WORKSHOP Linkages of Agriculture, Nutrition and Economic Development Co-Organized by IFPRI, UPNG, INA, Australian National University, and Department of Foreign Affairs and Trade JUN 12, 2019 - 09:00 AM TO 12:30 PM +10

1. Child growth & development in rural Papua New Guinea:
Insights from new anthropometric data
Rachel Gilbert and Emily Schmidt
International Food Policy Research Institute
June 13, 2019
Port Moresby, Papua New Guinea

2. Research motivated by need for updated child health data
▪ Sporadic data on prevalence of child malnutrition
▪ 2010-11: High malnutrition rates, even in relatively wealthy
households (Hou 2015)
▪ Evidence of poor infant feeding practices and
maternal health
▪ Low rates of exclusive breastfeeding (Kuzma 2013b, Vallely
2013)
▪ Food taboos + low nutrition knowledge affecting mother’s
health (Kuzma 2013a)
▪ We use the socioeconomic and anthropometric data from
four rural areas of PNG

3. What is anthropometric data?
▪ Anthropometry is a fancy word for body
measurements
▪ Body size helps us understand whether
children are growing and developing
normally
▪ Newly-trained local enumerator team
▪ IFPRI linked with the Department of Health,
University of PNG and UNICEF for training
▪ All anthropometry equipment provided by
UNICEF & donated to rural health posts in
survey areas

4. Indicators of child growth and nutritional status
▪ We compare the size of children in our survey areas to global body size standards based on how
children grow under optimal conditions
▪ The World Health Organization developed these standards by studying children across the world
▪ Create a score for each child based on standard deviations from the global average
Standardized measurement
Height-for-age z-score (HAZ)
Weight-for-height z-score (WHZ)

5. Indicators of child growth and nutritional status
▪ We compare the size of children in our survey areas to global body size standards based on how
children grow under optimal conditions
▪ The World Health Organization developed these standards by studying children across the world
▪ Create a score for each child based on standard deviations from the global average
Standardized measurement Used to estimate What does it mean?
Height-for-age z-score (HAZ) Stunting HAZ < - 2
Children are too short for their age
Weight-for-height z-score (WHZ) Wasting WHZ < - 2
Children are too light for their height

6. Height-for-age z-scores (HAZ) in our sample
▪ A negative height-for-age value
(HAZ) indicates that a child is
shorter than they should be for
their age.
▪ Larger negative values = worse
growth

7. Height-for-age z-scores (HAZ) in our sample
▪ A negative HAZ value indicates
that a child is shorter than they
should be for their age.
▪ Larger negative values = worse
growth
▪ Majority of the sample is below
HAZ = 0
Average HAZ = 0
under optimal
growth conditions
HAZ less than
- 2 = child is
stunted

8. Stunting is not just about shortness – it represents an extreme deviation from expected growth.
▪ increase children’s vulnerability to sickness and premature death
▪ have inter-generational effects – mothers who were malnourished or stunted as children often have
difficult births and babies who are too small
▪ highlight a deficient environment for kids’ growth, for example:
▪ Food/nutrient availability
▪ Inappropriate child feeding or care practices
▪ Repeated infections or illness
Wasting is not just about being thin
▪ Evidence of acute deprivation or illness
▪ Increased risk of mortality for wasted children
Why do we care about stunting and wasting?

9. • 32% of children under 5 years of age
are stunted in their growth
▪ Above 30% is considered a “very
high prevalence” by WHO
▪ 9% of children in sample are wasted
▪ Particular concern in survey area
surrounding Middle Ramu, Madang
▪ Stunting rates not comparable to
previous studies due to sampling and
location
32% 32%
42%
24%
36%
9%
7%
4%
13%
8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
All children ARoB East Sepik Madang West Sepik
Shareofchildrenunderfiveyearsofage
Stunted Wasted
Stunting and wasting prevalence by survey area

