Two-fifths of women are not autonomous in maternal health service utilization: A community-based cross-sectional study

doi:10.21203/rs.3.rs-959108/v1

Background: Autonomy of women in health care decision-making is tremendously crucial for improved maternal health outcomes and women’s empowerment. Women with greater freedom of movement are more likely to receive maternal health services. However, little has been investigated about women’s autonomy in maternal health care decision-making and contributing factors in Ethiopia. The aim of this study was to assess decision-making autonomy on maternal health care services utilization and associated factors among women.

Methods: A community-based cross-sectional study was conducted in Mettu rural Woreda, Ilu Aba Bor zone, southwest Ethiopia from June 19 to August 20, 2021. Data was collected using a pretested interviewer-administered questionnaire from 541 randomly selected women. The collected data was entered into Epi-Data version 3.1 and exported to SPSS version 22 for analysis. Bivariate and multivariate logistic regression was used to identify factors associated with women's decision-making autonomy on maternal health service utilization. The significance of association was declared by using the odds ratio with a 95% confidence interval and a p-value less than 0.05 in the multivariable model.

Results: Out of 522 women included in the analysis, 322 (60.5%) (95% CI: 56.2%-64.7%) were found to be autonomous on maternal health service utilization. Age category from 30-39 years, AOR=4.27 (95%CI: 1.59-11.43), attending primary education and above, AOR=3.87 (95%CI: 2.15-6.99), greater than five family size, AOR=0.25 (95%CI: 0.15-0.41), and distance from the health facility, AOR=5.33 (95%CI: 2.50-11.33) were significantly associated with women's decision-making autonomy on maternal health care services utilization.

Conclusion: Even though every woman has the right to participate in her own health care decision-making, around two fifths of them have no role in making health care decisions about their own health. Socio-demographic factors like age and education were found to influence women’s autonomy. Special attention has to be given to women living in rural areas in order to reduce their dependency through education.

Maternal & Fetal Medicine

women

autonomy

maternal health service utilization

Ethiopia

Autonomy is the power to obtain information and arrive at decisions about personal concerns. Women’s autonomy refers to women’s ability and freedom to choose and act independently, including women’s capability to articulate strategic choices, access to and control over resources, and participation in decision-making. It is the control women have over their own lives and the extent to which a woman has equal voice with her husband in all matters affecting themselves and their families, control over resources, access to information, authority to take independent decisions and freedom of mobility (1).

The United Nations International Conference on Population and Development (UNICPD) widely declared that increased gender equality among families is a requirement for achieving advances in all matters of development. Its program of action highlighted the need for improving women’s status for the enhancement of their decision-making capacity at all levels in all spheres of life (2).

Women's status in many societies, particularly in developing or low-income countries, frequently inhibits their autonomy and ability to make decisions about many elements of their own lives. These societies have strong social structures that rigorously define men's and women's roles, which are frequently encoded in religious, tribal, and social traditions. These limits frequently characterize the circumstances in which women have or do not have autonomy to make health-related decisions for themselves (3).

The relationship between women’s decision-making autonomy and use of maternal health services is due to women’s power to realize their preferences, which includes a stronger preference for ensuring their own health (4). Evidence shows that adequate health service utilization and empowering women in decision-making about their own health have a positive impact on improving maternal health care utilization and are key to tackling maternal morbidity and mortality (5).

The World Health Organization has specifically stated that meeting the maternal health goal requires guaranteeing universal healthcare coverage for sexual, reproductive, and maternity health care, as well as eliminating inequities in access and quality of sexual, reproductive, and maternal health care by addressing all causes of maternal mortality, illness, and disability, as well as enhancing healthcare systems to meet the needs and priorities of women (6).

Studies have also shown that higher female autonomy confers benefits, including total fertility reduction, higher child survival rates, and allocation of resources in favor of children in the household (7). Women with high autonomy are assumed to have high self-esteem, not accept gender inequalities in power, and disagree with any justification for wife beating. Many studies elsewhere have shown that a woman's decision-making ability and attitudes toward domestic violence are valid measures for assessing a woman’s autonomy (8 ,9).

