Determinants of stunting and poor linear growth in children under 2 years of age in India: an in‐depth analysis of Maharashtra's comprehensive nutrition survey

Abstract We use a representative sample of 2561 children 0–23 months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one‐third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5‐fold higher odds of being stunted [odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96–3.27]; children 6–23 months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24–2.14); and lower consumption of eggs was associated with a two‐fold increased odds of stunting in children 6–23 months old (OR 2.07; 95% CI 1.19–3.61); children whose mother's height was < 145 cm, had two‐fold higher odds of being stunted (OR 2.04; 95% CI 1.46–2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17–3.02). Attained linear growth (height‐for‐age z‐score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was < 145 cm, children born with a low birthweight and children 6–23 months old who were not fed dairy products, fruits and vegetables. In Maharashtra children's birthweight and feeding practices, women's nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2 years. Key messages One in five (22.7%) of children 0–23 months old in the state of Maharashtra were stunted, and one‐third (7.4%) of the stunted children were severely stunted. Birthweight, child feeding, women's nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2 years. Children born to mothers whose height was below 145 cm, had two‐fold higher odds of being stunted; children born with a low birthweight had a 2.5‐fold higher odds of being stunted. Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6–23 months old. Children of households without access to improved sanitation had 88% higher odds of being severely stunted.


Introduction
Global figures indicate that 25% of children under age 5 years (i.e. 159 million) have stunted growth (United Nations Children's Fund, UNICEF, World Health Organization, WHO, World Bank Group, WBG 2015). It is estimated that stuntinga height-for-age below minus two z-scores of the median height-for-age in the World Health Organization Child Growth Standardsis the cause of about one million child deaths annually (Black et al. 2013). For the children who survive, stunting causes lasting damage, including poor cognition and educational performance in childhood, reduced productivity and lower earnings in adulthood and, when accompanied by excessive weight gain in later childhood, increased risk of chronic diseases (Victora et al. 2008;Dewey & Begum 2011;Black et al. 2013).
India's latest National Family Health Survey in 2006 showed that 48% of Indian children 0-59 months old were stunted (International Institute of Population Sciences (IIPS) 2007). Thus, it is estimated that at any one point an average, 61 million Indian children are stunted and therefore unable to survive, grow and develop to their full potential, which is the same potential as that of children in developed countries (Bhandari et al. 2010;World Health Organization (WHO) 2006). Recent reports indicate that the current (2014) prevalence of child stunting in India would be 38.8% (Ministry of Women and Child Development, MWCD, Government of India 2015). This means that between 2006 and 2014, the prevalence of child stunting in India declined at an average 2.4% rate annually, well above the rate of 1.7% estimated on the basis of previous surveys (International Food Policy Research Institute, IFPRI 2014). However, India remains in the category of countries with a high prevalence of stunting (30.0-39.9%) (Onis de et al. 2012).
In Maharashtra -India's second most populous state with a population over 112 million people (Office of the Registar General and Census Commissioner of India. Ministry of Home Affairs, Government of India 2011)the poor nutrition situation of children was confirmed by India's National Family Health Survey, which indicated that 38.8% of Maharashtra's children 0-23 months old were stunted and over one-third of the stunted children (14.7%) were severely stunted (IIPS 2007). In response to this situation, the Government of Maharashtra created the State Nutrition Mission under the chairmanship of the State Chief Minister. The Mission was mandated to coordinate inter-sectoral efforts to reduce child undernutrition, initially (2005) in the five districts with the highest levels of child undernutrition and eventually (2009 onwards) across Maharashtra's 35 districts.
In 2012, the Government of Maharashtra commissioned an independent survey to assess progress and identify priority areas for action. The Comprehensive Nutrition Survey in Maharashtra (CNSM) showed that the prevalence of stunting in children under 2 years had declined from 38.6% in 2006 to 23.3% in 2012 (International Institute for Population Studies, IIPS 2012).
