Women's autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study.
Agency
Autonomy
Child
Empowerment
Health
Maternal
Redesign
Women
Journal
BMC women's health
ISSN: 1472-6874
Titre abrégé: BMC Womens Health
Pays: England
ID NLM: 101088690
Informations de publication
Date de publication:
19 Mar 2024
19 Mar 2024
Historique:
received:
08
11
2023
accepted:
11
02
2024
medline:
20
3
2024
pubmed:
20
3
2024
entrez:
20
3
2024
Statut:
epublish
Résumé
Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women's ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women's processes of decision-making in seeking maternal health care and how these affect women's ability to access and use antenatal, delivery, and post-natal services. We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of "female autonomy", and "women's agency" with the latter incorporating 'voice', 'choice' and 'power'. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12. The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare. Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women's voices for sustained use.
Sections du résumé
BACKGROUND
BACKGROUND
Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women's ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women's processes of decision-making in seeking maternal health care and how these affect women's ability to access and use antenatal, delivery, and post-natal services.
METHODS
METHODS
We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of "female autonomy", and "women's agency" with the latter incorporating 'voice', 'choice' and 'power'. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.
RESULTS
RESULTS
The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.
CONCLUSIONS
CONCLUSIONS
Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women's voices for sustained use.
Identifiants
pubmed: 38504293
doi: 10.1186/s12905-024-02965-9
pii: 10.1186/s12905-024-02965-9
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
181Subventions
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Organisme : Bill and Mellinda Gates Foundation
ID : # 263771.5119872.
Informations de copyright
© 2024. The Author(s).
Références
Crossing the quality chasm: a new health system for the 21st century - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/25057539/ . Cited 2020 Jul 25.
Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med. 2011;9:100–3.
doi: 10.1370/afm.1239
pubmed: 21403134
pmcid: 3056855
Ells C, Hunt MR, Chambers-Evans J. Relational autonomy as an essential component of patient-centered care. IJFAB. 2011;4(2):79–101.
Prata N, Tavrow P, Upadhyay U. Women’s empowerment related to pregnancy and childbirth: introduction to special issue. BMC Pregnancy Childbirth. 2017;17(2):1–5.
Imo CK. Influence of women’s decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018. BMC Pregnancy Childbirth. 2022;22(1):141.
doi: 10.1186/s12884-022-04478-5
pubmed: 35193504
pmcid: 8861477
Bloom SS, Wypij D, Das GM. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography. 2001;38:67–78.
doi: 10.1353/dem.2001.0001
pubmed: 11227846
Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190.
doi: 10.1371/journal.pone.0011190
pubmed: 20585646
pmcid: 2890410
Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009;69(6):926–33.
doi: 10.1016/j.socscimed.2009.07.008
pubmed: 19656604
Thapa NR. Women’s autonomy and antenatal care utilization in Nepal: a study from Nepal demographic and health survey 2016. MOJ Women’s Heal. 2019;8(4):1–7.
Vedam S, Stoll K, McRae DN, Korchinski M, Velasquez R, Wang J, et al. Patient-led decision making: measuring autonomy and respect in Canadian maternity care. Patient Educ Couns. 2019;102(3):586–94.
doi: 10.1016/j.pec.2018.10.023
pubmed: 30448044
Gagliardi AR, Dunn S, Foster A, Grace SL, Green CR, Khanlou N, et al. How is patient-centred care addressed in women’s health? A theoretical rapid review. BMJ Open. 2019;9(2):e026121.
doi: 10.1136/bmjopen-2018-026121
pubmed: 30765411
pmcid: 6398665
Sadiq UA. Women autonomy and the use of antenatal and delivery services in Nigeria. MOJ Public Heal. 2017;6(2):273–7.
Prata N, Fraser A, Huchko MJ, Gipson JD, Withers M, Lewis S, et al. Women’s empowerment and family planning: a review of the literature. J Biosoc Sci. 2017;49(6):713–43.
doi: 10.1017/S0021932016000663
pubmed: 28069078
pmcid: 5503800
Corroon M, Speizer IS, Fotso J-C, Akiode A, Saad A, Calhoun L, et al. The role of gender empowerment on reproductive health outcomes in urban Nigeria. Matern Child Health J. 2014;18:307–15.
doi: 10.1007/s10995-013-1266-1
pubmed: 23576403
pmcid: 4022125
Do M, Kurimoto N. Women’s empowerment and choice of contraceptive methods in selected African countries. Int Perspect Sex Reprod Health. 2012;38(1):23–33.
doi: 10.1363/3802312
pubmed: 22481146
Adhikari R. Effect of women’s autonomy on maternal health service utilization in Nepal: a cross sectional study. BMC Womens Health. 2016;16(1):1–7.
doi: 10.1186/s12905-016-0305-7
Rominski SD, Gupta M, Aborigo R, Adongo P, Engman C, Hodgson A, et al. Female autonomy and reported abortion-seeking in Ghana, West Africa. Int J Gynecol Obstet. 2014;126(3):217–22.
doi: 10.1016/j.ijgo.2014.03.031
Jejeebhoy SJ. Women’s autonomy in rural India: its dimensions. In: Determinants and the influence of context, IUSSP seminar paper on Female Empowerment and Demograpi, ic c’roce. 2000.
SDG Indicators. SDG indicators. Available from: https://unstats.un.org/sdgs/metadata/ . Cited 2023 Jan 6.
