# The role of gender in early childcare practices in low- and middle-income countries: a systematic review and meta-analysis

## TL;DR

This study finds that girls in low- and middle-income countries face gender discrimination in early childcare practices like breastfeeding and immunization, though recent trends suggest some progress toward equality.

## Contribution

The study provides the first comprehensive meta-analysis of gender disparities in early childcare practices across low- and middle-income countries.

## Key findings

- Girls experience significant discrimination in breastfeeding and immunization practices in low- and middle-income countries.
- Gender disparities are linked to a country’s ranking on the Gender Inequality Index, with higher inequality correlating with worse outcomes for girls.
- Recent data suggests a narrowing gender gap in early childcare practices, indicating potential progress toward equity.

## Abstract

Gender disparities in early childcare practices impede gender equality and create long-lasting barriers to girls’ health, well-being, and future opportunities. Through this systematic review and meta-analysis, we aimed to quantitatively synthesise evidence on gender disparities in low- and middle-income countries (LMICs) across the World Health Organization’s five components of nurturing care: breastfeeding, immunisation, prenatal check-ups, postnatal check-ups, and healthcare expenditure for children under five.

We searched sixteen scientific databases, journals, and repositories in November 2021 and again in January-February 2024, for studies examining gender differences in early childcare practices in LMICs, covering breastfeeding, immunisation, prenatal, and postnatal check-ups, and healthcare expenditure for children under five. We set no restrictions on publication type or date, but with limitations to English-language studies with sample sizes over 30. We standardised effect estimates from individual studies into Hedges’ g effect sizes and meta-analysed them using robust variance estimation. We assessed the quality of the included studies using the Joanna Briggs Institute quality appraisal tool.

We identified 78 eligible studies covering 55 LMICs, with 52 studies and 231 effect sizes included in the meta-analysis. The pooled analysis showed gender discrimination against girls across outcomes (52 studies; Hedges’ g = −0.082; 95% confidence interval (CI) = −0.133, 0.030), particularly pronounced in breastfeeding (17 studies; Hedges’ g = −0.051; 95% CI = −0.089, −0.012) and immunisation (32 studies; Hedges’ g = −0.073; 95% CI = −0.13, −0.016). While we also observed significant differences in favour of boys in pre- and post-natal check-ups (four studies; Hedges’ g = −0.029; 95% CI = −0.058, −0.000), the results were less robust due to a limited number of studies. We found no gender differences in healthcare spending patterns (seven studies; Hedges’ g = −0.278; 95% CI = −0.641, 0.083). Our meta-regression highlighted significant associations between a country’s ranking on the Gender Inequality Index and effect sizes, indicating stronger health-related penalties for girls. Effect sizes did not significantly vary by regions and the quality of included studies.

s Our findings emphasise significant gender disparities in early childcare practices and point to the need for more evidence on inequalities in healthcare access and expenditures. We simultaneously observed signs of a narrowing gender gap in recent years, suggesting gradual progress toward more equitable child health outcomes.

PROSPERO: CRD42021286151.