Women's empowerment and the use of antenatal care services: analysis of demographic health surveys in five Southeast Asian countries

Factors associated with decision-making autonomy in healthcare utilization among married women from the Indonesia demographic health survey 2017

Women's autonomy in healthcare decision-making is crucial not only for improving maternal health but also enhancing their overall health and well-being. However, most studies focused solely on fertility, child health, or maternal healthcare use, often overlooking the broader aspects of women's health. Due to this reason, the magnitudes and factors associated with women's autonomy in other types of healthcare remain unclear. Therefore, this study aimed to estimate the magnitude and identify factors associated with healthcare decision-making autonomy among married women in Indonesia. A national cross-sectional study was conducted among married women using the Indonesia Demographic and Health Surveys 2017. Women's healthcare decision-making autonomy was measured based on responses regarding the individual typically responsible for making healthcare decisions on behalf of the respondent. Potential factors, such as intrapersonal, interpersonal, community, and policy-related were obtained. Multinomial logistic regression was used to determine the associations between potential factors and outcomes. The odds ratio (OR) and 95% confidence intervals (CI) of the analysis were reported. The respondents in this study comprised 16,050 married women across 34 provinces in Indonesia. Most respondents (46.4%) reported making healthcare decisions independently. The result showed that several factors were associated with either women's full autonomy or jointly with the husbands in the healthcare decision-making. These factors included ownership of mobile telephones, urban living, residency in Java, Bali, Sulawesi, Maluku and Papua islands, participation of women in decision-making on how to spend their earnings, on large household purchases, no financial barrier in accessing treatment, and independence in visiting a medical center. Public health interventions should focus on vulnerable women, such as those who live in rural areas, participate less in the decision-making of earnings spending and household purchase, and are incapable of visiting a medical center alone to increase the healthcare decision-making autonomy. Collaborative efforts with health facilities in each region can support the implementation of this intervention.

Does women empowerment impact child well-being? Evidence from India

This study intends to examine how women's empowerment directly or indirectly impacts their children's well-being. Since prior research primarily focussed on the effects of maternal empowerment on specific domains of child well-being, such as healthcare or education, this study seeks to explore a more comprehensive understanding of child well-being, where child well-being is quantified using four domains, viz., physical well-being, psycho-social well-being, educational well-being and awareness of safety. For the study, a primary sample of 416 married women who have a child aged between 6 and 18 years was collected using a multistage purposive sampling method from the Barak Valley of Assam, India. Then, exploratory factor analysis is employed to construct two indices, one on women empowerment and the other on child well-being. The index of child well-being was then used as the regressand, and the women empowerment index, along with other children, mother and household characteristics, were used as the regressors in multiple linear regressions. Besides, the moderating role of women's empowerment on child well-being is also studied by creating interactions between the women's empowerment index and other mothers, children, and household characteristics. The study finds that women's empowerment has a strong and positive direct impact on the well-being of children aged 6 to 18. The study also reveals that women's empowerment indirectly impacts child well-being as it moderates between child well-being and other attributes, viz., the mother's working status, child's age, place of residence, and standard of living. A key implication of our study is that maternal empowerment is essential for enhancing child well-being during the early developmental years. We also find that maternal empowerment, when interacted with paid employment, profoundly uplifts their child's well-being.

Individual and community-level determinants of quality antenatal care in six South Asian countries

Maternal health is a global public health concern. The paucity of antenatal care (ANC) during pregnancy is directly associated with maternal mortality. This study assessed the individual and community-level determinants of quality  ANC in six South-Asian countries. Data were obtained from a Demographic health survey of six South-Asian countries. This study included a sample of 180,567 (weighted) women aged 15-49 who had given birth in the preceding three years prior to the survey. The quality of ANC was determined by assessing whether a woman had received blood pressure monitoring, urine and blood sample screening, and iron supplements at any ANC visits. Frequency, percentage distribution, and inferential analysis (multilevel mixed-effects model) were conducted. The proportion of quality antenatal care utilization in South Asia was 66.9%. The multilevel analysis showed that women aged 35-49 years (AOR = 1.16; 95% CI = 1.09-1.24), higher education (AOR = 2.84; 95% CI = 2.69-2.99), middle wealth status (AOR = 1.55; 95% CI = 1.49-1.62), richest wealth status (AOR = 3.21; 95% CI = 3.04-3.39), unwanted pregnancy (AOR = 0.92; 95% CI = 0.89-0.95) and 2-4 birth order (AOR = 0.86; 95% CI = 0.83-0.89) were among the individual-level factors that were significantly associated with quality ANC utilization. In addition, rural residence (AOR = 0.77; 95% CI = 0.74-0.8), and big problem - distance to health facility (AOR = 0.63; 95% CI: 0.53-0.76) were the among community level factors there were also significantly associated with use of quality ANC. Meanwhile, women who lived in India (AOR: 22.57; 95% CI: 20.32-25.08) and Maldives (AOR: 33.33; 95% CI: 31.06-35.76) had higher odds of quality ANC than those lived in Afghanistan. Educational status, wealth status, pregnancy wantedness, sex of household head, birth order, place of residence, and distance to health facility were associated with quality ANC. Improving educational status, improving wealth status, reducing the distance to health facilities, and providing rural area-friendly interventions are important to increase the quality of ANC in South Asia.

Does women's empowerment and socio-economic status predict adequacy of antenatal care in sub-Saharan Africa?

BACKGROUND

Quality and adequate antenatal care (ANC) are key strategies necessary to achieve Sustainable Development Goal 3.1. However, in sub-Saharan Africa (SSA), there is a paucity of evidence on the role women's empowerment and socio-economic status play in ANC attendance. This study aimed to examine whether women's empowerment and socio-economic status predict the adequacy of ANC in SSA.

METHODS

Data from the recent Demographic and Health Surveys (DHSs) of 10 countries in SSA were used for the study. We included countries with a survey dataset compiled between 2018 and 2020. We included 57 265 women with complete observations on variables of interest in the study. Frequencies and percentages were used to summarize the results of the coverage of adequate ANC services across the 10 countries. A multivariable binary multilevel regression analysis was employed to examine the association between women's empowerment and socio-economic status indicators and the adequacy of ANC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used to present the findings of the regression analysis.

RESULTS

The average prevalence of adequate ANC in SSA was 10.4%. This ranged from 0.2% in Rwanda to 24.5% in Liberia. Women with medium (aOR 1.24 [CI 1.10 to 1.40]) and high (aOR 1.24 [CI 1.07 to 1.43]) decision-making power had higher odds of adequate ANC compared to those with low decision-making power. Women with higher levels of education (aOR 1.63 [CI 1.36 to 1.95]) as well as partners with higher education levels (aOR 1.34 [CI 1.14 to 1.56]) had the highest odds of adequate ANC compared to those with no formal education. Additionally, those working (aOR 1.35 [95% CI 1.23 to 1.49]) and those in the richest wealth category (aOR 2.29 [CI 1.90 to 2.76]) had higher odds of adequate ANC compared to those who are not working and those in the poorest wealth category. Those with high justification of violence against women (aOR 0.84 [CI 0.73 to 0.97]) had lower odds of adequate ANC compared to those with low justification of violence against women.

