Breaking Barriers: How Women's Empowerment Affects Children's Nutrition Status – Further Analysis of the 2016 and 2019 Ethiopian Demographic and Health Survey

doi:10.21203/rs.3.rs-3020139/v1

Background: The issue of women and children is integral to the 17 SDGs adopted by all UN member states in 2015 and all dimensions of inclusive and sustainable development. But women's empowerment and children's nutritional status are challenges at different levels across the globe, especially in developing countries, including Ethiopia, making it essential to identify the characteristics of these children and their caregivers. Thus, the overarching objective of this study was to investigate how women's empowerment affects the nutritional status of children in Ethiopia.

Methods: We used the 2016 Ethiopia Demographic and Health Survey (EDHS) and 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) data to investigate how women's empowerment affects the nutritional status of children in Ethiopia. Stunting and wasting were the two indicators of a child's nutritional status. We tried to operationalize women's empowerment by three validated measures which comprised three latent domains from the survey: social and human assets, intrinsic agency, and instrumental agency. We used multivariate probit regression to find out the significant factors which influence the children’s health status.

Results: The study found that improvements in women's empowerment were not significantly associated with a reduction in stunting and wasting in Ethiopia. But the study discovered that women's educational attainment and other variables significantly influenced their children's nutrition status.

Conclusions: The insignificant direct association between women's empowerment and stunting or wasting in children in Ethiopia could be due to various factors, including the lack of standardized indexes for measuring women's empowerment, social desirability bias in survey responses, and missing data. However, it is still essential to consider and prioritize women's empowerment because it may indirectly contribute to reducing stunting and wasting in children by improving other underlying factors. Therefore, we recommend future research should carefully select women's empowerment indicators in context-specific ways, aggregate them meaningfully, and use appropriate statistical methods to account for desirability bias and related issues.

children’s nutrition

women’s empowerment

developing country

Demographic and Health Survey

desirability bias

Infectious diseases and inadequate dietary intake are the direct causes of malnutrition (undernutrition in children), while poor parenting practices, food insecurity, family socio-demographic traits, lack of access to clean water and health care, and political and cultural factors are the indirect causes (1, 2, 3, 4, 5). Malnutrition in early childhood can result in increased mortality and morbidity, as well as significant damage to physical growth and brain development, especially when the nutritional deficiencies are severe, long-lasting, and untreated (6, 7, 8). It can also have an impact on their mental well-being, socio-emotional behavior, intelligence, productivity, and endurance (9, 10). Stunting, wasting, and underweight are all possible symptoms of undernutrition in children (11, 12, 13, 14). Stunting (low height for age) is usually linked to ongoing exposure to unfavorable economic conditions, insufficient dietary standards, and unsatisfactory healthcare practices since birth (15, 16, 17). It has a negative impact on children's learning and working abilities, raises their risk of developing non-communicable diseases later in life, and dramatically raises healthcare expenditures in healthcare systems with limited resources (18, 19). Wasting (low weight-for-height) develops when a child is not given enough nutritious food or suffers from frequent or persistent illnesses (20, 21). The issue of childhood wasting, which has a negative impact on how children's neuroanatomical, emotional, and behavioral systems, is one that many developing nations, including Ethiopia, must deal with. It is possible for a child to be stunted, wasted, or both if they are underweight (3, 22, 23).

The term women's empowerment has been defined in many different ways, and different scholars and experts have developed various indices over the years to measure it (24, 25, 26). However, there is currently no standardized definition of women's empowerment (27). The existing indices are often criticized for various reasons, for example for heterogeneity of the manifestation of women’s empowerment and for missing factors in the analysis (25, 28, 29). In this paper we use the Women's Empowerment Index developed by (25), comprising three dimensions: enabling conditions, intrinsic agency, and instrumental agency, which has been validated for use in five Eastern African countries, including Ethiopia. According to the authors of the paper, this measure allows comparisons across countries in the region and provides a more comprehensive analysis than focusing only on one or two dimensions. The association between women's empowerment and children's nutritional status is of policy interest due to its effect on human development, labor supply, productivity, economic growth, and development (30, 31, 32). Several studies suggest that empowering women can have a positive impact on reducing child undernutrition in developing countries like Ethiopia (12, 33, 34). Researchers have also found that increasing women's empowerment significantly decreases the co-occurrence of anaemia and stunting in children (35). Empowered women have greater access to education, healthcare, and resources, all of which can contribute to improved child nutrition and growth (36). Additionally, empowered women are more likely to have decision-making power within the household, leading to better food choices and feeding practices for their children (37). Therefore, empowering women is a critical factor in achieving the Sustainable Development Goals, especially “Goal 5: Gender equality” and “Goal 2: Zero hunger” (38, 39, 40).

Thus, studies such as (41), (42), (43) and (44) recommend investing in women to increase their human capital, especially in terms of child nutrition, health, and education. Accordingly, many national and international organizations and initiatives, including the Un Women, The Institute for Economic Empowerment of Women, the UN's Scaling-Up Nutrition Initiative, have stressed that women's empowerment requires stepping up efforts across all Sustainable Development Goals (SDGs) and their targets, not just SDG 5, to improve nutritional outcomes for children (45, 46). Aside from that, the Ethiopian government has also designed several national and regional policies that target women's empowerment and the nutritional status of children and is engaged in various national and international fora and agreements related to women's and children's rights for proper nutrition (47).

Women's empowerment has a positive correlation with child nutritional status. When women are empowered, they have more autonomy and agency in making decisions, particularly about food and care provision for their children. Empowered mothers have more control over financial resources, which allows them to provide better nutrition for their children. Research has shown that improving women's status can significantly reduce child undernutrition (33, 34). Thus, the following conceptual framework presents the adaptation of a pathway through which interventions that improve women's conditions can contribute to the better nutrition status of children [see figure 1]. For the purposes of this paper, we adapt the framework on the determinants of nutrition developed by (30) to demonstrate how women's empowerment is vital for children's nutrition outcomes.

As shown in Figure 1, having more bargaining power enables women to negotiate for access to resources for themselves and their children, which in turn helps improve their children's nutrition outcomes, as argued in (48, 49). Malnutrition and women's disempowerment still remain significant challenges in developing countries like Ethiopia (50, 51, 52). According to the Ethiopian Mini Demographic and Health Survey 2019 report, the prevalence of stunting and wasting are among the highest in the world (50). Unfortunately, available studies showing the effect of women's empowerment on children's nutrition outcomes in Ethiopia have several drawbacks: they are not correctly weighted, missing values are not adequately considered, and/or are not generalizable to Ethiopia. For instance, one study was conducted in Ethiopia using DHS data by (53) to show the effect of women empowerment on children's nutritional outcomes using a 24-hour recall approach and SWPER index. However, this paper must be taken with a grain of salt because it used the highly criticised SWPER index to measure women's empowerment, which has been condemned for relying on ad hoc selections of available items (25). Also, a 24-hour recall approach for measuring dietary diversity may provide an inaccurate estimate of children's nutrient and energy intake (54).

