View with images and charts Malnutrition in Bangladesh Mothers and child care in a BARD program area, Comilla. Introduction The widespread malnutrition of Bangladesh throughout the country is a significant public health problem which hinders the national development. Under-five children are the worst victims of hunger and malnutrition. The infant mortality rate (IMR) is 41 per 1000 (2009) and under-five mortality rate is 52 per 1000 (2009) with annual number of under-five deaths of 171 per 1000 (2009). About 43% of under five children are stunted and 16% severely stunted, 17% of them are wasted and 3% severely wasted and 41% of them are underweight with 12% severely underweight (BDHS,2007) UNICEF estimates that about 10 percent of under-five children in the world are wasted today. Stunting is much more common than wasting, affecting an estimated 32 percent of children worldwide. The combination of wasting and stunting mean an estimated 146 million children are underweight. Of the undernourished children in the world, more than half are found in South and Central Asia. The three underlying causes of malnutrition in under-five children are inadequate food, inadequate health and inadequate care. Of these three, the least investigated has been the inadequate care. Care refers to care giving behaviors such as breastfeeding, diagnosing illness, determining when a child is ready for supplementary feeding, stimulating language and other cognitive capacities and providing emotional support. The relationship between care and nutrition is especially stronger for those who depend on others for feeding and for other actions that contribute to nutritional well being i.e. the under five children. There has been little systematic investigation of child care practices. Almost all (98%) Bangladeshi children are breastfed for some period, 23% of infants put to the breast within 1 hour of birth, and 83% started breastfeeding within the first day. About 54% of children in rural Bangladesh are reported to be exclusively breastfed. Overall, only 36% of infants less than 6 months old are exclusively breastfed. Generally complementary foods are not introduced to infants before four months, with the average age of about 7 months. About 69% of children aged 6-9 months receive complementary foods while being breastfed. In about 87% children, breastfeeding is continued for about two years along with other foods. The rate of fully immunized children by 12 months of age in urban areas of Bangladesh has been found to be 81% on average with much more little in rural areas. Cleanliness of the child, mother and surroundings has been observed to be significantly correlated with child nutritional status and morbidity. In Bangladesh, the mother is usually the main caregiver for the infant and very young child. The mother’s child care practices are influenced by international factors such as those related to equity, to availability of good health and education services; local factors such as land distribution, climate, water supply, and primary health care; and finally, family factors such as presence of other family members, type of house, availability of water, household hygiene, and mother’s knowledge. These factors, important to the child not only for survival but also to ensure optimal physical and mental development, and good health, are not in favorable conditions to the mother to practice good child care resulting in an increased under nutrition in under-five children. The current study will reveal these factors influencing mother’s child care practices and consequent nutrition profile of under- five years children in a BARD program area in Comilla district of Bangladesh.
RATIONALE Rationale Adequate dietary intake and health status are the immediate determinants of good nutrition, but care-giving ultimately determines the delivery of adequate food and health to the child. Although closely linked to household food security, the actual amount of food ingested by the young child is determined by care-related feeding behaviors such as breast feeding, complementation, food preparation, and overseeing the progression of the child from complete dependence to partaking of adult family food. Similarly, care-related behaviors determine how available health services, for both preventive and curative purposes, are utilized to optimize child health and thereby influence nutrition. The current study may be used as a platform in which interventions may be planned to take actions to ensure adequate care of children including the protection of good caring practices in the study area; to support mothers and families to help them in maintaining good caring practices when these are threatened or otherwise difficult; and to promote those caring practices likely to improve the nutrition and health of children. Globally, nutritional status is considered the best indicator of the well- being of young children, a parameter for monitoring progress towards the achievement of Millennium Development Goals (MDGs), especially MDG 1. This study identifies the determinants of nutritional indicators of MDGs, which will contribute to policy intervention that will effectively influence health and nutritional outcomes of under five children, who are the future generation of tomorrow’s world. OBJECTIVE Objectives General objective: The study is undertaken to reveal mother’s child care practices and also to reveal the nutrition profile of under-five children in the study area. Specific objective: Specific objective includes to: • Observe the nutrition profile of under-five children of the elected area through anthropometric indices (height, weight etc). •
Identify breastfeeding practices, complementary feeding practices, hygienic practices, health-seeking behaviors that are practiced in the selected study area.