CONCLUSIONS

Adequacy of ANC was low across all 10 countries we included in this study. It is evident from the study that women's empowerment and socio-economic status significantly predicted the adequacy of ANC. As such, promoting women's empowerment programs without intensive improvements in women's socio-economic status would yield ineffective results. However, when women's empowerment programs are combined with active improvements in socio-economic status, then women will be encouraged to seek adequate ANC.

Women's empowerment and contraceptive use: Recent evidence from ASEAN countries

BACKGROUND

A fundamental element of gender equity are women's rights to reproductive choice. Women's empowerment is often linked to enabling decisions around contraceptive use and reduced fertility worldwide, although limited evidence is currently available around contraceptive use and decision making in ASEAN countries.

OBJECTIVE

To examine the association between women's empowerment and contraceptive use in five selected ASEAN member states.

METHODS

Data from the latest Demographic and Health Survey of Cambodia, Indonesia, Myanmar, The Philippines, and Timor-Leste were used. The main outcome was contraceptive use among married women (15-49 years) from these five countries. We considered four indicators of empowerment: labor force participation; disagreement with reasons for wife beating; decision-making power over household issues; and knowledge level.

RESULTS

Labor force participation was found to be significantly associated with contraceptive use in all nations. Disagreement with justification of wife beating was not significantly related to contraceptive use in any country. Decision-making power (higher) was only associated with contraceptive use in Cambodia, while higher knowledge levels were associated with contraceptive use in Cambodia, and Myanmar.

CONCLUSION

This study suggests women's labor force participation is an important determinant of contraceptive use. Policies designed to open the labor market and empower women through education should be implemented to enable women's participation. Gender inequality may also be tackled by engaging women in decision-making processes at national, community and family levels.

Linkages between women's empowerment, religion, marriage type, and uptake of antenatal care visits in 13 West African countries

Characteristics which reflect a particular context and unique to individuals, households, and societies have been suggested to have an impact on the association between women's empowerment and women's well-being indicators. However, there is limited empirical evidence of this effect. We used access to antenatal care (ANC) to examine the main and interaction effects of women's empowerment, religion, marriage type, and uptake of services in 13 West African countries. Data was extracted from Phase 6 and 7 of the Demographic and Health Survey, and we measured women's empowerment using the survey-based women's empowerment (SWPER) index for women's empowerment in Africa. ANC visits as the outcome variable was analyzed as a count variable and the SWPER domains, religion, and marriage type were the key independent variables. We utilised ordinary least square (OLS) and Poisson regression models where appropriate to examine main and interaction effects and analyses were appropriately weighted and key control variables were applied. Statistical significance was established at 95% confidence interval. Findings suggest that being Muslim or in a polygynous household was consistently associated with disempowerment in social independence, attitude toward violence, and decision-making for women. Although less consistent, improved social independence and decision-making for women were associated with the probability of increased ANC visits. Polygyny and Islamic religion were negatively associated with increased number of ANC visits. Decision-making for Muslim women appear to increase the probability of increased number of ANC visits. Improving the conditions that contribute towards women's disempowerment especially for Muslim women and to a lesser extent for those who reside in polygynous households is key towards better uptake of antenatal care services. Furthermore, targeting of interventions and polices that could empower women towards better access to health services should be tailored on existing contextual factors including religion and marriage type.

The relationship between women's breastfeeding empowerment and conformity to feminine norms

BACKGROUND

Women empowerment is effective in successful breastfeeding. Hence,identifying the relationship between psychosocial factors, such as acceptance of feminine norms, and empowerment can be beneficial in designing interventions.. Therefore, this study aimed to determine the relationship between breastfeeding empowerment and conformity to feminine norms.

METHODS

This cross-sectional study was conducted on 288 primiparous mothers in the postpartum period using validated questionnaires of conformity to gender norms and breastfeeding empowerment in the following domains: "sufficient knowledge and skills for breastfeeding," "a sense of breastfeeding competence," "conscious belief in the value of breastfeeding," "overcoming breastfeeding problems," "negotiation and obtaining family support" and "self-efficacy in breastfeeding" which were completed through the self-report method. Data were analyzed using the multivariate linear regression test.

RESULTS

The mean score of 'conformity to feminine norms' and 'breastfeeding empowerment' were 142.39 and 144.14, respectively. The score of breastfeeding empowerment was positively related to conformity to feminine norms (p = 0.003). Among the dimensions of breastfeeding empowerment, 'mothers' adequate knowledge and skills for breastfeeding' (p = 0.001), 'belief in the value of breastfeeding' (p = 0.008), and 'negotiation and obtaining family support' (p = 0.01) were positively related to conformity to feminine norms.

CONCLUSIONS

The results indicate a positive relationship between the level of conformity to feminine norms and breastfeeding empowerment. Accordingly, it is recommended that supporting breastfeeding as a valuable role of women be considered in programs designed to improve breastfeeding empowerment.

Maternal Depression during Pregnancy and Postpartum Period among the Association of Southeast Asian Nations (ASEAN) Countries: A Scoping Review

Identification of mothers with depression is important because untreated perinatal depression can have both short- and long-term consequences for the mother, the child, and the family. This review attempts to identify the prevalence of antenatal and postnatal depression (AD and PD, respectively) of mothers among the ASEAN member countries. A literature review was conducted using PubMed, Scopus, and the Asian Citation Index. The reviews covered publications in peer-reviewed journals written in the English language between January 2010 and December 2020. Of the 280 articles identified, a total of 37 peer-reviewed articles conducted in 8 out of 11 ASEAN member countries were included. The Edinburgh Postnatal Depression Scale (EPDS) was the most common instrument used to identify depression. This study showed the number of studies reporting the prevalence of AD was 18 in five countries. For PD, 24 studies in eight countries were included. The prevalence of AD ranged from 4.9% to 46.8%, and that of PD ranged from 4.4% to 57.7%. This first review among ASEAN countries showed very few studies conducted in lower-middle-income and substantial heterogeneity in prevalence among studies reviewed. Further research should be conducted to estimate the prevalence using a large representative sample with a validated assessment tool among the ASEAN countries.

Women's empowerment indicators and short- and long-acting contraceptive method use: evidence from DHS from 11 countries

BACKGROUND

With a population of about 1.1 billion, sub-Saharan Africa is projected to overtake Eastern, Southern and Central Asia to become the most populous region by 2060. One effective approach for slowing this rapid population growth is the use of modern contraception and this may be short-acting or long acting. Previous studies have explored the association between women empowerment indicators contraception use, however, there is limited evidence on how women empowerment indicators associate with type of contraception. Hence the present study investigated the association between women empowerment indicators and type of contraception used by women in 11 sub-Saharan African countries.

