Child Malnutrition in Sub-Saharan Africa: An Assessment of the Trend across Socio-economic Groups Soumya Alva, ICF Macro Loren Bausell, RTI Amanda Pomeroy, JSI APHA, November 2010

Presenter Disclosure Soumya Alva – no relationships to disclose

Overview Child undernutrition: A concern Research questions Data and methods Findings Discussion and implications

Child Undernutrition Associated with Child Mortality: Underweight in Sub-Saharan Africa

Child Undernutrition Associated with Child Mortality: Stunting in Sub-Saharan Africa

Child Undernutrition: A Concern Child undernutrition is one of the most serious health and development issues Responsible for more than half the under 5 deaths in low and middle income countries Slows growth, perpetuates poverty through productivity loss, poor cognitive function, higher health care costs Contributes to malaria survival, AIDS, diet related chronic diseases High economic impact (UN Standing Committee on Nutrition - $20-30 billion per year) Especially true in South Asia and Sub-Saharan Africa

Child Undernutrition: A Concern Millennium Development Goal 1: to eradicate extreme poverty and hunger By 2015, reduce by half the proportion of people who suffer from hunger Target 1.8: Prevalence of underweight children under-five years of age Important to assess trends and level of undernutrition Important to compare extent of child undernutrition based on New WHO Child Growth standard NCHS/CDC/WHO international reference standard

Focus of this Analysis Examine trends in undernutrition in Sub-Saharan Africa using both standards (new WHO Child Growth standard and NCHS/CDC/WHO reference population) Examine the nutrition situation of the poorest socioeconomic groups over time Urban-rural differences

Data: DHS from 19 countries in Sub-Saharan Africa

Data: DHS from 19 countries in Sub-Saharan Africa Countries with two or more data points since 1990 East/Southern Africa: 10 countries Kenya, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe West/Central Africa: 5 countries Benin, Cameroon, Ghana, Guinea, Nigeria Sahel: 3 countries Mali, Niger, Senegal Ethiopia

Data and Indicators Anthropometric Indicators: Sample: Underweight (weight for age) Stunting (height for age) Moderate and severe (z scores below -<2 standard deviations from the mean) Comparison to NCHS/CDC reference population and the new WHO Child Growth standard Sample: Among children under-five All children under-five, poorest 40%, children in urban and rural areas

Methodology Median interval between DHS surveys: 5 years Values calculated for each country for four time periods: Calculated using Stata 1990-95, 1995-2000, 2000-2005, 2005-current Missing time period imputed with annual country estimates for each indicator Based on available survey data between 1990 and most recent data point using a linear trend line distribution Sub-regional averages calculated over time Weighted by the number of children 0-5 years/country

Trends in Percent Children Underweight (NCHS/CDC & WHO) East/Southern Africa West/Central Africa Sahel Ethiopia NCHS/CDC WHO

Trends in Percent Children Stunted (NCHS/CDC & WHO) East/Southern Africa West/Central Africa Sahel Ethiopia NCHS/CDC WHO

Trends in Percent Children Underweight & Stunted Slowly declining levels of undernutrition in most countries, smaller declines for stunting (except Sahel – slow increase) Undernutrition based on WHO std. as compared to CDC ref pop. is lower for underweight but not for stunting Underweight levels lowest in East/Southern Africa and highest in Ethiopia Stunting levels considerably higher than underweight and highest in Ethiopia

Percent Children Underweight: The Poorest 40% (WHO) East/Southern Africa West/Central Africa Sahel Ethiopia Poorest 40% All children (WHO)

Percent Children Stunted: The Poorest 40% (WHO) East/Southern Africa West/Central Africa Sahel Ethiopia Poorest 40% All children (WHO)

Trends in Percent Children Underweight & Stunted (Poorest 40%) Overall, undernutrition levels are higher among the poorest groups although differences in Ethiopia are small Among the poorest group, decline in stunting over time is small. Also, an increase in countries in the Sahel

Percent Children Underweight: Urban vs. Rural (WHO) East/Southern Africa West/Central Africa Sahel Ethiopia Urban (WHO) Rural (WHO)

Percent Children Stunted: Urban vs. Rural (WHO) East/Southern Africa West/Central Africa Sahel Ethiopia Urban (WHO) Rural (WHO)

Trends in Percent Children Underweight & Stunted (Urban vs. Rural) Overall, undernutrition levels are higher among the rural population Very slow decline in stunting levels in both urban and rural areas Urban-rural divide appears to be increasing particularly in Ethiopia and Sahel

Discussion and Implications Given MDG1, important to assess trend and level of undernutrition Undernutrition in SSA has declined over time but less so if measured in terms of stunting If measured using WHO std., % underweight is low, but not so for stunting Programs need to be targeted to certain countries e.g. certain regions such as the Sahel and Ethiopia have considerably lower nutrition levels Special consideration for poorest groups, those in rural areas, and geographical disparities within a country