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

doi:10.1016/j.socscimed.2016.08.001

Social Science & Medicine

Volume 169, November 2016, Pages 119-131

https://doi.org/10.1016/j.socscimed.2016.08.001 Get rights and content

Highlights

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Women's empowerment is generally positively associated with maternal and child health outcomes.
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Approaches to measure women's empowerment vary widely.
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Most studies do not aggregate indicators into meaningful dimensions.

Abstract

Research on the association between women's empowerment and maternal and child health has rapidly expanded. However, questions concerning the measurement and aggregation of quantitative indicators of women's empowerment and their associations with measures of maternal and child health status and healthcare utilization remain unanswered. Major challenges include complexity in measuring progress in several dimensions and the situational, context dependent nature of the empowerment process as it relates to improvements in maternal and child health status and maternal care seeking behaviors. This systematic literature review summarizes recent evidence from the developing world regarding the role women's empowerment plays as a social determinant of maternal and child health outcomes. A search of quantitative evidence previously reported in the economic, socio-demographic and public health literature finds 67 eligible studies that report on direct indicators of women's empowerment and their association with indicators capturing maternal and child health outcomes. Statistically significant associations were found between women's empowerment and maternal and child health outcomes such as antenatal care, skilled attendance at birth, contraceptive use, child mortality, full vaccination, nutritional status and exposure to violence. Although associations differ in magnitude and direction, the studies reviewed generally support the hypothesis that women's empowerment is significantly and positively associated with maternal and child health outcomes. While major challenges remain regarding comparability between studies and lack of direct indicators in key dimensions of empowerment, these results suggest that policy makers and practitioners must consider women's empowerment as a viable strategy to improve maternal and child health, but also as a merit in itself. Recommendations include collection of indicators on psychological, legal and political dimensions of women's empowerment and development of a comprehensive conceptual framework that can guide research and policy making.

Section snippets

Introduction and objectives

Women's empowerment has long been hypothesized to drive maternal and child health outcomes in the developing world (Dyson and Moore, 1983; Filippi et al., 2006, Murthi et al., 1995). Despite a growing literature on the linkages between the promotion of gender equality and improvement of maternal health outcomes and child survival, measurement of women's empowerment remains a major challenge (Mason, 1986, Kishor, 2005, Carlson et al., 2015).

Key issues in establishing the linkages between women's

Overview of included studies and summary statistics

Fig. 1 displays the selection of eligible articles for review. Database searches retrieved 14,584 articles. 13,251 of these were discarded through reviewing article titles and abstracts, after which 1,333 articles remained. These articles were further scanned for eligibility and 1145 articles were discarded, resulting in 118 eligible studies. All of these 118 studies were scored for quality using the CCEERC tool which resulted in another 65 articles being discarded after which a total of 53

Conclusion and discussion

This systematic literature review summarizes the existing literature regarding the relationship between quantitative indicators of women's empowerment and maternal and child health outcomes including indicators on self-reported health service uptake. It highlights the main gaps and areas of consensus in current theory and practice regarding the measurement of women's empowerment and its associations with maternal and child health outcomes. The main findings are that measurement of women's

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Child undernutrition remains a major global health issue, particularly in sub-Saharan Africa (SSA). Given the important role mothers play in early childhood health and development, we examined how individual-level women’s empowerment and country-level Gender Inequality Index (GII) are jointly related with child undernutrition in SSA.
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Overall, 32.85% of children were stunted, 17.63% were underweight, and 6.68% had wasting. Children of mothers with low-level of empowerment for all domains of SWPER had higher odds of stunting (attitude to violence: OR=1.15; 95% CI, 1.11-1.19; social independence: OR=1.21; 95% CI, 1.17-1.25; decision-making: OR=1.16; 95% CI, 1.12-1.20), and consistent results were found for underweight and wasting. Independent of women’s empowerment, country-level GII increased the probability of underweight (ranging ORs=1.46; 95% CI, 1.15-1.85 to 1.50; 95% CI, 1.18-1.90) and wasting (ranging ORs=1.56; 95% CI, 1.24-1.97 to 1.61; 95% CI, 1.27-2.03). Significant interaction was found between women’s empowerment and country-level GII for stunting and underweight (p<0.05).
In SSA countries with greater gender inequality, improving women’s social independence and decision-making power in particular can reduce their children’s risk of anthropometric failures. Policies and interventions targeted at strengthening women's empowerment should consider the degree of gender inequality in each country.
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The dynamics in intra-household decision-making are often neglected in literature on the adoption of agricultural innovations. However, households’ farm management decisions are often made following negotiations between female and male farmers. These may differ in terms of individual bargaining power and personal preferences. A better understanding of the links between gender roles in household decision-making and the adoption of technologies is postulated to enhance the uptake of innovations in smallholder farming systems. In this study, we use survey data from 1,088 wheat-producing households in Ethiopia to analyze the links between women’s role in household decisions concerning crop production and the adoption and turnover rates of rust-resistant wheat varieties. We interviewed female and male respondents from the same households, but separately, which facilitated capturing individual perceptions and the intra-household dynamics in decision-making. To account for observed heterogeneity that may simultaneously determine the level of women’s agency and varietal adoption by households, we employed Inverse Probability-Weighted Regression Adjustment (IPWRA). A positive association was found between women’s role in decision-making concerning choice of wheat seed and household adoption of rust-resistant wheat varieties and wheat varietal turnover. Spouses may be in agreement or have different opinions regarding their decision-making roles. The disagreement scenario in which the wife claims to have a role in decision-making is associated with lower adoption rates of rust-resistant wheat varieties and less frequent testing of new varties in recent growing seasons, compared to a scenario where both spouses agree that wives do not have a role. We conclude that gender-disaggregated data and the examination of intra-household decision-making can offer novel and valuable insights for designing and implementing strategies to enhance the uptake of agricultural technologies among smallholders. The results emphasize the need to include complementary perspectives on the intra-household decision-making process.
Falling behind in school: Mother's economic empowerment and its association with children's grade progression in Malawi
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Malawi has experienced slow and uneven progress in school progression and completion rates, thus there is need to rethink the approaches needed for reforming education systems. Mothers are more likely to invest in children’s nutrition and well-being and take primary responsibility for children’s education. However, the association between women’s economic empowerment and their offspring’s school progression rates is not systematically understood in Malawi, or elsewhere. We investigate how economic empowerment of mothers is associated with children’s progression through grades at appropriate ages. Using the 2016/17 Malawi Integrated Household Survey data, we show that women’s economic empowerment is positively associated with being on-time for grade, with a steeper slope for girls than boys, particularly at secondary school level. The stronger association for girls in secondary school, who otherwise typically experience a higher risk of dropping out of school than boys, implies higher education attainment, and probably lower teen pregnancies and early marriage. We conclude that investment in women’s economic empowerment can significantly enhance school progression and completion rates and can contribute to human capital development and poverty reduction in Malawi and elsewhere in sub-Saharan Africa.
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Review articleAssociations 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

