a factsheet on women’s malnutrition in india

7/29/2019 a Factsheet on Womens Malnutrition in india

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Economic & Political Weekly EPW august 16, 2008 61

a Fch on Womn Mnuron n ind

Sunny Jose, K Navaneetam

This paper analyses levels of womens malnutrition

in India over the seven years between 1998-99 and

2005-06, based on the National Family Health Survey.

During a period of higher growth and a reasonable

pace of reduction in poverty, malnutrition especially

iron-deficiency anaemia has increased among women

from disadvantaged social and economic groups. The

adverse influence of maternal malnutrition extends

beyond maternal mortality to causing intrauterine

growth retardation, child malnutrition and an increasing

prevalence of chronic diseases.

We thank, without implicating, S Subramanian, Keshab Das, Aparna

Sundar and Amruth or comments and suggestions.

Sunny Jose ([email protected]) is with the Gujarat Institute oDevelopment Research, Ahmedabad. K Navaneetham ([email protected])

is with the Centre or Development Studies, Thiruvananthapuram.

This paper deals with womens malnutrition in India. It

presents a preliminary actsheet on the levels o womens

malnutrition at present including the spatial, social and

economic disparities and also the extent o decline during the

past seven years. India has not only a large number o malnour-

ished women, it also has one o the highest proportions o mal-

nourished women in the developing countries. For instance, a re-

cent estimate suggests that in 2000 about 70 per cent o non-

pregnant and 75 per cent o pregnant women aged 15-49 years in

India were anaemic in terms o iron-deciency [Mason et al

2005]. It is important to know whether the current levels o mal-

nutrition among women remain as high.

Why has malnutrition been so high among women in India?

The reasons are multiple and complex. Seemingly, the discrimi-

natory practices associated with the rigid social norms and the

excessive demands made on the time and energies o women join

hands with the usual determinants in blighting womens nutri-

tion [Ramalingaswamy, Jonsson and Rohde 1996; Osmani and

Bhargava 1998]. However, one o the usual determinants, namely

poverty, seems equally important: not only is poverty one o the

basic causes o malnutrition, but also malnutrition is considered

to be both an outcome and a maniestation o poverty [ACC/SCN1997, ch 3-5]. I so, then, the higher rates o economic growth

during the past 10 years or more coupled with a reasonable re-

duction in poverty, especially between 1999-2000 and 2004-05,

would normally imply a decline in womens malnutrition. Thus, it

is also important to assess whether such good times are good

or women as well.

1 sgnfcnc of Womn Nuron

Nutrition embodies a central role in human well-being. It is both

an essential element o, and also a critical input to other aspects

o, well-being. Adequate nutritional attainment is essential

equally or men and women. However, womens nutrition as-

sumes additional importance due to its critical but complex asso-

ciation with their well-being and the implication it has or human

development. Yet, it is womens nutrition to that extent their

well-being which has oten been subsumed under the umbrella

o amily welare and ignored ostensibly due to constraints

rom culture in India and other south Asian countries. How is

womens nutrition important or their well-being? How does it

impinge on aspects o human development?

Undernutrition would denote a deprivation o the basic aspect

o well-being: the lack o reedom to lead a minimally healthy

lie. The implications that womens malnutrition have or humandevelopment are multiple and cumulative. For instance, maternal

malnutrition tends to increase the risk o maternal mortality.


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august 16, 200 8 EPW Economic & Political Weekly62

Maternal short stature and iron deciency anaemia, which in-

crease the risk o death o the mother at delivery, account or at

least 20 per cent o maternal mortality [Black et al 2008]. Addi-

tionally, maternal malnutrition impinges signicantly on such

important but interconnected aspects as intrauterine growth re-

tardation, child malnutrition and rising emergence o chronic

diseases, among others [Osmani and Sen 2003; Victora et al

2008]. Thereore, analysis o the nutritional attainment owomen, which is the primary ocus o the present paper, assumes

signicance and relevance.

The major questions the paper endeavours to examine are the

ollowing: what is the extent o womens malnutrition? How large

are the spatial, social and economic disparities in womens mal-

nutrition? Has womens malnutrition declined or increased over

the years? We hope to address these questions by analysing the

National Family Health Survey-3 (NfhS-3) data, 2005-06 and

also through a comparative analysis between NfhS-3 and National

Family Health Survey-2 (NfhS-2) data, 1998-99. It is important to

state, at the outset, that the ocus o the paper is limited in scope:

it is not on issues o causation or on providing an explanation,

but rather on presenting a preliminary actsheet on womens

malnutrition in India.

2 Dffrn lv

Beore getting on with the analysis, a note on the indicators o

nutrition used here is in order. The body mass index (BMI), which

measures the weight to squared height (w/h2), below 18.5 indi-

cates undernutrition, reerred to as chronic energy deciency(CED).

By contrast, BMI above 25.0 and 30.0 reer to overweight and

obesity respectively, which are also indicative o poor nutrition.

However, CED tends to indicate the absence o reedom to lead aminimally healthy lie, and hence is structurally dierent rom

overweight and obesity, which relate also to, inter alia, an un-

healthy, afuent liestyle. Iron deciency anaemia, one o the

most widespread orms o womens malnutrition in developing

countries, is indicated usually by 11.9 grams/decilitre o haemo-

globin in the blood. Haemoglobin below 9.0 and 7.0 grams/decilitre

denotes moderate and severe anaemia, respectively.