Various studies have shown that women's flexibility in decision-making in health care is crucial to better outcomes in maternal and child health. For example, research from Nepal found that higher levels of female autonomy were connected with increased use of maternal services (1). Another Indian study also found that female autonomy was associated with increased use of maternity care services, particularly prenatal and postnatal care (10).

Evidence from Africa and South-East Asian countries has shown that girls usually have less power and higher cognitive process autonomy than men, concerning issues associated with their own health care. Moreover, they sometimes have unequal access to nutrition, education, and health care, yet as a limited opportunity to earn income and have control over resources, as well as few effective legal rights (11). In addition, according to the DHS Kenyan report, 39% of women are the primary decision-makers in their own health care, while 40% of women decide jointly with their husbands and 21% decide primarily with their husbands. Less than a quarter of women are the primary decision makers for visits to family or relatives—23% and major household purchases, 20%, respectively (12).

Other studies have identified negligible correlations between the participation of women in decision-making and the use of antenatal and delivery care services (13). Such studies in the sense of African countries are, however, minimal. For one study conducted using the 2005 Ethiopian DHS, the use of maternal health services (14) was correlated with the participation of women for household decision-making. Also, other factors such as age, education, employment or labor force participation and wealth quintile have also been found to be associated with maternal healthcare utilization (15–18). Evidence from Ethiopian demographic and health surveys has shown that approximately six out of every ten married women were employed, whereas almost all currently married men aged 15–49 were employed in the 12 months preceding the survey. Furthermore, nearly a quarter of married women (19) had no control over their health-care decisions.

More than 80% of women in Ethiopia reside in rural areas where they are considered the subordinates of their husbands. This would restrict women's ability to fully exercise their reproductive health rights. Overall, few studies from Ethiopia have examined the relationship between women’s autonomy and maternal health-care-seeking behavior. There is a need to study the major determinant factors influencing women’s decision-making autonomy in the South-west Ethiopia regarding reproductive health services, which are crucial for designing locally feasible, contextually appropriate, and practically sound interventions to empower women in reproductive health decision-making autonomy. Hence, this study was designed to determine women’s decision-making autonomy on maternal health services utilization among reproductive age women in Mettu rural Woreda, Oromia region, Southwest Ethiopia.

Study area, design and period

A community based cross-sectional study was conducted in Mettu rural district, Ilu Aba Bor zone, Oromia Regional state, Southwest Ethiopia. Mettu Rural District is one of 13 rural districts in the Ilu Aba Bor zone, located 600km to the south-west of Addis Ababa, the capital city of Ethiopia. The Woreda has 29 rural kebeles with an estimated total population of 87,771, of whom 44,448 (50.6%) are females and 43,323 are male rural dwellers. A total of 5/5 health centers and 29 health posts are available in the Woreda. From the total females, 18.63% were women of child-bearing age (WCBA), which implies a total of 16,352 WCBA residing in the Mettu Woreda. The study was conducted from June 19 to August 20 in the year 2021.

Sample size determination and sampling technique

Married women who had given birth at least once and lived in Mettu rural Woreda for at least 6 months were included in the study. The sample size was determined by using a single population proportion formula considering 95% confidence level, 5% margin of error and taking 80% of women making autonomous decision regarding their own health care needs from a study done in southern Ethiopia (21).These assumptions are substituted in the formula below:

Where: n =is initial sample sizes, Zα/2 = is critical value for normal distribution at 95% confidence level which equals to 1.96 (z value at α =0.05), p = proportion of women who participate in decision-making regarding their own health care 80% (0.80) taken from the study conducted in the Wolaita zone, Southern Ethiopia (21) and d= is a margin of error, 5% (0.05). The calculated sample size is multiplied by a design effect of 2 and 10% nonresponse rate is added and the final sample size was 541 women. Sample size calculation was also considered for factors associated with decision making autonomy of women by considering different factors associated with women’s decision making autonomy on maternal health service utilization using Epi-info version 7 software by the following assumption made, two sided confidence level of 95%, power 80%, exposed to unexposed ration of 1:1, design effect 2, 10% non-response rate. The factors considered are taken from studies conducted in different parts of Ethiopia (46, 47, 35). See Table 1

