Rwanda
2000
Nutrition of Young Children
and Mothers
l’Office National de la Population
DU
TWONGERE UMUSARURO TUBYARE TURERE
HA
RA
NIR
E IM
IBER
EHO MYIZA Y
'A B
AT U
RA
GE
U.S. Agency for International Development
ORC Macro
AFRICA NUTRITION CHARTBOOKS
NUTRITION OF YOUNG CHILDREN AND MOTHERS
IN RWANDA
Findings from the 2000 Rwanda Demographic and Health Survey
ORC Macro
11785 Beltsville Drive
Calverton, Maryland, USA
October 2001
This chartbook was produced by the MEASURE DHS+ program, which is funded by the U.S. Agency for International Development (USAID) through the
Global Bureau Office of Health and Nutrition. The chartbook benefited from funds provided by the USAID Bureau for Africa Office of Sustainable
Development's Health and Human Resources Analysis for Africa project (HHRAA). Copies of this chartbook may be obtained by contacting the MEASURE
DHS+ program, ORC Macro, at the above address, or by telephone at (301) 572-0200, or by fax at (301) 572-0999.
TABLE OF CONTENTS
INTRODUCTION..................................................................................................................................................................................... 1
FIGURE 1: INFANT AND CHILD MORTALITY, RWANDA COMPARED WITH OTHER SUB-SAHARAN COUNTRIES ........................................................ 2
FIGURE 2: CONTRIBUTION OF UNDERNUTRITION TO UNDER-FIVE MORTALITY, RWANDA ...................................................................................... 4
FIGURE 3: SURVIVAL AND NUTRITIONAL STATUS OF CHILDREN, RWANDA ............................................................................................................. 6
MALNUTRITION IN RWANDA ........................................................................................................................................................... 9
FIGURE 4: MALNUTRITION AMONG CHILDREN UNDER FIVE YEARS, RWANDA ...................................................................................................... 10
FIGURE 5: CHANGES IN UNDERNUTRITION RATES AMONG CHILDREN UNDER FIVE YEARS, RWANDA 1992 AND 2000 ........................................ 12
FIGURE 6: STUNTING, WASTING, AND UNDERWEIGHT BY AGE, RWANDA ............................................................................................................. 14
FIGURE 7: UNDERNUTRITION AMONG CHILDREN UNDER FIVE YEARS WHO DO NOT RESIDE WITH THEIR MOTHER, RWANDA ........................... 16
FIGURE 8: UNDERWEIGHT AMONG CHILDREN UNDER THREE YEARS, RWANDA COMPARED WITH OTHER SUB-SAHARAN COUNTRIES............... 18
FIGURE 9: STUNTING AMONG CHILDREN UNDER THREE YEARS, RWANDA COMPARED WITH OTHER SUB-SAHARAN COUNTRIES....................... 20
CONCEPTUAL FRAMEWORK FOR NUTRITIONAL STATUS .................................................................................................. 22
IMMEDIATE INFLUENCES OF MALNUTRITION ....................................................................................................................... 25
FIGURE 10: USE OF IODIZED SALT AMONG HOUSEHOLDS WITH CHILDREN UNDER FIVE YEARS BY REGION, RWANDA ....................................... 26
FIGURE 11: NIGHT BLINDNESS AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS, RWANDA .......................................................................... 28
FIGURE 12: VITAMIN A SUPPLEMENTATION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY REGION, RWANDA .................................. 30
FIGURE 13: VITAMIN A SUPPLEMENTATION AMONG CHILDREN UNDER FIVE YEARS BY REGION, RWANDA ........................................................ 32
FIGURE 14: IRON SUPPLEMENTATION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS, RWANDA ............................................................... 34
FIGURE 15: DIARRHEA AND COUGH WITH RAPID BREATHING AMONG CHILDREN UNDER FIVE YEARS COMPARED WITH
MALNUTRITION RATES, RWANDA ........................................................................................................................................................ 36
UNDERLYING BIOLOGICAL AND BEHAVIORAL INFLUENCES OF MALNUTRITION ................................................... 39
FIGURE 16: FERTILITY AND BIRTH INTERVALS, RWANDA COMPARED WITH OTHER SUB-SAHARAN COUNTRIES ................................................. 40
FIGURE 17: UNDERNUTRITION AMONG CHILDREN AGE 12-23 MONTHS BY MEASLES VACCINATION STATUS, RWANDA .................................... 42
FIGURE 18: MEASLES VACCINATION COVERAGE AMONG CHILDREN AGE 12-23 MONTHS, RWANDA COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 44
FIGURE 19: FEEDING PRACTICES FOR INFANTS UNDER SIX MONTHS, RWANDA ..................................................................................................... 46
iii
FIGURE 20: INFANTS UNDER FOUR MONTHS WHO ARE EXCLUSIVELY BREASTFED AND THOSE WHO RECEIVE A BOTTLE,
RWANDA COMPARED WITH OTHER SUB-SAHARAN COUNTRIES .......................................................................................................... 48
FIGURE 21: FEEDING PRACTICES FOR INFANTS AGE 6-9 MONTHS, RWANDA ......................................................................................................... 50
FIGURE 22: INFANTS AGE 6-9 MONTHS RECEIVING SOLID FOODS IN ADDITION TO BREAST MILK, RWANDA COMPARED
WITH OTHER SUB-SAHARAN COUNTRIES ............................................................................................................................................. 52
FIGURE 23: CHILDREN 10-23 MONTHS WHO CONTINUE TO BE BREASTFED, RWANDA COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 54
UNDERLYING SOCIAL AND ECONOMIC INFLUENCES OF MALNUTRITION................................................................... 57
FIGURE 24: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY MOTHER’S EDUCATION, RWANDA ......................................... 58
FIGURE 25: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY SOURCE OF DRINKING WATER, RWANDA .............................. 60
FIGURE 26: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY TYPE OF TOILET, RWANDA..................................................... 62
BASIC INFLUENCES ........................................................................................................................................................................... 65
FIGURE 27: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY REGION, RWANDA .................................................................. 66
FIGURE 28: STUNTING AND WASTING AMONG CHILDREN UNDER FIVE YEARS BY URBAN-RURAL RESIDENCE, RWANDA ................................... 68
MATERNAL NUTRITIONAL STATUS ............................................................................................................................................. 71
FIGURE 29: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY REGION, RWANDA ........................................................... 72
FIGURE 30: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY RESIDENCE, RWANDA ...................................................... 74
FIGURE 31: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER FIVE YEARS BY EDUCATION, RWANDA ..................................................... 76
FIGURE 32: MALNUTRITION AMONG MOTHERS OF CHILDREN UNDER THREE YEARS, RWANDA COMPARED WITH OTHER
SUB-SAHARAN COUNTRIES ................................................................................................................................................................... 78
APPENDICES ......................................................................................................................................................................................... 81
APPENDIX 1 STUNTING, WASTING, AND UNDERWEIGHT RATES BY BACKGROUND CHARACTERISTICS RWANDA 2000 ....................................... 83
APPENDIX 2 WHO/CDC/NCHS INTERNATIONAL REFERENCE POPULATION COMPARED WITH THE DISTRIBUTION OF
MALNUTRITION IN RWANDA ............................................................................................................................................................... 84
iv
Introduction
Malnutrition1 is one of the most important health and welfare problems among infants and young children in Rwanda.
It is a result of both inadequate food intake and illness. Inadequate food intake is a consequence of insufficient food
available at the household level, improper feeding practices, or both. Improper feeding practices include both the
quality and quantity of foods offered to young children as well as the timing of their introduction. Poor sanitation puts
young children at increased risk of illness, in particular diarrheal disease, which adversely affects their nutritional
status. Both inadequate food intake and poor environmental sanitation reflect underlying social and economic
conditions.
Malnutrition has significant health and economic consequences, the most serious of which is an increased risk of
death. Other outcomes include an increased risk of illness and a lower level of cognitive development, which results
in lower educational attainment. In adulthood, the accumulated effects of long-term malnutrition can be a reduction in
workers’ productivity and increased absenteeism in the workplace; these may reduce a person’s lifetime earning
potential and ability to contribute to the national economy. Furthermore, malnutrition can result in adverse pregnancy
outcomes.
The data presented here are from the 2000 Rwanda Demographic and Health Survey (RDHS 2000), a nationally
representative survey of 10,206 households, requested by the Rwandan Ministry of Health and conducted by the
National Population Office (ONAPO). ORC Macro provided technical assistance through its MEASURE DHS+
program. Financial Assistance was provided by the U.S. Agency for International development (USAID), the United
Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF).
Of the 8,188 children age 0-59 months who were part of the study, 6,490 are alive and have complete anthropometric
data and are therefore included in the nutrition analyses. Unless otherwise noted, all analyses include only children
who reside with their mother. Nutritional data collected on these children include height, weight, age, breastfeeding
history, and feeding patterns. Information was also collected on the prevalence of diarrhea and acute respiratory
infection (ARI) in the two weeks prior to the survey and on relevant sociodemographic characteristics. For
comparison, data are presented from Demographic and Health Surveys conducted in other sub-Saharan countries.
