Malnutrition: a key barrier to women and girls’ empowerment

March 8^th marks International Women’s Day, an annual celebration of the social, economic, cultural and political contributions of women. Since 1911, International Women’s Day has been an official day to measure and celebrate progress towards gender parity. Many individuals and institutions have come to focus on women’s economic and social empowerment as a critical facet in achieving progress.

Malnutrition is a key barrier to women and girls’ empowerment. Malnutrition includes undernutrition, inadequate consumption of vitamins and minerals, overweight, and obesity. Women are at particular risk for malnutrition and can be disproportionately affected by hunger due to economic, social, and cultural influences [1]. Progress towards gender parity must include eliminating hunger and malnutrition worldwide.

Women of reproductive age face unique nutritional vulnerabilities. Inadequate nutrition weakens women and their ability to generate income and care for their families. Targeting the nutritional needs among women of reproductive age (WRA)—those between 15-49 years of age—is an opportunity to empower women and break intergenerational cycles of poverty and malnutrition [2]. A number of evidence-based interventions are recommended to address nutritional problems in WRA. However, decision makers need timely and actionable information to be able to effectively select, target and monitor progress of their policies, programs and investments. In low and middle-income countries, the Demographic Health and Survey (DHS) is a leading source of such information.

Progress on reducing WRA malnutrition requires more evidence and data on consumption and nutrition status. Data for Decisions to Expand Nutrition Transformation (DataDENT) has been working with a diverse group of lead authors and technical reviewers from the nutrition community to develop a set of ten recommendations for the Demographic and Health Surveys (DHS)-8 core questionnaire. The table below highlights data needs, current availability and 6 recommendations specifically relevant to WRA. To access all 10 of the DHS recommendations and forum, please visit this site.

For more information on WRA interventions post pregnancy, please visit our latest post on breastfeeding counseling.

WRA Lifecycle Stage	What kind of data is needed?	Why is this information needed?	What is currently available in DHS?	Proposed Recommendations for DHS core questionnaire
Non Pregnant Women	Diet	WRA are at higher risk of overweight and obesity than adult males; consumption of unhealthy foods among WRA is of particular concern [3]. In most low- and middle-income countries, increasing consumption of sugar sweetened beverages (SSBs) and savoury, fried and sweet snacks contribute to overweight among WRA [4].	The core DHS questionnaire does not ask about diet diversity of adult populations. The DHS collects information on anemia status of WRA through biomarker testing.	Minimum dietary diversity for women (MDD-W): Proportion of women 15–49 years of age who consumed at least five out of ten defined food groups the previous day or night [5]. Percent of women of reproductive age who consumed sugar-sweetened beverages (SSB) in the previous day or night: Proportion of women 15-49 years of age who consumed any sugar-sweetened beverages the previous day or night [6]. Percent of women of reproductive age who consumed “junk food” in the previous day or night: Proportion of women 15-49 years of age who consumed any savoury or fried snacks, or any sweets during the previous day or night. [link to recommendation on DHS-8 Questionnaire Forum]
Non Pregnant Women	Nutritional Status	The weight of women prior to conception is a significant factor in pregnancy outcomes. Pre-pregnancy underweight contribute to a 32% higher risk of preterm birth. Obesity more than doubles the risk for preeclampsia, gestational diabetes [7].
Pregnant Women	Intervention coverage: Nutrition counseling	Nutrition counseling during pregnancy significantly improves gestational weight gain, reduces risk of anemia in late pregnancy, increases birthweight, and lowers the risk of preterm delivery [8]. Nutrition-specific interventions during pregnancy are a key component of updated 2016 WHO guidelines on ANC for a positive pregnancy experience.	The core DHS questionnaire includes questions about iron folic acid coverage during pregnancy, but does not collect data on other dietary interventions during pregnancy.	Counseling about healthy eating during pregnancy: The proportion of women 15-49 who attended ANC for the most recent live birth in the 5 years* preceding the survey that received counseling about what foods to eat during pregnancy. [link to recommendation on DHS-8 Questionnaire Forum]
Pregnant Women	Intervention coverage: Monitoring of Weight gain	Weight monitoring during pregnancy is important for prevention of low birth weight (LBW), birth complications, and excess weight gain during pregnancy. Specific recommendations for normal weight gain during pregnancy based on pre-pregnancy BMI are available from the US Institute of Medicine, Weight Gain During Pregnancy, 2009 [9]. Routine weight monitoring during pregnancy informs counseling on healthy eating and physical activity which are specific recommendations in the WHO ANC guidelines.		Weight measured during at least 2 ANC visits: The proportion of women 15-49 who attended ANC for the most recent live birth in the 5 years* preceding the survey that reported weight being measured over at least two ANC visits. Monitoring of weight gain during pregnancy (weight assessed + talk with provider): The proportion of women 15-49 who attended ANC for the most recent live birth in the 5 years* preceding the survey that reported weight being measured over at least two ANC visits AND discussed weight with provider. [link to recommendation on DHS-8 Questionnaire Forum]

*We support the newborn community’s recommendation to modify all Section 4. Pregnancy and Postnatal Care to include live births occurring in the previous 2 years. This would be advantageous to reduce data collection burden, align with MICS, and improve data quality. If this recommendation is adopted, the recall period for this proposed recommendation can be changed to 2 years.

WRA face unique nutritional vulnerabilities. Inadequate nutrition weakens women and their ability to generate income and care for their families. Progress on reducing WRA malnutrition requires more evidence and data on consumption and nutrition status.

[1] WHO. Malnutrition fact sheet. February 16, 2018. Retrieved from https://www.who.int/news-room/fact-sheets/detail/malnutrition

[2] Truebwasser U. Landscape Analysis of Adolescent Health and Nutrition in Ethiopia. Alive & Thrive. September 2017. Retrieved from https://www.aliveandthrive.org/wp-content/uploads/2018/10/Ethiopia-adolescent-report-9-17.pdf

[3] Kanter R, Caballero B. Global gender disparities in obesity: a review. Advances in nutrition. 2012 Jul 6;3(4):491-8.

[4] Mamun AA, Finlay JE. Shifting of undernutrition to overnutrition and its determinants among women of reproductive ages in the 36 low to medium income countries. Obesity research & clinical practice. 2015 Jan 1;9(1):75-86.

[5] FAO and FHI 360. 2016. Minimum Dietary Diversity for Women: A Guide for Measurement. Rome: FAO.

[6] Dean SV, Lassi ZS, Imam AM, Bhutta ZA. Preconception care: nutritional risks and interventions. Reproductive health. 2014 Dec;11(3):S3.

[7] Girard AW, Circumstances O. Nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes. Paediatric and perinatal epidemiology. 2012 Jul;26:191-204.

[8] WHO. WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Retrieved from https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/