Within households, nutrition disparities
are the outcome of six important channels. One, in many poor agricultural households, the low opportunity cost of time, reflected by low (agricultural) wages of women and girls relative to men and boys, creates a nutrition-productivity spiral in favor of the men and at the expense of women. This problem is particularly harsh in income-constrained households where members may allocate more market work to the higher-paid members, thus reinforcing a productivity nutrition trade-off in their favor (J. R. Behrman & Deolalikar,
1993,
1990; Deolalikar,
1988). These trade-offs become salient when households experience income shocks. For example, nutritional outcomes of women and girl children worsen when there are agriculture-related shocks such as droughts or floods, during price shocks and during labor market
shocks such as health shocks, migration-related shocks and economic downturns (Agüero & Marks,
2011; Akresh, Verwimp, & Bundervoet,
2011; Alderman et al.,
2006; Baez & Santos,
2007; D’Souza & Jolliffe,
2013; del Ninno & Lundberg,
2005; Ferreira & Schady,
2009; J. Hoddinott,
2006; R. Jensen,
2000). Two, women are often relegated to household tasks such as water and firewood collection or threshing and harvesting on the fields. These tasks are energy intensive, but they are undervalued in the market (H. R. Barrett et al.,
2005; Kadiyala, Harris, Headey, Yosef, & Gillespie,
2014). Even though there is no strong evidence that malnutrition outcomes of children worsen when mothers go back to work, women maybe expected to stay home and involve themselves in child care (Bennett,
1988; Glick & Sahn,
1998; Kes & Swaminathan,
2006; Leslie,
1988). These services too are undervalued and thus women’s (girls) household contributions tend to be undervalued in favor of men (boys) thus reducing access. Studies from Mexico have found that changing returns to household work through cash transfers
for girl children can be one way to help reduce their time spent on household work and to keep them in schools (Parker & Skoufias,
2000). Three, Jayachandran and Pande (
2017) found the oldest male child within a household had better nutrition-related outcomes compared to similar children in Africa. However, any other child (with a higher birth order) fared worse than a comparable group of children from the same context. Hoddinott and Kinsey (
2001) and Maccini and Yang (
2009) also found that when there were rainfall shocks, within the same household, girls’ malnutrition and schooling outcomes worsened in relation to boys’ malnutrition outcomes. Thus discriminatory practices based on birth order of gender often lead to different nutrition outcomes between groups of children within the same households. Four, intra-household bargaining literature shows that when women have more bargaining power within households nutritional outcomes of all members improve. For example, when households are headed by women rather than men, the nutrition outcomes of children are better in the former even if their incomes were lower on average (Headey,
2013; C. Johnson & Rogers,
1993). Multiple authors have found that women’s education is a powerful channel through which household malnutrition, as well as intergenerational health outcomes of children, can improve (Case & Ardington,
2006; Currie & Moretti,
2003; Oreopoulos, Page, & Stevens,
2006; Thomas, Strauss, & Henriques,
1991). Intra-household bargaining power of women is also reflected in the amount of freedom they have to control resources when they belong to male-dominated households. Multiple researchers have found that increase in empowerment of women within households, represented by greater financial control and more physical mobility outside the home, played an important role in improving child nutrition indicators (Imai, Annim, Kulkarni, & Gaiha,
2014; Shroff, Griffiths, Adair, Suchindran, & Bentley,
2009; M. R. Shroff et al.,
2011). Thus increasing women’s education, bargaining power and empowering women to take decisions within households will be important towards decreasing intra-household disparities. Five, within households, it can also be the case that households may not have proper information on nutritional behaviors that can impact malnutrition. In sub-Saharan Africa, evaluations of behavior change communication programs on breastfeeding have been found to be effective in increasing knowledge, duration of breastfeeding and health outcomes especially for babies whose mothers are HIV positive (Coovadia et al.,
2007; Thior et al.,
2006). Interventions such as the distribution of vitamin A
and iron
tablets in India have been unsuccessful in reducing micronutrient
deficiency since households lack information on the benefits of following treatment protocols properly. Six, cultural practices often prevent women and children from accessing the necessary care from interventions that are focused on improving their health. In some cases, cultural beliefs about the micronutrients’
effects on health play a role in reducing whether women and children continue treatment. For example, in India, Nichter (
2008) found that women were discouraged to take iron
supplements since midwives from the villages believed it would increase the size of the baby in utero and thus increase complications for child mortality in women who were giving birth. However, the flip side to the argument was that women who were anemic were highly susceptible to maternal mortality risks. Changing these behaviors require education interventions for all household members, informational campaigns about the importance of nutrition and economic growth policies that are inclusive.