1
The technical method of identifying a malnourished population as defined by the U.S. National Center for Health Statistics (NCHS), the Centers for Disease
Control and Prevention (CDC), and the World Health Organization (WHO) is presented in Appendix 2.
1
Figure 1: Infant and Child Mortality, Rwanda Compared with
Other Sub-Saharan Countries
Malnutrition compromises child health, making children susceptible to illness and death. Infectious diseases such
as acute respiratory infections, diarrhea, and malaria account for the greatest proportion of infant and under-five
mortality. The infant mortality rate (under-one rate) is a commonly used measure of infant health and is a sensitive
indicator of the socioeconomic conditions of a country. The under-five mortality rate is another informative
indicator of infant and child survival.
• Rwanda’s under-one mortality rate (107 deaths per 1,000 births) indicates that more than 10
percent of children born in Rwanda will die before their first birthday. This rate is in the upper
fourth among sub-Saharan countries surveyed.
• Rwanda’s under-five mortality rate (196 deaths per 1,000 births) indicates that almost 20 percent
of children born in Rwanda will die before their fifth birthday. Again, this rate places Rwanda in the
upper fourth among sub-Saharan countries surveyed.
2
Figure 1
Infant and Child Mortality, Rwanda Compared with
Other Sub-Saharan Countries
Deaths per 1,000 Births
300
Under-One Mortality Rate
280
Under-Five Mortality Rate
274
260
238
240
219
220
200
189
177
180
201
181
166 167
157 159
160
146 147 147
151
136 139
135
140
123 123
120
94
100
74
80
60
194 196 197
65
66
77
77
80
96
97
97
98
99
107 109
103 104 105
112
102 104
108
112
81
68
57
40
20
0
8
0
0 6
8 98 5 7 8 9 5
9
5 7 0 96 99
6 98 7
6 8
00 96
98 99 95 7 99 8 6 98 95 96 7 5 00 99 99 7 00
99 1996 199 19 199 199 199 199 199 1998 199 199 200 19 19 99 i 200 1997 200 199 997 99 199 r 199
19 19 a 19 l 199 a 1 199 199 o19 a 19 in 19 r 199 -199 a 20 a 19 19 -199 i 20 999 a 20 a 19 999 -199 r 19 199
1
o
a
l
n
1
a
a
9
a
i
a
a
a
9
a
a
r
e
e
i
i
an we itre ega eny oon res Tog and Ben sca 1994 iopi uine zania 996 alaw 98-1 and mb 8-1 995 Nig ique
we res an ny itre ga og nia nd on 94 ca pi en ine -1 law 96 nd b ue -1 95 ig
g
ab omo Gh Ke Er ene T nza Uga ero R 19 gas Ethio B Gu 998 Ma 19 Rwa Zam biq 1998 li 19 N
a R Eth G an 1 M 19 Rw Za 99 li 1
b
Gh bab Er Sen K mer omo
b
g
U
a
m
a
a
1
1
d
d
S
m
m
a
a
T ha
T
a
o
e
e
za
za so M
Zim
Ca C
Zim C
Ca CA ad
ad CA
as
oir M
oir
C
Ch
M
M
Mo
Mo a Fa
d'Iv
d'Iv
aF
n
n
e
e
i
i
t
t
rk
rk
Cô
Cô
Bu
Bu
3
Source: DHS Surveys 1995-2000
Figure 2: Contribution of Undernutrition to Under-Five Mortality,
Rwanda
Undernutrition is an important factor in the death of many young children. Even if a child is only mildly
malnourished, the mortality risk is increased. Under-five mortality is largely a result of infectious diseases and
neonatal deaths in developing countries. Respiratory infections, diarrhea, malaria, measles, and other infectious
diseases take their toll on children.
Formulas developed by Pelletier et al. 1 are used to quantify the contributions of moderate and severe malnutrition
to under-five mortality.
In Rwanda,
• Thirty-seven percent of all deaths that occur before age five are related to malnutrition (severe and
moderate malnutrition).
• Because of its extensive prevalence, moderate malnutrition (31 percent) contributes to more deaths
than severe malnutrition (6 percent).
• Moderate malnutrition is implicated in 84 percent of deaths associated with malnutrition.
Pelletier, D.L., E.A. Frongillo, Jr., D.G. Schroeder, and J.P. Habicht. 1994. A methodology for estimating the contribution of
malnutrition to child mortality in developing countries. Journal of Nutrition 124 (10 Suppl.): 2106S-2122S.
1
4
Figure 2
Contribution of Undernutrition to Under-Five Mortality,
Rwanda
How undernutrition
contributes to death
Neonatal
deaths
Underfive
mortality
Deaths
from
other
causes
AIDS
deaths
Malaria
deaths
Severe malnutrition
6%
Measles
deaths
Moderate malnutrition
31%
ARI
deaths
Diarrhea
deaths
Pathway to Death
Note: Calculation based on Pelletier et al., 1994.
5
Source: Rwanda DHS 2000
Figure 3: Survival and Nutritional Status of Children, Rwanda
Malnutrition and mortality both take a tremendous toll on young children. This figure illustrates the proportion of
children who have died or are undernourished at each month of age.
In Rwanda,
• Between birth and 19 months of age, the percentage of children who are alive and not
malnourished drops rapidly from about 82 percent to 30 percent. Thereafter, the rate remains stable
between 30 and 40 percent through 59 months.
• Between birth and 19 months of age, the percentage of children who are moderately or severely
malnourished1 increases dramatically from 10 percent to 58 percent. This percentage subsequently
levels off and remains stable between 40 and 50 percent through 59 months.
• From birth until 59 months, the percentage of children who have died increases gradually, ranging
from 10 percent at birth to a peak of 23 percent at age 48 months.
A child with a Z-score below minus three standard deviations (-3 SD) on the reference standard is considered severely
malnourished, while one with a Z-score between -2 SD and -3 SD is considered moderately malnourished.
1
6
Figure 3
Survival and Nutritional Status of Children, Rwanda
100%
Dead
80%
60%
Moderately or severely
malnourished
40%
20%
Not malnourished
0%
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58
Age (months)
Note: A child with a Z-score below -3 SD on the reference
standard is considered severely malnourished (stunted, wasted,
or underweight), while a child with a Z-score between -3 SD and
-2 SD is considered moderately malnourished. Values have
been smoothed using a five-month rolling average.
7
Source: Rwanda DHS 2000
Malnutrition in Rwanda
9
Figure 4: Malnutrition among Children under Five Years, Rwanda
In Rwanda,
• Forty-three percent of children age 0-59 months are chronically malnourished. In other words, they
are too short for their age, or stunted.1 The proportion of children who are stunted is more than 20 times
the level expected in a healthy, well-nourished population.
• Acute malnutrition, manifested by wasting,2 results in a child being too thin for his or her height. It
affects 7 percent of children, which is 3 ½ times the level expected in a healthy population.
• Twenty-four percent of children under five years are underweight3 for their age. This is more than 12
times the level expected in a healthy, well-nourished population.
• Fifteen percent of children under five are overweight.4 This is slightly less than the level expected in a
healthy, well-nourished population.
1
A stunted child has a height-for-age Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. Chronic malnutrition is
the result of an inadequate intake of food over a long period and may be exacerbated by chronic illness.
2
A wasted child has a weight-for-height Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. Acute malnutrition is
the result of a recent failure to receive adequate nutrition and may be affected by acute illness, especially diarrhea.
3
An underweight child has a weight-for-age Z-score that is below -2 SD based on the NCHS/CDC/WHO reference population. This condition can
result from either chronic or acute malnutrition or a combination of both.
4
An overweight child has a weight-for-height Z-score that is above 1 SD based on the NCHS/CDC/WHO reference population.
10
Figure 4
Malnutrition among Children under Five Years, Rwanda
Percent
50
43
40
30
24
16
20
15
7
10
2
0
Reference
Stunted
Wasted
Note: Stunting reflects chronic malnutrition; wasting
reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both.
Underweight
11
Reference Overweight
Source: Rwanda DHS 2000
Figure 5: Changes in Undernutrition Rates among Children under
Five Years, Rwanda 1992 and 2000
• The findings of the 2000 RDHS suggest that chronic malnutrition rates in Rwanda have declined
since the 1992 survey, while acute malnutrition rates have increased.
• In 1992, stunting affected 48 percent of children under five, compared with 43 percent in 2000. Four
percent of children were wasted in 1992 compared with 7 percent in 2000. In 1992, 29 percent of children
were underweight, while in 2000, the rate was 24 percent.
12
Figure 5
Changes in Undernutrition Rates among Children under
Five Years, Rwanda 1992 and 2000
Percent
70
60
1992
2000
48
50
43
40
29
30
24
20
10
7
4
2
0
p.
o
f. P
e
R
ted
n
u
St
ted
s
a
W
ted
n
u
St
t
ie gh
w
er
d
Un
Note: Stunting reflects chronic malnutrition; wasting
reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both.
