Women Empowerment and Women Health in Sub Saharan Africa

Women Empowerment and Women Health in Sub Saharan Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Women Empowerment and Women Health in Sub Saharan Africa Anjdilee Taka, Verena Tandrayen-Ragoobur This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5281312/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The study links up women empowerment to health and wellbeing outcomes of women in sub-Saharan Africa. Existing literature suggests that women empowerment influences reproductive health outcomes such as fertility, birth interval and contraceptive use. The evidence however remains mixed and tends to be country specific owing to the difficulties in measuring empowerment and health. The study links different dimensions of women empowerment to health outcomes of women in sub-Saharan African countries. Micro data from the Demographic Health Surveys for 26 sub-Saharan African countries from 2008 to 2020 is used to assess the link between women empowerment and health status. The Women Empowerment Index is built from four main dimensions namely economic, social, psychological and legal/political empowerment. Family planning use and maternal health are indicators used for women’s health. Women’s empowerment is hypothesised as a predictor of reproductive health outcomes. There is evidence of a positive link between women empowerment and women health. Multidimensional Women Empowerment Index Health Outcomes Sub Saharan Africa Women’s Health Figures Figure 1 1. Introduction Women's health is progressively recognised as a very important aspect for economic development. Women’s health encompasses physical and mental health issues [ 13 ]. In the African context, women face many challenges mainly in terms of ill health resulting in high morbidity and mortality rates. Moreover, women who live in poverty or have low levels of schooling have shorter life spans, higher rates of illness, limited access to high quality of health care services, disability and death [ 53 ]. Significant discrepancies continue to exist in terms of access to maternal and reproductive health services among women in SSA. It is estimated that half of women in sub Saharan African countries (SSA) do not have access to the basic health care during pregnancy [ 6 ]. Tracey et al [ 50 ] further observed that there are 546 maternal deaths for every 100,000 live births in SSA. Further, around 25 percent of women who want to delay or stop having children do not use contraception. The fertility rate is the highest in the world at 5.2 children per woman between 15–44 years of age and the region accounts for 2/3 of total deaths globally. The main cause of death and disability among women principally among low-income background are maternal health problems resulting from insecure abortion [ 53 ]. Empowering women contributes to health and productivity of the population [ 50 ]. Existing literature suggests that women empowerment influences reproductive health outcomes such as fertility[ 3 ],birth interval [ 51 ] and contraceptive use [ 25 ] as well as nutritional outcomes of women. The concept of women’s empowerment is vital for achieving good outcomes for the welfare of women as well as their families. Women’s empowerment is multifaceted and can be measured using various indicators [ 29 , 33 , 41 ].Zereyesus et al [ 54 ] use the Women Empowerment in Agriculture Index (WEAI) derived from five domains of empowerment and link it with children’s health status in northern Ghana. They observe that there is a positive relationship between children’s health and variables such as mother’s education and age. They conclude that it is important to empower women for them to make better important decisions in life that will impact positively on their wellbeing and that of their child. Women's health is progressively recognised as a global health priority [ 52 ]. Many women in SSA do not have access to the basic health care when they are pregnant and giving birth [ 50 ]. The use of contraceptives is very poor amongst women in SSA. Approximately, 842 million women use contraceptive methods out of 1.9 billion women in SSA. Empowering women contributes to a healthy population [ 30 ]. Although some studies have focused on analysing women’s empowerment [ 23 , 36 ] the association between women’s empowerment and women’s health status in developing countries in general and sub-Saharan African countries, in particular, is scant. Moreover, the existing empirical evidence analyse women empowerment and health mainly in terms of access to jobs, education, income and reproductive health but considering the fundamental aspects of women empowerment based on their participation in the level of making decisions, ownership of assets, legal aspects, psychological dimension of women, medical help, medical insurance and health facility used by women is limited in existing literature. This undermines the overall perspective that is needed to formulate appropriate policies. This study thus bridges an important gap in the literature and brings in new theoretical dimensions and evidence in measuring women empowerment and health outcomes. This research models the complex relationship between women’s empowerment and health in sub Saharan Africa using comparable data for the region. The investigation innovates by building on the existing theoretical literature and extending the existing conceptual empowerment framework of Muluneh et al [ 37 ]. To our knowledge there is no study that have computed the Women Empowerment Index (WEI) and use that index to establish a relationship with health outcomes of women. The empirical strategy of this study uses the multinomial regression model to analyse the complex relationship between women’s health and women’s empowerment that is adapted from the work of Muluneh et al [ 37 ]. We used multinomial regression model as the outcome variable predicted has more than two categories that do not have a given rank or order. Amongst many multivariate analysis techniques, the multinomial regression model generates more suitable and accurate findings in terms of model fit and correctness. Moreover, Htun et al [ 27 ] in their study of empowerment and health care access barriers among currently married women in Myanmar used similar methodology to understand the relationship between empowerment and health care access. Furthermore, the paper establishes a link between the different magnitudes of women empowerment to health outcomes of women using the WEI developed. The study will elaborate extensively on the relationship between the four dimensions of women empowerment and women’s health in sub Saharan Africa. The WEI is built through a combination of 37 indicators across four dimensions. The four dimensions are economic, social, psychological and legal spheres. The economic variable captures data on asset ownership in terms of land and house. It also includes the variable control over earnings.Moreover, to analyse the social dimension of the women empowerment index variables such as participation in decision making in terms of visits to family or the woman’s own healthcare and current use of contraception are used in the study. The psychological variables are used to capture the way in which wife beating is reasonable and acceptable by both the respondent (the woman) and their partners. The variables include wife beating justified if wife refuses to have sex with husband, wife beating justified if she goes out without telling husband, wife beating justified if wife neglects the children, wife beating justified if wife argues with husband and wife beating justified if wife burns food. Sought help to stop violence from police ,lawyer and doctor are the variables that capture the extent to which the women are able to go for help from different sources. All the health variables namely health facility, health insurance, medical help and use of contraceptives are positively related with the dependent variable (medium and high level of empowerment). The benchmark category is low level of women empowerment. The higher the level of women empowerment in the different countries the more the respondents are likely to have positive health outcomes. The results are in line with the work of Hameed et al [ 25 ], when they tried to analyse the connection between women empowerment and contraceptive use and medical help. It is also consistent with the study by Kawuki et al [ 31 ] in trying to understand the link between women empowerment and health insurance in Rwanda. The results for health facility variable go in line with prevailing literature where Shibre et al [ 45 ] used the same variable to analyse women empowerment inequalities. The paper is structured as follows: Section 2 reviews the existing literature on women empowerment and women health in developing countries with particular focus on Sub Saharan Africa. Section 3 sets out the conceptual framework that combines different dimensions of women empowerment and health status of women. Section 4 explains the data and methodology used. Section 5 analyses the data and findings based on different indicators of women empowerment and health status of women. Section 6 concludes with relevant policy options. 