Khan et al.

BMC Public Health (2019) 19:358

https://doi.org/10.1186/s12889-019-6688-2

RESEARCH Open Access

ARTICLE

Determinants of stunting, underweight and wasting

among children < 5 years of age: evidence from
2012-2013 Pakistan demographic and health
survey
Sadaf Khan1,2*, Sidra Zaheer3 and Nilofer Fatimi Safdar3

Abstract
Background: Childhood malnutrition is a critical public health concern in Pakistan. We aimed to explore factors associated
with malnutrition in Pakistani children (< 5 years of age) using the Pakistan Demographic and Health Survey (PDHS) 2012–
2013.
Methods: Sample of 3071 Pakistani children aged 0–59 months from the PDHS 2012–2013, with complete anthropometric
measurements were included in the study. Nutritional status was evaluated using anthropometric indices; height-for-age, weight-for-
height and weight-for-age, as proxy measures of three forms of under-five malnutrition including stunting, wasting and
underweight respectively. Uni- and multivariate binary logistic regressions were used to examine the association between selected
maternal-socio-demographic and child level variables (such as child sex, age, size at birth, antenatal clinic visits, recent diarrheal
incidence and breastfeeding status) and three proxy measures of child nutritional status.
Results: About 44.4% of under-five children were stunted, 29.4% were underweight and 10.7% were wasted. Children whose mothers
lived in rural areas (aOR = 0.67, 95%CI 0.48–0.92), were aged ≥18 years at marriage (aOR = 0.76, 95%CI 0.59–0.99) and had visited
antenatal clinic more than 3 times during pregnancy (aOR = 0.61, 95%CI 0.38–0.98) were less likely to be stunted. Mother’s low
educational level (aOR = 2.55, 95%CI 1.26–5.17), short stature (aOR = 2.31, 95%CI 1.34– 3.98), child’s small size at birth (aOR = 1.67,
95%CI 1.14–2.45) and mother’s BMI were significantly associated with child’s underweight status. Children whose mothers had
no education were more likely to be wasted (aOR = 3.61, 95%CI 1.33–9.82).
Conclusion: The study suggests that most of the analysed factors that accounted for malnutrition in Pakistani children
(such as mother’s age at marriage, educational level and mothers’ nutritional status) are preventable. Therefore, to reduce
the burden of malnutrition interventions that can address these factors are required such as community based education
and targeted nutritional interventions.
Keywords: Malnutrition, Stunting, Wasting, Underweight, Children

* Correspondence: [email protected]
1
Department of Biochemistry, Dow International Medical College, Dow University of
Health Sciences, Karachi, Pakistan
2
Dow Research Institute of Biotechnology and Biomedical Sciences, Dow University of
Health Sciences, Karachi, Pakistan
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
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 Khan et al. BMC Public (2019) Page 2 of

Background in the country based on nationally representative data set.

Malnutrition remains a critical public health problem
Therefore, the current study utilized the nationally repre-
among children under the age of five years in
sentative Pakistan Demographic and Health Survey
developing countries including Pakistan. Malnutrition
(PDHS) 2012–2013 data, to examine the factors
is caused by multiple interlinked factors and has both
associated with malnutrition among Pakistani children
short and long term detrimental health effects [1, 2]. It
aged 0–59 months.
affects the cog- nitive and physical development of
children, increases the risk of infections and
significantly contributes to the child’s morbidity and Methods Study
mortality [3, 4]. Stunting, wasting and underweight are design Cross-
three widely recognized indicators of child's nutritional sectional.
status [5]. While stunting and wast- ing indicates
chronic and acute malnutrition respect- ively, Data set
underweight is a composite indicator and includes both Secondary analysis of the PDHS 2012–2013 data set was
acute (wasting) and chronic (stunting) malnutrition [5]. carried out. The PDHS 2012–2013 was a nationally rep-
However, different forms of malnutrition can also resentative third survey conducted by the National Insti-
occur concurrently in children [6]. tute of Population Studies (NIPS), Pakistan, as a part of
Malnutrition significantly contributes to the global the international MEASURE DHS (Demographic and
burden of several diseases. Globally, undernutrition ac- Health Surveys) program. The survey was carried out
counts for at least half of all the deaths annually in chil- with the support of ICF International and United States
dren under five [7]. In 2016, according to World Health Agency for International Development (USAID) [26].
Organization (WHO), at least 155, 52 and 99 million This survey collected the information of Pakistani
children under the age of five years were stunted, wasted households related to socio-demographic, maternal and
and underweight worldwide respectively [8, 9]. In child health indicators [26].
addition, around 6 million children were reported with
stunting and wasting simultaneously [6]. Malnutrition is Study sampling and participants
clustered in developing countries, particularly in Africa A two stage stratified sampling design was used in order
and South Asia [9, 10]. In South Asia, three countries of to obtain a nationally representative sample of Pakistani
the region, India, Pakistan and Bangladesh, have particu- households for the PDHS 2012–2013. The survey in-
larly high prevalence of the condition [11]. cluded the rural and urban population of all four prov-
In Pakistan, malnutrition is the major contributor of inces of Pakistan (Punjab, Sindh, Khyber Pakhtunkhwa
morbidity and mortality in children under five years of and Balochistan) and regions of Gilgit Baltistan and
age, and the country ranks 22nd in the world for under- Islamabad Capital Territory (ICT). However, the survey
five child mortality [12, 13]. The 2011 national nutrition did not collect the data from some parts of the country
survey reported that 44% of under-five children in including Federally Administrated Tribal Areas (FATA),
Pakistan were stunted, 15% were wasted and 31% were Azad Jammu and Kashmir (AJK) and restricted military
underweight [14]. The high magnitude of all three areas due to security concerns [26]. For the purpose of
indicators of malnutrition in country reflects the poor the PDHS 2012–2013, 13,944 households were selected
nutritional and health status among under-fives in coun- and interviews were successfully completed in 96%
try, thus necessitating the need to conduct this study to households by trained interviewers using the structurally
explore factors associated with malnutrition in Pakistani validated questionnaire. Women who were ever married
children.
(n = 14,569, age 15–49 years) were interviewed and an-
There are multiple factors that contribute to childhood
thropometric measurements of eligible children (n =
malnutrition. The common determinants reported by sev-
3466) were recorded from a subset of these households.
eral studies include socioeconomic inequalities, geograph-
Eligible children included were born within the five years
ical differences, suboptimal feeding practices, household
preceding the survey and had valid record of dates of
food insecurity, maternal literacy and childhood morbid-
birth. Measurements of children were recorded for both
ities [15–19]. Previous studies that have been conducted
height (in centimeter) and weight (in kilograms) using the
on childhood malnutrition in Pakistan were mostly based
digital SECA scales and measuring boards of Shorr pro-
on hospital, schools, regional and community settings
ductions. Recumbent length was measured in children
[20–23]. Limited studies, that have reported the national
who were either less than 2 years of age or 85 cm in length
level data, were either restricted to socio-demographic de-
and for the rest standing height was measured [26].
terminants or children less than two years of age [24, 25]. The sample of children (n = 3071, aged 0–59 months)
In addition, there is a paucity of literature regarding the that had complete anthropometric measurements were
correlates of all three indicators of childhood malnutrition
 Khan et al. BMC Public (2019) Page 3 of

