Development of indicators of women’s empowerment for optimal infant and young
child feeding and related maternal nutrition practices in rural Bangladesh
INTRODUCTION
Although research has been done to come up with ways of measuring and assessing
levels of women’s empowerment in general, little has been done to relate these indicators
specifically to infant and young child feeding and related maternal nutrition (IYCF and
rMN). A full literature review of the current research on definitions of IYCF/rMN
empowerment accompanies this document as Annex A. While literature exists on the
definitions of women’s empowerment in rural Bangladesh, none of this is directed
specifically at the issues of IYCF and rMN. Additionally, CARE Bangladesh’s Strategic
Impact Inquiry (SII) on Women’s Empowerment addresses empowerment in Bangladesh,
but again, does not include the specifics of how it relates to the ability of women to
practice optimal IYCF and rMN. With this in mind, and based on the body of literature
surrounding the subject of women’s empowerment as it relates specifically to IYCF and
rMN, it is evident that culturally tailored indicators to assess women’s empowerment in
this sphere are a necessity if one is to get an accurate picture of how this empowerment
impacts IYCF and rMN practices in any specific population. In order for CARE
Bangladesh (CARE BD) to assess the impact of their women’s empowerment
interventions on optimal IYCF practices in the future, it is essential to develop culturally
specific indicators and make sure that they are well understood by the target population.
The indicators should highlight attitudinal barriers to optimal IYCF and rMN practices.
The research project will thus fill the knowledge gap in this area by establishing wellunderstood, culturally specific indicators that measure women’s empowerment in the
domain of IYCF and rMN practices in rural Bangladesh.
The purpose of the research recently conducted in Karimganj, Bangladesh, was to
determine and define culturally specific ideas of women’s empowerment as they relate to
infant and young child feeding practices and related maternal nutrition specifically.
Ultimately, the aim of the research was to provide CARE Bangladesh with the
information necessary to evaluate the efficacy of their nutrition interventions in
improving women’s empowerment for optimal IYCF and rMN practices. Qualitative
methods and systematic literature review were used to conduct formative research on the
definitions of IYCF/rMN empowerment in rural Bangladesh, and inform the development
of a structured data collection instrument for future use. Indicators for IYCF/rMN
empowerment were developed by the researchers, based on this formative research, and
made into a survey tool to assess levels of IYCF/rMN empowerment in women. The
researchers then field-tested the survey tool to make sure that it was well understood by
the target population and could be used without hesitation to evaluate future nutrition
programs in the area of women’s empowerment.
CARE Bangladesh conducted this study with the help of a graduate researcher from
Emory University, between June and August 2012 in the Karimganj Upazilla in northeastern Bangladesh. The formative research was done primarily in CARE’s current
nutrition intervention (Akhoni Shomay) area, though a number of interviews were
conducted outside of this area to gain perspectives from a variety of people who’ve had
differing experiences with IYCF and rMN interventions.
METHODS
Qualitative Data Collection:
Qualitative research was conducted using qualitative methods including participatory
learning and action (PLA) activities and in-depth interviews (IDI). The PLA activities
were used in order to allow the participants to explore their personal attitudes and
opinions through an active and flexible means. Four different PLA activities were
employed; social mapping, pile sorting, problem tree, and 10-seed technique. Facilitators
for both the PLA activities and the IDIs were the community mobilizers of the Akhoni
Shomay project, who were given 2 half-day training sessions, one for PLA activities, and
one for IDIs. Guides for the PLA activities and IDIs were translated into Bangla and
back translated into English to ensure proper translation and reliability.
Social mapping allowed the researchers to gain an understanding of the most important
social influences on women for optimal IYCF and rMN practices. Participants were
asked to draw a woman in the center of a poster, and then asked to draw all the sources of
influence regarding IYCF and rMN surrounding the woman. Probing questions about the
map allowed the researchers to assess what sources in the community offer women
support and information for IYCF and rMN, what sources have influences on the
women’s behavior, how information regarding IYCF and rMN is shared within the
community, how decisions are influenced by certain relationships, and barriers to social
communications about IYCF and rMN.
Pile sorting was used to help determine how women in the communities perceive being
empowered to practice optimal IYCF and rMN and how they perceive self-efficacy.
