South Asia
Both women’s decisionmaking power relative to men’s within households and the degree of gender equality at the community level have positive effects on the nutritional status of chil- dren one to three years old in South Asia. Improvements in women’s relative decisionmaking power have a strong influence on both long-term and short-term nutritional status, leading to reductions in both stunting and wasting. Gender equality at the community level only influ- ences children’s long-term nutritional status. It has a considerably weaker effect than relative decisionmaking power in households.
The malnutrition costs of inequality in the status of women and men in the region are high. The study estimates that, holding all other factors constant, if such status were equalized, the
CONCLUSIONS AND POLICY IMPLICATIONS 127
percentage of underweight children under three years old would drop by approxi- mately 13 percentage points, from 46 to 33 percent; the number of underweight chil- dren would drop by 13.4 million. Why do increases in women’s status lead to im- provements in children’s nutritional status? The empirical results demonstrate that in this region, where more than 40 percent of women are underweight, increases in women’s decisionmaking power relative to their husbands’ lead to improvements in women’s own nutritional status. Because women’s nutritional status is in turn closely linked with children’s birth weights and the quality of care for children, this finding ver- ifies that women’s own health and nutri- tional status is one of the pathways through which women’s status influences child nu- trition in the region.
The study also finds that increases in women’s decisionmaking power relative to men’s have a powerful positive effect on child nutritional status because they im- prove a wide range of caring practices for women and children. These include
prenatal and birthing care for women;
complementary feeding of children, including timely introduction, food quality, and feeding frequency;46 timely initiation of breastfeeding;
treatment of illness of children;
immunization of children; and
quality of substitute caretakers for children.
Evidently, the more decisionmaking power a women has relative to her husband, the more actions are taken to improve care for the woman herself and for her children. There is one important exception, however. Women’s relative decisionmaking power has a negative effect on breastfeeding prac- tices in the region, including the degree of exclusive breastfeeding in a child’s
first four months and the duration of breastfeeding.
It is not only at the household level that women’s status influences the nutritional status of children in South Asia. As noted, increased gender equality at the community level also improves child nutritional status. Its pathways of influence include the fol- lowing care practices:
prenatal and birthing care for women,
timely initiation of breastfeeding,
timely introduction of complementary foods to children,
treatment of illness of children, and
immunization of children.
It is notable that most of these are related to the use of services provided at the commu- nity level.
Strong differences in the impact of women’s status on child nutritional status between poor and rich households are found. When women’s status is raised in poorer households, it has a greater positive impact on child nutritional status than when women’s status is raised in rich households. Women’s ability to influence decisions over the allocation of economic resources is ap- parently more important for children’s nu- trition when those resources are scarce. Sub-Saharan Africa
In SSA, as in South Asia, women’s deci- sionmaking power relative to men’s has positive effects on both long- and short- term nutritional status of children. The costs of inequality between women and men in the region are not as high as those in South Asia, but they are still substantial. It is esti- mated that an equalization of status of the genders would reduce the region’s under- weight rate for children under three years old from 30.0 to 27.2 percent, representing a reduction in the number of underweight children of 1.7 million.
46
In SSA, women’s nutritional status is far better than in South Asia. Only 12 per- cent of women are underweight. A woman’s decisionmaking power relative to her hus- band’s is found to improve her nutritional status, but only up to a point. As this power rises, it begins to exert a slightly negative influence, one that has little consequence for women’s and, most likely, children’s nu- tritional health. Women’s nutritional status may thus be a pathway through which in- creases in women’s status lead to improve- ments in child nutrition in SSA, but only for women with very low decisionmaking power relative to their husbands. Societal gender equality does not appear to be asso- ciated with women’s nutritional status in the region.
The caring practices for women and children that women’s status improves include
prenatal and birthing care for women;
complementary feeding of children, in- cluding timely introduction and feeding quality and quantity;
immunization of children; and
quality of substitute caretakers for children.
As in South Asia, increases in women’s rel- ative decisionmaking power reduce the du- ration of breastfeeding. Such increases have no effect on breastfeeding initiation or the likelihood of exclusive breastfeeding among infants 0- to 4-months old.