13
ted
s
a
W
t
ie gh
w
er
d
Un
Sources: RDHS 1992 and RDHS 2000
Figure 6: Stunting, Wasting, and Underweight by Age, Rwanda
In Rwanda, the time between two months and 20 months of age is a vulnerable period.
• The proportion of children stunted rises sharply from zero to 20 months of age, peaking at 60
percent. The proportion of children stunted then declines to 42 percent by 26 months of age and then
rises and falls, ranging between a low of 44 percent at age 39 months to a high of 56 percent at age 58
months.
• The proportion of children wasted rises to 15 percent at 13 months and then declines to 6 percent
at 23 months. The proportion then remains fairly constant, ranging between 8 percent and 3 percent.
• The proportion of children underweight sharply rises from four to 13 months of age, when it
reaches 40 percent. The proportion then steadily declines to 19 percent by 47 months. Then the
proportion rises again to between 20 and 25 percent until age 59 months.
14
Figure 6
Stunting, Wasting, and Underweight by Age, Rwanda
Percent
70
Vulnerable Period
60
50
40
30
#
#
0
# ## # ## #
#
#
20
10
#
# # # ##
# ))
#
) ) ) )# )# ) ) )
# ##
0
2
4
6
8
)) ) ))
)
)
)
) )) ) ))
Stunted average
) Wasted average
# Underweight average
# # ## # # # ## # # ## # # ## # # # #
) )) ) )) ) )) ) ) )) )
#
##
#
# ## # # #
#
# ## #
)) ) )) ) )) ) )) ) ) )) ) )) ) )) )
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58
Age (months)
Note: Stunting reflects chronic malnutrition; wasting reflects
acute malnutrition; underweight reflects chronic or acute
malnutrition or a combination of both. Plotted values are
smoothed by a five-month moving average.
15
Source: Rwanda DHS 2000
Figure 7: Undernutrition among Children under Five Years Who Do
Not Reside with Their Mother, Rwanda
Previously, anthropometric data from DHS surveys excluded children whose mother did not live in the household
or was not present to be interviewed. Currently, all children in the household are measured despite their mother’s
residence status. In the RDHS, 348 children under five years did not reside with their mother.
In Rwanda,
• Forty-seven percent of children age 0-59 months who do not reside with their mother are stunted,
compared with 42 percent of children who do live with their mother.
• There is no statistical difference in either rates of wasting or of underweight between children who
reside with their mother and those who do not.
16
Figure 7
Undernutrition among Children under Five Years
Who Do Not Reside with Their Mother, Rwanda
Percent
60
Children Who Reside with Their Mother
Children Who Do Not Reside with Their Mother
47
50
42
40
(No Statistical Difference)
30
25
22
20
(No Statistical Difference)
7
10
7
0
Stunted
Note: Stunting reflects chronic malnutrition; wasting
reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both.
Wasted
17
Underweight
Source: Rwanda DHS 2000
Figure 8: Underweight among Children under Three Years, Rwanda
Compared with Other Sub-Saharan Countries
Among the sub-Saharan countries surveyed,
• The percentage of children under three years who are underweight ranges from 14 to 50 percent. With
25 percent of children under three years being underweight, Rwanda is in the lower quartile of
sub-Saharan countries surveyed. Underweight status is indicative of children who suffer from chronic
or acute malnutrition, or both, and may be influenced by both short- and long-term determinants of
malnutrition. Underweight is often used as a general indicator of a population’s health status.
18
Figure 8
Underweight among Children under Three Years,
Rwanda Compared with Other Sub-Saharan Countries
Percent
60
50
44 45
50
36
40
30
20
22 22
39 40 40
30
28 29
27
27
26
26
26
25 25 25 25
14
10
0
6
8
8 8
7
99 998 199 999 199 199 2000 996 996 997 995 995 000 199 999 9 199 997 996 995 000 998
9
1 1 a a 1 a o a s 1 ia 1 1 a 1 -1 i 2 in a 1 99 d r 1 -1 a 1 a 2 er 1
e
w roon eny ine han Tog and oro mb ique and 994 alaw en ani 98-1 Cha sca 995 ritre iopi Nig
b
B nz 9
w om Za mb Ug R 1 M
ba me K Gu G
ga ali 1 E Eth
a o1
R
a
m
A
a
C
T
i
a
Z C
C
ad M
as
oz
F
M
M
ina
k
r
Bu
Note: Underweight reflects chronic or acute
malnutrition or a combination of both.
19
Source: DHS Surveys 1995-2000
Figure 9: Stunting among Children under Three Years, Rwanda
Compared with Other Sub-Saharan Countries
Among the sub-Saharan countries surveyed,
• The percentage of children under three years who are stunted ranges from 20 to 48 percent. At
36 percent, the proportion of children under three years who are stunted in Rwanda is in the third
quartile among the sub-Saharan countries surveyed. 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, and recent shifts in social or economic
policies.
20
Figure 9
Stunting among Children under Three Years, Rwanda
Compared with Other Sub-Saharan Countries
Percent
60
48
50
41
40
34 34 35
27
30
20
29 29
36 36 36
42
44 45
38 38
30 31 31
22 23
20
10
0
7
8
0
6
0
5
5
98 998 999 999 996 98 96 998
95 996 199 997 199 200 199 999 199 199 200 000 997
9
9
9
9
1
9
1
1
1
1
2
1
a go ea
e nin on 1 95-1 nya -199 94-1 ros 1 had e 1 da da rea nia 1 iger bia awi pia ar 1
n
o
w
a T
in b Be ro 19
C biqu gan wan Erit za
N am al thio asc
Ke 1998 R 19 omo
e li
Gh
M E
n
Gu mba
Z
g
U
m a
a
m
R
a
A
i
C
a
T
o
da
M
z
s
Z
C
C
a
o
M
Fa
M
a
n
i
rk
Bu
Note: Stunting reflects chronic malnutrition.
21
Source: DHS Surveys 1995-2000
Conceptual Framework for Nutritional Status
Nutrition is directly related to food intake and infectious diseases such as diarrhea, acute respiratory infection,
malaria, and measles. Both food intake and infectious diseases reflect underlying social and economic conditions
at the household, community, and national levels that are supported by political, economic, and ideological
structures within a country.
The following diagram is a conceptual framework for nutrition adapted from UNICEF.1 It reflects relationships
among factors and their influences on children’s nutritional status. Although political, socioeconomic,
environmental, and cultural factors (at the national and community levels) and poverty (at the household level)
affect the nutritional status of women and children, the only variables included in this chartbook are those that can
be collected as part of a national household survey. The highlighted areas of the framework depict selected factors.
These factors are
• Immediate influences, such as food intake (micronutrient status and supplementation) and infectious
diseases (diarrhea and respiratory infections)
• Underlying biological and behavioral influences, such as maternal fertility, measles vaccinations, and
feeding patterns of children under two years
• Underlying social and economic influences, such as maternal education, drinking water, and sanitation
• Basic influences, such as area of residence.
1
Bellamy, C. 1998. State of the World’s Children 1998. New York: UNICEF
22
Conceptual Framework for Nutritional Status
Manifestations
Nutritional Status
Food Intake
(Micronutrient Status/Supplementation)
Infectious Diseases
(Diarrhea and Cough with Rapid Breathing)
Feeding Patterns
(Infants Under 6 Months: Exclusive Breastfeeding,
6-9 Months: Complementary Feeding,
10-24 Months: Continued Breastfeeding)
Intrahousehold
Food Distribution
Household Assets
Health Services
Immunization, Health Care
(Measles Vaccination
12-23 Months)
Marital Status
Employment
(Parents’ Working
Status)
Hygiene
Behavior
Child Care
Maternal Fertility, Age,
Antenatal Care, Health Status
(Total Fertility Rate, Birth Interval,
Maternal Malnutrition)
Education
(Maternal)
Food Availability
Water, Sanitation
(Source of Drinking Water, Type of Toilet)
Political, Economic, and Ideological Structure
(Residence: Urban/Rural, Region)
23
23
Immediate
Influences
Underlying
Biological and
Behavioral
Influences
Underlying
Social and
Economic
Influences
Basic
Influences
Adapted from: UNICEF,
State of the World's Children, 1998
Immediate Influences of
Malnutrition
25
Figure 10: Use of Iodized Salt among Households with Children
under Five Years by Region, Rwanda
Iodine deficiency is known to cause goiter, cretinism (a severe form of neurological defect), spontaneous abortion,
premature birth, infertility, stillbirth, and increased child mortality. One of the most serious consequences to child
development is mental retardation caused by iodine deficiency disorder (IDD), which puts at stake social
investments in health and education. IDD is the single most common cause of preventable mental retardation and
brain damage in the world. It decreases the production of hormones vital to growth and development. Children
with IDD can grow up stunted; apathetic; mentally retarded; and incapable of normal movement, speech, or
hearing. IDD in pregnant women may cause miscarriage, stillbirth, and mental retardation in infants.
