INFANT NUTRITIONAL  PATTERNS  AND TRENDS  IN SIJB-SAHARAN  AFRICA:

EVIDENCE  FROM  DEMOGRAPHIC  AND HEALTH  SURVEYS  1986-19981

Research  Review  New  Scries  15.2  (1999)  1-1S

Sam uel  Agyei-Mensah

Introduction

The problem  of malnutrition  is an  important health  and welfare  problem  among infants  and young

children  in  Sub-Saharan  Africa.  It  results  in  increased  risk  of  illness  and  death.  In  addition,

malnutrition  can  result  in a lower  level  of cognitive  development,  which  results  in  lower  educational

attainment.  Malnutrition  also  has  inter-generational  effects.  Infants  born  to  women  who  themselves

were  malnourished  during early  childhood  are  smaller than  infants  born  to  better  nourished  women.

Infants  born  with  low birth  weight,  defined  as  less than  2.5  kg, are at greater  risk  of illness and  death

compared with  normal  weight  infants.

The  number  of  deaths  arising  from  malnutrition  among  children  in  Sub-Saharan  Africa  is
relatively  high.  In  Mali  an  estimated  57  percent  of  all  deaths  among  children  under  the  age  of  five

years  are related  to malnutrition  (Haggerty et ai,  1998) whereas  in  Kenya and  Senegal  the  percentage

is  38  percent  (Macro  International  1996  Kenya;  Macro  International  Senega!  1996).  Recent  studies

indicate that  in some countries  in Sub-Saharan  Africa  the toll of hunger and malnutrition  is increasing

rather  than  decreasing.  This  poses  a  serious  health  challenge  with  policy  implications.  For  example,

inadequate  nutrition  may  stunt  growth  and  increase  mortality  of  infants.  Understanding the  changing

patterns  of  malnutrition  in  Sub-Saharan  Africa  is  thus  critical  in  devising  effective  strategies  and

programs  in combating the problem.

This  paper  provides  an  overview  of  the  nutritional  situation  in  Sub-Saharan  Africa  looking  at

patterns  and  trends.  The  analysis  is  based  on  data  from  the  first,  second  and  third  phases  of  the

Demographic  and  Health  Surveys (DHS). To explore  variations  within  Sub-Saharan  Africa  in  levels
of malnutrition,  we focus  on  countries  for  which  we have ample nutritional  data from  the DHS, such

as Cameroon, Ghana, Kenya, Madagascar,  Mali, Niger, Rwanda,  Senegal, Tanzania,  Uganda, Zambia

and  Zimbabwe.  The  paper  begins  with  a  description  of  the  sources  of  data.  The  patterns  of

malnutrition  based  on  the  percentage  of  children  who  are  stunted  and  underweight  as  well  as  the

patterns  of  breast  feeding  are then  described,  In the third  section  we examine  trends  in  malnutrition

based  on the percentage  of children  who are stunted,  wasted  and  underweight.  And finally  comes the

discussion  and  conclusion.  The  results  reveal  that  many  children  in  Sub-Saharan  Africa,  are

malnourished,  even though  there are significant  geographical  differences.  Levels of malnutrition  also

appear to be on the  increase  in many countries  in the region.

Data  and  Methods

Until  recently  statistical  data  on  infant  nutritional  patterns  in  Sub-Saharan  Africa  were  virtually

absent.  To  estimate  patterns  and  trends  in  malnutrition,  this  paper  has  drawn  upon  data  from

Nutritional  Chart  Books  derived  from  Demographic  and  Health  Surveys  conducted  since  the  early

1980s.  Three  major  rounds  of  DHS  surveys  have  been  conducted  since  the  late  1980s.  DHS  I

conducted  between  1985-1990; DHS II from  1991-1994 and DHS 111 1995-1998.

