Mothers child care practices & nutrition profile of under-five children in a BARD program area

Introduction

The widespread malnutrition of Bangladesh throughout the country is a significant public health problem which hinders the national development. Under-five children are the worst victims of hunger and malnutrition. The infant mortality rate (IMR) is 41 per 1000 (2009) and under-five mortality rate is 52 per 1000 (2009) with annual number of under-five deaths of 171 per 1000 (2009). About 43% of under five children are stunted and 16% severely stunted, 17% of them are wasted and 3% severely wasted and 41% of them are underweight with 12% severely underweight (BDHS,2007)

UNICEF estimates that about 10 percent of under-five children in the world are wasted today. Stunting is much more common than wasting, affecting an estimated 32 percent of children worldwide. The combination of wasting and stunting mean an estimated 146 million children are underweight. Of the undernourished children in the world, more than half are found in South and Central Asia.

The three underlying causes of malnutrition in under-five children are inadequate food, inadequate health and inadequate care. Of these three, the least investigated has been the inadequate care. Care refers to care giving behaviors such as breastfeeding, diagnosing illness, determining when a child is ready for supplementary feeding, stimulating language and other cognitive capacities and providing emotional support. The relationship between care and nutrition is especially stronger for those who depend on others for feeding and for other actions that contribute to nutritional well being i.e. the under five children.

There has been little systematic investigation of child care practices. Almost all (98%) Bangladeshi children are breastfed for some period, 23% of infants put to the breast within 1 hour of birth, and 83% started breastfeeding within the first day. About 54% of children in rural Bangladesh are reported to be exclusively breastfed. Overall, only 36% of infants less than 6 months old are exclusively breastfed. Generally complementary foods are not introduced to infants before four months, with the average age of about 7 months. About 69% of children aged 6-9 months receive complementary foods while being breastfed. In about 87% children, breastfeeding is continued for about two years along with other foods. The rate of fully immunized children by 12 months of age in urban areas of Bangladesh has been found to be 81% on average with much more little in rural areas. Cleanliness of the child, mother and surroundings has been observed to be significantly correlated with child nutritional status and morbidity.

In Bangladesh, the mother is usually the main caregiver for the infant and very young child. The mother’s child care practices are influenced by international factors such as those related to equity, to availability of good health and education services; local factors such as land distribution, climate, water supply, and primary health care; and finally, family factors such as presence of other family members, type of house, availability of water, household hygiene, and mother’s knowledge. These factors, important to the child not only for survival but also to ensure optimal physical and mental development, and good health, are not in favorable conditions to the mother to practice good child care resulting in an increased under nutrition in under-five children. The current study will reveal these factors influencing mother’s child care practices and consequent nutrition profile of under- five years children in a BARD program area in Comilla district of Bangladesh.

Rationale

Adequate dietary intake and health status are the immediate determinants of good nutrition, but care-giving ultimately determines the delivery of adequate food and health to the child. Although closely linked to household food security, the actual amount of food ingested by the young child is determined by care-related feeding behaviors such as breast feeding, complementation, food preparation, and overseeing the progression of the child from complete dependence to partaking of adult family food. Similarly, care-related behaviors determine how available health services, for both preventive and curative purposes, are utilized to optimize child health and thereby influence nutrition. The current study may be used as a platform in which interventions may be planned to take actions to ensure adequate care of children including the protection of good caring

practices in the study area; to support mothers and families to help them in maintaining good caring practices when these are threatened or otherwise difficult; and to promote those caring practices likely to improve the nutrition and health of children.

Globally, nutritional status is considered the best indicator of the well- being of young children, a parameter for monitoring progress towards the achievement of Millennium Development Goals (MDGs), especially MDG 1. This study identifies the determinants of nutritional indicators of MDGs, which will contribute to policy intervention that will effectively influence health and nutritional outcomes of under five children, who are the future generation of tomorrow’s world.

Objectives

General objective:The study is undertaken to reveal mother’s child care practices and also to reveal the nutrition profile of

under-five children in the study area.

Specific objective: Specific objective includes to:

observe the nutrition profile of under-five children of the elected area through anthropometric indices (height, weight etc).identify breastfeeding practices, complementary feeding practices, hygienic practices, health-seeking behavior that are practiced in the selected study area. identify the resources available for mother’s good child care practices.observe the association of nutritional status of under-five years children with different variables (e.g. exclusive breastfeeding, complementary feeding etc).

