Vous êtes sur la page 1sur 91

ANTSI

MA

TOA
Madagascar
2003
A/RIVO

FI

TOL

Nutrition of Young Children


and Mothers

ORC Macro
AFRICA NUTRITION CHARTBOOKS

NUTRITION OF YOUNG CHILDREN AND MOTHERS


IN MADAGASCAR
Findings from the 2003-2004 Madagascar Demographic and Health Survey

ORC Macro
11785 Beltsville Drive
Calverton, Maryland, USA

August 2005

This chartbook was produced by the MEASURE DHS program, which is funded by the U.S. Agency for International Development (USAID) through the Bureau
for Global Health, Office of Health, Infectious Diseases and Nutrition (GH/HIDN). The chartbook benefited from funds provided by the USAID Bureau for
Africa through its Office of Sustainable Development. Copies of this chartbook may be obtained by contacting the MEASURE DHS program, ORC Macro, at
the above address, or by telephone at (301) 572-0200, or by fax at (301) 572-0999, or on the web at www.measuredhs.com.
CONTENTS

INTRODUCTION............................................................................................................................................................................................................ 1
FIGURE 1: INFANT AND CHILD MORTALITY, MADAGASCAR COMPARED WITH OTHER SUB-SAHARAN COUNTRIES ................................................ 2
FIGURE 2: CONTRIBUTION OF UNDERNUTRITION TO UNDER-FIVE MORTALITY, MADAGASCAR .............................................................................. 4
FIGURE 3: SURVIVAL AND NUTRITIONAL STATUS OF CHILDREN, MADAGASCAR ..................................................................................................... 6
MALNUTRITION IN MADAGASCAR............................................................................................................................................................................ 9
FIGURE 4: MALNUTRITION AMONG CHILDREN UNDER FIVE YEARS, MADAGASCAR .............................................................................................. 10
FIGURE 5: CHANGES IN UNDERNUTRITION RATES AMONG CHILDREN UNDER FIVE YEARS, MADAGASCAR 1992, 1997, AND 2003-2004 ............ 12
FIGURE 6: STUNTING, WASTING, AND UNDERWEIGHT BY AGE, MADAGASCAR ..................................................................................................... 14
FIGURE 7: UNDERNUTRITION AMONG CHILDREN UNDER FIVE YEARS WHO DO NOT RESIDE WITH THEIR MOTHER, MADAGASCAR ................... 16
FIGURE 8: UNDERWEIGHT AMONG CHILDREN UNDER FIVE YEARS, MADAGASCAR COMPARED WITH OTHER SUB-SAHARAN COUNTRIES.......... 18
FIGURE 9: STUNTING AMONG CHILDREN UNDER FIVE YEARS, MADAGASCAR COMPARED WITH OTHER SUB-SAHARAN COUNTRIES.................. 20
CONCEPTUAL FRAMEWORK FOR NUTRITIONAL STATUS ................................................................................................................................. 22

IMMEDIATE INFLUENCES OF MALNUTRITION ...................................................................................................................................................... 25


FIGURE 10: CHILDREN UNDER FIVE YEARS LIVING IN HOUSEHOLDS WITH ADEQUATELY IODIZED SALT BY REGION, MADAGASCAR................. 26
FIGURE 11: NIGHT BLINDNESS AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS, MADAGASCAR .................................................................. 28
FIGURE 12: VITAMIN A SUPPLEMENTATION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY REGION, MADAGASCAR .......................... 30
FIGURE 13: VITAMIN A SUPPLEMENTATION AMONG CHILDREN AGE 6-59 MONTHS IN THE PAST SIX MONTHS BY REGION, MADAGASCAR ....... 32
FIGURE 14: ANEMIA AMONG CHILDREN AGE 6-59 MONTHS AND MOTHERS BY REGION, MADAGASCAR ............................................................. 34
FIGURE 15: IRON SUPPLEMENTATION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS, MADAGASCAR ....................................................... 36
FIGURE 16: DIARRHEA AND COUGH WITH RAPID BREATHING AMONG CHILDREN UNDER FIVE YEARS COMPARED WITH MALNUTRITION
RATES, MADAGASCAR .......................................................................................................................................................................... 38
UNDERLYING BIOLOGICAL AND BEHAVIORAL INFLUENCES OF MALNUTRITION ......................................................................................... 41
FIGURE 17: FERTILITY AND BIRTH INTERVALS, MADAGASCAR COMPARED WITH OTHER SUB-SAHARAN COUNTRIES......................................... 42
FIGURE 18: UNDERNUTRITION AMONG CHILDREN AGE 12-23 MONTHS BY MEASLES VACCINATION STATUS, MADAGASCAR ............................ 44
FIGURE 19: MEASLES VACCINATION COVERAGE AMONG CHILDREN AGE 12-23 MONTHS, MADAGASCAR COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 46
FIGURE 20: FEEDING PRACTICES FOR INFANTS UNDER SIX MONTHS, MADAGASCAR ............................................................................................ 48
FIGURE 21: INFANTS UNDER FOUR MONTHS WHO ARE EXCLUSIVELY BREASTFED AND THOSE WHO RECEIVE A BOTTLE, MADAGASCAR
COMPARED WITH OTHER SUB-SAHARAN COUNTRIES .......................................................................................................................... 50

iii
FIGURE 22: FEEDING PRACTICES FOR INFANTS AGE 6-9 MONTHS, MADAGASCAR ................................................................................................. 52
FIGURE 23: INFANTS AGE 6-9 MONTHS RECEIVING SOLID FOODS IN ADDITION TO BREAST MILK, MADAGASCAR COMPARED WITH
OTHER SUB-SAHARAN COUNTRIES....................................................................................................................................................... 54
FIGURE 24: CHILDREN AGE 10-23 MONTHS WHO CONTINUE TO BE BREASTFED, MADAGASCAR COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 56
UNDERLYING SOCIAL AND ECONOMIC INFLUENCES OF MALNUTRITION ...................................................................................................... 59
FIGURE 25: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY MOTHER’S EDUCATION, MADAGASCAR ................................. 60
FIGURE 26: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY SOURCE OF DRINKING WATER, MADAGASCAR ...................... 62
FIGURE 27: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY TYPE OF TOILET, MADAGASCAR ............................................ 64
BASIC INFLUENCES .................................................................................................................................................................................................. 67
FIGURE 28: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY REGION, MADAGASCAR .......................................................... 68
FIGURE 29: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY URBAN-RURAL RESIDENCE, MADAGASCAR .......................... 70
MATERNAL NUTRITIONAL STATUS ........................................................................................................................................................................ 73
FIGURE 30: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY REGION, MADAGASCAR ................................................... 74
FIGURE 31: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY RESIDENCE, MADAGASCAR.............................................. 76
FIGURE 32: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY EDUCATION, MADAGASCAR............................................. 78
FIGURE 33: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS, MADAGASCAR COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 80
APPENDICES.............................................................................................................................................................................................................. 83
APPENDIX 1: STUNTING, WASTING, UNDERWEIGHT, AND OVERWEIGHT RATES BY BACKGROUND CHARACTERISTICS,
MADAGASCAR 2003-2004..................................................................................................................................................................... 85
APPENDIX 2: NCHS/CDC/WHO INTERNATIONAL REFERENCE POPULATION COMPARED WITH THE DISTRIBUTION OF MALNUTRITION
IN MADAGASCAR................................................................................................................................................................................... 86

iv
Introduction
Malnutrition1 is one of the most important health and welfare problems among infants and young children in
Madagascar. It is a result of both inadequate food intake and illness. Inadequate food intake is a consequence of
insufficient food being available at the household level, improper feeding practices, or both. Improper feeding
practices include both the quality and quantity of foods offered to young children as well as the timing of their
introduction. Poor sanitation puts young children at increased risk of illness (in particular, diarrheal disease), which
adversely affects their nutritional status. Both inadequate food intake and poor environmental sanitation reflect
underlying social and economic conditions.
Malnutrition has significant health and economic consequences, the most serious of which is an increased risk of
death. Other outcomes include an increased risk of illness and a lower level of cognitive development, which results in
lower educational attainment. In adulthood, the accumulated effects of long-term malnutrition can be a reduction in
workers’ productivity and increased absenteeism in the workplace; these may reduce a person’s lifetime earning
potential and ability to contribute to the national economy. Furthermore, malnutrition can result in adverse pregnancy
outcomes.
The data presented here are from the 2003-2004 Madagascar Demographic and Health Survey (EDSMD-III), a
nationally representative survey of 8,420 households, conducted by Institut National de la Statistique (INSTAT),
Ministère de l’Économie, des Finances et du Budget, Antananarivo, Madagascar. ORC Macro furnished the technical
assistance to the survey as part of the MEASURE DHS program, while funding was provided by INSTAT, ORC
Macro, the World Bank, the U.S. Agency for International Development (USAID), the United Nations Population
Fund (UNFPA), and the United Nations Children’s Fund (UNICEF).
Of the 6,284 children age 0-59 months who were part of the study, there were 5,013 who were alive, whose mothers
were interviewed, and who had complete anthropometric data. All nutritional analysis includes these children unless
otherwise noted. Nutritional data collected on these children include height, weight, age, breastfeeding history, and
feeding patterns. Information was also collected on the prevalence of diarrhea and acute respiratory infection (ARI) in
the two weeks preceding the survey and on relevant sociodemographic characteristics. For comparison, data are
presented from Demographic and Health Surveys conducted in other sub-Saharan countries.