The overarching objective of this study is to show the association between women's empowerment and childhood nutritional status in Ethiopia using the 2016 EDHS and 2019 EMDHS. We believe that the reliability of the data counts very much, and to obtain a sensible result we try to circumvent the desirability bias of the respondents. We anticipate the results will significantly benefit scholars and policymakers by providing an additional reference on how to contribute to women's empowerment and improve children's nutrition status. Also, it will facilitate the necessary dialogue among stakeholders about the actions that need to be taken to improve the Ethiopian national development goals of women's empowerment and children's nutrition in line with the SDG 2 and 5.

We begin with the assumption that more evidence is needed on the types of interventions that can potentially improve women's empowerment in a way that addresses the underlying determinants of child undernutrition. After explaining the methodology, the paper presents descriptive and econometric results on the relationship between women's empowerment and child nutrition. In order to contribute to the broader question of how women's empowerment interventions can be made more nutrition-sensitive for children, the paper concludes by summarizing findings, pointing out evidence gaps, and recommending research for the future.

Data

Our raw data came from nationally representative and substantially comparable databases. We used the combined 2016 Ethiopia Demographic and Health Survey and 2019 Ethiopia Mini Demographic and Health Survey established by the US Agency for International Development (USAID). The questionnaires used for each survey are available from the report of the Ethiopian Central Statistical Agency (55).

The DHS is one of the most important publicly available data sources for low- and middle-income countries. The Ethiopian Central Statistical Agency (CSA) collected EDHS data with the help of the Federal Ministry of Health. The data was gathered in a cross-sectional survey of Ethiopia's regional states and city administrations. Data was collected using an interviewer-administered questionnaire. The EDHS used a two-stage stratified random sampling technique. Enumeration areas were selected in the first stage, while households were selected in the second stage. Due to the two-stage cluster sampling design in the EDHS dataset, sample weights were used in all the data analyses. The details of the sampling methodology and related aspects are available from the EDHS report (55).

Though DHS often includes different types of questionnaires, this study uses only data from women's and children's questionnaires since the focus is on women's empowerment and children's nutritional status. We considered married women aged 15–49 years and children under age 5 in Ethiopia to analyze the effect of women's empowerment on the nutritional status of children. The analyses did not include missing values from the dataset.

The DHS program officially granted access to the data sets on February 1, 2020, after a request for accessing data for research purposes was submitted. After getting permission, the authors accessed the data from the program's official database (DHSdataset).

Outcome Variable

Our basic question was how much the empowerment of mothers influences the proper feeding of their children. Wasting, stunting, and being underweight are the three most common manifestations of undernutrition. Since being underweight is the composite of stunting and wasting, we avoided analyzing it in the present study following (56). Our study, therefore, consisted of two estimations, where the outcome variable in the first estimation was stunting and in the second wasting.

Explanatory Variables

The explanatory variables of the study were broadly categorized into two groups: socio-economic (see in the additional file1 table A2) and women empowerment related (see in the additional file table A3). Our focused variable, women empowerment, is considered a multidimensional phenomenon. Following the works of (25), we constructed a proxy measure of women empowerment using a composite score index, which was validated for use in eastern African countries, including Ethiopia. In this index, empowerment was operationalized as comprising three dimensions: enabling conditions, intrinsic agency, and instrumental agency. More specifics about items used in the development of women’s empowerment index are found in the additional file 1 table A1.

The variables identified by (25) were combined into each of the three dimensions of empowerment and created an individual score in each domain for all participants. Following the works of (28), these recorded values for each dimension of women empowerment were then added to get a score ranging from 0 to 3 (for enabling conditions), 0 to 5 (for the intrinsic agency) and 0 to 4 (for the instrumental agency). These scores were then categorized into three categories: disempowered if the score value is 0, partially empowered if the score value is between zero and the maximum value of the dimension, and fully empowered if she got a maximum score. Analyzing each dimension of empowerment separately acknowledges the multidimensional nature of women's empowerment and the differential influence of each dimension on children's nutritional status.

Statistical Analysis and Empirical Specification

The study used descriptive and inferential statistical analysis to examine the effect of women's empowerment on the nutritional status of children under age 5. The data were weighted to account for disproportionate sampling and non-response. A Variance Inflation Factor was used to check for multicollinearity before running the final analysis, and hence no highly correlated variables were included in the final analysis.

Pearson's chi-square test for proportions was first used to assess the potential relationship between the various explanatory variables and children's nutritional status. After the Pearson Chi-Square test, a multivariable probit regression model was used to assess the relationship between the list of explanatory variables and children's nutritional status in the form:

Household socio-demographic characteristics

As we wrote earlier in this paper, we used the data of women aged 15–49 years and children aged 0–59 months in the 2016 EDHS and 2019 EMDHS surveys. First, a total of 15,687 women and 14,404 children were in our sample. Next women who had no children aged 0–59 months were excluded from the analysis. Ninety-four percent of sampled women reported that they are married or living together, and we include only them in our analysis because empowerment measures focus on the context of marriage (57), and the dynamics of power within marriage have a significant impact on the health and economic well-being of women (25). The sample exhibits a paternalistic feature of Ethiopian households, with most of the household heads being male. The average household size was six family members. The average respondent had about the same number of sons and daughters. Furthermore, the majority of women (79% of them) had a pregnancy interval of 24 months or more before giving birth, and 74% had a normal BMI. The mean age of the children was 29.17 months (standard deviation of 17.54), while that of the woman was 29.22 years (standard deviation of 6.51). Women’s husbands (partners) had an average age of 37.19 (standard deviation 9.78).

Only a few women had completed primary school or higher, while about two-thirds (62%) had no formal education. It is also noteworthy that nearly half of the respondents' partners have no formal education. The place of residence often determines access to information and services regarding health and other aspects of life. The majority of the survey’s participants (85% of them) live in rural areas. More than three-quarters of women were located in just three regions; the highest number of female respondents reside in Oromia (43%), followed by SNNP (21%) and Amhara (19%). Apart from a few respondents, most indicated that improved healthcare, toilets, and cooking facilities were unavailable. The most common primary occupation of a woman's husband was subsistence farming and related activities (54%), followed by market-oriented agriculture (10%), day labor (7%), and sales work (7%). Unemployment affects approximately 8% of women's husbands.