•
Identify the resources available for mother’s good child care practices.
•
Observe the association of nutritional status of under-five year’s children with different variables (e.g. exclusive breastfeeding, complementary feeding etc). Hypothesis
Hypothesis
Health and nutritional status of under-five children of Joypur village are up to the mark. Most of the people’s income level is sufficient to meet their well-being. So the resources available to maintain good child caring practices are satisfactory. Again breastfeeding, complementary feeding, food preparation and storage and hygienic practices are good to maintain child’s nutritional well-being.
METHODOLOGY
Methodology
Study design: The study was a census in nature. The components of the study were; (a) sociodemographic characteristics and related aspects; (b) service utilization; (c) child care practices; and (d) anthropometric information.
Study population: The objective of the study was to assess the nutritional status of the under-five children and mother’s child care practices in a BARD program area in Joypur (south and north) Comilla. So, all the households having at least one under-five children in that area were included in the study.
Study subjects: The study subjects included under-five children and their mothers of various groups of households of Joypur (south and north).
Survey instruments: One printed structured questionnaire in Bengali was used for data collection. The questionnaire was consisted of queries on identification of care resources, breastfeeding practices, complementary feeding practices, hygienic practices, service utilization and anthropometry. The questionnaire was framed and finalized by course-in-charge to conform the objectives of the study. For measuring anthropometric parameters, weighing machine (wt), height scale (ht) and specialized tape (MUAC) were used.
Duration of study (field-level data collection): The study (field-level data collection) was carried out during a period of 3 days from 24 December to 26th December, 2010. th
Data collection procedure: Before starting the field data collection, an overall idea on the location and its people was shared with data collectors by a local officer of BARD. However in the field the data collection procedure was constantly supervised by course in charge with his scholarly guidance.
Data about resource for care: Information regarding care resources was collected as an essential part of the survey by a personal interview with either the mother in most cases or the household head in some cases depending on their presence. Information such as number of family member and income earner, income level, monthly expenditure spent on food, education and medicine, maternal health and nutritional knowledge and safety and stability of the home environment were carefully investigated and recorded in the specified portion of the questionnaire.
Data about child care practices: Information on child care practices such as breastfeeding and complementary feeding practices, food preparation practices, hygienic practices, psychosocial care and other caretaking behaviors (or practices regarding services utilization and trading) was collected through a close sitting with the mother and recorded in the specified portion of the questionnaire.
Anthropometric data: To assess the nutritional status, the anthropometric measures such as height (or length when necessary), weight and MUAC of under- five children and their mothers was measured using approved and standardized method and recorded in the specified portion of the questionnaire.
Quality control: During survey (data collection phase) the quality of data was ensured by the supervisor. After each day’s fieldwork, after dinner, the supervisor set together with all the enumerators, jointly check the completed questionnaires of the day and planned for the next day’s fieldwork. Any mistake or inconsistency arose was verified either with the households or informed sources and corrected. Result and discussion A. Care Resources 1. Percent distribution of the respondents by monthly income (taka)
Income level <5000 5000-9999 10000-14999 ≥15000
Frequency
Percent 9.9 35.5 26.4 28.1
12 43 32 34
≥15000
28.1
Income 10000-14999 level(taka)
Percent
26.4
5000-9999
35.5
<5000
9.9 0
10
20
30
40
Percent
The table displays the income level of the under-5 children’s family. It indicates that lowest percentage of (9.9%) family fall in to income level <500 & highest percentage (35.5%) family fall in the range 5000-9999. 2. Percent distribution of households according to monthly expenditure on basic needs Basic needs
Expenditure level
Frequency
Percent
Food
≤2000 2001-3500 3501-8000 >8000 ≤500
9 22 76 14 55
7.4 18.2 62.8 11.6 45.5
Medicine
501-1500 >1500
37 29
30.6 24.0
<1000
79
65.3
1000-3000 >3000
34 8
28.1 6.6
Education
The table shows the monthly expenditure of the families in 3 three basic sectors (food, medicine, & education). From the table we come to know that the highest percentage of the monthly income is expended on food by most of the families. 3. Percent distribution of the under 5 children mothers by their literacy
Literacy Illiterate Can read & sign only Primary passed S.S.C. passed H.S.C. passed
Frequency 8 9 14 10 12
Percent 7 7.9 12.3 8.8 10.5
percent literacy type
10.5
H.S.C
8.8 12.3
primary passed 7.9 7
Illiterate
4. Percent distribution of the under 5 children mothers by their age and BMI. Variable
Category <20 20-24 25-29 ≥30 <18.5 18.5-24.9 ≥25.00
Age
BMI
Frequency 5 49 44 16 14 68 32
percent 4.4 43.0 38.6 14.0 12.3 59.6 28.1
According to this table, 43.0% under-five children mothers fall in the age range and 59.6% mother has a BMI in the range 18.5-24.9.
