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Does gender inequality matter for access to and utilization of maternal healthcare services in Bangladesh?

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There is a high prevalence of gender gap in Bangladesh which might affect women’s likelihood to receive maternal healthcare services. In this backdrop, we aim to investigate how gender inequality measured by intrahousehold bargaining power (or autonomy) of women and their attitudes towards intimate partner violence (IPV) affects accessing and utilizing maternal health care services. We used Bangladesh Demographic and Health Survey (BDHS) data of 2014 covering 5460 women who gave birth at least one child in the last three years preceding the survey. We performed logistic regression to estimate the effect of women’s autonomy and their attitude towards IPV on access to and utilization of maternal healthcare services. Besides, we employed different channels to understand the heterogeneous effect of gender inequality on access to maternal healthcare services. We observed that women having autonomy positively influenced attaining five required antenatal care (ANC) services (AOR: 1.17; 95% CI: 0.98–1.41) and women’s negative attitudes towards IPV were positively associated with five ANC services (AOR: 1.42; 95% CI: 1.02–1.97), sufficient ANC visits (COR: 1.55; CI: 1.19–2.01), skilled birth attendant (SBA) (AOR: 1.43; 95% CI: 1.05–1.94) and postnatal care (PNC) services (AOR: 1.44; 95% CI: 1.12–1.84). Besides, rural residency, religion, household wealth, education of both women and husband were found to have some of the important channels which were making stronger effect of gender inequality on access to maternal healthcare services. The findings of our study indicate a significant association between access to maternal healthcare services and women’s autonomy as well as attitude towards IPV in Bangladesh. We, therefore, recommend to protect women from violence at home and mprove their intrahousehold bargaining power to increase their access to and utilization of required maternal healthcare services.
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RESEARCH ARTICLE
Does gender inequality matter for access to
and utilization of maternal healthcare services
in Bangladesh?
Firoz AhmedID*, Fahmida Akter Oni ID, Sk. Sharafat Hossen
Economics Discipline, Social Science School, Khulna University, Khulna, Bangladesh
*firoz.ahmed@econ.ku.ac.bd
Abstract
There is a high prevalence of gender gap in Bangladesh which might affect women’s likeli-
hood to receive maternal healthcare services. In this backdrop, we aim to investigate how
gender inequality measured by intrahousehold bargaining power (or autonomy) of women
and their attitudes towards intimate partner violence (IPV) affects accessing and utilizing
maternal health care services. We used Bangladesh Demographic and Health Survey
(BDHS) data of 2014 covering 5460 women who gave birth at least one child in the last
three years preceding the survey. We performed logistic regression to estimate the effect of
women’s autonomy and their attitude towards IPV on access to and utilization of maternal
healthcare services. Besides, we employed different channels to understand the heteroge-
neous effect of gender inequality on access to maternal healthcare services. We observed
that women having autonomy positively influenced attaining five required antenatal care
(ANC) services (AOR: 1.17; 95% CI: 0.98–1.41) and women’s negative attitudes towards
IPV were positively associated with five ANC services (AOR: 1.42; 95% CI: 1.02–1.97), suf-
ficient ANC visits (COR: 1.55; CI: 1.19–2.01), skilled birth attendant (SBA) (AOR: 1.43; 95%
CI: 1.05–1.94) and postnatal care (PNC) services (AOR: 1.44; 95% CI: 1.12–1.84). Besides,
rural residency, religion, household wealth, education of both women and husband were
found to have some of the important channels which were making stronger effect of gender
inequality on access to maternal healthcare services. The findings of our study indicate a
significant association between access to maternal healthcare services and women’s auton-
omy as well as attitude towards IPV in Bangladesh. We, therefore, recommend to protect
women from violence at home and mprove their intrahousehold bargaining power to
increase their access to and utilization of required maternal healthcare services.
Background
Globally, access to and utilization of maternal healthcare services is considered as an important
predictor to reduce maternal mortality [1]. Higher maternal deaths are the results of lack of
access to proper healthcare and emergency services during and after pregnancy [2]. Moreover,
the risks associated with pregnancy and delivery systems are the major causes of maternal
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OPEN ACCESS
Citation: Ahmed F, Oni FA, Hossen S.S (2021)
Does gender inequality matter for access to and
utilization of maternal healthcare services in
Bangladesh? PLoS ONE 16(9): e0257388. https://
doi.org/10.1371/journal.pone.0257388
Editor: Enamul Kabir, University of Southern
Queensland, AUSTRALIA
Received: January 10, 2021
Accepted: September 1, 2021
Published: September 16, 2021
Copyright: ©2021 Ahmed et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All data are freely
available upon request and the dataset can be
obtained from the website of the Demographic and
Health Survey (DHS) (https://dhsprogram.com/
data/dataset/Bangladesh_Standard-DHS_2014.
cfm?flag=0). The data used for this study were
downloaded from the afore-mentioned website
after taking permission for the current research.
Funding: This research received no specific grant
from any funding agency in the public, commercial,
or not-for-profit sectors.
mortality, which is severe, especially in developing countries [3]. However, access to and utili-
zation of maternal healthcare services, including antenatal care service [4], assistance from
skilled professionals during childbirth [5], access to emergency obstetric care [6], and appro-
priate postpartum care [7], can raise the probability of smooth and safe motherhood [8].
According to an estimation by World Health Organization (WHO) in 2013, globally, a total of
289,000 women died during their pregnancy and childbirth [9]. In Bangladesh, the maternal
mortality rate is declining over time, but the rate is relatively higher compared to other South
Asian countries [1]. According to Bangladesh Maternal Mortality and Health Care Survey
(BMMS) 2010, the country experienced around 40% decline in maternal mortality between
2001 and 2010 [10]. Despite some positive changes, there is a limitation of providing universal
access to maternal healthcare services in Bangladesh [11].
In recent times, the research agenda on maternal healthcare services focus on gender
inequality at household level in achieving their right share of assets, capacity to raise their
voice, and autonomy in decision making process [1,2,12]. Gender inequality (or equality) is
often identified as a multidimensional and influential issue to women’s healthcare utilization
in various ways [13]. The term ‘gender inequality’ is measured by different dimensions includ-
ing economic, social, and political participation of women [14]. Even, there are multiple social
and economic variables related to gender inequality. The indicators of gender inequality or
gender gap play negative roles for the development of women’s capabilities, their freedom of
choice, and self-esteem [13]. The autonomy of women in the household ensures their equal
rights. Moreover, the improved bargaining power (autonomy) within household represents
more gender equality in decision making and eventually, it shapes the attitude of women
towards intimate partner violence (IPV) [1517]. In the context of Bangladesh, women’s
autonomy in intrahousehold decision making leads to a lower risk of IPV [1820]. The linkage
between women’s decision making power and attitude towards IPV can be explained by the
fact that women with more autonomy in decision making pose negative attitudes towards IPV
[17,19]. Gender norms towards IPV represent self-esteem of women as well women’s personal
choices towards their own life, and if women justified IPV then this can be defined as low self-
esteem and low status of women in their households [21,22]. Gender gap in decision making,
roles and rights in the households, and self-esteem of women compared to their husbands rep-
resents gender inequality and disempowerment. Therefore, the combination of women’s
autonomy or independence on intrahousehold decision making and their attitude toward IPV
is used to measure gender equality or empowerment [15,2123].
Studies found that women’s autonomy was positively related to use of maternal healthcare
services [24]. Besides, the changing gender norms also help in getting access to and use of
maternal healthcare services when needed [5,13,19]. In many low- and middle-income coun-
tries, women, during pregnancy and childbirth, do not get access to maternal healthcare ser-
vices due to the persistent gender inequality [2527]. The differences in autonomy,
domination of males over females, and gender-based violence are some of the deterrence
revealed in the context of gender inequalities that limit the access to healthcare facilities of
women [2830]. IPV is often shaped by gender norms and communities’ ethics that places
women in an inferior position compared to men [31].
The detailed pathway of how gender-based inequality at the household level shapes the
well-being of women to achieve quality in healthcare services is depicted in Fig 1. However,
there has been little discussion on gender inequality and maternal well-being in quality health-
care in Bangladesh based on the dimensions mentioned earlier in the pathway. Therefore, we
aim to investigate the linkage between gender inequality and access to and utilization of mater-
nal healthcare services in Bangladesh.
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Competing interests: We have no conflicts of
interest to disclose.
