Next Article in Journal
Correlation of Different MRI Scoring Systems with Long-Term Cognitive Outcome in Cooled Asphyxiated Newborns
Next Article in Special Issue
A Longitudinal Investigation on the Effects of Sodium and Potassium Intake on the Development of Hypertension and Abdominal Obesity from Childhood to Young Adulthood amongst Ellisras Rural Population, South Africa
Previous Article in Journal
Impact of Physical Activity Counselling on Children with Medical Conditions and Disabilities and Their Families
Previous Article in Special Issue
Association of Stunting with Socio-Demographic Factors and Feeding Practices among Children under Two Years in Informal Settlements in Gauteng, South Africa
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Children
Volume 10
Issue 8
10.3390/children10081294
children-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa

by
Lucy Nomsa Masilela
1 and
Perpetua Modjadji
1,2,*
1
Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, 1 Molotlegi Street, Ga-Rankuwa, Pretoria 0208, South Africa
2
Non-Communicable Disease Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
*
Author to whom correspondence should be addressed.
Children 2023, 10(8), 1294; https://doi.org/10.3390/children10081294
Submission received: 30 June 2023 / Revised: 20 July 2023 / Accepted: 26 July 2023 / Published: 27 July 2023
(This article belongs to the Special Issue Selected Papers from the 3rd Ellisras Longitudinal Study and Other Non-communicable Diseases Studies International Conference)
Review Reports Versions Notes

Abstract

:
Poor nutrition outcomes among children have become one of the major public health concerns in South Africa, attributed to poor feeding practices and maternal nutrition-related knowledge with conflicting data. In view of this, a cross-sectional study was conducted to determine the association of nutrition outcomes of children aged under two years with feeding practices and maternal nutrition-related knowledge in Mbombela, South Africa. Mothers’ nutrition-related knowledge was estimated using an adapted structured questionnaire on colostrum, continued breastfeeding, diarrhea prevention and treatment using oral rehydration solution, immunization, and family planning, and scored as excellent (80–100), good (60–79), average (40–59), and fair (0–39). This was along with questions on socio-demographic factors and obstetric history, as well as anthropometric measurements. Child nutrition outcomes were estimated by WHO classification using z-scores for stunting (length-for-age (LAZ)), underweight (weight-for-age (WAZ)), and thinness (body mass index-for-age (BAZ)). Using STATA 17, 400 pairs of children (8 ± 6 months) and their mothers (29 ± 6 years) participated in the study and were living in a poor socio-economic status environment. Half of children were stunted (50%) and over half (54%) were obese, while mothers were underweight (39%) and overweight (34%). In addition to one third of mothers reporting obstetric complications, two thirds, initiated breastfeeding within one hour of delivery, 30% exclusively breastfed, 48% introduced early complementary feeding, and 70% practiced mixed feeding. Twenty-eight percent (28%) of mothers had fair nutrition-related knowledge, while 66% had average knowledge, 6% good knowledge, and none of the mothers had excellent knowledge. A chi-square test showed that mothers’ nutrition-related knowledge was significantly associated with child stunting. The final hierarchical logistic regression showed significant associations of stunting with mothers’ nutrition-related knowledge (average: AOR = 1.92, 95%CI: 1.12–3.29), child’s age (6–11 months: AOR = 2.63, 95%CI: 1.53–4.53 and 12–23 months: AOR = 3.19, 95%CI: 1.41–7.25), and education (completing Grade 12: AOR = 0.36, 95%CI: 0.15–0.86). Contextual and intensified interventions on continued education for mothers to gain accurate information on nutrition-related knowledge and feeding practices could ultimately enhance child nutrition outcomes in poorer settings. Efforts should therefore be made to ensure that nutrition knowledge is appropriately provided based on the phases of child growth from 0 to 2 years, even beyond infancy into school age.

1. Introduction

Child nutrition outcomes (i.e., stunting, underweight, and thinness) are key to tracking the nutrition and health status of children in a population [1]. In particular, stunting (i.e., linear growth retardation or low length-for-age (LAZ)) is affecting 21.9% of children under five years, on a global level, and 41% in Sub-Saharan Africa (SSA) [2]. Stunting is common in the first two years of life and is an indicator of chronic undernutrition [3]. In developing countries, the predominance of stunting is attributed to dietary quality, which ultimately interrupts early linear growth in stages of life into adulthood, affecting body size and intellectual functioning [4,5]. In the long term, stunting among children predisposes them to short adult stature, reduced lean body mass, less schooling, diminished intellectual functioning, and overweight or obesity later in life as well as a higher risk of coronary heart disease, stroke, hypertension, and type 2 diabetes and unproductivity later in life [4,6,7,8,9].
In South Africa, child nutrition outcomes remain a public health concern [10,11,12,13]. Approximately 27% to 32.3% of children under five years in the country are stunted, followed by underweight (9%) and wasted (2.5%) [11]. Stunting, being a multifactorial phenomenon, is attributable to factors such as poor socio-economic status, poor maternal health and nutrition, inadequate infant and young child feeding (IYCF), and micronutrient deficiencies [14]. Appropriate IYCF entails the initiation of breastfeeding within one hour of birth, exclusive breastfeeding (EBF) for six months, a continuation of breastfeeding for up to two years and beyond, as well as timely introduction of complementary foods [15,16]. According to the South African Demographic and Health Survey (SADHS), the percentage of exclusive breastfeeding was 32% in 2016, while 19% of children (12–23 months) were breastfed. Recent studies have estimated stunting among children aged under five years as between 45.3% to 55% [17,18] and associated delayed introduction of solid foods with stunting [11] due to inappropriate food supplementation [17]. Other studies conducted in Burkina Faso [19] and Ethiopia [20] reported that stunting is worsened by breastfeeding continuing with proper complementary feeding specific for age, making infants beyond six months vulnerable to poor nutrition outcomes [21].
Several developing countries have adopted a multisectoral approach and implemented specific and sensitive nutrition interventions to reduce childhood stunting [22]. Further, most countries are prioritizing policies and programs that improve mothers’ ability to provide optimal care until the age of two years, a critical period for child growth and cognitive development and the origin of non-communicable diseases (NCDs) [22,23,24]. This is because the availability of parental resources in the first two years of a child’s life influences proper growth and cognitive development [3,4,5]. For instance, a mother’s knowledge in relation to food choices, feeding, health seeking, and her education has been studied [9,10,11,12,13,14,15]. According to the UNICEF Model of Care, the fundamental role of care in child nutrition indicates that caregivers require education, time, and support to provide adequate care [25]. Maternal knowledge and understanding of the aspects of basic nutrition and healthcare determine the care they give to their children [22,26,27]. It is worth noting that nutrition-related knowledge may be obtained from various sources [27], and if correct and put to practice, the nutrition-related knowledge may result in good child nutrition outcomes but, on the contrary, poor nutritional outcomes (i.e., stunting, underweight, and thinness) may result if incorrect information is put into practice [28]. Nonetheless, inconsistencies of the association of poor nutrition outcomes, nutrition-related knowledge, and feeding practices have been reported [29,30,31,32,33]. For instance, other studies reported significant associations [27,29,30], while others showed that adequate nutrition-related knowledge is not always translated into appropriate feeding practices [21,31,34,35].
The relationship of child nutrition outcomes and maternal nutrition-related knowledge in the South African context remains unclear. Few studies in the country have investigated several aspects of mothers regarding feeding knowledge [31], beliefs [36], practices [37], or dietary diversity [38] in relation to child nutrition outcomes. Nonetheless, stunting remains relatively high among South African children [17,18], and different forms of stunting and overweight/obesity in the same individuals [8,39], households, and settings coexist [38,40,41,42,43]. In view of this, the current study determined the association of nutrition outcomes of children aged under two years with feeding practices and maternal nutrition-related knowledge in Mbombela, South Africa. We hypothesize that in rural Mbombela, there is a significant relationship among feeding practices, nutrition-related knowledge, and child nutrition outcomes, especially with stunting. South Africa has promulgated several policies regarding feeding of children, including the Mother Baby Friendly Initiative (MBFI) and IYCF program [24,44]. Therefore, efforts to translate nutrition-related knowledge into appropriate action in an impoverished environment might be of help to mothers [45].

