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THE NEXUS BETWEEN EXTREME WEATHER EVENTS, MATERNAL CARE, AND CHILD NUTRITION PRESERVATION THROUGH A GENDER LENS
ERLIDIA F. LLAMAS - CLARK, MD (PHIL) , MPH (UNIVERSITY OF ADELAIDE)
PHD (EPIDEMIOLOGY AND POPULATION HEALTH, ANU)
FELLOW, PHILIPPINE OBSTETRICAL AND GYNAECOLOGICAL SOCIETY
FELLOW, PHILIPPINE SOCIETY ULTRASOUND IN OBSTETRICS AND GYNAECOLOGY
CLINICAL ASSOCIATE PROFESSOR AND ATTENDING CONSULTANT OBSTETRICIAN-GYNAECOLOGIST
UNIVERSITY OF THE PHILIPPINES - PHILIPPINE GENERAL HOSPITAL
COLLEGE OF MEDICINE, DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
SECTION OF OB-GYN ULTRASOUND
email: [email protected]
September 1-2, 2016 Australian National University PHILIPPINE UPDATE
OBJECTIVES
GENERAL OBJECTIVES
To present the links between Extreme Weather events (typhoon flooding disaster), maternal care and child nutrition preservation through a Gender perspective
SPECIFIC OBJECTIVES
To review the gender roles of women and men operating in the Filipino households and communities
To examine what happens to these gender roles during and after a disaster
To highlight that maternal care strongly contributes to child nutrition preservation in pre-disaster conditions and more so during EWEs and disasters
PURPOSE AND ADVOCACY
Gain support for women in pre, disaster and post disaster conditions to ensure better health and nutrition outcomes for children
September 1-2, 2016 Australian National University
OUTLINE
Introduction
State of Extreme weather Events, Health and Nutrition, and Gender in the Philippines
Conceptual Framework: EWE/Disaster Food Security and Undernutrition Conceptual Framework
Objective
Methods
Results /Discussion
Characteristics of the mothers, her children and households
Women as the main actors who exercised their agency to ensure that the children’s and household’s nutritional condition is not worsened by the EWEs.
Women’s experience of the TS Ketsana / TY Parma and flooding
Understanding of flood causes
Their actions during and after the flood
Coping with the challenges of their role as a mother to their children in a calamity
Conclusion/Summary
Implications of this typhoon-flood experience to local nutrition, health and disaster policies and practice
September 1-2, 2016 Australian National University
INTRODUCTION: EXTREME WEATHER EVENTS
September 1-2, 2016 Australian National University
MOST COMMON WEATHER/
DISASTER EVENTS:
TYPHOONS
FLOODS
STORM SURGES
-DROUGHTS
El Nino Southern Oscillation(ENSO)
VOLCANOES
TSUNAMIS
EARTHQUAKES
Source: law.georgetown.edu
INTRODUCTION: HEALTH AND NUTRITION
Maternal health Indicators
95% antenatal care at least 1 visit
73% of livebirths attended by skilled attendants
55% contraceptive prevalence rate
Main causes of maternal deaths are hemorrhage (30%), indirect causes (17%), hypertension (15%)
1990-2015 maternal mortality ratio =
110-120 /100,000 livebirths
(Millennium Development Goal (MDG) 5 Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio 209 to 52)
Child health Indicators High coverage of immunization for DPT,
influenza, measles
20% underweight and 30% stunting in children under 5.
34% are exclusively breastfed
45% of child deaths are in neonatal period
31 under-five mortality rate
MDG 4 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate 80 to 27)
1990-2015 Infant mortality = 58-28/1,000 livebirths (MDG Target 4 = 19)
http://www.countdown2015mnch.org/documents/2015Report/Philippines_2015.pdfhttp://www.nscb.gov.ph/stats/mdg/mdg_watch.asp
INTRODUCTION GENDER REVIEW: DEFINITION OF TERMS
September 1-2, 2016 Australian National University
Gender
the state of being male or female typically used with reference to social and cultural differences rather than biological ones
Oxford Dictionary. Oxford University Press, 2013
socially and culturally constructed and change over time and are reflected in:
roles and responsibilities
access to resources
constraints, opportunities, needs
perceptions and views
not a synonym for women but considers both women and men and their interdependent relationships
Moser, C. Gender Planning and Development: Theory, Practice and Training. London: Routledge, 1993.