Percent
50 40 30 20 10 0
Percent <20 20- 25- ≥30 24 29 Age
20-24
59.6
60 50 40
28.1
Percent 30 20
Percent
12.3
10 0
<18.5
18.5-24.9
≥25.00
BMI
5. Safety and stability of the home environment • •
Percent distribution of households with safe home environment in time of bad weather
Having safe environment YES NO •
home Frequency 87 34
Percent 71.9 28.1
Percent distribution of households with forceful migration in last 1 (one) year
Having stable environment YES NO
home Frequency 13 108
Percent 10.7 89.3
6. Maternal knowledge: percentage of mothers giving right or positive (YES) answer to different nutrition related questions Question content
Frequency
Percent
Definition of balanced diet
48
39.7
Idea on nutritious food
76
62.8
Ideal milk for baby
118
97.5
Duration of exclusive breastfeeding Etiology of diarrhea
86
71.1
32
26.4
Definition of malnutrition
36
30.8
The table shows 39.7%, 62.8%, 97.5%, 71.1%, 26.4%, 30.8% under-5 mothers think positively about balanced diet, nutritious food, milk as an ideal food for baby, duration of exclusive breast-feeding, diarrhea & malnutrition respectively. B. Breastfeeding Practices
1. Percent distribution of breastfeeding period Breastfeeding period Up to 6 months 7-18 months More than 18 months
Frequency 26 20 75
Percent 21.5 16.5 62
The table represents that 62% mother of under-5 children breastfed their babies for more than 18 months.
22%
â&#x2030;¤6months 7-18months â&#x2030;Ľ18months
17%
61%
2. Percent distribution of exclusive breastfeeding period Exclusive period <6 months 6 months >6 months
breastfeeding Frequency
Percent
18 60 43
14.9 49.6 35.5
The percentage of exclusive breastfeeding up to 6 months is found 49.6%
15% 36%
<6months 6months >6months 49%
3. Percentage of mothers giving positive (YES) answer to different breastfeeding related questions Question content Baby getting adequate breast-milk Mother taking adequate food during lactation Mother with hygienic practices before and after breastfeeding
Frequency
Percent
99
81.8
86
71.1
98
81.0
The above table shows the overall situation of breastfeeding practices among under-five childrenâ&#x20AC;&#x2122;s mothers. During breastfeeding period, 71.1% mother take adequate food, and 81.0% follow hygiene practices. C. Complementary Feeding Practices 1. Percent distribution of mothers giving complementary food to their child Question YES NO
Frequency 108 13
Percent 89.3 10.7
2. Percent distribution of patterns of introducing complementary foods Pattern Gradually Abruptly
Frequency 91 29
Percent 75.8 24.2
Table 1 shows that 89.3% under-five childrenâ&#x20AC;&#x2122;s mothers give complementary food to their child. 75.8% of them give this food gradually shown in table 2.