Accordingly, from the magnitude (541) and factors (440) sample sizes, the largest sample size was taken, which was 541. A multi-stage sampling technique was used to choose study participants in the Woreda. The Woreda had twenty-nine kebeles (the lowest administrative unit in Ethiopia), and nine kebeles were selected using a simple random sampling method in the first stage. The total sample size was allocated to each selected kebele using proportional allocation. See Figure 1

A systematic random sampling method was used to select eligible married women from households in selected kebele in the second stage. The first household selected from the list was number 2, by lottery method, and then every tenth interval was included in the study. A woman in the reproductive age group was interviewed from the selected households, and if there were more than one woman in the selected households, a lottery method was used to select only one.

Data collection procedures

A structured, pre-tested, and interviewer-guided questionnaire was used to collect data. The questionnaire consists of 29 pre-coded items; 17 items were socio-demographic related questions, and 2 sub-sections are maternal health services related to autonomous questions. The questionnaire was prepared originally in English and then translated into the local language (Afaan Oromo). It was pre-tested on 5% of women selected at Medalu Kebele, which is outside of the study kebeles but with similar characteristics of women to the study subjects inclusive. The pre-tests on 5% of the women were conducted earlier to learn and get lessons for any modifications to the tools used during the actual data collection. After that, the data collection process was carried out following amendments incorporated within the final questionnaire. Three public health officers administered the questionnaire, and five female nurse workers were assigned as data collectors/interviewers.

Women’s autonomy in household decision making was measured through aspects of women’s decision-making power in the household using the answers to the following six questions: Who decides matters pertaining to (a) the woman’s health (personal decision-making authority), (b) major household purchases (economic decision-making authority), and (c) visits to friends or family (mobility decision-making authority)? A score of 1 was given if a woman decided alone or together with her husband or someone else, and a score of zero (0) was scored if the decision was made only by her partners who decided independently, or if it was made by others. Finally, those scoring mean and above were categorized as having higher decision-making power (coded as 1), whereas those scoring less than the mean were categorized as having lower decision-making power (coded as 0) for analysis (16,21).

Women's autonomy in health care decision making was assessed by asking women about who makes decisions concerning their own health care using the answers to the following six questions: on ANC, delivery at a health institution, PNC services, where to get maternal health services, when to give birth, and continuation or stopping of using/intending maternal health services. Accordingly, their responses were classified into any of the following four choices: "mainly wife"; "wife and husband jointly"; "mainly husband"; or "someone else". As a result, a woman was considered autonomous in healthcare decision-making if she usually made that decision alone or in collaboration with her husband. A score of 1 was given if women decided independently or together, and a score of zero (0) was scored by partners who decided independently or whose decision was made by others. Likewise, the maximum score was six and the minimum was zero. Women’s decision-making autonomy on utilization of maternal healthcare services was below the mean. That means those scoring less than three points have no decision-making power and those scoring greater than or equal to the mean, meaning greater than or equal to three points, have decision-making power. Finally, women's decision-making autonomy on maternal health care service utilization was dichotomous, with having decision-making autonomy if the score was above three and having no decision-making autonomy if the score is below three and three (31).

Data quality management

The quality of the data was assured through careful design, pretesting of the tools, proper training of the data collectors and supervisors, close supervision of the data collectors and proper handling of the data. Two days of training were given on methods of extracting the needed information through interviewing women and how to fill in the information on the structured questionnaire. The interviewer was collecting data by home-to-home visit. The supervisors were assigned to check the day-to-day activities of data collectors regarding the completion of questionnaires, clarity of responses and proper coding of respondents. Incomplete and unclearly filled questionnaires were given back to the interviewer and were completed. The principal investigator was also close to supervising the field activity on a daily basis. At the end of each data collection day, the principal investigator would also check the completeness of the filled questionnaires to see if the recorded information makes sense to ensure the quality of the data collected. Besides, the principal investigator had carefully entered and thoroughly cleaned the data before the beginning of the analysis.