1
The technical method of identifying a malnourished population as defined by the U.S. National Center for Health Statistics (NCHS), the Centers for Disease
Control and Prevention (CDC), and the World Health Organization (WHO) is presented in Appendix 2.

1
Figure 1: Infant and Child Mortality, Madagascar Compared with
Other Sub-Saharan Countries

Malnutrition compromises child health, making children susceptible to illness and death. Infectious diseases, such
as acute respiratory infections, diarrhea, and malaria, account for the greatest proportion of infant and under-five
mortality. The infant mortality rate (under-one rate) is a commonly used measure of infant health and is a sensitive
indicator of the socioeconomic conditions of a country. The under-five mortality rate is another informative
indicator of infant and child survival.

• Madagascar’s under-one mortality rate (58 deaths per 1,000 births) indicates that 6 percent of
children born in Madagascar will die before their first birthday. This rate is among the lowest of the
sub-Saharan countries surveyed.

• Madagascar’s under-five mortality rate (94 deaths per 1,000 births) indicates that 9 percent of
children born in Madagascar will die before their fifth birthday. This rate is near the lower end of the
range of sub-Saharan countries surveyed.

2
C

0
50
100
150
200
250
ô
te
d'
Iv
oi
re
M 1
ad G 998
a

48
ab -9
ga o 9
sc n 2

57
ar 00
Z 0
im 20
ba 03

58
bw -0
e 4
B K 1

65
u r e n 99
ki
n a ya 9
U

77
F 200
g a
an so 3
da 2 0

81
20 03
Deaths per 1,000 Births

B 00 -

88
Z en 01
am in
bi 2
a

89
00
2 1
E 00
th

95
io 1 -0
p 2
G ia 2
ui 0

97
ne 0
T 0
an a 1
9

98
za
n 99
N ia
ig 1

99
er 99
ia 9
M 20
al 0

100
aw 3
C
ô Rw i 2
te an 00 104
d' 0
I v da
oi
107

re 200
19 0
9
M 8-
112

al 99
i2
00
113

1
Under-One Mortality Rate

3
G
ab
M o
ad E n2
Figure 1

a rit r 00
ga e 0
89

sc a 2
ar 00
Z
93

im 20 0 2
ba 3
bw -04
94

e
K
e 19
T nya 9 9
102

an
2
U zan 00
g 3
115

an i a
da 1 9
20 99
147

B 00 -
en 0
E in 1
152

th 2
Other Sub-Saharan Countries

Z iop 001
am ia
160

bi 2
a 0
Under-Five Mortality Rate

C 20 00
166

ô G 01
te u -
d' in e 0 2
a
168

Iv
B oi 19
u r re 99
ki
177

n a 199
F 8-
as 99
181

M o2
al
a 00
3
184

R wi
w 20
an 00
N da
189

ig 20
er
ia 00
196

2
Infant and Child Mortality, Madagascar Compared with

M 003
al
201

i2
00
Source: DHS surveys 1999-2004

1
229
Figure 2: Contribution of Undernutrition to Under-Five Mortality,
Madagascar
Undernutrition is an important factor in the death of many young children. Even if a child is only mildly
malnourished, the mortality risk is increased. Under-five mortality in developing countries is largely a result of
infectious diseases and neonatal death. Respiratory infections, diarrhea, malaria, and measles particularly take their
toll on these children.

Formulas developed by Pelletier et al. 1 are used to quantify the contributions of moderate and severe malnutrition
to under-five mortality.

In Madagascar—

• Fifty percent of all deaths that occur before age five are related to malnutrition (severe and
moderate malnutrition).

• Because of its extensive prevalence, moderate malnutrition (41 percent) contributes to more deaths
than severe malnutrition (9 percent).

• Moderate malnutrition is implicated in 82 percent of deaths associated with malnutrition.

1
Pelletier, D.L., E.A. Frongillo, Jr., D.G. Schroeder, and J.P. Habicht. 1994. A methodology for estimating the contribution of
malnutrition to child mortality in developing countries. Journal of Nutrition 124(10 Suppl.): 2106S-2122S.

4
Figure 2
Contribution of Undernutrition to Under-Five Mortality,
Madagascar

Causes of Under-5
Mortality
Other Malaria
causes Contribution to
Under-5 Mortality

Moderate Malnutrition - 41% ARI


AIDS
Severe Malnutrition - 9%

Diarrhea
Measles
Neonatal
deaths
Note: Calculation is
based on formulas by
Pelletier et al. (1994). Source: EDSMD-III 2003-2004
5
Figure 3: Survival and Nutritional Status of Children, Madagascar

Malnutrition and mortality both take a tremendous toll on young children. This figure illustrates the proportion of
children who have died or are undernourished at each month of age.

In Madagascar—

• Between birth and 20 months of age, the percentage of children who are alive and not
malnourished drops rapidly from 74 to 20 percent. The rate rises to 41 percent at 38 months,
fluctuates between 20 and 40 percent thereafter, and levels off at 30 percent by 59 months.

• Between birth and 20 months of age, the percentage of children who are moderately or severely
malnourished1 increases from 15 to 70 percent. This percentage then varies between 55 and 65 percent
through 59 months.

• From birth until 20 months of age, the percentage of children who have died increases from 7 to 10
percent. The mortality rate goes up to 12 percent at 42 months and then gradually declines to 5 percent
by 59 months.

1
A child with a Z-score below minus three standard deviations (-3 SD) on the reference standard is considered severely
malnourished, while one with a Z-score between -2 SD and -3 SD is considered moderately malnourished.

6
Figure 3
Survival and Nutritional Status of Children, Madagascar
100%
Dead

80%

Moderately or severely
60% malnourished

40%

20%
Not malnourished

0%
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58

Note: A child with a Z-score below -3 SD on the reference Age (months)


standard is considered severely malnourished (stunted,
wasted, or underwe ight), while a child with a Z-score between
-3 SD and -2 SD is considered moderately malnourished.
Values have been smoothed using a five-month moving
average. Source: EDSMD-III 2003-2004
7
8
Malnutrition in Madagascar

9
Figure 4: Malnutrition among Children under Five Years,
Madagascar

In Madagascar—

• Forty-seven percent of children age 0-59 months are chronically malnourished. In other words, they
are too short for their age, or stunted.1 The proportion of children who are stunted is almost 24 times the
level expected in a healthy, well-nourished population.

• Acute malnutrition, manifested by wasting,2 results in a child being too thin for his or her height. It
affects 13 percent of children, which is more than 6 times the level expected in a healthy population.

• Forty-one percent of children under five years are underweight3 for their age. This is about 21 times
the level expected in a healthy, well-nourished population.

• Four percent of children under five are overweight.4 This is twice what is expected in a healthy, well-
nourished population.

1
A stunted child has a height-for-age Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. Chronic malnutrition is
the result of an inadequate intake of food over a long period and may be exacerbated by chronic illness.
2
A wasted child has a weight-for-height Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. Acute malnutrition is
the result of a recent failure to receive adequate nutrition and may be affected by acute illness, especially diarrhea.
3
An underweight child has a weight-for-age Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. This condition can
result from either chronic or acute malnutrition or a combination of both.
4
An overweight child has a weight-for-height Z-score that is above +2 SD based on the NCHS/CDC/WHO reference population.

10
Figure 4
Malnutrition among Children under Five Years, Madagascar
Percent

60

50
47
41
40

30

20
13

10
4
2 2
0
Reference Stunted Wasted Underweight Reference Overweight
population population

Note: Stunting reflects chronic malnutrition; wasting


reflects acute malnutrition; underweight reflects Source: EDSMD-III 2003-2004
chronic or acute malnutrition or a combination of both. 11
Figure 5: Changes in Undernutrition Rates among Children under
Five Years, Madagascar 1992, 1997, and 2003-2004

The findings of the EDSMD-III 2003-2004 suggest that the nutritional status of children in Madagascar has
changed since the two previous surveys (ENDS 1992 and EDS 1997).1

• Compared with 1992, chronic malnutrition (stunting) in 1997 and 2003 went down by 6 and 7
percentage points, respectively. The decrease of 1 percentage point in the rate of stunting between 1997
and 2003 is not statistically significant.

• Compared with 1992, there was an increase in acute malnutrition (wasting) in 1997 and 2003 by 8
and 13 percentage points, respectively. However, because of the seasonality of wasting, meaningful
interpretation of these increases cannot be made.