Thus, a 15.3% point decline over a 6-year period, with an average annual rate of reduction (AARR) of 2.6, significantly higher than the AARR of~0.5 reported until 2005 (United Nations Children's Fund, UNICEF 2013). Findings from a multidisciplinary analysis on the drivers of the decline of stunting in Maharashtra have indicated that the vision and skills of the Nutrition Mission's leadership and staff allowed much to be accomplished, from maintaining political impetus and focus to motivating frontline workers to deliver better quality services at greater scale (Haddad et al. 2014).
However, despite such significant progress, Maharashtra's 2012 survey indicated that almost onefourth (23.3%) of children 0-23 months old were stunted and that one-third of the stunted children (7.8%) were severely stunted. Therefore, the goal of this research is to support the State Nutrition Mission to identify future policy, programme and investment priorities on maternal and child nutrition in Maharashtra through an in-depth understanding of the most important determinants of child stunting and poor linear growth. Specifically, the objective of our analysis is four-fold: (1) to characterize the epidemiology of stunting in children 0-23 months old in Maharashtra; (2) to identify the most significant predictors of stunting in children 0-23 months old; (3) to identify the most significant correlates of linear growth (height-for-age) in children 0-23 months old; and (4) to identify policy, programme and investment priorities in the context of Maharashtra's Nutrition Mission Phase III post-2015.

Key messages
• One in five (22.7%) of children 0-23 months old in the state of Maharashtra were stunted, and one-third (7.4%) of the stunted children were severely stunted.
• Birthweight, child feeding, women's nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2 years.
• Children born to mothers whose height was below 145 cm, had two-fold higher odds of being stunted; children born with a low birthweight had a 2.5-fold higher odds of being stunted.
• Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6-23 months old.
• Children of households without access to improved sanitation had 88% higher odds of being severely stunted.

Methods
We use data from the CNSM, the independent nutrition household survey conducted in 2012 at the request of the Government of Maharashtra. CNSM was designed and supervised by the International Institute for Population Studies (IIPS), the lead research agency for India's three national Family Health Surveysthe customized version of the Demographic and Health Survey to suit the data and information needs of India in 1992India in , 1999India in and 2006 The representative sample of Maharashtra's Comprehensive Nutrition Survey was designed to provide estimates of a series of key indicators on the nutrition situation of children under 2 years (0-23 months old) and their mothers in urban areas, rural areas and each of the six administrative divisions of the state: Amaravati, Aurangabad, Konkan, Nagpur, Nashik and Pune. The survey used three questionnaires: • The household questionnaire: used to collect information on all de jure (usual residents) household members, the household and the dwelling. For each person listed, information was collected on age, sex, literacy, caste/tribe and household food security and assets among other variables.
• The mother's questionnaire: administered to all women who had at least one living child in the age group 0-23 months at the time of the survey. It collected information on mother's age, marital status, age at marriage, educational attainment, exposure to mass media, decision-making power and access to essential services among other variables.
• The child's questionnaire: administered to the mother or principal caretaker of children 0-23 months old. It was used to collect information on birth date, birthweight and feeding practices, including breastfeeding and complementary feeding practices in the 24 h preceding the survey, to assess internationally agreed Infant and Young Child Feeding (IYCF) indicators (World Health Organization, WHO, United Nations Children's Fund, UNICEF 2008).
The nutritional status of children and their mothers was assessed by measuring their height and weight following internationally agreed upon anthropometry measurement procedures (World Health Organization, WHO 1995). A detailed description of the survey design and sample selection can be found elsewhere (IIPS 2012). In brief, a 30% prevalence of stunting in children 0-23 months old and a 10% non-response rate for anthropometry were assumed to estimate the size of the sample. The selection of the sample used a multi-stage stratified procedure. The rural sample was selected in two stages. In the first stage, villages were randomly selected with probability proportional to population size as Primary Sampling Units (PSU). In the second stage, households with at least one child 0-23 months old were randomly selected within each of the selected PSUs. In urban areas, a three-stage sampling procedure was used. In the first stage, wards were randomly selected with probability proportional to population size. In the second stage, Census Enumeration Blocks (CEB) were randomly selected with probability proportional to size. Lastly, in the third stage, a household listing was carried out in each of the selected CEB, and households with at least one child 0-23 months old were randomly selected. The survey received ethical clearance from IIPS' Research Ethics Board. Data collection was carried out during February-April 2012. Caregivers were asked for individual consent to participate in the survey.
