Malnutrition and pregnancy wastage in Zambia

0277-9536/83/090539-05 $03.00/0 Copyright © 1983 Pergamon Press Ltd

Soc. Sci. M ed. Vol. 17, No.9, pp. 539-543, 1983 Printed in Great Britain. All rights reserved

MALNUTRITION AND PREGNANCY WASTAGE IN ZAMBIA KWAMIE KWOFIE, EKOW BREw-GRAVES and G. H. AOIKA University of Lusaka, Zambia Abstract-An analysis of recent nutritional status and dietary surveys in Zambia reveal a widespread prevalence of malnutrition. Pregnant women suffer from serious protein inadequacy. Variations in the nutritional status of the population is shown to vary with respect to different ecological conditions and to the level of socio-economic development within each province. Because of the interdependence between the nutritional health of the mother and the outcome of pregnancy, there is reason to believe that the prevailing malnutrition among pregnant women may be responsible, not only for lower birth weight and congenital malformations, but also, for increased maternal and perinatal mortality and morbidity in Zambia. Long-term solutions lie in the integration of nutrition concerns into sectoral development strategies; a commitment to reduce existing income disparities between the rural and urban areas; and innovative attempts to improve the efficiency of rural health institutions in the country.

INTRODUCTION

Sukhani et ai. [IJ reported in Lusaka, Zambia that among the major factors causing congenital malformations are "ill-understood environmental influences which acting on the uterus during the first ten weeks of pregnancy contribute significantly to peri-natal mortality" [1]. There are ample reasons to implicate maternal nutrition and the state of health of the mother during pregnancy as contributary factors in these "ill-understood environmental influences". This paper attempts to examine available evidence in an attempt to narrow the knowledge gap linking the outcome of pregnancy to maternal nutritional status. The principal sources, both direct and indirect evidence, are derived from relevant documented information, including food consumption and nutrition status, urban household surveys and morbidity and mortality statistics from health institutions in Zambia. EVIDENCE FROM AVAILABLE LITERATURE

The lowering of birth weight has been observed in acute famine situations lasting less than the total period of pregnancy [15]. On the other hand, a relatively small dietary improvements of the order of 100 kcals/day appeared to raise the birth weight [11]. Lechtig et al. [11 J indicated that in countries with a high degree of undernutrition, a large proportion of children have a birth weight below 2.5 kg. Belavady [4, 16J reported that a high percentage of babies born in India by mothers of lower socio-economic class tended to have weight below 2.5 kg. This is because the diet of pregnant women of the upper socio-economic class contained more energy, protein, calcium and vitamin than the diet of women in the lower socioeconomic class [2]. The nutritional status of women which is known to affect menstruation, ovulation and the likelihood of conception [17, 18J has also an effect on the course and outcome of pregnancy [19, 20]. Serious complications of pregnancy, delivery and pauperium can be attributed to poor nutrition during pregnancy [21, 22].

The relationship between socio-economic status, maternal nutrition and birth weight are well documented [2-5]. This relationship exists among and between countries with different standards of living and levels of development [6]. Birth weights are influenced by socio-economic status of the family, family size, birth order, maternal weight, genetic factors, marital status, cigarette smoking, parental care, still birth and death rate among siblings, toxic effects, infections and infestations during the period pregnancy [7-9]. Available evidence also indicates that supplementary food during pregnancy can influence the birth weight significantly [10-11]. Thus, various critical limits of birth weight and the percentage of newborns below this critical weight limit have been suggested as an index of maternal nutrition. The suggested critical limits are 2000 g [12J, 2500 g [13J and 3000 g [14].

EVIDENCE FROM FOOD CONSUMPTION AND NUTRITION STATUS SURVEYS

The national Food and Nutrition Commission (NFNC) has established from the National Nutrition surveys [23] carried out from 1969 to 1972, that there is a high prevalence of malnutrition in Zambia varying with geographical zones. The survey indicated a range of 60% of under five children in the Northern Province to 46% in the Southern Province. Food consumption data from the national nutrition surveys and the urban household budget survey similarly indicated the inadequacy of dietary intakes varying with socio-economic conditions between the urban and rural population [24]. According to the UNDP/FAO Nutritional Status Survey [23J, 95.3% of 572 pregnant and lactating mothers examined had low or deficient serum albumin levels, using 35 gil as the standard for protein deficiency. High serum globulin levels, suggestive of chronic infections and infestations, were also 0 bserved in 90.5% of the same group of women.

Dr Kwofie is now with the Food and Agriculture Organisation, United Nations, Via delle Termedi Caracalla 00100, Rome, Italy.

539 S.S.M.

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540

KWAME KWOFIE

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50

et al.