Table A3 in the additional file1 depicts the data about the decision-making characteristics of ever-married women, which represent their empowerment level. Enabling conditions were represented by the age at which they first had sex, first cohabitation, and first birth. Only 33% of respondents started having sex over the age of 18, more than 63% of them were younger than 18 when they started to live with their current or former partner, and more than 40% of women had their first child before they were 18. The intrinsic agency is characterized by the percentage of respondents who did not justify wife-beating under certain conditions. Here the numbers differed by the conditions. For example, 47% of respondents did not justify a wife beating if a woman neglected her children, 50% if a woman went out without telling her husband, and 55% if a woman burned food. Furthermore, 55% and 58% of all respondents did not consider arguing with their spouse or refusing sex with their husband to be grounds for abuse. Concerning instrumental agency, which was the third dimension to ask about women empowerment, 75% or more of respondents reported sole or joint decision-making on spending their partner's earnings, health care, large household purchases, and family visits. Looking at the three dimensions of women's empowerment – enabling conditions, intrinsic agency, and instrumental agency - and aggregating the response scores within the dimensions, the lowest level of empowerment was found in enabling conditions. The value is higher in the case of intrinsic agency and highest in the instrumental agency, where almost 70% of women are fully empowered. As shown in the additional file1 Table A3, the women's empowerment index reveals that most Ethiopian women at least looking at the results of the survey are empowered: 67.53% fully, 21.22% partially, and only 11.25% not at all. The sample mean is 2.56, indicating that the women interviewed are very close to being fully empowered.

Bivariate analysis using a chi-square test was applied to see if there is a relationship between children's nutrition outcomes and respondents' characteristics. These results indicate a statistically significant relationship between children's nutrition outcome and all explanatory variables in the analysis except the maternal Working Status (for stunting only), paternal Working Status and Women asset index (for wasting only) [For details, please see the additional file 1 table A4]. In bivariate analysis, maternal enabling conditions and intrinsic agency were significantly associated with child stunting and wasting, whereas the association of instrumental agency with wasting was insignificant in the study.

Econometric Analysis: Multivariate probit regression model

Multivariable probit regression was used to determine the associations between predictors and nutritional outcomes after adjusting for other covariates. Table 1 provides probit regression results for stunting and wasting.

We conducted our model estimation with the hypothesis that mothers' empowerment variables will be significantly associated with their children's wasting and stunting. The more empowered a woman is, the less likely her child is to stunt and waste. However, in our study, all the women's empowerment indices were statistically insignificant in explaining stunting and wasting. The coefficient estimates for other control variables from the elaborated specifications reveal that child nutrition outcomes are significantly affected by a range of other covariates.

Table 1

Relationship between socio economic variables, women empowerment and children's nutritional status, based on the probit regression model.
Variables	Stunting				Wasting
Stunting	Coef.	St.Err.	p-value	Sig	Coef.	St.Err.	p-value	Sig
Maternal_edu	− .089	.036	.013	**	− .079	.046	.086	*
Maternal_work	.067	.044	.13		.000	.056	.996
Maternal_BMI	− .137	.036	0	***	− .245	.043	0	***
Maternal_birth_interval	− .089	.045	.05	*	− .091	.055	.096	*
child_age	.014	.001	0	***	− .010	.001	0	***
Female child	− .076	.037	.039	**	− .160	.046	.001	***
Perceivedweightatbirth	− .211	.043	0	***	− .196	.051	0	***
Female hh head	− .039	.056	.483		− .025	.067	.712
Age_household_head	− .001	.003	.661		.001	.003	.666
Religion	.077	.030	.009	***	.053	.039	.176
Rural Residence	− .053	.075	.481		− .294	.091	.001	***
Afar	− .319	.103	.002	***	.072	.127	.573
Amhara	.024	.084	.773		− .042	.111	.705
Oromia	− .249	.088	.004	***	− .083	.115	.467
Somali	− .658	.100	0	***	.274	.123	.026	**
Benishangul	− .039	.095	.685		− .041	.125	.742
SNNPR	− .177	.086	.04	**	− .304	.119	.01	**
Gambela	− .534	.107	0	***	.185	.128	.147
Harari	− .364	.116	.002	***	.066	.145	.649
Addis Ababa	− .341	.153	.026	**	− .206	.209	.325
Dire Dawa	− .023	.118	.848		− .072	.153	.641
Wealth_index	− .063	.020	.001	***	− .057	.025	.025	**
Husband_edu	− .101	.043	.019	**	− .010	.054	.85
Husband_work	.137	.064	.032	**	.051	.076	.505
Husband_age	.005	.003	.1		.000	.003	.994
household_size	− .015	.010	.141		.004	.013	.753
Water	− .028	.041	.502		− .043	.052	.406
Toilet	− .010	.049	.84		.009	.061	.881
Fuel	− .261	.124	.035	**	− .193	.165	.241
Women_decision_index	− .001	.027	.961		.016	.033	.638
Women_attitude_index	− .023	.024	.344		− .043	.030	.156
Women_asset_index	.022	.024	.371		− .023	.030	.432
Constant	.008	.205	.969		.010	.255	.967
	P = 0.000.				265.32P = 0.000.

*** p < .01, ** p < .05, * p < .1

Meaning of the variables in Table 1: Maternal_edu: Educational status of the woman; Maternal_work: Women's Occupational Status; Maternal_BMI: Woman's BMI; Maternal_birth_interval: Preceding birth interval of the woman; Child_age: Child's age; Female child: Gender of the child; Perceivedweightatbirth: Size of the child at birth; Female household head: Gender of the household head; Age_household_head: Age of the household head; Religion: Religion of the Woman; Rural Residence: Region of the woman (see the list of the regions in the table); Wealth_index: Wealth index combined; Husband_edu: Husband/partner's education level; Husband_work. Husband/partner's occupation; Husband_age: Husband/partner's age; Household size: Household Size; Water: Drinking water source; Toilet: Type of toilet; Fuel: Type of cooking fuel; Women_decision_index, Women_attitude_index, Women_asset_index: Exactly what the names contain.

The literature on the definition of women's empowerment and its association with children's nutrition outcomes is diverse and often contentious. The combined 2016 Ethiopia Demographic and Health Survey (EDHS) and 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) data were used to develop and test the effect of women's empowerment on children's nutrition status in Ethiopia. In our analysis, based on the intrinsic agency and instrumental agency dimensions of women empowerment, we found a significant number of empowered women compared to the disempowered ones. This result is supported by a study by (58), where they found that women in East Africa may hold much more autonomy in, for example, economic decision-making than their South Asian and Middle Eastern counterparts. However, considering the information presented below, it is possible to question the validity of these findings using scientific inquiry.

In this study, multivariable probit regression analysis was used to examine whether women's empowerment contributed to reducing wasting and stunting among children aged 0 to 59 months. In the study, we found that improvements in women's empowerment indices were not associated with a reduction in stunting or wasting, unlike previous studies conducted in the country, for instance, a study by (53) and (49). This result is also in contrast to results obtained from Burkina Faso (36), Bangladesh (59), Pakistan (28) and East Africa (58).

