Afghan women’s empowerment and antenatal care utilization: a population-based cross-sectional study

Abstract

Background Although antenatal care (ANC) offers a unique opportunity to diagnose and prevent complications by mitigating modifiable risk, 38.2% of women did not complete any ANC visits in Afghanistan in 2015. Women empowerment is associated with increased use of ANC; however, there is no evidence of the effect of women empowerment on ANC in the country. Addressing this gap, we aimed to evaluate the association between women’s empowerment and ANC utilization based on the conceptual framework of women’s empowerment. Methods We analyzed data from the 2015 Afghanistan Demographic and Health Survey for 11,056 women. The association between four domains of women’s empowerment, including capability, access to resources, security, and decision-making and power, and at least four ANC visits was analyzed using a multivariable logistic regression. Results After adjusting for covariates, access to information (AOR 1.38, 95%CI 1.24, 1.54) and decision-making (AOR 1.16, 95%CI 1.08, 1.24) were positively associated with four or more ANC visits. Compared to those without any education, women with primary education (AOR 1.67, 95%CI 1.02, 2.72), secondary education (AOR 2.43, 95%CI 1.25, 4.70), and higher education (AOR 3.03, 95%CI 1.30, 7.07) had higher odds of least four ANC visits. However, asset ownership was negatively associated with ANC visits (AOR 0.72, 95%CI 0.56, 0.92). Variables related to security and literacy were not associated with the minimum ANC visits. Conclusions The mixed results of the study highlight the complex natures of women’s empowerment, warranting a more nuanced understanding of women’s empowerment in the context and future research that capture multidimensionality of women’s empowerment. Also, efforts to empower women, particularly those with no education and had less decision-making power and access to health information, could be an effective strategy to enhance ANC use in Afghanistan.

Contents of antenatal care services in Afghanistan: findings from the national health survey 2018

“…This finding was in line with the results of a systematic review undertaken in developing countries [ 50 ]. Other studies in Afghanistan have also highlighted the important role of husbands’ education in decision-making regarding seeking healthcare during pregnancy [ 21 , 51 ]. Consistent with previous studies, a husband with better education may have better understanding of the benefits of ANC services his wife would receive during ANC visits and such husbands are more likely to discuss with their spouses about issues related to women’s reproductive health and maternal health services [ 13 , 21 , 50 ].…”

“…However, cultural norms in Afghanistan, such as the expectations placed on new brides or first-time mothers, may also impact these associations. The status of a woman in her family and community, control over decision-making, traditional beliefs (about childbirth), and employment can also shape her access to and utilization of MNH services including ANC [ 21 ]. Although this finding is critical in understanding the factors influencing the utilization of ANC contents, some other studies have reported that higher parity decreases the likelihood of receiving higher ANC services by pregnant women [ 53 , 54 ].…”

“…In a country like Afghanistan, which faces one of the world’s highest maternal mortality rates at 638 per 100,000 live births [ 20 , 21 ] and an infant mortality rate of 36 per 1,000 live births [ 22 ], optimizing ANC services is vital. In spite of three decades of dedicated efforts by both national and international community, Afghanistan faces significant challenges in achieving the recommended eight ANC visits.…”

“…The low uptake of at least four ANC sessions underscores a critical issue; there is little to gain in pushing for an increase to eight visits when the existing structure fails to retain women through even half of the recommended visits. This is one reason why the standards for reproductive health services in Afghanistan and the WHO both recommend at least four ANC visits [ 21 , 28 ]. Efforts must initially focus on improving retention for the first four visits before expanding to the eight-visit schedule.…”

“…In addition, research in Afghanistan indicates that several factors significantly influence ANC service utilization. These include the spouse’s educational background, women’s literacy rates, their employment status, financial standing, place of residence, and access to private transportation [ 21 ].…”