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Stunting Reduction in Nigeria

Overview

The University of Ibadan, in partnership with the Centre for Global Child Health at the Hospital for Sick Children (SickKids), conducted research to identify key factors to reduce stunting in Nigeria. This research followed a convening of Nigerian governors in November 2019, organized with the Aliko Dangote Foundation and the Gates Foundation. During this meeting, participants expressed interest in collaborating with Exemplars in Global Health to undertake a subnational research study aimed at accelerating progress in stunting reduction in Nigeria. The resulting project generated actionable findings for a wide range of stakeholders in Nigeria and was shared at the National Nutrition Data and Results Conference in Abuja in October 2022.

Despite strong economic growth, declines in stunting prevalence in Nigeria have not matched expectations. From 1990 to 2018, Nigeria’s GDP per capita increased by 250%, from US$568 to US$2,028.1 However, during the same period, the national stunting rate fell by just over 5 percentage points, from 43.1% to 36.8%.2

Figure 1: Nigeria Stunting prevalence and GDP per capita from 1990 - 2018

Figure 1: Nigeria Stunting prevalence and GDP per capita from 1990 - 2018
The World Bank, The Organization for Economic Co-Operation and Development (OECD) GDP per capital (current US$): Demographic and Health Surveys 2008 and 2018

Many Nigerian states have faced challenges in translating their economic growth into tangible improvements in child growth and development. In these “opportunity” states, the prevalence of stunting actually increased slightly, from 42% in 2008 to 43% in 2018 .3,4 Understanding the specific barriers faced by these states is critical, as they highlight clear areas for action to reduce malnutrition. The most significant challenges identified through our analysis are detailed in the Challenges section.

Progress in reducing stunting has varied substantially across the country. While national-level improvements have been limited, some states have achieved much faster reductions in stunting. These “Exemplar” states—defined as those with an average annual reduction in stunting prevalence greater than 0.8% between 2008 and 2018—saw stunting rates fall from 37% to 24%.3,4 The experiences of these states offer valuable insights into effective strategies for addressing child malnutrition.

Because of this variation, our research focused on the period between 2008 and 2018 to identify lessons from Exemplar states and explore how these approaches can be adapted to improve nutrition and advance other human development priorities across Nigeria.

Figure 2: Identification of Exemplar and Opportunity states in Nigeria

Figure 2: Identification of Exemplar and Opportunity states in Nigeria
Demographic and Health Surveys 2008 and 2018

Why did we study Nigeria and its Exemplar states?

Stunting remains a major challenge for low- and middle-income countries. Although global stunting rates have declined, progress has been uneven, and many countries are not on track to meet global targets. Nevertheless, some countries have made remarkable reductions in stunting among children under five—beyond what would be expected based on economic growth alone.

To support government stakeholders in addressing malnutrition, the Exemplars team conducted research to identify key drivers of stunting reduction and variation between countries. Initially focused on national-level analyses, the research later expanded to subnational studies. This approach revealed that, despite limited progress at the national level, some states achieved substantial reductions in stunting. By studying these “bright spots,” we can uncover effective, context-specific strategies to improve nutrition.

As part of this effort, the Exemplars team examined stunting reduction in Nigeria, where progress has varied across states. Collaborative research by the University of Ibadan, SickKids, and Exemplars in Global Health focused on three central questions:

  • Do differences between Exemplar and opportunity states reveal actionable lessons about best practices and policies that drove progress?
  • For Exemplar states, what key drivers contributed to stunting reduction between 2008 and 2018?
  • At the national level, why did Nigeria experience only moderate declines in stunting despite substantial economic growth?

A mixed methods approach was used to conduct this research. First, a systematic search of peer-reviewed and grey literature was reviewed. This was followed by quantitative and qualitative analyses, complemented by policy and program reviews and financing analyses . Quantitative analysis was conducted using the Nigeria Demographic and Health Survey (DHS) from 2008 and 2018,3,4 and a Oaxaca-Blinder Decomposition was used to identify the drivers of stunting reduction. Risk factor analyses were conducted to identify variables or conditions that increase the likelihood of stunting in children under five years of age. Finally, qualitative analyses included expert and community interviews to understand stakeholder and community perspectives on drivers of stunting decline.