2. Literature Review Improvements in maternal health can be organised through family planning programs where women and couples can take proper decisions about contraception that will help them to improve their maternal health [ 28 ]. Reinforcing women’s health strengthens women’s empowerment. Poorly empowered women have led to lack of essential health services for women. Better access to health, increased emancipation of women in the economy, higher levels of education and control over assets are vital factors that contribute towards improving health outcomes [ 40 ]. Greater women empowerment will definitely improve the health and quality of life of women and their family members in two different ways as suggested by Kuche et al [ 32 ]. The authors argued that the more the women are empowered they will have a greater decision-making power thus having greater access to health services and control over health resources that will improve their health status. Secondly, they are more likely to have fewer children with better childcare thus improving the health outcomes of the children. The benefits of empowerment are not essentially restricted to women themselves but have the potential to extend to those around her, including her own children [ 33 , 43 , 41 , 48 , 1 ]. Women’s greater level of empowerment play a vital role in managing their fertility and health outcomes [ 10 ]. Furthermore, having access to information on reproductive and sexual health is very important to the physical health of women where education increase women’s chances of following school and moving out of poverty. Women empowerment is mainly recognised as a very important tool to allow access to reproductive and sexual health care services for improved health [ 14 ]. The higher the level of women empowerment, the more they are likely to take independent decisions [ 48 ]. Women empowerment positively influences family planning use [ 37 ]. Fertility rates in sub Saharan Africa remains higher and contraceptive levels are low compared to other countries in the developing world. Evidence show that fertility decline has slowed during the past decade. Fertility developments in SSA are not uniform [ 15 ]. Though there are significant investments in family planning programs over the past years and knowledge of contraception does not necessarily mean there is an increase in the use of contraceptives [ 16 ]. Phan [ 40 ] analysed four main spheres of women empowerment (female education, female labour force participation, decision-making and use of contraceptives) and its relationship with women’s fertility. He found that an improvement in women empowerment is linked with low fertility rates. Additionally, maternal mortality is one of the very important health debates in sub-Saharan Africa. In 2015, approximately three hundred maternal deaths occurred related to pregnancy and child birth where almost all of the deaths could have been prevented. These maternal deaths are related directly to obstetric complications. A thorough understanding of the link between women’s empowerment and utilisation of maternal healthcare services may help to decrease maternal deaths in SSA. There should be implementation of complete empowerment programs that would help women in SSA to contribute in deciding about their own health and access to health [ 52 ]. Evidence show that women empowerment definitely affects family planning use [ 9 ]. Poorly empowered women do not have access to quality family planning services and therefore are unable to negotiate family planning and use of contraceptive efficiently. Women empowerment is positively associated with positive maternal outcomes [ 38 ]. Consistently, a regional analysis of SSA shown that dimensions of women empowerment have an effect on maternal health and utilisation of health services. 3. Conceptual framework of Women health and Women Empowerment Research on the link between women health and empowerment is sparse in SSA. While the importance of these is undeniable, this study believes that it is important to extend on the dimensions of women empowerment by understanding the dynamic relationship between women health and women empowerment to better formulate policies to improve the quality of life of women in SSA. Women empowerment is vital for the utilisation of maternal healthcare services and overall women’s wellbeing. To the best of our knowledge, there is no study on SSA region that attempts to measure a broad aspect of women empowerment and its relationship with women’s health. Additional variables of the dimensions of women empowerment such as psychological and legal have not been included in other studies to calculate the women empowerment index and analysis of the link between the developed index and women health. Moreover, supplementary variables to capture women health has been used which is in contrast from the work of Muluneh et al [ 37 ]. The association between women health and women empowerment is shown in Fig. 1.1 . This study uses the Women Empowerment Index (WEI) developed to analyse the complex association between women empowerment and women health. The WEI is a summary measure of attainments in four vital dimensions of women empowerment: economic, social, psychological and legal/political. The index comprises of the four dimensions of women empowerment. The work contributes to the existing theoretical literature by building on and extending the existing conceptual frameworks on women empowerment and women health. It tries to capture variables from four different dimensions of women empowerment namely economic, social, psychological and legal spheres. Variables such as control of earnings, ownership of house and land, control of visits, control of health, decisions over husband’s income, refusal of having sex, goes out without informing, neglects children, burn food, argue with husband, violence, seek help from social service organisation, police, lawyer and doctor are used. Family planning use measured as ever using contraceptives amongst women who were married or had a male partner is used as health variable. Contraceptive use is vital in preventing neonatal risks. Women who face healthcare challenges experience gendered power inequalities that prevent them from attaining their reproductive health benefits [ 44 ]. Maternal health is measured in terms of maternal mortality. Research show that empowered women are more likely to plan their pregnancies receive prenatal care, receive healthcare services in terms of prenatal care and visit a skilled healthcare provider during pregnancy and childbirth, delay marriage and normally are employed in either public or private sector with a secure job. The greatest number of maternal deaths have been found in countries where women do not have the assistance of skilled practitioner when they deliver. Women living in rural areas and with less education are more vulnerable to maternal mortality. High rates of maternal mortality levels are an indication of deep-rooted gender inequalities which limit access to healthcare services and the ability for women to take decisions. 4. Data and Methodology 4.1 Data The publicly available data from the Demographic and Health Surveys (DHS) for 26 sub-Saharan African countries from 2008 to 2020 is used for the analysis which are representative and covering a wide range of households. The sample of the study consists of women of reproductive age 15 to 49. They have a large coverage of around 5,000 to 30,000 families and are conducted each 5 years to be able to compare with different years over time. To achieve this, typical questionnaires are developed where women of reproductive age are interviewed. Information is collected on basic demographic and health topics such as fertility, mortality, family planning, marriage and reproductive health amongst others. In addition, particular questions are included considering the differences between the countries. The methodology rests on the multinomial regression model to analyse the complex relationship between women’s health and women’s empowerment that is adapted from the work of Muluneh et al [ 37 ]. The multinomial logistic model is used when the dependent variable has different categories. 