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

Background: 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. Methods: 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. Results: 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. Conclusion: 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. Registration: PROSPERO: CRD42021286151.