METHODS

We utilised Demographic and Health Survey data of 22,637 women from 11 countries, collected between 2018 and 2021. The outcome variable was type of contraception used. Descriptive and inferential analyses were executed. The descriptive analysis reflected women empowerment indicators and the proportion of women using contraceptives. Multinomial logistic regression was considered for the inferential analysis. The results for the multinomial logistic regression were presented as adjusted odds ratios (aORs) along with the respective 95% confidence intervals (CIs) signifying precision. The sample weight (wt) was used to account for the complex survey (svy) design. All the analyses were done with Stata version 13 and SPSS version 25.

RESULTS

The study showed that on the average, 15.95% of the women do not use modern contraceptives, whilst 30.67% and 53.38% use long-acting and short-acting contraceptives respectively. The adjusted models showed that women who were working had higher odds of using long-acting (aOR = 1.44, CI 1.28-1.62) and short-acting (aOR = 2.00, CI 1.79-2.24) methods compared with those who were not working. The analysis revealed higher likelihood of long-acting method use among women with high decision-making capacity (aOR = 1.27, CI 1.09-1.47) compared with women with low decision-making capacity. Women with medium knowledge level had a higher likelihood (aOR = 1.54, 1.09-2.17) of using long-acting methods than their counterparts with low knowledge level.

CONCLUSION

Our findings show that most women in the 11 countries use modern contraceptives, however, different empowerment indicators align with different contraceptive type. It therefore behoves governments of the studied countries to review current interventions and embrace new ones that are more responsive to the peculiar contraception needs of empowered and non-empowered women.

Women empowerment indicators and uptake of child health services in sub-Saharan Africa: a multilevel analysis using cross-sectional data from 26 countries

BACKGROUND

The sustainable development goal 3, target 2, seeks to reduce under-five mortality to as low as 25 deaths per 1000 live births by 2030. As such, seeking child health services has become a priority concern for all countries, particularly those in sub-Saharan Africa (SSA). Evidence suggests that empowered women are more likely to seek child health services. Hence, this study examined the association between women empowerment indicators and uptake of child health services in SSA.

METHODS

The study used data from the Demographic and Health Surveys of 26 SSA countries, which were conducted between 2010 and 2019. Two different samples were considered in the study: a total of 12 961 children within the vaccination age of 12-23, and 9489 children under age 5 with diarrhoea symptoms in the last 2 weeks before the survey. Women empowerment indicators comprised disagreement with reasons to justify wife beating, decision-making power and knowledge level, while child health services constituted complete vaccination uptake and seeking diarrhoea treatment. Frequencies, percentages and multivariable, multilevel binary logistic regression models were employed.

RESULTS

The study shows that women with high decision-making power [adjusted odds ratio (AOR) = 1.20, 95% confidence interval (CI) = 1.07, 1.35] had higher odds of seeking treatment for childhood diarrhoea compared to those with low decision-making power. It was also observed that among children aged 12-23 months [AOR = 1.28, 95% CI = 1.14, 1.43], mothers had higher odds of seeking diarrhoea treatment for them compared to those who were aged less than 12 months. Children whose mothers had medium decision-making power [AOR = 1.30, 95% CI = 1.19, 1.41] were more likely to seek complete immunization for their children compared to those with low decision-making power. Also, those with medium [AOR = 1.19, 95% CI = 1.07, 1.31] and high knowledge [AOR = 1.25, 95% CI = 1.10, 1.42] had higher odds of completing immunization for their children compared to those with low knowledge. Women with medium acceptance had lower odds [AOR = 0.76, 95% CI = 0.67, 0.83] of completing immunization for their children compared with those with low acceptance of wife beating.

CONCLUSIONS

This study has demonstrated a strong association between women empowerment indicators and the uptake of child health services. Therefore, efforts should be made to seek policy tools to empower women to help improve the well-being of women and the children they care for.

Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data

OBJECTIVES

To identify and investigate complex pathways to stunting among children aged 6-24 months to determine the mediating effects of dietary diversity and continued breast feeding on the association between socioeconomic factors and child stunting.

DESIGN, SETTING AND PARTICIPANTS

We analysed the most recent cross-sectional Demographic and Health Survey data from Cambodia (2014). We applied structural path analysis on a sample of 1365 children to model the complex and inter-related pathways of factors determining children's height for age. Explanatory variables included a composite indicator of maternal employment, household wealth, maternal education, current breastfeeding status and dietary diversity score. Results are presented both in terms of non-standardised and standardised coefficients.

OUTCOME MEASURE

The primary outcome measure was height-for-age Z-scores as a continuous measure.

RESULTS

Findings suggest that children's dietary diversity and continued breast feeding mediate the association between socioeconomic status and children's height. While there was no significant direct effect of maternal education on children's height, results suggested significant indirect pathways through which maternal education effects children's height; operating through household wealth, maternal employment, dietary diversity and continued breastfeeding status (p<0.001). Most notably, 41% of the effect of maternal employment on children's height was mediated by either dietary diversity or continued breast feeding.

CONCLUSION

We provide evidence to support targeted nutrition interventions which account for the different ways in which underlying socioeconomic factors influence infant and young child feeding practices, and the potential impact on child nutritional status.

A non-linear decomposition analysis of children's dietary diversity scores: explaining rural-urban inequality

Sufficient and nourishing foods during the early years of a child's life are essential for optimal growth and healthy life. The existing disparities among rural-urban populations also affect the dietary pattern as well. Therefore, this study aims to identify the factors that contribute towards the rural-urban disparity in children's dietary diversity (CDD) and quantify their importance for the reduction of rural-urban disparities in achieving a minimum dietary diversity level. Using Pakistan Demographic and Health Survey (PDHS) data, version 2017-18, a non-linear decomposition analysis was performed. Eighty-one (81%) of the gap in CDD between rural-urban areas is attributed to the differences in the observed factors (endowments) and of these most of the difference is explained by three factors i.e. number of antenatal care visits (45%), maternal education (18%) and type of toilet facility (15%). There is a need to explore maternal education-related interventions to decrease the rural-urban gap regarding CDD as maternal education may affect CDD through different dimensions. Moreover, such programs should be initiated that may be helpful to enhance women's role in society, such as skilled education, well-paid job opportunities and better health facilities.