Participants were shown picture cards of people, places, foods, and activities that are
common during pregnancy and lactation in Bangladesh and asked to sort these cards into
piles of related items based on their perceived barriers and positive influences to IYCF
and rMN decision making. This activity helped to determine what community members
saw as important for women’s empowerment and what terms they used to describe it.
The problem tree activity allowed the researchers and participants to explore the causes
and effects of women’s empowerment as it relates to optimal IYCF. It helped to answer
the question of what makes some women more likely to be able to make IYCF and rMN
decisions than others. The participants drew a tree on a piece of poster paper and labeled
the trunk with a “problem” specific to IYCF and rMN decision making. The facilitator
then asked participants to identify causes of the problem and write them on the roots of
the tree and subsequently identify effects of the problem and place them in the tree
branches. When the full complexity of the causes and their effects were clear, the
participant group was asked to suggest possible solutions to the root causes they
identified.
The 10-seed technique helped the researchers to determine to what extent different people
in the population make decisions that influence IYCF and rMN behaviors and thus
determine the general attitudes in the population towards women’s autonomy in this area.
The participants were given a group of 100 seeds and asked to consider them to represent
the entire population under study. They were then asked to move the seeds around into
groups representing decision-making about different IYCF/rMN topics under study.
In-depth interviews (IDI) were conducted following PLA activities in order to probe and
explore certain topics further, and gain an understanding of the personal context of
mothers’ attitudes and perceptions about IYCF/rMN empowerment. As some of the
information sought by the researchers was sensitive, the IDIs allowed for more effective
discussion of these core issues.
The research occurred through an iterative process; guides and probing questions were
adapted throughout data collection to allow the researchers to probe further into relevant
topics as they came up in the activities.
Discussion during each of these activities was recorded using multiple note-takers who
took notes in Bangla. The notes were translated each day into English for review of the
researcher.
Survey Data Collection Methods:
After analysis of qualitative data and the development of a set of IYCF/rMN women’s
empowerment indicators specific to rural Bangladesh, the indicators were tested in a
cross-sectional survey form, for reliability, validity, and accessibility. The facilitators of
the survey met daily to discuss challenges they faced when administering the survey to
participants, and make changes to the language and structure of the survey of indicators
accordingly.
Sampling Methods:
PLA activities were held in focus groups of 7-8 people at a time. Activities were
conducted with groups of men, groups of elderly women, and groups of pregnant and
lactating mothers separately. Gathering data from these three different groups of people
allowed the researchers to gain a more complete perspective of community perceptions of
what constitutes women’s IYCF and rMN empowerment. The Akhoni Shomay team
members chose respondents purposively for the study. The Akhoni Shomay nutrition
intervention takes place in 11 geographical areas (unions); four of these unions were
chosen as locations for the formative research based on their performances in the midterm report. The two highest performing unions and the two lowest performing unions
were chosen. Participating groups within these unions were chosen by the community
mobilizers for the Akhoni Shomay project assigned to those areas. A total of 12 PLA
activities were conducted in each union.
IDIs were conducted in two unions that had not done PLA activities as well as in two
regions outside of the Akhoni Shomay intervention area. Regions outside the
intervention area were chosen so as to gain perspective from those who had not been
exposed to Akhoni Shomay’s specific programs, thus increasing the validity and
reliability of the data for use in creating a tool to assess women’s IYCF/rMN
empowerment with any Bangladeshi population. Participants were chosen randomly,
door-to-door. Eligible participants for the IDIs were lactating mothers with children
under 2 years. A total of 12 IDIs were conducted.
The survey of indicators was conducted in four of the Akhoni Shomay unions that had
not participated in the qualitative data collection, as well as 2 regions outside of the
Akhoni Shomay intervention area, so as to validate the tool with a population that had not
been involved in its creation. Respondents for the survey were mothers with children
under 2 years old, selected randomly, with each interviewer searching for eligible
participants every three houses.
Data Analysis:
Data from the PLA activities and the IDIs was coded and analyzed using standard
qualitative analysis techniques by the Emory University Graduate Intern. In analyzing
the data, the researcher kept in mind the goal of the project, which was to gain insight
into perceptions of IYCF and rMN women’s empowerment for the creation of an
indicator system for use in future assessment of programs that wish to measure their
effectiveness in empowering women to perform optimal IYCF/rMN practices.
