a shift to cash-cropping will ultimately produce higher household incomes that will lead to better household diets, and thus to improved nutritional status for all members of the household. The most rigorous examination of the effects of cash-crop production on child health and nutrition comes from a comparative analysis of six methodologically similar studies carried out by researchers associated with the International Food Policy Research Institute, four of which were in countries of Sub-Saharan Africa (Kennedy et al., 1992)—The Gambia, Kenya, Malawi, and Rwanda—while the other two study sites were in Guatemala and the Philippines. Findings from the four African countries comparing child outcomes in households that participated in a cash-cropping scheme with otherwise similar, nonparticipating households found no evidence of a negative effect on child nutritional status from household participation in cash-cropping, but only very weak evidence of a positive effect. Comparison with the findings from the Guatemala study is illuminating: Guatemala was the only one of the six study sites where household participation in cash-cropping was significantly associated with better child health and nutrition outcomes, and this was attributed to the decision of the vegetable production and marketing cooperative to directly invest some of its profits in community health and social services. A separate and earlier analysis of data from the same study in Kenya examined the effects of the commercialization of agriculture on allocation of time and patterns of food consumption by women, as well as on their nutritional status (Kennedy and Cogill, 1987). The central findings were that women from sugarcane-producing households did not spend more time away from home than women from non-sugarcane-producing households; there were no significant differences in the amount of time spent on the various household activities (the amount of time women spent on sugarcane production was negligible); and the mean weights of women from sugar- and non-sugar-producing households were similar. In sum, these studies suggest that agricultural intensification strategies do not necessarily affect child nutritional status adversely.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Seasonality The seasonal patterns of the agricultural cycle in Sub-Saharan Africa impose different demands on women's energy expenditure throughout the year and have a significant influence on household food availability and women's energy intake and nutritional status. The periods of greatest nutritional stress for rural women usually occur during the preharvest period (generally known as the "soudure" or "lean" months), when household food stocks are low, the energy demands of agricultural work are highest, and energy intake is below normal levels (Bailey et al., 1992; Bleiberg et al., 1980; Holmboe-Ottesen et al., 1989; Lamba and Tucker, 1990; Loutan and Lamotte, 1984). When there are two or more poor harvests in a row, particularly in areas where there is only one rainy season annually, the lean period will not be limited to just one or two months, but may stretch throughout most of the year and can lead to true famine (see Chapter 2). In urban areas, periods of nutritional stress are more frequently linked to the market availability of basic food supplies and occur when market prices of basic food commodities are highest. The effect of seasonality on women's nutritional status in Sub-Saharan Africa is particularly well illustrated by a study carried out in southern Benin on the effects of seasonal changes in food availability on women's nutritional status in both rural and periurban areas (Fakambi, 1990). Findings were reported for a sample of 567 nonpregnant (but lactating) women, of whom 366 lived in rural areas and 201 lived in a periurban setting. The study found significant nutritional status changes between what was defined as Phase I (November, the preharvest season) and Phase II (May–June, the postharvest season), as well as noteworthy differences in seasonal effect between rural and periurban settings. In rural areas, household food stocks were at their lowest during Phase I, because households had been forced to sell much of the produce from the big harvest (of June–July) because of inadequate household storage facilities to preserve food during the humid months. In contrast, most of the production from the second harvest (in December) could be stored during the subsequent dry season, thus ensuring adequate food supply between Phase I and Phase II. Twenty-five percent of the rural women gained more than two kilos between Phase I and Phase II, and average body mass index (BMI) also increased significantly during this period. In the periurban setting, the pattern was different. Phase I was characterized by relatively low food prices because of an excess supply of basic food commodities in the market. Between Phase I and Phase II, however, food prices began to rise, and periurban women were increasingly less able to buy adequate amounts of food. In contrast to the rural women, 25 percent of periurban women lost more than 2 kilos between Phase I and Phase II, and their BMI decreased, although the decrease was not statistically significant. The Benin study indicates that the food security and nutritional consequences of seasonal changes in food availability can differ significantly between rural women, who depend mostly on food from their own production, and periurban women, who purchase a large proportion of their food. The findings of this study are significant in view of the growing integration of rural populations into national cash economies and the consequent increase in the number of families in both rural and urban areas who are not direct producers of food for home consumption. Dietary Intake and Energy Expenditure of Pregnant and Lactating Women With an average regional fertility rate of 6.5 in 1990, women in Sub-Saharan Africa experience significantly higher fertility than women in any other region of the world (World Bank, 1992b). Studies of food consumption during pregnancy and lactation in Sub-Saharan African countries indicate that macronutrient intakes are low, in the range of 1,400 to 2,000 kilocalories (Kcal) of energy and 25 to 50 grams of protein daily, while vitamin and mineral intakes are often extremely low as well (McGuire and Popkin, 1989; Prentice, 1980). Nevertheless, several detailed, country-specific studies suggest that when the energy cost of activity, reproduction, and lactation can be partially met by mobilization of maternal tissue stores, the impact of low energy intake on fetal growth and lactation performance is less than might be anticipated (Kusin et al., 1984; Lawrence et al., 1985, 1987a). Given that the energy demands of lactation are higher than those of pregnancy, however, it is essential to increase energy intake and/or reduce energy expenditure during breastfeeding in order to protect women's long-term nutritional status (Parker et al., 1990).