The remedy for IDD is relatively simple. A teaspoon of iodine is all a person requires in a lifetime. Since iodine
cannot be stored for long periods by the body, tiny amounts are needed regularly. In areas of endemic iodine
deficiency, where soil and therefore crops and grazing animals do not provide sufficient dietary iodine to the
population, food fortification and supplementation have proven to be highly successful and sustainable
interventions. The fortification of salt or oil with iodine is the most common tool to prevent IDD. Iodized salt that
is commercially packaged in plastic sacks and not stored properly can lose its concentration of iodine. Proper
packaging and storage of iodized salt is essential to ensure that the population benefits from iodine fortification.
• In Rwanda, 92 percent of households with children under five years use salt that has an adequate
level of iodine to prevent IDD ( ≥15 ppm). Iodization of salt is lowest in the Butare and Gikongoro
regions and is highest in Umutara.
26
Figure 10
Use of Iodized Salt among Households with Children
under Five Years by Region, Rwanda
Percent
100
92
84
86
89
89
93
90
93
93
94
94
95
99
80
60
40
20
0
tal
o
T
o
re
le
a
t
or
ra
u
g
u
n
B
ko
li R
Gi
gi a
K
i
a
ri
a
u
ye
ba
go
)
ny
e
g
u
m
tar
n
e
g
K
u
m
b
a
i
u
s
u
n
g
r
i
u
b
K
y
PV
G
ita
he
an
(
B
Ki
Um
y
u
G
C
li le
R
li V
a
g
Ki
27
Source: Rwanda DHS 2000
Figure 11: Night Blindness among Mothers of Children under Five
Years, Rwanda
Globally, vitamin A deficiency (VAD) is the leading cause of childhood blindness. The damage to vision
(xerophthalmia) is only one of the harmful outcomes of VAD. Vitamin A is crucial for rapid growth and recovery
from illness or infection. Children who are vitamin A deficient have reduced immunity and are less likely to
recuperate from common childhood illnesses, such as diarrhea, ARI, and measles, and are twice as likely to die as
children who are not vitamin A deficient.
A mother’s vitamin A status during pregnancy can be an indicator of the vitamin A status of her child. One sign of
VAD in women during pregnancy is night blindness.
• In Rwanda, 7 percent of all women who had given birth in the previous five years reported having
some form of night blindness during their last pregnancy.
• However, only 4 percent of women reported having trouble with their vision during the night but
not during the day during their last pregnancy. Although this figure corrects for women with vision
problems, in general, it may slightly underestimate the rate of night blindness.
28
Figure 11
Night Blindness among Mothers of Children under
Five Years, Rwanda
Seven percent of all women had
reported some form of night
blindness during their last
pregnancy.
Four percent of women had
trouble with their vision during
the night but not during the day
during their last pregnancy.
29
Source: Rwanda DHS 2000
Figure 12: Vitamin A Supplementation among Mothers of Children
under Five Years by Region, Rwanda
Recent studies show that pregnant women who are vitamin A deficient are at a greater risk of dying during or
shortly after delivery of the child. Pregnancy and lactation strain women’s nutritional status and their vitamin A
stores. For women who have just given birth, vitamin A supplementation helps to bring their level of vitamin A
storage back to normal, aiding recovery and avoiding illness.
Vitamin A supplementation also benefits children who are breastfed. If mothers have vitamin A deficiency, their
children can be born with low stores of vitamin A. Low birth weight babies are especially at risk. Additionally,
infants often do not receive an adequate amount of vitamin A from breast milk when mothers are vitamin A
deficient. Therefore, supplementation is important for postpartum women within the first eight weeks after
childbirth.
In Rwanda,
• Fourteen percent of mothers received vitamin A supplements within two months after delivery.
• Vitamin A supplementation of mothers varies by region. Only 9 percent of mothers in Kigali Rurale
received vitamin A, while 18 percent of mothers in Butare and Gikongoro did.
30
Figure 12
Vitamin A Supplementation among Mothers of Children
under Five Years by Region, Rwanda
Percent
20
18
16
15
14
11
12
13
14
13
16
18
16
14
9
10
5
0
tal
o
T
le
K)
ra
V
u
(P
li R
e
l
a
l
i
g
Ki
li V
gi a
K
i
o
ri
a
ra
ba
g
ny
e
a
m
t
n
e
g
m
a
u
s
en
yu
ibu
m
tar
Gi
i
h
B
K
U
u
G
R
31
ye
gu
u
bu
i
g
K
an
y
C
e
o
tar
or
u
g
n
B
ko
i
G
Source: Rwanda DHS 2000
Figure 13: Vitamin A Supplementation among Children under Five
Years by Region, Rwanda
Vitamin A deficiency is common in dry environments where fresh fruits and vegetables are not readily available.
Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, red palm oil, mangos, papayas, carrots,
pumpkin, and dark leafy greens. Unlike iron or folate, vitamin A is a fat-soluble vitamin, which means that
consumption of oils or fats are necessary for its absorption into the body. The liver can store an adequate amount
of the vitamin for four to six months. Periodic dosing (every four to six months) with vitamin A supplements is a
rapid, low-cost method of ensuring children at risk do not develop VAD. National Immunization Days for polio or
measles vaccinations are ideal for reaching a large number of children with vitamin A supplements.
In Rwanda,
• Sixty-nine percent of children under five received a vitamin A dose in the last six months.
• The rate of vitamin A supplementation of children varies throughout Rwanda. The rates of
supplementation were lowest in Kigali Rurale and Kigali Ville (42 and 48 percent) and highest in
Gisenyi, Ruhengeri, Cyangugu, Kibuye, and Butare.
32
Figure 13
Vitamin A Supplementation among Children under
Five Years by Region, Rwanda
Percent
100
78
80
69
60
60
48
61
82
83
84
84
84
66
52
42
40
20
0
tal
o
T
le
K)
ra
V
u
(P
li R
e
l
a
il
g
Ki
la i V
g
Ki
o
yi
ri
u
a
ra
ro
ba
g
n
e
g
a
o
m
t
n
e
g
u
gu
is
ra
um ong
bu
en
n
i
a
m
G
t
i
h
a
By
K
k
U
i
y
u
G
C
G
R
33
e
e
tar
uy
u
b
i
B
K
Source: Rwanda DHS 2000
Figure 14: Iron Supplementation among Mothers of Children under
Five Years, Rwanda
Anemia is the lack of an adequate amount of hemoglobin in the blood. It can be caused by several different health
conditions; iron and folate deficiencies are some of the most prevalent conditions related to anemia. Vitamin B12
deficiency, protein deficiency, sickle cell disease, malaria, and parasite infection also cause anemia.
Iron-deficiency anemia is the most common form of nutritional deficiency worldwide. This type of nutritional
deficiency develops slowly and does not manifest symptoms until anemia becomes severe. Diets that are heavily
dependent on one grain or starch as the major staple often lack sufficient iron intake. Iron is found in meats,
poultry, fish, grains, some cereals, and dark leafy greens (such as spinach). Foods rich in vitamin C increase
absorption of iron into the blood. Tea, coffee, and whole-grain cereals can inhibit iron absorption. Anemia is
common in children 6-24 months of age who consume purely a milk diet and in women during pregnancy and
lactation. Iron-deficiency anemia is related to decreased cognitive development in children, decreased work
capacity in adults, and limited chances of child survival. Severe cases are associated with the low birth weight of
babies, perinatal mortality, and maternal mortality.
In Rwanda,
• Only 22 percent of mothers received some iron supplementation.
• Of those women who received iron supplementation, only 1 percent reported taking the
recommended dosage during their pregnancy (90 or more pills).
34
Figure 14
Iron Supplementation among Mothers of Children under
Five Years, Rwanda
Percent
100
Of the 22% who did take supplements:
78
76
80
60
40
22
20
20
3
1
0
Took
supplements
Did not take
supplements
Took on
1-59 days
35
Took on
60-89 days
Took on 90+ days
(Recommended)
Don't know
how often
were taken
Source: Rwanda DHS 2000
Figure 15: Diarrhea and Cough with Rapid Breathing among
Children under Five Years Compared with Malnutrition Rates,
Rwanda
Acute respiratory infection and dehydration due to diarrhea are major causes of morbidity and mortality in most
sub-Saharan countries. To estimate the prevalence of ARI, mothers were asked whether their children under five
years had been ill with coughing accompanied by short, rapid breathing in the past two weeks. For diarrhea,
mothers were asked whether their children under five years had symptoms of diarrhea in the past two weeks. Early
diagnosis and rapid treatment can reduce the rates of illness or death caused by these conditions.
In Rwanda,
• Twenty-two percent of children under five years of age experienced cough with rapid breathing in
the two weeks preceding the survey. Rwanda’s prevalence of cough with rapid breathing increases
from 24 percent to 34 percent in the first 11 months and then gradually declines to 10 percent by
59 months of age.
• Eighteen percent of children under five years of age had diarrhea in the two weeks preceding the
survey. The prevalence of diarrhea increases rapidly from birth to 12 months when it peaks at 39 percent.
