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Women's Autonomy and Utilisation of Maternal Healthcare Services in 31 Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-023128 on 13 March 2019. Downloaded from Women’s autonomy and utilisation of maternal healthcare services in 31 Sub- Saharan African countries: results from the demographic and health surveys, 2010–2016 Chol Chol,1 Joel Negin,1 Kingsley Emwinyore Agho,2 Robert Graham Cumming1 To cite: Chol C, Negin J, ABSTRACT Strengths and limitations of this study Agho KE, et al. Women’s Objectives To examine the association between autonomy and utilisation of women’s autonomy and the utilisation of maternal maternal healthcare services ► We used nationally representative Demographic and healthcare services across 31 Sub-Saharan African in 31 Sub-Saharan African Health Survey (DHS) datasets from 31 Sub- Saharan countries. countries: results from the African countries. Design, setting and participants We analysed the demographic and health ► We used four separate measures of women’s surveys, 2010–2016. BMJ Open Demographic and Health Survey (DHS) (2010–2016) autonomy. 2019;9:e023128. doi:10.1136/ data collected from married women aged 15–49 ► DHS data are cross-sectional, and so the direct bmjopen-2018-023128 years. We used four DHS measures related to women’s relationship between women’s autonomy and the autonomy: attitude towards domestic violence, attitude ► Prepublication history for utilisation of maternal healthcare services cannot be this paper is available online. towards sexual violence, decision making on spending of determined with certainty. To view these files, please visit household income made by the women solely or jointly the journal online (http:// dx. doi. with husbands and decision making on major household org/ 10. 1136/ bmjopen- 2018- purchases made by the women solely or jointly with INTRODUCTIOn 023128). husbands. We used multiple logistic regression analyses to Maternal mortality, measured as maternal examine the association between women’s autonomy and Received 22 March 2018 mortality ratio (MMR), remains a major the utilisation of maternal healthcare services adjusted for http://bmjopen.bmj.com/ Revised 22 October 2018 concern despite the decline globally from 385 Accepted 16 January 2019 five potential confounders: place of residence, age at birth of the last child, household wealth, educational attainment to 216 maternal deaths per 100 000 live births 1 and working status. Adjusted ORs (aORs) and 95% CI were between 1990 and 2015. Sixty-six per cent used to produce the forest plots. of all maternal deaths occur in sub-Saharan Outcome measures The primary outcome measures Africa (SSA).1 This is of concern if SSA is to were the utilisation of ≥4 antenatal care visits and delivery achieve the Sustainable Development Goal by skilled birth attendants (SBA). 3 target of fewer than 70 maternal deaths Results Pooled results for all 31 countries (194 883 per 100 000 live births by 2030.1 The leading women) combined showed weak statistically significant causes of maternal deaths in SSA are abor- on September 25, 2021 by guest. Protected copyright. associations between all four measures of women’s tion, haemorrhage, hypertension, obstructed autonomy and utilisation of maternal healthcare © Author(s) (or their labour and sepsis.2 Increasing the utilisation services (aORs ranged from 1.07 to 1.15). The strongest employer(s)) 2019. Re-use of antenatal care (ANC) and skilled birth associations were in the Southern African region. For permitted under CC BY-NC. No attendants (SBA) could help reduce the high commercial re-use. See rights example, the aOR for women who made decisions on 3–7 and permissions. Published by household income solely or jointly with husbands in number of maternal deaths in SSA. BMJ. relation to the use of SBAs in the Southern African region A better understanding of the relationship 1Sydney School of Public Health, was 1.44 (95% CI 1.21 to 1.70). Paradoxically, there were between women’s autonomy and the utilisation Faculty of Medicine and Health, three countries where women with higher autonomy of maternal healthcare services may contribute The University of Sydney, on some measures were less likely to use maternal to reducing maternal deaths in SSA. However, Sydney, New South Wales, healthcare services. For example, the aOR in Senegal Australia examining women’s autonomy is not without 2 for women who made decisions on major household School of Science and Health, challenges, especially disagreements related to 8–11 Western Sydney University, purchases solely or jointly with husbands in relation to the its measurement and definition. Similar to Penrith, New South Wales, use of SBAs (aOR=0.74 95% CI 0.59 to 0.94). several other studies conducted in developing Australia Conclusion Our results revealed a weak relationship countries, in this study, we assessed women’s between women’s autonomy and the utilisation of autonomy using four measures included in Correspondence to maternal healthcare services. More research is needed to