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Kusin and colleagues (1984) analyzed cross-sectional data on food consumption in the Machakos area of Kenya among pregnant, nonpregnant, and lactating women over the period from October 1977 to December 1979, and found that the diets of pregnant women, and to a lesser extent lactating women, were inadequate when compared by the World Health Organization (WHO) with both the daily intakes it recommends, and the diets of nonpregnant, nonlactating women in the same population. Compared with the WHO recommended daily intakes, pregnant women received adequate amounts of protein, thiamin, and ascorbic acid, but their energy intakes were low, with median values ranging from 70 percent of recommended intake during the first trimester to 62 percent during the third trimester. An even larger deficit was recorded in the median calcium, iron, retinol equivalents, and riboflavin intakes of pregnant women. The authors could not explain clearly why food intake was reduced in the last trimester of pregnancy, but they suggested that cultural factors could be major determinants, because food availability was not a constraint in the region. Similarly, the Machakos data indicated that the dietary intake of lactating women was found to be inadequate in energy and all nutrients except protein and ascorbic acid. The deficits noted were lower, however, than the deficits among pregnant women. The study found that mean weights remained the same during the first and second trimesters of pregnancy, and were only two kilos higher in the third trimester. The mean weight-for-height of lactating women at 15 to 24 months was slightly lower than the mean for women during the first year of lactation. Kusin and colleagues concluded from these findings that there was deterioration in the nutritional status of women as pregnancy and lactation progressed. Studies of European and American women report significant increases in skinfold thickness at triceps and subscapular sites of the body between 10 and 20 weeks of pregnancy. Comparable analyses of changes in skinfold thickness at various stages of pregnancy in Africa are rare. A study of pregnant Nigerian women is one of the few published on the subject (Hussain and Akinyele, 1980). It provides an excellent analysis of the magnitude and patterns of subcutaneous fat deposition at triceps and subscapular sites in a group of "normal" pregnant Yoruba women living in low socioeconomic conditions in rural areas. All the women in the study had experienced multiple pregnancies, their mean age was 27 years, and, on the average, each woman had completed four pregnancies at the time of the study. Other anthropometric measurements collected on the women included arm circumference, weight, height, age, and parity number. In keeping with the findings from the Kenya study and other research from Sub-Saharan Africa, low weight gains during pregnancy were found; total mean weight gain between 20 and 30 weeks of pregnancy was 3.8 kilos, which was about half that reported for elite Nigerian women in Ibadan. The study also reported gradual declines in arm circumference, triceps, and subscapular skinfold thickness throughout pregnancy; the average total decline for the group was 4.1 millimeters. Thus, instead of showing the expected increase between 20 and 30 weeks of pregnancy, both individual and combined skinfold thickness at the triceps and subscapular sites among low-income pregnant Nigerian women declined. The authors interpret these declines as indicating a continuous depletion of energy stores during the course of pregnancy to compensate for inadequate dietary intake. In addition, the study found a negative correlation between parity and subscapular skinfold thickness, which was interpreted to mean that the ability of pregnant women to store body fat at the subscapular site decreased as parity increased. There is mixed evidence concerning the extent to which women reduce energy expenditure to compensate for the increased energy demands of pregnancy or lactation. The majority of research has found little evidence of a change in activity patterns or energy expenditure during pregnancy or lactation by women in Sub-Saharan Africa or elsewhere in the developing world (IOM, 1992; Lamba and Tucker, 1990). Nevertheless, a recent detailed study of the functional consequences of malnutrition among the Embu in Kenya found that reduction in energy expenditure during the third trimester was a major mechanism used by pregnant women to achieve reasonable infant birthweights in the face of inadequate dietary intake (Neumann et al., 1992). Evidence of the contribution of energy-sparing mechanisms to partially meet the additional energy demands of pregnancy has also emerged from a series of studies of women in three rural Gambian villages. Although expenditure of energy by pregnant women on activities with relatively low energy demands did not appear to change over the course of pregnancy, activities with higher energy demands were reduced during the second and third trimester (Heini et al., 1991; Lawrence et al., 1987a; Lawrence and Whitehead, 1988). A similar finding of a reduction in energy-intensive activities in one, but not both, of the Zairian tribal groups studied is

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa reported by Peacock (1992). Among Efe women, who are seminomadic foragers, the proportion of time spent in the most energy-intensive activities was reduced during pregnancy, and diminished further during lactation. No compensatory reduction in energy expenditure was found among the pregnant or lactating Lese women, who work as swidden cultivators. The general problem of meeting the nutritional demands of pregnancy and lactation on top of the already substantial energy demands of a long and energy-demanding workday is particularly acute during seasonal periods of food shortage. This is well illustrated by research in The Gambia. Fifty women subsistence farmers were followed through pregnancy (during which some were provided with food supplements), and seasonal changes in basal metabolic rate (BMR), body fat, activity patterns, and total energy expenditure were assessed (Lawrence et al., 1987b). Seasonal variations in body fat content occurred in all women, whether pregnant or not, and pregnancy fat gain in individual women was found to be dependent upon the times of the year through which the pregnancy progressed. Seasonal fluctuations in body fat content of rural Gambian women were as large or larger than the changes resulting from pregnancy. Weight loss during the rainy season among unsupplemented, nonpregnant, nonlactating women averaged 5 kilos, most of which was adipose tissue. Among pregnant women, unsupplemented women who gave birth at the end of the rains (when agricultural activity was intense and food supplies were very low) lost 4.7 kilos of body fat, whereas those who were pregnant during the dry season (when little agricultural work was done and the food supplies increased) gained as much as 3 kilos of body fat. The interaction between seasonality and supplementation was highly significant. In supplemented women, neither weight nor fat gain during pregnancy varied as much with season as in the unsupplemented group. Overall, supplementation increased fat gain during pregnancy by about 2 kilos and gave some protection against seasonal weight loss. Lawrence and colleagues interpreted their combined findings concerning changes in BMR, fat deposition, and energy expenditure as demonstrating that maternal nutritional status is significantly compromised in rural Gambian women by pregnancy during the rainy season. Given the marginal food availability in most of rural Sub-Saharan Africa and the need for women to continue with heavy physical work throughout most, if not all, of the time they are pregnant and lactating, the importance of ensuring an adequate interval to replenish maternal reserves of fat and other nutrients after the end of lactation and before the next pregnancy cannot be overemphasized. It is estimated, for example, that even when food intake is adequate, it may take two years to replenish body iron stores after a pregnancy (WHO, 1992). In addition, efforts to reduce the energy demands on women through easier access to needed resources and labor saving devices—during the preconception period as well as during pregnancy and lactation —would be extremely beneficial. EXTENT OF MALNUTRITION AMONG FEMALES IN SUB-SAHARAN AFRICA Our brief analysis of the nutritional implications of the multiple demands of time and energy of the roles of Sub-Saharan African women, particularly when considered within the broader context of the health and welfare risks reviewed in other chapters of this volume, would lead the reader to anticipate a high prevalence of malnutrition among Sub-Saharan African females. As this section makes clear, girls and women in this region are, indeed, severely malnourished. Given their limited economic resources and their physically arduous lives, however, it is surprising that their nutritional status is not even worse than it is. Micronutrient Disorders Protein-Energy Malnutrition The United Nations Administrative Committee on Coordination/A System of National Accounts (ACC/SCN) recently published the most thorough and up-to-date global review available of the nutritional situation of women of reproductive age as part of its Second Report on the World Nutrition Situation. The ACC/SCN report provides the starting point for this chapter's assessment of the nutritional status of females in Sub-Saharan Africa. 1 The four anthropometric measures of nutritional status that the ACC/SCN was able to use to make regional

