Original Research

Food and Nutrition Bulletin

2017, Vol. 38(3) 291-301
ª The Author(s) 2017
Factors Influencing the Reprints and permission:
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Prevalence of Stunting Among DOI: 10.1177/0379572117710103
journals.sagepub.com/home/fnb

Children Aged Below Five

Years in Bangladesh

Haribondhu Sarma, MSS1,2, Jahidur Rahman Khan, MSc1,

Mohammad Asaduzzaman, MSS1, Fakhar Uddin, MSS1,
Sayeeda Tarannum, MSS1, Md. Mehedi Hasan, MSc3,
Ahmed Shafiqur Rahman, PhD1, and Tahmeed Ahmed PhD1

Abstract
Background: Poor nutrition during childhood impedes physical and mental development of children,
which propagate the vicious cycle of intergenerational under nutrition. This paper is aimed at
understanding the determinants of stunting among children aged 0 to 59 months in Bangladesh.
Methods: The study used Bangladesh Demographic and Health Survey 2011 data and a multistage
stratified cluster-sampling design. Anthropometric data (for height and weight) were collected and
analysis was limited to 7647 children. Multiple binary logistic regression analysis was performed to
assess the association of stunting with potential socioeconomic and demographic factors.
Results: The prevalence of stunting has been found to be about 41% among children aged less than 60
months and higher in rural setting than in urban areas (43% vs 36%). Adjusted model revealed that
several factors were influencing stunting. The children living in moderately food-insecure households
had higher odds of becoming stunted (odds ratio [OR] ¼ 1.27, 95% confidence interval [CI]: 1.05-1.54,
P ¼ .01) compared to the children living in food-secure households. The derived ORs of stunting for
children delivered at institutions facilitated particularly by public (OR ¼ 0.80, 95% CI: 0.67-0.96; P ¼
.02) or private (OR ¼ 0.81, 95% CI: 0.67-0.97; P ¼ .02) sectors were less than for children delivered at
home. Similarly, wealth index, exposure of mother to the mass media, age of child, size of child at birth,
and parents’ education were significantly associated with stunting.
Conclusions: Moreover, the demographic characteristics and other indicators appeared to have
significant influence in the prevalence of stunting. Public health programs are needed to avert the risk
factors of stunting among children in Bangladesh.

1
Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali,
Dhaka, Bangladesh
2
Research School of Population Health, ANU College of Medicine, Biology and Environment, Australian National University,
Acton, Australia
3
Helen Keller International, Dhaka, Bangladesh

