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Introduction In 2017, the highest global maternal deaths occurred in sub-Saharan Africa (SSA). The WHO advocates that maternal deaths can be mitigated with the assistance of skilled birth attendants (SBAs) at childbirth. Women empowerment is also acknowledged as an enabling factor to women’s functionality and healthcare utilisation including use of SBAs’ services. Consequently, this study investigated the association between women empowerment and skilled birth attendance in SSA. Materials and methods This study involved the analysis of secondary data from the Demographic and Health Surveys of 29 countries conducted between January 1, 2010, and December 3, 2018. For this study, only women who had given birth in the five years prior to the surveys were included, which is 166,022. At 95% confidence interval, Binary Logistic Regression analyses were conducted and findings were presented as adjusted odds ratios (aORs). Results The overall prevalence of skilled birth attendance was 63.0%, with the lowest prevalence in Tanzania (13.8%) and highest in Rwanda (91.2%). Women who were empowered with high level of knowledge (aOR = 1.60, 95% CI = 1.51, 1.71), high decision-making power (aOR = 1.19, 95% CI = 1.15, 1.23), and low acceptance of wife beating had higher likelihood of skill birth attendance after adjusting for socio-demographic characteristics. Women from rural areas had lesser likelihood (OR = 0.53, 95% CI = 0.51-0.55) of skilled birth attendance compared to women from urban areas. Working women had a lesser likelihood of skilled birth attendance (OR = 0.91, 95% CI = 0.88-0.94) as compared to those not working. Women with secondary (OR = 2.13, 95% CI = 2.03-2.22), or higher education (OR = 4.40, 95% CI = 3.81-5.07), and women in the richest wealth status (OR = 3.50, 95% CI = 3.29-3.73) had higher likelihood of skilled birth attendance. Conclusion These findings accentuate that going forward, successful skilled birth attendant interventions are the ones that can prioritise the empowerment of women.
Questionnaires and procedures for the surveys were reviewed and approved by the Ethics Committee of Opinion Research Corporation Macro International Inc and ICF Institutional Review Board (IRB). As nationally representative surveys, the DHS survey protocols for the various countries were also reviewed and approved by the ICF IRB and the relevant IRBs of the various countries. All data were completely anonymized, de identified, and/or aggregated before access and analysis. Detailed information on the ethical procedures observed by the DHS program can be accessed via http://goo.gl/ny8T6X. As we used secondary data for our analysis, we did not require further ethical approval from our named institutional bodies as the national level ethical clearance was sufficient for our analysis to be carried out. The study used pooled data from the most recent Demographic and Health Surveys (DHS) conducted between January 1, 2010, and December 3, 2018, in 29 countries in sub-Saharan Africa (SSA) (see Table 1). The DHS is a countrywide representative study undertaken in a five-year period in several low–and middle–income countries in Asia and Africa. It focuses on maternal and child health by interviewing women in their reproductive age (15–49 years). The DHS follows standardized procedures in areas such as sampling, questionnaires, data collection, cleaning, coding, and analyses, which allow for comparability across countries. For this study, only women who had given birth in the five years prior to the surveys were included, which is 166,022. The main outcome variable was skilled birth attendance. The outcome variable was derived from the response to the question “who assisted with the delivery?” Responses were categorized under health personnel ‘1’ and other persons ‘0’. Health personnel included doctor, nurse, nurse/midwife, an auxiliary midwife; other person also consisted of a traditional birth attendant (TBA), traditional health volunteer, community/village health volunteer, neighbours/friends/relatives, other. For this study, skilled birth attendance referred to births assisted by a doctor, nurse, auxiliary midwife, nurse/midwife [4]. Women empowerment was the main explanatory variable. The elements of women empowerment consisted of; 1. labour force participation (working, not working); 2. acceptance of wife beating (neglect of a child, burning of food, arguing with husband/partner, refusal to have sex with husband/partner, going out without permission); 3. decision making power (this was measured by the person who decides for respondents’ health care, house earning and household purchase and visiting family members); and 4. knowledge level (comprising listening to radio, reading newspaper/magazine, watching television, and educational level). Decision making power, knowledge level and acceptance of wife beating were coded based on previous methodology [31]. This is in accordance with the methods of previous authors [31,32]. Nine other explanatory variables or covariates were included namely: age, residence, partner’s level of education, wealth status, number of antenatal care (ANC) visits, skilled ANC provider, getting medical help for self: money needed for treatment, distance to a health facility and getting permission to go. These explanatory variables were selected due to their positive association with skilled birth attendance as found by prior studies [4,8,33]. Age was grouped in 5 –year interval and captured as 15–19 = 1, 20–24 = 2, 25–29 = 3, 30–34 = 4, 35–39 = 5, 40–44 = 6, and 45–49 = 7. Residence was categorized as urban = 1 and rural = 2. Women and partner’s levels of education were captured as no education = 1, primary = 2, secondary = 3, and higher education = 4. Wealth status was categorized as poorest = 1, poorer = 2, middle = 3, richer = 4, and richest = 5. Marital status was captured as married = 1, cohabitation = 2, widowed = 3, divorced = 4 and separated = 5. The number of Antenatal Care (ANC) visits was captured as less than four visits = 1 and four or more visits = 2. Skilled ANC provider was categorised as no = 0 and yes = 1. Getting medical help for self: money needed for treatment, distance to a health facility, and getting permission to go were captured as a big problem = 1 and not a big problem = 2. Descriptive and inferential analyses were done. The descriptive analysis reported results on the four elements of women empowerment, explanatory variables, and the country specific, and pooled prevalence of skilled birth attendance in sub-Saharan Africa. Inferential analysis was used to explore the relationship between skilled birth attendance, women empowerment, and the covariates. Binary Logistic Regression was conducted. All results of the binary logistic analyses were presented as odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All analyses were done using Stata version 14. The complex nature of the sampling structure of the data was adjusted using the Stata Survey command ‘svyset v021 [pweight = wt], strata (v023)’.
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