Table 1 presents the levels o malnutrition among women (15-49

years) in India during 2005-06. While more than one-third o women

suer rom CED, around 10 per cent are overweight or obese. Thus,

close to 50 per cent o women in India suer rom malnutrition o

one orm or the other. CED persists as

the dominant orm o malnutrition in

rural India aecting around 40 per cent

o women, which is about 15 percent-

age points larger than the incidence

among urban women. On the contrary,

overweight or obesity, rom which

nearly one-ourth o urban women su-

er, is slowly emerging as an important

nutritional problem in urban India.

Again, about 50 per cent o women in

both rural and urban India suer rommalnutrition, though its nature varies

between rural and urban regions.

Equally, over hal the women in the age group o 15-49 years

suer rom iron deciency anaemia. Unlike in CED where the gap

between rural and urban regions is signicantly large, the re-

gional gap is relatively lower in anaemia. Thus, more than 50 per

cent o women, irrespective o their place o residence, are anae-

mic, whether mild, moderate or severe. The last two, the serious

orms o anaemia, afict more than 15 per cent o women in both

rural and urban India. The incidence o anaemia among preg-nant women is even higher: nearly 59 per cent, o which moder-

ate or severe orms o anaemia constitute more than hal (33 per

cent). The higher incidence o malnutrition among rural women

would imply that a substantially large proportion o malnour-

ished women more than 77 per cent with CED and 70 per cent

with any anaemia live in rural India.

It is likely that a signicant proportion o women who suer

rom CED may also be anaemic. Hence, we have created yet an-

other category combining both CED and anaemia so as to assess

the combined incidence o both types o malnutrition. What pro-

portion o women in India suers rom both CED and anaemia

together? As is evident, the proportion is as high as 21 per cent;

only about 31 per cent o women are ree rom both CED and

anaemia. About one-ourth o rural women suer rom both CED

and anaemia, which is 10 percentage points larger than the inci-

dence in urban India. An equal measure o dierence exists or

those ree rom both CED and anaemia. Here too, 78 per cent o

women with both CED and anaemia live in rural India.

Considering women o 15-49 years as a single group may lead to

cloaking the variation in the incidence o malnutrition across age

groups. Also, they may have dierent marital status. Given their

economic or social disadvantages, or instance, it is likely that

widows or separated women suer rom malnutrition more thanothers. It may be useul, thereore, to look at the levels o nutri-

tion among women o dierent age groups and marital status. As

ar as the BMI is concerned, two contrasting patterns can be seen

rom Table 2 (p 63). The incidence o CED goes down with an

increase in age and the reverse holds good or overweight or

obesity. Surprisingly, nearly hal o women in the younger age

group (below 20 years) suer rom CED, which is closer to double

the proportion o older women (40-49 years) in that category.

Age appears to be no deterrent to anaemia: around 55 per cent

o all women are anaemic in one orm or another. What is more,

the incidence o moderate or severe anaemia does not vary with

age. Nevertheless, age seems to mat-

ter or the incidence o both CED and

anaemia together: as high as 27 per

cent o younger women as against 17

per cent o older women suer rom

both. Thus, a dierence o 10 per-

centage points is ound between

younger and older women on the in-

cidence o both CED and anaemia.

Surprisingly, the incidence oCED

is higher among never married

women, which is 10 percentagepoints higher than the incidence

among widowed women and also

tb 1: lv of Mnuron m ong Womn (15-49 Yr)(2005-06)

All India Rural Urban% N % N % N

BMI*

CED 35.61,11,782

40.675,416

25.036,366

Overweight or obese 12.6 7.4 23.5

Anaemia

Any anaemia 55.31,16,855

57.479,888

50.936,967

Moderate and severe 16.8 17.5 15.1

CED and anaemia**

Both 21.6 25.0 14.3

Either 47.5 1,09,414 47.7 47,186 47.1 35,228

Neither 30.9 27.3 38.6

* Excludes women who were either pregnant at the time of, or who gave birth

within two months preceding the survey.** Confined to 109,414 women for whom information on both BMI and

anaemia is available. The previous note applies here as well.Source: Computed from NFHS-3 data.


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among divorced, separated or deserted women considered to-

gether. Even as it appears bafing, this is understandable given the

act that never married women constitute the bulk o younger

women (70 per cent) among whom, as we just saw, the incidence

oCED is relatively larger. The reverse is true or anaemia. How-

ever, the incidence o both CED and anaemia does not dier signi-

cantly: more than 20 per cent o women, irrespective o their marital

status, suer the double nutritional deprivation oCEDand anaemia.The regional disparity in womens nutrition, noted above, in-

duces us to look at other orms o disparities as well, mainly, so-

cial and economic. The results, reported in Table 3, seem to sug-

gest the presence o huge socio-economic disparities in womens

malnutrition in India. A major gap is seen between social groups

nearly 47 and 68 per cent o women (15-49 years) rom the

scheduled tribes (ST) suer rom CED and anaemia, respectively.

What is more, more than one-third o them suer rom the

double burden oCED and anaemia together. The incidence o

malnutrition declines with the so-called rise in social status. By

extension, such decline also means huge disparities between

social groups: more than 15 percentage points dierence is

ound between women rom ST and others. Thus, the proportion

o women suering rom CED and anaemia together among

ST comes closer to double the proportion o the same among

advantaged social groups.

Beore discussing the disparity between wealth groups, a

methodological note on the construction o wealth groups used

or the analysis needs to be mentioned. SinceNfhS-3 data do not

contain inormation on income or expenditure, inormation re-

lated to household assets and durables were combined to create

household wealth, based on which households were grouped into

ve quintiles with the help o the approach developed by Filmerand Pritchett (1998).1 As per this methodology, nearly 20 per cent

o all households that orm the bottom quintile would qualiy as

the poorest, ollowed by yet another 20 per cent o households as

the second quintile or the poor. By contrast, 20 per cent o house-

holds constitute the upper quintile [IIPS and ORC Macro 2007].

