UNIT 22 MATERNAL MALNUTRITION

Structure 22.1 22.2 22.3 22.4 .22.5 22.6 22.7

22.8

22.9

Introduction Matemal Malnutrition Nutritional Status of Indian Women The Heavy Price of Matemal Malnutrition Risk Factors in Pregnancy The Importance of Health Care Let Us Sum Up Glossary Answers to Check Your Progress Exercises

22.1 INTRODUCTION
In the previous units of this block we have looked at several nutrition-related disorders. They-ranged from PEM and IDD which affect the younger child to lathyrism and fluorosis which manifest themselves in the years of adolescence and adulthood. We also covered the spectrum of undernutrition (e.g. PEM) and overnutrition (fluorosis and the diseases of affluence). This unit now focusses on malnutrition in women. Why do we need to emphasize this aspect? Ycyl would probably know the answer. The health of the woman influences the nutritional status of her children and the family a~a-wiwle.A significant proportion of women in our country are poorly n o h h e d . This increases the likelihood of infection and death. Pregnancy and lactation are periods of particular stress as you already know. Too many closely spaced qregnancies usually have very adverse effects on the health of women. We will discuss in some detail the important features of maternal malnutrition and its impact on the health of the newborn and young child. As you read on, you will find that there are ways in which we can identify women who need special care particularly during pregnancy and take action to help them remain healthy as well as maintain the health of their children.

Objectives
After studying this unit, you should be able to describe the influence of maternal nutritional status on the nutritional status of children identify high risk factors in pregnancy and discuss their influence on the outcome of pregnancy.

22.2 MATERNAL MALNUTRITION

The word maternal refers to the mother. "Maternal malnutrition" therefore means malnutrition of mothers. It can be extended to include women in the reproductive age. The physiological stress of added nutrient demands makes pregnancy and lactation high-risk periods in the life of a woman. The woman's tissues become depleted of essential nutrients as she enters the vicious cycle of too many closely spaced p ~ p m i e and s prolonged breast feeding (see fig.). This is the main reason why so many of our women die. They are vulnerable to disease and infections which ultimately take their toll. We must also remember that most maternal deaths in our country are due to poor antenatal care i.e. care of the mother during pregnancy. And

even when women survive they continue to suffer from the consequences of inadequate health care and malnutrition. Too many closely pregnancies. Prolonged breast feeding

What causes maternal malnutrition? The answer, obviously, is less food and not enough food of the right kind. This accounts for the lower heights and weights of women particularly in rural areas and urban slums. It also explains why so many Indian women suffer from anaemia and vitamin Bcomplex deficiences. The diets of these women are inadequate largely because they are poor and do not have the money to purchase enough food. Ignorance adds to their problems. They do not have the knowledge to make wise food choices for themselves or their families. In fact we do not often realize that maternal malnutrition begins with poor nutrition during the years of adolescence. Our health and nutrition programmes should also be targeted at adolescent girls so that they can be better equipped for safe motherhood. We discussed this aspect in detail in Unit 10 of Block 3. Now what are the consequences of maternal malnutrition? We mentioned the effects of maternal malnutrition for the woman herself. It results in ill health and often, even death. However, maternal malnutrition also affects the health and well-being of the foetus, the infant and the young child. It often results in death of the child. Even if the child survives, it can condemn the child to a lifetime of poor health. We will return to this aspect in Section 22.4.

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Depbtion of essential nutrients.

22.3 NUTRITIONAL STATUS OF INDIAN WOMEN

You are aware that we make use of body weight and height to measure the nutritional status of an individual. An Indian woman belonging to a low income group living in villages or urban slums, on the average, weighs about 40-45 kg according to surveys conducted in different parts of the country. A well nourished woman's weight is about 55 to 60 kg. Thus, a poor Indian woman is about 10 to 15 kg lighter than a well fed and healthy woman. Similarly, the height of the low income group Indian woman is 150 cm as against the average height of about 160 crn ih the case of a healthy, well nourished woman. These figures directly show the effect of poverty on1nutritional status. As a result of short stature the woman can have a difficult delivery and may even die during such difficult labour. It is also a fact that women with low body weights deliver babies who are underweight. Children born with weight less than '2.5 kg are considered underweight and are known as low birth weight babies. Among the children born to poorly nourished women of low income groups, the rate of low birth weight is high as you will find on reading the next section. The dangers of low birth weight are two fold. First the child is at a

Nutrition-Related Dlrorderr

high risk of death. Secondly, even if the child survives, the child ends up as a short statured, malnourished adult whose productive capacity in turn is very low.