Materials and methods
Data and sampling
We used Bangladesh Demographic and Health Survey (BDHS) data of 2014 covering 17,863
women of reproductive age (15–49 years) [32]. This is nationally representative and compre-
hensive data covering multiple issues related to maternal and child health status. The standard
demographic and health survey (DHS) dataset can be obtained from the DHS program web-
site, detailed path is mentioned in the data availability section. This is a good source of data
with high quality and standard to conduct a study on social and health-related issues [33]. The
details of the sampling and survey strategies are discussed in several papers [32,34]. To address
the study objectives, we used the children’s recode (KR) data file (file name—BDKR72FL).
This dataset contains information on women (mothers) of each of these children born in the
last five years preceding the survey and covers around 7,886 women. The information is
mainly on maternal and newborn health which includes antenatal care, delivery, postnatal
care, and women’s individual as well as household characteristics. For convenience, the study
population comprised of women who gave birth at least one child in the last three years pre-
ceding the survey. Among the total of 7,886 women from this dataset, 5,460 women were
found to be eligible to be included in this current study as the target respondents. To address
the objective, we extracted information on socioeconomic characteristics of the respondents
and their husbands, access to and utilization of maternal healthcare services, women’s auton-
omy and attitude towards IPV, and the household level data (e.g. wealth status of the house-
hold) from the same data file (children’s recode (KR) data—BDKR72FL).
Outcome variables
Access to and utilization of antenatal care (ANC) service during pregnancy, skilled birth atten-
dant (SBA) during delivery and access to postnatal care (PNC) were taken into consideration
to measure maternal healthcare services. While estimating access to and utilization of ANC,
Fig 1. Pathways explaining how gender inequality shapes maternal healthcare services.
https://doi.org/10.1371/journal.pone.0257388.g001
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we consider at least four ANC visits (or ANC visit 4) as sufficient and termed as ‘yes’ as
opposed to insufficient ANC visits (ANC visit <4) termed as ‘no.’ Though the recent 2016
WHO model recommends eight ANC visits, the country guideline of Bangladesh still pro-
motes at least four ANCs to ensure sufficient ANC coverage [35,36]. Therefore, we used at
least four ANC visits (or ANC visits 4) to indicate the sufficient number of ANC visits.
Along with the number of ANC visits, five different types of ANC services, including measure-
ment of weight and blood pressure, assessment of urine and blood samples, and an ultrasono-
gram, were considered to define quality ANC services. We considered these five components
of ANC services to understand whether sufficient ANC visits ensure proper monitoring of
women to assess complications during pregnancy. By using these five required ANC compo-
nents, we covered only access to and utilization of clinical examination and laboratory testing
services and we excluded the information provision. If women reported yes in all five ANC
services, then the response was coded as ‘yes’ that ensures quality ANC services while the infe-
rior ANC service was considered as ‘no’ when the respondent did not get the five required
ANC services. During the time of giving birth, women require SBA, such as a qualified doctor,
trained nurse, or midwife. If the women give birth under the care of professional and trained
birth attendants in–public or private hospital/community clinic or NGO static clinic–it was
counted as ‘yes,’ when the delivery was carried out at home under unskilled or traditional birth
attendant (TBA) the response was coded as ‘‘no’. PNC is categorized as ‘yes’ if the respondents
received any type of postnatal services after delivery, and it was ‘no’ when the respondents did
not receive any post-delivery checkup.
Explanatory variables
In our study, we incorporated two sets of explanatory variables. The first set of explanatory
variables includes women’s autonomy constructed from their intrahousehold decision making
power in large purchases, own healthcare and own mobility (visit to family or relatives), and
attitude towards intimate partner violence (IPV), such as justification of beating by their hus-
bands while a woman goes out without having permission from her husband, neglects children
at home, argues with husband, refuses to have sexual intercourse with her husband, burns
food while cooking following some literature [16,2123]. Women’s autonomy is coded as ‘yes’
if at least two decisions of the three are taken by a woman alone or jointly with her husband as
opposed to ‘no’ if the decisions taken in a similar way are less than two or a woman has no role
in making household decisions. While the attitude towards IPV is coded as ‘yes’ if a woman
disagrees more than one of five questions (i.e., (i) goes out without telling her husband; (ii)
neglects the children; (iii) argues with her husband; (iv) refuses to have sex with him; (v) burns
the food) related to her attitude towards IPV, and it was ‘no’ for otherwise. When a woman
agrees that her husband can hit her for the above-mentioned reasons, this is termed as positive
attitudes towards IPV as opposed to disagree for negative attitudes towards IPV. The second
set of explanatory variables is related to respondents’ demographic and socioeconomic charac-
teristics, including age, education, exposure to media (e.g., newspaper and/or television), place
of residence, religion, wealth status of the household, last child’s birth order, and earlier experi-
ences in pregnancy related complications.
Analytical framework
In this study, we used descriptive statistics to reveal the socioeconomic and demographic char-
acteristics of the respondents. In addition, we used logistic regression to estimate how women’s
autonomy, attitude towards IPV, and other socioeconomic and demographic features influ-
enced their access to and utilization of five ANC services, ANC visits, SBA, and PNC services.
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To estimate the factors of access to and utilization of maternal healthcare services, we relied on
four outcome variables mentioned above. Both the simple and multivariate logistic regression
models were constructed to examine the unadjusted and adjusted effects of women’s auton-
omy and their attitudes towards IPV on access to and utilization of maternal healthcare ser-
vices. Therefore, we estimated two separate logistic regressions for each of the four outcome
variables at 5% level of statistical significance. The study results were reported in both the
unadjusted or crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence
interval (CI). Before estimating four separate multivariate logistic regressions, we started to
estimate five ANC services as the outcome variable and tried to find out the effects of different
variables adding them stepwise and check their goodness of fit. The reason for stepwise adding
explanatory variables is to check how they raised the goodness of fit in the estimation. More-
over, this procedure also helped to assess the unadjusted effect of each variable. However, we
have not reported the results in our results section for the sake of brevity.
To better understand the effect of gender inequality on access to and utilization of five ANC
services as a representation of maternal healthcare services, we focused on six different types of
heterogeneous channels. These channels included their place of residence, religion, education of
women, education of their husbands, watch TV, and wealth status of households. Considering
these heterogeneous channels, we tried to find the role of gender inequality on access to five
ANC services using both the simple and multivariate logistic regressions to estimate the unad-
justed and adjusted effect for split sample. For example, we split the sample in rural and urban to
address the heterogeneity by their place of residence. Finally, we also checked the effect of hetero-
geneous characteristics of women on their access to and utilization of maternal healthcare ser-
vices using logistic regression. To examine the heterogeneous effect of the covariates on five ANC
services, we relied on the interaction between women’s residence and education level, between
women’s and husband’s education level, and between women’s residence and watch TV. For
example, how far did access to information through watching TV affect maternal health care ser-
vices when they differ by the location of residence (rural/urban)? Also, how did women’s educa-
tion matter for their maternal healthcare services when their residence differs (rural/urban)? To
check the heterogeneity through interaction effect, we used only five ANC services as the out-
come variable as a representation of overall maternal healthcare services.
The BDHS sample was non-proportional in terms of urban-rural population distribution.
Therefore, all frequency distributions were weighted while the survey command (svy) in
STATA was used to adjust for the complex sampling structure of the data in the regression
analyses to enable generalization of results to the eligible population, women who gave birth at
least one child in the last three years preceding the survey. The data were analyzed using
STATA version 13.0 for Windows.
Ethical issues
We used BDHS 2014 data, which maintains strict ethical standards for protecting the privacy
and confidentiality of the respondents during data collection. Moreover, procedures and ques-
tionnaires used for the BDHS 2014 were reviewed and approved by the ICF Institutional
Review Board. Therefore, no further ethical approval is necessary since this study was based
on publicly available data with no identifiable information.
Results of the study
Summary statistics of outcomes and explanatory variables
Our study considered a total of 5,460 women who experienced childbirth at least once in the
last three years preceding the survey. Table 1 shows the distribution of the respondents across
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different socioeconomic and demographic features, and maternal healthcare services. We
observed that about 42.25% of the respondents received the required ANC services, 31.18%
attained sufficient ANC visits, 37.63% received SBA during delivery and 64.46% received the
services of postnatal checkup (Panel A in Table 1). We also found that around 58.79% of the
Table 1. Summary statistics of the outcome variables and explanatory variables.
