Abstract
BackgroundDespite various international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth. This research was guided by the following questions: 1) How does women's autonomy influence the choice of place of delivery in resource-poor urban settings? 2) Does its effect vary by household wealth? and 3) To what extent does women's autonomy mediate the relationship between women's education and use of health facility for delivery?MethodsThe data used is from a maternal health study carried out in the slums of Nairobi, Kenya. A total of 1,927 women (out of 2,482) who had a pregnancy outcome in 2004–2005 were selected and interviewed. Seventeen variable items on autonomy were used to construct women's decision-making, freedom of movement, and overall autonomy. Further, all health facilities serving the study population were assessed with regard to the number, training and competency of obstetric staff; services offered; physical infrastructure; and availability, adequacy and functional status of supplies and other essential equipment for safe delivery, among others. A total of 25 facilities were surveyed.ResultsWhile household wealth, education and demographic and health covariates had strong relationships with place of delivery, the effects of women's overall autonomy, decision-making and freedom of movement were rather weak. Among middle to least poor households, all three measures of women's autonomy were associated with place of delivery, and in the expected direction; whereas among the poorest women, they were strong and counter-intuitive. Finally, the study showed that autonomy may not be a major mediator of the link between education and use of health services for delivery.ConclusionThe paper argues in favor of broad actions to increase women's autonomy both as an end and as a means to facilitate improved reproductive health outcomes. It also supports the call for more appropriate data that could further support this line of action. It highlights the need for efforts to improve households' livelihoods and increase girls' schooling to alter perceptions of the value of skilled maternal health care.
Highlights
Despite various international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth
The results of this study show that in the Nairobi informal settlements, utilization of maternal health services for delivery is not enhanced by high levels of women's overall autonomy, freedom of movement, or decision making; a finding consistent with other studies that have examined the influence of women's autonomy on various health outcomes
Before we dismiss the important role of women's autonomy on maternal health services utilization, and in line with the interpretation mentioned above, we examine the interaction between women's autonomy and household wealth as determinants of maternal services utilization
Summary
Despite various international efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth. Despite various national and international initiatives to improve maternal health, more than half a million women from developing countries die each year as a result of complications related to pregnancy and child birth [1,2]. With approximately 247,000 maternal deaths per year, sub-Saharan Africa shares nearly half of the toll despite accounting for less than 12 percent of the world population [3]. In seeking to explain these low levels of health care utilization in developing countries, most studies have focused on provision and geographic accessibility of services, and relatively very few have looked at how factors such as women's autonomy influence use of services [5,6]. Items widely explored include women's freedom of movement, discretion over earned income, decision making related to economic matters, freedom from violence or intimidation by husbands, and decision making related to health care [11,12,13,14]
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