The increase in the use of maternal and child health services in Pakistan may be related to their expanded availability, mainly through the community-based Lady Health Worker (LHW) program, which is discussed in Section 7. The number of LHWs more than tripled from about 30,000 in 1996 to 110,000 in 2014 (Zhu et al. 2014; Sultan, Cleland, and Ali 2002).

In summary, the trends for Pakistan, and the comparison with Bangladesh, indicate especially persistent and acute shortfalls in the levels of potentially relevant factors in three areas: infant and young child feeding practices, prevention and management of early childhood infectious diseases, and fertility behavior. The international evidence is largely consistent that factors in these three areas are strongly associated with child undernutrition, and that diarrhea is more strongly associated with stunting status than other infectious diseases (Black et al. 2013).

# B. _Documented effects of potential determinants_

Empirical studies for Pakistan investigate the immediate and underlying factors associated with nutrition outcomes using different sources of observational data. A small set of studies use nationally-representative household sample surveys (such as the DHS or NNS) to examine factors at the national level (Headey, Hoddinott, and Park 2016; Di Cesare et al. 2015; Haddad et al. 2003; Mahmood 2001; Hazarika 2000; Ibrahim 1999). The World Bank provincial nutrition status notes use 2011 NNS data to examine factors at the province level. Arif et al. (2014) use the 2010 PPHS, which covers 16 districts across the four provinces, as well as the PPHS rural household panel subsample between 2001 and 2010. Several other studies use small purposive surveys of samples of children from different parts of the country.<sup>33</sup> Most studies only test small sets of factors. Some studies only test bivariate associations (for example, Laghari et al. 2015; Ullah et al. 2014; Khattak and Ali 2010). Other studies test bivariate associations and only include a subset of factors in regressions, such as those that were significant in bivariate tests (for example, the World Bank provincial nutrition status notes; Baig-Ansari et al. 2006; Fikree, Rahbar, and Berendes 2000). Yet other studies test associations in regressions but do not report the full set of results (for example, Di Cesare et al. 2015).

We discuss effects organized by whether the factor is at the child, mother, household, or community level. Unless otherwise noted, we discuss regression results from the various studies. Given that factors are measured differently across studies, we discuss the direction and significance of the factor’s effect and not the effect size. When the effect of the same factor is examined across multiple studies, we discuss the result from the study that uses data that are more recent and more widely representative.

> 33 For example: a hospital pediatric ward in Swat (Ullah et al. 2014); a government immunization facility in Rawalpindi city, in Punjab (Rahman et al. 2004a); squatter settlements in Karachi city, in Sindh (Fikree, Rahbar, and Berendes 2000; Baig-Ansari et al. 2006); rural Rawalpindi district, in Punjab (Rahman et al. 2004b); Sanghar district, in Sindh (Laghari et al. 2015); Dadu district, in Sindh (Farid-ul-Hasnain and Pradhan 2013); Thatta and Dadu districts, in Sindh (Fazal et al. 2013); Swabi district, in Khyber Pakhtunkhwa (KPK) (Khattak and Ali 2010); and four poor districts, in Balochistan, KPK, Punjab, and Sindh (Alderman and Garcia 1994).

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