Based on responses to the survey and interviewer suggestions, questions were iteratively
modified to hone in on easily understandable indicators of women’s empowerment as it
relates to IYCF and rMN.
Data from the survey was entered into an excel worksheet and initial analysis to identify
Akhoni Shomay’s strengths and weaknesses in the area of IYCF/rMN empowerment was
done using excel. Detailed analysis of the quantitative data from the survey was not
done, as the objective of the survey was to pre-test the developed indicator tool, and to
give CARE Bangladesh a foundational idea of how their nutrition programming is
working in the area of women’s empowerment.
RESULTS
Lit Review
Although the full literature review on the subject of women’s empowerment as it relates
to IYCF and rMN accompanies this document as Annex A, it is important to note the key
findings here, as they support the indicator tool developed for CARE Bangladesh.
Though various researchers define the domains of women’s empowerment for IYCF and
rMN differently, there were seven domains that stuck out as consistently important
throughout the literature. These domains are financial autonomy and control over assets,
decision-making autonomy, mobility autonomy, attitudes towards domestic violence,
social relations and support, education/knowledge, and self-efficacy.
CARE BD concept of Women’s Empowerment
The indicators developed in this project for IYCF/rMN women’s empowerment are
consistent with CARE BD’s concept of women’s empowerment. The attached
conceptual framework (Annex B) shows how the proposed indicators for IYCF/rMN
women’s empowerment fall directly in line with CARE BD’s concept of women’s
empowerment.
Qualitative Analysis Results
Thematic analysis of the PLA and IDI data revealed nine distinct domains of women’s
empowerment: financial autonomy/control over assets, decision making autonomy,
mobility autonomy, attitudes towards domestic violence, social relations and support,
knowledge/education, self efficacy, negotiation/accommodation habits, and psycho-social
well-being.
Financial Autonomy/Control over Assets: Almost without fail, every PLA group and
every individual person interviewed brought up poverty or lack of money as a barrier to
women’s IYCF/rMN decision making abilities. Although poverty itself is a well-known
social determinant of behavior that constitutes a general problem for achieving optimal
practices regardless of empowerment, (SOURCE), after some probing, it became clear
that women’s control over finances was an important aspect of their ability to practice
optimal IYCF and rMN. If women have no cash available in their possession, then they
have no way of purchasing foods for themselves and their children. This lack of
purchasing power was seen by the communities interviewed as a restriction to woman’s
capabilities in optimal complementary feeding of her children, as well as her own
nutrition during pregnancy and lactation. The group discussion during one pile sorting
activity demonstrates the common perspectives of the community members around this
issue:
“If mother has some money for herself, then she can bring some food from the market for
complementary feeding.”
In addition, maternal financial self-support was a common theme in the qualitative
research data. It was often brought up that women who have a means of making their
own money are better able to practice optimal IYCF and rMN. A few different groups
suggested the following during the problem tree activity as a solution to barriers mothers
face for nutrition during pregnancy and lactation:
“One solution to lack of nutrition during pregnancy is that the mother should rear hens
and ducks.”
One IDI respondent asserted that the way to gain power in her household would be to
garner a personal source of income:
“[To change my power relationships], I want to cultivate vegetables and grow up my
profit.”
Decision Making Autonomy: Through the PLA activities and IDIs, it emerged that
IYCF/rMN decision-making is often not left up to the mother of the child, despite the fact
that this facility is essential to women’s ability to achieve optimal practices. Respondents
in both IDIs and PLA activities frequently underscored the importance of mothers being
the primary decision makers when it comes to IYCF and rMN, as they are the primary
care-takers of the children. In an IDI respondent’s words:
“I think it is very essential for a mother to take her own decisions about her baby.
Mother is most related with baby than father. Mother take most care to her baby. If
mother take all the decision, baby remains sound and healthy. Mother should not listen
to what another people say.”
Although respondents implicated many members of the extended family in obstructing
the mother’s IYCF decision-making autonomy, husbands and mother in laws were
consistently highlighted as particularly hindering of women’s decision-making around
IYCF/rMN. Women quite often need permission from either their husband or their
mother in law to take a sick child to the hospital, to ensure a safe delivery for themselves,
to go to the market to choose nutritious foods for complementary feeding, to rest during
their pregnancy period, and even to attend gatherings outside the home where they can
get advice about IYCF and rMN.
