Dimensions of women’s empowerment on access to antenatal care in Uganda: a further analysis of the Uganda demographic health survey 2016

Background: Women empowerment has been viewed as a good strategy in the reduction of global maternal morbidity and mortality. Most of the recent studies in Uganda have focused on ANC frequency and the associated factors with no focus on the effect of women empowerment. Our study aims at examining the prevalence of optimal access to ANC by considering timing of initiation, type of ANC provider and ANC frequency and their association with women empowerment. Methods: We used Uganda Demographic and Health Survey (UDHS) 2016 data of 9957 women aged 15 to 49 years. Multistage stratied sampling was used to select study participants and we conducted multivariable logistic regression to establish the association between women empowerment and access to ANC using SPSS version 25. Results: Out of 9,957 women, 2,953 (29.7%: 95% CI: 28.5.0-30.2) had initiated ANC in rst trimester, 6,080 (61.1%: 95% CI: 60.4-62.3) had 4 or more ANC contacts, and 9,880 (99.2%: 95% CI: 99.0-99.3) had received ANC from a skilled provider. Overall, 2,399 (24.1%: 95% CI: 23.0-24.6) had optimal access to ANC. Economic empowerment and exposure to media were the only women empowerment indices that were positively associated with optimal access to ANC. Other factors that were signicant include; region, wealth index, age, level of education and working status. Women in younger age groups, those with higher wealth quintiles and those from the Northern and Western regions were also more likely to have optimal access to ANC compared to their older, poorest quintile and Eastern region counterparts respectively. Conclusion: To ensure increased access to ANC, policy-makers and other stakeholders should prioritize use of mass media in maternal health programs, equitable allocation of the limited nancial resources with a focus on older, poor and uneducated women.


Introduction
Globally, the de nition of empowerment has varied substantially and measuring empowerment has proven to be di cult 1 . It is therefore commonly inferred by indicators, such as decision-making, nancial independence, or mobility freedom 2 . Women empowerment has been viewed as a good strategy in the reduction of global maternal morbidity and mortality 1 . Autonomous women have been shown to have better maternal health seeking behavior and better maternal and child health outcomes 3,4 . Globally, over half of maternal mortalities are due to pregnancy-related complications and over 90% of these deaths are from low and middle income countries 5 . Majority of these maternal deaths are preventable through skilled birth attendance and increased antenatal care (ANC) contacts 5 . Focused antenatal care has been shown to increase the likelihood of skilled birth attendance 1,6 and also gives health workers an opportunity to advise pregnant women on essential pregnancy care to reduce malnutrition, stillbirths, maternal mortality and morbidity, and neonatal deaths 5,7 .
Proper access to ANC has been shown to reduce maternal mortality by up to 8 per 1000 live births 5 .
Globally, progress to achieve universal antenatal care (ANC) coverage is tracked mainly by the ability to have contact with a skilled health provider during ANC and the number of ANC visits/ contacts 8 .
Although the number of contacts do not guarantee good quality of ANC, in theory, the more points of contact that a woman has with a well-functioning and effective health system, the higher the likelihood of earlier prevention, detection and treatment of potential pregnancy complications 8 . ANC quality is tracked by three dimensions: number of visits, timing of initiation and content of the care received 9 . The timing of initiation of ANC, ANC provider and the total number of ANC contacts have been shown to affect the content and quality of ANC received 9 . Early initiation and increased ANC contacts have been reported to be associated with reduced low birth weights and lower infant mortality 9,10 .
Over the last two decades, Uganda has achieved a steady reduction in the maternal mortality ratio (MMR) currently standing at 336 deaths per 100,000 live births with substantial variation across Ugandan regions 11 . Despite the reduction in MMR, the current ratio remains a concern if we are to achieve the Sustainable Development Goal (SDG) 3 target of less than 70 maternal deaths per 100,000 live births by 2030 12 . Benova et al. conducted a repeated cross-sectional study using four UDHS data (1995, 2000, 2006 and 2011) where it was shown that ANC coverage was high over 90% from 2001 to 2011 however, there was insu cient ANC frequency 13 . Less than half of the women had received four or more ANC contacts and only 10% of these women who had received four or more contacts had received all the required ANC components 13 . However, this study de ned optimal ANC care with only number of ANC contacts and type of provider and only looked at four independent variables (region, wealth, residence, level of education and wealth index).
Most of the other recent studies in Uganda have mainly focused on ANC frequency alone and the associated factors with no focus on the effect of women empowerment on access to ANC. Yet women disempowerment may negatively affect the utilization and quality of ANC services 9 Decisions regarding access to healthcare may be made exclusively by men and for the women who may access ANC, limited nancial and decision making abilities may negatively affect the possibility of implementing the recommended practices at home. In order to ensure proper and effective implementation of the new WHO ANC guidelines aimed at reducing maternal mortality and morbidity 14 , there is need to evaluate access to ANC at a national level with the most recent data. Therefore, our study aims at examining the prevalence of optimal access to ANC by considering timing of initiation, type of ANC provider and ANC frequency and the association with women empowerment. This is the rst study in Uganda to look at the three indicators of access to ANC and the association with women empowerment.