selected from the subset of eligible children (n = 3466) status in the population and all the regression analysis
for the current analysis. models were adjusted to consider the complex sampling
design of the PDHS 2012–2013. The adjustment was
Evaluation of nutritional status of children < 5 years of age made by including the primary sampling units, final
We used three widely recognized anthropometric indices weights and strata in the models.
(height-for- age, weight-for-height and weight-for-age) to Two step wise models were constructed for the study,
assess the nutritional status of under-five children in the based on the categorization of the independent variables
PDHS 2012–2013 data set. The WHO Multicenter into sociodemographic-maternal and child level factors.
Growth Reference Study was used to calculate the three Model 0 reported the univariate association between
anthropometric indices in order to evaluate the nutri- child nutritional status and all independent study vari-
tional status [27]. The three indices were expressed in ables. Model 1 showed adjusted associations after in-
standard deviation (SD) units from reference population cluding type of residence, wealth index, mother’s
median. Children with Z-scores, below -2SD from the education level, employment status, age at marriage, par-
WHO reference population median, for height-for-age ity, access to information, consanguineous marriage,
(HAZ), weight-for-height (WHZ) and weight-for-age mother’s height and BMI. Model 2 reported the results
(WAZ) were considered stunted, wasted and under- after adjusting for child level factors which includes
weight respectively [26]. child age, sex, perceived child weight at birth, antenatal
clinic visits, recent diarrheal incidence, and breastfeeding
Study variables status. Results were given as crude odds ratios (cOR)
The coding plan of the selected study variables is given and adjusted odds ratios (aOR) with 95% confidence in-
in Table 1. To examine the factors linked with nutri- tervals (CI). P-values < 0.05 were considered statistically
tional status of the children less than 5 years of age, significant.
dependent variables were expressed as dichotomous var-
iables. The variables included category 0 [not stunted (> Ethical review
– 2SD), not wasted (> − 2SD to +2SD) and not The PDHS 2012–2013 has taken into account the
under- weight (> − 2SD)] and category 1 [stunted (< − stand- ard ethical guidelines of the measure DHS
2SD), wasted (< − 2SD) and underweight (< − 2SD)]. program [26]. The authors have obtained the data from
Obese children (WHZ above +2SD, n = 208) were not MEASURE DHS website (URL:
included in the analysis of wasted children (Table 2). https://www.dhsprogram.com/data/ available-
Explanatory variables were selected after conducting a datasets.cfm) following their data obtaining procedure.
de- tailed literature review [15–17, 19, 23, 24, 28] and However, no formal ethical clearance was ob- tained
only those variables showing association with nutritional because the study involved secondary analysis of
status of children and also available with complete publically available data.
information in the PDHS 2012–2013 data set were
included in the current analysis. Selected explanatory Results
variables were divided into two levels which included A total of 3071 children aged 0–59 months were in-
sociodemographic-maternal and child-level factors. Socio cluded in the study. Stunting (44.4%) was the most com-
demographic-maternal factors se- lected were types of mon nutritional abnormality observed in this study
residence, household wealth index, mother’s educational followed by underweight (29.4%) and wasting (10.7%)
level, employment status, age at mar- riage, parity, access (Table 2). Background characteristics of studied children
to information, consanguineous mar- riage, mother’s are presented in Table 3. Briefly, mean age of the chil-
height and mother’s body mass index (BMI). Child-level dren was 2.1 years (SD 1.4) of which majority were males
factors were sex of child, child age, child size at birth, (50.7%), lived in rural areas (56.7%) and had mothers
antenatal clinic visits, recent diarrheal incidence and with no formal education (52.3%). Only 20.4% of the
breastfeeding status. children had mothers with secondary education and
79.1% of the interviewed mothers were not working.
Statistical analysis About 20.6% of the children were from poorest house-
We used software SPSS 16.0 and SAS 9.1 for data ana- holds, whereas, 19.9% of the children were from richest
lysis. Analysis was done by descriptive statistics and lo- households. According to the maternal characteristics,
gistic regressions. Descriptive statistics were used to 41.7% of children had mothers who were married before
generate frequencies and to describe the study variables. 18 years of age, 62.3% had mothers who were consan-
Univariate and multivariate binary logistic regressions guineously married and 32.9% had mothers who had
were used to examine the determinants of all three indi- given birth to more than 5 children. About 22.3% of the
ces of child nutritional status. Prevalence of nutritional children had mothers who did not visit any antenatal
clinic during pregnancy, 28.0% had mothers who did not
 Khan et al. BMC Public (2019) Page 4 of

Table 1 Description and analysis coding plan of the selected study variables
Variables Description and Categorization Analysis Coding
Outcome variable
Stunting (Height-for-age index) Height/Age standard deviation (new WHO) 0 = Normal height-for-age/Not-stunted (HAZ -2SD and
(Continuous) Above) 1 = Stunted (HAZ < -2SD)
Underweight (Weight-for
age index) Weight/Age standard deviation (new WHO) 0 = Normal weight-for-age/Not-underweight (WAZ- 2SD
(Continuous) and Above) 1 = Underweight (WAZ < -2SD)
Wasting (Weight-for-height index) Weight/Height standard deviation (new WHO)
0 = Normal weight-for-height/Not-wasted (WHZ- 2SD
(Continuous)
to +2SD) 1 = Wasted (WHZ < -2SD)
Independent variables
Residence Type of place of residence (1 = Urban,2 = Rural) Used same coding for analysis
Mother’s educational level Highest educational level (0 = no education,1 =
Used same coding for analysis
primary,2 = secondary,3 = higher)
Wealth index Wealth index (1 = poorest, 2 = poorer, 3 = middle, 4 =
richer, 5 = richest) Used same coding for analysis

