Impact of Maternal Conditions on The Nutritional Health of Children in India

Background: The 2020 Global Nutrition Report by UNICEF highlights the high rate of deaths among children under five years of age, with India being one of the top five countries. Studies suggest that more than half of these early child deaths are attributable to malnutrition and its associated diseases, particularly in the case of countries with extreme poverty, scarcity of essential resources, lack of appropriate education, and wide disparities of wealth.


Introduction
Children malnutrition, like many other health outcomes, forms a multifaceted problem appear in triple burden namely undernutrition, micronutrient deficiencies, and overweight or obesity [1]. Malnutrition in its all forms primarily occurs due to the lack of nutritional adequacy in terms of limited or absence of consumption of diverse nutrients on a regular basis, characterized as imbalanced or bulky diet [2][3][4]. Malnutrition or lacking nutritional diet impairs the activity of immune cells and antibodies (HARVARD, tackle infectious diseases such as acute respiratory infections and diarrheal diseases, alongside with weight loss, mucosal damage, invasion by pathogens and further cause reduced dietary intake which could hamper a child's growth and overall development [5,6]. Furthermore, the prevalence of malnutrition in a child might result in mental illness including eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) [7][8][9], and malabsorption and maldigestion of the food consumed [10,11]. Consequently, malnutrition in a child, if not addressed appropriately, could lead to severe damage to a child's health and even mortality. Hence, malnutrition gets regarded as one of the major impediments to child well-being affecting all areas of a child's physical and mental health, body immunity, growth, and development [12,13].
The adverse consequences of malnutrition on health status of children compel us to understand the influencing factors of malnutrition in children. Existing literature demonstrates malnutrition and its associated diseases to occur due to factors like maternal health, faulty childcare, less access to health care facilities, lack of sanitation, and hygienic facilities and large economic disparities [14][15][16][17]. In this paper we investigate the maternal factors that influence the dietary adequacy and further, nutritional status of children. Evidence shows that maternal adverse physical health associated diseases such as anemia during pregnancy are strongly associated with a child's poor nutritional status and developmental outcomes [18,19]. Maternal malnutrition poses serious health effects on fetus or intrauterine growth retardation and increase the risk of poor pregnancy outcomes such as premature or low-birthweight babies and impairs the innate host defense mechanism, and further, diminishing the immune system of the body. This in turn leads to increasing susceptibility to infections associated with decreasing appetite, and consequently, causing child's poor dietary intake which aggravate the risk of malnutrition in a [20][21][22][23]]. Moreover, a child's dietary pattern, particularly at the young age, is primarily similar to the maternal dietary intake in a household [24]. Hence, due to this similarity in dietary patterns consumption, a malnourished mother with restricted nutritious or poor-quality dietary pattern strongly increases the risk of poor nutritional dietary consumption of a child and further increase the risk of malnutrition and its associated diseases in every phase of the childhood life [25,26]. Studies also emphasize the importance of maternal education as an essential intervention in promotion of a child's optimal health outcomes and nutritional status [27].
While several studies highlight the general determinants in maternal characteristics for children, existing literature lacks an empirical investigation on details of the maternal influencing factors including inequalities in terms of maternal health, healthcare activities, and maternal knowledge. This study attempts to address this gap and specifically explore the influence of inequalities in maternal characteristics in association with factors such as gender, wealth index, and child's anthropometric measurements on the nutritional status of a child, in the context of India. Dietary Diversity Score (DDS) forms the indicator for nutritional adequacy status. Dietary Diversity is defined as the number of different foods or food groups consumed in the previous day [28].

Materials and Methods
DDS was calculated by summing the number of times a unique food group was consumed during the last 24 hours. Food groups considered were cereals/roots, vegetables, fruits, legumes/lentils, high protein food, and milk/dairy products. DDS takes into account the quantity of any food group eaten that day. In other words, DDS gets calculated by considering the number of times a food group is eaten that day and not considers a minimum intake for that food group. The DDS ranges from 0 to 6. As an effective indicator of nutritional status, DDS forms the dependent variable in our study.
The independent variables in the study have been presented in Table 1.

Statistical Analysis
Multiple Linear Regression (MLR) analysis investigates the association between the DDS and the independent variables presented in Table 1. The assumptions of normality, linearity and homoscedasticity were checked in order to ensure the validity of all the regression models. Further, as the number of variables is high, Akaike Information Criteria (AIC) was used to narrow down to a set of uncorrelated variables, thereby avoiding the issue of multicollinearity. Backward and forward stepwise regression analysis on all the variables with DDS as the dependent variable gave 78 variables as uncorrelated and has some influence on DDS.
To address the research objective of the present study we adopted the variables presented in Table 1, among the 78 independent variables. Moreover, to ensure that the stepwise regression extracted variables were uncorrelated, bivariate correlation analysis was run as well. The correlation analysis suggested no significant correlation between any pair.

Result
Three regression models were constructed to understand the interaction of the variables (Table 1)  represented by an overall model and second, through the interaction of independent variables with various sub-groups of children through DDS. These sub-groups include gender and anthropometric measurements (height for age, weight for height, weight for age). The independent variables are regressed with DDS of 1,40,471 children.

Discussion
An overall significant relationship exists between a maternal physical health in terms of mother's anthropometric measurements including height, weight, and arm circumference, and the child's nutritional diversity. While the mother's level of anemia (long term health status) does not significantly impact the child height and weight, but the maternal anthropometric measurements are significantly related to indicators of her nutritional status which in turn exclusively indicates a child's nutritional status.
Maternal weight and DDS of children belonging to high wealth index households have a positive significant association. High wealth index contributes to better diet quality due to affordability of varied diverse food. Thus, inclusion of diverse nutritional food in a mother's diet, significantly increases the likelihood of a child consuming these nutrients, which would eventually lead to a better DDS [40,41]. However, in case of low wealth index households, even Postnatal care ensures a baby's optimal care as well as the health practices like vaccination. This contributes to improving a child's health with positive long-term consequences.
Maternal education is significantly positively associated with a child's DDS. Maternal education influences a positive attitude towards health-seeking behaviour including awareness of child's immunization, causes of illness, and essential awareness of prevention, and treatment of diseases. Therefore, maternal knowledge regarding nutritious diet also significantly helps to maintain a child's heath.

Conclusion and Implications
The findings together clearly bring out the fact that the Lastly, the results contends that a mother's accessibility to healthcare facilities have a considerable impact on a child's DDS as it helps in tackling various health issues that might lead to poor nutritional intake and hence poor DDS. Thus, health policies nationwide must lay an exclusive focus on providing better accessibility to healthcare facilities for women in order to improve the nutritional intake of a child. Hence, in the essence our study contributes to the health policy by implying the importance of maternal health and education, proper environmental condition, and better accessibility to health care facilities in ensuring better nutritional intake of children and thus, tackling the alarming situation of malnutrition in India.