A total of 2630 households were included in the survey. For our analysis, data from the child data set, which contains one record for every eligible child born in the 2 years prior to the survey, were used. Children with missing age and/or height were not included in the analytical sample. Stunting and severe stunting were defined as a height-for-age below À2 (moderate and severe stunting) or below À3 (severe stunting) z-scores of the median height-for-age of the World Health Organization Child Growth Standards (World Health Organization, WHO, 2006). Children with implausible height-for-age z-score (HAZ < À6 or HAZ > +6) were excluded from the analysis. In our analysis, we are interested in three outcome variables and the exposure variables that are significantly associated with them: stunting (HAZ < À2) as the indicator of choice both for surveys and global targets on child nutrition; severe stunting (HAZ < À3) to document the severity of child stunting in the population; and attained linear growth, measured as children's HAZ.
Analyses were performed using Stata Statistical software (College Station, TX, USA), release 12, 2011. We used sample weights to adjust standard errors for the complex survey design of CNSM. In models using stunting or severe stunting as the dependent variables, we report on odds ratios and 95% confidence intervals from logistic regression models. In models that regress the outcome variable (attained linear growth in HAZ) on exposure variables, we report on regression coefficients and 95% confidence intervals around point estimates from multiple linear regression. For all tests, p-values < 0.05 were considered statistically significant.

Findings
The survey included a representative sample of 2650 children 0-23 months old. The analysis presented here pertains to 2561 children (96.6%) for whom information on age and anthropometryand therefore on HAZ, stunting and severe stuntingwas available. Children that were stunted were 22.7%, and about one-third (32.7%) of the stunted children were severely stunted (Table 1). Table 2 summarizes the socio-economic characteristics of the children included in the analysis. Households: 91.7% had access to piped water, 57.0% were food secure, 45.0% were located in rural areas, 40% were from Scheduled Castes/Scheduled Tribes and 37.9% used improved sanitation facilities. Children: a significantly higher proportion (55.2%) were boys. Most children (91.9%) were weighed at birth, and about one in five (19.4%) of them had a low birthweight (<2500 g). Mothers: 17.5% had no/less than primary education, almost one in three (29.9%) was married before reaching age 18 years and over one-third (37%) was not involved in making decisionsjointly or aloneabout buying usual food items. Most women (90%) received nutrition counselling at antenatal care during their last pregnancy; however, a significant proportion ate less than normal (30%), and/or did not eat foods of animal origin (40.5%), eggs (48.8%) or milk/dairy products (55.4%). Regarding mothers' anthropometry, 10.5% of mothers were stunted (height < 145 cm) and 32.2% were too thin (BMI < 18.5 kg/m 2 ).
Table 3 summarizes infant and young child feeding practices. Breastfeeding was universal as 99.4% of children were breastfed; however, less than 60% were put to the breast within 1 hour of birth (59.4%) or were exclusively breastfed (59.8%) if they were under 6 months old. Almost all children (91.1%) continued to breastfeed at 1 year, and three in four (74.9%) continued to breastfeed at 2 years. Complementary feeding practices in children 6-23 months old were poor. Only 58.6% of children 6-8 months old were fed complementary foods (solid, semi-solid or soft foods) as recommended. Furthermore, while 77.0% of children 6-23 months old were fed complementary foods a minimum number of times per day (meal frequency), only 12.1% were fed iron-rich foods (diet quality), and a mere 6% were fed a minimum number of food groups daily (diet diversity).

