Influence of women's empowerment indices on the utilization of skilled maternity care: evidence from rural Nigeria.

There is increasing evidence that women with the ability to exercise control over their sexual and reproductive lives have greater access to prompt prevention and treatment of maternal health disorders, resulting in a concomitant reduction in maternal morbidity and mortality. This study assessed the association between indices of women's empowerment and utilization of skilled antenatal, intrapartum and postnatal maternity care in two rural Local Government Areas in Edo State, Nigeria. Data were taken from a household survey conducted in July and August 2017, and the study sample comprised 1245 ever-married women currently in a union who had given birth in the 5 years preceding the survey. A Gender Roles Framework guided the selection of independent women's empowerment variables. Using hierarchical logistic regression, the likelihood of receiving all three levels of skilled maternal health care service (antenatal, intrapartum and postnatal) by women's empowerment variables, grouped into resource, decision-making and influencer domains following the model of Anderson and Neuman, was assessed. Of the resource domain variables, respondent's education and respondent's participation in payment for their own health care positively predicted their use of all three levels of skilled maternal care, whereas their ownership of land negatively predicted this. Two decision-making domain variables were significantly associated with respondent's use of all three levels of service: those who made decisions alone about major household purchases were twice as likely to use all three levels of services than when decisions were made by their partners or others, while respondent making decisions alone about what food to cook each day was a negative predictor. Of the influencer variables, religion and a large spousal education gap were strong positive factors, whereas living in a consensual union rather than being legally married was a negative factor. Although health system factors are important, interventions geared towards changing gender norms that constrain women's empowerment are critical to achieving maternal health-related development goals in Nigeria. A composite strategy that targets all women's empowerment indices is recommended, as Nigeria strives towards achieving SDG-3.