Gender equity in childhood nutrition is feasible only by accelerating interventions that aim to improve IYCF practices at a community level. There is growing evidence that IYCF practices are influenced by various social, economic, and cultural factors [16, 30,31,32]. Findings from an exploratory research study indicate the need to shift focus from nutrition-specific interventions to contextually-appropriate interdisciplinary solutions, incorporating environmental improvements to address the problem of child undernutrition [33]. Our study provides insights on how IYCF practices vary in the context of gender, parental migration, environmental, and contextual factors in the tribal district of Banswara, Rajasthan. Children in this area had relatively good access to immunization services (57%) and access to AWC services (74%), and Ghatol block had access to two crops a year, yet IYCF practices were still found to be sub-optimal. Breastfeeding practices in these areas were better than the dietary practices. In terms of dietary practices, 55% (95% CI: 49–60%) of children received a diet with MMF, while only 7% (95% CI: 5%–11%) received a diet with MDD and 6% (95% CI: 4–10%) received a diet with MAD. Iron-rich food consumption was almost negligible (1.5%;: 95% CI: 0.5–3.6%).
Our study found that male children had significantly better access to a diet with MDD and MAD than the female children – 4.1 times higher for MDD and nearly four times higher for MAD. Gender discrimination in IYCF practices began at infancy, with consumption of each of the seven standard food groups being higher among boys than girls. Children from non-migrant households also had better access to MDD and MAD diets compared to children from migrant households, while the reverse was true for diet with MFF, however, the differences were not statistically significant for all the three key IYCF practices. Migration for livelihood was a common phenomenon in the study population with at least one member (usually a parent, mostly fathers) of the family having migrated for work in the previous year in 46% of households. Children from households without parental migration had higher consumption of milk, eggs, fruit, and vegetables compared to children from households with parental migration. A child from a non-migrant house was 1.9–2.0 times more likely to get a diet with MDD and MAD compared to a child from a migrant house, but this difference was not statistically significant. The insignificant association between migration and MDD and MAD may be because of the huge block-wise variations in migration practices (Kushalgarh-74% Vs Gatol-19%), and the sample size of Kushalgarh block alone was not adequately powered enough to assess this exposure against MDD and MAD.
Apart from the above two effect modifiers, the two other strongest predictors of improving complementary-feeding practices of MDD and MAD were the presence of milk-producing animals in households and consumption of milk/milk products by children in the previous 24 h. Both these variables were significantly and independently associated with MDD and MAD separately. Children living in households with milk-producing animals had 5.6–5.8 times increased access to a diet with MDD and MAD compared to those living in households without milk-producing animals, while children who had consumed milk/milk products in the previous 24 h had 6 times higher access to MDD and MAD compared to those who did not consume milk/milk products. Overall, a large number of households (60–85%) had milk-producing animals, but less than 40% of children (95% CI: 33.1–44.0) had consumed milk in the previous 24 h. Interestingly, access to animal milk at the household level did not translate to improved consumption of milk or milk products for the children. On the contrary, consumption of milk by children in households with access to animal milk was lower compared to those in households with no/poor access to animal milk (36% vs. 41%) (Fig. 1). One reason for this may be that the majority of households with milk-producing animals sold the milk they got from the domestic animals at the local market to make additional income. This pattern was also observed in the project’s qualitative study [28].
The other significant predictors for improving IYCF practices included literacy of the head of the household (for both MDD and MAD), accessibility of nutrition services at AWC (for MFF only), awareness about the Clean India mission (for MAD only), and use of a clean source of cooking fuel (for MDD only).
How comparable are our results with other studies?
Two-thirds of the mothers were literate, and 60% of families were aware of the Clean India Mission (a nationwide campaign to eliminate open defecation and improve solid waste management [34]), statistics of this study reflecting the national average. Similarly, study findings also reflected national figures on immunization – 62% of the respondents’ children were fully immunized, 60% received Vitamin supplementation, and 31% were dewormed [13].
According to NFHS-4 (2015–16) in rural Banswara, 39% of children received breastfeeding within 1 hour of birth, 56% were exclusively breastfed, and only 0.8% children aged 6–23 months received MAD. On the other hand, in rural Rajasthan, 29% initiated breastfeeding within 1 hour; 58% exclusively breastfed; 29% of children aged 6–8 months received solid and semi-solid food; and 3.3% received MAD [13]. Most recent findings from CNNS in Rajasthan (2016–18) estimated that while 43.6% of children aged 6–23 months received a diet with MMF, the figures for other complementary feeding indicators were quite low - 11.6% for MDD, 3.5% for MAD and 1.4% for iron-rich foods [12]. Compared to the findings of NFHS-4 and the state CNNS data for both Banswara district and Rajasthan state, the IYCF practices in the PANChSHEEEL study area show improvement (Table 3), but the results are still far from optimal. Additionally, the Banswara district has a higher female-to-male child sex ratio (934) than the state (888) average. Despite this, gender differentials in Banswara district were quite evident on literacy and type of work, with a higher proportion of males being literate (male 70% vs female 43%) and males constituting the main workforce (male 40% vs female 20%), while a higher number of females were marginal workers (male 13% vs female 23%) and agricultural labourers (male 13% vs female 32%) [35]. We also noticed that around one-third of children had consumed convenience foods like biscuits and tea in the previous 24 h. This was also noticed in the formative research, where it was found that when a mother or caregiver is busy with household chores, convenience foods like biscuits, tea, khichdi (savoury rice and pulse gruel), dalia (porridge with ground wheat with milk or water, mostly sweet) or small pieces of roti dipped in milk are provided to pacify a child’s hunger [28].
