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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Effect of Women’s autonomy on maternal health service utilization in Nepal: a cross sectional study</title><author><name sortKey="Adhikari, Ramesh" sort="Adhikari, Ramesh" uniqKey="Adhikari R" first="Ramesh" last="Adhikari">Ramesh Adhikari</name><affiliation><nlm:aff id="Aff1">Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, P.O.Box 1048, Kathmandu, Nepal</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27177683</idno><idno type="pmc">4867085</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4867085</idno><idno type="RBID">PMC:4867085</idno><idno type="doi">10.1186/s12905-016-0305-7</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000827</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000827</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Effect of Women’s autonomy on maternal health service utilization in Nepal: a cross sectional study</title><author><name sortKey="Adhikari, Ramesh" sort="Adhikari, Ramesh" uniqKey="Adhikari R" first="Ramesh" last="Adhikari">Ramesh Adhikari</name><affiliation><nlm:aff id="Aff1">Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, P.O.Box 1048, Kathmandu, Nepal</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Women's Health</title><idno type="eISSN">1472-6874</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Women’s role has been a priority area not only for sustainable development, but also in reproductive health since ICPD 1994. However, very little empirical evidence is available about women’s role on maternal health service utilization in Nepal. This paper explores dimensions of women’s autonomy and their relationship to utilization of maternal health services.</p></sec><sec><title>Methods</title><p>The analysis uses data from the Nepal Demographic and Health Survey, 2011. The analysis is confined to women who had given birth in the 5 years preceding the survey (n = 4,148). Women’s autonomy related variables are taken from the standard DHS questionnaire and measured based on decision in household about obtaining health care, large household purchases and visit to family or relative. The net effect of women’s autonomy on utilization of maternal health services after controlling for the effect of other predictors has been measured through multivariate logistic regression analysis.</p></sec><sec><title>Results</title><p>The findings indicate only about a half of the women who had given birth in the past 5 years preceding the survey had 4 or more ANC check up for their last birth. Similarly, 40 % of the women had delivered their last child in the health facilities. Furthermore, slightly higher than two-fifth women (43 %) had postnatal check up for their last child. Only slightly higher than a fourth woman (27 %) had utilized all the services (adequate ANC visit, delivered at health institution and post natal check up) for their last child. This study found that many socio-demographic variables such as age of women, number of children born, level of education, ethnicity, place of residence and wealth index are predicators of utilizing the maternal health services of recent child. Notably, higher level autonomy was associated with higher use of maternal health services [adjusted odds ratio (aOR) =1.40; CI 1.18–1.65].</p></sec><sec><title>Conclusions</title><p>Utilization of maternal health services for the recent child among women is very low. The study results suggest that policy actions that increase women’s autonomy at home could be effective in helping assure good maternal health.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Abadian, S" uniqKey="Abadian S">S Abadian</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Adhikari, R" uniqKey="Adhikari R">R Adhikari</name></author><author><name sortKey="Sawangdee, Y" uniqKey="Sawangdee Y">Y Sawangdee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Matsumura, M" uniqKey="Matsumura M">M Matsumura</name></author><author><name sortKey="Gubhaju, B" uniqKey="Gubhaju B">B Gubhaju</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mullany, Bc" uniqKey="Mullany B">BC Mullany</name></author><author><name sortKey="Hindin, Mj" uniqKey="Hindin M">MJ Hindin</name></author><author><name sortKey="Becker, S" uniqKey="Becker S">S Becker</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mistry, R" uniqKey="Mistry R">R Mistry</name></author><author><name sortKey="Galal, O" uniqKey="Galal O">O Galal</name></author><author><name sortKey="Lu, M" uniqKey="Lu M">M Lu</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Gill, K" uniqKey="Gill K">K Gill</name></author><author><name sortKey="Pande, R" uniqKey="Pande R">R Pande</name></author><author><name sortKey="Malhotra, A" uniqKey="Malhotra A">A Malhotra</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Basu, Am" uniqKey="Basu A">AM Basu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kishor, S" uniqKey="Kishor S">S Kishor</name></author><author><name sortKey="Subaiya, L" uniqKey="Subaiya L">L Subaiya</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abou Zahr, Cl" uniqKey="Abou Zahr C">CL Abou Zahr</name></author><author><name sortKey="Wardlaw, T" uniqKey="Wardlaw T">T Wardlaw</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Castle, Se" uniqKey="Castle S">SE Castle</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Balk, D" uniqKey="Balk D">D Balk</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Beegle, K" uniqKey="Beegle K">K Beegle</name></author><author><name sortKey="Frankenberg, E" uniqKey="Frankenberg E">E Frankenberg</name></author><author><name sortKey="Thomas, D" uniqKey="Thomas D">D Thomas</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sado, L" uniqKey="Sado L">L Sado</name></author><author><name sortKey="Spaho, A" uniqKey="Spaho A">A Spaho</name></author><author><name sortKey="Hotchkiss, Dr" uniqKey="Hotchkiss D">DR Hotchkiss</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Jejeebhoy, S" uniqKey="Jejeebhoy S">S Jejeebhoy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dyson, T" uniqKey="Dyson T">T Dyson</name></author><author><name sortKey="Moore, M" uniqKey="Moore M">M Moore</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Maitra, P" uniqKey="Maitra P">P