Gender Discrimination in Infant and Young Child Feeding Practices in India: Evidence from NFHS-4

Abstract

Undernutrition among children continues to be a serious issue. The study examines the prevalence of the gender gap in the infant and young child feeding (IYCF) practices in India based on recent National Family and Health Survey Data, 2015 (NFHS-4). A binary logistic regression model has been used to determine the factors responsible for achieving exclusive breastfeeding, minimum dietary diversity and minimum meal frequency of the index child, that is, youngest child in the households. A separate regression model was run for both boys and girls. Girls faced discrimination not only in terms of exclusive breastfeeding but also in terms of receiving the required number of complementary meals. Logistic regression results indicate that the birth order of the children and the sex composition of the siblings are the important determinants of IYCF practices. Girls are more deprived in terms of receiving exclusive breastfeeding and other age-appropriate protein-rich food items when born in a household with more than two older daughters. Media exposure, mother’s autonomy and access to health and nutrition-related education are prominent factors in determining IYCF practices. The results suggest that there is a need to improve gender sensitisation in terms of feeding practices within the households.

Keywords

Last-born children gender discrimination breastfeeding feeding practices gender gap

Introduction

Nutrition is essential for health and survival. Globally, nearly half of all deaths in children under five years of age are linked to undernutrition (Black et al., 2013). Undernutrition in infants and young children leads to growth retardation, increased rates of morbidity, increased risks to survival, impaired cognitive development, reduced learning capacity, poor school performance in children and sub-optimal productivity in adults, all of which reduce the rate of economic growth for the nation (UNICEF, 2019). India is home to 40% of the world’s malnourished children and 35% of low birth weight infants in developing nations (UN Inter-agency Group for Child Mortality Estimation, 2019). Malnutrition continues to be a matter of grave concern in India. Undernutrition leads to low birth weight, childhood illnesses and disease. Poor maternal and child care and feeding practices are compounded by gender discrimination and exclusion. For instance, a male child may be breastfed for a longer duration than a female child, reflecting son preference. There is a large volume of literature in the Indian context that documents empirical evidence for son preference (Agnihotri, 2003; Echávarri & Ezcurra, 2010; Pande & Astone, 2007). Gender inequalities begin early in childhood even pre-birth and continue through adulthood. The target of Goal 5: Gender equality is to end discrimination against women and girls everywhere. In a socio-economic and cultural context that is as diverse as in India, achieving development targets concerned with the quality of life and status of not only women but also infant girls in society, remains a persistent challenge. This warrants a study of the gender gap in infant and young child feeding (IYCF) practices in India and an analysis of the data to understand the risk factors associated with the gender gap in IYCF.

Proper nutrition in the first two years of life is critical to a child’s survival and development. Appropriate IYCF includes various age-specific feeding practices such as breastfeeding within one hour of birth, exclusive breastfeeding for the first six months, complementary feeding at 6 to 8 months and optimum frequency of meal consumption among 6 to 23 months children. Breastfeeding within the first hour of life is recognised as the most important intervention for infant survival. Exclusive breastfeeding along with age-appropriate complementary feeding can reduce 20%of under-five mortality (Lamberti et al., 2011; UNICEF, 2019). Hence, children should be exclusively breastfed in the first six months of their life. After the first six months, breast milk is no longer enough to meet the nutritional needs of the infant; therefore, complementary and diverse foods should be added to the diet of the child.

IYCF practices are determined by maternal health, education, household wealth and food security status and further affect the child’s nutrition status (WHO, 2010a, 2010b). Moreover, there exists socio-economic inequality in terms of accessing age-appropriate complementary feeding. Children of households in the poorest wealth class are in a disadvantaged position in terms of having complementary foods compared with those in the richest wealth class (Barros et al., 2010).

A previous study highlights the existence of gender differentials to food, nutrition and health care utilisation (Singh & Patel, 2017). Studies have shown that infant girls are breastfed less frequently, for a shorter duration, and over shorter periods than boys after controlling for socio, demographic variable, maternal age, education and household economic condition. If the mother values the health of her son more than that of her daughter then she allocates more resources to him and breastfeeds him for a longer duration than her daughter (Oster, 2009; Pande, 2003). Preference for future sons also causes a gender gap in breastfeeding practices (Arnold et al., 1998; Retherford & Roy, 2003). Basu et al. (2018) find that the prevalence of exclusive breastfeeding was 46.4% in 2005–2006 and 54.9% in 2015–2016. Fledderjohann et al. (2014) used National Family and Health Survey (NFHS) (2005–2006) data to assess the magnitude of gender disparities in feeding practices. If the mother is literate then there is no prevalence of gender discrimination in terms of child feeding practices. However, if the mother is illiterate then girls were 5% less likely to be breastfed than their brothers (Borooah, 2004). The birth order of the child is also an important determinant of breastfeeding the child. A previous study found that breastfeeding increases with the birth order of the child. However, if the family has a son preference then breastfeeding of girl children may be limited in order to try to have a son (Jayachandran & Kuziemko, 2011). Nguyen et al. (2018) found a worsening in the situation regarding complementary feeding with a 10 percentage point decline in the timely introduction of semi-solid foods (55% to 45%) and a reduction in minimum meal frequency (MMF) (42% to 36%) between 2005–2006 and 2015–2016. As per the recently published NFHS-5 fact sheet, child feeding practices have improved in 2019–2021 as compared with 2015–2016. The percentage of children below three years of age who were exclusively breastfed when they were under six months old increased from 55% in 2015–2016 to 64%in 2019–2021. However, the percentage of children younger than three years who were breastfed within an hour remained almost unchanged over the two above-mentioned rounds (41.6% in 2015–2016 to 41.8% in 2019–2021).

