Dimensions of Women Empowerment and its association with Utilization of Pregnancy Related Care Services in Selected Rural Area

doi:10.21203/rs.3.rs-3324062/v1

Pregnancy-related care utilization is a fundamental urgency but family and community interference results in unattainability, though influence of different dimensions of women empowerment upon it is mostly unidentified. The study aims to identify the association between women empowerment dimensions and pregnancy-related care utilization. A cross-sectional study was conducted among conveniently selected 90 women attending purposively selected Chowgacha Upazila Health Complex, Jessore, for institutional normal vaginal delivery, between January and December, 2022. Maintaining human ethics protocol, an exit interview was done through a pretested semi-structured questionnaire. Women empowerment was assessed by a 3-point Likert scale under six dimensions (socio-cultural, educational, health-related, economic, technological, and life course) developed by country contextual modification of women empowerment index. Each dimension was recoded into two categories based on mean score. In multi-variate analysis, the health-related dimension was associated with iron-supplementation (OR=0.18; 95% CI 0.056-0.577), calcium-supplementation (OR=0.17; 95% CI 0.05-0.54), taking nutritious food (OR=0.07; 95% CI 0.02-0.29). The socio-cultural dimension was associated with nutritional supplementation (OR=0.17; 95% CI 0.04-0.7). The technological dimension was associated with ANC visits (OR=2.97; 95% CI 1.23-7.15). The economic dimension was associated with planned savings (OR=0.16; 95%CI 0.05-0.49). In bivariate analysis, the socio-cultural dimension was associated with frequency of meals (OR=11.1; 95%CI 1.4-89.1) and birth companionship (OR=3.3; 95%CI 1.4-8). The economic dimension was associated with frequency of meals (OR=7.22; 95% CI 1.4-33.6) and birth companionship (OR=2.7; 95% CI 1.1-6.4). The technological dimension was associated with frequency of meals (OR=4.9; 95%CI 1-23.3) and birth companionship (OR=2.7; 95% CI 1.1-6.5). The health-related dimension was found to be mostly associated with pregnancy-related care utilization. Hence, promotion of health-related dimension to enhance women empowerment could bring a successful pregnancy-related care utilization towards achieving SDG-5.

pregnancy-related care

pregnancy-related care utilization

women empowerment

women empowerment dimension

In every 24 hours, approximately 810 women die during pregnancy and childbirth, with 94% of the deaths occurring in poor and middle-income nations (1). Recommended Antenatal, intra natal care and postnatal care may help to prevent maternal and neonatal mortality by identifying pregnancy-related complications in due time. The percentage of women with four or more antenatal care (ANC) visits declined from 46% in 2017–18 to 41% in Bangladesh. Although the government of Bangladesh developed and implemented programs to promote national safe motherhood, birth preparedness, and complication readiness to increase Ante-natal care visit and quality antenatal care, only 21% of women received quality ante-natal care (2). Existing studies have documented the significant association between women’s empowerment and maternal health service utilization in different countries even in Bangladesh [(3)(4)(5)(6)]. However, it is still debatable how precisely to quantify women's empowerment in different geographical area and cultural settings. Some researchers have employed education, economic status, household decision making, attitude towards gender-based violence and support from family and kin. At the same time some other researchers documented women’s empowerment considering decision making power, physical assets, and economic opportunity to measure the influence of women’s empowerment on access to maternal health care services (7). However, what explicitly measures women’s empowerment in different contexts and cultural backgrounds is still argumentative. Different dimensions of women’s empowerment might be independently effective in different contexts and cultural backgrounds such as in Africa, Asia, and other countries [(8)(9)(10)]. Women empowerment index says that to evaluate women empowerment correctly we should give emphasize on different dimensions of women empowerment [(8)(11)]. This study focuses on different dimension (socio-cultural dimension, Economic dimension, educational dimension, Health-related dimension, Technological dimension) of women empowerment and used a modified women empowerment index. The study's goal was to investigate the association between different dimensions of women's empowerment and its association with utilization of pregnancy-related care services.

An interview-based cross-sectional study was conducted among pregnant women aging from 15 to 49 years came for institutional delivery at Chowgacha Upazila Health Complex, Jessore.