Mother’s employment status Respondent currently working (0 = Non-working, 1

Used same coding for analysis
= Working)
Mother’s access to information 1. Frequency of reading newspaper or magazine
Options for all the three variables were recoded as
2. Frequency of listening to radio
3. Frequency of watching television (0 = Not at all, 1 = follows
Occasionally, 2 = Atleast once a week, 3 = Daily) 0 as 0 = No (No Access)
1,2&3 as 1 = Yes (Access to at least one of the
information source)
Consanguineous marriage Blood relation with husband (0 = No, 1 = Yes) Used same coding for analysis
Mother’s age at marriage Age at first cohabitation (Continuous,Range:10–49) Constructed as
1= < 18
2= > 18
Parity Total children ever born (Continuous,Range:1–19) Constructed as
1= 1–4
2= > 4 (5+)
Mother’s height (cm) Respondent’s height in centimeters (1
Constructed as follows 1
decimal)(Continuous)
= Normal (>145 cm)
2 = Short Stature (< 145 cm)
Mother’s BMI (kg/m2) Body Mass Index (Continuous, calculated using
1 = Underweight (<18.5 kg/m2)
measured height and weight)
2 = Normal (18.5–24.9 kg/m2)
3 = Overweight (25.0–29.9 kg/m2)
4 = Obese (≥ 30 kg/m2)
Age of Child (years) Current age of the child (Continuous) Constructed as
0 = < 12 months
1= 12–23 months
2= 24–35 months
3= 36–47 months
4= 48–59 months
Sex of child Sex of child (1 = Male, 2 = Female) Used same coding for analysis
Child size at birth Size of child at birth
Options were recoded as follows 4
(1 = very large,2 = larger than average,3 = average,4 =
& 5 as 1 = smaller than average
smaller than average,5 = very small,6 = Don’t know)
3 & 6 as 2 = average
1 &2 as 3 = larger than average
Antenatal clinic visits Number of antenatal visits during pregnancy (0
Constructed as follows
= No antenatal visit, 98 = Don’t know)
0 & 98 as 0 = No Visit 1–3 as 1 = Less frequent visits Visit
frequency > 3 as 2 = Frequent visits (3+)
Recent diarrheal incidence
Had diarrhea recently (0 = No,1 = Yes, last 24 h,2 = Yes, last Recoded as
(last two weeks)
2 weeks, 8 = Don’t Know) 0as 0 = No
1&2as1 = Yes 8
= Excluded
Breastfeeding status Duration of breastfeeding (93 = Ever breastfeeding,
Used same coding for analysis (No data were found for
94 = Never breastfeed, 95 = Still breastfeeding, 96 = Breastfed
until died,97 = Inconsistent, 98 = Don’t know) 96,97,98)
 Khan et al. BMC Public (2019) Page 5 of 15

Table 2 Prevalence of different forms of malnutrition in Pakistani children aged 0-59 months (n = 3071)
Variable N Weighted % Mean (SD)
Stunting (HAZ)
-2SD and above (Normal/Non-stunted) 1691 55.59 −0.57 ± 0.04
Below -2SD (Moderately stunted) 587 21.14 – 2.48 ± 0.01
Below -3SD (Severely stunted) 793 23.27 −3.97 ± 0.03
Mean Z score (SD) −1.77 ± 0.04
Underweight (WAZ)
-2SD and above (Normal/Not-underweight) 2255 70.62 −0.77 ± 0.03
Below -2SD (Moderately underweight) 549 19.97 – 2.46 ± 0.02
Below -3SD (Severely underweight) 267 9.41 −3.68 ± 0.05
Mean Z score (SD) −1.38 ± 0.04
Wasting (WHZ)
Above +2SD (obese) 208 3.27 2.84 ± 0.09
-2SD to +2SD (Normal/Not-wasted 2544 86.05 −0.35 ± 0.02
Below -2SD (Moderately wasted) 217 7.56 – 2.34 ± 0.02
Below -3SD (Severely wasted) 102 3.12 −3.68 ± 0.06
Mean Z score (SD) −0.50 ± 0.04
Stunted, underweight and wasted children include both moderately and severely stunted, underweight and wasted children respectively. Obese (WHZ above
+2SD) were not included in the wasted children analysis

