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Abstract

Childhood malnutrition remains a major public health concern in developing countries, including Ethiopia. This is mainly due to inappropriate child-feeding practices. One promising solution is to enhance women’s decision-making autonomy. This study was designed to explore comprehensive understanding of socio-cultural barriers that hinder women’s involvement in making decisions within households regarding child-feeding practices in the rural regions of south Ethiopia, from the perspectives of caregivers and key figures. We conducted six focus group discussions and 12 individual interviews with a total of 63 participants in three rural communities in south Ethiopia. Additionally, 20 key informant interviews were completed with healthcare providers. We used thematic content analysis to analyze the data. Socio-economic barriers, including limited income and job opportunities, a lack of property ownership, and low levels of women’s education, greatly influenced women’s decision-making about child feeding. Cultural practices such as having large families, practicing polygamy, and having significant age differences between spouses, along with limited freedom of partner choice and gender inequalities, were also found to be barriers affecting women’s involvement in making household decisions. In the local setting of rural southern Ethiopia, interventions should include culturally sensitive workshops in local languages that focus on the importance of nutrition and child feeding practices for both mothers and fathers, with collaboration from community leaders to ensure trust and relevance. Efforts to empower women economically through income-generating activities like small-scale farming or livestock rearing can strengthen their role in household decision-making, while microfinance opportunities further support their influence. Engaging husbands in child nutrition and care through group discussions and counseling fosters shared responsibility in family health. Tailored nutritional support, aligned with local food availability and traditional diets, can be promoted to ensure sustainability. Additionally, partnering with health workers and community organizations can make maternal health services and nutritional counseling more accessible, reinforcing overall family well-being.

Plain language summary

Multiple barriers of women decision making on child feeding in rural context of Ethiopia

Childhood malnutrition in developing nations, including Ethiopia, is a significant public health issue. Inappropriate feeding practices for children are the primary cause. Empowering women and enhancing their decision-making abilities is one potential solution. This research investigated the socio-cultural obstacles impacting women’s decision-making practices in rural South Ethiopia. Six focus group discussions, 12 individual interviews, and 20 key informant interviews were conducted. Socio-economic barriers, cultural practices, and gender inequalities were identified as obstacles to women’s involvement in household decision-making. Economic and cultural factors should be prioritized in interventions to address this issue, taking into account the specific cultural context and local needs of each community.

Keywords

women socio-cultural barrier women decision-making child feeding rural context

Introduction

Childhood malnutrition remains a significant public health concern in much of the developing world (Black et al., 2008). In Ethiopia, the burden and severity of childhood malnutrition put children at risk of dying from preventable diseases (Akombi et al., 2017; World Health Organization, & UNICEF, 2003). Additionally, childhood malnutrition has lifelong consequences, increasing the risk of nutrition-related chronic diseases in adulthood (De Sanctis et al., 2021; Dewey & Begum, 2011). Child feeding practices are essential components of child nutrition, with particular emphasis on breastfeeding, complementary feeding, and dietary diversity. The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life, followed by the introduction of nutritionally adequate and safe complementary foods (Koletzko et al., 2020). Women’s ability to implement these practices is closely tied to their decision-making power. Research shows that empowered women are more likely to follow optimal breastfeeding practices, which significantly reduce child mortality and improve long-term health outcomes (Aubel, 2012). Inappropriate child-feeding practices remain the main contributing factor to childhood malnutrition (Bégin et al., 2017; Hassen et al., 2021). Initiating complementary feeding at 6 to 8 months of age and meeting the criteria for a minimum acceptable diet are vital; practices that fail to meet these standards are inadequate (WHO, UNICEF, USAID, AED, UCDAVIS, & IFPRI, 2008)

The international community clearly acknowledges that proper feeding practices for infants and young children (IYCF) are essential for promoting healthy growth and development in children (Hassen et al., 2021). The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) advocate for a global strategy that includes key infant and young child feeding (IYCF) practices, such as exclusively breastfeeding for the first 6 months after birth and continuing breastfeeding for up to 2 years or longer (Anees et al., 2020).

In Ethiopia, various efforts have been undertaken to improve children’s nutritional status, including alignment with international goals and the development of national policies and action plans (Baye & Hirvonen, 2020; Woldeyohannes et al., 2023). However, inappropriate feeding practices significantly threaten children’s health (Dagne et al., 2022; Hassen et al., 2021).

Despite the progress that has been made, a significant number of children under 2 years old in developing countries continue to be fed inadequately, with estimates ranging from 25% to 50% (Hassen et al., 2021). Women’s limited roles in household decision-making impact child feeding practices (Thankian, 2020), and mothers with all household decision-making autonomy have shown a significant difference in the exposure of their children to malnutrition (Agaba et al., 2022). Enhancing women’s decision-making autonomy in child feeding and health is vital for community well-being (Agaba et al., 2022). Maternal participation in household decision-making is a key determinant of improved nutrition and health outcomes for infants and young children (Baduge et al., 2023; Rahman et al., 2015; Saaka, 2020). In Ethiopia, both mothers’ and fathers’ participation in decision-making significantly influences child malnutrition rates (Girma & Alenko, 2020). A gender-transformative intervention demonstrated that promoting joint decision-making through skills-based activities effectively addressed the root causes of child malnutrition (Doyle et al., 2018). Research shows that enhancing women’s decision-making autonomy is a promising strategy for improving child feeding practices and children’s nutritional status (Doyle et al., 2018; Saaka, 2020). This is especially important for low-income countries like Ethiopia, where women’s decision-making autonomy is often low (Kebede et al., 2021).

Most of the existing studies focus on the association between women’s decision-making and maternal and child healthcare (Dadi et al., 2020; Ganle et al., 2015; Kebede et al., 2021; Thankian, 2020). However, limited data on barriers to women’s decision-making practices hampers policymakers, practitioners, and researchers in effectively targeting public health efforts and developing scalable solutions. Therefore, this study aims to comprehensively understand the socio-cultural barriers that hinder women’s involvement in making decisions about child feeding practices in the rural regions of southern Ethiopia.

