Washington: Over 40 per cent of Indian women are underweight when they begin pregnancy compared to 16.5 per cent of pre-pregnant females in sub-Saharan Africa, a region where people are poorer and fertility rates are higher than in India, a new study has found. The study by researchers at Princeton University’s Woodrow Wilson School of Public and International Affairs also found that on average women in both India and sub-Saharan Africa gain only 7 kg throughout pregnancy – just half of the recommended amount.
“These findings should be a wake-up call about maternal nutrition in India,” said lead author Diane Coffey, a PhD student at the Wilson School’s Office of Population Research. “The health of children is one of the most important measures of the wellbeing of a society, and that starts during pregnancy. India must invest more in its most important resource: human capital formed at the very beginning of life,” Coffey said.
In 2012, Coffey – who is a co-founder of the research institute for compassionate economics (r.i.c.e.), a non-profit in India – conducted a qualitative study about the health mothers and infants in three Indian villages.
She noticed a pattern: mothers were not gaining weight at the expected rates. Body mass and weight gain during pregnancy are important indicators of maternal health. Babies born to undernourished mothers are more likely to be underweight, a characteristic influencing height, cognition and productivity across a lifetime.
Unlike the US, where the Centers for Disease Control and Prevention monitors health in pregnancy, there is no national health monitoring system in India, researchers said. As a result, prior studies of maternal health in India have severely missed the mark when calculating pre-pregnancy body weight, researchers said.
The most recent maternal health data was collected in 2005 by the Demographic and Health Survey, which showed that 35.5 per cent of women aged 15 to 49 are underweight. While this figure is commonly cited, it is actually inaccurate, Coffey said, as women who become pregnant are different from those who do not with regards to body mass.
Using a variety of econometric strategies, Coffey estimated the pre-pregnancy body mass and weight gain during pregnancy in India and sub-Saharan Africa. Using reweighting techniques to correct body mass index scores (BMI), she found that the average BMI of pre-pregnant women in India is 19.5 per cent and the fraction of women who begin pregnancy underweight is 42.2 per cent.
This is almost 7 percentage points higher than the fraction of underweight women between ages 15 and 49. “These findings point to the need for a national health monitoring system. That way we wouldn’t need to rely on outdated cross-sectional surveys to estimate these important indicators of maternal health,” said Coffey.
Coffey’s reweighting analysis found that only 16.5 per cent of women in sub-Saharan Africa are underweight before pregnancy, and the average pre-pregnancy BMI is 2 points higher than women in India, at 21.5.
One commonality is that women gain only 7 kg on average in both regions, just half of what is recommended by the US Institute of Medicine.
While women in both regions gain similar amounts of weight, Indian women weigh much less when beginning pregnancy – putting them at a severe deficit from the start, researchers said.
That maternal health in India is so poor seems puzzling considering its economic successes, but past social scientific and epidemiological literatures offer some clues, researchers said. It is widely recognised that the status of women in India is much worse than in sub-Saharan Africa. In India, young, newly married women are at the bottom of household hierarchies and have even lower status than older women, researchers said.
Sex ratios in sub-Saharan Africa are a bit more balanced, and the sex gaps in education, work outside the home and child mortality are not as large. “Throughout India, pregnant women and their babies suffer the consequences of living in a deeply patriarchal society,” Coffey said.
“Young, newly married women, who are the most likely to become pregnant, are often expected to keep quiet, work hard and eat little,” Coffey added. In addition to having low social status, these women live in exceptionally poor disease environments.
Around 70 per cent of rural Indian households defecate in the open, a practice that spreads intestinal diseases and parasites, making it difficult for people to use the energy and nutrients food.
It is likely that infectious disease is responsible for a significant proportion of India’s pre-pregnancy underweight problem, Coffey concluded. The findings are published in the Proceedings of the National Academy of Sciences (PNAS).