The result is, however, consistent with a study conducted in Mozambique, where they found no clear-cut conclusion concerning the possible impact of women's empowerment on the nutritional status of children (60) and Ghana, where they found no statistically significant association between the composite empowerment score measuring women's empowerment in agriculture and its decomposed components and the latent health status of children (61). A related study in India (62) and Nepal (63) found no association between a woman's ability to control her own health care and child stunting. Furthermore, (36) reported that the hypothesis that women's empowerment will improve child nutrition has limited empirical support. Based on these findings, we argue that the association between women's empowerment and child nutrition outcomes may be affected by additional underlying factors not captured by the analyses.

These findings might provide the impression that women's empowerment is not a pathway to improving child stunting and wasting in Ethiopia. However, it is advisable to take these results with some level of caution for some significant reasons. First of all, it is possible that the current lack of evidence is likely not due to the absence of an underlying relationship between women's empowerment and child nutrition but rather to limitations in survey design and data collection techniques. For instance, the survey might be subject to a typical study problem often caused by respondents' self-reports, namely social desirability bias (64, 65, 66). Social desirability bias is the tendency of survey respondents to answer questions in a way that conforms to social norms and expectations, rather than providing honest answers, resulting in inaccurate measurements of women's empowerment (67, 68, 69, 70). Nederhof's definition of social desirability bias is widely cited, and it is considered the most common reason why a survey may fail to reveal actual correlations (71). The bias arises when respondents deceive themselves or explicitly seek to mislead others by indicating that their opinion conforms to the socially expected one. The presence of desirability bias in survey responses can be challenging to detect, but some variables are more susceptible than others (71). For instance, questions about specific facts, such as educational attainment, are less likely to be affected by the bias because respondents can provide certificates as proof. However, questions about personal experiences, such as domestic violence, are more likely to be influenced by the bias, especially if there is no official proof of the facts (72). Social desirability bias can be present in all responses to a survey, and it can make a survey completely unrealistic if its non-systematic effect cannot be eliminated (73).

Furthermore, prevailing gender norms within a particular cultural context can have an impact on women's empowerment. Social customs in Ethiopia encourage people to conform to organizational norms in all circumstances, and the political environment is also very conducive to encourage people to conform to organizational norms in all circumstances (74, 75). For instance, according to (76), when Ethiopian women were asked how often they gave birth at home, almost all respondents answered that they never did. However, collected data indicate that most mothers give birth at home. These authors explained this phenomenon by pointing out that there was a lack of care in asking these questions. Similar ideas were expressed by (74) and (75). In addition, the survey results contradict the commonly held belief that women in developing countries, including Ethiopia, have limited independence in making decisions on their own or household affairs (77). The other factor might be the way the sample respondents were recruited. These inconsistencies might also likely be caused by methods/conceptualizations of women's empowerment, as well as the specific domains researched. In earlier studies, women's empowerment was defined and operationalized differently, which might have contributed to its significance.

However, other variables such as maternal BMI (56, 58, 60), gender of the child (78), child's perceived weight at birth (56, 79), region (56, 80), wealth index (31, 56, 58, 60) were found to have a significant counteracting effect on stunting and wasting. Maternal Body Mass Index (BMI) is an important signal of the quality of how mothers feed their children (30, 58, 81). Mothers with a healthy BMI usually provide much healthier food to their children as well.

The religion of the respondent, the working status of the husband, and the type of cooking fuel (56) were found to have a significant mitigating effect on stunting. The place of residence (56) was found also to decrease the level of wasting. Norms and factors linked with labour market opportunities guide sex preference towards male children (82). Giving birth to the preferred sex will likely give women more access to resources and decision-making (49). In our study, female children still showed less stunting and wasting than male children (83, 84). These differences could be explained by biological factors, such as differences in immune and endocrine systems between boys and girls, as well as social factors, such as gender dynamics and preferential feeding practices (83). The more educated the husband was the better nutritional status his child has (85). In our case, we have such evidence of stunting, despite no significant difference in wasting. However, the maternal working status had an insignificant decreasing effect on child malnutrition. Because most of women work in low-paying jobs, it is sometimes possible that women who stay at home take better care of their children.

Longer childbirth interval had a significant mitigating effect on child stunting, despite having an inconclusive effect on child wasting. Child age had a significant increasing effect on child stunting and a significant decreasing effect on child wasting. The age of the child is positively associated with stunting, perhaps suggesting that risk of stunting increases with age (86), while the risk of wasting decreases with age (21). This can easily be explained by the fact that the growth of the child's length starts to occur mainly after infancy so in children who are stunted, this becomes apparent mainly after the age of one. The paper (87) directly demonstrates that stunting most often occurs between the ages of 2-3 years.

Undernutrition in children has a spatial dimension that is strongly influenced by the degree of urbanization, as measured by nutrition indices such as stunting and wasting (88). It appeared that rural Ethiopian children are less wasted than their urban counterparts, despite no significant difference in stunting. The coefficients of the region dummies are interpreted using the omitted Tigray region dummy. Apart from Amhara, Benishangul Gumuz, and Dire Dawa City Administration, children in all other regions are more stunted than children in the Tigray region. However, suppose the data were collected after 2019/20, the results of this study may have been reversed as Ethiopia has experienced widespread internal displacement and a devastating civil war (especially in the Amhara, Afar, Tigray, and Oromia regions). Furthermore, the study shows that children in Somalia and Southern Nations, Nationalities, and Peoples Region (SNNPR) are not only stunted but also wasted. This makes sense given that Somalia region lies within the severely food-insecure and dry eastern part of Ethiopia. As a region, SNNPR is also characterized by a majority of its inhabitants who live far away from minimum standard infrastructures, which might result in poor infant feeding practices (food choice).

In the study, it was found that there was no statistically significant association between any of the women's empowerment indices and the adequacy of women’s child nutrition. This lack of association may be due to the difficulty of establishing the direct effect of women's empowerment because personal statements may be biased. However, the study further explored variables associated with women’s empowerment and promoting better child nutrition and found that women's educational attainment had a significant impact on child nutrition status. It is worth noting that the beneficial effect of women's educational attainment on their children's health is less prone to desirability bias and therefore highly relevant information. Because none of the three latent empowerment variables include mothers' educational attainment, there can only be an indirect relationship between our empowerment variables and mothers' educational attainment.