Characteristics of the study site and the population:

Chowgacha upazila health complex, Jessore is a sub district level women friendly hospital. Jessore is situated at the south west part of Bangladesh. Health assistant maintain the monthly birth record by a specially developed format. It is a model hospital and highest number of normal vaginal delivery occur in this hospital.

A considerable proportion of respondent’s husband were farmer and few respondents were working in the cities as employees. Most of the respondents were Muslims.

Sampling techniques of study population and study place:

The study place was taken purposively as highest number of pregnant mothers came here for institutional normal vaginal delivery. So, it was easier for us to reach the target population.

Non-probability convenience sampling technique was used to select the respondents for exit interview aging from 15 to 49 years. This was the most appropriate method of sampling because this way data could be collected quickly from the respondents within a short timeframe of one month.

Interview of study participants:

A pre-tested semi structured questionnaire was used for data collection. At the beginning, the study was explicitly explained to each eligible respondent and informed written consent was obtained. Then the data were collected from the respondents through face-to-face interview. Privacy was maintained.

Variables:

We wanted to find out the association of women empowerment and pregnancy related care utilization. We initially selected two dependent variables regarding utilization of pregnancy related care and five proxy variables representing the different dimensions of women empowerment, aggregated from several indicator variables. Those dimension and relevant questions are listed in Table-1.

Dependent variables

There are two dependent variables to indicate whether each respondent had utilized pregnancy related care during her pregnancy and child birth. The first variable was whether the respondents had taken antenatal care (ANC). Variables related to ANC were Four ANC visit, planned savings, nutritional supplementation, Birth preparedness, Attendant during visit. The second variable was Intra natal care (INC). Variables related to INC were whether the delivery was assisted by SBA and birth companionship.

Independent variables

Women empowerment was categorized into five different dimensions namely (socio-cultural, educational, health-related, economic, and technological dimension) and compared the association of each dimension with health service utilization. This procedure of measuring many components of empowerment was important, because more than two dimensions were likely to be associated with outcome indicators at the same time, as well interacting with each other. Initially, five key dimensions of empowerment was set up based on a study conducted in Bangladesh by Schuler and Hashemi and each variable were allocated in the questionnaire to the most appropriate dimensions [(8)(9)]. We modified the women empowerment index and like Schuler and Hashemi, who arbitrarily gave scores for each question and simply added these to obtain the overall empowerment score, we also gave scores for each question and computed these to obtain the overall score. If the respondents got higher score, considered as more empowered and lower score as less empowered.

Data analysis:

To maintain consistency, the data were checked and edited manually. Then compilation, processing, and analysis of the data were done by using IBM SPSS Software version 26. The findings were presented by frequency percentage in tables and graphs. Means and standard deviations for continuous variables and frequency distributions for categorical variables were done. The statistical significance of the observed proportional difference was evaluated using bivariate analysis. To determine the strength of the association between the dependent and independent variables, bivariate logistic regression analyses were used. Statistical significance was defined as a P-value of less than 0.05.

As shown in Table 2 the mean (± standard deviation) age of the mothers was 24.03 (± 5.21) years with majority of them being housewives (91.1%) and more than two third (67.8%) of the respondents completed primary level of education. Nearly three quarter of the respondents belonged to a joint family (73.3%) and majority of the respondents had their own house (94.4%).

As shown in Table 3 Maximum respondents (85.6%) stated that they required permission from their family to go anywhere. Majority (84.4%) always required permission before getting any medical help. Maximum respondents (95.6%) had to discuss with others family members on family planning. Nearly three quarter (70%) of the mother’s educational qualification was equal to their husband or more than their husband but they are not involving any decision-making process. They could not even decide the delivery place by themselves (0.0%).

As shown in Table 4 Two fifth (40%) of the respondents had completed four and more than four ANC visits, more than a quarter (28.9%) had planned savings for delivery and majority (83%) of the respondents took nutritional supplementation. Three fifth (59%) of the respondent’s birth companionship was from their parental side.