The rate then steadily decreases to 8 percent by 44 months of age where it remains between 4 and
8 percent until age 59 months.
The rapid rise in the prevalence of diarrhea during infancy reflects the increased risk of pathogen contamination
associated with the early introduction of water, other liquids, and solid foods. In addition, when infants begin to
crawl and move around, they tend to put objects in their mouth, again increasing the risk of pathogen
contamination.
36
Figure 15
Diarrhea and Cough with Rapid Breathing among
Children under Five Years Compared with
Malnutrition Rates, Rwanda
Percent
40
30
20
10
&
&&
&
&
&
&&
&
&&
&&&&
&
&
& Diarrhea
&&&
&&
&& &
& &&&&&&&&&&
&
&&&&&&&
Cough with rapid breathing
& & & && & & & &
& & & & & &&
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
56
58
70
60
)
#
50
Stunted average
Wasted average
Underweight average
40
30
20
10
0
#
# # # ## # # # # #
#
##
#
# # # # # # # # # # # # ## # # # # # # # #
# # # ## # # # # ##
#
#
#
#
#
) ) ) )) ) ) ) ) )
)
)
#
) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )) ) ) ) ) ) ) ) ) ) ) )) ) ) ) ) ) ) )
) ) #) )# )# ) ) )
#) ##
)
0
2
4
6
8
10
12
14
16
18
20
22
24
26
Note: Plotted values are smoothed by a five-month moving
average.
28
37
30
32
34
36
38
40
42
44
46
48
50
52
54
56
Source: Rwanda DHS 2000
58
Underlying Biological and
Behavioral Influences of
Malnutrition
39
Figure 16: Fertility and Birth Intervals, Rwanda Compared with
Other Sub-Saharan Countries
High fertility rates, especially when accompanied by short birth intervals, are detrimental to children’s nutritional
status. In most countries in sub-Saharan Africa, families have scarce resources to provide adequate nutrition and
health care for their children. As the number of children per woman increases, fewer household resources are
available for each child. High fertility also has a negative impact on maternal health, thus influencing a mother’s
ability to adequately care for her children. The most widely used measure of current fertility is the total fertility
rate, which is defined as the number of children a woman would have by the end of her childbearing years if she
were to pass through those years bearing children at the currently observed age-specific rates.
Information on the length of birth intervals provides insight into birth spacing patterns. Research has shown that
children born too soon after a previous birth are at increased risk of poor nutrition and health and increased risk of
mortality, particularly when that interval is less than 24 months. The odds of stunting and underweight have been
shown to be higher when birth intervals are less than 36 months. Short birth intervals are associated with small
birth size and low birth weight, both of which are precursors to poor nutritional status in early childhood.
• At the current fertility rate, a woman in Rwanda will have an average of 5.8 children by the end of
her childbearing years. This rate is in the midrange of all of the sub-Saharan countries surveyed
between 1995 and 2000.
• Rwandan mothers have a median birth interval of 32 months. This rate is also in the midrange of all
other countries surveyed.
40
Figure 16
Fertility and Birth Intervals, Rwanda Compared with
Other Sub-Saharan Countries
Children per Woman
Months
10
50
Total Fertility Rate
Median Birth Interval in Months
40
38
7.5
36 36
35
6.8 6.9
6.6 6.7
5.8 5.9
5.6 5.6 5.7
5.5
5.4
35
34 34
33
6.3 6.4
6
40
36
32
31 31
6.1 6.1
29 29 29
33 33 33
32 32
31 31
30
30
5.1 5.1 5.2 5.2
5
4.6 4.7
4
20
10
0
0
8
9 7 0 0 7 96 5 96 00 7 6
98 99
9 98 98 5 8 8
95 98 998 995 97 996 95 998 97 995 98 996 000 998 000 997 999 996 000 97 9 9 199 999 998 99
99 19 19 94-9 199 199 99 o 19 19 1997 199 l 199 200 200 199 19 199 19 i 20 -199 -199 999 19 r 19
9 -1 -19 r 1 -19 1 19 a 1 2 a 1 2 l 1 1 n 1 i 2 19 99 99 o a 1 a 1 19
1
1
1
1
a
a
n
9
a
a
s a r 5 4 e 6 a n i a y ia a ia i w
1 1 g e n e
e n y 19 os n -1 g e e ia a da ia r bi ea ni w 6 5 -1 da ge
oro gand sca 199 199 Nig 199 ritre roo amb and Ken hiop neg zan Ben ala ique 98- 98- To uin ha abw
bw ha en R or roo 8 To uin biqu zaneneg wan thiop asca am Eritr Be Mala 199 i 199 998 gan Ni
9
E
m
e
b
a
w
i
9
M
e
t
n
l
l
G m an S R E g Z
G G b
ba G K CA om me 199
Z
o
1
1
g
1
U
U
R
d a
d
a
R
E S Ta
m
m
a
C a ire
C
da M CA
za T
za aso oire
ha M aso
ha
Zim
Zim
C o
Ca
ad
a
o
o
C
C
v
v
F
F
M
M
I
M
M
'dI
'
na
na d
te
rki
rki ôte
Cô
Bu
Bu C
41
Source: DHS Surveys 1995-2000
Figure 17: Undernutrition among Children Age 12-23 Months by
Measles Vaccination Status, Rwanda
Measles is estimated to kill two million children a year, all in developing countries. It is one of the most common
diseases during childhood in areas without high immunization coverage. Measles not only increases the risk of
death but is also an important direct cause of malnutrition. The occurrence of measles in poor environments is
associated with faltering growth, vitamin A deficiency, and immune suppression. Even though infants are not
protected after birth by their mother’s breast milk, they are protected by their mother’s measles antibodies while in
the womb. These antibodies can last up to 15 months in an infant, but due to malnutrition, they only last up to
eight or nine months in children in developing countries. Therefore, measles vaccination is an important child
health strategy.
• In Rwanda, measles vaccination status is statistically related to undernutrition. Children who did not
receive a measles vaccination have a 6 percent higher rate of wasting, and a 13 percent higher rate of
being underweight than those children who did receive measles vaccinations.
• Measles vaccination status is not statistically related to stunting levels.
42
Figure 17
Undernutrition among Children Age 12-23 Months by
Measles Vaccination Status, Rwanda
Percent
70
(No Statistical Difference)
Vaccinated
Not vaccinated
56
60
51
47
50
40
34
30
17
20
11
10
0
Stunting
Wasting
Note: Stunting reflects chronic malnutrition; wasting
reflects acute malnutrition; underweight reflects
chronic or acute malnutrition or a combination of both.
43
Underweight
Source: Rwanda DHS 2000
Figure 18: Measles Vaccination Coverage among Children Age 12-23
Months, Rwanda Compared with Other Sub-Saharan Countries
In Rwanda,
• Eighty-seven percent of children 12-23 months of age have been vaccinated against measles. This is
the highest rate of coverage among countries surveyed in sub-Saharan Africa.
44
Figure 18
Measles Vaccination Coverage among Children Age 12-23
Months, Rwanda Compared with Other Sub-Saharan
Countries
Percent
100
73
80
60
43 46
78 79 79
84 87 87
64
60 63
58
56
51 51 51 52 54
35
40
23
27
20
0
6 8
8 0 6 0
9
8 8
5
97 000 199 199 997 99 996 995 995 998 199 997 199 998 199 199 999 999 199 200 199 200
9
1
2
1 1
1 1 1
1
1
i
1
6- pia iger ogo car 8-19 95- trea 94- on inea ue 1 nda ros enin ana nia we nya law bia nda
9
19 thio N T gas 199 li 19 Eri R 19 ero Gu biq ga omo B Gh nza bab Ke Ma Zam wa
m U C
R
A Cam
Ta Zim
ad E
da aso Ma
za
h
C
a
o
C
M aF
M
n
i
rk
Bu
45
Source: DHS Surveys 1995-2000
Figure 19: Feeding Practices for Infants under Six Months, Rwanda
Improper feeding practices, in addition to diarrheal disease, are important determinants of malnutrition. WHO and
UNICEF recommend that all infants be exclusively breastfed from birth until six months of age. In other words,
infants should be fed only breast milk during the first six months of life.
In Rwanda, the introduction of liquids, such as water, sugar water, and juice; formula; and solid foods takes place
earlier than the recommended age of about six months. This practice has a deleterious effect on nutritional status
for a number of reasons. First, the liquids and solid foods offered are nutritionally inferior to breast milk. Second,
the consumption of liquids and solid foods decreases the infant’s intake of breast milk, which in turn reduces the
mother’s supply of milk. (Breast milk production is determined, in part, by the frequency and intensity of
suckling.) Third, feeding young infants liquids and solid foods increases their exposure to pathogens, thus putting
them at greater risk of diarrheal disease.
• In Rwanda, 84 percent of children under the age of six months are exclusively breastfed, as is
recommended by WHO and UNICEF.
• Fourteen percent of infants under six months old are given some form of liquid or solid food other
than breast milk and/or water. Additionally, 2 percent of infants under six months of age are given
a combination of breast milk and water.
