Tiwari et al.

BMC Pediatrics 2014, 14:239

http://www.biomedcentral.com/1471-2431/14/239

RESEARCH ARTICLE Open Access

Determinants of stunting and severe stunting

among under-fives: evidence from the 2011
Nepal Demographic and Health Survey
Rina Tiwari1*, Lynne M Ausman2 and Kingsley Emwinyore Agho3

Abstract
Background: Stunting remains a major public health concern in Nepal as it increases the risk of illness, irreversible
body damage and mortality in children. Public health planners can reshape and redesign new interventions to
reduce stunting and severe stunting among children aged less than 5 years in this country by examining their
determinants. Hence, this study identifies factors associated with stunting and severe stunting among children aged
less than five years in Nepal.
Methods: The sample is made up of 2380 children aged 0 to 59 months with complete anthropometric
measurements from the 2011 Nepal Demographic and Health Survey (NDHS). Simple and multiple logistic
regression analyses were used to examine stunting and severe stunting against a set of variables.
Results: The prevalences of stunting and severe stunting were 26.3% [95% confidence Interval (CI): 22.8, 30.1] and
10.2% (95%CI: 7.9, 13.1) for children aged 023 months, respectively, and 40.6 (95%CI: 37.3, 43.2) and 15.9% (95%CI:
13.9, 18.3) for those aged 059 months, respectively. After adjusting for potential confounding factors, multivariable
analyses showed that the most consistent significant risk factors for stunted and severely stunted children aged
023 and 059 months were household wealth index (poorest household), perceived size of baby (small babies)
and breastfeeding for more than 12 months (adjusted odds ratio (AOR) for stunted children aged 023
months = 2.60 [95% CI: (1.87, 4.02)]; AOR for severely stunted children aged 023 months = 2.87 [95% CI: (1.54, 5.34)];
AOR for stunted children aged 059 months = 3.54 [95% CI: (2.41, 5.19)] and AOR for severely stunted children aged
059 months = 4.15 [95% CI: (2.45, 6.93)].
Conclusions: This study suggests that poorest households and prolonged breastfeeding (more than 12 months)
led to increased risk of stunting and severe stunting among Nepalese children. However, community-based
education intervention are needed to reduce preventable deaths triggered by malnutrition in Nepal and should
target children born to mothers of low socioeconomic status.

Background in monitoring nutritional and health status of the

Stunting and other effects of under-nutrition increase the population and survival [5,6].
risk of illness, irreversible body damage, and increased sub- Under-nutrition hinders socioeconomic development
optimal brain development and affect cognitive ability and of a nation [1]. Consequently, its eradication has gained
mortality in children [1]. It is estimated that about 165 mil- global recognition and sustainable development. In
lion children in many low- and middle-income countries Nepal, stunting remains a serious problem as nearly half
are stunted [2]. Stunting is one of the leading causes of the (41 per cent) of children aged under five years are stunted
global burden of disease in childhood and 80% of this [7]. The causes of childhood under-nutrition in Nepal are
burden is in developing countries [3,4]. Childhood complex, multidimensional, and interrelated, ranging from
under-nutrition plays an important public health role fundamental factors such as slow economic growth, to
specific factors such as respiratory infection and diar-
* Correspondence: rinatiwari@hotmail.com rhoeal diseases [8,9].
1
Nutrition Promotion and Consultancy Service, Kathmandu, Nepal
Full list of author information is available at the end of the article

2014 Tiwari et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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Previous studies in Nepal have found factors such as sex yielded a response rate of 98%. The 2011 NDHS collected
of child, childs age and birth weight, birth order, number of anthropometric data for all children. Non-biological
siblings, wealth index, mothers education, mothers body children of women were included in the interviews.
mass index and access to health care to be common deter- Each team of interviewers carried a scale and measuring
minants of stunting [9,10]. Additionally, various efforts have board. Measurements were made using lightweight
been made to reduce under-nutrition in Nepal [11]. Despite SECA scales (with digital screens) on children with valid
these commitments and investment, the prevalence of dates of birth (month and year) and valid measurement
stunting is still high [7]. In order to reduce the burden of both height and weight. Recumbent heights were
of disease on Nepalese children, it is important to target measured for children aged 2 years or younger, or
those children who are most at risk, such as stunted those who were shorter than 85 cm. Standing heights
children [12-14]. This study utilized the most recent were measured for all other children [7]. This present
Nepal Demographic and Health Survey (NDHS 2011) analysis was restricted to children with complete anthropo-
data to examine the determinants of stunting and severe metric measurements, children aged 059 months, and the
stunting among children aged less than five years. Findings total weighted sample was 2380.
from this study can be generalised to cover populations
with similar characteristics and would be useful to public Stunting (Height-for-age)
health researchers and policy makers in reviewing and de- Height-for-age z-scores were used to assess the chronic
signing new intervention strategies aimed at reducing the nutritional status of children under-5 years. This was
number of malnourished children. The results will also pro- accomplished by adapting the Child Growth Standards
vide vital information on preventable illnesses and identify of the World Health Organization (WHO) [15]. The
where health gains can be made to prevent stunting. The height-for-age z-score, as defined by the WHO, ex-
findings may also allow policy-makers to direct resources presses a childs height in terms of the number of
to the most vulnerable segments of the population, and standard deviations above or below the median height
thus make better use of resources. of healthy children in the same age group or in a refer-
ence group. We classified children with a measurement
Ethics of < 2 SD from the median of the reference group as
The NDHS surveys were approved by Nepal Health short for their age (stunted), while children with meas-
Research Council, Nepal and ICF Macro Institutional urement of < 3SD from the median of the reference
Review Board in Calverton, Maryland, USA. The NDHS group were considered to be severely stunted [16].
obtained written consent from the respondents. Mothers
provided consent of their children to provide the informa- Potential risk factors
tion. For analysis, Principal Investigator (PI) received per- The explanatory variables were classified into four levels:
mission from Macro International online for the use of parental-, child-, household- and community-level factors.