However, there has been little research on gender differences in IYCF practices in India. This is an important issue because gender discrimination that contributes to poorer IYCF status for girls than boys can contribute to the poorer health status of the girls and may perpetuate this across a generation (Merchant & Kruz, 1992; Mosley & Becker, 1991). In this context, this paper examines the prevalence of the gender gaps in IYCF indicators based on the NFHS 2015–2016 (NFHS-4) data. It identifies the determinants of IYCF indicators in terms of exclusive breastfeeding, minimum dietary diversity (MDD) and MMF, and how those determinants vary across gender. The binary logit regression model is used to understand the determinants of IYCF indicators. The study has used both within-group models as well as between-group models to estimate the determinants of IYCF indicators. The between-group model includes gender as separate independent variables and explores the impact of gender on the IYCF indicators. On the other hand, in the within-group model, a separate model is used for both boys and girls by using the same set of covariates. The parameter estimates are compared on similar predictor variables.

The study contributes to the literature on child nutrition by investigating the determinants of IYCF indicators in terms of exclusive breastfeeding, MDD and MMF for both boys and girls. Previous literature has identified that the mother’s education, health and nutritional services have a positive impact on IYCF practices. This paper explores the determinants of IYCF practices for both youngest boys and girls to determine whether the birth order of children and sex composition of the siblings are the most important determinants of IYCF practices that need attention in order to improve child nutrition. If so, then special attention must be given to girl children and higher birth order children to achieve better nutritional outcomes.

The paper is organised as follows. Section 2 explains the data and statistical methods for the study. Section 3 highlights the main findings. Section 4 discusses the results and concludes the study.

Data and Methodology

The study is based on data from the NFHS-4 (2015–2016) round. The NFHS data in India is similar to the Demographic and Health Survey in other countries. The multistage sampling framework is used to create a representative sample for India. The full sample of NFHS-4 includes data on 699,686 women aged 15–49 years and 259,627 children aged below 60 months. Details of sampling design, sampling frame and the questionnaire were reported by NFHS and are publicly available at https://dhsprogram.com/methodology/survey/survey-display-355.cfm. The analysis in our paper is restricted to the last-born child who is below two years of age. In other words, the analysis is based on the youngest child born during the two years preceding the survey. So, the eligible sample size for our analysis is 97,275. The survey provides information on households’ standard of living, child mortality, health care services, reproductive health and nutritional status of women, breastfeeding practices, food frequency, age-appropriate feeding of children as well as anthropometric measures at the national and state level.

Dependent Variables

Exclusive Breastfeeding

If zero to five months children are exclusively fed breast milk, it takes a value of one and otherwise zero.

MDD: Detailed information on 21 food items that the child consumed the previous day of the survey was collected from the mothers. These food items are converted into seven food groups to calculate the MDD of the children. The child has achieved MDD if received at least four food groups out of seven food groups. If a child received at least four food groups it is coded one and otherwise zero.

MMF: MMF among the currently breastfeeding children is defined as children who received solid or semi-solid foods two times or more daily for children aged six to eight months and three times or more daily for children 9 to 23 months. For non-breastfed children aged 6 to 23 months children, it is defined as receiving solid, semi-solid or milk at least four times a day. If a child fulfils MMF then it takes value one and otherwise zero.

Predictors/Determinants

Gender is the key independent variable. It takes the value one if the youngest child is a girl and zero otherwise. The other independent variables are the place of residence (rural/urban), household wealth class, social and religious groups, maternal characteristics (education, exposure to media,¹ decision-making autonomy,² working status, education related to health and nutrition of child), age of the mother at the time of birth of the youngest child, access to maternal health care services (postnatal check-up), child-related factors (birth order) and sibling composition. Various combinations of sex composition of siblings are used: none, one brother but no sister, one sister but no brother, two brothers but no sister, two sisters but no brother and mix (both brother and sister). Details are given in Table 1.

Table 1.

Description of Determinants

Place of residence	Urban location, (rural location as a base)
Region	EAG³ (non-EAG states as a base)
Household wealth class	Middle, richer and richest (poorest and poor as a base)
Social groups	Scheduled caste, scheduled tribe, OBC (others as a base)
Religious	Muslim ( non-Muslim as a base)
Sex of the child	Girl (boy as a base)
Maternal characteristics
Mothers’ education	Secondary and above (illiterate as a base)
Mother’s autonomy	High decision-making autonomy (low decision-making autonomy as a base)
Mother’s exposure to media	High media exposure (low media exposure as a base)
Mother engaged in paid work	Working (non-working as a base)
Mother’s age at birth	Below 19 years, and above 34 years (20–34 years as a base)
Postnatal care	Within 48 hours of delivery (more than 48 hours as a base)
Mother received health and nutrition education	Mother received health and nutrition-related education (did not receive as a base)
Birth order of child	Child born in second and above birth order, (Child born in first birth order as a base)
Sibling composition	One brother but no sister, one sister but no brother, two brothers but no sister, two sisters but no brother, mix (both brother and sister) (No siblings as a base)

Determinants of IYCF Among Children

The unit of analysis is births that occurred during the two years preceding the survey. The analysis is restricted to the most recent birth, that is, the youngest child in the family (index child). The binary logistic model is used to find out the impact of birth order, sex composition of the siblings on the exclusive breastfeeding (Model 1), MDD (Model 2) and MFF (Model 3) of the index child after controlling for other background variables. Three separate binary logistic models are used: (a) the full sample, (b) when the index child is male and (c) when index child is female. An odds ratio (OR) greater than one indicates that the odds of an outcome are higher than the odds of the outcome of the base category and vice versa. If the OR is one, this indicates that the odds of the outcome are the same as the base category outcome.

