Gender Inequality: The Husband-Wife Relationship and its Impact on Under-Five Children with Stunted Growth in Labotan Kandi Village, Banggai Islands Regency, Central Sulawesi, Indonesia

Literature Review

In many developing countries, women bear the burden of being caregivers, which requires them to have the autonomy to decide which health services to choose for themselves and their children (Ahmed et al., 2022). However, despite their roles as caregivers, rural women in Indonesia do not have the autonomy to determine health services for themselves or their children. The role of men as decision-makers in the family remains dominant because of their more powerful positions. Consequently, gaps arise in family decision-making processes. In cases where women are allowed to negotiate with their husbands when deciding something, the final decision remains in the husband’s hands (Dwyer et al., 2022).

Even if a household has adequate resources, the wife’s limited participation in household decision-making can lead to a low uptake of maternal health services. A study by Alemayehu and Meskele in Ethiopia revealed that a woman’s healthcare decision-making autonomy is broadly influenced by her age, household literacy, household economy, family size, and her involvement in income-generating activities (Alemayehu & Meskele, 2017).

Studies conducted in other developing countries in Africa have shown that gender disparities in health are heavily influenced by individual and societal attitudes that undervalue women's health and prioritize men's health (Azad, Charles, Ding, Trickey, & Wren, 2020). In subordinate positions, women have limited decision-making power related to access to resources and less economic and social utility than men. Additionally, parents, children, and the environment are stunting risk factors for children under five (Huriah & Nurjannah, 2020). Adequate nutritional intake, especially for children, often cannot be achieved because of several factors, including the mother's level of education, knowledge of nutrition and health, socioeconomic conditions, and the availability of food (Nurmaliza & Herlina, 2019).

The government of the Banggai Islands Regency has also attempted to implement a series of stunting prevention and handling intervention programs at the district and sub-district or Puskesmas (primary health services centers at the sub-district level) levels (Team to Accelerate Stunting Decrease in Banggai Kepulauan Regency, 2021). In addition, the Central Sulawesi Provincial Government has organized food security development programs (Food Security Agency, 2019). These intervention programs above will not favorably impact stunting in children under five unless the existing culturally rooted problems are remedied first. Family and community approaches are valuable in understanding stunting problems in this region.

Consequently, the convergence of these problem-solving programs remains a priority in this region. According to data from the Banggai Islands Regency Government's official portal (https://banggaikep.go.id/), this district has managed to reduce the prevalence of stunting from 23% in 2020 to 21.80% in 2021. However, this figure is still far from reaching the target of 14% by the end of 2024. Stunting is often considered as a medical problem. Women's low levels of education, early marriage, and inadequate parenting, especially in child feeding practices, are the main problems in the Banggai Islands Regency.

These factors indicate that families play a crucial role in fulfilling children's nutritional needs. Families should be able to provide attention and support to children and adopt appropriate behaviors, especially in providing nutritious food, teaching proper eating behaviors, and taking advantage of the health services provided to support the improvement of children's nutritional status (Noorhasanah & Tauhidah, 2021).

Husbands and wives in families with stunted toddlers play a determining role in the success of maintaining nutritional status and decision-making regarding health issues faced by the family. However, gender inequality in husband-wife relations may have an unfavorable impact on family members. Previous research (Dwyer et al., 2022) relates gender inequality the decision-making processes in family planning, child health, and nutrition issues. The contribution of the social sciences (anthropology) to addressing the issue of stunting will be meaningful because the husband’s and wife's roles are comprehensively examined in studying the cultural problems that hinder the handling of stunting. Björnberg and Kollind (2018) mentioned that some political actions are significantly related to the strength of individual rights in the family and society. A work structure that creates and maintains inequality that places women at a disadvantage compared to men is seen in the division of labor in the family.

Poor people in developing countries may have cultural views that lead to gender inequalities. Relations characterized by gender inequality can be explained by the development process in which society-specific factors are at play many underdeveloped countries today hold cultural norms that exacerbate favoritism toward males. Societal norms such as patrilocality and concern for women's purity help explain the male-skewed sex ratio in Indonesia and China specifically and the generally low female development in India, Asia, the Middle East, and North Africa (Jayachandran, 2015).