4.2 Econometric Model The regression equation is as follows: The equation above tries to capture the relationship between WEI and Health facility. Four separate regression models have been stipulated where each health variable has been considered at one point in time. Other proxies for health indicator are replaced in the equation namely health insurance, medical help and contraception through different regression equations to analyse the relationship between women empowerment and women health. Dependent variable Considering the conceptual framework, the outcome variable is women empowerment. It captures the level of women empowerment in terms of four different dimensions namely social, economic, legal and psychological. To some extent, similar variable has been used in preceding studies namely Ewerling et al [ 23 ] which used SWPER Index. Moreover, four different regression models have been stipulated to analyse the relationship between women empowerment and health. Each health variable has been analysed at a time. The study by Annan et al [ 5 ] also analysed women’s power in 23 sub Saharan countries in relation to the health of women. Furthermore, Asaolu et al [ 7 ] try to analyse the link between health and empowerment with variables such as contraceptive use. Variables namely control of earnings, ownership of house and land, control of visits, decisions over husband’s income, refusal of having sex, goes out of house without informing, neglects children, burn food, argue with husband, violence, seek help from social service organisation, seek help from police, seek help from lawyer amongst others are used to capture the level of women empowerment in 26 sub Saharan countries. Independent variables The main independent variables are the health variables namely health insurance, health facility, medical help and use of contraceptives amongst women aged 15 to 49 years. A dummy value of 1 implies that the woman has a health insurance, has access to medical facility, seek medical help when in need and use contraceptives and 0 otherwise. Muluneh et al [ 37 ] show how women empowerment is vital for the health of women. Other control variables in terms of personal features of the respondent has been captured. The age of woman has been spilt into seven categories where those being less than 20 years old is the benchmark category. Ackerson et al [ 2 ] used similar age categorisation in analysing domestic violence and psychological health in India. Moreover, the wealth index has been categorized into 4 categories namely poorer, middle, richer and richest with poorest set as benchmark category. Bamiwuye and Odimegwu [ 8 ] and Cools and Kotsadam [ 18 ] used the wealth index to investigate the relationship between poor woman and partner violence in Sub Saharan African countries. In addition, educational attainment is categorised into six categories namely no education, incomplete primary, complete primary, incomplete secondary, complete secondary and higher education. Higher education is set as the reference category. Mokdad et al [ 35 ] used similar categorisation in their study of health. Husband’s level of education as well is considered as a controlled variable where husband with no education is set as dummy 1 and 0 otherwise. This variable has been used by Ali et al [ 4 ] in their study of healthcare in Ethiopia. Help from ministry of gender, promotion and planning as well is catered for in the regression to try to understand whether this form of help is being widely used by the respondent in the study. This variable has been used by Muluneh et al [ 37 ]. Two forms of violence against women has been taken into account in the analysis namely emotional violence and sexual violence in the household. The respondent is asked about whether they have experienced any of these two types of violence from partner or husband. For example, emotional violence is measured by questions as to whether women have ever been humiliated by husband/partner. Furthermore, sexual violence implies whether the respondents have ever been physically forced into unwanted sex or unwanted sexual acts by husband/partner. Diop-Sidibé et al [ 20 ] used these variables in trying to establish a relationship domestic violence and health outcomes of women in Egypt. The main health variables namely health facility, health insurance, medical help and use of contraceptives have been captured in the analysis to be able to understand the relationship between women empowerment and women health in 26 sub Saharan African countries. Similar variables have been used by Asaolu et al [ 7 ] and Muluneh et al [ 37 ]. However, awareness and knowledge about contraceptive methods and family planning programs and the link between women empowerment have not been explicitly captured by existing studies. The multinomial logit regression is used to capture each health variables associated with high and medium levels of women empowerment. The low level of empowerment is set up as the benchmark category. The women empowerment index (WEI) developed encompasses the four different dimensions of women empowerment. (economic, social, psychological and legal). The cut off points are as follows with low WEI 0.417. The low WEI is the empowerment dummy variable. Four different multinomial regression has been analysed taking into consideration each health variable at one instance. 5. Results and Discussion The link between women empowerment and health indicators is explicitly measured as shown in table 1.1 in the appendix section. All the health variables namely health facility, health insurance, medical help and use of contraceptives are positively related with the dependent variable. The higher the level of women empowerment in the different countries the more the respondents are likely to have positive health outcomes. When the woman is not educated or has an incomplete primary, complete primary or even an incomplete secondary the level of empowerment decreases leading to lack of information towards access and use of health facilities provided by the ministry of family, gender and promotion. The reference category for level of education here is higher education. The findings for example of woman who does not have any level of education show a negative relationship at 0.0481 and is statistically significant at 1percent with the level of women empowerment in terms of social, economic, psychological and legal aspects. The results are robust and go in line with existing literature namely Asaolu et al [ 7 ] and Muluneh et al [ 37 ]. The education variable categories have also been used by Bazargan-Hejazi et al [ 11 ]in their attempt to find the different trends in female victims of partner violence in Malawi. In Kenya, the level of empowerment is highly dependent on the level of education of the women. The women who are more empowered are those having the highest level of education; the medium level of empowerment is linked with those having completed secondary education and lastly the least empowered are those who did not attend school at all [ 34 ]. Considering the individual characteristics, findings show a positive relationship between age of respondents and level of women empowerment. The coefficients of the age variable which is categorised in 6 levels, increases as we move to higher age categories that is from age 20–24 to age 40–44, showing higher level of empowerment at higher age. Those women aged 15–19 are classified as the benchmark category. Ackerson et al [ 2 ] used the same age categorisation in their study of domestic violence among women and children in India. Besides, the different age classification has as well been adopted by Paul [ 39 ] while studying the relationship between women labour force participation and domestic violence in India. The results for wealth index posit positive findings as well. The wealth index combined is classified into four categories namely poorer, middle, richer and richest. The poorest category of the wealth index combined is used as the reference type. The results show that the middle and the richest level of income having the highest coefficient (0.0045 and 0.031 respectively) are statistically significant at 1 percent level. This postulates that poor women are less likely to be empowered. The results and variable used are consistent with existing literature. The wealth index variable has been used by Bamiwuye et al [ 8 ]and Cools et al [ 18 ] in their study of poor women in SSA who are more likely to experience partner violence. Countries such as Burundi, Cote D’Ivoire, Ethiopia, Kenya, Comoros, Malawi, Mozambique, Namibia, Rwanda, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe show negative coefficients. These results display that there is a poor level of women empowerment in the country which will negatively affect the health outcomes of the respondents in the study. The findings are coherent with existing literature for example Shiferaw et al [ 46 ] in their study to understand the use of contraception and proximity of healthcare in Ethiopia where they concluded that the use of contraceptives is highly and positively related amongst women who live nearer to health facilities. Additionally, the husband or partner of the respondent with no education has an impact on the level of empowerment of the women. The findings demonstrate that women empowerment is negatively related to husband who are not literate. The level of empowerment decreases when the husband does not have any educational background. The variable is statistically significant at 1 percent. Geshaw et al [ 24 ] has used this variable as well