Corresponding Author:
Haribondhu Sarma, Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh
(icddr,b), Mohakhali, GPO Box 128, Dhaka 1000, Bangladesh.
Email: hsarma@icddrb.org
292
Keywords
stunting, prevalence, influencing factors, children aged below five, Bangladesh
Introduction
Globally, an estimated 165 million children aged
below 5 years had stunting or chronic under nutri-
tion in 2011, among whom, 36% were residing in
African countries and 27% in Asian countries.1
The prevalence of stunting in South Asia has been
found to be 39%, which is a concerning issue for
public health.2 In Bangladesh (a South Asian
country), approximately 41% of children were
reported to be stunted in 2011,3 and in 2004, the
figure was higher (51%).4 This decline occurred
due to initiatives and interventions that were
implemented by the Government and other public
health organizations. Although the country has
been reducing the prevalence of stunting with
annual average reduction rate of 1.3% during
2004 to 2011, the progress is still quite low com-
pared to the global rate of 2.1% decline during
1990 to 2011.5 According to the World Health
Organization’s (WHO) threshold, 15% refers to
an emergency situation; this current prevalence of
stunting indicates an alarming situation of
chronic undernutrition in Bangladesh.6 In gen-
eral, lower mental capacity, low school perfor-
mance, and reduced level of future productivity
are consequences of this form of childhood under-
nutrition, which is linked with poverty and poor
access to health services.7 It also increases the risk
of children’s death, inhibits cognitive develop-
ment, and affects health status in their future years.
Therefore, childhood undernutrition not only
impedes the physical and mental development of
children but also contributes to hindering the
socioeconomic development of a country.8,9
The underlying causes of undernutrition dur-
ing childhood are multifactorial, such as poor
maternal health and nutrition, lower maternal
education, inadequate infant and young child
feeding (IYCF) practices, low birth weight and
size at birth, and short birth intervals.10,11 How-
ever, these factors relating to food, health, and
care differ from country to country, and under-
standing these differences is critical in delivering
appropriate, effective, and sustainable solutions.8
Previous studies in Bangladesh show that
Food and Nutrition Bulletin 38(3)
different sociodemographic, health, and feeding-
related factors are the common determinants of
stunting.10-12 Reduction of undernutrition among
below five children, particularly stunting and
wasting, has received emerging attention by the
development partners and has been included in
the Sustainable Development Goals (SGD 2: tar-
get 2.2).13 The rate of below five stunting is
decreasing steadily in Bangladesh but is still at
41% which exceeds the cutoff for very high pre-
valence and is of public health significance.3,14 A
study conducted in Dhaka city illustrates that the
height of mothers, birth weight of children, edu-
cation level of fathers, knowledge of mothers on
nutrition, and frequency of feeding have been
identified as significant factors that have indepen-
dent and direct influences on the stunting of pre-
school children.12 However, the findings from the
study were not representative of the whole Ban-
gladesh since this was carried out only in Dhaka
city of Bangladesh. Several other studies con-
ducted in Bangladesh aimed to illustrate the rela-
tionship between some identified determinates,
such as socioeconomic status and household
wealth, and stunting among children. 11,12,15
Moreover, previous studies conducted in Ban-
gladesh have identified several factors as deter-
minants of severe and moderate stunting among
below five children in Bangladesh.10 There is a
scarcity of recent literature determining the
underlying factors of stunting.
Prevalence of stunting and its associated fac-
tors have also already been demonstrated in other
country contexts, such as in Ethiopia, China, and
Indonesia.16-19 In addition, these studies were
carried out using different methodologies, such
as for data collection, analysis, and type and
selection of study sites and participants. These
studies were based on primary data sources, and
most of these were conducted with small sample
size. Our study used large data sets as well as
large sample sizes that represent the whole coun-
