Page 33 such as commercial sales of medicines or contraceptives. Measures outside the health system, including formal and nonformal education and improved earning opportunities for women, can also improve maternal health by encouraging women to seek health care, improving their well-being and self-esteem, and encouraging communities to give greater priority to maternal health and family planning.

# Women's Nutrition

78. Frequent childbearing and poor nutrition combine to weaken maternal health, harm reproductive outcomes, and diminish women's strength and efficiency in market, household, and child care activities. Improving women's nutritional status should improve women's health and increase productivity in both household and market activities.

79. Women are often exhausted by the combination of reproductive demands, heavy workload, and inadequate diet (Hamilton, Popkin, and Spicer 1984). Since pregnancy and lactation increase nutritional requirements, women are considered to be under "possible nutritional stress" at these times. In Africa, women spend from one-third to almost half of their reproductive years pregnant or lactating. In Asia that figure varies from about 60 percent in Bangladesh to 50 percent in Pakistan, 40 percent in Indonesia, and just over 20 percent in Malaysia. In Latin America, only about 22 to 35 percent of the reproductive years are spent pregnant or lactating.

80. Careful, systematic analysis of woment's diet and nutritional status is rare. Data from small-scale studies of women's anthropometry, iron status, itnd dietary intake suggest that they are at high nutritional risk, but far more research is needed (Hamilton, Popkin, and Spicer 1984). One thing is clear: anemia and sheer caloric intake are pressing problems.

81. Anemia. Anemia is defined as a substandard concentration of hemoglobin in the blood and/or deficient red blood cell count. As noted earlier, iron deficiency anemia is a particular threat because it reduces work capacity and increases fatigue and the risk of hemorrhage and death in childbirth (Edgerton and others 1979; Spurr and others 1984). Most women in the developing world are anemic, largely because of inadequate iron intake and excessive blood loss due to parasites, menstruation, and closely spaced births. (Among other problems, malaria produces severe anemia.) In Africa, for example, three of every five pregnant women and two of every five nonpregnant women are anemic. In South Asia, two of every three pregnant women and over half the nonpregnant women are anemic (see figure 2). Anemia occurs two to three times more frequently in nonpregnant women than in men, and up to 20 times more frequently in pregnant women (Buchanan 1975).

82. Dietary intake. Caloric intake is often low among women (see table), regardless of physiological status. In a few studies, pregnant women actual consume less than nonpregnant women; in other studies they consume more than they should. Lactating women generally consume more than their non-pregnant counterparts, as they should, but not enough to meet their increased requirements. Where caloric intake is reported by income level, low-income women appear to consume less. Women generally meet a smaller percentage of