Logit (p_{i j}) = β_{0} + β_{g} G_{i j} + β_{s} S_{i j} + X β_{x}

where

Model 1

$p_{i j} = t h e p r o b a b i l i t y o f i t h c h i l d (0 t o 5 m o n t h s) i n j t h h o u s e h o l d h a v i n g b e e n e x c l u s i v e l y b r e a s t f e d$

$G_{i j} = 1 i f t h e i t h c h i l d i n t h e j t h h o u s e h o l d i s a g i r l$

$β_{g} = G e n d e r d i f f e r e n c e s i n e x c l u s i v e b r e a s t f e e d i n g a f t e r c o n t r o l l i n g f o r b a c k g r o u n d v a r i a b l e s$ .

$S_{i j} = v e c t o r o f t h e s e x c o m p o s i t i o n o f s i b l i n g s o f i t h c h i l d i n j t h h o u s e h o l d s$

$β_{s} = E f f e c t o f s e x c o m p o s i t i o n o f a s i b l i n g o n t h e p r o b a b i l i t y o f e x c l u s i v e b r e a stfeeding of Index$

$c h i l d a f t e r c o n t r o l l i n g f o r o t h e r i n d e p e n d e n t v a r i a b l e s$

Model 2

$p_{i j} = t h e p r o b a b i l i t y o f i t h c h i l d (0 t o 5 m o n t h s) i n j t h h o u s e h o l d h a v i n g b e e n r e c e i v e d M D D$

$G_{i j} = 1 i f t h e i t h c h i l d i n t h e j t h h o u s e h o l d i s a g i r l$

$β_{g} = G e n d e r d i f f e r e n c e s i n M D D a f t e r c o n t r o l l i n g f o r b a c k g r o u n d v a r i a b l e s$

$S_{i j} = v e c t o r o f t h e s e x c o m p o s i t i o n o f s i b l i n g s o f i t h c h i l d i n j t h h o u s e h o l d s$

$β_{s} = E f f e c t o f s e x c o m p o s i t i o n o f a s i b l i n g o n t h e p r o b a b i l i t y o f M D D o f I n d e x$

$c h i l a f t e r c o n t r o l l i n g f o r o t h e r i n d e p e n d e n t v a r i a b l e s$

Model 3

$p_{i j} = T h e p r o b a b i l i t y o f i t h c h i l d (0 t o 5 m o n t h s) i n j t h h o u s e h o l d h a v i n g b e e n r e c e i v e d M M F$

$G_{i j} = 1 i f t h e i t h c h i l d i n t h e j t h h o u s e h o l d i s a g i r l$

$β_{g} = G e n d e r d i f f e r e n c e s i n M M F a f t e r c o n t r o l l i n g f o r b a c k g r o u n d v a r i a b l e s$

$S_{i j} = v e c t o r o f t h e s e x c o m p o s i t i o n o f s i b l i n g s o f i t h c h i l d i n j t h h o u s e h o l d s$

$β_{s} = E f f e c t o f s e x c o m p o s i t i o n o f a s i b l i n g o n t h e p r o b a b i l i t y o f M M F o f I n d e x$

$c h i l d a f t e r c o n t r o l l i n g f o r o t h e r i n d e p e n d e n t v a r i a b l e s$

X is a vector of other background variables in all the three models such as the place of residence, region, social group, religious group, wealth index, education of mother, working status of the mother, media exposure of the mother, mother’s autonomy, age of the mother at the time of the birth of the index child, the timing of postnatal care after delivery and whether mothers received education related to health and nutrition of the child.

Results

Gender Differences in Breastfeeding and Complementary Feeding of the Youngest Child

Breastfeeding is almost universal in India and 95% of children born in the two years before the NFHS-4 survey were breastfed at some point in time. However, several issues need attention in the context of breastfeeding. Around 60% of all newborn children were not started on breastfeeding within an hour of birth. This is a serious concern.

An overwhelming majority, nearly 45% of the youngest children in the sample households were not exclusively breastfeeding during the first six months after birth. Further, the youngest children in the sample households were also deprived of age-appropriate foods. For example, more than half of the youngest children in these households were deprived of complementary foods between six and eight months of age. Only 22% of last-born children aged 6 to 23 months achieved the stipulated MDD compared with the global prevalence of 29.3% (Global Nutrition Report, 2020). Regardless of gender, place of residence and wealth class the proportion of youngest children who received the minimum acceptable diet is very low.

There is evidence of last-born female disadvantage in terms of exclusive breastfeeding irrespective of place of residence. However, the disadvantage faced by girls relative to boys was very high in urban areas as the gender gap in percentage terms was as high as 8.2%. Girls born in households in the richest wealth class also experienced gender discrimination in exclusive breastfeeding and also being breastfed within one hour of birth.

While the magnitude of last-born female disadvantage in terms of complementary feeding among children in the age group six to eight months is relatively low, youngest girls in the age groups of 6 to 23 months were 3% more deprived in the richest wealth class in terms of access to MDD. Regarding MFF and minimum acceptable diet, regardless of the place of residence, last-born girls in this age group were more deprived than last-born boys. For example, approximately 7% to 8% more girls were deprived of receiving a minimum acceptable diet and meal frequency than boys in urban areas. This indicates that girls are not only deprived in terms of being exclusively breastfed but also in terms of age-appropriate complementary foods (Table 2).

Table 2.

