Investigating pathways linking women’s status and empowerment to skilled attendance at birth in Tanzania: A structural equation modeling approach

Abstract

Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa where use of a skilled birth attendant (SBA) at delivery has remained low. Despite the recognized importance of women’s empowerment as a key determinant of maternal and newborn health, evidence from sub-Saharan Africa is more limited. Using data from the 2010 Tanzania Demographic and Health Survey (n = 4,340), this study employs a robust method–structural equation modeling (SEM)–to investigate the complex and multidimensional pathways through which women’s empowerment affects SBA use. The results show that women’s education and household decision-making are positively associated with SBA use. However, not all empowerment dimensions have similar effects. Attitudes towards sex negotiation and violence as well as early marriage are not significant factors in Tanzania. Mediation analysis also confirms the indirect effect of education on SBA use only through household decision-making. The findings underscore the utility of structural equation modeling when examining complex and multidimensional constructs, such as empowerment, and demonstrate potential causal inference to better inform policy and programmatic recommendations.

Dimensions of women’s empowerment on access to skilled delivery services in Nepal

“…Among the three variables in socio-cultural empowerment, educational attainment was found to be influential in both urban and rural areas as higher educated women reported greater odds of using SBAs. Similar results were reported in other studies in Nepal [ 11 , 34 ] and elsewhere [ 7 , 12 , 35 – 39 ]. A possible reason might be that lower educated women lack awareness and tend to follow traditional delivery methods.…”

“…Decision making was not influential in both urban and rural areas in this study, which is consistent with the result of a study conducted in Senegal [18]. However, women's decision making power was significantly associated with using SBAs in other studies in Nepal [16] and elsewhere [6,8,11,12,19,22,24,[48][49][50]. We did not analyze three aspects (health decisions, movement and larger household purchases) of decision making separately and whether each aspect may have a different effect; rather, we combined them into one variable with two levels.…”

“…It has also been one of the major UN Sustainable Development Goals (SDGs) [10]. The influence of women's empowerment on access to skilled delivery service has already been associated with maternal health services [11][12][13][14][15]. Existing studies have documented the significant association between women's empowerment and maternal health service utilization [11,[16][17][18][19][20][21].…”

Social Determinants of Health Affecting Utilization of Maternal Health Services in Africa: A Narrative Review

“…Some African women often have limited autonomy and control over their health. Autonomy and decision making power facilitate the use of health services [12], [13], [16]- [19], [22]- [24]. Studies conducted in Ethiopia [16], Tanzania [22] and Nigeria [17] found a strong association of community-level women's autonomy and maternal healthcare service utilization while others found a weak relationship [23].…”

“…Autonomy and decision making power facilitate the use of health services [12], [13], [16]- [19], [22]- [24]. Studies conducted in Ethiopia [16], Tanzania [22] and Nigeria [17] found a strong association of community-level women's autonomy and maternal healthcare service utilization while others found a weak relationship [23]. On the other hand, lack of power to make decisions [25], no one to assist at the onset of labor at night [18], heavy workloads especially in the rainy season [18], [19], gender-based violence, lack of women empowerment [18], [19], lack of spousal support, lack of support from family and community, require permission from husband or family [19], [21] and health workers' attitudes towards women [12] are gender-related barriers identified in the review.…”