Methods

Study Design

A phenomenological qualitative study. Specifically, the study employs a descriptive phenomenological approach, rooted in Husserlian philosophy, to focus on capturing and describing participants’ lived experiences regarding socio-cultural barriers to decision-making in child feeding practices. This approach was chosen to align with the research objective of exploring the essence of participants’ direct experiences without interpreting or assigning external meaning to them, as required in interpretative phenomenology.

To ensure rigor, the researchers employed bracketing, setting aside personal assumptions and preconceptions throughout the study. This was achieved by maintaining reflexive journals and engaging in regular discussions with qualitative experts during data analysis. By doing so, the study sought to prioritize the participants’ perspectives authentically.

The descriptive phenomenological approach was particularly suited to this study as it facilitated an in-depth understanding of the socio-cultural factors shaping women’s decision-making roles in rural Ethiopia. This methodology allowed for the identification of shared meanings across individual experiences, offering insights into common themes without superimposing interpretative layers

Sampling and Sampling Procedure

This study was carried out in the Gamo zone, an administrative zone in the new south Ethiopia region. According to the 2007 Ethiopian Central Statistics Agency census, the Gamo zone had a total population of 1,341,901, with 668,230 males and 673,671 females. The majority of the population, 1,292,653 (96.33%), lives in rural areas. There are 15 districts in the zone, and the study took place in the Chencha, Mirab-Abaya, and Arba Minch Zuria districts from July 14 to September 22, 2023. The zone has a total of 3,767 health professionals and 587 health extension workers (Gamo Zone Health Department, 2019).

The study included both men and women. Married women with children aged 6 to 23 months and married men with lactating partners and children aged 6 to 23 months, who have resided in the area for a minimum of 12 months and provided informed consent, were eligible to take part in this research. The focus group discussions (FGDs) were carried out with groups consisting of 8 to 10 participants for both the mothers and fathers groups who have children whose age was between 6 and 23 months. Each group conducted three FGDs. To address sensitive socio-cultural issues, we employed key informant interviews and then compared the insights gathered from these interviews with the perspectives obtained from focus group discussions. Key Informant Interviews (KIIs) were conducted with three Health Extension Workers (HEWs), three Health Development Army (HDA) members, three community elders, and three religious leaders. Participants were chosen using a purposive sampling technique to ensure adequate data collection. Any men and women who met the inclusion criteria and expressed a desire to participate were allowed. No participants withdrew from the study. The principle of information sufficiency was used to determine the sample size, meaning no new data were gathered beyond 12 interviews (Guest et al., 2020). Key informants were selected based on their influence on the health aspects of the communities.

Data Collection Procedure

We conducted semi-structured interviews for both FGDs and KIIs using an interview guide and follow-up and probing questions. We used a pretested, semi-structured interview and FGD guide to collect the data. An interview guide was developed after reviewing literature relevant to the purpose of the study. We tested the questionnaire with a small group of married women in the Humbo district to rephrase unclear questions and adapt more understandable concepts. An experienced independent researcher and an experienced person from the same culture moderated the FGD. We conducted the FGDs in Amharic, the official language of the country. However, the facilitators and assistants were fluent in the first language of the participants. We recorded all interviews and FGDs and transcribed them later. We also used field notes to amend the audio-recorded data. Each FGD lasted from 45 min to 1 hr, while the KII lasted between 35 and 45 min. To ensure the quality of the KII and FGD data, we gave 2 days of training on how to conduct KIIs and facilitate FGDs, overseen by senior qualitative research experts, before fieldwork. A senior public health expert supervised the process daily during the fieldwork. The same senior qualitative research expert did quality control of the transcripts and translation on 10% of the audio records.

Data Analysis

The use of voice recorders was essential in capturing all Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs) in their entirety. This ensured that no information was missed or misinterpreted during the data collection process. Field notes, taken during the KIIs and FGDs, were transcribed word for word into the local language. This was done by the KII/FGD field facilitators on a daily basis. These transcriptions were then translated into English by the same facilitators. To ensure accuracy, experienced data collectors and supervisors were responsible for translating the transcripts. Back translation was also conducted to verify the accuracy of the translations. Additionally, supervisors independently verified the transcripts to ensure their reliability. Thematic content analysis was employed to analyze the data collected from the KIIs and FGDs. The major themes were derived from the study’s objectives, while sub-themes were identified through repeated readings by the research team. Emergent themes, which were not initially anticipated, were also identified and coded for each theme to specify individual topics discussed. This allowed for a comprehensive analysis of the data. To facilitate the coding process, the research team utilized NVivo-11, a software program designed for qualitative data analysis. Five members of the research team were involved in coding the transcripts. The statements within the transcripts were grouped according to their corresponding themes. Transcripts were reread to ensure accuracy and to confirm that all relevant information was captured. All identified themes were confirmed by the researchers to accurately represent the discussions from the KIIs and FGDs. This ensured that the findings were trustworthy, emphasizing credibility, transferability, dependability, and confirmability. The final step in presenting the findings was organizing them into narratives based on the thematic areas. Quotes from the transcripts were included to exemplify the emergent themes and provide further context to the findings. This allowed for a more comprehensive and nuanced understanding of the data.

Results

A total of 63 community members participated in the study, with 51 taking part in the FGDs (two in each rural community) and 12 involved in KIIs. The mean age of the FGD participants was 34.75 years (SD ± 6.88), ranging from 30 to 50 years. Among them, 47.1% were aged between 35 and 40 years, followed by 29.2% in the age group of 30 to 34 years. Females accounted for slightly more than half (50.9%) of the participants. The majority (35.3%) had not received any formal education. In terms of occupation, 45.1% of the participants were farmers (see Table 1).

Table 1.

Socio-demographic Characteristics of FGD Participants, in Rural Districts of south Ethiopia, 2023.

FGD participants characteristics	Frequency	Percentage
Age in years
30–34	20	39.2
35–40	24	47.1
41–50	7	13.7
Sex
Female	26	50.9
Male	25	49.1
Educational status
No formal education	18	35.3
Primary school	12	23.5
Secondary school	11	21.6
College and above	10	19.6
Occupational status
Farmer	23	45.1
Government employer	13	25.5
Merchant	7	13.7
Private employer	6	11.8
Day laborer	2	3.9

The average age of KII participants was 39.4 (SD ± 5.4) years, ranging from 30 to 50 years. Among the key informant interviewees, seven (58.4%) were aged between 30 and 40 years. Half of the participants (50%) were female KIIs. Additionally, half of the participants (50%) had attained a college certificate or higher education. Furthermore, the majority of KIIs (58.3%) were government employees by occupation (see Table 2).