24%
Gradually Abruptly
76%
3. Percent distribution of types of complementary foods given to the child Type Home-made Canned
Frequency 98 8
Percent 81.7 6.7
Others
14
11.7
From the table 3, we know the type of complementary food given to the child. It shows that 81.7% complementary food is homemade whereas 6.7% is canned. 12% 7% Hom e-m ade Canned Others
81%
4. Percent distribution of the complementary feedingâ&#x20AC;&#x2122;s frequency Daily frequency 5-6 times 7-8 times 9-10 times 11-12 times According to need
Frequency 65 7 3 1 44
Percent 54.2 5.8 2.5 0.8 36.7
From the table 4, we know the frequency of complementary food offered to the child. The table shows that 54.2% under-five children receive 5-6 times feeding compared to 36.7% child, who receives complementary food according to need. 5-6times 7-8times 9-10times 11-12times According to need
D. Psychosocial care 1. Percent distribution of babies in respect of playing
Answer YES NO
Frequency 109 8
Percent 93.2 6.8
2. Percent distribution of fathers taking care of baby Answer YES NO
Frequency 69 48
Percent 59 41
From table 2, we have the idea of caring practices. Table 2 shows 59% of under-5 fathers taking care of their own babies in some way, 3. Percent distribution of care provider during eating of baby Care provider Mother Other family member Other member outside family Baby itself
2% 3%
Frequency 100 4 2
Percent 85.5 3.4 1.7
11
9.4
9%
Mother Other family member Other member outside family Baby itself
86% From table 3, we have the idea of caring practices. Table 3 shows, 85.5% mother play the role of main care provider during eating. E. Food preparation and storage practices 1. Percent distribution of sources of water used for food preparation Water source Tube-well Well
Frequency 80 3
Percent 66.1 2.5
Pond River/Lake
35 3
28.9 2.5
In 66.1% households, the source of water for food preparation is tube-well. Only 33.9% households use water from other sources like pond, lake etc.
3% 29%
Tube-well Well Pond
3%
65%
River/ Lake
2. Percent distribution of under-five children’s mothers giving “YES’’ answer to different food storage related questions Question content Frequency Whether babies foods are 107 covered or not Whether babies food ,once 43 cooked, are stored day long
Percent 91.5 36.8
F. Hygienic practices 1. Percent distribution of babies with hygienic practices Practices Using shoe(always) Washing hands well before eating Taking bath regularly Brushing teeth, cutting nail, and wearing clean cloth regularly
Frequency 72 101
Percent 59.5 86.3
102 88
87.2 75.2
G. Other care taking behaviour / practices 1. Percent distribution of under-five mothers giving “YES” answer to different health related questions
Question content Vaccination course completed or not Babies taking VAC in last 6 months or not Under 6 babies taking deworming drugs or not
Frequency 108
Percent 89.3
84
71.8
69
60
2. Percent distribution of choice for treating baby Choice Allopathic doctor having degree Homeopathy Quack doctor Kobiraj Paramedics
Frequency 78
Percent 67.8
1 13 1 7
0.9 11.3 0.9 6.1
3. Percent distribution of treatments to prevent diarrhea Treatment Home-made saline Saline packet Rice powder Drugs Drugs and oral saline Others
Frequency 4 58 17 3 35 3
Percent 3.3 48.3 14.2 2.5 29.2 2.5
Nutritional profile of under-five children H. Distribution of age and sex of sample Age(months) 6-17 18-29 30-41 42-53 54-59 Total
Boys frequency 13 12 11 15 21 72
percent 18.1 16.7 15.3 20.8 29.2 100
Girls frequency 13 20 20 17 9 79
percent 16.5 25.3 25.3 21.5 11.4 100
Total frequency 26 32 31 32 30 151
