Part I: Accounting for Maternal and Foetal Nutrition Losses
- Sregurupriya Ayappan*
Introduction
Poverty, today, is more than its economic dimension and is characterised by low personal income, lack of opportunities, lack of access to medical care and other environmental and physical factors.[1] This broader understanding, which includes capabilities and dimensions of freedom, has revealed the interrelationship between poverty, malnutrition and food and nutrition security. The first Millennium Development Goal too was to ‘Eradicate Extreme Poverty and Hunger’, which thereby illustrated the need to look at both poverty and food security in conjunction. Hence, if legislative and executive efforts to alleviate either food security or poverty are to succeed, they must factor in the other issue as well.
It is against this backdrop that I shall argue, in a series of two posts, that the National Food Security Act, 2013 [hereinafter “the Act”] does not recognize the link between poverty and food security, and its own provisions defeat the object of the Act which states that it is an “Act to provide for food and nutritional security in human life cycle approach, by ensuring access to adequate quantity of quality food at affordable prices to people to live a life with dignity and for matters connected therewith or incidental thereto (emphasis supplied).”[2] In this post, I shall focus on how the provisions of the Act as they currently stand are insufficient to deal with the twin problems of maternal and foetal malnutrition. Further, I shall show how this is exacerbated by nutritional practices post birth and that the graduated method of identifying malnutrition as envisaged by the Act leaves children in the bracket of 0-6 months vulnerable. This causes long term health implications and reduces capabilities, both, making it harder to escape the poverty trap and ensuring the intergenerational transfer of undernutrition.
Maternal Malnutrition: A Haunting Spectre
Maternal malnutrition spells several adverse implications on the unborn child which impedes the competency of the child in the long run.[3] A mother’s constitution impacts more than her individual health. There is overwhelming medical evidence today that growth failure begins in utero, that is, during pregnancy.[4] This implies that any intervention, legislative or otherwise, must consider the period before and during pregnancy to be a priority time frame. Else, the inevitable consequence would be that of foetal malnutrition. The limited nutrition provision from the mother is characterised by failure to attain the normal growth of the foetus.[5]
This makes it necessary to intervene and correct nutritional deficiencies, especially that of vital micronutrients, at the stage of pre-conception itself. Any intervention at the stage of pregnancy is too late to ensure building of sufficient nutrient stores in the mother.[6] Unfortunately due to the blight of poverty, many women in poorer communities lack access to and affordability of nutrition food during pregnancy. Many of them already suffer from a history of undernutrition which increases their susceptibility to maternal malnutrition.[7] The situation is more worrisome because their poverty reduces the likelihood of their availing good sanitation facilities and clean drinking water making them vulnerable to illness and disease which further siphons off from their nutrition. At times, this interplay between poverty and pregnancy adopts a more sinister character where malnourished mothers with stunted bodies actively under-eat in order to avoid complications during childbirth.[8]
Hence, if the Act seeks to achieve its objective of providing nutrition security in a “human life cycle approach”, it is essential that it tackles the twin problems of maternal and foetal malnutrition. Regrettably, the Act merely has a single express provision for the “pregnant and lactating mother”. This too is subject to riders prescribed in other schemes of the Central government and the terms of employment of the mother, if she is working.[9] The prescribed nutritional requirement for pregnant and lactating mothers in the form of take home ration amounts to 600 kCal[10] which is to be dispensed through the apparatus of the Integrated Child Development Scheme [hereinafter “ICDS”]. This is extremely insufficient, even in terms of quantity since the ideal calorific requirement during pregnancy ranges between 2200-2900 kCal, adjusted for the weight of the mother.[11]
The ICDS also has a supplementary nutrition programme, which seeks to provide additional energy requirement and protein intake to pregnant and lactating mothers (and children). However, neither this scheme nor the Act has any focus on women and adolescent girls in the pre-conception stage. The Act merely mentions “nutritional, health and education support to adolescent girls”[12] in Schedule III which contains provisions for progressive realisation and there is nothing in the Act that currently caters to this important category of individuals. Intervention during adolescence can help ensure healthy pregnancies and decrease the incidence of maternal and foetal malnutrition. However, at the moment, the only scheme which has a target group of girls aged 11-18 years is the recently renamed Scheme for Adolescent Girls.[13] This scheme too is woefully inadequate as it extends to just 200 districts and has a greater focus on vocational and educational support than on the nutrition component. Nonetheless, it should be integrated with the Act itself to reiterate the importance of intervention in this stage.