INTRODUCTION GENDER ROLES
set of societal norms that guide one’s behaviors which are generally considered acceptable, appropriate, or desirable for people based on their actual or perceived sex/sexuality
Gender roles are embedded in the generalized gender belief system
how people have come to view men and women
qualities of masculinity and femininity
ascribed values, norms, roles surrounding gender in a society
September 1-2, 2016 Australian National University
INTRODUCTION: GENDER
MDG 3. Promote gender equality and empower women
MDG 3.1 a-c Participation in elementary to tertiary education
MDG 3.2 Share of women in wage employment in the non-agricultural sector
MDG 3.3 Proportion of seats held by women in national parliament
September 1-2, 2016 Australian National University http://www.mb.com.ph/vp-robredo-receives-most-influential-filipina-woman-award/
http://www.mb.com.ph/de-lima-urges-duterte-admin-to-stop-tolerating-extra-judicial-killings/
http://www.unicef.org/philippines/reallives_11785.html
http://www.rappler.com/move-ph/47204-un-resolution-violence-women-migrant-workers
Duterte draws support of gender rights groups
Duterte comes out strongly for family planning, reproductive health
REVIEW AND APPLICATION: GENDER DIVISION OF LABOUR AND ROLES IN FILIPINO HOUSEHOLDS AND COMMUNITIES
Male Roles Female Roles
ustralian National
http://blogs.reuters.com/photographers-blog/2013/12/13/challenging-gender-roles-in-the-philippines/
http://pulitzercenter.org/reporting/asia-philippines-gender-role-family-migrant-labor-domestic
https://filipinolifeinpictures.wordpress.com/category/mother/page/2/
SIGNIFICANCE OF GENDER IN DISASTER AND HEALTH RESEARCH
vulnerability and helplessness of women during disasters due to socio-cultural norms
Enarson & Meyreles, 2004; Enarson & Morrow, 1998; Fothergill, 1998; Ikeda, 1995; Islam, 2011; Rashid, 2002
September 1-2, 2016 Australian National University
HYPOTHESIS FOR PHILIPPINE CONTEXT• women are not just vulnerable
and helpless victims• capable of agency• gender division of labour-
women’s caring role for children influence nutrition and health outcomes
PROCESS : HOW?
SIGNIFICANCE OF GENDER IN DISASTER AND HEALTH RESEARCH
Argument: To improve the overall health of
Filipinos, including women and children’s health in disaster settings, there is a need to address the social determinants of health including the gender dimensions in the Filipino’s way of life.
September 1-2, 2016 Australian National University
Application:
During a flooding disaster, how will gender division of labour and gender roles operate?My assumption women protected her child’s health
and nutrition and household’s food security which can be compromised during episodes of EWEs, particularly in a post-flooding disaster.
CASE STUDY OF THE EWES : TROPICAL STORM KETSANA ( ONDOY) AND TYPHOON PARMA (PEPENG) (2009)
September 1-2, 2016 Australian National University
September 1-2, 2016 Australian National University
EWE/DISASTER FOOD AND NUTRITION SECURITY CONCEPTUAL FRAMEWORK
CONCEPTUAL FRAMEWORKMATERNAL CHARACTERISTICS AND CHILD NUTRITION
14
Care for Mother/ Children- Inadequate care
Health Status-Disease
statesNutritional
Status0-5 years Children
Normal Malnutrition
UndernutritionOvernutrition
Maternal characteristics- Age, education, occupation, employment status, income, reproductive history, cultural: food habits, preferences, feeding practices http://www.childslife.nl/typo3temp/pics/b0fa81e289.jpg
Extreme Weather Events
Food Supply/
Production-Decrease
Food Access
Inadequate access
Food Use
Inadequate access
Household Food Security
METHOD
•Extreme weather events - effects of tropical cyclones and its related flooding (most common)
• The geographical site : randomly selected local villages in District 4, Laguna Province,
Philippines affected by the Ketsana/Parma flooding disaster Sept- Oct, 2009
• nutritional status of 0-5 years of age children
•Household and Maternal characteristics
September 1-2, 2016 Australian National University
METHOD
Phase 1 Cross-sectional Study (Quanti/Qualitative)Child Health and Nutrition SurveyHousehold Food Security Survey Key Informant Interviews
Children 0-5 yrs Sept 2009Mothers Ketsana/Parma lag time March/Apr 2011
18 months Village Growth Data CollectionmonitoringSurveillance
Phase 2 Qualitative: MOTHERS’ n-depth Interviews, Key informant Interview
September 1-2, 2016 Australian National University
RESULTS AND DISCUSSION
September 1-2, 2016 Australian National University
72.7%
27.3%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Normal weight Underweight
Child underweight
63.3%
36.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Normal height Underheight
Child Stunting
27.3% underweight children vs 20% National Nutriton National Survey (2013)
36.9% stunting vs 30%National Nutriton National Survey (2013)
RESULTS: PREDICTORS OF UNDERWEIGHT
Association with underweight
Older children >24 mos.
higher number of siblings
water sourced outside premises
September 1-2, 2016 Australian National University
RESULTS: PREDICTORS OF STUNTING
Child health status
Children with illness experience slower growth
Maternal education
Low maternal education associated with stunting
Flood level and duration (inconsistent)
Low flood level is associated with stunting
Up to 2 weeks flood exposure is associated with child stunting
September 1-2, 2016 Australian National University
RESULTS: CHANGE IN UNDERWEIGHT BEFORE AND AFTER FLOOD
September 1-2, 2016 Australian National University
There was a significant change in
WAZ scores (underweight)
More children became underweight versus underweight who improved-62/946 nearly two years post-flooding disaster -193/946 (20.4%)
Hypothesis: Can the household food security mechanism explain this?