The  DHS surveys are nationally representative  sample surveys designed to provide information  on

fertility,  mortality,  family  planning  and  maternal  and  child  health.  The  individual  questionnaires  are

based  on  information  on  fertility,  nuptiality,  fertility  preferences,  family  planning,  infant  and  child

mortality,  maternal  mortality,  child  health,  breastfeeding,  nutritional  status  of  mothers  and  young

children,  and  snore recently  HIV/AIDS,  Data  collected  at the  household  level  concern  characteristics

of all household nembers, housing characteristics and possession of certain specific durable goods. At

the community  level, data were collected  on the availability  of health and family  planning services  for

each  community.  Nutritional  data  collected  on  children  usually  include  weight,  height,  age,

breastfeeding  history, and feeding  patterns. The size of the sample varies from  country to country. For

example  in the  1995/96  Mali  DIIS  a sample  of  9704  women  aged  1.5 to 49 years  belonging  to  8716

households and 2474 men from  15-59 years belonging to 2869 households were interviewed,  whereas

in  the  1998  Ghana  DHS  a  total  of  4,843  women  aged  15-49  and  1,546  men  aged  15-59  were

interviewed  (Statistical Service of Ghana  1999).

Nutritional  status  is  measured  by  three  indicators:  stunting,  wasting  and  underweight.  We  also

draw on estimates of breast-feeding  patterns  in terms of their duration  and exclusivity, The indices of

nutritional  status  are  expressed  as  standardized  (z-score)  deviation  units  from  the  median  of  a

reference  population  recommended  by the World  Health  Organization  (WHO). The  rationale for  the

use of the  reference  population  is based  on the  finding  that well nourished  children  in all  population

groups  for  which  data  exist  follow  similar  growth  patterns  before  puberty  and  thus, exhibit  similar

distributions  with  respect  to  height  and  weight  at  given  ages  (Martorell  and  Habicht  1986).  The

reference  population  used  here  is the  international  reference  population  defined  by the  United  States

National  Centre  for  Health  Statistics (NCHS). Here children  who fall  below two standard  deviations

from  the reference  median are regarded  as  malnourished.

Stunting, defined  as height-for  age, more than two standard deviations below (-2SD) the median of

the  NCHS  reference  population,  is  the  failure  to  grow  adequately  in  height  in  relation  to  age.  It

reflects  past  or  chronic  malnutrition  and  results  from  inadequate  food  intake  over  a  long  period  of

time and  /or  repeated  episodes  of  illness, particularly  diarrhoea.  In other  words, the  children  are too

short  for  their  age.  Stunting  is  a  good  long-term  indicator  of  the  nutritional  status  of  a  population

because  it  is not  markedly  affected  by short-term  factors  such  as season  of data collection,  epidemic

illnesses,  acute  food  shortages,  or  recent  shifts  in  social  or  economic  policies  (Macro  International

1998).

Wasting, defined  as weight-for  height more than  two standard  deviations below (-2SD) the median

of  the NCHS  reference  population,  is the  failure  to  gain  weight  adequately  in  relation  to  height  and

reflects  recent or acute malnutrition.  Wasting results  from  a recent  shortage of adequate  nutrition  and

/or  recent  or current acute  illness, especially diarrhoea.  In other words the child  becomes too thin  for

his or her height. Underweight,  defined  as weight-for-age  more than two standard  deviations  below (-

2SD)  the  median  of  the  NCHS  reference  population,  is  a  composite  indicator  that  reflects  either

chronic  or acute malnutrition,  or both, It does not add additional  information  beyond  that  provided  by

the  indicators  of  stunting  and  wasting,  however,  it  is  often  used  as  a  general  indicator  of  a

population's  health  status.  This  condition  can  result  from  either  chronic  or  acute  malnutrition,  or a

combination  of both.

With  regard  to  data  quality  there  are  several  issues  that  might  affect  the  interpretation  of

anthropometric  findings-  It  is  important  to  know  whether  the  children  who  were  measured  are

representative of the larger  population; whether the height and weight measurements are accurate, and

whether  the  age  information  is  reliable  (Sommerfelt  and  Stewart  1994),  Comparison  of  nutritional

status  among  Sub-Saharari  countries  must  be  done  with  caution,  as  the  season 

in  which

anthropometric  data  are collected  can  greatly  affect  the proportion  of children  categorized  as stunted,

wasted,  or  underweight.  For  example,  data  for  the  1988  GDHS  was  collected  during  a  hot,  rainy

period  (February  to  June  1988)  while  the  1993  GDHS  was  conducted  during  a relatively  dry  period

following  the harvest (September  1993 to February  1994) (Agble et al. 1995),

Some shortcomings with respect to the analysis of the trends of malnutrition  should  be noted. First

not  all  the  countries  participated  in  the  round  of  surveys.  Second,  anthropometric  data  was  not

collected  for  all  the  surveys.  Third  the  age  of  the  children  varied  from  one  survey  to  the  other.