available dataset. PI also obtained approval from Social, Parental-level factors included maternal working status,
Behavioural and Educational Research, Institutional Review maternal education, mothers age, mothers age at child
Board, Tufts University as exempt category 4 as defined in birth, mothers breastfeeding status, duration of breast-
45 CFR 46.101 (b). feeding, marital status, mothers literacy, partners educa-
tion, partners occupation, birth order, preceding birth
Methods interval, type of delivery assistance, antenatal clinic visits,
Data sources timing of postnatal check-up and place of delivery. Mode
The data examined were from the 2011 NDHS. This survey of delivery was divided into three categories: delivered at
was conducted by the Department of Health Services, home, delivered at health facility with non-caesarean
Ministry of Health and Population in collaboration with section, and delivered at a health facility with caesarean
USAID. The survey data were a two-stage, stratified, na- section. Child-level factors were: sex of the baby and acute
tionally representative sample of households. At the first respiratory infection (defined as having symptoms of cough
stage of sampling, 289 Primary Sampling Units (PSUs) accompanied by short, rapid breathing which was chest
(95 sub-wards in urban areas and 194 groups of wards related during 2 weeks preceding the survey). Any child
in rural areas) were selected using systematic sampling with watery or blood and mucus stool in the preceding
with probability proportion to size. 2 weeks was considered as having diarrhoea. Household-
In the selection of households, 12,918 women were level factors were household food insecurity, household
identified as eligible for the individual interview. A total wealth index, and sources of drinking water; community-
of 12,674 women aged between 15 and 49 years were level factors were: type of residence, caste group, ecological
interviewed. Out of this number, 3,701 were resident in zone, geographical zones and sub-region. The household
urban areas and 8,973 were rural dwellers. The interviews food insecurity factor was calculated by summing all
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the seven household food insecurity (access) frequency Results

questions withscores ranging from 0 to 27. Food secure Characteristics of the sample
was a score of 0, and mild (12), moderate (3 to 10), Of the total sample of 2380 children aged 059 months,
and severe (more than 10) food insecurity represented majority (91.1%) lived in rural areas. More than half
the three groupings [7]. The caste and ethnic group (56.6%) of the interviewed mothers were employed in
variables were merged into six categories. This was the last 12 months, and 32.6% had secondary or higher
done by merging all Brahmin Chhetris irrespective of level of education. Of the total births, 65.5% took place at
their ecological locations into a single category referred home and by non-caesarean section, and 30% (see Table 1)
to as Brahmin/Chhetri. Similarly, the Janajati from were delivered at the health care facility and by non-
Terai was merged with other Terai castes to make a caesarean section or vaginal birth. The remaining 4.5%
single category and referred to as TeraiJanajati and other were delivered by caesarean section at the health care facil-
Terai castes and Dalits from Hill and Terai were also ity. In the sample, male and female children were almost
combined as one. Likewise, Muslims and other castes equally represented. About 83% of mothers had made at
were put together as Muslims and others [7]. least one antenatal clinic visit during pregnancy and a ma-
Household wealth index was calculated as a score jority of the mothers in the sample were within 2029 years
of household assets such as ownership of means of of age. Also, approximately 44% of households reported
transport, ownership of durable goods, and household food security and 16% reported severe food insecurity.
facilities. These were weighted using the principal According to the mothers perception, 64.5% of children
components analysis method [17]. This index was di- were average size, 17.7% were small or very small size, and
vided into five categories (quintiles), and each house- 17.8% were large size at birth. As shown in Table 1, the
hold was assigned to one of these categories. The bottom proportion of mothers who could not read a sentence was
40% of the households was referred to as the poorest 42.7%. Nearly 24% of children lived in the Eastern geo-
and poorer households, the next 20% as the middle- graphical zones and 31.6%, 18.2%, 15.1% and 11.3% of
class households, and the top 40% as rich and richest children lived in Central, Western, Mid-western, and
households. Far-western geographical zones respectively.
As shown in Figure 1, the prevalence of stunted children
Statistical analyses aged 023 months was 26% and a higher 41% for children
To determine factors associated with stunting and severe aged 059 months. The overall prevalence of severely
stunting in children aged 023 months and children 059 stunted children aged 023 months and 059 months
months the dependent variable was expressed as a di- were 10% and 16%, respectively.
chotomous variable, i.e. category 0 [not stunted (> 2SD)
or not severely stunted (> 3SD)] and category 1 [stunted Multivariate analyses
(> 2SD) or severely stunted (> 3SD)]. Tables 2 and 3 show the unadjusted and adjusted ORs
Analyses were performed using Stata version 12.0 for the association between stunted and severely
(StataCorp, College Station, TX, USA). Svy commands stunted children by parental-, child-, household- and
were used to allow for adjustments for the cluster sam- community-level characteristics of children aged 023
pling design, weights and the calculation of standard and aged 059 months.
errors. The Taylor series linearization method was used
in the surveys when estimating confidence intervals Risk factors for stunting
(CIs) around prevalence estimates of stunting and As shown in Table 2, children aged 023 months delivered
severe stunting among children aged 059 months. by older mothers (adjusted OR = 7.36, 95%CI: 2.11, 25.75;
Survey logistic regression was used to adjust for the p = 0.002 for mothers aged 40 and above) were significantly
complex sampling design and weights. First, univariate more likely to be stunted than those delivered by younger
binary logistic regression analysis was performed to mothers (mothers less than 20 years old).