Data source
We used data from the 2016 UDHS which was a nationally representative population based crosssectional survey funded by the United States Agency for International Development (USAID) implemented between 20th June 2016 to 16th December 2016 by the Uganda Bureau of Statistics. UDHS is a periodical survey that is carried out every ve years as part of the MEASURE DHS global survey and collects Information on demographic, health and nutrition indicators. The UDHS used strati ed two-stage cluster sampling design that resulted in the random selection of a representative sample of 20,880 households 11 . A detailed explanation of the sampling process is available in the UDHS 2016 report 11 . Women who were aged 15-49 years and were permanent residents of the selected households or visitors but had stayed in the household the night before the survey were eligible for inclusion in the survey.
Our secondary analysis included women who had given birth in the last 5 years preceding the survey and had attended at least one ANC contact. Out of the total 18,506 women in the survey, 10,263 women had given birth in the last 5 years preceding the survey, and a nal weighted number of 9,957 women had attended at least one ANC contact. Where a woman had more than one birth in the last 5 years, ANC information for the most recent birth was considered. UDHS 2016 had four different questionnaires that included; household, men's, women's and the biomarker questionnaires. Our secondary analysis used data collected by the women's and household questionnaires that focused on women's background characteristics, reproductive health, domestic violence and nutrition. Women were asked a number of questions about antenatal health care that included; type of ANC provider, the number of ANC visits, the timing of the rst ANC visit and the components included in the ANC provided.

Study Setting
Uganda currently has a population of about 44 million people 15 . Uganda's health system has six levels ranging from the highest level of national referral hospitals to the lowest level at the community level 16 .
Agriculture is the main source of income for the 84% of Ugandans living in rural areas 16 . The Ugandan government abolished user fees in 2001 in all public health facilities. However, the health system still faces inadequate sta ng, low pay, shortage of medicines and poor infrastructure that have negatively affected health service provision and utilisation 17 . The private sector owns almost half of Uganda's health facilities 13 . However, less than 20% of these private health facilities are at the level of health centre III or above, which is the minimum level at which maternal health services are to be provided 13 .