Crissman HP, Adanu RM, Harlow SD. Women’s sexual empowerment and contraceptive use in Ghana. Stud Fam Plann. 2012;43(3):201–12.
doi: 10.1111/j.1728-4465.2012.00318.x
pubmed: 23185863
Burkitt I. Relational agency: relational sociology, agency and interaction. Eur J Soc Theory. 2016;19(3):322–39.
doi: 10.1177/1368431015591426
Ahinkorah BO, Dickson KS, Seidu A-A. Women decision-making capacity and intimate partner violence among women in sub-Saharan Africa. Arch Public Health. 2018;76(1):1–10.
doi: 10.1186/s13690-018-0253-9
Tesha J, Fabian A, Mkuwa S, Misungwi G, Ngalesoni F. The role of gender inequities in women’s access to reproductive health services: a population-level study of Simiyu Region Tanzania. BMC Public Health. 2023;23(1):1–9.
doi: 10.1186/s12889-023-15839-w
Fernando P, Porter G. Bridging the gap between gender and transport. In: Balanc load women, Gend Transp. 2002. pp. 1–14.
Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175.
doi: 10.1037/0003-066X.44.9.1175
pubmed: 2782727
Merrell LK, Blackstone SR. Women’s empowerment as a mitigating factor for improved antenatal care quality despite impact of 2014 Ebola Outbreak in Guinea. Int J Environ Res Public Health. 2020;17(21):8172.
doi: 10.3390/ijerph17218172
pubmed: 33167397
pmcid: 7663814
Mirghafourvand M, Bagherinia M. Relationship between maternal self-efficacy and functional status four months after delivery in Iranian primiparous women. J Psychosom Obstet Gynecol. 2018;39(4):321–8.
doi: 10.1080/0167482X.2017.1394290
Kadengye DT, Atahigwa C, Kampire P, Mucunguzi S, Kemigisha E, Nyakato VN, et al. Effect of women’s intra-household bargaining power on postnatal and infant healthcare in rural Uganda-results from a cross sectional survey in Kyenjojo district. Midwifery. 2020;84:102665.
doi: 10.1016/j.midw.2020.102665
pubmed: 32087395
Field E, Pande R, Rigol N, Schaner S, Moore CT. On her account: Can strengthening women’s financial control boost female labor supply? Growth labour markes low income. In: Ctries Program Work Pap. 2016(32).
Heath R, Tan X. Intrahousehold bargaining, female autonomy, and labor supply: theory and evidence from India. J Eur Econ Assoc. 2020;18(4):1928–68.
doi: 10.1093/jeea/jvz026
Croke K, Gage A, Fulcher I, Opondo K, Nzinga J, Tsofa B, et al. Service delivery reform for maternal and newborn health in Kakamega County, Kenya: study protocol for a prospective impact evaluation and implementation science study. BMC Public Health. 2022;22(1):1727.
doi: 10.1186/s12889-022-13578-y
pubmed: 36096770
pmcid: 9465958
Strauss A, Corbin J. Basics of qualitative research techniques. 1998.
Seidu A-A, Ahinkorah BO, Hagan JE Jr, Ameyaw EK, Abodey E, Odoi A, et al. Mass media exposure and women’s household decision-making capacity in 30 sub-Saharan African countries: analysis of demographic and health surveys. Front Psychol. 2020;11:581614.
doi: 10.3389/fpsyg.2020.581614
pubmed: 33192898
pmcid: 7655773
Jensen R, Oster E. The power of TV: cable television and women’s status in India. Q J Econ. 2009;124(3):1057–94.
doi: 10.1162/qjec.2009.124.3.1057
Dasgupta S. Impact of exposure to mass media on female empowerment: evidence from India. Int J Dev Issues. 2019;18(2):243–58.
doi: 10.1108/IJDI-10-2018-0156
SolnesMiltenburg A, van Pelt S, Lindskog B, Sundby J, Meguid T. Understanding women’s decision-making process for birth location in Tanzania based on individual women’s reproductive pathways: a life-course perspective. Glob Health Action. 2022;15(1):2040149.
doi: 10.1080/16549716.2022.2040149
Scott J, Onyango MA, Burkhardt G, Mullen C, Rouhani S, Haider S, et al. A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo. BMC Pregnancy Childbirth. 2018;18(1):1–9.
doi: 10.1186/s12884-018-1942-7
Osamor PE, Grady C. Autonomy and couples’ joint decision-making in healthcare. BMC Med Ethics. 2018;19:1–8.
doi: 10.1186/s12910-017-0241-6
Chace Dwyer S, Mathur S, Kirk K, Dadi C, Dougherty L. “When you live in good health with your husband, then your children are in good health….” A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger. BMC Public Health. 2022;22(1):1–9.
doi: 10.1186/s12889-022-13683-y
Raman S, Srinivasan K, Kurpad A, Ritchie J, Razee H. “We have to ask and only then do”: unpacking agency and autonomy in women’s reproductive health in urban India. Health Care Women Int. 2016;37(10):1119–37.
doi: 10.1080/07399332.2016.1140171
pubmed: 26894817
Dakura J, Yidana A, Kuganab-lem R. Spousal communication in decision making during pregnancy in Northern Ghana. Public Health Res. 2022;12(3):69–77.
Debnath S. The impact of household structure on female autonomy in developing countries. J Dev Stud. 2015;51(5):485–502.
doi: 10.1080/00220388.2014.983909
Ghimire D, Zhang Y, Williams N. Husbands’ migration: increased burden on or more autonomy for wives left behind? J Ethn Migr Stud. 2021;47(1):227–48.
doi: 10.1080/1369183X.2019.1675502
pubmed: 33716547
Japhet P, Maluka S. Effects of male engagement interventions on women’s autonomy in decision making in Iringa Region, Tanzania. Tanzania J Dev Stud. 2021;19(1).