in the analysis of partner violence during pregnancy. Sexual and emotional violence is prevalent when the women are least empowered as shown in the results. These variables have been used by Rahman et al [ 42 ] and Bengesai et al [ 12 ]. Moreover, women who seek help from the Ministry of Gender and promotion are more likely to understand their rights thus they are more empowered as proved by the findings of the study with a positive coefficient. Effendi et al [ 22 ] have used similar variables in their study while they tried to analyse the relationship between contraceptive use and women empowerment. Table 1.2 (refer to appendix section) shows the multinomial regression results with use of contraceptives as health indicator as used by Diop-Sidibé, et al [ 20 ] in their study to understand the relationship between domestic violence and health outcomes in Egypt. To protect the rights of women, contraceptive use is very important to improve the quality of life of women in sub-Saharan Africa. Worldwide, the use of contraceptives act as a preventing tool to decrease the number of 2.7 million infant deaths [ 19 ]. The coefficients for contraception are positive and highly significant. The value of the coefficients increases from medium to high WEI. The results are consistent with the empirical findings of Corroon et al [ 17 ] in urban Nigeria where they concluded that high empowered women in general are more likely to use contraception measures and to use a health facility accessible to them. The multinomial logit results where health facility is the health variable is showing robust and positive health coefficient for both medium and high empowerment as compared to low empowerment that is the benchmark category. The individual characteristics as well are positive. Women empowerment is a powerful factor that help women use health facilities [ 47 ]. Holland et al [ 26 ] provide evidence that the level of women empowerment has a significant effect on the ability of women to have access to health care facilities. The results go in line with prevailing literature. Shibre et al [ 45 ] used the same variable to analyse women empowerment inequalities while using maternal health care services in Ethiopia, where they found that the use of health facilities available to women are more likely to occur when they know about their rights. Moreover, Tessema et al [ 49 ] found that health care access is only at 42.6 percent amongst women of reproductive age 15 to 49 years in 36 sub Saharan countries. Furthermore, the importance of health facility is undisputed in the study by Doctor et al [ 21 ] in trying to understand the challenges of health facility delivery in sub Saharan African countries. Their results show that women in the richest category of the wealth index are 68 percent more likely to give birth in health facilities provided to them. Likewise, women who are more educated are more likely to be empowered and use health facilities compared to women with no formal education. Moreover, the health insurance as health indicator is used in analysing the effect of women empowerment on health outcomes of the respondent. The coefficients of the variable health insurance are positive for both medium and high level of empowerment as compared to the base outcome of low level of empowerment. Several measures have been put into practice to encourage health insurance coverage of women and it is viewed as improving the health outcomes of women. This is consistent with the study by Kawuki et al [ 31 ] in trying to understand the link between women empowerment and health insurance in Rwanda. Lastly, medical help from doctors and other medical professionals is used as indicator for health outcomes of women respondents of the DHS survey. The results are consistent and significant with existing literature. When the woman is more empowered as compared to low levels of empowerment, findings show a positive link between the medical help variable and medium and high level of empowerment compared to the base outcome of low levels of empowerment. These results go in line with the work of Hameed et al [ 25 ], when they tried to analyse the connection between women empowerment and contraceptive use. The results enrich the existing literature of women empowerment and women health. It illustrates positive link between medium and high level of empowerment with health outcomes of women in SSA. The access to healthcare services and ability for women to take economic and household decisions has improved the quality of living of many women in the SSA. However, the coefficient of education is negative, as it has been found that half of women in the sample are not educated. 6. Conclusion and Policy Recommendations The paper builds on a conceptual framework to analyse the relationship between women empowerment and women health in the 26 sub-Saharan countries of women to 15–49 reproductive age. Based on the theoretical model by Muluneh et al [ 37 ], indicators are collected to conceptualise women empowerment using four different dimensions of women empowerment namely economic, social, psychological and legal/political and women health. The study adopts the multinomial logit regression approach to analyse the dynamic link between women empowerment and women health. It has been found that most women in the sample do not have access to healthcare services and are poorly educated. They lack resources to allow them to improve their standard of living. Countries with low level of empowerment have poor access to healthcare available to women. This leads to a high percentage of maternal mortality amongst these countries. From the findings, we note that there is a need to revisit SSA’s countries policies to promote women health. Furthermore, there should be consistent and transparent reforms that will lead to efficiency in decision making and empower women who will create a positive impact in the economy as a whole. Investing in women health leads to a healthy population overall. Recognizing the health sector has an important role to play in preventing and responding to unequal access to healthcare services against women should be emphasised by policy makers. Greater involvement of non-governmental organisations and society-level interventions can better find solutions. Declarations Ethical Statement This article is the authors' own original work, which has not been previously published elsewhere. Funding No funds, grants, or other support was received Competing interest There was no potential conflict of interest Author Contribution All authors reviewed the manuscript and made significant contribution in writing the paper. Data Availability Data is provided within the manuscript. Code availability-Not applicable References Abreha, S. K., & Zereyesus, Y. A. (2021). Women’s empowerment and infant and child health status in sub-Saharan Africa: a systematic review. Maternal and child health journal , 25 , 95–106. Ackerson, L. K., & Subramanian, S. V. (2009). Intimate partner violence and death among infants and children in India. Pediatrics , 124 (5), e878–e889. Akram, N., & Anwar, T. (2022). 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(2023). Women’s empowerment and contraceptive use: Recent evidence from ASEAN countries. PloS One , 18(6), e0287442. Ewerling, F., Lynch, J. W., Victora, C. G., van Eerdewijk, A., Tyszler, M., & Barros, A. J. (2017). The SWPER index for women's empowerment in Africa: development and validation of an index based on survey data. The Lancet Global Health , 5 (9), e916–e923. Gashaw, B. T., Magnus, J. H., & Schei, B. (2019). Intimate partner violence and late entry into antenatal care in Ethiopia. Women and birth , 32 (6), e530–e537. Hameed, W., Azmat, S. K., Ali, M., Sheikh, M. I., Abbas, G., Temmerman, M., & Avan, B. I. (2014). Women's empowerment and contraceptive use: the role of independent versus couples' decision-making, from a lower middle-income country perspective. PloS one , 9 (8), e104633. Holland, C., & Rammohan, A. (2019). Rural women’s empowerment and children’s food and nutrition security in Bangladesh. World Development , 124 , 104648. Htun, N. M. M., Hnin, Z. L., & Khaing, W. (2021). Empowerment and health care access barriers among currently married women in Myanmar. BMC public health , 21 , 1–9. Huq, N. L., Ahmed, A., Haque, N. A., Hossaine, M., Uddin, J., Ahmed, F., & Quaiyum, M. A. (2015). Effect of an integrated maternal health intervention on skilled provider’s care for maternal health in remote rural areas of Bangladesh: a pre and post study. BMC pregnancy and childbirth , 15 , 1–15. Kabeer, N. (1999). Resources, agency, achievements: Reflections on the measurement of women's empowerment. Development and change , 30 (3), 435–464. Kantorová, V., Wheldon, M. C., Ueffing, P., & Dasgupta, A. N. (2020). Estimating progress towards meeting women’s contraceptive needs in 185 countries: A Bayesian hierarchical modelling study. PLoS medicine , 17(2), e1003026. Kawuki, J., Gatasi, G., & Sserwanja, Q. (2022). Women