percent 17.2 21.2 20.5 21.2 19.9 100
Ratio Boy:Girl 1:1 1:1.67 1:1.81 1:1.13 1:0.43 1:1.08
100% 80% 17.20 21.2 20.5 21.2 19.9 percent
60% 40%
16.50 25.3 25.3 21.5
11.4 Total 29.2
Girl
20% 18.10 16.7 15.3 20.8 0% 6-17 18- 30- 42- 5429 41 53 59
Boy
month
I. Anthropometric measurements of the under-five children by their age and sex Sex of Height(cm) the Age(month) frequenc mean member y <6 1 72.60
SD
-
Weight(kg) frequenc mea y n 2 5.00
SD
1.41
6-17
5
70.02
4.45
5
9.00
1.22
18-29
6
81.08
2.88
6
1.85
30-41
5
72.10
5
42-53
4
94.97
23.0 6 8.81
10.4 1 9.80
3.08
54-59
11
6.03
11
Total
32
101.3 0 86.35
33
<6
2
61.60
16.3 5 0.56
4
12.5 0 14.1 1 11.2 6 4.75
6-17
3
71.03
4.33
3
7.50
2.78
18-29
9
77.56
5.72
10
9.95
1.84
30-41
8
95.26
8
42-53
9
93.44
22.8 3 4.44
11.8 5 2.77
54-59
4
98.72
8.32
4
Total
35
86.64
38
<6
3
65.26
15.9 3 6.36
6
15.8 7 12.7 2 14.0 0 11.5 3 4.83
6-17
8
70.40
4.11
8
8.43
1.91
Male
Female
4
9
1.92
3.22 3.47 1.25
1.82 6.47 1.16
MUAC(cm) frequenc mea y n 2 13.0 5 4 14.1 3 6 14.4 0 5 13.8 8 4 14.0 5 9 15.9 6 30 14.6 1 4 13.6 0 3 13.4 7 9 14.0 0 7 16.2 7 9 14.8 4 4 16.0 0 36 14.7 9 6 13.4 2 7 13.8 4
SD 1.62 0.22 1.13 1.31 0.10 1.50 1.40 1.99 1.81 1.17 4.95 1.13 1.41 2.51 1.09 1.11
Total
18-29
15
78.97
4.98
16
30-41
13
86.35
13
42-53
13
93.91
24.8 8 5.75
54-59
15
6.59
15
Total
67
100.6 0 86.50
13
16.0 71 1 The above table shows the mean height, weight and age and sex.
10.1 1.80 15 2 13.5 9.62 12 3 12.6 2.74 13 5 14.0 2.85 13 8 11.4 5.26 63 1 MUAC of under-five children by
14.1 6 15.2 7 14.6 0 15.9 7 14.7 0 their
J. Prevalence of malnutrition among under-five children according to age group Age(months ) 6-17 18-29 30-41 42-53 54-59 Total
Number Prevalence of wasting children Frequenc percent y 26 8 30.8 32 7 21.9 31 4 12.9 32 9 28.2 30 7 23.3 151 35 23.1
underweight stunting frequency percent frequency percent 10 17 12 15 10 64
38.4 53.1 38.7 46.9 33.4 42.4
11 16 12 10 8 57
42.3 50.0 38.8 31.3 26.7 37.7
According to this table, 23.1% of the under-five children are wasted, 42.4% are underweight and 37.7% are stunted. K. Percent distribution of under-five children by MUAC category MUAC(cm) ≤12.49
Frequency 20
Percent 11.8
12.50-13.49
18
10.7
≥13.50
128
75.7
Nutritional Status Severely malnourished Moderately malnourished Normal
The above table shows that, according to the MUAC category, 22.5% under-five children are malnourished. L. Prevalence of acute malnutrition by age based on weight for height z-scores Age(months) Frequenc y
Severe wasting (≤-3 z score) Frequenc y
percent
Moderate wasting Normal (>-3 and <-2 z (≥-2 z score) score) frequency percent frequency percent
1.13 3.94 1.00 1.42 2.08
6-17 18-29 30-41 42-53 54-59 Total
26 32 31 32 30 151
4 1 6 4 15
15.4 3.1 18.8 13.3 9.9
4 6 4 3 3 20
15.4 18.8 12.9 9.4 10.0 13.2
18 25 27 23 23 116
69.2 78.1 87.1 71.9 76.7 76.8
The above table shows that the highest prevalence of wasting is in the age group 6-17(months)
35 30
30.8
25 Percent wasting
20 15
28.2 23.3
21.9 15.4
18.8 12.9
Severe wasting Total wasting
13.2
10 3.1
5 0
6-17
0
18-29 30-41 42-53 54-59 Months
M. Prevalence of under weight by age based on weight for age z scores Age(months)
Frequency
Severe underweight (â&#x2030;¤-3 z score)
6-17 18-29 30-41 42-53 54-59 Total
26 32 31 32 30 151
frequency 5 8 7 4 5 29
percent 19.2 25.0 22.6 12.5 16.7 19.2
Moderate underweight(>-3 and<-2 z score) frequency percent 5 19.2 9 28.1 5 16.1 11 34.4 5 16.7 35 23.2
Normal (â&#x2030;Ľ-2 z score) frequency 16 15 19 17 20 87
percent 61.5 46.9 61.3 53.1 66.7 57.6
The above table shows that the highest prevalence of underweight is seen in the age group 18-29 (months).
