SEARCHCROSS-SECTIONALobstetrics and gynecology, public health

cross-sectional·obstetrics and gynecology, public health, epidemiology, global health, maternal-fetal medicine·PMC10138853

Decomposition analysis of women’s empowerment-based inequalities in the use of maternal health care services in Ethiopia: Evidence from Demographic and Health Surveys

PLOS ONE · 6 authors, 3 centres

AI SUMMARY

FIDELITY 80%

POPULATIONWomen of reproductive age (15–49 years) in Ethiopia who had a pregnancy or birth, drawn from four rounds of the Ethiopia Demographic and Health Surveys (2000, 2005, 2011, 2016).

INTERVENTIONWomen's empowerment, measured using the SWPER Global index across three domains: attitude towards violence, social independence, and decision-making.

COMPARISONWomen categorized as low, medium, and high empowerment within each domain.

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AGENT 01 · STRUCTURED SUMMARY

TRACE TO SOURCE

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TL;DR

This study analyzed inequalities in maternal health care use across women's empowerment levels in Ethiopia using DHS data from 2000–2016. Highly empowered women consistently received more early ANC, four or more ANC visits, quality ANC, and postnatal care than poorly empowered women, with Erreygers concentration indices ranging from 0.057 to 0.240 across empowerment domains. The findings indicate that redistributive policies addressing unequal wealth, education, and rural residence are needed to close the empowerment-based gap in maternal health service utilization.

Full summary

3,772 CHARS

**Background:** Maternal health care service use in low- and middle-income countries is known to vary by socioeconomic factors, but disparities specifically linked to women's empowerment have been underexplored. This study aimed to quantify and decompose inequalities in the uptake of early ANC, four or more ANC visits, quality ANC, and PNC within 2 days of birth using women's empowerment as the equity stratifier in Ethiopia.

**Methods:** Data were drawn from four rounds of the Ethiopia Demographic and Health Surveys (EDHS) conducted in 2000, 2005, 2011, and 2016. The pooled sample included 15,367, 14,070, 16,515, and 15,683 women aged 15–49 across the four surveys, with response rates of 97.8%, 95.6%, 95.0%, and 94.6%, respectively. Women's empowerment was measured using the SWPER Global index, which captures three domains: attitude towards violence, social independence, and decision-making. Each domain was categorized into low, medium, and high empowerment. Inequalities were assessed using the Erreygers normalized concentration index (ECI) and concentration curves. Decomposition analysis using generalized linear models with binomial family and logit link was performed to identify the percent contribution of explanatory variables (e.g., wealth, education, residence, region, media exposure, survey year, and the empowerment domains themselves) to the observed inequalities. All analyses accounted for the complex survey design using Stata v16.

**Key Results:** All maternal health services were disproportionately concentrated among highly empowered women across all three empowerment domains. For the attitude towards violence domain, the ECIs were: quality ANC 0.240 (95% CI 0.207, 0.273); early ANC 0.083 (95% CI 0.071, 0.095); at least four ANC 0.122 (95% CI 0.106, 0.138); PNC within 2 days 0.067 (95% CI 0.053, 0.081). For the social independence domain, ECIs were: quality ANC 0.20 (95% CI 0.169, 0.231); early ANC 0.067 (95% CI 0.055, 0.079); at least four ANC 0.122 (95% CI 0.108, 0.136); PNC 0.071 (95% CI 0.057, 0.085). For the decision-making domain, ECIs were: quality ANC 0.122 (95% CI 0.087, 0.157); early ANC 0.065 (95% CI 0.053, 0.077); at least four ANC 0.092 (95% CI 0.074, 0.11); PNC 0.057 (95% CI 0.043, 0.071).

Decomposition analysis revealed that the largest contributors to these inequalities included wealth (e.g., richest wealth contributed 7.7%–24.3% depending on service and domain), maternal education (secondary education contributed 6.1%–15.7%), rural residence (6.9%–10.8%), survey year (especially 2016, contributing 12.4%–42.8%), and the women's empowerment domains themselves (e.g., high decision-making contributed 36.5%–37.7% for at least four ANC). Rural residence had negative elasticities and concentration indices but positive percentage contributions, indicating that poorly empowered women clustered in rural areas were disproportionately unable to access services, widening the gap.

