Does maternal autonomy influence feeding practices and infant growth in rural India?

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Abstract

The high prevalence of child under-nutrition remains a profound challenge in the developing world. Maternal autonomy was examined as a determinant of breast feeding and infant growth in children 3–5 months of age. Cross-sectional baseline data on 600 mother-infant pairs were collected in 60 villages in rural Andhra Pradesh, India. The mothers were enrolled in a longitudinal randomized behavioral intervention trial. In addition to anthropometric and demographic measures, an autonomy questionnaire was administered to measure different dimensions of autonomy (e.g. decision-making, freedom of movement, financial autonomy, and acceptance of domestic violence). We conducted confirmatory factor analysis on maternal autonomy items and regression analyses on infant breast feeding and growth after adjusting for socioeconomic and demographic variables, and accounting for infant birth weight, infant morbidity, and maternal nutritional status. Results indicated that mothers with higher financial autonomy were more likely to breastfeed 3–5 month old infants. Mothers with higher participation in decision-making in households had infants that were less underweight and less wasted. These results suggest that improving maternal financial and decision-making autonomy could have a positive impact on infant feeding and growth outcomes.

Highlights

► We examined maternal autonomy as a determinant of feeding practice and infant growth in India. ► Autonomy could potentially influence self-motivation to bring about positive behavior processes. ► Confirmatory factor analysis was conducted to develop multiple dimensions of maternal autonomy. ► Individual domains of autonomy could operate differently to influence child growth and well-being.

Introduction

Child malnutrition and related morbidity and mortality are continuing challenges faced throughout the developing world. India, a country with a population of more than one billion, has one of the highest rates of undernourished children in the world: 48% of children under 5 years of age are short for their age (stunted) and 43% children are underweight (International Institute for Population Sciences and ORC Macro, 2007).

The literature identifies several determinants (inadequate dietary intake, infection & acute illness, lack of health services, and social and economic factors) of poor infant and child nutritional status (Black et al., 2008, Frongillo et al., 1997). Within the household, the role of the mother in child feeding is central. Variables associated with maternal status, such as education, are associated with child survival (Cleland, 2010) and child nutritional status (Frost, Forste, & Haas, 2005). Mothers with more education are also more likely to have children with better growth (Basu and Stephenson, 2005, Cleland, 2010, Miller and Rodgers, 2009), but this relation is not universal (Agee, 2010, Moestue and Huttly, 2008, Thang and Popkin, 2003). In South Asia, where child malnutrition is very high, mothers regardless of their education may be constrained by gender-based rules that restrict opportunities to make decisions and move around the community.

About 15 years ago, Ramalingaswami, Jonsson, and Rohde (1996) proposed that low women’s status in India was a major contributing factor to poor child health and growth. The implication is that even a woman with sufficient knowledge and resources, accrued as a result of education or SES, will be unable to use these skills to her child’s benefit if she is not enabled to make decisions. The concept of autonomy has been employed by several researchers to capture behaviors such as decision-making and mobility that may or may not be under the mother’s control. One possibility of the mechanism through which maternal autonomy acts to affect child care behaviors lies in the theory of self-determination (Ryan & Deci, 2000). This theory conceptualizes autonomy as an inner psychological need for self-motivation to bring about positive behavior processes. We hypothesize that maternal autonomy is one of the psychological needs that according to the self-determination theory results in intrinsic motivation and behavioral regulation, which in turn will bring about positive, sustained, and long-term behavioral change to impact child health and well-being (Ryan & Deci, 2000).

Demographers and sociologists have defined women’s autonomy in several ways. For example, Dyson (1983) emphasizes decision-making power regarding a woman’s life and those close to her, whereas, Dixon (1978) and Jejeebhoy (2000) focus on control over resources like food, income, knowledge, and prestige, within the family and in society at large. In line with previous research (Agarwala and Lynch, 2006, Jejeebhoy, 2000, Mason, 1986, Shroff et al., 2009), we conceptualize women’s autonomy as consisting of seven dimensions in which women make decisions and control resources within the family: household decision making autonomy, child-related decision-making autonomy, financial control and access (financial autonomy), decisions regarding mobility (mobility autonomy), freedom of movement (mobility), acceptance of domestic violence, and experience of domestic violence. These dimensions are relevant to India where women tend to have limited access to resources such as knowledge, information and finances, and are restrained in their movements in and out of the house (Dharmalingam and Morgan, 1996, Visaria et al., 1999, Vlassoff, 1992). Women’s autonomy has been examined in past research as a determinant of contraceptive use, smaller family size, and larger birth intervals (Jejeebhoy, 1991, Schuler and Hashemi, 1994, Upadhyay and Hindin, 2005). However, its effect on child health outcomes is less studied.