Prevalence of Gender Gap in IYCF Indicators in India: 2015–2016

		Place of Residence			Wealth Class
		Rural	Urban	Total	Poorest	Richest
Early initiation of breastfeeding (all children)	Total	40.9	42.9	41.5	38.9	39.9
	Boys	40.7	43.4	41.4	38.7	40.2
	Girls	41.2	42.4	41.5	39.1	39.5
	Gender gap	−1.1	2.3	−0.1	−1.0	1.7
Exclusive breastfeeding (youngest child below 6 months)	Total	56.1	52.2	55.0	56.0	53.8
	Boys	56.9	54.3	56.2	55.8	54.3
	Girls	55.2	49.8	53.2	56.3	53.3
	Gender gap	3.0	8.2	5.3	−0.8	1.9
Complementary feeding (youngest child 6 to 8 months)	Total	41.9	54.3	45.2	43.2	53.0
	Boys	42.1	54.2	45.4	36.4	52.7
	Girls	41.6	54.2	45.0	36.1	53.4
	Gender gap	1.2	0.1	1.0	0.8	−1.4
MDD (youngest child 6 to 23 months)	Total	19.8	27.6	22.0	16.3	27.2
	Boys	19.6	27.2	21.7	16.4	27.6
	Girls	20.0	28.1	22.2	16.2	26.9
	Gender gap	−2.4	−3.4	−2.4	1.5	2.6
MMF (youngest child 6 to 23 months)	Total	33.7	33.8	34.9	31.8	41.1
	Boys	33.9	39.2	35.4	31.5	42.1
	Girls	33.5	36.2	34.3	32.0	39.8
	Gender gap	1.2	7.7	3.1	−1.6	5.5
MAD (youngest child 6 to 23 months)	Total	8.3	10.5	8.8	6.9	10.8
	Boys	8.4	10.9	9.1	7.1	10.9
	Girls	8.3	10.2	8.8	6.7	10.7
	Gender gap	1.9	6.7	3.5	5.8	2.2

Source: The authors (calculation based on NFHS-4 unit-level data).

Note: All the figures are adjusted by sample weight given in NFHS-4.

The gender gap is calculated based on the percentage difference between boys and girls: (boys–girls)/boys*100.

Gender Differences in Exclusive Breastfeeding, MDD and MFF of the Youngest Child Based on the Number and Sex Composition of Older Siblings

The earlier section has highlighted the evidence regarding gender differences in the IYCF indicators of the youngest child in the sample households. It is now important to explore the pattern of IYCF practices of the youngest child in these households conditioned upon the sex composition of the other siblings.

Figures 1–3 suggest that the pattern of gender differences in IYCF indicators for the youngest child is associated with the sex composition of the older siblings. All girls do not face the same level of discrimination. The youngest girl, born after one or two sons, receives relatively fair treatment in terms of exclusive breastfeeding. On the other hand, the youngest girl, born after one or two daughters, is less likely to be exclusively breastfed for the first six months after birth. In terms of age-appropriate feeding practices also, the youngest girl is deprived if she is born in a household that already has one, two or more daughters. However, if the youngest girl is born in a household which has one, two or older sons, then she is better off in terms of receiving both diversified food and the minimum frequency of meals. However, if a boy is born in a household which already has two or more sons, then the youngest boy is relatively neglected in terms of receiving age-appropriate foods.

Figure 1.

Source: The authors (calculation based on NFHS-4 unit-level data).

Figure 2.

Source: The authors (calculation based on NFHS-4 unit-level data).

Figure 3.

Source: The authors (calculation based on NFHS-4 unit-level data).

Determinants of Exclusive Breastfeeding for the First Six Months of Last-Born Children

Exposure to media, a mother’s autonomy, and health and nutrition-related awareness and knowledge are important determinants of exclusive breastfeeding of the child. The OR presented in Table 3 reveals that the youngest child born in an urban area has 11% less chance of being exclusively breastfed than a child born in a rural area. Additionally, if a child belongs to the richer/richest wealth class compared with the poorer or poorest wealth class then the chances of exclusive breastfeeding are reduced by 14%. Other factors that influence the exclusive breastfeeding of the child are media exposure and the mother’s autonomy. Further, a child born to a mother with higher autonomy has 47% higher chance of being exclusively breastfed than if the mother has low autonomy (95% CI: 1.16–1.89). Additionally, if the mother receives health and nutrition-related education during the time she is breastfeeding her child, there is a 34% higher chance of the child being exclusively breastfed. The study has incorporated gender variables in the model to capture the gender effect on exclusive breastfeeding. It is seen that compared with boys, girls have 19% fewer chances of being exclusively breastfed (95% CI: 0.61–0.97). Further, last-born girls in urban areas have a 20% lower chance of being exclusively breastfed compared with those in rural areas (95% CI: 0.60–0.90). On the contrary, last-born boys in urban areas have a 13% lower chance of being exclusively breastfed than their counterparts in rural areas (95% CI: 0.56–0.94).

Maternal education and knowledge related to health and nutrition are key determinants of exclusive breastfeeding of children. The likelihood of a girl being exclusively breastfed increases by 9% if her mother has completed secondary and above level of education, compared with one who is illiterate. Further, if a mother receives education related to health and nutrition while breastfeeding, the chances of exclusive breastfeeding increase by 42% for girls and 38% for boys (see Table 3). However, for infant boys, a mother’s education is found to be insignificant in explaining exclusive breastfeeding.

Table 3.