Table 2.

Socio-demographic Characteristics of KII Participants, Rural Districts of South Ethiopia, 2023.

KII participants characteristics	Frequency	Percentage
Age in years
30–40	7	58.4
41–50	5	41.6
Sex
Female	6	50
Male	6	50
Educational status
Primary school	2	16.7
Secondary school	4	33.3
College plus	6	50
Occupational status
Farmer	4	33.3
Government employer	7	58.3
Private employer	1	8.3

There were three main themes generated from the FGD and KII data that explain the barriers to the use of appropriate child-feeding practices in rural districts in southern Ethiopia. The themes were economic status, demographic conditions, and socio-cultural aspects (see Table 3).

Table 3.

Themes and Subthemes of Barriers to Appropriate Child Feeding Practices in Rural Parts of Gamo Zone, South Ethiopia, 2023.

Themes	Subthemes
Decision making experiences	♦ Forms of decision making
Socio-economic	♦ Income
	♦ Being aware of husband’s income
	♦ Employment
Socio-cultural	♦ Gender
	♦ Polygamy
	♦ Couples age difference
	♦ Virginity
	♦ Pre-marital pregnancy
	♦ Fear due to dominance
	♦ Living with family relatives

Participants’ Decision Making Experiences

Many of the individuals interviewed in the study shared their experiences with decision-making. Participants explained that the mother, as the primary caregiver, is intimately familiar with the child’s needs, while the husband serves as the primary provider for the family. As a result, joint decision-making is crucial to ensure that both partners share responsibility and can contribute to their child’s health.

Joint Decision Making

We decide together what children need in terms of nutrition, and if necessary, we can jointly provide financial support for their dietary requirements. This way, we can ensure that they have a healthy and balanced diet. [36 years old Housewife, KII, participant].

……Husband and wife should make the decision jointly…… If not……the pressure is only on the husband, thus the wife's representation will be affected……. ……It is from this point of view that the decision has been made. [Female health extension worker, KII participant]

…… Collaboration (joint decision) between husband and wife is a must. …… If he (husband) exerts pressure ……, it affects the family as a whole. Therefore, collaboration (joint decision) is very important. I believe that these affect children's growth…… [42-years-old Male, FGD participant]

Participants highlighted the importance of collaboration and shared responsibility in managing a joint bank account. By working together, mothers can gain financial autonomy and showcase their independence. Moreover, by pooling their resources and working together, couples can ensure that they have enough funds to cover not only immediate needs but also future expenses, such as education or healthcare. This empowerment enables them to secure necessary food supplies for their children while also fostering a sense of equality and stability within the family unit.

……the money I earn will be kept in a shared bank account with my husband's earnings. Though we don't have a lot of money in the account, we both have access to the account and ATM password in case we need to save up. We're planning to provide the best possible diet for our child. [39-years-old, housewife KII participant].

Saving family money together …… yes it can have an impact on children's feeding. Saving together induces one to be aware of the transaction. So, they consult each other if withdrawal is needed and women can also buy things for babies…… [37-years-old female, KII participant]

The participant further explained that parental support is not only seen as an opportunity to foster self-confidence in children but also as a means to acquire knowledge. In situations where couples lack experience or face difficulties, the wisdom and guidance of older individuals can be invaluable in resolving predicaments or disputes. Moreover, the presence of parental support ensures that the child receives attention from everyone involved. This, in turn, grants the wife greater autonomy in making decisions related to household matters, including those concerning child feeding. The participants emphasized that this autonomy allows the wife to take charge and make informed choices for the well-being of the child.

In our context, the newly married couples will have the opportunity to consult the elder….…. For example, a wife will spend her first childbirth with her mother as the new mother lacks experience, it is considered as opportunity to learn under her mother’s watch while smooth recovery is undergoing side by side. [35-years-old male, FGD participant]

…if a couple chooses to live near their family, such as their parents or other close relatives, they can seek advice and support from them during household challenges. This can give the woman more confidence in getting involved and coming up with more convincing ideas, especially if the decision was made after receiving information from experienced relatives……[37-years-old male KII participant]

When the wife's family supports, everyone takes care of the children. So, it looks good for the children. It seems that the wife's family also supports taking care of their children as well. Therefore, in the presence of family support the wife's decision on the child's diet will not be affected. [35-years-old male, KII participant]

No Joint Decision Making

Key informants and discussants explained that there are households in which the husband dominates the decision-making process in their community. The study participants explained that this is due to the customary practice within their rural context, where the woman marries a man and moves to his house to live there. As a result, in some cases, sole decision-making becomes practical, as the husband is responsible for seeking employment and generating income to meet the needs of his family. However, women living in this household may feel excluded from important decision-making processes, such as financial planning, education choices for their children, or even decisions regarding their own lives. This can result in a lack of autonomy, limiting their ability to contribute to the overall well-being of the family. Addressing these underlying factors is crucial for promoting gender equality and empowering women to actively participate in decision-making processes within their households and communities.

……The majority of our village's men can leave their home village in pursuit of work. Then, they may go to Addis Ababa or elsewhere. The men, however, make the decisions. Therefore, they make their decision based on their earnings….…. [Male Religious Leader, KII Participant]

Whether at home or while discussing a social issue, it is the men who make the final decision. …… At the end, he may ask her (the wife), "I did this to you; what do you think?" however, due to her perceived inferiority, she (the wife) remain silent and refrain from responding.…… [38-years-old female health extension worker, KII participant]

Men provide money to purchase food items……….when she (the wife) says this is not enough, and he says why that is not sufficient……….This stuff of argument and dialogue is not appropriate for her as it can hampers her decision-making capacity and freedom. [35-years-old men, FGD participant]

Review of Socio-Economic Status Influences Decision-Making on Child Feeding Practice

Income

Couples who have a restricted income may need to make tough choices about their spending, leading to debates about what should take precedence. As a result, the amount of money allocated for child nutrition may be compromised, potentially leading to a power imbalance where one spouse controls the finances. Mothers who do not have their own income may feel dependent on their husband’s financial support, which can hinder their involvement in household planning and discussions.