Maitra</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Womens Health</journal-id><journal-id journal-id-type="iso-abbrev">BMC Womens Health</journal-id><journal-title-group><journal-title>BMC Women's Health</journal-title></journal-title-group><issn pub-type="epub">1472-6874</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27177683</article-id><article-id pub-id-type="pmc">4867085</article-id><article-id pub-id-type="publisher-id">305</article-id><article-id pub-id-type="doi">10.1186/s12905-016-0305-7</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Effect of Women’s autonomy on maternal health service utilization in Nepal: a cross sectional study</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Adhikari</surname><given-names>Ramesh</given-names></name><address><email>rameshipsr@gmail.com</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><aff id="Aff1">Geography and Population Department, Mahendra Ratna Campus, Tribhuvan University, P.O.Box 1048, Kathmandu, Nepal</aff></contrib-group><pub-date pub-type="epub"><day>13</day><month>5</month><year>2016</year></pub-date><pub-date pub-type="pmc-release"><day>13</day><month>5</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>16</volume><elocation-id>26</elocation-id><history><date date-type="received"><day>18</day><month>10</month><year>2014</year></date><date date-type="accepted"><day>11</day><month>5</month><year>2016</year></date></history><permissions><copyright-statement>© Adhikari. 2016</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>Women’s role has been a priority area not only for sustainable development, but also in reproductive health since ICPD 1994. However, very little empirical evidence is available about women’s role on maternal health service utilization in Nepal. This paper explores dimensions of women’s autonomy and their relationship to utilization of maternal health services.</p></sec><sec><title>Methods</title><p>The analysis uses data from the Nepal Demographic and Health Survey, 2011. The analysis is confined to women who had given birth in the 5 years preceding the survey (n = 4,148). Women’s autonomy related variables are taken from the standard DHS questionnaire and measured based on decision in household about obtaining health care, large household purchases and visit to family or relative. The net effect of women’s autonomy on utilization of maternal health services after controlling for the effect of other predictors has been measured through multivariate logistic regression analysis.</p></sec><sec><title>Results</title><p>The findings indicate only about a half of the women who had given birth in the past 5 years preceding the survey had 4 or more ANC check up for their last birth. Similarly, 40 % of the women had delivered their last child in the health facilities. Furthermore, slightly higher than two-fifth women (43 %) had postnatal check up for their last child. Only slightly higher than a fourth woman (27 %) had utilized all the services (adequate ANC visit, delivered at health institution and post natal check up) for their last child. This study found that many socio-demographic variables such as age of women, number of children born, level of education, ethnicity, place of residence and wealth index are predicators of utilizing the maternal health services of recent child. Notably, higher level autonomy was associated with higher use of maternal health services [adjusted odds ratio (aOR) =1.40; CI 1.18–1.65].</p></sec><sec><title>Conclusions</title><p>Utilization of maternal health services for the recent child among women is very low. The study results suggest that policy actions that increase women’s autonomy at home could be effective in helping assure good maternal health.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Women’s autonomy</kwd><kwd>Maternal health</kwd><kwd>Cross sectional</kwd><kwd>Nepal</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2016</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p>Maternal and Child mortality continues to be a major health problem in developing countries. One estimate made in 2015 puts the maternal death at 303000. Developing regions account for approximately 99 % of the global maternal deaths, with Sub-Saharan Africa alone accounting for roughly 66 %, followed by South Asia 22 % [<xref ref-type="bibr" rid="CR1">1</xref>]. Improving maternal health is one of the eight Millennium Development Goals [<xref ref-type="bibr" rid="CR2">2</xref>]. Despite various international efforts initiated to improve maternal health, about 287,000 women worldwide die each year as a result of complication arising from pregnancy and child birth [<xref ref-type="bibr" rid="CR3">3</xref>]. A substantial body of research has examined the role of women’s autonomy on health and behavioral outcomes such as fertility [<xref ref-type="bibr" rid="CR4">4</xref>], infant mortality [<xref ref-type="bibr" rid="CR5">5</xref>] and child rearing and pregnancy care [<xref ref-type="bibr" rid="CR6">6</xref>–<xref ref-type="bibr" rid="CR8">8</xref>].</p><p>Reducing levels of maternal mortality and morbidity depends on increasing use of reproductive and maternal health services. Nepal has now met the MDG 5 target of reducing the maternal mortality ratio by ¾ by 2015 [<xref ref-type="bibr" rid="CR9">9</xref>]. Maternal mortality ratio in Nepal has decreased significantly (901 per 1,00,000 live births in 1990 to 258 per 1,00,000 live births in 2015) over a time period, however, it is very high compared to other countries [<xref ref-type="bibr" rid="CR1">1</xref>]. Although the government of Nepal has been implementing free delivery policy since 2009, it is one of the countries in Southern Asia where MMR is still high (258 per 100,000 live births) [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>]. Little and inequitable utilization of maternal health services is one of the reasons for such high number of maternal deaths in Nepal [<xref ref-type="bibr" rid="CR11">11</xref>]. Fertility declined from 4.6 births per woman in the 1996 NFHS to 2.6 births per woman in the 2011 NDHS; a drop of two births per woman in the past 15 years. Nepal has also made an impressive increase in the use of modern contraceptive methods from 26 % in 1996 to 43 % in 2011 [<xref ref-type="bibr" rid="CR10">10</xref>].