Predictors of child stunting: bivariate and multivariate regression analysis
The prevalence of stunting was significantly higher in boys (25.4% vs. 19.3% in girls) and children 12-23 months old (34.8% vs. 11.7% in children 0-11 months old). Geographically, the prevalence of stunting was lowest in Pune (18%) and highest in Nashik (31%). Bivariate analysis indicates that the variables that were significantly associated with stunting were as follows: (1) child-level variables: male sex, not weighed at birth, birthweight <2500 g, incomplete vaccination, unsafe disposal of child's stools, untimely introduction of complementary foods and feeding frequency (Table 4); (2) mother-level variables: age, age at marriage <18 years, low education, no access to print/electronic media, tobacco consumption, age at first birth <18 years, antenatal iron and folic acid (IFA) supplements <90, home delivery, no consumption of milk and/or milk products weekly during pregnancy, height <145 cm and BMI <18.5 kg/m 2 (Table 5); household-level variables: rural residence, region of residence, caste/tribe, wealth, use of unimproved sanitation, food insecurity and access to Integrated Child Development Services (Table 6). The exposure variables that were significantly associated with the outcome variables (stunting, severe stunting and HAZ) in bivariate analysis (Tables 4-6) were included in multivariate linear and logistic regression analysis (Tables 7-8).   Breastfeeding practices Children ever breastfed: proportion (%) of children born in the last 24 months who were ever breastfed 99.4 Early initiation of breastfeeding: proportion (%) of children 0-23 months who were put to the breast within 1 h of birth 59.4 Prelacteal feeding: proportion (%) of children 0-23 months old who received prelacteal feeds 3.7 Exclusive breastfeeding under 6 months: proportion of infants 0-5 months of age who are fed exclusively with breast milk 59.8 Predominant breastfeeding under 6 months: proportion (%) of infants 0-5 months of age who are predominantly breastfed 92.2 Continued breastfeeding at 1 year: proportion (%) of children 12-15 months of age who are fed breast milk 91.1 Continued breastfeeding at 2 years: proportion of children 20-23 months of age who are fed breast milk 74.9 Complementary feeding practices Introduction of solid, semi-solid or soft foods: proportion (%) of infants 6-8 months of age who receive solid, semi-solid or soft foods 58.6 Minimum meal frequency: proportion (%) of children 6-23 months who receive solid/semi-solid/soft foods a minimum number of times/day 77.0 Minimum dietary diversity: proportion of children 6-23 months of age who receive foods from four or more food groups 6.0 Consumption of iron-rich or iron-fortified foods: proportion of children 6-23 months who are fed iron-rich foods † 12.1 *For full definitions of the indicators for assessing infant and young child feeding practices, refer to the following: World Health Organization (WHO), United Nations Children's Fund (UNICEF). (2008) Indicators for assessing infant and young child feeding practices. WHO. Geneva, Switzerland. † Or an iron-fortified food that is specially designed for infants and young children, or that is fortified in the home.
Multivariate regression analysisafter controlling for potential confoundingindicates that the most significant household-level predictors of stunting were household wealth and access to sanitation. The odds of stunting in children from the four lower wealth quintiles were 70-90% higher than in children from the highest wealth quintile. Children from households without access to improved sanitation facilities had 32% higher odds of being stunted [odds ratio (OR) 1.32; 95% confidence interval (CI) 1.02-1.75] and 88% percent higher odds of being severely stunted (OR 1.88; 95% CI 1.17-3.02) ( Table 7). The most significant mother-level predictors of stunting were maternal height, maternal diet, decisionmaking power about food, access to electronic media and age at marriage. Children of mothers with a height <145 cm had two-fold higher odds of being stunted (OR 2.04; 95% CI 1.46-2.81) and a 2.6-fold higher odds of being severely stunted (OR 2.62; 95% CI 1.67-4.13). The odds of severe stunting were 60% higher in CFoods, complementary foods.
