Towards contextually adjusted measures of child growth

1. Towards contextually adjusted measures of child growth Hinke Haisma Rosalind Franklin Fellow Dept Demography Faculty of Spatial Sciences University of Groningen

2. Overview • Child mortality; • Child growth monitoring; • Sen’s capability approach; • Research design; • Some findings: • Demographic Health Survey (India); • Ethnography.

3. Child mortality • 6.3 million children under the age of five died in 2013. • Leading causes of death in under-five children are preterm birth complications, pneumonia, birth asphyxia, diarrhoea and malaria. About 45% of all child deaths are linked to malnutrition. • Children in sub-Saharan Africa are more than 15 times more likely to die before the age of five than children in developed regions.

4. What has been achieved? • Overall, substantial progress has been made towards achieving Millennium Development Goal (MDG) 4. Since 1990 the global under-five mortality rate has dropped from 90 deaths per 1000 live births in 1990 to 46 in 2013. But the rate of this reduction in under-five mortality is still insufficient to reach the MDG target of a two-thirds reduction of 1990 mortality levels by the year 2015.

5. Growth monitoring • Periodic anthropometric measurements; • Universal scale (WHO growth standards – how children around the world should grow)

6. Critique • Biomedical perspective only; • Not sensitive to context; • Mono-dimensional outcomes (anthropometry); • Has implications for advise to carers; • Calls for interventions that are directed towards improving the mono-dimensional outcomes rather than focussing on the opportunities and capabilities of people

7. Current indicators are not sensitive to context Mother back to work, grandma babysits Netherlands Tanzania Introduction solid foods/ water WHO Growth standard – weight for age (kg)

8. VIDI research – Normative indicators of child health and nutrition – one size fits all? To increase our understanding of biomedical, sociological and anthropological dimensions of children’s growth, aiming to contribute to the development of a new set of indicators that are sensitive to the differences in context in which children live.

9. Research translationtopolicy Tailor-made advice to mothers in well-baby clinics (micro-level); To develop policies and interventions that are embedded into local circumstances of how people; Compare children’s growth between countries by WHO/ UNICEF taking into account differences in context between countries and making (macro-level).

11. Sen’s capability approach Amartya Sen, economist, Nobel Prize (1998): Economic growth as mono-dimensional indicator for development; Replaced by set of indicators for development, based on capabilities and freedom to achieve what people defined as valuable aspirations in the context they live in; Implemented by UNDP (multi-dimensional Human Development Index).

12. Capability approach in child growth

13. Research design • Ethnography of child growth: • Electronic Human Relations Area Files (Yale University) – Shirish Darak; • Tanzania (PhD) – Zaina Mchome; • Analysis of Demographic Health Survey data: • India – Sepideh Yousefzadeh.

14. Research questions • What is healthy growth? • What underlies healthy growth? • Endowments (resources); • Conversion factors (internal and external); • Opportunities and capabilities • Freedom; • Agency.

15. Some findings - eHRAF • Growth is development of elementary and manipulative bodily skills • From infancy an attempt is made to mold the child's features. The ears are pulled outward and the bridge of the nose is pulled upward, to prevent a flat nose (Burman culture, Burma, Southeast Asia)

16. Growth is change in size and strength • The age of a child was never calculated by years, but [growth is assessed]by its size and strength and by the natural episodes of its life (Banyoro, culture, Uganda, Africa) • Traditional Bororo beliefs about the maturation of infants and children concern their growing degree of “hardness”, (Bororo culture, South America)

17. Growth is starting to explore the world and getting ‘sense’ • It is during infancy and childhood that whimsical behavior, even errant behavior, is expected and tolerated of youngsters. Indeed, the mischievous child is often praised for its likeness to Lord Krishna, who was also a consummate prankster and breaker of rules while very young. (Bengali Culture, Asia)

18. Growth is getting accustomed to the surroundings • The infant is petted and encouraged by all his female relatives. When he cries his wishes are usually fulfilled. He becomes accustomed to the presence of people, noise, and light, and under these conditions he falls asleep, wakes, and sucks. As a result, a healthy child does not cry often or long, but is placid, good-natured, and content. He likes attention, and responds to it with a smile.( Lau Fijians Culture, Polyneise)

19. Gender differences • It is also recognized that a boy is usually nursed less than a girl, which also differs from the custom in Artas. The purpose is that though both should be infused with the mother's compassion, the girl is supposed to be imbued with more of it than the boy, and consequently her nursing should be longer (Fellahin Culture, Egypt, North Africa) .

20. Some findings - DHS Preliminary findings Sepideh Yousefzadeh and Femke Hitzert

21. International network • International Union of Nutrition Sciences (IUNS) Task Force: • Multi-disciplinary research group; • Establishing links with WHO/ UNICEF.

22. In conclusion • Work in progress: • Further analysis of DHS data; • Repeat in other databases, DHS or cohort data; • Ethnography of child growth in Tanzania; • In-depth interviews with health professionals in the Netherlands; • (Hopefully) research on contextual factors influencing child growth in Bangladesh.