Hypothesis

Health and nutritional status of under-five children of Joypur village are up to the mark. Most of the people’s income level is sufficient to meet their well-being. So the resources available to maintain good child caring practices are satisfactory. Again breastfeeding, complementary feeding, food preparation and storage and hygienic practices are good to maintain child’s nutritional well-being.

MethodologyStudy design:

The study was a census in nature. The components of the study were; (a) socio-demographic characteristics and related aspects; (b) service utilization; (c) child care practices; and (d) anthropometric information.

Study population: The objective of the study was to assess the nutritional status of the under-five children and mother’s child care practices in a BARD program area in Joypur (south and north) Comilla. So, all the households having at least one under-five children in that area were included in the study.

Study subjects:The study subjects included under-five children and their mothers of various groups of households of

Joypur (south and north).

Survey instruments:One printed structured questionnaire in Bengali was used for data collection. The questionnaire was

consisted of queries on identification of care resources, breastfeeding practices, complementary feeding practices, hygienic practices, service utilization and anthropometry. The questionnaire was framed and finalized by course-in-charge to conform the objectives of the study. For measuring anthropometric parameters, weighing machine (wt), height scale (ht) and specialized tape (MUAC) were used.

Duration of study (field-level data collection):The study (field-level data collection) was carried out during a period of 3 days from 24 th December to

26th December, 2010.

Data collection procedure:Before starting the field data collection, an overall idea on the location and its people was shared with

data collectors by a local officer of BARD. However in the field the data collection procedure was constantly supervised by course in charge with his scholarly guidance.

Data about resource for care:Information regarding care resources was collected as an essential part of the survey by a personal

interview with either the mother in most cases or the household head in some cases depending on their presence. Information such as number of family member and income earner, income level, monthly expenditure spent on food, education and medicine, maternal health and nutritional knowledge and safety and stability of the home environment were carefully investigated and recorded in the specified portion of the questionnaire.

Data about child care practices:Information on child care practices such as breastfeeding and complementary feeding practices, food

preparation practices, hygienic practices, psychosocial care and other caretaking behaviors (or practices regarding services utilization and trading) was collected through a close sitting with the mother and recorded in the specified portion of the questionnaire.

Anthropometric data: To assess the nutritional status, the anthropometric measures such as height (or length when necessary),

weight and MUAC of under- five children and their mothers was measured using approved and standardized method and recorded in the specified portion of the questionnaire.

Quality control:During survey (data collection phase) the quality of data was ensured by the supervisor. After each day’s

fieldwork, after dinner, the supervisor set together with all the enumerators, jointly check the completed questionnaires of the day and planned for the next day’s fieldwork. Any mistake or inconsistency arose was verified either with the households or informed sources and corrected.

A. Care Resources

1. Percent distribution of the respondents by monthly income (taka)

Income level Frequency Percent<5000 12 9.9

5000-9999 43 35.510000-14999 32 26.4

≥15000 34 28.1

The table displays the income level of the under-5 children’s family. It indicates that lowest percentage of (9.9%) family fall in to income level <500 & highest percentage (35.5%) family fall in the range 5000-9999.

2. Percent distribution of households according to monthly expenditure on basic needs

Basic needs Expenditure level Frequency Percent

Food

≤2000 9 7.42001-3500 22 18.23501-8000 76 62.8

>8000 14 11.6

Medicine

≤500 55 45.5

501-1500 37 30.6>1500 29 24.0

Education

<1000 79 65.3

1000-3000 34 28.1>3000 8 6.6

The table shows the monthly expenditure of the families in 3 three basic sectors (food, medicine, & education).

From the table we come to know that the highest percentage of the monthly income is expended on food by

most of the families.