60
53.1
50 40 percent underweight
46.9 38.8
38.4
30
25
20 19.2
22.6
6-17
Severe underweight Total underweight
16.7
12.5
10 0
33.4
18-29 30-41 42-53 54-59 Months
N. Prevalence of stunting by age based on height for age z scores
Severe stunting (â&#x2030;¤-3 z score) Frequenc percent y 7 26.9 8 25.0 6 19.4 3 9.4 2 6.7 26 17.2
Age(months) Frequenc y 6-17 18-29 30-41 42-53 54-59 Total
26 32 31 32 30 151
Moderate stunting (>-3 and <-2 z Normal score) (â&#x2030;Ľ-2 z score) frequency percent frequency percent 4 8 6 7 6 31
15.4 25.0 19.4 21.9 20.0 20.5
15 16 19 22 22 94
57.7 50.0 61.3 68.8 73.3 62.3
The table shows that the highest prevalence of stunting is observed in the age group 617(months).
50 40 Percent stunting
30
50 42.9 26.9
20
38.8 25
31.3
Severe stunting 9.4
10 0
6-17
18-29
26.7
19.4
30-41 Months
42-53
6.7 54-59
Total stunting
Conclusion Malnutrition is still dominant problem in Bangladesh that has been evidenced in part by different studies, particularly National Nutrition Surveys. Nutrition is a multidimensional subject, which is related to adequate food intake and supply, proper care and health practice, hygiene and sanitation and socioeconomic condition of people. In this study an attempt has been made to asses the mother’s child care practices and nutritional status of under-five children in Joypur village of Comilla. According to anthropometric analysis, the malnutrition exists which is expressed through the prevalence of stunting, wasting and underweight. All (100%) children were breastfed at least for sum period. About 50% of under-five children were reported to be exclusively breastfed. In 62% under five children, breastfeeding is continued for more than 18 months. Among them, 89% receives complementary food while being breastfed. In about 75% under five children, complementary foods are introduced gradually. About 81% mother give home-made complementary foods to their children. The rate of fully immunized children has been found to be 89.3%. About 68% mothers choose allopathic doctor having degree to treat their sick child. Cleanliness of the child, mother and surroundings has been observed to be satisfactory. About 60% children always use shoe, 86% wash hands well before eating, 87% take bath regularly and 75% brush teeth, cut nail and wear clean cloth regularly. 81% under five children’s mothers follow hygienic practices before and after breastfeeding. 92% of the respondents store child’s foods covered. 64% do not store child’s foods, once cooked, day long. About 38% of under-five children were stunted and 17% severely stunted, 23% of them are wasted and 10% severely wasted and 42% of them are underweight with 19% severely underweight. May be the survey findings do not reflect the actual situation due to the limitation of short duration, lack of skill and biased information from respondents. It is difficult to draw any conclusion from such an investigation. Recommendation The constraints to better nutritional status are mainly inadequate food intake, inadequate primary health services, lack of sanitation, hygienic condition, proper care etc. all of the constraints from the survey are should be removed.
The wasting rate is considerable amount under-five children. Wasting indicates acute malnutrition. So food supply and food intake as well as proper treatment of acute illness will reduce the wasting rate. Mother should be motivated to eat more food during lactation. Family member should encourage mother to do that. Mother and household members should be motivated to seek health care facilities for their sick children and also for themselves. Children should be fed colostrum. Breastfeeding should be started immediately after birth. Exclusive breastfeeding should be for 6 months. Appropriate complementary foods should be given to the child besides breast-milk after 6 months of age. The frequency of feeding should be according to need of the child. The style of feeding should be responsive. Proper hygiene and sanitation practices should be improved, especially for the infant and children. The most important is to carry out nutrition education activities. This component needs to be strengthened through all available channels. Emphasis should be given to ensure efficient use of available resources. All these recommendations can be carried out by Governments and nongovernment organizations