have access to any source of information and 21.9% of (cOR = 1.38, 95%CI 1.04–1.81), consanguineous marriage
the children had diarrhea in last two weeks before the (cOR = 1.74, 95%CI 1.36–2.23) and male sex of the child
survey was conducted. (cOR = 1.30, 95%CI 1.03–1.63) were risk factors for child’s
low weight-for-age status. Multivariate analysis with the
Determinants of stunting
addition of maternal and child related factors (Model 1
Univariate analysis (Model 0) indicated that children and Model 2) indicated that mother’s educational level
born to mothers that lived in rural areas (cOR = 1.57, (aOR = 2.55, 95%CI 1.26–5.17), child’s small size at birth
95%CI 1.25–1.96), had no education (cOR = 4.66, 95%CI (aOR = 1.67, 95%CI 1.14–2.45) and mother’s nutritional
3.10–7.00), had married consanguineously (cOR = 1.64, status were significantly associated with child’s low
95%CI 1.31–2.05) and had the poorest wealth index weight-for-age status. Children whose mothers were short
(cOR = 5.41, 95%CI 3.91–7.48) were more likely to be in height (aOR = 2.31, 95%CI 1.34–3.98) and had a BMI <
stunted. Mother’s height was significantly associated 18.5 (aOR = 1.78, 95%CI 1.00–3.17) were more likely be
with child stunting as children whose mothers had short underweight (Table 5).
stature (< 145 cm) were more likely to be stunted (cOR
= 3.05, 95%CI 1.68–5.55). This association remained the Determinants of wasting
same after the adjustment of all other factors in Model 1 Multivariate analysis with the addition of maternal and
and 2. However, children whose mothers were aged ≥18 child related factors (Model 1 and Model 2) indicated that
years at marriage (aOR = 0.76, 95%CI 0.59–0.99) and children whose mothers had no education were more
children whose mothers had visited antenatal clinics likely to be wasted (aOR = 3.61, 95%CI 1.33–9.82). Simi-
more than 3 times during pregnancy (aOR = 0.61, 95%CI larly, children whose mothers had a BMI < 18.5 were more
0.38–0.98) were less likely to be stunted. Children within likely to be wasted as compared to the children of obese
the age group of 24–35 months (aOR = 3.65, 95%CI mothers (aOR = 2.79, 95%CI 1.15–6.73) (Table 6).
2.23–5.95) and children that were of smaller than aver-
age size at the time of birth (aOR = 1.48, 95%CI 1.02– Discussion
2.16) were more likely to be stunted (Table 4). This study presents the risk factors associated with child
malnutrition in terms of stunting, underweight and
Determinants of underweight
wasting among under-five Pakistani children using the
Univariate analysis (Model 0) indicated that rural 2012–2013 PDHS data. Our study showed that place of
residence (cOR = 1.52, 95%CI 1.17–1.97), poorest wealth
residence, wealth index, BMI of mother, mothers’ age at
index (cOR
marriage, child size at birth and antenatal clinic visits
= 5.01, 95%CI 3.47–7.22), mother’s employment status
 Khan et al. BMC Public (2019) Page 6 of 15

Table 3 Socio-demographic characteristics of Pakistani children in the age range of < 5 years (n = 3071)
Variables Total Stunted Underweight Wasted
Maternal factors n % (%) (%) (%)
Residence
Urban 1330 43.3 39.9 21.4 9.8
Rural 1741 56.7 48.8 30.5 10.9
Mother’s educational level
No education 1606 52.3 55.0 34.0 12.3
Primary 497 16.2 45.7 26.8 8.9
Secondary 626 20.4 29.1 15.7 8.3
Higher 342 11.1 25.7 11.4 7.6
Wealth index
Poorest 634 20.6 62.3 37.9 12.8
Poorer 613 20.0 54.8 32.8 11.1
Middle 554 18.0 44.0 25.8 10.6
Richer 658 21.4 38.8 20.7 8.8
Richest 612 19.9 24.5 15.7 8.7
Mother’s employment status (n = 3064)
Non-Working 2423 79.1 43.0 24.8 10.4
Working 641 20.9 52.7 33.4 10.3
Mother’s age at marriage (years)
< 18 1281 41.7 52.1 31.9 11.0
≥ 18 1790 58.3 39.8 22.7 9.9
Parity
1–4 2060 67.1 40.7 26.4 10.1
5+ 1011 32.9 53.5 26.9 10.9
Mother’s access to information
No 859 28.0 54.1 32.5 12.5
Yes 2212 72.0 41.1 24.3 9.6
Consanguineous marriage
No 1159 37.7 38.4 21.0 9.8
Yes 1912 62.3 48.9 30.0 10.7
Mother’s height (cm) (n = 3064)
Short Stature (< 145 cm) 132 4.3 70.5 50.0 11.4
Normal (≥ 145 cm) 2924 95.7 43.9 25.6 10.4
2
Mother’s BMI (kg/m ) (n = 3061)
Underweight (<18.5 kg/m2) 364 11.9 58.5 45.3 15.7
2
Normal (18.5–24.9 kg/m ) 1657 54.3 45.6 28.2 11.1
Overweight (25.0–29.9 kg/m2) 696 22.8 43.1 18.7 8.5
2
Obese (≥ 30 kg/m ) 336 11.0 32.1 16.1 5.1
Child Factors
Sex of child
Male 1558 50.7 46.8 28.2 11.6
Female 1513 49.3 43.0 24.9 9.2
Child size at birth (n = 3066)
Smaller than average 542 17.7 51.8 34.7 12.7
 Khan et al. BMC Public (2019) Page 7 of 15

Table 3 Socio-demographic characteristics of Pakistani children in the age range of < 5 years (n = 3071) (Continued)
Variables Total Stunted Underweight Wasted
Maternal factors n % (%) (%) (%)
Average 2280 74.4 44.7 25.4 10.0
Larger than average 244 8.0 32.0 18.4 8.6
Antenatal clinic visits (n = 1967)
None 439 22.3 57.4 33.0 13.9
1–3 716 36.4 44.4 30.0 12.7
3+ 812 41.3 33.1 20.0 10.8
Recent diarrheal incidence (last two weeks) (n = 3076)
No 2395 78.1 44.8 25.4 9.6
Yes 672 21.9 45.7 31.0 13.4
Breastfeeding status (n = 3066)
Ever breastfeed 2016 65.8 48.5 25.3 8.0
Never breastfed 84 2.7 33.3 19.0 8.3
Still breastfeeding 966 31.5 38.6 29.8 15.4
Age of Child (months)
0 (< 12 months) 580 18.9 25.0 24.0 15.2
1 (12-23 months) 551 17.9 45.2 28.7 15.6
2 (24-35 months) 652 21.2 54.3 28.5 8.1
3 (36-47 months) 633 20.6 50.1 25.6 7.7
4 (48–59 months) 655 21.3 48.1 26.1 6.6
Region
Punjab 1018 33.1 37.7 23.8 8.3
Sindh 704 22.9 55.1 40.1 12.9
Khyber Pakhtunkhwa 541 17.6 37.9 24.0 11.5
Balochistan 292 9.5 78.8 33.6 12.7
Gilgit Baltistan 301 9.8 41.5 12.0 7.0
Islamabad capital territory (ICT) 215 7.0 22.3 13.0 11.2

