The impact of women's empowerment on their children's early development in 26 African countries

Early childhood development and nutritional status in urban Ethiopia

Early childhood development (ECD) is crucial for better health and well-being throughout life, but few studies have examined how ECD relates to child malnutrition. This is mainly due to lack of reliable and disaggregated data on ECD. We estimated the prevalence of ECD delays (communication, fine motor, gross motor, problem-solving and personal-social) and examined how different ECD domains were associated with child nutritional status in urban Ethiopia. Using a community-based cross-sectional survey design, 627 mother-child (12-36 months old) pairs were included in the study. The ECD was assessed using the Age and Stage Questionnaire (ASQ-3), and the nutritional status was assessed using anthropometric measurements. The association between the ECD domains and nutritional status was analysed using ordinal logistic regression, adjusting for confounding variables. Delays in ECD domains were common, especially in fine motor domain (41.9%); and more than half of the children were stunted (52.8%). Stunting and underweight were associated with ECD delays, while wasting was not. Accordingly, stunted children were more likely to have worst ECD delays in fine motor (odds ratios [OR] = 1.54; 95% confidence interval [CI]: 1.11; 2.15), gross motor (OR = 1.47; 95% CI: 1.05; 2.04) and problem-solving (OR = 1.41; 95% CI: 1.02; 1.96) domains compared to non-stunted children. Similarly, underweight children were more likely to have worse ECD delays in gross motor (OR = 1.91; 95% CI: 1.20; 3.04) and fine motor (OR = 1.90; 95% CI: 1.15; 3.15) domains compared to normal children. Coordinated and targeted ECD interventions, such as nurturing care, should be promoted and implemented widely to improve ECD outcomes and child nutrition.

Relations of maternal health literacy and parenting practices with early childhood development: a cross-sectional study

This study aimed to examine the relations of early childhood development with maternal health literacy and mothers' early parenting practices. This cross-sectional study was conducted on mothers with children aged 36-59 months (n = 503) with a survey form, Early Childhood Development Index (ECDI) and Turkish Health Literacy Scale-32. Children of mothers with sufficient/excellent health literacy levels, children who are breastfed for 12 months and longer, and children with a screen time of 2 h or less were more likely to be ECDI-on-track (AOR (CI) = 2.52 (1.53-4.15); 2.28 (1.41-3.70); 2.04 (1.18-3.50); respectively). In conclusion, children whose mothers were adequately health literate, who were breastfed longer and who had less screen time were better on ECDI indicators. Increasing the knowledge and skills of mothers on early parenting practices and supporting them to be good health literacy will contribute positively to the early development of children.

Contraceptive Adoption and Changes in Empowerment in Kenya, Nigeria, and Senegal

Women's empowerment and contraceptive use are critical to achieving gender equality. The positive association between more empowered women and higher rates of contraceptive use has been well-established by cross-sectional research. However, there remains a gap in understanding the longitudinal relationship between contraceptive adoption and changes to women's empowerment. This study represents a novel approach to understanding the relationship between contraceptive adoption and women's empowerment longitudinally, at the individual level. To the authors' knowledge, this is the first attempt to measure the relationship between contraceptive adoption and women's empowerment using more than one wave of panel data. We leverage the longitudinal design of the Urban Reproductive Health Initiative data to code empowerment items by change over time (e.g., more empowered, no change, less empowered). We use sparse principal component analysis to establish empowerment change domains and calculate individual scores standardized by country-level averages. We estimate mixed effects models on these change domains, to investigate the link between contraceptive adoption and empowerment. We find common themes in empowerment across contexts-but contraceptive adoption has both positive and negative effects on those domains, and this varies across context. We discuss the need for cohort studies to examine this relationship.

The Association of Women's Empowerment with HIV-Related Indicators: A Pooled Analysis of Demographic and Health Surveys in Sub-Saharan Africa

BACKGROUND

Women's empowerment is an important factor for HIV prevention, but the association with HIV-related indicators has never been quantified. In this study, we examined the association between women's empowerment and selected HIV-related indicators.

METHODS

We used the latest Demographic and Health Surveys that included HIV testing among other biomarkers of 31 countries in sub-Saharan Africa. Empowerment was measured by the Survey-based Women's EmPowERment (SWPER) index and was compared to the HIV-related indicators: HIV status, HIV testing (ever and in the past 12 months), condom use at last high-risk sex, the ability to ask the partner to use a condom, and the ability to refuse sex.