More than 50 and 64 per cent o women rom the poorest quin-

tile suer rom CED and anaemia, respectively. Also, about one-

third o them suer rom the double disadvantage o CED and

anaemia. As we have observed among social groups, malnutrition

among women goes down drastically with a rise in the household

wealth status, creating equally large disparity between the wealth

groups. The proportion o the poorest women suering rom CED

and anaemia together comes around to more than three times

that ound in the highest quintile. It is also important to add here

that the proportion o women suering rom anaemia is not low

even within the richest quintile. This suggests that a substantially

large proportion o women in India, irrespective o the household

wealth status, suer rom iron deciency anaemia.

3 soc nd economc Dpry

It appears rom the above that a large proportion o women be-

longing to the bottom o the hierarchy, both social and economic,

are at the receiving end o multiple orms o malnutrition. Thehuge disparity in womens malnutrition between economic and

social groups in India is a matter o serious concern, as the levels

o nutritional attainment appear to be not only unequal but also

unjust. Here, it may be worthwhile to probe into the relative im-

portance o wealth over social groups or vice versa. Simply put, is

it possible to identiy what matters more or womens nutrition:

household assets or social status? Table 4 is the outcome o an at-

tempt made towards this end.

At least two broad patterns emerge rom Table 4. One, the inci-

dence o malnutrition among women declines drastically alongwith a rise in the wealth status. This is clearly in consonance with

the patterns we have observed above. Moreover, what is interest-

ing is that such a decline is observable among all social groups,

albeit the extent o decline varies. The decline is apparent in all

the three aspects o malnutrition as well. Two, poor women not

tb 2: Womn Mnuron n ind, 2005-06 ag nd Mr su (in %)

BMI Anaemia CED and Anaemia

CED Overweight Moderate Any Both Either Neitheror Obese or Severe

Age

15-19 46.8 2.4 16.6 55.8 26.9 48.6 24.5

20-29 38.1 8.2 17.6 56.1 23.0 47.8 29.2

30-39 31.0 17.4 16.2 54.2 19.2 46.6 34.2

40- 49 26.4 23.7 16.1 55.0 17.1 47.2 35.7

Marital Status

Never-married 44.9 4.5 14.6 51.9 24.3 48.3 27.4

Currently marr ied 33.0 14.9 17.1 56.0 20.7 47.3 32.0

Widowed 33.5 14.4 19.0 59.0 22.1 48.3 29.6

Divorced/separated/

deserted 33.9 14.4 21.4 59.1 23.7 44.9 31.4

Source: Computed from NFHS-3 data.

tb 3: soc nd economc Group (in %)


CED Overweight Moderate Any Both Either Neither

or Obese or Severe

Social groups*ST 46.6 3.5 23.7 68.5 33.5 47.8 18.7

SC 41.1 8.9 19.0 58.3 25.7 47.7 26.6

OBC 35.7 11.6 16.2 54.4 20.8 48.3 30.9

Others 29.2 18.6 14.2 51.1 16.8 46.6 36.6

ST/others** 1.60 0.19 1.67 1.34 1.99 1.03 0.51

Wealth groups

Lowest 51.5 1.8 20.7 64.3 34.0 47.5 18.5

Second 46.3 3.9 18.9 60.3 29.0 48.3 22.7

Middle 38.3 7.4 17.7 56.0 22.9 48.2 28.9

Fourth 28.9 15.4 15.3 52.2 16.4 48.2 35.4

Highest 18.2 30.5 12.1 46.1 9.4 45.5 45.1

Low/high** 2.83 0.06 1.71 1.39 3.62 1.04 0.41

* Excludes women who did not report any social group.** Indicates ratio of ST percentages to corresponding percentages of others and ratio of

percentages of lowest quintile to that of highest quintile respectively.

Scheduled tribe, scheduled caste, Other Backward Classes and others (than the above) areabbreviated as ST, SC, OBC and OT respectively.


tb 4: economc Group whn soc Group (in %)

CED Anaemia CED and Anaemia

Wealth Groups ST SC OBC OT ST SC OBC OT ST SC OBC OT

Lowest 53.4 54.2 48.1 52.0 73.8 63.9 59.5 61.3 40.2 35.4 29.3 32.9

Second 48.0 48.2 44.7 47.0 68.7 60.7 58.0 59.9 33.4 30.5 26.2 30.3

Middle 43.0 38.8 38.7 36.6 61.9 56.7 55.9 54.4 28.2 23.3 22.9 21.4

Fourth 31.6 29.8 29.0 28.4 61.8 55.2 51.9 50.7 22.0 18.2 16.5 15.2

Highest 22.6 23.1 19.4 16.6 52.8 49.6 46.7 45.0 14.8 12.4 10.0 8.4

Low/high* 2.36 2.35 2.48 3.13 1.40 1.29 1.27 1.36 2.72 2.85 2.93 3.92

Scheduled tribes, scheduled castes, Other Backward Classes and others (than the above) are

abbreviated as ST, SC, OBC and OT respectively.* Indicates ratio of percentages of t he lowest quintile to corresponding percentages of highestquintile.