• Only one-tenth of 1 percent of infants under six months were fully weaned.
46
Figure 19
Feeding Practices for Infants under Six Months,
Rwanda
Weaned
0.1%
Breast milk and
solid foods
9%
Exclusively breastfed
84%
Breast milk
and water
2%
Recommended
Breast milk and
other liquids
5%
Note: WHO and UNICEF recommend that all
infants be breastfed exclusively up to six
months of age.
47
Source: Rwanda DHS 2000
Figure 20: Infants under Four Months Who Are Exclusively
Breastfed and Those Who Receive a Bottle, Rwanda Compared with
Other Sub-Saharan Countries
The failure to exclusively breastfeed young infants and the introduction of liquids and solid foods at too early an
age increases the risk of diarrheal disease, an important cause of mortality in Africa.
• In most of the sub-Saharan countries surveyed, relatively few mothers of infants even under four months
follow the recommended practice of breastfeeding exclusively. However, in Rwanda, 90 percent of
these mothers breastfeed their young infants exclusively. This is by far the highest rate among all
sub-Saharan countries surveyed.
• Bottle-feeding is practiced by 3 percent of mothers of infants under four months in Rwanda. This
rate is in the midrange among countries surveyed. Bottle-feeding is not recommended because
improper sanitation with bottle-feeding can introduce pathogens to the infant. Additionally, infant
formulas (which are often watered down) and other types of milk do not provide nutrition comparable to
breast milk for infants less than six months of age. For these reasons, bottle-feeding puts infants at a
higher risk of illness and malnutrition.
48
Figure 20
Infants under Four Months Who Are Exclusively Breastfed
and Those Who Receive a Bottle, Rwanda Compared
with Other Sub-Saharan Countries
Percent
Percent
100
25
90
Exclusively breastfed
Receive a bottle
22
21 21
80
20
61 62 63
65
68
60
13
15
43
40
36
38 39
8
7 7
26
20
12 13 13
15 16
6 6
17
4 5
1 2
0
10
4 4 4 4
3 3 3 3 3
5
2 2
1
0
0
8
8
9 6 8
0
8 6 8
7 8 5 00 7 6 95 9 00 4 98 7 96 96 95 99 99 99 00 98 8 98
99 97 95 9 96 99 99 99 98 99 99 99 7 99 99 97 00 00 95 95 00
99 199 -199 i 20 199 -199 19 199 20 199 r 19 -199ia 19 in 19 19 o 1 19 a 19 20 a 19 199 a 19
r 1 6-19 -19 199 5-19 a 1 in 1 go 1 19 a 1 ia 1 a 1 199 e 19 ia 19 r 19 a 20 wi 2 a 19 19 a 20
1
a
e
e
a
w
g a
e n
4 i
n y b n e
g
e a d
ue so 94 la car 995 itre we nd ire ig 96 b en da To zani uine iopia eny roon han
Ni 199 199 998 i 199 uin Be To eroo Ken am Gha biqu abw zan asca hiop ala Eritr and wan
biq a Fa R 19 Ma gas ali 1 Er bab Rwa d'Ivo Nd 19 Zam B gan
n G Eth K me G
g
l G
b an ag Et M
Z
1
R
a
d
a
R
m
m
m
U
U
a M
a CA so M
a
im
a
a Zim T ad
a kin CA
T
e
d
t
z
z
h
h
Z
C
Ca
a
r
ô
o
o
C
C
Fa
M
M
C
M
M Bu
a
n
rki
Bu
Note: Information on feeding practices is based on the 24 hours
before the survey. WHO and UNICEF recommend that all infants
should receive nothing but breast milk up to six months of age.
49
Source: DHS Surveys 1995-2000
Figure 21: Feeding Practices for Infants Age 6-9 Months, Rwanda
UNICEF and WHO recommend that solid foods be introduced to infants around the age of six months because
breast milk alone is no longer sufficient to maintain a child’s optimal growth. Thus, all infants over six months of
age should receive solid foods along with breast milk.
• In Rwanda, 79 percent of infants age 6-9 months are fed solid foods in addition to breast milk. This
means that about three-fourths of all infants age 6-9 months are fed according to the recommended
practice.
• Twenty percent of infants age 6-9 months are not fed solid foods in addition to breast milk, putting
these children at risk of malnutrition.
• About 1 percent of infants are fully weaned and not receiving the additional nutritional and emotional
support of breastfeeding.
50
Figure 21
Feeding Practices for Infants Age 6-9 Months,
Rwanda
Breast milk and
solid foods
79%
Recommended
Weaned
1%
Breast milk and
water
0.3%
Breast milk and
liquids
3%
Exclusive
breastfeeding
17%
Note: WHO and UNICEF recommend that by the
age of six months all infants should receive solid
foods and liquids in addition to breast milk.
51
Source: Rwanda DHS 2000
Figure 22: Infants Age 6-9 Months Receiving Solid Foods in
Addition to Breast Milk, Rwanda Compared with Other
Sub-Saharan Countries
In Rwanda,
• Seventy-nine percent of infants age 6-9 months receive solid food in addition to breast milk. This is
in the midrange among all the sub-Saharan countries surveyed.
52
Figure 22
Infants Age 6-9 Months Receiving Solid Foods in
Addition to Breast Milk, Rwanda Compared
with Other Sub-Saharan Countries
Zambia 1996
CAR 1994-1995
Malawi 2000
Togo 1998
Kenya 1998
Zimbabwe 1999
Madagascar 1997
Benin 1996
Mozambique 1997
Rwanda 2000
Cameroon 1998
Niger 1998
Chad 1997
Tanzania 1999
Uganda 1995
Ghana 1998
Burkina Faso 1998-1999
Eritrea 1995
Ethiopia 2000
Mali 1995-1996
Guinea 1999
94
94
93
89
89
87
87
86
84
79
72
71
71
64
64
63
50
45
43
32
27
0
20
40
60
80
100
Percent
Note: WHO and UNICEF recommend that by the age
of six months all infants should receive solid foods
and liquids in addition to breast milk.
53
Source: DHS Surveys 1995-2000
Figure 23: Children 10-23 Months Who Continue to Be Breastfed,
Rwanda Compared with Other Sub-Saharan Countries
For older infants and toddlers, breast milk continues to be an important source of energy, protein, and
micronutrients. Studies have shown that, in some populations, breast milk is the most important source of vitamin
A and fat among children over 12 months of age. Breastfeeding older infants also reduces their risk of infection,
especially diarrhea.
Additionally, breastfeeding up to 24 months can help reduce a woman’s fertility, especially in areas where
contraception is limited. Women who breastfeed for longer periods have lower fertility rates than women who
breastfeed for shorter periods.
In Rwanda,
• Eighty-five percent of children age 10-23 months are still given breast milk. This is in the upper
third of all the sub-Saharan countries surveyed.
54
Figure 23
Children 10-23 Months Who Continue to Be Breastfed,
Rwanda Compared with Other Sub-Saharan Countries
Percent
100
80
70
70
71
76
76
77
78
80
81
82
82
83
84
84
85
87
89
89
90
92
95
64
60
40
20
0
6
5
5
5
6
9
9
8
7
98
7
98
98
96 997 000 996 000 000 999 998 9
99 199 199 199 19 199 199 199 19 94-9 r 19 199 199 951
1
1
9
2
1
2
1
i2
ia
n ros
ia
na 19 ige ue itrea li 19 had nda enin law pia inea ogo 8-19
da we nya car
b
o
n
a
n
o
o
T 99
N biq Er
C wa
a
a
B Ma thio Gu
ab Ke gas nza Zam Gh AR
er
M
1
C
a
m Com Ug imb
m
R
E
a
a
a
T
so
z
Z
C
ad
a
o
F
M
M
na
i
k
r
Bu
Note: Information on feeding practices is based on the 24 hours
before the survey. WHO and UNICEF recommend that all children
should continue to be breastfed up to 24 months of age.
55
Source: DHS Surveys 1995-2000
Underlying Social and
Economic Influences of
Malnutrition
57
Figure 24: Stunting and Wasting among Children under Five Years
by Mother’s Education, Rwanda
Maternal education is related to knowledge of good child care practices and to household wealth. In Rwanda,
35 percent of the mothers of children under five years of age have never attended school, while 55 percent have
some primary education and 10 percent have a secondary or higher education. There are variations in school
attendance, especially between urban and rural areas. In the rural areas, 38 percent of the mothers have never
attended school, 57 percent have attended primary school, and only 6 percent have gone to secondary school or
higher. In contrast, only 10 percent of the mothers in urban areas have never attended school, 50 percent have
attended primary school, and 40 percent have gone to secondary school or higher. Outside of Kigali Ville, mothers
living in Gisenyi, Cyangugu, Ruhengeri, and Kibungo regions had the highest percentage of receiving at least a
secondary school education (17 percent, 12 percent, 12 percent, and 11 percent, respectively). The percentage of
mothers reporting a secondary school education is much lower in the Gikongoro (2 percent) and Kibuye (3 percent)
regions.
