Individual and community-level determinants of women's healthcare decision-making autonomy in extremely high and very high maternal mortality sub-Saharan African countries: a multilevel mixed effect analysis.

Abstract

This study was conducted to identify the individual and community level determinants of women's autonomy of healthcare decision-making in extremely high and very high maternal mortality sub-Saharan African countries. The study utilised secondary data from the recent Demographic and Health Surveys conducted between 2014 and 2024. A multilevel mixed-effect logistic regression model was fitted. Adjusted OR (AOR) with a 95% CI was used to assess the strength and direction of association and statistical significance was considered at p value <0.05. The study focused on sub-Saharan African countries identified as having extremely high or very high maternal mortality ratios. A weighted sample of 98 910 women who were married or living with their partners were included in this study. Women's autonomy in decision-making for their own healthcare was the outcome variable in this study. The pooled prevalence of women's healthcare decision-making autonomy in extremely high and very high maternal mortality sub-Saharan African countries was 50.40% (95% CI 50.09 to 50.71). Age 15-24 years (AOR=1.43, 95% CI 1.36 to 1.50) and 35-49 years (AOR=2.11, 95% CI: 2.02 to 2.22), rich wealth quantile (AOR=1.10, 95% CI 1.04 to 1.15), women's primary education status (AOR=1.56, 95% CI 1.49 to 1.64), secondary (AOR=1.88, 95% CI 1.78 to 1.98) and higher (AOR=2.58, 95% CI 2.33 to 2.87), partner's primary education status (AOR=1.51, 95% CI 1.43 to 1.59), secondary (AOR=1.16, 95% CI 1.11 to 1.22) and higher (AOR=1.13, 95% CI 1.06 to 1.21), having media exposure (AOR=1.11, 95% CI 1.07 to 1.15), rural residence (AOR=0.92, 95% CI 0.87 to 0.96), high community literacy (AOR=2.15, 95% CI 1.86 to 2.50), high community wealth status (AOR=1.25, 95% CI 1.09 to 1.44), not big problem of distance (AOR=1.08, 95% CI 1.05 to 1.13) were significant determinants of women's autonomy of healthcare decision-making. This study concluded that half of the women in extremely high and very high maternal mortality sub-Saharan African countries were autonomous in making decisions about their own healthcare. The study recommends policies that prioritise improving women's education, economic empowerment and employment opportunities to enhance women's autonomy in healthcare decision-making. Additionally, policymakers should enact laws and policies that protect women's healthcare rights. Moreover, efforts should leverage media to raise awareness of women's healthcare autonomy, address gender inequalities through partner education, and reduce healthcare access barriers, especially in rural areas.