PLOS ONE

RESEARCH ARTICLE

Stunting among children under two years in

Indonesia: Does maternal education matter?
Agung Dwi Laksono ID1,2, Ratna Dwi Wulandari ID2,3*, Nurillah Amaliah4, Ratih
Wirapuspita Wisnuwardani ID5
1 National Research and Innovation Agency, Republic of Indonesia, Jakarta, Indonesia, 2 The Airlangga
Centre for Health Policy, Surabaya, Indonesia, 3 Faculty of Public Health, Universitas Airlangga, Surabaya,
Indonesia, 4 Center for Research and Development of Public Health Efforts, Ministry of Health of The
Republic of Indonesia, Jakarta, Indonesia, 5 Faculty of Public Health, Mulawarman University, Samarinda,
Indonesia
a1111111111
a1111111111 * [email protected]
a1111111111
a1111111111
a1111111111 Abstract
Background
Measuring height for age is one of the essential indicators for evaluating children’s growth.
OPEN ACCESS The study analyzes the association between maternal education and stunting among chil-
Citation: Laksono AD, Wulandari RD, Amaliah N, dren under two years in Indonesia.
Wisnuwardani RW (2022) Stunting among children
under two years in Indonesia: Does maternal Methods
education matter? PLoS ONE 17(7): e0271509.
https://doi.org/10.1371/journal.pone.0271509 The study employed secondary data from the 2017 Indonesia Nutritional Status Monitoring
Editor: Marcello Otake Sato, Dokkyo Medical
Survey. The unit of analysis was children under two years, and the study obtained weighted
University, JAPAN samples of 70,293 children. Besides maternal education, other independent variables ana-
Received: July 2, 2021
lyzed in this study were residence, maternal age, maternal marital status, maternal employ-
ment, children’s age, and gender. In the final stage, the study occupied a multivariate test by
Accepted: July 4, 2022
binary logistic regression test.
Published: July 25, 2022

Peer Review History: PLOS recognizes the Results

benefits of transparency in the peer review
The results show the proportion of stunted children under two years in Indonesia nationally
process; therefore, we enable the publication of
all of the content of peer review and author is 20.1%. Mothers in primary school and under education categories are 1.587 times more
responses alongside final, published articles. The likely than mothers with a college education to have stunted children under two years (95%
editorial history of this article is available here: CI 1.576–1.598). Meanwhile, mothers with a junior high school education have a chance of
https://doi.org/10.1371/journal.pone.0271509
1.430 times more than mothers with a college education to have stunted children under two
Copyright: © 2022 Laksono et al. This is an open years (95% CI 1.420–1.440). Moreover, mothers with education in the senior high school
access article distributed under the terms of the
category have 1.230 times more chances than mothers with a college education to have
Creative Commons Attribution License, which
permits unrestricted use, distribution, and stunted children under two years (95% CI 1.222–1.238).
reproduction in any medium, provided the original
author and source are credited. Conclusion
Data Availability Statement: The 2017 Nutrition The study concluded that the maternal education level was associated with stunting children
Status Monitoring Survey data used to support
under two years in Indonesia. The lower the mother’s level of education, the higher the
these findings of this study were supplied by the
Directorate of Community Nutrition of the chances of a mother having stunted children under two years.
Indonesian Ministry of Health under license and so

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PLOS ONE Stunting among children under two years in Indonesia

