Children's Nutritional Status
Crude Mortality Rates
Given the non-emergency context, statistics in Cambodia do not provide the Crude Mortality Rate (CMR) in number of deaths per ten thousand per day. The General Population Census of Cambodia, however, presents projected mortality figures per thousand per year for 2001-2006. These figures were transformed to the equivalent of ten thousand per day.
With the exception of Rotanak Kiri (0.62/10,000/day), all the provinces have figures between 0.14 and 0.43, falling below the IPC threshold of 0.5/10,000/day for both chronic food insecure and generally food secure areas. While this fact corroborates the general picture of chronic food insecurity in Cambodia, the Cambodian CMR (as an emergency measure) does not provide meaningful information to differentiate health outcomes between provinces.
Two different indicators are therefore used to help differentiate mortality: The infant mortality rate (IMR) and the under-five mortality rate (U5MR).
Infant and Under-Five Mortality Rates
The CDHS (2005) report shows that IMR declined between 2000 and 2005 from 95 to 66 deaths for every 1,000 live births per year. Rural areas have a much higher IMR than urban areas (92 against 65 deaths/1,000 live births/year). Pronounced differences also exist between provinces. Mondol Kiri, Rotanak Kiri and Prey Veng have rates above 120 deaths for every 1,000 live births per year, while Phnom Penh, Siem Riep and Kampot/Krong Kep have only 42, 67 and 67 deaths, respectively. Yet, Phnom Penh is the only province with figures lower, i.e. better, than the national average.
Under-five mortality rates (U5MR) declined significantly from 124 to 83 for every 1,000 live births per year. This represents a decrease of over 30 percent and a significant improvement. Still, one in every 12 Cambodian children dies before reaching the age of five. Again, rural areas are worse off with 111 compared to 76 deaths for every 1,000 live births per year in urban areas. Similar to the IMR, Mondol Kiri and Rotanak Kiri show the highest rates with 165, followed by Prey Vihear and Steung Treng with 146, whereas Phnom Penh has a low of 52 deaths (Figure 4.1).
Child and infant mortality do not have a consistent relationship with per capita consumption, although estimated mortality is lowest in the richest consumption quintile. The CSES data suggests, however, that child mortality is strongly and negatively correlated with the education of a mother. A child born to a mother with secondary and higher education is about two-and-a-half times likely to survive (Figure 4.2). The statistical analysis of the CSES data also suggests that child mortality is negatively correlated with access of health services and positively correlated with malaria prevalence. Deaths among children below five years of age make up 20 percent of all deaths in the poorest socio-economic quintile, compared to 13 percent among the richest. This reflects the “fertility trap”. Significantly higher mortality rates among the poor create an incentive for more births, which increase the health risks for the mother and reduce the level of per capita spending on health and education available for each child (WB, 2006).
Though it is difficult to establish a single cause of death, it is anticipated that the major causes are diarrhoea, respiratory infections and fever. Twenty-five percent of neonatal deaths were among low birth weight infants. Birth weight remains a major determinant of infant and child mortality.
Figure 4.1: Infant and Under 5 Mortality Rates (# of deaths/1,000 live birth)
Source : CDHS 2005
Maternal Mortality Ratio
According to the 2005 CDHS report, the maternal mortality radio, which is obtained by dividing the age-standardized maternal mortality rate by the age-standardized general fertility rate, is often considered a more useful measure of maternal mortality since it measures the obstetric risk associated with each live birth. The 2005 CDHS report shows that maternal mortality rose to 472 deaths per 100,000 live births per year, up from 437 deaths per 100,000 live births per year in 2000. However, the report indicates that this change is not statistically significant.
Children's Nutrition Status
Overall, the nutritional status of children under 5 years
in Cambodia has improved in the past five
years. In 2005, 37.2 percent of children were stunted, 35.6 percent
underweight and 7.3 percent were wasted nationwide, compared with 45
percent stunting, 45 percent underweight and 15 percent wasting in 2000
Figure 4.2: Trends of Nutritional Status of Children Under Five Years
Source: CDHS 2005
Malnutrition remains a serious problem for Cambodian children and Cambodia generally. The 2004 CSES indicates that only 59 percent of individuals in the poorest quintile reported having had adequate food supply for every day in the past 12 months compared to 88 percent of the richest quintile. In Cambodia, even the children of the relatively rich suffer from high rates of malnutrition (WB, 2006). This supports the perception that while inadequate food access (and by extension low incomes and low and variable productivity of food crops for household consumption) is critical, poor infant and child feeding practices (e.g. too early or too late introduction of complementary feeding and inappropriate complementary food) and poor public health also play a significant role.