• The rate of underweight has remained unchanged since 1992 (41 percent).

1
Enquête Nationale Démographique et Sanitaire 1992 and Enquête Démographique et de Santé 1997

12
Figure 5
Changes in Undernutrition Rates among Children under
Five Years, Madagascar 1992, 1997, and 2003-2004
Percent
70
Stunting Wasting Underweight
60 54
48 47
50
41 40 41
40

30

20 13
8
10 5
2
0
92

97

92

97

92

97
n

4
io

00

00

00
19

19

19

19

19

19
at

-2

-2

-2
ul

03

03

03
op

20

20

20
.P
ef
R

Note: Stunting reflects chronic malnutrition; wasting


reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both. 13 Source: ENDS 1992, EDS 1997, and EDSMD-III 2003-2004
Figure 6: Stunting, Wasting, and Underweight by Age, Madagascar

In Madagascar, the time between 2 and 20 months of age is a vulnerable period.

• The proportion of children stunted rises sharply between 2 and 20 months of age, peaking at 64
percent. The proportion drops to 44 percent at 29 months, goes up again to 64 percent at 46 months, and
then drops and rises to 58 percent by 59 months.

• The proportion of children wasted rises between 4 and 19 months of age, when it peaks at 23
percent. Then it gradually declines to 10 percent at 47 months and remains about the same through 59
months.

• The proportion of children underweight rises sharply to 55 percent at 20 months. Thereafter, the
proportion varies between 40 and 50 percent through 59 months.

14
Figure 6
Stunting, Wasting, and Underweight by Age,
Madagascar
Percent
70
Vulnerable Period
60

  
50       
      
     
 
40 
 Stunted average
30
 Wasted average
 Underweight average
20  

      
           
10 


0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58

Age (months)
Note: Stunting reflects chronic malnutrition; wa sting reflects
acute malnutrition; underweight reflects chronic or acute
malnutrition or a combination of both. Plotted values are
smoothed by a five-month moving average. 15 Source: EDSMD-III 2003-2004
Figure 7: Undernutrition among Children under Five Years Who Do
Not Reside with Their Mother, Madagascar
Previously, anthropometric data from Demographic and Health Surveys excluded children whose mother did not
live in the household or was not present to be interviewed. Currently, all children in the household are measured,
regardless of their mother’s residence status. In the EDSMD-III 2003-2004, 120 children under five years were
included in the survey even though they did not reside with their mother.

In Madagascar—

• No statistical relationship was found between malnutrition rates and whether or not children
resided with their mother.

16
Figure 7
Undernutrition among Children under Five Years Who Do
Not Reside with Their Mother, Madagascar
Percent

70 Children Who Reside with Their Mother


(No statistical difference) Children Who Do Not Reside with Their Mother
60
53
(No statistical difference)
50 45
40
37
40
(No statistical difference)
30

20 14 12
10

0
Stunting Wasting Underweight

Note: Stunting reflects chronic malnutrition; wasting


reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both. 17 Source: EDSMD-III 2003-2004
Figure 8: Underweight among Children under Five Years,
Madagascar Compared with Other Sub-Saharan Countries

Among the sub-Saharan countries surveyed—

• The percentage of children under five years who are underweight ranges from 13 to 47 percent. With 41
percent of children under five years of age underweight, Madagascar is second highest among the
sub-Saharan countries surveyed. Underweight status is indicative of children who suffer from chronic
or acute malnutrition or a combination of both, and it may be influenced by both short- and long-term
determinants of malnutrition. Underweight is often used as a general indicator of a population’s health
status.

18
Figure 8
Underweight among Children under Five Years,
Madagascar Compared with Other Sub-Saharan
Percent Countries
60

47
50
40 41
38
40 33
28 29 29
30 24 25
22 23 23 23
20
20
13

10

0
9

00

20 0

03

1
h a 00 3

ne 0 1

an 02

e r 99

r 2 02

00
3

20 9
an -01

tre 0 3

o p 04
K e 19 9

00

Fa 00
Be 00

20

20
20

19

ca 2 0

20
-
19

20

3-
01
00

i2

2
2

00
e

da

ia

ia
li
a

na

ia

a
aw

so
a
bw

ni
ny

M
al

a
a

ig
ui
ba

ad E ri

hi
nz
bi
nd

M
w
G

N
G

Et
a
m

m
R

as
Ta
ga

in
Za
Zi

rk

ag
U

Bu

M
Note: Underweight reflects chronic or acute
malnutrition or a combination of both. 19 Source: DHS surveys 1999-2004
Figure 9
Stunting among Children under Five Years, Madagascar
Compared with Other Sub-Saharan Countries
Percent
60
51
49
47 47
50
43 43
39 39 40
38 38
40
30 31
29
26 27
30

20

10

0
1

an 00

99

2
99

03

04
99

03

01

03

02

03

00
-0

-0
00

00
19

20

20

19
19

20

20

20

20

20

20
3-
00

01

i2
li 2

00
20

ia
a

ia

20
na

ea

so

ia
aw
bw

nd
ne

r2
ni

ny

er

op
M
ha

Fa
it r

a
Be

al
ig

wa
Ke
ui

nz
ba

nd

ca

bi

hi
Er
G

M
N
G

Et
Ta
m

as
ga
in

Za
Zi

ag
rk

U
Bu

ad
M

Note: Stunting reflects chronic malnutrition. 21 Source: DHS surveys 1999-2004


Conceptual Framework for Nutritional Status
Nutrition is directly related to food intake and infectious diseases, such as diarrhea, acute respiratory infection,
malaria, and measles. Both food intake and infectious diseases reflect underlying social and economic conditions at
the household, community, and national levels, which are supported by political, economic, and ideological
structures within a country.

The following diagram is a conceptual framework for nutrition adapted from UNICEF.1 It reflects relationships
among factors and their influences on children’s nutritional status. Although political, socioeconomic,
environmental, and cultural factors (at the national and community levels) and poverty (at the household level)
affect the nutritional status of women and children, the only variables included in this chartbook are those that can
be collected as part of a national household survey. The highlighted areas of the framework depict selected factors.

These factors are—

• Immediate influences, such as food intake (micronutrient status and supplementation) and infectious
diseases (diarrhea and respiratory infections)

• Underlying biological and behavioral influences, such as maternal fertility, measles vaccinations, and
feeding patterns of children under two years

• Underlying social and economic influences, such as maternal education, drinking water, and sanitation

• Basic influences, such as area of residence.

1
United Nations Children’s Fund. 1998. State of the World’s Children, 1998. New York: Oxford University Press.

22
Conceptual Framework for Nutritional Status
Nutri tional Status M anife stations

Food Intake Infectious Diseases


(Micronutrient Status/Supplementation) (Diarrhea and Cough with Rapid Breathing) Immediate
Influences

Feeding Patterns Hygiene


(Infants under 6 Months: Exclusive Breastfeedi ng, Chil d Care
Behavior
6-9 Months; Compl ementary Feeding;
10-24 Months; Continued Breastfeeding)
Underlying
Maternal Ferti lity, Age, Biological and
Immunization, Heal th Care Antenatal Care, Health Status Behavioral
Intrahousehol d
Food Distri bution (Measl es Vaccination (T otal Ferti lity Rate, Birth Interval, Influences
12-23 Months) Maternal Malnutrition)

Household Assets Mari tal Status Education Food Availabili ty


(Maternal) Underlying
Social and
Employment Water, Sanitation Economic
Health Services (
Par
ents’Wor k
ing (Source of Drinking Water, T ype of Toilet)
Status) Influences

Political, Economic, and Ideological Structure Basic


(Resi dence: Urban/Rural, Regi on) Influences

Adapted from: UNICEF,


23 Stat
eoft heWor l
d’sChi l
dren,1998
Figure 9: Stunting among Children under Five Years, Madagascar
Compared with Other Sub-Saharan Countries

Among the sub-Saharan countries surveyed—

• The percentage of children under five years who are stunted ranges from 26 to 51 percent. With
47 percent of children under five years of age stunted, Madagascar is at the upper end of the range
of the sub-Saharan countries surveyed. Stunting is a good long-term indicator of the nutritional status
of a population because it is not markedly affected by short-term factors such as season of data collection,
epidemic illnesses, acute food shortages, and recent shifts in social or economic policies.

20
24
Immediate Influences of
Malnutrition

25
Figure 10: Children under Five Years Living in Households with
Adequately Iodized Salt by Region, Madagascar

Iodine deficiency is known to cause goiter, cretinism (a severe form of neurological defect), spontaneous abortion,
premature birth, infertility, stillbirth, and increased child mortality. One of the most serious consequences to child
development is mental retardation caused by iodine deficiency disorder (IDD). IDD is the single most common
cause of preventable mental retardation and brain damage in the world. It decreases the production of hormones
vital to growth and development. Children with IDD can grow up stunted, apathetic, mentally retarded, and
incapable of normal movement, speech, or hearing. IDD in pregnant women may cause miscarriage, stillbirth, and
mental retardation in infants.