100 150 200 250 300

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Fig. 1. _Provinces of Zambia.

Haemoglobin levels of pregnant and lactating women show that 12% of those examined had deficient levels (below 9.5 g/100 ml) and 10.2% had low levels (9.5-10 g/100 ml). Nearly 2% (1.8%) of the women in the group had deficient retinol or vitamin A levels; and 8.2% were classified as having low retinal levels. The results indicated that a significant number of pregnant and lactating women tended to have low haemoglobin and serum albumin levels during the months of June to September when rural food reserves are at the lowest levels. Globulin levels, however, indicating the presence of parasitism and chronic infections, remain high throughout the year. EVIDENCE FROM HEALTH INSTITUTIONS

In Zambia, much loss of life occurs as a result of

fetal deaths. Records of hospital in-patient admissions in Zambia in 1972 show that congenital anomalies, disorders of newbo~n/perinatal and disorders of pregnancy/childbirth or pauperium accounted for 54.11 % (30,344) of the total normal deliveries (56,058). The percentage of in-patient admissions and deaths from disorders of pregnancy for childbirth or pauperium was highest among women above 13 years old. Inpatient deaths from congenital anomalies occur most frequently among infants of less than 1 year old. In 1972, this group accounted for 77.24% of the total in-patients deaths from congenital anomalies. This age group has also the highest case fatality rate (108.32). Similarly, a high proportion (23.91 %) of infants of less than 1 year admitted in hospitals died of perinatal disorders.

Table 1. Total births and fetal deaths in all hospitals by province, Zambia, 1972 Total births

Province Central Copperbelt Eastern Luapula Northern North Western Southern Western Total FDR

Df

= ---

B

+

Df

x 1000.

Live births (B) No. (%)

Fetal deaths (Df) No. (%)

Fetal death rate (FDR)

19,665 16,820 5200 1995 2115 2480 7425 3660

19,085 16,335 4970 1800 1980 2360 7145 3510

33.3 28.6 8.7 3.2 3.5 4.1 12.5 6.1

600 485 230 145 135 120 280 150

28.0 22.6 10.7 6.8 6.3 5.6 13.1 7.0

30.51 29.69 44.23 72.68 63.83 48.39 37.71 40.98

59,360

57,215

100.00

2145

100.00

36.14

541

Malnutrition and pregnancy wastage in Zambia Table 2. Total births and fetal deaths in all health centers by province, Zambia, 1972 Province Central Copperbelt Eastern Luapula Northern North Western Southern Western Total

=

FRD

Live births (B) No. (%)

Total births

Fetal deaths (Df) No. (%)

Fetal death rate (FDR)

1750 13,940 2225 1260 2020 1340 2065 770

1685 13,755 2125 1190 1935 1290 1985 735

6.8 55.7 8.6 4.6 7.8 5.2 8.0 2.9

65 185 100 70 85 50 80 35

9.7 27.6 14.9 10.9 12.7 7.5 11.9 5.2

37.14 13.27 44.94 55.56 42.08 37.31 38.74 45.45

25,370

24,700

100.0

760

100.0

26.41

Df - - - f x 1000. B+D

Although there is a relatively low probability (0.624) of mothers dying from disorders of pregnancy/ childbirth/pauperium, the chances of their offsprings dying as a result of disorders of newborn (239.5) and congenital anomalities (108.32) is quite high. Additional evidence of pregnancy wastage in Zambia is reflected in the high fetal death rates in all the provinces in Zambia. Table 1 shows total births and fetal death rate in all hospitals for each of the provinces in Zambia for 1972. The fetal death rate for the whole of Zambia was 36.14. The fetal death rate for the provinces ranges between 29.69-72.68. Luapula (72.68) and the Northern (63.83) provinces show the highest fetal death rates followed in order, by the North Western (48.39), Eastern (44.23), Western (40.98), Southern

I

(37.71), Central (30.15) and the Copperbelt (29.69) provinces. The pattern of fetal deaths from health centers, which cater largely for the rural areas, is depicted in Table 2. In the rural areas, Luapula (55.56), Western (45.45), Eastern (44.94) and Northern (42.08) provinces all have fetal death ratios above 40.0. Figure 2 shows the spatial distribution of fetal deaths in all health centres and hospitals in Zambia in 1972. Luapula (66.05) and the Northern (53.20) provinces have the highest concentration of fetal death rates. These are followed, in order, by North Western (45.81), Eastern (44.44) and the Western (41.76) provinces. Fetal death rates below 40.0 were recorded in the Southern (37.93), Central (31.05) and Copperbelt (21.78) provinces. These last three provinces are

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. 1-29 29-39 39-50 50-62 above 62

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Fig. 2. Spatial distribution of fetal death in Zambia 1972.

