Maternal empowerment, feeding knowledge, and infant nutrition: Evidence from rural China

Background: Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers. Methods: We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes. Results: Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P < 0.01) and 11-13 percentage points (P < 0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P < 0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P < 0.01), less likely to formula feed (9-10 percentage points, P < 0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P < 0.01) and weight-for-age (0.24-0.25, P < 0.05). Effects remained after controlling for maternal feeding knowledge. Conclusions: While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers). Registration: Parent trial registration: ISRCTN16800789.