Variables Category Frequency (N) Percentage (%)
Panel A:Outcome variables
Access to five ANC services Yes 1491 42.25
No 2038 57.75
Sufficient ANC visits (4) Yes 1401 31.18
No 3092 68.82
Receiving service from SBA Yes 1777 37.63
No 2947 62.38
Receiving PNC service Yes 2897 64.46
No 1597 35.54
Panel B:Characteristics related to respondents
Having autonomy Yes 3172 58.79
No 2223 41.21
Attitude towards IPV Negative 4559 83.50
Positive 901 16.50
Age 20 1398 25.61
21–30 3240 59.34
31 822 15.05
Education No education 829 15.19
Primary 1550 28.39
Secondary 2560 46.89
Higher 520 9.53
Last child’s birth order 1 2269 41.56
2–3 1601 29.32
4 1590 29.12
Had pregnancy complications Yes 1645 46.66
No 1880 53.34
Reading newspaper At least once in a week 285 5.23
Not at all 5175 94.77
Watching television (TV) At least once in a week 2569 47.06
Not at all 2891 52.94
Education of husband No education 1368 25.06
Primary 1660 30.40
Secondary 1683 30.82
Higher 749 13.72
Panel C:Household level characteristics
Religion Muslim 5020 91.94
Others 440 8.07
Place of residence Rural 4088 74.87
Urban 1372 25.13
Wealth index Poor 2340 42.86
Middle 2105 38.55
Rich 1015 18.59
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respondents had autonomy and 83.5% had negative attitudes towards IPV (Panel B in
Table 1). Most of the respondents were Muslims (91.94%), nearly 75% lived in rural areas and
42.86% of them were poor (Panel C in Table 1). One of the interesting findings is that com-
pared to their husbands the respondents were relatively more educated. For instance, 15.19%
of the women were not educated which is lower than their husbands with no education
(25.06%).
Effect of gender inequality on access to and utilization of maternal
healthcare services
We explored how women’s access to and utilization of maternal healthcare services differ
depending on existing gender inequality within their household. To ensure effective service
during pregnancy, women should have access to all five ANC services and sufficient ANC vis-
its (visits 4) to ensure smooth and risk-free delivery. From the estimation, we observed that
women with higher inequality were deprived of getting access to antenatal care services. Wom-
en’s autonomy and attitude towards IPV were associated with required ANC services and suf-
ficient ANC visits. The unadjusted estimation revealed that women having autonomy in
decision making were 1.20 (95% CI: 1.01–1.43) times more likely to receive five ANC services
and women with negative attitudes towards IPV were 1.93 (95% CI: 1.46–2.56) times more
likely to receive five ANC services (Model 1 in Table 2). Moreover, women with negative atti-
tudes towards IPV were 1.55 (95% CI: 1.19–2.01) times more likely to attain sufficient ANC
visits (Model 3 in Table 2). After adjusting for socioeconomic and demographic features, we
found that women having autonomy in decision making were 1.17 (95% CI: 0.98–1.41) times
more likely to receive five ANC services (Model 2 in Table 2). While women’s negative atti-
tudes towards IPV (which represents equality) were positively associated with women’s access
to five required ANC services. We found that women with negative attitudes towards IPV
were 1.42 (95% CI: 1.02–1.97) times more likely to receive five ANC services. From our result,
it is evident that women who enjoyed equality in terms of decision making and attitude
towards IPV were more likely to receive required ANC services to avoid pregnancy-related
complications.
In addition to gender inequality, education of women and their husband was positively
associated with ANC services and sufficient ANC visits. Compared to women with no educa-
tion, women having secondary and higher education were more likely to attain all five ANC
services and more than four ANC visits. For example, compared to the women with no educa-
tion, women having higher education were 1.80 (95% CI: 1.04–3.12) times more likely to get
five ANC services (Model 2 in Table 2) and 1.97 (95% CI: 1.21–3.21) times more likely to attain
sufficient ANC visits (Model 4 in Table 2). Moreover, husband’s education has a profound
role in shaping access to five ANC services as well as sufficient ANC visits. Compared to
women with no educated husband, women having higher educated husbands were 2.42 (95%
CI: 1.71–3.41) times more likely to receive five ANC services and 1.51 (1.05–2.17) times more
likely to receive sufficient ANC visits. Women living in rural areas were 22% (95% CI: 0.61–
1.00) less likely to attain sufficient ANC visits.
Exposure to media also affected the access to five ANC services and sufficient ANC visits.
Women who read newspapers were 1.53 (95% CI: 0.93–2.53) times more likely to receive suffi-
cient ANC visits. Besides, women who watched television (TV) at least once a week were 1.24
(95% CI: 0.98–1.56) times more likely to receive the required ANC services and 1.35 (95% CI:
1.09–1.67) times more likely to attain sufficient ANC visits. Expectedly, we observed that com-
pared to poor households, women from households with middle wealth were 1.85 (95% CI:
1.43–2.40) times more likely to get the required five ANC services, while women from rich
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Table 2. Factors influencing access to and utilization of five ANC services and ANC visits.
Variables Five ANC Services ANC visits (4 times)
Model 1 Model 2 Model 3 Model 4
COR 95% CI P value AOR 95% CI P value COR 95% CI P value AOR 95% CI P value
Have autonomy [Ref.No] 1.20 1.01–
1.43
0.041 1.170.98–
1.41
0.087 1.13 0.96–
1.32
0.151 1.06 0.89–
1.27
0.504
Negative attitude towards IPV [Ref.No] 1.931.46–
2.56
0.000 1.42 1.02–
1.97
0.036 1.551.19–
2.01
0.001 0.98 0.73–
1.33
0.921
Age [Ref.age 20]
21–30 1.40 1.06–
1.85
0.018 0.94 0.71–
1.24
0.667
31 2.001.22–
3.28
0.006 0.93 0.64–
1.34
0.690
Education [Ref.Illiterate]
Primary education 1.23 0.85–
1.78
0.275 1.13 0.70–
1.84
0.615
Secondary education 1.550.93–
2.58
0.091 1.51 1.04–
2.18
0.030
Higher education 1.80 1.04–
3.12
0.037 1.971.21–
3.21
0.007
Last child’s birth order [Ref.one child]
2–3 0.81 0.60–
1.09
0.161 1.04 0.81–
1.34
0.736
40.68 0.50–
0.93
0.017 0.87 0.66–
1.14
0.316
Had pregnancy complications [Ref.No] 1.911.56–
2.33
0.000 1.891.54–
2.33
0.000
Read newspaper at least once in a week
[Ref. No]
1.44 0.90–
2.33
0.130 1.530.93–
2.53
0.097
Watch TV at least once in a week [Ref. No] 1.240.98–
1.56
0.073 1.351.09–
1.67
0.007
Husband’s Education [Ref.Illiterate]
Primary education 1.29 0.81–
2.04
0.286 1.11 0.83–
1.49
0.479
Secondary education 1.581.14–
2.21
0.007 1.11 0.74–
1.68
0.603
Higher education 2.421.71–
3.41
0.000 1.51 1.05–
2.17
0.026
Muslim [Ref.others] 0.81 0.51–
1.28
0.359 0.90 0.65–
1.27
0.559
Live in rural area [Ref. Urban] 0.92 0.71–
1.19
0.532 0.780.61–
1.00
0.053
Wealth Status [Ref.Poor]
Middle 1.851.43–
2.40
0.000 1.13 0.82–
1.55
0.456
Rich 4.252.88–
6.29
0.000 1.57 1.09–
2.27
0.017
Constant 0.370.27–
0.51
0.000 0.090.04–
0.19
0.000 0.290.23–
0.37
0.000 0.280.16–
0.50
0.000
Observations 3,494 3,492 4,438 3,492
Note
p<0.01
 p<0.05
p<0.1.
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households were 4.25 (95% CI: 2.88–6.29) times more likely to attain five ANC services and
1.57 (95% CI: 1.09–2.27) times more likely to attain sufficient ANC visits. Previous pregnancy
complications among women were positively associated with required ANC service and suffi-
cient ANC visits. Moreover, age of the women is positively linked with access to ANC services.
One of the interesting results of our study is that the last child’s birth order significantly
affected women’s access to five ANC services. Women with higher birth orders of their last
child were less likely to receive the required five ANC services during their most recent
pregnancy.
