Trends and determinants of childhood stunting and underweight in Sri Lanka.

INTRODUCTION: Child undernutrition is a major risk factor for child mortality and adult ill-health. Despite substantial progress in most health indicators, undernutrition remains high in Sri Lanka, with recent trends being unclear, owing to methodological differences in national surveys. METHODS: This study uses data from the 1987, 1993, 2000 and 2006-07 Demographic and Health Surveys (DHS) and the 2009 Nutrition and Food Security Survey (NFSS) to investigate trends and determinants of child undernutrition in Sri Lanka. The prevalence rates of stunting, underweight and wasting were re-estimated using the 2006 WHO growth standards to ensure consistency. Multivariate regression analysis was then undertaken to analyse the determinants of height-forage in children aged 9-23 months, and 24-59 months, and the relative impact of key factors was assessed using prediction models. RESULTS: Stunting and wasting substantially improved from 1987 to 2000, but rates stagnated from 2000 to 2006/07. Whilst economic inequalities in under nutrition were greater than in most other countries, the multivariate analysis found that maternal height, household wealth, length of breast-feeding and altitude are significant determinants of stunting, but differences in child feeding practices and other factors were not. Of these, maternal height and household wealth had the most influence. CONCLUSION: The results are consistent with the finding that food insecurity is the main driver of undernutrition, but more research is required to validate this. The strong relationship of child height with maternal height suggests that epigenetic factors, proxied by short maternal height, constrain the applicability of the WHO growth standards in Sri Lanka.

Trends, inequalities and determinants of low birth weight in Sri Lanka.

INTRODUCTION: This study analyses the DHS 1993, 2000 and 2006-07 and NFSS 2009 survey data to investigate trends, inequalities and determinants of low birth weight (LBW) in Sri Lanka. METHODS: We re-evaluated recent trends in LBW incidence, adjusting for changes in the coverage of DHS surveys to ensure comparability, and used multivariate logistic regression to investigate determinants. We quantified the degree of economic inequality using wealth and concentration indices, and assessed the contribution of determinants to inequality by decomposition. RESULTS: There was a continuing, but slowing decline in LBW incidence, reaching 17% during 2001/02-2006/07, whilst very low birth weight incidence declined from 0.9% to 0.6%. Concentration indices reveal persistent, large economic inequalities in LBW incidence. Maternal body mass index (BMI), height and education, altitude and Indian Tamil ethnicity were the major determinants of LBW, with supply of 'Thriposha' having no significant impact. Accounting for maternal BMI and height largely eliminates the impact of economic status, and reduces the impact of ethnicity. Decomposition analysis reveals the major contributors to the inequalities are maternal BMI (21%), height (12%) and education (14%), ethnicity (9%) and altitude (7%). CONCLUSIONS: The results imply that food insecurity mediates the association of LBW with poverty, and is the major amenable risk factor. The impact of maternal height and Indian Tamil ethnicity suggests that epigenetic mechanisms play a role, and that reductions in LBW incidence will take considerable time. There is a need to substantially improve the effectiveness of interventions to reduce LBW in coming generations.

Fertility transition in Sri Lanka: programme and non-programme factors.

PIP: During the past 4 decades, Sri Lanka has experienced significant changes in the level and pattern of fertility. The total fertility rate and crude birth rate showed a steady decline, and age specific fertility rates have shown continuous declines in fertility in all age groups. This is attributed to a host of program and non-program factors, which have been in operation in Sri Lanka and facilitated the development of the social environment in which reduced fertility is an important demographic trend. This paper examines these factors under several distinctive areas. With regard to program factors, the areas of policy environment and strategies, institutional development, managerial processes, and contraceptive services are examined. In the context of non-program factors, the areas examined include participation of nongovernmental organizations, socioeconomic development, rise in age at marriage, induced abortion, breast-feeding, and decline in fertility. Overall, it is noted that in the Sri Lankan experience social development policies and programs have been accompanied by the commitment and dedication of health personnel and population planners who brought about the desired changes in fertility.^ieng

Emerging population issues among adolescents and youth.

