A mixed-methods study of the drivers of stunting reduction among children under-5 in Sierra Leone, 2005-2017

Childhood stunting prevalence declined dramatically in Sierra Leone after the end of the civil war in 2002, despite major challenges of postwar recovery and the West Africa Ebola epidemic in 2014-2016.

This study aims to identify the factors associated with declining stunting prevalence among children under-5 in Sierra Leone between 2005 and 2017.

Mixed methods including literature review, primary qualitative research, narrative policy and program review, and secondary analysis of household survey data on children under-5 with valid height-for-age z-scores (HAZ) (n = 4915 in 2005, n = 7736 in 2010, and n = 11,447 in 2017), including Oaxaca-Blinder decomposition analysis.

Under-5 stunting prevalence declined from 46.9% in 2005 to 26.4% in 2017 and mean HAZ increased from -1.75 to -1.13, with some narrowing of inequalities in child growth by wealth, maternal education, and sex, but not between urban and rural children. Stakeholders highlighted several policies and programs that evidenced government commitment to improving maternal and child health and nutrition and likely contributed to improved child growth over time, including the Free Health Care Initiative introduced in 2010. Our quantitative modeling predicted only 29% of the observed 0.62 HAZ increase over the study period but highlighted expanded coverage of antenatal care, increased urbanization, and increased household wealth as key drivers of nutritional change over time.

Rapid reduction in under-5 stunting in Sierra Leone coincided with strong economic growth and declining urban poverty, along with high-profile health and development policies supported by external partners that targeted and/or benefited poorer and rural populations especially. Had the Ebola and COVID-19 epidemics not occurred, positive pre-2014 trajectories in child growth and other maternal and child health and nutrition outcomes in Sierra Leone may well have continued, yielding gains even larger than those observed over the study period.