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only rom the disadvantaged social groups, such as ST and SC, but

also rom advantaged social groups suer disproportionately rom

malnutrition. Indeed, the disparity ound between wealth quintiles

within the same social group is signicantly larger than the disparity

ound between social groups at each wealth quintile. This would

suggest that though economic and social disparities matter signi-

cantly and independently, the ormer seems to matter more, at

least as ar as womens malnutrition is concerned, than the latter.However, i social and economic disadvantages are combined, the

outcome is likely to be ar more regressive. That is what we can see

rom the levels o malnutrition among poor ST women.

4 s-w Dffrnc

How do major states in India perorm as ar as womens nutrition

is concerned? Table 5 provides levels o womens malnutrition in

18 major states. To begin with, CED aects close to hal o the

women in Bihar (45 per cent), which is ollowed closely by Chhat-

tisgarh, Jharkhand (43 per cent each), Madhya Pradesh and

Orissa (41 per cent each). West Bengal, with an incidence o

around 39 per cent, is not ar rom these states. These states tend

to have more than double the proportion o undernourished

women o states such as Kerala and Punjab, which are at the other

end o the spectrum. Rather than

CED, what seems to be an

important issue in these two states is

overweight or obesity: nearly 30 per

cent o women suer rom overweight

and obesity taken together. However,

what these states have in common

with the others is that in all these

states about 50 per cent o women

suer rom malnutrition o one orm

or another.Assam and Jharkhand, with nearly

70 per cent o women suering rom

some orm o anaemia, remain at the top among these states.

Close on their heels come Bihar with 67 per cent, West Bengal,

Andhra Pradesh and Orissa. In Assam and Andhra Pradesh,

nearly one-ourth o women suer rom moderate and severe

anaemia. Here too, Kerala and Punjab remain at the lower end:

both in terms o overall incidence as well as moderate and severe

anaemia. Thus, the incidence o anaemia in Assam is over two

times more than that in Kerala. Over 30 per cent o women inboth Bihar and Jharkhand suer rom CED and anaemia together,

with Orissa and West Bengal (about 27 per cent each) as close ol-

lowers. Again, Kerala and Punjab, with much lower proportions,

remain at the other end.

It appears that, with a much higher incidence o malnutrition,

the eastern states, mainly Bihar, Jharkhand, Orissa and West

Bengal, emerge as the repository o womens malnutrition in India.

Though these our states account or 22 per cent o women

considered or the analysis (1,09,414), 30 per cent o women

suering rom CED and anaemia together live in these states. Do

these higher levels o womens malnutrition suggest that norms

and discriminatory practices against women are more rigid and

intense in these states? Or alternatively, do they relate to the levels

o poverty and o human development? Or, do they simply refect

the ood habits o the region, and the lack o adequate nutritive

components in them? Only detailed analysis can cast light on

why womens malnutrition is so high in the region.

5 th Good tm

The decline in womens malnutrition in India during the period

assessed here is based upon a comparative analysis o theNfhS-2

and NfhS-3. It needs to be mentioned that the NfhS-2 collected

nutritional inormation only rom ever-married women unlikethe NfhS-3, which collected data rom unmarried women as well.

To ensure uniormity in comparison, the analysis in this section

is conned to ever-married women only. Interestingly, the seven-

year period covered by these two rounds, between 1998-99 and

2005-06, is also a period o signicant and sustained surge in the

economy, ollowed by an onset o signicant reduction in poverty

in India.2 It would, thereore, be interesting to examine the extent o

progress on the levels o nutrition among women during the

good times.

In keeping with the good times, the incidence oCED among

ever-married women has come down in India during the period

under consideration (Table 6). Though the extent o decline is

marginal, it points towards a progres-

sive phenomenon. Interestingly, the

decline, though varying in size, has

been registered in both rural and urban

regions. By contrast, overweight or

obesity among ever-married women

has increased in both the regions

leading to an overall increase in the

all-India proportion as well. While

the decline in the CED is about 3 per-

centage points, the rise in overweightor obesity is around 4 percentage

points. Like CED where the decline is

tb 5: Womn Mnuron cro Mjor s n ind (2005-06 , in %)


CED Overweight Moderate Any Both Either Neither

or Obese or SevereKerala 18.0 28.1 7.1 32.8 7.6 35.5 56.9

Punjab 18.9 29.9 11.8 38.0 8.1 40.6 51.3

Tamil Nadu 28.4 20.9 15.8 53.2 16.7 47.9 35.3

Uttaranchal 30.0 12.8 14.8 55.2 18.1 48.7 33.1

Haryana 31.3 17.4 18.5 56.1 18.5 49.6 31.9

Andhra Pradesh 33.5 15.6 23.9 62.9 22.5 51.3 26.2

Karnataka 35.5 15.3 17.1 51.5 19.8 46.9 33.3

Uttar Pradesh 36.0 9.2 14.7 49.9 18.9 47.6 33.5

Maharashtra 36.2 14.5 15.6 48.4 19.0 46.1 34.9

Gujar at 36.3 16.7 19.1 55.3 22.8 45.5 31.7

Assam 36.5 7.8 24.7 69.5 26.2 53.3 20.5

Rajasthan 36.7 8.9 17.9 53.1 20.2 48.5 31.2

West Bengal 39.1 11.3 17.4 63.2 27.1 48.2 24.7

Orissa 41.4 6.6 16.3 61.2 27.5 47.2 25.3

Madhya Pradesh 41.7 7.6 15.1 56.0 25.2 47.0 27.8

Jharkhand 43.0 5.3 19.9 69.4 31.2 50.1 18.7

Chhattisgarh 43.4 5.6 17.6 57.5 26.5 47.3 26.2

Bihar 45.1 4.6 16.9 67.4 31.7 49.5 18.7

India 35.6 12.6 16.8 55.3 21.6 47.5 30.9


tb 6: Mnuron mong evr-Mrrd Womn(1998-99 and 2005-06, in %)