The results also indicate that gender inequality significantly affected access to SBA and
PNC. The crude analysis revealed that women having negative attitudes towards IPV were
2.11 (95% CI: 1.67–2.65) times more likely to receive assistance from SBA (Model 1 in Table 3)
and 1.83 (95% CI: 1.49–2.25) times more likely to receive PNC (Model 3 in Table 3). The
results from adjusted analysis, we observed that women who had negative attitudes towards
IPV were 1.43 (95% CI: 1.05–1.94) times more likely to receive assistance from SBA (Model 2
in Table 3) and 1.44 (95% CI: 1.12–1.84) times more likely to receive PNC (Model 4 in
Table 3). Women living in rural areas were 33% (95% CI: 0.51–0.87) less likely to receive assis-
tance from SBA and 36% (95% CI: 0.45–0.93) less likely to get PNC services. The respondents
and their husband’s education were positively associated with SBA and PNC services. Com-
pared to no educated women, women having secondary education were 1.81 (95% CI: 1.22–
2.70) times more likely to receive assistance from SBA, while women having higher education
were 2.75 (95% CI: 1.66–4.55) times more likely to receive assistance from SBA and 2.19 (95%
CI: 1.22–3.92) times more likely to attain PNC services. Moreover, compared to women with
no educated husband, women having higher educated husbands were 2.58 (95% CI: 1.74–3.82)
times more likely to receive SBA and 1.64 (95% CI: 1.12–2.40) times more likely to attain PNC
service.
Exposure to mass media is a crucial influencing factor of access to and utilization of SBA
and PNC. Women who watched TV at least once in a week were 1.30 (95% CI: 0.98–1.73)
times more likely to receive SBA and 1.43 (95% CI: 1.12–1.83) times more likely to receive
PNC services. Regarding wealth status, women from households with middle wealth were 1.37
(95% CI: 1.00–1.90) times more likely to receive SBA, while women from rich households
were 2.48 (95% CI: 1.74–3.54) times more likely to receive service from SBA and 2.60 (95% CI:
1.77–3.83) times more likely to attain PNC compared to women from poor households.
Women who had an experience of pregnancy related complications were more likely to attain
SBA and receive PNC. Last child’s birth order of women was negatively associated with SBA,
while women’s age was positively associated with SBA. This indicates women with higher birth
orders of their last child were less likely to receive assistance from SBA during their most
recent pregnancy and women with higher age during their most recent pregnancy were more
likely to receive SBA.
Understanding the channels of the effect of gender inequality on maternal
healthcare services
To examine the effect of gender inequality on maternal healthcare services through different
heterogeneous channels, we split the sample based on the category of their characteristics
(Table 4). For instance, within religion, we looked at the effect of women’s autonomy and their
attitude towards IPV on access to and utilization of maternal healthcare services but split them
by Muslims and others. This analysis should help illuminate the channels that might be driving
the differences in the effect of women’s autonomy and their attitude towards IPV between
women from Muslim households and from other religions who are mostly dominated by
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Table 3. Factors influencing access to and utilization of SBA and PNC services.
Variables SBA PNC
Model 1 Model 2 Model 3 Model 4
COR 95% CI P value AOR 95% CI P value COR 95% CI P value AOR 95% CI P value
Have autonomy [Ref.No] 1.10 0.94–
1.29
0.249 1.07 0.88–
1.29
0.485 1.02 0.84–
1.22
0.876 0.83 0.64–
1.07
0.155
Negative attitude towards IPV [Ref.No] 2.111.67–
2.65
0.000 1.43 1.05–
1.94
0.022 1.831.49–
2.25
0.000 1.441.12–
1.84
0.004
Age [Ref.age 20]
21–30 1.551.14–
2.11
0.005 1.03 0.73–
1.45
0.872
31 1.861.27–
2.71
0.001 1.36 0.79–
2.34
0.260
Education [Ref.Illiterate]
Primary education 1.55 1.03–
2.33
0.036 1.01 0.67–
1.54
0.950
Secondary education 1.811.22–
2.70
0.003 0.93 0.59–
1.46
0.754
Higher education 2.751.66–
4.55
0.000 2.191.22–
3.92
0.009
Last child’s birth order [Ref.one child]
2–3 0.69 0.51–
0.93
0.017 1.00 0.77–
1.30
0.985
40.480.36–
0.65
0.000 0.85 0.62–
1.17
0.313
Had pregnancy complications [Ref.No] 1.461.21–
1.76
0.000 1.601.32–
1.93
0.000
Read newspaper at least once in a week
[Ref. No]
1.10 0.69–
1.75
0.682 0.85 0.46–
1.56
0.600
Watch TV at least once in a week [Ref. No] 1.300.98–
1.73
0.070 1.431.12–
1.83
0.004
Husband’s Education [Ref.Illiterate]
Primary education 1.32 1.02–
1.70
0.036 1.331.00–
1.76
0.050
Secondary education 1.561.16–
2.09
0.003 1.581.12–
2.23
0.009
Higher education 2.581.74–
3.82
0.000 1.64 1.12–
2.40
0.011
Muslim [Ref.others] 0.73 0.49–
1.10
0.135 0.73 0.46–
1.16
0.188
Live in rural area [Ref. Urban] 0.670.51–
0.87
0.002 0.64 0.45–
0.93
0.019
Wealth Status [Ref.Poor]
Middle 1.371.00–
1.90
0.054 1.05 0.75–
1.47
0.784
Rich 2.481.74–
3.54
0.000 2.601.77–
3.83
0.000
Constant 0.300.23–
0.39
0.000 0.200.11–
0.38
0.000 1.09 0.84–
1.40
0.527 1.53 0.79–
2.99
0.208
Observations 4,667 3,490 4,439 3,492
Note
p<0.01
 p<0.05
p<0.1.
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Hindu (among the others more than 90% are Hindu followed by Buddhist and Christian).
Likewise, to understand the channels of the heterogeneous effect of women’s autonomy and
their attitude towards IPV, we spilt the sample depending on their place of residence (rural or
urban), respondent’s education, husband’s education, watch TV, and household wealth status
(Table 4). To understand the channels of the effect of gender inequality on maternal healthcare
services, we performed both the simple and multivariate logistic regression models to estimate
Table 4. Effect of gender inequality on access to five ANC services: Understanding the heterogeneous channels.
Panel A
Variables Residence Education of the respondent
Urban Rural No education Primary Secondary Higher
(1) (2) (3) (4) (5) (6)
Have autonomy [Ref.No] 0.88 1.29 1.28 1.39 1.061.04
(0.62–1.24) (1.04–1.60) (0.59–2.81) (0.94–2.07) (0.84–1.34) (0.61–1.77)
Negative attitude towards IPV [Ref.No] 1.09 1.50 0.87 1.751.443.18
(0.66–1.79) (1.00–2.24) (0.36–2.07) (0.96–3.20) (0.95–2.18) (1.24–8.15)
Constant 0.020.140.04 0.110.201.16
(0.01–0.07) (0.06–0.29) (0.00–0.49) (0.04–0.35) (0.09–0.45) (0.11–12.51)
Other controls Yes Yes Yes Yes Yes Yes
Observations 1,260 2,232 327 837 1,828 500
Panel B
Variables Religion Education of her husband
Others Muslims No education Primary Secondary Higher
(1) (2) (3) (4) (5) (6)
Have autonomy [Ref.No] 0.76 1.23 1.25 1.340.90 1.74
(0.40–1.44) (1.02–1.49) (0.70–2.24) (0.95–1.90) (0.68–1.19) (1.10–2.75)
Negative attitude towards IPV [Ref.No] 0.49 1.54 1.09 1.18 1.77 2.24
(0.19–1.24) (1.10–2.16) (0.51–2.33) (0.75–1.84) (1.05–2.99) (0.94–5.34)
Constant 0.14 0.07 0.140.05 0.15 0.09
(0.02–0.85) (0.04–0.13) (0.02–0.78) (0.02–0.17) (0.05–0.46) (0.00–2.08)
Other controls Yes Yes Yes Yes Yes Yes
Observations 284 3,208 632 969 1,239 652
Panel C
Variables Watch TV Household Wealth Status All Sample
No Yes Poor Middle Rich
(1) (2) (3) (4) (5) (6)
Have autonomy [Ref.No] 1.321.05 1.581.06 0.97 1.17
(0.98–1.78) (0.84–1.32) (1.13–2.22) (0.82–1.38) (0.64–1.47) (0.98–1.41)
Negative attitude towards IPV [Ref.No] 1.68 1.17 1.20 1.29 2.221.42
(1.04–2.71) (0.78–1.73) (0.74–1.94) (0.86–1.95) (0.93–5.26) (1.02–1.97)
Constant 0.090.100.120.16 0.08 0.09
(0.04–0.22) (0.03–0.37) (0.05–0.30) (0.05–0.51) (0.01–0.51) (0.04–0.19)
Other controls Yes Yes Yes Yes Yes Yes
Observations 1,489 2,003 1,126 1,512 854 3492
Note: Table 4 represents adjusted odds ratio (AOR) and 95% confidence intervals are in parentheses.
p<0.01
 p<0.05
p<0.1.