Determinants of Exclusively Breastfeeding: OR

	Index Child	95% CI	Boy	95% CI	Girl	95% CI
Place of residence
Urban (rural base)	0.89**	(0.78–0.98)	0.87**	(0.56–0.94)	0.80**	(0.60–0.90)
Gender of child
Girl (boy as base)	0.81***	(0.61–0.97)
Wealth quintile
Poorest and poor (as base)
Middle	0.95*	(0.87–0.99)	0.92*	(0.76–0.98)	0.91*	(0.81–0.94)
Richer/Richest	0.86**	(0.74–0.94)	0.87**	(0.78–0.98)	0.85**	(0.67–0.96)
Social group
None of them (base)
SC	1.02	(0.95–1.07)	1.06	(0.94–1.09)	1.03	(0.87–1.09)
ST	1.05*	(1–1.09)	1.09**	(1.08–1.21)	1.08**	(1.04–1.32)
OBC	1.02	(0.87–1.08)	1.04	(0.87–1.17)	1.02	(0.78–1.07)
Religion
Muslim (non-Muslim as base)	0.94	(0.81–1.09)	0.92	(0.87–1.09)	0.93	(0.82–1.05)
Maternal character
Mothers’ education (illiterate as base)
Secondary and above	1.03	(0.91–1.09)	1.02	(0.87–1.08)	1.09**	(1.05–1.19)
Mother is working (non-working as base)	0.94**	(0.75–0.96)	0.98**	(0.87–0.99)	0.96**	(0.84–0.98)
Media exposure
Low (base)
Medium	1.21**	(1.19–1.45)	1.22**	(1.08–1.56)	1.20**	(1.15–1.87)
High	1.67**	(1.32–1.89)	1.64**	(1.21–1.78)	1.63**	(1.21–1.77)
Mother’s autonomy (low as base)
High autonomy	1.47***	(1.16–1.89)	1.50***	(1.21–1.65)	1.54***	(1.32–1.65)
Mother age at the birth of index child
<20 years as base
20–34 years	1.10**	(1.03–1.21)	1.12**	(1.08–1.21)	1.15**	(1.06–1.34)
Postnatal check-up
Immediately after birth (as base)
Within 48 hours and above	0.92	(0.87–1.09)	0.98	(0.67–0.99)	0.94	(0.87–0.98)
Mother received health and nutrition education while breastfeeding	1.34**	(1.21–1.65)	1.38***	(1.21–1.61)	1.42***	(1.21–1.76)
Child character
Birth order of child
Birth order 1 (base)
Birth order 2 and above	0.84**	(0.65–0.96)	0.95**	(0.78–0.97)	0.70**	(0.56–0.98)
Sibling composition
None (base)
1 brother	1.21	(0.87–1.34)	1.08**	(1.01–1.18)	1.03**	(1.01–1.18)
>2 brother	1.23**	(1.11–1.45)	1.05**	(1.02–1.09)	1.21**	(1.06–1.34)
1 sister	1.01**	(1–1.09)	1.14**	(1.02–1.34)	0.91**	(0.61–0.96)
>2 sister	1.98**	(1.32–2.23)	2.12***	(2.02–2.32)	0.74**	(0.32–0.87)
Both brother and sister	1.02	(0.67–1.08)	1.04	(0.87–1.07)	0.93	(0.80–1.06)
Region dummy
Non-EAG (EAG as base)	1.02	(0.87–1.08)	1.05	(0.87–1.09)	1.04	(0.92–1.06)

Source: The authors (calculation based on NFHS-4 unit-level data).

Note: ***P < 0.01, **P < 0.05 and *P < 0.10.

Irrespective of the gender of the child, the likelihood of being exclusively breastfed is less for children who are second and above in birth order as compared with those with birth order one.

The model has incorporated the sex composition of the older siblings to understand the impact of siblings on the gender differences in breastfeeding practices. The level of discrimination faced by the girls depends on the sex composition of the older siblings within the households. A girl born after two or more brothers may face less discrimination than a boy who has two or more older brothers. The analysis shows that when the girl child is born in a family that has two or more boys, the likelihood of her being exclusively breastfed increases by 21% (95% CI: 1.06–1.34). On the other hand, girls who are born in a family that already has two or more daughters and no sons are the most deprived of exclusive breastfeeding. In terms of the OR, there is a 26% lower chance of exclusive breastfeeding when the youngest girl child belongs to a family that has already two or more daughters (95% CI: 0.32–0.87).

It is also clear that when the youngest boy is born in a family after two or more girls, the likelihood of exclusive breastfeeding increases by 2.12 times (95% CI: 2.02–2.32). A boy with one older brother and no older sisters also has a better chance of being exclusively breastfed. However, a boy faces discrimination when the family already has two sons. In such cases, the youngest son appears to be relatively neglected and faces a lower chance (5%) of being exclusively breastfed. However, the composition of siblings is not significant when they already have both a brother and sister.

Girls Disadvantage in Terms of Consumption of Age-appropriate Foods

Table 4 presents the findings regarding whether girls in the age group of 6 to 23 months receive the same food groups as boys based on the OR. Girls are significantly less likely to consume fresh milk, breast milk and high-protein foods, such as egg, fish and meat, when born in a household that has one or more surviving girls. For example, a girl who is born in a household with one or more older sisters is less likely to consume fresh milk (OR = 0.79, 95% CI: 0.67–0.95), breast milk (OR = 0.70, 95% CI: 0.62–0.97), chicken (OR = 0.84, 95% CI: 0.74–0.98), fish (OR: 0.86, 95% CI 0.79–0.94) and egg (OR = 0.91, 95% CI: 0.81–0.93).

Table 4.