The remedy for IDD is relatively simple. A teaspoon of iodine is all a person requires in a lifetime. Since iodine
cannot be stored for long periods by the body, tiny amounts are needed regularly. In areas of endemic iodine
deficiency, where soil and therefore crops and grazing animals do not provide sufficient dietary iodine to the
population, food fortification and supplementation have proven to be highly successful and sustainable
interventions. The fortification of salt or oil with iodine is the most common tool used to prevent IDD. Iodized salt
that is commercially packaged in plastic sacks and not stored properly can lose its concentration of iodine. Proper
packaging and storage of iodized salt are essential to ensure that the population benefits from iodine fortification.

• In Madagascar, 71 percent of children under five years live in a household that uses salt containing
an adequate level of iodine (≥15 parts per million [ppm]). Use of iodized salt is lowest in the Toliara
region (21 percent) and highest in Mahajanga (93 percent).

26
Figure 10
Children under Five Years Living in Households with
Adequately Iodized Salt by Region, Madagascar
Percent

100 91 93
90

80 71 72
65

60

40

21
20

na

ga
al

ra

oa

in
riv
t

lia
To

na

an
ts

as
na
To

an

ir a

aj
am
na

ah
ar

ts

To
ta
an

An

M
An
Fi

Note: Adequately iodized salt is >15 ppm. 27 Source: EDSMD-III 2003-2004


Figure 11: Night Blindness among Mothers of Children under Five
Years, Madagascar

Globally, vitamin A deficiency (VAD) is the leading cause of childhood blindness. The damage to vision
(xerophthalmia) is only one of the harmful outcomes of VAD. Vitamin A is crucial for rapid growth and recovery
from illness or infection. Children who are vitamin A deficient have reduced immunity and are less likely to
recuperate from common childhood illnesses, such as diarrhea, ARI, and measles, and are twice as likely to die as
children who are not vitamin A deficient.

A mother’s vitamin A status during pregnancy can be an indicator of the vitamin A status of her child. One sign of
VAD in women during pregnancy is night blindness.

• In Madagascar, 8 percent of all women who had given birth in the past five years reported having
some form of night blindness during their last pregnancy.

• However, 1 percent of women reported having trouble with their vision during the night but not
during the day during their last pregnancy. Although this figure corrects for women with vision
problems, in general, it may slightly underestimate the rate of night blindness.

28
Figure 11
Night Blindness among Mothers of Children under
Five Years, Madagascar

Eight percent of all women


reported night blindness during
their last pregnancy.

One percent of women had


trouble with their vision during
the night but not during the day
during their last pregnancy.

29 Source: EDSMD-III 2003-2004


Figure 12: Vitamin A Supplementation among Mothers of Children
under Five Years by Region, Madagascar

Recent studies show that pregnant women who are vitamin A deficient are at a greater risk of dying during or
shortly after delivery of the child. Pregnancy and lactation strain women’s nutritional status and their vitamin A
stores. For women who have just given birth, vitamin A supplementation helps to bring their level of vitamin A
storage back to normal, aiding recovery and helping them to avoid illness.

Vitamin A supplementation also benefits children who are breastfed. If mothers have vitamin A deficiency, their
children can be born with low stores of vitamin A. Low birth weight babies are especially at risk. Additionally,
infants often do not receive an adequate amount of vitamin A from breast milk when mothers are vitamin A
deficient. Therefore, supplementation is important for postpartum women within the first eight weeks after
childbirth.

In Madagascar—

• Ninteen percent of mothers received vitamin A supplements within two months after delivery.

• Vitamin A supplementation of mothers varies by region. Only 9 percent of mothers in the Toliara
region received vitamin A, while 30 percent in Antananarivo did.

30
Figure 12
Vitamin A Supplementation among Mothers of Children
under Five Years by Region, Madagascar
Percent

35
30
30 27

25
21
19
20

14
15
11
9
10

0
ra

ga

oa

na

o
al

riv
in
t

lia
To

an

na
ts

as

na
To

an

ir a
aj

am

na
ah

ar

ts
To

ta
an

An
M

An
Fi

31 Source: EDSMD-III 2003-2004


Figure 13: Vitamin A Supplementation among Children Age 6-59
Months in the Past Six Months by Region, Madagascar

Vitamin A deficiency (VAD) is common in dry environments, where fresh fruits and vegetables are not readily
available. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangos, papayas,
carrots, pumpkin, and dark leafy greens. Unlike iron or folate, vitamin A is a fat-soluble vitamin, which means that
consumption of oils or fats are necessary for its absorption into the body. The liver can store an adequate amount of
the vitamin for four to six months. Periodic dosing (every four to six months) with vitamin A supplements is a
rapid, low-cost method of ensuring children at risk do not develop VAD. National Immunization Days for polio or
measles vaccinations reach large numbers of children with vitamin A supplements as well.

In Madagascar—

• Seventy-eight percent of children age 6-59 months received a vitamin A dose in the past six months.

• The rate of vitamin A supplementation among children varies by region. Supplementation is lowest
in the Mahajanga region (70 percent) and highest in Antananarivo (84 percent).

32
Figure 13
Vitamin A Supplementation among Children Age 6-59
Months in the Past Six Months by Region, Madagascar
Percent

100
84
78 77 78 79
80 74
70

60

40

20

0
ga

na

a
al

ra

oa

o
in

riv
t

lia
To

an

na

ts

as

na
To

an
ir a
aj

am

na
ah

ar
ts

To

ta
an
An
M

An
Fi

33 Source: EDSMD-III 2003-2004


Figure 14: Anemia among Children Age 6-59 Months and Mothers
by Region, Madagascar
Anemia is the lack of an adequate amount of hemoglobin in the blood. It can be caused by several different health
conditions; iron and folate deficiencies are some of the most prevalent conditions related to anemia. Vitamin B12
deficiency, protein deficiency, sickle cell disease, malaria, and parasite infection also cause anemia.

In Madagascar—

• Seventy percent of children age 6-59 months and 49 percent of mothers are anemic.

• Anemia rates for children are highest in Toliara (76 percent) and lowest in Antananarivo region
(64 percent).

• Anemia rates for mothers are highest in the Mahajanga region (62 percent) and lowest in
Antananarivo region (33 percent).

34
0
20
40
60
80
100
To
t al
-C
hi
To ld
t al r en
-M
ot

70
Percent

he
rs
A

49
nt
Severe

an
an
A ar
iv
nt o
an -C
an hi
ar ld
iv re
o- n
M
ot
64

To he
Moderate

am rs
as 33
To in
a-
am C
hi
as ld
Mild

in re
a- n
M
ot
70

M he
ah rs
aj
an
50

35
M ga
ah -C
aj hi
an ld
ga re
-M n
Figure 14

o
74

Fi th
an er
ar s
an
t
62

Fi
an s oa
ar -C
an hi
ts ld
oa re
-M n
by Region, Madagascar

ot
75

A he
nt rs
si
ra
na
51

A na
nt -C
si
ra hi
na ld
re
na n
-M
75

ot
he
rs
To
60

lia
ra
-
To Ch
lia i ld
ra re
-M n
ot
76

he
rs
Source: EDSMD-III 2003-2004
Anemia among Children Age 6-59 Months and Mothers

45
Figure 15: Iron Supplementation among Mothers of Children under
Five Years, Madagascar

Iron-deficiency anemia is the most common form of nutritional deficiency worldwide. This type of nutritional
deficiency develops slowly and does not manifest symptoms until anemia becomes severe. Diets that are heavily
dependent on one grain or starch as the major staple often lack sufficient iron intake. Iron is found in meats,
poultry, fish, grains, some cereals, and dark leafy greens (such as spinach). Foods rich in vitamin C increase
absorption of iron into the blood. Tea, coffee, and whole-grain cereals can inhibit iron absorption. Anemia is
common in children age 6-24 months who consume purely a milk diet and in women during pregnancy and
lactation. Iron-deficiency anemia is related to decreased cognitive development in children, decreased work
capacity in adults, and limited chances of child survival. Severe cases are associated with the low birth weight of
babies, perinatal mortality, and maternal mortality. The worldwide anemia prevalence data indicate that normal
dietary intakes of iron are insufficient to cover the increased requirements for a significant proportion of pregnant
women. Providing iron supplements to pregnant women during this critical period is one of the most widely
practiced public health measures to prevent and treat anemia.

In Madagascar—

• Thirty-three percent of mothers took some iron supplementation during pregnancy.

• Of those women who received iron supplementation, only 8 percent reported taking iron the
recommended minimum number of days during their pregnancy (90 or more days).