A good indicator of the nutritional status of the mother as well as the growth of the foetus is the weight gain during pregnancy. In fact, the amount of weight a woman puts on during her pregnancy is dependent on her nutritional status. Do you recall what contributes to the weight gain during pregnancfl Generally, the weight of the foetus, enlargement of reproductive organs i.e. uterus and placental weight, increase in volume of blood, extracellular fluids and fat contribute to the weight gain during pregnancy. A well fed woman gains 10-12 kg during the period of pregnancy i.e. she adds 10-12 kg to her pre-pregnant weight. In India, however, a very large proportion of pregnant women gain only about 6.5 kg due to undernutrition, Low weight gain is injurious to the health of the mother. In addition, it causes low birth weight in the offspring. Table 22.1 highlights the alarming impact of poor maternal nutritional status on the health of the child. Poor diets, increased physical activity and absence of proper health care during pregnancy are the main reasons for this situation.
Table 22.1 Maternal Nutritional Status and Outcome of Prqnancy Group (according to nutritional status in childhood) Average Birth weight (kg) 2.41 2.57 2.55 2.62 Birth weight helow 2.5 kg (%) 52.9 42.2 37.1 38.3

Foetal loss

Death during infancy

%'
Severely undernourisheh (37) Moderately undernourished (49) Mildly undernourished (66) Normal (30)
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%
11.8 8.9 3.3 6

11.8 8.9 8.2 3.3

Source : Women and Nutrition in India, Edited hy C. Gopalan and Suminder Kaur, Nutrition Foundation of India. New Delhi. 1989.

Highlight 2 discusses adequacy of the diets of pregnant and lactating women as revealed by dietary surveys.

HIGHLIGHT 4 Diets During Pregnancy and Lactation

You know that a woman needs extra nutrients, particularly energy and protein, during pregnancy or lactation. The diet of an Indian woman is usually not different whatever be her physiological status, i.e. she consumes the same amount of food whether she is pregnant, lactating or non-pregnant and non-lactating. The home diets of women provide as low as 1500-1600 kilocalories during pregnancy and lactation. Indian women particularly women living in villages are also physically very active even during pregnancy. They carry out agricultural and other jobs in addition to household jobs. Thus, if these physical tasks are taken into account the energy deficit in the diets of pregnant women can be as high as 800-1000 Kcal per day. Why are the intakes so low? The low intakes are due to poverty or low purchasing power. In addition, due to ignorance, taboos and false beliefs pregnant women do not consume certain foods and sometimes even reduce their intake of food. They believe that if they eat more food during pregnancy they will deliver bigger and heavier babies. They fear that this may lead to difficult delivery. Hence they do 'not consume adequate diets. There is, therefore, a need to educate women along with providing dietary supplements during pregnancy and lactation. Dietary supplements based on locally available foods can, to a large extent, bridge the dietary gap. These food supplements for the pregnant woman should be made much more culture specific. For instance, pregnant women in Gujarat and Maharashtra traditionally consume a high energy food called 'Methipak' during the last stages of pregnancy and throughout lactation. Similarly, other regions of the country have typical traditional snacks offered to pregnant and lactating women. The use of such foods can be encouraged. This will not only improve the nutritional status of women but reduce the incrdence of low birth weight among the babies. The Government has started supplementary feeding programmes for pregnant women during the last three months of pregnancy and first six months of lactation to fill up the dietary deficit.

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Lei us now summarize the specific points we have learnt from this discussion: i) ii) iii) Maternal d ~ e is t related tn the birth weight of the infant. Women of low stature or low weight for height tend to have infants with low birth weights. Infants born with low birth weight are more prone to infections and death. Even if they do survive, their mental and physical growth is affected.

