Nutritional status of female prisoners in Antanimora prison, Madagascar

Introduction The prison population in low-income countries is a group vulnerable to undernutrition, particularly incarcerated women. The aim of the study is to assess the nutritional status of women in prison and to determine the social profile and prison conditions related to undernutrition. Methods A cross-sectional study was conducted among 125 women prisoners in Antanimora prison located in the city of Antananarivo, Madagascar. All women detained for 3 months or more at the time of the survey were included in the study. Data collection was conducted in May and June 2013. A survey of women and anthropometric measurements were carried out to collect the data. Results The proportion of undernourished female prisoners is 38.4%. Five percent of pregnant and lactating women and 44.3% of non-lactating and non-pregnant women are undernourished. The factors related to undernutrition of women prisoners are: taking two meals a day instead of three meals (p = 0.003), insufficient energy intake (p < 0.001), incarceration duration of more than 10 months (p < 0.001), absence of family visits (p = 0.013) and lack of financial assistance from family (p = 0.013). Conclusion Improving the prisoners' diets and assistance from family both help to fight against prisoner undernutrition in prisons.


Introduction
Prisoners are a population particularly vulnerable to undernutrition, even before incarceration. They are often in very precarious social situations, marginalized, without income and in a state of health weakened by chronic undernutrition. In addition to all of these stressors, their state of detention is often not in accordance with human rights [1]. In high-income countries, undernutrition in prisons is not a problem because the regulations concerning the diet of

Methods
A cross-sectional study was conducted among women prisoners in Antanimora prison. Antanimora prison is a penitentiary institution located in the city of Antananarivo, the capital of Madagascar. The prison accommodates all kinds of prisoners regardless of sex, age, or type of offense. The study includes all female prisoners of all ages who were detained for 3 months or more at the time of data collection.
Data collection was conducted in May and June 2013. Information on social profile and prison conditions was collected by a survey of women using a pre-tested questionnaire. The 24-hour dietary recall method was used to calculate the energy intake of women's diets. Women were weighed with a Seca digital scale (accurate within 100g).
Height was measured with a Seca wall-mounted measuring rod (accurate within 1cm). MUAC was measured on the left arm, midway between the acromion and the olecranon with adult-specific measuring tape (accurate within 1mm). Nutritional status was estimated from BMI for non-pregnant women and from MUAC for pregnant women. BMI is calculated by dividing weight in kilograms by height in meters squared. Undernutrition is defined as a BMI less than 18.5 kg/m 2 or a MUAC less than 220mm. The study was approved by the National Institute of Public and Community Health's Ethics

Results
Sample description: a total of 125 female prisoners are included in the study. Table 1 shows the description of the social profile and the detention conditions of these women. The ages of the prisoners ranged from 16 to 62 years. The mean age (± SD) was 33.4 years (± 11.8) and three women were under 18 years old. At the time of the study, sixteen women (12.8%) were breastfeeding and three (2.3%) were pregnant.
Nutritional status of women: forty-eight women (38.4%) were undernourished (BMI < 18.5 kg/m 2 or MUAC < 220mm). The 3 pregnant women included in the study were well-nourished and only 1 of the 16 breastfeeding women was undernourished. For the group of pregnant and lactating women, the prevalence of undernutrition is estimated at 5.3%. This prevalence was 44.3% for non-pregnant and non-lactating women, a significantly higher value (p = 0.001).
Factors associated with the nutritional status: Table 2 shows the association between women's social profile and their nutritional status. Among the studied characteristics, only the number of children was significantly associated with nutritional status. Women with more than three children were more frequently among undernourished compared to well-nourished (43.7% against 23.4%). The association between women's detention conditions and their nutritional status is displayed in Table 3. For undernourished women, the proportion of those with an incarceration duration more than 4 months, who had no family visit or financial assistance, with two meals a day and with a low total energy intake (< 1400 kcal per day) were significantly higher.  All of these factors related to the nutritional status of female prisoners contribute to the single underlying variable that is diet. Diet is the main determinant of nutritional status [8]. Women who were able to consume three meals a day were more likely to be well-nourished (OR = 7.5 [1.6-9.4], p = 0.003), as well as those with a daily energy intake greater than 1400 kcal (OR = 22.3 [5.9-8.8], p < 0.001). In Antanimora prison, meals are only served once per day, consisting of one ladle of cassava per person. For 60% of prisoners, the food ration is not enough to provide the basal energy expenditure known as "basal metabolic rate" estimated at an average of 1400 kcal per day.

Discussion
This value is the minimum amount of vital energy that is essential for the functioning of the body's main vital organs (breathing, heartbeat, etc.) [9]. Insufficient caloric intake is common among prison populations in low-income countries. According to the United Nations Human Rights Committee, the energy allowance of prisoners in Madagascar is 800 kcal/day, 30% of the 2500 kcal necessary for maintaining basic health [10]. Across all of sub-Saharan Africa, the nutrition of female prisoners is suboptimal [11]. In comparison, prisons in high-income countries like France provide diets for prisoners that are well-balanced, of good quality and with adequate nutritional value [12].

Conclusion
The prevalence of undernutrition is high among women detained in Antanimora prison. Undernutrition is attributed to inadequate diet because the quantity and quality of food provided by the administration responsible for the prison was largely insufficient.
Those who had the option to receive food from outside sources were less susceptible to undernutrition. Support by family and food aid programs are important ways to improve nutrition of prisoners.

What is known about this topic
• The prison population in low-income countries is a group vulnerable to undernutrition because the regulations concerning the diet of prisoners are not generally respected; • Women of reproductive age are a group vulnerable to undernutrition; • Inadequate prison conditions are related to undernutrition.

What this study adds
• Prevalence of undernutrition among female prisoners in Madagascar; • Knowledge about diet of female prisoners in Madagascar; • Identify factors related to undernutrition in prison.

Competing interests
The authors declare no competing interests.

Authors' contributions
Lantonirina Ravaoarisoa conceived of the study, participated in its design, acquisition of data, analysis and interpretation of data and drafted the manuscript. Arivony Hanitriniaina Pharlin conceived of the study, participated in its design, acquisition of data, analysis and interpretation of data, and drafted the manuscript. Niaina ZR Andriamifidison participated in the design of the study and helped to draft the manuscript. Roger Andrianasolo participated in the design of the study and helped to draft the manuscript. Jean de DM Rakotomanga participated in the design of the study, helped to draft the manuscript and revised it. Julio Rakotonirina participated in the design of the study, helped to draft the manuscript and given final approval of the version to be published. Table 1: social profile and detention conditions of female prisoners