Maternal empowerment holds the key to reducing stunting during first 1000 days of life: Evidence from a case–controlled study


Objective: Stunting during the first 2 years of life can affect child’s cognitive development, schooling, and earning potential. The objective of the study is to identify the determinants of severe stunting among children aged 2 years of age. Materials and Methods: We conducted a case–control study involving 289 severely stunted children as cases and 578 children with normal height as controls. Household-, maternal-, pregnancy-, and child care-related data were collected. Adjusted odds ratio (AOR) with confidence interval (CI) was calculated. Results: Multivariate regression analyses indicated that mother having short stature (AOR = 1.92 [95% CI = 1.14–3.52]), severe anemia during pregnancy (AOR = 1.98 [95% CI = 1.13–3.82]), weight gain <8 kg during pregnancy (AOR = 6.36 [95% CI = 4.08–10.81]), birth weight <2 kg (AOR = 5.96 [95% CI = 4.22–8.92]), a younger sibling (AOR = 12.62 [95% CI = 8.63–18.52]), and not receiving Vitamin A supplementation (AOR = 2.78 [95% CI = 1.87–4.45]) were associated with higher odds of severe stunting among children aged 2 years. Conclusion: Most of the factors associated with severe stunting were directly or indirectly related to child’s mother. Thus, educating and empowering mother (s) for self-care before, during, and after pregnancy and about child care practices during first 2 years of life are crucial for reducing stunting in the first 1000 days of life.

Keywords: 1000 days, children, India, severe, stunting

How to cite this article:
Pandey P, Bajpai P, Jain S, Sharma A. Maternal empowerment holds the key to reducing stunting during first 1000 days of life: Evidence from a case–controlled study. Ann Trop Med Public Health 2017;10:667-77


How to cite this URL:
Pandey P, Bajpai P, Jain S, Sharma A. Maternal empowerment holds the key to reducing stunting during first 1000 days of life: Evidence from a case–controlled study. Ann Trop Med Public Health [serial online] 2017 [cited 2021 Mar 1];10:667-77. Available from:



Every type of malnutrition increases the risk of childhood mortality and morbidities.[1],[2] However, the type which has profound long-term consequences is childhood “stunting.” Researchers believe that childhood stunting (especially severe stunting) is mostly irreversible and almost all severely stunted children who survive beyond first few years of life suffer from a lasting damage including poor cognition, poor performance in school, reduced total duration of schooling, reduced productivity, and lower earning potential in adulthood.[3],[4],[5] Stunting has detrimental effects on the brain by causing deviations in the temporal sequence of brain maturation, which in turn disturb the formation of neural circuits and resulting in cognitive deficits.[6],[7]

Earliest evidence(s) linking childhood stunting with poor long-term outcome(s) came from many individual cohort studies and were later reaffirmed by a pooled analysis of several cohort studies.[8] In this study, “height at 2–3 years of age” was identified as a crucial factor determining the school performance and other important adult outcomes.[8] Close scrutiny of evidence generated over the last two decades pointed that period from conception until 2 years of age, i.e., first 1000 days of life, is “critical phase” or “window of opportunity” in child’s total growth period.[3],[9],[10] It is because evidence suggests that growth at older ages does not have the same effect on brain development as during first 2 years of life.[10] Scientists, as well as economists, thus believe that an investment in this “window of opportunity” has the potential of highest returns for the world by permanently locking-in good human capital.[11],[12]

As per the National Family Health Survey-3, the prevalence of severe stunting among children aged 18–23 months and 24–35 months was 30.4% and 28.9%, respectively.[13] Rapid survey of children reported that prevalence of severe stunting among Indian children under 5 years of age was 17.3%.[14] Thus, a considerable proportion of Indian children are unable to grow and acquire their full potential because of stunting. To promote the linear growth of children and reduce the prevalence of stunting in the first 2–3 years of age, we first need to delineate the biological, social, demographical, dietary, and other factors responsible for stunting among children. Therefore, we undertook this study with the objective to assess the determinant of severe stunting among children aged 2 years, i.e., at the end of 1000 days of existence.

Materials and Methods

Study design

This was a community-based unmatched case–control study.

Study location

The present study was conducted in Rajnandgaon district of Chhattisgarh state, India.

Study duration

The total duration of the study was 12 months (February 2016 to January 2017). The period of data collection was 7 months (June–December 2016).

