Assessing the Role of Women’s Autonomy and Acceptability of Intimate Partner Violence on Maternal Health Care Utilization in 63 Low- and Middle-Income Countries

Despite recent global progress towards reducing maternal morbidity and mortality, nearly 830 women continue to die each day from preventable causes related to pregnancy and childbirth, with most of these deaths occurring in low- and middle-income countries. Maternal health services like antenatal and skilled delivery care can both improve maternal health and reduce maternal deaths related to childbirth, but utilization of these and other basic health services in low- and middle-income settings remains low.

A large body of literature has investigated obstacles leading to poor care-seeking behavior by women, including distance to care, lack of transport, health-system constraints and key demographic and socio-economic risk factors for low utilization of reproductive health services. In contrast, fewer studies have examined the extent to which sociocultural dimensions that shape women’s status and autonomy are related to their use of health services.

In a new International Journal of Epidemiology article, Mahesh Karra and coauthors investigate the relationship between women’s autonomy and attitudes toward the acceptability of intimate-partner violence against women (IPVAW) and maternal healthcare utilization outcomes. They combine data from 113 Demographic and Health Surveys conducted between 2003 and 2016, leading to a pooled sample of 765,169 mothers and 777,352 births from 63 countries. Using this data, they generate composite scores of women’s autonomy on a six-point scale and acceptability of IPVAW on a five-point scale, then assess the associations between these measures and women’s use of antenatal care services and facility delivery.

Main findings:

• A change in a woman’s autonomy score from “no contribution to any decision-making domain” (a composite autonomy score of 0) to “contribution to all decision-making domains” (a score of 6) is associated with a 31.2 percent increase in her odds of giving birth in a healthcare facility and a 42.4 percent increase in her odds of receiving at least eight antenatal care visits over the course of her pregnancy. 
• In contrast, a change in a woman’s attitude towards acceptability of IPVAW from “IPVAW is not acceptable under any scenario” (a score of 0) to “IPVAW is acceptable in all scenarios” (a score of 5) is associated with an 8.9 percent decrease in her odds of giving birth in a facility and a 20.3 percent decrease in her odds of receiving eight antenatal care visits.

The authors find strong and significant associations between women’s reported autonomy and decision-making capacity, women’s reported attitudes towards IPVAW and their utilization of maternal health-care services, reinforcing the need to take maternal autonomy and empowerment into consideration when designing programs and policies that aim to improve health services for women. The findings also highlight the need for further study on the relationships between women’s health, autonomy and empowerment, which in turn will serve to promote the development of effective interventions that improve maternal health and wellbeing.