try. To our knowledge, this is the first study in
Bangladesh that used recent data from Bangladesh
Demographic and Health Survey (BDHS) 2011 to
identify the most crucial factors of stunting among
Sarma et al
below five children. Findings from this study may
help public health researchers, stakeholders, and
policymakers to understand the current situation
of stunting and its potential risk factors based on
the current scenario, which may help in taking
required steps and initiating interventions to
improve the condition of chronic undernutrition
among children aged 0 to 59 months in Bangladesh.
Materials and Methods
Data for this study came from the nationally rep-
resentative BDHS 2011. This survey was con-
ducted by the National Institute of Population
Research and Training under the authority of the
Ministry of Health and Family Welfare, in colla-
boration with The United States Agency for Inter-
national Development (USAID). The BDHS
report is publicly available and may be accessed
upon request (http://dhsprogram.com/data/avail-
able-datasets.cfm).
The BDHS 2011 is nationally representative and
covers the entire population, using the sampling
frame prepared for the 2011 population and housing
census, provided by the Bangladesh Bureau of Sta-
tistics. The primary sampling unit for the survey is
an enumeration area (EA) that was created to have
an average of about 120 households. The survey is
based on a 2-stage stratified sample of households.
In the first stage, 600 EAs were selected with prob-
ability proportional to the EA size, with 207 clusters
in urban areas and 393 clusters in rural areas. A
complete household listing operation was then car-
ried out in all selected EAs to provide a sampling
frame for the second stage of selection of house-
holds. In the second stage, a systematic sample of
30 households per EA was selected, on average, to
provide statistically reliable estimates of key demo-
graphic and health variables for the country as a
whole, for urban and rural areas separately, and for
each of the 7 administrative divisions. The survey
was conducted in 18 000 residential households
with 6210 and 11 790 in urban and rural areas,
respectively. A total of 18 222 ever married women
were identified in these households, and 17 842
were interviewed with a response rate of 98% (Fig-
ure 1). Interviews were conducted in the same
dwelling place of the respondents. Among those
households, the survey identified a total of 7861
293
The survey conducted in 18,000
residential households
Total 17,842 ever married women
were interviewed
Total number of children aged 0-59 Number of children excluded
months in BDHS2011 = 7861 for missing Height-for-Age
= 214
Number of children selected for
the study = 7647
Figure 1. Sampling and participants enrollment.
children aged 0 to 59 months (Figure 1). For this
analysis, we first extracted the children’s data set
from the BDHS 2011 original file; then, we
excluded 214 children whose height-for-age
z score (HAZ) values were implausible (6 >
HAZ > 6) or missing, and finally, our final sample
size for this analysis was 7647 children (Figure
1). The survey involved well-trained data collec-
tors for conducting interviews with the caregivers
of children aged 0 to 59 months and for collecting
anthropometric data (for height and weight)
using standardized procedures.20
Chronic undernutrition status of children aged 0
to 59 months has been assessed by HAZ. Accord-
ing to the definition of WHO, HAZ explains the
height of a child in terms of the number of standard
deviations (SD) above or below the median height
of healthy children in the same age group.21 A
child was classified as stunted (dependent vari-
able) if he/she had a z score below 2 SD.
Previous studies have shown that different risk
factors (independent variables) were associated
with stunting in Bangladesh.9-11 Based on those
studies, we classified the potential risk factors
into different groups (such as parental, child,
household, and community factors). Mothers’
and fathers’ education (no education, primary,
secondary, or higher), fathers’ occupation (unem-
ployed, farm worker, day laborer, semi-skilled
worker, and service holder/businessman), moth-
ers’ exposure (yes, no) to the mass media (radio,
television, newspapers, and magazines), and birth
place of the child (home, public sector facility,