**Clinical Implications:** The study demonstrates that women's empowerment-based inequalities in maternal health care are substantial and are driven by unequal distribution of socioeconomic determinants such as wealth, education, and geographic location. Policymakers should adopt redistributive and pro-poor policies to equitably distribute these determinants between empowered and poorly empowered women. The findings also highlight the need to integrate intersectionality frameworks into national health strategies, such as Ethiopia's 10-Year Development Plan (2021–2030), to address the compounded disadvantages faced by women who are poor, uneducated, and live in rural areas. Achieving SDG targets 3.8 and 5.6 by 2030 will require explicit prioritization of gender equality and women's empowerment in health policy.

PICO

PPOPULATION

Women of reproductive age (15–49 years) in Ethiopia who had a pregnancy or birth, drawn from four rounds of the Ethiopia Demographic and Health Surveys (2000, 2005, 2011, 2016).

IINTERVENTION

Women's empowerment, measured using the SWPER Global index across three domains: attitude towards violence, social independence, and decision-making.

OOUTCOME

Utilization of maternal health care services: early antenatal care (ANC within first 3 months), at least four ANC visits, quality ANC (blood pressure check, blood test, urine test), and postnatal care (PNC within 2 days of birth).

STUDY TYPE

cross-sectional

SPECIALTY

obstetrics and gynecology

SUMMARISED BY

AI pipeline

FIDELITY CHECK

80% · B

ORIGINAL PAPER

PMC10138853

Decomposition analysis of women’s empowerment-based inequalities in the use of maternal health care services in Ethiopia: Evidence from Demographic and Health Surveys

PLOS ONE

READ THE FULL PAPER

ABSTRACT

Abstract Background The use of maternal health care services tends to rise with women’s empowerment. However, disparities in the use of maternal health care services in Ethiopia that are founded on women’s empowerment are not sufficiently addressed. In light of women’s empowerment equity stratifier, this study seeks to assess inequalities in the uptake of maternal health care services (early antenatal care, four or more antenatal care and postnatal care services). Methods Drawing on data from the four rounds of Ethiopia Demographic and Health Surveys (EDHSs) conducted between 2000 and 2016, we conducted analysis of inequalities in utilization of maternal health care services using women’s empowerment as equity stratifier. We utilized concentration index and concentration curve for assessing the inequalities. We used clorenz and conindex Stata modules to compute the index and curve. Decomposition of the Erreygers normalized concentration index was done to explain the inequalities in terms of other variables’ percent contributions. Complex aspect of the EDHSs data was considered during analysis to produce findings consistent with the data generating process. All analyses were done using Stata v16. Results Utilization of maternal health care services was inequitably distributed between empowered and poorly empowered women, with women in the highly empowered category taking more of the services. For instance, the Erreygers index for quality ANC are 0.240 (95% CI 0.207, 0.273); 0.20 (95% CI 0.169, 0.231) and 0.122 (95% CI 0.087, 0.157), respectively, for the attitude towards violence, social independence and decision-making domains of women’s empowerment. Inequalities in the distribution of other variables like wealth, education, place of residence and women’s empowerment itself underpin the inequalities in the utilization of the services across the women’s empowerment groups. Conclusions Equity in maternal health care services can be improved through redistributive policies that attempt to fairly distribute the socioeconomic determinants of health such as wealth and education between highly and poorly empowered women.

CITATION EXPORT

Gebretsadik Shibre, Wubegzier Mekonnen, Damen Haile Mariam et al.. Decomposition analysis of women’s empowerment-based inequalities in the use of maternal health care services in Ethiopia: Evidence from Demographic and Health Surveys. PLOS ONE. (2023). https://doi.org/10.1371/journal.pone.0285024

AUTHORS

6 · 3 CENTRES

Gebretsadik Shibre, Wubegzier Mekonnen, Damen Haile Mariam, Kannan Navaneetham, Kannan Navaneetham, Kannan Navaneetham

1Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
2Department of Health system and Policy, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
3University of Botswana, BOTSWANA