An analysis by Fledderjohann showed that breastfeeding patterns were similar for boys and girls until about 12 months of age, when a gender gap begins to emerge. Among the firstborns, the median duration of breastfeeding was around 21 months for females and 23.2 months for males, while second-born females experienced only a slight disadvantage (23.1 months for females and 24.0 for males), highlighting the importance of both gender and birth order in IYCF practices[19].
Based on the variations of type of food consumed and IYCF practices by gender (Table 4), we are unable to provide conclusive evidence that females are discriminated against on all key IYCF practices. However, it is evident that girls were at a disadvantage for most of the complementary-feeding practices compared to the boys, especially access to MDD and MAD. Other studies have reported a lack of conclusive evidence of female children being nutritionally disadvantaged [36] and shown heterogeneity in nutrient intake in different states [37]. One of the reasons for this inconsistency could be because our analysis is aggregated only by gender and not further according to birth order or wealth quintile of children, as these two factors play a key role in gender-based discrimination [37]. A deeper analysis was not possible due to sample size constraints, particularly for MDD and MAD.
Findings from our qualitative formative research in the same nine villages substantiates our finding that girls are at a disadvantage on the education front, particularly those from families with parental migration. In addition, teachers of this area reported that ‘elder siblings, especially girls, were often absent from school to take care of younger siblings, especially in families where both parents have migrated (seasonally) or if primary caregiver was unavailable’. It was also noticed that, although families do receive food supplements for infants, many mothers don’t know how to prepare them, resulting in children still not getting these benefits [28]. On gender-based labour participation, women were engaged in agriculture and livestock farming throughout the year whilst men took part in agriculture only during sowing and harvesting seasons. Some women with children aged less than 2 years also participated in the National Rural Employment Guarantee Scheme. The men of Ghatol mostly relied on local wage labour due to the proximity of the block to the district headquarters and a cloth mill. Circular migration to urban areas in the adjacent states of Madhya Pradesh and Gujarat was common among men in Kushalgarh.
A study conducted in rural parts of southern Rajasthan (including Banswara district) documented how environmental and contextual factors push families to economic distress, forcing young males to migrate to the neighbouring state of Gujarat for seasonal unskilled jobs [38]. In these migrant households, pressure on financial resources might have led to scarcity of nutritious food and limited the mother’s time and energy that is required to provide adequate care to the young ones. However, in our study we could not find conclusive evidence of parental migration having an independent and statistically-significant effect on a child’s access to key IYCF practices.
Strengths and limitations
There is limited evidence on the influence of socio-economic factors on IYCF practices [11] and insufficient understanding on the inequalities that shape malnutrition in India [30], particularly in tribal areas [39]. As far as we are aware, this is the first in-depth assessment of inequalities in IYCF practices with respect to gender and parental migration in a tribal district. The study also demonstrates how the factors affecting nutrition for 6–23-month-old children are complex, affected by elements such as gender; poverty and its associated migration; maternal health literacy; home environment; dietary practices; hygiene practices; and access to milk-producing animals. Since data for this study is derived from two divergent blocks of Banswara district and the interventions were co-developed with community stakeholders, findings of this research are applicable to both rural and tribal parts of India.
One of the major limitations of the study is that the findings are based on results from only nine villages and 325 households. Also, the nine villages were selected purposively using a set of inclusion and exclusion criteria, and the eligible households were selected by using a list of lactating mothers made by the AWW/ASHA and not by conducting our own listing and mapping exercise. This approach might have resulted in missing some eligible children from these villages. However, as we adopted a three-step recruitment policy the chances of having missed many eligible households are minimal. Even though there was general improvement in IYCF practices with positive shifts in HEEE factors, most of these associations were not significant/close to significant, perhaps due to limitations of the sample size. Some of the associations between HEEE and IYCF factors have wide confidence intervals due to this limitation. Additionally, this study and other qualitative surveys were conducted during the months January–March 2017, a period of lean agricultural activity, which may have some influence on the IYCF practices.
Significance
Despite robust programs like ICDS (1975); National Diarrhoeal Diseases Control Programme (1981); National Health Mission & promotion of IYCF (2013); National Deworming Day; Nutritional Rehabilitation Centres (2015); and the Poshan Abhiyaan/National Nutrition Mission (2018), it is evident from our research and recent NFHS-5 (2019–20) findings that the quality of dietary and IYCF practices and the prevalence of child undernutrition is not encouraging [40]. Also, India’s child nutrition issue is characterized by significant inequalities across socioeconomic groups and areas of residence and has made very limited progress in addressing these inequalities.
Although IYCF is generally understood to be shaped by household-level factors, this study emphasizes that IYCF practices are also shaped by contextual factors – especially gender. However, by promoting universal access to animal milk, by engaging with the literate heads of the households in promotion of optimal IYCF, and through effective and targeted implementation of ICDS services, existing gender inequalities in complementary-feeding practices could be minimized. Household-level factors are thus interconnected with the village and HEEE level factors. These should, therefore, be considered when planning an optimum intervention to address IYCF practices in low- and middle-income countries. The challenge of child malnutrition calls for a multidisciplinary approach that targets multiple underlying factors like PANChSHEEEL’s intervention strategy [21], which adopted a multi-disciplinary, participatory, and life-course approach to tackle the multi-dimensional problems of childhood malnutrition and IYCF practices.