10. What influences inadequate child growth in our survey areas?

11. What factors are associated with child growth (HAZ)?
Regression
variables
Mother’s height (cm)
Mother’s body mass index (kg/m2)
Age of mother (years)
Child's birth order (1 = first born, 2 = second born…)
Born less than 18 months after older sibling
Born less than 18-23 months after older sibling
Born less than 24-35 months after older sibling
Born less than 36 months or more after older sibling
Controlling for: district (fixed effects), child’s age in months, gender of child, difficulty measuring child, household
size, number of children under 5 in the household, distance to nearest market, asset and housing indices,
educational achievement of mother and household head, and receipt of extension/advice on IYCF.
*** p<0.01, ** p<0.05, * p<0.1

12. What factors are associated with child growth (HAZ)?
▪ +/- signs tell us how HAZ and the
likelihood of stunting are related
to a particular variable
▪ Significance level tells us how
confident we are in the
association
▪ More stars = more confident
Regression
variables
Direction of
relationship with
HAZ
Significance
level
Mother’s height (cm) + ***
Mother’s body mass index (kg/m2) + *
Age of mother (years) + *
Child's birth order (1 = first born, 2 = second born…) - **
Born less than 18 months after older sibling -
Born less than 18-23 months after older sibling -
Born less than 24-35 months after older sibling + **
Born less than 36 months or more after older sibling + *
Controlling for: district (fixed effects), child’s age in months, gender of child, difficulty measuring child, household
size, number of children under 5 in the household, distance to nearest market, asset and housing indices,
educational achievement of mother and household head, and receipt of extension/advice on IYCF.
*** p<0.01, ** p<0.05, * p<0.1

13. What factors are associated with child growth (HAZ)?
▪ For example, as mother’s
height increases, height-for-
age also increases (+)
▪ Taller mothers have children
who are less likely to be too
short for their height
Regression
variables
Direction of
relationship with
HAZ
Significance
level
Mother’s height (cm) + ***
Mother’s body mass index (kg/m2) + *
Age of mother (years) + *
Child's birth order (1 = first born, 2 = second born…) - **
Born less than 18 months after older sibling -
Born less than 18-23 months after older sibling -
Born less than 24-35 months after older sibling + **
Born less than 36 months or more after older sibling + *
Controlling for: district (fixed effects), child’s age in months, gender of child, difficulty measuring child, household
size, number of children under 5 in the household, distance to nearest market, asset and housing indices,
educational achievement of mother and household head, and receipt of extension/advice on IYCF.
*** p<0.01, ** p<0.05, * p<0.1

14. Maternal health is important for optimal child growth
▪ Shorter mothers are more likely to have
stunted children
▪ Intergenerational effects of inadequate
growth
▪ We see a similar positive association
between mother’s body mass index
(BMI) and mother’s age
▪ Younger and underweight mothers have
children who are more likely to be short
for their age

15. What factors are associated with child growth (HAZ)?
▪ Alternatively, as birth order
increases, height-for-age
decreases (-)
▪ So the second born child is
more likely to be stunted than
the first born child
Regression
variables
Direction of
relationship with
HAZ
Significance
level
Mother’s height (cm) + ***
Mother’s body mass index (kg/m2) + *
Age of mother (years) + *
Child's birth order (1 = first born, 2 = second born…) - **
Born less than 18 months after older sibling -
Born less than 18-23 months after older sibling -
Born less than 24-35 months after older sibling + **
Born less than 36 months or more after older sibling + *
Controlling for: district (fixed effects), child’s age in months, gender of child, difficulty measuring child, household
size, number of children under 5 in the household, distance to nearest market, asset and housing indices,
educational achievement of mother and household head, and receipt of extension/advice on IYCF.
*** p<0.01, ** p<0.05, * p<0.1

16. Family planning and birth spacing are important for healthy growth
▪ Each additional child born to a mother is more likely
to be stunted in their growth
▪ Months between the birth of the child and it’s older
sibling
▪ Children who were born 24 months or more after their
immediate older sibling are less likely to be too short for
their age