</p><p>Women’s autonomy can be defined as the capacity and freedom to act independently. It encompasses women’s ability to formulate strategic choices, control resources, and participate in decision making. Researchers also identified some of the direct measures of women’s autonomy include access to and control over resources, participation in economic decisions, self-esteem, and mobility [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR12">12</xref>, <xref ref-type="bibr" rid="CR13">13</xref>].</p><p>Regular antenatal care is very helpful in identifying and preventing adverse pregnancy outcomes. WHO has recommended that a woman should have at least four ANC visit. ANC is a key maternal service in improving a wide range of health outcomes for women and children. It is an opportunity to provide interventions for improving maternal nutrition and to encourage skilled attendance at birth and use of facilities for emergency obstetric care [<xref ref-type="bibr" rid="CR14">14</xref>]. A birth delivered in health facilities is important for reducing deaths arising from complications of pregnancy. The expectation is that if complications arise during delivery in a health facility, a skilled attendant can manage the complication or refer the mother early to the next level of care. The postpartum period is particularly important for women, as during this period they may develop serious, life-threatening complications after delivery. Evidence has shown that a large proportion of deaths occur during this period, with postpartum hemorrhage being an important cause [<xref ref-type="bibr" rid="CR10">10</xref>].</p><p>Researchers have shown that higher status for women correlates positively with their health [<xref ref-type="bibr" rid="CR15">15</xref>] and that of their children [<xref ref-type="bibr" rid="CR5">5</xref>]. Study found that positive associations between women’s empowerment and lower fertility, longer birth interval and lower rates of unintended pregnancy [<xref ref-type="bibr" rid="CR16">16</xref>]. Studies also found that use of maternal health care services is influenced by women’s roles in decision-making [<xref ref-type="bibr" rid="CR17">17</xref>–<xref ref-type="bibr" rid="CR19">19</xref>].</p><p>This paper examines whether women’s autonomy is associated with maternal health service utilization (adequate ANC visit, delivered at health facilities and postnatal check up) in the context of Nepal. It is found that women in Nepal are disadvantaged compared to men in terms of their access to assets, employment, health care, and education. Since the social status and level of autonomy of Nepalese women is low, their status at the household level needs to be further explored in terms of health services utilization, which has a direct impact on maternal and infant morbidity and mortality. This relationship clearly warrants further attention, particularly in settings such as Nepal, where maternal and child health utilization is low [<xref ref-type="bibr" rid="CR10">10</xref>]. We hypothesize that women with higher autonomy are more likely to seek health care during pregnancy, delivery and Post natal care than those with lower autonomy. This paper aims to close the knowledge gap in the literature with regards to a society in which women suffer gross disadvantages in the context of a patriarchal culture, which in turn can help guide reproductive health program planners and policy makers to understand various factors influencing maternal health service utilization and to assist in implementation of reproductive health programs that will decrease maternal morbidity and mortality.</p></sec><sec id="Sec2"><title>Methods</title><sec id="Sec3"><title>Data source</title><p>This paper uses data from the Nepal Demographic and Health Survey, 2011, a nationally representative sample survey. The 2011 NDHS was carried out under the aegis of the Population Division of the Ministry of Health and Population. The primary purpose of this survey was to provide current and reliable data on fertility and family planning, child mortality, children’s nutritional status, utilization of maternal and child health services, domestic violence, and knowledge of HIV/AIDS. The study protocol was approved by the Nepal Health Research Council and the ICF Macro Institutional Review Board in Calverton, Maryland, USA. All respondents had provided verbal informed consent to be interviewed prior to data collection. Therefore, an independent ethical approval was not required. For this study, we used publicly available dataset from the measure DHS website [<xref ref-type="bibr" rid="CR20">20</xref>].</p></sec><sec id="Sec4"><title>Study participants</title><p>Interviews were completed for 12,674 women of reproductive age. However, this analysis is confined to women who had given at least one singleton birth in the five-year preceding the survey (<italic>n</italic> = 4,148). Detail methodology and questionnaire used in the survey can be found in the published report of Nepal demographic and health survey [<xref ref-type="bibr" rid="CR10">10</xref>].</p></sec><sec id="Sec5"><title>Data analysis</title><p>Association between women’s autonomy and maternal health service utilization (adequate ANC care, delivery at health facility and postnatal care) was assessed via bivariate analysis using chi-square tests. Then logistic regression was used to assess the net effect of women’s autonomy on maternal health service utilization after controlling for several other independent variables. Two models were run in the analysis. The first model contained women’s autonomy only and dependent variable i.e. maternal health service utilization for ANC, delivery and PNC. In the second model, i.e. full model added the other socio-demographic and economic characteristics such as age of women, total children, ethnicity, education, religion, place of residence, wealth index and women’s involvement in community level activities.</p></sec><sec id="Sec6"><title>Dependent variable</title><p>Dependent variable in this paper is made from composite index of the variables related to utilization of maternal health services (4 or more ANC visit, delivery at health facility, and postnatal care) of recent child within the past five years preceding the survey. The value of 1 is assigned if the respondents had visited 4 or more ANC, delivered at health facilities and had visited for post natal check up; and 0 was assigned if respondents did not utilize all these services for the recent child.