2. Materials and Methods

2.1. Study Design and the Conceptual Frameworks

This paper is an excerpt from a Master of Public Health dissertation written by the first author, which determined maternal feeding practices and nutritional knowledge, as well as the nutritional status of infants in community health facilities of the Mbombela sub-district in Mpumalanga Province. The entire study used a cross-sectional study design collecting data from mothers and their children under two years on anthropometry, obstetric history, socio-demographic status, feeding practices, and nutrition knowledge. The study was conducted from September 2021 to December 2021. From this umbrella study, the first published paper was “Evidence of Concurrent Stunting and Obesity among Children under two Years from Socio-Economically Disadvantaged Backgrounds in the Era of the Integrated Nutrition Programme in South Africa” [13]. The current paper is focused on child nutrition outcomes and maternal nutrition-related knowledge.
The methods used in this study have been described in detail in the first paper [13]. In a nutshell, the study was anchored on the Bronfenbrenner’s social ecological model [46] and UNICEF conceptual framework for malnutrition [47]. In addition to inadequate dietary intake and disease, food access, household factors, poverty, maternal care practices, health services, the family context, and social values have been implicated in child nutrition outcomes [46,48,49,50]. Furthermore, nutrition-related knowledge of mothers influenced by living standards and the food environment, as an important component of their care and practices, is necessary although not adequate for optimal healthy child nutrition and positive behavioral change [51,52]. Lastly, data were further informed by the WHO core indicators for optimal IYCF [21,53,54].

2.2. Study Setting and Population

The study was conducted in Mbombela, a local municipality situated in Ehlanzeni District, Mpumalanga Province, described in detail in the previous paper [13]. Mbombela is the capital city of Mpumalanga Province in South Africa with a mixed rural and urban population [55]. In this area, cultural values and norms are highly important. The total population in this district is estimated at 695,913, and there are six community health centers (CHCs) and 31 primary healthcare (PHC) facilities [56]. The six CHCs were chosen based on the fact that they were situated in the rural sections of the settings with poor infrastructure. In such settings, several public health issues such as feeding practices and poor nutritional status are less studied.
This study included children aged under two years and their mothers as a study population. Children were identified during visits to the selected facilities in the study setting for childcare services with their biological mothers and were further eligible to participate in the study after their mothers gave written consent. Children who were brought to these facilities by non-biological mothers were excluded from the study. We further excluded children aged above two years, reported to be sick and on treatment, as well as mothers who were sick with any medical condition that might have affected their feeding practices during the first 6 months prior to giving birth to the participating child, mentally unfit to be interviewed, and below 18 years.

2.3. Sample Size and Sampling Technique

A minimum representative sample size was calculated using total population of 3000 children visiting CHCs [57] and 95% confidence level [58]. A sample size of 405 children paired with their mothers was obtained from the selected CHCs using systematic random sampling. Recruitment of children was conducted when mothers were in the queues for consultation with slips requesting their availability for interviews and anthropometric measurements.

2.4. Data Collection and Tools

2.4.1. Socio-Demographic Status

Data were collected using a validated questionnaire administered by trained research assistants. The questionnaire was adapted from studies conducted with a similar research concept [8,17,18] to collect data on anthropometry, obstetric history, socio-demographic status, feeding practices, and nutrition knowledge from mothers and their children under 2 years. SiSwati-speaking independent translators conversant in English translated the questionnaire forward and backward between the two languages [59]. Content, construct, and face validity were ensured and approved by an expert committee. Following obtaining ethical approval from the Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC) (SMUREC/H/290/2020: PG) and permission to access facilities in Mpumalanga Province (MP_202012_005), the study commenced. First, research assistants were trained to collect data, followed by a pilot study conducted among 30 participants to test the feasibility of the study and assess the efficiency of the research assistants to measure anthropometry and administer the questionnaire to participants. A reliability coefficient of 0.82 (i.e., Cronbach’s alpha) for the questionnaire was obtained. The results of the pilot study did not form part of the main study but informed improvement of the questionnaire in terms of the wording and structure.

2.4.2. Anthropometric Measurements

Anthropometry of both children and mothers was measured according to WHO procedures [60]. Seca 354 baby (Medicare, Germany) and smart D-quip electronic scales were used to measure weights (i.e., three measurements) of children and mothers to the nearest 10 g and 0.1 kg, respectively. Recumbent length (L) of children and height of mothers were measured using a Seca 210 measuring mat (Medicare, Germany) and stadiometer to the nearest 0.1 cm. Waist and hip circumferences were also measured from mothers using a non-stretchable tape measure to the nearest 0.1 cm. Identity number, date of birth, age, sex, weight, and height of children were captured on the WHO Anthro software version 3.2.2.1 and analyzed according to WHO z-score classification for length-for-age (LAZ), weight-for-age (WAZ), and body mass index-for-age (BAZ) [61]. Stunting (i.e., low LAZ/HAZ), underweight (i.e., low WAZ), and thinness (low BAZ) were defined at <−2SD, while overweight was defined by BAZ > 2SD, and obesity by BAZ > 3SD [60]. The calculated body mass index (BMI) defined underweight (<19 kg/m2), normal weight (19–24.99 kg/m2), overweight (≥25 kg/m2), and obesity (≥30 kg/m2), while abdominal obesity was defined as waist circumference (WC) ≥ 88 cm, waist–hip ratio (WHR) ≥ 0.85, and waist-to-height ratio (WHtR) ≥ 0.5.

2.4.3. Mothers’ Feeding Practices and Nutrition-Related Knowledge

Feeding practices include early initiation of breastfeeding, exclusive breastfeeding under 6 months, continued breastfeeding at 1 year, introduction of solid, semi-solid, or soft foods, dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich or iron-fortified foods (eight WHO core indicators of IYCF) [21,53,62].
Adapted from Fadare et al. [30], we used colostrum, continued breastfeeding, diarrhea prevention and treatment using oral rehydration solution, immunization, and family planning to assess mothers’ nutrition-related knowledge. Mothers’ ability to answer “yes” or “no” to a set of questions relating to child health and nutrition was assessed, and the nutrition-related knowledge was ascertained using frequencies and percentages of the correct, incorrect, or “don’t know” answers and categorized into excellent (80–100), good (60–79), average (40–59), and fair (0–39).

2.5. Data Analysis

Descriptive and inferential statistics were computed using STATA version 17 (StataCorp. 2021. Stata Statistical Software: Release 14, College Station, TX, USA). Missing data were assessed using complete case analysis. Distribution of data was assessed using the Shapiro–Francia test. Results are presented as median (interquartile range (IQR)). A chi-square test (or Fisher’s exact test for cells with fewer than five cases) was used to compare child nutrition outcomes and selected feeding practices by maternal nutrition-related knowledge. Univariate (p < 0.20) and multivariate logistic regression (p < 0.05) analyses were used to determine the association of stunting with covariates, controlling for confounding. The main nutritional outcome of interest is child LAZ, which measures long-term nutritional outcomes, and association of stunting and covariates was determined using the crude odds ratio (COR) and adjusted odds ratios (AOR) and significance was considered at p < 0.05.

3. Results

3.1. Socio-Demographic Status

3.1.1. Characteristics of Mothers

Information on socio-demographic factors, anthropometry, and obstetric history of mothers is presented in Table 1. The study consisted of mothers participating with their children (n = 400). The mean age of mothers was 29 ± 6 years with the youngest aged 15 years and the oldest aged 42 years. Two age groups were created in this study with 63% of women being younger (<30 years) and 39% being older women. BMI was defined as underweight (<19 kg/m2), normal weight (19–24.99 kg/m2), overweight (≥25 kg/m2), and obesity (≥30 kg/m2). Mean average BMI of mothers was 28.2 kg/m2 (±SD = 5) with a range of 19–39 kg/m2. Most mothers were underweight (39%) or overweight (34%). Abdominal obesity was defined as waist circumference (WC) ≥ 88 cm, waist–hip ratio (WHR) ≥ 0.85, and waist-to-height ratio (WHtR) ≥ 0.5. WC was 72 cm (±SD = 6.3) with a minimum of 64 cm and maximum of 100 cm and WHtR was 0.45 ± 0.37 (range: 0.39–0.60). Abdominal obesity was observed among mothers by WHtR (39%). Most mothers in this study were single (73%) and unemployed (83%) and 40% had attained secondary school education. Thirty-five percent (35%) of women lived in self-headed houses and 45% in parent-headed houses, while 76% lived in larger households (≥5 members). Household income was determined using monthly income from family members in South African rands (ZAR) and converted to US dollars (USD). Most mothers (30%) lived with their children in households with less than USD 5542/month (i.e., ZAR 5000/month) in income, followed by USD 5548–27,710 (i.e., ZAR 5000–ZAR 10,000) (27%). Parity of 1 to 2 was observed in 69% of women, and 30% reported having had obstetric complications.

3.1.2. Characteristics of Children

Table 2 shows the characteristics of children. Out of 400 children, there were 220 girls and 180 boys (mean age: 8 ± 6 months). Few children (n = 92) were aged 12–23 months, while 153 were aged 6–11 months and 155 aged 0–5 months. Low birth weight (LBW) was observed among 20% of children, while 49% were born at a normal weight, and 88% were born at a clinic (38%) or hospital (50%).