examine the association between stunted and severely For children aged 023 months, those who were de-
stunted children aged 023 months and overall stunted livered at the health facility by non-caesarean section
children 059 months. Second, the factors associated (adjusted OR = 0.55, 95%CI: 0.33, 0.92; p = 0.022) were
with stunting and severe stunting were examined in a significantly less likely to be stunted compared with
multiple logistic regression model. A stepwise back- children delivered at home. Babies who were perceived
ward elimination approach was applied and collinearity to be large by their mothers were 58% less likely to be
was tested in the final model and reported. The odds stunted than those who were perceived to be small
ratios with 95% CIs were calculated in order to assess (adjusted OR = 0.42, 95%CI: 0.22, 0.81; p = 0.010 for
the adjusted risk of independent variables, and those large babies). Also, children aged 023 months who were
with P < 0.05 were retained in the final model. breastfed for up to 12 months were significantly less
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Table 1 Characteristics of parental-, child-, household- and Table 1 Characteristics of parental-, child-, household- and
community-level factors of stunted children aged 059 community-level factors of stunted children aged 059
months in Nepal 2011 months in Nepal 2011 (Continued)
Characteristic n % Combined Place and mode of delivery
Parental factors Home delivery 1560 65.5
Maternal working status Health facility with non-caesarean 713 30.0
Non-working 1033 43.4 Health facility with caesarean 107 4.5
Working (past 12 months) 1347 56.6 Type of delivery assistance
Maternal education Health professional 772 32.4
No education 1128 47.4 Traditional birth attendant 44 1.9
Primary 469 19.7 Relatives and other untrained personnel 1490 62.6
Secondary and above 782 32.9 No one 74 3.1
Partners occupation Antenatal clinic visits
Non agriculture 1679 70.6 None 317 16.8
Agriculture 593 24.9 1-3. 647 34.3
Not working 108 4.5 4+ 921 48.9
Partners education Timing of postnatal check-up
No education 530 22.4 No postnatal check-up 1756 73.8
Primary 578 24.4 0-2 days 429 18.0
Secondary and above 1262 53.3 Delayed 196 8.2
Mothers age Currently breastfeeding
15-24 years 997 41.9 Yes 1830 76.9
25-34 years 1103 46.3 No 550 23.1
35-49years 281 11.8 Duration of breastfeeding
Mothers age at birth Up to 12 months 498 20.9
< 20 years 492 20.7 > 12 months 1882 79.1
20-29 years 1458 61.3 Mothers literacy
30-39 years 367 15.4 Cant read at all 1016 42.7
40 years 62 2.6 Can read 1364 57.3
Marital status Child level factors
Currently married 2361 99.2 Sex of baby
Formerly married^ 19 0.8 Male 1208 50.7
Birth order Female 1172 49.3
First-born 835 35.1 Perceived size of baby at birth
2nd -4th 1235 51.9 Small 421 17.7
5 or more 310 13.0 Average 1531 64.5
Preceding birth interval Large 424 17.8
No previous birth 835 35.1 Childs age in months
< 24 months 324 13.6 0-5 206 8.8
> 24 months 1219 51.3 6-11 240 10.3
Place of delivery 12-17 269 11.6
Home 1560 65.6 18-23 215 9.2
Health facility 820 34.4 24-29 227 9.8
Mode of delivery 30-35 252 10.8
Non-caesarean 2273 95.5 36-41 273 11.7
Caesarean 107 4.5 42-47 230 9.9
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Table 1 Characteristics of parental-, child-, household- and Table 1 Characteristics of parental-, child-, household- and
community-level factors of stunted children aged 059 community-level factors of stunted children aged 059
months in Nepal 2011 (Continued) months in Nepal 2011 (Continued)
48-53 220 9.5 Far-western 269 11.3
54-59 195 8.4 Sub-Region
Child had diarrhoea recently Eastern Mountain 46 1.9
No 2028 85.2 Central Mountain 42 1.7
Yes 352 14.8 Western Mountain 101 4.3
Child had fever in last two weeks Eastern Hill 174 7.3
No 1883 79.1 Central Hill 215 9.0
Yes 497 20.9 Western Hill 274 11.5
Household level factors Mid-Western Hill 165 6.9
Household food insecurity (Access) Far-Western Hill 112 4.7
Food secure 1004 43.6 Eastern Terai 348 14.6
Mildly insecure 129 5.6 Central Terai 495 20.8
Moderately 803 34.9 Western Terai 160 6.7
Severely 365 15.9 Mid-Western Terai 136 5.7
Wealth index Far-Western Terai 113 4.7
^
Poorest 608 25.6 divorced/separated/widowed.
Household food insecurity scores: Food secure (score, 0); mildly insecurity
Poorer 483 20.3 (score, 12), moderately (score, 310) and severely (score, 1027).
Middle 555 23.3
Rich 406 17.1 likely to be stunted than those breastfed for more than
Richest 328 13.8 12 months.
Children aged 023 months from middle-income house-
Source of drinking water
holds (adjusted OR = 0.53, 95%CI: 0.33, 0.85; p = 0.009),
Unprotected 409 17.2
those from richer households (adjusted OR = 0.28, 95%CI:
Protected 1972 82.8 0.15, 0.53; p < 0.001) and those from richest households
Community level factors (adjusted OR = 0.26, 95%CI: 0.11, 0.60; p = 0.002) were sig-
Type of residence nificantly less likely to be stunted compared to those from
Urban 211 8.9 poorest households. Children aged 023 months who had
no access to protected drinking water were 1.74 times more
Rural 2169 91.1
likely to be stunted than those who had access to protected
Caste group
drinking water. In the final model, we removed household
B/C (Hill and Terai) 724 30.4 wealth index and replaced with fathers education. The re-
Newar 63 2.7 sult indicated that children aged 023 months whose fa-
Hill Janajati 541 22.8 thers attained secondary education or higher were 44% less
TeraiJanajati and other Terai castes 469 19.7 likely to be stunted compared with children whose fathers
Dalit 434 18.2
Muslim and others 149 6.3
10
Ecological Zone 0-23 months
26
Mountain 189 7.9
Hill 940 39.5
16
Terai 1252 52.6 0-59 months
41
Geographic Zones
Eastern 567 23.8 0 10 20 30 40 50
Percentage of children
Central 751 31.6
Severe stunng Stunng
Western 434 18.2
Figure 1 Prevalence of stunting and severe stunting among
Mid-western 359 15.1
children aged 0-59 months.
