This population-based study provides valuable insights into the prevalence and correlates of underweight and stunting among women of reproductive age (15-49 years) in Sierra Leone (Table 1, Figure 1, and Figure 2). The prevalence of stunting in Sierra Leone, at 1.5%, is higher than that reported in the DHS of Kenya (less than 1%)35, and Uganda (1.3%)30,36 but lower than Tanzania (less than 3%)37.
Stunting among women of reproductive age is a significant concern, as it reflects long-term exposure to inadequate nutrition, infection, and environmental stress38. The consequences of stunting are far-reaching, particularly for girls and women of reproductive age39, and these effects are experienced at individual, community, and national levels40. It is alarming to note that an estimated 450 million adult women in developing countries are stunted due to malnutrition during childhood41.Therefore, addressing stunting among women is crucial for improving maternal and child health outcomes.
Stunting among women of reproductive age (15-49 years) in Sierra Leone from the 2019 DHS. Women with primary level of education were 47% less likely to be stunted compared to those with secondary level of education. Similarly, women in the poorest wealth index were 51% less likely to be stunted compared to those in the middle wealth index. These findings highlight the importance of education and socioeconomic status in mitigating the risk of stunting among women. However, no other factors were found to be significantly associated with stunting in this study population (Table 2).
In contrast, the correlates of being underweight differed from those of stunting (Table 2 and Table 3). Parity of one-to-four and listening to radios were identified as significant factors associated with underweight (Table 2). Women with a parity of one-to-four were 1.48 times more likely to be underweight compared to those who had never given birth. (Table 3). On the other hand, age-groups of 15-19 years and 40-49 years, as well as primary education, were less likely to be underweight. These findings suggest that different factors contribute to underweight compared to stunting among women (15-49 years) in Sierra Leone (Table 3)42.
The underlying reasons for the low likelihood of primary level of education on both stunting and underweight in the study population remain unclear, highlighting the need for in-depth exploration through qualitative research. Conducting qualitative studies would allow for a deeper understanding of the factors and mechanisms that contribute to the observed association between primary level of education and improved nutritional outcomes. By delving into the lived experiences and socio-cultural context of women, qualitative research can provide valuable insights to unravel the complex dynamics at play. Further investigation through qualitative research is warranted to gain a comprehensive understanding of why primary level of education emerges as a protective factor against stunting and underweight in this population.
It is interesting to note that women in the poorest wealth index were less likely to be stunted compared to women in the middle wealth index (Table 2). This finding contradicts many studies conducted in other African countries where stunting is more prevalent among women in the poorest wealth indices30,36,43.
Studies on stunting among children in Sierra Leone from the same 2019 SLDHS shows a high prevalence of stunting among children below five years44. However, our findings that women in reproductive age-group (15-49 years) from the same data source (2019 SLDHS) had no likely association with any age-group was unique while children below five years experienced high prevalence of stunting (31.6% in rural versus 24.0% in urban areas)44.
The unique finding in Sierra Leone necessitates further investigation to explore the underlying factors contributing to this difference. It is plausible that low-income households have adopted favorable eating habits and practices, such as the consumption of locally available foods like plasas. Plasas, a mixture of green leaves with palm oil and fish, is not only affordable but also highly nutritious. Understanding the dietary choices and affordability of nutritious foods among low-income households could provide valuable insights into the observed findings.
Stunting is a chronic condition that begins during the prenatal period and persists through early childhood and adolescence, with the first two years of life being particularly critical37,43. Previous studies have highlighted the high prevalence of stunting among women of reproductive age in low-to-middle income countries, as stunted children often continue to experience stunting into adulthood44,45. However, it is important to note that some individuals who were stunted in childhood managed to overcome these challenges by accessing education, obtaining better employment opportunities, increasing their income, or marrying into higher socioeconomic strata. As a result, they may have transitioned from lower to higher wealth indices, indicating the potential for social mobility and improvement in their overall well-being. This socioeconomic progress achieved by these women may have played a role in the observed outcome of low socio-economic status being unlikely for undernutrition.
In addition, many studies show that the use of improved drinking-water was associated with lower risk of stunting and that improved water was a proxy for less exposure to enteric pathogens46. Watanabe and Petri discussed that environmental enteropathy is a chronic disease caused by continuous exposure to faecally contaminated food and water that does not produce symptoms but contributes to poor physical development46. This may have been a factor experienced among populations in other countries but not in Sierra Leone.
These findings on stunting among women in Sierra Leone contrasts with another in Uganda where the population in Southwestern northeastern (pygmies and Batwa) were found to be naturally shorter compared to the average Ugandan population47,48,49. More to this could be explained by genetic factors which play part at individual level where it is likely that women in the reproductive age in Sierra Leone were generally taller because of their genetic makeup12. A contrasting scenario was observed in western Uganda among the pygmies and others who were generally shorter compared to the average Ugandan population30,47,48. However, the situation can be determined further by conducting more comprehensive studies on the height profiles of women in Sierra Leone over several decades to determine the changing patterns of women’s heights stratified by regions of the country.