The literature provides numerous examples of how women's literacy and education can greatly improve the health of their children. For example, in Sub-Saharan countries, improved educational level is a very important factor in women's conscious behavior (32), and in Malawi, Tanzania, Zimbabwe, and Mozambique, there is a positive impact of women's education on their decision-making ability in the household (89). Similarly, studies conducted in Uganda (90) and Nigeria (91) have shown a positive relationship between women's educational attainment and effective care for their children. Similar thoughts can be found in (51) and (52). It is known that knowledge empowers women, enabling them to change both their own lives and their children's lives for the better.

Thus, while the direct effect of women's empowerment on child nutrition adequacy may be difficult to establish, indirect data, like women’s educational attainment suggests that women's empowerment plays an important role in their children's health status. Many studies have shown that women with good circumstances and proper education feed their children much healthier than their less empowered counterparts.

Different studies have shown that empowered women are more likely to be informed about proper nutrition and feeding practices that will lead to improved child growth and development. However, it must be noted that women's empowerment is only one piece of the puzzle among many in addressing stunting and wasting in children, as the problems are complex issues that are influenced by various factors. Thus, while we found no significant direct association between women's empowerment and stunting or wasting in our study, it is still essential to consider and prioritize women's empowerment. Women's empowerment is probably the best way to ensure that their children eat healthily. However, to show this fact directly from a survey, it is necessary to design the survey so that participants give their answers without desirability bias.

We recommend future research should carefully select women's empowerment indicators in context-specific ways, aggregate them meaningfully, and use a sound study design to conduct and clarify the relationship between women's empowerment and child nutrition. Similar recommendations can be found in (27). While an investigation into husbands' reports on women's empowerment was beyond the scope of this study, we also encourage future investigations into the measurement properties of women's empowerment items in surveys administered to men.

The lack of significant association between the Women's Empowerment Index and children's nutrition status in the studied cases could be due to the presence of social desirability bias in survey responses. The fact that empowerment questions are self-reported means that women may have given responses assumed to be socially desirable, thereby favoring empowerment (65). The bias is challenging to detect, and it can make a survey unrealistic if its non-systematic effect cannot be eliminated. In the Ethiopian context, the bias may be exacerbated by the cultural and political environment. Thus, cultural barriers can hinder women's empowerment and have a detrimental impact on child nutrition and achieving Sustainable Development Goals. Addressing these cultural barriers requires a multifaceted approach that takes into account the unique social and cultural contexts of different communities in Ethiopia. General strategies that may be effective include challenging harmful cultural practices and promoting gender equality, providing education and resources to women to improve their knowledge and skills related to nutrition and childcare, and engaging men and boys in the process of promoting women's empowerment (92). By working with communities to implement multifaceted approaches, it might be possible to improve the lives of women and children in developing countries.

Therefore, researchers should be aware of the potential impact of social desirability bias on survey responses and take steps to mitigate it. To address this limitation, future researchers might consider using a more objective measure of women's empowerment that are less prone to reporting bias. For instance, (68) suggests that researchers can use non-survey instruments such as interviews and focus group discussions to obtain more accurate information. It is also important to note that proxy measures of empowerment may not accurately represent empowerment. Rather, future researchers might also consider using multiple measures and methods to obtain a more comprehensive understanding of women's empowerment (70). Thus, researchers should exercise caution when quantifying women's empowerment and consider selecting metrics that minimize the risk of social desirability bias. Tailoring survey questions to the local context can also be useful in obtaining more accurate information.

There are some additional limitations of the study and areas that require further investigation. First, the study is limited by the lack of standardized indexes for measuring women's empowerment (36, 93). Moreover, the absence of a single indicator for measuring women's empowerment hinders the comparability of the results of different authors. Therefore, future related studies would benefit from empowerment metrics that address additional aspects of women's empowerment such as self-confidence or political representation, to capture a complete picture of empowerment and are highly comparable across countries. Similar arguments have been made in (93) and (36). The study is also limited by missing data for many variables, primarily those related to women's empowerment, from the 2019 EMDHS. Therefore, the study was not able to show patterns or changes in empowerment and other variables between periods. To address this limitation, future studies should aim to collect comprehensive data that covers all the variables that are necessary for conducting an in-depth analysis of women's empowerment. Another limitation of the study is that the DHS data is cross-sectional, which means that the results may not reflect causality but rather an association. To overcome this limitation, future studies should aim to use longitudinal data to determine the causal relationships between women's empowerment and children's nutritional status. Finally, the analysis focused specifically on Ethiopia, and it would be beneficial to replicate it in other developing countries to determine how the empowerment of women impacts children's nutritional status in different contexts.

CSA Ethiopian Central Statistical Agency

EDHS Ethiopia Demographic and Health Survey

EMDHS Ethiopia Mini Demographic and Health Survey

ICF Intermediate Care Facility

SDG Sustainable Development Goals

USAID United States Agency for International Development

UN United Nations

Ethics approval and consent to participate

The National Ethics Review Committee of the Federal Democratic Republic of Ethiopia, the Ministry of Science and Technology, and the Institutional Review Board of ICF International reviewed and approved the 2016 Ethiopia Demographic and Health Survey (EDHS) and 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) protocols. After getting permission, data sets in STATA format were downloaded from the DHS Program webpage. As a result, the ethical responsibility for the EDHS data rests with the institutions that conducted the surveys in Ethiopia, and we did not need ethics approval for our study.

Consent for publication

The DHS data center provide consent letter to publish

Availability of data and materials

The data sets used in this study can be found at the DHS programs repository:

https://www.dhsprogram.com/

Competing interests

There are no conflicts of interest declared by the authors.

Funding

The paper does not have a funding source.

Authors' contributions

Éva Berde was in charge of supervising the workflow, and she did a certain part of the calculations and part of the paper writing.

Seyoum Teffera Mengesha was responsible for proposing the study topic, downloading and cleaning the data. He was partly responsible for calculating the results and writing the article.

Zerihun Yohannes Amare proposed the study topic, review the first draft manuscript, compared the conclusions of the article with the facts and served as the brainstorming.

Acknowledgements

The authors are grateful to the DHS program for granting us permission to use the data.