Completion of this research provided a large body of evidence, enabling a deeper understanding of the factors influencing stunting in Nigeria. By triangulating quantitative, qualitative, policy and program reviews, and financing analyses —and collaborating closely with in-country experts—the research team identified several key explanations described below.

What did Nigeria and Exemplar states do?

What were key drivers for stunting reduction nationally from 2008 to 2018?

Figure 3: National Nigeria Decomposition Analysis

Figure 3: National Nigeria Decomposition Analysis
Demographic and Health Surveys 2008 and 2018

Before focusing on the Exemplar states, we first examined trends at the national level. The synthesized findings from Nigeria’s Exemplar states reveal a clear multisectoral approach, highlighting the importance of investments both within and beyond health systems. It is important to note that data limitations—particularly around nutrition-specific interventions (e.g., dietary intake)—may explain why a portion of the observed stunting reduction remains unexplained.

A multisectoral approach was taken to improve child health and nutrition, with findings highlighting the importance of investments outside the health sector. Key factors contributing to improved outcomes included parental education, increased household wealth, and better household sanitation.

  • Improved parental education (paternal and maternal)

    Targeted investments in universal compulsory education boosted educational attainment. In Exemplar states between 2008 and 2018, the mean years of education increased from 8.3 to 9.7 (paternal), and from 6.8 to 8.2 (maternal).3,4

    • Illustrative key educational policies:

    • 2004: Universal Basic Education Act – Provided compulsory, free universal basic education for all children of primary and junior secondary school age in the country.5
    • 2007: Education Reform Act – Replaced the Universal Basic Education Act. Aimed to strengthen the education sector by consolidating key agencies into the Basic and Secondary Education Commission and reinforcing the mandate for free, compulsory, and universal basic education for all school-age children in Nigeria.6
    • 2010: Nomadic Education Program – Aims to provide quality basic education to nomadic populations. The program focuses on equipping nomads with relevant skills, enhancing their literacy, and integrating them into the national social and economic fabric.7
    • 2014: Girls Education Project Phase 3 Cash Transfer Program – The program, in collaboration with UNICEF, aimed to improve basic education, increase social and economic opportunities for girls, and reduce disparities in learning outcomes between girls and boys in northern Nigeria by addressing barriers such as sociocultural norms, economic constraints, and challenges in governance, educational materials, staff capacity, and funding.8

    Key informant perspectives on education provide additional details:

    "...there is correlation between the level of education and stunting and wasting because the more education the mother has the more she will know the difference of food to give the child."

    - National Stakeholder
  • Increased household wealth: Reductions in stunting were attributed to increased wealth, as measured by the household wealth index.
  • Access to proper sanitation: Access to water and sanitation increased slightly between 2008 and 2018. Access to an improved sanitation facility increased from 20% to 24%, and access to an improved water source increased from 59% to 69%.3,4 However, open defecation rates remain high in some regions.

Targeted health interventions are essential to address critical determinants of stunting. These interventions focus on infection prevention, maternal care, maternal nutrition, and size of child at birth.

  • Malaria prevention – Significant expansion of key malaria interventions led to reductions in both malaria prevalence and stunting. Between 2008 and 2018, the proportion of women receiving two or more doses of intermittent preventive treatment of malaria in pregnancy (IPTp) increased from 7.6% to 41.6%.3,4 During the same period, coverage of households with at least one insecticide-treated bed net (ITN) increased from 12.2% to 61.6%.3,4 These improvements were supported by ambitious national targets and extensive coordination across key programs and policies.