Data processing and analysis

The collected data was coded, cleaned and entered into Epi–data version 3.1 and exported to SPSS version 22 for analysis. The analysis results output of the participants’ socio-demographic characteristics and outcome variables were summarized using descriptive summary measures. Bivariate and multivariable logistic regression analysis was used to identify the presence of an association between the dependent and independent variables. The goodness of fitness of the model was checked by Hosmer and Lemeshow's goodness of fit test, which indicates that, p = 0.292. Statistical significance was declared using 95% confidence intervals of adjusted odds ratios and a p-value of less than 0.05.

Ethical considerations

The study was conducted according to the Declaration of Helsinki. Ethical clearance for the study was obtained from the ethical review committee of Mettu University, College of Health Science, and an official support letter from the administrative bodies of Mettu Woreda. After an explanation of the whole purpose of the study, verbal and informed consent was secured from the study participants, and the participants were assured that the information would be kept confidential and secured. The names of the study participants were not included in the questionnaire. Participation in this study was on a voluntary basis. They were also guaranteed the full right to choose not to answer any individual question or all of the questions.

Socio- demographic characteristics of respondents

A total of 532 married women were involved in the study, making up 98% of the response rate. Two hundred twenty (41.4%) respondents were in the age group of 30–39 years, and the minimum respondents from the age group 15-19 years represented eight (1.5%) with an age range from 17 to 48 years. The mean (±SD) age of women was 32.17 (±8.599) years. Regarding the educational status, two hundred twelve (39.9%) of women have not attended formal education and 72.2% of the husbands of participants have. As for the occupation of respondents, two hundred sixty six (50%) of the respondents were housewives, and 60.4% of the respondents' husbands were farmers. Regarding monthly income of households, 15.8% of the respondents got 2,500-10,000 ETB, while forty-eight (9.2%) of the respondents got > 10,000 ETB per month. Four hundred six (76.3%) had family sizes of five or less than five members. See Table 2

Maternal health service utilization of the respondents

Five hundred twenty five (98.7%) of the study participants reported having attended antenatal care (ANC) during their pregnancy time. However, only 46.7% of them had attended the recommended ANC4+ visits per pregnancy. A majority of the participants, 71.3%, go to health facilities by public transportation. Regarding postnatal care services, 14.8% of the mothers reported getting checkups while they were in the health institutions. Ninety eight (18.4%) of the participants were less than or equal to 30 minutes away from the health facility (by foot). See Table 3

Women’s participation in household decision-making

Overall, three hundred eight (57.9%) of married women have high autonomy and participation in household decision-making. Specifically, women's decision-making autonomy concerning participation in household decisions, twenty-eight (5.3%) of the participants decide on their husband's earning alone, two hundred fifty-two (47.4%) jointly, and two hundred thirty-eight (44.7%) on household purchases jointly, twenty-eight (5.3%) alone. About fifty-six (10.5%) of participants made decisions related to visiting family, friends, or relatives alone and one hundred sixty-eight (31.6%) with their husband. Also, concerning women's decision-making autonomy with regard to their own health care, 5.3% of them usually make decisions themselves. In 42.1% of the study participants, women's health care decisions are made by their husbands or partners. Two hundred fifty-two (47.4%) of the respondents reported that they decided to visit a health facility jointly. (Table 4)