Recent literature suggests that women’s autonomy may be one of the important social variables responsible for influencing child nutritional status (Brunson et al., 2009, Shroff et al., 2009, Smith, 2003). In particular, Begin, Frongillo, Jr., and Delisle (1999) found that mothers’ higher decision-making power surrounding child feeding is a significant predictor of improved height-for-age z-scores. Engle (1993) found that mothers with a higher contribution of money to the family income had children with significantly better nutritional status. Mothers are more likely to use scarce resources for the benefit of their child if they are free to do so (Castle, 1993, Engle et al., 2000, Mason et al., 1999, Schmeer, 2005). Mothers with greater autonomy may also benefit in other ways that indirectly affect their child. For example, they make greater use of antenatal care despite a variation in socioeconomic status (Mistry, Galal, & Lu, 2009). This could impact her infant’s birth weight, morbidity and her own nutritional status (Fikree & Pasha, 2004). Thus we examined the influence of factors such as infant morbidity, birth weight, and maternal nutritional status on the associations in our study.

Our research adds to the past work on linkages between autonomy and child health in the following ways. It builds on past research showing the positive link between women’s autonomy and child health (Abadian, 1996, Dreze and Murthi, 2001, Malhotra et al., 1995, Miles-Doan and Bisharat, 1990, Smith, 2003). Some have used proxy (or indirect) measures to operationalize autonomy (such as education, labor force participation, employment status, age at marriage) (Mason, 1986). Others have included specific items to measure autonomy (Balk, 1997, Bloom et al., 2001, Mistry et al., 2009). However, despite recognition that autonomy is a multi-dimensional construct (Agarwala & Lynch, 2006), the majority of past research focuses on one of two dimensions of autonomy such as decision making autonomy (Balk, 1997, Begin et al., 1999, Dharmalingam and Morgan, 1996, Miles-Doan and Brewster, 1998, Senarath and Gunawardena, 2009). Our study differs by examining maternal autonomy as a multi-dimensional concept and develops distinct dimensions of autonomy using confirmatory factor analysis. The underlying premise is that each dimension of women’s autonomy may relate differently to health behaviors and outcomes.

Finally, in previous studies, the child health outcomes examined were primarily growth outcomes in older infants (Begin et al., 1999, Brunson et al., 2009, Johnson and Rogers, 1993, Miles-Doan and Bisharat, 1990, Shroff et al., 2009) and infant morbidity or mortality (Caldwell, 1986, Castle, 1993). Yet maternal autonomy may more directly influence an infant’s nutrition status through the practice of breastfeeding. Exclusive breastfeeding is a practice known to reduce infant morbidity and mortality, enhance development and also protect maternal health by lengthening pregnancy intervals (Black et al., 2008). Hence, in our study, in addition to the growth outcomes, we examined exclusive breastfeeding, a key modifiable feeding behavior.

In India, only 46.3% of infants between 0 and 5 months of age are exclusively breastfed (IIPS & Macro International, 2007). In addition to demographic and health system determinants of early cessation of exclusive breast feeding (Bhandari et al., 2008, Chandrashekhar et al., 2007, Gupta et al., 2010, Madhu et al., 2009, Tiwari et al., 2009), autonomy may be relevant because of its effect on health system use and depression during and after delivery, though the findings are not consistent for depression and breast feeding practices (Dennis and McQueen, 2009, Harpham et al., 2005, Navaneetham and Dharmalingam, 2002, Pallikadavath et al., 2004, Simkhada et al., 2010).

Thus, the objectives of this study were to: (1) identify several dimensions of autonomy through confirmatory factor analysis, and (2) examine how autonomy relates to exclusive breast feeding behavior and infant growth indicators. Specifically, we examined whether rural Indian mothers with higher levels of autonomy were more likely to exclusively breast feed infants and have infants with better growth, after accounting for potentially confounding covariates.

Section snippets

Study design and study population

We used baseline data from a 3-arm longitudinal randomized education intervention trial aimed at improving the feeding, growth, and development of 3–15 month old infants. Between September 2005 and July 2006, data were collected from 600 mother-infant pairs in 60 villages in the district of Nalgonda in the state of Andhra Pradesh, India. Sixty villages were selected purposively from three project areas (20 villages in each area) of the Integrated Child Development Services (ICDS) -- the largest

Description of sample

The study sample consisted of 600 mother-child dyads, with an equal distribution of nuclear and joint family households (Table 1). These households were predominantly Hindu and 65% of the sample belonged to the “backward caste” of the caste system. 1

Discussion

In a sample of 600 mother-infant dyads in rural Andhra Pradesh, India, we examined the association of different dimensions of maternal autonomy with exclusivity of breastfeeding as well as infant growth in the first 3–5 months of life. Mothers with higher levels of financial autonomy were more likely to exclusively breastfeed, independent of other autonomy dimensions and controlling for covariates. Further, household decision making autonomy was positively associated with infant WLZ and WAZ.

Acknowledgments

The authors thank Dr Linda Adair for her valuable comments on previous drafts of this paper and Dr Sharon L. Christ for her inputs during the analysis. This study was supported by the funding received from NIH/NICHD (R01 HD042219-03S1).

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