empowerment and health insurance utilisation in Rwanda: a nationwide cross-sectional survey. BMC Women's Health , 22 (1), 378. Kuche, D., Moss, C., Eshetu, S., Ayana, G., Salasibew, M., Dangour, A. D., & Allen, E. (2020). Factors associated with dietary diversity and length-for‐age z‐score in rural Ethiopian children aged 6–23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation. Maternal & child nutrition , 16(1), e12852. Mabsout, R. (2011). Capability and health functioning in Ethiopian households. Social Indicators Research , 101 , 359–389. McOmber, C., McNamara, K., Ryley, T. D. A., & McKune, S. L. (2021). Investigating the conceptual plurality of empowerment through community concept drawing: Case studies from Senegal, Kenya, and Nepal. Sustainability , 13 (6), 3166. Mokdad, A. H., Forouzanfar, M. H., Daoud, F., Mokdad, A. A., El Bcheraoui, C., Moradi-Lakeh,M., … Murray, C. J. (2016). Global burden of diseases, injuries, and risk factors for young people's health during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 387(10036), 2383–2401. Miedema, S. S., Haardörfer, R., Girard, A. W., & Yount, K. M. (2018). Women’s empowerment in East Africa: Development of a cross-country comparable measure. World development , 110 , 453–464. Muluneh, M. D., Francis, L., Ayele, M., Abebe, S., Makonnen, M., & Stulz, V. (2021). The effect of women’s empowerment in the utilisation of family planning in western Ethiopia: a structural equation modelling approach. International Journal of Environmental Research and Public Health , 18 (12), 6550. Osborn, D., Cutter, A., & Ullah, F. (2015). Universal sustainable development goals. Understanding the transformational challenge for developed countries , 2 (1), 1–25. Paul, S. (2016). Women’s labour force participation and domestic violence: Evidence from India. Journal of South Asian Development , 11 (2), 224–250. Phan, H. G. (2013). Bonds of Citizenship: Law and the Labors of Emancipation (Vol. 19). NYU. Pratley, P. (2016). Associations between quantitative measures of women's empowerment and access to care and health status for mothers and their children: a systematic review of evidence from the developing world. Social science & medicine , 169 , 119–131. Rahman, M., Nakamura, K., Seino, K., & Kizuki, M. (2014). Intimate partner violence and symptoms of sexually transmitted infections: are the women from low socio-economic strata in Bangladesh at increased risk. International journal of behavioral medicine , 21 , 348–357. Richards, E., Theobald, S., George, A., Kim, J. C., Rudert, C., Jehan, K., & Tolhurst, R. (2013). Going beyond the surface: gendered intra-household bargaining as a social determinant of child health and nutrition in low- and middle-income countries (Vol. 95, pp. 24–33). Social science & medicine. Robinson, J. L., Narasimhan, M., Amin, A., Morse, S., Beres, L. K., Yeh, P. T., & Kennedy, C. E. (2017). Interventions to address unequal gender and power relations and improve self-efficacy and empowerment for sexual and reproductive health decision-making for women living with HIV: A systematic review. PloS one , 12 (8), e0180699. Shibre, G., Mekonnen, W., & Haile Mariam, D. (2023). Decomposition analysis of women’s empowerment-based inequalities in the use of maternal health care services in Ethiopia: Evidence from Demographic and Health Surveys. Plos one , 18(4), e0285024. Shiferaw, K., & Musa, A. (2017). Assessment of utilization of long acting reversible contraceptive and associated factors among women of reproductive age in Harar City, Ethiopia. Pan African medical journal , 28(1). Sserwanja, Q., Mukunya, D., Musaba, M. W., Mutisya, L. M., Kamara, K., & Ziaei, S. (2023). Women empowerment indices and utilization of health facilities during childbirth: evidence from the 2019 Sierra Leone demographic health survey. BMC Health Services Research , 23 (1), 109. Stiyaningsih, H., & Wicaksono, F. (2017). Impact of women’s empowerment on infant mortality in Indonesia. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal) , 11 (4), 185–191. Tessema, Z. T., Worku, M. G., Tesema, G. A., Alamneh, T. S., Teshale, A. B., Yeshaw,Y., … Liyew, A. M. (2022). Determinants of accessing healthcare in Sub-Saharan Africa:a mixed-effect analysis of recent Demographic and Health Surveys from 36 countries.BMJ open, 12(1), e054397. Tracy, R. P., Kwon, D. S., Tsai, A. C., Kakuhire, B., … Okello, S. (2018). Increased systemic inflammation and gut permeability among women with treated HIV infection in rural Uganda. The Journal of infectious diseases , 218 (6), 922–926. Upadhyay, U. D., Gipson, J. D., Withers, M., Lewis, S., Ciaraldi, E. J., Fraser, A.,… Prata, N. (2014). Women's empowerment and fertility: a review of the literature. Social science & medicine , 115 , 111–120. World Health Organization. (2016). World Health Statistics 2016 [OP]: Monitoring Health for the Sustainable Development Goals (SDGs) . World Health Organization. World Health Organization. (2019). Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary (No. WHO/RHR/19.23) . World Health Organization. Zereyesus, Y. A. (2017). Women's Empowerment in Agriculture and Household-Level Health in Northern Ghana: A Capability Approach. Journal of International Development , 29 (7), 899–918. Additional Declarations No competing interests reported. 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Introduction","content":"\u003cp\u003eWomen's health is progressively recognised as a very important aspect for economic development. Women\u0026rsquo;s health encompasses physical and mental health issues [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the African context, women face many challenges mainly in terms of ill health resulting in high morbidity and mortality rates. Moreover, women who live in poverty or have low levels of schooling have shorter life spans, higher rates of illness, limited access to high quality of health care services, disability and death [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Significant discrepancies continue to exist in terms of access to maternal and reproductive health services among women in SSA. It is estimated that half of women in sub Saharan African countries (SSA) do not have access to the basic health care during pregnancy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Tracey et al [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] further observed that there are 546 maternal deaths for every 100,000 live births in SSA. Further, around 25 percent of women who want to delay or stop having children do not use contraception. The fertility rate is the highest in the world at 5.2 children per woman between 15\u0026ndash;44 years of age and the region accounts for 2/3 of total deaths globally. The main cause of death and disability among women principally among low-income background are maternal health problems resulting from insecure abortion [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpowering women contributes to health and productivity of the population [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Existing literature suggests that women empowerment influences reproductive health outcomes such as fertility[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e],birth interval [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and contraceptive use [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] as well as nutritional outcomes of women. The concept of women\u0026rsquo;s empowerment is vital for achieving good outcomes for the welfare of women as well as their families. Women\u0026rsquo;s empowerment is multifaceted and can be measured using various indicators [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].Zereyesus et al [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] use the Women Empowerment in Agriculture Index (WEAI) derived from five domains of empowerment and link it with children\u0026rsquo;s health status in northern Ghana. They observe that there is a positive relationship between children\u0026rsquo;s health and variables such as mother\u0026rsquo;s education and age. They conclude that it is important to empower women for them to make better important decisions in life that will impact positively on their wellbeing and that of their child. Women's health is progressively recognised as a global health priority [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Many women in SSA do not have access to the basic health care when they are pregnant and giving birth [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The use of contraceptives is very poor amongst women in SSA. Approximately, 842\u0026nbsp;million women use contraceptive methods out of 1.9\u0026nbsp;billion women in SSA. Empowering women contributes to a healthy population [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although some studies have focused on analysing women\u0026rsquo;s empowerment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] the association between women\u0026rsquo;s empowerment and women\u0026rsquo;s health status in developing countries in general and sub-Saharan African countries, in particular, is scant.