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Child malnutrition in sub-Saharan Africa


Abstract

Background

Sub-Saharan Africa has one of the highest levels of child malnutrition globally. Therefore, a critical look at the distribution of malnutrition within its sub-regions is required to identify the worst affected areas. This study provides a meta-analysis of the prevalence of malnutrition indicators (stunting, wasting and underweight) within four sub-regions of sub-Saharan Africa.

Methods

Cross-sectional data from the most recent Demographic and Health Surveys (2006–2016) of 32 countries in sub-Saharan Africa were used. The countries were grouped into four sub-regions (East Africa, West Africa, Southern Africa and Central Africa), and a meta-analysis was conducted to estimate the prevalence of each malnutrition indicator within each of the sub-regions. Significant heterogeneity was detected among the various surveys (I2 >50%), hence a random effect model was used, and sensitivity analysis was performed, to examine the effects of outliers.

Results

Stunting was highest in Burundi (57.7%) and Malawi (47.1%) in East Africa; Niger (43.9%), Mali (38.3%), Sierra Leone (37.9%) and Nigeria (36.8%) in West Africa; Democratic Republic of Congo (42.7%) and Chad (39.9%) in Central Africa. Wasting was highest in Niger (18.0%), Burkina Faso (15.50%) and Mali (12.7%) in West Africa; Comoros (11.1%) and Ethiopia (8.70%) in East Africa; Namibia (6.2%) in Southern Africa; Chad (13.0%) and Sao Tome & Principle (10.5%) in Central Africa. Underweight was highest in Burundi (28.8%) and Ethiopia (25.2%) in East Africa; Niger (36.4%), Nigeria (28.7%), Burkina Faso (25.7%), Mali (25.0%) in West Africa; and Chad (28.8%) in Central Africa.

Conclusion

The prevalence of malnutrition was highest within countries in East Africa and West Africa compared to the WHO Millennium development goals target for 2015. Appropriate nutrition interventions need to be prioritised in East Africa and West Africa if sub-Saharan Africa is to meet the WHO global nutrition target of improving maternal, infant and young child nutrition by 2025.

Introduction

Child undernutrition is a major public health problem, especially in many low-income and middle- income countries [1]. It adversely affects the productivity of nations as well as creating economic and social challenges among vulnerable groups. Poor nutrition is associated with suboptimal brain development, which negatively affects cognitive development, educational performance and economic productivity in adulthood [2]. Child growth is the most widely used measure of children’s nutritional status. The first 1000 days of life (0-23months) is a very critical phase in a child's life during which rapid physical and mental development occurs [3]. Undernutrition during this critical phase can have irreversible consequences on the child's growth leading to an increased risk of morbidity and mortality in children. Undernutrition is commonly assessed through the measurement of a child's anthropometry (height, weight), as well as through screening for biochemical and clinical markers [4]. Wasting, stunting and underweight are expressions of undernutrition and the anthropometric indicators for the assessment of a child’s nutritional status. Undernutrition is the underlying cause of child mortality in about 45% of all deaths reported for children under-5 years of age [5]. In 2015, globally about 7.7% of children were wasted, 24.5% were stunted and 15% were underweight. The African region and South-East Asia have reported the highest prevalence of undernutrition, with the former accounting for about 39.4% of the stunted, 24.9% of the underweight and 10.3% of the wasted children under-5 years of age [6]. According to the 2015 Millennium development goal (MDG) report, sub-Saharan Africa (SSA) accounts for one third of all undernourished children globally, highlighting that malnutrition still remains a major health concern for children under 5 years in the sub-region, thus buttressing the need for urgent intervention [7]. There have been individual studies reporting the burden and determining factors of childhood undernutrition in SSA [8]. These individual studies have varied in design and geographic operationalisation, making it difficult to make regional comparisons and put in place regional initiatives to meet global agendas such as the MDGs. There have also been regional disparities in progress towards the MDG hunger and malnutrition targets, factors that contribute to these disparities are poorly understood. A pooled analysis can contribute towards addressing this gap and making informed regional comparisons. However, despite previous studies reporting the burden of child malnutrition across Africa, no study has critically analysed the pooled prevalence of each malnutrition indicator within the World Health Organization (WHO) geographical regions of SSA: West Africa, East Africa, Central Africa and Southern Africa. Hence, the aim of this study was to conduct a meta-analysis of malnutrition indicators in SSA using the most recent, nationally-representative Demographic and Health Surveys (DHS) (between 2006 and 2016) from 32 countries. Information from the pooled regional data will provide insight to the sub-regional distribution of undernutrition within SSA, thus assisting policy makers, global organizations, government and non-governmental organisations, the private sector and public health researchers in identifying the most vulnerable sub-regions within SSA where urgent nutrition related interventions are needed.

Data sources

The data analysed in this study were extracted from the most recent Demographic and health survey (DHS) (2006–2016) of 32 SSA countries. The datasets are publicly available from the DHS website [9]. DHS collate data that are comparable across countries. The surveys are nationally representative and population-based with large sample sizes (usually between 5,000 and 30,000 households). Most surveys use a multi-stage cluster sampling method. Three core questionnaires are used in DHS surveys: a household questionnaire, a women’s questionnaire, and a men's questionnaire. In all households, women aged 15–49 years are eligible to participate; in many surveys men aged 15–59 years are also eligible to participate. Details on data collection and sampling methodology employed by DHS are described elsewhere [9].

Study selection and inclusion criteria

Only countries with recent DHS (2006–2016) and comprehensive data on the anthropometric indicators of children under-5 years were included in this study. This inclusion of countries with DHS from 2006 to 2016 was so as to ensure the prevalence estimate is kept within a 10 year period given the high rates of malnutrition observed in the early 2000s following incidences of war and severe drought experienced in many countries prior to 2006. And also due to the introduction of the WHO child growth standards [10] in 2006, which estimated new values for the assessment of anthropometric indicators. Fig 1 shows the flow chart for country selection based on the inclusion criteria, while Table 1 presents the 32 countries included in this study, their respective sub-regions based on the United Nations (UN) geoscheme classification for SSA and the characteristics of their anthropometric indicators for children under-5 years.
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