17. Height-for-age z-scores decline sharply between 0-24 months
▪ On average, children are
already too small at birth
▪ Sharp decline in HAZ
during period from birth to
about 2 years of age
▪ Period of transition from
exclusive breastfeeding >
weaning & feeding other
liquids and family foods

18. Adherence to recommended child feeding practices
▪ Room to improve,
particularly in Madang
▪ Positively, we see higher
rates than average in the
East Asia and Pacific
Region (22%)

19. Most households are using untreated water for drinking and food preparation
▪ 65% of households obtain their
drinking water from unprotected /
surface water sources
▪ Only 6% of households use an
effective form of treating water
(boiling or chlorine tablets)
▪ Untreated water can expose
children to recurrent diseases
which can impact ability to absorb
nutrients from food
65% 60%
48%
90%
58%
0%
20%
40%
60%
80%
100%
Allhouseholds
ARoB
EastSepik
Madang
WestSepik
Province
Source of drinking water
Unprotected/ surface water Rainwater Piped/ protected water

20. Less than half of households have received advice on child and family health
▪ Households were asked about
advice they received in the last two
years
▪ Breastfeeding and family planning
are most common topics
▪ Ability to benefit from advice and
programming on child health
improves with increased education
for mothers (Black et al. 2013)

21. What can be done?
▪ Educate and advocate for better women’s health
▪ Nutrition and health of mothers is important even before the child is born
▪ Need to recognize increased nutrient needs of adolescent girls and mothers
▪ Help households plan how many children to have, and when
▪ Involve fathers and men in these activities – moms can’t work alone!
▪ Child health programming
▪ Promote best feeding practices – exclusive breastfeeding and not introducing foods too early
▪ Provision of clean water/water treatment education & resources
▪ Adjust governance structure to support food & nutrition goals
▪ Re-invest in nutrition specialists at the provincial or district level
▪ Collaborations between agriculture and nutrition to improve diets and livelihoods
HEALTHY MOTHERS = HEALTHY CHILDREN = HEALTHY PNG

22. References
▪ Black, Robert E, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, et al.
“Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet 382, no. 9890
(August 3, 2013): 427–51. https://doi.org/10.1016/S0140-6736(13)60937-X.
▪ DOH, UNICEF, UPNG, CDC, SEAMO-TROPMED RCCN, ANU, UNDP/UNFPA, and Mahidol University. “National Nutrition
Survey Papua New Guinea, 2005.” Pacific Journal of Medical Sciences 8, no. 2 (May 2011).
▪ Hou, Xiaohui. Stagnant Stunting Rate Despite Rapid Economic Growth in Papua New Guinea—Factors Correlated with
Malnutrition among Children under Five. Policy Research Working Papers 7301. The World Bank, 2015.
https://doi.org/10.1596/1813-9450-7301.
▪ Kuzma, Jerzy, Delma Paofa, Nathan Kaugla, Totona Catherina, Sophie Samiak, and Ethel Kumei. “Food Taboos and Traditional
Customs among Pregnant Women in Papua New Guinea: Missed Opportunity for Education in Antenatal Clinics.” Contemporary
PNG Studies: DWU Research Journal 19 (November 2013).
https://search.informit.com.au/documentSummary;dn=846982897061954;res=IELIND.
▪ Kuzma, Jerzy. “Knowledge,Attitude and Practice Related to Infant Feeding among Women in Rural Papua New Guinea: A
Descriptive, Mixed Method Study.” International Breastfeeding Journal 8, no. 1 (November 21, 2013): 16.
https://doi.org/10.1186/1746-4358-8-16.
▪ Leroy, Jef L, and Edward A Frongillo. “Perspective: What Does Stunting Really Mean? A Critical Review of the Evidence.”
Advances in Nutrition 10, no. 2 (March 1, 2019): 196–204. https://doi.org/10.1093/advances/nmy101.
▪ WHO. “The WHO Multicentre Growth Reference Study (MGRS).” World Health Organization.Accessed June 5, 2019.
https://www.who.int/childgrowth/mgrs/en/.