542

K W AME KWOFIE et al. Table 3. % Change in health facilities by province, Zambia, 1964-1975 Province

1964

1975

50 40

% Change

1964-1975

Copperbelt Central Southern Eastern Western Northern Luapula North Western

61 48 41 44 41 47 33 37

145 122 95 77 80 80 69 81

137.70 154.17 131.70 75.00 95.12 70.21 109.09 118.92

Total Zambia

352

749

112.78

0 0

Q

30

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Q)

~

20

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/

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................

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10

1969

1970

1971

1972 1973 1974 - - - All Hospitals - - - All Health Cent,.s

197!5

Fig. 3. Fetal death rates Zambia (1969-1975).

regions of very high population concentration. The main towns in these provinces are also centres of major economic activities such as mining, manufacturing industries and tourism. The Copperbelt is the most urbanized of the provinces of Zambia. As Table 3 shows, since 1964 there has been a quantitative change in the number of health facilities in all the provinces in Zambia. However, the fetal death rates in the rural areas, where approx. 65% of the population live, have not declined over the past 7 years. The decline of fetal death rates in hospitals is due largely to the quality of the health care (Fig. 3). The % change in health facilities for all the predominantly rural provinces, e.g. Luapula, Northern, Western and Northwestern, where fetal death rates and malnutrition are high, are lower than in the more urbanized Copperbelt, Central and Southern provinces.

The spatial distribution of malnutrition and anemia in Zambia emphasizes the existing regional disparities in socio-economic development between the urban and rural areas of Zambia. The highest prevalence of malnutrition and anemia, as the high fetal deaths, are concentrated in Luapula (185.0), Northern (124.9), North Western (119.3), Western (95.7) and Eastern (95.7) provinces. These are among the least developed of the provinces in Zambia (Fig. 4).

DISCUSSION

Variations in the spatial pattern of fetal deaths in Zambia reflects the existing differences in the per capita availability of food, the distribution of, and

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Fig. 4. Malnutrition and anemia in Zambia, 1975.

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543

Malnutrition and pregnancy wastage in Zambia

relative accessibility to existing health facilities, as well as the per capita distribution of income. And malnutrition and fetal deaths are manifestations of such differences. As Fig. 2 clearly shows, the prevalence of malnutrition and anemia is lowest in the Central, Copperbelt and Southern provinces. The capita production of food in these provinces is quite high. Compared with the rest of Zambia, these provinces, commonly referred to as the 'line of rail' provinces, are better served by a more efficient transport network. A considerable proportion of the population are also wage earners. A combination of such factors as high per capita income, ready access to health facilities~ and essential food commodities in the Copperbelt, help to explain the low fetal deaths in the Copperbelt province. Conversely, malnutrition and fetal deaths are highly concentrated in all the provinces where a disproportionate percentage of the population are living in high dispersed rural communities; and where the principal occupation is subsistence agriculture. In the provinces of Luapula, Northern, Western, North Western and Eastern, per capita incomes are quite low, health facilities are inadequate and accessibility to existing health centers is difficult, owing to inadequate transport facilities. Although several of the rural areas in Zambia are served by health centers, coverage is still inadequate in view of the dispersed pattern of the rural population. For several of the rural areas, the mean distance to health centers is 15-20 km. For this reason, many pregnant women have no access to health services. Nearly 80% of all deliveries in the rural areas, therefore, take place at home, usually assisted by traditional birth attendants. This tends to increase the risk of neonatal mortality. Our analysis shows that differences in the socioeconomic development of a given region within Zambia is positively associated with the degree of spatial concentration of malnutrition, fetal deaths and other related birth disorders. Malnutrition in Zambia is but one of several manifestations of the environmental influences which affect the nutritional health of the mother and the outcome of pregnancy. Long-term solutions to malnutrition and pregnancy wastage in Zambia will depend on the formulation and implementation of policies that are deliberately conceived to ensure the availability of food and the minimization of existing disparities in the distribution of income. Due attention will also need to be given to the training of traditional birth attendants and, perhaps, to their integration into the existing rural health institutions.

REFERENCES

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21. Albanese, A. A. Nutr. Rep. Int. 7, 241, 1973. 22. Habicht 1.-P., Yarbrough C., Lechtiq A. and Klein R. E. Nutr. Rep. Int. 7, 533, 1973. 23. Food and Agricultural Organization. National Food

and Nutrition Programme, Zambia: Report on Project Results, Conclusions and Recommendations. ESN: DP/

ZAM/69/512, Technical Report, Rome, 1974. 24. Kwofie K. Patterns or Food Consumption in Rural Zambia. National Food and Nutrition Commission, Lusaka, Zambia, 1977.