……Income is the key factor that determines whether people belong to a lower or higher social class. One of the biggest challenges in making decisions about providing a balanced diet for children is the limited income of the family. Despite wanting to provide nutritious foods like milk and rice, the source of income may not allow for it [35-year-old Male, FGD participant].

…if she has no income she needs to ask her husband. Husbands are willing to give for their babies if they have money. [25-years-old housewife, FGD Participant]

…….the biggest loss is the loss of income. If she has a source of income, she can do whatever she wants and discuss and plan with her husband. [35-years-old female health extension worker, KII Participant].

Being Aware of Husband’s Income

Knowing a partner’s income can promote open communication and collaborative planning to improve or sustain the budget for children’s nutrition. When both partners are aware of each other’s income, it allows for a more transparent discussion about financial resources and priorities. This knowledge can help them make informed decisions about how much they can allocate toward providing nutritious meals for their children. In addition to the role of income knowledge,

Knowing the spouse's source of income or salary is crucial; if the wife finds out about her husband's income, they can plan together.….for their baby. [37-year-old male, KII participant].

….first we have to know our income then……we will decide….what to feed our child based on our income level. So, we (the wives) have to discuss it with our husbands. [30-year-old, female Health extension worker, KII participant].

……when the household income is known, people tend to make plans according to their income level. I noticed this from my neighbors and also learned (any property earned during marriage is a joint property of the spouses) about it from healthcare workers. It made me curious about my husband's income level, and I started asking more questions (do I have to share the responsibility of managing my finances equally with my wife, even if it is me who makes money for the family?). Knowing the income level allows women to prepare plans according to their financial situation, which can lead to further discussions.…… [37-year-old male, FGD participant].

Employment

Based on the insights provided by the FGD discussant and key informant, many housewives face obstacles in maintaining their decision-making authority due to their husbands being the primary providers, which can result in being overpowered. However, a clever woman can capitalize on opportunities to secure income and effectively juggle her familial and work-related obligations. Employment not only serves as a way to earn personal income but also promotes a culture of trust and collaboration and provides learning opportunities to enhance decision-making skills. This implies that the employment status of a wife can have a significant impact on their decision-making process.

………employed women can participate easily, but if a woman has no means to earn money, she may have to rely on her husband financially. However, a clever woman (creates opportunities to learn and shape her own life and knows how to make decisions involving her spouse) can manage both childcare and work, even if she needs support [43-year-old male, FGD participant]

……I can’t participate (I wish I had a means of getting money but I couldn't) in certain activities because I am a housewife. So, my husband takes care of almost everything (my involvement is minimal). He fulfills the needs of our family and provides for our children [36-year-old homemaker, KII participant].

If a couple has good communication (employment provides an opportunity to improve communication skills), there is no problem with one partner going out to work and bringing in money. However, if one partner tries to exert dominance over the other and says things like “You are just a housewife, I am the one who made the money,” it can hurt the relationship (affects women's participation in making decisions to secure appropriate child feeding) [43-year-old female, KII participant].

Review of Socio-Cultural Status Influences Decision-Making on Child Feeding Practice Gender

The social construction of gender roles and patriarchal norms have been identified as barriers to women’s decision-making abilities. The respondent pointed out that in the rural community they reside in, there is a lack of awareness regarding child feeding, with the perception that it is solely a woman’s responsibility. Sometimes husbands hold women responsible for not giving attention because of the feeling that women are the only responsible person who takes control of child-feeding. This situation can arise not only when the child falls ill but also during regular daily routines, as mentioned by the respondent. Respondents have explained this phenomenon based on the context of their community.

Yes, it affects decision making on children's feeding. Since our area is in a rural setting, there is a lack of awareness. For example, in rural areas, men do not cook lunch……… If the children at home are hungry, but he sits and watches, do not attempt to work on feeding them. [43-year-old female, KII participant]

In our community ……the wife is expected to spend her full time on child care and feeding, unless the child gets sick. Most of the time, husbands don’t get involved. Sometimes, he blames his wife if the child gets sick because he perceives that she is the only responsible person.[30-year-old female, KII participant]

Some husbands are not willing to give their children already-prepared meals; they wait until she comes back from where she went. I myself simply wait, even if the mother has some tasks or if she has social issues. [35-years-old male, FGD participant].

Polygamy

Polygamy can have detrimental effects on women’s decision-making abilities, particularly when it comes to providing for their children. The limited resources that are shared among multiple wives or due to the choices made by husbands can result in a lack of financial stability for mothers. As participants pointed out, this can make it difficult for them to even sustain their own lives, let alone adequately feed their children. This highlights the negative impact that polygamy can have on women’s ability to make decisions regarding their children’s well-being.

……in household with polygamy…… women are struggling to pursue their own lives rather than focusing on their children. This affects their decision-making abilities…… leaving them with the sole task of pushing through life……; hence, this compromised the mother's capacity to make decisions regarding the feeding of her child. [50-years-old male, FGD participant]

Polygamy is clear. Only the mother makes the decisions of the children because the husband can create a gap in expenses when he is here and there. Therefore, it has a lot of influence on the children. [39-years-old housewife, KII participant]

In situation where multiple wives coexist within a shared household, it is often observed that equal treatment may not be extended to all. In our community, typically, the first wife is granted the utmost recognition……. [36-years-old male, KII participant]

Moreover, the explanations provided by other participants shed light on the impact of polygamy when it comes to the distribution of economic resources among the wives. In situations where the available resources are insufficient to support all the wives, the husband may opt to allocate more resources to the wife who treats him the most favorably. Such a dynamic can greatly influence the extent of women’s participation in household decision-making.

……the credit or value of both wives is equal. However, the distribution of resources can be biased. This can lead to a situation where limited resources are shared among multiple wives in an unfair manner, which can result in women being unable to choose appropriate feeding options based on the needs of their children. [35-years-old male, FGD participant].