3.2. Nutritional Outcomes of Children

Comparison of children’s nutrition outcomes by sex and age using a chi-square test (or Fisher’s exact test for cells with fewer than five cases) is presented in Table 3. WHO z-score classification and definitions for length-for-age (LAZ), weight-for-age (WAZ), and BMI-for-age (BAZ) were used to determine the nutrition outcomes: stunting (LAZ < −2 SD), underweight (WAZ < −2SD), overweight (BAZ > 2SD), and obesity (BAZ > 3SD). The prevalence of stunting (50%) was higher than that of underweight (1%) and thinness (4%) among children. In addition, the prevalence of obesity was high (54%), while overweight (13%) and overweight risk (13%) were also observed. No significant differences in stunting, underweight, overweight, and obesity were observed by sex. Significant differences by age were observed for all the nutritional outcomes among children. Children aged 6–12 months had a higher prevalence of stunting compared to their counterparts, while growth problems and obesity increased with age among children aged ≥12 months.

3.3. Associations of Stunting, Feeding Practices, and Nutrition-Related Knowledge

Mothers’ Feeding Practices and Nutrition-Related Knowledge

Child nutrition outcomes (dichotomized) and selected feeding practices are compared by mothers’ nutrition-related knowledge using a chi-square test (or Fisher’s exact test for cells with fewer than five cases) in Table 4. First, 63% of mothers, initiated breastfeeding within 1 h of delivery and 30% exclusively breastfed. Almost half of mothers (48%) introduced complementary feeding when their children were aged less than 3 months and 70% practiced mixed feeding. Twenty-eight percent (28%) of mothers had a fair nutrition knowledge, while 66% had average knowledge, 6% good knowledge, and none of the mothers had excellent knowledge. Mothers’ nutrition knowledge was significantly associated with stunting (p = 0.027) among children.
Table 5 shows the relationship of stunting with independent variables. In univariate logistic regression, stunting was associated with average mother’s nutrition-related knowledge, child’s age, and education (i.e., completed Grade 12) (p ≤ 0.20). Multivariate analysis showed significant associations of stunting with mother’s nutrition-related knowledge (average: AOR = 1.92, 95%CI: 1.12–3.29), child’s age (6–11 months: AOR = 2.63, 95%CI: 1.53–4.53 and 12–23 months: AOR = 3.19, 95%CI: 1.41–7.25), and education (completing Grade 12: AOR = 0.36, 95%CI: 0.15–0.86). Therefore, average mother’s nutrition-related knowledge had a likelihood to predispose children to stunting, while the odds of stunting were high for children aged 6–11 and 12–23 months compared to those aged 0–5 months and completing grade 12 among mothers was protective against stunting in children compared to having no education.

4. Discussion

This study reports a high prevalence of stunting (50%) among children, accompanied by an alarming rate of obesity (54%). South Africa continues to experience persistent stunting affecting 22–55% of children [8,11,17,18,38,40], like in other African countries such as Ghana [29], Ethiopia [63], and Nigeria [30,63]. In addition to stunting predisposing children to poor cognition and educational performance as they advance in age [6], impaired fat oxidation associated with stunting makes children susceptible to obesity, including later in life [64,65]. Furthermore, a high prevalence of obesity among children in this study is consistent with other reports in South Africa [11,40,66]. Surprisingly, most women in this study were underweight (39%), like in Ethiopia (30%), Uganda (12%), and Tanzania (11%) [67], where high prevalence of underweight have been reported, which could be multifactorial. The prevalence of overweight (34%) reported in this study contributes to public health concerns in South Africa, although it is lower compared to maternal overweight/obesity in South Africa other studies, estimated at 54–76% [68,69,70]. High consumption of energy-dense food and reduced physical activity are always implicated in overweight/obesity in other countries [71,72,73], and in South Africa [41,68], nutrition transition is associated with frequent intake of processed and sugary foods as well as high-calorie and high-fat diets, socio-demographic characteristics, etc. [74,75,76,77].
Researchers have implicated chronic nutritional deprivation in stunting [78], usually associated with poor socio-economic conditions, poor maternal health and nutrition, frequent illness, and/or inappropriate infant and young child feeding and care in early life [79]. We attribute stunting in this study to household poverty, as indicated by the poor socio-economic status. Further, feeding practices, especially breastfeeding, are associated with socio-economic status, and in the current study poor feeding practices are characterized by a low level of exclusive breastfeeding and an early introduction of solid foods like in other studies in Africa [80,81,82] and locally [17,36,83]. On the other hand, children who consume formula milk become overweight/obese due to high protein and energy [66,67]. Furthermore, children who are susceptible to weight gain in the first week of life have a higher risk of weight gain between one and two years, and this doubles as they grow older [39,84,85]. During the first 6 months of life, exclusive breastfeeding protects children against overweight and obesity, among other benefits [13,48,86]. We attribute obesity in this case to poor feeding practices, such as early introduction of solid foods.
In this study, mothers and their children lived in socio-economically poor households and reported poor obstetric history, as also reported in similar South African studies [17,80]. Socio-economic status is one of the most important factors associated with health and medical outcomes of women of reproductive age [81,82]. In addition, women with lower socio-economic status are less likely to receive prenatal care, which is associated with poor obstetric outcomes [81,82,83]. Socio-economic differences across countries play a significant role [87] and are known to affect the prevalence of the double burden of malnutrition in LMICs, in addition to nutrition transition [42,43,88,89]. Therefore, the coexistence of maternal underweight and obesity, as well as child stunting and obesity, in poorer households suggests a household double burden of malnutrition [41,42,89]. Health implications of the double burden of malnutrition include increased mortality and morbidity risks, as well as poor cognition, health, and development with adult health risks [1,90].
The study has reported increased odds of stunting in children aged 6–11 months and 12–23 months. Increased odds of stunting with age have been reported among children in parts of Ethiopia [91], Indonesia [92], and Zambia [93]. Additionally, this study found average nutrition-related knowledge (66%) among mothers, similar to the 61.5% reported among caregivers in Ghana [94] and 59% in Kenya [95]. However, this knowledge does not seem to be reflected in practice since low levels of exclusive breastfeeding and early introduction of solids were observed, although two thirds were able to initiate breastfeeding within one hour in this study. It could be that in settings like our setting, a low level of parental education in terms of tertiary education might have no significant effect on child nutrition outcomes [60,96]. This kind of education status is unlikely to reinforce a mother’s nutrition knowledge for the purposes of reducing poor child nutrition outcomes.
On the contrary, high nutritional knowledge has been reported to be essential to promote good feeding practices and prevent poor nutrition outcomes among children in Kenya [97]. Our study reported a positive relationship between stunting and the mother’s education level, the same as in the study of Negash et al. [98] in Ethiopia and Fadare et al. [30] in Nigeria. A higher chance that a mother who completed Grade 12 would have a child who is less likely to be stunted compared to a mother with no education was observed in this study. It has been suggested that mothers with above a primary-level education can significantly reduce stunting in children [30]. Furthermore, the odds of mothers with average nutrition-related knowledge to have stunted children were 1.92 [29]. In Ghana, a positive link between a caregiver’s nutritional knowledge and stunting was reported among children aged 6–36 months [99]. Another study in Ghana, documented the effect of nutritional knowledge of mothers on children’s nutritional status and child feeding knowledge and practices were associated positively with appropriate feeding practices [96].
The significant difference in feeding practices of children in different stages of growth is well documented, and this requires mothers to have diverse nutrition knowledge to cater for those stages [30,100]. In this study, mothers were expected to recall their feeding practices from the outset after birth to the time the study was conducted. From our results, it is shown that the nutrition knowledge of mothers was not significantly different by children’s age group for the phases of exclusive breastfeeding in the first 6 months, introduction to solid food, as well as mixed feeding. This suggests a needed change in nutrition knowledge of mothers to feed their children appropriately as they advance in the various stages of growth, because their knowledge of food choices, feeding, and healthcare seeking is vital for producing normal child nutrition outcomes. For instance, as infants age beyond six months, they become more vulnerable to poor nutrition outcomes during the transition period from a milk diet to a diet that includes complementary food, predisposing them to stunting. This nutritional outcome is worsened by continued breastfeeding not accompanied by adequate complementary feeding at the appropriate age, due to nutritional demand [19,20,21].
Lastly, the context in which children grow up in can never be ignored as one of the influences on their nutrition outcomes, and the literature documents family context, ethnicity, and social values [12,101,102]. The impact of cultural beliefs and traditional practices is acknowledged in this study considering that the study setting is known for strong cultural values and norms, as well as poverty. First, the context of poverty in the current study, explained by poor living conditions, predisposes households to food insecurity through limited availability, access, and affordability and this will ultimately prevent children from meeting their nutrient requirements for growth [12]. Second, cultural beliefs and traditional practices contribute to feeding practices and vary across communities and countries [10,103,104,105]. Like in other countries, the role of mothers/caregivers regarding childcare is highly emphasized in most traditional cultures, where intergenerational influences on meal preparation inform systems and practices [105,106]. For instance, over two thirds of children in this study were non-exclusively breastfed and mixed fed. These are normalized feeding practices in other African societies with health impacts on children’s health due to exposure to the risk of diarrhea and malnutrition [5,102,107,108,109,110,111]. Furthermore, the pressure exerted by the family to give the baby other food further exacerbates the problem of early introduction of solids and other liquids [108,110], which might explain why almost half of the children in this study started to consume solid foods under 3 months of age. However, other researchers have acknowledged that some traditional practices, while often times misleading and not scientifically always sound, have been shown under certain circumstances to actually improve health/nutritional outcomes in children because they capitalize optimally on limited resources [105]. Therefore, in settings such as ours, challenges remain on how to assist mothers to make informed decisions regarding IYCF practices, considering culturally appropriate infant feeding messages.