3. Percent distribution of the under 5 children mothers by their literacy

Literacy Frequency PercentIlliterate 8 7

Can read & sign only 9 7.9Primary passed 14 12.3S.S.C. passed 10 8.8H.S.C. passed 12 10.5

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

Variable Category Frequency percent

Age<20 5 4.4

20-24 49 43.025-29 44 38.6≥30 16 14.0

BMI<18.5 14 12.3

18.5-24.9 68 59.6≥25.00 32 28.1

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

5. Safety and stability of the home environment

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

Having safe home environment

Frequency Percent

YES 87 71.9NO 34 28.1

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

Having stable home environment

Frequency Percent

YES 13 10.7NO 108 89.3

6. Maternal knowledge: percentage of mothers giving right or positive (YES) answer to different nutrition related questions

Question content Frequency Percent

Definition of balanced diet 48 39.7

Idea on nutritious food 76 62.8

Ideal milk for baby 118 97.5

Duration of exclusive breastfeeding

86 71.1

Etiology of diarrhea 32 26.4

Definition of malnutrition 36 30.8

The table shows 39.7%, 62.8%, 97.5%, 71.1%, 26.4%, 30.8% under-5 mothers think positively about balanced diet, nutritious food, milk as an ideal food for baby, duration of exclusive breast-feeding, diarrhea

& malnutrition respectively.

B. Breastfeeding Practices

1. Percent distribution of breastfeeding period

Breastfeeding period Frequency PercentUp to 6 months 26 21.5

7-18 months 20 16.5More than 18 months 75 62

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

2. Percent distribution of exclusive breastfeeding period

Exclusive breastfeeding period

Frequency Percent

<6 months 18 14.9

6 months 60 49.6>6 months 43 35.5

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

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

Question content Frequency PercentBaby getting adequate

breast-milk 99 81.8

Mother taking adequate food during lactation 86 71.1

Mother with hygienic practices before and after

breastfeeding98 81.0

The above table shows the overall situation of breastfeeding practices among under-five children’s mothers. During breastfeeding period, 71.1% mother take adequate food, and 81.0% follow hygiene practices.

C. Complementary Feeding Practices

1. Percent distribution of mothers giving complementary food to their child

Question Frequency PercentYES 108 89.3NO 13 10.7

2. Percent distribution of patterns of introducing complementary foods

Pattern Frequency PercentGradually 91 75.8Abruptly 29 24.2

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

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

Type Frequency PercentHome-made 98 81.7

Canned 8 6.7Others 14 11.7

From the table 3, we know the type of complementary food given to the child. It shows that 81.7% complementary food is homemade whereas 6.7% is canned.

4. Percent distribution of the complementary feeding’s frequency

Daily frequency Frequency Percent5-6 times 65 54.27-8 times 7 5.89-10 times 3 2.511-12 times 1 0.8

According to need 44 36.7

From the table 4, we know the frequency of complementary food offered to the child. The table shows that 54.2% under-five children receive 5-6 times feeding compared to 36.7% child, who receives complementary food according to need.

D. Psychosocial care

1. Percent distribution of babies in respect of playing

Answer Frequency PercentYES 109 93.2NO 8 6.8

2. Percent distribution of fathers taking care of baby

Answer Frequency PercentYES 69 59NO 48 41

From table 2, we have the idea of caring practices. Table 2 shows 59% of under-5 fathers taking care of their own babies in some way,

3. Percent distribution of care provider during eating of baby

Care provider Frequency PercentMother 100 85.5

Other family member 4 3.4Other member outside

family2 1.7

Baby itself 11 9.4

From table 3, we have the idea of caring practices. Table 3 shows, 85.5% mother play the role of main care provider during eating.

E. Food preparation and storage practices

1. Percent distribution of sources of water used for food preparation

Water source Frequency PercentTube-well 80 66.1

Well 3 2.5Pond 35 28.9

River/Lake 3 2.5

In 66.1% households, the source of water for food preparation is tube-well. Only 33.9% households use water from other sources like pond, lake etc.