private sector facility, and Non-governmental
organization [NGO] facility) were included in the
parental factors; age of child (0-11, 12-23, 24-35,
294
36-47, and 48-59 months) and the size of child at
birth (average or larger, very small, and small)
were considered the child-level factors.
Household-level factors included household food
insecurity (secure, mildly insecure, moderately
insecure, and severely insecure), wealth index
(richest, richer, middle, poor (poorer and poorest),
and types of toilet facilities (improved, non-
improved); the community-level factor included
the place of residence (urban, rural).
Statistical Analysis
A description about the sampled participants was
revealed using univariate analysis and reported in
terms of percentages, along with respective 95%
confidence interval (CI). Bivariate analysis was
done to see the differentials in the prevalence of
stunting over geographical characteristics
(administrative division and place of residence).
As our dependent variable is dichotomous in
nature (stunted or not stunted), we fitted simple
and multiple binary logistic regression analysis to
see the association of the independent variables
with dependent variable (stunting status of chil-
dren). To explore the factors that influenced
stunting, we built multiple regression model
adjusted with variables having significant associ-
ation with dependent variable in simple logistic
regression model only to best fit the regression
model and predict the outcome variable. A
P value less than .05 has been considered for
statistical significance. Variations in the errors
due to complex survey design were controlled
during analysis. The results of logistic regression
analyses have been presented in terms of odds
ratio (OR), 95% CI, and P value. Data of this
study were analyzed using R (version 3.1.0) and
STATA (version 12.0).
Ethical Approval
The institutional review board of the Bangladesh
Medical Research Council approved the BDHS
2011. Informed consent was obtained from each
respondent in the survey before interviewing, and
again, separately before taking weight and height
measurements.3 The DHS Program also removed
Food and Nutrition Bulletin 38(3)
all personal information of the respondents in the
database prior to making these available online.
Results
Among the study children, almost 42% were living
in poor (poorer 21%, poorest 21%) households, and
about 51% of households had non-improved toilet
facilities. About 64% fell in the category of food-
secure households and 26% in mildly food-
insecure households. About 75% of the children
were delivered at home, and the size at birth was
average or larger for 83% of the children. Large
proportions of the parents (20% mothers and 30%
fathers) had no formal education (Table 1). The
prevalence of stunting in below five children was
higher in the rural regions (43%) compared to the
urban regions (36%). Administrative division–wise
distribution of prevalence shows that Sylhet was a
high-risk area for stunting, where the prevalence
was about 50%, and Khulna and Rajshahi division
were the low-risk areas for stunting (Figure 2).
Table 2 shows the ORs derived from simple
and multiple logistic regression analysis for
assessing the association between stunting status
of children aged 0 to 59 months and sociodemo-
graphic characteristics of their households.
Results from multiple logistic regression analysis
are described here. Child’s age in months was
statistically associated with stunting; children
aged 12 to 23 months were more likely to be
stunted (OR ¼ 3.98, 95% CI: 3.32-4.76; P ¼
.00) than those aged 0 to 11 months. Children
living in the poorest households were 2.17 times
more likely to be stunted (OR ¼ 2.17, 95% CI:
1.70-2.76; P ¼ .00), and those who lived in
poorer households were 1.79 times more likely to
be stunted (OR ¼ 1.79, 95% CI: 1.43-2.23; P ¼ .00)
compared to those born in the richest households.
Exposure of mothers to the mass media seemed to
play an important role in the stunting status of chil-
dren as children of mothers with no media exposure
were 1.20 times more likely to be stunted (OR ¼
1.20, 95% CI: 1.06-1.36; P ¼ .00) compared to
children of mothers exposed to the media.
The result indicates that children whose par-
ents’ attained secondary educations were less
likely to be stunted compared to those whose par-
ents had no formal education. Children who were
Sarma et al 295