As shown in Table 5, The mean (± SD) women empowerment score of the respondents was 17.33(±4.69) ranging from 8 to 33. As shown in Table 6, In multi-variate analysis, Health-related dimension was associated with iron-supplementation (OR=0.18; 95% CI 0.056-0.577), calcium-supplementation (OR=0.17; 95% CI 0.05-0.54), taking nutritious food (OR=0.07; 95% CI 0.02-0.29). Socio-cultural dimension was associated with nutritional supplementation (OR=0.17; 95% CI 0.04-0.7). Technological dimension was associated with ANC visits (OR=2.97; 95% CI 1.23-7.15). Economic dimension was associated with planned savings (OR=0.16; 95%CI 0.05-0.49). As shown in Table 7, In bivariate analysis, socio-cultural dimension was associated with frequency of meal (OR=11.1; 95%CI 1.4-89.1), birth companionship (OR=3.3; 95%CI 1.4-8). Economic dimension was associated with frequency of meal (OR=7.22; 95% CI 1.4-33.6), birth companionship (OR=2.7; 95% CI 1.1-6.4). Technological dimension was associated with frequency of meal (OR=4.9; 95%CI 1-23.3), birth companionship (OR=2.7; 95% CI 1.1-6.5).

This cross-sectional study was conducted to explore the association of women empowerment and pregnancy related care utilization in selected rural area. The study was conducted among the pregnant women who came for institutional normal vaginal delivery at Chowgacha upazila health complex. To capture the real picture, this place was selected purposively. At the same time, we tried our level best to take each and every data with caution, maintaining the respondent’s privacy. Finally, our utmost priority was there to collect the samples as convenient as it was possible.

The study found among the respondents the mean age was 24.03 years SD ± 5.21, mostly Muslims (89%) and (67.7%) were primary completed. In BDHS 2017-18 the female proportion of primary completed was (10.1%). In most of the respondents were housewife (91.1%) and their husbands were farmer (32.2%). Study revealed that most of the respondents were from joint family (73.3%) and half of the respondents live in kacca home (52.2%) (12).

This study was aimed to investigate the dimensions of women’s empowerment which are associated with utilization of pregnancy health services. We found that there was statistically significant between the dimension “socio-cultural dimension, economic dimension, technological dimension” and the utilization of pregnancy related health services in the area studied.

The study found an association between the economic stability of the participants and pregnancy related health service utilization, A possible explanation of this finding is that women who are economically powerful can directly participate in health care decision-making, service utilization and have stronger control over their own lives. This result is consistent with Dalal; et al (13).

In majority of the family, 85.6% of the respondents need to get permission always if they wish to go outside from home and 84.4% of the respondents always need to took permission before getting any medical help, in most of the cases, 90.0% of the respondents had to discuss with other family members for taking any health care. Similarly, Zaman; et al.,2008 found that, treatment autonomy for own was 70.9% (14).

There is evidence to suggest that women’s involvement in household financial decision making has been increasing (15). More than two third (72.2%) respondents need to discussed with other family members in case of household purchases and 14.4% of the respondents could take decision alone about their household purchases.

In this study more than three fourth (86.7%) of the respondents were never involved in any cash income. Almost 37.8% of the respondents gave history of monthly family income 10000 taka and less than 10000 takas, around 34.4% of them had family income between 10001to 19999 and 27.8% had family income between 20000 to more. Similarly, another study showed, one third of the respondents, 34% were engaged in job and 66% had no job. Highest percentage had monthly family income taka 10001 to 20000, 30.1% followed by 28.2% had monthly family income less than taka 10000, whereas 24.8% had monthly family income 30001 taka and above and 30.1% had income taka 20001 to 30000 (14). In spite of, high average monthly income of the families in both the studies, women had lesser part in the procedure of income generation.

Only 10.0% were found to listen to radio sometimes. Whereas, almost 67.8% had history of watching television. While 77.8% were both husband and wife mobile user. Regular media exposure was positively associated with both the cumulative empowerment index and the decision-making index. This can be attributed to the fact that the media exposes women to the world outside their homes including to new ideas and non-traditional roles for women (16). These results are consistent with (Mahmud; et al.,2012) findings (17). In our study we also found that technological dimension of women empowerment is associated with different pregnancy related service utilization. Our findings document that women exposed to mass media were more likely to use maternal health care services. It is possibly due to the increased dissemination of health education messages through popular mass media.