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa estimates of prevalence of PEM among women were height, weight, body mass index (BMI = weight in kilos/height in meters squared), and arm circumference. Women in Sub-Saharan Africa were found to be surprisingly tall. Average height was 158 centimeters, only 3 centimeters less than the average height of 161 centimeters for European women, while mean female height in South America and most of Asia was only about 151 centimeters. Although these differences might be assumed to be attributable to differences in genetic potential, the finding that mean female height in China was exactly the same as for Sub-Saharan African women suggests that factors other than genetic potential must be important determinants. Short stature or stunting among adults is usually taken as an indicator of cumulative malnutrition during childhood and adolescence, and it is associated with a range of negative functional outcomes, including reduced work capacity and poorer reproductive outcomes (Buzina et al., 1989; Royston and Armstrong, 1989). The cutoff point for the definition of stunting used by the ACC/SCN is a height of 145 centimeters, which is quite conservative. (As will be discussed in greater detail later, increased obstetrical risk has been associated with short stature, even at heights well above 145 centimeters.) Using this cutoff point, fewer than 5 percent of women in Sub-Saharan Africa were classified as stunted, compared with more than 15 percent in Middle America and Asia (excluding China), and about 12 percent in South America. The three other anthropometric measures of nutritional status included in the ACC/SCN report are interpreted as indicative of current nutritional status. By these measures, women in Sub-Saharan Africa also do fairly well compared with other regions, but the differences are not so striking as they are for height. Absolute weight, of course, is highly correlated with height. Using 45 kilos as the cutoff point (again, quite conservatively), the ACC/SCN study finds 20 percent of African women to be underweight, about the same percentage as in Middle America and China. This is a larger segment than is found in South America, but a significantly lower percentage than in Asia (excluding China). It was found that 45 percent of women in Southeast Asia and a shocking 60 percent of women in South Asia are underweight. The percent of women with arm circumference below 22.5 centimeters could only be calculated for Sub-Saharan Africa, South Asia, and Southeast Asia, and these percentages followed very closely those for weight below 45 kilos. The relative position of women in Sub-Saharan Africa is least good when BMI, a measure of relative thinness, is considered. Using BMI below 18.5 as the cutoff point, fewer than 20 percent of women in Middle America, South America, and China; slightly more than 20 percent of women in Sub-Saharan Africa; and about 40 percent of women in South and Southeast Asia were excessively thin. It is helpful to compare the regional information on child nutritional status from the Second Report on the World Nutrition Situation with the information on women's nutritional status, although unfortunately the ACC/SCN does not report child nutritional status disaggregated by gender. Anthropometric indicators of child nutrition have been more routinely collected than information on adult nutritional status, so it is possible to estimate regional trends in child nutrition over the past 20 years. It is when trends in child nutrition are examined that the basis for the current concern about the nutritional situation in Sub-Saharan Africa becomes clearer. While between 1975 and 1990 all other regions of the developing world show a marked decline in the prevalence of underweight preschool children (defined as the percent below two standard deviations from the mean weight-for-age in the age range from birth to 5 years), ranging from a 50 percent decline in South America to a 10 percent decline in South Asia, their prevalence in Sub-Saharan Africa appears to have remained essentially unchanged. Because of the continuing rapid rates of population growth in Sub-Saharan Africa, the absolute number of undernourished preschool children increased from 18.5 million in 1975 to 28.2 million in 1990. This means that there are now almost as many undernourished preschool-age girls in Sub-Saharan Africa as there were total undernourished preschool children in the region in 1975. It also appears that the relative nutritional status of children is somewhat less favorable than that of women in Sub-Saharan Africa when compared with other regions of the developing world. Perhaps, given their smaller size and less mature immune systems, children have been less able than adults to withstand the particularly harsh conditions that have been endured by most Sub-Saharan Africans over the last decade. Any attempt to assess the nutritional situation of women and girls in individual countries, or to compare one part of the region with another beyond the aggregate regional estimates of PEM in Sub-Saharan Africa available from the Second Report on the World Nutrition Situation becomes more problematic. Although a substantial amount of research has been carried out to investigate the nutritional situation in Sub-Saharan Africa during the

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa postcolonial period, the number, scope, and quality of nutrition studies vary substantially from one country to another, and many otherwise excellent studies (particularly of child malnutrition) do not report gender-disaggregated results. Two approaches have been taken in this chapter to begin to disaggregate the extent and diversity of nutritional problems of females within the Sub-Saharan African region. The first approach is to examine three indirect indicators related to women's nutritional status that are available for essentially all countries in the region: the daily per capita energy supply, the percent of infants with low birthweight, and the maternal mortality rate for all countries in Sub-Saharan Africa for which such data could be found (see Table 3-2).2 Daily per capita energy supply is not specific to individual households, much less to females within those households, but countries with a per capita energy availability below 2,100 kilocalories are usually designated as food insecure and believed to be at risk of having a substantial number of food-deficient households (FAO and WHO, 1992). We also know that in the Sub-Saharan African region, women who live in the most food-deficient households are usually the women who do the most physically demanding work and who are pregnant with and breastfeed the largest number of infants. Therefore, without being able to estimate a specific number, it seems safe to assume that in any country with a per capita energy supply below 2,100 kilocalories, there will be a reasonably high prevalence of female malnutrition. Of the 37 countries in Table 3-2 with available kilocalorie estimates of daily per capita energy supply in 1989, 12, or about one-third, were below 2,100 kilocalories. Several studies in Sub-Saharan Africa (as well as many studies from other parts of the world) have demonstrated a relationship between women's nutritional status—both current and past—and the birthweight of their infants (Harrison et al., 1985; Neumann et al., 1992; Prentice et al., 1987). Although low birthweight can occur in the absence of maternal malnutrition, and moderately malnourished women can give birth to infants of adequate birthweight, the correlation between poor maternal nutritional status and low birthweights at the aggregate level is sufficiently strong that it is appropriate to use the percent of low birthweight infants as an indirect indicator of female nutritional status. In general, we would expect to find a substantial degree of malnutrition among women of reproductive age (both stunting and thinness) in countries reporting a rate of more than 10 percent low birthweight infants. Of the 37 countries in Table 3-2 for which low birthweight data are given, 26, or approximately two-thirds, reported more than 10 percent low birthweight infants in the mid-1980s. The maternal mortality ratio is also a reasonable indicator of maternal nutritional status, particularly in the absence of adequate, accessible prenatal and childbirth services. Stunting is associated with a greater risk of obstructed labor, and both obstructed labor and anemia are among the major causes of maternal mortality in Sub-Saharan Africa (see Chapter 5, Obstetric Morbidity and Mortality). Therefore, while the maternal mortality ratio does not differentiate among the different kinds of nutritional problems that may affect girls and women, a high maternal mortality ratio is strongly suggestive of a high prevalence of female malnutrition. Virtually all of the countries in Table 3-2 had maternal mortality ratios in 1980 over 100 maternal deaths per 100,000 live births, and 11 of 36 had maternal mortality ratios above 500. Comparisons among countries and even subregions of Sub-Saharan Africa based on the