M Rahman, S Nasrin
bangladesh, body mass index, logistic regression analysis, nutrition, women's health
M Rahman, S Nasrin. Mothers nutritional status in an impoverished nation: Evidence from rural Bangladesh. The Internet Journal of Nutrition and Wellness. 2008 Volume 7 Number 1.
Possessing a land area of 147,570 square kilometers and over 15 million populations, Bangladesh is the ninth most populous country and one of the most densely populated countries in the world 1 . Over population and poverty are pervasive in Bangladesh and causing population hazards like the problems of malnutrition. Specially, women are particularly vulnerable; suffering from social, economic and nutritional deprivation to a far greater extent than men 2. The high prevalence of under nutrition in Bangladesh is popularly attributed to a combination of extreme poverty, environmental insult and poor health.
Maternal malnutrition is a chronic problem in rural Bangladesh. Even though the country is self-sufficient in rice production, the diet of rural people is very low in energy and micronutrients because households do not have access to the resources they need to grow or purchase enough food. The typical diet is predominantly rice because people cannot afford other nutritious foods such as pulses, vegetables, fruits and animal products. Girls and women often eat last and least in the household due to the persistence of cultural practices that favour boys and men. Consequently, mothers do not eat enough food to meet their energy and micronutrient needs, particularly during pregnancy when these needs are greatest 3 . For social and biological reasons, women in the reproductive age group and children are most vulnerable to malnutrition due to low dietary intakes, inequitable distribution of food within the household, improper food storage and preparation, dietary taboos, infectious diseases, and care. Particularly for women, the high nutritional costs of pregnancy and lactation also contribute significantly to their poor nutritional status. Under nutrition threatens both the health and survival of mothers because it increases their susceptibility to life-threatening diseases and their risk of dying, especially during childbirth. Undernourished mothers are often physically weak and are unable to perform income-earning activities and household work to their full potential. Mothers who are undernourished before or during pregnancy are more likely to give birth to underweight infants. These infants face a disadvantaged future: they may grow poorly during childhood, do less well at school, and have less productive working lives. In addition infant girls with low birth weight are more likely to become undernourished mothers themselves, thereby perpetuating the cycle of under nutrition from one generation 4 .A recent small-sale study of carried out by NSP survey 2000 of 57000 women revealed that almost one half (45%) of rural mothers and one third (34%) of mothers in urban slums have a BMI less than 18.5 kg/m2 and are undernourished. Using population projections from the 1991 census, an estimated 9 million women of childbearing age (15-44 years) are undernourished in rural Bangladesh compared with only 0.8 million women in a developed 5 .
As under nutrition impedes social and economic development, policies and programs are needed to address the factors responsible for mothers' poor nutritional status. In order to design appropriate interventions, key stakeholders in health and development need to understand how many mothers are affected, which mothers are at greatest risk, and why these mothers are undernourished. This paper documents the extent of under nutrition among rural Bangladeshi women of childbearing age, and explores a number of socioeconomic factors thought to explain its genesis and distribution. For the purposes of analysis, we employ BMI as a simple and reliable measure of adult nutritional status. It is expected that the findings will lead to consider alternative program strategies for the reduction of poor nutritional status of the mothers of reproductive ages.
Materials and methods
This study utilizes the data extracted from 2004 Bangladesh Demographic and Health Survey (BDHS), which were conducted under the authority of the National Institute of Population Research and Training of the Ministry of Health and Family Welfare in Bangladesh. This study considered only the case for rural children of last five years before the survey i.e., children under five years of age only (N=3269). Bivariate analysis was performed to determine the differentials of nutritional status among women by explanatory variables. Pearson's Chi-square test of independence was performed to test the existence of significant association between categories of nutritional status and selected risk factors. Considering the fact that among multivariate techniques the Cox's linear logistic regression model is algebraically simple, computationally straightforward and efficient with acceptable degree of precision for a binary dependent variable, this study applied Cox's linear logistic regression model 6 for multivariate analysis.
This study considered the U.S. National Center for Health Statistics (NCHS) standard, for the classification of malnutrition, because of it's widely acceptance and is a common recommendation of the World Health Organization. Based on the available information, this study examined the influences of the following risk factors affecting nutritional status of women. Demographic and health care factors: mother's age at birth, children ever born, respondent's say on own health care, micronutrient intake, Socio-economic factors: geographic region, mother's education, mother's occupation, father's education, father's occupation, exposure to media, religion, and household assets index. The study considered 13 independent variables in bivariate analysis, which were categorized as they were in the original data file. In multivariate analysis some variables were recoded for more specification on categories. Mother's body mass index was classified as acute malnourished mother who had less than 18.5 kg/m2 body mass index (BMI), and nourished mother who had greater than or equal to 18.5 kg/m2 BMI. The classification of BMI adopted from WHO, 1995; WHO, 2000; WHO, 2004.