Odds of Specific Food Item Consumption for Girls Compared with Boys by the Sex Composition of the Siblings: 2015–2016

Food Items	One or More Surviving Sister(s)	One or More Surviving Brother(s)
Tinned powder or fresh milk	0.79 (0.67–0.95)	0.89(0.79–0.92)
Breast milk	0.70 (0.62–0.97)	0.85(0.72–0.93)
Chicken	0.84 (0.74–0.98)	1.08(1.02–1.14)
Eggs	0.91 (0.81–0.93)	1.06(1.01–1.11)
Fish	0.86 (0.79–0.94)	1.06(1.02–1.13)
Bread	1.04 (1.01–1.07)	1.04 (1.01–1.07)
Potatoes	1.07 (1.04–1.11)	1.07(1.04–1.11)
Dark green vegetables	0.96 (0.86–0.99)	1.03(1.02–1.07)
Mangoes and other vitamin A fruits	0.93 (0.87–0.98)	1.04 (1.01–1.08)

Source: The authors (calculation based on NFHS-4 unit-level data).

On the other hand, when a girl is born in a household with one or more brothers, then although the youngest girl faces some kind of discrimination in terms of consuming both fresh milk and breast milk, no female disadvantage was found in consuming other food items including protein-rich foods such as eggs, fish, chicken as well as vitamin A rich fruits and other green vegetables.

MDD and MFF

Tables 5 and 6 report the findings regarding the associated factors that increase or reduce the MDD and MMF of the child based on the OR derived from the logistic regression model.

Table 5.

Determinants of MDD: OR

	Index Child	95 % CI	Boy	95% CI	Girl	95% CI
Place of residence
Urban (rural base)	1.21**	(1.08–1.34)	1.20**	(1.11–1.34)	1.19**	(1.07–1.34)
Gender of child
Girl (boy as base)	0.86***	(0.74–0.94)
Wealth quintile
Poorest and poor (base)
Middle	1.11	(0.91–1.18)	1.13	(0.87–1.32)	1.11	(0.90–1.41)
Richer/Richest	1.17**	(1.09–1.31)	1.18**	(1.09–1.32)	1.19**	(1.09–1.32)
Social group
None of them (base)
SC	0.93***	(0.67–0.99)	0.95***	(0.77–0.98)	0.85***	(0.62–0.96)
ST	0.87***	(0.32–0.92)	0.89***	(0.78–0.94)	0.78***	(0.62–0.87)
OBC	0.98	(0.94–1.05)	0.96	(0.87–1.07)	0.94	(0.87–1.08)
Religion
Muslim (non-Muslim as base)	0.94	(0.87–1.07)	0.97	(0.86–1.02)	0.93	(0.80–1.08)
Mother’s character
Mothers’ education (illiterate as base)
Secondary and above	1.11**	(1.04–1.21)	1.13**	(1.03–1.43)	1.12**	(1.03–1.19)
Mother is working	1.19**	(1.07–1.32)	1.21**	(1.11–1.41)	1.23**	(1.08–1.29)
Media exposure
Low (base)
Medium	1.19	(0.89–1.21)	1.21	(0.88–1.26)	1.13	(0.90–1.21)
High	1.12**		1.22**		1.27**
Mother’s autonomy (low as base)
High autonomy	1.12***	(1.09–1.32)	1.10***	(1.03–1.24)	1.13***	(1.09–1.34)
Mother received health and nutrition education while breastfeeding	1.09**	(1.03–1.17)	1.11**	(1.01–1.18)	1.12**	(1.06–1.34)
Mother age at the birth of index child
<20 years as base
20–35 years	1.12**	(1.02–1.34)	1.13**	(1.08–1.32)	1.10**	(1.03–1.32)
Child character
Birth order
Birth order 1 (base)
Birth order 2 and above	0.84**	(0.78–1.09)	0.82**	(0.54–0.87)	0.72**	(0.34–0.87)
Sibling composition
None
1 brother	1.02	(0.87–1.08)	1.05	(0.90–1.07)	1.09	(0.81–1.12)
>2 brother	1.08**	(1.03–1.14)	1.04**	(1.01–1.23)	1.16**	(1.02–1.23)
1 sister	1.01**	(1–1.21)	1.24**	(1.03–1.32)	0.89***	(0.78–0.94)
>2 sister	0.92**	(0.67–0.98)	2.32***	(2.01–2.45)	0.85**	(0.56–0.98)
Both brother and sister	1.02	(0.98–1.08)	1.12	(0.67–1.09)	1.08	(0.80–1.15)
Region dummy
Non-EAG (EAG as base)	1.67**	(1.21–1.78)	1.62**	(1.21–1.89)	1.61**	(1.32–1.89)

Source: The authors (calculation based on NFHS-4 unit-level data).

Note: ***P < 0.01, ** P < 0.05 and * P < 0.10.

Table 6.