</p></sec><sec id="Sec7"><title>Independent variables</title><p>In the present study, key explanatory variable was made from the indicators related to women’s autonomy from the standard DHS questionnaire. Women’s autonomy refers to women’s decision-making autonomy, which was measured based on responses to “Who makes the following decisions in (respondent’s) household about: 1) obtaining health care for yourself; 2) large household purchases; and 3) visits to family or relatives?” Response options were: a) respondent alone; b) respondent and husband/partner; c) respondent and other person; d) husband/partner alone; e) someone else; f) other. The value of 1 is assigned if the response was (a), (b), or (c), that is, involvement of the respondent, or else 0, for no involvement of the respondent. The other independent variables included in this study were demographic and socioeconomic variables such as age, number of children born, caste/ethnicity, religion, place of residence, wealth status of households, involvement in community group. In order to avoid bias towards the over-sampled sub populations, sample weight were applied for all estimates (mean and percentages). After assessing multicollinearity in the variables, it was found that the variables ‘age of women’ and ‘number of children ever born’ were highly correlated. So the variable ‘number of children ever born’ was not entered in the logistic regression model.</p></sec></sec><sec id="Sec8"><title>Results</title><p>Two-fifth of the married women who had given birth in the five years preceding the survey (40 %) was youth aged 15–24. More than a fifth of them had four or more children. A considerable proportion of them (37 %) were from Janajati ethnic group followed by Brahmin/Chhetri (31 %). Only about two in five women (36 %) had secondary or above education. An overwhelming majority of women believe Hindu religion (83 %), and live in rural area (90 %). Involvement in community group among women was low (39 %). Similarly, women’s autonomy regarding household decision was low in the country. Only less than two in five women (38 %) had autonomy on household decisions (Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Background characteristics of respondents</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Percent</th><th>Number</th></tr></thead><tbody><tr><td>Age group</td><td></td><td></td></tr><tr><td> Less than 25 years</td><td>40.1</td><td>1662</td></tr><tr><td> 25–29 years</td><td>31.6</td><td>1310</td></tr><tr><td> 30 years or above</td><td>28.4</td><td>1176</td></tr><tr><td>Total children</td><td></td><td></td></tr><tr><td> One</td><td>31.4</td><td>1302</td></tr><tr><td> Two</td><td>28.0</td><td>1161</td></tr><tr><td> Three</td><td>17.7</td><td>733</td></tr><tr><td> Four or more</td><td>22.9</td><td>952</td></tr><tr><td>Ethnicity</td><td></td><td></td></tr><tr><td> Brahmin/Chhetri</td><td>30.9</td><td>1282</td></tr><tr><td> Janajati</td><td>36.7</td><td>1523</td></tr><tr><td> Dalit</td><td>16.5</td><td>683</td></tr><tr><td> Other</td><td>15.9</td><td>660</td></tr><tr><td>Education</td><td></td><td></td></tr><tr><td> No education</td><td>43.9</td><td>1822</td></tr><tr><td> Primary</td><td>20.1</td><td>835</td></tr><tr><td> Secondary or above</td><td>36.0</td><td>1491</td></tr><tr><td>Religion</td><td></td><td></td></tr><tr><td> Hindu</td><td>83.0</td><td>3444</td></tr><tr><td> Non-Hindu</td><td>17.0</td><td>704</td></tr><tr><td>Place of residence</td><td></td><td></td></tr><tr><td> Urban</td><td>10.1</td><td>418</td></tr><tr><td> Rural</td><td>89.9</td><td>3730</td></tr><tr><td>Wealth index</td><td></td><td></td></tr><tr><td> Poor</td><td>45.3</td><td>1878</td></tr><tr><td> Middle</td><td>21.0</td><td>873</td></tr><tr><td> Rich</td><td>33.7</td><td>1397</td></tr><tr><td>Involvement in community group</td><td></td><td></td></tr><tr><td> Not involved in any community group</td><td>60.9</td><td>2526</td></tr><tr><td> Involvement in community group</td><td>39.1</td><td>1622</td></tr><tr><td>Women’s autonomy</td><td></td><td></td></tr><tr><td> Not involved in all three household decisions</td><td>62.1</td><td>2575</td></tr><tr><td> Has any say in all three household decisions</td><td>37.9</td><td>1573</td></tr><tr><td>Total</td><td>100.0</td><td>4148</td></tr></tbody></table></table-wrap></p><p>A half of the women who had given birth in the past five years preceding the survey had 4 or more ANC check up for their last birth. Similarly, 40 % of the women had delivered their last child at the health facilities. Slightly higher than two in five women (43 %) reported that they had post natal check up for their last birth. Notably, only a fourth women (27 %) had utilized the all above services (4 or more ANC visit, delivered last birth at health facilities and postnatal check up) for the most recent live birth in the 5 years preceding the survey (Table <xref rid="Tab2" ref-type="table">2</xref>).<table-wrap id="Tab2"><label>Table 2</label><caption><p>Maternal health service utilization for the most recent live birth in the five year preceding the survey</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Percent</th><th>Number</th></tr></thead><tbody><tr><td>Number of ANC visits</td><td></td><td></td></tr><tr><td> less than 4 visit</td><td>49.9</td><td>2071</td></tr><tr><td> 4 or more visits</td><td>50.1</td><td>2077</td></tr><tr><td>Place of delivery</td><td></td><td></td></tr><tr><td> Home</td><td>59.8</td><td>2480</td></tr><tr><td> Health facilities</td><td>40.2</td><td>1668</td></tr><tr><td>Postnatal check up</td><td></td><td></td></tr><tr><td> No</td><td>56.8</td><td>2357</td></tr><tr><td> Yes</td><td>43.2</td><td>1791</td></tr><tr><td>Utilization of all above services</td><td></td><td></td></tr><tr><td> No</td><td>72.8</td><td>3021</td></tr><tr><td> Yes</td><td>27.2</td><td>1127</td></tr><tr><td>Total</td><td>100.0</td><td>4148</td></tr></tbody></table></table-wrap></p><p>Women’s autonomy as measured by household decision making was associated with maternal health service