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BMC Pregnancy and Childbirth
Published in: BMC Pregnancy and Childbirth 2/2017

Open Access 01-11-2017 | Research

Examining the mechanisms by which women’s status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach

Authors: Kyoko Shimamoto, Jessica D. Gipson

Published in: BMC Pregnancy and Childbirth | Special Issue 2/2017

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Abstract

Background

Despite the reduction in maternal deaths globally, maternal mortality rates remain unacceptably high, particularly in some regions of the world. In sub-Saharan Africa, maternal mortality rates have even increased recently, with 201,000 deaths in 2015 as compared to 179,000 in 2013. Use of a skilled birth attendant (SBA) at delivery has remained low, despite evidence of the effectiveness of SBAs in reducing maternal deaths. Women’s empowerment is increasingly recognized as a key determinant of maternal health care-seeking and outcomes, yet empirical examinations of the linkages between women’s empowerment and delivery care use are particularly limited, especially from sub-Saharan Africa.

Methods

Using data from the 2010 Senegal Demographic and Health Survey (n = 7451), in this study we employed structural equation modeling (SEM) to investigate the complex and multidimensional pathways by which three women’s empowerment domains (household decision-making, attitudes towards violence, and sex negotiation) directly and indirectly affect SBA use.

Results

Although variations were observed across measures, many of the women’s status and empowerment measures were positively related to SBA use. Notably, women’s education demonstrated a substantial indirect effect: higher education was related to older age at first marriage, which was associated with higher levels of empowerment and SBA use. In addition to age at first marriage, gender-role attitudes (e.g., progressive attitudes towards violence and sex negotiation) were significant mediators in the relationship between education and SBA use. However, household decision-making was not significantly associated with SBA use.