data in Table 3-2 must be made quite cautiously because of missing data and some lack of comparability among the data (for example, maternal mortality ratios for some countries are based entirely on hospital data). In addition, there is some inconsistency in data between the two sources used to compile this table. Nonetheless, with these caveats in mind, the data in Table 3-2 do present some slightly surprising findings when the four subregions are compared. In food availability, Table 3-2 suggests that eastern Africa and middle Africa are the two most food-insecure parts of the region. In both subregions, more than half the countries have a daily per capita energy supply below 2,100 kilocalories, and for most of the remainder of the countries, per capita energy availability is only slightly above the 2,100 kilocalorie level. Food availability appears to be distinctly better in southern and western Africa. When the other two indicators related to female nutritional status are examined, however, a somewhat different picture emerges. Based on percentage of low birthweight infants and maternal mortality ratios, female malnutrition seems to be greatest in western Africa (this is consistent with the estimated subregional prevalences of anemia, as shown in Table 3-4). In western Africa, 10 of the 13 countries for which there are data have more than 10 percent of infants born with low birthrights, and the remaining three are at the 10 percent level. Similarly, in maternal mortality ratios, 6 of 13 countries in western Africa have more than 500 maternal deaths per

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 3-2 Selected Health and Agricultural Indicators Related to Female Nutritional Status in Sub-Saharan Africa Country Daily per Capita Energy Supply (1989)a Percent Babies with Low Birthweight (1985)b Maternal Mortality Rate (per 100,000 live births) (1980)b Eastern Africa       Burundi 1,932 14/18 800 Comoros (89%) 7 460 Ethiopia 1,667 13 360 Kenya 2,163 13/18 170c Madagascar 2,158 10 300 Malawi 2,139 10 250 Mauritius 2,887 9/8 99 Mozambique 1,680 15/11 479/300d Rwanda 1,971 17 210 Somalia 1,906 — 1,100 Uganda 2,153 10 300/500 United Republic of Tanzania 2,206 14/13 185 Zambia 2,077 14 110 Zimbabwe 2,299 15/6 90 Middle Africa       Angola 1,807 17/21   Cameroon 2,217 13 303 Central African Republic 2,036 15 600 Chad 1,743 11 700/1,000 Congo 2,590 12 200 Gabon 2,383 16/8 130 Zaire 1,991 16 800 Southern Africa       Botswana 2,375 8 300/200 Lesotho 2,299 10 370 Namibia 1,946 — — South Africa 3,122 12 550e Swaziland (110%) 7 — 100,000 live births, 6 fall into the range of 100 to 500, and the data for one. Mauritania, are difficult to interpret. The situation in middle Africa appears to be similarly poor in the percentage of low birthweight infants—all seven countries have in excess of 10 percent low birthweight infants—and only slightly better in maternal mortality, with three countries recording more than 500 maternal deaths per 100,000 live births, and three in the 100 to 500 range. In contrast, the situation in eastern Africa looks noticeably better. Of the 13 countries for which there are data on low birthweight, 7 have percentages above 10; 3 are at 10 percent; 2 are below 10 percent; and 1, Zimbabwe, is difficult to classify because the rates given in the two sources, 15 percent and 6 percent, are so different. In maternal mortality ratios, only two countries in eastern Africa have a rate above 500 per 100,000 live births, 10 are in the 100 to 500 range, and 2 have rates below 100. The number of countries for which there are data in southern Africa is small, but both percentage of low birthweight infants and maternal mortality rates seem to be similar to, or slightly better than, those in eastern Africa.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Daily per Capita Energy Supply (1989)a Percent Babies with Low Birthweight (1985)b Maternal Mortality Rate (per 100,000 live births) (1980)b Western Africa       Benin 2,305 10 1,680d Burkina Faso 2,288 18/11 600 Cape Verde (112%) — 107 Côte D'Ivoire 2,577 14/15 — The Gambia (97%) — 1,034 Ghana 2,248 17 1,070d Guinea 2,132 18 — Guinea Bissau (105%) 14 400 Liberia 2,382 — 173 Mali 2,314 17/13 — Mauritania 2,685 10 119/1,100 Niger 2,308 20 420 Nigeria 2,312 25 1,500 Senegal 2,369 10 530f Sierra Leone 1,700 14 450 Togo 2,214 20 418 a Entries in Kilocalories are from the 1992 World Development Report (WDR). Those printed in bold face are below 2,100 kilocalories/person/day, which a recent FAO/WHO document labels as indicative of household food insecurity based on a very low level of average food consumption (FAO and WHO, 1992). For countries with populations of less than one million, no data were available from the WDR, and the estimated daily per capita energy supply in 1985 as a percentage of the requirement from Better Health in Africa (BHA) is given. Although figures vary from country to country based on the age and sex distribution of the population, the daily per capita energy supply needs to be about 2,300 to be equivalent to 100 percent of average requirements. b Where two numbers are given, the first is from the WDR and the second from BHA. Where only one number is given, the two sources agreed or only one source had an entry for that indicator and country. c Before 1980. d Hospital data only. e Rural data only. f Hospital data only, before 1980. SOURCE: All data are from World Bank, 1992a,b. Unlike daily per capita energy availability, both the percentage of infants born with low birthweights and maternal mortality ratios are specific to females. Therefore, Table 3-2 appears to suggest that western and middle Africa are the two subregions where female malnutrition is the most prevalent, despite better overall food security. An issue that may warrant further investigation is whether there are any dietary or behavioral factors in eastern Africa that contribute to protecting female nutritional status within the context of extremely low household food availability, or factors in western or middle Africa that are significantly detrimental. Alternatively, it may be that access to health care is better in eastern and southern Africa, thus to some extent compensating for the negative effect of food insecurity. Data are presented in Table 3-3 that measure the nutritional status of women more directly, using BMI as a measure of chronic energy deficiency. Table 3-3 also presents the available BMI data for men, but discussion of the gender differences shown in Table 3-3 is reserved for later in this section. Although different cutoff points have been recommended, in general a BMI below 18 or 18.5 is considered excessively thin, and a person below this mark is categorized as suffering from chronic energy deficiency (CED).3 Among the countries in eastern Africa with BMI data, it is clear that the situation is most severe in Ethiopia, where half the women suffer from CED. Twelve percent of women in the Zimbabwe study, and probably a similar percentage in the Kenya study,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa would be considered malnourished. For middle Africa, data are only available from two studies done in Zaire. Although the data are not presented in percentages below a cutoff, the relatively low range of the mean BMI values (19.7 to 21.7) suggests that the percentage of women suffering from CED in these Zairian populations would be lower than in Ethiopia, but higher than in Zimbabwe or Kenya. In western Africa, except for Côte d'Ivoire, where the mean BMI of women is similar to that found in the Kenya study, the BMI data support the conclusion of substantial female malnutrition suggested by the indirect indicators in Table 3-2. The data in Table 3-3 are consistent with the estimated regional average of 21 percent of women in Sub-Saharan Africa with a BMI below 18.5 (UN, 1992). It seems reasonably clear from the information presented in Tables 3-2, 3-3, and 3-5 (see below) that the problem of protein-energy deficiency is of considerable magnitude among females in Sub-Saharan Africa, with somewhere in the range of 5–10 percent of girls suffering from acute PEM, and 20–40 percent suffering from chronic PEM. Among adult women, somewhere in the range of 1–6 percent may suffer from severe CED (chronic energy deficiency based on low BMI), and 10–40 percent may have mild to moderate CED. During acute famine, of course, the proportion of females suffering from acute PEM will be much higher. Obesity While inadequate energy intake is certainly the major macronutritional problem among females in Sub-Saharan Africa, it is important to consider the prevalence of excess energy intake, or obesity. Obesity is known to substantially increase the risk of many chronic diseases (see Chapter 8, Chronic Diseases) and, with the decline in rates of many infectious diseases and increasing life expectancy, a rapid increase in the prevalence of noncommunicable diseases can be expected in the near future in Sub-Saharan Africa (Feachem et al., 1991). The prevalence of obesity is an issue that has received little attention from researchers concerned with nutrition in Sub-Saharan Africa; relevant data are thus extremely limited. One of the few studies to examine simultaneously the prevalence of CED and obesity in the same population groups was a comparative study of adult nutritional status in India, Ethiopia, and Zimbabwe (Ferro-Luzzi et al., 1992). In the Ethiopian population, there