Strengths and Limitations of the Study

Inferences made in this cross-sectional study are reliable, with limitations on establishing causality using this type of study design. We were able to obtain a random sampling, which mitigated selection bias. However, when it comes to collecting information from mothers, social desirability is the most concerning limitation since mothers might have withheld information or falsified their responses, especially on feeding practices, with the aim to be acceptable. We relied on self-reported information mostly, and having to remember previous events and practices might have also introduced recall biases. We cannot explain the high prevalence of underweight among women, as South Africa is known to have minimal levels of underweight among women of reproductive age and high levels of overweight/obesity compared to their counterparts. Conducting a health assessment of mothers including medical history might have provided a better explanation of underweight among mothers. Further, care should be taken when determining feeding practices; nonetheless, we used a WHO questionnaire, which was piloted prior to commencing the main study and entailed training research assistants on conducting interviews and anthropometry. Lastly, we did not measure the HIV status of mothers, which could have provided a better indication regarding their feeding practices, especially regarding breastfeeding. Also, confounding factors such as medication use and smoking and alcohol use as lifestyle factors should be considered in future studies. The results of this study are applicable to rural localities in Mbombela, Mpumalanga Province in South Africa and cannot be generalized to other areas because setting variations may influence feeding practices. Nevertheless, this study has reported on poor child nutrition outcomes, feeding practices, mothers’ nutritional knowledge, and their relationship.

5. Conclusions

The high prevalence of stunting and obesity among children found in this study has great policy implications for South Africa, considering the lack of improved child nutrition outcomes, despite the introduction of the Integrated Nutrition Programme. Furthermore, poor feeding practices remains in South Africa even after having promulgated several policies regarding feeding of children. At the same time, poor maternal nutrition-related knowledge was prevalent, but most mothers had average nutrition knowledge. These findings contribute significant information for understanding the relationship between maternal nutrition-related knowledge and child nutrition outcomes in the context of a poverty-stricken environment. A significant association of stunting and mothers’ nutrition-related knowledge might be helpful in reducing stunting occurrences; however, this knowledge might not reflect good feeding practice. In addition, the association of mothers completing Grade 12 with lower odds of stunting among children could suggest that a low level of parental education in terms of tertiary education might not likely reinforce mothers’ nutrition knowledge for the purposes of reducing poor child nutrition outcomes. Therefore, contextual, and intensified interventions on continued education for mothers to gain accurate information on nutrition and feeding practices could ultimately enhance child nutrition outcomes in poorer settings. Efforts should therefore be made to ensure that nutrition knowledge is appropriately provided based on the phases of child growth from 0 to 2 years, even beyond infancy into school age.

Author Contributions

Conceptualization, L.N.M. and P.M.; methodology, L.N.M. and P.M.; software, P.M.; validation, L.N.M.; formal analysis, P.M.; investigation, L.N.M.; resources, L.N.M.; data curation, L.N.M.; and P.M.; writing—original draft preparation, P.M.; writing—review and editing, L.N.M. and P.M.; supervision, P.M.; project administration, L.N.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted according to the guidelines laid down in the Declaration of Helsinki [112] and all procedures involving human subjects were approved by Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC) (SMUREC/H/290/2020: PG), approved on 1 June 2017. The study further received permission, from the Provincial Department of Health Research Committee, in Mpumalanga Province of South Africa (MP_202012_005), on 21 December 2020.

Informed Consent Statement

Mothers attending childcare services received information about the study. Following recruitment and information distribution, mothers gave written informed consent to participate in the study with their children.

Data Availability Statement

The dataset for the study groups generated and analyzed during the current study is available from the corresponding author upon reasonable request due to ethical restrictions.