have significant independent association with child nu- Our study showed that among the various factors re-
tritional status. The magnitude of malnutrition observed
lated to stunting, household wealth index was most sig-
in this study reinforced the need to take actions to im-
nificantly associated. The odds of being stunted were
prove the nutritional status of children in Pakistan. The
substantially higher among children with lowest socio-
most common form of malnutrition among the studied
economic background. This finding was in line with pre-
population (n = 3071) was stunting (44.4%) followed by
vious cross-sectional studies carried out in countries
underweight (29.4%) and wasting (10.7%).
such as Bangladesh, Nepal and Peru [15, 16, 31]. Socio-
In Pakistan, the prevalence of stunting in children < 5
economic status has an impact on household food security
years is very high (44%) as compared to other neighbor-
and subsequently the growth of children [19]. Children
ing regional countries like Bangladesh (36%) and Nepal
from poor households have limited access to food and
(35.8%) [15, 29]. The magnitude of stunting was only re-
health services, which makes them more sus- ceptible to
duced by 5% when compared with the country’s previous
growth failures [19]. Therefore, policies which are
demographic health survey conducted in 1990–1991
focused on poverty alleviation and improving the
[30]. This showed that the prevalence of stunting in
nutritional status of poorer children (either through cash or
Pakistan remains consistently high over past 20 years.
food support program [32, 33]) are needed to address the
This study highlights both maternal and child factors,
under-five malnutrition issue in Pakistan.
associated with stunting, that should be thoroughly in-
Mother’s nutritional status is associated with child’s
vestigated for implementing appropriate interventions to
nutritional state [17]. The risk of wasting and under-
reduce the burden of stunting in Pakistan.
weight was higher in those children whose mothers’
 Khan et al. BMC Public (2019) Page 8 of 15

Table 4 Univariate and multivariate analysis of Stunting (Height-for-age index)

Variables Model 0 (n = 3071) Model 1 (n = 3046) Model 2 (n = 1950)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Maternal factors
Residence
Urban 1 1 1
Rural 1.57 (1.25–1.96) < 0.01 0.70 (0.53–0.92) 0.01 0.67 (0.48–0.92) 0.01
Mother’s educational level
Higher 1 1 1
Secondary 1.28 (0.80–2.00) 0.28 0.98 (0.62–1.55) 0.94 0.93 (0.56–1.56) 0.80
Primary 3.21 (1.96–5.24) < 0.01 1.95 (1.15–3.28) 0.01 1.40 (0.79–2.50) 0.24
No education 4.66 (3.10–7.00) < 0.01 2.11 (1.29–3.43) < 0.01 1.59 (0.88–2.88) 0.12
Wealth index
Richest 1 1 1
Richer 2.01 (1.39–2.91) < 0.01 1.70 (1.14–2.52) < 0.01 1.23 (0.76–2.00) 0.41
Middle 2.22 (1.55–3.17) < 0.01 1.60 (1.02–2.53) 0.04 1.20 (0.66–2.17) 0.53
Poorer 4.16 (2.93–5.88) < 0.01 2.64 (1.59–4.39) < 0.01 1.72 (0.93–3.18) 0.08
Poorest 5.41 (3.91–7.48) < 0.01 3.22 (1.86–5.59) < 0.01 2.09 (1.05–4.14) 0.03
Mother’s employment status
Non-working 1 1 1
Working 1.45 (1.18–1.77) < 0.01 0.94 (0.77–1.16) 0.61 0.92 (0.73–1.16) 0.49
Mother’s age at marriage (years)
< 18 1 1 1
>18 0.52 (0.42–0.64) < 0.01 0.79 (0.63–0.99) 0.04 0.76 (0.59–0.99) 0.04
Parity
1–4 1 1 1
5+ 1.40 (1.10–1.78) < 0.01 0.99 (0.76–1.29) 0.97 1.06 (0.78–1.45) 0.67
Mother’s access to information
No 1 1 1
Yes 0.53 (0.39–0.71) < 0.01 0.98 (0.66–1.45) 0.94 1.02 (0.68–1.53) 0.91
Consanguineous marriage
No 1 1 1
Yes 1.64 (1.31–2.05) < 0.01 1.22 (0.96–1.54) 0.09 1.19 (0.91–1.55) 0.20
Mother’s height (cm)
Normal (≥145 cm) 1 1 1
Short (< 145 cm) 3.05 (1.68–5.55) < 0.01 2.37 (1.34–4.23) < 0.01 1.91 (1.04–3.51) 0.03
Mother’s BMI (kg/m2)
Obese (≥30) 1 1 1
Overweight (25.0–29.9) 1.17(0.80–1.70) 0.41 1.11 (0.77–1.60) 0.56 1.36 (0.87–2.12) 0.17
Normal (18.5–24.9) 1.67 (1.13–2.47) < 0.01 1.20 (0.81–1.77) 0.35 1.34 (0.87–2.06) 0.17
Underweight (< 18.5) 2.39(1.47–3.88) < 0.01 1.42 (0.79–2.52) 0.23 1.72 (0.96–3.03) 0.06
Child Factors
Sex of child
Female 1 1
Male 1.28 (1.05–1.56) 0.01 1.47 (1.14-1.89) < 0.01
 Khan et al. BMC Public (2019) Page 9 of 15

Table 4 Univariate and multivariate analysis of Stunting (Height-for-age index) (Continued)

Variables Model 0 (n = 3071) Model 1 (n = 3046) Model 2 (n = 1950)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Age of Child (months)
0 (< 12) 1 1
1 (12–23) 2.33 (1.62–3.37) < 0.01 2.56 (1.67–3.91) < 0.01
2 (24–35) 2.92 (2.17–3.93) < 0.01 3.65 (2.23–5.95) < 0.01
3 (36–47) 2.42 (1.76–3.32) < 0.01 3.61 (2.05–6.25) < 0.01
4 (48–59) 2.13 (1.54–2.95) < 0.01 2.28 (1.16–4.46) 0.01
Child size at birth
Average 1 1
Smaller than average 1.56 (1.21–2.01) < 0.01 1.48 (1.02–2.16) 0.03
Larger than average 0.54 (0.34–0.86) 0.01 0.55 (0.33–092) 0.02
Antenatal clinic visits
None 1 1
1–3 0.57 (0.39–0.84) < 0.01 0.68 (0.45–1.00) 0.05
3+ 0.35 (0.24–0.51) < 0.01 0.61 (0.38–0.98) 0.04
Recent diarrheal incidence
No 1 1
Yes 1.14 (0.90–1.45) 0.26 1.06 (0.79–1.40) 0.67
Breastfeeding status
Never breastfed 1 1
Ever breastfed 1.49 (0.72–3.05) 0.27 0.94 (0.37–2.43) 0.91
Still breastfeeding 1.19 (0.58–2.45) 0.62 1.34 (0.50–3.55) 0.55
Model 0 = Univariate Analysis (cOR: Crude Odds Ratio)
Model 1 = Adjusted with Residence, mother’s education level, wealth index, mother’s employment status, mother’s age at marriage, parity, mother’s access to information,
consanguineous marriage, mother’s height and mother’s BMI (aOR: Adjusted Odds Ratio)
Model 2 = Model 1 + Sex of child, age of child, child’s size at birth, antenatal clinic visits, recent diarrheal incidence, and breastfeeding status (aOR: Adjusted Odds Ratio)