All India Rural Urban

1998-99 2005-06 1998-99 2005 -06 1998-99 2005-06

BMI

CED 36.2 33.0 41.1 38.8 22.7 19.8

Overweight or obese 10.8 14.9 6.0 8.7 23.8 29.0

Anaemia

Any anaemia 51.8 56.2 53.9 58.2 45.7 51.5

Moderate and severe 16.7 17.3 13.7 18.1 17.8 15.5

CED and Anaemia

Both 20.7 20.8 23.7 24.6 12.5 12.1

Either 46.6 47.3 47.7 47.4 43.6 46.8

Neither 32.7 31.9 28.6 28.0 43.9 41.1

Source: Computed from NFHS-2 and NFHS-3 data.


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marginally higher in urban India, the increase in overweight or

obesity is also relatively higher in urban than in rural India.

The progressive phenomenon noted or CED does not extend to

other aspects o malnutrition considered or the analysis.

Instead, what we nd is a reversal o the trend. The incidence o

iron deciency anaemia, or instance, among ever-married

women has increased during the same period. The increase,

around 4 percentage points, is evident in both rural and urbanareas. Also, there is a marginal increase in the incidence o mod-

erate and severe anaemia in the country, though it has declined

in urban India. There is no noticeable change in the incidence o

CED and anaemia together during the period. A marginal increase

is ound in rural India as against a negligible decline in urban India.

Thus, we nd that there is no signicant decline in anaemia

and more importantly in the dual burden oCED and anaemia.

Even the extent o decline in CED appears to be rather small (only

3 percentage points). Additionally, the levels o undernutrition

continue to be high among ever-married women. While nearly

one-third o them suer rom CED, more than hal o them are

anaemic. The proportion o women having both CEDand anaemia is

not low either: it is around 21 per cent. Taken together, these

conficting trends seem to indicate a regressive phenomenon o

deteriorating nutritional levels during the period o higher

growth and reduction in poverty. These trends call or a dis-

aggregated analysis across age and marital status to assess who,

among these women, lost and gained.

Table 7 shows that the incidence o

CED has come down in almost all the

age groups except the youngest age

group (15-19 years); however, the size

o decline appears to vary, between 2and 4 percentage points, across age

groups. Not only has the incidence o

anaemia risen among ever-married

women o all age groups, the increase

is rather large among the youngest

age group (7 percentage points). The

trend arising rom both CED and

anaemia seems to be rather negative.

Excepting among the oldest age group,

ever-married women o the remain-

ing age groups have witnessed an in-

crease in the incidence o both CED

and anaemia. The increase, though

marginal, is largest among the young-

est age group. Thus, there seems to

be an overall increase in malnutrition

among younger women in India.

As ar as marital status is con-

cerned, CED has declined among all

the three groups o women. Oddly

enough, the decline appears to be rela-

tively large (around 7 percentage

points) among women who are di-vorced, separated or deserted; they

are ollowed by widowed women

with about 5 percentage points decline. On the contrary, all the

three groups o women experienced an increase in the incidence

o anaemia. In CED and anaemia together, although there is a

marginal increase among currently married women, the inci-

dence in this group is relatively lower than in the remaining

groups. By contrast, the other two groups o women seemed to

have experienced a marginal decline.

6 Ddvngd Group

Given these broad trends, it is important to look into the trends

emerging rom social and economic groups. Table 8 presents

changes in ever-married womens nutrition over time across social

and economic groups. The incidence o CED has come down

among women rom all social groups. The extent o decline is

rather large among the advantaged social groups (4 to 5 percent-

age points) and quite marginal among the ST women. Contrarily,

women rom all social groups seemed to have experienced an in-

crease as ar as incidence o anaemia is concerned. In both CED

and anaemia, there has been an increase in the incidence among

tribal women as against a decline, though negligible, among

women rom other social groups, especially theSC and OBC. Thus,

the levels o malnutrition, which were already higher, have in-

creased urther among tribal women in India. In act, the dispar-

ity between social groups, especially between ST and others, has

increased over time in CED as well as CED and anaemia together.

The trends emerging rom the

wealth groups correspond closely to

those observed rom the social groups.

In all the three aspects o malnutri-

tion considered or the analysis, ever-

married women rom poor house-holds nd themselves in a regressive

state o deteriorating nutritional at-

tainments. Again, women rom the

second quintile also appear to have

experienced an increase in anaemia

as well as in both CED and anaemia.

In CED, though there is a decline, the

size o the decline is marginal indeed.

Only among the other three quintiles

in general and the last two quintiles

in particular are there signs o

progress. While CED has come down

among women rom these wealth

groups, the reverse is true or anae-

mia. In both CED and anaemia, again,

there is a decline over the years in the

last two groups.