can not be made freely available. Requests for Introduction

access to these data should be made to the
Directorate of Community Nutrition of the Stunting is when children under five years old (toddlers) have a length or height less than their
Indonesian Ministry of Health (https://gizi.kemkes. age—the condition by a length or height of more than minus two standard deviations of
go.id/; Email: [email protected]). WHO’s median child growth standard [1–3].
Funding: The authors received no specific funding Stunting is irreversible due to inadequate nutrition and repeated infections during the first
for this work. 1000 days of a child’s life. Childhood stunting is one of the most significant barriers to human
Competing interests: The authors have declared
development and globally affects an estimated 162 million children under five. Stunting has
that no competing interests exist. long-term associations on individuals and society, including decreased cognitive and physical
development, reduced productive capacity and poor health, and an increased risk of degenera-
tive diseases such as diabetes [2, 4]. Stunting is a well-established risk marker of poor child
development, and Stunting before age two predicts poorer cognitive and educational outcomes
in later childhood and adolescence. Child stunting has immediate and long-term conse-
quences, including increased morbidity, mortality, and adverse impact on child development
and adult health contributes to the cycle of malnutrition, and hampers economic development
[3, 5].
The prevalence of short toddlers in Indonesia tends to be static. The 2007 Indonesian Basic
Health Survey results showed the prevalence of stunting in Indonesia was 36.8%. In 2010,
there was a slight decrease to 35.6%. However, most stunted toddlers increased again in 2013
to 37.2%. In 2018, the survey found that the prevalence of stunting in children under two years
is 29.9%. In toddlers, it is 30.8% [6]. Moreover, the stunting prevalence in 2019 was 27.67%
[7].
The incidence of stunting is still one of the nutritional problems experienced by toddlers in
the world today. In 2017, 22.2% or around 150.8 million under-five experienced stunting.
However, this figure has decreased compared to the stunting rate in 2000, which was 32.6%. In
2017, more than half of stunted children under five came from Asia (55%), while more than a
third (39%) lived in Africa. Of the 83.6 million small children under five in Asia, the highest
proportion came from South Asia (58.7%). Data on the prevalence of stunting under five col-
lected by WHO, Indonesia is included in the third country with the highest majority in the
Southeast Asia/South-East Asia Regional (SEAR) region. The average prevalence of stunting
under five in Indonesia from 2005 to 2017 was 36.4% [8, 9].
The WHO Conceptual Framework on Childhood Stunting describes how stunting is caused
by a complex combination of family, environmental, social, and cultural variables [10]. Stunt-
ing is a chronic nutritional problem (a condition that lasts a long time) caused by many factors
such as socioeconomic conditions, maternal nutrition during pregnancy, and infant pain [11].
Other causes are unhealthy living behavior, and lack of food intake for a long time from
infancy can cause children to become short [6].
One of the demographic characteristics that became the focus is maternal education. Edu-
cation is a critical factor that does not directly affect nutritional status because this education
will affect the pattern of parenting for children [12]. The study analyzed data on 85,932 chil-
dren aged 6–59 months in Vietnam and found that there was no maternal education among
children 6–23 months, compared with a graduate education (OR 1.77; 95% CI, 1.44–2.16).
Meanwhile, for children 24–59 months, the strongest associations with child stunting were no
maternal education compared with a graduate education (OR 2.07; 95% CI 1.79–2.40) [13].
Meanwhile, another study conducted in Indonesia with a cohort-prospective study yielded
similar conclusions. The study performs between August 2012 and May 2014 at three health
centers in Jakarta, Indonesia. Subjects were healthy children under two years old, in which the
study measured their weight and height serially (at 6–11 weeks old and 18–24 months old). Of
160 subjects, 14 (8.7%) showed declined growth pattern from regular to stunted and 10 (6.2%)

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PLOS ONE Stunting among children under two years in Indonesia

to severely stunted. As many as 134 (83.8%) subjects showed consistent standard growth pat-
terns. Only two (1.2%) showed improvement in linear growth. Maternal education duration of
fewer than nine years (OR 2.60, 95% CI 1.23–5.46) showed a statistically significant association
with declined linear growth in children. Mother with an education duration of fewer than nine
years was the determining socio-demographic risk factor contributing to the decreased linear
growth in children under two years of age [14]. Based on the description of the background
narrative, we intend this study to analyze the association between maternal education level
and the stunting among children under two years in Indonesia.

