The joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa: Analysis of cross-sectional surveys on children from 31 countries

Nutrients, Volume 13, No. 5, Year 2021

Interpretation

The current study sought to investigate the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. Data in the children’s files of 31 sub-Saharan African countries were pooled from the Demographic and Health Surveys collected between 2010 and 2019. The outcome variables were three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). The joint effect of maternal marital status and type of household cooking fuel on child nutritional status was examined using multilevel regression models. The results were presented as adjusted odds ratios (aORs) at p < 0.05. The percentages of children who were stunted, wasted and underweight in the 31 countries in sub-Saharan Africa were 31%, 8% and 17%, respectively. On the joint effect of maternal marital status and type of household cooking fuel on stunting, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who use unclean household cooking fuel, children born to single women who use clean household cooking fuel, and children born to married women who used unclean household cooking were more likely to be stunted. With wasting, children born to single mothers who used unclean household cooking fuel and children born to married women who used unclean household cooking fuel were more likely to be wasted compared to children born to married mothers who used clean household cooking fuel. With underweight, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who used unclean household cooking fuel, children born to single women who used clean household cooking fuel and children born to married women who used unclean household cooking were more likely to be underweight. It is imperative for the governments of the 31 sub-Saharan African countries to double their efforts to end the use of unclean household cooking fuel. This goal could be achieved by promoting clean household cooking fuel (e.g., electricity, gas, ethanol, solar, etc.) through effective health education, and promotion programmes. The attention of policymakers is drawn to the urgent need for children’s nutritional status policies and programmes (e.g., dietary supplementation, increasing dietary diversity, improving agriculture and food security) to be targeted towards at-risk sub-populations (i.e., single mothered households). Data for this study were obtained from the Demographic and Health Surveys (DHS) of 31 countries in SSA counducted from 2010 to 2019. The DHS Program has since 1984 assisted in the conduct of over 400 surveys in many low-and middle-income countries around the world. These cross-sectional surveys provide nationally representative household data on various nutrition, population and health indicators in more than 90 countries. Standardized protocols and instruments are employed to gather data of children, women, men and households. For this study, data in the children’s files were pooled from the DHS. The surveys employ a two-stage stratified sampling in selecting participants. The first stage involves the selection of clusters, usually called enumeration areas (EAs), and the second stage consists of the selection of households for the survey. To ensure consistency in data collection across countries, the DHS use a standard questionnaire comparable across countries for data collection, and the questionnaire is often translated into the major local languages of the countries involved. To ensure validity of the translated questionnaires, the DHS reports that the translated questionnaires, together with the version in English, are pretested in English and the local dialect [16,17]. Figure 1 shows the countries included in this study. We followed the Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) statement in writing the manuscript. The dataset is freely accessible for download at: https://dhsprogram.com/data/available-datasets.cfm (accessed on 3 February 2021). Map showing the 31 sub-Saharan African Countries. The outcome variables are three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). These variables were defined and coded using the WHO child growth standard which is followed by the DHS program [18]. The coding was done as follows: The main predictor variables used were generated based on literature and potential contextual implications of findings. They were maternal marital status and type of household cooking fuel. The variable “maternal marital status” was coded to produce two responses as follows: never married, widowed and separated/divorced were coded together as “Single” and married and living with a partner as “Married” [9]. For parsimony, theoretical and contextual relevance, the variable “type of household cooking fuel” was also coded into two response categories “Clean” and “Unclean” following previous studies [19,20]. Clean fuels included electricity, liquefied petroleum gas (LPG) and natural gas while charcoal, firewood, grass/straw, dung, shrubs, agricultural crop waste represented unclean cooking fuels [19,20]. The two variables “maternal marital status” and “type of household cooking fuel” were then combined [19,20] to produce the variable “Maternal marital status-Type of cooking fuel” with four (4) mutually exclusive categories: “Single mother-clean” (single mothers living in a household that uses clean cooking fuel), “Single mother-unclean” (single mothers living in households that uses unclean cooking fuel), “Married -clean” (mothers who are married or living with a partner in a household that uses clean cooking fuel” and “Married -unclean” (mothers who are married or living with a partner in a household that uses unclean cooking fuel). To observe the effect of maternal marital status and the type of household cooking fuel on the nutritional status of children under the age of 5 years, married-clean is used as the reference group. In the analysis of the effect of maternal marital status and household cooking fuel type on the nutritional status of children under age 5, three categories/clusters of variables (individual level factors-child and mother’s characteristics, household characteristics, and contextual factors) were considered ascovariates. The selection of these variables was based on their significant associations with CNS in previous studies (6–8). Variables under individual level factorsconsidered include the age of the child (0, 1, 2 and 4); sex of child (female and male); birth order of child (1, 2 to 4, and 5 and above); and perceived size at birth (small, average and large) (see [21]). Other included maternal age (re-coded into two categories “15–19” years and “20–49” years (see [22]); educational attainment (no formal education, primary, secondary and higher); working status (yes and no); antenatal visits during pregnancy (yes, no, and “Don’t know”); postnatal check within 2 months (yes and no); and place of delivery (home, health facility, other). At the household level, relevant variables included wealth status (recode as “poor”, “middle” and “rich”); the age of household head (recoded as ages below 35 years “young adults”, between 35 and 55 years “middle-aged adults” and those above 55 years “old-aged adults”; sex of household head (male and female); access to electricity (yes and no); type of toilet facility (re-coded into “improved” and unimproved”; source of drinking water (re-coded as “improved” and “unimproved” (see [23]); and access to media (yes, no) which was derived from the three variables “access to television”, “radio” and “newspaper/magazine”. The contextual factors considered are Urbanicity (rural and urban) and geographic region. The variable “Country” was re-coded to generate “Geographic region” following the UN’s list of countries and geographic regions in SSA. Stata SE version 14.2 (StataCorp, College Station, TX, USA) was used for statistical analyses of data. Descriptive statistics, including frequencies, percentages (weighted) and 95% confidence intervals (CIs) of percentages at p < 0.05 were used to summarize and present the data in tables. To enhance visualization and appreciation of the distributions of the outcome variables across the study countries, the data was integrated into a GIS environment and presented in map images. This procedure was then followed with a bivariate chi-square test of independence to determine the associations between the outcome variables and each of the key predictor variables and covariates. Collinearity diagnosis tests, including Variance Inflation Factors (VIF), Square VIF, Tolerance and R-squared were conducted for the key predictor variables and covariates. The joint effect of maternal marital status and type of household cooking fuel on CNS was examined using six multilevel regression models for each of the outcome variables (stunting, wasting, and underweight). The first model (Model 0) showed the variance in nutritional status attributed to the clustering of the primary sampling units (PSUs), without the explanatory variables. Model I contained only the key predictor variable (maternal marital status-type of household cooking fuel). Model II and III controlled for the individual and household level factors, respectively, while Model IV controlled for the contextual level factors. The final model (Model V) controlled for all the the individual, household, and contextual level factors. The Stata command “melogit” was used in fitting these models. We used Akaike’s Information Criterion (AIC) tests for Model comparison. All the results were presented using adjusted odds ratios (aOR) at 95% Confidence Interval (CI). To prevent potential challenges of oversampling or under-sampling and clustering of samples emerging from the multi-stage sampling technique used in the data collection, the weighting, cluster and strata variables were used to adjust the effect sizes. For DHS reports, ethical clearance are sought from the Ethics Committee of ORC Macro Inc. as well as Ethics Boards of partner institutions (e.g., Ministries of Health) of the studied countries. The DHS protocols ensure that standards for the protection of respondents’ privacy and confidentiality are adhered. Inner City Fund International also make sure that the survey conforms with the United States Department of Health and Human Services’ regulations for the respect of human subjects. This study used a secondary data, hence, no further ethical approval was required. The datasets are freely available for download in the public domain. Further information about the DHS data usage and ethical standards is available at http://goo.gl/ny8T6X (accessed on 3 February 2021).