BMI were below normal (<18.5 kg/m2). Maternal height

address nutritional issues among young girls, pregnant
has been used as a marker to assess the intergenerational
and lactating women in country with different nutrition
health linkages between a mother and her offspring.
programs such as “Tawana Pakistan Project” [40]. How-
Previous evidence had shown several adverse health re-
ever, the female adolescent nutrition in Pakistan is very
lated consequences, including the nutritional outcomes,
recent and needs a greater focus.
in children of mothers of low height (or short stature)
Our analysis showed that children of mothers with no
[34, 35]. Thus, mother’s height can be used as
formal education were more prone to be acutely mal-
predictor of child’s nutritional status [36]. In our study,
nourished (wasted and underweight) as compared to
children of short stature mothers (height = < 145 cm) were
children of educated mothers. The association found in
found more likely to be stunted and underweight. These
this study between maternal education, wasting and
find- ings of the effect of mothers’ anthropometry
underweight in children is consistent with several previ-
(BMI and low height) on children were in accordance
ous studies [19, 41, 42]. Educated mothers are well in-
with previ- ous studies [17, 34, 37, 38]. Since
formed about the nutritional and health needs of their
mother’s nutritional and health status has critical
children and hence prefer to use better hygiene and
importance in early child growth and development [39],
sanitation facilities. Moreover, they make comparative
mother’s nutritional sta- tus should be considered when
choices of available health services over traditional prac-
making policies for redu- cing the child malnutrition.
tices for improved healthcare of their children [24].
Emphasis on reproductive health of adolescent females is
Early marriage (before 18 years) increased the risk of
now being considered very important in developing
child stunting and underweight. Young women are at an
countries, particularly for the outcome of improved
age when they still need to provide for their own growth
nutrition of children < 5 years of age [39, 40]. There
and developmental needs. Pregnancy in such women
have been efforts in the past to
 Khan et al. BMC Public (2019) Page 10 of

Table 5 Univariate and multivariate analysis of Underweight (Weight-for-age index)

Variables Model 0 (n = 3071) Model 1 (n = 3046) Model 2 (n = 1950)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Maternal factors
Residence
Urban 1 1 1
Rural 1.52 (1.17–1.97) < 0.01 0.69 (0.49–0.99) 0.04 0.80 (0.56–1.16) 0.25
Mother’s educational level
Higher 1 1 1
Secondary 1.64 (0.96–2.80) 0.06 1.43 (0.81–2.50) 0.21 1.24 (0.66–2.34) 0.51
Primary 3.42 (1.82–6.40) < 0.01 2.59 (1.26–5.31) < 0.01 1.75 (0.84–3.72) 0.14
No education 5.55 (3.51–8.77) < 0.01 3.18 (1.76–5.74) < 0.01 2.55 (1.26–5.17) < 0.01
Wealth index
Richest 1 1 1
Richer 1.57 (0.99–2.49) 0.05 1.18 (0.74–1.87) 0.49 0.86 (0.52–1.43) 0.57
Middle 1.90 (1.26–2.87) < 0.01 1.14 (0.68–1.90) 0.61 0.97 (0.56–1.71) 0.93
Poorer 2.80 (1.95–4.03) < 0.01 1.45 (0.86–2.51) 0.17 1.14 (0.63–2.05) 0.65
Poorest 5.01 (3.47–7.22) < 0.01 2.41 (1.32–4.39) < 0.01 1.78 (0.95–3.34) 0.06
Mother’s employment status
Non-working 1 1 1
Working 1.38 (1.04–1.81) 0.02 0.87 (0.66–1.15) 0.33 0.96 (0.67–1.38) 0.85
Mother’s age at marriage (years)
<18 1 1 1
>18 0.52 (0.40–0.66) < 0.01 0.76 (0.61–0.96) 0.02 0.78 (0.57–1.04) 0.09
Parity
1–4 1 1 1
5+ 0.96 (0.76–1.20) 0.73 0.68 (0.51–0.88) < 0.01 0.73 (0.50–1.05) 0.09
Mother’s access to information
No 1 1 1
Yes 0.55 (0.41–0.71) < 0.01 0.94 (0.69–1.29) 0.73 0.94 (0.65–1.36) 0.75
Consanguineous marriage
No 1 1 1
Yes 1.74 (1.36–2.23) < 0.01 1.27 (0.99–1.63) 0.05 1.14 (0.86–1.50) 0.34
Mother’s height (cm)
Normal (≥145 cm) 1 1 1
Short (< 145 cm) 2.87 (1.69–4.89) < 0.01 2.42 (1.48–3.92) < 0.01 2.31 (1.34–3.98) < 0.01
Mother’s BMI (kg/m2)
Obese (≥30) 1 1 1
Overweight (25.0–29.9) 0.87 (0.57–1.33) 0.53 0.82 (0.51–1.31) 0.41 0.79 (0.45–1.36) 0.39
Normal (18.5–24.9) 1.94 (1.25–3.01) < 0.01 1.44 (0.89–2.33) 0.13 1.30 (0.76–2.22) 0.33
Underweight (<18.5) 3.40 (2.19–5.26) < 0.01 2.04 (1.19–3.51) < 0.01 1.78 (1.00–3.17) 0.04
Child Factors
Sex of child
Female 1 1
Male 1.30 (1.03–1.63) 0.02 1.24 (0.94–1.63) 0.12
 Khan et al. BMC Public (2019) Page 11 of