    • Illustrative key malaria control policies:

    • 2001: Roll Back Malaria Partnership – Aimed to ensure that 60% of children under five and pregnant women in Nigeria had access to affordable ITNs and 60% of households had access to case management by 2005. While some progress was made, a 2005 evaluation revealed implementation challenges due to limited resources, lack of access to ACTs (artemisinin-based combination therapy) and ITNs, and growing malaria drug resistance.9,10
    • 2008: Support to the National Malaria Program – From 2008 to 2016, the Malaria Consortium’s UK aid-funded SuNMaP program scaled up malaria prevention and treatment in nine Nigerian states. During this period, the program distributed over 4 million nets, provided 5.6 million doses of SP (sulfadoxine-pyrimethamine, an anti-malarial drug) for malaria in pregnancy, and supplied 2.7 million ACT doses. In addition, SuNMaP supported the sale of over 5 million ACTs, trained over 23,000 health workers, and reached 40% of the population with awareness activities. Collectively, these efforts saved an estimated 48,000 lives of children under five.11,12
    • 2009, 2014: National Malaria Strategic Plan – Aimed to reduce malaria-related morbidity and mortality in Nigeria by 50% by 2013, with objectives to scale up malaria interventions, strengthen health systems, and lay the groundwork for future malaria elimination. Key interventions included vector control, prompt diagnosis, and malaria prevention and treatment in pregnancy. The plan targeted the distribution of 63 million long-lasting insecticidal nets, and by 2010, over 58 million were distributed.13,14
    • 2013: Rapid Access Expansion Program – Launched in collaboration with the World Health Organization, the program aimed to reduce childhood mortality in hard-to-reach areas of Nigeria and four other countries by scaling up integrated community case management (iCCM) for malaria, pneumonia, and diarrhea in children under five.15

    Key informant perspectives on malaria prevention provide additional details:

    “We are doing great in terms of IPTp; routinely, mothers are given medication during antenatal care and that seems to take care of the issues of maternal anemia and malaria in pregnancy and with this, the nutrition status of the mother will improve, and the child is going to be born healthier…”

    - National Stakeholder
  • Improved access to and utilization of maternal care – Moderate improvements in antenatal care coverage and an increase in births attended by a skilled birth attendant (SBA) led to moderate improvement in linear growth. From 2008 to 2018, coverage of at least four antenatal care visits increased from 67% to 70.7%.3,4 During the same period, coverage of SBA at delivery increased from 59% to 65.4%.3,4
  • Improvements to maternal nutrition – Reductions in the proportion of underweight women showed strong intergenerational effects on stunting. From 2008 to 2018, the percentage of non-pregnant women with low BMI (<18.5 kg/m2) decreased from 11.9% to 9.6%.3,4

    • Illustrative key policies include:

    • 2003: National Program for Food Security
    • 2004, 2008: Second and third National Fadama Development Projects
    • 2013: Agricultural Transformation Agenda
  • Size of child at birth – Although birth size is strongly associated with postnatal growth, only minor gains were observed in the proportion of children born at average size or above during the study period. In 2008, 88% of children were at average size or above at birth versus 90% in 2018.3,4 This minor increase limited the overall contribution of birth size to the predicted change in linear growth over time.

Building on our findings at the national level, we examined trends at the state level, focusing on both Exemplar and opportunity states to better understand subnational drivers of progress and stagnation in stunting. Variations in findings from decomposition analyses and risk factor analyses across states in the northern and southern regions reveal the importance of tailored intervention strategies at the state level.