AI Digest

Study Justification:

The study aimed to investigate the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. This research is important because it provides insights into the factors that contribute to child malnutrition in the region. By understanding the relationship between maternal marital status, household cooking fuel, and child nutritional status, policymakers can develop targeted interventions to improve child health outcomes.

Highlights:

– The study analyzed data from 31 sub-Saharan African countries collected between 2010 and 2019.
– The outcome variables were stunting, wasting, and underweight, which are indicators of child malnutrition.
– The study found that children born to single mothers who used unclean household cooking fuel were more likely to be stunted, wasted, and underweight compared to children born to married mothers who used clean household cooking fuel.
– The percentages of children who were stunted, wasted, and underweight in the 31 countries were 31%, 8%, and 17%, respectively.
– The study highlights the urgent need for governments to promote clean household cooking fuel and implement policies and programs to improve children’s nutritional status.

Recommendations for Lay Reader:

– Governments in sub-Saharan Africa should prioritize efforts to end the use of unclean household cooking fuel.
– Health education and promotion programs should be implemented to promote clean household cooking fuel options such as electricity, gas, ethanol, and solar.
– Policies and programs should be targeted towards at-risk sub-populations, such as single mothered households, to improve children’s nutritional status.
– Increasing dietary diversity, improving agriculture, and ensuring food security should be key components of children’s nutritional status policies and programs.