Level of women’s decision-making autonomy on maternal health service utilization

In the study, women who had autonomy in maternal health care decision-making were 322 (60.5%). Concerning women’ decision-making autonomy on when to give birth, 5.3 % of them made decisions themselves, whereas 60.9 % made decisions jointly with their husbands. In addition, women's decision-making autonomy concerning participation in and attendance at ANC is diminished. 7.9% of participants decide alone and 44.4% of PNC participants are sought by their husbands. About 42 (7.9%) of participants made decisions on continuation or stopping of using intending maternal health services alone, and 296 (55.6%) with their husbands. Table 5

Factors associated with decision-making autonomy of women on maternal health care services utilization

In bivariate logistic regression, the respondent's age, educational status, household income, family size, women's occupation, number of ANC visits, and distance to the health facility were found to be significantly associated with women's decision-making autonomy, and variables with p-values of 0.2 were used in multivariable logistic regression analysis.

After controlling for confounding using backward stepwise multivariable logistic regression analysis, women’s age, women’s education, family size, and distance from the health facility were identified as independent predictors of women’s health care decision making autonomy. Accordingly, the odds of women aged 30–39 years old's decision-making autonomy on maternal health services were four times higher compared to women aged 40-49, AOR=4.27 (95%CI: 1.59-11.43). Also, the odds of participating in health care decision making among women who have a primary education are around four times higher than compared to women who have no formal education; AOR =3.874 (95%CI: 2.146-6.99). In addition, the odds of women who had a family size of less than or equal to five were 75% less likely to have decision-making autonomy on maternal health care services compared to women who had greater than five members, AOR = 0.249 (95%CI: 0.150-0.414). Furthermore, the odds of decision-making autonomy on maternal health services are higher among women who live less than thirty minutes from a health facility than among women who live more than thirty minutes from a health facility, AOR=5.328 (95%CI: 2.505-11.33). See Table 6

Women’s autonomy is likely to vary according to characteristics at the individual, interpersonal, community and macro political and societal level. The present study assessed women’s health care decision making autonomy and associated factors among women living in Mettu rural districts, Oromia region, Southwest Ethiopia. Accordingly, 322 (60.5%) at 95% CI (56.2%-64.7%) of study participants have autonomy in making health care decisions either alone or jointly.

This finding was higher than that of a study conducted in Dawro, Southern Ethiopia, and lower than that of Dabat, Northern Ethiopia, and of an Ethiopian demographic and health survey (16, 19, 20). This finding is also higher than the study conducted in the Bale zone (21). This difference may be due to the fact that in Ethiopia, over a period of time (since the study was conducted in Bale), there has been a strong commitment and effort made by the Ethiopian government on maternal health. This finding is also somewhat higher compared to the study conducted in Ghana (22) which found that nearly half of the maternal health service utilization is independently decided by husbands, and women have very little autonomy in deciding about their maternal health service utilization. The difference might be due to the difference in the study populations. For example, those previous studies conducted in Dawro, Southern Ethiopia and Dabat, Northern Ethiopia (16) focused on women's decision-making autonomy among less than twenty-five to greater than thirty-year old age groups, whereas the current study focused on the age group of fifteen to forty-nine years of age. This difference might be the result of a discrepancy in the scope of studies, as the current study only involved rural women while the former studies incorporated both rural and urban women. It is known that urban women have relatively better education, the economy, and information. Hence, the current study found a relatively lower rate of health care decision making autonomy than the aforementioned study.

Furthermore, the possible difference might also be due to a difference in the education and socioeconomic status of study participants, as evidenced by the presence of low participation in the decision-making autonomy of maternal health services in the current study. About two hundred ten study participants in the current study actually thought decision-making was the responsibility of the husband. What this means is that women did not practice well enough the decision-making autonomy that could help them to get maternal health services and freedom from household decision-making in their lives. Additionally, the differences in the socio-economic characteristics and geographical contexts across countries and the time period of studies might also explain the observed inconsistencies of the findings.