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the unadjusted and adjusted effects. However, for the sake of brevity, the results of the adjusted
effect are reported in the main text (Table 4) and the results of the unadjusted effect are
reported in the appendix as S1 Table.
Our findings from both the unadjusted and adjusted analysis revealed that the effects of
autonomy and negative attitude towards IPV were stronger for women living in rural areas
compared to urban areas in providing access to and utilization of five required ANC services.
We found that women having autonomy and lived in rural areas were more likely to receive
five ANC services (AOR: 1.29, 95% CI: 1.04–1.60) compared to women who lived in rural
areas without having autonomy (Column 2 in Panel A of Table 4). Similarly, our crude analysis
also revealed that women having autonomy and lived in rural areas were more likely to receive
five ANC services (COR: 1.20, 95% CI: 0.97–1.48) compared to women who lived in rural
areas without having autonomy (Column 2 in Panel A of S1 Table). While women with nega-
tive attitudes towards IPV and lived in rural areas were more likely to receive five required
ANC services (COR: 1.85, 95% CI: 1.31–2.60 and AOR: 1.50, 95% CI: 1.00–2.24) relative to
women who lived in rural areas having positive attitudes towards IPV (Table 4,S1 Table).
Moreover, we found that women’s negative attitudes towards IPV and lived in urban areas
were more likely to receive five ANC services (COR: 2.10, 95% CI: 1.30–3.39) compared to
women who lived in urban areas having positive attitudes towards IPV (Column 1 in Panel A
of S1 Table). Based on the effect of rural residency, it appears that place of residence is an
important driver for accessing maternal healthcare services through women empowerment.
Regarding split sample by respondent’s education, women’s autonomy and their attitude
towards IPV are performing a profound role in ensuring their access to five required ANC ser-
vices. For instance, women with secondary education and having autonomy were more likely
to attain five ANC services (AOR: 1.06, 95%: 0.84–1.34) compared to women with secondary
education without having autonomy (Column 5 in Panel A of Table 4). While, for the same
sample, women with negative attitudes towards IPV were 1.44 (95% CI: 0.95–2.18) times more
likely to receive five ANC services compared to women with secondary education having posi-
tive attitudes towards IPV. Moreover, women with higher education and having negative atti-
tudes towards IPV were more likely to get access to five ANC services (COR: 2.72, 95% CI:
1.08–6.85 and AOR: 3.18, 95% CI: 1.24–8.15) as opposed to women with higher education hav-
ing positive attitudes towards IPV (S1 Table,Table 4). It is evident that women’s autonomy
and their attitude towards IPV were performing positively for accessing maternal healthcare
services through education. Similarly, husband’s education of the respondents was also playing
a significant role to explain the linkage between women’s autonomy and their access to five
required ANC services and the linkage between women’s negative attitude towards IPV and
access to five ANC services (Panel B in Table 4).
We observed that women’s autonomy and their negative attitude towards IPV are playing a
significant positive role in access to and utilization of five required ANC services for the Mus-
lim households compared to women from other religions. We found that women from Mus-
lim households having autonomy were more likely to attain five ANC services (COR: 1.26,
95% CI: 1.05–1.52 and AOR: 1.23, 95% CI: 1.02–1.49) relative to women from Muslim house-
holds without having autonomy, and women from Muslim households with negative attitudes
towards IPV were more likely to receive five ANC services (COR: 2.08, 95% CI: 1.56–2.78 and
AOR: 1.54, 95% CI: 1.10–2.16) as opposed to women from Muslim households having positive
attitudes towards IPV (S1 Table,Table 4). We did not observe any significant effect of women’s
autonomy and their attitude towards IPV on access to and utilization of five ANC services for
the sample of other religions. The findings indicate that respondent’s religion is playing an
important role to shape the effect of women’s empowerment on their access to maternal
healthcare services. Watching TV (or without watching TV) was used as another important
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channel to play a significant role on access to and utilization of five required ANC services.
Women without watching TV but having autonomy were more likely to get five ANC services
(AOR: 1.32, 95% CI: 0.98–1.78) relative to women without having autonomy and not watching
TV (Table 4). For the same subsample (women without watching TV), women with negative
attitudes towards IPV were more likely to receive five ANC services (COR: 1.85, 95% CI: 1.22–
2.82 and AOR: 1.68, 95% CI: 1.04–2.71) as opposed to women not watching TV but having
positive attitudes towards IPV (S1 Table,Table 4). Moreover, women with negative attitudes
towards IPV and watching TV were more likely to receive five ANC services relative to
women watching TV but having positive attitudes towards IPV (Column 2 in Panel C of S1
Table). The findings from the adjusted logistic regression model revealed that gender inequal-
ity significantly influenced women’s access to maternal healthcare services for the subsample
of women without access to information (not watching TV) compared to women having
access to information. Besides, households’ wealth status is an important channel in providing
access to maternal healthcare services through women’s autonomy and their negative attitude
towards IPV. We found that, among the poor households, women’s autonomy revealed a
stronger effect on access to and utilization of five ANC services. For the poor households,
women having autonomy were more likely to get five ANC services (COR: 1.49, 95% CI: 1.06–
1.42 and AOR: 1.58, 95% CI: 1.13–2.22) compared to women from the poor households with-
out having autonomy (S1 Table,Table 4). While women from rich households having negative
attitudes towards IPV were more likely to receive five ANC services (COR: 2.81, 95% CI: 1.13–
7.02 and AOR: 2.22, 95% CI: 0.93–5.26) relative to women from rich households having posi-
tive attitudes towards IPV.
In addition to understanding the channels through which women’s autonomy and their
negative attitudes towards IPV help to shape their access to and utilization of maternal health-
care services, we explored whether access to and utilization of maternal healthcare services var-
ied by their heterogeneous characteristics. To better understand the factors that facilitate
access to maternal healthcare services, we zoomed in on the place of residence, women’s edu-
cation, their husband’s education, and watch TV to examine the heterogeneity (Table 5). For
instance, how does respondent’s education affect their access to maternal healthcare services
depending on their location (rural or urban)? In our earlier estimation, we found women liv-
ing in rural areas were less likely to receive ANC services while their education was positively
associated with their access to maternal health services. Therefore, to find this heterogeneous
effect, we relied on the interaction between the residence of women (rural/urban) and their
education level. Moreover, an interaction between education of the respondents and their hus-
bands was estimated to find the effect of women’s education level depending on their hus-
bands’ education. The interaction effects demonstrate some significant effect of women’s
heterogeneous characteristics on access to and utilization of maternal healthcare services.
We found strong evidence from the interaction effect of education and residence on access
to maternal healthcare services. The results show that heterogeneity in respondent’s education
significantly affected access to and utilization of five ANC services with respect to the location
where they reside. Women having higher education and living in urban areas were 21.22 (95%
CI: 10.66–42.27) times more likely to receive five ANC services compared to women having
no education and living in urban areas (Panel C in Table 5). In case of rural women, similar
inference can be drawn. The results show that women living in rural areas were less likely to
receive five ANC services. But the likelihood of receiving five ANC services significantly
increased for women living in rural areas and having higher education. However, considering
the effect size compared to women with higher education and living in urban areas (OR: 21.22;
95% CI: 10.66–42.27), women with higher education but living in rural areas were less likely to
receive five ANC services (OR: 5.05; 95% CI: 2.56–9.96). These findings suggest that the effects
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Table 5. Heterogeneity in factors influencing access to and utilization of five ANC services.