children of mothers who did not consume milk/dairy products at least once weekly during pregnancy (OR 1.60; 95% CI 1.08-2.32). Similarly, the odds of severe stunting were twice higher in children of mothers without decision-making power about food (OR 1.98; 95% CI 1.31-2.99), while mothers' lack of access to electronic media increased the odds of stunting in children by 34%. Lastly, children 6-23 months old born to mothers who married before age 18 years had a 70% higher odds of being severely stunted (OR 1.70; 95% CI 1.07-2.70) ( Table 7). The most significant child-level predictors of stunting were birthweight and feeding practices. Children born with a low birthweight had an~2.5 higher odds of being stunted (OR 2.49; 95% CI 1.96-3.27) or severely stunted (OR 2.37; 95% CI 1.62-3.46). Feeding frequency and diet diversity were significantly associated with stunting in children 6-23 months old. The odds of stunting or severe stunting were >60% higher in children 6-23 months old who were not fed a minimum number of times per day (OR 1.63; 95% CI 1.24-2.14; and OR 1.65; 95% CI 2.01-2.99, respectively); lower HAZ, height-for-age z-score; IFA, iron and folic acid. consumption of grains, roots and tubers was associated with a 34% increased odds of stunting (OR 1.34; 95% CI 1.01-1.78), while low consumption of eggs was associated with a two-fold increase in the odds of stunting in children (OR 2.07; 95% CI 1.19-3.61, respectively) ( Table 7). The models regressing the continuous outcome variable HAZ on the exposure variables indicate that the likelihood of poor linear growth in children was significantly higher among children from households without access to improved water or sanitation and children of mothers who did not have access to electronic media, did not have decision-making power regarding food, consumed tobacco and/or whose height was less than <145 cm. Four child-level variables were significantly associated with poor linear growth in children: low birthweight, being a boy, being 12-23 months old andamong children 6-23 months oldnot being fed dairy products, fruits and vegetables (P < 0.05) ( Table 8).

Discussion
Between 2006 and 2012, the prevalence of stunting in children 0-23 months old in Maharashtra declined from 38.6% (IIPS 2007) to 23.3% (IIPS 2012), with an AARR of 2.5% points. Despite this significant decline, one of the fastest documented (Haddad et al. 2014), one in four children under age 2 years in Maharashtra has stunted growth. We used data from the 2012 Comprehensive Nutrition Survey to characterize the epidemiology of child stunting in Maharashtra, identify the most significant predictors of stunting and poor linear growth in infants and young children 0-23 months old andon the basis of these findingsidentify advocacy, policy, programme and research priorities post-2015.
We find that 22.7% of the children were stunted and one-third of the stunted children (7.4%) were severely stunted. The mean HAZ deteriorated significantly with children's agefrom À0.25 in infants 0-5 months old to À1.74 in children 18-23 months oldreflecting the chronic/cumulative nature of nutrition deprivation in infancy and early childhood. Similarly, the prevalence of stunting was four-fold higher among children 18-23 months old than among children 0-5 months old (40.5% vs. 9.2%, respectively). Studies in nine countries in Africa, Asia and the Caribbean have reported similar findings, indicating that poor linear growth and stunting set very early in children's life (Jones et al. 2014).
We find significant gender differentials in linear growth and stunting. Poor linear growth was significantly higher among boys than among girls (mean HAZ in boys À1.06 vs. À0.88 in girls; P = 0.001) and so was the prevalence of stunting (25.4% in boys vs. 19.3% in girls; P = 0.001). Multivariate regression analysis indicates that the odds of stunting were 38% higher in boys than in girls. Studies in Bangladesh, Bhutan, Ghana and Indonesia among others have also documented a 10% to 30% higher prevalence of stunting in boys than in girls (Hong 2007;Semba et al. 2008;. Poor linear growth and stunting were significantly less prevalent among children living in urban areas (20.1% vs. 24.7% in rural areas; P < 0.005) and children from the richest wealth quintile (12.8% vs. ≥22.9% in HAZ, height-for-age z-score; ICDS, Integrated Child Development Services. Age (     the other wealth quintiles). However, multivariate adjusted models, after controlling for potential confounding, indicate that the odds of being stunted were not significantly different between children living in rural or urban areas. On the contrary, the stunting differential associated with household wealth remained statistically significant in multivariate regression models as the odds of being stunted were~70% lower in children from the richest wealth quintile compared with children from the other wealth quintiles (P < 0.01). Studies in Asia and Africa have shown thatlike in Maharashtrachildren from the poorer households had significantly higher odds of stunted growth, even after adjustment for other household, maternal and child variables (Hong et al. 2006;Hong 2007;. Our analysis indicates that in Maharashtra, the most consistent predictors of stunting and poor linear growth in children under 2 years were birthweight and child feeding (child-level variables), women's nutrition and status (mother-level variables) and household sanitation and poverty (household-level variables).
Children born with low birthweight had a 2.5-fold higher odds of being stunted and a 2.4-fold higher odds of being severely stunted. Low maternal height predicted stunting in children under 2 years even after controlling for birthweight, as children of mothers with a height <145 cm had two-fold higher odds of being stunted than children of mothers with a height ≥145 cm. In addition, children born to women who married before the age of 18 years had significantly higher odds of being severely stunted.
