Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline

Abstract

Background: Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.

Objective: This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.

Methods: We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time.

Results: Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height.

Conclusions: Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.

Keywords: child; height; infant; length; linear growth; nutrition; stunting.

FIGURE 1

Global and regional comparison of the total number of children aged 0–59 mo experiencing linear growth stunting in 1990 and 2019. Source of data: UNICEF, World Bank Group joint malnutrition estimates, 2020 edition (6). Data not available for Europe and Central Asia.

FIGURE 2

Stunting prevalence for children under 5 y based on the most recently available country-level estimates. Map based on longitude (generated) and latitude (generated). Color shows sum of stunting prevalence. Details are shown for country. Source of data: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2020 edition (6). Data not available for Europe and Central Asia.

FIGURE 3

Global and regional trends in stunting prevalence, 1990–2019. Source of data: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2020 edition (6). Data not available for Europe and Central Asia.

FIGURE 4

Stunting prevalence, top-performing countries. Source of data: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2020 edition (6).

FIGURE 5

Conceptual framework of child stunting determinants. Determinants include those identified during the review process, and are based on those originally described in the UNICEF Undernutrition Conceptual Framework (8) and 2013 Lancet Maternal and Child Nutrition Series framework (1).