The impact extends beyond the children and also encompasses the wives. Economic sharing occurs among the wives, leading to competition between them. The husband's preference for one wife results in increased care from her, consequently affecting the other wives. [43-years-old male, FGD participant]

………even if a family has a high income, having multiple wives can lead to one wife being favored over the others, resulting in the neglected wife having limited options and little control over household decisions…… [50-years-old male, FGD participant]

Age Differences

Based on the majority of participants’ responses, it was found that husbands tend to sometimes dictate, order, or even insult their wives if they are in a marriage with a significant age gap. This means women may not discuss opinions with husbands openly due to the dominance that the age difference brings about, even if they feel the thought could be beneficial. This can eventually push mothers to lose interest in struggling further for their rights and give up everything (feeling lonely) for their husbands while being engaged in household routines to avoid conflicts.

……although she may have a good idea, her husband orders, insults, and prescribes everything in the house due to their age difference. Consequently, communication, dealing, dialogue, and discussion are highly compromised…… [39-year-old male FGD participant]

……With minimum age difference ……the disagreement is only between them (the couples), in this case she does not compromise child care. This (the negative influence) is mostly due to wider age difference between them (couples). The wider age discrepancy is barrier for communication. [27-year-old female FGD participant]

……When faced with the hopelessness that can arise from age disparities, women may struggle to effectively communicate and persuade others on important household matters, such as decisions regarding child feeding options [42-years-old male FGD Participant]

I think it affects the decision-making in children's nutrition. For example……if it is not an equal marriage (marriage with wider age difference), there will be a small conflict, and children may get hurt……As a result, women ……cannot make a coherent decision. [35-year-old farmer, KII participant]

Virginity

The research findings propose that women who engage in sexual activity before getting married might encounter challenges when it comes to making decisions. As per one participant, if a husband discovers that his wife has lost her virginity before their wedding day, he may not hold her in high regard, have trust in her, or allow her the freedom to express herself. Additionally, another participant also mentioned that a woman may pretend to still be a virgin to avoid humiliation or criticism from her parents, friends, or herself. Conversely, the respect and love shown by the community and husbands toward a woman who is a virgin when married can impact her involvement in decision-making within the household.

The married virgin will be respected and loved in the community where she lives; and her husband also fulfills her every request…… the respect goes up to family, neighbor, and the community at large. If the wife has no virgin during the wedding day, she has no respect…… freedom to ask……. [37-years-old male, FGD participant]

There is always disagreement, he insults her, hit her, scorns her, and communication is rough. No love, no agreement. Even though her husband did not take it as seriously, her family and his family will not accept it so easily. Not being a virgin is not easy. [37-years-old female, FGD participant]

……neither of them trusts the other. The woman claims to be a virgin to protect the groom's and his family's feelings. However, if it is discovered that she is not a virgin, which is expected by the groom's family, the wife's family, and their friends, she will be harshly criticized [25-years-old housewife, KII participant].

Moreover, some key informants’ conveyed their viewpoint that certain husbands might not be inclined to assist their spouses during the process of giving birth if the woman’s virginity had been forfeited before marriage. Consequently, preserving their virginity and entering into marriage enables women to gain respect not only from their husbands but also from their respective parents, as well as facilitate their active participation in matters about child feeding practices. While these beliefs and attitudes may vary across different cultures and societies, it is important to recognize the impact they can have on women’s lives and the choices they make.

…….….some men are not even willing to take care of their partners when they give birth. This can make it difficult for women to participate in household matters unless couples have a mutual understanding to lie to their family and claim that the woman is a virgin [38-years-old male, KII participant]

……the decision-making process of a girl is significantly influenced by her virginity and marriage. Both the girl's and the boy's families will be pleased if the girl remains a virgin until marriage. This will also earn her lifelong respect in the community [37-years-old male, KII participant].

……if she kept her virginity and got married so that there would be harmony between the two, it's good for her……in this case, it won't affect her decision. [37-years-old farmer, KII participant]

Pre-Marital Pregnancy

Pre-marital pregnancy may result in coerced marriage, causing a lack of trust between partners. With a foundation lacking trust, one spouse may become apathetic or disrespectful toward the other. This emotional disconnect can lead to feelings of hopelessness and depression. Consequently, this can have a detrimental impact on the couple’s intimacy and lead to conflicts that may ultimately lead to separation. Participants also added that, in some cases, the woman may even consider abandoning her child.

……In our community, if a woman becomes pregnant before marriage, the man is held responsible and is forced to marry her, regardless of whether or not they both consent to the marriage. This is done to avoid punishment and the negative stigma is associated with having a child out of wedlock. Unfortunately, this type of marriage can also affect a woman's ability to make decisions about how to feed her child. [48-years-old male, FGD Participant].

If the marriage was due to pregnancy, he (the man) says, ‘this pregnancy is not mine; I know you’ve relationships with many other men.' This creates no trust, which can lead to being ignorant ……….so, it has implications for women's involvement in decision-making. [38-years-old housewife, FGD participant]

……In our community if the woman get pregnant before marriage, the men’s family send elders and make them marry each other. In this case, the women becomes hopeless, depressed or may abandon her child. So, it will result in poor communication between the couples……. [28-years-old male, FGD participant]

Fear due to Dominance

Based on the feedback from the majority of key informants and focus group discussants, it has been observed that women might feel hesitant or embarrassed when broaching certain topics with their husbands. This is especially true in cases where there is a significant age difference between the spouses or when there is a close relationship between the husbands and the women’s parents. As a result, women may struggle with self-confidence and find it challenging to openly communicate thoughts and feelings with their spouse, leading to discomfort in the couple’s communication dynamics.

Young wives are afraid to ask their old husbands for something. There is a fear to keep the moral of her old husband. He is my father's friend. How can I ask him, may he insult me? This fear and lack of freedom may have an effect on her children. [40-year-old male, FGD participant]

If a mother is too afraid to express her feelings to her husband or remains silent out of fear, it may be difficult for her to convince him during discussions regarding child feeding issues. As a result, important decisions related to the children's well-being may be left unresolved. Both parents need to have open and honest discussions, free of fear and intimidation when it comes to their children's need (feeding). [38-year-old male, KII participant].