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Maternal Malnutrltlon

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22.4

THE HEAVY PRICE OF MATERNAL MALNUTRmON

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We have already learnt that the nutritional status of the woman decides her reproductive performance, particularly the outcome of pregnancy. A woman who is well fed ahd healthy can complete pregnancy successfully giving birth to a healthy, normal child. If, on the other hand, the woman is poorly nourished we pay a henw price-the ill health and death of mother and child.

We have already mentioned that poor maternal nutrition and low birth weight are related. The frequency of births with weights below 2.5 kg among poor income groups is more because of extensive malnutrition among the women. In a normally fed population, for every 100 births 8 to 10 childrkn may have low birth weights (less than 2.5 kg). In the case of poorly nourished women, however, 30-40% of their children will have low birth weights. Children with low birth weights are at a higher risk of death as compared to those with normal weights. This is one of the reasons for high death rate among infants (referred to as infant mortality rate). The lower the b ~ n h weight, the higher will be the risk of death in the case of the child. Besides high mortality rates, low birth weight babies also tend to have: greater incidence of infections fewer brain cells lower growth rates and greater incidence of mental retardation As you have just seen, lack of food is a major culprit in causing maternal malnutrition and therefore low birth weights. Lack,of specific nutrients such as iron and folic acid in the diet of the mother can also cause low birth weight as you learnt in Unit 18. You know that the prevalence of anaemia is very' high in pregnant women (Unit 18, Block 5). Severe anaemia leads to premature births (birth before 37 weeks of pregnancy) and low birth weights. There are risks for the mother as well. In anaemic pregnant women, the deaths during delivery are also more. Anaemic women will not be able to do normal physical work. In fact, the physical capacity of women with anaemia has been shown to be much less. The high rate of anaemia is mainly due to consumption of inadequate dietary iron and folic acid by pregnant women. The Government of India has a programme for distribution of tablets containing iron and folic acid to pregnant women to control anaemla and its consequences.' Research studies have proved that such supplementation also helps to ensure that the birth brt~ghr of the infant would be normal. You will learn more about this programme in rhe next block.
Check Your Progress Exercise 1

1) Look at the following IIOW cham (A) and (B). They depict the causes and effects of maternal malnutrition. Can you complete them? Write your answers in the boxes provided.

NutritioaRelated DLsordws

MATERNAL MALNUTRITION

INADEQUATE DIETS

MATERNAL MALNUTRITION

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Flow Chart (A)

INFANT DEATHS

Flow Chart (B)

22.5 RISK FACTORS IN PREGNANCY

In the earlier section we have discussed the causes and impact of maternal malnutrition. The crucial question we must now talk about is-how do we tackle this problem? How do we predict which woman will become malnourished? Much research has been done on this aspect in India and abroad. The results indicate that a woman would be likely to be malnourished if any one or more of the following conditions exist: repeated pregnancies closely spaced births high infection rate heavy workload smoking and alcohol consumption
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Repeated pregnancies
An average woman in India (particularly in rural areas) goes through the cycles of pregnancy and lactation a number of times. Such multiple and repeated pregnancies adversely aflect the lrealth of the woman and child. The prevalence of anaemia is higher in these women. The children born to women who had multiple pregnancies are also likely to be low in birth weight.

Closely spaced births

Many women in our country have the next child when the older child is just about one year of age. The spacing or the gap between the two children, therefore, is very small. Such clise spacing of births is harmful not only for the health of the mother but aho for the child Pregnancy and lactation are conditions which impose additional nutritional stress on the part of the mother. Closely spaced deliveries do not provide enough time for the woman to recover from the physiological stress caused by the previous pregnancy. You may know that the gap between two children should be atleast 3 years. Only then will the mother have an opportunity to recover and * maintain a good nutritional status. Similarly, the children born with very little gap between them are likely to be of low birth weight. They are at a higher risk of developing severe forms of malnutrition like kwashiorkor or marasmus. If the gap between the children is adequate the mother can breast feed the child for sufficient time and provide proper child care as well.

