Geographical and socioeconomic inequalities in women and children's nutritional status in Pakistan in 2011: an analysis of data from a nationally representative survey

Abstract

Background: Pakistan has one of the highest levels of child and maternal undernutrition worldwide, but little information about geographical and socioeconomic inequalities is available. We aimed to analyse anthropometric indicators for childhood and maternal nutrition at a district level in Pakistan and assess the association of nutritional status with food security and maternal and household socioeconomic factors.

Methods: We used data from the 2011 Pakistan National Nutrition Survey, which included anthropometric measurements for 33 638 children younger than 5 years and 24 826 women of childbearing age. We estimated the prevalences of stunting, wasting, and underweight among children and of underweight, overweight, and obesity in women for all 143 districts of Pakistan using a Bayesian spatial technique. We used a mixed-effect linear model to analyse the association of nutritional status with individual and household sociodemographic factors and food security.

Findings: Stunting prevalence in Pakistan's districts ranged between 22% (95% credible interval 19-26) and 76% (69-83); the lowest figures for wasting and underweight were both less than 2·5% and the highest were 42% (34-50) for wasting and 54% (49-59) for underweight. In 106 districts, more women were overweight than were underweight; in 49 of these districts more women were obese than were underweight. Children were better nourished if their mothers were taller or had higher weight, if they lived in wealthier households, and if their mothers had 10 or more years of education. Severe food insecurity was associated with worse nutritional outcomes for both children and women.

Interpretation: We noted large social and geographical inequalities in child and maternal nutrition in Pakistan, masked by national and provincial averages. Pakistan is also beginning to face the concurrent challenge of high burden of childhood undernutrition and overweight and obesity among women of reproductive age. Planning, implementation, and evaluation of programmes for food and nutrition should be based on district-level needs and outcomes.

Funding: Bill & Melinda Gates Foundation, Grand Challenges Canada, UK Medical Research Council.

Figure 1

Map of Pakistan

Figure 2

Child and maternal anthropometric indicators (A) Indicators by deciles for household economic status. (B) Indicators by categories for maternal education. Prevalence refers to the proportion of individuals with HAZ more than 2 SD below median for stunting, WAZ more than 2 SD below median for underweight, WHZ more than 2 SD below median for wasting, and BMI less than 18·5 kg/m² for underweight. HAZ=height-for-age Z score. WAZ=weight-for-age Z score. WHZ=weight-for-height Z score. BMI=body-mass index.

Figure 3

Distribution of economic status and literacy (A) Proportion of households in the two lowest quintiles of household economic status. (B) Proportion of women by district who are illiterate. The figures show posterior prevalences from a Bayesian spatial model.

Figure 4

Prevalence of stunting, underweight, wasting, and stunting-plus-wasting among children younger than 5 years Prevalences were estimated with a Bayesian spatial model with covariates. *Average prevalence of all developing countries in 2011. †Pakistan national prevalence in 2011. ‡Highest national prevalence all developing countries in 2011.

Figure 5

Prevalence of overweight among children younger than 5 years The district-level prevalences were estimated using a Bayesian spatial model with covariates.

Figure 6

Prevalence of underweight, normal weight and overweight, and obesity among women of childbearing age The prevalences were estimated with a Bayesian spatial model with covariates. *Average prevalence of all developing countries in 2011. †Pakistan national prevalence in 2011. ‡Highest national prevalence in all developing countries in 2011.