During a 10-seed technique activity, while discussing safe delivery, one group stated the
following:
“In delivery period, mother in law takes most of the decisions. Grandfather and
grandmothers decisions are accepted more.”
A striking quote from one woman during an IDI demonstrates the extent to which she felt
suppressed in her decision-making autonomy, the effects this has on her children’s health,
and the frustration and helplessness she feels as a result:
“We are village women and so our husbands forbid to go hear many things. They tell to
do family work. We cannot take any decision. Our health is not good. Our baby’s
health is also bad. I pass my day with sufferings.”
Women who’s husbands or mother in laws were no longer around, however, often felt
empowered to make their own decisions regarding IYCF and rMN, and attributed this to
the absence of their traditionally more powerful husbands or mother in laws:
“I think I have enough power. Husband remains out of home and so I take all of the
decisions about the baby. So I think I have the most power to take decisions about baby’s
feeding and mothers nutrition.”
Family size was also repeatedly cited as a barrier to a mother’s IYCF/rMN decisionmaking. Large, extended families were brought up as having a negative influence on the
ability of a mother to practice optimal IYCF and rMN decision-making, as were families
with many children to take care of. Participants asserted that mothers that lived in
extended family situations were restricted in their decision-making due to the volume of
opinions offered to them and their obligation to heed their family’s views and wishes. In
an IDI discussion of one woman’s decision-making capabilities around IYCF/rMN, the
respondent stated that:
“It is not possible to feed child if ten person forbade to feed it because we live together. I
should obey to family members word.”
Thus four sub-themes were identified in the domain of decision-making autonomy:
mother-in-law influence, husband influence, family size, and the importance of the
mother being the primary decision maker for IYCF/rMN.
Mobility Autonomy: Qualitative findings suggest that community members view a
mother’s mobility autonomy as an important factor in her empowerment to practice
optimal IYCF and rMN. Mobility is heavily interconnected with each of the other
identified domains of women’s empowerment. If a mother has no mobility autonomy to
reach a health center, she is severely restricted in her ability to reach a doctor or hospital
in the case of her child’s illness or to ensure a safe delivery for her child. Market
accessibility becomes much more difficult if a woman has no mobility autonomy to reach
the market. An IDI participant summarized this point by saying:
“Husband is the most powerful person to feed child. Mother cannot bring all the
necessary things. Husband brings all the things from the market.”
Restrictions on mobility also influence a mother’s social connectedness and her ability to
seek advice and suggestions regarding IYCF from those outside of her family:
“I can not go to others homes, so I can not know it clearly [information about
IYCF/rMN].”
Attitudes towards Domestic Violence: Aggressiveness of family members towards
mothers who wish to practice optimal IYCF and rMN was a recurrent theme throughout
the qualitative data. Community members discussed the fact that women who felt fear of
their husbands or of their mother in laws were less likely to feel empowered to practice
optimal IYCF and rMN. Participants claimed that mothers that accepted aggressive
deprivation of food or support by either their husbands or mother in laws were less likely
to have satisfactory IYCF and rMN behaviors. During a pile sorting activity when
discussing barriers women face to taking enough rest during pregnancy, one group
explained:
“Aggressive grandmothers do not give mother to take rest. If mother takes rest,
grandmother picks quarrels with them.”
This evidence suggests that a woman who is empowered in the area of IYCF and rMN
should not be one who accepts being quarreled with for making positive decisions for her
own health.
Social Relations and Support: Perhaps the most commonly discussed subject among the
respondents was the importance of a social network, and support from others in order for
a mother to be empowered to practice optimal IYCF and rMN. Social relations were
examined by the participants on multiple fronts, and found to encourage and empower
women to improve their IYCF and rMN practices.
Access to television was considered an empowering factor due to the fact that television
was a positive source of information for women and allowed them to increase their
knowledge of optimal IYCF and rMN:
“Now everyone learn from TV. In previous time, mother did not know anything [about
IYCF].”
Similarly, access to a mobile phone was found to strengthen women’s social networks for
information sharing about IYCF and rMN, allowing them to consult with their family
members and doctors for advice and suggestions on the matter:
“Sometimes mother can learn many things from doctor by mobile phone.”