\u003c/p\u003e \u003cp\u003eMoreover, the existing empirical evidence analyse women empowerment and health mainly in terms of access to jobs, education, income and reproductive health but considering the fundamental aspects of women empowerment based on their participation in the level of making decisions, ownership of assets, legal aspects, psychological dimension of women, medical help, medical insurance and health facility used by women is limited in existing literature. This undermines the overall perspective that is needed to formulate appropriate policies. This study thus bridges an important gap in the literature and brings in new theoretical dimensions and evidence in measuring women empowerment and health outcomes. This research models the complex relationship between women\u0026rsquo;s empowerment and health in sub Saharan Africa using comparable data for the region. The investigation innovates by building on the existing theoretical literature and extending the existing conceptual empowerment framework of Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. To our knowledge there is no study that have computed the Women Empowerment Index (WEI) and use that index to establish a relationship with health outcomes of women.\u003c/p\u003e \u003cp\u003eThe empirical strategy of this study uses the multinomial regression model to analyse the complex relationship between women\u0026rsquo;s health and women\u0026rsquo;s empowerment that is adapted from the work of Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe used multinomial regression model as the outcome variable predicted has more than two categories that do not have a given rank or order. Amongst many multivariate analysis techniques, the multinomial regression model generates more suitable and accurate findings in terms of model fit and correctness. Moreover, Htun et al [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] in their study of empowerment and health care access barriers among currently married women in Myanmar used similar methodology to understand the relationship between empowerment and health care access.\u003c/p\u003e \u003cp\u003eFurthermore, the paper establishes a link between the different magnitudes of women empowerment to health outcomes of women using the WEI developed. The study will elaborate extensively on the relationship between the four dimensions of women empowerment and women\u0026rsquo;s health in sub Saharan Africa. The WEI is built through a combination of 37 indicators across four dimensions. The four dimensions are economic, social, psychological and legal spheres. The economic variable captures data on asset ownership in terms of land and house. It also includes the variable control over earnings.Moreover, to analyse the social dimension of the women empowerment index variables such as participation in decision making in terms of visits to family or the woman\u0026rsquo;s own healthcare and current use of contraception are used in the study. The psychological variables are used to capture the way in which wife beating is reasonable and acceptable by both the respondent (the woman) and their partners. The variables include wife beating justified if wife refuses to have sex with husband, wife beating justified if she goes out without telling husband, wife beating justified if wife neglects the children, wife beating justified if wife argues with husband and wife beating justified if wife burns food. Sought help to stop violence from police ,lawyer and doctor are the variables that capture the extent to which the women are able to go for help from different sources.\u003c/p\u003e \u003cp\u003eAll the health variables namely health facility, health insurance, medical help and use of contraceptives are positively related with the dependent variable (medium and high level of empowerment). The benchmark category is low level of women empowerment. The higher the level of women empowerment in the different countries the more the respondents are likely to have positive health outcomes. The results are in line with the work of Hameed et al [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], when they tried to analyse the connection between women empowerment and contraceptive use and medical help. It is also consistent with the study by Kawuki et al [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] in trying to understand the link between women empowerment and health insurance in Rwanda. The results for health facility variable go in line with prevailing literature where Shibre et al [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] used the same variable to analyse women empowerment inequalities.\u003c/p\u003e \u003cp\u003eThe paper is structured as follows: Section 2 reviews the existing literature on women empowerment and women health in developing countries with particular focus on Sub Saharan Africa. Section 3 sets out the conceptual framework that combines different dimensions of women empowerment and health status of women. Section 4 explains the data and methodology used. Section 5 analyses the data and findings based on different indicators of women empowerment and health status of women. Section 6 concludes with relevant policy options.\u003c/p\u003e"},{"header":"2. Literature Review","content":"\u003cp\u003eImprovements in maternal health can be organised through family planning programs where women and couples can take proper decisions about contraception that will help them to improve their maternal health [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Reinforcing women\u0026rsquo;s health strengthens women\u0026rsquo;s empowerment. Poorly empowered women have led to lack of essential health services for women. Better access to health, increased emancipation of women in the economy, higher levels of education and control over assets are vital factors that contribute towards improving health outcomes [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Greater women empowerment will definitely improve the health and quality of life of women and their family members in two different ways as suggested by Kuche et al [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The authors argued that the more the women are empowered they will have a greater decision-making power thus having greater access to health services and control over health resources that will improve their health status. Secondly, they are more likely to have fewer children with better childcare thus improving the health outcomes of the children. The benefits of empowerment are not essentially restricted to women themselves but have the potential to extend to those around her, including her own children [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s greater level of empowerment play a vital role in managing their fertility and health outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, having access to information on reproductive and sexual health is very important to the physical health of women where education increase women\u0026rsquo;s chances of following school and moving out of poverty. Women empowerment is mainly recognised as a very important tool to allow access to reproductive and sexual health care services for improved health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The higher the level of women empowerment, the more they are likely to take independent decisions [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWomen empowerment positively influences family planning use [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Fertility rates in sub Saharan Africa remains higher and contraceptive levels are low compared to other countries in the developing world. Evidence show that fertility decline has slowed during the past decade. Fertility developments in SSA are not uniform [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Though there are significant investments in family planning programs over the past years and knowledge of contraception does not necessarily mean there is an increase in the use of contraceptives [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Phan [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] analysed four main spheres of women empowerment (female education, female labour force participation, decision-making and use of contraceptives) and its relationship with women\u0026rsquo;s fertility. He found that an improvement in women empowerment is linked with low fertility rates. Additionally, maternal mortality is one of the very important health debates in sub-Saharan Africa. In 2015, approximately three hundred maternal deaths occurred related to pregnancy and child birth where almost all of the deaths could have been prevented. These maternal deaths are related directly to obstetric complications. A thorough understanding of the link between women\u0026rsquo;s empowerment and utilisation of maternal healthcare services may help to decrease maternal deaths in SSA. There should be implementation of complete empowerment programs that would help women in SSA to contribute in deciding about their own health and access to health [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence show that women empowerment definitely affects family planning use [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Poorly empowered women do not have access to quality family planning services and therefore are unable to negotiate family planning and use of contraceptive efficiently. Women empowerment is positively associated with positive maternal outcomes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Consistently, a regional analysis of SSA shown that dimensions of women empowerment have an effect on maternal health and utilisation of health services.