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Background: Women’s autonomy in health-care decision is a prerequisite for improvements in maternal and child health. Little is known about women’s autonomy and its influencing factors on maternal and child health care in Ethiopia. Therefore, this study was conducted to assess women’s autonomy and identify associated factors in Southeast Ethiopia.Method: A community based cross-sectional study was conducted from March 19th until March 28th, 2011. A total of 706 women were selected using stratified sampling technique from rural and urban kebeles. The quantitative data were collected by interviewer administered questionnaire and analyzed using SPSS for window version 16.0. Descriptive statistics, bivariate and multiple logistic regression analyses were carried out to identify factors associated with women’s autonomy for health care utilization.Result: Out of 706 women less than half (41.4%) had higher autonomy regarding their own and their children’s health. In the multiple logistic regression model monthly household income >1000 ETB [adjusted odds ratio(AOR):3.32(95% C.I: 1.62-6.78)], having employed husband [AOR: 3.75 (95% C.I:1.24-11.32)], being in a nuclear family structure [AOR: 0.53(95% C.I: 0.33-0.87)], being in monogamous marriage [AOR: 3.18(95% C.I: 1.35-7.50)], being knowledgeable and having favorable attitude toward maternal and child health care services were independently associated with an increased odds of women’s autonomy.Conclusion: Socio-demographic and maternal factors (knowledge and attitude) were found to influence women’s autonomy. Interventions targeting women’s autonomy with regards to maternal and child health care should focus on addressing increasing awareness and priority should be given to women with a lower socioeconomic status. © 2014 Nigatu et al.; licensee BioMed Central Ltd.
A community based cross sectional study using quantitative methods of data collection was conducted in the Goba District in March 2011. The Goba district is one of the 18 districts in Bale Zone, Oromia Region of Ethiopia and located 444 km from Addis Ababa. The district has 24 rural and 4 urban kebeles with an estimated total population of 73,653 (including the Goba administrative town) of whom 37,427 were females; 32,916 (44.7%) of its population were urban dwellers [13]. A total of 43 health institutions were available in the district of which 13 were in urban areas of Goba district while 30 health facilities were found in the rural part of the district. The estimated total number of under-five children in the district (both rural and urban) is 12,153 [Goba Woreda Health Office: Annual report, unpublished]. All women who had under-five children in 12 randomly selected kebeles of Goba district were the source population. The sample size was determined using a single population proportion formula considering 95% confidence level, 5% margin of error and 66% (p = 0.66) estimated proportion of married women who were able to decide on their own health matters with full or partial autonomy [14]. These figures were substituted in the formula bellow: Where: n i is initial sample sizes, Z α/2 is critical value for normal distribution at 95% confidence level which equals to 1.96 (z -value at α =0.05), P is national level proportion of women who participate in decision making regarding their own health care (0.66) [14], d is a margin of error (0.05). The calculated sample size, 345, was multiplied by a design effect of 2 and 10% of the calculated sample size, 69, was added for non-response. This made the final sample size 759. A total of 759 women who had under-five child from 12 kebeles (2 urban and 10 rural) were selected using stratified cluster sampling from both urban and rural settings. Preliminary household enumeration (census) was done to identify the number of eligible women (married and had under-five child) in randomly selected kebeles. After getting the list of eligible women through census, the total sample size was allocated proportionally to the size of the selected kebeles. Then the women were selected by lottery method. The quantitative data were collected using structured, pre-tested, and interviewer guided questionnaire adapted from similar studies [5,6,11,14-16]. The interview was conducted in the study participants’ usual place of residence. The questionnaire was first prepared in English and it was contextualized to suit to the research objective, local situations and language. The quality of the data was assured by translation to Afan Oromo & retranslation to English, pre-testing of the questionnaire, training of the data collectors & supervisors, and close supervision of the data collection processes. The Afan Oromo version (local language) of the instrument was used to collect the quantitative data. The data were collected by community health agents (CHA) who were intensively trained for two days on the questionnaire and general approaches to data collection. Women’s autonomy was measured by the composite index of the three constructs of women’s autonomy: control over finance, decision-making power and extent of freedom of movement [5,6,10,16]. A composite measure for each construct was created using the sum of equal weighted binary (1 = responses contributed for higher degree of autonomy versus 0 = otherwise) and three input variables (2 = for women who were able to decide independently, 1 = for joint decision and 0 = otherwise). Based on these values the overall score is found to be 27. Therefore, those women who scored half of the total score i.e. 13.5 and above were considered as highly autonomous while those who scored less than 13.5 were less autonomous. The index for decision-making power