Background
Maternal mortality remains unacceptably high in low- and middle-income countries, where 99% of maternal deaths occur. In 2015, 303,000 women died from causes related to pregnancy and childbirth globally, most of which were preventable. Sub-Saharan Africa (SSA) has some of the highest rates of maternal mortality, with an average maternal mortality ratio (MMR) of 546 (per 100,000 live births), as compared to the global average of 216. The risk of maternal death has even increased most recently in SSA, and stark disparities remain in the lifetime risk of maternal death when comparing SSA (1 in 36) to the global average (1 in 180) [
1].
Delivery assistance by a skilled health professional is critical to reduce maternal and newborn deaths: it is the most effective and cost-effective approach [
2‐
4]. The global World Health Organization (WHO) definition of a skilled birth attendant (SBA) is “an accredited health professional — such as a midwife, doctor, or nurse — who is proficient in the skills needed to manage normal (uncomplicated) pregnancies and childbirth, and to identify, manage and refer complications in women and newborns” [
2]. Availability and quality of delivery care with an SBA is estimated to avert 16–33% of maternal deaths [
5].
Despite such evidence, levels of SBA use remain low, particularly in SSA where only half of deliveries have an SBA present [
6]. In SSA and other low-resource settings, further reductions in maternal mortality are inhibited by a complex set of factors that affect women’s access to and use of maternity health care services. For example, low socioeconomic status (low education and economic status), long distances to facilities, insufficient transportation, lack of qualified staff and supplies, and poor quality of care are negatively associated with delivery care use and health outcomes for mothers and newborns [
7‐
10]. There is growing evidence that women’s social status and the power they wield in their households, communities, and societies are key determinants of delivery care use and its associated health outcomes [
7,
10‐
13], which are necessary to achieve social development, economic growth, and poverty reduction [
14].
Women’s status and empowerment are inherently complex constructs referred to in the empirical literature that serve to represent the social standing of women in society and their ability to participate in decision-making and to take action on issues affecting their own wellbeing and that of their families.
Women’s status is generally understood as “women’s overall position in society” [
15] and is often operationalized as women’s education, economic status, or employment [
16]. On the other hand,
women’s empowerment is defined as “women’s ability to make strategic life choices” — comprising three interrelated dimensions such as resources, agency, and achievements [
16]. The existing literature often uses proxy measures for “resources” and “agency,” including women’s participation in household decision-making, access to and control over household resources, and attitudes towards gender relationships [
11,
16,
17].
Despite the recognized importance of women’s status and empowerment on health and social outcomes, the empirical literature examining the impacts of women’s empowerment is insufficient in some substantive areas, and specific geographic regions are underrepresented in the literature. Although increasing, there are relatively few studies on the relationships between women’s empowerment and delivery care use (i.e., presence of an SBA at delivery, institutional delivery) from African contexts despite increasing programmatic efforts and evidence indicating the influence of gender norm transformation on reproductive, maternal, and child health in SSA and elsewhere [
18,
19]. In the subset of SSA studies that examine women’s empowerment as a multidimensional construct, we find unique and disparate effects of empowerment dimensions on delivery care use [
4,
20‐
23]. For example, a multi-country study in eight African countries found varied influences of women’s empowerment domains (i.e., household decision-making, financial decision-making, attitudes towards violence and sex negotiation) on the likelihood of women delivering at a health care facility [
20,
22]. In particular, women’s household decision-making was positively associated with delivery at a health facility only in Nigeria, yet in the rest of the seven countries this showed no significant effect on facility-based delivery care.
Examination of the linkages between women’s empowerment and SBA use is particularly important in Senegal, where continuous social and development efforts towards gender equality are resulting in gradual shifts in gender norms and relations [
24‐
26]. Women’s higher social status has been found to be a critical determinant of facility-based delivery care-seeking in Senegal [
27,
28], suggesting that efforts to improve gender equality may also further promote SBA use.
The varied effects of women’s empowerment on maternal health care-seeking may be due, at least in part, to two key methodological challenges in this area of study. First, there are inconsistent operationalizations and measurements of empowerment across studies and settings [
11,
17]. Despite the importance of capturing the multiple dimensions of empowerment [
16], summative measures or composite indices are often used that likely mask the unique and potentially countervailing influences of each empowerment dimension, though there are some exceptions of studies that have incorporated multidimensional measures [
4,
20‐
23,
29,
30].
Second, although structural equation modeling (SEM) has been used to examine mechanisms influencing pregnancy and child health in studies from higher income countries [
31,
32], there are no known studies using SEM that empirically test the complex linkages between multidimensional measures of empowerment and delivery care use from low-income countries.
Given these identified gaps in the literature, this study employed SEM and aimed to examine the mechanism linking women’s status, empowerment, and SBA use in Senegal, a setting where women’s status and empowerment remain constrained and a substantive proportion of births are unattended by an SBA. In particular, this study first examined the relationship of women’s education, age at first marriage, and multiple empowerment dimensions with SBA use. Second, the mediation effects of age at first marriage and empowerment dimensions were assessed as potential intervening constructs in the pathway between women’s education and SBA use.