Exemplar states

  • Northern Exemplar States: Importance of improved sanitation as a driver and detractions due to conflict-related deaths and diarrhea – When comparing drivers of increased child height in northern and southern Exemplar states, improved sanitation was a modest driver in northern states but was not relevant in southern states.3,4 Additionally, conflict-related deaths and incidence of diarrhea detracted from increases in child height, highlighting instability in the north over the study period.3,4
  • Southern Exemplar States: Importance of women’s decision-making, interpregnancy interval (i.e., birth spacing), and women receiving at least two doses of intermittent preventive treatment of malaria (IPTp2+) during their last pregnancy – When comparing the factors driving increased child height in northern and southern Exemplar states, notable differences emerge. In the southern Exemplar states, women’s decision-making power and longer interpregnancy intervals were key drivers. However, these factors were not relevant in northern Exemplar states, highlighting the need for region-specific approaches to gender equity and family planning.3,4 Additionally, IPTp2+ during the last pregnancy was an important driver of increased child height in both northern and southern Exemplar states. However, the impact of IPTp2+ was greater in the south where it contributed significantly more to increased child height.3,4

Opportunity states

  • Northern Nigeria: Wealth inequality, especially in the north, is likely linked to disparities in dietary adequacy and health care access – Despite overall progress, gaps in stunting burden across wealth quintiles have remained. An especially stark contrast is seen in northern Nigeria where the difference in stunting prevalence between the richest and poorest wealth quintiles remained around 23 percentage points during the study period.3,4 In particular, northern opportunity states (Abia, Kano, and Yobe) have faced especially severe challenges. High rates of unemployment, lack of well-paying jobs, inflation of food prices, and inadequate women’s empowerment programs (among other factors) have led to poverty and a high burden of malnutrition in these states.3,4
  • Northern and Southern Opportunity States: Risk factors vary between northern and southern opportunity states – When comparing risk factors in 2018 between northern and southern opportunity states, low maternal height (less than 145 cm) emerged as the greatest risk factor across both regions.3,4 However, in southern opportunity states, non-exposure to mass media and non-improved sanitation were additional leading risk factors.3,4 In northern opportunity states, being in the poorest wealth quintile and early age pregnancy (before age 18) were leading risk factors.3,4 This variation reflects the nuances of stunting prevalence in different regions in Nigeria.

Going forward, it will be critical to implement interventions at both the national and state levels to reduce stunting across all regions. When developing these strategies, it is important to consider the specific context of each area, such as levels of wealth inequality and other determinants. Continuous monitoring at the state level is also necessary to ensure that interventions are both effective and equitable across states.

Despite large increases in GDP per capita over the past two decades, Nigeria’s progress in reducing stunting has been moderate. This section explores the key barriers that have limited the translation of economic growth into widespread nutritional gains. While not exhaustive, these findings highlight some of the most pressing challenges impeding faster progress in stunting reduction.

  • Food insecurity and reaching marginalized populations – Poverty, high cost of food, poor economic status (e.g., unemployment), and larger family sizes have contributed to limited progress in improving children’s nutritional status, including their inability to consume diverse food groups. Children’s access to adequate nutrition is largely dependent on the parents’ income. Significant disparities in stunting persist across wealth quintiles and between rural and urban populations. Risk factor analysis of 2018 data also highlighted being in the poorest wealth quintile as a key risk factor for stunting.3,4          

    • Key informant perspectives provide additional details:

    “But I didn't have much food and, because of that, had to stop breastfeeding after two months. I started introducing other feeds like pap and milk, which I could afford…”

    - Community Mother, Urban, Akwa Ibom
  • Gender disparities and women’s empowerment – Improving women’s education and empowerment, particularly in key domains such as health care, is important to accelerate progress in reducing stunting. Despite increases in women’s participation in decision making, Nigeria continues to rank poorly on global gender indices, including in domains such as health care. Risk factor analysis of 2018 data highlights that early age pregnancy (before age 18), low levels of maternal education, and lack of women’s empowerment are key risk factors for stunting.3,4 Women’s empowerment programs have not been implemented consistently across states, with community stakeholders reporting substantial differences in the extent and quality of these programs. Notably, low levels of education and lack of financial independence among mothers potentially exacerbated malnutrition during the study period.

    • Key informant perspectives provide additional details:

    "We need to do more in the area of policies because we have not yet made policies on increasing the maternity leave of mothers; people are advocating for one year maternity leave, what we have today is three months but some states have adopted six months."