RESULTS

208,947 women were included in the analysis, of whom 100,924 (48%) were considered highly empowered and 21,933 (10%) as lowly empowered. There was no association between empowerment and HIV status (OR = 1.12, 95% confidence interval [CI] 0.98-1.28). Highly empowered women were more likely to have ever been tested for HIV (OR = 1.67, 95% CI 1.60-1.74) but less likely to have been tested for HIV in the past 12 months (OR = 0.92, 95%CI 0.88-0.96). Highly empowered women were more commonly able to ask the partner to use a condom (OR = 1.69, 95% CI 1.63-1.75) and to refuse sex (OR = 1.78, 95%CI 1.72-1.85).

CONCLUSIONS

Women's empowerment does not seem to be linked to HIV status, but it is strongly associated with a woman's ability to make decisions about their sexual behavior. Empowering women and young girls has the potential to contribute toward achieving the United Nations' goal of ending AIDS by 2030.

Integrated Early Childhood Development in Cambodia: Protocol of a Cluster Stepped-Wedge Trial

OBJECTIVES

Limited evidence is available on mechanisms linking integrated, multisector interventions with early childhood development. The Integrated Early Childhood Development program aims to improve children's development by promoting targeted caregiving behaviors beginning prenatally through age 5 years, in partnership with the Royal Government of Cambodia.

METHODS

This cluster stepped-wedge trial is being conducted in Cambodia among 3 cohorts, encompassing 339 villages and 1790 caregivers who are pregnant or caring for a child aged <5 years. The 12- to 15-month intervention is delivered to each cohort using a staggered stepped-wedge design. Among all cohorts, enrollment evaluations will be followed by 3 data collection waves. Targeted caregiving interventions are provided through community, group, and home-visiting platforms. Child development is measured using the Caregiver Reported Early Development Instrument and the Early Childhood Development Index 2030. The evaluation assesses mediation through targeted caregiving behaviors: responsive caregiving, nutrition, health and hygiene, and household stability and support; moderation by household wealth, caregiver education, and child birth weight; and sustainability after the intervention concludes.

CONCLUSIONS

This protocol article describes the plans for a cluster randomized controlled trial to measure the impact of an integrated, multisector intervention on children's development. By partnering with the Royal Government of Cambodia and addressing intervention pathways and moderators, this trial will provide guidance for policies and programs to promote early childhood development using principles of implementation science and equity, including increased investment for vulnerable families.

Effects of engaging fathers and bundling nutrition and parenting interventions on household gender equality and women's empowerment in rural Tanzania: Results from EFFECTS, a five-arm cluster-randomized controlled trial

Advancing gender equality and women's empowerment (GE/WE) may contribute to better child nutrition and development in low-resource settings. However, few empirical studies have generated evidence on GE/WE and examined the potential of engaging men to transform gender norms and power relations in the context of nutrition and parenting programs. We tested the independent and combined effects of engaging couples and bundling nutrition and parenting interventions on GE/WE in Mara, Tanzania. EFFECTS (ClinicalTrials.gov, NCT03759821) was a cluster-randomized 2 × 2 factorial trial plus control. Eighty village clusters were randomly assigned to one of five intervention conditions: standard of care, mothers nutrition, couples nutrition, mothers bundled nutrition and parenting, or couples bundled nutrition and parenting. Between October 2018-May 2019, 960 households were enrolled with children under 18 months of age residing with their mother and father. Community health workers (CHWs) delivered a bi-weekly 24-session hybrid peer group/home visit gender-transformative behavior change program to either mothers or couples. GE/WE outcomes were analyzed as intention-to-treat and included time use, gender attitudes, social support, couples' communication frequency and quality, decision-making power, intimate partner violence (IPV), and women's dietary diversity (WDD). Data were collected from 957 to 815 mothers and 913 and 733 fathers at baseline and endline, respectively. Engaging couples compared to mothers only significantly increased paternal and maternal gender-equitable attitudes, paternal time spent on domestic chores, and maternal decision-making power. Bundling increased maternal leisure time, decreased maternal exposure to any IPV, and increased WDD over 7 days. A combination of engaging couples and bundling was most effective for paternal gender attitudes, couples communication frequency, and WDD over 24 h and 7 days. Our findings generate novel evidence that CHWs can deliver bundled nutrition and parenting interventions to couples in low-resource community settings that advance GE/WE more than nutrition interventions targeting only women.