Acknowledgments

We thank mothers for willingly participating in this study with their children. We acknowledge the Mpumalanga Provincial Department of Health Committee, in South Africa. We are grateful to the facility managers for granting us access to conduct this research and further assisting us with recruitment during visits to the facilities, as well as the research assistants for data collection.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. De Onis, M.; Blössner, M.; Borghi, E.; Morris, R.; Frongillo, E.A. Methodology for estimating regional and global trends of child malnutrition. Int. J. Epidemiol. 2004, 33, 1260–1270. [Google Scholar] [CrossRef] [Green Version]
  2. Quamme, S.H.; Iversen, P.O. Prevalence of child stunting in Sub-Saharan Africa and its risk factors. Clin. Nutr. Open Sci. 2022, 42, 49–61. [Google Scholar] [CrossRef]
  3. UNICEF. Reduce Stunting. Chronic Malnutrition Will Result in Stunting—An Irreversible Condition That Literally Stunts the Physical and Cognitive Growth of Children. 2022. Available online: https://www.unicef.org/esa/reduce-stunting (accessed on 15 August 2022).
  4. Dewey, K.G.; Begum, K. Long-term consequences of stunting in early life. Matern. Child Nutr. 2011, 7 (Suppl. S3), 5–18. [Google Scholar] [CrossRef]
  5. Martorell, R.; Melgar, P.; Maluccio, J.A.; Stein, A.D.; Rivera, J.A. The nutrition intervention improved adult human capital and economic productivity. J. Nutr. 2010, 140, 411–414. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  6. de Onis, M.; Branca, F. Childhood stunting: A global perspective. Matern. Child Nutr. 2016, 12 (Suppl. S1), 12–26. [Google Scholar] [CrossRef] [PubMed]
  7. Devkota, M.D.; Adhikari, R.K.; Upreti, S.R. Stunting in Nepal: Looking back, looking ahead. Matern. Child Nutr. 2016, 12 (Suppl. S1), 257–259. [Google Scholar] [CrossRef] [Green Version]
  8. Symington, E.A.; Gericke, G.J.; Nel, J.H.; Labadarios, D. The relationship between stunting and overweight among children from South Africa: Secondary analysis of the National Food Consumption Survey—Fortification Baseline I. S. Afr. Med. J. 2015, 106, 65–69. [Google Scholar] [CrossRef] [Green Version]
  9. World Health Organization. Global Nutrition Targets 2025: Stunting Policy Brief; World Health Organization: Geneva, Switzerland, 2014. [Google Scholar]
  10. Modjadji, P.; Madiba, S. The Multidimension of Malnutrition among School Children in a Rural Area, South Africa: A Mixed Methods Approach. Nutrients 2022, 14, 5015. [Google Scholar]
  11. NDoH; Stats SA; SAMRC; ICF. South Africa Demographic and Health Survey 2016: Key Indicators; Statistics South Africa: Pretoria, South Africa; Rockville, MD, USA, 2017.
  12. Modjadji, P. Engaging Mothers on the Growth of School-Age Children in a Rural South African Health and Demographic Site: A Qualitative Insight. Healthcare 2021, 9, 225. [Google Scholar]
  13. Modjadji, P.; Masilela, L.N.; Cele, L.; Mathibe, M.; Mphekgwana, P.M. Evidence of Concurrent Stunting and Obesity among Children under 2 Years from Socio-Economically Disadvantaged Backgrounds in the Era of the Integrated Nutrition Programme in South Africa. Int. J. Environ. Res. Public Health 2022, 19, 12501. [Google Scholar] [CrossRef]
  14. Amaha, N.D.; Woldeamanuel, B.T. Maternal factors associated with moderate and severe stunting in Ethiopian children: Analysis of some environmental factors based on 2016 demographic health survey. Nutr. J. 2021, 20, 18. [Google Scholar] [CrossRef] [PubMed]
  15. Das, N.; Chattopadhyay, D.; Chakraborty, S.; Dasgupta, A. Infant and young child feeding perceptions and practices among mothers in a rural area of West Bengal, India. Ann. Med. Health Sci. Res. 2013, 3, 370–375. [Google Scholar] [PubMed] [Green Version]
  16. Sanghvi, T.; Martin, L.; Hajeebhoy, N.; Abrha, T.H.; Abebe, Y.; Haque, R.; Tran, H.T.T.; Roy, S. Strengthening systems to support mothers in infant and young child feeding at scale. Food Nutr. Bull. 2013, 34, S156–S168. [Google Scholar] [CrossRef] [PubMed]
  17. Modjadji, P.; Mashishi, J. Persistent Malnutrition and Associated Factors among Children under Five Years Attending Primary Health Care Facilities in Limpopo Province, South Africa. Int. J. Environ. Res. Public Health 2020, 17, 7580. [Google Scholar] [CrossRef]
  18. Modjadji, P.; Pitso, M. Maternal Tobacco and Alcohol Use in Relation to Child Malnutrition in Gauteng, South Africa: A Retrospective Analysis. Children 2021, 8, 133. [Google Scholar] [CrossRef]
  19. Thiombiano-Coulibaly, N.; Rocquelin, G.; Eymard-Duvernay, S.; Zougmore, O.; Traore, S. Effects of early extra fluid and food intake on breast milk consumption and infant nutritional status at 5 months of age in an urban and a rural area of Burkina Faso. Eur. J. Clin. Nutr. 2004, 58, 80–89. [Google Scholar] [CrossRef]
  20. Derso, T.; Tariku, A.; Biks, G.A.; Wassie, M.M. Stunting, wasting and associated factors among children aged 6–24 months in Dabat health and demographic surveillance system site: A community based cross-sectional study in Ethiopia. BMC Pediatr. 2017, 17, 96. [Google Scholar] [CrossRef]
  21. Black, R.E.; Allen, L.H.; Bhutta, Z.A.; Caulfield, L.E.; de Onis, M.; Ezzati, M.; Mathers, C.; Rivera, J. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008, 371, 243–260. [Google Scholar] [CrossRef]
  22. Saito, K.; Korzenik, J.R.; Jekel, J.F.; Bhattacharji, S. A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India. Yale J. Biol. Med. 1997, 70, 149–160. Available online: https://pubmed.ncbi.nlm.nih.gov/9493847/ (accessed on 29 June 2023).
  23. Haddad, L.; Achadi, E.; Bendech, M.A.; Ahuja, A.; Bhatia, K.; Bhutta, Z.; Blössner, M.; Borghi, E.; Colecraft, E.; De Onis, M. The Global Nutrition Report 2014: Actions and accountability to accelerate the world’s progress on nutrition. J. Nutr. 2015, 145, 663–671. [Google Scholar] [CrossRef] [Green Version]
  24. Sayed, N.; Schönfeldt, H.C. A review of complementary feeding practices in South Africa. S. Afr. J. Clin. Nutr. 2020, 33, 36–43. [Google Scholar] [CrossRef]
  25. UNICEF. Strategy for Improved Nutrition of Children and Woman in Developing Counties; UNICEF: New York, NY, USA, 1990. [Google Scholar]
  26. Bengre, A. Mothers knowledge on Malnutrition: Community Based Cross Sectional Study. Indian J. Public Health Res. Dev. 2018, 9, 37–41. [Google Scholar] [CrossRef]
  27. Glewwe, P. Why does mother’s schooling raise child health in developing countries? Evidence from Morocco. J. Hum. Resour. 1999, 34, 124–159. [Google Scholar] [CrossRef]
  28. Gittelsohn, J.; Vastine, A.E. Sociocultural and household factors impacting on the selection, allocation and consumption of animal source foods: Current knowledge and application. J. Nutr. 2003, 133, 4036S–4041S. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  29. Appoh, L.Y.; Krekling, S. Maternal nutritional knowledge and child nutritional status in the Volta region of Ghana. Matern. Child Nutr. 2005, 1, 100–110. [Google Scholar] [CrossRef]
  30. Fadare, O.; Amare, M.; Mavrotas, G.; Akerele, D.; Ogunniyi, A. Mother’s nutrition-related knowledge and child nutrition outcomes: Empirical evidence from Nigeria. PLoS ONE 2019, 14, e0212775. [Google Scholar] [CrossRef] [Green Version]
  31. Motadi, S.; Malise, T.; Mushaphi, L. Breastfeeding knowledge and practices among mothers of children younger than 2 years from a rural area in the Limpopo province, South Africa. S. Afr. J. Child. Health 2019, 13, 115. [Google Scholar] [CrossRef] [Green Version]
  32. Webb, P.; Block, S.A. Nutrition Knowledge and Parental Schooling as Inputs to Child Nutrition in the Long and Short Run. Tufts University Friedman School of Nutrition Science and Policy. Nutrition Working Paper 3. 2003. Available online: https://www.researchgate.net/profile/Steven-Block-4/publication/5057561_Nutrition_Knowledge_and_Parental_Schooling_as_Inputs_to_Child_Nutrition_in_the_Long_and_Short_Run/links/0fcfd50e445abb37b3000000/Nutrition-Knowledge-and-Parental-Schooling-as-Inputs-to-Child-Nutrition-in-the-Long-and-Short-Run.pdf (accessed on 29 June 2023).
  33. Novitasari, P.; Wanda, D. Maternal Feeding Practice and Its Relationship with Stunting in Children. Pediatr. Rep. 2020, 12, 8698. [Google Scholar] [CrossRef] [PubMed]
  34. Claeson, M.; Waldman, R.J. The evolution of child health programmes in developing countries: From targeting diseases to targeting people. Bull. World Health Organ. 2000, 78, 1234–1245. Available online: https://pubmed.ncbi.nlm.nih.gov/11100618/ (accessed on 29 June 2023). [PubMed]
  35. Lee, R.G.; Garvin, T. Moving from information transfer to information exchange in health and health care. Soc. Sci. Med. 2003, 56, 449–464. [Google Scholar] [CrossRef]
  36. Chakona, G. Social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in South Africa. Nutr. J. 2020, 19, 47. [Google Scholar] [CrossRef]
  37. Mushaphi, L.; Mbhenyane, X.; Khoza, L.; Amey, A. Infant-feeding practices of mothers and the nutritional status of infants in the Vhembe District of Limpopo Province. S. Afr. J. Clin. Nutr. 2008, 21, 36–41. [Google Scholar] [CrossRef]
  38. Modjadji, P.; Molokwane, D.; Ukegbu, P.O. Dietary Diversity and Nutritional Status of Preschool Children in North West Province, South Africa: A Cross Sectional Study. Children 2020, 7, 174. [Google Scholar] [CrossRef]
  39. Mamabolo, R.L.; Steyn, N.P.; Alberts, M. Can the high prevalence of micronutrient deficiencies, stunting and overweight in children at ages 1 and 3 years in the Central Region of Limpopo province be explained by diet? S. Afr. J. Clin. Nutr. 2006, 19, 102–113. Available online: http://www.sajcn.co.za/index.php/SAJCN/article/view/146 (accessed on 29 June 2023). [CrossRef]
  40. Mamabolo, R.L.; Alberts, M.; Steyn, N.P.; Delemarre-van de Waal, H.A.; Levitt, N.S. Prevalence and determinants of stunting and overweight in 3-year-old black South African children residing in the Central Region of Limpopo Province, South Africa. Public Health Nutr. 2005, 8, 501–508. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  41. Modjadji, P.; Madiba, S. The double burden of malnutrition in a rural health and demographic surveillance system site in South Africa: A study of primary schoolchildren and their mothers. BMC Public Health 2019, 19, 1087. [Google Scholar] [CrossRef] [Green Version]
  42. Kimani-Murage, E.W. Exploring the paradox: Double burden of malnutrition in rural South Africa. Glob. Health Action 2013, 6, 19249. [Google Scholar] [CrossRef] [PubMed]