• Maternal education has an inverse relationship with stunting in Rwanda. As the level of maternal
education increases, the level of stunting decreases. There is a 6 percentage point difference in
stunting rates between children of mothers with no education and those whose mothers have a primary
education, and there is a 22 percentage point difference between children of mothers with no education
and those whose mothers have a secondary education or higher.
• Maternal education has no statistically significant relationship with wasting in Rwanda.
58
Figure 24
Stunting and Wasting among Children under Five
Years by Mother's Education, Rwanda
Percent
60
Stunting
Wasting
48
50
42
42
40
26
30
(No Statistical Difference)
20
7
10
7
7
5
0
tal
o
T
No
n
tio
a
uc
d
E
y
ar
im
Pr
tal
o
T
ry+
a
d
on
c
Se
Note: Stunting reflects chronic malnutrition;
wasting reflects acute malnutrition
No
59
n
tio
a
uc
d
E
y
ar
im
Pr
ry+
a
d
on
c
Se
Source: Rwanda DHS 2000
Figure 25: Stunting and Wasting among Children under Five Years
by Source of Drinking Water, Rwanda
A household’s source of drinking water is linked with its socioeconomic status. Poor households are more likely to
obtain drinking water from contaminated sources such as surface water or open wells. Without an adequate supply
of good-quality water, the risks of food contamination, diarrheal disease, and malnutrition rise. Infants and
children from households that do not have a private tap are at greater risk of being malnourished than those from
households with this amenity. Among the households surveyed with children under five years, 35 percent use
piped water, 10 percent obtain their drinking water from a well, and 55 percent use surface water.
• In Rwanda, children whose drinking water is well water or surface water are more likely to be
stunted (49 percent and 45 percent, respectively) than children with access to piped water
(37 percent).
• Source of drinking water has no statistically significant relationship with wasting in Rwanda.
60
Figure 25
Stunting and Wasting among Children under Five
Years by Source of Drinking Water, Rwanda
Percent
60
Stunting
Wasting
49
50
45
42
37
40
30
20
(No Statistical Difference)
7
10
6
6
7
0
tal
o
T
r
ate
dW
e
p
Pi
r
ate
W
el
W
tal
o
T
r
ate
eW
c
rfa
u
S
Note: Stunting reflects chronic malnutrition;
wasting reflects acute malnutrition.
61
r
ate
dW
e
p
Pi
r
ate
W
el
W
r
ate
eW
c
rfa
u
S
Source: Rwanda DHS 2000
Figure 26: Stunting and Wasting among Children under Five Years
by Type of Toilet, Rwanda
The type of toilet used by a household reflects its wealth, and poor households are less likely to have adequate
toilet facilities. Inadequate sanitation facilities result in an increased risk of diarrheal disease, which contributes to
malnutrition. Infants and children from households that do not have ready access to a flush toilet are at greater risk
of being malnourished than children from households with this amenity. In Rwanda, 95 percent of households have
access to a pit latrine, 4 percent have no facilities, and 1 percent of surveyed households have access to a flush
toilet.
• Households that do not have any toilet facilities have the highest proportion of stunting in children
under five years of age (54 percent).
• Households with access to flush toilets have the lowest proportion of children stunted (12 percent).
• There is no relationship between type of toilet and wasting.
62
Figure 26
Stunting and Wasting among Children under Five
Years by Type of Toilet, Rwanda
Percent
60
54
Stunting
Wasting
50
42
42
40
30
20
(No Statistical Difference)
12
7
10
9
7
6
0
tal
o
T
t
ile
o
hT
s
Flu
ine
r
t
a
tL
i
P
Note: Stunting reflects chronic malnutrition;
wasting reflects acute malnutrition.
tal
o
T
ne
o
N
63
t
ile
o
hT
s
Flu
ine
r
t
a
tL
i
P
ne
o
N
Source: Rwanda DHS 2000
Basic Influences
65
Figure 27: Stunting and Wasting among Children under Five Years
by Region, Rwanda
In Rwanda,
• Stunting ranges from 23 to 50 percent among children in the 12 regions. Stunting rates were much
lower in Kigali Ville than elsewhere in the country.
• Wasting ranges from 4 to 9 percent among regions. Kibungo shows the highest level of wasting.
66
Figure 27
Stunting and Wasting among Children under
Five Years by Region, Rwanda
Percent
60
Stunting
Wasting
50
47
50
48
48
44
43
42
39
40
42
42
40
40
30
23
20
7
10
7
4
5
5
7
7
8
8
8
8
5
0
ri u ra yi
a o a re ye ro
tal
To K) nge gug uta isen urale ram ung umb uta ibu ngo
B K o
b
V e
a
k
(P h an Um G ali R Git Ki By
Gi
li e Ru Cy
g
i
V
K
li
ga
i
K
Note: Stunting reflects chronic malnutrition;
wasting reflects acute malnutrition.
i a u
ri re ye o
a
tal ro
ra y
To ngo urale ram K) uta isen umb gug nge uta ibu ung
V
e B K Kib
ko i R Gita (P Um G By yan uh
Gi igal
C R
li e
K
li V
ga
i
K
67
Source: Rwanda DHS 2000
9
Figure 28: Stunting and Wasting among Children under Five Years
by Urban-Rural Residence, Rwanda
In Rwanda,
• Forty-five percent of rural children are stunted. In the capital city of Kigali, 23 percent of children are
affected by chronic malnutrition. In other urban areas (small cities or towns), the rate of stunting is
29 percent.
• There is no statistical difference in the rates of wasting between children living in rural areas and those
living in urban areas.
68
Figure 28
Stunting and Wasting among Children under Five
Years by Urban-Rural Residence, Rwanda
Percent
50
45
43
Stunting
Wasting
40
29
30
23
20
(No Statistical Difference)
7
10
7
5
7
0
tal
o
T
K)
wn
V
o
T
(P
or
lle
i
y
it
li V
C
a
l
g
a
Ki
m
S
Note: Stunting reflects chronic malnutrition;
wasting reflects acute malnutrition.
l
ra
u
R
tal
o
T
K)
wn
V
o
T
(P
or
lle
i
y
it
li V
C
a
l
g
a
Ki
m
S
69
l
ra
u
R
Source: Rwanda DHS 2000
Maternal Nutritional Status
71
Figure 29: Malnutrition among Mothers of Children under Five
Years by Region, Rwanda
Besides being of concern in its own right, a mother’s nutritional status affects her ability to successfully carry,
deliver, and care for her children. There are generally accepted standards for indicators of malnutrition among
adult women that can be applied.
Malnutrition in women can be assessed using the body mass index (BMI), which is defined as a woman’s weight in
kilograms divided by the square of her height in meters. Thus, BMI = kg/m2. When the BMI is below the
suggested cutoff point of 18.5, this indicates chronic energy deficiency or undernutrition for non-pregnant, nonlactating women. When the BMI is above 25, women are considered overweight.
• Six percent of all mothers of children under age five in Rwanda are undernourished.
• The highest levels of maternal undernutrition are in the Umutara, Gitarama, and Butare regions
(15, 11, and 10 percent of mothers of children under five, respectively). The lowest levels of
maternal undernutrition are in the Ruhengeri and Byumba regions (2 percent) and the Gisenyi
Region (3 percent).
• Thirteen percent of all mothers of children under five are overweight.
• The highest levels of overnutrition are in Kigali Ville (28 percent) and in Gisenyi (21 percent). The
lowest levels of maternal overnutrition are in Gikongoro and Butare (8 percent) and
Gitarama (9 percent).
72
Figure 29
Malnutrition among Mothers of Children under Five
Years by Region, Rwanda
Percent
40
Overnutrition
(overweight)
Undernutrition
(chronic energy deficiency)
28
30
21
20
16
15
10
6
2 2 3 3
5 6 6
8 8
13
10 11
14
14
13
8
10 11
10
8 9
0
tal
o
T
tal
o
T
i
i
er mba eny buye K) oro ugu ale ngo tare ma tara
g
en Byu Gis Ki (PV ong ang Rur Kibu Bu itara mu
h
ik y li
G U
Ru
ille G C iga
V
K
li
gi a
K
Note: Maternal undernutrition is the percentage
of mothers whose BMI (kg/m2) is less than 18.5.
Maternal overnutrition is the percentage of
mothers whose BMI is greater than 25.
i
i
er mba eny buye K) oro ugu ale ngo tare ma tara
g
en Byu Gis Ki (PV ong ang Rur Kibu Bu itara mu
h
ik y li
G U
Ru
ille G C iga
V
K
li
gi a
K
73
Source: Rwanda DHS 2000
Figure 30: Malnutrition among Mothers of Children under Five
Years by Residence, Rwanda
In Rwanda,
• The undernutrition rate (chronic energy deficiency) for mothers of children under five is lowest in
small cities and towns (4 percent) and is highest in rural areas (6 percent).
• The overnutrition rate (overweight) for mothers of children 0-59 months is lowest (11 percent) in
rural areas and largest in small cities and towns (30 percent).