Alaaraj N, Soliman A, Rogol AD. Growth of malnourished infants and children: how is inflammation involved? Expert Review of Endocrinology & Metabolism. 2021;16(5):213-6, doi:https://doi.org/10.1080/17446651.2021.1956903
Ghosh-Jerath S, Singh A, Jerath N, Gupta S, Racine EF. Undernutrition and severe acute malnutrition in children. BMJ. 2017:j4877, doi:https://doi.org/10.1136/bmj.j4877
De Onis M, Blossner M, Organization WH. WHO global database on child growth and malnutrition. World Health Organization; 1997.
Organization WH. Community-based management of severe acute malnutrition: a joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund: World Health Organization; 2007.
Stephenson L, Latham M, Ottesen E. Global malnutrition. Parasitology. 2000;121(S1):S5-S22,
Martorell R. The Nature of Child Malnutrition and Its Long-Term Implications. Food and Nutrition Bulletin. 1999;20(3):288-92, doi:https://doi.org/10.1177/156482659902000304
De P, Chattopadhyay N. Effects of malnutrition on child development: Evidence from a backward district of India. Clinical Epidemiology and Global Health. 2019;7(3):439-45, doi:https://doi.org/10.1016/j.cegh.2019.01.014
Ricciuti HN. Developmental Consequences of Malnutrition in Early Childhood. In: Lewis M, Rosenblum LA, editors. The Uncommon Child. Boston, MA: Springer US; 1981. p. 151-72.
Bhutta ZA, Berkley JA, Bandsma RH, Kerac M, Trehan I, Briend A. Severe childhood malnutrition. Nature reviews Disease primers. 2017;3(1):1-18, doi:https://doi.org/10.1038/nrdp.2017.67
Has EMM, Efendi F, Wahyuni SD, Mahmudah IZ, Chotimah K. Women’s Empowerment and Socio Demographic Characteristics as Determinant of Infant and Young Child Feeding Practice in Indonesia. Current Research in Nutrition and Food Science Journal. 2022;10(2):607-19, doi:http://dx.doi.org/10.12944/CRNFSJ.10.2.17
Unicef. Levels and trends in child malnutrition. eSocialSciences; 2018.
Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The lancet. 2013;382(9890):427-51, doi:https://doi.org/ 10.1016/S0140-6736(13)60937-X
Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51, doi:https://doi.org/10.1016/s0140-6736(13)60937-x
Black RE, Brown KH, Becker S. Malnutrition is a determining factor in diarrheal duration, but not incidence, among young children in a longitudinal study in rural Bangladesh. The American Journal of Clinical Nutrition. 1984;39(1):87-94, doi:https://doi.org/10.1093/ajcn/39.1.87
Dewey KG, Begum K. Long-term consequences of stunting in early life. Maternal & Child Nutrition. 2011;7:5-18, doi:https://doi.org/10.1111/j.1740-8709.2011.00349.x
Mbuya NV, Demombynes G, Piza SFA, Adona AJV. Undernutrition in the Philippines: scale, scope, and opportunities for nutrition policy and programming: World Bank Publications; 2021.
Stewart CP, Iannotti L, Dewey KG, Michaelsen KF, Onyango AW. Contextualising complementary feeding in a broader framework for stunting prevention. Maternal & Child Nutrition. 2013;9:27-45, doi:https://doi.org/10.1111/mcn.12088
Martorell R, Khan LK, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. European Journal of Clinical Nutrition. 1994;48 S45-57, https://pubmed.ncbi.nlm.nih.gov/8005090/
Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM. Early Childhood Stunting Is Associated with Poor Psychological Functioning in Late Adolescence and Effects Are Reduced by Psychosocial Stimulation. The Journal of Nutrition. 2007;137(11):2464-9, doi:https://doi.org/10.1093/jn/137.11.2464
Ezzati M, Lopez AD, Rodgers AA, Murray CJL. Comparative quantification of health risks, volume 1: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004.
Mulu N, Mohammed B, Woldie H, Shitu K. Determinants of stunting and wasting in street children in Northwest Ethiopia: A community-based study. Nutrition. 2022;94:111532, doi:https://doi.org/10.1016/j.nut.2021.111532
Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. The American Journal of Clinical Nutrition. 2020;112(Supplement_2):777S-91S, doi:https://doi.org/10.1093/ajcn/nqaa159
De Sanctis V, Soliman A, Alaaraj N, Ahmed S, Alyafei F, Hamed N. Early and Long-term Consequences of Nutritional Stunting: From Childhood to Adulthood. Acta Biomed. 2021;92(1):e2021168, doi:https://doi.org/10.23750/abm.v92i1.11346
Larson EL. United nations fourth world conference on women: action for equality, development, and peace (beijing, china: september 1995). Emory International Law Review1996. p. 695-740.
Miedema SS, Haardörfer R, Girard AW, Yount KM. Women’s empowerment in East Africa: Development of a cross-country comparable measure. World Development. 2018;110:453-64, doi:https://doi.org/10.1016/j.worlddev.2018.05.031
Phan L. Measuring women’s empowerment at household level using DHS data of four Southeast Asian countries. Social Indicators Research. 2016;126(1):359-78, doi:https://doi.org/10.1007/s11205-015-0876-y
Santoso MV, Kerr RB, Hoddinott J, Garigipati P, Olmos S, Young SL. Role of Women's Empowerment in Child Nutrition Outcomes: A Systematic Review. Advances in Nutrition. 2019;10(6):1138-51, doi:https://doi.org/10.1093/advances/nmz056
Akbar M, Asif AM, Hussain F. Does maternal empowerment improve dietary diversity of children? Evidence from Pakistan demographic and health survey 2017–18. The International Journal of Health Planning and Management. 2022;37(6):3297-311, doi:https://doi.org/10.1002/hpm.3558
Cueva Beteta H. What is missing in measures of women's empowerment? Journal of Human Development and Capabilities. 2006;7(2):221-41, doi:https://doi.org/10.1080/14649880600768553
Herforth A, Harris J. Understanding and Applying Primary Pathways and Principles. Brief 1. Improving Nutrition through Agriculture Technical Brief Series. Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.; 2014.
Shafiq A, Hussain A, Asif M, Hwang J, Jameel A, Kanwel S. The Effect of “Women’s Empowerment” on Child Nutritional Status in Pakistan. International Journal of Environmental Research and Public Health. 2019;16(22):4499, doi:https://doi.org/10.3390/ijerph16224499
Yaya S, Odusina EK, Uthman OA, Bishwajit G. What does women’s empowerment have to do with malnutrition in Sub-Saharan Africa? Evidence from demographic and health surveys from 30 countries. Global Health Research and Policy. 2020;5(1):1, doi:https://doi.org/10.1186/s41256-019-0129-8
Cunningham K, Ruel M, Ferguson E, Uauy R. Women's empowerment and child nutritional status in South Asia: a synthesis of the literature. Maternal & Child Nutrition. 2015;11(1):1-19, doi:https://doi.org/10.1111/mcn.12125