\u003c/p\u003e"},{"header":"3. Conceptual framework of Women health and Women Empowerment","content":"\u003cp\u003eResearch on the link between women health and empowerment is sparse in SSA. While the importance of these is undeniable, this study believes that it is important to extend on the dimensions of women empowerment by understanding the dynamic relationship between women health and women empowerment to better formulate policies to improve the quality of life of women in SSA. Women empowerment is vital for the utilisation of maternal healthcare services and overall women\u0026rsquo;s wellbeing. To the best of our knowledge, there is no study on SSA region that attempts to measure a broad aspect of women empowerment and its relationship with women\u0026rsquo;s health. Additional variables of the dimensions of women empowerment such as psychological and legal have not been included in other studies to calculate the women empowerment index and analysis of the link between the developed index and women health. Moreover, supplementary variables to capture women health has been used which is in contrast from the work of Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The association between women health and women empowerment is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1.1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThis study uses the Women Empowerment Index (WEI) developed to analyse the complex association between women empowerment and women health. The WEI is a summary measure of attainments in four vital dimensions of women empowerment: economic, social, psychological and legal/political. The index comprises of the four dimensions of women empowerment. The work contributes to the existing theoretical literature by building on and extending the existing conceptual frameworks on women empowerment and women health. It tries to capture variables from four different dimensions of women empowerment namely economic, social, psychological and legal spheres. Variables such as control of earnings, ownership of house and land, control of visits, control of health, decisions over husband\u0026rsquo;s income, refusal of having sex, goes out without informing, neglects children, burn food, argue with husband, violence, seek help from social service organisation, police, lawyer and doctor are used. Family planning use measured as ever using contraceptives amongst women who were married or had a male partner is used as health variable. Contraceptive use is vital in preventing neonatal risks. Women who face healthcare challenges experience gendered power inequalities that prevent them from attaining their reproductive health benefits [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Maternal health is measured in terms of maternal mortality. Research show that empowered women are more likely to plan their pregnancies receive prenatal care, receive healthcare services in terms of prenatal care and visit a skilled healthcare provider during pregnancy and childbirth, delay marriage and normally are employed in either public or private sector with a secure job. The greatest number of maternal deaths have been found in countries where women do not have the assistance of skilled practitioner when they deliver. Women living in rural areas and with less education are more vulnerable to maternal mortality. High rates of maternal mortality levels are an indication of deep-rooted gender inequalities which limit access to healthcare services and the ability for women to take decisions.\u003c/p\u003e"},{"header":"4. Data and Methodology","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Data\u003c/h2\u003e \u003cp\u003eThe publicly available data from the Demographic and Health Surveys (DHS) for 26 sub-Saharan African countries from 2008 to 2020 is used for the analysis which are representative and covering a wide range of households. The sample of the study consists of women of reproductive age 15 to 49. They have a large coverage of around 5,000 to 30,000 families and are conducted each 5 years to be able to compare with different years over time. To achieve this, typical questionnaires are developed where women of reproductive age are interviewed. Information is collected on basic demographic and health topics such as fertility, mortality, family planning, marriage and reproductive health amongst others. In addition, particular questions are included considering the differences between the countries. The methodology rests on the multinomial regression model to analyse the complex relationship between women\u0026rsquo;s health and women\u0026rsquo;s empowerment that is adapted from the work of Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The multinomial logistic model is used when the dependent variable has different categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Econometric Model\u003c/h2\u003e \u003cp\u003eThe regression equation is as follows:\u003c/p\u003e\u003cp\u003e\u003cimg 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\" width=\"535\" height=\"61\"\u003e\u003c/p\u003e \u003cp\u003eThe equation above tries to capture the relationship between WEI and Health facility. Four separate regression models have been stipulated where each health variable has been considered at one point in time. Other proxies for health indicator are replaced in the equation namely health insurance, medical help and contraception through different regression equations to analyse the relationship between women empowerment and women health.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDependent variable\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConsidering the conceptual framework, the outcome variable is women empowerment. It captures the level of women empowerment in terms of four different dimensions namely social, economic, legal and psychological. To some extent, similar variable has been used in preceding studies namely Ewerling et al [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] which used SWPER Index.\u003c/p\u003e \u003cp\u003eMoreover, four different regression models have been stipulated to analyse the relationship between women empowerment and health. Each health variable has been analysed at a time. The study by Annan et al [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] also analysed women\u0026rsquo;s power in 23 sub Saharan countries in relation to the health of women. Furthermore, Asaolu et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] try to analyse the link between health and empowerment with variables such as contraceptive use.\u003c/p\u003e \u003cp\u003eVariables namely control of earnings, ownership of house and land, control of visits, decisions over husband\u0026rsquo;s income, refusal of having sex, goes out of house without informing, neglects children, burn food, argue with husband, violence, seek help from social service organisation, seek help from police, seek help from lawyer amongst others are used to capture the level of women empowerment in 26 sub Saharan countries.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIndependent variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe main independent variables are the health variables namely health insurance, health facility, medical help and use of contraceptives amongst women aged 15 to 49 years. A dummy value of 1 implies that the woman has a health insurance, has access to medical facility, seek medical help when in need and use contraceptives and 0 otherwise. Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] show how women empowerment is vital for the health of women. Other control variables in terms of personal features of the respondent has been captured. The age of woman has been spilt into seven categories where those being less than 20 years old is the benchmark category. Ackerson et al [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] used similar age categorisation in analysing domestic violence and psychological health in India.