Bihar's Burden of Child Stunting
Source: Flickr, Mitwa AV

The Indian state of Bihar has very high rates of child stunting, estimated at 48 percent in 2016 by the International Institute for Population Sciences.  This average masks disparities at the district level which are needed to implement policies to target malnutrition. A recent paper in Economic and Political Weekly provides a disaggregated district- level analysis of child stunting in the Indian state of Bihar. The analysis also provides a number of recommendations on designing and strengthening nutrition-specific and nutrition-sensitive programmes to lower the incidence of stunting.

The district-level data used in the study is drawn from a range of sources including the fourth National Family Health Survey conducted (NFHS4) in 2016, the Annual Health Survey conducted in 2013, the 2011 India Census, and data from the 68th round survey of the National Sample Survey Office. Child stunting is calculated as a proportion using the number of stunted children (aged 0–59 months old with a height-for-age two standard deviations below the median height-for-age of the reference population) in a district as measured by the NFHS4 survey, divided by the total Census 2011 population aged 0–59 months in that district. The study also calculates the annual rate of reduction in stunting in each district and calculates the number of years required for each district to achieve the World Health Organization target of reducing child stunting by 40 percent. Based on UNICEF’s conceptual framework for the causes of stunting, the study estimates the correlation between 26 socio-economic indicators and stunting.

The study finds that the prevalence of child stunting is high across all 38 districts, ranging from 36 percent in Gopalganj to 57 percent in Sitamarhi. Seven districts (Gaya, Madhubani, Muzaffarpur, Patna, Purba, Champaran, Samastipur and Sitamarhi) have particularly high numbers of stunted children, accounting for 31 percent of the 6.1 million stunted children in Bihar.  The paper highlights that for the state as a whole, the rate of stunted children has decreased slowly from 56 percent in 2005 to 48 percent in 2016.  More specifically, the study finds that between 2012 and 2015, thirteen districts have experienced no change or an increase in the prevalence of stunting. By contrast, 25 districts have reduced stunting between 2012 and 2015, with 15 on track, if rates in reduction continue, to reduce stunting by 40 percent by 2025.

Regarding indicators, 11 of the 26 indicators are found to be ‘moderately’ correlated with stunting, finding no correlation between stunting and the other 16 indicators. Regarding pre-pregnancy indicators, the study finds that increased childhood stunting is associated with early marriage, early pregnancy, and when a mother is chronically undernourished. Counterintuitively, the study also finds that contraceptive coverage is also correlated with stunting. In terms of pregnancy indicators, access to four or more antenatal check-ups and the consumption of the recommended nutrient supplements is found to be correlated with less stunting in all districts. Evaluating socioeconomic and gender indicators, a positive correlation is found between stunting and households that have no or few assets, are landless, and are part of scheduled castes.

The study argues that the diversity of indicators that are shown to correlate with stunting suggests that a multipronged approach, focusing on supporting pre-pregnancy and pregnancy care as well as overall poverty alleviation and social inclusion is required to address child stunting across Bihar. More specifically, referencing a previous study that focuses on nutrition interventions that reduce stunting, the study argues that ten nutrition interventions and practices (if implemented across Bihar and at 90 percent coverage) have the potential to reduce the current total of deaths in children under five by 15 percent and reduce stunting by 20 percent. These interventions and practices include the following: the initiation of breastfeeding within an hour of birth; breastfeeding children for the first six months; the timely introduction of complementary feeding; adequate complementary feeding for children aged 6–24 months, the safe handling of complementary foods and hygienic feeding practices, adequate feeding during and after illness, providing immunisation and micronutrient supplementation (vitamin A, iron and zinc), supporting adequate feeding for the severely undernourished, and the provision of adequate nutrition for adolescent girls and women of reproductive age. Implementing interventions are generally low cost, especially relative to the likely returns an individual will experience throughout their lifetime.

By: Bas Paris

Photo credit:Flickr, Mitwa AV