was a high prevalence of CED (58 percent of women had BMI below 18.5; 6 percent were below 16) and essentially no obesity, defined as BMI greater than 25. In contrast, in the Zimbabwean population, 12 percent of women had a BMI below 18.5 (only 1 percent were below 16), and 17 percent were defined as obese, with 2.5 percent having a BMI over 30. It is clear that a high prevalence of CED is correlated with a low prevalence of obesity and vice versa, but also that a moderate prevalence of each can be found in the same population. In Zimbabwe, the average BMI for females was reported to be 22 (SD, 2.3). This figure is not dissimilar to the average BMI reported for females in a number of other Sub-Saharan African populations (see Table 3-3). Therefore, it seems probable that in at least some countries in the region we could expect to find a prevalence of obesity among adult females in the range of 5–10 percent. Micronutrient Deficiencies Iron-Deficiency Anemia Iron-deficiency anemia is the most common nutritional deficiency in the world, and given that it particularly affects preschool children and reproductive age women, it is certainly the most widespread nutritional problem affecting girls and women in Sub-Saharan Africa. It is generally accepted that about half of worldwide anemia is the result of iron-deficiency, and there is emerging evidence that low iron stores, even in the absence of anemia, can have negative functional consequences (UN, 1992; WHO, 1992). Therefore, the prevalence of iron-deficiency anemia can be taken as a minimum estimate of both the problems of anemia and of iron-deficiency.4 A 1992 publication prepared jointly by the Maternal Health and Safe Motherhood Programme and the Nutrition Programme of WHO offers the most recent estimates of the prevalence of nutritional anemias in the world's women, based on studies carried out since 1970 (WHO, 1992). Table 3-4 presents the WHO data on the number and percentage of women with hemoglobin levels below the norm for the four Sub-Saharan African subregions; most of the anemia is attributable to iron-deficiency. 5 The relative nutritional situation of women

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 3-5 Child Health and Nutrition Status Indicators by Gender, Selected Sub-Saharan African Countries (late 1980s) Region/ Country Child Mortalitya Height-for-Ageb Weight-for-Heightb Weight-for-Ageb Children with Diarrhea (5)c Children Taken to Health Facility for Diarrhea (%)   Male Female Male Female Male Female Male Female Male Female Male Female Eastern Africa                         Burundi 101.0 113.8 48.3 47.8 6.2 5.1 37.5 39.0 17.7 17.0 12.8 11.7 Uganda 97.3 86.0 47.3 41.6 1.8 1.9 23.1 23.4 25.4 23.2 13.8 15.8 Zimbabwe 30.2 32.5 29.9 28.0 1.4 1.3 11.3 11.9 20.5 19.0 33.5 33.2 Western Africa                         Ghana 78.3 79.4 30.2 29.8 9.0 6.9 30.3 31.1 27.0 26.1 40.8 45.6 Mali 166.0 174.0 23.8 24.9 12.0 9.8 30.0 32.2 35.7 33.0 68.4 68.3 Nigeria 93.7 89.1 43.4 42.7 9.8 8.3 35.8 35.7 19.4 16.4 23.6 26.8 Senegal 131.0 129.7 24.8 20.6 7.6 4.1 22.5 20.6 38.9 36.9 19.4 19.4 Togo 74.9 90.1 32.2 26.9 6.2 4.4 25.0 23.8 29.6 29.2     NOTE: Data were kindly provided by Kenneth Hill of the World Bank. They are assembled from Demographic and Health Survey Reports and are for all Sub-Saharan African countries for which data on these indicators were available. a Child mortality is usually considered most indicative of child nutritional status. b For children 3–36 months old, percent below 2 standard deviations. c Percent of children under age 5 with diarrhea during the two weeks preceding the survey.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Mortality and Morbidity Mortality The ultimate consequence of severe malnutrition is death. Malnutrition is a particularly significant contributing cause of infant and child mortality, and of maternal mortality. Based on estimates made by UNICEF and others, it seems likely that at least one-third of infant and child deaths in Sub-Saharan Africa are partially attributable to PEM (Pinstrup-Andersen et al., in press). In times of famine, both the rates of infant and child mortality and the proportion of total deaths attributable to malnutrition increase dramatically (WHO, 1990). Low birthweight, which can be the result of either prematurity or intrauterine growth retardation (IUGR), is the most significant nutritional risk factor for subsequent infant and child mortality. It has been estimated that maternal nutritional factors account for approximately half the influence of established determinants of intrauterine growth retardation in developing countries (Kramer, 1987, cited in Merchant and Kurz, 1993). Current or past maternal malnutrition—as evidenced by short stature, low weight-for-height, poor quality dietary intake, and excessive energy expenditure—is a significant risk factor for bearing infants of low birthweight, a relationship that shows a direct intergenerational transmission of malnutrition. Stunting and wasting among preschool-age children, whether attributable to low birthweight, poor diet and disease postnatally, or both, significantly increases risk of death. A study in Iringa, Tanzania, for example, found a sharp increase in mortality risk at weight-for-age below 60 percent of the median, weight-for-height below 70 percent of the median, and height-for-age below 85 percent of the median (Yambi, 1988, cited in Pinstrup-Andersen et al., in press). Another analysis, based on data from six countries, concluded that infant and child mortality increase at a compounded rate of 7.6 percent for every 1 percent deterioration in weight-for-age, even when the weight deficit is not severe (Pelletier et al., in press, cited in Habicht, 1992). The finding of an increased mortality risk even among mildly to moderately malnourished children has important programmatic and policy implications, given the much larger number of such children compared with those who are severely malnourished. After infants and preschool-age children, those most at risk of mortality associated with malnutrition are women during pregnancy and childbirth. Given the extremely high rates of maternal mortality in Sub-Saharan Africa (see Table 3-2), assessing and reducing as many of the major causes of maternal death as possible will be a particularly important component of improving women's health in this region (see Chapter 5). Obstructed labor and its sequelae are the most important causes of maternal death in Sub-Saharan Africa (Royston and Armstrong, 1989). The risk of experiencing obstructed labor, in which the birth canal is too small or too deformed to allow passage of the baby, is directly related to maternal age, developmental stage, and stature. Growth of the birth canal is not complete until about three years after height growth ceases, and PEM both slows down the rate at which girls mature, and, in many cases, permanently stunts their growth. Thus, PEM directly increases the risk of obstructed labor, particularly among adolescent mothers. A study in Nigeria found that among a group of primigravidae who received prenatal care, the proportion who required operative delivery because of a small pelvis ranged from 40 percent among women under 1.45 meters, to 14 percent among those of at least 1.50 meters, to less than 1 percent among those who were 1.60 meters or taller (Fortney, 1986, cited in Royston and Armstrong, 1989). A population-based case-control study in Harare, Zimbabwe, reported similar findings. Controlling for other factors, women of short stature (less than 1.60 meters) were twice as likely as taller women to have an operative delivery (caesarean section, vacuum extraction, or forceps) because of cephalopelvic disproportion (Tsu, 1992). Given the relatively low rate of stunting among women in Sub-Saharan Africa compared with other regions of the developing world, the importance of obstructed labor as a cause of maternal mortality may seem somewhat surprising. The proportion of births in Sub-Saharan Africa among young mothers who are not yet fully physically mature is part of the explanation. Even more significant is the widespread lack of access to timely medical intervention in the case of obstructed labor. The other nutritional deficiency that significantly increases the risk of maternal mortality is anemia. When anemia is acute, it can cause death directly through heart failure or shock. Fortunately, even among malnourished women, anemia this severe is quite rare. Yet, while less severe anemia may not be a direct cause of maternal death, it is a significant contributory cause. Anemic women are much less able to tolerate hemorrhage, both antepartum