Critically Neglected Period of Infant Nutrition
The problems in the form of intergeneration transfers do not end with maternal and foetal malnutrition. It subsists and is exacerbated in the period immediately after birth. The first 1000 days is known as the ‘critical period’ of human growth. Poor nutrition in this crucial time frame is as strong a contributor as foetal malnutrition. This leads to a “double nutrition problem”. The child will carry the nutrition losses incurred in this period for the rest of his/her life.[14] According to medical studies, any interventions introduced after this period will not break the transfer of malnutrition. Hence, it is important to institute programmes that address the nutritional and poverty-related aspects of undernutrition in this phase itself. This is because although foetal nutrition is essential to break out of the poverty-undernutrition trap, low-birth weight babies too have an opportunity to have ‘catch-up’ growth during this critical period.[15]
In order to achieve this, it is essential that lactating mothers have good micronutrient stores and exclusively breast feed their child for the first six months, if not longer.[16] Unfortunately, this is not as easy to implement considering the ground realities of most women. For example, a poor woman working in the informal sector on a daily wage basis will be constrained to abandon her child in the care of, usually, an older sibling immediately after child birth. The infant then suffers a double nutritional setback. S/he is deprived of breastfeeding and might be more vulnerable to infections if the alternative feeding practices are unsanitary.
Further, between six months and three years of age, the dietary intakes need to be sufficiently nutrient dense to ensure this ‘catch-up’ growth takes place. Diets need to include fruits and vegetables and must contain adequate levels of energy to ensure proper growth of the child. It is extremely important to identify children who are born malnourished so that they may be given appropriate attention throughout.[17]
The Act, however, does not seem cognizant of these issues. It merely states free meals shall be provided to malnourished children according to nutritional standards specified in its Schedule.[18] The Schedule itself only prescribes nutritional standards from the age of 6 months onwards. Moreover, it provides the same nutritional requirement throughout the age group between 6 months to 3 years. This is also problematic since the intake and absorption capacity varies across this category.[19]
Another point of concern is that the stage at which malnutrition is identified. It should be identified at birth itself if weight is below healthy levels since the child is likely to have been born malnourished.[20] The incidence of low birth weight babies[21] continues to be high in India[22] and nearly ninety percent of them suffer from foetal malnutrition.[23] Low birth weight also creates extremely high risk of stunted growth, thereby perpetuating intergenerational transfer.
To address these issues, the Act could include provisions categorising underweight babies as malnourished and warranting special attention. The same status should be accorded to malnourished pregnant and lactating mothers. There are various methods to determine nutritional status of newborns at birth and at least the Clinical Assessment of Nutritional Status score of newborns must be compulsorily recorded in government hospitals on birth.[24] The total energy requirement of the children between the age of 6 months and 3 years should be calculated on a gradation according to their age and weight.[25] Further, there is a high likelihood that the 500 kCal provided to children in this age group uniformly[26] may not pull up them out of malnutrition. Many of them suffer from interconnected issues like poor sanitation and micronutrient deficiencies which reduce the rate of absorption of food thereby rendering the energy insufficient.
Conclusion
While the Act is headed in the right way with its special focus on women, the focus on foetal and maternal nutrition should be supported by appropriate interventions throughout the life cycle of the ‘high-risk’ child to prevent stunting and improving competence, which in turn can aid in escaping poverty. Moreover, this must be increased and accompanied by a deeper understanding of the interrelationship between poverty and nutrition. The effect of intergenerational transfers of undernutrition on the capabilities of the affected individuals and the vicious cycle of structural poverty share an almost reciprocal and mutual relationship which I shall explore further in the next post. The provisions of the Act need to account for this and go beyond mere token references if a large majority of the population is to benefit from this legislative effort and break out of this vicious cycle.