Because of these  problems,  not all countries are included  in the assessment.  We include only those  for

which  we  have  at  least  two  rounds  of  survey  data.  Secondly,  the  ages  of  the  children  differ.  For

example whereas  in the analysis  of patterns  we  restrict  the data  to children  under  3 years, the  trends

are  based  on the  most convenient  estimates  between  the  surveys  provided.  We  provide three  periods

for  purposes of ths trends based  on the DHS data.  1986-1990,  1991-1994 and  1995-1998,

Patterns  of  Malnutrition

Despite  these  data  limitations,  there  are  noticeable  and  significant  regional  differences  in  the

proportion  of  children  suffering  from  malnutrition  in  Sub-Saharan  Africa.  Fig  1 shows  the  level  of

stunting among children  under 3 years in Sub-Saharan  African  countries between  1986-1998. Figure 2

shows the level of underweight  among the same category of children  and the time period. The

Rg.1

Malnutrition (Stuting) among Children under 3 Yeas in SubSaharan

Countries, DHS Surveys 1991-1996

43

45

40

35

u  30
c
\  25

-24- 25

%  £

30

A

S

Rf.Rp

Source:  DHS Nutrition Chart Books on Individual Countries  1991-1998

Fig. 2  Underweight among Children under 3 Years in Sub-SaharanCountries,

DHS Surveys 1991-1998

50

45

40

35

30-

20-

15-

10-

5

15

T

M
i  i

40  40

26  26  26 2  27  2  27

2929

23"

!.

Country

A 

<n  <n  en  ok  ot  m

I 1 I I I 1 I
s |  ™ •  » I 

i

Source:  DHS Nutrition Chart Books on Individual Countries  1991-1998

statistics  clearly  show  that  children  in  Sub-Saharan  Africa  are  malnourished  irrespective  of  the

geographical  area.

The percentage of children  less than 3 years who are stunted ranges from  22 to 48 percent. Levels

of stunting  are  relatively  low  in countries  such as  Senegal  (22  percent), Zimbabwe (22  percent)  and

Cote d'lvoire  (24 percent). Countries with the highest  levels of stunting are made up of Madagascar,

(48),  Rwanda  (''8),  Malawi  (49). Tanzania  (43)  and  Zambia  (43).  In the  middle  of this  range  can  be

found  countries  such  as  Ghana  (26)  and  Benin  (25  percent),  Significant  regional  differences  also

emerge  in levels of underweight.

The  percentage  of  children  below  36  months  who  are  underweight  ranges  from  16  to  50  percent.

Niger  has  the  highest  underweight  count  of  50  percent  with  Zimbabwe  the  lowest  (16  percent).  Of

particular  interest  are countries  within  the  Sahelian  region.  Eritrea  reported  a percentage  of 44, Mali,

40  percent,  Burkina  Paso  30 percent,  Niger  50 percent.  Consistent  with  the  findings  for  stunting  we

find  relatively  low underweight  figures  for Zimbabwe, Cote d'lvoire  and  Senegal.

Important  differences  also emerge  with  respect to urban  and  rural  areas.  Demographic  and  Health

Survey data  show that  rural  areas generally  have higher  rates of stunting compared  to  urban  areas. In

Senegal  for  instance the rate of stunting was  15 percent  for  urban areas and 31 percent  for  rural  areas.

Zimbabwe  recorded  18  percent  for  urban  and  23  percent  for  rural  areas,  Kenya,  Mali  and  Ghana

follow  a  similar  trend  with  the  urban  areas  recording  21  percent,  22  percent  and  16  percent

respectively as against 35 percent, 33 percent and 30 percent for rural areas.

The picture  for underweight children  is not different.  There are significant  differences  in the  levels

of  underweight  between  urban  and  rural  areas  with  higher  rates  prevailing  in  the  rural  areas.  For

example  in Senegal, rural  areas  recorded  26 percent as against  14 percent  in urban  areas. Ghana  also

recorded  32  percent  for  rural  areas  and  18  percent  for  urban  areas.  In  Zimbabwe  however,  the

variation  between  urban  and rural  levels  is much  less. Urban  areas recorded  13 percent and rural  areas

17 percent.