Vitamin A deficiency is linked to access to vitamin--rich food for children, poor breastfeeding practices, and high prevalence of childhood diseases such as acute respiratory infections, diarrhea and measles. According to the 2004 CSES, 82 percent of children under 5 were given vitamin A, a significant increase from 29 percent reported in the 2000 DHS. Children of mothers with at least primary schooling are at least 7 percent more likely to receive vitamin A than those without schooling (Figure 4.3).
Cambodia has also reported high levels of iron deficiency -- 62 percent among children, 47 percent among women, 57 percent among pregnant women, (DHS 2005). This is likely a contributory factor in high maternal death rates in Cambodia -- 472 per 100,000 births (DHS 2005).
As with other health indicators, child malnutrition sharply declines with increases in the level of the mother’s education, in particular between primary and secondary level schooling (Table 4.1). Thus it is clear that that educating women is a critical factor in reducing malnutrition over time. Education is important and links need to be sought with the education sector for school-based interventions (e.g. school feeding programs or micro-nutrient initiatives). Effective nutrition programs are likely to have a significant impact in rural areas given the higher prevalence of malnutrition amongst the poorer quintiles.
Table 4.1: Mean rates (%) of moderate and sever malnutrition among children under 5 by mother level of schooling, 2004
source: CSES 2004
Figure 4.3: the level of mother education is strongly and positively associated with children’s immunization
Weight-for-age (underweight) is a composite index of height-for-age (stunted) and weight- for-height (wasted). It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the mean of the reference population are classified as underweight.
According to the 2005 CDHS report, the highest prevalence of underweight in children under five is observed in Ratanak Kiri and Mondol Kiri provinces, where it is more than 50 percent. The prevalence of underweight in Pursat, Siem Reap, Preah Vihear, Prey Veng and Stueng Treng provinces is between 40 and 50 percent.. The lowest prevalence of underweight is observed in Phnom Penh, Bat Dambang, Banteay Mean Chey and Pailin provinces (Map 4.1).
Map 4.1: Prevalence of Global Underweight (<-2zscore)
The weight-for-height index (wasted) measures body mass in relation to body length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the mean of the reference population are considered thin (wasted) for their height and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition.
According to the 2005 CDHS report, the highest prevalence of wasting among children under 5 is observed in Pursat province, where it is more than 15 percent. The prevalence of wasting in Otdar Mean Chey, Prey Veng and Kandal provinces is between 10 percent and 15 percent (Map 4.2).
Map 4.2: Prevalence of Global Wasting (<-2zscore)
The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the mean of the reference population are considered short for their age (stunted) and are chronically malnourished. Stunting reflects the failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and does not vary according to recent dietary intake.
According to the 2005 CDHS report, the highest prevalence of
stunting among children under five is observed in Siem Reap, Pursat,
Ratanak Kiri and Mondol Kiri provinces, where it is greater than 50
percent. The prevalence of underweight in Otdar Mean Chey, Preah
Vihear, Kampong Thom and Stueng Treng provinces is between 40 percent
and 50 percent, while the lowest prevalence of underweight is observed
in Phnom Penh, Kep, Kandal and Kampot provinces (Map 4.3).
Map 4.3: Prevalence of Global Stunting
Prevalence of Anemia in Children
Common causes of anemia include inadequate intake of iron, folate, vitamin B12 or other nutrients. Anemia can also result from thalassemia, sickle cell disease, malaria, and intestinal worm infestation. Anemia may be the underlying cause of maternal mortality, spontaneous abortion, premature birth, and low birth weight.
According to the CDHS 2005 data more than half (62 percent) of Cambodian children between the age -59 months are anemic, with 29 percent mildly anemic, 32 percent moderately anemic, and 1 percent severely anemic. Anemia is highest among children age 9-11 months, and children who live in Pursat province.
Some of the important measures to reduce anemia includes iron and folic acid supplementation, antimalarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bed-nets and deworming for children.
Figure 4.4: Trends in anemia status among children age 6-59 months
Source: CDHS 2005