Pridmore P, Carr-Hill R. Tackling the drivers of child undernutrition in developing countries: what works and how should interventions be designed? Public Health Nutrition. 2011;14(4):688-93, doi:https://doi.org/10.1017/s1368980010001795
Christian AK, Atiglo DY, Okyere MA, Obeng‐Dwamena A, Marquis GS, Jones AD. Women's empowerment, children's nutritional status, and the mediating role of household headship structure: Evidence from sub‐Saharan Africa. Maternal & Child Nutrition. 2023, doi:https://doi.org/10.1111/mcn.13520
Heckert J, Olney DK, Ruel MT. Is women's empowerment a pathway to improving child nutrition outcomes in a nutrition-sensitive agriculture program?: Evidence from a randomized controlled trial in Burkina Faso. Social Science & Medicine. 2019;233:93-102, doi:https://doi.org/10.1016/j.socscimed.2019.05.016
Yaya S, Odusina EK, Uthman OA, Bishwajit G. What does women's empowerment have to do with malnutrition in Sub-Saharan Africa? Evidence from demographic and health surveys from 30 countries. Glob Health Res Policy. 2020;5:1, doi:https://doi.org/10.1186/s41256-019-0129-8
Women U. Women and the sustainable development goals (SDGs). New York: UN Women Retrieved November. 2018;18:2018,
Mishra PK, Tripath P. Women and Sustainable Development Goals. Sustainability Science. 2018;12:29-38,
UN. Department of Economic and Social Affairs, Sustainable Development. 2021.
Cornwall A. Women's Empowerment: What Works? Journal of International Development. 2016;28(3):342-59, doi:https://doi.org/10.1002/jid.3210
Duflo E. Women Empowerment and Economic Development. Journal of Economic Literature. 2012;50(4):1051-79, doi:https://doi.org/10.1257/jel.50.4.1051
Van den Bold M, Quisumbing AR, Gillespie S. Women s empowerment and nutrition: an evidence review. Washington, D.C.; 2013.
Essilfie G, Sebu J, Annim SK. Women's empowerment and child health outcomes in Ghana. African Development Review. 2020;32(2):200-15, doi:https://doi.org/10.1111/1467-8268.12428
Agarwal B. Gender equality, food security and the sustainable development goals. Current Opinion in Environmental Sustainability. 2018;34:26-32, doi:https://doi.org/10.1016/j.cosust.2018.07.002
UNESCO. UNESCO strategy on education for health and Well-being: contributing to the sustainable development goals. UNESCO Paris; 2016.
UNESCO:. UNESCO and Gender Equality in Sub-Saharan Africa: Innovative Programmes, Visible Results. 2017,
Malapit HJL, Quisumbing AR. What dimensions of women’s empowerment in agriculture matter for nutrition in Ghana? Food Policy. 2015;52:54-63, doi:https://doi.org/10.1016/j.foodpol.2015.02.003
Melesse MB. The effect of women's nutrition knowledge and empowerment on child nutrition outcomes in rural Ethiopia. Agricultural Economics. 2021;52(6):883-99, doi:https://doi.org/10.1111/agec.12668
Jisso M, Tesfaye T, Biadgilign S, Tareke AA, Zerfu TA. The role of multi-dimensional women's empowerment in agriculture to improve the nutritional status of under-five children in rural cash crop producing, resource-limited settings of Ethiopia. J Nutr Sci. 2022;11:e92, doi:https://doi.org/10.1017/jns.2022.86
Madzorera I, Fawzi W. Women empowerment is central to addressing the double burden of malnutrition. EClinicalMedicine. 2020;20:100286, doi:https://doi.org/10.1016/j.eclinm.2020.100286
Mengesha ST. Analysis of Food System Topics from the Consumers’ Perspective in a Developing Country Context: Key Insights from ANRS Metropolitan Cities, Ethiopia. Risk Management and Healthcare Policy. 2021;14:3883 - 91, doi:https://doi.org/10.2147/RMHP.S318858
Baye K, Laillou A, Chitekwe S. Empowering women can improve child dietary diversity in Ethiopia. Maternal & Child Nutrition. 2021, doi:https://doi.org/10.1111/mcn.13285
Alemayehu AA, Abebe Y, Gibson RS. A 24-h recall does not provide a valid estimate of absolute nutrient intakes for rural women in southern Ethiopia. Nutrition. 2011;27(9):919-24, doi:https://doi.org/10.1016/j.nut.2010.10.015
Central Statistical Agency - CSA/Ethiopia, ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia: CSA and ICF; 2017.
Amare ZY, Ahmed ME, Mehari AB. Determinants of nutritional status among children under age 5 in Ethiopia: further analysis of the 2016 Ethiopia demographic and health survey. Global and Health. 2019;15(1):62, doi:https://doi.org/10.1186/s12992-019-0505-7
Kabeer N. Resources, Agency, Achievements: Reflections on the Measurement of Women's Empowerment. Development and Change. 1999;30(3):435-64, doi:https://doi.org/10.1111/1467-7660.00125
Jones R, Haardörfer R, Ramakrishnan U, Yount KM, Miedema S, Girard AW. Women's empowerment and child nutrition: The role of intrinsic agency. SSM - Population Health. 2019;9:100475, doi:https://doi.org/10.1016/j.ssmph.2019.100475
Kabir A, Rashid MM, Hossain K, Khan A, Sikder SS, Gidding HF. Women’s empowerment is associated with maternal nutrition and low birth weight: evidence from Bangladesh Demographic Health Survey. BMC Women's Health. 2020;20(1), doi:https://doi.org/10.1186/s12905-020-00952-4
Deutsch J, Silber J. Women’s Empowerment and Child Malnutrition: The Case of Mozambique. South African Journal of Economics. 2019;87(2):139-79, doi:https://doi.org/10.1111/saje.12223
Zereyesus YA, Amanor-Boadu V, Ross KL, Shanoyan A. Does Women’s Empowerment in Agriculture Matter for Children’s Health Status? Insights from Northern Ghana. Social Indicators Research. 2017;132(3):1265-80, doi:https://doi.org/10.1007/s11205-016-1328-z
Dancer D, Rammohan A. Maternal autonomy and child nutrition: evidence from rural Nepal. Indian growth and development review. 2009;2(1):18-38,
Shroff M, Griffiths P, Adair L, Suchindran C, Bentley M. Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India. Maternal & Child Nutrition. 2009;5(1):64-74, doi:https://doi.org/10.1111/j.1740-8709.2008.00161.x
Reynolds CR. Comprehensive clinical psychology: Vol. 4: Assessment: Pergamon/Elsevier Science Ltd; 1998.
Porth JM, Wagner AL, Moyer CA, Mutua MK, Boulton ML. Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth. American Journal of Preventive Medicine. 2021;60(1, Supplement 1):S87-S97, doi:https://doi.org/10.1016/j.amepre.2020.08.015
Voronca D, Walker RJ, Egede LE. Relationship between empowerment and wealth: trends and predictors in Kenya between 2003 and 2008–2009. International Journal of Public Health. 2018;63(5):641-9, doi:https://doi.org/10.1007/s00038-017-1059-1