The  levels  of wasting  on  the other  hand  follow  a different  pattern.  In Zimbabwe,  Kenya and  Mali

there  are  no  significant  differences  between  urban  and  rural  areas.  Zimbabwe  and  Kenya  record  6

percent  and  24  percent  respectively  for  urban  and  rural  areas. This  shows  a slightly  higher  incidence

in levels of wasting. Kenya recorded  5 percent  for  urban  and 6 percent  for rural areas. There are slight

variations  in  the  figures  recorded  for  Ghana  and  Senegal.  Urban  areas  recorded  9  percent  in  Ghana

and 7 percent in Senegal as against  13 percent and  10 percent  for the rural  areas  respectively.

Patterns  Of Breast-Feeding

Like  the  indicators  of  malnutrition  discussed,  breast-feeding  is  also  a  critical  factor  in  infant

nutrition  and  grewth, health  and survival. Since the mid  1980s Demographic and Health  Surveys have

demonstrated  for  a  number  of  countries  that  the  median  duration  of  breast-feeding  varies  among

countries  within  Sub-Saharan  Africa  (see Fig.  3). Countries  with  relatively  high  duration  of  breast-

feeding  include

Fig. 3 

Median  Duration (Months) of Breastfeeding Sub-Saharan

Africa Countries

30

25

20

15

10

i
t
n
o
M

,»  20 

iO  20

21 

21  21

,..  - 1S

28

21  21  n 

24 

«
n iH

rHF

f.L 

i J 

t J  J.  .

U LJ i_ LJ U Li

&

Source:  Adapted From Macro  International  (1997)  page 12

Rwanda,  Burundi  and  Burkina  Faso,  Reckoning  of  exclusive  breast-feeding  however  gives  quite  a

different  picture  and  the  distribution  is  crucial.  Internationally  recognized  guidelines  for  breast-

feeding  suggest  that  all  children  should  be  breast-fed  exclusively  for  at  least  four  months.  However

DHS country results have shown that  in only very few countries does the percentage of children  under

four  months  of  age  being  exclusively  breast-fed  exceed  30. As  shown  in  Figure  4, only  in  Rwanda,

Eritrea, Madagascar  and  Tanzania  does  the percentage of exclusive  breast-feeding  exceed  30 percent.

This  indicates that  substitutes  such  as water,  powdered  milk, porridge  and other foods  are  introduced

very early  in most countries  (see figure  4), But there are high risks of other foods  being  contaminated

and causing diarrhoea.

Fig 4 

Infants Under 4 months who are Exclusively

Breastfed Sub-Saharan Mican Countries

100
9D '
80 i
70
80
93
40
30  i
20 •
10 \
0 
l 

- • --

4 

7 

"8 

„

1f 

22nn

I 

J 

_J

65

bl

'•2

44  4

Source:  OHS Malnutrition Chart  Books  1986-1998

6

Trends  In  Malnutrition

An  analysis  of the nutritional  situation  through  time  also  provides  interesting  patterns  (see  Table

1). There  is overwhelming  evidence  from  the  DHS  to  show  that  malnutrition  has  been  increasing in

most  of  the  countries  in  Sub-Saharan  Africa.  The  situation  in  West  Africa,  especially  the  Sahelian

region,  is very  disturbing.  Data  from  Mali  shows that  the  nutrition  situation  has  worsened  markedly

since the  1987 Mali an  Demographic and Health  Survey (MDHS). Between  1987 and  1995/96, among

children  between  3  to  35  months  of  age.  the  proportion  stunted  appears  to  have  increased  by  38

percent (from  24 to 33 percent), the proportion  wasted  appears to have more than doubled  rising  from

(from  11  to  25),  and  the  proportion  underweight  may  have  increased  by  42  percent  (31  to  44)

(Haggerty et al.  !998).

Data  from  the  1991  and  1998  Cameroon  Demographic  and  Health  Surveys  (CDHS)  also  show

significant  increases  in  all  the  three  indicators  of  malnutrition.  The  percentage  of  children  under  3

years  who  are  stunted  increased  from  23  percent  in  1991  to  29  percent  in  1998; wasting  increased

from  4 percent  in  1991 to 6 percent  in  1998 and underweight  increased  from  16 percent to 22 percent

during  the  same  period  (Macro  International,  USA1D  1999).  The  nutritional  situation  in  Niger  has

also  worsened.  The  proportion  of  children  stunted  increased  from  36  percent  in  1991-1994  to  41 in

1995-98, wasted  increased from  18 to 21 and underweight  from  44 to 50 percent.