Variables Five ANC Services
OR P value 95% CI
Panel A
Live in rural area [Ref.Urban] 0.58 0.000 0.46–0.74
Education [Ref. No education]
Primary education 1.32 0.208 0.86–2.04
Secondary education 2.500.001 1.48–4.24
Higher education 6.070.000 3.69–9.98
Watch TV at least once in a week [Ref.No] 2.01 0.000 1.63–2.47
Constant 0.320.000 0.19–0.54
Observation 3,529
Panel B: Interaction between place of residence and watch TV
Rural x Watch TV [Ref.Urban x Do not watch TV]
Urban x Watch TV 3.240.000 2.22–4.73
Rural x Do not watch TV 0.74 0.100 0.52–1.06
Rural x Watch TV 1.71  0.004 1.19–2.45
Constant 0.510.000 0.37–0.69
Observation 3,529
Panel C: Interaction between place of residence and education of women
Rural x Respondent education [Ref.Urban x No education]
Urban x Primary education 2.320.007 1.26–4.24
Urban x Secondary education 5.410.000 3.00–9.77
Urban x Higher education 21.220.000 10.66–42.27
Rural x No education 1.10 0.829 0.48–2.52
Rural x Primary education 1.24 0.514 0.65–2.36
Rural x Secondary education 2.520.004 1.34–4.72
Rural x Higher education 5.05 0.000 2.56–9.96
Constant 0.270.000 0.15–0.49
Observation 3,529
Panel D: Interaction between respondent’s education and her husband’s education
(R) Education x (H) Education [Ref.(R) No education x (H) No education]
(R) No Education x (H) Primary Education 1.25 0.627 0.50–3.14
(R) No Education x (H) Secondary Education 3.21 0.021 1.19–8.64
(R) No Education x (H) Higher Education 2.27 0.532 0.17–29.60
(R) Primary education x (H) No education 1.21 0.492 0.70–2.11
(R) Primary education x (H) Primary education 1.67 0.229 0.72–3.85
(R) Primary education x (H) Secondary education 2.58 0.017 1.18–5.62
(R) Primary education x (H) Higher education 1.98 0.305 0.54–7.28
(R) Secondary education x (H) No education 1.58 0.358 0.60–4.17
(R) Secondary education x (H) Primary education 2.370.082 0.89–6.28
(R) Secondary education x (H) Secondary education 4.070.000 1.87–8.89
(R) Secondary education x (H) Higher education 7.910.000 4.17–14.99
(R) Higher education x (H) No education 6.03 0.175 0.45–81.30
(R) Higher education x (H) Primary education 5.65 0.003 1.78–17.95
(R) Higher education x (H) Secondary education 5.370.000 2.37–12.16
(R) Higher education x (H) Higher education 14.45 0.000 6.67–31.30
Constant 0.230.000 0.11–0.48
Observations 3,529
Note
p<0.01
 p<0.05
p<0.1; (R) Education means respondent’s education and (H) Education means husband’s education.
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of education might be stronger among women living in urban areas compared to those from
rural areas. Likewise, the effect of women’s education significantly changed the likelihood of
access to and utilization of maternal healthcare services depending on their husband’s educa-
tion. For example, women having higher education and their husbands having primary educa-
tion were 5.65 (95% CI: 1.78–17.95) times more likely to receive five ANC services whereas
both the women and their spouses having higher education were 14.45 (95% CI: 6.67–31.30)
times more likely to receive five ANC services compared to women and their partners with no
education (Panel D in Table 5). Moreover, differences in watching TV significantly affected
the access to and utilization of five ANC services with respect to their location. It has already
been mentioned that women living in rural areas were less likely to receive five ANC services.
But the likelihood of receiving five ANC services increased significantly for women living in
rural areas and watching TV (Panel B in Table 5). These findings clearly reflect the heteroge-
neous effect of women on their access to and utilization of maternal healthcare services.
Discussion
We observed that gender inequality expressed by lack of autonomy or lack of intrahousehold
decision making power by women and their attitude towards IPV is associated with access to
and utilization of maternal healthcare services, i.e., the number of ANC services, sufficient
ANC visits, giving birth with SBA, and PNC services in Bangladesh. These findings suggest
that gender inequality has a sizable effect on access to and utilization of maternal healthcare
services. Women with higher autonomy were more likely to attain the required number of
ANC services. Similarly, negative attitudes towards IPV (represents equality) positively influ-
enced maternal healthcare during prenatal, delivery, and postpartum care. These two indica-
tors of gender inequality affected the access to and utilization of maternal healthcare services
in the expected direction. Though we observed the sizable effect of these two indicators of gen-
der inequality in shaping maternal health services, the larger effect (in odds ratio) is observed
for attitudes towards IPV than autonomy. In the social settings of Bangladesh, women who
make at least two decisions within their households alone or jointly with their husbands
regarding their healthcare, household large purchase and visit to family or relatives have a
higher chance of utilizing the maternal healthcare services than those who are deprived of
making such household decisions. This indicates that women’s autonomy matters to ensure
their healthcare services. These results have some similarities with the findings in India [37]
and Tanzania [38]. Similar to women’s autonomy, women who disagree with the questions
related to women’s attitude towards IPV were more likely to ensure their maternal healthcare
services. Women’s negative attitudes towards IPV signify their thought that male has no right
to beat them. This attitude justifies their access to and utilization of maternal healthcare ser-
vices as they are relatively more expressive and conscious about their rights. This result sub-
stantiates previous findings that women’s negative attitudes towards IPV are positively
associated with receiving SBA [12,37]. Though the government in Bangladesh has enacted the
Domestic Violence Act 2010 to control violence against women, the rates of IPV are still high
in the country [39]. It is reported that around two-thirds of ever-married women experienced
IPV at least once during their lives [40], which is a serious public health concern for women,
especially during their pregnancy [41]. A higher prevalence of IPV in Bangladesh might be the
reason for the underutilization of maternal healthcare services.
The findings of our study also confirmed that women with higher education are more likely
to receive ANC, assistance from SBA, and PNC services as they are more aware of maternal
healthcare services. Moreover, women having an educated husband were more likely to attain
required maternal health services. More importantly, the results of interaction between the
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education of women and their husbands revealed that the effect of the education of a woman is
more profound if she had an educated husband. Therefore, better educational opportunities
can act as a mediator in ensuring access to maternal healthcare services. Women with higher
education may have greater autonomy at the household level and may experience more con-
tact with health professionals about their problems without any restrictions. This study finding
supports earlier literature in different study settings both in Bangladesh and abroad [34,37,
4247]. In a study, it is found that respondent’s education is an influential factor to receive
SBA in Tanzania while this is not true for Senegal, and the possible reason for the differences
could be attributed to the structural and religious settings of these two countries [38].
Women’s access to mass media has a positive effect on maternal health services. Access to
information broadens their sense of receiving guidance regarding maternal healthcare services
during pregnancy. The study result confirms that watching television positively affected the
access to and utilization of maternal healthcare services. However, the effect of watching televi-
sion depends on the difference of their residence (rural/urban). As the televisions channels in
Bangladesh broadcast different programs covering the importance of maternal health services
to avoid pregnancy-related complications, this might have positively contributed to provide
more access to maternal health services. One of the studies in India supports this result where
exposures to mass-media among women have played a significant role in accessing and utiliz-
ing health services [47]. Besides, women who lived in urban areas were more likely to receive
required maternal health services. Our result confirms that urban women were more likely to
attain sufficient ANC visits, assistance from SBA during delivery, and PNC after delivery. The
possible reason could be higher socio-economic conditions of women in urban areas, the exis-
tence of better healthcare facilities, and greater accessibility. The result goes in line with the
findings of studies in India and Mali, where the respondents of rural areas have less likelihood
of attaining sufficient ANC visits, whereas the wealthy urban households have a higher proba-
bility in this regard [47,48].
Our study also confirms that women who had experienced pregnancy complications earlier
are more likely to receive sufficient ANC visits, five ANC services, SBA, and PNC services dur-
ing their most recent pregnancy. A study in Ethiopia observed a similar outcome [48]. The
risk aversion tendency by the women starting from prenatal to postpartum care could be
attributed to this kind of precautionary behavior. Moreover, the study findings suggest that the
higher birth order of the last child has a notable negative influence on access to the required
ANC services and utilization of SBA during delivery. Particularly, the last child’s higher birth
order reduced mother’s likelihood to receive different categories of maternal health services.
Women with more than one pregnancy history were less likely to receive required and quality
maternal healthcare services. Studies in different social settings found similar findings [2,21,
47,4951], while a study in Zambia shows a positive association between higher birth order of
the last child and sufficient ANC visits by women [23]. This heterogeneity might be the result
of country-specific family planning policy and campaigns towards lowering population
growth. Bangladesh is doing well in terms of family planning and lowering population growth
[52], while Zambia still experiencing higher population growth because of the lower education
level among women [53] and a restricted psycho-social setting [54]. From economic perspec-
tives, women from comparatively rich households were more likely to attain required maternal
healthcare services because of their higher affordability of meeting costs of those services. Pre-
vious studies have shown that households’ ability to pay for services is a significant predictor
of access to maternal healthcare services [47,55,56]. From these findings, it can be claimed
that in developing countries, majority of healthcare services are financed through out-of-
pocket expenditure and the richer households are in a better position to ensure more access to
quality maternal healthcare services.