utilization. Maternal health service utilization was higher among those women who had autonomy in household decisions (32 %) compared to those who did not have autonomy (24.5 %). A significantly higher percentage of women who were less than 30 years (30 %) had utilized maternal health services compared with those who had 30 years and above (20 %). About half women who had one child while only less than tenth women who had four or more children (9 %) utilized maternal health services. A higher percentage of women from Brahmin/Chhetri (39 %) compared with Janajati (25 %) and Dalit (17 %) had utilized maternal health services. Similarly, a higher percentage of women who had secondary or above education (51 %), who live in urban area (57 %), who believed Hindu religion (29 %), who were from rich household (53 %) and who involved in community group utilized maternal health services compared with other categories (Table <xref rid="Tab3" ref-type="table">3</xref>).<table-wrap id="Tab3"><label>Table 3</label><caption><p>Background characteristics of respondents by maternal health service utilization <italic>(Adequate ANC check up, delivered in health facility and PNC check up)</italic> for the most recent live birth in the five year preceding the survey</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Utilized all maternal health services</th><th>Not utilized all maternal health services</th><th>N</th></tr></thead><tbody><tr><td>Women’s autonomy ***</td><td></td><td></td><td></td></tr><tr><td> Not involved in all three household decisions</td><td>24.5</td><td>75.5</td><td>2575</td></tr><tr><td> Has any say in all three household decisions</td><td>31.6</td><td>68.4</td><td>1573</td></tr><tr><td>Age group***</td><td></td><td></td><td></td></tr><tr><td> Less than 25 years</td><td>30.0</td><td>70.0</td><td>1662</td></tr><tr><td> 25–29 years</td><td>30.1</td><td>69.9</td><td>1310</td></tr><tr><td> 30 years or above</td><td>19.9</td><td>80.1</td><td>1176</td></tr><tr><td>Total children ***</td><td></td><td></td><td></td></tr><tr><td> One</td><td>43.7</td><td>56.3</td><td>1302</td></tr><tr><td> Two</td><td>29.5</td><td>70.5</td><td>1161</td></tr><tr><td> Three</td><td>17.1</td><td>82.9</td><td>733</td></tr><tr><td> Four or more</td><td>9.4</td><td>90.6</td><td>952</td></tr><tr><td>Ethnicity ***</td><td></td><td></td><td></td></tr><tr><td> Brahmin/Chhetri</td><td>38.7</td><td>61.3</td><td>1282</td></tr><tr><td> Janajati</td><td>24.6</td><td>75.4</td><td>1523</td></tr><tr><td> Dalit</td><td>17.3</td><td>82.7</td><td>683</td></tr><tr><td> Other</td><td>20.8</td><td>79.2</td><td>660</td></tr><tr><td>Education ***</td><td></td><td></td><td></td></tr><tr><td> No education</td><td>10.4</td><td>89.6</td><td>1822</td></tr><tr><td> Primary</td><td>21.5</td><td>78.5</td><td>835</td></tr><tr><td> Secondary or above</td><td>50.8</td><td>49.2</td><td>1491</td></tr><tr><td>Religion ***</td><td></td><td></td><td></td></tr><tr><td> Hindu</td><td>28.8</td><td>71.2</td><td>3444</td></tr><tr><td> Non-Hindu</td><td>19.2</td><td>80.8</td><td>704</td></tr><tr><td>Place of residence ***</td><td></td><td></td><td></td></tr><tr><td> Urban</td><td>57.1</td><td>42.9</td><td>418</td></tr><tr><td> Rural</td><td>23.8</td><td>76.2</td><td>3730</td></tr><tr><td>Wealth index ***</td><td></td><td></td><td></td></tr><tr><td> Poor</td><td>10.3</td><td>89.7</td><td>1878</td></tr><tr><td> Middle</td><td>22.4</td><td>77.6</td><td>873</td></tr><tr><td> Rich</td><td>52.7</td><td>47.3</td><td>1397</td></tr><tr><td>Involvement in community group **</td><td></td><td></td><td></td></tr><tr><td> Not involved in any community group</td><td>25.7</td><td>74.3</td><td>2526</td></tr><tr><td> Involvement in community group</td><td>29.5</td><td>70.5</td><td>1622</td></tr><tr><td>Total</td><td>27.2</td><td>72.8</td><td>4148</td></tr></tbody></table><table-wrap-foot><p>*** Significant at <italic>p</italic> < 0.001; ** = <italic>p</italic> < 0.01 and * = <italic>p</italic> < 0.05</p></table-wrap-foot></table-wrap></p><p>In the first model, women’s autonomy has positive and statistically significant effect on maternal health service utilization.. The results indicate that women who have involved in household decisions were more likely utilized all maternal health service (OR = 1.42) compared with those who did not have autonomy. Women’s autonomy variable retained its significance even after inclusion of demographic and socio-economic variables in the model 2. The slighly reduction on the odds ratio of women’s autonomy (adjusted odds ratio = 1.40) after inclusion of demographic and social economic variables were also important predictors of utilization of maternal health service. Model 2 further explained that women aged 30 years or above were less likely to use maternal health services (aOR = 0.77) compared to youth women aged 15–24 keeping all other variables constant in the model. Similarly, women from Janajati were less likely to utilize the services (aOR = 0.75) than women from Brahmin/Chhetri. Likewise, women who lived in rural women were less likely to use maternal health services (aOR = 0.51) than women from Urban. On the other hand, women who have primary and secondary or above education were about 2 times (aOR = 1.8) and 4 times (aOR = 4.06) respectively more likely to use maternal health service than illiterate women. Similarly, women who were from middle and rich households were about 1.9 and 4.5 times respectively more likely to use maternal health services than women from poor households (Table <xref rid="Tab4" ref-type="table">4</xref>).<table-wrap id="Tab4"><label>Table 4</label><caption><p>Adjusted odds ratios (aOR) from multivariable logistic regression assessing the likelihood of utilizing maternal health services of recent child within the past five years preceding the survey by women’s autonomy and selected social and demographic characteristics</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Selected predicators</th><th colspan="3">Model I</th><th colspan="3">Model II</th></tr><tr><th>OR</th><th colspan="2">95 % CI</th><th>OR</th><th colspan="2">95 % CI</th></tr></thead><tbody><tr><td>Women’s autonomy</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Not involved in all three household decisions (ref.)