Outcome variable
Based on WHO's de nition of 'effective ANC' and previous studies 9,18,19 regarding quality and access of ANC, a nal criterion was developed for determining optimal access to ANC. The outcome variable 'optimal access to ANC' was measured as a composite index and was dichotomized. The outcome optimal access to ANC was coded as 1 and suboptimal access as 0. Three indicators were used to de ne access to ANC and these included; timing of initial visit, number of visits and provider of the ANC.
Optimal access to ANC was considered as ANC package that was initiated in the rst trimester, included a minimum of four ANC contacts and was provided by a skilled health provider 13,20 . Timing of initiation of contacts describes how many months of pregnancy a woman was during her rst ANC contact. This was initially numerical ranging from 0-10 months and was categorized as: ' rst three months' (coded as 1) and 'more than three months' (coded as 0). Total number of ANC contacts is the number of times a woman received ANC and was initially a numerical variable categorized as 'four or more visits' (coded as 1) and 'less than 4 visits' (1-3 visits and coded as 0). We considered a minimum of four visits since it was the recommendation of WHO at the time of the survey. Type of ANC provider referred to the service provider who provided ANC to the woman in her last pregnancy. It was categorized as the 'skilled provider' (doctor, clinical o cer, nurse and midwife coded as 1) and 'non-skilled provider' (coded as 0). Where multiple providers provided care to one woman, the highest skilled provider was recorded. The total score from the three indicators for each woman was determined, with the maximum score being '3' if the woman initiated ANC in the rst trimester, had a minimum of four ANC visits and was seen by a skilled provider. Score of 3 was considered as optimal ANC access and any score below 3 was considered as suboptimal ANC access.

Explanatory variables
Measures of women's empowerment Four indices were created to measure empowerment of women: decision making, economic empowerment, sexual empowerment and exposure to media indices. Women's empowerment indices were measured as composite scores 1,19,21 .
Decision making included women's ability to be involved in making decisions regarding; their own health; large household purchases; visits to their family and control over their earnings 5 . Re-coding to the responses was done to have two categories (1 = woman involved in decision making alone or with partner, 0 = woman not involved in decision making). To create an index, we added up all the scores for each woman with the total score ranging from 0 to 4 and we nally categorized the score into four groups. The highest score was four which meant that the woman was involved in the decision making for the four used indicators. Medium decision making ability meant that women were involved in 2 or 3 indicators, low decision making meant that the woman was involved in only one indicator and no decision making meant that the woman was not involved in any decision making 21,22 . Decision making had about 1,846 missing responses since these questions were asked during the domestic violence survey sessions and yet not all women in the UDHS were included in the domestic violence section of the survey. These missing observations were assumed to be zero 19 and hence we risked overestimating low decision making. To ensure that this doesn't affect our ndings, we did a sensitivity analysis were we only considered women who had decision making responses and excluded those who were missing decision making responses. This showed no signi cant difference with the original analysis and more details are included in the sensitivity analysis section of the results. For background characteristics, we provided frequencies of decision making considering only women who had responded to decision making questions.
Economic empowerment included women's owning of a house, land and the type of earning from her work 22,23 . Each of the three economic empowerment indicators was re-coded 1 if the women owned a house or land (either alone or jointly with a partner) or received cash payment for their work and 0 if not owning a house, land or cash payment for work. To create an index, we added up all the scores for each woman with the total score ranged from 0 to 3 and we nally categorized the score into four groups. The highest score was 3 which meant that the woman was owning a house, land and earned cash for her work. Score 2 was considered medium economic empowerment, score 1 considered low economic empowerment and 0 no economic empowerment.
Sexual empowerment was considered as women's ability to refuse sex and ask a partner to use condoms 23,24 . Responses were coded (1 if the woman could refuse sex or ask for a condom and 0 if the woman could not) and sexually empowered women were those who were able to refuse sex or ask their partners to use condoms. To create an index, we added up all the scores for each woman with the total score ranged from 0 to 2 and we nally categorized the score into three groups. Highest score was 2 and these were considered to have high sexual empowerment, score 1 low sexual empowerment and 0 as no sexual empowerment.
Exposure to media was considered as the women's ability to have the opportunity to read newspaper or a magazine, listen to the radio and watch TV. Responses were re-coded (1 if the woman was exposed to newspaper, radio or TV and 0 if the woman was not). To create an index, we added up all the scores for each woman with the total score ranged from 0 to 3 and we nally categorized the score into four groups 21 . A value of 0 meant no access to any of the three, 1 exposure to only one medium (low) , 2 as exposure to only two (media) and 3 as exposure to all the three media channels (high) 21,22 .