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Gender inequality and maternal healthcare services
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As already reported, we observed a strong and statistically significant effect of gender
inequality on access to and utilization of maternal healthcare services. However, the effect var-
ies depending on heterogeneous channels in terms of women’s personal and household char-
acteristics. Using split sample, we observed that place of residence is an important channel in
shaping the effect of gender inequality on access to maternal healthcare services. One of the
possible reasons behind the locational difference (rural vs. urban) is that easy access to institu-
tional facilities in urban areas may be the cause of the weaker effect of women’s autonomy and
their negative attitude towards IPV on access to maternal healthcare services. Easy access to
healthcare facilities in urban areas may ensure higher access to maternal healthcare services
irrespective of their gender gap at the household level. While trying to understand the effect of
women’s intrahousehold bargaining power and their attitude towards IPV through the chan-
nel of religion, we observed that the effect is stronger for Muslim women in getting access to
and use of maternal healthcare services. Usually, traditional religious norms which impose var-
ious restrictions on women’s mobility, intrahousehold decision making, where the constraints
are often stronger for Muslim than for other religion [57]. Because of social norms for women
in Muslim households and the presence of social prejudice in taking healthcare facilities from
hospitals and qualified doctors restricts women to attain quality maternal healthcare services.
However, those who were more aware of their intrahousehold decision making and intimate
partner violence, made a big difference in accessing maternal healthcare services. Therefore,
under the Muslim sample, women are experiencing inequality in ensuring access to maternal
healthcare services depending on their degree of autonomy and attitude towards IPV. We
found an interesting pattern to assess the effect of gender inequality on maternal healthcare
services through the household’s economic perspective. For instance, women from rich house-
holds having negative attitudes towards IPV were more effective to ensure five required ANC
services. While, for poor households, their attitude towards IPV was not effective, rather wom-
en’s autonomy was more effective in ensuring access to maternal healthcare services. Studies
found that women from poor households were more likely to justify IPV because relatively
they experienced more IPV [58,59]. This can be explained in a way that women from poor
households may seem IPV is a usual phenomenon as well as they may not be aware of their
rights regarding IPV. Therefore, this might be a possible reason for the insignificant effect of
IPV on access to quality ANC services in poor households. However, women from poor
households enjoy more autonomy in intrahousehold decision making relative to women from
middle and richer households [60]. This might be a reason for the positive role of women’s
autonomy in ensuring access to maternal healthcare services.
Strengths and limitations
We used nationally representative and comprehensive data covering multiple issues related to
gender inequality and maternal healthcare which maintains strict ethical standards for protect-
ing the privacy and confidentiality of the respondents during data collection. In addition, we
employed an established analytical framework based on recent literature to address the study
objective. Moreover, four separate outcome variables are used to represents access to and utili-
zation of maternal healthcare services from four dimensions which could be a unique contri-
bution of the study from a methodological viewpoint. Besides, we tried to cover how do
women’s autonomy and their attitude towards IPV generating heterogeneous effects on access
to maternal healthcare services through different channels related to individual and household
characteristics. For instance, women in rural areas should be empowered more to attain
greater access to maternal healthcare. However, there are few limitations and therefore
requires some cautions in interpretation. For instance, the BDHS survey covered information
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Gender inequality and maternal healthcare services
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about women’s autonomy on some limited aspects of intrahousehold decision making.
Besides, the survey covered different aspects of IPV but mostly rely on their attitudes towards
physical violence. Both the psychological and emotional violence that they usually experienced
were not explored here. Therefore, some important aspects of gender inequality within house-
holds are not considered to explain women’s access to and utilization of maternal healthcare
services.
Concluding remarks
The evidence from our study indicates that gender inequality, expressed by the participation of
women in intrahousehold decision making and their attitudes towards IPV, exists in Bangla-
desh. Women, deprived of expressing their opinions regarding their individual as well as
household well-being and having positive attitudes towards IPV, have lower access to and utili-
zation of required maternal healthcare services. This study has demonstrated that women have
more autonomy in the household decision making process when they have the right to make
decisions, whether alone or jointly with their husbands, and when they could raise their voice
against the justifications of domestic violence. Finally, the results of our study revealed that
women who were enjoying more equality (inequality) were more (less) likely to get antenatal
care services, trained or skilled persons’ assistance during giving birth, and postnatal care ser-
vices in Bangladesh. This indicates that gender inequality is a matter of ensuring higher access
to and utilization of maternal healthcare services. To ensure more access to maternal health-
care services, it is needed to raise the autonomy of women and change their norms towards
IPV. The country is experiencing a higher prevalence of IPV, thus, we recommend strong sur-
veillance and monitoring by the law enforcement authority and proper implementation of the
domestic violence act to reduce the prevalence of IPV which in turn could positively contrib-
ute to gender equality and improve access to and utilization of maternal healthcare in
Bangladesh.
Supporting information
S1 Table. Unadjusted effect of gender inequality on access to five ANC services: Under-
standing the heterogeneous channels. Note: S1 Table represents crude odds ratio (COR) and
95% confidence intervals are in parentheses.  p<0.01, p<0.05, p<0.1.
(DOCX)
Acknowledgments
The authors are grateful to the DHS program for allowing us to use the BDHS data for this
study. We are thankful to Mr. Sanjoy Kumar Chanda, Mr. Md. Tanvir Hossain, and Dr. Tarun
Kanti Bose for their constructive suggestions and guidelines. We would like to thank the editor
and two anonymous referees for many helpful comments.
Author Contributions
Conceptualization: Firoz Ahmed, Fahmida Akter Oni.
Data curation: Firoz Ahmed, Fahmida Akter Oni.
Formal analysis: Firoz Ahmed, Fahmida Akter Oni, Sk. Sharafat Hossen.
Methodology: Firoz Ahmed, Fahmida Akter Oni, Sk. Sharafat Hossen.
Project administration: Firoz Ahmed.
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Gender inequality and maternal healthcare services
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Software: Firoz Ahmed, Fahmida Akter Oni, Sk. Sharafat Hossen.
Supervision: Firoz Ahmed.
Writing – original draft: Firoz Ahmed, Fahmida Akter Oni, Sk. Sharafat Hossen.
Writing – review & editing: Firoz Ahmed, Fahmida Akter Oni, Sk. Sharafat Hossen.
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... Parental son preference and valuation of sons over daughters are common phenomena in many cultures worldwide, introducing sexbiased economic and demographic inequalities in some societies (Ahmed et al., 2021;Barot, 2012;Vlassoff, 2007). The adverse effects of overvaluing sons include sex differences in immunization coverage, perceptions of illness and need for care, quality of medical care-seeking, medical-care expenditure, and female-biased infant and child mortality in South Asian countries (Chowdhury et al., 2003;Hanifi et al., 2018;Ismail et al., 2019;Najnin et al., 2011;Shah et al., 2014;Subedi et al., 2022;Willis et al., 2009). ...
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Valuation of sons over daughters introduces sex-biased health, economic, and socio-demographic inequalities in many societies. This study aims to examine fetus-sex differences in maternity services and infant sex differences in medical care for terminally ill neonates in Bangladesh, using secondary data from the Matlab Health and Demographic Surveillance System (HDSS), maintained by icddr,b since 1966 along with data from the Bangladesh Maternal Mortality and Health Care Survey (BMMS) 2016. HDSS follows a well-defined rural population (0.24 million in 2018) to register vital events and migrations and records the use of maternity services for the index birth and medical care-seeking during the terminal illness of each death in verbal autopsy. The BMMS 2016 recorded maternity care and maternal complications for the last live birth of mothers in the same population (n = 27,133). Bivariate analyses estimated the use (in %) of maternity services for the index live births and medical services for terminally ill neonates for each socio-demographic variable. Logistic regression models estimated odds ratios (AORs) adjusted for socio-demographic variables and clustering of births to the same mothers. HDSS registered 49,827 live births and 1049 neonatal deaths during 2009–2018. We found similar prenatal care-seeking for male and female fetuses but higher facility delivery (AOR = 1.17, 95% CI:1.12–1.23) and C-sections (AOR = 1.20, 95% CI:1.15–1.25) for male fetus pregnancies, differences that remain after adjusting for maternal complications. Sex differences persisted in seeking care for terminally ill neonates. Trained provider consultation (AOR = 1.46, CI:1.00–2.12); hospital admissions (AOR = 1.43, CI:1.01–2.03); and dying in hospital (AOR = 1.91, CI:1.31–2.78) were all higher for male neonates. Other variables positively associated with delivery care and medical care-seeking were lower birth order of the child, higher maternal education, and higher family wealth status. Policy and decision-makers need to be aware of gender disparities in maternity care and care of sick neonates and plan remedial actions.