Study settings

Integrated Child Development Services (ICDS) scheme is run by the Government of India for promoting the overall development of young children.[15] The administrative unit of ICDS is numerous “developmental projects” each headed by the Child Development Project Officer (CDPO). Building blocks of ICDS are numerous anganwadi center (AWC-courtyard) located on every 800–1000 population and managed by an anganwadi worker (AWW-grass root worker of ICDS) along with a helper.[15]

Source of participants

Every AWC enrolls children aged 6 months–6 years residing in its catchment area and provides them with a range of services for aiding child’s physical and mental development.[15]

Case definition

Children of either gender aged 2 years (±2 weeks) who were severely stunted (height for age <−3 standard deviation [SD]).[16]

Inclusion criteria for cases

(i) Children who were born in the health facility and not at home and (ii) children whose mother had at least three or more antenatal visits during the index pregnancy.

Exclusion criteria

(i) Children who did not have a birth certificate as a proof of their age, (ii) a child whose mother died any time before completion of 2 years of age, and (iii) children belonging to those AWCs which did not have AWWs.

Control definition

Children aged 2 years (±2 weeks) and same gender as the case with no stunting (height for age >−2SD).[16] Inclusion and exclusion criteria for controls were similar to cases.

Selection of cases and controls

From all (nine) ICDS blocks of Rajnandgaon district, we selected one rural and one tribal block for recruiting study participants. All children belonging to each and every AWC from two selected blocks who completed 2 years of age during the period of data collection were screened for potential cases and controls. Those who fulfilled selection criteria were included in the study. We included two controls for each case.

Participant recruitment

Two months before starting data collection, all the AWWs from selected AWCs attended a 2-h orientation program in batches of 30–40 AWWs. During this program, all AWWs were instructed to prepare a list of all children enrolled at their center who will complete 2 years of age during the period of data collection along with their exact date of birth. During the next monthly meeting, AWW handed over the list of potential study participants to data collectors. On the basis of this list, a time schedule was created for data collectors to go and visit AWCs and screen the children. Every data collector was allotted 20–30 AWCs and visited allotted AWCs twice a month, once between 1st and 15th, and again between 16th and 30th/31st of every month. Thus, all children who completed 2 years of age between 1st and 15th of the month were screened during first visit and rest during a subsequent visit. In this way, data collectors were able to record anthropometric measurements of potential study participants within ±2 weeks of the date when one or more children from a given AWC completed 2 years of age.

During their visit to AWC, data collector recorded the anthropometric measurements of the child after obtaining permission from AWW. All anthropometric measurements were taken as per the procedure recommended by the World Health Organization (WHO).[17] Parents of only those children whose anthropometric measurements matched with those required for either cases or controls were approached by the data collector. Child’s mother was asked set of questions to screen for selection criteria. Once both the child and his/her mother fulfilled the selection criteria for either case or control, mother of the child was explained the purpose of the study; thereafter, mother was asked for informed (oral) consent. After obtaining consent, mother of the case/control was interviewed at their home with the help of a predesigned questionnaire.

Data collection

A questionnaire was designed after literature review on potential determinants of stunting among infant and young children.[18],[19],[20],[21],[22] The questionnaire was translated from English to local language (Chhattisgarhi) by a translator, and the responses were translated back to English. The questionnaire was pretested on the mother of thirty children aged between 18 and 24 months who came for routine immunization at community health center; thereafter, modifications were done to improve the language of the questionnaire. The questionnaire had three parts. first part collected data related to household and family variables, second part collected data related to maternal and antenatal variables, and third part collected data related to the postnatal variables. Dietary intake was measured by 24-h recall method. Data related to infant and young child feeding practices were collected as per the WHO guidelines.[23],[24] There were two sources of collected data. first was the interview of the mother using study questionnaire and second was the medical record (s) of the index pregnancy, immunization card, and other medical records of cases/controls.


Measurements of weight for age, height for age, and weight for height were classified as per the WHO child growth standards.[16] In the present study, the risk factors for severe stunting among children aged 2 years were examined in terms of household, maternal, prenatal, and postnatal factors.

Sample size

We collected data from 289 cases and 578 controls.

Filled questionnaires were cross-checked for completeness of data by authors before entering into IBM Corporation, 2011 for analysis. Crude associations between severe stunting and study variable were investigated using bivariate analysis. Those independent variables that were found to be significantly associated with the severe stunting in bivariate analysis were then included in multivariate analysis. Adjusted odds ratios along with 95% confidence intervals and P values were calculated. P < 0.05 was considered statistically significant. The present study was approved by the Ethical Committee on Human Research of the Government Medical College.