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Table 2 Unadjusted and adjusted odds ratios (OR) (95% CI) for stunted children aged 023 and 059 months
Characteristic Stunted children 023 Months Stunted children 059 Months
Unadjusted P Adjusted P Unadjusted P Adjusted P
Odd Ratio Odd Ratio Odd Ratio Odd Ratio
(OR) [95%CI] (AOR) [95%CI] (OR) [95%CI] (AOR) [95%CI]
Parental factors
Maternal working status
Non-working 1.00 1.00
Working (past 12 months) 1.60 (1.09, 2.34) 0.015 1.30 (0.99, 1.70) 0.057
Maternal education
No education 1.00 1.00
Primary 0.75 (0.47,1.18) 0.205 0.77 (0.58, 1.03) 0.079
Secondary and above 0.39 (0.24, 0.62) <0.001 0.46 (0.35, 0.60) <0.001
Partners occupation
Non agriculture 1.00 1.00
Agriculture 1.80 (1.24,2.63) 0.002 1.68 (1.30, 2.18) <0.001
Not working 0.28 (0.07,0.62) 0.071 0.57 (0.29, 1.13) 0.109
Partners education
No education 1.00 1.00
Primary 0.67 (0.40, 1.11) 0.121 0.91 (0.62, 1.33) 0.620
Secondary and above 0.40 (0.26, 0.60) <0.001 0.58 (0.42, 0.79) 0.001
Mothers age
15-24 years 1.00 1.00
25-34 years 1.16 (0.81,1.67) 0.420 1.16 (0.94,1.43) 0.159
35-49years 3.14 (1.54, 6.01) 0.001 1.91 (1.39, 2.63) <0.001
Mothers age at birth
< 20 years 1.00 1.00 1.00
20-29 years 0.98 (0.60,1.62) 0.944 1.02 (0.58, 1.80) 0.955 0.91 (0.68, 1.21) 0.508
30-39 years 1.17 (0.65,2.11) 0.595 0.95 (0.48, 1.87) 0.877 1.06 (0.75, 1.52) 0.728
40 and above 11.06 (4.26, 28.72) <0.001 7.31 (2.12, 25.22) 0.002 2.28 (1.27, 4.11) 0.006
Marital status
Currently married 1.00 1.00
Formerly married^ 3.10 (0.26, 36.98) 0.370 1.52 (0.51, 4.52) 0.450
Birth order
First-born 1.00 1.00
2nd -4th 1.60 (1.13, 2.25) 0.008 1.25 (1.00, 1.56) 0.052
5 or more 3.45 (1.91, 6.23) <0.001 2.15 (1.57, 2.94) <0.001
Preceding birth interval
No previous birth 1.00 1.00
< 24 months 2.20 (1.35, 3.58) 0.002 1.64 (1.22, 2.20) 0.001
> 24 months 1.77 (1.22, 2.57) 0.003 1.34 (1.08, 1.66) 0.009
Type of delivery assistance
Health professional 1.00 1.00
Traditional birth attendant 0.88 (0.19, 4.04) 0.873 1.24 (0.58, 2.64) 0.578
Relatives or other 3.14 (2.00, 4.94) <0.001 2.39 (1.87, 3.06) <0.001
No one 5.10 (2.16, 12.04) <0.001 5.63 (3.39, 9.32) <0.001
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Table 2 Unadjusted and adjusted odds ratios (OR) (95% CI) for stunted children aged 023 and 059 months
(Continued)
Combined Place and mode of delivery
Home delivery 1.00 1.00 1.00 1.00
Health facility with non-caesarean 0.33 (0.21,0.51) <0.001 0.54 (0.33, 0.90) 0.018 0.42 (0.33, 0.52) <0.001 0.65 (0.51, 0.84) 0.001
Health facility with caesarean 0.22 (0.07, 0.66) 0.007 0.53 (0.16, 1.75) 0.298 0.28 (0.16, 0.50) <0.001 0.53 (0.29, 0.95) 0.033
Timing of postnatal check-up
No postnatal check-up 1.00 1.00
0-2 days 0.39 (0.24, 0.63) <0.001 0.38 (0.30, 0.49) <0.001
Delayed 0.45 (0.23, 0.87) 0.019 0.40 (0.26, 0.60) <0.001
Antenatal clinic visits
None 1.00 1.00
1-3. 0.71 (0.36, 1.39) 0.312 0.69 (0.47, 1.01) 0.056
4+ 0.41 (0.23, 0.73) 0.003 0.46 (0.32,0.65) <0.001
Currently breastfeeding
Yes 1.00 1.00 1.00
No 1.02 (0.33, 3.18) 0.971 0.97 (0.75, 1.26) 0.841 0.70 (0.53, 0.94) 0.017
Duration of breastfeeding
Upto 12 months 1.00 1.00 1.00 1.00
> 12 months 2.80 (1.91, 4.09) <0.001 2.60 (1.87, 4.02) <0.001 4.22 (3.12, 5.69) <0.001 3.54 (2.41, 5.19) <0.001
Mothers literacy
Cant read at all 1.00 1.00
Can read 0.52 (0.35, 0.76) 0.001 0.58 (0.45, 0.73) <0.001
Child level factors
Child age
Sex of baby
Male 1.00 1.00
Female 0.75 (0.53, 1.06) 0.104 0.93 (0.78, 1.10) 0.392
Perceived size of baby at birth
Small 1.00 1.00 1.00 1.00
Average 0.51 (0.32, 0.84) 0.008 0.61 (0.36, 1.04) 0.070 0.64 (0.49, 0.83) 0.001 0.68 (0.51, 0.90) 0.008
Large 0.40 (0.22, 0.75) 0.004 0.42 (0.36, 0.83) 0.013 0.46 (0.33, 0.65) <0.001 0.47 (0.33, 0.67) <0.001
Childs age in months 2.39 (1.59, 3.59) <0.001 1.34 (1.25, 1.44) <0.001 1.11 (1.01, 1.23) 0.031
Child had diarrhoea recently
No 1.00 1.00
Yes 1.29 (0.83, 2.02) 0.254 0.91 (0.66, 1.27) 0.589
Child had fever in last two weeks
No 1.00 1.00
Yes 1.20 (0.79,1.84) 0.389 0.79 (0.63, 0.98) 0.035
Household level factors
Food insecurity (Access)
Food secure 1.00 1.00
Mildly insecurity 0.79 (0.34, 1.82) 0.571 1.11 (0.71, 1.76) 0.638
Moderately 2.34 (1.48, 3.70) <0.001 1.66 (1.28, 2.16) <0.001
Severely 2.94 (1.54, 5.63) 0.001 2.22 (1.54, 3.20) <0.001
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Table 2 Unadjusted and adjusted odds ratios (OR) (95% CI) for stunted children aged 023 and 059 months
(Continued)
Wealth index
poorest 1.00 1.00 1.00 1.00