Higher rate of infections

The rate of infections in pregnancy tends to be high. In fact, pregnant women are

more susceptible to urinary infection, They also suffer from diarrhoea, malaria and hepatitis. In oddition, anaemia, which is very common among them, increuea the risk of infections. Ivectlons can slow down foetal growth and may lead to still birth or low birth weight. They also seriously weaken the mother.

Hmvy work lord

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Indian women even during pregnancy continue t o participate in agricultural labour in addition to household activities. In view of poverty more women from lower income groups have to work as labourers. You may also know that in remote rural areas women have to walk long distances to collect water or gather fuewood. 271e energy needs of such women are, therefore, higher. Since these women subsist on inadequate diets the weight gain divlngpregnancy is low and they have smaIler children.

Smoking and alcohol consumption have deleterious eficts, particularly on the weight of oflspring. The prevalence of low birth weights in women who are regular smokers is about twice that of non-smokers. If the smokers are also regular consumers of alcohol the prevalence of low birth.weight is estimated to be 4 times that of nonsmokers and non-alcohol consumers. In India, smoking and alcohol abuse is increasing in the case of women and this is a cause for concern.
We have so far looked at some of the major conditions associated with health of the mother and child.' On the basis of this information we can identify the major risk factors in pregnancy. What are risk fictors? A risk factor is a condition which can cause problems for both the mother and the child. The the number of risk factors sssockged with a particular woman, the more the chances of ill health and even death of mother and child. Let us now list the risk factors. These are: i) ii) iii) iv) v)
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Age below 18 years or above 35 years. Height less than 14.5cm. Weight less than 42 kg. Woman with previous child weighing less than 2 kg a t birth. History of twin births. Woman having severe anaemia (haemoglobin below 8 g per cent)

vii) Closely spaced pregnancy. viii) Repeated pregnancies (four or more). ix)
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Woman who had lost her previous child. Woman belonging to very poor family.

xi) Woman who had difficult labour during the earlier pregnancy. xii) Women suffering from diseases such as diabetes, heart disease, high blood pressure. xiii) Woman who is heavy smoker or drinker or is addicted to drugs.

22.6 THE IMPORTANCE OF HEALTH CARE

The previous discussion has highlighted the fact that the health of the pregnant woman t o a large extent determines the health of the children and the community. Proper care is vital in keeping both mother and child well nourished and healthy. We must take care of them properly. Pregnant women should be observed periodically throughout their pregnancy so that prompt remedial measures can be taken, C necessary, They should contact a medical off~cer regularly and undergo medical check u p frequently. These contacts or visits are called antenatal (hefore birth) d e c k ups. Antenatal check ups are recommended

Nutrition-Related Disorders

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monthly in the first trimester fortnightly during the second trimester and weekly in the third trimester.

It has, however, been found that even three minimum antenatal check ups by trained health personnel are adequate to recognize possible problems. The following chart lists the guidelines for these check ups given by the World Health Organization (WHO) for health personnel:

CHECK UP First Check Up (Early three months of pregnancy)

TASK FOR HEALTH PERSONNEL ;

Find out history of previous pregnancies Exclude anaemia Determine size of uterus Rule but the possibility of the foetus growing in any region outside the uterus. Detect any rise in blood pressure Detect any swelling of the legs Determine haemoglobin level Assess foetal growth so as to identify any cases of growth retardation Make sure that the foetus's head is correctly positioned and is not too big to cause problems in delivery.