Conclusions

Findings indicate significant effects of women’s education, early marriage, and some dimensions of women’s empowerment on SBA use. SEM was particularly useful in examining the complex and multidimensional constructs of women’s empowerments and their effects. This study informs policy recommendations and programmatic efforts to reduce maternal mortality in sub-Saharan Africa by strengthening support for women’s access to higher education, delaying marriage and childbearing among girls and young women, and supporting more equitable gender norms.
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Literature
1.
WHO. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: WHO Press; 2015.
2.
WHO. Making pregnancy safer: the critical role of the skilled birth attendant: a joint statement of WHO, ICM, and FIGO. Geneva: WHO Press; 2004.
3.
World Health Organization. Every newborn: an action plan to end preventable deaths. Geneva: World Health Organization; 2014.
4.
Shimamoto K, Gipson JD. The relationship of women’s status and empowerment with skilled birth attendant use in Senegal and Tanzania. BMC Pregnancy Childbirth. 2015;15(1):154.CrossRefPubMedPubMedCentral
5.
Graham WJ, Bell JS, Bullough CH. Can skilled attendance at delivery reduce maternal mortality in developing countries. Safe Motherhood Strateg. 2001;17:97–130.
6.
Nations U. The Milennium Development Goals Report 2015. New York: United Nations; 2015.
7.
Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, Achadi E, Adjei S, Padmanabhan P, van Lerberghe W, et al. Maternal Survival 3 — going to scale with professional skilled care. Lancet. 2006;368(9544):1377–86.CrossRefPubMed
8.
Shiffman J. Can poor countries surmount high maternal mortality? Stud Fam Plan. 2000;31(4):274–89.CrossRef
9.
Ronsmans C, Graham WJ. Lancet Maternal Survival Series steering group. Maternal survival 1 — Maternal mortality: who, when, where, and why. Lancet. 2006;368(9542):1189–200.CrossRefPubMed
10.
Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110.CrossRefPubMed
11.
Malhotra A, Shuler SR, Boender C. Measuring women's empowerment as a variable in international development. In: World Bank workshop on poverty and gender: New perspectives. Washington, DC: The World Bank; 2002.
12.
Tunçalp Ö, Souza J, Hindin M, Santos C, Oliveira T, Vogel J, Togoobaatar G, Ha D, Say L, Gülmezoglu A. Education and severe maternal outcomes in developing countries: a multicountry cross‐sectional survey. BJOG Int J Obstet Gynaecol. 2014;121(s1):57–65.CrossRef
13.
World Health Organization. Strategies towards ending preventable maternal mortality (EPMM). Geneva: World Health Organization; 2015.
14.
World Bank. World Development Report 2012: gender equality and development. Washington, DC: World Bank Publications; 2012.
15.
Safilios-Rothschild C. Female power autonomy and demographic change in the Third World. In: Anker R, Buvinic M, Youssef NH, editors. Women's roles and population trends in the Third World. London: Routledge; 1982.
16.
Kabeer N, McFadden P, Arnfred S, Dominguez E, Saaadallah S. Discussing women's empowerment: theory and practice. Sida studies no.3. Stockholm: Sida; 2001.
17.
Upadhyay UD, Gipson JD, Withers M, Lewis S, Ciaraldi EJ, Fraser A, Huchko MJ, Prata N. Women's empowerment and fertility: a review of the literature. Soc Sci Med. 2014;115:111–20.CrossRefPubMed
18.
Muralidharan A, Fehringer J, Pappa S, Rottach E, Das M, Mandal M. Transforming gender norms roles and power dynamics for better health: evidence from a systematic review of gender-integrated health programs in low- and middle-income countries. Washington, DC: Futures Group; 2015.
19.
Interagency Gender Working Group. A summary report of new evidence that gender perspectives improve reproductive health outcomes. Washington, DC: Population Reference Bureau; 2011.
20.
Singh K, Bloom S, Brodish P. Influence of gender measures on maternal and child health in Africa. MEASURE Evaluation Technical Report 66. Chapel Hill: MEASURE Evaluation; 2011.
21.
Singh K, Bloom S, Haney E, Olorunsaiye C, Brodish P. Gender factors and facility delivery: Nigeria and MDG5. Afr J Reprod Health. 2012;16:122–8.
22.
Singh K, Bloom S, Brodish P. Gender equality as a means to improve maternal and child health in Africa. Health Care Women Int. 2015;36(1):57–69.CrossRefPubMed
23.
Woldemicael G, Tenkorang EY. Women's autonomy and maternal health-seeking behavior in Ethiopia. Matern Child Health J. 2010;14(6):988–98.CrossRefPubMed
24.
Patterson A. The impact of Senegal's decentralization on women in local governance. Can J Afri Stud/La Revue Canadienne des Etudes Africaines. 2002;36(3):490–529.
25.
Agence Nationale de la Statistique et de la Demographie (ANSD) Senegal et ICF International. Enquete Demographique et de Sante a Indicateurs Multiples au Senegal (EDS-MICS) [DHS Senegal] 2005. Rockville: ANSD et ICF International; 2006.
26.
Agence Nationale de la Statistique et de la Demographie (ANSD) Senegal et ICF International. Enquete Demographique et de Sante a Indicateurs Multiples au Senegal (EDS-MICS) [DHS Senegal] 2010-2011. Rockville: ANSD et ICF International; 2012.
27.
Faye SL. Devenir mère au Sénégal: des expériences de maternité entre inégalités sociales et défaillances des services de santé. Cahiers d'études et de recherches francophones/Santé. 2008;18(3):175–83.
28.
Faye A, Faye M, Bâ I, Ndiaye P, Tal-Dia A. Facteurs déterminant le lieu d’accouchement chez des femmes ayant bénéficié au moins d’une consultation prénatale dans une structure sanitaire (Sénégal). Rev Epidemiol Sante Publique. 2010;58(5):323–9.CrossRefPubMed
29.