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa and postpartum, and hemorrhage is one of the four leading causes of maternal deaths in Sub-Saharan Africa (Royston and Armstrong, 1989). Anemia is estimated to account for one-fifth to one-tenth of all maternal deaths in many countries of the region; in the extreme circumstances of two refugee camps in Somalia, over 90 percent of maternal deaths were associated with anemia (WHO, 1992). Again, however, it is probably more accurate to say that it is the combination of preexisting anemia, hemorrhage, and lack of access to medical care that causes women to die. Morbidity Scientific studies relating malnutrition to both infectious and noncommunicable diseases have proliferated over the past decade. A large number of micronutrient deficiencies have been found to impair the function of the immune system, particularly through their effect on cellular immunity (Buzina et al., 1989; Rose and Martorell, 1992). The negative effect of zinc deficiency on the immune system seems to be particularly notable. As far as noncommunicable diseases are concerned, the effect of malnutrition is cumulative, and primarily manifests itself in disease outcomes during the postreproductive years. Obesity, and probably excess dietary fat, are risk factors for both diabetes and coronary heart disease, while low consumption of the antioxidant vitamins—A, E, and C—increases the risk of developing most, if not all, cancers (Slater and Block, 1991; UN, 1992). Although the negative impact of specific nutrient deficiencies on the effectiveness of the immune system has been demonstrated, the functional significance in increased morbidity is less well established. The largest body of scientific evidence concerns the relationship between PEM and diarrhea. While virtually all studies show a strong association between these two widespread health problems of childhood, the direction of causality has been more difficult to establish. Careful longitudinal studies suggest that preexisting PEM has a limited effect on the incidence of diarrhea, but significantly increases duration (Leslie, 1982; Tomkins and Watson, 1989). A study of over 300 children between the ages of 6 and 32 months in northern Nigeria at the end of the rainy season found that diarrhea lasted 37 percent longer in stunted children and 79 percent longer in wasted children; in this particular study, wasted children also had diarrhea more frequently (Tomkins, 1981). A longitudinal study of the functional consequences of malnutrition in the Embu district of Kenya produced several important findings concerning the relationship between nutritional deficiency and subsequent morbidity, not only among preschool-age children, but also among reproductive age women (Neumann et al., 1992). One of the most striking results of the research was the finding that morbidity rates for the study sample as a whole doubled during a drought-related food shortage in 1984 compared with 1985, when dietary intake had returned to more normal levels. The same research found that stunting among toddlers (18 to 30 months) and, to a lesser extent, low weight-for-age significantly increased risk of acute lower respiratory tract infections (Neumann et al., 1992). The percentage of time that female infants and toddlers spent ill was somewhat higher than for boys (47 percent versus 42 percent), and girls were found to have a duration of severe illness that was, on average, twice as long as for boys. Girls also experienced an energy deficit during severe illness that was more than double that of boys, although this was somewhat balanced by a larger food intake during convalescence. Lagged analysis showed improved quality and quantity of food intake to be protective against severe illness among girls and boys, with both incidence and duration affected. Insight into the life span effects of malnutrition was offered by the particularly notable finding of the Embu study that lower rates of maternal illness and a higher fat intake among mothers were both significant predictors of less morbidity among their toddlers. The researchers interpreted both factors as indicative of higher levels of energy among mothers, who would then be better able to prevent or treat their children's illness. Morbidity rates among Embu women were significantly higher among pregnant women than among nonpregnant women of reproductive age (Neumann et al., 1992). In addition to the well-established negative effects of pregnancy on the immune system, the researchers attributed the greater morbidity among pregnant women to their lower food intake. As with toddlers, among both pregnant and nonpregnant women, higher levels of food intake (particularly total energy, fat, and animal protein) were found to be protective against severe illness. Overall, women in this study had higher illness rates than men, a difference that persisted even when pregnant women were

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa excluded from the comparison. The authors caution, however, that because women were the main informants, male illness may have been underreported. Cognitive Development and School Performance One of the clearest intergenerational effects of female malnutrition is the significant level of cretinism, deafness, and other congenital abnormalities among infants born to mothers who are severely iodine-deficient. Endemic cretinism is estimated to affect up to 10 percent of the population living in severely iodine-deficient areas (Hetzel, 1988). There are pockets of severe iodine deficiency in the majority of Sub-Saharan African countries; in the region as a whole, there are estimated to be at least 500,000 overt cretins whose condition is ascribed to maternal iodine deficiency during pregnancy (UN, 1992). In addition to congenital cretinism, children who suffer from iodine deficiency during their preschool or school years also show delayed mental development—although unlike cretinism, these cognitive impairments can be reduced with appropriate nutritional intervention. PEM in children is also strongly associated with impaired motor and mental development (Pinstrup-Andersen et al., in press; Pollitt, 1990). The effects appear to be both direct and indirect. A child who is malnourished is often apathetic or irritable, and thus tends to receive less attention and positive stimulation than a better-nourished child in a similar environment. PEM is negatively associated both with the likelihood that children will go to school and with how well they are able to learn there (Leslie and Jamison, 1990). The study of the functional consequences of malnutrition among the Embu in Kenya discussed above found negative effects of malnutrition on cognitive development among both toddlers and school-age children (Neumann et al., 1992). In both age groups, stunted children were found to do less well on cognitive tests than children with normal height for age, controlling for other factors. Better dietary quality, particularly increased intake of animal source protein, fat, and several micronutrients (including but not limited to iodine), was found to have a significant positive effect on cognitive development. In addition, current activity level was strongly related to concurrent energy intake, and activity level and exploratory behavior were found to be positively linked to learning among school-age children. There are very few studies—in Sub-Saharan Africa or elsewhere—of the effect of malnutrition on attendance, repetition, or drop-out rates among school-age children, although it is virtually inevitable that a high prevalence of malnutrition or other health problems among school-age children will make them "inefficient" users of educational resources. A detailed study of health and nutrition problems among school-age Yoruba children in Nigeria documents a high proportion of children who go to school without breakfast and a high prevalence of growth retardation and micronutrient deficiencies. The study concludes that these lead to a high drop-out rate, poor intellectual performance, and low educational attainment that must represent a serious economic loss to the government of Nigeria, which spends a quarter of its annual recurrent budget on primary school education (Oduntan, 1975). The life span consequences of malnutrition are also well illustrated by the linkages between malnutrition and schooling. Malnutrition during the preschool and school years has negative effects on girls' (as well as boys') school participation and performance. Low levels of maternal education are, in turn, significantly associated with poor child nutritional status, as well as higher levels of child mortality (Cochrane et al., 1982). Reproductive Function The functional impact of childhood malnutrition discussed above is felt by both males and females, although the long-term consequences may be different, and in some cases more severe, among females. The detrimental effect of malnutrition on reproductive function, however, is specific to females (with the possible exception of the effects of severe malnutrition on male fertility) and has grave life span and intergenerational consequences. Significant declines in fertility during famine, as well as a predictable return to previous levels of fertility once the famine is over, have been well-documented (Stein and Susser, 1978). Frisch (1978) has developed a comprehensive model that relates female malnutrition to a shorter and less efficient reproductive span through delayed menarche; reduced fecundity; lengthened postpartum amenorrhea; and, perhaps, earlier menopause. Nonetheless,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa there remains considerable debate about the magnitude of any effects of female malnutrition on fertility in the context of the chronically mildly to moderately malnourished populations of Sub-Saharan Africa. An analysis of data from unrelated nutrition and fertility surveys in Senegal, for example, found evidence of, at most, a minor negative effect of malnutrition on fertility (Cantrelle and Ferry, 1978). Two studies from Zaire, however, reached conclusions that suggest a much more significant effect of nutritional status on