The increased level of communication offered by mobile phones also allowed women to
consult with their husbands or other family members if they needed permission to leave
the house in order to deal with pressing IYCF or rMN issues:
“To help mothers be able to take their sick children to the hospital, they need mobile
phone for communication with their family members.”
Social networks were also shown to lead to information sharing about IYCF and rMN,
which empowered women to achieve optimal practices. Mothers who got suggestions
from peers outside of their family were perceived by the community to have increased
levels of empowerment and were more likely to change their behaviors:
“If mother finds good suggestions she can change her habit.”
“Sometimes shopkeepers forbids mother from giving another food before 6 months.”
Support from family members, in the form of monetary and material support as well as
advisory support was also deemed important for the empowerment of women to practice
optimal IYCF and rMN. As women’s mobility is often restricted, support from other
family members such as the husband, who can bring home nutritious foods and soap for
hygiene, is clearly important to a mother’s ability to practice optimal IYCF and rMN. In
a social mapping activity exploring women’s social relationships in terms of IYCF and
rMN, one group stated that:
“Mother gets help from husband. Husband gives different types of foods like fish, milk,
eggs, etc. to baby’s mother. He provides financial support.”
Similarly, from a pile sorting activity:
“The husband can help with hand washing by bringing soap home from the market.”
Not only do family members help empower the mother through material goods, but
equally as important are suggestions and advice about feeding. Mothers who receive this
type of support from their family feel more emotionally equipped to manage their
children’s nutritional health. With the support and encouragement from their families,
women feel comfortable making positive decisions regarding IYCF and rMN. A few
examples from both PLA activities and IDIs underscore the importance of this type of
support for women’s empowerment:
“Those who cannot make the decision to practice infant feeding and mother’s nutrition
have little relation with family.” -IDI
“New mother does not know about baby’s care, so sister in law teaches baby’s mother
how to feed child.” – Social Mapping
“Grandparents can give suggestion to the mother to rest during pregnancy top help the
mother make the decision to rest.” – Pile Sorting
“I think it is essential to take my own decision. But I cannot do it. I need help from
another. Husband helps mother to take decision. Grandmother and grandfather also
helps mother.” – IDI
Another common perspective that emerged was that mothers who received help with their
housework from their family members could become empowered to practice positive
IYCF and rMN. In exploring possible solutions to lack of mother’s empowerment to
achieve complementary feeding, one Problem Tree group came up with the following
suggestion:
“A solution to problems with complementary feeding is that all the family members
should help the baby’s mother by doing work.”
Advice from health workers was also seen as an important factor in empowering women.
When discussing barriers to empowerment to practice early initiation, one Problem Tree
group suggested:
“One solution to early initiation is for the mother to communicate with health workers.”
Thus from the domain of social relations and support, four sub-categories were apparent:
access to television and mobile phones, social network, support from family members, in
the forms of material, advisory, and labor help, and support from health workers.
Knowledge and Education: Formal education and literacy allow mothers the ability to
gather information from posters and pamphlets, and gives them the obvious advantage of
having learned about health and nutrition in school, thus empowering them to make
positive choices in their practices. The respondents saw education as an empowering
factor for IYCF and rMN, and the lack thereof was a perceived barrier to achieving
optimal practices. In one IDI, the respondent explained the respect that educated women
garner from their community, and how this affects their IYCF and rMN behaviors:
“Those who can make the decision to practice infant and young child feeding and
mother’s nutrition are more literate and they have more honor. They learn most and so
people respect them.”
Not only was education of the mother important, but education of the elder children in the
family was also seen as an advantage for women’s empowerment, as these children could
provide their mothers with support and knowledge:
“Elder boys and girls learn many things about exclusive breastfeeding from school and
tell their mothers.”
Similarly, community members underscored the fact that once a woman feels she has
sufficient knowledge about IYCF and rMN, she feels empowered to practice what she has
learned, as well as teach it to others. The perceived level of knowledge a woman has
about IYCF and rMN practices is linked to her confidence and self-efficacy in achieving
these practices. Thus empowerment in the domain of knowledge comes from a woman
perceiving her knowledge of IYCF and rMN to be sufficient for her to teach others what
she has learned. This concept is expressed by an example from an IDI:
“I am most aware person in the village. I have one sister in law. She knew little about
babies care. So I try to teach her about babies care. Now she also knows about babies
care. Her health is very good and her baby is also healthy. The villagers tell them very
well and respect them. Her children are not remain dirty. Her children remain at good
environment.”
