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Lifetime economic impact of the burden of childhood stunting attributable to maternal psychosocial risk factors in 137 low/middle-income countries
  1. Mary C Smith Fawzi1,
  2. Kathryn G Andrews2,
  3. Günther Fink3,
  4. Goodarz Danaei2,4,
  5. Dana Charles McCoy5,
  6. Christopher R Sudfeld2,
  7. Evan D Peet6,
  8. Jeanne Cho Cho7,
  9. Yuanyuan Liu8,
  10. Jocelyn E Finlay9,
  11. Majid Ezzati10,
  12. Sylvia F Kaaya11,
  13. Wafaie W Fawzi2,4,12
  1. 1 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  3. 3 Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
  4. 4 Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  5. 5 Harvard Graduate School of Education, Cambridge, Massachusetts, USA
  6. 6 RAND, Pittsburgh, Pennsylvania, USA
  7. 7 Sala Institute for Child and Family Centered Care at NYU Langone Health, New York City, New York, USA
  8. 8 Health Science Center, University of Texas School of Public Health, Houston, Texas, USA
  9. 9 Harvard Center for Population and Development Studies, Harvard TH Chan School of Public Health, Cambridge, Massachusetts, USA
  10. 10 Department of Epidemiology and Biostatistics, MRC-HPA Centre for Environment and Health, Imperial College London, London, UK
  11. 11 Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  12. 12 Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Mary C Smith Fawzi; mary_smith-fawzi{at}


Introduction The first 1000 days of life is a period of great potential and vulnerability. In particular, physical growth of children can be affected by the lack of access to basic needs as well as psychosocial factors, such as maternal depression. The objectives of the present study are to: (1) quantify the burden of childhood stunting in low/middle-income countries attributable to psychosocial risk factors; and (2) estimate the related lifetime economic costs.

Methods A comparative risk assessment analysis was performed with data from 137 low/middle-income countries throughout Asia, Latin America and the Caribbean, North Africa and the Middle East, and sub-Saharan Africa. The proportion of stunting prevalence, defined as <−2 SDs from the median height for age according to the WHO Child Growth Standards, and the number of cases attributable to low maternal education, intimate partner violence (IPV), maternal depression and orphanhood were calculated. The joint effect of psychosocial risk factors on stunting was estimated. The economic impact, as reflected in the total future income losses per birth cohort, was examined.

Results Approximately 7.2 million cases of stunting in low/middle-income countries were attributable to psychosocial factors. The leading risk factor was maternal depression with 3.2 million cases attributable. Maternal depression also demonstrated the greatest economic cost at $14.5 billion, followed by low maternal education ($10.0 billion) and IPV ($8.5 billion). The joint cost of these risk factors was $29.3 billion per birth cohort.

Conclusion The cost of neglecting these psychosocial risk factors is significant. Improving access to formal secondary school education for girls may offset the risk of maternal depression, IPV and orphanhood. Focusing on maternal depression may play a key role in reducing the burden of stunting. Overall, addressing psychosocial factors among perinatal women can have a significant impact on child growth and well-being in the developing world.

  • psychosocial
  • risk factors
  • childhood stunting
  • depression
  • maternal education
  • intimate partner violence
  • orphanhood

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  • Handling editor Seye Abimbola

  • Contributors MCSF drafted the manuscript and contributed to study concept and design, statistical analysis and interpretation of data. KGA conducted the statistical analysis, drafted the manuscript and contributed to study concept and design as well as interpretation of data. GF and GD contributed to study concept and design, drafting the manuscript, statistical analysis and interpretation of data. DCMC, EDP, JC, YL and JEF contributed to drafting the manuscript and interpretation of data. CRS, ME, SFK and WWF contributed to study concept and design, drafting the manuscript and interpretation of data. WWF obtained funding for the study. All authors had full access to the data (including statistical reports and tables) and take responsibility of the integrity of the data and the accuracy of the data analysis.

  • Funding Grand Challenges Canada (No 0073-03) funded the research.

  • Disclaimer The funder was not involved in any aspect of the study design, data analysis and interpretation, writing the report, or the decision to submit the article for publication. All authors are independent of the funder.

    The content is solely the responsibility of the authors and does not necessarily represent the official views of the Cancer Prevention and Research Institute of Texas.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Data for the current study are at the aggregate level and no individual-level data are analysed. Therefore, institutional review board approval is not required for this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are freely available upon request.

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