Clues as to the origins of the insignifi- cant effect of societal gender equality on child nutritional status in SSA can be found by looking at its effects on caring practices for women and children. It has no statisti- cally significant effect on birthing care, breastfeeding and complementary feeding practices, treatment of illness in children, or substitute caretaker quality. While it has a positive effect on immunization of children, it has a negative effect on prenatal care for women.
As for South Asia, the effect of women’s relative decisionmaking power on
child nutritional status in SSA is strongest among the poorest households.
Latin America and the Caribbean LAC exhibits quite a different pattern from South Asia and SSA. Women’s decision- making power relative to men’s has a posi- tive effect only on children’s short-term nu- tritional status. This effect is strong only for households in which women’s relative deci- sionmaking power is very low. Gender equality at the community level has no in- fluence on children’s nutritional status. While inequality in the status of women and men is likely to have malnutrition costs where such inequality is very high (in the form of child wasting), it has no measurable costs when considered at the aggregate re- gional level.
In LAC, very few women are under- weight and, in fact, a substantial percentage is overweight. Increases in women’s rela- tive decisionmaking power are associated with reductions in women’s body mass index (the measure of nutritional status), which likely reflects the greater tendency to “weight watch” among women with higher status and is not harmful to children’s nutri- tional status.
The list of caring practices that women’s relative decisionmaking power improves, which is shorter than that of the other regions, includes
prenatal and birthing care for women,
frequency of child feeding,
immunization of children, and
quality of substitute caretakers for children.
As for the other regions, women’s relative decisionmaking power has a negative effect on the duration of breastfeeding, which combined with the absence of positive ef- fects for many of the other determinants of child nutritional status may explain the weak overall effect of decisionmaking power on child nutritional status. Gender equality at the community level has a posi-
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tive influence on prenatal care for women and immunization of children.
Following the same pattern as South Asia and SSA, the effect of women’s rela- tive decisionmaking power on child nutri- tional status in LAC is strongest among the poorest households.
The Asian Enigma
This study identifies three broad socioeco- nomic factors contributing to the large child nutritional status gap between South Asia and SSA. The first, and the one that makes by far the greatest contribution, is women’s status. Women’s status contributes to the gap for two reasons. First, it is slightly lower in South Asia than in SSA. The esti- mated contribution of this difference be- tween the regions to the gap is on the order of 7 percent. The second reason is that the costs in child malnutrition of women’s sta- tus being lower than men’s are higher in South Asia than SSA because its positive influence is stronger in the former. The esti- mated contribution of this difference to the nutritional status gap is on the order of 50 percent. Thus the differential costs factor contributes far more to the gap than the dif- ferential levels factor; the latter is the sub- ject of Ramalingaswami, Jonsson, and Rhode’s (1996) Asian Enigma hypothesis.
The other behavioral factors that con- tribute to the nutritional status gap are dif- ferences between the regions in sanitation and urbanization. The use of toilet facilities is much lower in South Asia than in SSA, yet the importance of such use for improv- ing child nutritional status is much greater in South Asia. Additionally, the use of well water is actually found to be harmful to child nutritional status in South Asia. Ur- banization, contrary to current thought, is also found to have a negative effect on child nutrition in South Asia.
The study identifies several proximal determinants that are known to contribute positively to child nutritional status in both regions but that are lower in South Asia. These are women’s nutritional status, pre-
natal and birthing care for women, and the quality of feeding practices for children (with the exception of the extent of exclu- sive breastfeeding, which is higher in South Asia). Women’s own nutritional status, and important aspects of the quality of care for women and children, must also be added to the list of factors that place a wedge be- tween child nutritional status in South Asia and SSA.
Finally, factors specific to the South Asian region that have not been measured in this study but that have a negative impact on child nutrition further widen the gap be- tween the region’s malnutrition rates. These may be related to climate, population densi- ties, or culture, for example.
While this study has helped to solve the Asian Enigma, its full origins remain a mystery in need of further investigation. An area that still needs clarification is why the influence on child nutrition of women’s sta- tus is so much stronger in South Asia than in SSA. Another area is the roles sanitation and urbanization play in widening the wedge between the regions’ malnutrition rates. Finally, the national-level factors that drive child malnutrition rates in South Asia so much higher than those in SSA need to be identified. Research on these subjects would inevitably require interdisciplinary collaboration.