Despite various efforts maternal mortality is still high in most low resource countries of Sub-Saharan Africa and South East Asia. Nepal has made remarkable progress in maternal mortality reduction. However, most indicators of Millennium Development Goal Five i.e. completion of four antenatal care visits, skilled care at birth, institutional deliveries and postnatal care visits have not attained set targets. The high utilization of maternal health care services makes it possible to reduce maternal and neonatal morbidity and mortality. Demographic factors, socio-economic characteristics of women, geographical location, availability and accessibility of health care services, needs of health care are some factors which determine the utilization of maternal health care services.
Women’s autonomy is one of the determinants of maternal health care services utilization in developing countries. Most studies have focused on assessing the association with the demographic and socioeconomic factors and the utilization of maternal health care services rather than exploring the role of women’s autonomy as a mediating factor in the utilization of maternal health care services. There are a few studies which looked at women’s autonomy and its influence on the utilization of maternal health care in Nepal; however, most women’s autonomy measurement tools included very limited components of women’s autonomy. Only in a few cases their psychometric characteristics were assessed.
Autonomy is regarded as a multidimensional construct and difficult to quantify. However, it is explained as the capacity of a person to work independently in accordance with his/her aims and objectives. Women’s autonomy has contextual meaning and it depends upon the personal attributes of women as well as norms, values and practices of the society. There is no unanimous view on women’s autonomy. Most researchers prefer proxy indicators i.e. educational attainment, employment, income, spousal age difference, and type of family to measure women’s autonomy and utilization of maternal health care services.
The plains area of western Nepal has access to road transportation and various health care facilities. However, there is the low utilization of maternal health care services for achieving the target of the Millennium Development Goal five in Kapilvastu district. It is a challenge for Nepal as one of the signatory members of the Millennium Declaration 2000. For assessing women’s autonomy and the utilization of maternal health care services, and for better understanding of its key predictors in Nepal, we chose this district as the study area and conducted this study.
The overall aim of this study was to study women’s autonomy and its influence on the utilization of maternal health care services. Specific objectives were - 1) to construct and validate a women’s autonomy measurement scale based on the field evidence; 2) to examine the relationship between women’s demographic and socioeconomic characteristics, and their utilization of maternal health care services; 3) to correlate women’s autonomy with their demographic characteristics and socioeconomic factors; and, 4) to examine the role of women’s autonomy as a mediating factor in the utilization of maternal health care services. Our study hypothesis is- women who have high autonomy utilize more maternal health care services than women with restricted or low autonomy.
This was a population based cross-sectional study, conducted in two phases. First, we constructed a women’s autonomy scale using a sample of 250 women from Rupandehi scale, and tested its psychometric characteristics as well as validated it. Second, we conducted a cross-sectional survey for assessing women’s autonomy and factors associated with the utilization of maternal health care services in Kapilvastu District, Nepal, using the scale which we developed. We used the survey data also for the validation of the scale using factor analysis for assuring the construct validity of the scale.
For constructing a new scale, we defined women’s autonomy (construct) as a capacity of the women to control decision-making, financial and physical resources, and freedom of mobility. We generated an items pool reviewing published literature and prepared a preliminary draft of the scale. We conducted pretest, psychometric analysis and validation test for assuring measurement capacity of the scale. Development of the scale was done on a non-random sample of 250 women of child-bearing age in Rupandehi district, which is similar to the study area in its characteristics.
Study population of the survey comprised all women of reproductive age who had full term delivery in the preceding year and completed their postnatal period preceding the survey. We selected ten village development committees (VDCs) out of 76 VDCs of the district using simple random sampling method. The final number of women at VDC level was fixed proportionately considering the total population of VDC. We interviewed 500 women from all five electoral constituencies (ECs) areas and 10 VDCs of the district.
