Women's Empowerment Promotes Children Thriving Globally

See corresponding article on page 685.

Caregiving behaviors are closely linked to children's health and nutrition, particularly early in life when children are highly dependent on their primary caregivers (1). Throughout the world, mothers provide most of the daily caregiving behaviors to young children (2). In low-income settings with limited resources, caregiving often involves difficult choices as mothers manage their children's daily care along with household responsibilities. In response to global evidence that women's empowerment supports children's health and nutrition, attention to women's empowerment has increased (3). However, little is known about the pathways linking empowerment to maternal caregiving behavior or strategies to increase women's empowerment.

The primary goal of caregiving is to provide nurturing care that enables children to thrive. Nurturing care includes the provision of adequate health care, nutritious food, protection from potential hazards, and opportunities to learn and explore, within the context of a loving relationship with responsive caregivers (4). Achieving these goals requires complex management capabilities, including the ability to recognize alternative choices, the problem-solving skills to evaluate alternatives, and the agency to make and implement multiple choices throughout the day (5). Effective caregiving requires women's empowerment, the ability to make strategic choices, and the agency to carry them out (6). Agency develops from self-regulatory skills, including the ability to manage the personal behavior and emotions required to implement nurturing care (6, 7).

In addition to women's personal capabilities, empowerment is dependent on the presence and accessibility of community and household resources (6). At a basic level, skilled health-care providers, health-care facilities, and sources of healthy food are prerequisites to providing nurturing care. Even if resources are available, women may face financial, time, and logistical household constraints in accessing these goods and services. In the absence of gender equality, women's ability to access community resources may be restricted if their husband's permission is required. As shown in a recent report from Africa, gender equality has been positively associated with access to health facility care for mothers and children and with their positive health outcomes (8).

The association between egalitarian gender attitudes—the belief that men and women should have equal access to resources and opportunities—and maternal caregiving behavior is highlighted in an article by Matare and colleagues (9) in this issue of the Journal of Nutrition. The authors investigated associations between maternal capabilities and maternal caregiving behaviors among mothers of young children in rural Zimbabwe. The maternal capabilities represented a comprehensive set of personal attributes, behaviors, and attitudes, ranging from maternal physical and mental health and time stress to social support and attitudes regarding self-efficacy, gender norms, and decision-making autonomy. A primary finding was that mothers’ egalitarian gender attitudes were positively associated with 5 of 7 evidence-based caregiving behaviors, more than any of the other maternal capabilities. The caregiving behaviors associated with egalitarian gender attitudes included institutional delivery, early initiation of breastfeeding, exclusive breastfeeding for months 1–3 and months 3–6, and full immunization of the child. Only dietary diversity and handwashing were not related to egalitarian gender attitudes.

Empowerment is a complex, domain-specific concept, such that empowerment in 1 domain (e.g., economic) does not necessarily translate to empowerment in other domains (e.g., caregiving). The empowerment module in the Demographic and Health Surveys includes economic empowerment, socio-familial empowerment, and legal empowerment, and has been examined in relation to children's nutrition and feeding practices (10). For the most part, child feeding practices have been positively related to economic empowerment, but inversely related to socio-familial empowerment (11). These findings may be partially explained by considering the educational level of women in the community. When women socialized with other women in the context of low education, they may have adopted maladaptive feeding practices rather than evidence-based practices. These findings illustrate the need to consider multiple domains of empowerment, along with the context, to achieve a positive impact on children's health and nutrition.

Gender equality can be difficult to measure and, at times, it is narrowly defined as the absence of a justification for wife beating. Questionnaires on decision making have had limited use in defining gender equality, as men and women tend to differ in their perceptions of decision making (12). Alternative possibilities are to rely on direct measures, such as savings or, in the case of caregiving, the health and well-being of the child. However, children's health and well-being are impacted by multiple factors, and relying on distal outcomes does not provide evidence of the underlying mechanisms. Measures of gender equality and women's empowerment also include social independence and decision-making, as measured in the Survey-Based Women's Empowerment Index (SWPER) (13). The dimensions of SWPER relate positively to the United Nations Development Programme Gender Development Index, emphasizing the association between egalitarian gender attitudes and empowerment.

Women's education and empowerment have been associated with health-promoting practices, although the mechanisms vary. Using structural equation modeling, recent studies have shown that maternal education may work through promoting household decision making for health-promoting practices (14) and that women's empowerment may promote improvements in child length, mediated through hygienic practices (15). In a longitudinal investigation, a nutrition-sensitive agriculture program improved spousal communication, which reduced wasting in children (16). These findings illustrate that empowerment may operate through multiple mechanisms, emphasizing the relevance of considering the context.

Education can provide a basis for some of the personal capabilities that underlie empowerment across domains, including problem-solving and self-regulation (7). These capabilities are best developed when education for girls proceeds through secondary school and includes opportunities that advance skills in problem-solving and self-regulation. While UNICEF reports striking increases in primary school enrollment over the past 2 decades, only 66% of countries report gender parity in primary schools (17). Secondary school enrollment has also increased but continues to lag, with 45% and 25% of countries reporting gender parity in lower and upper secondary schools, respectively (17). Policies are needed to prevent obstacles that interfere with girls continuing their education into secondary school, including school fees, household demands, gender-based violence, child marriage, and conflict.

In addition to education, strategies to increase women's empowerment include cash transfer programs, such as unconditional cash transfers that provide financial resources to women without requiring them to engage in conditioned activities. These strategies empower women by enabling them to purchase goods and services that they choose for themselves and their children. The evidence on unconditional cash transfer programs and women's empowerment has been mixed. A recent analysis of Zambia's Child Grant Program found that although the women who received the cash transfers were able to demonstrate financial empowerment by investing in their household and saving for emergencies, intrahousehold relationships were stymied by entrenched gender norms (12). Thus, the program altered women's behavior by giving them more control over resources, but the women were still disempowered, as the program did not alter gender norms within the community.

Gender equality is explicitly incorporated into the Sustainable Development Goals (SDGs) as Goal 5, based on the principle that not only is gender equality a human right, but its positive association with women's ability to seek care for themselves and their children, as reported in the Matare et al. (9) study, underpins the attainment of other SDGs.

In summary, we provide 4 recommendations to promote women's empowerment related to caregiving. First, provide access to secondary education that enables girls to develop the personal capabilities (problem-solving and self-regulatory skills) needed for agency to make and implement strategic caregiving choices. Second, continue efforts to improve context-specific measures of women's empowerment across multiple domains, including caregiving, and to measure gender equality beyond avoidance of wife beating. Third, continue to examine the mechanisms linking maternal empowerment to the caregiving behaviors that enable children to thrive, as outlined in the nurturing care framework. Fourth, develop, evaluate, and invest in strategies to advance women's empowerment, with careful consideration of shifting social norms by promoting policies and systems that support gender equality.

Notes

This commentary received support from the National Institute of Diabetes, Digestive & Kidney Disorders (R01 DK107761).

Author disclosures: The authors report no conflicts of interest.