Hidden Hunger and Gendered Poverty in the 1000-day Window Trade-offs in Pregnant and Nursing Women’s Diet Quality in Southern Mozambique
Background: Pregnant and nursing women (PNW) in low-resource settings like the southern African country of Mozambique are at increased risk of hidden hunger, or micronutrient deficiencies, which result in devastating consequences for health. Maintaining a diversified diet is one of the most effective ways to ensure adequate micronutrient intake and prevent adverse outcomes. While factors associated with maternal dietary diversity and nutritional status are complex and contextual, gender is a critical cross-cutting determinant. Yet evidence on how gender comes to impact PNW’s dietary diversity in resource-constrained settings is fragmented and in Mozambique, scarce.
Objective: This mixed methods study aimed to understand how gendered poverty manifests in Mozambican PNW’s everyday lives to influence their diet quality by exploring barriers and facilitators to diversified intake from PNW and formal and informal healthcare worker perspectives, alongside measures of PNW’s dietary diversity and composition.
Method: A multi-level, cross-sectional investigation grounded in a socio-ecological framework with a gender lens was undertaken January – February 2016, in Homoine district, southern Mozambique in collaboration with CARE Mozambique’s Early Child and Development Program (ECD). A convenience sample, totaling 68 PNW, 14 community health workers (CHW) of the ECD program, and 4 formal healthcare workers (HCW), recruited from two urban health facilities, one semi-urban, and one rural community, contributed data through 19 in-depth interviews (n=11 PNW, n=4 CHW, n=4 HCW), two focus group discussions (n=5 CHW, n= 6 PNW), and participatory activities in three community meetings attended by mixed groups of PNW (n=16) and CHW (n=11). A sub-sample of PNW (n=51), completed 24-hour dietary diversity recalls for which MDD-W (Minimum Dietary Diversity for Women) scores were calculated, and responded to qualifying questions in face-to-face interviews.
Results: 18 (35.3%) of PNW achieved minimum dietary diversity, an MDD-W score >5. Mean score was 4.18 (SD+1.03). Diets were monotonous, high in starchy staples and low in animal-source foods, fruits, and vegetables, with the exception of seasonal vitamin A-rich greens. Women, family, and healthcare providers engaged in trade-offs related to food acquisition and utilization and nutritional services provision and uptake, which contributed to PNW inadequate dietary quality. Trade-offs resulted from the complex interplay of biological, socio-cultural, economic, and environmental pressures strongly mediated by gendered norms and expectations and women’s internalization of their gendered identity as care providers.
Conclusion: Mozambican PNWs’ challenges with meeting minimum dietary diversity requirements when most vulnerable to deficiencies affirm the importance of gender-transformative approaches in strategies for tackling hidden hunger and call attention to the need for further research to better unpack drivers of maternal dietary decision-making in the 1,000-day window in order to devise effective solutions for improving maternal nutritional status.