A cross-sectional analysis of long-term exposure to ambient air pollution and cognitive development in children aged 3-4 years living in 12 low- and middle-income countries

Exposure to ambient air pollution may affect cognitive functioning and development in children. Unfortunately, there is little evidence available for low- and middle-income countries (LMICs), where air pollution levels are highest. We analysed the association between exposure to ambient fine particulate matter (≤2.5 μm [PM_2.5]) and cognitive development indicators in a cross-sectional analysis of children (aged 3-4 years) in 12 LMICs. We linked Demographic and Health Survey data, conducted between 2011 and 2018, with global estimates of PM_2.5 mass concentrations to examine annual average exposure to PM_2.5 and cognitive development (literacy-numeracy and learning domains) in children. Cognitive development was assessed using the United Nations Children's Fund's early child development indicators administered to each child's mother. We used multivariable logistic regression models, adjusted for individual- and area-level covariates, and multi-pollutant models (including nitrogen dioxide and surface-level ozone). We assessed if sex and urban/rural status modified the association of PM_2.5 with the outcome. We included 57,647 children, of whom, 9613 (13.3%) had indicators of cognitive delay. In the adjusted model, a 5 μg/m³ increase in annual all composition PM_2.5 was associated with greater odds of cognitive delay (OR = 1.17; 95% CI: 1.13, 1.22). A 5 μg/m³ increase in anthropogenic PM_2.5 was also associated with greater odds of cognitive delay (OR = 1.05; 95% CI: 1.00, 1.10). These results were robust to several sensitivity analyses, including multi-pollutant models. Interaction terms showed that urban-dwelling children had greater odds of cognitive delay than rural-dwelling children, while there was no significant difference by sex. Our findings suggest that annual average exposure to PM_2.5 in young children was associated with adverse effects on cognitive development, which may have long-term consequences for educational attainment and health.

Life history trade-offs associated with exposure to low maternal capital are different in sons compared to daughters: Evidence from a prospective Brazilian birth cohort

Background

Environmental exposures in early life explain variability in many physiological and behavioural traits in adulthood. Recently, we showed that exposure to a composite marker of low maternal capital explained the clustering of adverse behavioural and physical traits in adult daughters in a Brazilian birth cohort. These associations were strongly mediated by whether or not the daughter had reproduced by the age of 18 years. Using evolutionary life history theory, we attributed these associations to trade-offs between competing outcomes, whereby daughters exposed to low maternal capital prioritised investment in reproduction and defence over maintenance and growth. However, little is known about such trade-offs in sons.

Methods

We investigated 2,024 mother-son dyads from the same birth cohort. We combined data on maternal height, body mass index, income, and education into a composite "maternal capital" index. Son outcomes included reproductive status at the age of 18 years, growth trajectory, adult anthropometry, body composition, cardio-metabolic risk, educational attainment, work status, and risky behaviour (smoking, violent crime). We tested whether sons' early reproduction and exposure to low maternal capital were associated with adverse outcomes and whether this accounted for the clustering of adverse outcomes within individuals.

Results

Sons reproducing early were shorter, less educated, and more likely to be earning a salary and showing risky behaviour compared to those not reproducing, but did not differ in foetal growth. Low maternal capital was associated with a greater likelihood of sons' reproducing early, leaving school, and smoking. High maternal capital was positively associated with sons' birth weight, adult size, and staying in school. However, the greater adiposity of high-capital sons was associated with an unhealthier cardio-metabolic profile.

Conclusion

Exposure to low maternal investment is associated with trade-offs between life history functions, helping to explain the clustering of adverse outcomes in sons. The patterns indicated future discounting, with reduced maternal investment associated with early reproduction but less investment in growth, education, or healthy behaviour. However, we also found differences compared to our analyses of daughters, with fewer physical costs associated with early reproduction. Exposure to intergenerational "cycles of disadvantage" has different effects on sons vs. daughters, hence interventions may have sex-specific consequences.

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

Associations between women’s empowerment, care seeking, and quality of malaria care for children: A cross-sectional analysis of demographic and health surveys in 16 sub-Saharan African countries

Background

Methods

Results

Conclusions

Women's Empowerment as It Relates to Attitudes Towards and Practice of Female Genital Mutilation/Cutting of Daughters: An Ecological Analysis of Demographic and Health Surveys From 12 African Countries