Recommendations for Policy Maker:

– Double efforts to end the use of unclean household cooking fuel in sub-Saharan Africa.
– Implement effective health education and promotion programs to promote clean household cooking fuel options.
– Develop and implement policies and programs that target at-risk sub-populations, particularly single mothered households, to improve children’s nutritional status.
– Allocate resources to increase dietary diversity, improve agriculture, and ensure food security as part of children’s nutritional status policies and programs.

Key Role Players:

– Government agencies responsible for health, nutrition, and energy.
– Non-governmental organizations (NGOs) working in the areas of health, nutrition, and energy.
– Community leaders and influencers.
– Health professionals and educators.
– Researchers and academics specializing in child nutrition and public health.

Cost Items for Planning Recommendations:

– Development and dissemination of health education materials.
– Training programs for health professionals and educators.
– Implementation of clean household cooking fuel promotion campaigns.
– Research and data collection on child nutritional status.
– Monitoring and evaluation of policies and programs.
– Infrastructure development for clean household cooking fuel options.
– Subsidies or financial incentives for households to switch to clean cooking fuels.
– Support for agricultural and food security programs.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on data from 31 sub-Saharan African countries and uses multilevel regression models. The results are presented as adjusted odds ratios (aORs) at p < 0.05. However, to improve the evidence, the abstract could provide more information on the sample size and the representativeness of the data. Additionally, it would be helpful to include information on potential confounding variables that were controlled for in the analysis.