Mothers Nutritional Status (an assessment measured by BMI index)
If a mother has normal weight we consider that she is not suffering from malnutrition i.e., she is well-nourished. Table 1 revels that although maximum numbers of rural mothers have normal weight (56.5%) a large portion of them have unhealthy weight (40.1%) of them 25.3% mild thin, 9.5% moderate thin and 5.3 % severe thin mothers. Only 3.1% rural mothers were over weighted and obesity is about rare (0.2 %).
Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004
Data on the height and weight of ever-married women ages 10-49 were used to derive two measures of nutritional status: Height and Body Mass Index (BMI). A woman height can be used to predict the risk of having difficulty in pregnancy, given the relationship between height and pelvic size. The risk of given birth to low-weight babies is also higher among women of small stature. The cutoff point at which mothers can be considered at risk because of short stature is normally taken to be between 140 and 150 centimeters. The main advantage of the BMI is that it does not require a reference table from a well -nourished children population. Table 2 shows the percentage distribution of rural mother's weight status, mean height and mean BMI according to current age.
The result in the table 2 indicates that mean height for all ages of women is 150.43 centimeters and mean BMI is 19.36. The table 2 shows that maximum normal weighted women (58.2%) are in the age group 20-29 years and the minimum (46.1%) are in the age group 40-49 years. The table also reveals that among the married women whose current age is <20 years and between 40-49 years, 45.0% and 52.9% fall in the under weighted category respectively. It is also seen that, the percentage of over weighted mothers is higher (4.9%) in the 30-39 years age group as compared to the mothers of other age groups and there are few mothers in the obesity group, only 1.0% mothers of 40-49 years age group are in obesity and this percentage is comparatively higher than the mothers of other age groups.
Differentials of Rural Mothers Nutritional status by Selected Characteristics
Table 3 presents differentials of rural mother's nutritional status (an assessment measured by BMI) by selected characteristics. The results presented in table 3 elucidates that about 57.5% respondents have normal weight who gave their first birth when they were 20-30 years old followed by 56.1% and 47.4% respondents have normal weight who gave their first birth at below age 20 and ?30 years. The percentage of under weighted and over weighted mothers is found to be highest (47.4% and 5.3% respectively) among aged respondents (?30 years).The respondents who have 1-2 child have normal weight (56.8%), under weight (40.1%), over weight (2.9%) and obesity (0.2%). The percentage of healthy weighted mothers is found to be highest (58.2%) in Sylhet division and the percentage of under weighted (41.4%) respondents is found to be highest in Rajshahi division. The percentage of over weighted mothers is lowest (1.8%) in Chittagong division.
Regarding respondents level of education it is observed that 57.6% secondary educated respondents have normal weight followed by 56.4% primary educated, 55.6% higher educated and 53.6% illiterate respondents. The percentage of under weighted respondents (40.8%) is same among the respondents who are illiterate and higher educated. Incase of over weight, 5.6% illiterate respondents were over weighted followed by 2.6% secondary, 3.2% primary educated and 3.3% higher educated respondents. In case of husband's education 57.3% respondents whose husbands were higher educated have normal weight followed by 38.3% have under weight, 4.4% have over weight. It is also seen that about 58.3% respondents who were not working for cash i.e. who were engaged in their household activities have normal weight followed by 53.8% respondents who were working for cash. The percentage of normal weighted respondents is highest (55.5%) among the respondents whose husbands are non-manual worker followed by 56.5% manual worker also 56.7% Muslim mothers have normal weight followed by 51.9% non-Muslim mothers.
The percentages of respondents who were exposed to mass media of them 56.9% who have healthy weight, 40.1% were under weighted and the remaining 2.4% were over weighted. The table 3 also depicts that 57.5% of the respondents who received vitamin “A” within two months after delivery have normal weight followed by 56.2% respondents who did not take that vitamin. The mothers whose mobility about own health care was not restricted are in the higher percentage of normal weight (57.9%) followed by 55.1% respondents whose mobility was restricted about that matter.
Determinants of Rural Mothers' Nutritional Status: A Multivariate Logistic Regression Analysis
From table 4 it is appeared that mothers who gave first birth at age 20-30 years have 1.34 times higher probability of nourished and the mothers who gave their first birth at age ?30 years having 0.875 times lower probability of becoming nourished than among the adolescence mothers ( <20 years). Mothers who received vitamin “A” tablets and iron supplementation in the first month after delivery have 1.46 and 1.10 times higher probability of becoming nourished as compared to the mothers who did not received vitamin “A” tablets and iron supplementation. Considering no education as reference category, the relative odds ratio corresponding to primary, secondary and higher educated mothers are 1.028, 1.003 and 1.001, indicating that primary, secondary and higher educated mothers were 1.028, 1.003 and 1.001 times more probability of becoming nourished than among mothers with no education..