*Sregurupriya Ayappan is a third year student at the National Law School of India University, Bangalore.
[1] Amartya Sen, The Possibility of Social Choice, Economic Sciences, 194 (1998).
[2] National Food Security Act (2013). “Act to provide for food and nutritional security in human life cycle approach, by ensuring access to c at affordable prices to people to live a life with dignity and for matters connected therewith or incidental thereto (emphasis supplied).”
[3] T.D. Wachs, The Nature and Nurture of Child Development, 20(1) Food and Nutrition Bulletin, 7 (1999). It compromises growth and changes to body composition, the percentage of muscle mass in specific. It also alters brain development and changes the metabolic processing of lipids and glucose. The hormone, receptor and gene functions may also be negatively affected.
[4] Reynaldo Martorell & Amanda Zongrone, Intergenerational Influences on Child Growth and Undernutrition, 26(1) Pediatric and Perinatal Epidemiology, 302 (2012).
[5] Id. The insufficient placental transport mechanisms and weak metabolic processes in the mother lead to inadequate accumulation of subcutaneous fat and muscle.
[6] Reynaldo Martorell, supra note 4.
[7] Reynaldo Martorell, supra note 4.
[8] Reynaldo Martorell, supra note 4. Due to their stunted growth, these women have narrower pelvic inlets. This can often cause death during childbirth if the head circumference of the child is too large to deliver the child naturally and because of their poverty, they do not have access to medical facilities to undergo a caesarean.
[9] National Food Security Act §4 (2013).
[10] National Food Security Act Schedule II (2013).
[11] Thomson, A and Hytten, F., Calorie requirements in human pregnancy, 20(1) Proceedings of the Nutrition Society, 76 (1961).
[12] National Food Security Act §3(c) Schedule III (2013).
[13] Earlier known as ‘Rajiv Gandhi Scheme for Empowerment of Adolescent Girls’. It was launched in 2010.
[14] Reynaldo Martorell, supra note 6.
[15] Andy Sumner et al, Rethinking Intergeneration Transmissions: Will a Wellbeing Lens Help? The Case of Nutrition, 40(1) Institute of Development Studies Bulletin (2009).
[16] Reynaldo Martorell, supra note 6.
[17] Reynaldo Martorell, supra note 6.
[18] National Food Security Act §6 (2013). “The State Government shall, through the local anganwadi, identify and provide meals, free of charge, to children who suffer from malnutrition, so as to meet the nutritional standards specified in Schedule II.”
[19] Nancy Butte et al, Energy Requirements Derived from Total Energy Expenditure and Energy Deposition During the First 2 Years of Life, 72 American Journal of Clinical Nutrition, 1558 (2000).
[20] Sanjay Mehta et al, Clinical Assessment of Nutritional Status, 35(1) Indian Paediatrics Journal (1998). This can be evidenced by the condition of the hair, cheeks, chest etc. in the new born baby.
[21] Less than 2.5 kgs.
[22] At about 30% in contrast to 5-7% in developed countries.
[23] About 10% are babies born prematurely.
[24] Vikram Singhal et al, Detection of Fetal Malnutrition by CAN Score at Birth and its Comparison with other Methods of Determining Intrauterine Growth, 22(11) Indian Journal of Clinical Practice, 22 (2012). This score looks at the condition of the new born’s hair, cheeks, neck and chin, arms, legs, back, buttocks, chest and abdomen and grades each on a scale of 1 to 4 where 1 shows a high degree of malnutrition in the baby.
[25] Energy Requirements of Infants from Birth to 12 Months, Food and Agriculture Organisation (Sept. 4, 2017), www.fao.org/docrep/007/y5686e/y5686e05.htm.
[26] National Food Security Act Schedule II (2013).