Background: Women's empowerment may play a role in shaping attitudes towards female genital mutilation/cutting (FGM/C) practices. We aimed to investigate how empowerment may affect women's intention to perpetuate FGM/C and the practice of FGM/C on their daughters in African countries. Materials and methods: We used data from Demographic and Health Surveys carried out from 2010 to 2018. The countries included in our study were Benin, Burkina Faso, Chad, Côte d´Ivoire, Ethiopia, Guinea, Kenya, Mali, Nigeria, Senegal, Tanzania, and Togo. This study included 77,191 women aged 15-49 years with at least one daughter between zero and 14 years of age. The proportion of women who reported having at least one daughter who had undergone FGM/C as well as the mother's opinion towards FGM/C continuation were stratified by empowerment levels in three different domains (decision-making, attitude to violence, and social independence) for each country. We also performed double stratification to investigate how the interaction between both indicators would affect daughter's FGM/C. Results: The prevalence of women who had at least one daughter who had undergone FGM/C was consistently higher among low empowered women. Tanzania, Benin, and Togo were exceptions for which no differences in having at least one daughter subjected to FGM/C was found for any of the three domains of women's empowerment. In most countries, the double stratification pointed to a lower proportion of daughters' FGM/C among women who reported being opposed to the continuation of FGM/C and had a high empowerment level while a higher proportion was observed among women who reported being in favor of the continuation of FGM/C and had a low empowerment level. This pattern was particularly evident for the social independence domain of empowerment. In a few countries, however, a higher empowerment level coupled to a favorable opinion towards FGM/C was related to a higher proportion of daughters' FGM/C. Conclusion: Women's empowerment and opinion towards FGM/C seems to be important factors related to the practice of FGM/C in daughters. Strategies to improve women's empowerment combined with shifts in the wider norms that support FGM/C may be important for achieving significant reductions in the practice.

Assessing the Inequality of Early Child Development in China - A Population-Based Study

Background

As a country with the second largest child population in the world, China has little population-level evidence on who has been left behind in early childhood development (ECD). Knowledge of inequalities in ECD will inform the Chinese government in policies on promoting ECD and guide global-level monitoring on ECD progress.

Methods

Using data from the first wave of ECD surveys conducted in China at the least-developed region, most-developed region, and a megacity (Shanghai) in 2017 and 2018, we measured population-level ECD with early Human Capability Index for a total of 63,559 children aged 36-59 months old. A child was classified as developmentally on track if his/her overall development score was above the 20^th percentile of the pooled populations. We measured inequalities in ECD with the absolute inequality in five domains: gender/sex, family income, maternal schooling, residential Hukou, and migrant- or left-behind status. Besides observed inequalities, we used a multilevel logistic regression model to generate adjusted inequalities.

Findings

Children developmentally on track ranges from 71% (95% CI 70 to 72%) in the least-developed region, 82% (95% CI 81 to 83%) in the most-developed region, and 86% (95% CI 85 to 87%) in Shanghai. Significant unadjusted inequalities in ECD were observed in all five dimensions. After controlling for other socioeconomic factors, significant differences remained in three dimensions: those living in the poorest families, or with lower maternal schooling, or boys were less likely to be developmentally on track than their counterparts (lower by 10[95% CI 8 to 11]-15[95% CI 13 to 17], 7[95% CI 5 to 10]-10[95% CI 7 to 12], and 5[95% CI 4 to 6]-6[95% CI 5 to 8] percentage points respectively).

Interpretation

Efforts of reducing ECD inequalities in China shall focus primarily on reducing poverty and improving maternal education.

Funding

National Natural Science Foundation of China (81773443), Shanghai Committee of Science and Technology (2018SHZDZX05), Shanghai Municipal Health Commission (GWV-10.1-XK07; GDEK201708), Shanghai Education Committee, Chinese Social Science Foundation (BFA140046), Macao Tong Chai Charity Association, Beijing Sany Charitable Foundation, China Medical Board (#20-388), UNICEF, Faculty Grant of Brigham & Women's Hospital, Economic and Social Research Council [grant reference number ES/T003936/1’] as a UKRI Collective Fund Award “UKRI GCRF Harnessing the Power of Global Data to Support Young Children's Learning and Development Collaborative."

Associations between women's empowerment and child development, growth, and nurturing care practices in sub-Saharan Africa: A cross-sectional analysis of demographic and health survey data

BACKGROUND

Approximately 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Women's empowerment may help provide inputs of nurturing care for early development and growth by building caregiver capacity and family support. We examined the associations between women's empowerment and child development, growth, early learning, and nutrition in sub-Saharan Africa (SSA).