Regarding factors associated with decision-making autonomy, this study indicated that age of respondents or women was significantly associated with women’s decision-making autonomy on maternal health care services. In this study, younger women have higher decision-making power in maternal health care as compared to older women. This finding is similar to that of a study conducted in Legatafo, Eastern Ethiopia (23); however, a study conducted in Mizan-Aman, South Ethiopia (24) found that women aged 30–44 have greater decision-making power in maternal health care than younger women. This difference might be due to the educational coverage of women age below 39 years old more educated, level of current government, and other stakeholder efforts to increase women's empowerment in decision-making related to maternal health.

The odds of women's decision-making autonomy on maternal health care were higher among those who had received primary or higher education than their counter parts or illiterate counterparts. This finding is in line with the study conducted in Nepal (25) and also consistent with a study from Ethiopia (26) in which women who have received primary or higher education were four times more likely to make decisions on seeking health care than uneducated women. This might be because the more a woman is educated, the more she will accept gender equality and believe in equal participation in decision-making with her husband. This means that improving education has a significant impact on later-life decision-making participation in maternal health care services.

Women with a family size greater than or equal to six was 75% less likely to have decision-making autonomy over maternal health care services than a woman with a family size less than or equal to five. Similarly, this finding is supported by a study conducted by Delbiso in which having fewer children was associated with better reproductive health decision making (27). As a result, having a smaller family would help women exercise freedom of health care decision making, and end male dominance in a family. Also, the study conducted in southern Ethiopia reveals that the probability of a woman participating in health care decision-making decreases when women with a family size of five to six people have a lower chance of participating in health care decision-making as compared to women with a family size of less than five people. Similarly, women with a family size of six people or above have a lower chance of participating in decision-making (16).

Also, the odds of decision-making autonomy on maternal health care services among women from the distance of the health facility being less than thirty minutes is higher compared with the distance of a health facility being greater than thirty minutes. The study conducted in Nigeria revealed that, the further a patient lives from a health facility, the less likely they are able to utilize the services (28). A study in Kenya also identified distance, physical proximity of the facility or care source among the barriers to the use of skilled attendance (29). The preferred care source was often the closest one. In the African context, the principal barriers to accessibility are transport and cost; so, distance is mostly reported as a single obstacle to the utilization of delivery care services (30).

Limitations of the study

As the participants were only women, there remains a potential for bias/discordance regarding the level of autonomy enjoyed by women, as this is to a large extent a subjective phenomenon. Since the study was a cross-sectional study design, the temporal relationship between dependent and independent variables was not addressed. In addition, spousal autonomy is a complex concept and difficult to quantify, and there is no universally agreed-upon definition or tool for measurement.

Even though every woman has the right to participate in her own health care decision-making, two fifths of them have no role in making health care decisions about their own health. Husbands play a major role in making health care decisions about their wives. Age, education, family size, and distance from the health facility were identified as factors associated with women’s decision-making autonomy on maternal health service utilization. Women's empowerment and education actions that increase women’s autonomy at home could be effective in helping assure good participation in maternal health decision making.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Ethical Review Board of Mettu University and presented to the Mettu rural district Administration and Health Office. An official letter was obtained from the Mettu rural district Administration and Health office and presented to the respective Kebeles. The purpose and importance of the study were explained to study participants, who were informed of their right to withdraw at any time during the study period. The participants were interviewed after accent and verbal consent was obtained, and the privacy and confidentiality of participants was maintained at all levels.

Consent for publication

Not applicable.

Data Availability Statement

All data used in this research article is available and can be accessed from the corresponding author at any time.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors’.

Author contributions

AK made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. AZ had participated in drafting the work or revising it critically for important intellectual content. AZ was involved in designing the final manuscript. Both authors are involved in the final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgements

First of all thanks to the almighty God, who always with me, next my deepest gratitude goes to Mettu University for giving this opportunity and supporting me. Next I would like to extend my sincere appreciation to my advisor Mr. Asrat Zewdie for their precious guidance and valuable advice to develop this thesis paper. My appreciation also goes to Mettu Woreda Health office, data collectors, supervisors and study participants for their valuable contribution to the realization of this study.

