Karar Zunaid Ahsan and Shams El-Arifeen Under-nutrition and feeding practices among children living in slums of urban Bangladesh Karar Zunaid Ahsan and Shams El-Arifeen In today’s presentation, we would like to shed some light on Nutrition status and feeding practices among children living in slums of urban Bangladesh

Objective This presentation aims to: describe the current under-nutrition status and feeding practices among children living in slums in urban Bangladesh Identify potential factors affecting children’s nutrition status and feeding practices in slum settings Assess the ‘influence’ of identified factors. In this analysis, we aimed to:   Describe the current under-nutrition status and feeding practices among children living in slums in urban Bangladesh Identify potential factors affecting children’s nutrition status and feeding practices in urban slum settings and Assess the magnitude of influence of the identified factors. [CLICK TO NEXT SLIDE] 2

Data and Methods Data came from 2013 Bangladesh Urban Health Survey (UHS) – household sample survey designed to measure changes in key health outcomes and service use in urban slums and non-slums 2013 UHS collected information from 50,898 HHs from urban Bangladesh, 14,806 of which are from City Corporation slums Bivariate analysis performed to identify potential factors Multivariate logistics regression performed to assess the level of impact, after controlling confounders. Data for this analysis came from 2013 Bangladesh Urban Health Survey – this is a household sample survey specifically designed to measure changes in key health outcomes and service utilization in urban slums and non-slums 2013 UHS collected information from 51,000 HHs from urban Bangladesh, out of which nearly 15,000 HHs are from City Corporation slums We performed Bivariate analysis to identify potential socio-economic factors to examine their linkages with children’s nutrition status and feeding practices We also conducted Multivariate logistics regression models to assess the level of impact, after controlling for possible confounders. [CLICK TO NEXT SLIDE] 3

Childhood mortalities in slums remain higher than national levels Before we go into nutritional status and feeding practices, let us set the context by highlighting the stark disparity in childhood mortality levels between urban slums and overall Bangladesh. In 2013, infant mortality rate is 49 deaths per 1,000 live births, and under-five mortality rate is 57 deaths per 1,000 live births – this means 1-in-every 18 children in slums dies before reaching their 5th birthday. When compared with the closest national estimate [click], which is Bangladesh DHS 2014, infant and under-five mortality rates remain substantial higher than the national average. [CLICK TO NEXT SLIDE] 4 Note: Data source for national level is BDHS 2014

Nutritional status among under-5 children is worst in slums In order to show the nutritional status of under-5 children in urban areas, we used underweight and stunting rates in this slide. This slide shows that under-nutrition status is the worst among children living in slums, where 43% of the under-5 children are underweight, i.e. too thin for age and one in every two children is stunted, i.e. too short for age, Of the urban domains, under nutrition levels the lowest in CC non-slums - only one in four under-5 children in CC non-slums are underweight and one in three are stunted. 5

Exclusive breastfeeding similar in slums and non-slums, higher in other urban areas Now, we will move onto the childhood feeding practices Here we can see that exclusive breastfeeding among children up to 6 months approached 60% in city corporation slums and non-slums, which is in line with the findings from other recent surveys at national level exclusive breastfeeding rate in other urban areas is the highest, where two in every three children up to 6 months are exclusively breastfed during the first 6 months of their lives This is indeed a good progress towards ensuring better nutrition status among younger children in the coming years. [CLICK TO NEXT SLIDE] 6

Proper IYCF practice is lowest in slums In terms of Infant and young child feeding (IYCF) practices, meaning feeding children covering different food groups and age-appropriate number of times in a day, We can see that only one-in-four children in slums are fed with proper IYCF practices; which is much lower than in non-slums and other urban a Despite good progress in breastfeeding status, proportion of younger children (6-23 months) fed with proper IYCF practices remain suboptimal [CLICK TO NEXT SLIDE] 7

What are the reasons for low nutritional status and suboptimal feeding practices in slums? Sickness due to adverse environment? Poverty? Recent migrants with weak social network? Lack of care due to mothers’ working outside home? In the last few slides, we saw slums fare the worst in terms of child nutrition and feeding practices – now, the question comes, why is that? Is this due to higher prevalence of childhood sicknesses attributable to adverse environment in slums? Or is this just due to poverty and lack of access to food? Could migration be the reason? Are recent migrants with weak social network bringing slum status down? OR, is this the lack of care due to mothers’ working outside home? Let us look into the issues and try to find out the reasons for low nutrition and suboptimal feeding practices in slums 8