Programs such as the ICDS
focus on addressing malnutrition by providing pregnant women and new mothers with reproductive healthcare such as ante-natal checkups, nutrition supplements such as iron
tablets, nutritious meals and information on managing nutrition intake during their pregnancies. For newborn children, the ICDS
provides post-natal care, monitors anthropometric health of newborn children and educate mothers on the importance of breastfeeding and eating healthy. Information on nutrition supplements and nutrition intake for children are also provided to new mothers with the view to change behavior. Evaluations of these programs have found that iron-related nutrition outcomes of children improved after women were educated on the same (Kapur, Sharma, & Agarwal,
2003). With regard to undernutrition, additional interventions
such as encouraging early initiation of breastfeeding practices were found to be more effective than just providing individuals with more information on nutrition practices (Kumar, Goel, Mittal, & Misra,
2006). Introduction of complementary feeding practices along with breastfeeding was found to be associated with better nutrition outcomes for children in some areas as well (Menon, Bamezai, Subandoro, Ayoya, & Aguayo,
2015). In states such as Maharashtra, regular monitoring of babies and mothers and strict protocols to identify and treat groups that are at high risk of malnutrition have played an important role in reducing its severity. Greater citizen involvement has also been thought to be the key motivation for creating efficient systems in Maharashtra. The MDMS
program, on the other hand, has been found to be an extremely cost-effective program in improving nutrition outcomes of students. Afridi (
2010) found that for less than Rs. 20 a day, a child attending a school with access to MDMS
reduced their daily dietary calorie
deficiency by 30%, iron
deficiency by 10% and reduced protein
deficiency by 100%.
India has some of the world’s worst rates of anemia for men, women and children, and this burden exists across states and economic development outcomes in the country. Anemia has been linked to the lack of micronutrient
availability in diets and is known to have many long-term negative health effects on individuals as well. Many interventions implemented by the health department in India have focused on improving the last mile access with regard to micronutrients
. For example, distribution of vitamin A
and iron
capsules for pregnant women and babies have long been part of the strategy to improve reproductive and child health in the country. However, there have not been many rigorous evaluations of these programs. For example, Semba et al. (
2010) found some evidence that vitamin A
interventions in India did reduce child undernutrition, especially wasting
in children. However, the effects were modest at best. In cases where it has worked, experts have shown that there are significant improvements to child health. Adhvaryu and Nyshadham (
2016) found that when children were exposed to iodine supplementations in utero, they were more like to have better health and cognitive outcomes compared to a sibling who was not exposed.
The other important and growing phenomenon in the malnutrition burden is obesity
incidence. A systematic review of the nature of obesity
within households reveals that in less developed countries, obesity
is an outcome of income and is equally prevalent between men and women in rich households. However, greater economic development becomes associated with obesity
of women in the lower income strata, but male obesity
tended to more malleable to economic growth (Dinsa, Goryakin, Fumagalli, & Suhrcke,
2012). In these contexts, obesity
of women is also associated with a higher premium in labor markets
regarding reduced wages as well as greater health spending (Cawley,
2004,
2010). These effects are known to spill over on poor health outcomes that have negative effects for both women and their children. In India, S. Gulati et al. (
2013) find that socio-economic indicators and the lack of knowledge on obesity
explain the high overweight
rates of girls and boys in urban schools. However, other than the income and information pathways, there is very little known about why women and children may be susceptible to obesity
in the country. Given its challenges for health, this becomes an extremely crucial investment area as we think ahead to improve nutrition outcomes.