Demographic and Health Survey (DHS) ques- Chol Chol; understand why these associations are not stronger. ccho0230@ uni. sydney. edu. au tionnaires.8–11 Some scholars have used the Chol C, et al. BMJ Open 2019;9:e023128. doi:10.1136/bmjopen-2018-023128 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-023128 on 13 March 2019. Downloaded from terms ‘autonomy’ and ‘empowerment’ interchangeably child by SBA. The utilisation of SBA included births while others have argued that the two words differ.12–16 In attended by doctors, midwives and village midwives; this study, we use the term 'autonomy' to indicate women’s non-utilisation included births attended by traditional ability to make an independent decision, to manipulate the birth attendants, family members and other relatives.31 environment and control resources, as well as to engage The utilisation of ANC services was based on mothers and hold accountable institutions.17–20 who had at least four ANC visits as recommended by the Most of the studies that have examined the relationship WHO.5 There was no data on the time of each ANC visit. between women’s autonomy and women’s health were Primary outcome measures took a binary form: women conducted in South and South-East Asia.14 15 18 21–23 These with the recommended four or more ANC services were studies have found that women’s autonomy is essential assigned ‘1’, and women who reported less than the four for the utilisation of maternal healthcare services and recommended ANC services were assigned ‘0’. Delivery women’s well-being. However, a recent review by Osamor with any SBA was categorised as‘1’, and delivery without and Grady found few relevant studies from SSA, making SBA was categorised as ‘0’. it difficult to know if these results apply there.10 24–28 The aim of our study was to examine the association between Explanatory variables four measures of women’s autonomy and utilisation of We used four DHS indicators related to women’s autonomy maternal healthcare services across 31 SSA countries in two areas: women’s attitudes to sexual and domestic using DHS data collected during 2010–2016. violence32–38 and participation in decision-making (solely or jointly with the husband) on spending of household income and major household purchases.9 10 39–41 METHODS Attitude to sexual violence was measured based on Data source responses to a question that asked if beating a wife by Data from DHS surveys were used. This study is restricted a husband for refusing sexual intercourse with him is to married women aged 15–49 years at the time the DHS acceptable. We coded a woman with a score of 1 if she surveys were conducted. DHS surveys are standardised responded ‘no’ (positive association with autonomy) cross-sectional data sets that are publicly available. Data and 0 if she responded ‘yes’ (agreement). Attitude to are collected by the National Statistics Agencies in collab- domestic violence was based on responses of women to oration with the United States Agency for International four DHS questions asking whether a husband was justi- 29 Development. fied in beating his wife if she goes out without telling him; neglects the children; argues with him; or burns the food. Sampling methods We coded a woman with a score of 1 if she responded with DHS surveys use probability sampling methods to produce 'no' to all four DHS questions (positive association with representative national samples of women aged 15–49 http://bmjopen.bmj.com/ empowered) and 0 if she responded ‘yes’ (agreement) to years. The sample results are weighted to ensure the any question. results are relevant to each country.30 DHS surveys collect Autonomy about household income was based on a information on a wide range of topics using mainly iden- question on spending of household income. Autonomy tical questionnaires in all countries. concerning decision-making on major household Study selection and inclusion criteria purchases was based on a question regarding who decides From the 49 SSA countries, we selected the 31 countries on major household purchases. We coded the answers to these two questions as 1 (positive association with that had had DHS data collected during 2010–2016. We on September 25, 2021 by guest. Protected copyright. divided the 31 countries into four regions, as used by the autonomy) if a woman chooses solely or jointly with the Global Burden of Disease Study2: Central Africa (Congo, husband and 0 if the husband alone or someone else Democratic Republic of Congo and Gabon); Eastern makes the decision. Africa (Burundi, Comoros, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda and Zambia); Potential confounding factors Southern Africa (Lesotho, Namibia, and Zimbabwe); and We adjusted for five potential confounding factors based Western Africa (Benin, Burkina Faso, Cameroon, Chad, on previous literature in low-income and middle-in- 42–45 Cote d'Ivoire, Gambia, Ghana, Guinea, Liberia, Mali, come countries: place of residence (urban/rural), 46 Niger, Nigeria, Senegal, Sierra Leone and Togo).
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