Table 1. Percentage Distribution of Background Table 1. (continued)

Characteristics of the Study Participants (Weighted).
Variable Percentage 95% CI
Variable Percentage 95% CI Food security status of
household (n ¼ 7630)
Household wealth index Secure 64.29 62.28-66.29
(n ¼ 7647) Mildly insecure 25.61 24.03-27.20
Richest 17.53 15.95-19.12 Moderately insecure 8.57 7.55-9.59
Richer 19.60 18.03-21.17 Severely insecure 1.53 1.16-1.91
Middle 20.49 19.07-21.92 Type of toilet facilities at
Poorer 20.89 19.46-22.32 household (n ¼ 6930)
Poorest 21.48 19.42-23.54 Improved 49.36 46.76-51.96
Exposure of mothers to Non-improved 50.64 48.04-53.24
media (n ¼ 7633)
No 37.03 34.53-39.53 Abbreviation: CI, confidence interval.
Yes 62.97 60.47-65.47
Age of child, in completed perceived by their mothers to be small in size (OR
months, (n ¼ 7647) ¼ 1.65, 95% CI: 1.30-2.08; P ¼ .00) and those
0-11 19.51 18.47-20.55 who were perceived to be very small (OR ¼ 1.64,
12-23 18.77 17.79-19.74 95% CI: 1.41-1.92; P ¼ .00) at the time of deliv-
24-35 18.47 17.49-19.45 ery were significantly more likely to be stunted
36-47 22.17 21.17-23.17
than children who were perceived to be average
48-59 21.08 20.07-22.08
Mothers’ education level or larger at the time of delivery (Table 2). Place of
(n ¼ 7647) delivery and stunting status of children have a
No education 20.04 18.12-21.95 significant association as children who were born
Primary 30.66 28.92-32.40 at health facilities (such as public or private hos-
Secondary 42.33 39.95-44.70 pital/clinic) were less likely to be stunted com-
Higher 6.98 6.17-7.79 pared to children born at home. Our result
Fathers’ educational level reveals that households that reported mild and
(n ¼ 7641)
moderate food insecurity were 1.18 (OR ¼ 1.18,
No education 29.70 27.71-31.70
Primary 29.08 27.67-30.50
95% CI: 1.04-1.33; P ¼ .01) and 1.27 (OR ¼ 1.27,
Secondary 28.64 27.03-30.25 95% CI: 1.05-1.54; P ¼ .01), respectively, times
Higher 12.57 11.41-13.73 more likely to have stunted children than those that
Fathers’ occupation reported being food secure (Table 2).
(n ¼ 7613)
Unemployed 2.07 1.59-2.55
Farm worker 29.07 26.89-31.24 Discussion
Day laborer 22.91 21.10-24.72 Stunting still remains a major public health
Semi-skilled worker 19.18 17.77-20.60
problem in Bangladesh as in other developing
Service holder/ 26.77 25.10-28.43
businessman
countries. Despite having several interventions
Place of delivery (n ¼ 7646) in place, the prevalence of stunting in Bangladesh
Home 75.33 73.59-77.07 among below five children is 41%.3 The findings
Public sector facility 10.36 9.33-11.39 of this study reveal that household wealth, moth-
Private sector facility 12.53 11.37-13.69 ers’ exposure to mass media, age of the child, size
NGO facility 1.78 1.36-2.20 of the child at birth, place of delivery, parents’
Size of child at birth education, food security status of the household,
(n ¼ 7644) place of residence, and type of toilet facilities are
Very small 4.87 4.23-5.52
Small 12.19 11.25-13.13
the factors associated with stunting among below
Average or larger 82.94 81.79-84.08 five children in Bangladesh. In our analysis, the
factors that have been identified to be signifi-
(continued) cantly associated with stunting are household
296
Figure 2. Distribution of stunting across place of residence and geographical divisions.
wealth, food insecurity, mass media exposure,
age of the child, size of the child at birth, and
place of delivery. Our analysis also reveals that,
sometimes, these factors are also interrelated.
Mass media exposure, age of the child, size of
child at birth, and place of delivery are directly
dependent on household wealth index as well as
on parental education.
Our study indicates that household wealth is
significantly associated with stunting. Children
from the poorest households are more likely to
be stunted than those from middle, richer, and
richest households. These children may become
stunted due to their mothers’ lower educational
status and lack of sources of knowledge on child
nutrition. Moreover, a study in Bangladesh illus-
trates that the mothers who have more knowledge
about child health and nutrition are educated and
come from richer households; they also have
greater access to media compared to mothers
from poorer households.3 Financial ability of a
household is also important for ensuring that the
child gets the required amount of nutritious foods.
A study in Bangladesh found that mothers from
poor households did not have the financial ability
to purchase nutritious foods for their children.22
A study in Nepal revealed that richer households
have more financial ability or access to nutritious
foods and are more capable of ensuring proper
care for the children residing in those house-
holds.7 On the contrary, the children from richer
Food and Nutrition Bulletin 38(3)
households may also be affected by stunting. The
World Bank report suggests that in the richer
households stunting may also arise due to inade-
quate knowledge on food, feeding practices, inap-
propriate food allocation, and poor hygiene
practices.23 Lack of maternal education, lack of
maternal knowledge about child nutrition, and
lack of financial ability to purchase appropriate
foods are the factors associated with stunting.
One study in Northeastern Peninsular Malay-
sia showed that food insecurity was associated
with stunting and underweight.24 Another study
from Kenya found that stunting was highest
among severely food-insecure households ranked
in the poorest tertile and lowest among food-
secure households in the middle wealth tertile.25
Similarly, our study found that mildly and mod-
erately food-insecure households were more
likely to have stunted children than those reported
as being food secure. Similar findings were also
obtained from other studies in Bangladesh,
Ethiopia, Vietnam, and Colombia.26,27 In Ban-
gladesh, approximately 25% of the population is
food insecure.28 Approximately 31% of the rural
population in Bangladesh suffers from “chronic
poverty,” which is characterized by low con-
sumption, lack of access to basic health services,
and undernutrition.29 Another study also illu-
strated that, in Bangladesh, household food
security is significantly associated with child
feeding practices.30
Sarma et al 297