It brings problems to her involvement in decision making because a fearful wife will not have a courage or self-confidence to express her heart felts to her husband. So, she may prefer hiding her feelings and cannot say whatever she desire to talk to, in turn could impose negative implications to the child’s feeding and development. [37-years old health extension worker, KII participant]

Living with Relatives or Family Members

The inclusion of the spouse’s mother within the couple’s dynamic could impede the active participation of wives in decision-making, as the mother-in-law may prioritize her own role as the guardian of the grandchildren. This could potentially limit the mother’s involvement, leading to a sense of discouragement, especially if husbands are not supportive in such matters. Ultimately, this situation has the potential to deteriorate the relationship and potentially result in separation.

……the mother in -laws don't let the mother feed her child ……as she desired to do because the mother-in-law could put herself first and conveniently to ensure the safety of her grandchildren. Therefore, it significantly implicated the decision-making engagement of the wife [37-years-old health extension worker, KII participant]

…….…. When I married and moved here and, since I was a city girl, my husband's family was not pleased with me……then his family began to talk a lot about me not giving delivery. They referred to me as a burden carrier ……I was terrified …… and almost chose to end the marriage. [25-years-old housewife, FGD participant]

Living with other family members can discourage a wife's participation and even lead to separation. For instance, my mother-in-law considers me a disgrace to the family simply because I did not agree with her. Surprisingly, my husband was not very supportive in this matter……. [38-years-old male, FGD participant]

Discussion

This study aimed to explore the social and cultural barriers to women’s engagement in intra-household decision-making. The findings of this study indicate that socio-cultural barriers—such as income, gender dynamics, polygamy, age differences between spouses, loss of virginity before marriage, and premarital pregnancy—impede women’s decision-making in the study area. Specifically, income was identified as a significant obstacle to women’s participation in intra-household decision-making. Furthermore, having a source of income, such as employment, was noted to influence women’s decisions regarding child nutrition. This aligns with quantitative research conducted in Nepal, which found that women’s decision-making power was significantly impacted by their income and employment status (Acharya et al., 2010). The reason might be due to the fact that being employed can empower women by providing them with financial independence, access to valuable connections, and opportunities to develop important skills. These benefits can lead to a more equal distribution of power within the family, as women are able to contribute more actively to decision-making processes and take on leadership roles. Ultimately, being employed can have a positive impact on women’s autonomy toward child feeding (Mainuddin et al., 2015). When a woman has her own source of income, she is more likely to actively participate in decision-making regarding household matters through joint discussions and planning with her husband. Additionally, employed women can build social networks and seek better information from healthcare providers, which enhances their understanding of their roles as decision-makers within the household. This exchange of knowledge and support helps women feel more confident and empowered in their decision-making abilities, ultimately enabling them to take an active role in household decisions related to child nutrition.

In rural communities in Ethiopia, women are dominated by and permeated with patriarchal values, especially after marriage. Fear due to partner dominance could potentially escalate into conflicts between partners, as women may eventually feel compelled to confide in someone else other than their husbands, which could largely affect child feeding practices. Moreover, women living in patriarchal family settings may be discouraged from changing their behavior due to pressure from their spouses. Our finding is in agreement with the findings of a study conducted in rural Gambia, which reveal that due to the patriarchal nature of the household, men have the right to make decisions that affect members of the family, such as the allocation of resources to education, healthcare, and high-end expenditure item (Lowe et al., 2016). This might be due to the traditional belief that women have to do house duties, take care of children, garden, and do kitchen work rather than participate in outside activities while men go on duty (Kassa, 2015). Cultural stigmas and societal expectations can restrict women’s access to education and health information, perpetuating cycles of malnutrition in communities, such as those in rural Ethiopia, where child nutrition is seen solely as a woman’s responsibility (Muraya et al., 2016).

Further, the unequal distribution of household tasks, including child feeding, can have negative implications for the feeding practices of children, as women may not have the time or energy to provide proper feeding (Hadisuyatmana et al., 2021; Mainuddin et al., 2015). Overall, gender issues significantly influence the roles of men and women in families and communities, impacting child health and nutrition. To address these gender-related issues, a multifaceted approach is necessary. Community-based educational programs can raise awareness about the importance of shared responsibilities in child nutrition, engaging both men and women to challenge traditional norms (Levy et al., 2020). Empowering women economically through access to income-generating activities can enhance their decision-making participation (Abreha & Zereyesus, 2021). When women have their own income, they are more likely to advocate for their children’s nutrition and health.

Involving men in health discussions and programs can also transform perceptions of parenting roles. Encouraging fathers to participate in workshops can foster a sense of partnership in child-rearing, allowing both parents to contribute to their children’s health and nutrition (Moura & Philippe, 2023).

Ultimately, addressing these gender issues requires a collective effort from community members, organizations, and policymakers. By promoting educational initiatives, empowering women, and engaging men in health discussions, communities can create an environment conducive to equitable participation in household health decisions, ultimately improving child nutrition outcomes for the entire community.

The study’s findings reveal that women’s decision-making is hindered by the cultural emphasis on virginity before marriage, with significant implications for child feeding practices and overall family nutrition. In many societies, a woman’s virginity is linked to her social status, family honor, and her role within the household (Fejza, 2014; Ghanim, 2015). Virginity is seen as a symbol of honor, modesty, and a way of existing socially for women, according to Ghanim (2015). A woman who enters marriage as a virgin also gains empowerment. For example, Fejza (2014) who wrote about Kosovo society, provides an example of how losing virginity before marriage negatively impacts a woman’s life. In this cultural context, no one wants to marry a girl who has lost her virginity before marriage, as it results in the loss of her property rights. However, in contexts where women lose their virginity before marriage, their decision-making power in the household, including in areas such as child nutrition, can be negatively affected due to the stigma they face. Various practices and institutions uphold the value of virginity for unmarried girls (Chen, 2020; Nagpal & Sathyanarayana, 2016). Examples from Turkey demonstrate the commonality of virginity reconstruction through surgery (Ergun, 2013). Chen (2020) also illustrates how healthcare institutions contribute to preserving the value of premarital virginity by offering surgery to restore their virginity. This call for multidisciplinary intervention that focuses on raising awareness and providing continuous support while community representatives and key influencers are engaged. Ruptured hymen using modern technology. A marriage in which the woman is a virgin secures her position as the rightful wife of her initial spouse and affirms his paternity over their offspring. It also establishes the legitimacy of her children’s birth (Chala & Haro, 2023). This might be associated with premarital pregnancy stigma, which is often cited as a major barrier to women’s decision-making in many African communities (Gyan, 2018; Kinati et al., 2022). The correlation between the necessity of virginity for marriage in rural developing countries and relationships with older husbands exhibiting wide age variations can have profound implications for women’s autonomy and decision-making power within the household. In many African contexts, child nutrition and feeding practices are closely tied to family honor and the woman’s perceived role within the household. When a woman is ostracized or marginalized because of premarital pregnancy, her ability to influence these practices is severely limited, potentially leading to poorer health outcomes for her children (Muraya et al., 2016).