poorer 0.79 (0.50, 1.25) 0.314 0.93 (0.58, 1.50) 0.711 0.65 (0.47, 0.88) 0.005 0.67 (0.48, 0.94) 0.020
middle 0.45 (0.28, 0.72) 0.001 0.59 (0.36, 0.97) 0.039 0.42 (0.30, 0.59) <0.001 0.47 (0.33, 0.68) <0.001
richer 0.25 (0.14, 0.45) <0.001 0.31 (0.16, 0.59) <0.001 0.33 (0.24, 0.46) <0.001 0.38 (0.25, 0.56) <0.001
richest 0.16 (0.07, 0.34) <0.001 0.29 (0.12, 0.67) 0.004 0.26 (0.18, 0.37) <0.001 0.37 (0.25, 0.55) <0.001
Source of drinking water
Unprotected 1.00 1.00 1.00
Protected 1.50 (0.95, 2.36) 0.084 1.08 (0.81, 1.43) 0.609
Community level factors
Type of residence
Urban 1.00 1.00
Rural 2.14 (1.26, 3.64) 0.005 1.95 (1.47, 2.58) <0.001
Caste group
B/C (Hill and Terai) 1.00 1.00
Newar 0.72 (0.26, 2.05) 0.542 0.77 (0.40, 1.48) 0.423
Hill Janajati 1.14 (0.71, 1.85) 0.577 1.35 (0.98, 1.84) 0.063
TeraiJanajati and other terai castes 1.52 (0.94, 2.43) 0.086 1.11 (0.77, 1.62) 0.566
Dalit 1.46 (0.92, 2.33) 0.110 1.53 (1.18, 1.99) 0.002
Muslim and others 0.91 (0.36, 2.26) 0.832 0.80 (0.48, 1.32) 0.382
Ecological Zone
Mountain 1.00 1.00 1.00
Hill 0.55 (0.35, 0.87) 0.010 0.63 (0.47, 0.84) 0.002 0.68 (0.50, 0.93) 0.015
Terai 0.48 (0.30, 0.77) 0.002 0.52 (0.39, 0.70) <0.001 0.80 (0.57, 1.12) 0.193
Geographic Zones
Eastern 1.00 1.00
Central 1.28 (0.75, 2.17) 0.366 1.04 (0.72, 1.49) 0.832
Western 1.13 (0.61, 2.10) 0.692 1.07 (0.72, 1.60) 0.738
Mid-western 1.64 (0.96, 2.77) 0.068 1.71 (1.15, 2.55) 0.008
Far-western 1.28 (0.73, 2.25) 0.387 1.47 (0.96, 2.24) 0.075
^
divorced/separated/widowed.
Household food insecurity scores: Food secure (score, 0); mildly insecurity (score, 12), moderately (score, 310) and severely (score, 1027).

had no formal education (adjusted OR = 0.56; CI: 0.37, 0.86; less likely to be stunted than children of the same age
p = 0.007 for fathers with secondary education or higher). perceived to be small at the time of delivery.
Children aged 059 months who were currently being Children aged 059 months from poorer households
breastfed were significantly less likely to be severely stunted (adjusted OR = 0.67, 95%CI: 0.48, 0.94; p = 0.020), middle-
compared with children of the same age group who income households (adjusted OR = 0.47, 95%CI: 0.33, 0.68;
were not currently being breastfed (adjusted OR = 0.70; p < 0.001), and richer households (adjusted OR = 0.38, 95%
CI: 0.54, 0.94; p = 0.017); and children aged 059 CI: 0.25, 0.56; p < 0.001) and those from richest households
months who breastfed for more than 12 months were (adjusted OR = 0.37, 95%CI: 0.25, 0.55; p < 0.001) were
more likely to be stunted than those breastfed for up to significantly less likely to be stunted compared with
12 months. Children aged 059 months who were per- those from poorest households. Increasing age of the
ceived by their mothers to be average size (adjusted child was significantly associated with stunting (adjusted
OR = 0.68, 95%CI: 0.51, 0.90; p = 0.008) and those per- OR = 1.11, 95%CI: 1.01, 1.23; p = 0.031) andchildren aged
ceived to be large (adjusted OR = 0.47, 95%CI: 0.33, 059 months from the Hill zone (adjusted OR = 0.68, 95%
0.67; p < 0.001) at the time of delivery were significantly CI: 0.50, 0.93; p = 0.015) were significantly less likely to be
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Table 3 Unadjusted and adjusted odds ratios (OR) (95% CI) for severely stunted children aged 023 and 059 months
Characteristic Severely stunted children 023 Months Severely stunted children 059 Months
Unadjusted p Adjusted p Unadjusted p Adjusted p
OR [95%CI] Odd Ratio OR [95%CI] Odd Ratio
(AOR) [95%CI] (AOR) [95%CI]
Parental factor
Maternal working status
Non-working 1.00 1.00
Working (past 12 months) 2.10 (1.16, 3.80) 0.015 1.10 (0.78, 1.55) 0.603
Maternal education
No education 1.00 1.00
Primary 0.69 (0.34, 1.42) 0.313 0.56 (0.37, 0.84) 0.005
Secondary and above 0.44 (0.21, 0.91) 0.027 0.35 (0.24, 0.52) <0.001
Partners occupation
Non agriculture 1.00 1.00
Agriculture 1.39 (0.77, 2.52) 0.270 1.75 (1.20, 2.54) 0.004
Not working 0.59 (0.10, 3.54) 0.558 0.40 (0.14, 1.15) 0.088
Partners education 1.00
No education 1.00 0.73 (0.46, 1.15) 0.172
Primary 0.62 (0.26, 1.47) 0.277 0.43 (0.28, 0.65) <0.001
Secondary and above 0.39 (0.19, 0.78) 0.008
Mothers age
15-24 years 1.00 1.00
25-34 years 1.29 (0.71,2.33) 0.406 1.07 (0.77, 1.49) 0.684
35-49years 4.50 (2.04, 9.94) <0.001 1.84 (1.28, 2.65) 0.001
Mothers age at birth
< 20 years 1.00 1.00
20-29 years 0.72 (0.36, 1.44) 0.351 0.79 (0.55, 1.14) 0.213
30-39 years 1.36 (0.60, 3.10) 0.457 1.17 (0.76, 1.79) 0.481
40 and above 5.85 (1.81, 18.96) 0.003 1.53 (0.76, 3.08) 0.232
