Is gender inequality the main roadblock to achieving nutrition targets? The Global Nutrition Report on gender equality

To mark International Women's Day I wanted to write about something that has been niggling me.  

While the Global Nutrition Report has been well received, one of the things people said we could have done better was to draw out messages about women and gender.  I agree, hence this blog.

What are the links between nutrition and women’s empowerment?

What are the links between nutrition, women’s empowerment and gender equality?  First of all, the Report makes it clear that improvements in nutrition are important to achieve gender equality and to empower all women and girls (Sustainable Development Goal 5, Table 2.2).  While globally there are no large differences between male and female stunting or wasting rates at the under 5 level (see the UNICEF 2013 Report), the difference in power between males and females really becomes visible as girls reach adolescence.   Very young age at marriage is a sign of gender asymmetries in power and young age at marriage is followed by young age at first birth which tends to be bad for the health of baby and mother as the mother is still a child herself.  In addition married girls are more likely will be taken out of school if they are enrolled or be discouraged from entering in the first place (Africa’s female secondary school enrollment rate is still low at 53%, Figure 6.3). Wherever there are gender differences in stunting rates (and it would be good to find a global analysis of this-we couldn’t) addressing them will help minimize schooling attainment gaps and wage rate gaps later on in life.   

What impact would a reduction in gender asymmetries have on under 5 stunting rates?

Second, the report uses a model published here to understand how underlying determinants of nutrition status would have to change to get stunting rates below 15% (equivalent to the WHA 2025 target, see Panel 2.4).  The required increases in all underlying determinants (food security, water and sanitation coverage and secondary enrollment rates for females) are close to past performance, with one exception: the ratio female to male life expectancy at birth.  This ratio is about 1.07 for countries where, relatively, there is less discrimination against women.  For countries with well documented and strong discrimination against women, this ratio is closer to one and in some cases below one.  This ratio would have to increase substantially faster than historical rates of improvement to reach the WHA target.  So gender asymmetries are very likely to be the main constraint to reaching the WHA targets, at least at the global level and certainly for regions like South Asia where gender asymmetries are largest.

What is the state of women’s nutrition status?  

Third, we focus on key indicators of women’s nutrition status.  For example, anemia rates in women of reproductive age are shockingly high and going down very slowly. They were 32% in 2000 and 29% in 2011 (Table 3.1).  In fact only 5 countries out of 185 are on track to meet the World Health Assembly targets for anemia in women of reproductive age (Figure 3.7).  Some attribute the slow decline of anemia rates to the low political power of women in society. Women’s anthropometric indicators, such as stature and body mass index, show many missing data gaps.  In fact only 67 out of 193 countries have indicators on women’s short stature, thinness and overweight (Table 4.2).  Only one third of these 67 countries have women with good nutrition--that is they have rates for these three indicators that are all below public health cutoffs. That means two thirds of all countries have a serious problem with one or more of these conditions (Table 4.2).  

How well are we doing in scaling up nutrition interventions that address women’s nutrition status?

Fourth, on the coverage rates of direct nutrition interventions (nutrition specific) the report demonstrates the absence of national programmes that focus on the pregnant mother.  There are no national programmes for the 3 proven interventions during pregnancy: balanced energy-protein supplementation, calcium supplementation and multiple micronutrient supplementation (Table 5.1).   Moreover there are no national programmes on folic acid supplementation pre-pregnancy (and although there are national programmes during pregnancy, median coverage rates are well below 33%, Table 5.2). 

Empowering women makes interventions in nutrition relevant sectors more nutrition sensitive

Fifth, the report brings together evidence on how to make interventions in nutrition relevant sectors (e.g. agriculture, social protection, education and WASH) even more nutrition sensitive.  All of the different recommendations agree on one thing—involve women in a decision making way on the prioritization, design, implementation and evaluation of more nutrition sensitive versions (Table 6.3). This is because much empirical research has shown that when women exert more control over household resource allocation, the nutrition status of the children in the household—and everyone else—improves, even at a given income level.

Enactment of laws that protect mothers, babies and infants is weak

Finally, the report discusses the two laws that are vital to maternal and child well-being.  Only 54% of 164 countries for which we have data have enacted laws encompassing many provisions of the code of marketing of breastmilk substitutes.  In addition only 51% of 169 countries with data have ratified the ILO’s Convention 183 on maternity leave protection (Figure 7.3). Given the vital importance of the first 1000 days post conception to a child’s start in life, and the fact that passage of laws does not equal implementation and enforcement, these rates are definitely a case of cup half empty.

Does the report have much to say on women’s nutrition, gender asymmetries and women’s empowerment?

Most definitely.  The links between nutrition and women’s empowerment –in both directions—are clear.  Reductions in gender asymmetries in longevity outcomes seems to be the critical constraint to accelerating reductions in stunting.  Fully two-thirds of countries with data show women having serious public health nutrition issues in one or more of three nutrition dimensions: short stature, thinness or overweight. Improvements in women’s nutrition status indicators, especially anemia, seem slow. Coverage rates of programmes targeting the preconception and pregnancy periods are particularly weak.  Half of all countries do not have laws and conventions in the area of maternity leave and the marketing of breastmilk subsitutes, both of which would better protect women and infants in the first 1000 days after conception.

The nutrition status of women is vital in its own right and is of course closely linked to the nutrition status of their children, but it is also connected to the nutrition status of their household, community and nation. The empowerment of women makes policy interventions in a large number of sectors more nutrition sensitive.  The process of women’s empowerment must be supported more vigorously. Gender equality is fundamental to justice, and it is fundamental to nutrition.