Gender inequality was observed in the Labotan Kandi community in early January 2022 while studying anti-stunting efforts in the Banggai Islands. Men play prominent roles in family decision-making regarding health and economic issues. Men are also a determinant of the number of children a mother will have. Fathers are also the most powerful in the division of labor in households. Given the scarcity of husband-wife gender relations studies related to stunting issues, this study opens the door to other studies that have a similar agrarian background.

Under-five children with stunted growth condition

Of the 34 children under five in the village of Labotan Kandi, 18 were identified as having stunted growth, with 13 children judged to be severely stunted and five children as mildly stunted. The stunting identification provided by health workers toddlers was generally accompanied by a sense of shock from their mothers. They only knew the word “stunting” with the term pependek (in local language: short-bodied) to describe children with significantly shorter heights than their peers. Mothers do not understand and could not accept why their children under five years old are considered to have stunted growth. Parents believe that when toddlers are short, their bodies develop on their own, similar to other children of their age. In other words, they assume that shortness is only temporary, and children will naturally be as tall as children of other ages.

The explanation from health workers about the causes of stunting resulted in the mothers eventually accepting the stunting condition of their under-five children, as stated by Participant A: “I learned that my boy suffers from stunting from Puskesmas. I used to think that my son is just the same as other children his age, only a bit smaller. I thought he might be pependek.”

Children with pependek conditions do not cause shame to their parents because they believe they have provided feeding and drinking to their younger children as they did to their older children. Some mothers noted that if their children had snacks such as bread or crackers, they would skip meals. Parents tend to do nothing when their children want to skip their meals because they cannot afford to offer their children food alternatives other than what they have in stock, such as rice or cassava. This condition is different from that of urban mothers, in that when their children have difficulty eating, they will try to offer food alternatives that vary in tastes, appearance, and processing methods to make their child more willing to eat.

Maternal education and age at marriage

The gender inequality visible in the Labotan Kandi village community included the loss of schooling opportunities for girls. Mothers of under-five children with stunted growth believe that the prohibition on attending school they experienced as children is a form of filial piety for their parents. They do not dare to break their parents' rules. Parents argue that schools are expensive, far to reach, and prevent children from helping their parents work in gardens/forests. Informant S said, “No schooling because my parents did not allow me to do so. I cannot write properly, only scribble.”

Although schools are currently available in the village (nearby), this old-fashioned view has not disappeared. If parents forbid their daughters from attending school, they will obey. The rule that only applies to girls adversely affects them as adults, which is evident in the finding that nine of the 18 mothers did not attend school (illiterate), seven graduated from elementary school, one graduated from senior high school, and one graduated from college.

Limited education has unfavorable impacts on many aspects of life, including the preservation of old-fashioned parenting practices. For example, babies are fed bananas or cassava porridge by their parents when they are 1-4 weeks old. The rationale for practicing early breast milk replacement is that the baby cries, which is interpreted as a sign of hunger. Feeding them with bananas or porridge calms them down and stops crying. Currently, recommendations made by midwives to provide exclusive breastfeeding do not work well because mothers are more compliant with their grandmothers than with the midwives’s advice.

Girls' obedience to their parents in Labotan Kandi is also manifested in early marriage. A girl may get married at the age of 16 or17 simply because a young man has proposed to her, as experienced by Informant L's daughter who was forced by the man who proposed to her: “Yes, she [the first daughter] has also been married. I don’t know whether they dated or not. This boy just came and proposed to her. My daughter was forced to accept the proposal otherwise it would cause shame to him.”

In the past, the age at marriage was 16 and 19 years for women and men, respectively. Local customs dictate that families are forbidden to refuse a marriage proposal. The low level of education of women and the high prevalence of early marriage affects the health status of the mothers of under-five children with stunted growth. Low literacy levels result in inadequate health knowledge, which leaves women unaware of anemia or reproductive health problems.

The weights-at-birth of all the under-five children with stunted growth in this area were generally within the normal range of between 2,700 and 3,500 grams, except for one “premi” who weighed 1,800 grams at birth (seven months 15 days of pregnancy). The underweight baby was treated with a traditional method of raising the body temperature by putting some bottles containing hot water near the baby, as practiced by mother informant I, under the assistance of stunting cadre R, who said:

Yes, the baby was born at 1.8 kilograms. I came to check because, according to the parents, this child is not alive. But all the veins look blue, the breath is still visible too. I told the mother not to give a bath to her baby and not to expose the baby to cold temperatures. Then I told her to put glass bottles filled with hot water on the left and right of the baby every night. That’s what I know. Yes, the child is small. The weight at birth was very low.