YES and Women and Children were disadvantaged
Change in WAZ scores before and after floodPost-flood WAZ score Total
normal
weight
Under
Weight
Pre-flood WAZ
score
normal
Count 626 193819
% within pre-
flood score 76.4% 23.6% 100.0%
% of Total 66.2% 20.4% 86.6%
underweight
Count 62 65 127
% within pre-
flood score48.8% 51.2% 100.0%
% of Total 6.6% 6.9% 13.4%
Total
Count 688 258 946
% within pre-
flood score72.7% 27.3% 100.0%
% of Total 72.7% 27.3% 100.0%
McNemar Test < .001
Source: BNS Record s and Child Health Survey 2011
RESULTS: CHARACTERISTICS OF MOTHERS OF UNDERWEIGHT CHILDREN
Mothers with more than one child had higher odds of being underweight with the odds being greatest (2.5 times) if their mothers had six or more children compared to mothers with one child (p=.002)
Children had 1.8 (p=.001) and 1.5 times (p=.043) the odds of being underweight if their mothers had an elementary or high school education, respectively, compared with a mother with a college/postgraduate degree.
Children had twice the odds of being underweight if their mothers read a newspaper less often compared to mothers who read a newspaper daily (p=.011 and p=.020, respectively).
Mothers listening to the radio less often compared to mothers more frequently (p=.048) had an underweight child
September 1-2, 2016 Australian National University
QUALITATIVE RESULTS AND DISCUSSION: MATERNAL INTERVIEWS
Women’s gender roles played a crucial role in the entire family and child nutrition preservation.
Specifically, she protected her child’s and household’s health and nutritional status by
using meticulous caring practices – strict sanitation and hygiene, cleaning, feeding well
using coping strategies during episodes of EWEs post-flooding disaster – giving up her food for them, engaging in income-generating activities like food vending, domestic work when husband cannot work
Thinks and acts for the FAMILY during and after calamities with GREAT DIFFICULTY.
September 1-2, 2016 Australian National University
QUALITATIVE RESULTS AND DISCUSSION: MATERNAL INTERVIEWS
In low-resourced settings frequented by EWEs and flooding, the disaster experience brings short-term protection from immediate food insecurity and low weight gain through relief assistance and maternal care.
However, when resources and coping are stretched, the development of child stunting post-flood is inevitable.
Women as the main actors exercised their agency to ensure that the children’s and household’s nutritional condition is not worsened by the EWEs – coping strategies
September 1-2, 2016 Australian National University
CONCLUSION
Using a gender lens, maternal care strongly contributes to child nutrition preservation in normal pre-crisis conditions and more so during EWEs and disasters.
This role is ultimately translated to the special care and overt coping strategies when these difficult situations arise.
In many circumstances during and after the disaster, women acted positively and used their capacity to assert and try to change their dire state.
Challenges in the performance of this social role highlight the need for acknowledgment and support for women in crisis situations to ensure that better nutrition and health outcomes are achieved for children.
September 1-2, 2016 Australian National University
REFLECTION/RECOMMENDATION
The typhoon-flood experience has many implications to local nutrition, health and disaster policies and practice
With the future threat of climate change, investment in public health initiatives incorporating food and nutrition security, livelihood support and gender-sensitive disaster-risk reduction measures need to be strengthened.
Investing on WOMEN is good value!
September 1-2, 2016 Australian National University
We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed.To him we cannot answer "Tomorrow". His name is "Today".“
- Gabriela Mistral, 1948
THANK YOU!SALAMAT PO!
University of the PhilippinesPhilippine General Hospital
Department of Obstetrics and Gynecology
University of the PhilippinesPhilippine General Hospital
Department of Obstetrics and Gynecology
ACKNOWLEDGMENTS
Australian National University – Scholarship , VC fieldwork and travel grant
National Centre of Epidemiology and Population Health
Australasian Society for Nutrition in Medicine, Student Conference Award
University of the Philippines (UP) System and its Libraries
Philippine Food and Nutrition Research Institute
UP College of Medicine and Philippine General Hospital Volunteer doctors
Laguna Provincial Government, District IV Municipality Mayors, Local Doctors, Village Captains, Health and Nutrition Workers
Family, friends and many nameless people who helped me with this research
Participants: Mothers and Children 27