fertility. Caräel's (1978) analysis of data on lactation status and duration of postpartum amenorrhea among women from two different ecological zones of Zaire finds a strong relationship between birth intervals and nutritional patterns. Although the study did not have dietary intake data at the individual level, the researchers conclude that, controlling for duration of lactation, severe seasonal inadequacies of protein and lipids among rural highland women prolong postpartum amenorrhea by seven to nine months. Even more compelling evidence comes from a more recent study in Zaire. Again, women living in different ecological zones were compared, but in this case the researchers were able to relate longitudinal anthropometric data and salivary measures of steroids (indicating ovarian function) to seasonal variations in conception. They conclude that "variability in the seasonal pattern of rainfall in the Ituri Forest causes variability in Lese garden size, which translates into significant changes in nutritional status. Declines in female nutritional status result in reduced ovarian function, which produces seasonal reductions in rates of conception and implantation" (Bailey et al., 1992, pp. 404–405). Despite widespread mild to moderate malnutrition, women in Sub-Saharan Africa achieve quite high levels of overall fertility. Even more surprising, perhaps, is that most Sub-Saharan African women also produce reasonably adequate birthweight infants and successfully breastfeed in spite of low energy intakes during pregnancy and lactation (in the range of 1,300 to 1,700 kilocalories) and a much lower weight gain during pregnancy (seven to eight kilos) than is recommended or observed among pregnant women in industrialized countries (Kennedy and Bentley, 1993; McGuire and Popkin, 1989). Part of the explanation for this is the high rate of fetal wastage and maternal and infant mortality—in Sub-Saharan Africa the most malnourished fetuses, infants, and mothers simply do not survive. Some researchers have also hypothesized an unusual capacity on the part of pregnant and lactating African women to adjust to or compensate for low food intake, but findings are not consistent. A series of studies in The Gambia, for example, led to the conclusion that women are able to produce adequate birthweight infants and adequate amounts of breast milk by mobilizing rather than building up fat stores during pregnancy, particularly during the wet season, and by achieving considerably greater metabolic efficiency than women in industrialized countries (Lawrence et al., 1987b; Prentice et al., 1987). Researchers in The Gabia report that women in their studies raise their BMR so little during pregnancy that the net extra cost of basal metabolism is only 1,000 kilocalories rather than the usual estimate of 36,000 kilocalories over the course of a pregnancy (Lawrence et al., 1980). These findings are not entirely supported by the results of a longitudinal study of reproduction among Embu women in Kenya (Neumann et al., 1992). The Kenya research also reports surprisingly good infant birthweight outcomes, in spite of low energy intake during pregnancy and a weight gain only half that recommended. In contrast with the reported findings from The Gambia, however, the Kenya study found no compensatory lowering of resting energy expenditure among pregnant women. Instead, the researchers found a compensatory behavioral adaptation: late in pregnancy women doubled their inactive time (at the expense of household care, child care, economic and agricultural activities, and food preparation) in order to accommodate to their low energy intakes in relation to the energy requirements at this stage of pregnancy. In addition, the study found that, as in industrialized countries, prepregnancy maternal size, energy intake during pregnancy, and pregnancy weight gain were all important determinants of infant birthweight and net postpartum maternal weight and fat gain. Physical Work Capacity Both the long-term consequences of childhood malnutrition and current nutritional deficiencies may have significant effects on women's capacity for physical work. Given the strenuous nature of the major tasks of rural women in Sub-Saharan Africa—pounding grain, carrying water and fuel, carrying out nonmechanized agricultural work, and undertaking long walks to and from markets—a woman's physical capacity for work may be one of the most important determinants of her own and her family's nutritional well-being.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa In attempting to assess the effects of female malnutrition on physical work capacity, considerable extrapolation must be done from studies of males, because surprisingly little research has been done on females in this area. The long-term effects of childhood malnutrition, acting through short stature and reduced muscle mass, was found to have a reasonably clear negative effect on the productivity of Guatemalan men engaged in strenuous activities such as cutting cane or moving earth (Martorell and Arroyave, 1988). In addition, deficiencies of several micronutrients, particularly iron, but also vitamin C and the B-complex vitamins, have been found to have a negative effect on physical work capacity (Buzina et al., 1989). Intervention studies in which anemic female tea pickers in Asia were given supplemental iron showed that those who were supplemented were significantly more productive than unsupplemented controls (Leslie, 1991). There is less consistency in studies that have tried to assess the association between energy status and physical work capacity, in part because a frequent initial response to inadequate energy intake is to mobilize fat stores rather than to reduce work (Pinstrup-Andersen et al., in press). One study from Kenya did find a positive association between nutritional status and work capacity among women in sugarcane farming households (Kennedy and Garcia, 1993). Women with higher BMI were able to spend more time in work-related activities, including home production, and at a given level of BMI, taller women appeared to engage in more energy-intensive work activities. In addition, the frequently cited report from researchers in The Gambia of women who received a dietary supplement and then sang while they worked in the fields (which they had not done previously) supports the importance of looking beyond physical capacity for work or labor productivity when assessing the functional consequences of adult malnutrition (Beaton, 1983). CONCLUSIONS The main cause of malnutrition among females in Sub-Saharan Africa is the same as it is for males—household food insecurity stemming from unreliable food availability, compounded by extremely low, and for the most part falling, incomes. Individual nutritional status of both males and females in Sub-Saharan Africa is further undermined by the continuing high burden of infectious disease in this region, which is particularly significant as a determinant of child nutritional status. Additional important causes of poor nutritional status among adult women in Sub-Saharan Africa are the high physiological burden of reproduction and the long hours of energy-intensive work common for rural women in the region. As in other parts of the developing world, the two most prevalent nutritional deficiencies among females in Sub-Saharan Africa are PEM and iron-deficiency anemia. As Table 3-6 indicates, PEM adversely affects female health status across most age categories, although for different reasons. POEM in the early years can lead to stunting, which is associated with increased risk of obstructed labor. PEM during the childbearing years is associated with elevated morbidity and mortality because of the increased nutritional demands of pregnancy. Iron-deficiency anemia is most commonly observed in women ages 15 to 40 years, and is itself a risk factor for maternal mortality. PEM and iron-deficiency anemia during the childbearing years are also major risk factors for low birthweight. In childhood, PEM and iron-deficiency anemia are important risk factors for poor learning. Evidence concerning other micronutrient deficiencies among girls and women in the region is limited, but it appears that iodine deficiency disorders are a major problem in many inland areas of Sub-Saharan Africa. As seen in Table 3-6, goiter has been observed in girls as young as age 10. IDD is also a cause of poor learning in childhood and adolescence. During the childbearing years, IDD is of concern because of the severe negative reproductive outcomes for both mothers and infants (cretinism). Vitamin A deficiency is quite prevalent in rural Sahelian communities, where there are significant seasonal fluctuations in the quantity and quality of the diet. There are no data, however, indicating that either prevalence or sequelae (for example, blindness) of vitamin A deficiency are worse in females than in males. Instead, vitamin A deficiency seems to be somewhat more prevalent among preschool-age boys than preschool-age girls. In comparison with other regions of the world, Sub-Saharan African females seem to be nutritionally better-off than females in South Asia, but are equally or more malnourished than females in most other parts of the developing world. In contrast with South Asia, there is no consistent pattern of a higher prevalence of PEM among females than among males, despite a generally higher work burden among adult women compared with men in