  43. Kimani-Murage, E.W.; Kahn, K.; Pettifor, J.M.; Tollman, S.M.; Dunger, D.B.; Gómez-Olivé, X.F.; Norris, S.A. The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children. BMC Public Health 2010, 10, 158. [Google Scholar] [CrossRef] [Green Version]
  44. Seonandan, P.; McKerrow, N.H. A review of infant and young child feeding practice in hospital and the home in KwaZulu-Natal Midlands. S. Afr. J. Clin. Nutr. 2016, 29, 111–115. [Google Scholar] [CrossRef] [Green Version]
  45. Mwangome, M.; Prentice, A.; Plugge, E.; Nweneka, C. Determinants of appropriate child health and nutrition practices among women in rural Gambia. J. Health Popul. Nutr. 2010, 28, 167–172. [Google Scholar] [CrossRef] [Green Version]
  46. Bronfenbrenner, U. Ecological models of human development. Int. Encycl. Educ. 1994, 3, 37–43. [Google Scholar]
  47. UNICEF. Conceptual frameworks. In UNICEF M&E Training Resources; Oxford University Press: New York, NY, USA, 1998. [Google Scholar]
  48. Bronfenbrenner, U. Ecology of the family as a context for human development: Research perspectives. Dev. Psychol. 1986, 22, 723–724. [Google Scholar] [CrossRef]
  49. Darling, N.; Steinberg, L. Parenting style as context: An integrative model. Psychol. Bull. 1993, 113, 487. [Google Scholar] [CrossRef]
  50. Pinquart, M.; Kauser, R. Do the associations of parenting styles with behavior problems and academic achievement vary by culture? Results from a meta-analysis. Cult. Divers. Ethn. Minor. Psychol. 2018, 24, 75. [Google Scholar] [CrossRef] [PubMed]
  51. Contento, I.R. Nutrition education: Linking research, theory, and practice. Asia Pac. J. Clin. Nutr. 2008, 17 (Suppl. S1), 176–179. Available online: https://pubmed.ncbi.nlm.nih.gov/18296331/ (accessed on 29 June 2023). [PubMed]
  52. Hawkes, C.; Smith, T.G.; Jewell, J.; Wardle, J.; Hammond, R.A.; Friel, S.; Thow, A.M.; Kain, J. Smart food policies for obesity prevention. Lancet 2015, 385, 2410–2421. [Google Scholar] [CrossRef]
  53. Miah, R.; Apanga, P.; Abdul-haq, Z. Risk Factors for Undernutrition in Children under Five Years Old: Evidence from the 2011 Ghana Multiple Indicator Cluster Survey. J. AIDS Clin. Res. 2016, 7, 585. [Google Scholar] [CrossRef] [Green Version]
  54. WHO Multicentre Growth Reference Study Group. Complementary feeding in the WHO multicentre growth reference study. Acta Paediatr. 2006, 450, 27–37. [Google Scholar]
  55. Mpumalanga Provincial Government. Municipalities of South Africa; Ehlanzeni District Municipality (DC32). 2012–2022. Available online: https://municipalities.co.za/overview/131/ehlanzeni-district-municipality (accessed on 2 February 2022).
  56. Drigo, L.; Luvhengo, M.; Lebese, R.T.; Makhado, L. Attitudes of Pregnant Women towards Antenatal Care Services Provided in Primary Health Care Facilities of Mbombela Municipality, Mpumalanga Province, South Africa. Open Public Health J. 2020, 13, 569–575. [Google Scholar] [CrossRef]
  57. South Africa Web DHIS. Available online: https://za.dhis.dhmis.org/dhis-web-pivot/index.html (accessed on 23 February 2021).
  58. Raosoft. Raosoft Sample Size Calculator. 2004. Available online: http://www.raosoft.com/samplesize.html (accessed on 2 February 2022).
  59. Tsang, S.; Royse, C.F.; Terkawi, A.S. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J. Anaesth. 2017, 11, S80. [Google Scholar] [CrossRef]
  60. World Health Organization. Guideline: Assessing and Managing Children at Primary Health-Care Facilities to Prevent Overweight and Obesity in the Context of the Double Burden of Malnutrition; World Health Organization: Geneva, Switzerland, 2017. [Google Scholar]
  61. World Health Organization. WHO Anthro for Personal Computers, Version 3.2. 2, 2011: Software for Assessing Growth and Development of the World’s Children; World Health Organization: Geneva, Switzerland, 2010. [Google Scholar]
  62. World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices: Part 1: Definitions: Conclusions of a Consensus Meeting Held 6–8 November 2007 in Washington DC, USA; World Health Organization: Geneva, Switzerland, 2008. [Google Scholar]
  63. Amare, M.; Benson, T.; Fadare, O.; Oyeyemi, M. Study of the Determinants of Chronic Malnutrition in Northern Nigeria: Quantitative Evidence from the Nigeria Demographic and Health Surveys International Food Policy Research Institute (IFPRI) Working Paper 45 (September 2017). Food Nutr. Bull. 2018, 39, 296–314. [Google Scholar] [CrossRef] [PubMed]
  64. Hoffman, D.J.; Sawaya, A.L.; Verreschi, I.; Tucker, K.L.; Roberts, S.B. Why are nutritionally stunted children at increased risk of obesity? Studies of metabolic rate and fat oxidation in shantytown children from Sao Paulo, Brazil. Am. J. Clin. Nutr. 2000, 72, 702–707. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  65. Gribble, J.N.; Murray, N.J.; Menotti, E.P. Reconsidering childhood undernutrition: Can birth spacing make a difference? An analysis of the 2002-2003 El Salvador National Family Health Survey. Matern. Child Nutr. 2009, 5, 49–63. [Google Scholar] [CrossRef] [PubMed]
  66. Tathiah, N.; Moodley, I.; Mubaiwa, V.; Denny, L.; Taylor, M. South Africa’s nutritional transition: Overweight, obesity, underweight and stunting in female primary school learners in rural KwaZulu-Natal, South Africa. SAMJ S. Afr. Med. J. 2013, 103, 718–723. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  67. Mtumwa, A.H.; Paul, E.; Vuai, S.A.H. Determinants of undernutrition among women of reproductive age in Tanzania mainland. S. Afr. J. Clin. Nutr. 2016, 29, 75–81. [Google Scholar] [CrossRef]
  68. Maimela, E.; Alberts, M.; Modjadji, S.E.P.; Choma, S.S.R.; Dikotope, S.A.; Ntuli, T.S.; Van Geertruyden, J.-P. The Prevalence and Determinants of Chronic Non-Communicable Disease Risk Factors amongst Adults in the Dikgale Health Demographic and Surveillance System (HDSS) Site, Limpopo Province of South Africa. PLoS ONE 2016, 11, e0147926. [Google Scholar] [CrossRef] [Green Version]
  69. Mashinya, F.; Alberts, M.; Cook, I.; Ntuli, S. Determinants of body mass index by gender in the Dikgale Health and Demographic Surveillance System site, South Africa. Glob. Health Action 2018, 11, 1537613. [Google Scholar] [CrossRef] [Green Version]
  70. Tydeman-Edwards, R. Obsesity, Undernutrition and the Double Burden of Disease in the Free State. Ph.D. Thesis, University of the Free State, Bloemfontein, South Africa, 2012. [Google Scholar]
  71. Alemu, F.M. Assessment of the impact of malnutrition on children at Dilla referral hospital and unity pediatric clinic, Ethiopia. Int. J. Nutr. Metab. 2013, 5, 105–113. [Google Scholar] [CrossRef]
  72. Dieffenbach, S.; Stein, A.D. Stunted child/overweight mother pairs represent a statistical artifact, not a distinct entity. J. Nutr. 2012, 142, 771–773. [Google Scholar] [CrossRef] [Green Version]
  73. Guthold, R.; Ono, T.; Strong, K.L.; Chatterji, S.; Morabia, A. Worldwide variability in physical inactivity a 51-country survey. Am. J. Prev. Med. 2008, 34, 486–494. [Google Scholar] [CrossRef]
  74. Adienbo, O. High Prevalence of Obesity among Indigenous Residents of a Nigerian Ethnic Group: The Kalabaris in the Niger Delta Region of South-South Nigeria. Greener J. Med. Sci. 2012, 2, 152–156. [Google Scholar] [CrossRef] [Green Version]
  75. Mukora-Mutseyekwa, F.; Zeeb, H.; Nengomasha, L.; Kofi Adjei, N. Trends in Prevalence and Related Risk Factors of Overweight and Obesity among Women of Reproductive Age in Zimbabwe, 2005–2015. Int. J. Environ. Res. Public Health 2019, 16, 2758. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  76. Rothman, M.; Ranneileng, M.; Nel, R.; Walsh, C. Nutritional status and food intake of women residing in rural and urban areas of Lesotho. S. Afr. J. Clin. Nutr. 2019, 32, 21–27. [Google Scholar] [CrossRef]
  77. Steyn, N.P.; Labadarios, D.; Nel, J.; Kruger, H.S.; Maunder, E.M.W. What is the nutritional status of children of obese mothers in South Africa? Nutrition 2011, 27, 904–911. [Google Scholar] [CrossRef]
  78. Perkins, J.M.; Kim, R.; Krishna, A.; McGovern, M.; Aguayo, V.M.; Subramanian, S.V. Understanding the association between stunting and child development in low- and middle-income countries: Next steps for research and intervention. Soc. Sci. Med. (1982) 2017, 193, 101–109. [Google Scholar] [CrossRef] [Green Version]
  79. WHO. Malnutrition; Whorld Health Organization: Geneva, Switzerland, 2021; Available online: https://www.who.int/news-room/fact-sheets/detail/malnutrition#:~:text=Low%20height-for-age%20is%20known%20as%20stunting.%20It%20is,young%20child%20feeding%20and%20care%20in%20early%20life (accessed on 27 June 2023).
  80. Goon, D.T.; Ajayi, A.I.; Adeniyi, O.V. Sociodemographic and lifestyle correlates of exclusive breastfeeding practices among mothers on antiretroviral therapy in the Eastern Cape, South Africa. Int. Breastfeed. J. 2021, 16, 18. [Google Scholar] [CrossRef]
  81. Lee, S.H.; Lee, S.M.; Lim, N.G.; Kim, H.J.; Bae, S.H.; Ock, M.; Kim, U.N.; Lee, J.Y.; Jo, M.W. Differences in pregnancy outcomes, prenatal care utilization, and maternal complications between teenagers and adult women in Korea: A nationwide epidemiological study. Medicine 2016, 95, e4630. [Google Scholar] [CrossRef] [PubMed]
  82. Riva, E.; Banderali, G.; Agostoni, C.; Silano, M.; Radaelli, G.; Giovannini, M. Factors associated with initiation and duration of breastfeeding in Italy. Acta Paediatr. 1999, 88, 411–415. [Google Scholar] [CrossRef]
  83. Pei, L.; Kang, Y.; Zhao, Y.; Cheng, Y.; Yan, H. Changes in Socioeconomic Inequality of Low Birth Weight and Macrosomia in Shaanxi Province of Northwest China, 2010–2013: A Cross-sectional Study. Medicine 2016, 95, e2471. [Google Scholar] [CrossRef]
  84. Koplan, J.P.; Liverman, C.T.; Kraak, V.I. Preventing Childhood Obesity: Health in the Balance; National Academies Press (US): Washington, DC, USA, 2005. Available online: https://pubmed.ncbi.nlm.nih.gov/22379642/ (accessed on 14 June 2023).
  85. Ong, K.K.; Loos, R.J. Rapid infancy weight gain and subsequent obesity: Systematic reviews and hopeful suggestions. Acta Paediatr. 2006, 95, 904–908. [Google Scholar] [CrossRef]
  86. Stewart, C.P.; Iannotti, L.; Dewey, K.G.; Michaelsen, K.F.; Onyango, A.W. Contextualising complementary feeding in a broader framework for stunting prevention. Matern. Child Nutr. 2013, 9, 27–45. [Google Scholar] [CrossRef]
  87. Garrett, J.L.; Ruel, M.T. Stunted child-overweight mother pairs: Prevalence and association with economic development and urbanization. Food Nutr. Bull. 2005, 26, 209–221. [Google Scholar] [CrossRef]
