Little women: Essays on maternal nutrition, social hierarchy, and health in India

Abstract

This thesis is a collection of four papers on maternal health in India, its causes, its implications for population health, and the inadequacy of government response. The first chapter introduces the dissertation and its themes. The second chapter defines the scope of maternal malnutrition in India: it provides, to my knowledge, the first estimates of pre-pregnancy underweight and weight gain during pregnancy. By applying reweighting techniques, it finds that 42.2% of pre-pregnant women are underweight, and that they gain only about 7 kilograms during pregnancy. This paper further documents the surprising fact that maternal nutrition is better in sub-Saharan Africa than it is in India. The third chapter is co-authored with Reetika Khera and Dean Spears, and examines an important cause of poor maternal nutrition in India: low intrahousehold status of young women. It documents how differences in social status between women in joint rural households lead to differences in nutrition during pregnancy. These differences in maternal nutrition are in part responsible for differences in the heights of their children: the children of lower-ranking mothers in joint rural households are about a quarter of a standard deviation shorter than their cousins born to higher-ranking mothers. The fourth chapter suggests population level health consequences of poor maternal nutrition in India. It documents a correlation between cohort height, a measure of health and human capital, and neonatal mortality in the cohort's year of birth, a measure of maternal health. These findings contribute what are, to my knowledge, the first evidence from within a developing country of associations between neonatal mortality and height. The final chapter is a qualitative study of India's Janani Suraksha Yojana (JSY), a conditional cash transfer for women who give birth in health facilities, rather than at home. This qualitative study from a rural district in Uttar Pradesh sheds light on why the program has not improved health outcomes, including neonatal mortality. The program is narrowly focused on delivery, rather than on promoting health in pregnancy. Health service providers are focused on capturing economic rents associated with the program, rather than on providing maternity care.