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

Question content Frequency PercentWhether babies foods are

covered or not107 91.5

Whether babies food ,once cooked, are stored day long

43 36.8

F. Hygienic practices1. Percent distribution of babies with hygienic practices

Practices Frequency PercentUsing shoe(always) 72 59.5

Washing hands well before eating

101 86.3

Taking bath regularly 102 87.2Brushing teeth, cutting nail,

and wearing clean cloth regularly

88 75.2

G. Other care taking behaviour / practices

1. Percent distribution of under-five mothers giving “YES” answer to different health related questions

Question content Frequency PercentVaccination course completed or not

108 89.3

Babies taking VAC in last 6 months or not

84 71.8

Under 6 babies taking de-worming drugs or not

69 60

2. Percent distribution of choice for treating baby

Choice Frequency PercentAllopathic doctor having

degree78 67.8

Homeopathy 1 0.9Quack doctor 13 11.3

Kobiraj 1 0.9Paramedics 7 6.1

3. Percent distribution of treatments to prevent diarrhea

Treatment Frequency PercentHome-made saline 4 3.3

Saline packet 58 48.3Rice powder 17 14.2

Drugs 3 2.5Drugs and oral saline 35 29.2

Others 3 2.5

Nutritional profile of under-five children

H. Distribution of age and sex of sample

Age(months)Boys Girls Total Ratio

frequency percent frequency percent frequency percent Boy:Girl6-17 13 18.1 13 16.5 26 17.2 1:118-29 12 16.7 20 25.3 32 21.2 1:1.6730-41 11 15.3 20 25.3 31 20.5 1:1.8142-53 15 20.8 17 21.5 32 21.2 1:1.1354-59 21 29.2 9 11.4 30 19.9 1:0.43Total 72 100 79 100 151 100 1:1.08

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

Sex of the

memberAge(month)

Height(cm) Weight(kg) MUAC(cm)frequency mean SD frequency mean SD frequency mean SD

Male

<6 1 72.60 - 2 5.00 1.41 2 13.05 1.626-17 5 70.02 4.45 5 9.00 1.22 4 14.13 0.2218-29 6 81.08 2.88 6 10.41 1.85 6 14.40 1.1330-41 5 72.10 23.06 5 9.80 1.92 5 13.88 1.3142-53 4 94.97 8.81 4 12.50 3.08 4 14.05 0.1054-59 11 101.30 6.03 11 14.11 3.22 9 15.96 1.50Total 32 86.35 16.35 33 11.26 3.47 30 14.61 1.40

Female

<6 2 61.60 0.56 4 4.75 1.25 4 13.60 1.996-17 3 71.03 4.33 3 7.50 2.78 3 13.47 1.8118-29 9 77.56 5.72 10 9.95 1.84 9 14.00 1.1730-41 8 95.26 22.83 8 15.87 11.85 7 16.27 4.9542-53 9 93.44 4.44 9 12.72 2.77 9 14.84 1.1354-59 4 98.72 8.32 4 14.00 1.82 4 16.00 1.41Total 35 86.64 15.93 38 11.53 6.47 36 14.79 2.51

Total

<6 3 65.26 6.36 6 4.83 1.16 6 13.42 1.096-17 8 70.40 4.11 8 8.43 1.91 7 13.84 1.1118-29 15 78.97 4.98 16 10.12 1.80 15 14.16 1.1330-41 13 86.35 24.88 13 13.53 9.62 12 15.27 3.9442-53 13 93.91 5.75 13 12.65 2.74 13 14.60 1.0054-59 15 100.60 6.59 15 14.08 2.85 13 15.97 1.42Total 67 86.50 16.01 71 11.41 5.26 63 14.70 2.08

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

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

Age(months)

Number of

children

Prevalencewasting underweight stunting

Frequency percent frequency percent frequency percent

6-17 26 8 30.8 10 38.4 11 42.318-29 32 7 21.9 17 53.1 16 50.030-41 31 4 12.9 12 38.7 12 38.842-53 32 9 28.2 15 46.9 10 31.354-59 30 7 23.3 10 33.4 8 26.7 Total 151 35 23.1 64 42.4 57 37.7

According to this table, 23.1% of the under-five children are wasted, 42.4% are underweight and 37.7% are stunted.

K. Percent distribution of under-five children by MUAC category

MUAC(cm) Frequency Percent Nutritional Status≤12.49 20 11.8 Severely

malnourished12.50-13.49 18 10.7 Moderately

malnourished≥13.50 128 75.7 Normal

The above table shows that, according to the MUAC category, 22.5% under-five children are malnourished.