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Second Check Up (20 week of pregnancy)

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Third Check Up (37th week of pregnancy)

The chart shows how health workers examine pregnant women. The growth of the foetus is carefully assessed. In addition, the physical state of the mother and her age, height, weight gain during pregnancy is recorded. Blood pressure and haemoglobin levels are also noted. In the case of women pregnant for the fust time, the breasts d nipples are also examined. During antenatal check ups suitable dietary advice and treatment fdr any ailments is also provided, if necessary. Preventive steps can be taken if any complication is suspected to occur during delivery. Anaemia and complications like pre-eclampsia can be promptly diagnosed and appropriate treatment can be provided. Iron and folic acid supplements and education regarding breast feeding after delivery can be provided during the antenatal check ups. In the case of poor women, dietary supplements are also provided during the last 3 months of pregnancy. During antenatal check ups, high risk pregnancies can be identified. All pregnant women who are at a greater risk can be monitored so that suitable steps can be taken to protect the health of the mother and the child. In the previous section we have already discussed the risk factors in pregnancy. Do you recall them? Health workers should be trained to identify high risk pregnant women i.e. women having risk factors and constantly keep track of their health during their routine home visits. In our country abowt'80 per cent of the deliveries are conducted by untrained dais under unhygienic and improper conditions. This is responsible for high maternal deaths. The health workers should arrange for supervised delivery of thes'e high risk pregnant women by trained health workers or doctors. The . improvement of the health of women should be considered as the stepping stone to promoting the health of the child, the jamily and the community.

Check Your Progress Exercise 2 I)\ List the factors i n the case of pregnant women that may influence the birth weight of infants.

Maternal Malnutrition

2) Fill in the blanks :

a) Weight gain in Indian pregnant women of low income groups may be only .....................

h) Maternal malnutrition means malnutrition of ..................... c) Normal women gain ..................... kg during their pregnancy. d) The children horn with very little gap between them are at a ..................... risk of malnutrition. e) Body weight less than ..................... kg is a risk factor during pregnancy.

3) List four major risk factors in pregnancy. Give one reason why it is important to identify high risk women.

2 2 . 7 IXI' US SUM UP
Maternal nutritional status has a substantial effect on the birth weight of the infant and the infant's subsequent growth. Many pregnant women in India are shorter apd lighter and the weight gain during pregnancy is much less than it should he. Research has revealed that their diets are not very different from those of nonpregnant women though the requirements are considerably increased during pregnancy and lactation. Ignorance, taboos and poverty contribute t o these low intakes. As a result there is a high prevalence of anaemia a t d other nutritional deficiency diseases in pregnant women and maternal deaths are many. For improvement of the nutritional status of pregnant women, apart from dietary supplements, proper antenatal care particularly of those who are at high risk is necessary.

22.8 GLOSSARY
Dai
High risk factors
: Traditional birth attendant (i.e. person from the community

who assists in delivering babies).

: Factors, if present in a pregnant woman are likely to lead to

complications during pregriancy or delivery. : Convulsions occuring during the later part of pregnancy. Eclampsia Infant Mortality Rate : Number of infant deaths for every 1000 born alive i.e. 1000 live births. Pre-eclampsia : A condition preceding eclampsia.

22.9 ANSWERS TO CHECK YOUR PROGRESS EXERCISES

Check Your Progress Exerclre 1
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1) A) a. Poverty b. ignorance. B) a. Maternal ill health and deaths b. foetal malnutrition c. Low birth wejght infants d. Infant deaths.
Check Your Progress Exerclse 2

1) Low weight gain, multiple pregnancies, anaemias, high rate of infections, smoking and alcohol abuse, ignorance and poverty. 2) a) b) c) d) e)
6.5kg Mother 10-12kg High 42 kg

3) Any four of the following :

1) Age less than 18 years or above 35 years. 2) Woman with height less than 145 cm. 3) Woman weighing less than 42 kg. ' 4) Woman with previous child weighing less than 2 kg at birth. 5) Woman having severe anaemia (haemoglobin below 8 g per cent) 6) Woman with history of twin births. 7) Closely spaced pregnancy. 8) Repeated pregnancies (four 2r more). 9) Woman who had lost her previous child. 10) Woman belonging to very poor family (below the poverty line). . I I) Woman who had difficult labour during the earlier pregnancy. 12) Woman suffering from diseases such as diabetes, heart disease, high blood pressure. 13) Woman who is a heavy smoker or drinker or is addicted to drugs. It is important to identify high risk women so that they can be given adequate care and more frequent medical check ups to ensure normal delivery and a healthy baby.