Family Size and its impact on malnutrition

Data from National Family Health Survey shows high correlation between number of children in the family and malnutrition

Analysis of data and article co-authored with?Disha Rathod

(This is the second in the series of analysis of the NFHS-5 data. The first one is here )

The World Health Organization (WHO) defines Stunting as “the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. Children are defined as stunted if their height-for-age is more than two standard deviations below the WHO Child Growth Standards median”.

It is the result of chronic or recurrent undernutrition, usually associated with poverty, poor maternal health and nutrition, frequent illness and/or inappropriate feeding and care in early life. Stunting prevents children from reaching their physical and cognitive potential.?The National Health and Family Survey – 5 (NFHS-5) conducted between 2019 and 2021, reports that 35.5% of the children in India under the ages of 5 are stunted. This number varies significantly across the states and Union Territories, from 20% in the Union Territory of Puducherry to 46.5% in the picturesque Meghalaya.

Stunting and Malnutrition is seen as the responsibility of the Department of Women and Child Development. There are many schemes like the Integrated Child Development Scheme (ICDS) which focusses on providing supplementary nutrition of calories and proteins through Anganwadis. The primary purpose of such schemes is to ensure that the state reduce the burden on malnutrition.

There is a lot of merit in this line of thinking as the children under the age of six, especially in the rural parts of the country may not have access to the right quality and quantity of nutrition. By providing this, the state aims to equip the children with not just the food but the habits and the knowledge for a healthy future.

But the reality is that even after 47 years (the ICDS program was launched in 1975), progress has been mixed. The country still is amongst the highest in our neighborhood (Bangladesh – 28%, Sri Lanka – 17.30%, Pakistan – 37.6% and Nepal 31.5%). We cannot continue to be doing what we have been doing and expect a different result.

The impact of wealth, social status, female literacy on the health and nutrition status of the child has been well documented. And an analysis of the NFHS-5 data reconfirms most of these.?

Our line of investigation was whether the size of the family has an impact on Stunting of children. While there is no direct data available, the NFHS data captures the birth order of children for which data has been collected. To put in context, If a child is the 4th one borne by a particular woman, the birth order of the child is 4.

What we see is that Stunting increases with birth order. Stunting amongst all children who are first born(74845) is at 31.2% and almost linearly increases to 54.1% amongst 12th born children (14).

The first scary proposition in this information (which was collected between 2019 and 2021) is that there are still a few children who are the 16th children to their mother.

The cause – effect relationship is not that straightforward, but the correlation is telling.

The map on the left shows what was the highest birth order of child surveyed in that state. It looks eerily like the malnutrition map above. We see the pattern with the southern states and Ladakh, Himachal, Delhi, Sikkim and Tripura having a maximum of 8th child, Bihar with 16 and Meghalaya with 15 lead on this front. The middle of the country from Gujarat all the way to Arunachal Pradesh have children who are 11th born or worse. While the story of central India has been well documented previously, the North East comes in as a little bit of a surprise.

The Survey also captures the household details of the family. We looked at of all the households surveyed, how many had at least one child in the preceding 5 years. The basic premise is that while the birth order gives the maximum number of child in a household, this metric gives how widespread the challenge is.

While the southern and the Himalayan states had lesser number of households which had at least one child in the preceding 5 years, the central part of India (Rajasthan, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkand) show higher number of households with more children

The next stop was to see what percentage of households had more than 1 child in the preceding 5 years. And Surprise, surprise. The picture is almost identical.?

Our health indicators on Infant Mortality Ratio (IMR) has fallen from 84 for every 1000 live births in 1992 to 28 in 2022 and Under 5 Mortality (Child Mortality) Ratio falling from 116 (1995) to 32 (2022).?One of the reasons (apart from gender preference) is because the parents fear that some of the children may not live to see their 5th birthday.

The correlation between family sizes and the level of Stunting is very strong. One of the key levers for fighting the malnutrition in the country is to keep the family size smaller. Without going into the religious and political aspect of family sizes, some of the steps that the policy makers should immediately start addressing include

• Reinvigorate the Information, Education, Communication (IEC) machinery of MoHFW towards keeping the family size small. The focus of this outreach should be in the vast middle swathes of the country with the message being the cost of fighting malnutrition.
• Build a consensus driven policy change to make family planning for both the man and the woman at the birth of the third child as an opt-out. Unless the woman and her partner voluntarily opt-out, the procedure should be performed.
• Make the family size the key message for the health care workers in the country – the Primary Health Center, ANMs and Asha workers. It is important to reach out to the women about the positive impact on their physical and mental health that a smaller family brings to them

The cost of fighting malnutrition for both the family and the Government is significantly high.?

India is expected to become the most populous nation during the course of this year (2023). We have had many programs (We two, ours two), which has helped us to stabilize our population growth. We can see that wherever there has been an acceptance of such measures (especially southern India), there has been progress on many of the social indicators. It is time that we double down on this to help the families as well as the nation.

All views are personal of the authors and does not necessarily reflect the opinion of the organization.

#malnutrition ?#india ?#familysize #nfhs5 ?#stunting ?#underweight