Determinants of MMF: Odds Ratio

	Index Child	95% CI	Boy	95% CI	Girl	95% CI
Place of residence
Urban (rural base)	1.19**	(1.08–1.32)	1.17**	(1.03–1.34)	1.12**	(1.03–1.34)
Gender of child
Girl (boy as base)	0.90**	(0.81–0.98)
Wealth quintile
Poorest and poor (base)
Middle	1.09	(0.81–1.11)	1.11	(0.74–1.16)	1.13	(0.80–1.21)
Richer/Richest	1.23**	(1.10–1.32)	1.20**	(1.09–1.32)	1.19**	(1.06–1.29)
Social group
None of them (base)
SC	0.90***	(0.54–0.98)	0.92***	(0.81–0.98)	0.87***	(0.78–0.93)
ST	0.81***	(0.76–0.97)	0.87***	(0.67–0.98)	0.85***	(0.72–0.96)
OBC	0.97	(0.80–1.07)	0.92	(0.81–1.05)	0.92	(0.80–1.06)
Religion
Muslim (non-Muslim as base)	0.92	(0.80–1.08)	0.93	(0.86–1.06)	0.91	(0.85–1.06)
Mother’s character
Mothers’ education (illiterate as base)
Secondary and above	1.05**	(0.81–1.09)	1.06**	(1.02–1.34)	1.06**	(1.04–1.22)
Mother is working	0.93**	(0.61–0.96)	0.92**	(0.80–0.98)	0.91**	(0.80–0.96)
Media exposure
Low (base)
Medium	1.2	(0.90–1.32)	1.19	(0.78–1.32)	1.18	(0.81–1.38)
High	1.21**	(1.11–1.78)	1.13**	(1.08–1.45)	1.14**	(1.03,1.34)
Mother’s autonomy (low as base)
High autonomy	1.14**	(1.03–1.45)	1.14**	(1.02–1.34)	1.18**	(1.09–1.32)
Mother received health and nutrition education while breastfeeding	1.09**	(1.01–1.34)	1.08**	(1.03–1.34)	1.10**	(1.01–1.32)
Mother age at the birth of index child
<20 years as base
20–35 years	1.11	(0.91–1.21)	1.09	(0.92–1.31)	1.13	(0.81,1.34)
Child character
Birth order
Birth order 1 (base)
Birth order 2 and above	0.82**	(0.34–0.87)	0.80**	(0.67–0.98)	0.74**	(0.56–0.90)
Sibling composition
None
1 brother	1.03	(0.81–1.09)	1.04	(0.80–1.06)	1.05	(0.92–1.11)
>2 brother	1.01	(0.81–1.09)	1.02	(0.81–1.06)	1.07**	(1.01–1.22)
1 sister	1.05	(0.81–1.06)	1.1	(0.92–1.09)	1.01	(0.80. 1.06)
>2 sister	1.02	(0.93–1.12)	1.09	(0.81–1.11)	1.01	(0.96–1.13)
Both brother and sister	1.03	(0.86–1.18)	1.02	(0.86–1.16)	1.02	(0.88–1.34)
Region dummy
Non-EAG (EAG as base)	1.55**	(1.21–1.87)	1.56**	(1.23–1.89)	1.50**	(1.32–1.89)

Source: The authors (calculation based on NFHS-4 unit-level data).

Note: ***P < 0.01, ** P < 0.05 and * P < 0.10.

The results show that girls have a 14% less chance of achieving MDD (95% CI: 0.74–0.94) and 10% lower chance of achieving MMF compared with boys (95% CI: 0.81–0.98). The birth order of the child is also an important indicator for explaining MDD and MMF. If a child belongs to birth order two then chances of MDD and MMF are 16% and 18% lower compared with a child born first in birth order. However, these results vary based on the gender of the child. If a girl is born second in birth order, then the chances that she gets MDD are 28% lower compared with a girl born first in birth order (95% CI: 0.34–0.87). On the contrary, when a boy is born second in birth order the chances of MDD are 18% lower compared with a boy born first in birth order (95% CI: 0.54–0.87).

The effect of sibling composition on MDD shows that when a boy is born to a family in which he has more than two older sisters then the odds of having MDD are 2.32 times higher than those for a boy who does not have an older sister (95% CI: 2.01–2.4). However, in the case of an infant girl, the results show that girls probably will be more deprived (15%) in a family that already has two daughters (95% CI: 0.56–0.98). On the other hand, when a girl is born in a family where there are already two sons then the chances that she will get fair treatment in terms of MDD are higher (16%) compared with those for a girl who is born in a family where there are no siblings (95 % CI: 1.02–1.23). In the case of MMF, the effect of siblings is found to be insignificant.

Maternal characteristics also play an important role in providing age-appropriate food to children irrespective of their gender. Children born to mothers with a secondary and above level of education have an 11% higher chance of MDD compared with children who are born to illiterate mothers. The working status of the mother has a positive impact on the child’s MDD and MMF. The odds of having MDD are 23% higher in the case of girls (95% CI: 1.08–1.29) and 21 % higher in the case of boys (95% CI: 1.11–1.41), with working rather than non-working mothers. However, when the mother is working then the chances that a child has achieved MMF are 7% less compared with a child of a non-working mother (95% CI: 0.61–0.96). Other associated factors that increase access to MDD and MMF of the child are exposure to media, access to health and nutrition-related awareness and education, residing in urban areas and belonging to the richest wealth class.

Discussion and Conclusions

This paper highlights three overarching issues in the context of children below two years of age that need policy attention. First, both boys and girls suffer deprivation in access to early initiation of breastfeeding, exclusive breastfeeding for the first 6 months after birth, complementary feeding during 6 to 8 months and continued breastfeeding in addition to foods with appropriate diversity, frequency and adequacy from 8 to 23 months. Second, girls face discrimination in getting access to each of these. Third, the extent of discrimination faced by last-born girls below two years of age depends on the sex composition of their siblings.

Gender gaps in IYCF practices have serious implications for the well-being of the girl child. Girls are breastfed less frequently than boys at the earliest stages of life. This study shows that girls have 19% less chance of exclusive breastfeeding than boys. Girls face discrimination not only in terms of breastfeeding but also in receiving the required frequency, diversity and adequacy of complementary foods.

There is evidence to show that empowered women often make better decisions that benefit the well-being of their children directly through intra-household resource allocation and childcare practices and indirectly through their health and nutritional status (Arulampalam et al., 2016; Ngom et al., 2003; Rahman et al., 2016; Shroff et al., 2009, 2011; Smith et al., 2003). Our analysis shows that if a mother has completed secondary or above level of education, the likelihood of infant girls being exclusively breastfed increases by 9% compared with situations where the mother is illiterate. If the mother receives education related to health and nutrition while she is breastfeeding, then chances of exclusive breastfeeding increase 42% for girls and 38 % for boys. Hence, it is important to invest in maternal education to increase the awareness level of the mother.

