Reducing child mortality and maternal

103 Riau Islands Bali Gorontalo Jakarta Papua Banten Lampung Central Java Aceh Central Kalimantan North Sumatra West Papua Bangka Belitung Islands North Sulawesi West Kalimantan West Java INDONESIA North Maluku East Java Jambi South Kalimantan Riau Southeast Sulawesi Central Sulawesi West Nusa Tenggara East Kalimantan West Sumatra East Nusa Tenggara South Sumatra Yogyakarta Maluku Bengkulu South Sulawesi West Sulawesi 0.0 20.0 40.0 60.0 80.0 100.0 120.0 31.5 59.7 36.6 40.9 30.1 24.7 33.9 45.6 33.8 41.5 35.4 34.0 23.4 43.3 41.8 45.9 41.2 25.1 42.7 43.1 37.7 31.7 36.9 53.2 39.0 41.8 34.3 42.1 38.9 54.7 42.0 42.8 44.2 40.7 Exclusively Breastfeeding 2007 Complementary feeding 2007 13.0 13.3 15.1 16.4 22.7 24.4 24.4 24.7 24.8 25.6 25.8 26.1 28.1 28.8 31.5 32.2 32.4 33.1 33.3 34.5 34.8 35.2 38.9 43.5 43.7 43.8 44.0 44.9 47.0 49.3 54.9 55.2 59.8 62.5 Source:฀IDHS฀2007 Notes:฀Complementary฀feeding:฀Percentage฀of฀children฀aged฀6–23฀months฀with฀3฀IYCF฀practices฀ Figure 3.13: Coverage of macronutrient intervention, by province, 2007 providing counselling on feeding practices, and providing micronutrient supplements to children and pregnant women. Unfortunately the government has often focused on underweight children weight-for-age and has given inadequate attention to the problems of stunting height-for-age and wasting weight-for-height, as was evident from the nutritional targets set by the government. Furthermore, the prevalence of cases of overweight children is increasing, not only in rich households but also in the poor ones. Yet the government so far has only issued policies aimed at preventing an increase in the prevalence of overweight children, and has no policies aimed at reducing the prevalence of overweight children. A number of government nutrition improvement activities are already easily accessible in communities, since they are channelled through the posyandu and puskesmas system. However, these programmes and activities are not specifically intended for poor households but are aimed at the general community. The increasing prevalence of malnutrition occurring in poor households from 2007–2010 is evidence that the government’s nutrition interventions have been ineffective for poor households. 104 Figure 3.14: Infant feeding practices, 2007 100 90 80 70 60 50 40 30 20 10 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 age months Weaned not breastfed Breastfed and non-milk liquids Breastfed and solid semi-solid foods Breastfed and plain water only Breastfed and other milk formula Exclusively breastfed Source:฀IDHS฀2007,฀in฀UNICEF,฀2009 Figure 3.15: Exclusively breastfed babies aged 0–5 months, by urbanrural location, gender and household expenditure, 2010 40 35 30 25 20 15 10 5 of 0-5 month old babies Boys Urban Girls Rural Q1 Q3 Q2 Q4 Q5 29 25.4 25.2 29.3 37.4 30.5 26.6 19.9 17.5 Household Consumption Level Source:฀RISKESDAS฀2010 105

3.4.6 Child nutritional status: Underweight, wasting, stunting and overweight

As illustrated in UNICEF’s conceptual framework on the determinants of nutritional status, the causes of malnutrition are multi-sectoral. Dietary intake and health status – which act in synergy – are the immediate determinants of nutritional status UNICEF, 1990. Dietary intake in turn will be affected by the food available and accessible to the household or its food security while health status will depend on the household’s access to health services as well as to safe water and appropriate sanitation or access to health. Access to food as well as access to health will both be modified by the household’s capacity to fulfill the care needs of women and children. From that perspective, household food security is a necessary but insufficient condition to ensure adequate nutritional status. Food security, adequate care for children and mothers as well as access to health services are all determined by underlying factors operating in the family, community and broader society. Beaurdy 1996 found that these conditions are related to the availability and control of human, economic and organizational resources in the society, themselves the results of current and previous technical and social conditions