A comparison  of the Senegal  Demographic and Health  Survey (EDS)  1986 and  1992/93 provides a

basis for looking at nutritional  trends  in the country  over the years. During the EDS  1 only children  6

to 36 months  of age  were  included, therefore  comparisons  in the text  between  1986 and  1992/93  are

based  on  the  6  to  36  months  age  range.  Compared  with  the  results  from  the  1986  EDS  1,  which

included  anthropometric  data  for  children  age  6 to  36  months only,  there  has  been  no change  in the

prevalence  of  malnutrition  during this  six-year  period.  Although  slight  changes  in the  prevalence  of

stunting and wasting are observed, they are small and not significantly  different  (Macro International,

MOH Senegal,  1996).

In Ghana among children  aged 3 to 35 months the level of stunting increased  from  28 to 30 percent

between  1988 and  1993. The percentage  of children  underweight  also went  up from  30 to 31  percent

whereas  wasted  children  increased  from  8 to  12 percent  within  the  same  time  periods  (Agble  et  al.

1995).  The  recent  statistics  on  nutrition  from  the  1998  GDHS  shows  that  there  has  been  some

improvement  in  the  nutritional  status  of  Ghanaian  children  (Statistical  Service  of  Ghana  1999).

However,  in the absence of detailed  information  on the nutritional  situation  as  usually  pertains  in the

Nutritional  Chart Books we are unable to make any definitive  analysis of the contemporary  situation.

The picture  in Eastern  and  Southern  Africa  is also  not very encouraging.  Data on Tanzania  shows

that the  percentage  of children  under  5 years who  are stunted  has  not changed  between  the period  of

the TDHS  1991-92 and the TDHS  1996. However, there was a  significant

7

T^LEJjJjnfarrt  NjLrtnjtt_qnal_Trends in Sub-Saharan Africa  *

COUNTRY 

DHS, 1985-1990  |  DHS, 1991-1994  |  DHS,  1995-1998

EAST AND  SOUTHERN  AFRICA

Tanzania

Zimbabwe

i

Zambia

Madagascar

43
Stunted 
6
Wasted 
Underweight 29

Stunted
43
7
Wasted 
Underweight  31

24
Stunted 
6
Wasted 
Underweight  13  !  Underweight  18

30  |  Stunted 
1  |  Wasted 

Stunted
Wasted

40
5
i  Underweight  25

Stunted 
Wasted 
Underweight  24

43  |
4  j

Stunted
Wasted
6
Underweight  38

45  |  Stunted
Wasted
Underweight  40

7  I

TABLE  1 

(consinuation)

COUNTRY 

I 
WEST AFRICA 

|
|  DHS, 1985-1990  j  DHS, 1991-1994  I  DHS, 1995-1998  !
!
i

] 
J 

I 

24
Stunted 
Wasted 
11
Underweight  31

33
Stunted 
Wasted 
25
Underweight  44

Stunted 
Wasted 
Underweight  30  I  Underweight  31

28  Stunted 
8  Wasted 

20  j
12  '

41
|  Stunted 
21
!  Wasted 
|  Underweight  44  Underweight  50

36  I  Stunted 
18  Wasted 

-f-

Stun-ed
23
Wasted
6
Underweight  22

Stunted
Wasted
Underweight  22  !

25
8

j  Stunted
i  Wasted

23  Stunted
29
6
Wasted
4
Underweight  22
Underweight  16

Sources:  DHS Nutrition Chart Books on Individual Countries  1985-1998

'Zimbabwe,  children 3 to 35 months; Niger, children under 3 years; Madagascar, children under 3 years; Zambia,
children  age  1 to  59  months;  Tanzania,  children  under  5 years;  Mali,  children  3  months  to  3  years  of  age;

Cameroon, children  under 3 years  of age; Senegal, children aged 6 to 36 months of age; Ghana, children 3 to 35
months,

increase  in the percentage  who were underweight  and those who were wasted. There was an  increase

in  the  percentage  of  underweight  children  from  29  to  31  percent.  Also  the  percentage  of  wasted

increased from the  1991-1992 figure of 6 to 7 percent (Macro TDHS, 1998).