Table 5 Univariate and multivariate analysis of Underweight (Weight-for-age index) (Continued)

Variables Model 0 (n = 3071) Model 1 (n = 3046) Model 2 (n = 1950)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Age of Child (months)
0 (< 12) 1 1
1 (12–23) 1.12 (0.77–1.64) 0.54 1.31 (0.88–1.94) 0.17
2 (24–35) 0.98 (0.72–1.33) 0.91 1.18 (0.70–1.96) 0.52
3 (36–47) 0.96 (0.67–1.39) 0.86 1.69 (0.89–3.21) 0.10
4 (48–59) 0.89 (0.62–1.28) 0.54 1.65 (0.80–3.35) 0.17
Child size at birth
Average 1 1
Smaller than average 1.69 (1.28–2.21) < 0.01 1.67 (1.14–2.45) <0.01
Larger than average 0.66 (0.41–1.06) 0.09 0.97 (0.53–1.76) 0.94
Antenatal clinic visits
None 1 1
1–3 0.81 (0.56–1.17) 0.26 1.03 (0.70–1.51) 0.78
3+ 0.46 (0.30–0.71) < 0.01 0.91 (0.57–1.46) 0.72
Recent diarrheal incidence
No 1 1
Yes 1.27 (0.99–1.62) 0.05 1.15 (0.85–1.55) 0.29
Breastfeeding status
Never breastfed 1 1
Ever breastfed 1.51 (0.63–3.59) 0.35 1.03 (0.43–2.46) 0.94
Still breastfeeding 2.08 (0.88–4.88) 0.09 1.71 (0.72–4.05) 0.22
Model 0 = Univariate Analysis (cOR: Crude Odds Ratio)
Model 1 = Adjusted with Residence, mother’s education level, wealth index, mother’s employment status, mother’s age at marriage, parity, mother’s access to information,
consanguineous marriage, mother’s height and mother’s BMI (aOR: Adjusted Odds Ratio)
Model 2 = Model 1 + Sex of child, Age of child, child’s size at birth, antenatal clinic visits, recent diarrheal incidence, and breastfeeding status (aOR: Adjusted Odds Ratio)

increases the drain of their already low reserve of nutri- Our study found that children who lived in urban areas
ents and thus increases the probability of delivering low of Pakistan were more vulnerable to become stunted.
birth weight infants [43]. These mothers are also at risk These results are consistent with the previous regional
to inadequately breastfeed their infants due to low studies carried out in Bangladesh and Iran [15, 46]. On
milk supply which results in undernourished children the contrary, several studies conducted in developing
[43, 44]. However, future studies and large scale na- countries (such as Nepal, Bangladesh, Malawi and Nigeria
tional surveys may be needed to record the age of etc.) have identified that children settled in rural areas, are
the first pregnancy, a more important factor than age at higher risk to be malnourished [47, 48]. In Pakistan, the
of marriage, to investigate relationships between high trend of stunting in urban areas may be due to the
mother’s age and child nutritional status. rapid urbanization of people migrating from rural areas
In our study several maternal factors are found to be as- for work and better living conditions. The increased inci-
sociated with child malnutrition (such as mother’s age at dence of stunting in urban areas could also be reflective of
marriage, education and nutritional status). These findings the dietary choices and life style of urban population [49].
indicate that nutrition interventional programs should, Our results showed that male children were more
therefore, encompass maternal socio-demographic factors likely to be stunted as compared to female children. The
for the betterment of nutritional status of children, below finding was consistent with the previous research re-
the age of five years, in Pakistan. Additionally, there is a ported that male children are more vulnerable to de-
need for national nutritional policy, focused on improving velop malnutrition because they require comparatively
both the maternal nutritional status (through adequate more calories for growth and development [46, 50]. One
food and micronutrients supplementation) and the better of the reasons for low caloric intake in children is their
care for infants and young children [45]. low socioeconomic status as observed in our study. This
 Khan et al. BMC Public (2019) Page 12 of

Table 6 Univariate and multivariate analysis of Wasting (Weight-for-height index)

Variables Model 0 (n = 2863) Model 1 (n = 2840) Model 2 (n = 1810)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Maternal factors
Residence
Urban 1 1 1
Rural 1.13 (0.75–1.72) 0.54 0.70 (0.42–1.14) 0.15 0.85 (0.49–1.46) 0.55
Mother’s educational level
Higher 1 1 1
Secondary 1.31 (0.56–3.15) 0.54 1.25 (0.52–3.27) 0.62 2.14 (0.87–5.85) 0.09
Primary 1.55 (0.76–3.25) 0.23 1.55 (0.69–3.44) 0.28 2.41 (0.89–7.15) 0.07
No education 2.46 (1.15–5.28) 0.02 1.87 (0.82–4.21) 0.13 3.61 (1.33–9.82) < 0.01
Wealth index
Richest 1 1 1
Richer 0.95 (0.60–1.56) 0.83 0.82 (0.45–1.49) 0.52 0.73 (0.34–1.58) 0.43
Middle 1.15 (0.70–1.98) 0.59 0.90 (0.44–1.84) 0.78 0.82 (0.35–1.93) 0.66
Poorer 1.21 (0.69–2.10) 0.49 0.87 (0.39–1.92) 0.73 0.72 (0.27–1.88) 0.50
Poorest 2.36 (1.40–3.98) < 0.01 1.69 (0.78–3.66) 0.18 1.65 (0.62–4.16) 0.32
Mother’s employment status (n = 3064)
Non-working 1 1 1
Working 0.94 (0.61–1.50) 0.81 0.66 (0.49–0.99) 0.04 0.72 (0.43–1.23) 0.24
Mother’s age at marriage (years)
<18 1 1 1
>18 0.77 (0.52–1.14) 0.19 1.03 (0.74–1.45) 0.85 0.93 (0.58–1.42) 0.69
Parity
1–4 1 1 1
5+ 1.07 (0.78–1.45) 0.68 0.96 (0.66–1.41) 0.85 1.10 (0.66–1.83) 0.67
Mother’s access to information
No 1 1 1
Yes 0.58 (0.40–0.83) < 0.01 0.78 (0.55–1.09) 0.14 0.94 (0.67–1.34) 0.76
Consanguineous marriage
No 1 1 1
Yes 1.20 (0.84–1.71) 0.31 1.01 (0.71–1.41) 0.95 0.96 (0.65–1.41) 0.83
Mother’s height (cm)
Normal (≥ 145 cm) 1 1 1
Short (< 145 cm) 1.46 (0.74–2.76) 0.24 1.30 (0.68–2.51) 0.42 1.29 (0.54–3.04) 0.55
Mother’s BMI (kg/m2)
Obese (≥30) 1 1 1
Overweight (25.0–29.9) 1.08 (0.50–2.25) 0.82 1.05 (0.48–2.28) 0.89 1.27 (0.51–3.15) 0.60
Normal (18.5–24.9) 1.85 (0.94–3.64) 0.07 1.61 (0.83–3.11) 0.15 1.77 (0.74–4.06) 0.19
Underweight (<18.5) 2.85 (1.43–5.68) < 0.01 2.39 (1.17–4.87) 0.01 2.79 (1.15–6.73) 0.02
Child Factors
Sex of child
Female 1 1
Male 1.15 (0.84–1.56) 0.38 1.25 (0.87–1.79) 0.21
 Khan et al. BMC Public (2019) Page 13 of

