Women empowerment (WE) is increasingly viewed as an important strategy to reduce maternal and child undernutrition,^1–3 which continues to be a major health burden in low- and middle-income countries causing 3.5 million preventable maternal and child deaths, 35% of the disease burden in children younger than 5 years, and 11% of total global disability-adjusted life years.^4,5Global data show that one of the worst affected regions is sub-Saharan Africa (SSA), where about 20% of children are malnourished.^6,7 Benin is no exception, as the prevalence of stunting, wasting, and underweight was 37%, 5%, and 17%, respectively, among children aged 6 to 59 months in the 2006 Benin Demographic and Health Survey (DHS),⁸ while 9% of women had chronic energy deficiency in the 2012 DHS.⁹ Greater rates were observed in rural areas where stunting was found in 40% of children, underweight in 19%, and wasting in 5%, while 10% of women had chronic energy deficiency.^8,9 Additionally, Beninese women and children have a limited dietary diversity score (DDS), with diets predominately composed of starchy staples with little or no animal products and few fresh fruits and vegetables.^10,11 Government, United Nation agencies, and nongovernmental organizations in Benin recognize that the state of maternal and child undernutrition requires multiple types of interventions.¹²

However, women’s low empowerment status in Benin can hinder the improvement in women’s and children’s undernutrition. Indeed, although females accounted for 47% of the economically active population in 2014,¹³ social and civil legislation is strongly influenced by tradition and customs, as women continue to be required to seek their husband’s authorization in certain areas such as family planning or health services.¹⁴ Rural women provided labor to the families’ commercial plots, were responsible for household food production and processing, and also had to work in the cooperative structures set up by the state in addition to their household tasks.¹⁴ In a more recent study of productivity differences by gender in central Benin, researchers noted that female rice farmers are particularly discriminated against with regard to access to land and equipment, resulting in significant negative impacts on their productivity and income.¹⁵ As in other areas of West Africa, women also have the responsibility of caring for children and preparing food for the household,¹⁶ but they may be vulnerable to food insecurity owing to unequal intrahousehold food distribution and their willingness to forego meals in favor of children during times of scarcity.¹⁷ Finally, no study to date has examined links between women’s empowerment and nutrition in Benin.

In addition, the evidence backing the effect of women’s empowerment on maternal and child undernutrition is inconsistent.¹⁸ Using the Women’s Empowerment in Agriculture Index (WEAI), Malapit et al¹⁹ reported positive and significant association between women’s group (WG) membership, control over income, overall empowerment, and women’s health (as measured by body mass index [BMI] and DDS) in Nepal. However, in Ghana, women’s aggregate empowerment and participation in credit decisions were positively correlated with women’s DDS, but not BMI.²⁰ Mixed findings were also observed between women’s empowerment and child anthropometry. Moestue et al²¹ found a positive association between maternal involvement in social groups and length-for-age z score of 1-year-old children, but De Silva and Harpham²²showed a negative association in 6- to 18-month-old children. Shroff et al²³ found positive association between decision-making and child weight-for-age z score (WAZ), but Begum and Sen’s²⁴ analysis of Bangladesh DHS data did not reveal any significant associations. Therefore, information about which domains of WE are associated with nutritional status is limited,²⁰ and this lack of knowledge constrains the set of policy options that can be used to empower women and improve nutrition.

In addition to a limited set of studies in SSA, examinations of the effects of WE on nutrition outcomes are constrained due to interstudy differences in population characteristics, settings, or methods/conceptualizations of WE.^25–27 For example, despite recognition of the complex, multidimensional, and culturally defined nature and influence of empowerment on nutrition,^20,26,28,29 only a few studies considered the multidimensional structure of empowerment domains in Africa or examined the varied relationships between each measure of WE and maternal and child nutrition status.^30,31 Furthermore, in 2012, the International Food Policy Research Institute developed WEAI constructed from 5 prespecified domains of empowerment,³²which may not be equally relevant in all areas. In contrast, in 2015, the United Nations adopted the Sustainable Development Goals (SDG), but the specific indicators for the SDG empowerment targets are largely equality metrics.³³ To address the need for multidimensional and contextual examinations of WE and its influence on maternal and child health outcomes, we draw from the concepts put forward in the WEAI and the SDGs but took an approach more along the lines of the World Bank which gathers indicators, both equity and empowerment related, that can be used in contextually appropriate ways.³⁴ The aims of this study were therefore to first explore the structure and domains of WE in Kalalé district of northern Benin and then to examine the effects of these constructs on nutritional status of women and their children in the region.

Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care. These “indirect” effects are too often invisible and not adequately assessed nor addressed by just war principles or global humanitarian response. This essay suggests that while the neglect of indirect effects has been longstanding, recent technical advances make such neglect increasingly unacceptable: 1) our ability to measure indirect effects has improved dramatically and 2) our ability to prevent or mitigate the indirect human toll of war has made unprecedented progress. Together, these advances underscore the importance of addressing more fully the challenge of indirect effects both in the application of just war principles as well as their tragic human cost in areas of conflict around the world.

Objective: To identify the magnitude of anaemia and deficiencies of Fe (ID) and vitamin A (VAD) and their associated factors among rural women and children.

Design: Cross-sectional, comprising a household, health and nutrition survey and determination of Hb, biochemical (serum concentrations of ferritin, retinol, C-reactive protein and α1-acid glycoprotein) and anthropometric parameters. Multivariate logistic regression examined associations of various factors with anaemia and micronutrient deficiencies.

Setting: Kalalé district, northern Benin. Subjects: Mother–child pairs (n 767): non-pregnant women of reproductive age (15–49 years) and children 6–59 months old.

Results: In women, the overall prevalence of anaemia, ID, Fe-deficiency anaemia (IDA) and VAD was 47·7, 18·3, 11·3 and 17·7%, respectively. A similar pattern for anaemia (82·4 %), ID (23·6%) and IDA (21·2%) was observed among children, while VAD was greater at 33·6%. Greater risk of anaemia, ID and VAD was found for low maternal education, maternal farming activity, maternal health status, low food diversity, lack of fruits and vegetables consumption, low protein foods consumption, high infection, anthropometric deficits, large family size, poor sanitary conditions and low socio-economic status. Strong differences were also observed by ethnicity, women’s group participation and source of information. Finally, age had a significant effect in children, with those aged 6–23 months having the highest risk for anaemia and those aged 12–23 months at risk for ID and IDA.

Conclusions: Anaemia, ID and VAD were high among rural women and their children in northern Benin, although ID accounted for a small proportion of anaemia. Multicentre studies in various parts of the country are needed to substantiate the present results, so that appropriate and beneficial strategies for micronutrient supplementation and interventions to improve food diversity and quality can be planned.

Objective

To identify the prevalence and predictors of malnutrition among 2-year old children in the Western Highlands of Guatemala.

Methods

Prospective cohort of 852 Guatemalan children in San Lucas Toliman, Guatemala followed from birth to age 2 from May 2008 to December 2013. Socio-demographic, anthropometric, and health data of children was collected at 2 month intervals.

Results

Among the 402 males and 450 females in the cohort, mean weight-for-age Z-score (WAZ) declined from -0.67 ± 1.01 at 1 year to -1.07 ± 0.87 at 2 years, while mean height-for-age Z-score (HAZ) declined from -1.88 ± 1.19 at 1 year to -2.37 ± 0.99 at 2 years. Using multiple linear regression modeling, number of children <5 years old, vomiting in the past week, fever in the past week, and WAZ at 1 year were significant predictors of WAZ at 2 years. Significant predictors of HAZ at 2 years included household size, number of children <5 years old, diarrhea in the past week, WAZ at 1 year, and HAZ at 1 year. Vomiting in the past week and WAZ at 1 year were significant predictors of weight-for-height z-score (WHZ) at 2 years.

Conclusions

Number of children <5 years old, symptoms such as vomiting or diarrhea in the previous week, and prior nutritional status were the most significant predictors of malnutrition in this cohort. Future research may focus on the application of models to develop predictive algorithms for mobile device technology, as well as the identification of other predictors of malnutrition that are not well characterized such as the interaction of environmental exposures with protein consumption and epigenetics.

Objective

To explore existing barriers and challenges to Early Intervention (EI) referral, enrollment, and service provision for very low birth weight (VLBW; <1500 g) infants.

Methods

We conducted 10 focus groups with parents of VLBW children (n = 44) and 32 interviews with key informants from EI (n = 7), neonatal intensive care units (n = 17), and outpatient clinics (n = 8) at 6 sites in 2 states. We used grounded theory to identify themes about gaps in services.

Results

Both parents and providers found EI helpful. However, they also identified gaps in the current EI system at the levels of eligibility, referral, family receptivity, and service provision and coordination with medical care. Inadequate funding and variable procedures for evaluation may affect children's eligibility. Referrals can be missed as a result of simple oversight or communication failure among hospitals, EI, and families; referral outcomes often are not formally tracked. Families may not be receptive to services as a result of wariness of home visits, social stressors, denial about potential developmental delays, or lack of understanding of the benefits of EI. Once a child is deemed eligible, services may be delayed or terminated early, and EI providers may have little specialized training. Communication and coordination with the child's medical care team is often limited.

Conclusions

Systemic barriers, including funding and staffing issues, state and federal regulations, and communication with families and medical providers, have led to gaps in the EI system. The chronic care model may serve as a framework for integrating community-based interventions like EI with medical care for VLBW children and other vulnerable populations.