Data collection had to be stopped at some AWC for 27 days between the months of July and August 2016; because of floods, data collectors were not able to reach some AWCs. In total, 2146 children who completed 2 years of age at selected; AWCs were screened for potential study participants. During the screening, we identified a total of 373 children with severe stunting, of which 84 children were excluded using selection criteria. A total of 949 children with normal height were identified during screening, of which 289 were excluded. We included 289 cases and 578 gender-matched controls in the study. Of the 660 controls who fulfilled selection criteria, we included 578 gender-matched controls following the chronological order of data collection. [Table 1] details the various anthropometric parameters of all children screened for recruitment of cases and controls.

Table 1: Anthropometric parameters of children screened for recruiting study participants (n=2146)

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[Table 2] summarizes the household- and family-related characteristics of cases and controls included in the study. Among cases, only 7.6% households used liquid petroleum gas as cooking fuel, 37.7% practiced open defecation, and 21.8% had a younger sibling. [Table 3] summarizes the maternal and prenatal characteristics of cases and controls. Mean age for marriage of case’s mother was lower (20.9 years) as compared to controls (22.4 years). Furthermore, higher proportions of the mother of cases (31.8%) were married before 18 years of age (legal age of marriage for women in India) as compared to controls (14.5%). During the index pregnancy, a higher proportion of mothers of cases consumed tobacco (28.4%), had severe anemia (34.6%), and had blood transfusion (18.0%) as compared to controls.

Table 2: Distribution of demographic characteristics of cases and controls

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Table 3: Distribution of maternal and prenatal factors among cases and controls

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[Table 4] summarizes the postnatal characteristic of cases and controls. In multivariate regression analysis [Table 5], most significant maternal predictors of severe stunting were mother’s age at birth of a child, maternal height, and reproductive intention of the mother (history of abortion, birth, or pregnancy in the last 2 years). Prenatal factors significantly associated with severe stunting in the decreasing order of importance are low weight gain during pregnancy (<8 kg), birth weight (<2 kg), short gestation age (<32 weeks), severe anemia, blood transfusion, and consuming tobacco. The most significant postnatal predictors of severe stunting were short duration of exclusive breastfeeding (EBF), inappropriate complementary feeding practices, lack of Vitamin A supplementation, and repeated episodes of diarrhea.

Table 4: Distribution of postnatal factors among cases and control

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Table 5: Predictors of severe stunting at 2 years of age; results of multivariate analysi

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The objective of this case–control study was to identify the predictors (household, family, maternal, prenatal, and postnatal) of severe stunting among children aged 2 years.

Maternal characteristics

We noted that low maternal height (<145 cm) predicted severe stunting among children at 2 years of age. Aguayo also reported similar observation from their survey conducted in Maharashtra, India.[18] Ozaltin et al. in their multi-country analysis also found that maternal height was inversely associated with odds of stunting among children.[25] An indirect association probably exists here; maternal height is an important determinant of low birth weight (LBW) and intrauterine growth retardation (IUGR), which in turn leads to stunting in early childhood. We observed that child whose mother was very young (<18 years) at the time of his/her birth had approximately five times higher odds of severe stunting. Aguayo et al. reported that children whose mother was married before the age of 18 years had higher odds of stunting.[18] Fall et al. in their pooled analysis noted that maternal age ≤19 years was associated with higher risk of LBW and stunting at 2 years of age.[8] They also concluded that stunting at 2 years of age was in turn associated with poorer outcomes in later life.[8] We found that poor reproductive intentions (family planning practices) of parent/mother were significantly associated with higher odds of severe stunting among children. Higher birth order, having a younger sibling and a gap of <18 months between index child and elder sibling, was associated with higher odds of severe stunting. Saxton et al. in their study conducted at Jharkhand and Odisha, India, concluded that birth spacing ≥24 months was protective against childhood stunting.[26] They noted that a child with the higher birth order (4th or higher) had poorer height for age Z (HAZ) score as compared to a first-born child. Fink et al. estimated that about 8.6% cases of stunting in South Asia can be averted by jointly eliminating teen pregnancies and narrow birth interval (<24 months).[27] Low gap between pregnancies depletes maternal reserves (both physical and emotional), thus making children vulnerable to malnutrition including stunting.[28] Large family size increases the competition for limited resources and the risk of acquiring repeated infections, thus making children prone to repeated bouts of malnutrition ultimately culminating in stunting.[28]