Throughout the interviews and PLA activities, community participants explained the
importance of a woman’s family members also having knowledge of IYCF and rMN
practices in order for a woman to be empowered to achieve optimal practices. In the
rural communities of Bangladesh, it is not sufficient for only the mother to be well versed
in IYCF and rMN if she is to be empowered in this area. Due to the common integrated
and extended family lifestyle in the villages, where multiple elder members of the family
may have the final say in decisions made, it is equally as important for additional family
members to be knowledgeable about IYCF and rMN. In a problem tree activity, one
group explained what would empower a mother to be able to take enough rest during her
pregnancy period:
“Health worker should teach husband, father in law, and mother in law about the
importance of rest during pregnancy.”
Self-Efficacy: A woman’s self-efficacy in terms of IYCF and rMN is a measure of her
confidence in own abilities to achieve optimal practices. During the interviews and PLA
activities, participants expressed aspects of IYCF and rMN empowerment that fall under
the domain of self-efficacy. Women were perceived by the community to be empowered
for IYCF and rMN if they had no feelings of discomfort or embarrassment in making
changes in their behavior that ran contrary to their social and cultural norms. Particular
sub-topics discussed under this category were personal drive and motivation to achieve
optimal practices, laziness, social consequences of optimal practices and common
superstitions, and confidence.
In discussing what makes some women more likely to change their behaviors around IYF
and rMN than other women, a common theme was the personal motivation and drive to
do so:
“Mother should have a wish to do [proper IYCF/rMN practices] because if mother have
no wish it is not easy for mother.”
“Who have wish, she can change. Who have no wish to change, she can not change.”
Related to personal drive and motivation was the subject of laziness. Although this is a
somewhat controversial subject, as laziness in itself must be the result of a multitude of
behavioral determinants (SOURCE), the consistency with which the subject was brought
up with the specific terminology used by the population being “laziness”, this should be
considered an important aspect of the Bangladeshi definitions of self efficacy and
women’s empowerment for IYCF. As one problem tree group stated:
“Idle mothers can not want to feed child complementary feeding. They feel bored to give
child different types of food.”
The social and religious culture of the rural villages of Bangladesh was a common topic
in the discussions of barriers to women’s empowerment to practice optimal IYCF and
rMN, and definitions of what constitutes a woman empowered in this area. For example,
when discussing safe delivery, participants agreed that many mothers do not feel
comfortable going to the hospital to ensure a safe delivery for fear of having to be seen
by a male doctor, something that would be counter to their faith. Groups also mentioned
that some mothers are not empowered to achieve optimal IYCF/rMN practices because
they feel shame when breastfeeding in public, or in front of guests in their home. Thus, if
the mother is outside of her home for an extended period of time, or if there are guests
around, she may not feel comfortable breastfeeding her child, and will supply it with
additional foods even if it has not reached 6 months of age. As one 10-seed technique
group discussed:
“Sometimes mother get shame and so she cannot give breastfeeding. Many mothers
remain out of the home, and so they need to give the baby additional food instead of
exclusive breastfeeding.”
Ability to withstand teasing and ridicule for practicing behavior change was also a
common theme explored by the PLA and IDI participants. Empowered mothers were
those who persisted in their improved activities in the face of ridicule from those around
them for practicing behaviors that were not traditionally accepted, such as hand washing
with soap. When discussing decision making for soap use, one 10-seed technique group
explored the reasons for which some women find it difficult to adopt the practice of using
soap:
“If mother uses soap, her brother in law and sister in law is teasing her.”
In another example from an in depth interview, a mother discussed her fear of social
consequences if she garnered more power in her household:
“I do not want to change my power relations. I want to live according to the rule of
society. If I talk about it, may be problem as I live in an extended family.”
One empowered mother recognized that she overcame this difficulty of societal
judgments in becoming empowered to practice optimal IYCF and rMN:
“I think I am the most powerful person to take decision about feeding child and nutrition.