Women's empowerment and fertility preferences of married women: analysis of demographic and health survey'2016 in Timor-Leste

A recently independent state, Timor-Leste, is progressing towards socioeconomic development, prioritizing women empowerment while its increased fertility rate (4.1) could hinder the growth due to an uncontrolled population. Currently, limited evidence shows that indicators of women's empowerment are associated with fertility preferences and rates. The objective of this study was to assess the association between women empowerment and fertility preferences of married women aged 15 to 49 years in Timor-Leste using nationally representative survey data. The study was conducted using the data of the latest Timor-Leste Demographic and Health Survey 2016. The study included 4040 rural residents and 1810 urban residents of Timor-Leste. Multinomial logistic regression has been performed to assess the strength of association between the exposures indicating women's empowerment and outcome (fertility preference). After adjusting the selected covariates, the findings showed that exposures that indicate women empowerment in DHS, namely, the employment status of women, house and land ownership, ownership of the mobile phone, and independent bank account status, contraceptive use, and the attitude of women towards negotiating sexual relations are significantly associated with fertility preferences. The study shows higher the level of education, the less likely were the women to want more children, and unemployed women were with a higher number of children. Our study also found that the attitude of violence of spouses significantly influenced women's reproductive choice. However, employment had no significant correlation with decision-making opportunities and contraceptive selection due to a lack of substantial data. Also, no meaningful data was available regarding decision-making and fertility preferences. Our findings suggest that women's empowerment governs decision-making in fertility preferences, causing a decline in the fertility rate.

Utilization of Postnatal Care Service in Indonesia and its Association with Women's Empowerment: An Analysis of 2017 Indonesian Demographic Health Survey Data

Objective

The coverage of postnatal care (PNC) is among the lowest globally when compared with other maternal and child interventions. This study aims to assess PNC utilisation in Indonesia and its association with women’s empowerment indicators to provide evidence for the need for policy change.

Methods

Data from the 2017 Indonesian Demographic Health Surveys was analyzed for any use of PNC, early first PNC (within 2 days of birth) and PNC after discharge for newborns. Women’s empowerment factors were calculated using a principal component analysis of 17 indicators. The association between women’s empowerment factors and PNC was assessed using logistic regression adjusted for covariates and complex survey design.

Results

The prevalence of any PNC by skilled professionals in Indonesia was high but PNC after discharge was very low. Labor-force participation and women’s knowledge level were associated with any PNC, but the association between women’s knowledge level and any PNC was modified by place of birth. Disagreement towards justification of wife beating and women’s knowledge level were associated with early PNC but the association was modified by place of birth. Decision-making power was also associated with early PNC but modified by infant’s gender. Disagreement towards justification of wife beating was negatively associated with PNC after discharge, but the association between decision-making power and PNC after discharge was modified by the infant’s size at birth.

Conclusions for Practice

PNC coverage after discharge in Indonesia needs improvement. Women’s empowerment indicators need to be addressed in improving PNC coverage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03324-y.

Do empowered women receive better quality antenatal care in Pakistan? An analysis of demographic and health survey data

INTRODUCTION

Quality antenatal care is a window of opportunity for improving maternal and neonatal outcomes. Numerous studies have shown a positive effect of women empowerment on improved coverage of maternal and reproductive health services, including antenatal care (ANC). However, there is scarce evidence on the association between women's empowerment and improved ANC services both in terms of coverage and quality. Addressing this gap, this paper examines the relationship between multi-dimensional measures of women empowerment on utilization of quality ANC (service coverage and consultation) in Pakistan.

METHODS

We used Pakistan Demographic and Health Survey 2017-18 (PDHS) data which comprises of 6,602 currently married women aged between 15-49 years who had a live birth in the past five years preceding the survey. Our exposure variables were three-dimensional measures of women empowerment (social independence, decision making, and attitude towards domestic violence), and our outcome variables were quality of antenatal coverage [i.e. a composite binary measure based on skilled ANC (trained professional), timeliness (1st ANC visit during first trimester), sufficiency of ANC visits (4 or more)] and quality of ANC consultation (i.e. receiving at least 7 or more essential antenatal components out of 8). Data were analysed in Stata 16.0 software. Descriptive statistics were used to describe sample characteristics and binary logistic regression was employed to assess the association between empowerment and quality of antenatal care.

RESULTS

We found that 41.4% of the women received quality ANC coverage and 30.6% received quality ANC consultations during pregnancy. After controlling for a number of socio-economic and demographic factors, all three measures of women's empowerment independently showed a positive relationship with both outcomes. Women with high autonomy (i.e. strongly opposed the notion of violence) in the domain of attitude to violence are 1.66 (95% CI 1.30-2.10) and 1.45 (95% CI 1.19-1.75) and times more likely to receive antenatal coverage and quality ANC consultations respectively, compared with women who ranked low on attitude to violence. Women who enjoy high social independence had 1.87 (95% CI 1.44-2.43) and 2.78 (95% CI 2.04-3.79) higher odds of quality antenatal coverage and consultations respectively, as compared with their counterparts. Similarly, women who had high autonomy in household decision making 1.98 (95% CI 1.60-2.44) and 1.56 (95% CI 2.17-1.91) were more likely to receive quality antenatal coverage and consultation respectively, as compared to women who possess low autonomy in household decision making.

CONCLUSION

The quality of ANC coverage and consultation with service provider is considerably low in Pakistan. Women's empowerment related to social independence, gendered beliefs about violence, and decision-making have an independent positive association with the utilisation of quality antenatal care. Thus, efforts directed towards empowering women could be an effective strategy to improve utilisation of quality antenatal care in Pakistan.

Is improvement in indicators of women's empowerment associated with uptake of WHO recommended IPTp-SP levels in sub-Saharan Africa? A multilevel approach

OBJECTIVES

The global burden of malaria has reduced considerably; however, malaria in pregnancy remains a major public health problem in sub-Saharan Africa (SSA), where about 32 million pregnant women are at risk of acquiring malaria. The WHO has recommended that pregnant women in high malaria transmission locations, including SSA, have intermittent preventive treatment of malaria during pregnancy with at least three doses of sulphadoxine-pyrimethamine (IPTp-SP). Therefore, we investigated the prevalence of IPTp-SP uptake and associated individual-level, community-level and country-level predictors in SSA.

DESIGN

A cross-sectional survey was conducted using recent Demographic and Health Surveys datasets of 20 SSA countries. A total of 96 765 women were included. Optimum uptake of IPTp-SP at most recent pregnancy was the outcome variable. We fitted three-level multilevel models: individual, community and country parameters at 95% credible interval.

RESULTS

In all, 29.2% of the women had optimal IPTp-SP uptake ranging from 55.1% (in Zambia) to 6.9% (in Gambia). The study revealed a high likelihood of optimum IPTp-SP uptake among women with high knowledge (aOR=1.298, Crl 1.206 to 1.398) relative to women with low knowledge. Women in upper-middle-income countries were more than three times likely to have at least three IPTp-SP doses compared with those in low-income countries (aOR=3.268, Crl 2.392 to 4.098). We found that community (σ²=1.999, Crl 1.088 to 2.231) and country (σ²=1.853, Crl 1.213 to 2.831) level variations exist in optimal uptake of IPTp-SP. According to the intracluster correlation, 53.9% and 25.9% of the variation in optimum IPTp-SP uptake are correspondingly attributable to community-level and country-level factors.