Marital status
Currently married -' -' 1.00
Formerly married^ -' -' 0.76 (0.23, 2.54) 0.653
Birth order
First-born 1.00 1.00
2nd -4th 2.08 (1.14, 3.79) 0.017 1.39 (1.01, 1.90) 0.042
5 or more 4.68 (2.19, 10.00) <0.001 2.14 (1.39, 3.30) 0.001
Preceding birth interval
No previous birth 1.00 1.00 1.00
< 24 months 3.59 (1.75, 7.38) 0.001 2.38 (1.12, 5.03) 0.024 2.25 (1.51, 3.34) <0.001
> 24 months 2.21 (1.18, 4.14) 0.014 1.54 (0.80, 2.99) 0.195 1.36 ( 0.97, 1.89) 0.073
Type of delivery assistance
Health professional 1.00 1.00 1.00 1.00
Traditional birth attendant 1.56 (0.20, 12.33) 0.674 1.58 (0.19, 13.14) 0.670 1.08 (0.24, 4.82) 0.922 0.65 (0.14, 3.11) 0.589
Relatives or other 3.67 (1.91, 7.03) <0.001 2.15 (0.98, 4.72) 0.056 2.65 (1.83, 3.83) <0.001 1.55 (1.05, 2.31) 0.029
No one 7.32 (2.53, 21.22) <0.001 3.69 (1.14, 11.93) 0.029 7.07 (3.84, 13.01) <0.001 2.88 (1.47, 5.67) 0.002
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Table 3 Unadjusted and adjusted odds ratios (OR) (95% CI) for severely stunted children aged 023 and 059 months
(Continued)
Combined Place and mode of delivery
Home delivery 1.00 1.00
Health facility with non-caesarean 0.33 (0.18,0.60) <0.001 0.41 (0.29, 0.58) <0.001
Health facility with caesarean 0.37 (0.07,1.90) 0.231 0.16 (0.04, 0.59) 0.006
Timing of postnatal check-up
No postnatal check-up 1.00 1.00
0-2 days 0.44 (0.23,0.85) 0.014 0.34 (0.23, 0.51) <0.001
Delayed 0.33 (0.11, 0.97) 0.045 0.29 (0.14, 0.62) 0.001
Antenatal clinic visits
None 1.00 1.00
1-3. 0.72 (0.34,1.49) 0.372 0.77 (0.52, 1.15) 0.201
4+ 0.50 (0.25,1.01) 0.053 0.46 (0.30, 0.71) 0.001
Currently breastfeeding
Yes 1.00 1.00 1.00
No 0.86 (0.27, 2.70) 0.789 0.58 (0.41, 0.82) 0.002 0.49 (0.34, 0.69) <0.001
Duration of breastfeeding
Up to 12 months 1.00 1.00 1.00 1.00
> 12 months 2.90 (1.81, 5.22) <0.001 2.87 (1.54, 5.34) 0.001 3.75 (2.30, 6.11) <0.001 4.15 (2.49, 6.93) <0.001
Mothers literacy
Cant read at all 1.00 1.00 1.00
Can read 0.55 (0.31, 0.97) 0.039 0.42 (0.31, 0.59) <0.001 0.61 (0.43, 0.86) 0.005
Child level factors
Sex of baby
Male 1.00 1.00 1.00
Female 0.46 (0.29, 0.72) 0.001 0.44 (0.28, 0.71) 0.001 0.95 (0.72, 1.26) 0.710
Perceived size of baby at birth
Small 1.00 1.00 1.00
Average 0.65 (0.37, 1.14) 0.133 0.70 (0.50, 0.98) 0.038 0.81 (0.57, 1.16) 0.243
Large 0.46 (0.20, 1.07) 0.070 0.43 (0.27, 0.68) <0.001 0.47 (0.29, 0.74) 0.001
Childs age in months 2.62 (1.41, 4.86) 0.002 1.23 (1.14, 1.33) <0.001
Child had diarrhoea recently
No 1.00 1.00
Yes 1.53 (0.80,2.93) 0.201 1.01 (0.69, 1.47) 0.968
Child had fever in last two weeks
No 1.00 1.00
Yes 1.50 (0.85, 2.65) 0.165 0.89 (0.64, 1.23) 0.478
Household level factors
Household Food Insecurity (Access)
Food secure 1.00 1.00
Mildly insecurity 1.77 (0.50, 6.34) 0.377 0.85 (0.43, 1.68) 0.637
Moderately 2.88 (1.27,6.55) 0.012 1.61 (1.06, 2.43) 0.024
Severely 4.80 (2.00, 11.50) <0.001 2.41 (1.47, 3.96) 0.001
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Table 3 Unadjusted and adjusted odds ratios (OR) (95% CI) for severely stunted children aged 023 and 059 months
(Continued)
Wealth Index
poorest 1.00 1.00 1.00 1.00
poorer 0.82 (0.42, 1.60) 0.558 0.81 (0.40, 1.66) 0.566 0.76 (0.52, 1.11) 0.156 0.91 (0.61, 1.36) 0.638
middle 0.42 (0.20, 0.87) 0.020 0.49 (0.22, 1.05) 0.067 0.45 (0.30, 0.69) <0.001 0.60 (0.40, 0.91) 0.016
richer 0.28 (0.11, 0.69) 0.006 0.36 (0.14, 0.93) 0.034 0.33 (0.20, 0.53) <0.001 0.49 (0.30, 0.82) 0.007
richest 0.19 (0.06, 0.60) 0.005 0.33 (0.10, 1.15) 0.081 0.19 (0.11, 0.33) <0.001 0.40 (0.20, 0.80) 0.009
Source of drinking water
Unprotected 1.00 1.00
Protected 0.91 (0.48,1.74) 0.779 0.87 (0.52, 1.24) 0.455
Community level factors
Type of residence
Urban 1.00 1.00
Rural 1.62 (0.79, 3.30) 0.187 3.00 (1.86, 4.83) <0.001
Caste group
B/C (Hill and Terai) 1.00 1.00
Newar 0.84 90.22,3.25) 0.796 0.82 (0.31, 2.13) 0.682
Hill Janajati 0.97 (0.45, 2.09) 0.935 1.25 (0.87, 1.80) 0.233
TeraiJanajati and other terai castes 0.99 (0.38, 2.64) 0.997 1.30 (0.72, 2.38) 0.385
Dalit 1.35 (0.68, 2.69) 0.389 1.74 (1.24, 2.44) 0.001
Muslim and others 0.69 (0.26, 1.87) 0.468 0.92 (0.46, 1.85) 0.825
Ecological Zone
Mountain 1.00 1.00
Hill 0.81 (0.39, 1.68) 0.565 0.69 (0.47, 1.01) 0.059
Terai 0.60 (0.28, 1.29) 0.191 0.63 (0.42, 0.94) 0.025
Geographic Zones
Eastern 1.00 1.00
Central 1.46 (0.64, 3.30) 0.363 1.37 (0.86, 2.20) 0.184
Western 2.13 (0.91, 5.03) 0.083 1.23 (0.72, 2.09) 0.449
Mid-western 2.41 (1.16, 5.00) 0.018 1.77 (1.12, 2.81) 0.015
Far-western 1.70 (0.68, 4.25) 0.254 1.46 (0.85, 2.52) 0.168
^
divorced/separated/widowed.
