Associations between quantitative measures of women's empowerment and access to care and health status for mothers and their children: A systematic review of evidence from the developing world

Women's experiences of mistreatment during childbirth: A comparative view of home- and facility-based births in Pakistan

INTRODUCTION

Respectful and dignified healthcare is a fundamental right for every woman. However, many women seeking childbirth services, especially those in low-income countries such as Pakistan, are mistreated by their birth attendants. The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. The study also examined the association between demographics (socio-demographic, reproductive history and empowerment status) and mistreatment, both in general and according to birth setting (whether home- or facility-based).

MATERIAL AND METHODS

In phase one, we identified 24 mistreatment indicators through an extensive literature review. We then pre-tested these indicators and classified them into seven behavioural types. During phase two, the survey was conducted (April-May 2013) in 14 districts across Pakistan. A total of 1,334 women who had given birth at home or in a healthcare facility over the past 12 months were interviewed. Linear regression analysis was employed for the full data set, and for facility- and home-based births separately, using Stata version 14.1.

RESULTS

There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%). In overall analysis, experience of mistreatment was lower among women who were unemployed (β = -1.17, 95% CI -1.81, -0.53); and higher among less empowered women (β = 0.11, 95% CI 0.06, 0.16); and those assisted by a traditional birth attendant as opposed to a general physician (β = 0.94, 95% CI 0.13, 1.75). Sub-group analyses for home-based births identified the same significant associations with mistreatment, with ethnicity included. In facility-based births, there was a significant relationship between women's employment and empowerment status and mistreatment. Women with prior education on birth preparedness were less likely to experience mistreatment compared to those who had received no previous birth preparedness education.

CONCLUSION

In order to promote care that is woman-centred and provided in a respectful and culturally appropriate manner, service providers should be cognisant of the current situation and ensure provision of quality antenatal care. At the community level, women should seek antenatal care for improved birth preparedness, while at the interpersonal level strategies should be devised to leverage women's ability to participate in key household decisions.

Proactive community case management and child survival in periurban Mali

The majority of the world's population lives in urban areas, and regions with the highest under-five mortality rates are urbanising rapidly. This 7-year interrupted time series study measured early access to care and under-five mortality over the course of a proactive community case management (ProCCM) intervention in periurban Mali. Using a cluster-based, population-weighted sampling methodology, we conducted independent cross-sectional household surveys at baseline and at 12, 24, 36, 48, 60, 72 and 84 months later in the intervention area. The ProCCM intervention had five key components: (1) active case detection by community health workers (CHWs), (2) CHW doorstep care, (3) monthly dedicated supervision for CHWs, (4) removal of user fees and (5) primary care infrastructure improvements and staff capacity building. Under-five mortality rate was calculated using a Cox proportional hazard survival regression. We measured the percentage of children initiating effective antimalarial treatment within 24 hours of symptom onset and the percentage of children reported to be febrile within the previous 2 weeks. During the intervention, the rate of early effective antimalarial treatment of children 0-59 months more than doubled, from 14.7% in 2008 to 35.3% in 2015 (OR 3.198, P<0.0001). The prevalence of febrile illness among children under 5 years declined after 7 years of the intervention from 39.7% at baseline to 22.6% in 2015 (OR 0.448, P<0.0001). Communities where ProCCM was implemented have achieved an under-five mortality rate at or below 28/1000 for the past 6 years. In 2015, under-five mortality was 7/1000 (HR 0.039, P<0.0001). Further research is needed to elucidate the mechanisms of action and generalizability of ProCCM.

A review of measures of women's empowerment and related gender constructs in family planning and maternal health program evaluations in low- and middle-income countries

BACKGROUND

Evidence suggests that gender-integrated interventions, which actively seek to identify and integrate activities that address the role of gender norms and dynamics, improve family planning (FP) and maternal health (MH). To understand the link between the gender components of interventions and FP and MH outcomes, it is critical to examine the gender measures used in evaluations.

METHODS

We conducted a systematic review of evaluations of gender-integrated FP and MH interventions in low- and middle-income countries. We examine characteristics of the interventions and their evaluations, and summarize women's empowerment and related gender measures.

RESULTS

Out of 16 evaluation articles, five reported the theoretical or conceptual model that guided the intervention. Twelve described how gender was quantitatively measured and identified 13 women's empowerment and related gender constructs. Gender scales or indexes were used in five evaluations, three of which noted that their scales had been validated. Less than one third of articles reported examining the effect of gender on FP or MH.

CONCLUSIONS

Evaluations of gender-integrated FP and MH interventions do not consistently describe how gender influences FP and MH outcomes or include validated gender measures within their studies. As a result, examining the pathways through which interventions empower women and the manner in which women's empowerment leads to changes in FP and MH outcomes remains a challenge. Valid measures of commonly reported women's empowerment and gender constructs, such as gender-equitable attitudes and women's decision-making power, must be adapted and used within evaluations to examine how empowerment and improvements in gender-related factors can produce positive FP and MH outcomes.

The SWPER index for women's empowerment in Africa: development and validation of an index based on survey data

BACKGROUND

The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. Our objective was to develop a novel women's empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women's empowerment.

METHODS

We used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. We identified items related to women's empowerment present in most surveys, and used principal component analysis to extract the components. We carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index.

FINDINGS

15 items related to women's empowerment were selected. We retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception.

INTERPRETATION

The index, named Survey-based Women's emPowERment index (SWPER), has potential to widen the research on women's empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey-based index provides.

FUNDING

Bill & Melinda Gates Foundation.

Empowerment: challenges in measurement

Empowerment is core to health promotion; however, there is a lack of consensus in the wider literature as to how to define it and at what level it may occur. Definitional inconsistency inevitably leads to challenges in measuring empowerment; yet if it is as important as is claimed, this must be addressed. This paper discusses the complexities of measuring empowerment and puts forward a number of recommendations for researchers and policy makers as to how this can be achieved noting some of the tensions that may arise between theoretical considerations, research and practice. We argue that empowerment is a culturally and socially defined construct and that this should be taken into account in attempts to measure it. Finally we conclude that, in order to build up the evidence base for empowerment, there is a need for research clearly defining what it is and how it is being measured.

Political gender inequality and infant mortality in the United States, 1990-2012

Although gender inequality has been recognized as a crucial factor influencing population health in the developing world, research has not yet thoroughly documented the role it may play in shaping U.S. infant mortality rates (IMRs). This study uses administrative data with fixed-effects and random-effects models to (1) investigate the relationship between political gender inequality in state legislatures and state infant mortality rates in the United States from 1990 to 2012, and (2) project the population level costs associated with women's underrepresentation in 2012. Results indicate that higher percentages of women in state legislatures are associated with reduced IMRs, both between states and within-states over time. According to model predictions, if women were at parity with men in state legislatures, the expected number of infant deaths in the U.S. in 2012 would have been lower by approximately 14.6% (3,478 infant deaths). These findings underscore the importance of women's political representation for population health.