The study founds association between socio-cultural dimension and health related dimension with iron supplementation. A cross-sectional study was carried out in four German states in 2015 where, with the help of midwives, women in childbed were asked to retrospectively answer a questionnaire about iron intake from various sources and reasons for supplementing iron during their recent pregnancy. 207 participants, 65.2% had supplemented iron. 84.4% reported to have done this because of a diagnosed iron deficiency anaemia. Six percent of the participating women had not supplemented iron in spite of a diagnosed iron deficiency anemia (18).

The study revealed association between socio-cultural, economic, and technological dimension and birth companionship. The possible explanation maybe women with independence in decision-making and right to use to economic resources, are more likely to choose their birth companion. Implementation of the presence of companions during hospital admission for childbirth: data from the Birth in Brazil national survey many women reported that having a companion was very helpful or helpful. Of those women who did not have a companion, this was mostly because of hospital prohibition (19).

Limitations:

The following limitations should be considered while reviewing this report:

The study population was selected purposively from one area with small sample size, so it does not necessarily represent situations prevailing in other part of the country.
In some section of questionnaire, the answers of the respondents were memory based. recall bias may hamper the quality of data.
The study has considered the delivery of last child, so we could not evaluate the situation during deliveries of other children, because it was out of our study area. but it is important to evaluate the situation of women empowerment in case of every child birth.
We included ANC and INC emphasized on a narrow range of indicators, which might underestimate the effects of women empowerment on pregnancy related care utilization.
Therefore, a future study might be helpful to evaluate the post-natal care utilization. a qualitative study might be helpful to evaluate the impact of dimensions of women empowerment on pregnancy related care utilization.

Findings from this study revealed that women empowerment is a significant medium of pregnancy related care utilization. Health-related dimension, Economic dimension and technological dimension were more influential than socio-cultural dimension. However, in particular, access to media and information technologies as well as education and encouragement for women to participate in economic activities may boost the number of women to ensure proper pregnancy related health care utilization.

Recommendation:

Around 1/3rd of the respondents even after completion of three or four ANC visits, only 1/4th of the respondents taking iron or calcium pill regularly. At the same time less than 1/5th of the respondents was taking nutritious food or increasing their meal frequency regularly. Evidence based improvement of the ANC service quality and continuous monitoring is required.
Around 70% of the mother’s educational qualification was equal to their husband or more than their husband but they were not involved in any decision-making process. They could not even decide the delivery place by themselves. So, it could be assumed that only education cannot change the scenario.
Other policies such as the establishment of income generating programs for women and education programs for enhancing their status and power in both the household and community can effectively improve women’s health through health care service utilization.
Lastly, women herself must break the silence towards women empowerment. They should raise their voice for their rights and take hold of their life and multi stake holder approaches is needed with ministry of health, ministry of education and ministry of women and children affairs can work together to educate them about sexual and reproductive health right from their primary education level.

Authors contribution

A. Habiba is the principal investigator of this research and she developed the methodological framework, performed data collection, analysis and developed the manuscript.

B. Zerin Shabnam Rahman helped with the result section and contributed in writing the manuscript.

C. Fouzia Ibrahim and Tasnia Fatema both authors contributed developing methodological framework and prepared the figures.

D. Irfan Nowroze Noor contributed to development of manuscript, data collection and methodological framework.

E. All the authors reviewed the manuscript and approved the final manuscript.

Authors information:

Habiba Habiba, BDS, MPH graduate from National Institute of preventive and social medicine, Dhaka, Bangladesh.

Zerin Shabnam Rahman, MBBS, MPH graduate from National Institute of preventive and social medicine, Dhaka, Bangladesh.

Fouzia Ibrahim, MBBS, MPH graduate from National Institute of preventive and social medicine, Dhaka, Bangladesh.

Tasnia Fatema, MBBS, MPH graduate from National Institute of preventive and social medicine, Dhaka, Bangladesh.

Irfan Nowroze Noor, MBBS, MPH, Doctoral student, ASEAN Institute for Health Development (AIHD), Mahidol University, Salaya,Thailand.

Funding:

None

Availability of data and materials:

The data supporting the findings of this study are available from the corresponding author, upon request.