It is also found that women whose husbands were primary and higher educated have 1.6269 and 1.334 times higher probability of nourished. The table 4 also depicts that Muslim mothers were 1.71 times more probability of becoming nourished as compared to the non-Muslim mothers and women whose husbands were non-manual workers ( service man, businessman etc., ) were 1.123 times more probability of becoming nourished than among mothers whose husbands were involved in manual works ( day labour, farmers etc., ). It is also found that women with upper class assets have 1.232 times more probability of becoming nourished.
This study was designed to give a scenario of mother's nutritional status in rural Bangladesh. Women's nutritional status was defined in terms of Body Mass Index (BMI\wt in kg/ht in m2). The study found that although maximum numbers of rural mothers were nourished a large portion of them was acute malnourished. A woman height can be used to predict the risk of having difficulty in pregnancy, given the relationship between height and pelvic size. The risk of given birth to low-weight babies is also higher among women of small stature. The cutoff point at which mothers can be considered at risk because of short stature is normally taken to be between 140 and 150 centimeters. The result in our study indicates that mean height for all ages of women is 150.43 centimeters.
Both bivariate and multivariate analyses indicated that the educational level of wife was positively related to the better nutritional status of women. This is likely to be attributed because education may enable women to make independent decisions, to be accepted by other household members, and to have greater access to household resources that are important to nutritional status 7 . A comparative study on maternal malnutrition in ten sub-Saharan African countries 8 and a study in the SNNPR of Ethiopia 9 showed that the higher the level of education, the lower the proportion of undernourished women.
In this study husbands' education and occupation emerged as important factors that were significantly associated with underweight status among mothers. Analysis showed that mothers whose fathers had higher level of education and professional workers were lower in proportion of weight deficiency than those with illiterate and manual workers fathers. Usually father is the main earner and decision maker of a family and so their higher level of education plays an important role to ensure better nutritional status of the family members. The Nutrition Survey of Rural Bangladesh illustrated that fathers engaged in professional works average per capita calorie intake increased by 300 cal from the lowest to than the fathers engaged with manual works.
The observation that mothers who worked for cash are better nourished is most likely to be attributed due to the fact that women's employment increases household income, with consequent benefit to household nutrition in general and the woman's nutritional status in particular. Employment may increase women's status and power, and may bolster a woman's preference to spend her earnings on health and nutrition. Though employed, women without control over their income and decision-making authority within the household are deprived of economic and social power and the ability to take actions that will benefit their own well-being. Studies in Africa have indicated that, at similar levels of income, households in which women have a greater control over their income are more likely to be food secure 10
Intake of Vitamin A and iron supplementation also has positive effect on better nutritional status of women. . Vitamin A supports growth especially sketal growth 11 . Our study revealed that the proportion of acutely malnourished mothers was significantly greater among those who had not taken vitamin A and iron supplementation. The household assets index is an indicator of child and maternal nutritional status. This study elucidates that women with upper class assets have 1.232 times more probability of becoming nourished than mothers with lower quality of household assets index. Rathavuth Hong (2006) 12 found from a case-control study on ,977 children aged 0-59 , in Bangladesh that mothers poorest household assets are more than three times as likely to suffer from acutely malnourished from the wealthiest households assets index.
Our study also elucidates that higher fertility women appear were more suffering from acute malnutrition this may be probably due to the fact that women with higher fertility to be at greater risk for poor nutritional status because of the stresses of multiple pregnancies and lactations with inadequate recuperative intervals between pregnancies rather than from the stress of excessively long duration of lactation. An overlap of pregnancy and lactation caused additional stress.
These results confirm the importance of programs to improve maternal nutritional status, especially in light of the high levels of chronic malnutrition in Bangladesh. There is a need to improve nutritional levels of girls and women prior to and subsequent to pregnancy, in order that the current patterns of maternal depletion syndrome seen among older, higher parity women can be prevented. These results suggest that much more attention needs to be placed on reducing household poverty, increasing rural nutritional resources. It was found that women's employment for cash is an important determinant of her nutritional status Therefore; strategies must be developed to increase women's productivity per unit of time both in paid work and in domestic production so that women can increase their incomes without scarifying additional time, their children's welfare, or their own health and nutritional status. This may include introducing appropriate technology, which can both augment income-earning opportunities and reduce time constraints. Supporting institutions seeking to empower rural women could be important interventions to improve their nutrition status. The results showed that education of husband and wife are important determinants for mother's nutritional status. Educated mothers are at a lower risk of malnutrition. It is therefore imperative that young girls and boys be enrolled in compulsory primary school education and opportunities should also be given to adult women and men to take part in non-formal education. Health and nutrition education should also be an integral part of the education process. Adequate birth spacing, especially for rural women, should be promoted; this means that access to family planning must be improved to make birth spacing. Dietary intake needs to be improved for older higher fertility women
Md. Mosiur Rahman Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi-6205, Bangladesh E-mail: firstname.lastname@example.org