It appears, thus, that ever-married

women, irrespect ive o their age or

marital status and the economic or

social groups they belong to, experi-

enced an increase in the incidence o

iron deciency anaemia. Thoughthere has been a decline, by and

large, over the years in the incidence

tb 7: Mnuron mong evr-Mrrd Womn ag nd Mr su (in %)


1998-99 2005-06 1998-99 2005-06 1998-99 2005-06

Age

15-19 41.7 41.9 56.0 63.1 25.0 28.4

20-29 41.1 38.4 52.5 57.5 23.0 24.030-39 33.4 31.0 50.4 54.2 18.9 19.1

40-49 30.8 26.4 50.7 54.9 18.2 17.0

Marital status

Currently married 36.0 33.0 51.5 56.0 20.4 20.7

Widowed 38.3 33.5 55.9 59.0 23.7 22.1

Divorced/separated/

deserte d 41.4 33.9 54.7 59.1 25.0 23.7Source: Computed from NFHS-2 and NFHS-3 data.

tb 8: Mnuron mong evr-Mrrd Womn soc nd economc Group (in %)


1998-99 2005-06 1998-99 2005-06 1998-99 2005-06

Social groups

ST 46.8 46.6 64.9 69.3 31.7 34.0SC 42.6 39.6 56.0 58.9 25.3 25.2

OBC 36.2 32.7 50.7 55.3 19.9 19.8

Others 30.7 25.6 47.6 51.9 16.7 15.6

ST/others* 1.52 1.82 1.36 1.34 1.90 2.18

Wealth groups

Lowest 50.4 51.2 62.7 65.1 32.8 34.1

Second 46.5 45.2 56.9 61.0 27.3 28.8

Middle 41.0 35.2 51.3 56.8 21.4 21.8

Four th 30.4 24.0 47.0 52.5 15.9 14.3

Highest 14.5 11.7 41.4 46.1 7.3 6.5

Lowest/highest* 3.48 4.38 1.51 1.41 4.49 5.25

Scheduled tribe, scheduled caste, Other Backward Classes and Others (than

the above) are abbreviated as ST, SC, OBC and OT respectively.

* Indicates ratio of ST p ercentages to corresponding percentages of Othersand ratio of percentages of Lowest quintile to that of Highest quintile

respectively.Source: Computed from NFHS-2 and NFHS-3 data.


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oCED, it does not hold true or women rom the poorest house-

holds. Does this then suggest that not only has the pace o

progress in womens nutrition been slow and ar rom satisac-

tory, but also that there are women, not small in number, who

have made no progress at all? Does the increase in womens mal-

nutrition among poor households and disadvantaged social

groups indicate that the benets rom sustained growth did not

touch their lives and alleviate their suering? Here we have toask yet another question. Did all ST women experience deteriora-

tion in their nutrition? Or, alternatively, did all poor women, ir-

respective o their social identity, experience a negative trend in

their nutrition? The results are re-

ported in Table 9.

Table 9 conveys a couple o dis-

quieting trends. To begin with, lev-

els o malnutrition continue to re-

main quite high among poor

women, irrespective o their social

identity. As noted earlier, the dis-

parity in nutritional attainments is

much larger between wealth

groups within the same or identical

social group than between social

groups with similar wealth status.

The disparity in malnutrition be-

tween bottom and top wealth

groups among ST is as high as that

ound between the wealth groups

in other social groups. This implies

that not only poor ST women,

but also poor women rom othersocial groups are endowed with

decient nutritional attainments.

Stated dierently, richer women

not only rom advantaged social

groups but also rom disadvan-

taged social groups, such as ST and

SC, seem to have much better

nutritional attainments.

The disparity between wealth

groups seems to have increased in

almost all social groups in both

CED and CED and anaemia together.

This is contrary to what is being

observed in the case o anaemia.

The decline in the disparity in anae-

mia is due to the overall increase

rather than decline in the inci-

dence, as shall be seen below. Such

increasing disparity would tell us

that not all women rom within

the same social group have had to

ace the increase in malnutrition

equally. Not only have the richerwomen rom all the social groups

seemed to have beneted more

than their poor sisters, but also the poor women rom almost all the

social groups (except OBC) ound themselves at the receiving end

o growing malnutrition. This, then, would mean that the decline

in malnutrition seems to have come almost entirely rom the non-

poor women, and, hence, much o the poorer women do not seem

to have beneted at all, at least as ar as their nutritional attain-

ment is concerned, rom the surge in the economy.

The extent o increase in anaemia among ever-married womenappears to be rather uneven across social groups and wealth

groups within them. The increase is rather sharp among the

bottom wealth groups among others and equally or the ourth

quintile in ST and the highest

quintile in OBC. That being the

case, it is also clear rom Table 9

that three-ourths o the poorest ST

ever-married women suer rom

anaemia. Add to this, more than 50

per cent o them suer rom CED

and above 40 per cent are endowed

with the double deprivation o both

CED and anaemia. Juxtapose these

with the levels o malnutrition

among richer ST women. Here too,

the relatively larger levels o mal-

nutrition among poor ST women

seem to suggest that i social disad-

vantage is combined with economic

disadvantage, the outcome is likely

to be ar more regressive.

Table 10 presents changes in ever-

married womens malnutritionacross major states. As noted

earlier, there has been a marginal

decline in the incidence o CED.

Except our states, namely Assam,

Madhya Pradesh, Bihar and

Haryana, other states registered a

decline. The larger decline, more

than 7 percentage points, is ound

in Orissa, ollowed closely by

Karnataka and Maharashtra. Uttar

Pradesh and Rajasthan, with less

than a 3 percentage points decline,

remain at the bottom. In contrast,

Assam with an increase o over

9 percentage points remains at the

top o the other end.

Contrary to undernutrition, the

incidence o anaemia among ever-

married women has risen in India.