METHODS AND FINDINGS

We pooled data on married women (15 to 49 years) and their children (36 to 59 months) from Demographic and Health Surveys that collected data on child development (2011 to 2018) in 9 SSA countries (N = 21,434): Benin, Burundi, Cameroon, Chad, Congo, Rwanda, Senegal, Togo, and Uganda. We constructed a women's empowerment score using factor analysis and assigned women to country-specific quintile categories. The child outcomes included cognitive, socioemotional, literacy-numeracy, and physical development (Early Childhood Development Index), linear growth (height-for-age Z-score (HAZ) and stunting (HAZ <-2). Early learning outcomes were number of parental stimulation activities (range 0 to 6) and learning resources (range 0 to 4). The nutrition outcome was child dietary diversity score (DDS, range 0 to 7). We assessed the relationship between women's empowerment and child development, growth, early learning, and nutrition using multivariate generalized linear models. On average, households in our sample were large (8.5 ± 5.7 members) and primarily living in rural areas (71%). Women were 31 ± 6.6 years on average, 54% had no education, and 31% had completed primary education. Children were 47 ± 7 months old and 49% were female. About 23% of children had suboptimal cognitive development, 31% had suboptimal socioemotional development, and 90% had suboptimal literacy-numeracy development. Only 9% of children had suboptimal physical development, but 35% were stunted. Approximately 14% of mothers and 3% of fathers provided ≥4 stimulation activities. Relative to the lowest quintile category, children of women in the highest empowerment quintile category were less likely to have suboptimal cognitive development (relative risk (RR) 0.89; 95% confidence interval (CI) 0.80, 0.99), had higher HAZ (mean difference (MD) 0.09; 95% CI 0.02, 0.16), lower risk of stunting (RR 0.93; 95% CI 0.87, 1.00), higher DDS (MD 0.17; 95% CI 0.06, 0.29), had 0.07 (95% CI 0.01, 0.13) additional learning resources, and received 0.16 (95% CI 0.06, 0.25) additional stimulation activities from their mothers and 0.23 (95% CI 0.17 to 0.29) additional activities from their fathers. We found no evidence that women's empowerment was associated with socioemotional, literacy-numeracy, or physical development. Study limitations include the possibility of reverse causality and suboptimal assessments of the outcomes and exposure.

CONCLUSIONS

Women's empowerment was positively associated with early child cognitive development, child growth, early learning, and nutrition outcomes in SSA. Efforts to improve child development and growth should consider women's empowerment as a potential strategy.

SWPER Global: A survey-based women's empowerment index expanded from Africa to all low- and middle-income countries

Background In 2017, a survey-based women's empowerment index (SWPER) was proposed for African countries, including three domains: social independence, decision making and attitude to violence. External validity and predictive value of the SWPER has been demonstrated in terms of coverage of maternal and child interventions and use of modern contraception. To determine its value for global monitoring, we explored the applicability of the SWPER in national health surveys from low- and middle- income countries (LMICs) in other world regions.

Methods

We used data from the latest Demographic and Health Survey for 62 LMICs since 2000. 14 pre-selected questions (items) were considered during the validation process. Content adaptations included the exclusion of women's working status and recategorization of the decision-making related items. We compared the loading patterns obtained from principal components analysis performed for each country separately with those obtained in a pooled data set with all countries combined. Country rankings based on the score of each SWPER domain were correlated with their rankings in the Gender Development Index (GDI) and the Gender Inequality Index (GII) for external validation.

Results

Consistency regarding item loadings for the three SWPER empowerment domains was observed for most countries. Correlations between the scores generated for each country and global score obtained from the combined data were 0.89 or higher for all countries. Correlations between the country rankings according to SWPER and GDI were, respectively, 0.74, 0.72 and 0.67 for social independence, decision-making, and attitude to violence domains. The correlations were equal to 0.81, 0.67, and 0.44, respectively, with GII.

Conclusions

The indicator we propose, named SWPER Global, is a suitable common measure of women's empowerment for LMICs, addressing the need for a single consistent survey-based indicator of women´s empowerment that allows for tracking of progress over time and across countries at the individual and country levels.

Regional variations of child development index in Bangladesh

Early development is a vital phase in childhood life. The study aimed to identify factors that were associated with the early development of 36–59 months children in Bangladesh. The findings of this study will formulate the design of appropriate policy and programmed responses.

Utilizing Multiple Indicator Cluster Survey data, influencing components of child development status were evaluated for both rural and urban areas of Bangladesh. A total of 23,099 children under the age of five were included in this analysis. Chi-square analysis was conducted to assess the association between outcome variables and selected covariates. At the same time, this study uses two separate multivariate binary logistics regression models (respectively for urban areas and rural areas) to determine the risk factors that are primarily related to child development.

Our research estimates that more than 70 percent of children develop early throughout the country. The multivariate analysis on the determinants of child development index among children aged between 36 and 59 months old regarding residence discovered a significant impact on child age and sex, maternal education, child education, wealth status, reading children's books. The adjusted odds of child nutrition status, playthings, and maternal functional difficulties have had a major impact on early child development in rural Bangladesh.

Based on the findings, educational status, nutritional status, wealth-status, and some determinants of children care the most noteworthy findings in this study. Hence, policymakers should emphasize on such factors for improving children's development in residence.