Stunting is affected by various factors from mother and child. Previous studies assessed only one or more influencing variables. Unfortunately, nor the significant influence of maternal and child factors nor the indicators contributing to maternal and child factors that affect the stunting incidence have ever been analyzed.
This study analyzed the effect of maternal and child factors on stunting and the significant indicators that shape the maternal and child factors that impact stunting.
This was a case-control study. Overall, 132 stunted children and 132 nonstunted children in Purbalingga Regency, Central Java Province, participated in the research. Direct interviews and medical record reviews were conducted to assess the studied variables. The research data were tested using the partial least squares structural equation with a formative model.
Maternal factors directly affected the occurrence of stunting (
Child factors have more significant and direct effects on stunting than maternal factors but are greatly affected by them.
A problem of growth disorder among children (stunting) is a malnutritional problem in the world, especially in the poor and developing countries. A child is said to have a stunted growth if his body growth compared to his age is under 2 standard deviation (-2 SD), under the median of World Health Organization Growth Charts. Stunting is frequently associated with a chronic malnutrition, making them too short in his age. The impact of stunting is not only bad for children, but for the future of a country. High rate of stunting can be a burden for a country in the future. It can be assumed that stunting is an indicator of a country's advancement. Children who suffered from stunting may experience pathological changes, such as decline of physics, cognitive performance, neurodevelopmental, and increase metabolic disease risk up to their adulthood. Unquestionably, those changes can burden the family's economy and the potential loss of skilled human resources for the country. Several experts view this condition as 'stunting syndrome [
Stunting is affected by various factors, both from the maternal and from the child. Many studies have proved the factors which contribute a significant role in stunting, including parental education [
However, previous studies only assessed few variables. The significant of the maternal and child factors, and the indicators contributing significantly to maternal and child factors have never been analyzed. In order to fill the existing gap, this study was aimed to analyze the immense effect of maternal and child factors have on the incidence of stunting and the variables/indicators contribute significantly to maternal and child factors that impact the occurrence of stunting.
This is a case-control study design.
The research was conducted in Purbalingga Regency from September 2019 to March 2020. The regency was selected since it has the highest number of stunting cases in Central Java, Indonesia. A total of 132 stunted child and 132 nonstunted child participated in this study [
The study samples were obtained randomly with the inclusion criteria of case group are male or female child, 2–5 years old, and their height-for-age z-score (HAZ) below -2SD. The exclusion criteria are the child with dwarfisme, down syndrome, and others with any data varible lost in the investigation process, incomplete medical record, and inaccurate information from the interview; these subjects will not taken into account in the analysis.
The inclusion criteria of control group are male and female child, 2–5 years old, and HAZ 0 (median) or >2SD. The exclusion criteria for control group include the individual with a data lost in one of the variabels, incomplete medical record, and the one with invalid data in the interview.
This study has 3 types of variables: manifest variables or indicators, latent variables, and moderating variables. Indicator variables which inform or construct latent variables for maternal factors are maternal education (whether or not they graduated from junior high school), maternal age (20–35 years or <20 years and >35 years), socioeconomic status (household income below or above the national standard), unintended pregnancy (intended or uninteded pregnancy, including extramarital), birth spacing (Interval between the deliveries <2 years or >2 years), milk/dairy consumption during pregnancy (whether or not the mother consumed milk during the pregnancy), supplement during pregnancy (whether or not the mother consumed the tablets of Fe, Vitamin, and folate acid), anemia during pregnancy (whether or not mother experienced anemia during pregnancy), nutritional status (the midupper arm circumference during pregnancy ≥23.5 cm or <23.5 cm), weight gain during pregnancy (the weight gain during pregnancy >7 kg or <7 kg), infectious disease during pregnancy (wether or not the mother suffered a severe infectious disease during pregnancy), and hyperemesis gravidarum (whether or not mother had a hyperemesis gravidarum).
The indicator variables that construct the latent variable of child factors are birth weight (birth weight <2.5 kg or ≥2.5 kg), duration of pregnancy/prematurity (whether the birth is aterm or preterm/premature), exclusive breastfeeding (whether or not the baby was exclusively breastfed for 6 months), a dose of infant formula consumption (whether or not the baby was given a formula feeding after 6 months to 2 years old according to the recommended dosage), and severe infectious disease (wheter or not the baby had a severe infections between 0–24 months).
