This study assesses the utilization of maternity services along the continuum of care among Afghan women aged 15–49 years using a country-specific index; namely, the survey-based women empowerment index in Afghanistan (SWEI-A). The primary objective was to assess the convergence validity of the index examining how well the index can predict the utilization of maternity services which are strongly associated with higher women empowerment. The study examined the prevalence of utilization of maternity services along the continuum of maternity care including ANC, institutional delivery, and PNC in relation to the seven domains of women empowerment that are measured by SWEI-A at both individual and community levels. The results showed that the rate of utilization of maternity services is considerably higher among those women with high scores in almost all domains except property-owning in which women with high scores appeared to have lower rates of utilization of such service as compared to those with low scores. Although owning land or a house is linked to higher women's abilities in decision-making at household in several countries (19, 20), in some Islamic states such as Afghanistan and Pakistan, particularly among those of low socioeconomic status living in poor families, receiving a piece of land or house is considered as a form of dowery that brides family received from the husband’s side and therefore, owing a land or house does not necessarily indicate higher women socioeconomic status and should not translate into more power (21). This could be a call for the re-evaluation of the developed index and assessing whether dropping the property-owning could improve the index construct validity and reliability.
Although at the individual level, the rate of adequate ANC; institutional delivery; and PNC appeared to be higher in women with high scores as compared to those with low scores in the labor force participation domain; at the community level, the communities with high participation of women in the labor force were less likely to have adequate ANC, institutional delivery, and PNC. The underlying explanation of this contradictory finding at the individual and community levels indicators has been inconsistent across previous studies. Some studies indicate that higher participation of women in the labor force could improve their empowerment through higher financial independence and decision-making ability (22–24); however, most studies fail to report on the differential effect that could exist between individual- and community-level indicators. Besides, the socioeconomic development status of the country is an important factor that should be considered in the interpretation of these results. It has been shown that women's participation in the labor force could be an indicator of higher empowerment and gender equality in high-income countries; however, in low-income countries such as Afghanistan, it could be an indication of lower households' socio-economic and welfare and in fact, it is poverty that pushes women to the labor market in order to contribute to the household income (25). Therefore, the better economy and welfare that could be provided by women's participation in the labor force at the household level should not always be translated into more women’s power in decision-making, and women’s autonomy may not necessarily be improved by women’s participation in the labor market, particularly in a patriarchal society such as Afghanistan that most of the decisions concerning the women’s health are made by a male partner (26). This could explain the lower utilization of maternity services in communities with high scores in this domain as compared to those communities with low scores.
Several studies have shown that women’s attitude toward violence is associated with higher women empowerment and decision-making abilities and led to better access and utilization of ANC, PNC, and institutional delivery (27–30). However, in our study, it was only associated with having adequate ANC at both individual and community levels and PNC at the individual level. Women with strong attitudes against spousal violence are less likely to tolerate domestic violence and involve more in household decision-making including the decisions related to their reproductive and maternity care which led to higher utilization of maternity services observed in this study (31). Nevertheless, our findings showed no association between women’s attitudes toward violence and institutional delivery. That could be due to the limited access and difficulties in reaching the institution with delivery services in Afghanistan and not merely the women's willingness or decision to use such services (32).
Age at critical life events, including the age at first marriage and age at first birth, is an important predictor of pregnancy outcomes. It has been shown that women who marry and get pregnant at very young ages are more likely to experience negative reproductive and maternal outcomes such as unmet needs for family planning, inadequate ANC, pre-term labor, miscarriage, abortion, non-institutional delivery, postpartum hemorrhage, and inadequate PNC (26, 33). This has been attributed not only to the physical immaturity of young brides but also to their low power in decision-making and inability in negotiating their reproductive and maternal rights with their partner which leads to lower access and utilization of maternity care (31, 34). Young brides are often the victim of spousal violence in patriarchal societies such as Afghanistan in which women are considered inferior to men (31). The findings of this study reflect the impact that early marriage and conception could have on the utilization of maternity care as women with high scores in Age at critical life events domain at both individual and community levels were more likely to have adequate ANC and institutional delivery as compared to those with low scores. However, there was no significant association between age at critical life events and PNC. The limitations in access to PNC aside; the low quality of such services is one of the discouraging factors in the utilization of it in poor-resourced settings such as Afghanistan (35). In addition, older mothers‒those with high scores in age at critical life events‒ often have more exposure to such services, and therefore; low quality of PNC could be a stronger disappointing factor for this age group as compared to younger groups abd this could further reduce the utilization of PNC by this age group. however, more studies are recommended to characterize the underlying drivers of such trend in Afghan population.
Literacy plays a vital role in improving the majority of health outcomes (36). It has been shown that literate women are more likely to use maternal and reproductive services (37). Regardless of the number of years, women who can read experience better pregnancy outcomes and appear more frequently for their regular maternity visits (38). Literacy also is an important predictor of women empowerment and higher education has been linked to higher decision-making abilities and more participation in the labor force which are associated with higher women empowerment (10). Nonetheless, our study showed that only individual-level literacy is associated with the utilization of maternity services. This emphasizes the important role of individual literacy rather than community literacy in the utilization of maternity care in a poor-resourced setting as individuals with higher literacy often have more health literacy and navigation skills to pursue health care even if they live in a community with low literacy.
All that being said, our results suggested an acceptable level of convergence validity for the developed index (SWEI-A) and it appeared that the index can reliably estimate and capture all the dimensions of women empowerment among married Afghan women aged 15–49 years in Afghanistan. The survey-based women empowerment index in Afghanistan (SWEI-P) could not only inform the future policies and interventions of different domains of women empowerment in Afghanistan but could also guide the design of future studies to produce comparable results. Despite these, some limitations should be considered in the interpretation of the results. First, the possibility of socially desirable responses due to the self-reported data could bias the estimates and distort the relationships between explanatory and outcomes variables. Second, the cultural difference in perception of women's empowerment is not considered in the DHS survey; thus, the answers for some variables, particularly the attitude toward violence may be biased. Third, the socioeconomic development of the country may influence the norms and cultural customs over time; therefore, periodical updates are crucial. Last but not least; most of the questions concerning women empowerment were only asked from married women and single, widows, divorced and separated women were excluded; therefore, the index is only applicable to married women in Afghanistan.