The world's longest running civil war and chronic childhood undernutrition in Myanmar: a propensity score matched analysis.

BACKGROUND

Childhood undernutrition remains a major public health challenge in low- and middle-income countries (LMICs), particularly in settings affected by armed conflict and fragility. Prolonged civil conflict disrupts livelihoods, food systems and service delivery, yet its nutritional consequences remain poorly quantified. This study assesses the association between regional exposure to armed conflict and chronic childhood undernutrition in Myanmar.

METHODS

We linked nationally representative data obtained from the 2015-16 Myanmar Demographic and Health Survey with conflict event records from the Uppsala Conflict Data Program (2010-2015). Administrative regions were classified as conflict-affected or conflict-insulated based on the spatio-temporal frequency of conflict-related fatalities. Using a propensity score matching (PSM) approach, we estimated the association between conflict exposure and stunting (height-for-age Z-score < -2 SD) among a sample of 3,792 children matched on the basis of various demographic, socioeconomic and environmental attributes using the Average Treatment Effect on the Treated (ATT). Robustness checks across alternative matching algorithms and covariate exposure classification were carried out as well as sensitivity analysis for unmeasured confounding.

RESULTS

The estimated ATT was 0.045 (95% bootstrap CI: 0.005-0.083), corresponding to a 4.5 percentage point higher prevalence of stunting among children residing in conflict-affected regions compared with matched children from conflict-insulated regions. As a secondary analysis, post-matching multivariable logistic regression yielded a 28% higher odds of stunting for the former group (95% CI 1.10-1.49). Exploratory subgroup analysis suggested more pronounced associations among children of mothers with no education or employment, from poorer households and without access to improved sanitation. Results were robust to alternative propensity score modeling frameworks and moderate levels of unmeasured confounding.

CONCLUSIONS

Protracted armed conflict is strongly associated with child undernutrition in Myanmar, compounding existing inequalities and undermining progress toward national and global nutrition targets. Thus, strengthening conflict-sensitive nutrition programming, community-based service delivery and health system resilience is essential to protect vulnerable children in fragile and conflict-affected contexts as in Myanmar.