Ethical approval and consent to participate:

Participants were informed of the objectives and the methods of this study, and informed written consent and assent from minor age group participants was obtained from each of the respondents and their guardians.

Ethical clearance for this study was obtained from Institutional Review Board of National Institute of Preventive and Social Medicine (Memo no-NIPSOM/IRB/2017/09).

No human tissues or blood sample were taken during the process of data collection. Only sociodemographic variables and data related to women empowerment and pregnancy related care utilization was taken during the data collection after getting informed written consent and assent. The study conformed to all relevant guidelines and regulations.

Consent for publication:

Not applicable

Competing interests:

We have no competing interests.

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Table 1 Dimensions of women empowerment and their corresponding questions in the questionnaire

Dimension										Characteristics
Socio-cultural dimension	Freedom of movement									Do you need to get permission from your family if you wish to go outside your home?
	Always	sometimes				Never
	0	1				2
	Never	sometimes				Always				Are you allowed to go alone to market/Health center/outside the village/visit your friends home?
	0	1				2
	Support by family/freedom from domination									Is physical support by your family available in household chores?
	Never	Sometimes							Always
	0	1							2
	Always	Sometimes							Never	Have you ever been hit by your husband?
	0	1							2
	Decision making in daily life									Who holds the final say in buying things for your family/for your child/for yourself
	Not involve in decision making	Discuss with others							Alone
	0	1							2
										Who makes decision on what to cook?
Economic dimension	Economic security and stability									Are you engaged in any activities with cash income?
	Never		Sometimes				Always
	0		1				2
	Never		Sometimes				Always			Can you spend money freely without anyone`s permission?
	0		1				2
										How much money does your household earn in a month?
Health	Decision making related to health									Who makes a decision on your health care.
	Not involve in decision making			Discuss with others				Alone
	0			1				2
										Who makes decision on your conception/family planning
	Not involve in decision making			Discuss with others				Alone
	0			1				2
	Always			Sometimes				Never		Receiving permission before getting medical help
	0			1				2
	Never			Sometimes				Always		Having money for health care
	0			1				2
Education	Education									Highest education level
	Illiterate				Can sign only			At least primary completed		Literacy
	0				1			2
	Less than husband				Equal to husband			More than husband		Educational difference with husband
	0				1			2
Life course	Less than 15 years	15-17 years				18-more				Age at first child birth
	0	1				2
Technology	Always	Sometimes				Never				Radio
	2	1				0
	Always	Sometimes				Never				Television
	2	1				0
	Both Husband & wife	Husband				None
										Mobile
	2	1				0

Table 2 Characteristics of the respondents:

Socio-demographic variables	Frequency	Percentage
Age
15-25 years	59	65.6
26-49 years	31	34.4
mean±SD	24.03±5.21
Religion
Muslim	89	98.9
Hindu	1	1.1
Educational Qualification
Upto Primary	61	67.8
Secondary and above	29	32.2
Occupation
housewife	82	91.1
others	8	8.9
Type of Family
Nuclear	24	26.7
Joint	66	73.3
Type of home
Kacca	47	52.2
Semi pacca	23	25.6
Pacca	20	22.2
Owner of the house
Own	85	94
Rent	5	6

Table 3 Findling related to dimensions of women empowerment:

Women empowerment related information
	Frequency	Percentage
Socio-cultural dimension
Permission needed to go out
Always	77	85.6
sometimes	11	12.2
Never	2	2.2
Allowed to go alone outside home
Always	14	16
sometimes	12	13
Never	64	71
Support in household chores
Always	33	37
sometimes	19	21
Never	38	42
Husbands physical assaults
Always	2	2.2
sometimes	20	22.2
Never	68	75.6
Decision making on household expenditure
Alone	13	15
Discuss with others	65	72
Not involve in decision making process	12	13
Economic dimension
Cash income
Always	4	4.4
sometimes	8	8.9
Never	78	86.7
Spends money freely
Always	11	12
sometimes	38	42
Never	41	46
Monthly family income
0 to 10000	34	38
10001 to 19999	31	34
20000 to more	25	28
Health related dimension
Decision making on getting medical help
Always	76	84.4
sometimes	12	13.3
Never	2	2.2
Decision on family planning
Alone	1	1.1
Discuss with others	86	95.6
Not involve in decision making process	3	3.3
Having money for health care
Always	2	2.2
sometimes	5	5.6
Never	83	92.2
Decision about fixing the place of delivery
Alone	0	0
Discuss with others	89	98.9
Not involve in decision making process	1	1.1
Educational dimension
Educational difference with husband
Less than husband	26	29
Equal to husband	51	57
More than husband	13	14
Technological dimension
Watching tv
Always	4	4.4
sometimes	61	67.8
Never	25	27.8
Mobile phone user
Husband	20	22
Both husband and wife	70	78
Life course
Age at first child birth
Less than 15 years	5	5.6
15 to 17 years	30	33.3
18 to more	55	61.1

