Maternal Decision-Making Autonomy, Mental Health, Gender Norm Attitudes, and Social Support During Pregnancy Predict Child Care-Giving and Stunting in Rural Zimbabwe

Abstract

Abstract Objectives To determine the predictive association of 7 maternal capabilities during pregnancy [physical and mental health (PH, MH), social support (SS), decision making autonomy (DMA), gender norm attitudes (GNA), mothering self-efficacy (MSE), and time stress (TS)] with subsequent child care behaviors and child length-for-age Z (LAZ) and stunting (LAZ< −2.0) at 18 months. Methods Capabilities were assessed by questionnaire among 4667 pregnant women enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE). Child care behaviors and LAZ were assessed at infant ages 1, 3, 6, 12, and 18 months. We used logistic regression or generalized estimating equation models accounting for within-cluster correlation and adjusted for pre-specified covariates to test the association between each maternal capability and each outcome. Results Food security was associated with stronger maternal capabilities, across all seven domains. Mothers with more egalitarian GNA were more likely to have an institutional delivery, initiate breastfeeding early, exclusively breastfeed (EBF) to 6 months, and have soap and water at a handwashing station. Mothers with TS were less likely to EBF. Mothers with greater SS were more likely to have an institutional delivery and feed their child a diverse diet; depressed mothers were less likely to have an institutional delivery and a fully immunized child. In fully adjusted analyses, GNA and SS were significantly associated with child LAZ at 18 months and DMA and SS were significantly associated with stunting (LAZ< −2.0). Depression was more weakly associated with LAZ (P = 0.08). Conclusions Mothers who hold more equitable GNA; who are empowered to independently make decisions affecting themselves and their children; who know someone they can count on for help during times of need; and who are not depressed, are more likely to provide optimal care for their children and their children are less likely to be stunted at 18 months of age. Interventions to strengthen these maternal capabilities within nutrition programs will likely increase impact on child nutritional status and health. Funding Sources Bill & Melinda Gates Foundation (OPP1021542, OPP1143707); UK Department for International Development, Wellcome Trust (09,3768/Z/10/Z,108,065/Z/15/Z), Swiss Agency for Development and Cooperation (8,106,727).