CONCLUSIONS

The outcome of our study suggests that low-income SSA countries should increase budgetary allocation to maternal health, particularly for IPTp-SP interventions. IPTp-SP advocacy behavioural change communication strategies must focus on women with low knowledge, rural dwellers, married women and those who do not meet the minimum of eight antenatal care visits.

The Determinants of Four or More Antenatal Care Visits Among Working Women in Indonesia

This study aimed to analyze the determinants of four or more antenatal care (ANC) visits among working women in Indonesia. The researchers extracted data from the Indonesian Demographic and Health Survey 2017 and obtained a sample size of 8239 working women aged between 15 and 49 years. Women’s residence, age, marital status, education level, parity, economic status, and health insurance were selected as the independent variables. Binary logistic regression was used for the analysis. Older working women, married working women, educated working women, those in higher economic status, and those with health insurance were more likely to complete four or more of their ANC visits. The more children the working women had, the less likely they would complete their ANC visits. In conclusion, age, marital status, education, parity, economic status, and health insurance are the determinants for completing ANC visits among working women in Indonesia. At the same time, place of residence does not affect the frequency of ANC visits.

Empirical analysis of socio-economic determinants of maternal health services utilisation in Burundi

BACKGROUND

Timely and appropriate health care during pregnancy and childbirth are the pillars of better maternal health outcomes. However, factors such as poverty and low education levels, long distances to a health facility, and high costs of health services may present barriers to timely access and utilisation of maternal health services. Despite antenatal care (ANC), delivery and postnatal care being free at the point of use in Burundi, utilisation of these services remains low: between 2011 and 2017, only 49% of pregnant women attended at least four ANC visits. This study explores the socio-economic determinants that affect utilisation of maternal health services in Burundi.

METHODS

We use data from the 2016-2017 Burundi Demographic and Health Survey (DHS) collected from 8941 women who reported a live birth in the five years that preceded the survey. We use multivariate regression analysis to explore which individual-, household-, and community-level factors determine the likelihood that women will seek ANC services from a trained health professional, the number of ANC visits they make, and the choice of assisted childbirth.

RESULTS

Occupation, marital status, and wealth increase the likelihood that women will seek ANC services from a trained health professional. The likelihood that a woman consults a trained health professional for ANC services is 18 times and 16 times more for married women and women living in partnership, respectively. More educated women and those who currently live a union or partnership attend more ANC visits than non-educated women and women not in union. At higher birth orders, women tend to not attend ANC visits. The more ANC visits attended, and the wealthier women are; the more likely they are to have assisted childbirth. Women who complete four or more ANC visits are 14 times more likely to have an assisted childbirth.

CONCLUSIONS

In Burundi, utilisation of maternal health services is low and is mainly driven by legal union and wealth status. To improve equitable access to maternal health services for vulnerable population groups such as those with lower wealth status and unmarried women, the government should consider certain demand stimulating policy packages targeted at these groups.

Do women empowerment indicators predict receipt of quality antenatal care in Cameroon? Evidence from a nationwide survey

BACKGROUND

World Health Organisation (WHO) recommends quality antenatal care (ANC) for all pregnant women, as one of the strategies for achieving targets 3.1 and 3.2 of the sustainable development goals. Maternal mortality ratio remains high in Cameroon (782 maternal deaths per 100,000 live births). Extant literature suggest a positive association between women empowerment indicators and maternal healthcare utilisation in general. In Cameroon, this association has not received scholarly attention. To fill this knowledge gap, we investigated the association between women empowerment indicators and quality ANC in Cameroon.

METHODS

Data of 4615 women of reproductive age were analysed from the women's file of the 2018 Cameroon Demographic and Health Survey. Quality ANC (measured by six indicators) was the outcome of interest. Binary Logistic Regression was conducted. All results of the Binary Logistic Regression analysis were presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All analyses were done using Stata version 14.

RESULTS

In all, 13.5% of the respondents received quality ANC. Women with low knowledge level (aOR = 0.66, CI 0.45, 0.98) had a lesser likelihood of receiving quality ANC compared to those with medium knowledge level. Women who highly approved wife beating (aOR = 0.54, CI 0.35, 0.83) had lesser odds of receiving quality ANC compared to those with low approval of wife beating.

CONCLUSION

The study has pointed to the need for multifaceted approaches aimed at enhancing the knowledge base of women. The Ministry of Public Health should collaborate and intensify female's reproductive health education. The study suggests that women advocacy and maternal healthcare interventions in Cameroon must strive to identify women who approve of wife beating and motivate them to disapprove all forms of violence.

Women empowerment and skilled birth attendance in sub-Saharan Africa: A multi-country analysis

Introduction

In 2017, the highest global maternal deaths occurred in sub-Saharan Africa (SSA). The WHO advocates that maternal deaths can be mitigated with the assistance of skilled birth attendants (SBAs) at childbirth. Women empowerment is also acknowledged as an enabling factor to women’s functionality and healthcare utilisation including use of SBAs’ services. Consequently, this study investigated the association between women empowerment and skilled birth attendance in SSA.

Materials and methods

This study involved the analysis of secondary data from the Demographic and Health Surveys of 29 countries conducted between January 1, 2010, and December 3, 2018. For this study, only women who had given birth in the five years prior to the surveys were included, which is 166,022. At 95% confidence interval, Binary Logistic Regression analyses were conducted and findings were presented as adjusted odds ratios (aORs).

Results

The overall prevalence of skilled birth attendance was 63.0%, with the lowest prevalence in Tanzania (13.8%) and highest in Rwanda (91.2%). Women who were empowered with high level of knowledge (aOR = 1.60, 95% CI = 1.51, 1.71), high decision-making power (aOR = 1.19, 95% CI = 1.15, 1.23), and low acceptance of wife beating had higher likelihood of skill birth attendance after adjusting for socio-demographic characteristics. Women from rural areas had lesser likelihood (OR = 0.53, 95% CI = 0.51–0.55) of skilled birth attendance compared to women from urban areas. Working women had a lesser likelihood of skilled birth attendance (OR = 0.91, 95% CI = 0.88–0.94) as compared to those not working. Women with secondary (OR = 2.13, 95% CI = 2.03–2.22), or higher education (OR = 4.40, 95% CI = 3.81–5.07), and women in the richest wealth status (OR = 3.50, 95% CI = 3.29–3.73) had higher likelihood of skilled birth attendance.

Conclusion

These findings accentuate that going forward, successful skilled birth attendant interventions are the ones that can prioritise the empowerment of women.