Table 4 Findling related to pregnancy related care utilization by the respondents:

Information related to Ante-natal care
	Frequency	Percentage
Number of ANC visits
Less than four	54	60
Four and more than four	36	40
Planned savings
Yes	26	29
No	64	71
Nutritional supplementation
Yes	75	83.3
No	15	16.7
Taking iron pill
Never	5	5.6
Regularly	23	25.6
Sometimes	62	68.9
Taking calcium pill
Never	4	4.4
Regularly	21	23.3
Sometimes	65	72.2
Nutritious food taking
Never	11	12
Regularly	13	14.4
Sometimes	66	73.3
Increasing frequency of meal
Never	21	23.3
Regularly	14	15.6
Sometimes	55	61.1
Information related to Intra-natal care
Birth companionship
Parental side	53	59
In laws side	37	41

Table 5 Distribution of the respondents according to their empowerment score:

Total women empowerment score
Mean	17.33
Median	17.00
Mode	17
Std. Deviation	4.686
Skewness	1.159
Std. Error of Skewness	.254
Minimum	8
Maximum	33

Table 6 Dimensions of women empowerment associated with the utilization of pregnancy related care- Multivariate logistic regression:

	OR	95% CI	p-value
Health-related dimension
Iron supplementation	0.18	(0.0056-0.577)	0.004
Calcium supplementation	0.17	(0.05-0.54)	0.003
Nutritious food taking	0.07	(0.02-0.29)	0.00
Socio-cultural dimension
Nutritional supplementation	0.17	(0.04-0.7)	0.01
Technological dimension
ANC visit	2.97	(1.23-7.15)	0.01
Economic dimension
Planned savings	0.16	(0.05-0.49)	0.001

Table 7 Association between dimensions of women empowerment and pregnancy related care utilization- Bivariate logistic regression:

	OR	95 % CI	p-value
(a) Iron supplementation
Socio-cultural dimension	3.1	(1-9.3)	0.04
Health-related dimension	6.6	(2.1-20.6)	0.001
(b) Calcium supplementation
Health-related dimension	5.7	(1.8-17.8)	0.001
(c) Nutritious food taking
Socio-cultural dimension	10	(1.2-80.7)	0.01
Health-related dimension	19.4	(4.8-77.7)	0.001
Economic dimension	6.3	(1-30.2)	0.01
(d)Increasing frequency of meal
Socio-cultural dimension	11.1	(1.4-89.1)	0.01
Health-related dimension	6.6	(1.9-22.8)	0.001
Economic dimension	7.22	(1.4-33.6)	0.01
Technological dimension	4.9	(1-23.2)	0.03
(e) Planned savings
Economic dimension	6.1	(2.1-18.4)	0.001
(f) Ante-natal visits
Technological dimension	0.34	(0.14-0.81)	0.01
(g) Birth companionship
Socio-cultural dimension	3.3	(1.4-8)	0.01
Economic dimension	2.7	(1.1-6.4)	0.02
Technological dimension	2.7	(1.1-6.5)	0.02

No competing interests reported.

Dimensions of Women Empowerment and its association with Utilization of Pregnancy Related Care Services in Selected Rural Area

Status:

Version 1

Abstract

Introduction

Materials and methods

Characteristics of the study site and the population:

Sampling techniques of study population and study place:

Interview of study participants:

Variables:

Data analysis:

Results

Discussion

Limitations:

Conclusion

Recommendation:

Declarations

References

Tables

Additional Declarations

Status:

Version 1