Table 6 Univariate and multivariate analysis of Wasting (Weight-for-height index) (Continued)

Variables Model 0 (n = 2863) Model 1 (n = 2840) Model 2 (n = 1810)
cOR (95% CI) p-value aOR (95% CI) p-value aOR (95% CI) p-value
Age of Child (months)
0 (< 12) 1 1
1 (12–23) 0.85 (0.57–1.25) 0.41 0.82 (0.52–1.30) 0.41
2 (24–35) 0.35 (0.23–0.54) < 0.01 0.26 (0.12–0.59) < 0.01
3 (36–47) 0.46 (0.23–0.98) 0.04 0.50 (0.18–1.41) 0.19
4 (48–59) 0.23 (0.13–0.41) < 0.01 0.25 (0.09–0.74) 0.01
Child size at birth
Average 1 1
Small 1.35 (0.89–2.03) 0.14 1.24 (0.78–1.96) 0.36
Large 0.66 (0.34–1.32) 0.25 0.78 (0.32–1.89) 0.59
Antenatal clinic visits
None 1 1
1–3 0.67 (0.39–1.14) 0.14 0.74 (0.46–1.16) 0.19
3+ 0.60 (0.29–1.17) 0.13 0.92 (0.51–1.67) 0.80
Recent diarrheal incidence
No 1 1
Yes 1.43 (1.02–1.98) 0.03 1.11 (0.74–1.64) 0.61
Breastfeeding status
Never breastfed 1 1
Ever breastfed 1.14 (0.36–3.78) 0.82 1.16 (0.32–3.87) 0.85
Still breastfeeding 2.42 (0.77–7.56) 0.12 0.82 (0.24–2.76) 0.74
Model 0 = Univariate Analysis (cOR: Crude Odds Ratio)
Model 1 = Adjusted with Residence, mother’s education level, wealth index, mother’s employment status, mother’s age at marriage, parity, mother’s access to information,
consanguineous marriage, mother’s height and mother’s BMI (aOR: Adjusted Odds Ratio)
Model 2 = Model 1 + Sex of child, age of child, child’s size at birth, antenatal clinic visits, recent diarrheal incidence, and breastfeeding status (aOR: Adjusted Odds Ratio)

may lead to increased susceptibility to stunting among are considered to be an indicator of access to health care
male children.
services and maternal health seeking behavior. This may
Our study also found that the odds of stunting signifi-
have indirect influence on child’s health both in the
cantly increased with child’s age. Children within the age
short and long term [52]. Previous studies have also
group of 12–59 months were more likely to be stunted
showed that access to health services are positively cor-
compared to younger children (less than 12 months).
related with child’s nutritional status [46, 53]. This find-
Similar findings were also reported by other studies con-
ing has important policy implications associated with
ducted in different parts of the world [16, 51]. The in-
access to either free or at least affordable health services
crease in child stunting with age, stresses the need of
to help in reducing the burden of childhood malnutri-
proper and timely initiation of supplementary feeding to
tion. Additionally, in Pakistan, there is a need to increase
meet the growing nutritional requirements of the chil-
the availability of quality primary health care facilities in
dren. Additionally, the risk of wasting was significantly
order to improve the child health status [54].
lower in children > 23 months as compared to children
Perceived child size at birth significantly determined
< 12 months. This data is consistent with previous find-
the nutritional status of the child [55], as low birth
ings that showed a decrease in wasting with child’s age
weight is considered to be an indicator of restricted
and thus, may be associated with the inclusion of other
intrauterine growth [56]. Our study found that chil-
food items along with breast milk in children’s diet
dren born with smaller than the average birth weight
after 6 months of age (15,17).
were more likely to be underweight, whereas those
Among the study population, children whose mother
born with larger than average weight were less likely
visited antenatal clinics more frequently were less likely
to be stunted. These findings were consistent with
to have chronic malnutrition (stunting). Antenatal visits
previous studies which showed that low birth weight
 Khan et al. BMC Public (2019) Page 14 of

infants have significantly higher odds of being stunted Consent for publication
and underweight later in life due to inadequate fetal Not applicable.

nutrition [57–59]. Competing interests

The strengths of our study includes the use of The authors declare that they have no competing interests.
nutritional data from the most recent population based
representative survey (PDHS-2012-13) to assess the mal- Publisher’s Note
nutrition in Pakistani children aged 0–59 months. Further- Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.
more, the survey had a large sample size and high
response rate (93%).The study also had certain limitations Author details
1
including the study design which was cross-sectional and Department of Biochemistry, Dow International Medical College, Dow University
of Health Sciences, Karachi, Pakistan. 2Dow Research Institute of Biotechnology and
hence, difficult to establish causal relationships between Biomedical Sciences, Dow University of Health Sciences, Karachi, Pakistan.
different variables. Moreover, micronutrient consumption 3
School of Public Health, Dow University of Health Sciences, Karachi, Pakistan.
and other dietary factors directly related to the nutritional
Received: 22 October 2018 Accepted: 20 March 2019
status of children were not available.

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