36
Figure 15
Iron Supplementation among Mothers of Children under
Five Years, Madagascar
Percent

100
Of the 33% who did take supplements
90

80
70
67
70

60

50

40 33

30

15 (Recommended)
20
7 8
10

0
Took Did not take Does not know how Took on Took on Took on
supplements supplements often were taken 1-59 days 60-89 days 90+ days
37 Source: EDSMD-III 2003-2004
Figure 16: Diarrhea and Cough with Rapid Breathing among
Children under Five Years Compared with Malnutrition Rates,
Madagascar
Acute respiratory infection and dehydration due to diarrhea are major causes of morbidity and mortality in most
sub-Saharan countries. To estimate the prevalence of ARI, interviewers asked mothers whether their children under
five years had been ill with coughing accompanied by short, rapid breathing in the past two weeks. For diarrhea,
mothers were asked whether their children under five years had symptoms of diarrhea in the past two weeks. Early
diagnosis and rapid treatment can reduce the rates of illness or death caused by these conditions.
In Madagascar—
• Nine percent of children under five years of age experienced cough with rapid breathing in the two
weeks preceding the survey. Madagascar’s prevalence of cough with rapid breathing increases from 2 to
16 percent in the first 11 months and then varies between 10 and 15 percent until 21 months. Thereafter,
the prevalence of cough with rapid breathing gradually decreases to 4 percent by 59 months of age.

• Ten percent of children under five years of age had diarrhea in the two weeks preceding the
survey. The prevalence of diarrhea increases rapidly between 2 and 8 months then it varies between 15
and 20 percent through 21 months. After that, the rate gradually decreases to 2 percent by 59 months.

The rapid rise in the prevalence of diarrhea during infancy reflects the increased risk of pathogen contamination
associated with the early introduction of water, other liquids, and solid foods. In addition, when infants begin to
crawl and move around, they tend to put objects in their mouth, again increasing the risk of pathogen
contamination.

38
Figure 16
Diarrhea and Cough with Rapid Breathing among
Children under Five Years Compared with
25
Percent Malnutrition Rates, Madagascar
Diarrhea
  Cough w ith rapid breathing
20
 
  
15  
  
 
10
 
  
5
   
  
0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58
70

60

    
50
            
    
40   

30  Stunted average Wasted average Underw eight average
  

20
    
10    

 
0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58
Age (months)
Note: Plotted values are smoothed bya 39 Source: EDSMD-III 2003-2004
five-month moving average.
40
Underlying Biological and
Behavioral Influences of
Malnutrition

41
Figure 17: Fertility and Birth Intervals, Madagascar Compared with
Other Sub-Saharan Countries
High fertility rates, especially when accompanied by short birth intervals, are detrimental to children’s nutritional
status. In most countries in sub-Saharan Africa, families have scarce resources to provide adequate nutrition and
health care for their children. As the number of children per woman increases, fewer household resources are
available for each child. High fertility also has a negative impact on maternal health, thus influencing a mother’s
ability to adequately care for her children. The most widely used measure of current fertility is the total fertility
rate, which is defined as the number of children a woman would have by the end of her childbearing years if she
were to pass through those years bearing children at the currently observed age-specific rates.

Information on the length of birth intervals provides insight into birth spacing patterns. Research has shown that
children born too soon after a previous birth are at increased risk of poor nutrition and health and at increased risk
of mortality, particularly when that interval is less than 24 months. The odds of stunting and underweight have
been shown to be higher when birth intervals are less than 36 months. Short birth intervals are associated with
small birth size and low birth weight, both of which are precursors to poor nutritional status in early childhood.

• At current fertility rates, a woman in Madagascar will have an average of 5.2 children by the end
of her childbearing years. This rate is in the lower range of the sub-Saharan countries surveyed between
1999 and 2004.

• Madagascar’s mothers have a median birth interval of 33 months. This interval is in the midrange of
the sub-Saharan countries surveyed.

42
0
2
4
6
8
10
Zi
m
ba
bw
G e
ab 1 9
o 9
G n 9

4 .0
ha 20

4.3
Er na 00
M i tr 20
ad ea 0

4.4
C a g Ke n 2 0 3
ôt as y 0
e

4.8
d ' ca r a 20 2
Iv

4.9
oi 20 03
re 03
1 -

5.2
G 99 04
Children per woman

ui 8
ne -9
9

5.2
B a1
Ta e n 99

5.5
nz in 2 9
a 0

5.6
N ni a 0 1
ig 1

5.6
R e ria 9 99
wa 2
E nd 0 03
5.7
Za thi o a 2
Bu m p ia 00 0 5.8
rk bi a 20
in
5.9

a 20 0 00
Fa 1
s -0
5.9

M o2 2
Total Fertility Rate

al 0
aw 03
6.2

U i
ga M 20
6.4

nd a li 00
a 20
20 0
6.8

00 1
-0
1
6.9

U
ga
nd
a

43
N 20 0
ig 0
R e ria -0 1
wa 2
29

nd 0 0
a 3
Figure 17

31

M 2 00
Ke a li 0
32

M 2
a d Et nya 00 1
32

a g hi o 20
a s p i 03
ca a 2
33

Ta r 2 0 0
0
33

Za n za 03 0
m ni -04
bi a
33

a 19
2
Er 0 0 99
33

i tr 1 -
0
G ea 2
33

ab 2 0
C M on 0 2
34

ôt a l 20
e aw 0
with Other Sub-Saharan Countries

34

d ' Be i 2 0
I
Bu vo ni n 0 00
Median Birth Interval in Months

34

rk i re
in 1 9 20 0
a
35

Fa 9 8 1
-9
G so 2 9
36

ui
n 00
G ea 3
36

Zi ha 1 9
m n 9
ba a 9
36

bw 20
Fertility and Birth Intervals, Madagascar Compared

e 03
38

19
99
40
Months

Source: DHS surveys 1999-2004


0
10
20
30
40
50
Figure 18: Undernutrition among Children Age 12-23 Months by
Measles Vaccination Status, Madagascar
Measles is estimated to kill two million children per year, all in developing countries. It is one of the most common
diseases during childhood in areas with low immunization coverage. Measles not only increases the risk of death,
but also is a direct cause of malnutrition. The occurrence of measles in poor environments is associated with
faltered growth, vitamin A deficiency, and immune suppression. Although infants are not protected from measles
after birth by their mother’s breast milk, they are protected while in the womb by their mother’s measles
antibodies. These antibodies can last up to 15 months in infants, but because of malnutrition, last only 8 or 9
months in children in developing countries. Therefore, measles vaccination is an important child health strategy.

In Madagascar—

• Stunting is not statistically related to measles vaccination status.

• Wasting is higher (by 5 percentage points) among children who did not receive a measles
vaccination than among children who did.

• Underweight is higher (by 10 percentage points) among children who did not receive a measles
vaccination than among children who did.

44
Figure 18
Undernutrition among Children Age 12-23 Months by
Measles Vaccination Status, Madagascar
Percent

70 (No statistical difference)


60
56 Vaccinated 57
60
Not Vaccinated
47
50

40

30
22
17
20

10

0
Stunting Wasting Underweight

Note: Stunting reflects chronic malnutrition; wasting


reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both. 45 Source: EDSMD-III 2003-2004
Figure 19: Measles Vaccination Coverage among Children
Age 12-23 Months, Madagascar Compared with Other
Sub-Saharan Countries
Among the sub-Saharan countries surveyed—

• Measles vaccination ranges from 27 to 87 percent. In Madagascar, 59 percent of children age 12-23
months have been vaccinated against measles. This level of coverage is in the midrange of the sub-
Saharan countries surveyed.

46
0
20
40
60
80
100
Et
hi
op
ia
N 20
ig

Percent
e r 00
ia

27
20
M 03
al
i

36
B u Ga 2 00
rk bo 1
in n

49
a 2
Fa 0 0
so 0
55
G
u i 2 00
U ne 3
M g an a 1
ad d 9
ag a 2 99
as 0
56 56

ca 00 -
r 2 01
00
B e 3- 0
ni 4
n
57 59

Ke 20

47
n 01
Ta ya
nz 20
an 03
Figure 19

Countries

Zi
71 73

m ia 1
ba 9
bw 99
e
G 1
ha 99
na 9
78 79

Er 2
itr 0 03
ea
M 20
al
Za aw 02
m
83 84

i2
bi
a 00
20 0
R
w 01
an -0
da 2
84 85

20
00
87
Months, Madagascar Compared with Other Sub-Saharan

Source: DHS surveys 1999-2004


Measles Vaccination Coverage among Children Age 12-23
Figure 20: Feeding Practices for Infants under Six Months,
Madagascar

Improper feeding practices, in addition to diarrheal disease, are important determinants of malnutrition. WHO and
UNICEF recommend that all infants be exclusively breastfed from birth until six months of age. In other words,
infants should be fed only breast milk during the first six months of life.