Abstract

Data for this study were obtained from the Demographic and Health Surveys (DHS) of 31 countries in SSA counducted from 2010 to 2019. The DHS Program has since 1984 assisted in the conduct of over 400 surveys in many low-and middle-income countries around the world. These cross-sectional surveys provide nationally representative household data on various nutrition, population and health indicators in more than 90 countries. Standardized protocols and instruments are employed to gather data of children, women, men and households. For this study, data in the children’s files were pooled from the DHS. The surveys employ a two-stage stratified sampling in selecting participants. The first stage involves the selection of clusters, usually called enumeration areas (EAs), and the second stage consists of the selection of households for the survey. To ensure consistency in data collection across countries, the DHS use a standard questionnaire comparable across countries for data collection, and the questionnaire is often translated into the major local languages of the countries involved. To ensure validity of the translated questionnaires, the DHS reports that the translated questionnaires, together with the version in English, are pretested in English and the local dialect [16,17]. Figure 1 shows the countries included in this study. We followed the Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) statement in writing the manuscript. The dataset is freely accessible for download at: https://dhsprogram.com/data/available-datasets.cfm (accessed on 3 February 2021). Map showing the 31 sub-Saharan African Countries. The outcome variables are three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). These variables were defined and coded using the WHO child growth standard which is followed by the DHS program [18]. The coding was done as follows: The main predictor variables used were generated based on literature and potential contextual implications of findings. They were maternal marital status and type of household cooking fuel. The variable “maternal marital status” was coded to produce two responses as follows: never married, widowed and separated/divorced were coded together as “Single” and married and living with a partner as “Married” [9]. For parsimony, theoretical and contextual relevance, the variable “type of household cooking fuel” was also coded into two response categories “Clean” and “Unclean” following previous studies [19,20]. Clean fuels included electricity, liquefied petroleum gas (LPG) and natural gas while charcoal, firewood, grass/straw, dung, shrubs, agricultural crop waste represented unclean cooking fuels [19,20]. The two variables “maternal marital status” and “type of household cooking fuel” were then combined [19,20] to produce the variable “Maternal marital status-Type of cooking fuel” with four (4) mutually exclusive categories: “Single mother-clean” (single mothers living in a household that uses clean cooking fuel), “Single mother-unclean” (single mothers living in households that uses unclean cooking fuel), “Married -clean” (mothers who are married or living with a partner in a household that uses clean cooking fuel” and “Married -unclean” (mothers who are married or living with a partner in a household that uses unclean cooking fuel). To observe the effect of maternal marital status and the type of household cooking fuel on the nutritional status of children under the age of 5 years, married-clean is used as the reference group. In the analysis of the effect of maternal marital status and household cooking fuel type on the nutritional status of children under age 5, three categories/clusters of variables (individual level factors-child and mother’s characteristics, household characteristics, and contextual factors) were considered ascovariates. The selection of these variables was based on their significant associations with CNS in previous studies (6–8). Variables under individual level factorsconsidered include the age of the child (0, 1, 2 and 4); sex of child (female and male); birth order of child (1, 2 to 4, and 5 and above); and perceived size at birth (small, average and large) (see [21]). Other included maternal age (re-coded into two categories “15–19” years and “20–49” years (see [22]); educational attainment (no formal education, primary, secondary and higher); working status (yes and no); antenatal visits during pregnancy (yes, no, and “Don’t know”); postnatal check within 2 months (yes and no); and place of delivery (home, health facility, other). At the household level, relevant variables included wealth status (recode as “poor”, “middle” and “rich”); the age of household head (recoded as ages below 35 years “young adults”, between 35 and 55 years “middle-aged adults” and those above 55 years “old-aged adults”; sex of household head (male and female); access to electricity (yes and no); type of toilet facility (re-coded into “improved” and unimproved”; source of drinking water (re-coded as “improved” and “unimproved” (see [23]); and access to media (yes, no) which was derived from the three variables “access to television”, “radio” and “newspaper/magazine”. The contextual factors considered are Urbanicity (rural and urban) and geographic region. The variable “Country” was re-coded to generate “Geographic region” following the UN’s list of countries and geographic regions in SSA. Stata SE version 14.2 (StataCorp, College Station, TX, USA) was used for statistical analyses of data. Descriptive statistics, including frequencies, percentages (weighted) and 95% confidence intervals (CIs) of percentages at p < 0.05 were used to summarize and present the data in tables. To enhance visualization and appreciation of the distributions of the outcome variables across the study countries, the data was integrated into a GIS environment and presented in map images. This procedure was then followed with a bivariate chi-square test of independence to determine the associations between the outcome variables and each of the key predictor variables and covariates. Collinearity diagnosis tests, including Variance Inflation Factors (VIF), Square VIF, Tolerance and R-squared were conducted for the key predictor variables and covariates. The joint effect of maternal marital status and type of household cooking fuel on CNS was examined using six multilevel regression models for each of the outcome variables (stunting, wasting, and underweight). The first model (Model 0) showed the variance in nutritional status attributed to the clustering of the primary sampling units (PSUs), without the explanatory variables. Model I contained only the key predictor variable (maternal marital status-type of household cooking fuel). Model II and III controlled for the individual and household level factors, respectively, while Model IV controlled for the contextual level factors. The final model (Model V) controlled for all the the individual, household, and contextual level factors. The Stata command “melogit” was used in fitting these models. We used Akaike’s Information Criterion (AIC) tests for Model comparison. All the results were presented using adjusted odds ratios (aOR) at 95% Confidence Interval (CI). To prevent potential challenges of oversampling or under-sampling and clustering of samples emerging from the multi-stage sampling technique used in the data collection, the weighting, cluster and strata variables were used to adjust the effect sizes. For DHS reports, ethical clearance are sought from the Ethics Committee of ORC Macro Inc. as well as Ethics Boards of partner institutions (e.g., Ministries of Health) of the studied countries. The DHS protocols ensure that standards for the protection of respondents’ privacy and confidentiality are adhered. Inner City Fund International also make sure that the survey conforms with the United States Department of Health and Human Services’ regulations for the respect of human subjects. This study used a secondary data, hence, no further ethical approval was required. The datasets are freely available for download in the public domain. Further information about the DHS data usage and ethical standards is available at http://goo.gl/ny8T6X (accessed on 3 February 2021).

Materials

N/A

Innovations

Based on the provided description, the study focuses on the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. The study recommends several innovations to improve access to maternal health:

1. Promoting clean household cooking fuel: The study emphasizes the need for governments in sub-Saharan African countries to double their efforts to end the use of unclean household cooking fuel. This can be achieved by promoting clean household cooking fuel options such as electricity, gas, ethanol, and solar through effective health education and promotion programs.

2. Health education and promotion programs: The study suggests that effective health education and promotion programs should be implemented to raise awareness about the importance of clean household cooking fuel for maternal and child health. These programs can provide information on the health risks associated with unclean cooking fuels and promote the use of clean alternatives.

3. Dietary supplementation: The study highlights the need for targeted policies and programs to improve children’s nutritional status, including dietary supplementation. Providing essential nutrients and vitamins to pregnant women and young children can help prevent malnutrition and improve maternal and child health outcomes.

4. Increasing dietary diversity: The study recommends interventions that focus on increasing dietary diversity for pregnant women and young children. Promoting a varied and balanced diet can help ensure adequate nutrient intake and support healthy maternal and child development.