74
Figure 30
Malnutrition among Mothers of Children under Five
Years, by Residence, Rwanda
Percent
Overnutrition
(overweight)
Undernutrition
(chronic energy
deficiency)
40
30
30
28
20
13
11
10
6
5
6
4
0
tal
o
T
ille
V
i
l
ga
i
K
K)
V
(P
ity n
C
al ow
m
S or T
l
ra
u
R
Note: Maternal undernutrition is the percentage
of mothers whose BMI (kg/m2) is less than 18.5.
Maternal overnutrition is the percentage of
mothers whose BMI is greater than 25.
tal
o
T
ille
V
i
l
ga
i
K
75
K)
V
(P
ity n
C
al ow
m
S or T
l
ra
u
R
Source: Rwanda DHS 2000
Figure 31: Malnutrition among Mothers of Children under Five
Years by Education, Rwanda
In Rwanda,
• There is no direct relationship between mother’s education and maternal undernutrition.
• The rate of maternal overnutrition is highest among women with at least a secondary school
education (30 percent).
76
Figure 31
Malnutrition among Mothers of Children under Five
Years, by Education, Rwanda
Percent
Overnutrition
(overweight)
Undernutrition
(chronic energy
deficiency)
40
30
30
20
(No statistical difference)
10
6
6
6
13
11
12
6
0
tal
o
T
n
tio
a
uc
d
E
No
y
ar
im
Pr
tal
o
T
ry+
a
nd
o
c
Se
Note: Maternal undernutrition is the percentage
of mothers whose BMI (kg/m2) is less than 18.5.
Maternal overnutrition is the percentage of
mothers whose BMI is greater than 25.
No
77
n
tio
a
uc
d
E
y
ar
im
Pr
ry+
a
nd
o
c
Se
Source: Rwanda DHS 2000
Figure 32: Malnutrition among Mothers of Children under Three
Years, Rwanda Compared with Other Sub-Saharan Countries
Malnutrition among mothers is likely to have a major impact on their ability to care for themselves and their
children. Women less than 145 centimeters in height are considered too short. Mothers who are too short (a
condition largely due to stunting during childhood and adolescence) may have difficulty during childbirth because
of the small size of their pelvis. Evidence also suggests there is an association between maternal height and low
birth weight. Underweight status in women assessed using the body mass index is also presented.
In Rwanda,
• Slightly more than 1 percent of mothers of children under three are too short (< 145 cm). This is in
the midrange among all sub-Saharan countries surveyed.
• Approximately 6 percent of mothers of children under three are undernourished (BMI < 18.5).
This is the second lowest rate among the sub-Saharan countries surveyed.
78
Figure 32
Malnutrition among Mothers of Children under Three Years,
Rwanda Compared with Other Sub-Saharan Countries
Percent
Percent
10
50
8.3
8
40.6
Short
Undernourished
40
6
30
24.9
4.8
20.1 20.6 20.7
3.8
4
20
15 15.3
2.5
2.3 2.4
2.7
12.3 12.3
2
2
9
1.6 1.6
1
1
1.2 1.2 1.2 1.3 1.3
4.9
5.6 5.9
9.2
16.4
13.1
10.9 10.9 10.9
9.9 10.3
10
6.6
0.7
0.4 0.4
0.2 0.3
0
0
8
96 5 6 7 7 98 00 95
6 98 98 98 98 96 99 00 8 96 99 95 00 95 5 00 96 6 7 7
7
99 00 8 00 96 96 95 6 99 7 98 98 99
99 999 -199 r 19 a 19 o19 a 19 a 19 a 19 a 20 199 in 19 19 a 19 20 19 -199 i 20 19 199 199 199
19 a 20 199 i 20 19 ia 19 a 19 s199 a 19 199 o19 a 19 a 1 999 in 19 -199 -199 -199 r 199 er 19 a 20 a 19
1
a
a
s
r
e
i
e
e
a
a
i
w
w
y
y
w nd on la ni b nd ro ne e og an n -1 en 94 95 96 a ig pi re
96 8-1 95 ig an og n b ine nd on en w nd p tre 94 la ni ro ue ca
ab wa ero Ma nza Zam Uga omo Gui biqu T Gh Ke 1998 B 19 li 19 19 gasc N thio Erit
19 199 li 19 N Gh T Ke Zam Gu Rwa ero B bab Uga Ethio Eri R 19 Ma nza omo biq gas
b
R a d a
R am
E
m
m
C
Ta C zam ada
Ta
ad o Ma
so
Zim
Zim
za
Ca
CA
C
CA M Cha ad
Ch Fas
M
Fa
Mo M
Mo
a
a
n
n
rki
rki
Bu
Bu
Note: Short is the percentage of mothers under 145 cm;
undernourished is the percentage of mothers whose BMI (kg/m 2)
is less than 18.5. Pregnant women and those who are less than
79
two months postpartum are excluded from BMI calculation.
Source: DHS Surveys 1995-2000
Appendices
81
Appendix 1
Stunting, Wasting, and Underweight Rates by Background Characteristics
Rwanda 2000
Background
characteristic
Stunted
Wasted
Underweight
Child’s age
in months
0-5
6-9
10-11
12-15
16-19
20-23
24-35
36-47
48-59
n=6,231
Background
characteristic
Stunted
Wasted
Underweight
48.2
47.1
39.9
49.7
42.0
42.4
44.3
48.0
22.8
42.2
38.8
39.8
p<0.001
7.9
7.0
7.7
4.0
7.1
5.3
8.9
8.2
5.2
5.0
7.8
6.7
p<0.05
31.5
26.0
25.5
30.3
18.5
25.2
27.7
26.0
13.7
23.8
22.2
22.1
p<0.001
Regions
9.5
20.0
35.7
44.9
54.4
56.4
45.4
49.2
54.3
p<0.001
4.9
7.4
11.3
15.5
10.1
7.6
7.5
4.1
4.0
p<0.001
3.0
18.2
38.8
37.5
32.2
35.0
27.3
25.1
21.7
p<0.001
Butare
Byumba
Cyangugu
Gikongoro
Gisenyi
Gitarama
Kibungo
Kibuye
Kigali Ville (PVK)
Kigali Rurale
Ruhengeri
Umutara
n=6,231
Urban-rural
residence
Gender of child
Male
Female
n=6,231
43.9
41.2
p<0.05
7.0
6.5
NS
25.1
23.4
NS
Urban
Rural
n=6,231
27.4
45.3
p<0.001
6.4
6.8
NS
15.2
25.9
p<0.001
Overall
42.6
6.8
24.3
Overall
42.6
6.8
24.3
Note: Level of significance is determined using the chi-square test.
NS=Not significant at p≤0.05
83
Appendix 2
WHO/CDC/NCHS International Reference Population Compared
with the Distribution of Malnutrition in Rwanda
The assessment of nutritional status is based on the concept that in a well-nourished population, the distributions of
children’s height and weight, at a given age, will approximate a normal distribution. This means that about 68 percent
of children will have a weight within one standard deviation of the mean for children of that age or height and a height
within one standard deviation of the mean for children of that age. About 14 percent of children will be between one
and two standard deviations above the mean; these children are considered relatively tall or overweight for their age or
relatively overweight for their height. Another 14 percent will be between one and two standard deviations below the
mean; these children are considered relatively short or underweight for their age or relatively thin for their height. Of
the remainder, 2 percent will be very tall or obese for their age or obese for their height; that is, they are more than two
standard deviations above the mean. Another 2 percent will fall more than two standard deviations below the mean and
be considered moderately or severely malnourished. These children are very short (stunted), very underweight for their
age, or very thin for their height (wasted). For comparative purposes, nutritional status has been determined using the
International Reference Population defined by the United States National Center for Health Statistics (NCHS standard)
as recommended by the World Health Organization and the Centers for Disease Control and Prevention.
Appendix 2 includes four curves: weight-for-age, height-for-age, and weight-for-height graphed against the normal
curve. The weight-for-height curve is closest to the normal curve. Therefore, the proportion of malnourished children
according to this index is closer to what would be seen in the reference population. Height-for-age and weight-for-age,
however, are greatly to the left of the standard curve indicating that there is a large number of malnourished children.
The implications are that interventions are necessary to address widespread malnutrition in order to improve child
health, which will result in a shift in the curves closer to the reference standard.
84
Appendix 2
WHO/CDC/NCHS International Reference Population
Compared with the Distribution of Malnutrition in Rwanda
Height-for-age
# Weight-for-height
) Weight-for-age
Normal curve
##
) ))
)
##
#
)
#
)
)
# ))
#
Malnourished
Malnourished
#
(Overweight)
(Stunted, wasted or
#
)
)
underweight)
#
)
#
#
)
)
)
#
#
)
)
#
)
#
) ))##
) ###
)
###
#
)# #
)
)
)
)
)))#
)#
)#
)###
)#
) #) #) #) #) #) #) #
#) #) #) #) #
)#
)#
)
-6
-5
-4
-3
-2
-1
0
1
2
Standard Deviations from Mean (Z-score)
85
3
4
5
6