Upadhyay UD, Karasek D. Womens empowerment and achievement of desired fertility in sub-Saharan Africa. DHS working papers. No. 80. US Aid: Calverton; 2010.
30.
31.
Walsh J, Hepper EG, Marshall BJ. Investigating attachment, caregiving, and mental health: a model of maternal-fetal relationships. BMC Pregnancy Childbirth. 2014;14(1):1.CrossRef
32.
Ruiz RJ, Dwivedi AK, Mallawaarachichi I, Balcazar HG, Stowe RP, Ayers KS, Pickler R. Psychological, cultural and neuroendocrine profiles of risk for preterm birth. BMC Pregnancy Childbirth. 2015;15(1):1.CrossRef
33.
Blumberg RL. A general theory of gender stratification. Sociol Theory. 1984;2:23–101.CrossRef
34.
Collins R, Chafetz JS, Blumberg RL, Coltrane S, Turner JH. Toward an integrated theory of gender stratification. Sociol Perspect. 1993;36(3):185–216.CrossRef
35.
Kline RB. Principles and practice of structural equation modeling. New York: Guilford Press; 2011.
36.
National Bureau of Statistics (NBS) Tanzania and ICF Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam: NBS and ICF Macro; 2011.
37.
McCloskey LA, Williams C, Larsen U. Gender inequality and intimate partner violence among women in Moshi, Tanzania. Int Fam Plan Perspect. 2005;31(3):124–30.CrossRefPubMed
38.
Larsen U, Hollos M. Women's empowerment and fertility decline among the Pare of Kilimanjaro region, Northern Tanzania. Soc Sci Med. 2003;57(6):1099–115.CrossRefPubMed
39.
Boye A-eK, Hill K, Isaacs S, Gordis D. Marriage law and practice in the Sahel. Stud Fam Plan. 1991;22(6):343–9.CrossRef
40.
Fuse K. Cross-national variation in attitudinal measures of gender preference for children: an examination of demographic and health surveys from 40 countries. DHS Working Papers No. 44. Calverton: US Aid; 2008.
41.
ICF International. Demographic and health survey sampling and household listing manual. In: Measure DHS. Calverton: ICF International; 2012.
42.
Hu L-t, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J. 1999;6(1):1–55.CrossRef
43.
Yu CY, Muthen B. Evaluation of model fit indices for latent variable models with categorical and continuous outcomes. In: Annual meeting of the American Educational Research Association, New Orleans, LA. 2002.
44.
Pett MA, Lackey NR, Sullivan JJ: Making sense of factor analysis: The use of factor analysis for instrument development in health care research: Sage; 2003.CrossRef
45.
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):e1190.
46.
Woldemicael G. Do women with higher autonomy seek more maternal health care? Evidence from Eritrea and Ethiopia. Health Care Women Int. 2010;31(7):599–620.CrossRefPubMed
47.
Jayaraman A, Chandrasekhar S, Gebreselassie T. DHS Working Papers: factors affecting maternal health care seeking behavior in Rwanda. No. 59. Calverton: US Aid; 2008.
48.
Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria: looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9(1):43.CrossRefPubMedPubMedCentral
49.
Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth. 2013;13(1):40.CrossRefPubMedPubMedCentral
50.
Ochako R, Fotso J-C, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: insights from the Kenya Demographic and Health Survey, 2003. BMC Pregnancy Childbirth. 2011;11(1):1.CrossRefPubMedPubMedCentral
51.
WHO. WHO guideline on preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries. Geneva: WHO Press; 2011.
52.
Mason E, McDougall L, Lawn JE, Gupta A, Claeson M, Pillay Y, Presern C, Lukong MB, Mann G, Wijnroks M. From evidence to action to deliver a healthy start for the next generation. Lancet. 2014;384(9941):455–67.CrossRefPubMed
53.
Requejo JH, Bryce J, Barros AJ, Berman P, Bhutta Z, Chopra M, Daelmans B, de Francisco A, Lawn J, Maliqi B. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet. 2015;385(9966):466–76.CrossRefPubMed
54.
Hindin M. The influence of women's early childbearing on subsequent empowerment in sub-Saharan Africa: a cross-national meta analysis. International Center for Research on Women Fertility & Empowerment Working Paper Series. 2012. p. 003-2012.
55.
Pulerwitz J, Gortmaker SL, DeJong W. Measuring sexual relationship power in HIV/STD research. Sex Roles. 2000;42(7-8):637–60.CrossRef
56.
Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: development and psychometric evaluation of the GEM scale. Men Masculinities. 2008;10(3):322–38.CrossRef
57.
Kishor S, Subaiya L. Understanding women's empowerment: a comparative analysis of Demographic and Health Surveys (DHS) data. DHS Comparative Reports No. 20. Calverton: Macro International; 2008.
58.
Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet. 2007;369(9568):1220–31.CrossRefPubMed
59.
Magadi MA, Agwanda AO, Obare FO. A comparative analysis of the use of maternal health services between teenagers and older mothers in sub-Saharan Africa: evidence from Demographic and Health Surveys (DHS). Soc Sci Med. 2007;64(6):1311–25.CrossRefPubMed
60.
Neal S, Matthews Z, Frost M, Fogstad H, Camacho AV, Laski L. Childbearing in adolescents aged 12–15 years in low resource countries: a neglected issue. New estimates from demographic and household surveys in 42 countries. Acta Obstet Gynecol Scand. 2012;91(9):1114–8.CrossRefPubMed
61.
Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N. Sexual behaviour in context: a global perspective. Lancet. 2006;368(9548):1706–28.CrossRefPubMed
Metadata
Title
Examining the mechanisms by which women’s status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach
Authors
Kyoko Shimamoto
Jessica D. Gipson
Publication date
01-11-2017
Publisher
BioMed Central
Published in
BMC Pregnancy and Childbirth / Issue Special Issue 2/2017
Electronic ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-017-1499-x

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