As child labor assisted by traditional birth attendants and family members has become a tradition, few mothers worry about their babies being stunted. They tended to react by denying it and believing that their children would grow and develop as normal children. However, after receiving an explanation that their child-ren's growths can be considered stunted, as seen from their physique and measurements made by health workers, the mothers who were initially passive began to be more motivated to find out what behaviors could overcome the stunting their children suffered. However, due to a lack of information sources (e.g., socialization from local cadres and health workers), they are not well informed about how to address stunting in children under the age of five.

Their limited nutritional knowledge, inadequate economic circumstances, and limited access to transportation make it difficult for them to access markets and health services. Many mothers are ignorant of their under-five children's health conditions and give up because they do not know what foods are appropriate for their children. As a result, they choose to take a passive position regarding the conditions from which their children suffer. Under-five children's stunting condition is expected to improve with Posyandu activities held once a month, which, among other activities, provide supplementary feeding for under-five children.

Supplementary feeding provided by Posyandu enables children to consume nutritious foods, including rice, vegetables, side dishes, and milk. Unfortunately, many children under five do not want to eat the foods offered by Posyandu cadres because they are not used to eating those kinds of food (e.g., mung beans, eggs, and assorted vegetables) that taste strange to them. The daily amount of food consumed did not vary. They only consume cassava, sweet potatoes, and rice, unaccompanied by vegetables and side dishes. Vegetables and side dishes are available only when there is additional extra money to buy fish and when they can obtain vegetables from the garden. All of these activities are the wife's responsibility as a mother, and very rarely receive help from her husband.

Family planning

Most families in this village have more than two children because of their husbands' desire for more children. The wives followed their husbands' wishes out of respect for their husbands as the head of the family. Despite the husbands' desire to have more children, wives in Labotan Kandi used contraceptives to separate their children's births, as stated by informant N: “I got the contraceptive shot once every three months for which I have to pay IDR 25,000 each.”

The informant's decision to choose the injection was also influenced by their husbands. Her husband wanted a cheap contraception method that did not interfere with the sexual relationship. Contraceptive injection was the preferred choice because this method suited her husband. However, problems can arise when the family does not have the money to pay for injectable contraceptives. Although it is relatively cost-efficient, couples sometimes cannot afford it. Consequently, patients often skip routine injections.

An option other than injection is a long-term (eight-year) contraception method known as an intrauterine device (IUD), which is the contraceptive of choice because it has a one-time payment method but works for eight years. For some women, IUD are a rational choice compared to injections because users do not need to remember that they have to receive interjections every three months. Users only need to remember the year of installation and change their IUD every eight years. Users believe that the long-term use of this particular contraceptive is very beneficial because if they want to get pregnant again, they can visit a midwife to help remove the contraceptive. For some users, IUD is chosen based on consultation with their midwife only but with their husbands' permission as well, as stated by informant A: “I use the IUD because my husband chose it.”

The educational level of both wives and husbands in Labotan Kandi is low, combined with the strongly held patrilineal tradition in society, gives rise to an unequal pattern of husband-wife relations. It seems that control over family life in every household remains with the husband, as indicated by the family decisions predominantly made by him. In the case of family planning, wives ask their husbands for their opinions on the contraceptive they choose. When the husband objects to an option, the wife obeys. The wife will obey even if the husband does not allow her to use contraceptive methods because he wants her to become pregnant again.

Children’s health

Children are valuable assets for the locals of Labotan Kandi. They regard child workers as help both in the forest/garden and in the household. The arrival of a long-awaited child is sometimes not accompanied by adequate preparations during pregnancy regarding the health of the mother and baby. This can be observed in the poor diet of pregnant women: as long as they are still able to eat kela, sweet potatoes, and rice, that is considered sufficient. Moreover, the health of pregnant women has received limited attention. They still go to the forest even though their pregnancies are almost over. Many are ignorant of the need for antenatal care (ANC), as informant I said, “I don’t routinely go to Posyandu for pregnancy examinations because I think my pregnancy is normal”

The preferred choice for childbirth is delivery by a traditional birth attendant. Ten of the 18 mothers of children under five years of age with stunted growth gave birth with the help of a traditional birth attendant, whereas the remaining eight chose to go to a midwife. Childbirth and labor with traditional birth attendants are preferable because they have a special place in the local people's hearts. Local people even believe that traditional birth attendants are more proficient than midwives because of incidents of labor difficulties faced by midwives handed over to traditional birth attendants. This perceived ability strengthens confidence in traditional birth attendants.