The indicator variable that informs or constructs the latent variable of stunting is the occurrence of stunting. The moderation variable is a combination of the mother's latent factor variable and the child's. The indicator variables were obtained directly from respondents by conducting interviews and checking maternal and child health medical records (or
The research data were tested using partial least squares structural equation modeling (PLS-SEM), a multivariate statistical technique used to analyze lots of response variables and explanatory variables simultaneously. PLS-SEM has achieved a universal highlight as the instrument of scientific analysis in medical field as it can be applied in Mediation and Moderation analysis [
PLS employs a Variance Based-SEM approach. PLS is used in a causal-predictive analysis with high complexity, and a weak theoretical foundation. Thus, it is useful to predict a dependent variable involving lots of independent variables, as it is the case in this study. In terms of the response, PLS can correlate a set of independent variables to several dependent variables (response). In terms of predictor, it can manage lots of independent variables, even if the predictor shows a multicolinearity. PLS can be implemented in a regression model, can predict one or more dependency in a set or more independent variables. It can be applied in path model, causal path connecting the predictor and its variable responses [
In order to assess the model matching in this study, the outer and inner models were measured. The outer models measurements include face validity, convergent validity (outer weights), discriminant validity (Fornell-Larcker Criterion, cross-loadings), collinearity statistics (variance inflation factor [VIF] inner and outer). The inner model measurement was conducted by assessing the latent variable R2, path coefficients, effect measurement of
All respondents have been provided with a sufficient explanation before the study, and they are willing to sign the agreement letter. This study has obtained approval from the Health Research Ethics Committee, Registration Number: KEPK/UMP/29/IX/2019.
The results of the cross-tabulation analysis in
A child with low birth weight (<2.5 kg) and born prematurely are more likely to be stunted. Besides, one not-exclusively breastfed also tended to be more stunted than another exclusively breastfed. A child consuming milk formula >400 g/wk at the age of more than 6 months was less likely to experience stunting. A child who often experienced severe infectious diseases at the age <2 years had a higher chance to be stunted than the one with milder infections (
For the measurement of the outer model, face validity assessment was conducted by observing the correlation between indicators and latent variables in the previous studies, which proved significant and robust. Several indicators in this study had outer weight values <0.20 and were not significant (
The inner models measurement obtained R2 of 0.515 which meant that the exogenous variable was able to explain endogenous variables in the moderate category. Path coefficients presented a positive and significant value (
To determine the influence path of maternal factors and child factors to the stunting incidcence and to ensure the significant indicators which constitute maternal and child factors, this study employed PLS Bootstrap method with 5,000 resamplings to reach an inferential statistics. The analysis results demonstrated a significant effect of maternal factors on the occurrence of stunting (path coefficien
The analysis results indicated that there was an effect of child factors on the occurrence of stunting (path coefficien
Maternal factors also significantly influenced child factors (path coefficien
The moderation analysis results demonstrated that maternal and child factors were moderating predictor variables of stunting occurrence (
Mother's knowledge about nutrition and child health may affect the nutritional status and health of children. Maternal nutritional knowledge such as selection and feeding, exclusive breastfeeding, and formula feeding according to the dosage after 6 months will produce good nutrition for their children [
There was a significant correlation between maternal age and the occurrence of stunting in previous studies. Children of adolescent mothers were 8 times more likely to be stunted than mature mothers [
Families with low socioeconomic levels (poor families) are at a much higher risk of having stunted child than high socioeconomic families [
Unintended pregnancy indicators did not significantly construct maternal factors that cause stunting in children. However, it may contribute to an indirect effect through child factors, such as in the provision of nutrition and exclusive breastfeeding. Previous studies found that 24%-40% of children from unintended pregnancies were stunted [
The interval between the births affects the occurrence of stunting. The interval between the births of children for more than 3 years will not cause the child to be malnutrition, which leads to stunting. The results indicated that the chance of stunting was significantly higher in children born to mothers with 2–3 births <3 years IBBSB (41.1%–46.8%,