Prenatal factors

We found that maternal malnutrition (low weight gain and severe anemia) during pregnancy was significantly associated with odds of severe stunting among children at 2 years of age. Neufeld et al. concluded that maternal weight gain from first to second trimester was strongly associated with fetal growth.[29] Black et al. also concluded that poor maternal nutrition during pregnancy accounts for about one-fifth of the total global burden of stunting.[30] Ludwig and Currie noted that an inverse relationship exists between weight gained during pregnancy and LBW.[31] We in our analysis noted that child with birth weight <2.0 kg had approximately six times higher odds of severe stunting. Aguayo et al. also reported that odds of severe stunting were higher among children with LBW.[18] A study from Indonesia found that being LBW was the most important predictors of stunting among children.[32] In our study, gestational age <32 weeks was associated with about five times higher odds of severe stunting. Christian et al. observed that the risk of postnatal stunting was markedly higher among infants born preterm, small for gestational age, and small for gestational age preterm.[33] They estimated that about 20% of all stunting begins in utero. Poor weight gain during pregnancy is strongly associated with LBW (including IUGR) among newborn. LBW (including IUGR), in turn, determines postnatal growth and is strongly associated with stunting in later childhood.[34] Thus, there appears to be an indirect association between weight gain during pregnancy and stunting among children which needs further investigation.[34]

Postnatal factors

We observed that children who were exclusively breastfed for <3 months had more than three times higher odds of severe stunting and termination of breastfeeding before 18 months of age were associated with two times higher odds of severe stunting. The strength of existing evidence (s) linking breastfeeding and stunting or linear growth among children is weak or unclear. Simondon et al. in their study noted that children who were breastfed for a longer duration had a significantly greater increase in length during 2nd and 3rd year of life.[35] Fikadu et al. in their case–control study noted that EBF for <6 months was associated with three times higher odds of stunting at 24–59 months of age.[36] They also noted that earlier discontinuation of breastfeeding (<24 months) was associated with five times higher odds of stunting among children at 24–59 months of age.[36] On the contrary, a randomized control trial for the promotion of EBF found that increased rates of EBF were not associated with improved length at 6 months.[37] A few other trials also concluded that increased EBF rates did not increase length/HAZ score as compared to nonintervention arm.[38] In the light of contradicting evidence, there is a need to explore the relationship between breastfeeding and stunting in greater details. We found that inappropriate complementary feeding practices, viz., low diet diversity, low feeding frequency, and overall inadequate diet, were associated with higher odds of severe stunting among children. Aguayo et al. noted that the odds of severe stunting were >60% higher in children aged 6–23 months who were not fed a minimum number of times per day.[18] Zongrone et al. reported that adoption of appropriate complementary feeding practices for children aged 6–8 months was associated with higher HAZ score.[39] They also observed that higher dietary diversity index was associated with higher HAZ score. A systematic review by Lassi et al. concluded that the merely providing education on complementary feeding practices to food secure families significantly improved HAZ score and reduced the stunting rates among children.[40]

In our study, repeated episodes of diarrhea (<7 episodes) were associated with 83% higher odds of severe stunting. Moore et al. observed that HAZ score significantly decreased among children after an episode of prolonged diarrhea as compared to the period before the onset of diarrhea.[41] This might be due to the faulty feeding practices adopted by parents during and following the episode of diarrhea, thus depriving growing children of essential nutrients.[19] We noted that not receiving even a single dose of Vitamin A till 2 years of age was associated with nearly three times higher odds of severe stunting. Kimani-Murage et al. reported that the odds of stunting were 50% higher among children who did not receive Vitamin A supplement as compared to those who did.[42] It is widely known that Vitamin A deficiency increases the duration, severity, and frequency of diarrhea, thus may indirectly contribute to poor nutritional outcome including stunting.[43]


Despite achieving impressive economic growth, a considerable proportion of Indian children fail to reach their full potential owing to high levels of stunting prevailing in India. We noted that most factors which predicted severe stunting among children at 2 years of age were either directly or indirectly associated with child’s mother. Factors related to child’s mother including height, age of marriage, age at childbirth, interpregnancy gap, antenatal care, breastfeeding, complementary feeding, and care during illness were the most important determinants of severe stunting. Thus, educating and empowering women for self-care before, during, and after pregnancy and about child care practices are the only possible solution for reducing the prevalence of stunting and securing the future of our children.


We would like to thank all the study participants and the complete staff of ICDS, Rajnandgaon for their support in successfully conducting this study. We express our gratitude toward the CDPO of the selected blocks for their corporation. In no words, we can thank all the data collectors who collected data in the adverse conditions against all odds.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.



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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_228_17


[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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