The choice to give birth with the help of a traditional birth attendant and other family members who can help with child labor is inseparable from the husband's role. Husbands decide on and prefer traditional birth attendants over midwifes as the birth attendant. Even in cases where the wives accessed ANC examinations with a midwife, expecting to give birth with the midwife's help, the final decisions regarding birth attendants were up to the husband. Husbands will look for the closest, fastest, easiest, and cheapest helper, namely a traditional birth attendant, as informant I stated: “Yes, when I gave birth to this boy, I was helped by the traditional birth attendant Piliani.”

From the descriptions regarding maternal and child health, husbands play a more dominant role than wives in health-related decisions. This shows that the health of the mother and child were mainly in the hands of the husband. If the husband disagrees with the health services chosen by his wife, the wife will follow her husband's decision.

Feeding practices and nutrition

The mothers' role as caregivers is central to the growth and development of under-five children. In Labotan Kandi Village, being a caregiver is not only considered a woman's role in the family but is also regarded as an instinct. It was a maternal instinct to breastfeed the baby. Breastfeeding usually lasts for 2.5 years or more. There were still children aged three or four years who suckled their mothers in this village. Mothers will only stop breastfeeding when their children no longer want to continue or when the breast milk is no longerproduced as stated by informant R: “Many mothers practice it. Mothers are used to breastfeeding their last child until four years of age.”

Although a minimum of two-year breastfeeding has become a tradition and is practiced by all mothers, this is not true of exclusive breastfeeding. Health workers in the village, such as Midwife R and stunting cadres, continuously socialize about the importance of exclusive breastfeeding. Unfortunately, the transgenerational tradition of feeding breast milk replacement foods to newborn babies is strongly adhered to. Babies aged two or three days are sometimes fed bananas mashed with a spoon. In addition to bananas, they were also fed instant soft porridge (brand S), which they usually buy in the 120 g. packages. Newborns are fed breast milk replacement food to prevent them from crying excessively. Parents believe that a baby's crying is a sign of hunger. Babies stop crying and sleep soundly after being fed bananas or porridge. With the baby sleeping soundly, the mother can perform the other household chores that are part of her responsibility.

Although the start of breastfeeding varies with age, the habit continues to be passed down from generation to generation. Breast milk replacement feeding starts at ages as young as 2-3 days or sometimes 2-4 weeks old. However, in most babies, it starts at 3, 6, or 12 months of age. Grandmothers play a determining role in encouraging and controlling mothers to provide breast milk replacement food to their infants as early as possible. Grandmothers are experienced persons whose advice and suggestions the younger generations feel obliged to follow. Parents regard grandmothers as the main determinants of breastfeeding and breastmilk replacement practices.

As children grow older, mothers determine their feeding patterns. Children aged one year or older are introduced to local foods. They were fed kela or Banggai tubers for breakfast, lunch, and dinner. Children are accustomed to eating them without vegetables or side dishes during the three meals. Economic constraints mean the mothers are not always able to provide side dishes. Fish cooked with salt and monosodium glutamate are served only when they can afford to buy it, which is usually only when they sell forest products or livestock, such as pigs, cows, dogs, and chickens. The habit of incubating chicken eggs instead of feeding them to under-five children is a sign that the need to feed children nutritious food is not a priority. Therefore, it is important to provide sufficient food to the entire family.

As toddlers are not introduced to a variety of vegetables and side dishes from the beginning, their appetite for food is formed at an early age through their environment. The provision of supplementary feeding to all under-five children once a month at the Posyandu seems to bring about a positive change in their eating behaviors. The eggs, vegetables, tofu, tempe, mung bean porridge, milk, and fruits served by Posyandu cadres were not enthusiastically consumed by under-five children. Many people did not want to try them. Efforts to provide healthy food choices to meet the nutritional needs of children under five years of age do not seem to work well. Toddlers still prefer kela, Banggai tubers, and rice, without side dishes or vegetables. Consequently, nutritious foods prepared once a month are consumed by other family members. One day, the Posyandu cadres tried to serve mung bean porridge to the under-five children, but it turned out that many children did not like it, as told by informant R, “I don't understand, I'm also confused. I served mung bean porridge as supplementary feeding [PMT], but many children didn't like it and didn't want to eat it.”