Women's empowerment and practice of maternal healthcare facilities in Bangladesh: a trend analysis

Purpose

This study aims to explore whether there is an association between women's empowerment and the utilization of maternal healthcare facilities.

Design/methodology/approach

This study considered four indices for measuring women's empowerment – labor force participation index (LFPI), decision-making power index (DMPI), attitude toward partner’s violence index (ATPVI) and knowledge level index (KLI) – and three healthcare facilities – number of antenatal visits, delivery with healthcare facilities and postnatal checkup after delivery. Data extracted for this study were from the Bangladesh Demographic and Health Survey 2011 and 2014. A chi-square test was used for bivariate analysis, and a three-level logistic regression model was applied for multivariate analysis.

Findings

An increment was observed in the practice of all considered healthcare facilities, and the percentage of highly empowered women in DMPI decreased from 2011 to 2014. This study found that higher empowerment of women in DMPI, KLI and ATPVI significantly (p-value < 0.05) increases the utilization of healthcare facilities. High empowerment of mothers in LFPI was found negatively associated with facility delivery and positively associated with the postnatal checkup.

Originality/value

Women's empowerment was found significantly associated with the utilization of maternal healthcare facilities. This study is seeking the attention of corresponding authority to come up with a more effective intervention program to empower women to utilize maternal healthcare facilities.

Women empowerment and uptake of antenatal care services : A meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African countries

Background

Women empowerment has been linked to increased skilled antenatal care (ANC) service use. However, there is no evidence on the net effect of women empowerment on ANC in the Sub-saharan African (SSA) region. We aim to address the knowledge gap on whether or not women empowerment positively influences the uptake of ANC at the SSA regional level.

Methods

We analyzed the Demographic Health Survey (DHS) datasets from 33 SSA countries. Following the DHS data analysis guideline, we measured women empowerment using two indicators. The first indicator is an index, which comprises decision-making on women’s own health, household purchase and visit to family or relatives whilst disagreeing statements that husband is justified in beating his wife constitutes the second indictor. We performed confounder-adjusted logistic regression analysis for the two indicators with ANC attendance in each of the 33 countries. Then, we pooled the adjusted Odds Ratios (OR) using the random effect model through the two-stage Individual Participant Data meta-analysis technique. Summary findings are reported in OR and corresponding 95 %CI and are presented in a forest plot.

Results

Moderately empowered women had marginally higher odd of skilled ANC service across the SSA region (aOR = 1.19; 95 %CI: 1.03, 1.38, with a prediction interval of 0.58, 2.45). Conversely, being involved in the three decisions (aOR = 1.15; 95 %CI: 0.99, 1.33, with prediction interval 0.57, 2.31), and attitude towards wife-beating (aOR = 0.97; 95 %CI: 0.88, 1.06, with prediction interval of 0.63, 1.48) had no statistically significant relationship with ANC.

Conclusions

Women empowerment did not predict the use of skilled ANC in the context of the SSA region. We recommend that further studies be conducted in order to understand how women empowerment affects skilled ANC service utilization in the region.

Women's empowerment and female genital mutilation intention for daughters in Sierra Leone: a multilevel analysis

BACKGROUND

Female genital mutilation is common in Sierra Leone. Evidence indicates that empowering women provides protective benefits against female genital mutilation/cutting (FGM/C). Yet, the relationship between women's empowerment and their intention to cut their daughters has not been explored in Sierra Leone. The aim of this study was to assess the association between women's empowerment and their intention to have their daughters undergo FGM/C in the country.

METHODS

Data for this study are from the 2013 Sierra Leone Demographic and Health Survey. A total of 7,706 women between the ages of 15 and 49 were included in the analysis. Analysis entailed generation of descriptive statistics (frequencies and percentages), and estimation of multi-level logistic regression models to examine the association between women's empowerment, contextual factors and their intentions to cut their daughters.

RESULTS

A significantly higher proportion of women who participated in labour force reported that they intended to cut their daughters compared to those who did not (91.2%, CI = 90.4-91.9 and 86.0%, CI = 84.1-87.8, respectively). Similarly, the proportion intending to cut their daughters was significantly higher among women who accepted wife beating than among those who rejected the practice (94.9%, CI = 93.8-95.8 and 86.4% CI = 84.9-87.8, respectively). A significantly higher proportion of women with low decision-making power intended to cut their daughters compared to those with high decision-making power (91.0%, CI = 89.0-92.8 and 85.0% CI = 82.2-87.4, respectively). Results from multivariate regression analysis showed that the odds of intending to cut daughters were significantly higher among women who participated in labour force (aOR = 2.5, CI = 1.3-4.7) and those who accepted wife beating than among those who did not (aOR = 2.7, CI = 1.7-4.5). In contrast, the likelihood of intending to cut daughters was significantly lower among women with high than low knowledge (aOR = 0.4, CI = 0.3-0.7), and among those aged 45-49  than among those aged 15-19  (aOR = 0.2, CI = 0.0-0.6).

CONCLUSION

The findings underscore the need to align anti-FGM/C policies and programmes to women who have undergone FGM/C, those with low knowledge, women who support wife beating and young women. Such interventions could highlight the adverse implications of the practice by stressing the psychological, health and social implications of FGM/C on its survivors.

Temporal relationship between Women's empowerment and utilization of antenatal care services: lessons from four National Surveys in sub-Saharan Africa

Background

In November 2016, the WHO four-visit focused antenatal care (FANC) model adopted in sub-Saharan Africa (SSA) was reverted to eight contacts or more as a response to reducing the global perinatal and maternal deaths and in achieving the sustainable development goal (SDG) 3. Women’s empowerment, which connote the social standing, position and the ability of women to make life decisions and choices has been associated with the maternal health seeking behaviour and outcomes. This study examined the association between women’s empowerment and the WHO ANC model of eight visits or more, and early first antenatal visit among pregnant women. In addition, we explored the association between women’s empowerment and the WHO FANC model to allow for comparison for countries that have not adopted the recent WHO ANC model.

Methods

The most recent (2018) Demographic and Health Survey (DHS) datasets conducted in SSA were used for analyses. We used all available indicators of women’s empowerment captured in the DHS. The 30 variables on women’s empowerment were classified into eight components using exploratory factor analysis. We fitted separate ordinal logistic regression to assess association between antenatal care utilization (number of visits and time of first antenatal visit) and women empowerment factors while adjusting for other covariates. Analysis was performed with STATA 15.0 and adjusted for complex survey design, p-value< 0.05 were used for interpretation of results.

Results

The proportion of women who attended eight or more ANC visits were 1.4, 2.7 and 3.5% in Zambia, Guinea and Mali, respectively. Zambia had the lowest prevalence of 8 or more ANC visits also had the highest prevalence of at least 4 visits (63.8%) and early first ANC visit (38.2%), while Nigeria with the highest prevalence of women with at least 8 visits (17.7%) had the lowest prevalence (17.6%) of women that attended ANC visit in their first trimester. Women’s empowerment was associated with more ANC visits and attending first ANC visit in the first trimester. However, these association with the women empowerment components varied significantly across the four SSA countries.