    - National Director, Family Health of the Primary Healthcare Management Board

    Regional stakeholders observed that many women will seek approval from their husbands before they could use family planning to space their children.


  • Limited progress in improved family planning – Limited progress was observed in key indicators related to family planning; for example, age at first birth remained mostly unchanged (around 20 years), and birth intervals remained short (less than 32 months).3,4 Risk factor analysis of 2018 data highlighted early-age pregnancy as a key risk factor for stunting, indicating a need for better coverage of family planning methods (e.g., modern contraceptives) to help prevent early pregnancies.3,4 From 2008 to 2018, the use of modern contraceptives remained stagnant at 10.5%.3,4 Additionally, a high unmet need for family planning persists as a result of supply shortages, procurement delays, and bureaucratic challenges in the management of family planning programs.

    • Key informant perspectives provide additional details:

    “[In some areas], initially, they don’t want [family planning] at all. We don’t call it family planning for some mothers because then they do not want it. And also, most of them don’t want to take the western one.”

    - Baby-Friendly Hospital Initiative focal person

    Figure 4: Factors associated with stunting in North and South opportunity states, 2008 and 2018

    Figure 4: Factors associated with stunting in North and South opportunity states, 2008 and 2018
    Demographic and Health Surveys 2008 and 2018

    Looking ahead, addressing these barriers—particularly among the most vulnerable populations—will be essential for achieving faster and more equitable gains in child growth and development across the country.

How might Nigeria and states implement moving forward?

Takeaways at the National level

The causes of maternal and child undernutrition are multifaceted and complex, and addressing them requires coordinated action across multiple systems, including health, education, sanitation, food, and social protection. The framework below provides a clear structure for summarizing the key takeaways and identifying the top priorities moving forward.

Our findings suggest that prioritizing interventions focused on determinants that showed limited progress between 2008 and 2018 could accelerate reductions in stunting across Nigerian states.

  • Prioritizing poverty reduction initiatives at state-level level to reduce stunting burden for marginalized and poorest communities.

    • Historically, poverty reductions strategies were prioritized at national level.

    Illustrative examples below:

    • Millennium Development Goals Conditional Grant Scheme (2007)
    • SURE-P: Community Services Women and Youth Employment (2012)
    • Government Enterprise and Empowerment Programme (2016)

    There is an opportunity to focus on state-level initiatives, particularly those aiming to reduce stunting burden among populations in the lowest wealth quintiles.
  • Drive focus for improving women’s empowerment and decision-making, particularly for key domains including health care.
    • Despite a historical focus on women empowerment programs (especially in southern areas), which promoted financial independence for women and improvement of nutritional status among families, these programs have not been consistently implemented across states.
  • Strengthen community-based delivery platforms to improve access to family planning and reduce high-burden pregnancies.
    • The most impactful policies during the study period used community-based delivery platforms.
    • National stakeholders indicated that disparities in family planning program implementation across the country led to high unmet need for contraceptives.
    • Community-based programs such as the Maternal, Newborn and Child Health Programme (MNCH2), Abia Rapid Access Expansion (RAcE) Program, Nigeria RAcE program, and Core Group Partners Project (CGPP), increased accessibility and quality of health care.
    • Community Health Influencers, Promoters, and Services (CHIPS), launched in 2018, is a promising initiative that builds upon the success of previous programs.
    • As community-based delivery platforms become more widely integrated in Nigerian policies and programs, a key area for future focus could be addressing gaps in family planning services and reducing the incidence of high-burden pregnancies.

While our analysis did not explicitly identify the impact of interventions to enhance dietary intake on stunting reduction—because of data limitations— it is important to emphasize that actions focused on improving dietary intake are crucial when developing a holistic approach to reduce stunting. As Nigeria continues to strengthen its nutrition data systems, new data is becoming available, including the National Food Consumption and Micronutrient Survey, that can be used to inform future nutrition action planning.
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