Sanitation ladder and undernutrition among under-five children in Pakistan.

While the state of sanitation in Pakistan has improved in the last decade, a significant proportion of its population is still using inadequate sanitation or no toilet facility at all. Open defecation has decreased over the years; however, it has been replaced by poor quality sanitation in rural areas that might still cause diarrhoea and undernutrition. The research regarding inadequate sanitation in Pakistan, especially in terms of the sanitation ladder, remains limited. The present research thus fills this research gap by assessing the impact of different types of sanitation on the prevalence of stunting and underweight (moderate as well as severe) among under-five children in Pakistan using the nationally representative micro survey, Pakistan Demographic and Health Survey (2017-18). The sanitation ladder comprises of piped to sewer (highest level, base) followed by flush to septic tank, flush to pit latrine, other improved, unimproved sanitation, and open defecation. In order to estimate the adjusted and unadjusted odds ratios of the determinants, this research uses logistic regressions are used to estimate adjusted and unadjusted odds ratios of the determinants. We show that toilets connected to piped sewerage network are rare in the rural areas of Pakistan and a large segment of the rural population is still practicing open defecation. The logistic regressions show that piped sewerage network and flush to septic tanks are associated with lowest odds (both adjusted and unadjusted) of stunting and underweight among under-five children. In multivariate regressions, pit latrines are associated with even higher adjusted odds of severe and moderate and severe stunting as well as underweight among under-five children, showing that poor quality pit latrines may bring the source of faecal contamination to the doorstep of the households. Therefore, interventions targeting reduction in open defecation should promote good quality toilets for sustainable long-term improvements in child health.