Conclusion

This study highlights the significant impact of women’s empowerment as a key factor for improving maternal health outcomes in SSA. It is imperative that government and development partners invest more on empowerment of women as part of strategic intervention to improve maternal health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03679-8.

Women's empowerment and child growth faltering in Ethiopia: evidence from the Demographic and Health Survey

BACKGROUND

Despite numerous national and international efforts to alleviate child growth faltering, it remains a global health challenge. There is a growing body of literature that recognizes the importance of women's empowerment in a wide range of public health topics, such as the utilization of maternal healthcare services, agricultural productivity, and child nutrition. However, in Ethiopia, the relationship between women's empowerment and child nutritional status is not studied at the national level. This study aimed to determine the association between women's empowerment and growth faltering in under-5 children in Ethiopia.

METHODS

The data source for this analysis is the 2016 Ethiopian Demographic and Health Survey (EDHS): a nationally representative household survey on healthcare. The EDHS employed a two-stage stratified cluster sampling technique. We computed standard women's empowerment indices, following the Survey-based Women's emPowERment index approach. A multilevel logistic regression model that accounted for cluster-level random effects was used to estimate the association between women's empowerment and child growth faltering (stunting, wasting and underweight).

RESULTS

Attitude to violence, social independence, and decision-making were the three domains of women's empowerment that were associated with child growth faltering. One standard deviation increase in each domain of empowerment was associated with a reduction in the odds of stunting: attitude towards violence (AOR = 0.92; 95% CI 0.88-0.96; p < 0.001), social independence (AOR = 0.95; 95% CI 0.89-0.99; p = 0.049), and decision-making (AOR = 0.93; 95% CI 0.87-0.99; p = 0.023). Similarly, each standard deviation increase in attitude towards violence (AOR = 0.93; 95% CI 0.89-0.98; p = 0.008), social independence (AOR = 0.91; 95% CI 0.86-0.97; p = 0.002), and decision-making (AOR = 0.92; 95% CI 0.86-0.99; p = 0.020) were associated with a decrease in the odds of having underweight child.

CONCLUSIONS

Ensuring women's empowerment both in the household and in the community could have the potential to decrease stunting and underweight in a rapidly developing country like Ethiopia. Policymakers and health professionals need to consider women's empowerment in this unique context to improve nutritional outcomes for children and alleviate growth faltering.

Women's Empowerment as a Mitigating Factor for Improved Antenatal Care Quality despite Impact of 2014 Ebola Outbreak in Guinea

Improving maternal outcomes and reducing pregnancy morbidity and mortality are critical public health goals. The provision of quality antenatal care (ANC) is one method of doing so. Increasing women’s empowerment is associated with positive women’s health outcomes, including the adequate timing and amount of ANC use. However, little is known about the relationship between women’s empowerment and quality ANC care. Despite a history of political instability, low women’s equality and poor maternal health, the Republic of Guinea has committed to improving the status of women and access to health. However, the 2014 Ebola outbreak may have had a negative impact on achieving these goals. This study sought to examine factors in the relationship between women’s empowerment and the receipt of quality ANC (indicated by the number of health components) within the context of the Ebola outbreak. This study conducted multiple logistic regressions examining associations between covariates and the number of ANC components received using data from the 2012 and 2018 Guinea Demographic Health Surveys. Several aspects of women’s empowerment (healthcare decision-making, literacy/access to magazines, monogamous relationship status, contraceptive use, socio-economic status/employment) were significantly linked with the receipt of a greater number of ANC components, highlighting the importance of women’s empowerment in accessing quality maternity care.

Dimensions of women's empowerment on access to skilled delivery services in Nepal

Background

Each day, approximately 810 women die during pregnancy and childbirth and 94% of the deaths take place in low and middle income countries. Only 45% of the births in South Asia are attended by skilled professionals, which is lower than that in other Asian regions. Antenatal and postnatal care received from skilled providers can help prevent maternal and neonatal mortality by identifying pregnancy-related complications. Women’s empowerment is considered to be a significant determinant of maternal health care outcomes; however, studies on the contextual influences of different dimensions of empowerment in Nepal are relatively limited. Therefore, this study analyzed nationwide survey data to examine the influence of women’s economic empowerment, sociocultural empowerment, familial/interpersonal empowerment and media and information technology empowerment on accessing skilled delivery services among the married women in Nepal.

Methods

This study examined the influence of women’s empowerment on skilled delivery services among married women (n = 4400) aged 15–49 years using data from the 2016 Nepal Demographic and Health Survey. Descriptive analysis and binary logistic regression analysis were employed to analyze the data.

Results

Significant associations were found between women’s media and information technology empowerment, economic empowerment and sociocultural empowerment and access to skilled birth attendants. Specifically, the education of women, their occupation, owning a bank account, media exposure, and internet use were significantly associated with the use of skilled birth attendants.

Conclusion

Focusing on women’s access to media and information technology, economic enhancement and education may increase the use of skilled birth attendants in Nepal.

The roles of women empowerment on attitude for safer sex negotiation among Indonesian married women

The situation of low women empowerment in household settings might influence women's attitude and ability to negotiate for protected sex in their marital relationship. This study aimed to investigate the association between women empowerment factors and the attitude for safer sex negotiation among Indonesian married women. The secondary data of 28,934 individual records of married women retrieved from the 2017 Indonesia Demographic and Health Survey (IDHS) was used. The dependent variable was the attitude for safer sex negotiation measured by women's acceptance toward a justification to ask her husband to use a condom if her husband has a sexually transmitted disease. Multivariate logistic regression analysis accounting for the complex survey design was performed. The results showed that women empowerment factors, that include higher level of education and participation in household decision-making had a positive effect on women's attitude for protected sex. Those women with higher levels of HIV knowledge and whoever talked about HIV with their husbands were also more likely to justify for protected sex. Therefore, women empowerment through education, improving socioeconomic conditions, and increasing HIV-related knowledge can help develop a positive attitude and enable women to negotiate for safer sex with their partners.