Also, compared to CED, the inci-

dence o anaemia among women

has come down only in our out o

the 16 major Indian states consid-ered here. Tamil Nadu is the state

with the largest decline (about 3

tb 9: Mnuron mong evr-Mrrd Womn economc Group whn soc Group (in %)

1998-99 2005-06

Wealth Groups ST SC OBC OT ST SC OBC OT

CED

Lowest 50.3 52.9 47.7 50.9 54.1 54.1 47.2 51.1

Second 51.3 48.2 44.7 45.1 47.0 47.9 42.9 46.1

Middle 45.3 41.8 40.1 40.8 43.1 36.2 34.9 33.3

Fourth 35.9 32.5 29.8 29.6 27.4 25.2 23.9 23.6

Highest 22.2 16.5 16.2 13.3 16.2 14.4 13.1 10.5

Lowest/highest* 2.27 3.21 2.94 3.83 3.34 3.76 3.60 4.87

Anaemia

Lowest 71.1 63.7 60.6 57.9 74.2 64.4 60.2 63.3

Second 67.2 57.7 55.7 53.9 69.8 61.3 58.6 60.1

Middle 58.5 51.7 51.3 49.6 61.6 57.6 57.1 54.5

Fourth 53.1 50.3 45.3 46.7 62.2 54.4 52.2 51.5

Highest 47.8 47.7 39.8 40.9 50.8 48.6 47.0 45.2

Lowest/highest* 1.49 1.34 1.52 1.42 1.46 1.33 1.28 1.40

CED and anaemia

Lowest 35.9 35.4 29.7 31.1 40.9 35.5 29.1 33.0

Second 35.9 28.2 25.3 25.4 33.2 30.7 25.7 30.3

Middle 26.4 21.6 21.3 20.4 28.9 22.7 21.3 20.3

Four th 21.8 18.5 14.5 15.7 19.7 15.4 14.4 13.4Highest 13.9 7.7 7.6 6.9 10.3 7.6 7.5 5.6

Lowest/highest* 2.58 4.60 3.91 4.51 3.97 4.67 3.88 5.89

Same as in Table 8.* Indicates ratio of percentages of the Lowest quintile to corresponding percentages

of Highest quintile.Source: Computed from NFHS-2 and NFHS-3 data.

tb 10: Mnuron mong evr-Mrrd Womn n Mjor s (in %)


States 1998-99 2005-06 1998-99 2005-06 1998-99 2005-06

Andhra Prade sh 37.4 30.8 49.8 62.7 19.9 20.9

Assam 27.1 36.5 69.7 69.6 20.3 26.8

Bihar 39.1 43.2 60.4 68.3 26.2 31.0

Gujarat 37.0 32.3 46.3 55.5 20.0 21.3

Haryana 25.9 27.8 47.0 56.6 13.9 17.3Himachal Pradesh 29.7 24.3 40.5 43.3 13.2 10.2

Karnat aka 38.8 31.4 42.4 52.2 19.1 18.1

Kerala 18.7 12.5 22.7 32.3 5.6 6.2

Madhya Pradesh 35.2 40.2 49.3 57.7 21.8 25.6

Maharashtra 39.7 32.6 48.5 49.1 21.5 17.9

Orissa 48.0 40.4 63.0 62.7 32.0 28.0

Punjab 16.9 13.5 41.4 38.2 8.4 5.8

Rajasthan 36.1 33.3 48.5 53.8 18.6 19.1

Tamil Nadu 29.0 23.5 56.5 53.9 18.9 14.6

Uttar Pradesh 36.5 34.1 49.0 50.9 19.4 18.5

West Bengal 43.7 37.6 62.7 63.8 30.2 26.3

India 36.2 33.0 51.8 56.2 20.7 20.8

For 2005-06, computed from NFHS-3 data.

For 1998-99, our estimates for some states do not match with those reported in keyfindings, mainly because of the formation of new states. Hence, except for CED andanaemia together, the sources for the other two aspects are the various reports of key

findings [IIPS and ORC Macro 2007a].


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percentage points), ollowed by Punjab, Assam and Orissa. In the

latter states, the decline is quite marginal. The sharpest increase

can be noted in Andhra Pradesh with over 12 percentage points.

Surprisingly, Kerala, along with Karnataka, with about a 10 per-

centage points increase comes next to Andhra Pradesh. Thus, the

largest increase in anaemia is ound in these two southern states.

As ar as CED and anaemia together is concerned, the incidence

has come down over the years in six states and has risen in theremaining six states. Tamil Nadu and Orissa emerge as states

with the largest decline with more than 4 percentage points.

West Bengal and Maharashtra, with nearly 4 percentage points

decline, ollow these states closely. On the contrary, the increase

is relatively largest in Assam (more than 6 percentage points)

ollowed by Bihar and Madhya Pradesh.

7 Dcuon

The above analysis, though preliminary in nature, reveals some

disquieting patterns and trends, and thereby raises a number o

issues. Not only do the levels o malnutrition among women in

India continue to be quite high, but the levels among women rom

disadvantaged social and economic groups are much higher.

While social disadvantage tends to go with a higher incidence o

malnutrition among women, economic disadvantage does more

so. The period o higher growth and onset o a reasonable reduc-

tion in poverty did not seem to improve womens nutrition signi-

cantly. Instead,we nd an increase in malnutrition, especially

anaemia. Poor women rom almost all social groups nd them-

selves at the receiving end o increasing malnutrition.

Since higher incidence o malnutrition among poor women in-

dicates the role o poverty, do the higher levels o anaemia among

women rom all economic groups, including the wealthier groups,suggest the role origid gender norms and discriminatory prac-

tices? Does higher incidence o malnutrition among younger

women relate to lack o autonomy or to the higher nutritional

requirements related to the physiological changes? Or, does it

relate to the rising impression among younger women that to

become beautiul one must be slim so as to provide a big boost to

the emerging market or beauty? Does the higher incidence o

malnutrition in the eastern region signiy something common in

these states which make them dierent rom other states? These

are one group o disparate but related questions that call or

detailed and careul enquiry.