Other explanatory variables or potential confounders
We included determinants of ANC access basing on available literature and data 1,25,26 . Ten variables were considered and of these, two were community level factors that included; place of residence categorized into rural and urban, and region of residence categorized into Central, East, West and North.
Two household level factors included; household size which was categorized into less than six and six and above and wealth index that was categorized into quintiles that ranged from the poorest to the richest quintile. Wealth index was calculated by DHS from information on household asset ownership using Principal Component Analysis. Six individual/maternal level factors were included in the analysis and these were; age (categorized as 15-24, 25-34, 35-49), parity (categorized as 0-4 and above 4), working status (categorized as working and not working), marital status (categorized as married and unmarried), health insurance (categorized as having insurance and not having) and level of education (categorized as no education, primary, secondary and tertiary levels).

Statistical analysis
We used the SPSS analytic software version 25.0 Complex Samples package for this analysis. Weighted data was used to account for the unequal probability sampling in different strata. Frequency distributions were used to describe the background characteristics of the women. We used cross-tabulations to examine associations between ANC access and women's empowerment indicators and sociodemographic factors. Pearson's chi-squared tests were used to investigate the signi cant differences between ANC access and the explanatory variables with the level of statistical signi cance set at p-value < 0.25.
Bivariable logistic regression was also conducted and we present crude odds ratio (COR), 95% con dence interval (CI) and p-values. Independent variables found signi cant at p-value less than 0.25 were included in the multivariable model. Independent variables that were non-signi cant at bivariable analysis level but had been shown to be associated with access to ANC in previous studies were also included in the multivariable logistic regression models. Two models were constructed in the multivariable analysis; one with only women empowerment variables and the nal model that included the women empowerment and other variables. Adjusted odds ratios (AOR), 95% Con dence Intervals (CI) and p-values were calculated with statistical signi cance level set at p-value < 0.05. We conducted sensitivity analysis where we separated the three indicators of optimal ANC access and we analyzed the association between women empowerment and each of the indicators (timing, frequency and provider) separately. Further sensitivity analysis was done with eight or more ANC contacts as the outcome and lastly, analysis where we only considered women with decision making responses and excluded those who had these responses missing. All variables in the model were assessed for collinearity, which was considered present if the variables had a variance in ation factor (VIF) greater than 10. However, none of the factors had a VIF above 3.

Results
A total of 9,957 women were included in this study (Table 1). Of these, 2,399 (24.1%) (95% CI: 23.0-24.6) had initiated ANC in the rst trimester, had 4 or more ANC contacts and received ANC provided by a skilled provider. Majority of the women were residing in rural areas (76.7%), married (81.5%), working (79%) and had primary as highest level of education (59.8%). The mean age of study participants and household size were 28.3 + 7.12 and 5.99 + 2.79 respectively. Access to ANC indicators have been shown in Table 2.   Table 3 shows results of bivariable analysis. In the nal logistic regression model, only economic empowerment and exposure to media were positively associated with optimal access to ANC. Other socio-demographic factors that were signi cant include; region, wealth index and age as indicated in Table 4. Women with exposure to media and those with economic empowerment were shown to have optimal access to ANC compared to those with no exposure to media or economic empowerment. Women in younger age groups, those with higher wealth quintiles and those from the Northern and Western regions were also more likely to have optimal access to ANC compared to their older, poorest quintile and Eastern region counterparts respectively.  Factors associated with timing of ANC initiation Four factors were positively associated with timing of the initiation of ANC and these included level of education, age, region, and exposure to media. Exposure to media was the only women empowerment factor that was positively associated with timing of ANC initiation and the strength of association did not vary signi cantly from the overall analysis. Unlike in the overall analysis of optimal ANC access, level of education was signi cant and higher level of education was negatively associated with earlier timing.
Women with primary (AOR:0.79 95% CI: 0.67-0.93) and secondary (AOR:0.75 95% CI: 0.61-0.92) levels of education were 21% and 25% less likely to initiate ANC in the rst trimester respectively compared to those with no education. No signi cant differences were observed regarding the associations of age and region with ANC initiation timing compared to those with optimal access to ANC in the overall analysis.
Factors associated with type of ANC provider Only wealth index was signi cantly associated with type of ANC provider and the association was stronger compared to the overall analysis. Women belonging to the middle (AOR:2.64 95% CI:1.06-6.57) and richer (AOR:3.35 95% CI:1.12-10.08) quintiles were 164% and 235% more likely to use a skilled ANC provider compared to those from the poorest quintile.