Household food insecurity scores: Food secure (score, 0); mildly insecurity (score, 12), moderately (score, 310) and severely (score, 1027).

stunted compared with those who lived in the Mountains. parental-, child-, household- and community-level factors
In the final model for stunted children aged 059 months, of children aged 023 months and 059 months. Girls aged
we removed household wealth index and replaced it with 023 months had statistically significantly reduced odds of
household food security and our result revealed that house- being severely stunted compared to boys aged 023 months
holds who reported moderate and severe food insecurity (AOR = 0.44, 95% CI: 0.28, 0.71; p = 0.001). Children
were 1.37 times and 1.67 times more likely to be stunted aged 023 months from rich household had reduced
than those who reported food security (adjusted OR = 1.37, odds of being severely stunted (AOR = 0.36, 95%CI: 0.14,
95%CI: 1.02, 1.85; p = 0.039 for moderately food inse- 0.93; p = 0.034) compared with those from poorest house-
cure households and adjusted OR = 1.67, 95%CI: 1.17, hold. Children aged 023 months who were delivered
2.38; p = 0.005) for severely food insecure households). without assistance to their mothers and mothers of chil-
dren with preceding birth interval less than 24 months
Risk factors for severe stunting were significantly more likely to be severely stunted than
Table 3 illustrates the unadjusted and adjusted odds ratios those children delivered by health professional and those
for the association between severely stunted children and with mothers with no previous birth. In the final model
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for severely stunted children aged 023 months, when among under-five children in Nepal, over the past 10 years,
household wealth index was removed and replaced with the prevalence remains consistently high [8]. This explains
household food security, the result indicated that household the fact that there are other underlying factors contributing
who reported severe food insecurity were 3.27 times more to the high rate of stunting among children aged less than
likely to be severely stunted than those who reported food five years. However, the reported prevalence of stunting
security (adjusted OR = 3.27, 95%CI: 1.30, 8.20; p = 0.016). and severe stunting among children aged under five years
Children aged 059 months who were delivered with in Nepal was within the highest range (40-58%) reported
assistance by relatives or others and those delivered with among other 20 developing countries [21].
no assistance were significantly more likely to be stunted This study indicated that increasing age of the child
compared with children who were delivered with assistance was significantly associated with stunting and severe stunt-
from a health professional. The odds for severely stunted ing and children aged 023 months significantly reported a
children aged 059 months for babies not currently being lower risk of stunting and severe stunting than those in the
breastfed and children whose mothers could not read de- older age group of 059 months. Similar results were found
creased significantly by 41% (adjusted OR = 0.49; CI: 0.34, by other researchers [22,23]. The finding could be explained
0.69; p < 0.001 for currently being breastfed children aged by the protective effect of breastfeeding as most chil-
059 months) and 51% (adjusted OR = 0.49; CI: 0.34, 0.69; dren in Nepal are breastfed even into the second year of
p < 0.001 for children whose mothers could read). Chil- life [24]. The high rate of stunting and severe stunting
dren aged 059 months who were breastfed for more observed among children 059 months may be associ-
than 12 months (adjusted OR = 4.15, 95%CI: 2.49, 6.93; ated with inappropriate food supplementation during
p < 0.001) were significantly more likely to be severely the weaning period [24,25].
stunted than those children aged 059 months who This study revealed that breastfed children for more
were breastfed for up to 12 months. than 12 months were significantly more likely to be
Children aged 059 months perceived by their stunted and severely stunted than those breastfed for
mothers to be large (adjusted OR = 0.47, 95%CI: 0.33, up to 12 months, which indicated that stunting and
0.67; p = 0.001) were significantly less likely to be stunted severe stunting correlated with prolonged duration of
than children of the same group perceived to be small breastfeeding. These findings support the study that
by their mothers at the time of delivery. Children aged stunting occurs most readily in the first 618 months
059 months from middle-income households (adjusted [26]. Another study [27] found that stunting was most
OR = 0.60, 95%CI: 0.40, 0.91; p = 0.016), richer households common among children aged 3647 months (51.89%)
(adjusted OR = 0.49, 95%CI: 0.30, 0.82; p = 0.007) and followed by 1223 age groups (50.64%) and it was low-
those from richest households (adjusted OR = 0.40, 95% est in the older age group of 4859 months (39.13%).