In this study, the milk/dairy indicator during pregnancy was not significant in forming maternal factors which cause stunting in children. However, this indicator may affect stunting indirectly through child factors. In various evidences, previous studies have revealed that mothers who consume milk during pregnancy have profitable fetal growth and have sufficient birth weight than mothers with low milk intake [
Previous studies discovered that women who did not take additional supplements during pregnancy experienced 1.67 (odds ratio [OR], 1.674; 95% confidence interval [CI], 1,118–2,087) chance of having stunted and underweight children. Nevertheless, the supplement indicator during pregnancy was not significant maternal factors that cause stunting in children. The supplements in this study were the intake of vitamins, iron, and folic acid during pregnancy. This study has proven that consumption of iron-folic acid supplement in the first 6 months of pregnancy significantly reduces the risk of stunting by 14% compared to women who did not [
The anemia indicator during pregnancy in this research is not significant in forming maternal stunting factors. A study involving 539 pregnant women found that the occurrence rate of anemia was 18.0%, and 2% of them experienced a severe anemia. There were 10 stillbirths found at delivery, 16 low birth weight babies, and 2 cases of premature birth. However, the statistical analysis found no significant correlation between anemia and low birth weight, premature birth, or stillbirth [
The nutritional status indicators significantly make up the maternal factors which affect the occurrence of stunting. In this study, nutritional status indicators were assessed based on the body mass index (BMI) and midupper arm circumference (MUAC). This study's results support previous studies which found preconception of maternal nutritional status affects the linear growth of the fetus and the risk of stunting during the first 1,000 days. Lower BMI (<17.5 kg/m2 or <18.0 kg/m2) was significantly associated with a 1.3-time increased risk of child stunting [
In this study, the weight gain indicator during pregnancy was significant in forming maternal factors in causing stunting. Pregnant women should pay attention to weight gain during pregnancy because it will affect the fetus's development. The Institute of Medicine recommends a range of total weight gain for pregnant women based on BMI (BMI<18.5 kg/m2=12.5–18 kg total gestational weight gain [TGWG]; BMI 18.5–24.9 kg/m2=11.5–16 kg TGWG; BMI 25–29.9 kg/m2=7–11.5 kg TGWG; dan BMI>30 kg/m2=5–9 kg TGWG) [
Infectious disease indicators during pregnancy are also significant in shaping maternal factors that cause stunting. The frequency of infection during pregnancy is one of the main determinants of growth in a child's first 2 years [
Hyperemesis gravidarum is related to pregnant women's nutritional adequacy, which affects to the nutritional adequacy of the fetus. Hyperemesis gravidarum can be very unsafe for pregnant women if it is unmanaged properly because it can lead to malnutrition, electrolyte imbalance, and poor fetal development, such as prematurity and low birth weight which can lead to stunting [
The low birth weight of newborns in this study was very significant in determining child factors of stunting. This result supports previous studies that stated that babies with low birth weight (<2,500 g) have the potential to cause stunting [
Premature indicators in this study significantly contributed stunting. Premature children were twice as likely to be stunted than normal born children (relative risk, 2.13; 95% CI, 1.93–2.36) [
Previous studies found a significant correlation between exclusive breastfeeding and the occurrence of stunting (
The dose indicator of infant formula consumption in this study was significant in forming child stunting factors. This indicator has the highest influential value among all. WHO recommends babies to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health. Subsequently, to meet their growing nutritional needs, babies should receive adequate nutritious and safe complementary foods while breastfeeding until the age of 2 years or more [
The indicator of severe infection disease in this study was also significant in forming child factors which affect the occurrence of stunting. The correlation between child nutrition and infection is two-way; frequent illness can interfere with nutritional status, and malnutrition can increase the risk of infection, both of which have an impact on children's growth and development [
In conclusion, the nutrition status, in perinatal period and nutrition intake postmaternity become the important factors to prevent stunting. Mothers who give birth with a relatively short interval, inadequate nutritional status during pregnancy, nonstandard weight gain during pregnancy, and experiencing infectious diseases during pregnancy are the indicators which contribute significantly to the formation of maternal factors which cause stunting. Children with low birth weight, premature, nonexclusively breastfed, consumption of formula milk after 6 months does not match the prescribed dose, and frequently experiencing severe infectious diseases are the indicators that contribute significantly to the formation of child factors which cause stunting. The occurrence of stunting is more affected by the children factor than the maternal factor. However, the maternal factor has a significant effect on the child factor, which impacts on stunting.
No potential conflict of interest relevant to this article was reported.