To address the link between virginity and gender roles, promoting educational initiatives challenging traditional views is crucial. Community-based programs can raise awareness about equitable relationships, encouraging both partners to participate in decision-making. Empowering women economically shifts power dynamics, enhancing confidence and decision-making authority (Abreha & Zereyesus, 2021). Active participation increased respect and credibility that enable women to have a stronger voice in determining how their children are nourished and cared for, as their opinions are more likely to be valued and taken into consideration by their husbands and other family members. Involving men in discussions on shared responsibilities in marriage and parenting helps dismantle harmful stereotypes (Moura & Philippe, 2023). By fostering a sense of partnership, couples can collaborate for improved family well-being. Ultimately, a multifaceted approach including community education, economic empowerment for women, and involvement of men in promoting gender equality is needed. These strategies can create a supportive environment that encourages equitable participation in household decisions, leading to better health and nutrition outcomes for children.

Living in polygamous families can create complex barriers to women’s decision-making, especially when it comes to child feeding practices and overall family nutrition. Economic dependence on husbands is a critical factor, as women in polygamous unions often have to share limited financial resources with other wives. This reduces their access to essential resources like food, healthcare, and the time needed to manage household tasks, all of which are critical for maintaining adequate child nutrition (Kinati et al., 2022). In such families, the division of attention and resources among co-wives may lead to conflicts and competition, leaving individual women with limited control over household decisions, including those related to feeding and nurturing their children. A qualitative study conducted in the Gedeo zone of South Ethiopia also reveals that women in polygamous unions, especially senior wives, may suffer from more psychological disorders as well as more familial and economic problems (Mengistu et al., 2022). Also psychological stress also plays a role in diminishing women’s decision-making power in polygamous unions. Women, particularly senior wives, may experience greater mental health challenges due to familial tensions, jealousy between co-wives, and the fear of losing the husband’s affection and financial support (Shaiful Bahari et al., 2021). These stressors can limit a woman’s ability to assert her needs, further complicating her role in ensuring adequate nutrition for her children.

To address this, culturally sensitive educational interventions that challenge the traditional norms surrounding polygamy and promote equitable decision-making could help mitigate the negative impacts of this family structure on child nutrition. In addition, involving men in these discussions is equally important. Programs that engage husbands in understanding the importance of shared decision-making, especially regarding child health and nutrition, could shift household dynamics and create a more supportive environment for women to exercise control over family resources. By promoting collaborative approaches to child-rearing and nutrition, families in polygamous settings can better ensure the health and well-being of their children.

Living with extended family members, particularly in-laws, presents significant barriers to women’s decision-making, including decisions related to child feeding practices and nutrition. Studies have shown that cohabiting with relatives, especially parents-in-law, often leads to shared decision-making in households, which can diminish women’s autonomy (Char et al., 2010; Jayaraman & Khan, 2023). In such settings, women may experience pressure from relatives, including their mother-in-law, who may hold authority over family matters, including child-rearing and feeding practices. This creates a complex family dynamic where women are often expected to defer to older family members, limiting their ability to make independent decisions regarding the nutrition and health of their children. The presence of co-residing relatives often means that household resources, such as income and assets, are managed collectively, which can further diminish a woman’s influence over household matters, including child nutrition. This financial dependency restricts women’s ability to advocate for improved dietary practices or health interventions, as they may lack the authority to prioritize spending on nutrition for their children (Jayaraman & Khan, 2023). These constraints on decision-making contribute to poor child nutrition outcomes in such households, as women may be unable to act on their knowledge or preferences for healthy child feeding practice.

Addressing challenges to women’s autonomy involves cultural shifts and empowering women within family structures. Community based educational programs that involve the entire family, including in-laws, are essential for changing restrictive norms. Engaging both genders in discussions about shared decision-making in child nutrition can challenge traditional hierarchies (De Groot et al., 2015). Workshops and family counseling can foster collaboration and emphasize mothers’ roles in feeding decisions (Jayachandran, 2015). Involving men is crucial, as they are often seen as primary decision-makers (Barker et al., 2007). Their support for equitable decision-making enhances women’s influence.

The negative influence of premarital pregnancy can profoundly hinder a woman’s active participation in child-feeding practices and broader decision-making processes within her household. In many cultural contexts, premarital pregnancy is stigmatized, often leading to social ostracism and diminished respect for the mother (Agaba et al., 2022). This stigma can create a sense of shame and inferiority, which may discourage women from asserting themselves in family discussions about nutrition and child care. As a result, mothers may feel marginalized and less empowered to advocate for their children’s nutritional needs, compromising the overall well-being of the family (Desai & Kiersten, 2005)

To address these challenges within the local context, it is essential to implement community-based education programs that promote gender equity and challenge the stigmatization associated with premarital pregnancies. These programs should aim to create an inclusive environment where women feel empowered to express their views and actively participate in decisions regarding child nutrition and health. Workshops that emphasize the shared responsibilities of both partners in child-rearing can help reshape perceptions and foster collaboration (Levy et al., 2020)

Additionally, empowering women economically is vital for enhancing their decision-making authority. Access to income-generating opportunities allows women to gain financial independence, which can boost their confidence and enable them to advocate for their children’s needs more effectively (Abreha & Zereyesus, 2021). When women have control over financial resources, they are more likely to prioritize nutritious food and health services, positively impacting their children’s nutritional outcomes.

