FCNDP No. 176 FCND DISCUSSION PAPER NO. 176 WHY IS CHILD MALNUTRITION LOWER IN URBAN THAN RURAL AREAS? EVIDENCE FROM 36 DEVELOPING COUNTRIES Lisa C. Smith, Marie T. Ruel, and Aida Ndiaye Food Consumption and Nutrition Division International Food Policy Research Institute 2033 K Street, N.W. Washington, D.C. 20006 U.S.A. (202) 862–5600 Fax: (202) 467–4439 March 2004 Copyright © 2004 International Food Policy Research Institute FCND Discussion Papers contain preliminary material and research results, and are circulated prior to a full peer review in order to stimulate discussion and critical comment. It is expected that most Discussion Papers will eventually be published in some other form, and that their content may also be revised. ii Abstract While ample evidence documents that urban children generally have better nutritional status than their rural counterparts, recent research suggests that urban malnutrition is on the rise. The environment, choices, and opportunities of urbanites differ greatly from those of rural dwellers—from employment conditions to social and family networks to access to health care and other services. Given these differences, understanding the relative importance of the various determinants of child malnutrition in urban and rural areas—and especially whether they differ—is key to designing context- relevant, effective program and policy responses for stemming malnutrition. This study uses Demographic and Health Survey data from 36 developing countries to address the question of whether the socioeconomic determinants of child nutritional status differ across urban and rural areas. The purpose is to answer the broader question of why child malnutrition rates are lower in urban areas. The socioeconomic determinants examined are women’s education, women’s status, access to safe water and sanitation, and household economic status. The analysis finds little evidence of differences in the nature of the socioeconomic determinants or in the strength of their associations with child nutritional status across urban and rural areas. As expected, however, it documents marked differences in the levels of these determinants in favor of urban areas. Large gaps in favor of urban areas are also found in the levels of key proximate determinants of child nutritional status, especially maternal prenatal and birthing care, quality of complementary feeding, and immunization of children. The conclusion is that better nutritional status of urban children is probably due to the cumulative effect of a series of more favorable socioeconomic conditions, which, in turn, seems to lead to better caring practices for children and their mothers. Given that the nature of the determinants of child nutritional status is largely the same across urban and rural areas, the same program and policy framework can be used to stem malnutrition in both. Efforts to alleviate the most critical socioeconomic constraints specific to the different environments should continue to be prioritized. iii Contents Acknowledgments............................................................................................................... v 1. Introduction.................................................................................................................... 1 2. Data and Analytical Strategy ......................................................................................... 3 Data......................................................................................................................... 3 Measures of Proximal and Socioeconomic Determinants of Child Nutritional Status ................................................................................................. 6 Analytical Strategy................................................................................................ 12 3. Results.......................................................................................................................... 15 Urban-Rural Differences in Childhood Malnutrition ........................................... 15 Urban-Rural Differences in the Effects of the Socioeconomic Determinants...... 16 Urban-Rural Differences in the Levels of the Socioeconomic Determinants....... 22 Urban-Rural Differences in the Levels of the Proximal Determinants................. 24 4. Discussion and Conclusions ........................................................................................ 28 Why Is Child Malnutrition Lower in Urban than Rural Areas? ........................... 28 Limitations of the Study........................................................................................ 30 Policy Implications ............................................................................................... 31 References......................................................................................................................... 33 Tables 1 Study countries, sample sizes, and percentage of children living in urban areas ......... 5 2 Measures of determinants of child nutritional status .................................................... 7 3 Comparison of child nutritional status across urban and rural areas, by country and region.................................................................................................................... 15 4 Determinants of child height-for-age Z-scores: Urban-rural differences .................. 18 5 Determinants of child weight-for-height Z-scores: Urban-rural differences............. 19 iv 6 Comparison of socioeconomic determinants of child nutritional status across urban and rural areas, by region.................................................................................. 23 7 Comparison of proximate determinants of child nutritional status across urban and rural areas, by region............................................................................................ 25 Figures 1 Stunting prevalences across urban and rural areas, by region .................................... 16 2 Wasting prevalences across urban and rural areas, by region .................................... 17 v Acknowledgments This research is an extension of a larger project examining the determinants of child malnutrition in developing countries that was generously funded by the Swedish International Development Agency. We thank the other project researchers, Usha Ramakrishnan, Lawrence Haddad, and Reynaldo Martorell, as well as all those who assisted in the construction of the multicountry data set: Denise Zabkiewicz, Sonu Khera, Heather Hustad, Morgan Hickey, Julia Hendrickson, Raymond Dogore, and Yasmin Ali. We also thank Agnes Quisumbing for her insightful review of this manuscript. Lisa C. Smith and Marie T. Ruel International Food Policy Research Institute Aida Ndiaye Consultant Key words: child nutritional status, malnutrition, urban, rural, Demographic and Health Survey data 1 1. Introduction Ample evidence shows that urban children generally have a better nutritional status than their rural counterparts (Hussain and Lundven 1987; von Braun et al. 1993; Ruel et al. 1998; Ruel 2001). This is particularly true for linear growth (stunting)1 and for underweight (low weight-for-age). Using Food and Agricultural Organization of the United Nations (FAO) data for 11 countries, most of which were African, Hussain and Lundven (1987) showed that stunting rates in urban areas were 55–78 percent of those in rural areas. Von Braun et al. (1993) corroborated these findings with United Nations Children’s Fund (UNICEF) data sets from 33 countries in Africa, Asia, and the Americas, showing that, on average, stunting was 1.6 times greater in rural than in urban areas. Using Demographic and Health Surveys (DHS) from 28 countries conducted between 1990 and 1998, Ruel (2001) also documented the consistently lower prevalence of stunting in urban areas, with wider urban-rural differences in Latin America than in Africa and Asia.2 For five of the seven Latin American countries studied, stunting prevalence in urban areas was about half that found in rural areas. Although, typically, wasting is also higher in rural areas, most studies have found very small urban-rural differences. In a few instances, slightly higher wasting in urban areas has been reported (Ruel et al. 1998; Ruel 2001; von Braun et al. 1993; Hussain and Lundven 1987). In spite of the overall nutritional advantage of children in urban areas, recent evidence suggests that urban poverty and malnutrition have been increasing, both in absolute and in relative terms (Haddad, Ruel, and Garrett 1999). Data from nine of 14 countries studied show that both the number of underweight preschoolers and the share of urban preschoolers in overall numbers of underweight children have been increasing in 1 Linear growth refers to growth in height. Stunting is defined as a height-for-age lower than –2 SD from the median of the CDC/WHO reference population (WHO 1979). Underweight is defined as a weight-for- age lower than –2 SD from the median of the reference population; wasting is defined as a weight-for- height lower than –2 SD. 2 This analysis included 18 countries from Africa, 7 from Latin America, and 3 from South Asia (Bangladesh, Nepal, and Pakistan). 2 the past 10–15 years.3 These nine countries constitute a large percentage of the developing world, given that they include China, Nigeria, Egypt, and the Philippines. Thus, although childhood malnutrition has typically been a less severe problem in urban than in rural areas, the accelerated rates of urbanization