Table 2. Odds Ratios in Simple and Multiple Logistic Regressions Assessing the Impacts of Selected Variables on
Stunting of Children below five in Bangladesh.

Simple Logistic Regression Multiple Logistic Regression

Stunting Status Stunting Status

Variable OR 95% CI P Value OR 95% CI P Value

Place of residence
Urban 1 1
Rural 1.39 1.26-1.54 .00 0.91 0.80-1.04 .20
Household wealth index
Richest 1 1
Richer 1.69 1.44-1.98 .00 1.34 1.11-1.61 .00
Middle 2.15 1.84-2.51 .00 1.55 1.27-1.90 .00
Poorer 2.88 2.47-3.37 .00 1.79 1.43-2.23 .00
Poorest 3.89 3.34-4.55 .00 2.17 1.70-2.76 .00
Food security status of household
Secure 1 1
Mildly insecure 1.65 1.48-1.83 .00 1.18 1.04-1.33 .01
Moderately insecure 2.31 1.96-2.72 .00 1.27 1.05-1.54 .01
Severely insecure 2.30 1.61-3.29 .00 1.32 0.89-1.94 .17
Type of toilet facilities at household
Improved 1 1
Non-improved 1.71 1.55-1.88 .00 1.11 0.99-1.24 .09
Exposure of mothers to media
Yes 1 1
No 1.84 1.68-2.03 .00 1.20 1.06-1.36 .00
Age of child (in completed months)
0-11 1 1
12-23 3.65 3.10-4.30 .00 3.98 3.32-4.76 .00
24-35 3.35 2.85-3.94 .00 3.46 2.88-4.14 .00
36-47 3.29 2.81-3.86 .00 3.27 2.75-3.90 .00
48-59 2.63 2.24-3.09 .00 2.52 2.12-3.01 .00
Size of child at birth
Average or larger 1 1
Very small 1.73 1.40-2.13 .00 1.64 1.41-1.92 .00
Small 1.65 1.43-1.89 .00 1.65 1.30-2.08 .00
Place of delivery
Home 1 1
Public sector facility 0.54 0.47-0.63 .00 0.80 0.67-0.96 .02
Private sector facility 0.42 0.36-0.49 .00 0.81 0.67-0.97 .02
NGO facility 0.69 0.50-0.96 .03 1.25 0.86-1.82 .23
Mothers’ educational level
No education 1 1
Primary 0.78 0.69-0.89 .00 0.95 0.82-1.10 .50
Secondary 0.48 0.43-0.55 .00 0.88 0.75-1.04 .15
Higher 0.23 0.18-0.29 .00 0.71 0.52-0.96 .03
Fathers’ educational level
No education 1 1
Primary 0.82 0.73-0.92 .00 1.03 0.89-1.18 .73
Secondary 0.51 0.45-0.58 .00 0.85 0.73-1.00 .05
Higher 0.28 0.23-0.33 .00 0.63 0.50-0.81 .00

