How are women’s empowerment and other social determinants of health associated with antenatal care in Nigeria? Empirical measurement of the empowerment process using the capability approach.

Pratley, Pierre (1,2) (2016). 'How are women’s empowerment and other social determinants of health associated with antenatal care in Nigeria? Empirical measurement of the empowerment process using the capability approach.' Paper presented at the annual conference of the HDCA, Tokyo 2016.


abstract
More than six percent of women in Sub Saharan Africa die during pregnancy or in childbirth and over a third of child deaths in the region are due to lack of adequate antenatal care. Women’s empowerment has been identified as a key driver of maternal and child health with the potential to increase health service uptake and ultimately help reduce maternal and child mortality. However, the literature is inconclusive as to what extent women’s empowerment is directly associated with antenatal care uptake, and to what extent it mediates associations of other social determinants of health with antenatal care. This study disentangles proxy measures and social determinants of health from women’s empowerment and measures each indicator’s relationship with antenatal care uptake for women, a health outcome women have reason to value. Using the capability approach, I operationalize proxies of women’s empowerment, social determinants of health and indicators of women’s agency and capability as resources, conversion factors and agency to construct a capability-oriented conceptual framework of the entire empowerment process. I then validate and test this framework with 2013 Nigerian Demographic and Health Survey in a structural equation framework to estimate the contribution of dimensions of women’s empowerment as well as other conversion factors such as for example educational attainment and location as well as resources such as household wealth to antenatal care uptake. I find a positive association with antenatal care uptake for women’s empowerment in terms of access to information and the ability to refuse sex, but no evidence for an association between household decision making, financial autonomy, justification for wife beating, partner controlling behavior and intimate partner violence and adequate antenatal care uptake. Moreover, over half of the total effect of the association between conversion factors and adequate antenatal care uptake is mediated by the dimensions of women’s empowerment access to information and a woman’s ability to refuse sex. These results validate use of a capability-based approach to the measurement of the empowerment process and suggest that conversion factors are both directly involved in the “production” of a valuable health functioning such as antenatal care uptake, but also are related to achieving antenatal care uptake through the creation of capability for empowerment. The academic community involved in measuring women’s empowerment and its role in the achievement of valuable health functionings for woman and their children should consider using the capability approach in the measurement of the empowerment process. In addition, policy makers and implementing agencies should consider the synergies of promoting women’s empowerment approaches in tandem with policies and programs that address the social determinants of health to increase antenatal care service uptake and ultimately, reduce maternal and child deaths in Nigeria.

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