MALNUTRITION IN BANGLADESH

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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

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) socio-demographic 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^th
December to 26^th December, 2010.

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

Frequency

Percent

12

9.9

5000-9999

43

35.5

10000-14999

32

26.4

?15000

34

28.1

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	9	7.4
	2001-3500	22	18.2
	3501-8000	76	62.8
	14	11.6
Medicine	?500	55	45.5
	501-1500	37	30.6
	29	24.0
Education	79	65.3
	1000-3000	34	28.1
	8	6.6

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	Frequency	Percent
Illiterate	8	7
9	7.9
Primary passed	14	12.3
S.S.C. passed	10	8.8
H.S.C. passed	12	10.5

4. Percent distribution of the under 5 children
mothers by their age and BMI.

Variable	Category	Frequency	percent
Age	5	4.4
	20-24	49	43.0
	25-29	44	38.6
	?30	16	14.0
BMI	14	12.3
	18.5-24.9	68	59.6
	?25.00	32	28.1

According to this table, 43.0% under-five children mothers fall in the
age range    20-24 and 59.6% mother has a BMI in the range 18.5-24.9.

5. Safety and stability of the home environment

Percent
distribution of households with safe home environment in time of bad weather

Having safe home environment	Frequency	Percent
YES	87	71.9
NO	34	28.1

Percent
distribution of households with forceful migration in last 1 (one) year

Having stable home environment	Frequency	Percent
YES	13	10.7
NO	108	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	86	71.1
Etiology of diarrhea	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	Frequency	Percent
Up to 6 months	26	21.5
7-18 months	20	16.5
More than 18 months	75	62

The table represents that 62%
mother of under-5 children breastfed their babies for more than 18 months.

2.
Percent distribution of exclusive breastfeeding period

Exclusive breastfeeding period	Frequency	Percent
18	14.9
6 months	60	49.6
43	35.5

The percentage of exclusive
breastfeeding up to 6 months is found 49.6% 

3. Percentage of mothers giving positive (YES) answer
to different breastfeeding related questions

Question content	Frequency	Percent
Baby getting adequate breast-milk	99	81.8
Mother taking adequate food during lactation	86	71.1
Mother with hygienic practices before and after breastfeeding	98	81.0

The above table shows the overall situation of breastfeeding practices
among under-five children’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	Frequency	Percent
YES	108	89.3
NO	13	10.7

2. Percent distribution of patterns of introducing
complementary foods

Pattern	Frequency	Percent
Gradually	91	75.8
Abruptly	29	24.2

Table 1 shows that
89.3% under-five children’s mothers give complementary food to their child.
75.8% of them give this food gradually shown in 
table 2. 

 

3. Percent
distribution of types of complementary foods given to the child

Type	Frequency	Percent
Home-made	98	81.7
Canned	8	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.

4. Percent
distribution of the complementary feeding’s frequency

Daily frequency	Frequency	Percent
5-6 times	65	54.2
7-8 times	7	5.8
9-10 times	3	2.5
11-12 times	1	0.8
According to need	44	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.

D. Psychosocial care

1. Percent
distribution of babies in respect of playing

Answer	Frequency	Percent
YES	109	93.2
NO	8	6.8

2. Percent
distribution of fathers taking care of baby

Answer	Frequency	Percent
YES	69	59
NO	48	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	Frequency	Percent
Mother	100	85.5
Other family member	4	3.4
Other member outside family	2	1.7
Baby itself	11	9.4

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

Water source	Frequency	Percent
Tube-well	80	66.1
Well	3	2.5
Pond	35	28.9
River/Lake	3	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.

2. Percent
distribution of under-five children’s mothers giving “YES’’ answer to different
food storage related questions

Question content	Frequency	Percent
Whether babies foods are covered or not	107	91.5
Whether babies food ,once cooked, are stored day long	43	36.8

F. Hygienic practices

1. Percent
distribution of babies with hygienic practices

Practices	Frequency	Percent
Using shoe(always)	72	59.5
Washing hands well before eating	101	86.3
Taking bath regularly	102	87.2
Brushing teeth, cutting nail, and wearing clean cloth regularly	88	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	Frequency	Percent
Vaccination course completed or not	108	89.3
Babies taking VAC in last 6 months or not	84	71.8
Under 6 babies taking de-worming drugs or not	69	60

2. Percent
distribution of choice for treating baby

Choice	Frequency	Percent
Allopathic doctor having degree	78	67.8
Homeopathy	1	0.9
Quack doctor	13	11.3
Kobiraj	1	0.9
Paramedics	7	6.1

3. Percent
distribution of treatments to prevent diarrhea

Treatment	Frequency	Percent
Home-made saline	4	3.3
Saline packet	58	48.3
Rice powder	17	14.2
Drugs	3	2.5
Drugs and oral saline	35	29.2
Others	3	2.5

Nutritional
profile of under-five children

H. Distribution of age
and sex of sample

Age(months)	Boys		Girls		Total		Ratio
	frequency	percent	frequency	percent	frequency	percent	Boy:Girl
6-17	13	18.1	13	16.5	26	17.2	1:1
18-29	12	16.7	20	25.3	32	21.2	1:1.67
30-41	11	15.3	20	25.3	31	20.5	1:1.81
42-53	15	20.8	17	21.5	32	21.2	1:1.13
54-59	21	29.2	9	11.4	30	19.9	1:0.43
Total	72	100	79	100	151	100	1:1.08

