Women's Empowerment, WaSH, and Child Feeding: Implications for Childhood Stunting in South Asia

Despite socio-economic progress, prevalence of childhood stunting remains high in South Asia-a phenomenon often referred to as the "Asian Enigma." This paradox stems from suppressed women's empowerment, poor water, sanitation, and hygiene (WaSH) conditions and inadequate child-feeding. Evidence shows that women's empowerment improves these underlying factors associated with improved stunting. We examined how domains of women's empowerment relate to the risk of childhood stunting in South Asia directly and indirectly in interaction with household improved WaSH facility and age-appropriate food consumption. Using recent Demographic and Health Survey data from Bangladesh, India, Nepal, and Pakistan, we analyzed a sample of 37,620 married women, aged 15-49 years, currently cohabiting with husbands and having an under-five child. We constructed three domains of survey-based women's empowerment index-global: social independence, intrinsic agency, and instrumental agency, by confirmatory factor analysis, using generalized structural equation modelling. We developed three different models by using generalized linear mixed-effects models with robust error variance to estimate the relative risk (RR) of stunting with 95% confidence interval (CI). We found social independence [RR: 0.86, 95% CI: 0.83, 0.90], intrinsic agency [0.98 (0.97, 0.99)] and instrumental agency [0.99 (0.98, 0.99)] were associated with reduced risk of stunting in South Asia. Though interaction between social independence and WaSH was associated with reduced risk [0.92 (0.86, 0.99)], interaction between social independence [1.12 (1.07, 1.17)] and instrumental agency [1.03 (1.01, 1.05)] and food consumption increased risk of stunting in South Asia. Interactions between women's empowerment and WaSH and food consumption reveal complex effects including both synergy and trade-offs, highlighting the need for integrated strategies combining women's empowerment, WaSH improvements, and targeted nutrition specific interventions in South Asia.