The trends emerging rom the analysis raise yet another set oquestions. Why has womens malnutrition increased during the

period o higher growth with a reasonable reduction in poverty?

Does the increase in malnutrition convey the limits o the market

in enhancing womens well-being? Or, does it indicate the poor

reach o welare programmes in general and to the poor women

in particular? Does the simultaneous increase in obesity and

overweight as well as in anaemia indicate the changing ood hab-

its and lack o adequate nutritive components in the oods? Do

the rising levels o anaemia among women indicate that they are

less cared or, or discriminated against, in ood allocation? Only

detailed empirical analysis will shed light on these questions.

The increase in malnutrition among women in India, whether

it is due to the ailure o the market or o the state or due to gen-

der inequality or because o changing ood habits, does not augur

well or various reasons. Malnutrition amounts to deprivation in

one o the most elementary and central aspects o well-being. It

also has implications or human development which are large

and cumulative. For instance, the adverse infuence o maternal

malnutrition extends beyond maternal mortality to intrauterine

growth retardation, child malnutrition and rising emergence o

chronic diseases, among others [Osmani and Sen 2003; Victora

et al 2008]. Thereore, it is important that womens malnutrition

be viewed as an important issue o human development, ratherthan as an isolated issue o health specic to women. Construing

womens malnutrition as an issue o human development would

entail both immediate measures to address malnutrition as well as

placing womens well-being rmly on the development agenda.

Notes

1 See IIPS and ORC Macro (2007) or details o as-sets and durables collected and weights assignedto each o those assets and durables. Based on thisapproach, Gwatkin et al (2000) examine the ex-tent o disparities in health and nutrition betweenthe wealth groups in India.

2 Though dierent estimates suggest vary ing paceo poverty reduction between 1999-2000 and2004-05, the broad trend is unmistakeably posi-tive. Compare, or instance, the estimates o Devand Ravi (2007) and Himanshu (2007) with thato Sundaram (2007).

Reerences

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Administrative Committee on Coordination/Sub-Committee on Nutrition, World Health Organisa-tion, Geneva.

Black, Robert E, Lindsay H Allen, Zulqar A Bhutta,Laura E Cauleld, Mercedes de Onis, Majid Ezza-

ti, Colin Mathers and Juan Rivera or the Mater-nal and Child Undernutrition Study Group (2008):Maternal and Child Undernutrition: Global andRegional Exposures and Health Consequences,

Lancet, published onl ine January 17. DOI: 10.1016/S0140-736(07)61690-0.

Dev, Mahendra S and C Ravi (2007): Poverty andInequality: All-India and States, 1983-2005,

Economic & Political Weekly, February 10.

Filmer, Deon and Lant Pritchett (1988): EstimatingWealth Eects without Expenditure Data or

Tears: An Application to Educational Enrolmentsin States o India, Policy Research Working PaperNo 1994, Development Economics ResearchGroup, The World Bank, Washington DC.

Gwatkin, Davidson R, Shea Rustein, Kiersten Johnson,Rohini P Pande and Adam Wagsta (2000): Socio-Economic Dierences in Health, Nutrition, andPopulation in India, World Bank, HNP/PovertyThematic Group, The World Bank, Washington DC.

Himanshu (2007): Recent Trends in Poverty andInequality: Some Preliminary Results,Economic& Political Weekly, February 10.

International Institute or Population Sciences (IIPS)and ORC Macro (2007): National Family HealthSurvey-3, 2005-06, India: Volume-I, IIPS Mumbai.

(2007a):Key Findings from National Family HealthSurvey-3, 2005-06: Various States of India, IIPS

Mumbai.Mason, John, Adams Bailes, Mary Beda-Andourou,Nancy Copeland, Teresa Curtis, Megan Deitchler,Leigh Foster, Marianna Hensley, Peter Horjus,

Christine Johnson, Tina Lloren, Anna Memdez,Mary Munoz, Jonathan Rivers and Gwyneth

Vance (2005): Recent Trends i n Malnutrit ion inDeveloping Regions: Vitamin A Deciency,

Anaemia, Iodine Deciency, and Child Under-weight , Food and Nutr ition Bulle tin, Vol 26,No 1, pp 59-162.

Osmani, Siddiq and Alok Bhargava (1998): Healthand Nutrition in Emerging Asia, Asian Develop-ment Review, Vol 16, No 1, pp 31-71.

Osmani, Siddiq and Amartya Sen (2003): The Hid-den Penalties o Gender Inequality: Foetal Ori-gins o Ill-health,Economics and Human Biology,

Vol 1, No 1, pp 105-21.

Ramalingaswami, Vulimiri, Urban Jonsson and JonRohde (1996): Commentary: The Asian Enigmain UNICEF, The Progress of Nations, pp 11-17,UNICEF, New York.

Sundaram, K (2007): Employment and Poverty in India,2000-2005,Economic & Political Weekly, July 28.

Victora, Cesar G, Linda Adair, Caroline Fa ll, Pedro CHallal, Reynaldo Martorell, Linda Richter andHarshpal Singh Sachdev or the Maternal andChild Undernutrition Study Group (2008):

Maternal and Child Undernutrition: Conse-quences or Adult Health and Human Capital,Lancet, published online on January 17.DOI:10.1016/S0140-6736(07)61692-4.

a factsheet on women’s malnutrition in india

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