5. Improving agriculture and food security: The study suggests that efforts to improve agriculture and food security should be prioritized. Enhancing agricultural practices, increasing access to nutritious food, and addressing food insecurity can contribute to better maternal and child health outcomes.

6. Targeting at-risk sub-populations: The study emphasizes the importance of targeting at-risk sub-populations, such as single mothered households, with specific policies and programs. Tailored interventions can address the unique challenges faced by these households and improve access to maternal health services.

It is important to note that these recommendations are based on the specific context and findings of the study. Implementing these innovations can help improve access to maternal health and contribute to better maternal and child health outcomes in sub-Saharan Africa.

AI Innovations Description

The study you described investigates the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. The findings suggest that children born to single mothers who use unclean household cooking fuel and children born to married women who use unclean household cooking fuel are more likely to experience stunting, wasting, and underweight compared to children born to married mothers who use clean household cooking fuel.

Based on these findings, a recommendation to improve access to maternal health and address the issue of unclean household cooking fuel is to promote the use of clean household cooking fuel. This can be achieved through effective health education and promotion programs. Governments of the 31 sub-Saharan African countries should prioritize efforts to end the use of unclean household cooking fuel and encourage the adoption of clean fuels such as electricity, gas, ethanol, and solar energy.

Additionally, policymakers should focus on implementing policies and programs that target at-risk sub-populations, particularly single mothered households. These programs could include interventions such as dietary supplementation, increasing dietary diversity, improving agriculture, and enhancing food security.

It is important to note that the data for this study were obtained from the Demographic and Health Surveys (DHS) conducted in 31 countries in sub-Saharan Africa between 2010 and 2019. The DHS Program collects nationally representative household data on various nutrition, population, and health indicators. The study used multilevel regression models to analyze the data and present adjusted odds ratios (aORs) at a significance level of p < 0.05.

The datasets used in this study are freely accessible for download from the DHS Program website. Ethical clearance and privacy protection measures were ensured during the data collection process.

AI Innovations Methodology

The study you provided focuses on investigating the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. The researchers used data from the Demographic and Health Surveys (DHS) conducted between 2010 and 2019 in 31 sub-Saharan African countries. The outcome variables were three child anthropometrics: stunting, wasting, and underweight. The study employed multilevel regression models to examine the joint effect of maternal marital status and type of household cooking fuel on child nutritional status.

To improve access to maternal health, here are some potential recommendations:

1. Promote clean household cooking fuel: Governments can implement programs to promote the use of clean household cooking fuels such as electricity, gas, ethanol, and solar. This can be achieved through effective health education and promotion campaigns.

2. Enhance health education: Implement comprehensive health education programs that focus on maternal health, including nutrition, antenatal care, and postnatal care. These programs can help raise awareness and knowledge among women about the importance of maternal health and the available services.

3. Strengthen antenatal and postnatal care: Improve the quality and accessibility of antenatal and postnatal care services. This can include increasing the number of healthcare facilities, training healthcare providers, and ensuring that essential services are available to all women, regardless of their marital status or household cooking fuel.

4. Increase dietary diversity: Promote the consumption of diverse and nutritious foods during pregnancy and lactation. This can be achieved through nutrition education programs and support for local food production and distribution.

5. Improve agriculture and food security: Address underlying factors that contribute to food insecurity and malnutrition, such as poverty, lack of access to land, and climate change. Implement sustainable agricultural practices and support small-scale farmers to improve food production and availability.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define indicators: Identify specific indicators that reflect access to maternal health, such as the percentage of women receiving antenatal care, the percentage of women delivering in healthcare facilities, or the percentage of women with adequate nutrition during pregnancy.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or existing data sources.

3. Implement interventions: Implement the recommended interventions, such as promoting clean household cooking fuel, enhancing health education, and improving healthcare services.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the interventions on the selected indicators. This can involve collecting data at regular intervals to assess changes in access to maternal health.

5. Analyze data: Analyze the collected data using appropriate statistical methods to determine the impact of the interventions. This can include comparing the baseline data with the post-intervention data and conducting statistical tests to assess the significance of any observed changes.

6. Interpret and report findings: Interpret the results of the analysis and report the findings to stakeholders, policymakers, and the public. Highlight the impact of the interventions on improving access to maternal health and provide recommendations for further action.

By following this methodology, it would be possible to simulate the impact of the recommended interventions on improving access to maternal health and assess their effectiveness in addressing the identified challenges.

Author

Dima Health

Statistics:

Citations: 9

Identifiers:

DOI: 10.3390/nu13051541

Research Areas:

Community Interventions, Disparities, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female