Background: Access to and receipt of high-quality care during pregnancy and childbirth is critical for preventing maternal mortality. In male-dominated societies, women’s lack of autonomy can be a barrier to accessing maternal health care. However, research often defines autonomy narrowly, although multiple components of empowerment may play a role. Our study assessed the relationship between maternal health care-seeking and measures of empowerment among women in Pakistan in order to identify persistent disparities in the utilization of maternal health services.
Methods: We analyzed data from currently married women with a recent live birth who were interviewed in Demographic and Health Surveys conducted in Pakistan in 2012-13 and 2017-18. We examined trends in antenatal care, skilled birth attendance, postnatal care, and a composite indicator of all three. We also assessed trends in empowerment using the validated, survey-based Women’s emPowERment (SWPER) index, which included three domains: attitude to violence, social independence, and decision making. We included an additional empowerment measure based on women’s report of problems accessing care. We conducted tests of association to examine the significance of the differences in care-seeking between survey years, and by levels of empowerment and background characteristics. Finally, we fitted adjusted logistic regression models to identify the magnitude of these associations after controlling for key sociodemographic characteristics.
Results: The results showed the social independence and decision-making domains of empowerment were each significantly and positively associated with maternal health care-seeking. However, the strength and magnitude of the relationship between wealth and care-seeking was greater than empowerment, with a nearly 15-fold increase in the odds of receiving all three maternal health care contacts if a woman was in the wealthiest quintile compared with the lowest wealth quintile. In addition, earlier maternal health care-seeking was associated with increased odds of skilled attendance at birth and postnatal care.
Conclusions: Although higher empowerment is independently related to increased maternal health care-seeking, wealth was a stronger determinant. Because empowerment may also work through wealth, stakeholders should consider evidence of “pro-poor” policies, in tandem with efforts towards empowerment, to encourage timely use of services during pregnancy and childbirth.