Materials and methods

Data source
The data used in this analysis is secondary data from the 2017 Indonesia Nutritional Status
Monitoring Survey. The 2017 Indonesian Nutritional Status Monitoring is a cross-sectional
survey on a national scale conducted by the Directorate of Nutrition of the Indonesian Minis-
try of Health. The design of this study is cross-sectional, which analyzes data of variables col-
lected at one given time across a sample population. The aim is to collect and present
systematic data to provide a factual description of a particular situation.
Sample determination of under five-year samples: Sample selected 300 households. Samples
of children under five years are all children under five years in homes chosen in each cluster.
Respondents are mothers of children under five years or household representatives who can
represent the sample [15].
The 2017 Indonesian Nutritional Status Monitoring uses a minimum of a nutrition
diploma graduate as interviewers and anthropometric measurements. Measure height using a
microtoise, while body length using a length board—measurement of body weight with a digi-
tal scale with an accuracy of 0.01 kg.
The population in this study were all children under two years in Indonesia. In this study,
the unit of analysis was children under two years (<23 months), with mothers as respondents.
The weighted sample was 70,293 children under two years with the multi-stage cluster random
sampling method.

Variables
The study employed stunted children under two years as an outcome variable. Stunting was a
nutritional status indicator based on height for age or the height of a child who is reached at a
certain age. Based on WHO growth standards, the height indicator for a period is determined
based on the z-score or height deviation from average height. Stunted children under two
years consist of two categories: not stunted and stunting. The limit for the nutritional status
category according to the height index/age is [15]:
• Stunted: < -3.0 SD to -2.0 SD
• Normal: � -2.0 SD
The research used maternal education as an exposure variable. The survey determines
maternal education based on the last certificate held by mothers of children under two years.
Maternal education consists of four levels: primary school and under, junior high school,
senior high school, and college.
Apart from maternal education level, other independent variables, as control variables,
were the type of residence, maternal age, maternal marital status, maternal employment status,
age of children under two years, and gender of children under two years. The type of residence

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PLOS ONE Stunting among children under two years in Indonesia

consists of two types: urban and rural. Maternal age is determined based on the last birthday
(in years). Maternal marital status includes never married, married, and widowed/divorced.
Moreover, maternal employment status consists of two categories: unemployed and employed.
Children under two years are determined based on the last month’s birthday (in months).
Meanwhile, the gender of children under two years consists of two types: boy and girl.
The inclusion criteria in this study were children under two years. On the other hand, the
exclusion criteria in this study were children under two years who did not have a mother, and
their anthropometry was not measured.

Data analysis
The study carried out a co-linearity test in the early stages of analysis. Then, the study used the
Chi-Square test to test the dichotomous variables, and the T-test for continuous variables. The
study used the statistical test to assess whether there is a statistically significant relationship
between the variable nutritional status of children under two years as the dependent variable
and the independent variable. The study uses a multivariable test in the final stage by utilizing
a binary logistic regression test. The analysis performed all statistical analyzes with IBM SPSS
Statistics 21 software.
Moreover, the research used ArcGIS 10.3 (ESRI Inc., Redlands, CA, USA) to create a distri-
bution map of stunted children under two years in Indonesia. The study issued a shapefile of
administrative boundary polygons by the Indonesian Bureau of Statistics for the task.

Ethical approval
The 2017 Indonesian Nutritional Status Monitoring Survey has an ethical license approved by
the national ethics committee (Number: LB.02.01/2/KE.244/2017). The survey used informed
consent during data collection, which accounted for aspects of the procedure for data collec-
tion, voluntary and confidentiality. Respondents gave written consent.

Results
The analysis results indicate that the proportion of nationally stunted children under two years
in Indonesia is 20.1%. The lowest proportion of stunted children under two years was in Bali
Province at 13.6%; meanwhile, the province with the highest proportion of stunted children
under two years was Central Kalimantan Province at 30.1%.
Table 1 shows that co-linearity tests indicate no collinearity between independent variables.
Based on Table 1, the analysis results show that the tolerance value for all variables is more sig-
nificant than 0.10. At the same time, the variance inflation factor (VIF) value for all variables is
less than 10.00. Then referring to the basis of decision-making in the multicollinearity test, the
study concluded that there are no symptoms of a strong relationship between two or more
independent variables in the regression model.

Descriptive analysis
Table 2 shows a statistical description of the characteristics of children under two years who
are the object of analysis in this study. The value of the proportion of children under two years
living in rural areas in Indonesia is 22.6% (95% CI 22.4%-22.8%). Children under two years
living in rural areas dominate all nutritional status categories based on the type of residence.
According to maternal education, mothers with senior high school education led in nutri-
tional status categories. Based on maternal age, stunted children under two years have mothers
with an average age slightly older than normal children.

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PLOS ONE Stunting among children under two years in Indonesia

Table 1. The results for the co-linearity test of nutritional status of children under two years in Indonesia
(n = 70,293).
Variables Collinearity Statistics
Tolerance VIF
Area context
Residence 0.961 1.040
Maternal Characteristics
Education level 0.936 1.069
Age (in years) 0.980 1.021
Marital status 0.997 1.003
Employment Status 0.962 1.040
Children under two years’ Characteristic
Age 0.996 1.004
Gender 1.000 1.000

Note: � Dependent Variable: Nutritional status of a toddler; VIF: variance inflation factor.

https://doi.org/10.1371/journal.pone.0271509.t001

Based on maternal marital status, married mothers led both nutritional status categories.
On the other hand, according to maternal employment status, unemployed mothers dominate
in both types of nutritional status.
Table 2 shows that average children under two years who are stunting are older than chil-
dren under two years who have normal nutritional status. Moreover, based on children under

Table 2. Descriptive statistic of nutritional status of children under two years in Indonesia (n = 70,293).
Variables Nutritional Status p-value
Not stunted (n = 55,142) Stunting (n = 15,152)
Residence < 0.001
• Urban 26.7% 22.6%
• Rural 73.3% 77.4%
Maternal Characteristics
Education level < 0.001
• Primary school and Under 26.4% 30.6%
• Junior high school 26.8% 28.6%
• Senior high school 37.8% 34.1%
• College 9.0% 6.6%
Age (in years; mean) 29.63 29.72 < 0.001
Marital status < 0.001
• Never married 0.3% 0.4%
• Married 98.9% 98.4%
• Divorce/Widowed 0.8% 1.1%
Employment Status < 0.001
• Unemployed 76.5% 76.4%
• Employed 23.5% 23.6%
Children under two years’ Characteristic
Age (in months; mean) 10.67 15.0 < 0.001
Gender < 0.001
• Boy 49.8% 56.7%
• Girl 50.2% 43.3%
https://doi.org/10.1371/journal.pone.0271509.t002

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PLOS ONE Stunting among children under two years in Indonesia

two years of gender, the boy led in the stunted category; On the contrary, the girl dominated
the not stunted type.

Multivariate analysis
Table 3 shows the results of the binary regression logistics to analyze the association between
maternal education level and the stunted among children under two years in Indonesia. The
study used the nutritional status "not stunted" category as a reference in this analysis.
Table 3 shows that mothers with education in the primary school and under category have
1.587 times more likely than mothers with a college education to have stunted children under
two years (AOR 1.587; 95% CI 1.576–1.598). Meanwhile, mothers with education in the junior
high school category have 1.430 times the probability of mothers with a college education to
have stunted children under two years (AOR 1.430; 95% CI 1.420–1.440). Moreover, mothers
in the senior high school education category are 1.230 times more likely than mothers with a
college education to have stunted children under two years (AOR 1.230; 95% CI 1.222–1.238).
This analysis indicates that the lower the level of education, the higher the probability of a
mother having stunted children under two years.
In addition to maternal education level, six other independent variables analyzed signifi-
cantly associated with stunted children under two years. Table 3 informs that mothers who
live in urban areas are 0.828 times less likely than mothers who live in rural areas to have
stunted children under two years (AOR 0.828; 95% CI 0.825–0.831). The result means that
those who live in rural areas have a higher probability of having stunted children under two
years.
Based on maternal marital status, mothers who were never married have 1.348 times more
likely than divorced/widowed mothers to have stunted children under two years (AOR 1.348;
95% CI 1.308–1.389). Married mothers are 0.804 times less likely than divorced/widowed
mothers to have stunted children under two years (AOR 0.804; 95% CI 0.792–0.817). This

Table 3. Binary logistic regression of nutritional status of children under two years in Indonesia (n = 70,293).
Predictors Stunting
p-value AOR 95% CI
Lower Bound Upper Bound
Residence: Urban < 0.001 0.828 0.825 0.831
Residence: Rural - - - -
Maternal Education: Primary school and under < 0.001 1.587 1.576 1.598
Maternal Education: Junior high school < 0.001 1.430 1.420 1.440
Maternal Education: Senior high school < 0.001 1.230 1.222 1.238
Maternal Education: College - - - -
Maternal age < 0.001 0.994 0.994 0.995
Maternal Marital Status: Never married < 0.001 1.348 1.308 1.389
Maternal Marital Status: Married < 0.001 0.804 0.792 0.817
Maternal Marital Status: Divorced/widowed - - - -
Maternal employment: Unemployed < 0.001 0.972 0.968 0.975
Maternal employment: Employed - - - -
Children under two years’ age < 0.001 1.111 1.111 1.112
Children under two years’ Gender: Boy < 0.001 1.352 1.347 1.356
Children under two years’ Gender: Girl - - - -

Note: AOR: Adjusted Odds Ratio; CI: Confidence Interval.

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PLOS ONE Stunting among children under two years in Indonesia

analysis informs that maternal marital status is one predictor of the possibility of children
under two years being stunting.
Table 3 indicates that an unemployed mother is 0.972 times less likely than an employed
mother to have stunted children under two years (AOR 0.972; 95% CI 0.962–0.975). This
information shows that the unemployed mother is a protective factor for having stunted chil-
dren under two years. Meanwhile, based on age, maternal age, and children’s age, the analysis
results were significantly associated with the possibility of stunted children under two years.
According to gender, the boy is 1.352 times more likely than the girl to be stunting (AOR
1.352; 95% CI 1.347–1.356). This analysis indicates that children with gender boys have risk
factors for experiencing stunting.

Discussion
We confirmed that the odds of stunting increased significantly among children aged <2 years
who had lower maternal education, older (both maternal age and children age), from the rural
area, and boys. On the other hand, the study also identified other factors; marital status and
occupation. Because of the cross-sectional study design, we cannot exclude the possibility of
reverse causation.
This study found lower maternal education is associated with a higher risk of stunting,
which agrees with systematic review studies [16–18]. Mothers, as caregivers, have all decisions
about healthy feeding practices, including breastfeeding [19, 20]. In addition, higher paternal
education was associated with protective caregiving behaviors, including vitamin A capsule
receipt, complete childhood immunizations, better sanitation, and the use of iodized salt [21].
We should consider that education is an essential issue for Indonesia, like many other develop-
ing countries. Many studies reported a better education level as a strong determinant of better
health outcomes [22–25]. Meanwhile, several studies also report poor education as a barrier to
achieving better health output [26, 27]. A better level of education can understand the risks
and benefits of behavior that will be chosen for adoption [12, 25].
A contradictory finding is older maternal age was associated with a higher risk of stunting.
The hypothesis was that younger maternal age could increase more increased risk of stunting.
For example, several studies showed the odds of women � 24 years having a stunted child
were between 1.09 and 1.23 more significant than women � 33 years [28–30]. Still, some stud-
ies have also found contradictory results for maternal age. A previous study found older mater-
nal age has a higher risk of stunting in Indonesia [31]. Older children were significantly
associated with a higher risk of stunting in this study, which agrees with a systematic review in
Sub-Sahara Africa [18] and a survey among 1366 children aged 0–23 months in Indonesia
[32]. We should consider that older children have higher nutrients that are needed. Children
who were not given age-appropriate feeding were significantly more likely to be stunted than
those fed appropriately [32].
Children who live in rural areas were associated with a higher risk of stunted children
under two years. A systematic review concluded that rural residents were associated with
stunting [16]. Indonesia’s rural health care system was associated with food poverty, low health
literacy among parents, mothers’ typical household decision-making power, and the conse-
quences of high persistent use of traditional birth attendants among ethnic minorities [33]. In
addition, rural subgroups were disadvantaged as the socioeconomic inequalities in maternal,
newborn, and child health in Indonesia, i.e., rural people may be insufficient without sufficient
skilled local health workers [34]. It suggests that rural area needs more attention for technical
and financial support to improve leadership and capacity building in the health sector.

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PLOS ONE Stunting among children under two years in Indonesia

Maternal marital status was associated with stunting in this study. Children with married
parents had a lower risk of stunting, and parents who were never married or divorced/wid-
owed had a higher chance of stunting children. In contrast with our study, maternal marital
status was not associated with infant growth outcomes in sub-Saharan Africa [35]. Neverthe-
less, a recent survey in Sub-Sahara Africa indicates that maternal marital status is combined
with household cooking fuel on child nutritional status [36].
Meanwhile, employed mothers were one of the risk factors for stunting in children under
two years, and employed mothers had a higher risk of stunting children. On the contrary, two
studies found no significant association between maternal employment and stunting in Indo-
nesia and Ethiopia [37, 38]. Still, recent studies have also found similar results for maternal
marital status in Iran and Ethiopia because housewife mothers have more time to spend with
their family and take care of their children [39, 40]. However, maternal marital status is not
the leading cause of stunting. Improvements in nutrition-specific and–sensitive sectors, focus-
ing on health care access, sanitation, and education, are critical points to decline in Nepal and
Ethiopia [41, 42].
Moreover, boys were more likely to be stunted than girls, and several studies found similar
findings in Indonesia, Mozambique, and meta-analysis [37, 43, 44]. We should note that sex
and follicle-stimulating hormones might play a role in further growth [45].

Strength and limitation

The study examines big data to provide results at the national level. Meanwhile, this study ana-
lyzed secondary data from the 2017 Indonesia Nutritional Status Monitoring Survey. The vari-
ables analyzed were limited to those offered by the survey. The analysis results cannot explain
several other variables that have been known from previous studies to affect stunting in chil-
dren under two years: antenatal care, maternal stature, maternal body mass index, wealth
index, diarrhea, anemia, and agri-food [40, 46–48].
On the other side, the study conducted with a quantitative approach cannot explain the
associated cultural factors that are still very strong in Indonesia, especially in rural areas. Sev-
eral previous studies informed the related results, including the value of children, food taboo,
parenting, and intake patterns [49–53].

Conclusions
The study results concluded that maternal education level was associated with stunting among
children under two years in Indonesia. The lower the maternal education level, the more likely
it is to have stunted children under two years.
Based on the results, the author recommended that the government conduct interventions
were focusing on mothers of children under two with poor education to reduce the proportion
of stunting under two. A more specific target is mothers of children under five who live in
rural areas, are never married, and are employed.

Author Contributions
Conceptualization: Agung Dwi Laksono.
Data curation: Ratna Dwi Wulandari, Nurillah Amaliah, Ratih Wirapuspita Wisnuwardani.
Formal analysis: Agung Dwi Laksono, Ratna Dwi Wulandari.
Funding acquisition: Ratna Dwi Wulandari.
Investigation: Ratna Dwi Wulandari, Nurillah Amaliah, Ratih Wirapuspita Wisnuwardani.

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PLOS ONE Stunting among children under two years in Indonesia

Methodology: Agung Dwi Laksono.

Project administration: Ratna Dwi Wulandari, Ratih Wirapuspita Wisnuwardani.
Resources: Ratna Dwi Wulandari, Nurillah Amaliah.
Software: Ratna Dwi Wulandari, Nurillah Amaliah, Ratih Wirapuspita Wisnuwardani.
Supervision: Agung Dwi Laksono, Ratna Dwi Wulandari.
Validation: Agung Dwi Laksono, Ratih Wirapuspita Wisnuwardani.
Visualization: Agung Dwi Laksono.
Writing – original draft: Agung Dwi Laksono, Ratna Dwi Wulandari, Nurillah Amaliah,
Ratih Wirapuspita Wisnuwardani.
Writing – review & editing: Agung Dwi Laksono.

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