The sample size was computed based on the proportion of skilled care at birth (15.92%) of Kapilvastu district, with design effect = 2 and non-response rate = 20% using online OpenEpi statistics software. For identifying the respondents in each village, we identified the center of the village and chose a random direction for identifying households with subjects. We continued the household visit in the clock-wise direction until obtaining the required number of respondents.
Considering Cronbach’s Alpha value (0.84), average content validity ratio/ index (0.8) and overall agreement- kappa value (0.83), we accepted all 24 items of the scale. The minimum and maximum score of the new women’s autonomy measurement scale was zero and forty eight respectively. We also did exploratory factor analysis with the survey data and finalized 23 items of the scale where the items had good convergent and discriminant validity. All 23 items were loaded in five factors. All five factors had single loading items by suppressing absolute coefficient value less than 0.45 and average coefficient was more than 0.60 for each factor. The new scale is a reliable tool for assessing women’s autonomy in developing countries which quantifies the possible score of women’s autonomy between zero and forty six. We suggest use and validate the scale for assuring the performance of the scale in large samples and different settings.
The mean score of the autonomy measured by our scale was 23.34 8.06 out of the possible maximum scoring forty-eight. We found 83.6% pregnant women sought at least one antenatal care visit in one year preceding the study period. More than one-third (37.6%) women sought institutional delivery for their last childbirth. Antenatal care visit had strong positive association with the place of delivery (chi-square = 20.05, df = 1 and P <0.001) and postnatal care (chi-square = 16.77, df = 1 and P <0.001). Nearly six per cent deliveries were conducted by general health workers in health facilities. Out of the total institutional deliveries, nearly 58% women visited health facilities for the self-reported emergency obstetric care services. A few home deliveries (6.2%) were assisted by health workers, 14.7% households used safe delivery kit (SDK) for home delivery care and 22.0% women sought postnatal care in their last postnatal period.
We examined the association with explanatory variables and outcome variables i.e. antenatal care, delivery care and postnatal care. We found that having at least one antenatal care visit and institutional delivery care had positive association with five years or greater difference of age with the spouse, some ethnic groups, better education of couples, occupation of husband, and economic status of the household. Having at least one postnatal care visit was found to be positively associated with women’s age more than 20 years at marriage, parity of two or below, some caste/ethnic groups, the better education of couple, occupation of the husband, and economic status of the household.
Women’s autonomy was found to be positively associated with five years or more of age difference with the spouse at marriage, some caste/ethnic groups, better employment for the husband, women’s and husband’s education more than 10 years schooling, and high economic status. Out of several explanatory variables, women’s education (OR = 8.14, CI = 3.77–17.57), husband’s education (OR = 2.63, CI = 1.69–4.10) and socio-economic status of the household (OR = 1.42, CI = 1.01–2.03) were found as major predictors of women’s autonomy.
Women’s education, husband’s education and women’s autonomy were found to be key predictors of the utilization of maternal health care services. Women’s education had strong positive association (OR = 24.11, CI = 9.43–61.64) with institutional delivery care. The stratified multivariate analysis further showed that when the husband is not educated, women’s education works independently of the effect of her autonomy, and is a dominant influence. On the other hand, when the husband is educated, women’s education seems to work partly through her autonomy where around 40% of the effect is explained by her autonomy.
Low education and economic status of women are significantly associated with the low utilization of maternal health care services in Kapilvastu district of Nepal. Women’s autonomy seems as a mediating factor of the pathways in the utilization of maternal health care services. Women’s education, husband’s education and economic status of the household are key predictors of women’s autonomy and the utilization of maternal health care services. Improvement of women’s education, husband’s education and economic status of the household would be among the effective strategies for increasing their autonomy and the utilization of maternal health care services in Kapilvastu district of Nepal.
In spite of intensive implementation of incentive programmes to increase the utilization of maternal health care services during pregnancy, childbirth and postnatal period, we do not see an encouraging response. It points to the very basic and strong relationship between women’s position in the household and the society, and their health status. There are limits to how far financial incentives can overcome these obstacles.