If I take decision, my baby and I will become healthy. The bad side is that people say to
me, ‘Why do you take the decision alone?’ They tell me bad.”
The last aspect of social norms discussed throughout the interviews was avoidance of
common harmful practices and superstitions by empowered mothers. There are a number
of traditional beliefs and practices that run contrary to the messages of optimal IYCF and
rMN, such as giving newborns honey or sugar water in order to make their voices sweet
when they start talking. This is a challenge to achievement of these practices, and
women who manage to circumvent these traditions in order to perform healthy behaviors
are considered by the community to be empowered.
Women’s confidence in their adequacy to provide for their children was another factor
mentioned consistently by the participants under the domain of self-efficacy. When
speaking about women who had not achieved empowerment, participants explained that
some women are not confident that they will produce enough breast-milk to sustain their
child, or that they can get their child to eat complementary feeding if the child does not
appear interested in the food. This lack of confidence hinders these women in their IYCF
and rMN capabilities, according to the respondents:
“When baby is crying, mother thinks that breastfeeding is not enough for child and so
they give other foods.”
The lack of confidence can also stem from illness in the mother. Throughout the
interviews and PLA activities, an extremely common concern was that mothers’ illness
impacts her confidence and thus empowerment to practice IYCF and rMN. A problem
tree group summed up the matter as follows:
“Illness reduces mother’s confidence that she will produce enough breast milk for the
baby.”
Negotiation/Accommodation Habits: Mothers in the rural villages of Bangladesh have
extremely heavy work-loads, which sometimes interferes with their ability to perform
optimal IYCF and rMN. Discussion between participants revealed that mothers who
showed negotiation skills in asking for help with their housework were perceived as
being more empowered, and those who persist with their work without asking for help
were less empowered. In a problem tree exercise, one group stated:
“Most of the mothers can not take rest during pregnancy because they have to do many
works. Mother in law tells to do work at first and then take rest. Mothers who cannot
avoid this work cannot take rest.”
Psycho-Social Well-Being: The idea of stress and tension came up often as a negative
impact on a woman’s empowerment for IYCF and rMN. Participants agreed that mothers
who often felt annoyed by their children, or mothers who were unhappy due to stress or
tension were seen as less empowered in the area of IYCF and rMN. Tension was a
common term used to describe something that could stop a mother from breastfeeding or
from cooking nutritious complementary foods for her child. An IDI participant talked
about how her sister in law was not empowered due to her ailing psycho-social wellbeing:
“I have an elder sister in law who can not take any decision about children health and
own health. She tension always and so she and her children is not healthy.”
Interpretation of Qualitative Findings:
The findings from this study indicate the important aspects of women’s empowerment as
it relates to IYCF and rMN according to the rural communities of Bangladesh. The
domains identified in the study reflect the common perceptions, definitions, and
terminology used by the population of rural Bangladesh to measure women’s
empowerment specifically for IYCF and rMN.
As the purpose of the study was to develop an indicator system that could be used as an
empowerment measurement tool, Annex C shows the proposed indicators, based on the
results of the research, accompanied by a breakdown of the indicators into their domains
and sub-domains, and qualitative research evidence supporting their inclusion in the tool.
The indicators fit under CARE’s conceptual framework (Annex B), as referenced above,
and remain consistent with the domains identified by the literature (see literature review,
Annex A) as important to women’s empowerment for IYCF and rMN.
Each domain identified has importance on its own; however, the domains are heavily
interconnected and should be seen as an all-encompassing total view of IYCF/rMN
empowerment only when taken together. Empowerment in one single area, or even
multiple areas is not sufficient for a woman to be considered fully empowered if she does
not have empowerment in all areas. For example, even if a woman fits the definition of
empowered based on the indicators for mobility autonomy, and can travel freely to the
market, if she has no financial autonomy, she will not be able to purchase her choice of
nutritious foods at her will. This lack of financial autonomy will negate her freedom of
mobility. Or if a mother has high social relations and support, and her family members
help her often by giving her advice and suggestions, but she has no self-efficacy and thus
no confidence in herself to act on this advice, this again will negate the positivity of her
social relations and support.