The  1994  Zimbabwean  Demographic  and  Health  Survey  collected  data  on  children  less  than  3

years of age whereas the  1988 ZDHS collected  data on children  less than  3 years  of age whereas the

1998 ZDHS  collected  data  on  children  aged  3 months to  5 years. To allow  for  comparison  of trends

using these two surveys, results from  both  surveys were re-analysed  using the common  age range of 3

to 35 months. The comparison  shows a decline  in the prevalence  of stunting during the 6 year  period

from  30  to  24  percent.  In  contrast,  the  prevalence  of  wasting  increased  from  1 to  6  percent  and

underweight  increased  from  13 to  18 percent  (Macro  International,  MOH  Zimbabwe;  University  of

Zimbabwe  1996),

In Madagascar  the evidence  also  suggests that the nutritional  status of  Malagasy  children  under 3

years  of  age  has  worsened  between  the  period  1992 and  1997. The  percentage  of  children  under  3

years  that  are  stunted  increased  from  the  1992  level  of 45 to 48  in  1997. The  percentage  of  children

wasted  also  increased  from  6  to  7  percent  and  underweight  children  rose  from  36  to  40  percent

(Macro International, USA1D, Madagascar,  1998).

Changes  in malnutrition  rates among children  age  1 to 59 months between  the period  1992 to  1996

in  Zambia  is  also-  interesting.  The  percentage  of  stunted  children  increased  from  40  percent  to  43

percent.  However,  there  was  a  decrease  in  underweight  from  25  to  24  percent.  Similarly,  the

percentage  of  wasted  children  went  down  from  5 percent  to 4 percent  (Macro  International/USAID

Zambia  1997).

Discussion  And  Conclusions

The results presented  here for  levels of malnutrition  over time and across countries within the Sub-

Saharan  African  region  reveal  interesting  geographical  patterns.  Levels  of  malnutrition  appear  to be

increasing particularly with respect to underweight and wasting. Significant  differences  also exist with

respect to breast-feeding  patterns. Among the countries  studied, the problem  of underweight  seems to

be  more  profound  in  the  Sahelian  region  with  high  percentages  being  recorded  in  Mali,  Niger  and

Burkina  Faso.  Stunting  follows  a  different  pattern  with  very  high  percentages  been  recorded  in

Eastern  and  Southern  Africa  notably  Burundi.  Rwanda,  Madagascar  and  Tanzania,  It  is  also

interesting  to  note  that  even  though  Senegal  and  Cameroon  have  relatively  low  malnutrition  levels

there has been a significant  increase  in recent years. Tanzania, Mali, Niger and  Madagascar have high

malnutrition  levels  and  the  trend  appears  to  be  worsening.  The  relatively  low  levels  of  exclusive

breast  feeding  raises  several  issues with  respect to possible contamination  of other foods  which  could

lead to diseases such as diarrhoea.

The  relative!}.' high  rate  of  underweight  among  countries  in  the  Sahelian  region  reflects  the  poor

weather  conditions  in  that  region  as  well  as  low  socio-economic  levels.  The  poor  climatic  regime

makes it extremely difficult  to cultivate a variety of crops year round. Poverty is also a major  factor as

most  of  the  countries  in  this  region  are  poor  economically.  The  apparent  high  levels  of  stunting  in

countries  in Southern Africa  may be explained  by poverty as well as civil wars.

What factors  have accounted  for changes  in malnutrition  levels  in recent years? While the analysis

does  not  provide  data  for  explaining  these trends,  some  inferences  could  be  made. Three  factors  are

instrumental.  First  and  most  important  is the  economic  difficulties  most  countries  within  the  region

have  undergone  in  recent  years.  This  lias  made  supporting  a family  increasingly  difficult.  Not  only

had  male  wage  rates  begun  to  stagnate  by the  end  of the  1980s, but there  have also  been  substantial

increases in the cost of social  services such as health, education  and transport along with an escalation

on the goods and  services.

A  second,  related  factor  is  changes  in  the  labour  force  behaviour  of  mothers  and  in  the

arrangements  they  make  for  the care of their  preschool  children.  Since  infant  feeding  is not  a  single

event  but  a process  which  takes place daily  over  months, the woman's  absence  from  home  can  have

adverse  effects  on  the  child's  nutritional  status.  There  is  a general  perception  that  African  mothers'

work  burdens  and  constraints  are  increasing just  as many  of their traditional  supports  are  dwindling.

These  are  happening  in  an  era  of  market  driven  reforms  and  globalisation.  A  result  is  that  many

women are having to work more intensively for  longer hours and often  further  away from  home—with

potentially  profound  consequences for nursing and mothering.