  88. Min, J.; Zhao, Y.; Slivka, L.; Wang, Y. Double burden of diseases worldwide: Coexistence of undernutrition and overnutrition-related non-communicable chronic diseases. Obes. Rev. Off. J. Int. Assoc. Study Obes. 2018, 19, 49–61. [Google Scholar] [CrossRef] [PubMed]
  89. Popkin, B.M. The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Health Nutr. 2002, 5, 205–214. [Google Scholar] [CrossRef] [Green Version]
  90. De Haas, H. Migration and development: A theoretical perspective. Int. Migr. Rev. 2010, 44, 227–264. [Google Scholar] [CrossRef] [Green Version]
  91. Lisanu Mazengia, A.; Andargie Biks, G. Predictors of Stunting among School-Age Children in Northwestern Ethiopia. J. Nutr. Metab. 2018, 2018, 7521751. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  92. Yasmin, G.; Kustiyah, L.; Dwiriani, C.M. Risk factors of stunting among school-aged children from eight provinces in Indonesia. Pak. J. Nutr. 2014, 13, 557. [Google Scholar] [CrossRef] [Green Version]
  93. Mzumara, B.; Bwembya, P.; Halwiindi, H.; Mugode, R.; Banda, J. Factors associated with stunting among children below five years of age in Zambia: Evidence from the 2014 Zambia demographic and health survey. BMC Nutr. 2018, 4, 51. [Google Scholar] [CrossRef] [Green Version]
  94. Forh, G.; Apprey, C.; Frimpomaa Agyapong, N.A. Nutritional knowledge and practices of mothers/caregivers and its impact on the nutritional status of children 6-59 months in Sefwi Wiawso Municipality, Western-North Region, Ghana. Heliyon 2022, 8, e12330. [Google Scholar] [CrossRef]
  95. Debela, B.L.; Demmler, K.M.; Rischke, R.; Qaim, M. Maternal nutrition knowledge and child nutritional outcomes in urban Kenya. Appetite 2017, 116, 518–526. [Google Scholar] [CrossRef]
  96. Gyampoh, S.; Otoo, G.E.; Aryeetey, R.N. Child feeding knowledge and practices among women participating in growth monitoring and promotion in Accra, Ghana. BMC Pregnancy Childbirth 2014, 14, 180. [Google Scholar] [CrossRef] [Green Version]
  97. Ongosi, A.N. Nutrient Intake and Nutrition Knowledge of Lactating Women (0–6) Months Postpartum) in a Low Socio-Economic Area in Nairobi, Kenya. Ph.D. Thesis, University of Pretoria, Pretoria, South Africa, 2010. [Google Scholar]
  98. Negash, C.; Whiting, S.J.; Henry, C.J.; Belachew, T.; Hailemariam, T.G. Association between Maternal and Child Nutritional Status in Hula, Rural Southern Ethiopia: A Cross Sectional Study. PLoS ONE 2015, 10, e0142301. [Google Scholar] [CrossRef]
  99. Saaka, M. Relationship between mothers’ nutritional knowledge in childcare practices and the growth of children living in impoverished rural communities. J. Health Popul. Nutr. 2014, 32, 237–248. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216960/ (accessed on 29 June 2023).
  100. Rohit, A.; Kirkham, R.; McCarthy, L.; Puruntatameri, V.; Maple-Brown, L.; Brimblecombe, J. Exploring differences in perceptions of child feeding practices between parents and health care professionals: A qualitative study. BMC Public Health 2021, 21, 1449. [Google Scholar] [CrossRef]
  101. Modjadji, P.; Seabela, E.S.; Ntuli, B.; Madiba, S. Beliefs and Norms Influencing Initiation and Sustenance of Exclusive Breastfeeding: Experiences of Mothers in Primary Health Care Facilities in Ermelo, South Africa. Int. J. Environ. Res. Public Health 2023, 20, 1513. [Google Scholar] [CrossRef]
  102. Madiba, S.; Modjadji, P.; Ntuli, B. Breastfeeding at Night Is Awesome; Mothers’ Intentions of Continuation of Breastfeeding Extreme and Very Preterm Babies upon Discharge from a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa. Healthcare 2023, 11, 1048. [Google Scholar] [CrossRef]
  103. Bhattacharjee, N.V.; Schaeffer, L.E.; Marczak, L.B.; Ross, J.M.; Swartz, S.J.; Albright, J.; Gardner, W.M.; Shields, C.; Sligar, A.; Schipp, M.F. Mapping exclusive breastfeeding in Africa between 2000 and 2017. Nat. Med. 2019, 25, 1205–1212. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  104. Cuartas, J.; Jeong, J.; Rey-Guerra, C.; McCoy, D.C.; Yoshikawa, H. Maternal, paternal, and other caregivers’ stimulation in low- and- middle-income countries. PLoS ONE 2020, 15, e0236107. [Google Scholar] [CrossRef]
  105. Kristo, A.S.; Sikalidis, A.K.; Uzun, A. Traditional Societal Practices Can Avert Poor Dietary Habits and Reduce Obesity Risk in Preschool Children of Mothers with Low Socioeconomic Status and Unemployment. Behav. Sci. 2021, 11, 42. [Google Scholar] [CrossRef]
  106. Martorell, R.; Zongrone, A. Intergenerational influences on child growth and undernutrition. Paediatr. Perinat. Epidemiol. 2012, 26 (Suppl. S1), 302–314. [Google Scholar] [CrossRef] [PubMed]
  107. Doherty, T.; Sanders, D.; Jackson, D.; Swanevelder, S.; Lombard, C.; Zembe, W.; Chopra, M.; Goga, A.; Colvin, M.; Fadnes, L.T.; et al. Early cessation of breastfeeding amongst women in South Africa: An area needing urgent attention to improve child health. BMC Pediatr. 2012, 12, 105. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  108. Jama, N.A.; Wilford, A.; Masango, Z.; Haskins, L.; Coutsoudis, A.; Spies, L.; Horwood, C. Enablers and barriers to success among mothers planning to exclusively breastfeed for six months: A qualitative prospective cohort study in KwaZulu-Natal, South Africa. Int. Breastfeed. J. 2017, 12, 1–13. [Google Scholar] [CrossRef]
  109. Madiba, S.; Langa, J. Cultural practices interfere with adherence to exclusive infant feeding: A qualitative study among HIV positive post natal women in Hammanskraal, South Africa: Child nutrition and feeding practices. Afr. J. Phys. Health Educ. Recreat. Danc. 2014, 20, 264–278. Available online: https://hdl.handle.net/10520/EJC162272 (accessed on 29 June 2023).
  110. Mphego, Z.; Madiba, S.; Ntuli, B. The influence of the family on adherence to exclusive breastfeeding: Experiences of women living in extended family households in poorly resourced communities of Mpumalanga Province, South Africa: Child nutrition and feeding practices. Afr. J. Phys. Health Educ. Recreat. Danc. 2014, 20, 279–290. Available online: https://hdl.handle.net/10520/EJC162271 (accessed on 29 June 2023).
  111. Ngoma-Hazemba, A.; Ncama, B.; Ahmed, Y. Mothers’ Perception of Infant Feeding Counselling in The Context of Prevention of Mother-to-Child Transmission of HIV in Lusaka, Zambia. Med. J. Zamb. 2015, 42, 58–67. Available online: https://www.ajol.info/index.php/mjz/article/view/130013 (accessed on 29 June 2023).
  112. World Medical Association. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA 2013, 310, 2191–2194. [Google Scholar] [CrossRef] [Green Version]
Table
Table 1. Socio-demography, anthropometry, and obstetric history of mothers.
Table 1. Socio-demography, anthropometry, and obstetric history of mothers.
VariablesCategoriesFrequency
(n)		Percentage
(%)		Median (Range)
Age (years)<30
≥30		250
150		63
37		29 (15–42)
Weight (kg) 73.6 (44–119)
Height (cm) 161.5 (150–171)
BMI (Kg/m2)Normal
Underweight
Overweight
Obesity		105
155
135
5		26
39
34
1		28.2 (19–39)
WC (cm)Normal
Abdominal obesity		374
26		97
3		72 (64–100)
WHtRNormal
Abdominal obesity		243
157		61
39		0.45 (0.39–0.60)
Marital statusSingle
Married
Divorced		292
56
52		73
14
13
Education levelNo education
Primary school
Secondary school
Completed Grade 12
Tertiary		72
50
158
58
62		18
13
40
15
16
Employment statusEmployed
Unemployed		83
317		21
79
Household HeadSelf
Spouse
Parents
Grandparents
Relatives		138
53
183
16
10		35
13
46
4
3
Household income (USD/monthly)<5542
5548–27,710
27,716–55,420
55,426–83,130
>83,130		61
61
109
93
76		15
15
27
23
19
Parity1–2
≥3		277
123		69
31
Number of children1–2
≥3		253
147		63
37
Obstetric complicationsNo
Yes		282
118		70
30
BMI stands for body mass index, WC stands for waist circumference, WHtR stand for weight-to-height ratio, and USD stands for US dollars ($).
Table
Table 2. Characteristics of children.
Table 2. Characteristics of children.
VariablesCategoriesn%
SexBoys
Girls		180
220		45
55
Age (months)0–5
6–11
12–23		155
153
92		39
38
23
Childbirth weight (g)<2500
≥2500		79
321		20
80
Childbirth orderFirst
Middle
Last		91
195
114		23
49
28
Place of birthHome
Clinic
Hospital		47
153
200		12
38
50
g stands for grams.
Table
Table 3. Comparison of children’s nutrition outcomes by sex and age.
Table 3. Comparison of children’s nutrition outcomes by sex and age.
VariablesAll
n (%)		Boys
n (%)		Girls
n (%)		p-Value
LAZ
Normal
Stunting
Tallness		111 (28)
202 (50)
87 (22)		50 (28)
90 (50)
40 (22)		61 (28)
112 (51)
47 (21)		0.975
WAZ
Normal
Underweight
Growth problem		267 (68)
3 (1)
121 (31)		116 (66)
2 (1)
57 (33)		151 (70)
1 (1)
64 (29)		0.595
BAZ
Normal
Thinness
Overweight risk
Overweight
Obesity		61 (16)
16 (4)
51 (13)
50 (13)
213 (54)		21 (2)
10 (6)
22 (13
27 (15)
95 (54)		40 (19)
6 (3)
29 (13)
23 (11)
118 (55)		0.168
Variables0–5 Months
n (%)		6–11 Months
n (%)		≥12 Months
n (%)		p-Value
LAZ
Normal
Stunting
Tallness		66 (43)
72 (46)
17 (11)		34 (22)
98 (64)
21 (14)		11 (12)
32 (35)
49 (53)		≤0.0001 *
WAZ
Normal
Underweight
Growth problem		128 (88)
2 (1)
19 (3)		120 (79)
1 (1)
30 (29)		19 (21)
0
72 (79)		≤0.0001 *
BAZ
Normal
Thinness
Overweight risk
Overweight
Obesity		42 (28)
4 (3)
27 (18)
21 (14)
55 (37)		10 (7)
12 (8)
15 (10)
18 (12)
96 (64)		9 (10)
0
9 (10)
11 (12)
62 (68)		≤0.0001 *
* Stands for significant difference, n stands for number of participants, IQR stands for interquartile range, LAZ stands for length-for-age z-scores, WAZ stands for weight-for-age z-scores, and BAZ stands for body mass index-for-age z-scores.
Table
Table 4. Comparison of child nutrition outcomes and feeding practices by mothers’ knowledge.
Table 4. Comparison of child nutrition outcomes and feeding practices by mothers’ knowledge.
VariablesAll
n (%)		Fair NK
n (%)		Average NK
n (%)		Good NK
n (%)		p-Value
Stunting
No
Yes
111 (35)
202 (65)
41 (45)
50 (55)
59 (31)
130 (69)
10 (53)
9 (47)
0.027 *
Underweight
No
Yes
267 (98)
3 (2)
76 (100)
0
163 (98)
3 (2)
16 (100)
0
0.431
Thinness
No
Yes
62 (79)
16 (21)
19 (83)
4 (17)
36 (78)
10 (22)
6 (86)
1 (14)
0.849
Child overweight/obesity
No
Yes
88
176
19 (19)
82 (81)
35 (15)
203 (85)
6 (26)
17 (74)
0.291
LBW
No
Yes
321 (80)
79 (20)
85 (79)
23 (21)
205 (81)
48 (19)
20 (83)
4 (17)
0.823
Initiation of breastfeeding
Within 1 h
>1 h (delayed)
202 (63)
119 (37)
44 (56)
37 (44)
134 (65)
71 (35)
15 (75)
5 (25)
0.196
Exclusive breastfeeding
No
Yes
261 (70)
108 (30)
79 (77)
23 (23)
158 (69)
72 (31)
15 (65)
8 (35)
0.220
Mixed feeding
No
Yes
120 (30)
277 (70)
35 (32)
73 (68)
76 (30)
175 (70)
4 (17)
19 (83)
0.360
Introduction of
complementary foods
≤3 months
>3 months