(continued)
298
Table 2. (continued)
Simple Logistic Regression
Variable OR
Fathers’ occupation
Unemployed 1 1
Farm worker 1.16
Day laborer 1.10
Semi-skilled worker 0.76
Service holder/businessman 0.64
Abbreviations: CI, confidence interval; OR, odds ratio.
Exposure to mass media is important as
sources of knowledge. The mass media provides
information that is essential to amplifying peo-
ple’s knowledge and awareness regarding issues
in their day-to-day life. Our study illustrates that
the children of mothers who did not listen to the
radio, did not watch television, and did not read
newspapers or magazines at least once a week
had higher risk of becoming stunted compared
to the children of those mothers who were
exposed to any type of mass media. Moreover,
the BDHS 2011 data suggest that almost 49%
of women have no access to mass media, and less
than 1% women were found to have all the media
sources.3 Mass media advertisements provide
information on health, nutrition, proper hygiene
practices, proper child feeding practices, and on
overall knowledge about health, which may con-
tribute to reduction of the prevalence of stunting
among below five children. It is well proven in
Bangladesh that mothers who have less access to
mass media are less likely to be exposed to appro-
priate messages and campaigns on heath and vac-
cines provided by the NGOs or government
organizations compared to those who have more
access to the mass media.3 A study conducted
among children below the age of 2 years in Ban-
gladesh revealed that mothers of undernourished
children were less educated and had less access to
the mass media,31 which indicates that mothers’
education and exposure to the mass media is an
important factor for their children’s health and
well-being.
Our study revealed that the likelihood of stunt-
ing was higher among children who had smaller-
Food and Nutrition Bulletin 38(3)
Multiple Logistic Regression
Stunting Status Stunting Status
95% CI P Value OR 95% CI P Value
0.84-1.61 .37 0.75 0.52-1.08 .12
0.79-1.53 .57 0.74 0.52-1.07 .11
0.55-1.06 .10 0.78 0.54-1.12 .18
0.46-0.89 .01 0.75 0.52-1.08 .13
than-average size at birth. One study illustrated
that stunting passes from one generation to
another in an intergenerational cycle; this indi-
cates that the children born to stunted mothers are
likely to be stunted themselves.23 Considering
such a reality, size of children at birth plays an
important role in the prevalence of stunting.
Besides, studies in Nepal, Bangladesh, and Ethio-
pia have also stated that children born with
smaller than average size were more prone to
stunting.7,10,32 Moreover, in Bangladesh, size of
child at birth is positively associated with the
level of maternal education. A study showed that,
in Bangladesh, educated mothers tend to give
birth to average or large-sized children; on the
other hand, smaller children are born to the moth-
ers who have no education at all.3 Furthermore,
the size of child at birth may also depend on
multidimensional factors, including maternal
nutrition status, antenatal checkup, and food
intake during pregnancy, intrauterine growth, size
for gestational age, timely delivery, maternal
sociodemographic status, and household eco-
nomic status.10 These need to be considered in
the prevention of stunting.
Our study indicated that children aged 12 to
23 months are mostly at risk of stunting compared
to children aged 0 to 11 months and 24 to
59 months. Appropriate complementary feeding
practices are essential for mental and physical
development of children of these age groups.
Studies conducted in rural Bangladesh and in
India among children below 2 years of age sug-
gest that the lack of knowledge about time of
initiation of complementary feeding, dietary
Sarma et al
diversity, and nutritional knowledge increases the
risk factors of stunting.31,33 Other studies con-
ducted in rural Uganda, Vietnam, and Ethiopia
also reported that mothers and caregivers who
have little knowledge or inadequate knowledge
about IYCF practice34-36 ultimately lead to induce
stunting in their children. This means that stunting
has a relationship with child feeding practices. So,
it can be said that children aged 12 to 23 months
are at a risk of stunting because of their inappropri-
ate child feeding practices. Stunting is a cumula-
tive process that can begin in the uterus and
continue up to the first 3 years of life.32 However,
after the second year of a child’s life, it seems to
steadily reduce again with time.10,11 The World
Bank report illustrates that the lack of care, access
to health service, and inappropriate feeding prac-
tices also lead to stunting.23 So, adequate knowl-
edge and appropriate feeding practices are
essential for the prevention of stunting.
Place of delivery is found to be another crucial
factor for stunting. In Bangladesh, 71% of child-
births still occur in the home while only 29% of
births take place in health facilities.3 Our study
indicates that children born in health facilities
with the help of health professionals were less
likely to be stunted compared to the children born
at home with the help of traditional birth atten-
dants (trained or untrained). Similarly, several
other studies conducted in Nepal, Bangladesh,
and India among below five children also suggest
that children born in health facilities were less
likely to be stunted compared to children born
at home.7,10,33 There are some factors associated
with delivery at health facilities and at home.
Studies conducted in Bangladesh and Nepal
revealed that educated mothers from richer fam-
ilies go to health facilities for antenatal visits and
child delivery.3,7 Health professionals at hospitals
and clinics provide counseling on antenatal care
for safe delivery and advise to receive postnatal
care. Besides, the counseling is given on IYCF
practices to the new mothers helping them to take
proper care of their children. However, the assur-
ance of safe delivery and counseling on IYCF
practices are not provided in the rural context
during home births in Bangladesh. Considering
the current situation, below five children are at
risk of stunting in Bangladesh.
299
Knowledge and awareness on child nutrition
among parents of below five children are important
factors for ensuring adequate and appropriate child
feeding practices and child care. In this regard,
parental education is important. Our study found
that parents’ education was a risk factor for stunt-
ing among children aged 6 to 59 months. A study
conducted in rural Bangladesh among children
below the age of 2 years revealed that educated
mothers were more conscious about their chil-
dren’s health and nutrition, enabling them to take
better care, better use of the health services, and
also to help ensure better hygiene practice.31 These
findings were also supported by another study con-
ducted in Indonesia.37 In Bangladesh, mothers and
fathers from richer families are more likely to be
educated than those from the poorest families.3 Our
analyses derived that there is a negative association
between educational status of parents and stunting,
which has been observed in all BDHS from 1999 to
2007.4,38,39 Besides, educated parents might have
better income as well as better household access to
food, higher proportion of wealth allocated for
children’s welfare, and improved standard of liv-
ing,10 which would ultimately help to provide bet-
ter care to the children. So, education is one of the
essential needs toward preventing stunting.
One of the limitations of this study is that we
depend only on secondary data sources which do
not contain detailed information on dietary diver-
sity or dietary practice of the study children. Our
study depends on data sources from other studies
for clarification or further explanation. This study
was unable to present sufficient information on
children’s birth weights as well as gestational age
from intrauterine growth restriction as a cause for
size at birth. Also, these data do not represent the
population or the children residing in urban slums,
although children of urban slums are more prone to
stunting than other children residing in the urban
areas. Despite these limitations, the strength of this
study is that our results have identified the most
vital factors for stunting, which will be important
contributions to the available literature on the asso-
ciation of socioeconomic and demographic vari-
ables with stunting of below five children.
Our results revealed that stunting is most com-
mon among the children aged 12 to 23 months in
Bangladesh. The demographic characteristics of
300
the study participants and other indicators,
including household socioeconomic status (poor-
est), place of delivery (home delivery), size at
birth (small size), and parents’ education (no for-
mal education) appeared to influence the preva-
lence of stunting significantly. Several potential
educational interventions by the policymakers are
needed for developing information that can serve
as a platform to prevent stunting among children
aged below five years in this country.
Authors’ Note
Jahidur Rahman Khan is currently affiliated with the
Center for Bioinformatics Learning Advancement and
Systematics Training (cBLAST), University of Dhaka,
Bangladesh. This study was conducted by team mem-
bers of Nutrition Program Evaluation Unit under Nutri-
tion and Clinical Services Division of icddr,b as part of
their research activities.
Acknowledgments
The authors acknowledge the contributions of the
Bangladesh Demographic and Health Survey 2011 team
for their efforts in providing open access to their dataset;
icddr,b is grateful to the Government of Bangladesh,
Canada, Sweden, and the United Kingdom for providing
core/unrestricted support. The authors thank Ms Antara
Kabir for support in editing the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship, and/or publi-
cation of this article: The Children’s Investment Fund
Foundation-UK (CIFF) was the funder for operating
research work of this unit. Authors invested their valu-
able time for this study. So, the study was indirectly
funded by CIFF for the time invested by authors.
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