</td><td>1.00</td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Has any say in all three household decisions</td><td>1.42***</td><td>1.24 -</td><td>1.64</td><td>1.40***</td><td>1.18 -</td><td>1.65</td></tr><tr><td>Demographic and socio-economic variables</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Age group</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Less than 25 years (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> 25–29 years</td><td></td><td></td><td></td><td>0.95</td><td>0.78-</td><td>1.15</td></tr><tr><td> 30 years or above</td><td></td><td></td><td></td><td>0.77*</td><td>0.62-</td><td>0.96</td></tr><tr><td>Ethnicity</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Brahmin/Chhetri (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Janajati</td><td></td><td></td><td></td><td>0.75**</td><td>0.61-</td><td>.91</td></tr><tr><td> Dalit</td><td></td><td></td><td></td><td>0.87</td><td>0.66-</td><td>1.14</td></tr><tr><td> Other</td><td></td><td></td><td></td><td>0.78</td><td>0.59-</td><td>1.03</td></tr><tr><td>Education</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> No education (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Primary</td><td></td><td></td><td></td><td>1.81***</td><td>1.42-</td><td>2.31</td></tr><tr><td> Secondary or above</td><td></td><td></td><td></td><td>4.06***</td><td>3.25-</td><td>5.07</td></tr><tr><td>Religion</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Hindu (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Non-Hindu</td><td></td><td></td><td></td><td>0.81</td><td>0.64-</td><td>1.04</td></tr><tr><td>Place of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Urban (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Rural</td><td></td><td></td><td></td><td>0.51***</td><td>0.40-</td><td>0.65</td></tr><tr><td>Wealth index</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Poor (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Middle</td><td></td><td></td><td></td><td>1.93***</td><td>1.53-</td><td>2.42</td></tr><tr><td> Rich</td><td></td><td></td><td></td><td>4.47***</td><td>3.61-</td><td>5.53</td></tr><tr><td>Involvement in community group</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td> Not involved in any community group (ref.)</td><td></td><td></td><td></td><td>1.00</td><td></td><td></td></tr><tr><td> Involvement in community group</td><td></td><td></td><td></td><td>1.02</td><td>0.86-</td><td>1.20</td></tr><tr><td><italic>Constant</italic></td><td colspan="3"><italic>0.324***</italic></td><td colspan="3"><italic>0.165***</italic></td></tr><tr><td>
<italic>- 2 log likelihood</italic></td><td colspan="3"><italic>4828.3</italic></td><td colspan="3"><italic>3799.5</italic></td></tr><tr><td>
<italic>Cox & Snell R Square</italic></td><td colspan="3"><italic>0.006</italic></td><td colspan="3"><italic>0.224</italic></td></tr></tbody></table><table-wrap-foot><p>*** Significant at <italic>p</italic> < 0.001; ** = <italic>p</italic> < 0.01 and * = <italic>p</italic> < 0.05</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec9"><title>Discussion</title><p>This study assessed the effect of women’s autonomy on the maternal health service utilization among women in Nepal. Three measures of maternal health service utilization were considered: 4 or more ANC visit, delivery at health facility, and postnatal care. Women’s autonomy is measured by women’s decision-making autonomy on obtaining health care for her; large household purchases and visits to family or relatives. Results show that maternal health service utilization is very low in Nepal, thus indicating an unmet need to be addressed by maternal and child health programs.</p><p>As do many other studies, this study also shows that educated women were more likely to utilize maternal health care services than illiterate women. It could be that educated women are more capable of accessing available health facilities and that they are able to greatly change the traditional balances of power and autonomy in familial relationships, with profound effects on health care. Another reason could be that schools are institutions that transform young girls into empowered, assertive, and confident women [<xref ref-type="bibr" rid="CR21">21</xref>].</p><p>This study showed that maternal health service utilization is significantly higher among those women who had autonomy in decisions regarding their household activities compared to those who were not. This study is similar to the study that suggests use of maternal health care services is influenced by women’s roles in decision-making [<xref ref-type="bibr" rid="CR19">19</xref>]. A possible explanation could be that women who have autonomy in decision making are more likely to have a higher level of autonomy on health care, which might lessen their reproductive behavior risks [<xref ref-type="bibr" rid="CR22">22</xref>]. Another study has confirmed that a women’s control over household resources (ability to keep money aside) has a significant positive effect on both the demand for prenatal care and the probability of hospital delivery [<xref ref-type="bibr" rid="CR23">23</xref>].</p><p>There are some limitations in the interpretation of the results of this study. Women’s autonomy is a complex phenomenon that cannot be completely measured by a few household decision-making indicators. Similarly, as pointed out previously, we restricted our subjects to women who had given at least one singleton birth in the five-year preceding the survey, so our results regarding the utilization of maternal health services should be generalized with care. Because the cross-sectional design of the study and all of the items analyzed in the logistic regression analysis came from information at the time of survey, the analysis can only provide evidence of statistical association between those items and utilization of health services and cannot show cause-effect relationships. Comparisons between surveys should also be interpreted with caution because quality of data and sample coverage varies.