Although the indicators are phrased in the “yes/no” format, the strengths of this format as
opposed to employment of a likert scale for those indicators that would lend themselves
to it, is questionable. Use of a likert scale may allow for more in-depth and specific
measurement of a woman’s level of empowerment. However, the yes/no format, it can
be argued, is more easily understood and makes for a faster survey. This may be an
important factor, as the length of the indicator tool is substantial, and the time it takes
those surveyed to answer the questions is an important consideration.
Tool Pre-Test Results:
The survey conducted to pre-test the indicator tool and to guarantee that the language and
structure was easily understood by the target population, revealed that the tool gives
consistent and expected results when used to measure empowerment in women in the
rural villages of Bangladesh. Most questions were well understood by the participants
from the start, and those that were not were adjusted in order to be clearer to the
respondents. For example, one indicator in the original tool asked:
If you had the opportunity to change your power relations in your household to gain
more power, would you take it?
This indicator was unclear to the respondents when phrased in this manner. The
facilitators of the survey thus discussed a better way to word this so that participants
would understand it consistently, and decided on the following:
In the family, there is a decision maker who makes all the decisions for the family. If you
get an opportunity to be this decision maker, would you want to take the opportunity?
Tool Pre-Test Interpretation:
After iterative amendments to the indicator tool, the indicators are easily understood and
accepted by the target population of pregnant and lactating women in the rural villages of
Bangladesh. While the tool was shown to be effective in terms of the language used and
understandability, further evidence is needed to show that it provides a valid measure of
women’s empowerment for IYCF and rMN.
Qualitative Research Limitations:
Although the Demographic Health Survey (DHS) often includes attitudes towards
domestic violence indicators such as justification of wife beating, this was never brought
up in the interviews or PLA activities. It is unlikely that this subject would have been
brought up without being probed for; but the researchers felt that probing for such an
issue would give a biased result. Thus since this idea did not present itself organically, it
was not included in the indicators or interpretations of findings from the qualitative
research. This area warrants further exploration.
Language barriers; it was not always clear that the translations fully captured the nuances
and detail of the discussion between the research subjects. Additionally, the language
barrier meant that the researcher often did not have an opportunity to probe the
participants during the interviews themselves, though much probing was done during the
IDIs based on information gathered during the PLA activities.
Personal biases: having already done the literature review and having an idea of what
typically constitutes women’s empowerment for IYCF and rMN may have skewed the
researchers interpretations of the data to fit with the accepted scholarly views of the
subject. The researcher also interpreted all data alone, without discussion with another
person, which eliminated the possibility of differing opinions to offset the subjective
biases of the researcher. This may have impacted the dependability of the data.
Contradictions in the data: some respondents in the IDIs contradicted themselves in
subsequent dialogue, a red flag for credibility of the data.
Survey Limitations:
Though the purpose of the survey was primarily to assess the acceptability of the
indicator system, some limitations of the survey emerged that should be considered
for its future use as an indicator tool:
In some cases, contradictions within women’s answers to the survey showed that
some women seemed to be answering questions based on desired rather than actual
decision-making responsibility. The reasons for this are unknown; however, there a
few different possibilities that may explain it and allow researchers to minimize it in
the future. One idea is that due to the inevitable lack of privacy when answering the
questions, women were uncomfortable sharing their actual responses. Another
reason may be interviewer bias. The researchers observed that some interviewers
asked the survey questions in a tone of voice that may have made the respondents
feel like there were “right” and “wrong” answers. This should be avoided with
further training of interviewers in the future.
CONCLUSIONS
Definitions of women’s empowerment for IYCF and rMN in rural Bangladesh fall
into nine domains; financial autonomy/control over assets, decision making autonomy,
mobility autonomy, attitudes towards domestic violence, social relations and support,
knowledge/education, self efficacy, negotiation/accommodation habits, and psycho-social
well-being. These domains fall nicely under CARE Bangladesh’s framework for
women’s empowerment, and are in concord with the current literature on the subject.
The indicator tool developed based on the qualitative research is both accepted and easily
understood by the target population based on the pre-tests conducted in the form of a
survey. The tool, however, must be further validated to assure that it will accurately
measure women’s empowerment for IYCF and rMN. One suggestion of a way to do
this is using triangulation between quantitative data collected by the survey and
qualitative follow up of the data to make sure that responses to the tool match up
with observed empowerment of the women to practice IYCF and rMN.