The authors "examine the emerging population issues of adolescents and youth [in Sri Lanka]. The demographic pressures have resulted in the expansion of the numbers in this age category which in turn has caused problems of employment creation. The educational expansion has brought about changes in the age at marriage and life styles, which in turn has created the need for greater attention on reproductive health issues among adolescents and youth."

Demographic implications of health care in Sri Lanka.

PIP: This article describes changes in population size, structure, and growth in Sri Lanka. The population aged under 15 years was 37% of total population in 1946, peaked at almost 42% in 1963, and declined to 31% in 1991. The age structure is the result of population growth patterns during 1946-91. The peak in 1963 and high rates of growth were due to improved mortality, effective application of DDT in malaria areas, improved health care, improved agricultural production, subsidized distribution of food, and expanded free education. The population growth rate declined primarily due to a decline in fertility. During 1980-93 the total fertility rate declined at an average annual rate of 4.0%. Fertility decline was strongly influenced by increased age at marriage and contraceptive prevalence. The mean age at marriage increased from 20.7 years in 1946 to 25.5 years in 1993. The contraceptive prevalence rate increased from 32.0% in 1975 to 66.1% in 1993. Fertility decline was initially influenced strongly by changes in nuptiality. After the early 1970s, fertility decline was primarily due to declines in marital fertility. During 1972-82, 75% of fertility decline was accounted for by contraceptive use. Given the present trends in fertility, mortality, and international migration, it is expected that Sri Lanka will increase in population size from 18.2 million in 1995 to 22.4 million in 2020. Stabilization of population is likely to occur around 24 million by 2050. Population size at stabilization would be 33% greater than present levels. Population age structure will continue to change. By 2030, the aging process will accelerate, and the working-age proportion will expand. The demands of this expanded population will be on health care services, employment, housing, and food. The demands on health care would be the greatest among persons aged 45-49 years.^ieng

Sex preference in South Asia: Sri Lanka an outlier.

PIP: At a 1994 symposium on sex preference in Asia, represented countries were grouped as follows: a) rapid fertility decline, strong son preference, and abnormal sex ratio at birth (China, Taiwan, and the Republic of Korea); b) rapid fertility decline, no son preference, and normal sex ratio at birth (Indonesia, Sri Lanka, and Thailand); and c) slow fertility decline, strong son preference, and normal sex ratio at birth (Bangladesh, India, and Pakistan). This article reviews the factors responsible for strong son preference in Bangladesh, India, and Pakistan and the reasons for the lack of son preference in Sri Lanka. Abnormal sex ratios are attributed to sex-selective abortions. Sex preference in South Asia results in excessive mortality of female children. Mention is made of a higher mortality risk of daughters in Indian households with more older female children. Bairagi is cited for his evidence that in Bangladesh daughters having older sisters have a higher mortality risk. In Pakistan survey results indicate that sons are preferred. Numerous authors are cited for evidence suggesting that fertility might be lower if son preference were reduced. Rajaretnam and Deshpande are cited for findings that contraceptive prevalence in south India would increase by about 12% in high-prevalence areas and about 25% in low-prevalence areas in the absence of sex preference. Bourne and Walker and Das Gupta are identified as authors providing evidence that increased economic opportunities for women, increased women's status, and increased value placed on women's work would reduce the desire for sons. Cain argues for better old-age security and better access to food and medical care. Abeykoon has shown that weakened son preference in Sri Lanka occurred over a 20-year period as improvements were made in women's status. Parents in Sri Lanka give greater value to the small-family norm than to the sex of the child. A slight preference was found in 1975 and 1992. Discrimination in food and medical care in Sri Lanka was apparent only prior to 1962. Sri Lankan women have experienced rapid expansion of literacy and educational attainment, improved life expectancy, and wide economic involvement. Women in Sri Lanka are also less vulnerable to oppression within the family.^ieng

Continuation and effectiveness of programme and non-programme methods of family planning in Sri Lanka.