L. Prevalence of acute malnutrition by age based on weight for height z-scores

Age(months) FrequencySevere wasting(≤-3 z score)

Moderate wasting(>-3 and <-2 z

score)

Normal(≥-2 z score)

Frequency percent frequency percent frequency percent6-17 26 4 15.4 4 15.4 18 69.218-29 32 1 3.1 6 18.8 25 78.130-41 31 - - 4 12.9 27 87.142-53 32 6 18.8 3 9.4 23 71.954-59 30 4 13.3 3 10.0 23 76.7Total 151 15 9.9 20 13.2 116 76.8

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

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

Age(months) FrequencySevere underweight(≤-3 z score)

Moderate underweight(>-3 and<-2 z score)

Normal(≥-2 z score)

frequency percent frequency percent frequency percent6-17 26 5 19.2 5 19.2 16 61.518-29 32 8 25.0 9 28.1 15 46.930-41 31 7 22.6 5 16.1 19 61.342-53 32 4 12.5 11 34.4 17 53.154-59 30 5 16.7 5 16.7 20 66.7Total 151 29 19.2 35 23.2 87 57.6

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

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

Age(months) FrequencySevere stunting(≤-3 z score)

Moderate stunting(>-3 and <-2 z score) Normal

(≥-2 z score)Frequency percent frequency percent frequency percent

6-17 26 7 26.9 4 15.4 15 57.718-29 32 8 25.0 8 25.0 16 50.030-41 31 6 19.4 6 19.4 19 61.342-53 32 3 9.4 7 21.9 22 68.854-59 30 2 6.7 6 20.0 22 73.3Total 151 26 17.2 31 20.5 94 62.3

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

Conclusion

Malnutrition is still dominant problem in Bangladesh that has been evidenced in part by different studies, particularly National Nutrition Surveys. Nutrition is a multidimensional subject, which is related to adequate food intake and supply, proper care and health practice, hygiene and sanitation and socioeconomic condition of people.

In this study an attempt has been made to asses the mother’s child care practices and nutritional status of under-five children in Joypur village of Comilla. According to anthropometric analysis, the malnutrition exists which is expressed through the prevalence of stunting, wasting and underweight.

All (100%) children were breastfed at least for sum period. About 50% of under-five children were reported to be exclusively breastfed.

In 62% under five children, breastfeeding is continued for more than 18 months. Among them, 89%

receives complementary food while being breastfed.

In about 75% under five children, complementary foods are introduced gradually. About 81% mother give home-made complementary foods to their children.

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

About 68% mothers choose allopathic doctor having degree to treat their sick child.

Cleanliness of the child, mother and surroundings has been observed to be satisfactory. About 60% children always use shoe, 86% wash hands well before eating, 87% take bath regularly and

75% brush teeth, cut nail and wear clean cloth regularly. 81% under five children’s mothers follow hygienic practices before and after breastfeeding. 92% of the respondents store child’s foods covered. 64% do not store child’s foods, once cooked, day

long.

About 38% of under-five children were stunted and 17% severely stunted, 23% of them are wasted and 10% severely wasted and 42% of them are underweight with 19% severely underweight.

May be the survey findings do not reflect the actual situation due to the limitation of short duration, lack of skill and biased information from respondents. It is difficult to draw any conclusion from such an investigation.

Recommendation

The constraints to better nutritional status are mainly inadequate food intake, inadequate primary health services, lack of sanitation, hygienic condition, proper care etc. all of the constraints from the survey are should be removed.

The wasting rate is considerable amount under-five children. Wasting indicates acute malnutrition. So food supply and food intake as well as proper treatment of acute illness will reduce the wasting rate.

Mother should be motivated to eat more food during lactation. Family member should encourage mother

to do that.

Mother and household members should be motivated to seek health care facilities for their sick children and also for themselves.

Children should be fed colostrum. Breastfeeding should be started immediately after birth. Exclusive breastfeeding should be for 6 months.

Appropriate complementary foods should be given to the child besides breast-milk after 6 months of

age. The frequency of feeding should be according to need of the child. The style of feeding should be responsive.

Proper hygiene and sanitation practices should be improved, especially for the infant and children.

The most important is to carry out nutrition education activities. This component needs to be strengthened through all available channels.Emphasis should be given to ensure efficient use of available resources.

All these recommendations can be carried out by Governments and nongovernment organizations