Highlights

Abstract

Section snippets

Introduction and objectives

Overview of included studies and summary statistics

Conclusion and discussion

Reprod. Health Matters

Soc. Sci. Med. (1982)

Lancet

The Lancet

Soc. Sci. Res.

World Dev.

Women's Health Issues

The Lancet

World Dev.

Soc. Sci. Med.

World Dev.

Soc. Sci. Med.

Soc. Sci. Med.

Soc. Sci. Med. (1982)

Rural Women of Nepal: An Aggregate Analysis and Summary of 8 Village Studies

Intimate partner violence and death among infants and children in India

Pediatrics

Refining the measurement of women's autonomy: an international application of a multi-dimensional construct

Soc. Forces

Determinants of institutional delivery in rural Jhang, Pakistan

Int. J. Equity Health

Economic status, education and empowerment: implications for maternal health service utilization in developing countries

PloS One

Subjective quantitative studies of human agency

Soc. Indic. Res.

Concepts and Measures of Agency, OPHI Working Paper

The quality of family relationships and use of maternal healthcare services in India

Stud. Fam. Plan.

Measuring Empowerment in Practice: Structuring Analysis and Framing Indicators

Women's Empowerment in Action: Evidence from a Randomized Control Trial in Africa

Women's Economic Empowerment in Action: Evidence from a Randomized Control Trial in Africa

Social cognitive theory in cultural context

Appl. Psychol.

Negative self-efficacy and goal effects revisited

J. Appl. Psychol.

Spousal communication and family planning behavior in Navrongo: a longitudinal assessment

Stud. Fam. Plan.

Dimensions of women's autonomy and the influence on maternal health care utilization in a North Indian city

Demography

Women's autonomy and its relationship to children's nutrition among the Rendille of northern Kenya

Am. J. Hum. Biol.

Guidelines for Preparation of Review Protocols

Associations between women's autonomy and child nutritional status: a review of the literature

Maternal Child Nutr.

Maternal behavior and experience, care access, and agency as determinants of child diarrhea in Bolivia

Rev. Panam. De. Salud Pública

The process of empowerment: a model for use in research and practice

Am. Psychol.

Maternal autonomy and low birth weight in India

J. Women's Health

Measuring women's empowerment: an assessment of the gender-related development index and the gender empowerment measure

J. Hum. Dev.

The effect of spousal violence on women's health: findings from the Stree Arogya Shodh in Goa, India

J. Postgrad. Med.

The role of gender empowerment on reproductive health outcomes in urban Nigeria

Maternal Child Health J.

Women's decision making and child health: familial and social hierarchies

A Focus Gend. Collect. Pap. Gend. using DHS Data

Joint effect of maternal depression and intimate partner violence on increased risk of child death in rural Ethiopia

Archives Dis. Child.

Rural Women at Work: Strategies for Development in South Asia

Women's empowerment and choice of contraceptive methods in selected African countries

Int. Perspect. Sex. Reproductive Health

On kinship structure, female autonomy, and demographic behavior in India

Popul. Dev. Rev.

Predictors of acute undernutrition among children aged 6 to 36 months in East rural Ethiopia: a community based nested case-control study

BMC Pediatr.

Intimate partner violence and reproductive health of women in Kenya

Int. Nurs. Rev.

When women deliver with no one present in Nigeria: who, what, where and so what?

PLoS ONE

Prevalence of institutional delivery and associated factors in Dodota Woreda (district), Oromia regional state, Ethiopia

Reprod. Health

Review article
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