Studies have shown that maternal height is an important determinant of intrauterine growth restriction and low birthweight, particularly in developing countries. In turn, intrauterine growth restriction and low birthweight are predictors of growth failure and stunting in early childhood. Analysis of data from 54 low-income and middle-income countries has shown that maternal height was inversely associated with stunting in infancy and childhood (Özaltin et al. 2010). It is estimated that intrauterine growth restriction due to maternal undernutrition (estimated by rates of low birthweight) accounts for 20% of the global burden of child stunting (Black et al. 2013). Similarly, adolescent pregnancy has been shown to be associated with low weight at birth and stunting in early childhood in the offspring. Longitudinal data from five countries show that younger maternal age (≤19 years) was associated with a significantly higher risk of low birthweight (OR 1.18; 95% CI 1.02-1.36) and 2-year stunting (OR 1.46; 95% CI 1.25-1.70) in the offspring, compared with mothers aged 20-24 years (Fall et al. 2015). In our analysis, mothers' access to improved dietsas marked by the consumption of milk and dairy products during pregnancywas associated with significantly lower odds of severe stunting in children under 2 years. Similarly, low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables in children 6-23 months old were associated with poor linear growth and stunting. Studies have indicated that complementary feeding indicators are positively associated with HAZ and a reduced risk of stunting. For example, diet diversity in children 6-23 months old was positively associated with HAZ in Bangladesh and India and with lower odds of stunting in India (Zongrone et al. 2012;Menon et al. 2015). A recent study including pooled data from 14 low-income countries found that all of the WHO indicators on complementary feeding (except the indicator defining minimum meal frequency) were associated with a significantly lower probability of stunting in children (Marriott et al. 2012). Global evidence suggests that greater dietary diversity and the consumption of foods from animal sources are associated with improved linear growth (Ruel & Menon 2002;Arimond & Ruel 2004;Steyn et al. 2006;Onyango et al. 2013).
In our analysis, household access to improved sanitation was associated with healthier linear growth in children. Conversely, children of households without access to improved sanitation had 88% higher odds of being severely stunted. Recent analyses in rural India have indicated that improved sanitation is significantly associated with reduced prevalence of stunting (Rah et al. 2015). Globally, it is recommended that community-based interventions to improve water, sanitation and hygiene, and to protect children from diarrhoeal diseases and malaria, intestinal worms and environmental causes of subclinical infection be an integral part of a comprehensive framework for action to improve children's linear growth and reduce stunting (World Health Organization, WHO 2015).

Conclusion
Despite significant progress in reducing child undernutrition over the last years, a significant proportion of infants and young children in Maharashtra fail to achieve their growth and development potential as indicated by the high levels of stunting and severe stunting in children 0-23 months old. Our analysis of the epidemiologyprevalence, severity, distribution and driversof child stunting in Maharashtra provides political leaders, policy makers and programme managers with important insights for the effective allocation of human and financial resources to improve children's linear growth and reduce further the prevalence of stunting in Maharashtra and, potentially, the rest of India.
Specifically, our analysis indicates that in its Phase III post-2015, the State Nutrition Mission in Maharashtra needs to prioritize policies, programmes and investments to achieve results in three key areas: (1) improve women's nutrition and reduce low birthweight; (2) improve complementary foods and feeding practices for children 6-23 months old; and (3) improve access to and use of sanitation facilities while mitigating household poverty through effective social safety nets coupled with effective communication and counselling.
Evidence indicates thatgiven the contribution of Maharashtra and the rest of India to the global burden of child stuntingaggressive and sustained policy and programme investments in these three results areas will contribute significantly to the achievement of the global target to reduce the number of stunted under 5 years of age by 40% by 2025 (World Health Organization, WHO 2015). Recent analyses indicate that the scale-up of high-impact interventions focused on the 1000-day windowfrom conception to age 2 yearscan be delivered at an additional cost of $US8.50 per child per year to meet the global target for the reduction of child stunting (World Bank Group 2015).