In Madagascar, the introduction of liquids (such as water, sugar water, and juice), formula, and solid foods takes
place earlier than the recommended age of six months. This practice has a deleterious effect on nutritional status
for a number of reasons. First, the liquids and solid foods offered are nutritionally inferior to breast milk. Second,
the consumption of liquids and solid foods decreases the infant’s intake of breast milk, which in turn reduces the
mother’s supply of milk. (Breast milk production is determined, in part, by the frequency and intensity of
suckling.) Third, feeding young infants liquids and solid foods increases their exposure to pathogens, thus putting
them at greater risk of diarrheal disease.

In Madagascar—

• Sixty-seven percent of children under the age of six months are exclusively breastfed, as
recommended by WHO and UNICEF.

• Ten percent of infants under six months of age are given a combination of breast milk and water;
additionally, 9 percent of infants under six months are given liquids other than water, and
13 percent receive solid food in addition to breast milk and/or water.

• One percent of infants under six months of age are fully weaned.

48
Figure 20
Feeding Practices for Infants under Six Months,
Madagascar

Exclusively
breastfed 67% Weaned 1%

(Recommended)
Breast milk
and solid
foods 13%

Breast milk
and water 10%

Breast milk
and other liquids
Note: WHO and UNICEF recommend that all 9%
infants be breastfed exclusively up to six
months of age. 49 Source: EDSMD-III 2003-2004
Figure 21: Infants under Four Months Who Are Exclusively
Breastfed and Those Who Receive a Bottle, Madagascar Compared
with Other Sub-Saharan Countries

The failure to exclusively breastfeed young infants and the introduction of liquids and solid foods at too early an
age increases the risk of diarrheal disease, an important cause of mortality in Africa.

• In most of the sub-Saharan countries surveyed, relatively few mothers of infants under four months
follow the recommended practice of breastfeeding exclusively. In Madagascar, 77 percent of mothers
breastfeed their young infants exclusively. This gives Madagascar the second highest rate of exclusive
breastfeeding among the sub-Saharan countries surveyed.

• Bottle-feeding is provided to only 2 percent of infants under four months in Madagascar. This rate
is one of the lowest of the Sub-Saharan countries surveyed. Bottle-feeding is not recommended because
improper sanitation and formula preparation with bottle-feeding can introduce pathogens to the infant,
putting the child at a greater risk of illness and malnutrition.

50
0
20
40
60
80
100
Bu K
rk e n
in
a ya
Fa 20
s 0

19
N o2 3
ig

Percent
e r 00 3
ia
20
Zi
m M
a 0

22 23
b a li 2 3

30
Ta bw e 00 1
nz 1
a n 99

39
ia 9
Za Be 19

43
m ni n 99
bi
a 20

49
Et 20 0 1
Exclusively breastfed
hi 01
op -0

53
M ia 2 2
al
a 00
G wi 0
ha 2 0
na 00
E
U ri t 20
M ga r e 0
62 63 64

be breastfed exclusively up to six months of age.


ad n a 3
ag da 20
66

a s 20 0 2
ca 0 0
r -
R 20 0 1
74
Receive a bottle

w a 03
nd -0
77

a 4
20

Note: Information on feeding practices is based on the 24 hours


00
89

Bu
r
M kin

preceding the survey. WHO and UNICEF recommend that all infants
ad a
a g Fa
a s so
ca 2

51
r 2 00
M 00 3
al 3-
a 0 1
2
Er wi 2 4
Zi i tr 0
Figure 21

m ea 00
2

ba 2
Za b 0
m we 02
2

bi
a 19
R 20 9 9
3

w a 01
nd -0
a 2
3

2
Ta Ma 00 0
4

n z li 2
a 00
G ni a 1
4

ui
ne 9 91
a 9
7

Be 1 9
ni 9 9
8

G n2
ha 0
with Other Sub-Saharan Countries

Et na 0 1
9

U hi o 20
g a p i 03
nd a 2
10

a 00
2
Ke 0 0 0
13

ny 0-0
N a2 1
19

ig
er 00
ia 3
23

20
03
25
Percent

0
5

Source: DHS surveys 1999-2004


10
15
20
25
30
and Those Who Receive a Bottle, Madagascar Compared
Infants under Four Months Who Are Exclusively Breastfed
Figure 22: Feeding Practices for Infants Age 6-9 Months,
Madagascar

UNICEF and WHO recommend that solid foods be introduced to infants around the age of six months because
breast milk alone is no longer sufficient to maintain a child’s optimal growth. Thus, all infants over six months of
age should receive solid foods along with breast milk.

In Madagascar—

• Seventy-seven percent of infants age 6-9 months are fed solid foods in addition to breast milk. This
indicates that more than a third of all infants age 6-9 months are fed according to the recommended
practice.

• Twenty percent of infants age 6-9 months are not fed solid foods in addition to breast milk, putting
these children at risk of malnutrition.

• Two percent of infants are fully weaned and are thus not receiving the additional nutritional and
emotional support of breastfeeding.

52
Figure 22
Feeding Practices for Infants Age 6-9 Months,
Madagascar

Weaned 2%
Breast milk and
solid foods 77% Breast milk
and other
liquids 7%

(Recommended)
Exclusively
breastfed 9%

Breast milk
and water 4%

Note: WHO and UNICEF recommend that all


infants age 6-9 months should receive solid Source: EDSMD-III 2003-2004
foods in addition to b reast milk. 53
Figure 23: Infants Age 6-9 Months Receiving Solid Foods in
Addition to Breast Milk, Madagascar Compared with Other Sub-
Saharan Countries

Optimal infant feeding practices include the introduction of complementary foods at about six months of age. The
introduction of complementary feeding is necessary because breast milk is no longer sufficient to satisfy the
developing infant’s energy, protein, and micronutrient needs. All infants age 6-9 months should receive
complementary foods in addition to breast milk.

• The percentage of infants age 6-9 months receiving solid food in addition to breast milk ranges from 27
to 93 percent among the sub-Saharan countries surveyed.

• In Madagascar, 77 percent of infants age 6-9 months receive solid food in addition to breast milk.
This puts Madagascar in the upper range of the sub-Saharan countries surveyed.

54
Figure 23
Infants Age 6-9 Months Receiving Solid Foods in
Addition to Breast Milk, Madagascar Compared
with Other Sub-Saharan Countries
Malawi 2000 93
Zambia 2001-02 87
Zimbabwe 1999 87
Kenya 2003 83
Rwanda 2000 79
Madagascar 2003-04 77
Uganda 2000-01 73
Benin 2001 65
Tanzania 1999 64
Ghana 2003 62
Nigeria 2003 61
Ethiopia 2000 43
Eritrea 2002 42
Burkina Faso 2003 38
Mali 2001 32
Guinea 1999 27

0 20 40 60 80 100

Percent
Note: WHO and UNICEF recommend that infants
age 6-9 months should receive so lid foods in
addition to breast milk. 55 Source: DHS surveys 1999-2004
Figure 24: Children Age 10-23 Months Who Continue to Be
Breastfed, Madagascar Compared with Other Sub-Saharan
Countries

For older infants and toddlers, breast milk continues to be an important source of energy, protein, and
micronutrients. Studies have shown that, in some populations, breast milk is the most important source of vitamin
A and fat among children over 12 months of age. Breastfeeding older infants also reduces their risk of infection,
especially diarrhea.

Additionally, breastfeeding up to 24 months can help reduce a woman’s fertility, especially in areas where
contraception is limited. Women who breastfeed for longer periods have lower fertility rates than women who
breastfeed for shorter periods.

In Madagascar—

• Seventy-seven percent of children age 10-23 months are still given breast milk. This rate is in the
lower range of the sub-Saharan countries surveyed.

56
Figure 24
Children Age 10-23 Months Who Continue to Be Breastfed,
Madagascar Compared with Other Sub-Saharan Countries

Percent

100 93
89 89 90
84 85 85 86
81 82
75 77 77
80 70 71 72

60

40

20

00
99

99
03

03

04

02

01

03

03
99

00
-0

-0

00

00
20
20

19

20

20

19

20
3-
19

20

20

20
00

01

i2

i2
00

ia
r ia

ea

20

so
e

20

na

da

al

aw

ne
ni

ni

op
ny
bw

r2

Fa
itr
ge

ha
za

Be

an
a
da

al

ui
Ke

hi
Er
ba

ca

bi
Ni

Rw

M
Et

G
an

a
m
as
Ta
m

in
Za
Ug

rk
Zi

ag

Bu
ad
M

Note: Information on feeding practices is based on the 24 hours


preceding the survey. WHO and UNICEF recommend that all children
57 Source: DHS surveys 1999-2004
should continue to be breastfed up to 24 months of age.
58
Underlying Social and
Economic Influences of
Malnutrition

59
Figure 25: Stunting and Wasting among Children under Five Years
by Mother’s Education, Madagascar
Maternal education is related to knowledge of good child care practices and to household wealth. In Madagascar,
26 percent of the mothers of children under five years of age have never attended school, 51 percent have some
primary education, and 23 percent have a secondary or higher education. There are variations in school attendance,
especially between urban and rural areas. In the rural areas, 30 percent of the mothers have never attended school,
53 percent have attended primary school, and only 17 percent have gone to secondary school or higher. In contrast,
3 percent of mothers in the capital and large cities and 12 percent of the mothers in small cities/towns have never
attended school, while 61 percent in the capital and large cities and 48 percent in small cities/towns have gone to
secondary school or higher. Thirty-six percent of mothers in Antananarivo region have received at least a
secondary school education, compared with 14 to 22 percent of mothers in the rest of Madagascar.