</p></sec><sec id="Sec10"><title>Conclusions</title><p>The findings of this study highlight the need for initiatives to improve women’s position in Nepal, both to attain gender equality and to promote women’s reproductive health. Women’s autonomy is a strong predictor among many other predictors of maternal health service utilization. Mothers’ decision-making power appears to be the most powerful predictors among many others for increasing maternal health service utilization. The study results suggest that policy actions that increase women’s autonomy at home could be effective in helping assure good maternal health.</p><sec id="Sec11"><title>Ethics approval and consent to participate</title><p>The study protocol was approved by the Nepal Health Research Council and the ICF Macro Institutional Review Board in Calverton, Maryland, USA. All respondents had provided verbal informed consent to be interviewed prior to data collection.</p></sec><sec id="Sec12"><title>Consent for publication</title><p>Not applicable</p></sec><sec id="Sec13"><title>Availability of data and materials</title><p>The data used are publicly available from the Measure DHS site.</p></sec></sec></body><back><fn-group><fn><p><bold>Competing interests</bold></p><p>The author declares that he has no competing interests.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>RA conducted data analysis, interpretation, and drafted the manuscript.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>Ramesh Adhikari holds a Ph.D. in Demography, from the Institute for Population and Social Research (IPSR), Mahidol University, Bangkok, Thailand and a Masters in Population and Reproductive Health from the same institution. He is currently working as associate professor at the Mahendra Ratna Campus, Tribhuvan University, Kathmandu.</p></fn></fn-group><ack><p>The author thanks MEASURE DHS + for providing access to the data. The author would also like to thank the reviewers of this paper for their valuable suggestions in this paper.</p><sec id="FPar1"><title>Funding</title><p>Not applicable</p></sec></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">WHO, UNICEF, UNFPA, Word Bank and UN (2015). Trends in Maternal Mortality 1990 to 2015. World Health Organization, Geneva, Switzerland. <ext-link ext-link-type="uri" xlink:href="http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1">http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1</ext-link></mixed-citation></ref><ref id="CR2"><label>2.</label><mixed-citation publication-type="other">World Health Organization (WHO) (2005). Health and Millennium Development Goals. WHO, Geneva. <ext-link ext-link-type="uri" xlink:href="http://www.who.int/topics/millennium_development_goals/maternal_health/en/">http://www.who.int/topics/millennium_development_goals/maternal_health/en/</ext-link></mixed-citation></ref><ref id="CR3"><label>3.</label><mixed-citation publication-type="other">UNFPA (2012). Maternal Deaths halved in 20 years, but faster progress needed. Press Release. <ext-link ext-link-type="uri" xlink:href="http://www.unfpa.org/public/home/news/pid/10730">http://www.unfpa.org/public/home/news/pid/10730</ext-link></mixed-citation></ref><ref id="CR4"><label>4.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Abadian</surname><given-names>S</given-names></name></person-group><article-title>Women’s autonomy and its impact on fertility</article-title><source>World Dev</source><year>1996</year><volume>24</volume><issue>12</issue><fpage>1793</fpage><lpage>1809</lpage><pub-id pub-id-type="doi">10.1016/S0305-750X(96)00075-7</pub-id></element-citation></ref><ref id="CR5"><label>5.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Adhikari</surname><given-names>R</given-names></name><name><surname>Sawangdee</surname><given-names>Y</given-names></name></person-group><article-title>Influence of women’s autonomy on infant mortality in Nepal</article-title><source>Reproduct Health</source><year>2011</year><volume>8</volume><fpage>7</fpage><pub-id pub-id-type="doi">10.1186/1742-4755-8-7</pub-id></element-citation></ref><ref id="CR6"><label>6.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Matsumura</surname><given-names>M</given-names></name><name><surname>Gubhaju</surname><given-names>B</given-names></name></person-group><article-title>Women’s status, household structure and utilization of maternal health services in Nepal</article-title><source>Asia Pacific Population J</source><year>2001</year><volume>16</volume><issue>1</issue><fpage>23</fpage><lpage>43</lpage></element-citation></ref><ref id="CR7"><label>7.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mullany</surname><given-names>BC</given-names></name><name><surname>Hindin</surname><given-names>MJ</given-names></name><name><surname>Becker</surname><given-names>S</given-names></name></person-group><article-title>Can women’s autonomy impede male involvement in pregnancy health in Kathmandu Nepal</article-title><source>Soc Sci Med</source><year>2005</year><volume>61</volume><issue>9</issue><fpage>1993</fpage><lpage>2006</lpage><pub-id pub-id-type="doi">10.1016/j.socscimed.2005.04.006</pub-id><pub-id pub-id-type="pmid">15922498</pub-id></element-citation></ref><ref id="CR8"><label>8.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mistry</surname><given-names>R</given-names></name><name><surname>Galal</surname><given-names>O</given-names></name><name><surname>Lu</surname><given-names>M</given-names></name></person-group><article-title>Women’s autonomy and pregnancy care in rural India: A contextual analysis</article-title><source>Soc Sci Med</source><year>2009</year><volume>69</volume><fpage>926</fpage><lpage>933</lpage><pub-id pub-id-type="doi">10.1016/j.socscimed.2009.07.008</pub-id><pub-id pub-id-type="pmid">19656604</pub-id></element-citation></ref><ref id="CR9"><label>9.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>WHO</collab></person-group><source>Safe abortion: technical and policy guidance for health system</source><year>2012</year><edition>2</edition><publisher-loc>Geneva, Switzerland</publisher-loc><publisher-name>Department of Reproductive health and research. World Health Organization</publisher-name></element-citation></ref><ref id="CR10"><label>10.</label><element-citation publication-type="book"><person-group person-group-type="author"><collab>Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc</collab></person-group><source>Nepal Demographic and Health Survey 2011</source><year>2012</year><publisher-loc>Kathmandu, Nepal</publisher-loc><publisher-name>Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland</publisher-name></element-citation></ref><ref id="CR11"><label>11.