CI: 0.20, 0.80; p = 0.009) were significantly less likely to be These variations could be linked to other contributing
severely stunted than those children aged 059 months factors such as culture, exclusive breastfeeding status,
from poorest households. In the final model for severely time of initiation of complementary feeding, socioeco-
stunted children aged 059 months, when household nomic dynamics and parents educational status in that
wealth index was removed and replaced with type of resi- community [24,25].
dence, we observed that children aged 059 months who Another risk factor for stunting and severe stunting in
lived in rural areas were more likely to be severely stunted this age group was household wealth index. Our study
than their urban counterparts (adjusted OR = 1.99, 95%CI: revealed that children from poorest households were
1.23, 3.25; p = 0.006 for rural residence). more likely to become stunted or severely stunted com-
pared to those from middle-income, richer and richest
Discussion households. This finding suggests that a childs health
This paper presents the risk factors for stunting and severe status depends upon the socio-economic standing of
stunting among children aged 023 and 059 months their household. Also, educated mothers who are more
using the 2011 NDHS data. The findings from this study conscious about their childrens health and nutritional
would enable public health researchers to reshape and needs are most likely to come from richer households.
redesign new educational interventions to reduce the Previous studies among Peruvian, Cambodian and
prevalence of stunting in Nepal. The prevalences of Bangladeshi children found household wealth index to be
stunting and severe stunting in children less than 23 months a key predictor for stunting and severe stunting among
of age were as high as the global estimate of 27% [18] while children under five years of age [25,28-30]. The associ-
the prevalences of stunting and severe stunting in children ation between low income and stunting has been observed
aged 059 months were also high (NDHS, 2011) but in several other studies [25,29,31-33]. Rich households
slightly lower than those of Bangladesh and India [19,20]. have greater purchasing power for food and other con-
Despite many interventions to reduce the level of stunting sumer goods needed to ensure the health of children.
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Such children are therefore not likely to be exposed to from richest wealth quintiles compared with 22% of
conditions that would lead to stunting or severe stunting. mothers from richest wealth quintiles who delivered
Our study also revealed that children perceived by their their babies at home.
mothers to be small had a higher risk of being stunted Our study also found that breastfed children were
compared to those perceived to be average or large. These significantly less likely to be stunted compared to non-
findings were supported by studies previously conducted in breastfed children. Also, children born to mothers who
Pakistan and Mexico [34,35] which indicated that children could read were significantly less likely to be stunted
less than 24 months of age with lower birth weight were 3 compared to those born to mothers who could not read
times more likely to be stunted than children of the same at all. This reflects the importance of mother education
age group with normal or higher birth weight. As the inci- and breastfeeding in the development of healthy children
dence of low birth weight (<2.5 kg) is high (21%) in Nepal and has been reported in previous studies [30,31,33].
[21], prevention of intrauterine growth retardation, prema- We also found that children who were breastfed and
ture delivery and maternal malnutrition should be one of born to educated mothers were less likely to be stunted
the basis in public health level intervention strategy for in- compared to those who were not breastfed and born to
fant stunting. The assessment of the babys size at birth by uneducated mothers.
health-care providers could be significant in identifying In addition, our study showed that children resident in
children at risk of stunting. In our analysis, maternal age the Hill zone were significantly less likely to be severely
at childs birth was found to be an important risk factor stunted compared to those from the Mountains. This
for childhood stunting and severe stunting. Children in finding is consistent with studies conducted in Bangladesh
the age group 023 months born to younger mothers [32,33] in which the region where a child was born played
(aged <20 years) were less likely to be stunted compared a significant role in predicting stunting. This association
with those born to older mothers (aged >20 years). These could be due to the nature of dietary intake, access to food
results were consistent with a study conducted in Iran and cultural diversity in that environment.
[36]. However, in the Iran study, it was found that children Replacing household wealth with household food inse-
born to mothers older than 35 years of age were more curity and type of residence in the final model, this study
likely to be stunted and severely stunted. On the contrary, found a strong association between household food inse-
a study in Mexico [35] found that maternal age at childs curity and stunting and severe stunting among children
birth was not a predictor for stunting. These discrep- aged 059 months and 023 months, respectively. These
ancies in findings could be attributed to differences in findings were consistent with a study carried out in
cultures, socioeconomic dynamics and nutritional fac- Colombia [38] which indicated that household food inse-
tors among the various communities, as the studies curity was significantly associated with stunting among pre-
were conducted in different continents of the world. school children. Our study also found that children aged
Among children aged 059 months, the type of deliv- 059 months who lived in the rural areas were significantly
ery assistance received was found to be a significant risk more likely to be stunted compared to their urban counter-
factor for stunting. Children who were delivered with as- parts. A two-stage cluster study carried out in Vietnam [23]
sistance from traditional birth attendants or relatives found that living in rural areas was a risk factor for malnu-
and those who were delivered without any assistance trition including stunting. This study also revealed that rich
were significantly more likely to be stunted compared to families were more likely to report food security and also
those who were delivered with assistance from health more likely to reside in urban areas.
professionals. This finding is supported by a study con- As the rate of stunting and severe stunting are still
ducted in India [37] in which children delivered at home high in Nepal, program intervention strategies target-
were more likely to be stunted compared to those deliv- ing long-term prevention of stunting in this country
ered at a health facility. In another study conducted in are needed to effectively and sustainably improve their
Bangladesh [33], it was reported that the place of delivery prevalence. Education of mothers and improvement of
and the assistance received were significantly associated household incomes should be given special attention.
with stunting and severe stunting among pre-school chil- This is because children born to uneducated mothers
dren. These findings could be explained by the health in- and from poor households have been found to have in-
formation given to mothers by health professionals during creased risk of stunting. In general, our findings are of
antenatal and postpartum periods. Possible health infor- major significance because they identify potential areas
mation that health professionals could offer to mothers for action plans that could improve and sustain the nu-
may include information on exclusive breastfeeding, initi- tritional status of children under-five years of age.
ation of complementary feeding as well as comprehensive One potential limitation of the study as a secondary data
care for the new-borns. Further analysis revealed that 78% analysis was that, there was no information on dietary
of mothers who go for institutional delivery are those habits or insufficient dietary practices to support stunted
Tiwari et al. BMC Pediatrics 2014, 14:239 Page 14 of 15
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and severely stunted children. Another limitation was the Massachusetts, USA. 3School of Science and Health, University of Western
indirect measure of household wealth in a developing Sydney, Sydney, New South Wales, Australia.

country such as Nepal. It is difficult to obtain consistent Received: 1 May 2014 Accepted: 22 September 2014
income and expenditure data in this country; however, an Published: 27 September 2014
asset-based index is generally considered a decent proxy
for household wealth status. References
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doi:10.1186/1471-2431-14-239
Cite this article as: Tiwari et al.: Determinants of stunting and severe
stunting among under-fives: evidence from the 2011 Nepal Demographic
and Health Survey. BMC Pediatrics 2014 14:239.

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