Discussion
To our knowledge, is the rst and to-date study to comprehensively examine the association between women empowerment and access to ANC in Uganda. The study showed that only 24.1% of the women had optimal access to ANC. Utilization of ANC was higher than that in Nepal 9 and Bangladesh 27 while slightly lower than that in Central Ethiopia 28 and Benin 5 . Earlier timing of ANC initiation was slightly higher by 2.7% compared to that in Nigeria 29 . The differences in the health facilities' access, health system capacity and economic development among these Countries could also explain the observed differences.

Women's Empowerment and access to ANC
Out of the four indices of women empowerment, only economic empowerment and exposure to media were positively associated with optimal access to ANC. Women who had weekly exposure to all the three media outlets and those exposed to only two media outlets were 44% and 33% respectively more likely to have optimal access to ANC. The association was still observed in the sensitivity analysis with ANC frequency and timing of ANC initiation. The association was stronger with 8 or more ANC contacts compared to the original analysis that looked at optimal access as a composite outcome. Women with medium and high media exposure were 124% and 125% respectively to have 8 or more ANC visits. The in uence of media on access to ANC could be attributed to the role media houses play in reducing knowledge gaps by sensitizing women on the bene ts of ANC utilization which leads to positive attitudes, challenges negative social norms and improves health seeking behavior 21,22 . Furthermore, people who are exposed to media are more likely to have discussions with others which interpersonal interactions contribute greatly in challenging negative norms that might lead to positive health seeking behavioral change 30 . Exposure to media has been shown in previous studies to have a positive association with access to ANC 20,21,26,27 .
Women who were economic empowered were shown to be more likely to have optimal access to ANC compared to their counterparts who were not economically empowered. This association was also observed in the sensitivity analyses regarding ANC frequency. A similar association was observed with wealth index were women who belonged to households with higher wealth quintiles were more likely to have optimal access to ANC compared to those in the poorest quintile. Poverty is a known determining factor of maternal health care utilization in low and middle income countries and women with limited economic resources or low economic empowerment are more likely to afford the direct and indirect costs associated with access to optimal ANC 26,31,32 . Although Uganda abolished user fees in public health facilities 17 , indirect and direct costs such as out of pocket costs for drugs that might not be available in the public hospitals and transport costs pose nancial barriers to optimal access to ANC 27,33 . Women belonging to the lower wealth quintiles and those who are not economically empowered are more likely to have difficulties in meeting transport and indirect costs related to maternal healthcare in government facilities which prevents/limits them from utilizing health facilities 34 and this is further worsened by the high costs of private health facilities 12 . This is most likely to lead women initiating ANC contacts late, have few or no ANC contacts and have an unskilled ANC provider 26 . Positive association between economic empowerment and wealth index with access to ANC has been documented in other studies 25,26,28,33,35 .
In this sample, decision making and sexual empowerment were not signi cant predictors of optimal access to ANC. Chol  where Uganda was grouped showed weak but signi cant associations 33 . Within the same study, country level analyses of three countries showed a negative association between high decision making ability, sexual autonomy with utilization of ANC 33 . Women with higher autonomy in these countries were less likely to utilize ANC 33 . Despite the non-signi cant association between decision making and access to ANC in our study, several other studies have shown a positive association 9,26,36 . Our analysis combined the four aspects of decision making and we were unable to ascertain whether each aspect has a different effect. Decisions on maternal healthcare seeking have been evidenced to be complex mainly in resource limited settings and depend on various logistical and structural factors 24 . Furthermore, the uneven distribution of resources and health facilities' availability in the different regions of Uganda might explain the observed non-signi cant association. Decision making has also been shown to have no signi cant association with maternal healthcare access and utilization in some previous studies 22,24,37,38 .
Other demographic factors Our study also showed age, level of education, wealth index, region and working status as the demographic and socioeconomic variables that were associated with optimal access to ANC. Resources, such as wealth and employment have been often identi ed as empowerment components or enabling factors 37 . For example, a woman who is in extreme poverty may not have high access to media or an illiterate woman will not be able to read newspapers.
Younger women were more likely to have optimal access to ANC. A similar positive association was observed even in the sensitivity analyses. Older women usually have higher number of births and tend to develop con dence given their accumulated experience and knowledge from the previous pregnancies, thus they become less motivated to initiate ANC early and to have more ANC contacts 26 . In addition, older women tend to have more traditional cohorts hence can easily resist modern health care services 39,40 . Age as a predictor of health facility utilization during childbirth has also been documented in several other studies 25,26 .
Women in the Northern and Western regions were more likely to have access to optimal ANC compared to those in the Eastern region. This was also observed in the sensitivity analyses as well with the association becoming stronger in the 8 or more ANC contacts were women in the Central region were 221% more likely to have 8 or more ANC visits compared to those from the East. The differences in health facilities' distribution and accessibility, sociocultural context and economic development contribute to the observed regional differences in utilization of health facility at birth 41  Although working status and level of education were non-signi cant in the original overall analysis, they were found to be signi cant with ANC frequency in the sensitivity analysis. Women who were not working were less likely to have four or more ANC visits compared to those who were working. Women who had higher levels of education were more likely to have 4 or more ANC contacts and less likely to initiate ANC in the rst trimester compared to those with no education. Working status is closely linked to wealth and level of education as women with higher levels of education tend to be employed and therefore earn income 26 . Beyond being a source of money to enable ANC access, working and education increase women's exposure and access to information. Working status has also been documented in previous studies as a positive predictor of ANC access 25,26 . However some studies have reported mixed results with some showing a negative association where working women were less likely to have a high number of ANC contacts and more likely to initiate ANC late 27,36 . This is attributed mostly to limited time availability which could also partly explain the observed result of women with higher levels of education being less likely to initiate ANC early.