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 3-6 Nutritional Disorders and their Adverse Health Effects in Sub-Saharan African Females, by Age In Utero Infancy/ Early Childhood (birth through age 4) Childhood (Ages 5–14) Adolescence (Ages 15–19) Adulthood (Ages 20–44) Post-menopause (Age 45+) IDDa (congenital birth defects) IDD (poor learning) IDD (poor learning, goiter) IDD (goiter)     Iron-deficiency a nemia (low birthweight) Iron-deficiency anemia (poor growth) Iron-deficiency anemia (poor learning) Iron-deficiency anemia (poor learning, hemorrhage during childbirth) Iron-deficiency anemia (hemorrhage during childbirth) Iron-deficiency anemia (fatigue) PEMb (low birthweight) PEM (poor growth/ stunting, increased risk of infection) PEM (poor growth/ stunting, poor learning) PEM (obstructed labor) PEM (obstructed labor)   a IDD = Iodine deficiency disorders. b PEM = Protein-energy malnutrition. Sub-Saharan Africa. Small-scale studies from a few countries have found evidence of discrimination or disadvantage experienced by Sub-Saharan females in food consumption. The lack of attention to gender differences in much of the work done on the nutritional problems of Sub-Saharan Africa, however, allows no firm overall conclusion to be reached about the relative nutritional status of males and females. Beyond that, there is also probably considerable variability from one community to another. Female malnutrition in Sub-Saharan Africa is responsible for a broad range of both short-term and long-term negative consequences. As a result of malnutrition, girls (like boys) suffer high levels of mortality and stunting in early childhood and poor school performance in later childhood. Malnutrition among adult women poses severe risks both to these women and to their infants. Although stunting is not as widespread among women in most Sub-Saharan African countries as in the rest of the developing world, the lack of access to timely medical intervention for cephalopelvic disproportion and prolonged labor puts women with inadequate pelvic development (whether because of size, age, or both) at extremely high-risk. In addition, the high proportion of low birthweight infants in many Sub-Saharan African countries is substantially attributable to maternal malnutrition, both prior to and during pregnancy. Although some researchers have suggested that Sub-Saharan African females seem to "accommodate" remarkably well to inadequate food intakes, multiple pregnancies, long duration of breastfeeding, and long hours of energy-intensive domestic and market work, appearances can be deceiving. On the one hand, the extremely high infant, child, and maternal mortality rates and the short life expectancy in Sub-Saharan Africa suggest that women and children who are severely malnourished in this region simply fail to survive, perhaps because they are thus predisposed to greater vulnerability to highly prevalent infectious diseases and lack access to medical care. Even among those who survive, it seems almost certain that their marginal nutritional status severely restricts the energy that they have for any activities beyond those essential for survival. It may turn out that it is this restriction on discretionary activities that is most responsible for the perpetuation of malnutrition from one generation to the next. RESEARCH NEEDS Considerably more information exists about the extent, causes, and consequences of malnutrition among Sub-Saharan African females than about many of the other causes of morbidity and mortality reviewed in this report.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Nonetheless, inconsistencies in the findings from available studies and the lack of data on particular subgroups—such as adolescent girls; nonpregnant, nonlactating women of reproductive age; and older women —suggest important areas for future research. Available data on nutrition in Sub-Saharan Africa have been generally biased toward preschool children and women of reproductive age. Thus, our analysis, despite an emphasis on the life span perspective, has been limited by the scarcity of reliable data on the female population outside these age groups. In addition, only rarely are the available data nationally representative or comparable over time. Research effort should, therefore, be directed to collection of data on the nutritional status of females beyond those of preschool children and women of reproductive age. Surveys should be designed to ensure that data collected are nationally representative and comparable over time. Although it is useful to compare the regional information on child nutritional status from the Second Report on the World Nutrition Situation with the information on women's nutritional status, the ACC/SCN does not report child nutritional status disaggregated by gender. Similarly, although a substantial amount of research has been carried out to investigate the nutritional situation in Sub-Saharan Africa during the postcolonial period, the number, scope, and quality of nutrition studies varies substantially from one country to another, and many otherwise excellent studies (particularly of child malnutrition) do not report gender-disaggregated results. Future surveys for the Report on the World Nutrition Situation and other studies of nutritional status in Sub-Saharan Africa should make every effort to collect and report data that are disaggregated by gender (including data on child nutritional status). Studies indicate that, in comparison with other Sub-Saharan African regions, female nutritional status in eastern Africa tends to be protected, even in the context of low household food availability. Further research is needed to determine if there are specific dietary or behavioral factors that contribute to the protection of nutritional status in eastern Africa, or the extent to which nondietary factors —for example, better access to health care—compensate for the negative effect of food insecurity. The prevalence of obesity is an issue that has received little attention from researchers concerned with nutrition in Sub-Saharan Africa; relevant data are thus extremely limited. Surveys of the prevalence of obesity in Sub-Saharan African populations are needed, particularly given the evidence of increasing obesity-related chronic diseases in the region (see Chapter 8, Chronic Diseases). Survey data should be disaggregated by age and gender and collected on representative populations. A higher prevalence of iodine deficiency diseases among adult women and a higher prevalence of vitamin A deficiency among preschool-age boys (and perhaps among older males) is documented by studies carried out in many different cultural settings. It appears to be primarily physiological, although the specific mechanisms are less well understood than in the case of iron-deficiency anemia. Further research is needed to determine if there may be local dietary practices that enhance or reduce the biological gender differences. Evidence concerning other micronutrient deficiencies among girls and women in the region is quite limited and requires further evaluation. In attempting to assess the effects of female malnutrition on physical work capacity, considerable extrapolation must be done from studies of males, because surprisingly little research has been done on women. Studies of the long-term effects of childhood malnutrition on female work capacity are needed. Studies of the effects of adult malnutrition should look at gender-specific effects beyond those associated with reproduction.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa NOTES 1. The ACC/SCN data base was compiled from about 340 small- and medium-scale studies of the nutritional status of women between the ages of 15 and 49 years carried out since the late 1970s (UN, 1992). 2. Table 3-2 (and all other tables in this chapter) is organized alphabetically by subregion, and then alphabetically by country within each subregion. The four subregions—eastern, middle, southern, and western Africa —and the countries within them are listed according to WHO usage (WHO, 1992). For Table 3-2, two World Bank sources were consulted (World Bank, 1992a,b); where conflicting numbers were encountered, both are presented in Table 3-2. In most cases the numbers were close, but in a few cases they were so different as to make one, or both, suspect. 3. It should be noted that while 18.5 seems to be an appropriate cutoff in obstetrical risk, a lower cutoff, perhaps as low as 16, is more predictive of increased morbidity risk (Kennedy and Garcia, 1993). 4. In addition to diets that are deficient in iron, folate, and/or B12, hemolysis because of malaria and hemorrhage from hookworm or schistosomiasis are important causes of anemia. In many African countries genetic disease such as sickle-cell anemia and HIV infection can also lead to severe anemia. 5. Cutoffs used by WHO were less than 120g/L hemoglobin for nonpregnant adult women and less than 110g/L for pregnant women. Almost all studies in the review by WHO included only women of reproductive age. REFERENCES Alderman, H. 1990. Nutritional Status in Ghana and Its Determinants. Social Dimensions of Adjustment in Sub-Saharan Africa. World Bank Working Paper 3. Washington, D.C.: The World Bank. Bailey, R. C., M. R. Jenike, P. T. Ellison, G. R. Bentley, A. M. Harrigan, and N. R. 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