I. Anthropometric measurements of the under-five
children by their age and sex

Sex of the member	Age(month)	Height(cm)			Weight(kg)			MUAC(cm)
		frequency	mean	SD	frequency	mean	SD	frequency	mean	SD
Male	1	72.60	–	2	5.00	1.41	2	13.05	1.62
	6-17	5	70.02	4.45	5	9.00	1.22	4	14.13	0.22
	18-29	6	81.08	2.88	6	10.41	1.85	6	14.40	1.13
	30-41	5	72.10	23.06	5	9.80	1.92	5	13.88	1.31
	42-53	4	94.97	8.81	4	12.50	3.08	4	14.05	0.10
	54-59	11	101.30	6.03	11	14.11	3.22	9	15.96	1.50
	Total	32	86.35	16.35	33	11.26	3.47	30	14.61	1.40
Female	2	61.60	0.56	4	4.75	1.25	4	13.60	1.99
	6-17	3	71.03	4.33	3	7.50	2.78	3	13.47	1.81
	18-29	9	77.56	5.72	10	9.95	1.84	9	14.00	1.17
	30-41	8	95.26	22.83	8	15.87	11.85	7	16.27	4.95
	42-53	9	93.44	4.44	9	12.72	2.77	9	14.84	1.13
	54-59	4	98.72	8.32	4	14.00	1.82	4	16.00	1.41
	Total	35	86.64	15.93	38	11.53	6.47	36	14.79	2.51
Total	3	65.26	6.36	6	4.83	1.16	6	13.42	1.09
	6-17	8	70.40	4.11	8	8.43	1.91	7	13.84	1.11
	18-29	15	78.97	4.98	16	10.12	1.80	15	14.16	1.13
	30-41	13	86.35	24.88	13	13.53	9.62	12	15.27	3.94
	42-53	13	93.91	5.75	13	12.65	2.74	13	14.60	1.00
	54-59	15	100.60	6.59	15	14.08	2.85	13	15.97	1.42
	Total	67	86.50	16.01	71	11.41	5.26	63	14.70	2.08

The above table shows the mean height, weight and MUAC
of under-five children by their age and sex.

J. Prevalence of malnutrition among under-five
children according to age group

Age(months)	Number of children	Prevalence
		wasting		underweight		stunting
		Frequency	percent	frequency	percent	frequency	percent
6-17	26	8	30.8	10	38.4	11	42.3
18-29	32	7	21.9	17	53.1	16	50.0
30-41	31	4	12.9	12	38.7	12	38.8
42-53	32	9	28.2	15	46.9	10	31.3
54-59	30	7	23.3	10	33.4	8	26.7
Total	151	35	23.1	64	42.4	57	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)	Frequency	Percent	Nutritional Status
?12.49	20	11.8	Severely malnourished
12.50-13.49	18	10.7	Moderately malnourished
?13.50	128	75.7	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)	Frequency	Severe wasting (?-3 z score)		Moderate wasting Normal (?-2 z score)
		Frequency	percent	frequency	percent	frequency	percent
6-17	26	4	15.4	4	15.4	18	69.2
18-29	32	1	3.1	6	18.8	25	78.1
30-41	31	–	–	4	12.9	27	87.1
42-53	32	6	18.8	3	9.4	23	71.9
54-59	30	4	13.3	3	10.0	23	76.7
Total	151	15	9.9	20	13.2	116	76.8

The above table shows that the
highest prevalence of wasting is in the age group 6-17(months)

M. Prevalence of under weight by age based on weight
for age z scores

Age(months)	Frequency	Severe underweight (?-3 z score)		Normal (?-2 z score)
		frequency	percent	frequency	percent	frequency	percent
6-17	26	5	19.2	5	19.2	16	61.5
18-29	32	8	25.0	9	28.1	15	46.9
30-41	31	7	22.6	5	16.1	19	61.3
42-53	32	4	12.5	11	34.4	17	53.1
54-59	30	5	16.7	5	16.7	20	66.7
Total	151	29	19.2	35	23.2	87	57.6

The above table shows that the
highest prevalence of underweight is seen in the age group 18-29 (months).

N. Prevalence of
stunting by age based on height for age z scores

Age(months)

Frequency

Severe stunting

(?-3 z score)

Moderate stunting

Normal

(?-2 z score)

Frequency

percent

frequency

percent

frequency

percent

6-17

26

7

26.9

4

15.4

15

57.7

18-29

32

8

25.0

8

25.0

16

50.0

30-41

31

6

19.4

6

19.4

19

61.3

42-53

32

3

9.4

7

21.9

22

68.8

54-59

30

2

6.7

6

20.0

22

73.3

Total

151

26

17.2

31

20.5

94

62.3

The table shows that the
highest prevalence of stunting is observed in the age group 6-17(months).

Conclusion

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.

The rate of fully immunized children has been found to
be 89.3%.

81% under five children’s mothers follow hygienic
practices before and after breastfeeding.

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

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