Author details

^{1, 2} Department of Public Health, College of Health Science, Mettu University, Mettu, Ethiopia

ANC: Antenatal Care; EDHS: Ethiopian Demographic and Health Survey; MHS: Maternal Health Service; PNC: Postnatal Care; UNICPD: United Nations International Conference on Population and Development; WCBA: Women child bearing age

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Table 1. Sample size calculation based different factors associated with women decision making autonomy in maternal health service

Variable	Proportion among exposed (p1)	Proportion among unexposed (p2)	Ratio of exposed to unexposed	Odds ratio	Non-response rate	Design effect	Total sample size
Age of woman* (46)	66.3	45	1:1	2.4	10%	2	416
Income** (47)	70.5	49	1:1	2.49	10%	2	396
Education of woman*** (35)	84	66	1:1	2.7	10%	2	440

*Women age “20-29’’ years” compared to “less than 20 years’’

**Women generating their own income compared to non-working women

***Educated woman compared to non-educated

Table 2. Socio-demographic characteristics of women in Mettu rural Woreda, Oromia Regional State, Southwest Ethiopia 2021 n=532

Variables	Category		Frequency		Percent
Age group	15-19		48		9
	20-29		156		29.5
	30-39		220		41.2
	40-49		108		20.3
Educational level	No formal education		212		39.8
	Primary level(1-8)		224		42.1
	Secondary and above		96		18
Religion	Orthodox		200		37.6
	Muslim		160		30.1
	Protestant		148		27.8
	Catholic		16		3
	Wakefata		8		1.5
Husband education	No formal education		148		27.8
		Primary level(1-8) Secondary and above		240 144		45.1 27.1
Occupation of respondent		Housewife		266		50
		Farmer		84		15.8
		Merchant		98		18.4
		government employee		56		10.5
		daily laborer		28		5.3
Husband occupation		Farmer		320		60.2
		daily laborer		60		11.3
		Merchant		80		15.0
		government employee		60		2.3
		Other		12		3.0
Monthly income of husband		< 2,500		399		75
		2,500-10,000		84		15.8
Family size		> 10,000 ≤ Five ≥ Six		49 406 126		9.2 76.3 23.6

Table 3.Maternal health service utilization of the respondents in Mettu Woreda, Iluababora Zone, Oromia Regional State, Southwest Ethiopia, 2021= (n =532)

Variables Category Frequency Percent
ANC follow up	Yes	525	98.7
ANC follow up	No	7	1.3
Number of ANC visits	< 4 times visits	280	53.3
Number of ANC visits	> 4 times visits	245	46.7
Time start ANC	< 4 month	294	56
Time start ANC	> 4 month	231	44
Means of transportation to reach health care facility Distance of HF	By foot	153	28.7
	By public transportation <30 min >30 min	379 98 434	71.3 18.4 81.6
postnatal checkup	Yes	105	19.7
postnatal checkup	No	427	80.3
First postnatal check up	< 24 hours	79	14.8
First postnatal check up	24- 48 hours	26	4.9
Number of postnatal	one times	69	14
	two times	23	4.3
	three times	13	2.4
Reasons for not seek postnatal care	Too much cost	43	8.1
	Too far	185	34
	No trust/poor quality	100	18.8
	No transportation	99	18

Table 4. Women’s household decision-making characteristics in Mettu rural woreda, Oromia region, Southwest Ethiopia 2021, n=532

Variables	Who decided	Frequency	Percent
Decision made husband earning	Husband/ other else	252	47.4
	Jointly	252	47.4
	women alone	28	5.3
Major decision house hold purchase	Husband /other else	266	50
	Jointly	238	44.7
	women alone	28	5.3
Decision made visiting family	husband/other else	168	31.6
	Jointly	308	57.9
	women alone	56	10.5
Decision made on respondent health Care	Husband /other else	224	42.1
Decision made on respondent health Care	Jointly	280	52.6
	women alone	28	5.3
Decision made on child health care	husband/other else	196	36.8
	Jointly	308	57.9
	women alone	28	5.3
Decision made visiting health Facility	Husband/ other else	238	44.7
Decision made visiting health Facility	Jointly	252	47.4
	women alone	42	7.9
Women participation on household decision making	low autonomy	224	42.1
Women participation on household decision making	high autonomy	308	57.9