Path model of the influence of maternal and child factors on the incidence of stunting. ADP, anemia during pregnancy; BS, birth spacing; BW, birth weight; DIFC, dose infant formula consumption; DoP, duration of pregnancy; EB, exclusive breastfeeding; HG, hyperemesis gravidarum; IDDP, infectious disease during pregnancy; MA, maternal age; MDP, milk/dairy during pregnancy; ME, maternal education; NS, nutritional status; SDP, supplement during pregnancy; SE, socioeconomic; SID, severe infection disease; UP, unintended pregnancy; WGDP, weight gain during pregnancy; Stunting occurrence (Y). Moderating effect variable of maternal factor plus (+) child factor. Considered significant if
Cross-tabulation of maternal characteristics in the stunting versus nonstunting group
Characteristic | Stunting (n=132) | Nonstunting (n=132) |
---|---|---|
Maternal education | ||
Not junior high school graduate | 74 (56.1) | 44 (33.3) |
Junior high school graduate | 58 (43.9) | 88 (66.7) |
Maternal age (yr) | ||
20–35 | 88 (66.7) | 106 (80.3) |
<20 or >35 | 44 (33.3) | 26 (19.7) |
Socioeconomic | ||
Middle-high income | 4 (3) | 10 (7.6) |
Low income | 128 (97) | 122 (92.4) |
Unintended pregnancy | ||
Intended pregnancy | 56 (42.4) | 84 (63.6) |
Unintended pregnancy | 76 (57.6) | 48 (36.4) |
Birth spacing (interval between birth and subsequent births) (yr) | ||
2–5 | 54 (40.9) | 88 (66.7) |
<2 yr or >5 yr | 78 (59.1) | 44 (33.3) |
Milk/dairy during pregnancy | ||
Routine | 30 (22.7) | 78 (59.1) |
Never or rarely | 102 (77.3) | 54 (40.9) |
Supplement during pregnancy | ||
Routine | 50 (37.9) | 92 (69.7) |
Never or rarely | 82 (62.1) | 40 (30.3) |
Anemia during pregnancy | ||
Yes | 84 (63.6) | 56 (42.4) |
No | 48 (36.4) | 76 (57.6) |
Nutritional status | ||
≥23.5 cm arm circumference | 30 (22.7) | 76 (57.6) |
<23.5 cm arm circumference | 102 (77.3) | 56 (42.4) |
Weight gain during pregnancy (total gestational weight gain) (kg) | ||
7–12 | 72 (54.5) | 102 (77.3) |
<7 | 60 (45.5) | 30 (22.7) |
Infectious disease during pregnancy | ||
No infection disease or mild infection | 38 (28.8) | 78 (59.1) |
Severe infection disease | 94 (71.2) | 54 (40.9) |
Hyperemesis gravidarum | ||
Yes | 82 (62.1) | 58 (43.9) |
No | 50 (37.9) | 74 (56.1) |
Valuesa are presented as number (%).
Cross-tabulation of child characteristics in the stunting versus nonstunting group
Characteristic | Stunting (n=132) | Nonstunting (n=132) |
---|---|---|
Sex | ||
Male | 74 (56.1) | 66 (50) |
Female | 58 (43.9) | 66(50) |
Age (yr) | ||
Male | 3.08 (2–4.9) | 3.06 (2–4.8) |
Female | 2.92 (2.2–4.2) | 2.96 (2–4.8) |
Length/high (cm) | ||
Male | 85.4 (78–99) | 95.8 (82–108) |
Female | 83.4 (74–93) | 93.4 (83–108) |
z score | ||
>2 SD (tall) | 0 (0) | 0 (0) |
-2 SD to 2 SD (normal) | 0 (0) | 132 (100) |
-3 SD to <-2 SD (short) | 104 (78.8) | 0 (0) |
<-3 SD (very short) | 28 (21.2) | 0 (0) |
Birth weight (kg) | ||
≥2.5 kg | 66 (50.0) | 106 (80.3) |
<2.5 kg | 66 (50.0 | 26 (19.7) |
Duration of pregnancy/premature | ||
Aterm | 76 (57.6) | 108 (81.8) |
Preterm/premature | 56 (42.4) | 24 (18.2) |
Exclusive breastfeeding | ||
Yes | 28 (21.2) | 88 (66.7) |
No | 104 (78.8) | 44 (33.3) |
Dose infant formula consumption/wek | ||
≥400 g | 18 (13.6) | 84 (63.6) |
<400 g | 114 (86.4) | 48 (36.4) |
Severe infection disease | ||
Yes | 98 (74.2) | 34 (25.8) |
No | 34 (25.8) | 98 (74.2) |
Valuesa are presented as mean (range) or number (%).
SD, standard deviation.