Also, one of the insignificant factors of stunting was age-group of 15-19 years which is linked to an age-group where there is rapid growth, increased activities, and high need for adequate nutrients (Table 2). The need for adequate nutrients and diet are paramount for the growth and development of persons in that age category. Our findings that there were no associated factors of stunting with women in specific age-group and poor household wealth indices were inconsistent with literatures from Bangladesh and other countries49-54.
Adult heights are mainly determined by genetic predilections and environmental factors51. In addition to genetic impacts, incomes, social status, infections, and nutrition have been shown to affect body height in European population54. Environmental factors are likely to be more important determinants of height in low-and-middle-income countries because environmental stress including food availability and infections are higher in those countries compared to high-income countries51,52.
Perkins et al. explained in their review that short adult stature in low-and-middle-income countries is mainly because of the cumulative net impact of nutrition associated with disease and environmental conditions, such as socio-economic status50.
The correlates of stunting and underweight among women in the reproductive age (15-49 years) in Sierra Leone were different and has raised our concerns (Table 1, Table 2). Many factors singly or collectively contribute to underweight and stunting including eating patterns, food types, their availability, infections, diseases, physical activity levels, and sleep routines5,6. In addition to social determinants of health, genetics, and taking certain medications have been shown to play important roles in undernutrition in a population5,6,10,55.
If compared with overweight and obesity, they are mainly caused by food consumption and activities where people gain weight when they eat more calories than they burn through daily activities55,56. Also, environmental factors around us matter in the development of obesity and overweight, just like stunting and underweight56. The world around us influences our ability to maintain a healthy weight and lifestyle56. That has been seen in many African communities where people who are obese are considered healthy and living a prosperous and fulfilling life, an issue which is admired by women in many African communities56.
On the other side of the spectrum, some communities have begun to admire smaller sizes and equate it to successful and healthy lives. In this, several blue colored individuals have begun to reduce their sizes by conducting regular exercises, eating organic foods, fasting, eating less of fast foods, less snacking, taking less salts and sugars, living less sedentary lifestyle, riding bicycles or walk to work, sleeping better, avoiding stressful and mental health situations56.
What is perhaps most interesting from this study is that correlates of underweight and stunting among women in Sierra Leone were different; a factor that should be determined through a comprehensive study, unearthing the underlying reasons. This contrasts with many studies in the African continent30,35,36,37,39.
Chronic effects of malnutrition in early childhood due to inadequate nutrients and unavailability food is reflected in later life by stunting and other lifelong consequences such as reduced cognitive function, maternal and child health complications which we did not find in this study population (Table 2).
It is important that these correlates of stunting are addressed in Sierra Leonne’s women if improvement in maternal and child health’s indicators are to be achieved soon in this country57. Feeding habits, diets, and availability of food for young women population in Sierra Leone are prioritized as soon as possible since many young women in the reproductive age are affected by stunting and underweight (Table 1 and Table 2).
In addition, early childhood nutrition programs (for example, school feeding programs) could be a welcome intervention for the school going female children.
It is worth noting that there is limited literature available on stunting among women of reproductive age in Sierra Leone, with most studies focusing on underweight. Therefore, the findings of this study contribute to filling this knowledge gap.
Strengths and limitations of this study: This study has several strengths. First, data quality of this study was assured as the 2019 SLDHS used a well-trained field personnel, standardized protocols, and validated tools in data collection processes. Second, this study utilized a nationally representative sample population of women in the reproductive age of 15-49 years. As a result, findings of the study can be generalizable to the target population in Sierra Leone and many low-to-middle income countries in the African continent. Third, the use of validated tools and calibrated instruments by the 2019 SLDHS, the generated estimates are more robust than other studies in Sierra Leone’s context. In addition, we used data with a large sample size which was collected, entered, and cleaned by a team of well trained and highly experienced scientists, thus limiting mistakes in the dataset used in the analysis. Finally, as we used concentration index, these findings are more robust in predicting socio-economic inequalities among the study population.
However, the study had limitations which warrant further discussion. First, the 2019 SLDHS was a cross-sectional survey. As a result, we cannot establish a sequential relationship between explanatory and outcome variables. Second, due to the absence of some important data, several significant variables, such as food security and dietary diversity, could not be included in the final model for the analysis. Third, the 2019 SLDHS did not collect individual incomes and expenditures but household data. It used a wealth index as a proxy indicator for household wealth. Fourth, SLDHS collected data only on 15–49 years old women of reproductive age in Sierra Leone. With the current changes in adolescents' reproductive actions and behaviors, there are children less than 15 years who have gone through a full cycle of reproduction. As a result, the distribution of undernutrition among women below and beyond this age group (15-49 years) were not factored in the analysis. Finally, most data on predictors of undernutrition were based on self-reported information and were not verified through records which risks socially acceptable answers hence social desirability bias in this result.
Generalizability of the results: Results from this study can be generalized to women in reproductive age (15-49 years) in resource settings in low-to-middle-income countries.