Table 5: Women’s decision-making autonomy on maternal health service utilization in Mettu Rural Woreda, Oromia region Southwest Ethiopia, 2021 (n ₌532)

Variable	Category	Frequency	Percent
Decision-making on attending ANC	husband/other else	218	41
	Jointly	272	51.1
	women alone	42	7.9
Decision-made giving birth at health Institution	husband/other else	220	41.3
Decision-made giving birth at health Institution	Jointly	284	53.4
	women alone	28	5.3
Decision made for seeking PNC services	husband/other else	236	44.4
Decision made for seeking PNC services	Jointly	268	50.3
	women alone	28	5.3
Decision made on when to give birth	husband/other else	180	33.8
	Jointly	324	60.9
	women alone	28	5.3
Decision made on where to get maternal health services	husband/other else	212	39.8
Decision made on where to get maternal health services	Jointly	292	54.9
	women alone	28	5.3
Decision made on continuation or stopping of using/intending MHS	husband/other else	194	36.5
	Jointly	296	55.6
	women alone	42	7.9
Decision-making autonomy On maternal health care services	Has no autonomy	210	39.5
Decision-making autonomy On maternal health care services	Has autonomy	322	60.5

Table 6:- Multivariate logistic regression showing factors associated with women’s decision- making autonomy on maternal health services utilization in Mettu rural Woreda, Oromia region, Southwest Ethiopia, 2021 n=532

Variable	Autonomy on maternal health service utilization			COR (95%C.I) AOR (95% C.I)
Variable	Has Autonomy	Has no Autonomy		COR (95%C.I) AOR (95% C.I)
Age of respondent 15-19	26		22	.830 (.225 – 3.061)	1.236( .324 -4.713)
20-29	96		60	.543 (.208 – 1.4)	1.941.749 – 5.026)
30-39	130		90	.220 (.081 – .597)	4.27(1.59 -11.43) *
40-49	70		38	1	1
Women Education No formal education	168		44	1	1
Primary level(grade1-8)	110		114	.253(.166-.386)	3.874(2.146-6.994) *
Secondary and above	44		52	.222(.132-.373)	.878(.493-1.563)
Household income ≤ 2,500 ETB	226		171	1	1
2,500- 10,000 ETB	48		34	1.068(.60 – 1.730)	.367(.134 – 1.004)
>10,000 ETB	48		5	7.264(2.831 – 18.636)	0.392(.128 – 1.198)
Family size Five and less members	280		126	1	1
Above five members	42		84	4.444(2.903- 6,804)	.249(.150 - .414) *
Woman’s occupation Housewife	186		80	1	1
Farmer	56		28	.923 (.548 – 1.556)	3.605(1.483 - 8.765)
Government employ	42		56	.346( .255 - .557)	2.4( .921 - 6.257)
Merchant	28		28	.462( .257 - .828)	.957( .357 - 2.569)
Daily laborer	10		18	.462( .211 - 1.011 )	.193 (.116 - 1.543)
Distance of HF ≤ 30 min	70		28	.554( .343 – .893 )	5.636 (2.689-11.814) *
>30 min	252		182	1	1
ANC Visits < four times	154		126	1	1
≥ four times	163		82	1.626 (1.141- 2.319)	.741(.478 – 1.149 )

* p- Value < 0.05 C.I: confidence interval COR: crude odds ratio AOR: adjusted odds ratio

No competing interests reported.

Two-fifths of women are not autonomous in maternal health service utilization: A community-based cross-sectional study

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Abstract

Figures

Introduction

Methods And Materials

Results

Discussion

Conclusions

Declarations

Abbreviations

References

Tables

Additional Declarations

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