Discussion
This study examined the pathways linking women’s status and empowerment to SBA use. The analysis provided evidence of the direct and indirect effects of education on SBA use through multiple empowerment dimensions, demonstrating evidence of potential causal mechanisms affecting SBA use. SEM is uniquely equipped to examine such complex mechanisms, by identifying and measuring intervening effects which are rarely empirically tested.
Four key findings arise from this analysis. First, the study showed the significant and positive effect of women’s education on SBA use, with a significant proportion of indirect effects of education operating through the empowerment dimensions. This finding is generally consistent with previous evidence that women’s education, as well as other sociodemographic characteristics, affect delivery care use and outcomes [
4,
8,
20‐
23,
30,
45‐
50]. Evidence from this study suggests the influence of education as a key, direct driver for increasing delivery care use from skilled providers, possibly by advancing knowledge generally on the importance of seeking care for delivery care services as a means of mitigating risks of potentially life-threatening complications for mother and baby. Further, the indirect effects of education on delivery care use through age at first marriage and gender-role attitudes (towards violence and sex negotiation) underscore the importance of policy and program interventions to promote women’s education for improving women’s health, through women’s empowerment and gender equity [
6,
51‐
53].
Second, the significant influence of age at first marriage on delivery care use — directly and indirectly — is in alignment with increasing evidence of the critical influence of early marriage and childbearing on empowerment, delivery care use, and other reproductive health behaviors and outcomes [
51,
54]. This study highlights the important linkages such that older age at first marriage is related to progressive gender-role attitudes, leading to higher likelihood of SBA use and likely better delivery outcomes.
Third, the evidence from this study highlights the critical role of gender-role attitudes in promoting delivery care-seeking in Senegal, and possibly other settings, where permissive gender norms persist. This finding is consistent with successes from sexual and reproductive health programs (e.g., HIV/AIDS prevention) which focused on transforming gender norms and integrating men as supportive partners [
19,
55,
56], as well as recent evidence from SSA finding positive influences of progressive gender-role attitudes on delivery care use [
4,
20‐
22].
Fourth, the use of SEM in this analysis provided the simultaneous comparison of several empowerment dimensions on SBA use, clearly outlining variations in the magnitude and significance of each domain. The variations in the effects of independent empowerment domains on SBA use affirm the importance of operationalizing and measuring women’s status and empowerment as a multidimensional construct, and the utility in identifying specific constructs or areas for subsequent intervention and policy efforts. For example, findings from this study suggest a prioritization of programs focusing on gender norm transformation and gender equality in Senegal, especially to promote equitable sexual negotiations between couples.
The null effects of household decision-making on SBA use, however, were unexpected yet consistent with previous studies showing an inconsistent influence of decision-making on delivery care use [
4,
20‐
22]. Our analysis using hierarchical multivariate regression also showed no effect of decision-making on SBA use in a model excluding the two attitudinal measures of empowerment, while there was a significant bivariate relationship [
4]. As noted by other scholars, the decisions on health care-seeking, particularly in a resource-constrained setting, are complex and contingent upon multiple logistical and structural factors [
7,
10,
13]. Thus, the null findings from this analysis may be due to the limitation of existing measures in the survey. Indeed significant correlations among the residuals for these three empowerment dimensions suggest that there may be similar or shared features in the unexplained aspects of these factors. Further empirical and programmatic investigations are essential given increasing recognition of the role of women’s status and empowerment as a means of achieving health and broader development goals [
13,
14,
52,
53].
This study entails some limitations. First, despite the rigor of SEM, any causal inference is tentative, and potential reciprocal effects may exist, especially given the cross-sectional nature of the DHS survey data. However, relevant theories and descriptive results support the hypothesized causal relationships. Second, the operationalization and measurement of women’s status and empowerment was limited by the available measures from the DHS, of which the relevance has been generally supported in Asia but less so in Africa [
57]. Multi-dimensionality of empowerment has been underscored by the conceptual definition by Kabeer (2001) (e.g., “agency”, “resources”, “achievement”) [
16,
33], which could have been better captured in the survey. Third, the representativeness of the study sample and generalizability of the results are limited due to the omission of currently unmarried women. These women contributed 7.1% of all births that occurred (
n = 576) in the study, yet since unmarried women were excluded from the decision-making questions, they were excluded from the analytic sample. Perhaps even more important to address in future program and research efforts is the omission of adolescents aged 10–14. Young adolescents are not interviewed in the DHS and other global surveys, despite the fact that a proportion of young adolescents will enter into marital relationships and begin childbearing at these ages in Senegal and several other African contexts. The underrepresentation of adolescents is critical, especially in light of growing evidence that adolescents are at greater risk of delivery without skilled professionals, unsafe abortion, and maternal deaths [
51,
58‐
61].