The third  factor  is mainly  geographical  and  political.  The  effects  of  climate  and  poor  cultivation

practices have  led to environmental  degradation  in many regions. Crop yields have declined  owing to

the decline  in  soil  fertility.  This  may have  particular  relevance  for  the  Sahelian  countries.  The  effect

of civil  war  in  countries  such  as  Rwanda  is also  likely  to have  affected  the  state  of child  health  and

nutrition. Many of the displaced  women  have to resort to food  aid by international  bodies.

Even though  the DHS Chart Books and Nutrition  Surveys do provide excellent  sources of data  for

analysing  infant  nutritional  patterns  and  trends  in  Sub-Saharan  Africa,  more  micro  level  analysis  of

infant  nutritional  patterns  and their determinants  in Sub-Saharan  Africa  is needed. A critical  nexus of

research  issues-involving  changes  in  women's  work  and  time;  infant  feeding  practices;  economic,

political, agricultural  and  health  related  factors  need  to studied  in depth  in order  to better  understand

the situation. Evidently, all these factors  have had a direct  impact on nutrition  levels of  infants.

10

References

Agble et al.,  1995. Nutrition and Health Status of Infants and  Young Children in Ghana. Findings from  the 1993

Ghana Demographic  and Health Survey. Macro Internationa.!,

Haggerty  et al.,1998. Nutrition  and  Health  Status of Young  Children  and Their Mothers  in  Mali.  Findings from

the  1995/96  Mali Demographic  and  Health  Survey.

Macro  International,  USAID.  1996, Nutrition of Infants And  Young Children In  Uganda. 1995. Africa  Nutrition

Chart Books.

Macro  International  Inc.,  1996,  Nutrition  and  Health  Status  of  Young Children  and  Their Mothers  in Kenya.

Findings from  the 1993 Kenya Demographic and Health Survey. October.

Macro  International.  MOH  Senegal,  Basics  Project  ORANA,  1996.  Nutrition  and  Health  Status  of  Young
Children  and  their  Mothers  in  Senegal.  Findings  from  the  1992/93  Senegal  Demographic  and  Health
Survey.

Macro  International,  MOH  Zimbabwe,  University  of  Zimbabwe,  1996. Nutrition  and  Health  Status  of  Young
Children and their Mothers  in Zimbabwe. Findings from  the  1992/93 Zimbabwean Demographic  and Health
Survey.  Macro International  (1997). Demographic and Health Surveys Newsletter.

Macro  International,  USAID, Zambia,  1997 Nutrition of Infants And  Young Children in Zambia, 1996.
Macro  International.  1998.  Nutrition  of  Young  Children  and  Their  Mothers  in  Madagascar,  1997.  Africa

Nutrition  Chart Books

Macro  International,  USAID,  Tanzania.  1998.  Nutrition  of  Infants  And  Young  Children  in  Tanzania,  1997.

Africa Nutrition Chart Books.

Macro  International,  USAID,  Madagascar,  1998.  Nutritional  of  Young  Children  and  Their  Mothers  in

Madagascar,  1997. Africa Nutrition Chart Books.

Macro  International,  1999. Nutrition of  Young Children and Their Mothers in Cameroon,  1998. Africa  Nutrition

Chart Books, Macro International  and U.S Agency for International  Development.

Martorell,  R. and j, P,  Habicht,  1986. Growth  in Early Childhood  in Developing Countries.  In Human Growth:

A Comprehensive  Treatise. Ed. F. Falkner and J. M. Tanner. Vol. 3. New York:  Plenum  Press.

Oppong,  C,  2000.  Smiling  Infants  or  Crying  Babies.  Occasional  Research  Papers  No.4,  Legon:  Institute  of

African  Studies

Sommerfelt,  A.E  and  M.  K.  Stewart,  1994.  Children's  Nutritional  Status.  Demographic  and  Health  Surveys

Comparative Studies No,  12. Caiverton, Maryland  USA: Macro International, Inc.

1 This paper is based on a presentation  given at a seminar on Hunger, held on World  Food  Day  1999 in the
Institute of African  Studies' seminar series on Issues in Sustainable  Human  Development.  The impetus to write
it was provided  by Opportg's paper "Smiling infants  or crying babies".  The analyses of malnutrition were
generously provided  by Macro  International,  Cordial  thanks are due to their staff,  in particular  Martin  Vaessen.

11