Determinants of safe delivery utilization among Indonesian women in eastern part of Indonesia

Background: Improving maternal health and reducing maternal mortality are part of the United Nations global Sustainable Development Goals for 2030. Ensuring every woman's right to safe delivery is critical for reducing the maternal mortality rate, especially in Indonesia. Our study aimed to identify determinants of safe delivery utilization among women in the eastern Indonesia. Methods: This study was cross-sectional and used data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 2,162 women who had their last child in the five years preceding the survey and lived in the eastern part of Indonesia were selected as the respondents. Chi-squared test and binary logistic regression were used to understand the determinants of safe delivery. Results: Higher child rank and interval ≤2 years (OR: 0.30, 95% CI: 0.19-0.47), unwanted pregnancy at time of becoming pregnant (OR: 1.48, 95% CI: 1.05-2.08), richest wealth quintile (OR: 5.59, 95% CI: 3.37-9.30), more than four antenatal care visits (OR: 3.62, 95% CI: 2.73-4.79), rural residence (OR: 0.49, 95% CI: 0.36-0.66), good composite labor force participation (OR: 1.47, 95% CI: 1.15-1.89), and a good attitude towards domestic violence (OR: 1.33, 95% CI: 1.04-1.69) were found to be significantly associated with facility-based delivery. Higher child rank and interval ≤2 years (OR: 0.49, 95% CI: 0.29-0.83), husband/partner having completed secondary or higher education (OR: 2.18, 95% CI: 1.48-3.22), husband/partner having a non-agricultural occupation (OR: 1.35, 95% CI: 1.00-1.81), being in the richest wealth quintile (OR: 15.69, 95% CI: 5.53-44.50), and three other factors were found to be significantly associated with skilled assistance delivery. Conclusions: Safe delivery and facility-based delivery among women in the eastern part of Indonesia were determined by several individual and household factors. An open innovation and partnership process that engages the full range of stakeholders should be developed based on local needs.

Determinants of safe delivery utilization among Indonesian women in eastern part of Indonesia

Background: Improving maternal health and reducing maternal mortality are part of the United Nations global Sustainable Development Goals for 2030. Ensuring every woman's right to safe delivery is critical for reducing the maternal mortality rate. Our study aimed to identify determinants of safe delivery utilization among women in the eastern Indonesia. Methods: This study was cross-sectional and used a secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS). A total of 2,162 women who had their last child in the five years preceding the survey and lived in the eastern part of Indonesia were selected as the respondents. Chi-squared test and binary logistic regression were used to understand the determinants of safe delivery. Results: Higher child rank and interval ≤2 years (OR: 0.30, 95% CI: 0.19-0.47), unwanted pregnancy at time of becoming pregnant (OR: 1.48, 95% CI: 1.05-2.08), richest wealth quintile (OR: 5.59, 95% CI: 3.37-9.30), more than four antenatal care visits (OR: 3.62, 95% CI: 2.73-4.79), rural residence, good composite labor force participation, and a good attitude towards domestic violence were found to be significantly associated with delivery at health facility. Higher child rank and interval ≤2 years (OR: 0.49, 95% CI: 0.29-0.83), husband/partner having completed secondary or higher education (OR: 2.18, 95% CI: 1.48-3.22), being in the richest wealth quintile, and four other factors were found to be significantly associated with the assistance of skilled birth attendants. Conclusions: This research extends our knowledge on the determinants of safe delivery among women in the eastern part of Indonesia. This study revealed that the economic status of household remains an important issue in improving safe delivery among women in eastern part of Indonesia. An open innovation and partnership process to improve safe delivery program that engages the full range of stakeholders should be developed based on economic situation.

Community-based savings groups, women's agency, and maternal health service utilisation: Evidence from Mozambique

This study, using data collected as part of an ongoing programme evaluation, investigates whether participation in Saving Groups (SGs)-a community-owned microfinance intervention focused on poor households - is associated with maternal health service utilisation, and whether this association is mediated by women's agency - as measured by self-efficacy and decision-making autonomy. We compared maternal health service utilisation among SG members (n=105) and non-members (n=100) in rural Mozambique. We estimated prevalence ratios for SG membership and women's agency using Poisson regression while controlling for confounding factors. We also estimated mediation effects for women's agency. The results showed that SG membership is associated with four or more antenatal care (ANC) visits, skilled birth attendant (SBA) use, and postnatal care within 48 h of delivery. Self-efficacy mediated the relationship between SG membership and ANC vists and SBAuse, but not postnatal care; whereas women's decision-making autonomy mediated the relationship with SBA use and postnatal care, but not ANC visits. This study suggests that the impact of SG membership on use of maternal health services goes beyond improvements in household income and may operate through women's agency by giving women the ability to realize their preference for quality health care.

Role of Information and Communication Technology and Women's Empowerment in Contraceptive Discontinuation in Indonesia

OBJECTIVES

This study investigated the role of information and communication technology and women's empowerment in contraceptive discontinuation in Indonesia.

METHODS

The study used data from the 2017 Indonesia Demographic and Health Survey and monthly contraceptive calendar data. A Gompertz proportional hazards model was used for analysis.

RESULTS

The 12-month contraceptive discontinuation rate was higher among women who had used the Internet in the past year, women who were mobile phone owners, and women who reported having fully participated in household decision-making than among their counterparts. These factors significantly impacted the risk of contraceptive discontinuation in Indonesia, even after controlling for contraceptive method, age, parity, contraceptive intent, education, work status, place of residence, and wealth status.

CONCLUSIONS

After adjustment for the control variables, a higher risk of contraceptive discontinuation was associated with having used the Internet in the past year, owning a mobile phone, and not participating in household decision-making. Higher contraceptive discontinuation risk was also associated with using contraceptive pills, older age, lower parity, intent of spacing births, more education, current unemployment, and rural residence, and the risk was also significantly higher for those in the lowest household wealth quintile than for those in the fourth household wealth quintile. The association of contraceptive discontinuation with the use of modern information and communication technology and relatively disempowerment in household decision-making may imply that information regarding family planning and contraception should be conveyed via social media as part of setting up an eHealth system. This must include a strong communication strategy to empower and educate women in contraceptive decision-making.

Determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among Indonesian children

Global child feeding practices remain suboptimal. In this study, we assess the determinants of age-inappropriate breastfeeding, dietary diversity, and consumption of 3+ types of animal source foods (ASFs) using 11,687 observations from combined data from the Indonesian Demographic Health Survey of 2012 and 2017. We used linear and logistic regression after adjusting for the complex sampling design. Child's age and quality of antenatal care (ANC) were associated with all outcomes. Socio-economic status and labour force participation were positively associated with higher dietary diversity score, ASF consumption, and age-inappropriate breastfeeding. More ANC visits and having consultation at ANC were associated with more dietary diversity. Higher women's knowledge level was associated with more dietary diversity and consuming more ASF. Compared with western Indonesia, more children in eastern Indonesia were age-inappropriately breastfed and had lower dietary diversity. The Indonesian government needs to develop programmes to improve child feeding particularly in eastern Indonesia, focusing on improving dietary diversity and ASF consumption in poorer households and on prolonging breastfeeding in richer households. Women's labour force participation should be encouraged, but programmes for working mothers are also needed to support continued breastfeeding and to express breast milk. ANC and postnatal programmes need improved consultation sessions for child feeding.