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gill</surname><given-names>K</given-names></name><name><surname>Pande</surname><given-names>R</given-names></name><name><surname>Malhotra</surname><given-names>A</given-names></name></person-group><article-title>Women deliver for development</article-title><source>Lancet</source><year>2007</year><volume>370</volume><issue>9595</issue><fpage>1347</fpage><lpage>57</lpage><pub-id pub-id-type="doi">10.1016/S0140-6736(07)61577-3</pub-id><pub-id pub-id-type="pmid">17933650</pub-id></element-citation></ref><ref id="CR12"><label>12.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Basu</surname><given-names>AM</given-names></name></person-group><source>Culture, the Status of Women and Demographic Behaviour: Illustrated with the Case of India</source><year>1992</year><publisher-loc>Oxford, the United Kingdom</publisher-loc><publisher-name>Clarendon</publisher-name></element-citation></ref><ref id="CR13"><label>13.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Kishor</surname><given-names>S</given-names></name><name><surname>Subaiya</surname><given-names>L</given-names></name></person-group><source>Understanding Women’s Empowerment: A Comparative Analysis of Demographic and Health Surveys (DHS) Data. DHS Comparative Reports No. 20.</source><year>2008</year><publisher-loc>Calverton, MD, USA</publisher-loc><publisher-name>Macro International Inc.</publisher-name></element-citation></ref><ref id="CR14"><label>14.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Abou Zahr</surname><given-names>CL</given-names></name><name><surname>Wardlaw</surname><given-names>T</given-names></name></person-group><source>Antenatal Care in Developing Countries. Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels, and Differentials, 1990–2001</source><year>2003</year><publisher-loc>Geneva, Switzerland</publisher-loc><publisher-name>WHO</publisher-name></element-citation></ref><ref id="CR15"><label>15.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Castle</surname><given-names>SE</given-names></name></person-group><article-title>Intra-household differentials in women’s status: household function and focus as determinants of children’s illness management and care in Rural Mali</article-title><source>Health Transition Rev</source><year>1993</year><volume>3</volume><issue>2</issue><fpage>137</fpage><lpage>157</lpage></element-citation></ref><ref id="CR16"><label>16.</label><mixed-citation publication-type="other">Upadhyay UD, Gipson JD, Withers M, Lewis S, Ciaraldi EJ, Fraser A, Huchko MJ, Prata N (2014).Women’s empowerment and fertility: a review of the literature. Soc Sci Med. 2014;115:111–20.</mixed-citation></ref><ref id="CR17"><label>17.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Balk</surname><given-names>D</given-names></name></person-group><article-title>Individual and Community Aspects of Women’s Status and Fertility in Rural Bangladesh</article-title><source>Population Stud</source><year>1994</year><volume>48</volume><issue>1</issue><fpage>21</fpage><lpage>45</lpage><pub-id pub-id-type="doi">10.1080/0032472031000147456</pub-id></element-citation></ref><ref id="CR18"><label>18.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Beegle</surname><given-names>K</given-names></name><name><surname>Frankenberg</surname><given-names>E</given-names></name><name><surname>Thomas</surname><given-names>D</given-names></name></person-group><article-title>Bargaining Power within Couples and Use of Prenatal and Delivery Care in Indonesia</article-title><source>Stud Family Plann</source><year>2001</year><volume>32</volume><issue>2</issue><fpage>130</fpage><lpage>46</lpage><pub-id pub-id-type="doi">10.1111/j.1728-4465.2001.00130.x</pub-id></element-citation></ref><ref id="CR19"><label>19.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sado</surname><given-names>L</given-names></name><name><surname>Spaho</surname><given-names>A</given-names></name><name><surname>Hotchkiss</surname><given-names>DR</given-names></name></person-group><article-title>The influence of women’s empowerment on maternal health care utilization: Evidence from Albania</article-title><source>Soc Sci Med</source><year>2014</year><volume>114</volume><issue>2014</issue><fpage>169</fpage><lpage>177</lpage><pub-id pub-id-type="doi">10.1016/j.socscimed.2014.05.047</pub-id><pub-id pub-id-type="pmid">24929918</pub-id></element-citation></ref><ref id="CR20"><label>20.</label><mixed-citation publication-type="other">Measure DHS: demographic and health surveys. <ext-link ext-link-type="uri" xlink:href="http://www.measuredhs.com/what-we-do/survey/survey-display-356.cfm">http://www.measuredhs.com/what-we-do/survey/survey-display-356.cfm</ext-link></mixed-citation></ref><ref id="CR21"><label>21.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Jejeebhoy</surname><given-names>S</given-names></name></person-group><source>Women’s education, autonomy and reproductive behavior: Experience from developing countries</source><year>1995</year><publisher-loc>Oxford</publisher-loc><publisher-name>Clarendon</publisher-name></element-citation></ref><ref id="CR22"><label>22.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Dyson</surname><given-names>T</given-names></name><name><surname>Moore</surname><given-names>M</given-names></name></person-group><article-title>On kinship structure, female autonomy, and demographic behavior in India</article-title><source>Population Dev Rev</source><year>1983</year><volume>9</volume><issue>1</issue><fpage>35</fpage><lpage>60</lpage><pub-id pub-id-type="doi">10.2307/1972894</pub-id></element-citation></ref><ref id="CR23"><label>23.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Maitra</surname><given-names>P</given-names></name></person-group><article-title>Parental bargaining, health inputs and child mortality in India</article-title><source>J Health Econ</source><year>2004</year><volume>23</volume><fpage>259</fpage><lpage>291</lpage><pub-id pub-id-type="doi">10.1016/j.jhealeco.2003.09.002</pub-id><pub-id pub-id-type="pmid">15019755</pub-id></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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