was composed of nine questions. The women were asked “who in her family usually has the final say on the following decisions”: 1. Health care for yourself, 2. Health care for your child, 3. Visit family or relative, 4. Number of children, 5. Use of maternal and child health (MCH) services such as contraception, antenatal care (ANC), preference of delivery site, and child immunization. The possible responses for each item was respondent alone, respondent and husband/partner jointly, respondent and someone else, husband/partner alone & someone else. For each items the response was scored as: 2 if a woman made sole decision, 1 if she was involved with someone [husband/partner or someone else] and 0 otherwise; the sum of the scores were made to represent an overall index of a woman’s decision-making power as indicated by different studies [15-17]. The total score on decision making power was 18. Hence, those women who scored nine and above were categorized as high decision making power whereas those scored less than nine were categorized as women with low decision making power. The index for control over finance was composed of four items: whether the woman had regular access to a source of money (including both wages earned and gifts or support from family) and whether she stated that she could spend this money without consulting anyone, who decides how the money she earned and her husband’s earnings were used. A score to each of the factors was given as that of index of decision-making power responses, except that 1 and 0 for items with binary responses (i.e. yes or no response). The total score on control over finance was 6. Those women with a score of three and above were considered as having high control over finance, while those women who scored less than three had low control over finance. The index of freedom of movement consisted of three items pertaining to the woman’s ability to leave the house without the company of another adult: whether she could go out to take a child to health facility, to visit family or relative and go to health facility for her own health care. These items were with binary responses (yes or no). Hence, those with ‘yes’ response scored 1 while those with ‘no’ response scored 0. The total score on freedom of movement was 3. Those women who scored one & half and above were considered as high freedom of movement whereas those who scored less than one and half were categorized as low freedom of movement. Knowledge of women on MCH was assessed by considering knowledge regarding the components of maternal and child health care mainly that addresses ANC, delivery, child immunization services and key danger signs during labor and childbirth. The desired answer were coded as 1; otherwise 0. The total knowledge score was 32. Hence, those mothers who scored above 84% (≥27) were knowledgeable, 50-84% (16–26) moderately knowledgeable and less than 50% (<16) less knowledgeable. To assess mother’s attitude towards MCH service: eleven items which were positively stated on attitude towards MCH were developed with possible response of agree, undecided and disagree. The measurement scales were given for each item: 3 for agree, 2 for undecided and 1 for disagree. The total attitude score was computed and this value was used for subsequent analysis. Women’s autonomy: is a reflection of women's degree of freedom, relative to men, regarding control over financial resources (economic autonomy); freedom of movement (physical autonomy); opportunity to participate in decisions (decision-making autonomy) about maternal and child health care utilization. Decision making power: the ability of women to make decision on what to do for their own and children’s health care need. Freedom of movement: the women’s ability to move to health care facility without seeking permission from other adult (husband’s/partner or someone else) for their own and children’s health care. Control over financial resources: women’s access to sources of money (her own earning, husband’s/partner’s earning and other sources) and ability to spend it without consulting anyone for their own and children’s health care concern. The data were checked for completeness and inconsistencies, edited, coded and entered into SPSS for window version 16.0 (SPSS Inc. version 16.1, Chicago, Illinois). Descriptive statistics, bivariate and multiple logistic regression analyses were carried out. All explanatory variables that showed statistically significant association in the bivariate logistic regression analysis with the outcome variable (women’s autonomy) were entered to the multiple logistic regression model. Hence, the variables entered to the multiple logistic regression analysis were age of the mother, residence, household monthly income, women’s educational status, women’s employment status, family structure, marriage type, husband’s educational status, husband’s employment status, women’s knowledge on MCH and women’s attitude towards MCH. All variables were entered into the model adjusting one another. All tests were two sided and statistical significance level was declared at p-value <0.05. A letter of ethical approval was obtained from Institutional Review Board (IRB) of Jimma University. Letters of cooperation were obtained from Goba district and Goba town administrative health offices. All women were informed about the purpose of the study and oral informed consent was sought before interview. Additionally, the women were informed about the potential risk and benefits of participating in the study including the right to withdraw from the study at anytime they want. The women were assured about the confidentiality of the information they provided.
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