144 (48)
158 (52)

41 (47)
46 (52)

86 (45)
104 (56)

11 (65)
6 (35)

0.306
NK stands for nutrition knowledge, LBW stands for low birth weight, * stands for significant difference.
Table
Table 5. Association of stunting with covariates.
Table 5. Association of stunting with covariates.
StuntingCOR (95%CI)p-ValueAOR (95%CI)p-Value
Mother’s nutrition-related
knowledge
Fair
Average
Good

1
1.81 (1.08–3.02)
0.74 (0.27–1.99)


0.024 *
0.548

1
1.92 (1.12–3.29)
0.63 (0.22–1.85)


0.018 *
0.403
Child’s age (months)
0–5
6–11
12–23
1
2.64 (1.58–4.42)
2.67 (1.24–5.71)

≤0.0001 *
0.012 *
1
2.63 (1.53–4.53)
3.19 (1.41–7.25)

≤0.0001 *
0.006 *
Mother’s education
No education
Primary
Secondary
Completed Grade 12
Tertiary
1
0.73 (0.31–1.74)
0.95 (0.48–1.86)
0.36 (0.16–0.80)
0.79 (0.34–1.85)

0.475
0.872
0.013 *
0.592
1
0.90 (0.36–2.27)
1.11 (0.54–2.28)
0.36 (0.15–0.86)
0.75 (0.30–1.85)

0.831
0.783
0.021 *
0.528
COR stands for crude odds ratio, AOR stands for adjusted odds ratio, and * stand for p < 0.05.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Masilela, L.N.; Modjadji, P. Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa. Children 2023, 10, 1294. https://doi.org/10.3390/children10081294

AMA Style

Masilela LN, Modjadji P. Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa. Children. 2023; 10(8):1294. https://doi.org/10.3390/children10081294

Chicago/Turabian Style

Masilela, Lucy Nomsa, and Perpetua Modjadji. 2023. "Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa" Children 10, no. 8: 1294. https://doi.org/10.3390/children10081294

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop