Background: High rates of stunting have persisted in Malawi for several decades. There is a need to better understand trends and determinants of childhood stunting in the population to inform effective policies and programmatic interventions.

Objective: To analyze levels, trends, and distribution of stunting in a nationally-representative population of Malawian children under age five, and to analyze determinants and micronutrient levels associated with stunting in a subset of children under age two.

Design: The study analyzes data from the Malawi Demographic and Health Surveys in 2000, 2004, 2010 and 2015–16 and the Malawi Micronutrient Survey in 2015–16. Stunting in children is defined as height-for-age index more than two standard deviations below the reference medium. Bivariate and multivariate analyses are used to estimate the change in stunting by socio-demographic variables, and impact of environmental enteropathy, water sanitation and hygiene, access to food, infant and young child feeding practices, women’s empowerment, domestic violence, and biomarkers of nutrition, specifically iron- deficiency anemia and vitamin A deficiency controlled for inflammation in children ages 0–59 months, adjusted for sampling design effects.

Setting: Malawi is a landlocked country, divided into three regions: the northern, central, and southern regions.

Subjects: Children ages 0–59 months with data on anthropometric measurements from the MDHS survey in 2000 (n=9,188), 2004 (n=8,090), 2010 (n=4,586), and 2016 (n=5,149), and from the MNS survey in 2015¬–16 (n=2,018).

Results: The prevalence of stunting decreased in children from 54.3 percent in 2000 to 36.6 percent in 2016. Child’s household structure (a finished roof), child’s age, gender, birth order and birth interval, household wealth, land ownership, mother’s education, mother’s stature and BMI, and mother’s age appear to be the strongest determinants of childhood stunting. With addition of biomarkers of nutrition, inflammation, and inherited disorders, age of the child, birth order, and mother’s report of child’s size at birth and household hunger are major determinants of childhood stunting. At the cellular level, serum ferritin, retinol binding protein, and sickle cell disease and alpha-thalassemia are strongly associated with stunting in children.