Van Der Windt P. Can Development Aid Empower Women? Evidence from a Field Experiment in the Congo. The Journal of Politics. 2018;80(3):1039-44, doi:https://doi.org/10.1086/697955
Jakiela P. Center for Global Development]. Retrieved from: . 2018. [cited 2023]. Available from: https://www.cgdev.org/blog/we-cant-measure-womens-empowerment-same-way-everywhere-should-we-try.
Gram L, Morrison J, Sharma N, Shrestha B, Manandhar D, Costello A, et al. Validating an Agency-based Tool for Measuring Women's Empowerment in a Complex Public Health Trial in Rural Nepal. J Human Dev Capabil. 2017;18(1):107-35, doi:https://doi.org/10.1080/19452829.2016.1251403
Amber P, Greg S. Research Post [Internet]: IFPRI. 2018. [cited 2023]. Available from: https://www.ifpri.org/blog/where-standardized-measure-womens-empowerment.
Nederhof AJ. Methods of coping with social desirability bias: A review. European journal of social psychology. 1985;15(3):263-80,
Cerri J, Thøgersen J, Testa F. Social desirability and sustainable food research: A systematic literature review. Food Quality and Preference. 2019;71:136-40, doi:https://doi.org/10.1016/j.foodqual.2018.06.013
Larson RB. Controlling social desirability bias. International Journal of Market Research. 2019;61(5):534-47, doi:https://doi.org/10.1177/1470785318805305
King R, Jackson R, Dietsch E, Hailemariam A. Utilisation of maternal health services in Ethiopia: a key informant research project. Development in Practice. 2016;26(2):158-69, doi:https://doi.org/10.1080/09614524.2016.1131244
Østebø MT, Cogburn MD, Mandani AS. The silencing of political context in health research in Ethiopia: why it should be a concern. Health Policy and Planning. 2017;33(2):258-70, doi:https://doi.org/10.1093/heapol/czx150
Bergen N, Labonté R. “Everything Is Perfect, and We Have No Problems”: Detecting and Limiting Social Desirability Bias in Qualitative Research. Qualitative Health Research. 2020;30(5):783-92, doi:https://doi.org/10.1177/1049732319889354
Osamor P, Grady C. Women&#39;s autonomy in health care decision-making in developing countries: a synthesis of the literature. International Journal of Women's Health. 2016:191, doi:https://doi.org/10.2147/ijwh.s105483
Ali Z, Saaka M, Adams A-G, Kamwininaang SK, Abizari A-R. The effect of maternal and child factors on stunting, wasting and underweight among preschool children in Northern Ghana. BMC Nutrition. 2017;3(1), doi:https://doi.org/10.1186/s40795-017-0154-2
Aboagye RG, Ahinkorah BO, Seidu AA, Frimpong JB, Archer AG, Adu C, et al. Birth weight and nutritional status of children under five in sub-Saharan Africa. PLoS One. 2022;17(6):e0269279, doi:https://doi.org/10.1371/journal.pone.0269279
Amegbor PM, Yankey O, Sabel CE. Examining the Effect of Geographic Region of Residence on Childhood Malnutrition in Uganda. J Trop Pediatr. 2020;66(6):598-611, doi:https://doi.org/10.1093/tropej/fmaa019
Rahman M, Rahman SM, Pervin J, Aktar S, El Arifeen S, Rahman A. Body mass index in early-pregnancy and selected maternal health outcomes: Findings from two cohorts in Bangladesh. J Glob Health. 2020;10(2):020419, doi:https://doi.org/10.7189/jogh.10.020419
Gorsuch MM. Gender, Sexual Orientation, and Behavioral Norms in the Labor Market. ILR Review. 2019;72(4):927-54, doi:https://doi.org/10.1177/0019793919832273
Thurstans S, Sessions N, Dolan C, Sadler K, Cichon B, Isanaka S, et al. The relationship between wasting and stunting in young children: A systematic review. Matern Child Nutr. 2022;18(1):e13246, doi:https://doi.org/10.1111/mcn.13246
Wamani H, Åstrøm AN, Peterson S, Tumwine JK, Tylleskär T. Boys are more stunted than girls in Sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. BMC Pediatrics. 2007;7(1):17, doi:https://doi.org/10.1186/1471-2431-7-17
Haque MA, Wahid BZ, Tariqujjaman M, Khanam M, Farzana FD, Ali M, et al. Stunting Status of Ever-Married Adolescent Mothers and Its Association with Childhood Stunting with a Comparison by Geographical Region in Bangladesh. International Journal of Environmental Research and Public Health. 2022;19(11):6748, doi:https://doi.org/ 10.3390/ijerph19116748
Degarege D, Degarege A, Animut A. Undernutrition and associated risk factors among school age children in Addis Ababa, Ethiopia. BMC Public Health. 2015;15(1), doi:https://doi.org/10.1186/s12889-015-1714-5
Adair LS, Guilkey DK. Age-Specific Determinants of Stunting in Filipino Children. The Journal of Nutrition. 1997;127(2):314-20, doi:https://doi.org/10.1093/jn/127.2.314
Antwi J, Quaidoo E, Ohemeng A, Bannerman B. Household food insecurity is associated with child’s dietary diversity score among primary school children in two districts in Ghana. Food & Nutrition Research. 2022;66, doi:https://doi.org/10.29219/fnr.v66.7715
Jayaweera S. Women, education and empowerment in Asia. Gender and Education. 1997;9(4):411-24,
Sell M, Minot N. What factors explain women's empowerment? Decision-making among small-scale farmers in Uganda. Women's Studies International Forum. 2018;71:46-55, doi:https://doi.org/10.1016/j.wsif.2018.09.005
Ojobo J. Education: A catalyst for Women Empowerment in Nigeria. Ethiopian Journal of Education and Sciences. 2009;4(1), doi:https://doi.org/10.4314/ejesc.v4i1.42995
Saluja OB, Singh P, Kumar H. Barriers and interventions on the way to empower women through financial inclusion: a 2 decades systematic review (2000–2020). Humanities and Social Sciences Communications. 2023;10(1):148, doi:https://doi.org/10.1057/s41599-023-01640-y
Ewerling F, Lynch JW, Victora CG, van Eerdewijk A, Tyszler M, Barros AJ. The SWPER index for women's empowerment in Africa: development and validation of an index based on survey data. The Lancet Global Health. 2017;5(9):e916-e23, doi:https://doi.org/10.1016/S2214-109X(17)30292-9

No competing interests reported.

additionalfile1.doc

Breaking Barriers: How Women's Empowerment Affects Children's Nutrition Status – Further Analysis of the 2016 and 2019 Ethiopian Demographic and Health Survey

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Abstract

Figures

Background and literature review

Methodology

Data

Outcome Variable

Explanatory Variables

Statistical Analysis and Empirical Specification

Results

Household socio-demographic characteristics

Econometric Analysis: Multivariate probit regression model

Discussion

Conclusions and Future Research Directions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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