In Madagascar—

• Maternal education has an inverse relationship with stunting at the secondary or higher level. However,
there is no difference in the levels of stunting in children between mothers with no education and mothers
with a primary education. There is a 12 percentage point difference in the level of stunting in children of
mothers with a secondary or higher education and children of mothers with no education or a primary
education.

• With increasing level of maternal education, wasting in children decreases. However, the difference in
the rate of wasting in children of mothers with primary and secondary levels of education is not
statistically significant.

60
Figure 25
Stunting and Wasting among Children under Five
Year sbyMot her ’
sEducat ion,Madagascar
Percent
60
Stunting Wasting
49 50
47
50

38
40

30

20 16
13 12 11
10

0
n

n
y

y
+

+
al

al
ti o

ti o
ar

ar
y

y
t

t
To

To
ar

ar
im

im
ca

ca
nd

nd
Pr

Pr
du

du
co

co
E

E
Se

Se
o

o
N

Note: Stunting reflects chronic malnutrition; Source: EDSMD-III 2003-2004


wasting reflects acute malnutrition. 61
Figure 26: Stunting and Wasting among Children under Five
Years by Source of Drinking Water, Madagascar

A household’s source of drinking water is related to its socioeconomic status. Poor households are more likely to
obtain drinking water from contaminated sources, such as surface water or open wells. Without an adequate supply
of good-quality water, the risks of food contamination, diarrheal disease, and malnutrition increase. Infants and
children in households that do not have a private tap are at greater risk of being malnourished than those in
households with this amenity. Among the households surveyed with children under five years, 18 percent use piped
water, 21 percent obtain their drinking water from a well, and 61 percent use surface water.

In Madagascar—

• Children whose drinking water is surface water are more likely to be stunted (53 percent) than children
with access to piped water or well water (39 percent).

• Children whose drinking water is surface water are more likely to be wasted (14 percent) than children
with access to piped water (11 percent) or well water (12 percent).

62
Figure 26
Stunting and Wasting among Children under Five
Years by Source of Drinking Water, Madagascar
Percent

60
53 Stunting Wasting

50 47

39 39
40

30

20
13 14
11 12

10

0
er

er

er

er

er

er
al

al
t

t
at

at

at

at

at

at
To

To
W

lW

lW

W
d

ce

ce
el

el
pe

pe
W

W
r fa

r fa
Pi

Pi
Su

Su
Note: Stunting reflects chronic malnutrition;
63 Source: EDSMD-III 2003-2004
wasting reflects acute malnutrition.
Figure 27: Stunting and Wasting among Children under Five Years
by Type of Toilet, Madagascar

The type of toilet used by a household is related to its socioeconomic status, and poor households are less likely to
have adequate toilet facilities. Inadequate sanitation facilities result in an increased risk of diarrheal disease, which
contributes to malnutrition. Infants and children in households that do not have ready access to a flush toilet are at
greater risk of being malnourished than children in households with this amenity. In Madagascar, 47 percent of
households surveyed with at least one child under five years have access to a latrine, 53 percent have no facilities,
and 1 percent of surveyed households have access to a flush toilet.

In Madagascar—

• Children who have no access to toilet facilities and those who have access to a latrine are more likely to
be stunted (51 and 44 percent, respectively) than children with access to a flush toilet (31 percent).

• Children who have access to flush toilets are less likely to be wasted (4 percent), compared with children
who have access to latrines (13 percent) or have no access to toilet facilities (13 percent). However, this
difference is not statistically significant.

64
Figure 27
Stunting and Wasting among Children under Five
Years by Type of Toilet, Madagascar
Percent

60
Stunting Wasting
51
47
50 44

40
31
No statistical difference
30

20
13 13 13

10 4

0
s

s
t

t
ne

ne
al

al
ile

ile
ie

ie
t

t
To

To
tri

tri
l it

l it
To

To
La

La
ci

ci
Fa

Fa
h

h
us

us
o

o
Fl

Fl
N

N
Note: Stunting reflects chronic malnutrition;
65 Source: EDSMD-III 2003-2004
wasting reflects acute malnutrition.
66
Basic Influences

67
Figure 28: Stunting and Wasting among Children under Five Years
by Region, Madagascar

In Madagascar—

• Stunting ranges from 37 to 52 percent among children in the six regions. Stunting rates are lowest in
Antsiranana region (37 percent) and highest in Antananarivo region (52 percent).

• Wasting ranges from 10 to 16 percent among children in the six regions. Wasting rates are lowest in
Antananarivo region (10 percent) and highest in Fianarantsoa region (16 percent).

68
Figure 28
Stunting and Wasting among Children under
Percent Five Years by Region, Madagascar
80
Stunting Wasting

60
52
47 47 48 48
41
37
40

16
20 13 14 14 14
12
10

0
na

am a

ga

na

ra
ir a l

al
oa

am o

oa
a

in

in

A n a ng
riv

riv
A n To t

t
lia

lia
na

an

To

na
ts

ts
as

as
na

na
To

To
an

an
ir a
aj

aj
na

na
ah

ah
ar

ar
ts

ts
To

To
ta

ta
an

an
M

M
An

An
Fi

Fi
Note: Stunting reflects chronic malnutrition;
69 Source: EDSMD-III 2003-2004
wasting reflects acute malnutrition.
Figure 29: Stunting and Wasting among Children under Five Years
by Urban-Rural Residence, Madagascar

In Madagascar—

• The rate of stunting is highest in the countryside (49 percent), compared with the capital/large cities
(41 percent) or small cities/towns (40 percent).

• In the capital/large cities, 8 percent of children are affected by acute malnutrition, compared with 14
and 13 percent, respectively, in small cities/towns and the countryside.

70
Figure 29
Stunting and Wasting among Children under Five
Years by Urban-Rural Residence, Madagascar
Percent

60
Stunting Wasting
49
47
50
41 40
40

30

20 14
13 13
8
10

0
n

n
e

e
al

al
ty

ty
ow

ow
id

id
t

t
ci

ci
To

To
s

s
/T

/T
ge

ge
ry

ry
ity

ity
nt

nt
ar

ar
ou

ou
lC

lC
l/L

l/L
C

C
al

al
i ta

i ta
Sm

Sm
ap

ap
C

Note: Stunting reflects chronic malnutrition;


71 Source: EDSMD-III 2003-2004
wasting reflects acute malnutrition.
72
Maternal Nutritional Status

73
Figure 30: Malnutrition among Mothers of Children under Five
Years by Region, Madagascar

In addition to being a concern in its own right, a mother’s nutritional status affects her ability to successfully carry,
deliver, and care for her children. There are generally accepted standards for indicators of malnutrition among adult
women that can be applied.

Malnutrition in women can be assessed using the body mass index (BMI), which is defined as a woman’s weight in
kilograms divided by the square of her height in meters; thus, BMI = kg/m2. When the BMI is below the suggested
cutoff point of 18.5, this indicates chronic energy deficiency or undernutrition for nonpregnant, nonlactating
women. When the BMI is 25 or higher, women are considered overweight.

• Twenty-one percent mothers of children under five years in Madagascar are undernourished. The
highest level of maternal undernutrition is in the Toliara region (30 percent). The lowest level is in
Antsiranana (15 percent).

• Six percent of mothers of children under five years are overweight. The highest level of maternal
overnutrition is in Antsiranana region (10 percent). The lowest level is in the Toamasina region (3
percent).

74
Figure 30
Malnutrition among Mothers of Children under Five Years
Percent
by Region, Madagascar
80 Undernutrition Overnutrition
(chronic energy deficiency) (overweight)

60

40
30
25
21 22
19
20 15 16
10
6 7
3 4 5 5

0
na

am a

oa

ra

oa

ga

na
ir a l

l
a

ta

an lia r
riv

A n a riv
g

an sin

in
A n To t

lia
na

an

To

an

na
ts

ts
as
na

an

To

To

an

ir a
aj

aj
am
na

na
ah

ah
ar

ar
ts

ts
ta

To

To

ta
M

M
An

An
Fi

Fi
Note: Maternal undernutrition is the percentage
of mothers whos e BMI (kg/m 2) is less than 18.5. Source: EDSMD-III 2003-2004
Maternal overnutrition is the percentage of
mothers whose BMI is 25 or higher. 75
Figure 31: Malnutrition among Mothers of Children under Five
Years by Residence, Madagascar

In Madagascar—

• The undernutrition rate (chronic energy deficiency) for mothers of children under five years is 11 percent
in the capital/large cities, 18 percent in small cities/towns, and 22 percent in the countryside.