of production together with political, economic and ideological- cultural factors see Figure 3.16. Anthropometry is a universal method to assess individual nutritional status, most commonly evaluated among under-fives, as their nutritional status constitutes an indicator of societal health and well-being. In a population of children, height-for-age, weight-for-height and weight-for- age indices are estimated using WHO growth standards Multicentre growth reference study group, 2006. Weight-for-age reflects body mass relative to age. Low weight-for-age is described as ‘lightness’ and reflects a pathological process referred to as ‘underweight’. Weight-for-age also reflects both weight-for-height and height- for-age; hence it fails to distinguish tall, thin children from those who are short with adequate weight. Height-for-age reflects the achieved linear growth that can be used as an index of past nutritional or health status. Low height- for-age is defined as ‘shortness’ and reflects either normal variation or a pathological process involving failure to reach linear growth potential referred to as ‘stunting’. Finally, weight-for- height measures body weight relative to height. Low weight-for-height in children is described as ‘thinness’ and reflects a pathological process referred to as ‘wasting’. This condition arises from a failure to gain sufficient weight relative to height or from losing weight Figure 3.17. The MDG target focuses on the prevalence of underweight children, which has been associated with an increased risk of mortality in under- fives in the 1990s. Since 1989, the number of underweight children under the age of five in Indonesia has tended to decrease each year. In 2010 the prevalence of undernourished under- fives in Indonesia was 17.9 per cent Figure 3.18, which is a good indicator of progress towards achieving the MDG target of 15.5 per cent in 2015. In 2007, East Nusa Tenggara was the province with the largest prevalence of underweight children 33.6 per cent, while West Nusa Tenggara had the greatest prevalence of underweight children in 2010 30.5 per cent. In 2007, Yogyakarta was the province with the lowest prevalence of underweight children at 10.9 per cent, and in 2010 North Sulawesi had the lowest prevalence, at 10.6 per cent. There was also a tendency for girls to be better off than boys with regard to all three nutritional status indicators. This is unlikely to have been caused by differential treatment of boys and girls by their parents but is most likely due to boys being more active than girls, and therefore needing a larger intake of nutritious food. This general difference between boys and girls should be understood and explained by puskesmas staff and posyandu personnel. The disparities in nutritional status between urban and rural areas and between wealthier and poorer households are apparent. The number of children under the age of five who were underweight was higher in rural areas compared to urban areas. Moreover, from 2007 to 2010 the prevalence of underweight children in urban areas decreased by 4.4 per cent while in rural areas it increased by 1.5 per cent Figure 3.19. The prevalence of underweight was higher among children in poor households. Although the national prevalence of underweight children decreased in 2010, the opposite was happening 106 Figure 3.16: Factors causing malnutrition Malnutrition Manifestation Immediate Causes Underlying Causes Basic Causes Inadequate education Economic Structure Potential resources Political and Ideological Factors Inadequate dietary intake Inadequate access to food Inadequate care for children and women Disease Source:฀UNICEF,฀‘Strategy฀for฀improved฀nutrition฀of฀children฀and฀women฀in฀developing฀countries’,฀A฀Policy฀review,฀New฀ York,฀1990 Figure 3.17: Anthropometrics of nutrition Underweight Wasting Stunting Height Age Weight Insufficient health services and unhealthy environment Resources and Control Human, economic and organizational resources 107 within poor households. The prevalence of underweight children in quintile 1 households the poorest had increased from 2007 to 2010 by 2.7 per cent. As for households in quintiles 2, 3, 4 and 5, the prevalence of