Strengths and limitations
This is the foremost nationwide analysis that explores association of women empowerment with access to ANC looking at all the three dimensions of access in Uganda, including the latest WHO recommendation of at least 8 ANC contacts. Therefore, it can be used as a yardstick and motivation for further studies on related subject matter. Secondly, we used the most current nationally representative data hence the ndings are generalizable to all women in Uganda. However, use of cross-sectional data only enables associations to be established but not causal relationships. Having information regarding the most recent birth, hindered us from getting estimates for each calendar year. The absence of some crucial variables such as distance to the nearby facility was a limitation in the data. Lastly, the possibility of recall bias due to self-reported answers could be a limitation in this study.

Conclusion
This study showed that less than a quarter of women are able to have 4 or more ANC contacts, initiate ANC contacts early and are seen by a skilled ANC provider. The observed insu cient frequency and timing gaps risks women getting less adequate ANC which coupled by the documented low quality of services could explain the slow reductions in maternal mortality levels. However, majority of the women (over 99%) are seen by a skilled provider at least once during their pregnancy. Although ANC frequency (both 4 or more and 8 or more contacts) increased from 2011 to 2016, utilization of 8 or more ANC contacts is still very low at 1.9%. Women empowerment indices which including exposure to mass media and economic empowerment had a positive association with optimal access to ANC. Other socioeconomic variables such as age, wealth index, region, level of education and working status were also signi cantly associated with access to ANC. To ensure that the 2016 WHO ANC guidelines that recommend eight 'contacts' instead of four 'visits' are effectively implemented and achieved, policymakers and other stakeholders should prioritize use of mass media in maternal health programs, equitable allocation of the limited nancial resources with a focus on older, poor and uneducated women. There is need for further studies to look at the quality of ANC and a deep analysis on the association of decision making and access to ANC. Declarations