Involving men in these initiatives is also critical. Encouraging fathers and male partners to engage in discussions about child feeding practices can help dismantle the traditional norms that limit women’s participation. By promoting a sense of partnership in parenting and family responsibilities, both men and women can work together to improve their children’s health and nutrition (Moura & Philippe, 2023)

An age difference between husband and wife was a barrier to women’s decision-making. The finding was in line with the study conducted in Ethiopia, India, and Colombian communities (Das & Das, 2013; Kitila et al., 2020; Minocher & Ross, 2022). Wider age difference between couples has negative implications for women’s participation and decisions on household matters, including the children’s nourishment, as highlighted by the respondents. In rural Bangladesh, there is a noticeable trend where women who marry men with significant age differences are often less empowered. This is primarily because these women are usually younger, typically under the age of 18, and are less likely to have received an education. The lack of empowerment in making decisions regarding child nutrition can be attributed to the cultural expectation that young girls are responsible for providing food to their fathers by working in the agricultural fields. Conversely, in rural areas where men marry much younger women, typically under 18 years old, traditional gender roles are often maintained within the marriage. This leads to less emphasis on equal participation between husband and wife in ensuring the well-being of their children (Mainuddin et al., 2015). This might also be associated with feeling shy or ashamed of talking to her husband due to age differences, which could cause a lack of self-confidence and difficulty for her to express what is in her heart (Das & Das, 2013; Lee & McKinnish, 2018). In Ethiopia, the issue of age differences is particularly pronounced in rural areas, where marriages involving older men and younger women are more common (Kitila et al., 2020). For example, in child feeding practices, younger wives may struggle to assert their preferences regarding nutritious diets or seek medical attention for their children, as their older husbands may control both financial resources and health-related decisions. The relationship between age differences and decision-making extends beyond the household. This power dynamic can have significant implications for child nutrition and family well-being. For instance, if a younger mother believes that breastfeeding or introducing certain foods is essential for her child’s health, but her older husband disagrees, she may feel powerless to act on her knowledge and instincts (Samuelsson, 2020)

Addressing these issues requires targeted interventions to promote gender equity, such as community-based educational programs that facilitate discussions on shared responsibilities in child nutrition (Levy et al., 2020).

Empowering women economically can also shift power dynamics. Access to income-generating opportunities enhances women’s decision-making authority regarding household matters (Abreha & Zereyesus, 2021). Financial independence enables women to advocate for their children’s nutritional needs effectively. Additionally, engaging men in educational initiatives can transform perceptions of parenting and household responsibilities, fostering a sense of partnership (Moura & Philippe, 2023)

Overall, addressing the implications of age variation in couples necessitates a collective effort from community leaders, organizations, and policymakers. By promoting gender equity, providing economic opportunities, and involving men in family health discussions, communities can create a supportive environment for equitable participation in household decisions, ultimately improving child nutrition outcomes for families and the broader community.

Limitations

The study focused solely on married couples currently living together, leaving out other important groups of caregivers. This omission highlights the need for future research to explore the perspectives of various caregivers, such as grandparents, women-led households, nannies, and other individuals involved in caregiving. Additionally, the study did not consider non-formally married couples or married couples who are not cohabitating, which could provide further insight into caregiving dynamics. Moreover, the transferability of the study’s findings may be limited to communities or contexts similar to the study area. Therefore, these findings may primarily apply to low-income countries with comparable social and economic conditions. Expanding research to other caregiver groups and diverse settings could offer a more comprehensive understanding of caregiving practices and decision-making in different cultural and socioeconomic contexts.

Conclusion

This study found that most participants reported making decisions jointly with their spouses; however, some indicated that either the wife or husband held sole responsibility for household decisions. Key economic barriers affecting women’s decision-making included their income, employment status, awareness of their husband’s income, and property ownership. Additionally, factors such as family size and women’s educational levels influenced their involvement in decision-making. Cultural barriers also significantly impacted women’s decision-making roles. These barriers included living with extended family members, reliance on support from their families, feelings of shyness or shame, the responsibility of managing food expenditures, and societal pressures related to virginity, premarital pregnancy, age differences, polygamy, and gender norms.

To address these barriers, economic empowerment programs are crucial for women in rural areas to gain financial autonomy and contribute to household decision-making. Village Savings and Loan Associations (VSLAs), Income-Generating Activities (IGAs), and awareness of land and property rights can help empower women economically. Educational interventions such as adult education programs and school retention programs for girls are essential for increasing women’s autonomy and decision-making roles. Cultural norms and gender equality initiatives, including community dialogs, family counseling, and engaging men as allies, can help address barriers to women’s decision-making. To address gender-based cultural barriers like early marriage and virginity norms, advocacy for delayed marriage and education campaigns are needed. Women-centered health and nutrition programs, including initiatives that empower women to make informed decisions about nutrition and strengthen maternal and child health programs, can help overcome economic and cultural barriers to women’s decision-making in these areas.

Footnotes

ORCID iD

Kassahun Fikadu Tessema

Ethical Considerations

Ethical approval for the study was obtained from the Institutional Research Ethics Review Board of a recognized university. Prior to the interviews and focus group discussions (FGDs), participants were informed about the study’s objectives before being invited to participate, and informed consent was obtained. Key informant interview (KII) and FGD participants were made aware that, although the conversations were audio-recorded, their identities would remain confidential. Verbal consent was obtained at the beginning of the FGDs and KIIs before initiating the discussions.

Consent for Publication

Consent was obtained from participants to use anonymous quotes to be published in peer reviewed journal publications.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

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

Data Availability Statement

The dataset used in this study is available from the corresponding author upon reasonable request.

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Socio-Cultural Barriers Affecting Women’s Decision on Child Feeding in Rural South Ethiopia: Perspectives of Caregivers and Key Figures

Abstract

Plain language summary

Keywords

Introduction

Methods

Study Design

Sampling and Sampling Procedure

Data Collection Procedure

Data Analysis

Results

Participants’ Decision Making Experiences

Joint Decision Making

No Joint Decision Making

Review of Socio-Economic Status Influences Decision-Making on Child Feeding Practice

Income

Being Aware of Husband’s Income

Employment

Review of Socio-Cultural Status Influences Decision-Making on Child Feeding Practice Gender

Polygamy

Age Differences

Virginity

Pre-Marital Pregnancy

Fear due to Dominance

Living with Relatives or Family Members

Discussion

Limitations

Conclusion

Footnotes

ORCID iD

Ethical Considerations

Consent for Publication

Funding

Declaration of Conflicting Interests

Data Availability Statement

References