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Imbalance of power and equality in sexual relationships is linked to health in various ways, including (1) reduced ability to get information or take action, (2) increased violence between partners, and (3) influence on the reduced use of health services. While there has been research assessing multiple social and economic variables related to gender inequality, studies have used many different definitions of gender inequality, and there is a lack of this research within a pregnancy context. Here, we attempt to identify social and economic predictors of gender inequality (measured by decision-making power and acceptance of intimate partner violence) within heterosexual couples expecting a child in central Kenya. We ran a secondary data analysis using data from a three-arm individually randomized controlled HIV self-testing intervention trial conducted in 14 antenatal clinics in central and eastern Kenya among 1410 women and their male partners. The analysis included Cochran Mantel-Haenszel, logistic regression, proportional odds models, and generalized linear mixed model (GLMM) framework to account for site-level clustering. Overall, we show that there are significant social and economic variables associated with acceptance of intimate partner violence including higher age, being married, “other” religion, lower partner education, higher wealth status, and variables associated with decision-making power including lower partner education and lack of equality in earnings. This study contributes to the literature on the influence of social and economic factors on gender inequality, especially in Kenya which has a high burden of HIV/AIDS. Our results show some areas to improve these specific factors (including education and employment opportunities) or create interventions for targeted populations to potentially improve gender equality in heterosexual pregnant couples in Kenya.
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Intimate partner violence (IPV) against pregnant or postpartum women is known to have multiple detrimental effects on women and their children. While results from past research suggest much continuity in trajectories of IPV, it is unclear whether pregnancy interrupts or augments these patterns. Little is known about how physical, sexual, and psychological IPV change and overlap throughout a woman's transition to parenthood. Relying on population-based data, this study examines the prevalence, co-occurring nature, and the changing patterns of physical, sexual, and psychological IPV before, during, and after pregnancy in Bangladesh. Cross-sectional survey data were collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15-49 years, who were in the first six months postpartum. IPV was assessed with a validated set of survey items. The frequencies of different types of IPV victimization according to the period of occurrence were calculated separately and in a cumulative, co-occurring manner. The prevalence of physical IPV before, during, and after pregnancy was 52.8%, 35.2%, and 32.2%, respectively. The comparative figures for psychological IPV were 67.4%, 65% and 60.8%, and for sexual IPV were 21.1%, 18.5% and 15.5%, respectively. The results demonstrate a notable continuity in IPV victimization before, during, and after pregnancy. Psychological IPV is the only type to exhibit a significant reduction during and after pregnancy, compared to before pregnancy, but it commonly overlaps with physical IPV, which shows a significant change during pregnancy and little change in the postpartum period. At the same time, pregnancy and childbirth offer little protection against IPV for women in relationships characterized by psychological or sexual victimization, both of which commonly overlap with physical IPV. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV, and to offer necessary help and support.
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Bangladesh is a culturally conservative nation with limited freedom for women. A number of studies have evaluated intimate partner violence (IPV) and spousal physical violence in Bangladesh; however, the views of women have been rarely discussed in a quantitative manner. Three nationwide surveys in Bangladesh (2007, 2011, and 2014) were analyzed in this study to characterize the most vulnerable households, where women themselves accepted spousal physical violence as a general norm. 31.3%, 31.9% and 28.7% women in the surveys found justification for physical violence in household in 2007, 2011 and 2014 respectively. The binary logistic model showed wealth index, education of both women and their partner, religion, geographical division, decision making freedom and marital age as significant household contributors for women’s perspective in all the three years. Women in rich households and the highly educated were found to be 40% and 50% less likely to accept domestic physical violence compared to the poorest and illiterate women. Similarly, women who got married before 18 years were 20% more likely accept physical violence in the family as a norm. Apart from these particular groups (richest, highly educated and married after 18 years), other groups had around 30% acceptance rate of household violence. For any successful attempt to reduce spousal physical violence in the traditional patriarchal society of Bangladesh, interventions must target the most vulnerable households and the geographical areas where women experience spousal violence. Although this paper focuses on women’s attitudes, it is important that any intervention scheme should be devised to target both men and women.
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Intimate partner violence is a persistent social problem in Zimbabwe and has been linked to patriarchal attitudes that promote the superiority of men in marital relationships while denying women agency. Using 2015 Zimbabwe Demographic and Health Survey data, we examined the influence of female autonomy on intimate partner violence. Our analysis was restricted to 2847 women who were in some form of sexual union. Consistent with earlier studies, our results show that more than 40% of the women had experienced some form of intimate partner violence. The most prevalent form of intimate partner violence was emotional violence, followed by physical violence and sexual violence. Low levels of economic autonomy and supportive attitudes towards wife-beating increased the risk of intimate partner violence, while late marriage reduced the risk of all forms of intimate partner violence. Findings provide a basis for interventions that may increase economic control and improve decision making for women, although the association between economic violence and economic decision making requires further research that examines the possibility of reverse causality.
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Purpose The purpose of this paper is to explore an association between women experience lifetime intimate partner violence (IPV) and women decision making with utilization of reproductive and maternal health services in Cambodia. Design/methodology/approach An analysis of secondary data of Cambodia Demographic and Health Survey (CDHS) 2014. The total number of sample size was 1,539 married women who had birth in the last five years prior to the time of interview and completed the domestic violence module in the CDHS 2014 questionnaire. χ ² test and binary logistic regression were performed in this study. Findings Results give an evidence that emotional violence had significant impact on receiving sufficient antenatal care (ANC) (OR: 0.7, 95%CI: 0.43–0.86) while physical violence had significant association with deliver with skilled birth attendance (SBA) (OR: 0.5, 95%CI: 0.27–0.79). Further, women’s participation in household decision making played as important factor in enabling women revive sufficient ANC (OR: 1.7, 95%CI: 1.19–2.29), and utilization of modern contraceptive method (OR: 1.5, 95%CI: 1.09–1.97). Originality/value This study provides significant finding on the impact of IPV and women’s decision making on reproductive and maternal health in Cambodia. Result has drawn an attention to policy makers, related ministries and stakeholder to promulgate and effectiveness of policies and program implementation within the country.
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Context: Previous studies have established women's autonomy as an important determinant of several demographic outcomes in Sub-Saharan Africa, yet very few have considered intimate partner violence as one of these outcomes. Methods: Data collected in 2017 from 2,289 women residing in 40 communities in Ghana were used to examine associations between three types of autonomy-economic decision making, family planning decision making and sexual autonomy-and women's experiences with physical, sexual, emotional and economic violence. Multilevel logistic regression was used to identify associations. Results: All three types of autonomy were associated with having experienced intimate partner violence, although in different ways, at the individual level or community level. At the individual level, after adjustment for theoretically relevant variables, family planning decision-making autonomy was negatively associated with all four types of violence (odds ratios, 0.7-0.8), while economic decision-making autonomy was positively associated with emotional and economic violence (1.2 for each). At the community level, living in a community where women had higher levels of sexual autonomy was associated with reduced odds of having experienced physical and economic violence (0.5 and 0.4, respectively). Conclusions: The findings underscore the relevance of women's empowerment programs as potential mechanisms for reducing intimate partner violence in Ghana. They also point to the need to move beyond individual-level interventions and consider community-level programs that empower women to be autonomous.
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Studies addressing the relationship between women's empowerment and intimate partner violence (IPV) have yielded conflicting findings. Some suggest that women's economic and social empowerment is associated with an increased risk of intimate partner violence (IPV), arguably because men use often IPV to enforce their dominance and reassert inegalitarian gender norms when patriarchal norms are challenged; other studies suggest the converse. It is important to understand why these findings are contradictory to create a more sound basis for designing both women's empowerment interventions and anti-violence interventions. The aim of this study is to clarify the relationship between women's empowerment and IPV in a setting where gender roles are rapidly changing and IPV rates are high. We examine some of the ways in which the nature of women's empowerment evolved in six villages in rural Bangladesh during a 12-year period in which surveys have documented a decline of 11 points in the percentage of married women experiencing IPV in the prior year. The paper is based on data from 74 life history narratives elicited from 2011 to 2013 with recently married Bangladeshi women from the six villages, whom other community residents identified as empowered. Our findings suggest that women's empowerment has evolved in several ways that may be contributing to reductions in IPV: in its magnitude (for example, many women are earning more income than they previously did), in women's perceived exit options from abusive marriages, in the propensity of community members to intervene when IPV occurs, and in the normative status of empowerment (it is less likely to be seen as transgressive of gender norms). The finding that community-level perceptions of empowered women can evolve over time may go a long way in explaining the discrepant results in the literature.