Studies have explained the impact of the mother’s early marriage, early motherhood, frequent childbirths, low level of education, lack of knowledge and decision-making power, domestic violence on the survival, and health and nutritional status of her children (Raj et al., 2012). Many studies have linked greater women’s household autonomy with a reduction in infant mortality and better child nutritional outcomes (Brunson et al., 2009).

Our analysis shows that the birth order of the children and sex composition of the siblings are important determinants of IYCF practices. For example, if the last-born child is a girl, she has a 26% lower chance of being exclusively breastfed in a household that already has two or more daughters. On the other hand, if she is born in a family that has two sons then the chances of fair treatment in access to MDD are 16% higher.

While there is no gender disparity among first born children, if the older sibling is female, the duration of breastfeeding for the second-born girl is shorter. This contrasts with the absence of gender disparity in the duration of breastfeeding when the first born child is male (Angadi & Jawaregowda, 2017; Arnold et al., 1998; Basu et al., 2014, 2018; Fledderjohann et al., 2014; Jayachandran & Kuziemko, 2011; Mishra et al., 2004). Household wealth matters but this is primarily significantly associated with the consumption of dairy products (Agrawal et al., 2019). Individual counselling also improves complementary feeding practices in India (Nair et al., 2017).

The findings of our study indicate that children born in urban areas and the richest wealth class have 11% less chance of exclusive breastfeeding than those born in rural areas; and 14% less chance if they belong to the richest wealth class compared with the poorest wealth class. An earlier study based on NFHS-3 also reported the lower prevalence of exclusive breastfeeding in urban areas and the richest wealth classes (Patel et al., 2010, 2012). Other factors that influence the exclusive breastfeeding of the child are media exposure (67%) and the mother’s autonomy (47%).

Previous studies have found that a girl child was likely to be severely stunted and unimmunised if she had more than two older sisters. Additionally, she also faced a high risk of under-five mortality (Fledderjohann et al., 2014; Jayachandran & Pandi, 2017; Pande, 2003, Raj et al., 2015). This study also reports a similar impact of sex composition of the siblings on IYCF practices. We found that girls are deprived in terms of access to exclusive breastfeeding below six months of age and high-protein foods at the age of 6 to 23 months. However, girls are relatively better off in terms of IYCF practices if they have one or more older brothers. As mentioned above, the youngest girl has a 26% lower chance of being exclusively breastfed when the family already has two or more daughters. On the contrary, the likelihood of the youngest boy being exclusively breastfed increases by 2.12 times when the family already has two or more girls. Infant girls are 15% more deprived in terms of access to MDD if they have more than two sisters. On the other hand, when a girl child is born in a family that already has two sons then the chances of fair treatment of the girl child in terms of MDD are higher (16%).

Existing policies do not address the gender gaps in feeding practices. This paper provides evidence regarding the existence of gender gaps and factors that lead to discrimination in access to nutrition of girls and children of higher birth order. It highlights the discrimination faced by last-born girls in households that only have daughters and want to have a son.

Exclusive breastfeeding must be promoted for children up to the age of six months. For this, it is critical that the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act (IMS Act) is enforced and implemented in all institutions engaged directly or indirectly in health care for mothers, infants or pregnant women, including private hospitals and nursing homes. There is a lack of knowledge regarding the techniques of breastfeeding and latching. IIT Bombay has prepared freely downloadable spoken tutorials (Mehta & Dalal, 2020) to provide knowledge on scientific techniques of breastfeeding in various Indian languages to help prevent growth faltering in the early months of life. All health care workers and Anganwadi workers must be made aware of the long-term damage caused by efforts to substitute breast milk with formula feeds. Their support is also critical in rectifying gender gaps and discrimination against girls, especially higher order girls in access to exclusive breast feeding for the first six months and age-appropriate foods after that.

Crèches must be available at workplaces so that mothers can bring their children with them and feed the infant. Special care must be taken to ensure the safety of girls in crèches. There is also a need for policies that remove barriers for optimal feeding practices and encourage breastfeeding through support systems at home, the workplace and in public places. Culturally sensitive individual counselling and awareness generation are important to improve feeding practices and bridge gender gaps in them. The Government of India launched the Breastfeeding and IYCF Report card which provides a score to each state based on their performance on the main indicators of IYCF. The Government of India has also developed an assessment tool to evaluate the performance of the states in terms of IYCF practices (Government of India, 2019).

Further, Poshan Abhiyaan which is a flagship programme on nutrition emphasises the provision of complementary feeding to all the children below two years of age. It also seeks to ensure take-home ration from ICDS centres for all the households with children below two years of age.

Adequate age-appropriate complementary feeding needs to be ensured for children from 6 to 12 months of age and adequate complementary foods with diversity should be provided from 12 months to 24 months along with continued breastfeeding.

Women’s empowerment through completion of secondary schooling, education related to health and nutrition, media exposure and autonomy are key determinants of child health and nutrition.

Although our paper does not discuss about the son preference of the households however gender disaggregated data on IYCF indirectly assessed the social norms regarding son preference and valuing more sons than daughters when it comes to exclusive breastfeeding as well as consumption of protein-rich food. There is a need to improve gender sensitisation in terms of feeding practices within households. AWWs, ASHA workers and frontline workers must be trained and sensitised to create awareness to bridge the gap in child care and feeding practices. This will improve the overall young child feeding practices and enables lowering the gender gap more sustainably.

Footnotes

Data Availability Statement

Data are publicly available and can be accessed from the Demographic and Health Survey Website at https://dhsprogram.com/methodology/survey/survey-display-355.cfm.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Note

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