"The objective of this paper is to examine continuation and effectiveness of contraception based on a 1986 survey of more than 3,200 women in rural Sri Lanka. Data on both programme and non-programme methods of contraception are analyzed. Programme methods are defined as including all those methods that are provided through the public or private family planning programmes (namely, oral pills, IUDs, injectables, condoms, female barrier methods and sterilization). Non-programme methods refer to those that are not provided through any structured programme; these methods include calendar rhythm (commonly referred to as 'safe period' in Sri Lanka), withdrawal, abstinence and other traditional methods."

Population, environment and sustainable development.

PIP: The present population of Sri Lanka (17.7 million) is sufficient to create concern about the use, limitations, and waste of natural resources. Between 1871 and 1946, the population grew at an average rate of 1.4% annually, with high fertility and mortality. The population doubled between 1946 and 1981, and mortality declined. Between 1971 and 1991, the rate of growth declined due to a decrease in fertility and an increase in emigration. With a growth rate of 1.4%, the population will again double to 35 million by 2040. Technological improvements in Sri Lanka have led to an eight-fold increase in metric tons of rice production, but the growth in population has caused a deficiency in output so that basic per capita caloric requirements are not being met. Increased productivity has almost depleted the area available for cultivation, and the use of fertilizers to increase yields has environmental drawbacks. The high fertility of the 1970s contributed to increased labor force participation rates of 2.2%, which resulted in more people joining the labor force than leaving. Thus, the employment market has been unable to absorb the unemployed or potential new workers. Growth of the employment market may also conflict with environmental protection, as exemplified by the mining of the coral reef on the southwestern coast. The conversion of forests to agriculture resulted in forest losses of about 42,000 hectares per year during 1956-83. Deforestation is also occurring in the high forests due to increased pressure for fuelwood. In the wet zone, the use of forests for fuelwood is declining, but rubber wood is being harvested for industrial production. In order to slow population growth to replacement levels by the year 2000 (with a total population of 25 million), contraceptive prevalence must be increased to 72% at a cost of about $25 million.^ieng

Ethnic models of fertility behaviour in Sri Lanka.

PIP: Ethnic differences in fertility behavior confirm that socioeconomic variables exert a strong influence on demographic and family planning variables in developing countries such as Sri Lanka. To explain the effects of ethnicity on fertility behavior, predictive path models were developed for the 4 ethnic groups in Sri Lanka--Sinhalese, Tamils, Moors, and Indian Tamils. The path models used in developing predictive models utilized a series of ordinary least squares regression equations. The data were drawn from the 1982 Contraceptive Prevalence Survey. Current residence had direct negative effects on education for all 4 ethnic groups, with women in urban areas achieving higher levels of education than those in rural or estate areas; current residence further had a direct positive effect on husband's occupation, with higher socioeconomic status reported for women from urban areas. Age at marriage--the most important determinant of children ever born-- had strong negative effects on fertility for all ethnic groups, but the effect was most marked among Sri Lankan Tamils. Contraceptive knowledge had the same effect on the effectiveness of contraceptive use in all ethnic groups, suggesting that informational campaigns would enhance the decline of fertility in the country as a whole. 47% of the variance in additional children desired was explained by children ever born (negative effect), ideal family size (positive effect), and child mortality (positive effect). 11% of the variance in contraceptive usage was contributed by education (positive effect), children ever born (positive effect), and husband's occupation (negative effect), while 24% of the variance in effectiveness of contraceptive use was explained by additional children wanted (negative effect) and contraceptive knowledge (positive effect). Overall, these findings suggest that socioeconomic assimilation, with consequent higher levels of education, will facilitate more modern behaviors such as later age at marriage and increased use of effective contraception among ethnic minorities in Sri Lanka.^ieng