underweight children had decreased and continued to decrease as the level of household expenditure increased. Besides the prevalence of underweight children, Indonesia actually faces a greater nutritional problem in stunting low height-for-age among under-fives. Based on RISKESDAS 2007 data, 36.8 per cent of under-fives were considered to be stunted. In 2010, this percentage had decreased slightly to 35.6 per cent but was still much higher than the prevalence of other nutritional problems Figure 3.20. In 2007 and 2010, the province that experienced the highest prevalence of stunting of children was East Nusa Tenggara with 46.8 per cent and 58.4 per cent respectively. In this province, the prevalence of stunting among under-fives was higher in rural areas than in cities. The province with the lowest rate of stunting in 2007 was Riau 26.2 per cent and in 2010 it was Yogyakarta 22.5 per cent. Nationally, the prevalence of stunting in Indonesia declined, but when analysed on the basis of household expenditure, the decline in stunting only occurred in wealthier households in quintiles 3, 4 and 5, where a greater decline was also associated with increases in household expenditure levels. In very poor households, or those in quintile 1, the prevalence of stunting among under-fives increased by 6.4 per cent between 2007 and 2010, to 43.1 per cent. In households with expenditures in quintile 2, the prevalence of stunted children was stagnant at approximately 39 per cent. In rural areas the prevalence increased by 0.25 per cent between 2007 and 2010, while in urban areas the prevalence decreased by 3.98 per cent in the same period. Nutritional status of under-fives can also be viewed on the basis of weight-for-height, where low weight-for-height indicates wasting. The prevalence of wasting among under-fives decreased by 2.2 per cent, from 13.6 per cent in 2007 to 13.3 per cent in 2010 Figure 3.18. The prevalence of wasting among under-fives was higher in rural areas than in urban areas. Based on the level of household expenditure, a decline in the prevalence of wasting between 2007 and 2010 only occurred in households with middle to upper levels of expenditure, while in households with expenditure levels in quintile 1 the prevalence of wasting actually increased by 15 per cent, and in quintile 2 it remained unchanged. In the quintile 5 wealthiest households the prevalence of wasting decreased 40 35 30 25 20 15 10 5 Boys Boys Boys Total Total Total Girls Girls Girls Underweight Stunting Wasting Source:฀RISKESDAS฀2007฀and฀2010 Figure 3.18: Nutritional status of children under age five years, 2007 and 2010 of under 5 years old children 2007 2010 108 by 17.8 per cent. No less important than the problem of undernourishment is the problem of obesity in children, which often escapes the attention of the government. The average prevalence of overweight children under the age of five in Indonesia in 2007 was 12.2 per cent, increasing to 14 per cent in 2010. There were 18 provinces that recorded a prevalence of obesity above the national average in 2007, and a decrease occurred in 12 provinces in the period between 25 20 15 10 5 50 45 40 35 30 25 20 15 10 5 Rural Rural Q2 Q2 Q5 Q5 Urban Urban 2007 2010 2007 2010 Q1 Q1 15.9 32.7 15.2 31.4 20.4 39.9 22.1 40.5 19.5 38.9 18.1 37.2 16.5 34.1 13.7 30.3 20.7 40.0 22.7 43.1 19.1 38.9 17.6 34.0 15.2 30.7 10.5 24.1 Q4 Q4 Q3 Q3 Source:฀RISKESDAS฀2007฀and฀2010 Source:฀RISKESDAS฀2007฀and฀2010 Figure 3.19: Prevalence of underweight children under age five by urbanrural location and household expenditure, 2007 and 2010 Figure 3.20: Prevalence of stunting among children under age five by urbanrural location and household expenditure, 2007 and 2010 2007 and 2010. The highest prevalence of obesity in 2007 occurred in South Sumatra Province 20.9 per cent and in 2010 it was in Jakarta 19.6 per cent. The lowest prevalence of overweight children in 2007 was in Gorontalo 6.8 per cent and in 2010 it was in North Maluku 5 per cent. Children who suffer from being overweight, a problem that has always been associated with rich households, are also found in poor households. In 2007, 12.2 per cent of under- fives were overweight. The data showed in the