• The overnutrition rate (overweight) for mothers of children under five years is 4 percent in the
countryside and 11 percent in the capital/large cities and in small cities/towns.

76
Figure 31
Malnutrition among Mothers of Children under Five
Years by Residence, Madagascar
Percent
50
Undernutrition Overnutrition
(chronic energy (overweight)
40 deficiency)

30
21 22
18
20
11 11 11
10 6
4

0
n

n
e

e
al

al
ty

ty
ow

ow
id

id
t

t
ci

ci
To

To
s

s
/T

/T
ge

ge
ry

ry
ity

ity
nt

nt
ar

ar
ou

ou
lC

lC
l/L

l/L
C

C
al

al
i ta

i ta
Sm

Sm
ap

ap
C

C
Note: Maternal undernutrition is the percentage
of mothers whos e BMI (kg/m 2) is less than 18.5.
Maternal overnutrition is the percentage of
77 Source: EDSMD-III 2003-2004
mothers whose BMI is 25 or higher.
Figure 32: Malnutrition among Mothers of Children under Five
Years by Education, Madagascar

In Madagascar—

• Maternal education has an inverse relationship with maternal undernutrition. As the level of
maternal education increases, the level of undernutrition goes down.

• The rate of maternal overnutrition is highest among women with a secondary school education (12
percent) and lowest among those with no education (2 percent).

78
Figure 32
Malnutrition among Mothers of Children under Five
Years by Education, Madagascar
Percent

60
Undernutrition Overnutrition
(chronic energy deficiency) (overweight)
50

40

27
30
21 20
20 16
12
10 6
2 4

0
y

y
+

+
n

n
al

al
ar

ar
ti o

ti o
y

y
t

t
To

To
ar

ar
im

im
ca

ca
nd

nd
Pr

Pr
du

du
co

co
E

E
Se

Se
o

o
N

Note: Maternal undernutrition is the percentage


of mothers whos e BMI (kg/m 2) is less than 18.5.
Maternal overnutrition is the percentage of
79 Source: EDSMD-III 2003-2004
mothers whose BMI is 25 or higher.
Figure 33: Malnutrition among Mothers of Children under Five
Years, Madagascar Compared with Other Sub-Saharan Countries

Malnutrition among mothers is likely to have a major impact on their ability to care for themselves and their
children. Women less than 145 centimeters in height are considered too short. Mothers who are too short (a
condition largely due to stunting during childhood and adolescence) may have difficulty during childbirth because
of the small size of their pelvis. Evidence also suggests there is an association between maternal height and low
birth weight. Malnutrition among mothers is also assessed using the body mass index (kg/m2). Pregnant women
and those who are less than two months postpartum are not included in the analysis of maternal malnutrition
because of weight considerations.

In Madagascar—

• Seven percent of mothers of children under five are too short (<145 cm). This proportion is the
highest among the sub-Saharan countries surveyed.

• Twenty-one percent of mothers of children under five are undernourished (BMI <18.5). This level
is in the upper range of the sub-Saharan countries surveyed.

80
Figure 33
Malnutrition among Mothers of Children under Five Years,
Madagascar Compared with Other Sub-Saharan Countries
Percent Percent
10 50

Short
8 Undernourished 38 40
7

6 30
25

21

4 18 20
14
2.5 13
2.3 12
11 11
1.9 2 2
9 9 9
2 1.6
7 7 10
1.3 1.3
1.1 1.2 1.2 5
6
0.7 0.8
0.3 0.3

0 0
i2 3

E 200 9

20 03
3

n e 00 3

99

00

01

99

20 0 3

2
1

on 0

00

04

na 0

n e 001

4
00
0

ya 1

ga aw 2

20 1

02
am w e 3
9

an 199

03
e n 00

ha 00

ab 200

-0

00

ab 00

00

ha 00

M 00

-0

io 3-0
M 20

e n 00

00

ar 2 0
19

0
19

19
-

B 00 -
20

20

0
3-
0

20
ba 20

E 000

ig 01

20
2

2
G a2

i2

2
M n2

G i2

G n2

E a2
M a2

an l i 2
0

0
o

R we

sc so
a

a
in

da

an ia

da

am ya
20

a
aw
as

im ia

M rkin ria
al

pi
n

o
re

en

re
U iop

Z en
an

b
r
F

F
e

da

da

e
ar
ui

al

ui
ba
rit

rit
a
B

bi

bi
ig
K

K
G

G
na

th

th
w

w
sc
N

N
im
R

E
ki

ga
g

g
Z

Z
ur

U
a

a
B

B
ad

ad
M

Note: Short is the percentage of mothers under 145 cm;


undernourished is the percentage of mothers whose BMI
(kg/m 2) is less than 18.5. Pregnant women and those who are
81
less than two months postpartum are excluded from BMI Source: DHS surveys 1999 -2004
calculations.
82
Appendices

83
84
Appendix 1:
Stunting, Wasting, Underweight, and Overweight Rates by Background Characteristics,
Madagascar 2003-2004

Background Stunted Wasted Underweight Overweight Background Stunted Wasted Underweight Overweight
characteristic characteristic
Child’s age
in months Regions
0-5 18.0 5.6 7.3 13.2 Antananarivo 52.4 10.3 40.4 4.9
6-11 36.8 12.8 37.1 7.4 Fianarantsoa 47.8 15.7 44.4 3.9
12-17 52.7 18.4 48.4 3.6 Toamasina 47.3 12.2 43.8 2.2
18-23 63.1 20.2 54.3 3.6 Mahajanga 47.6 13.6 41.9 2.0
24-29 47.0 16.1 44.7 0.8 Toliara 40.6 14.2 39.4 2.8
30-35 52.5 12.7 50.1 0.8 Antsiranana 37.1 14.0 31.7 4.1
36-47 50.6 11.7 46.0 1.0
48-59 52.4 10.3 40.8 1.2

p<0.000 p<0.000 p<0.000 p<0.000 p<0.000 p<0.000 p<0.000 p<0.000


n=5,014 n=5,013 n=5,012 n=5,014 n=5,015 n=5,014 n=5,012 n=5,013
Gender of Urban-rural
child residence

Female 46.2 11.2 40.7 3.5 Capital/Large city 40.7 7.6 29.8 5.6
Male 48.5 15.0 42.1 3.5 Small city/Town 39.9 14.4 36.1 3.8
Countryside 49.1 13.1 43.1 3.3

NS p<0.000 NS NS p<0.000 p<0.000 p<0.000 NS


n=5,012 n=5,014 n=5,013 n=5,012 n=5,012 n=5,013 n=5,012 n=5,012

Overall 47.3 13.0 41.4 3.5 Overall 47.3 13.0 41.4 3.5

Note: Level of significance is determined using the chi-square test. NS = Not significant at p ≤0.05
Appendix 2:
NCHS/CDC/WHO International Reference Population Compared
with the Distribution of Malnutrition in Madagascar
The assessment of nutritional status is based on the concept that in a well-nourished population, the distribution of
children’s height and weight, at a given age, will approximate a normal distribution. This means that about 68 percent
of children will have a weight within one standard deviation of the mean for children of that age or height and a height
within one standard deviation of the mean for children of that age. About 14 percent of children will be between one
and two standard deviations above the mean; these children are considered relatively tall or overweight for their age or
relatively overweight for their height. Another 14 percent will be between one and two standard deviations below the
mean; these children are considered relatively short or underweight for their age or relatively thin for their height. Of
the remainder, 2 percent will be very tall or obese for their age or obese for their height; that is, they are more than two
standard deviations above the mean. Another 2 percent will fall more than two standard deviations below the mean and
be considered moderately or severely malnourished. These children are very short (stunted), very underweight for their
age, or very thin for their height (wasted). For comparative purposes, nutritional status has been determined using the
International Reference Population defined by the United States National Center for Health Statistics (NCHS standard)
as recommended by the Centers for Disease Control and Prevention and the World Health Organization.

Appendix 2 includes four curves: height-for-age, weight-for-height, and weight-for-age, graphed against a normal
curve. The height-for-age, weight-for-height and weight-for-age curves are shifted to the left of the standard curve,
indicating that there is a large number of malnourished children in Madagascar. The implications are that interventions
are necessary to address widespread malnutrition. Improve child health will result in a shift of the curves closer to the
reference standard.
Appendix 2
NCHS/CDC/WHO International Reference Population
Compared with the Distribution of Malnutrition in
Madagascar
Height-for-age
Weight-for-height
Weight-for-age
 Normal curve

  
 
Malnourished  Malnourished
(Stunted, wasted or  (Overweight)
underweight)
  
 
 
  
 
 
    
  
   




 

 




-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Standard Deviations from Mean (Z-score)


87