Gender inequality

Gender inequality does not occur solely as a result of the patrilineal kinship system adopted by the local people. Several other factors contribute to this condition. The low education level of mother causes means they have limited knowledge, especially concerning child rearing, early breastfeeding, nutrition and food preparation, and are liable to do nothing when their under-five children refuse to eat.

The role played by the Labotan Kandi women in the family is overwhelming. Their duties are not only domestic, such as cooking and washing, but also public. Women work long hours in the forests. On average, women go to the garden/forest every day, although some go every two days. Consequently, parents who are too busy working outside the home (in the garden) means children receive less attention from their parents, do not receive supervision in the consumption of healthy and routine food, and rely on the care of a grandmother. Children eat anything without parental supervision.

When they come home from the garden/forest, they carry many things alone, including firewood, tubers, and vegetables, whereas men carry only machetes without any additional burden. Men do not help carry other things because that is considered part of women's work. They also have to walk as far as four to seven kilometers, which takes one to three hours. Informant P, one of the mother informants' husbands said, “We have farmland in the forest, but we don't have motorbikes. We [a family] have to walk nine kilometers, taking about three hours.” This division of labor on farms also affects the value of children. Both are regarded as important, however, boys are favored over girls. It is evident that girls skip school more often and prefer to go to the fields. Boys' grades take precedence over girls' grades.

The time allocation and type of work that the wife bears indicate unequal burdens on the husband and wife. The wife has to bear a heavy load due to an imbalance in the division of labor and autonomy in the family, in that she has a higher workload but less autonomy, so that gender equality does not occur (Björnberg & Kollind, 2018). Women not only play a role in planting and caring for crops but also play a vital role in harvesting them. Women whose families have sizeable farmlands may need to spend the night in the forest, especially during harvest time. When gender equality does not exist in the family, women have limited or no rights to control their bodies and make decisions about themselves (Mbombo, 2013). Taking too long to decide will result in delayed treatment of the child's health and may lead to other health problems.

Even if the wives in Labotan Kandi had to go to the garden/forest only once every two days instead of every day, they would likely miss the opportunity to take their children under five to Posyandu. Wives prioritize working in the garden/forest because they try to complete the tasks that are their biggest responsibility in the hope of bringing home an abundance of garden/forest products to support their families' food security, especially that of their children. The high stunting rate proves that the decision-making problem including food for toddlers remains in the hands of husbands. The food given to toddlers and what the mother cooks are based on what their husbands grow in the fields. If money is available, they can buy nutritious food according to their child’s needs.

Similar conditions apply in other villages on the Banggai Islands. The time-consuming tasks of women in the domestic sphere result in their lack of autonomy. Research by Fadjriah, Rusdianto, Herman, and Vidyanto (2021) at the Tikson Health Center, Banggai Laut, showed that exclusive breastfeeding, complementary breastfeeding, infectious diseases, primary health practices, environmental sanitation, and knowledge of maternal nutrition were associated with the incidence of stunting in toddlers. Mothers' knowledge regarding nutrition is also influenced by the family environment and culture because the history and social context of long-standing inequality directly affect pregnant women, infant care, and malnutrition (Lock & Nguyen, 2018).

This gender inequality negatively affects women, especially with regard to maternal and child health. They are unaware that their rights such as the human rights to education and health have been violated (Mbombo, 2013). This inequality results in unequal positions and roles in the family, leading to delayed decision-making on crucial issues such as health. Wives should be mandated as decision-makers in maternal and child health issues because they are directly concerned with women themselves and with their children. As women play a critical role in feeding, processing, and serving the food, decisions regarding the family diet is in the hands of women. Women also take care of babies when they are sick and serve as caregivers and first and foremost as nurses in the family. Even though the patrilineal culture continues to support this gender inequality, what goes into a child's mouth and stomach is determined by the mother, not the father or grandfather (Yuniati & Triratnawati, 2022). Women's autonomy appeared only in terms of providing food to their families.