Are slum children more likely to be sick? It is expected that due to high crowding and poor housing conditions, prevalence of ARI would be much higher among children in slums – [CLICK] however, 2013 UHS found very similar ARI prevalence in slums and non-slums.   In terms of careseeking, more children with ARI in non-slums were taken to a health facility or to a trained provider, whereas more children in slums received antibiotics for ARI. 9

Are poorer slum dwellers more malnourished than others? 32% 24% Slums are predominantly poor, with 74% of slum HHs belonging to the lowest two wealth quintiles When we examine the under-nutrition levels by socioeconomic status in slums, [CLICK] prevalence of underweight among under-5 children from the bottom two wealth quintiles is 32% higher than the non-poor. Prevalence of stunting is 24% higher among children from poorer HHs. However, such large variation by socio-economic status was not observed in breastfeeding or IYCF practices for children living in slums. 10

Are newer migrants more at risk of under-nutrition? 67% of females living in slums are migrant, and 20% within them are recent migrants, i.e. migrated within the last 5 years – For non-slums, migration rates are slightly lower (58% migrants with 15% migrating within the last 5 years) When we examine under-nutrition levels by migration status, we found that stunting or underweight do not vary much among the groups. Migration status also did not influence feeding practices. 11

Can mothers’ working outside home be a reason? 22% 12% 22% of mothers in slums work outside home, which is double than their non-slum counterparts. In 2013 UHS, we observed that in the absence of mothers, other family members like grandmother or elder sister takes care of the child. If we compare the undernutrition rates among children whose mother works outside home and whose not, we see that [CLICK] underweight prevalence is 22% higher for children whose mother works outside, and stunting prevalence is 12% higher. [CLICK TO NEXT SLIDE] 12

Impact of identified factors on feeding practices 2.21 We ran multivariate logistic regression models to quantify the impact of possible factors affecting feeding practices and nutrition status of children in urban slums of Bangladesh Of the six factors we primarily identified, that is, mothers age at birth, mother’s education level, migration status, mother’s working outside home, NGO membership, and socioeconomic status of the household, we found that [CLICK] Older mothers are significantly more likely to exclusively breastfed their children during the first 6 months of like than mothers age less than 25 years, whereas children with mothers working outside home are 66% less likely to exclusively breastfed than mothers staying at home. For feeding children age 6-23 months following proper IYCF practices, [CLICK] we found that older mothers are significantly less likely to follow IYCF practices than the younger mothers, whereas educated mothers are nearly twice as much more likely to fed their children following proper IYCF guideline than mothers with no education. [CLICK TO NEXT SLIDE] 11.45 13

Impact of identified factors on nutritional status Logistic regression models also showed that [CLICK] mothers’ age, secondary or higher educational attainment, working outside home, and socioeconomic status significantly affect stunting level among under five children – children of mothers age 25-34 are 20% less like likely to be stunted than children from younger mothers; and the children of mothers with secondary or higher education are nearly 30% less likely to be stunted than mothers with no education; as indicated in the bivariate analysis, children from non-poor households are 24% less likely to be stunted. However, children whose mother works outside home are 18% more likely to be stunted than the children whose mother stays at home. [CONTINUE TO NEXT SLIDE] Impact of the factors affecting underweight among children are also similar [CLICK], except the fact that the impact of mothers working outside home is more pronounced – children whose mother works outside home are 34% more likely to be underweight than the children whose mother stays at home. [CLICK TO NEXT SLIDE] 14

Summary Mother’s age and educational attainment significantly affect child feeding practices; mother's working status significantly affects only EBF. Poverty appeared to be the major detrimental factor on child nutrition status, with the mother's working status being an aggravator. In conclusion, we can say that, since the children in this analysis belonged primarily to low-income families in urban slums, they were at a double disadvantage.. This study indicate that mother's lack of time for child-care activities, coupled with poverty, aggravated the already poor health nutrition status of economically deprived children Several studies have supported this fact that nutrition status of the children of mothers working outside the home is poorer than those whose mothers remain at home - such findings could be due either to the quality of the alternative child care or to a relationship between poverty and the consequent necessity of working outside the home. [CONTINUE TO NEXT SLIDE] 15

Policy Implications Policy recommendations that might emanate from this study would be to provide (a) crèches for children in slums, (b) some training in simple child care for siblings and grandparents who care for these children, and (c) income-generating activities for women within the home for urban poor. In conclusion, we can say that, since the children in this analysis belonged primarily to low-income families in urban slums, they were at a double disadvantage.   Policy recommendations that might emanate from this study would be to provide (a) crèches for children in slums, (b) some training in simple child care for siblings and grandparents who care for these children, and (c) income-generating activities for women within the home for urban poor. 16

Thank you. Questions? Comments? Email: zunaid@email.unc.edu