\u003c/p\u003e \u003cp\u003eMoreover, the wealth index has been categorized into 4 categories namely poorer, middle, richer and richest with poorest set as benchmark category. Bamiwuye and Odimegwu [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Cools and Kotsadam [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] used the wealth index to investigate the relationship between poor woman and partner violence in Sub Saharan African countries. In addition, educational attainment is categorised into six categories namely no education, incomplete primary, complete primary, incomplete secondary, complete secondary and higher education. Higher education is set as the reference category. Mokdad et al [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] used similar categorisation in their study of health. Husband\u0026rsquo;s level of education as well is considered as a controlled variable where husband with no education is set as dummy 1 and 0 otherwise. This variable has been used by Ali et al [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] in their study of healthcare in Ethiopia. Help from ministry of gender, promotion and planning as well is catered for in the regression to try to understand whether this form of help is being widely used by the respondent in the study. This variable has been used by Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo forms of violence against women has been taken into account in the analysis namely emotional violence and sexual violence in the household. The respondent is asked about whether they have experienced any of these two types of violence from partner or husband. For example, emotional violence is measured by questions as to whether women have ever been humiliated by husband/partner. Furthermore, sexual violence implies whether the respondents have ever been physically forced into unwanted sex or unwanted sexual acts by husband/partner. Diop-Sidib\u0026eacute; et al [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] used these variables in trying to establish a relationship domestic violence and health outcomes of women in Egypt.\u003c/p\u003e \u003cp\u003eThe main health variables namely health facility, health insurance, medical help and use of contraceptives have been captured in the analysis to be able to understand the relationship between women empowerment and women health in 26 sub Saharan African countries. Similar variables have been used by Asaolu et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, awareness and knowledge about contraceptive methods and family planning programs and the link between women empowerment have not been explicitly captured by existing studies.\u003c/p\u003e \u003cp\u003eThe multinomial logit regression is used to capture each health variables associated with high and medium levels of women empowerment. The low level of empowerment is set up as the benchmark category. The women empowerment index (WEI) developed encompasses the four different dimensions of women empowerment. (economic, social, psychological and legal). The cut off points are as follows with low WEI\u0026thinsp;\u0026lt;\u0026thinsp;0.250, Medium WEI 0.250\u0026ndash;0.417 and high WEI\u0026thinsp;\u0026gt;\u0026thinsp;0.417. The low WEI is the empowerment dummy variable. Four different multinomial regression has been analysed taking into consideration each health variable at one instance.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Results and Discussion","content":"\u003cp\u003eThe link between women empowerment and health indicators is explicitly measured as shown in table 1.1 in the \u003cspan refid=\"Sec9\" class=\"InternalRef\"\u003eappendix\u003c/span\u003e section.\u003c/p\u003e \u003cp\u003eAll the health variables namely health facility, health insurance, medical help and use of contraceptives are positively related with the dependent variable. The higher the level of women empowerment in the different countries the more the respondents are likely to have positive health outcomes. When the woman is not educated or has an incomplete primary, complete primary or even an incomplete secondary the level of empowerment decreases leading to lack of information towards access and use of health facilities provided by the ministry of family, gender and promotion.\u003c/p\u003e \u003cp\u003eThe reference category for level of education here is higher education. The findings for example of woman who does not have any level of education show a negative relationship at 0.0481 and is statistically significant at 1percent with the level of women empowerment in terms of social, economic, psychological and legal aspects. The results are robust and go in line with existing literature namely Asaolu et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The education variable categories have also been used by Bazargan-Hejazi et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]in their attempt to find the different trends in female victims of partner violence in Malawi. In Kenya, the level of empowerment is highly dependent on the level of education of the women. The women who are more empowered are those having the highest level of education; the medium level of empowerment is linked with those having completed secondary education and lastly the least empowered are those who did not attend school at all [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering the individual characteristics, findings show a positive relationship between age of respondents and level of women empowerment. The coefficients of the age variable which is categorised in 6 levels, increases as we move to higher age categories that is from age 20\u0026ndash;24 to age 40\u0026ndash;44, showing higher level of empowerment at higher age. Those women aged 15\u0026ndash;19 are classified as the benchmark category. Ackerson et al [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] used the same age categorisation in their study of domestic violence among women and children in India. Besides, the different age classification has as well been adopted by Paul [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] while studying the relationship between women labour force participation and domestic violence in India.\u003c/p\u003e \u003cp\u003eThe results for wealth index posit positive findings as well. The wealth index combined is classified into four categories namely poorer, middle, richer and richest. The poorest category of the wealth index combined is used as the reference type. The results show that the middle and the richest level of income having the highest coefficient (0.0045 and 0.031 respectively) are statistically significant at 1 percent level. This postulates that poor women are less likely to be empowered. The results and variable used are consistent with existing literature. The wealth index variable has been used by Bamiwuye et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]and Cools et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] in their study of poor women in SSA who are more likely to experience partner violence.\u003c/p\u003e \u003cp\u003eCountries such as Burundi, Cote D\u0026rsquo;Ivoire, Ethiopia, Kenya, Comoros, Malawi, Mozambique, Namibia, Rwanda, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe show negative coefficients. These results display that there is a poor level of women empowerment in the country which will negatively affect the health outcomes of the respondents in the study. The findings are coherent with existing literature for example Shiferaw et al [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] in their study to understand the use of contraception and proximity of healthcare in Ethiopia where they concluded that the use of contraceptives is highly and positively related amongst women who live nearer to health facilities.\u003c/p\u003e \u003cp\u003eAdditionally, the husband or partner of the respondent with no education has an impact on the level of empowerment of the women. The findings demonstrate that women empowerment is negatively related to husband who are not literate. The level of empowerment decreases when the husband does not have any educational background. The variable is statistically significant at 1 percent. Geshaw et al [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] has used this variable as well in the analysis of partner violence during pregnancy. Sexual and emotional violence is prevalent when the women are least empowered as shown in the results. These variables have been used by Rahman et al [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] and Bengesai et al [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, women who seek help from the Ministry of Gender and promotion are more likely to understand their rights thus they are more empowered as proved by the findings of the study with a positive coefficient. Effendi et al [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] have used similar variables in their study while they tried to analyse the relationship between contraceptive use and women empowerment.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1.2\u003c/span\u003e(refer to \u003cspan refid=\"Sec9\" class=\"InternalRef\"\u003eappendix\u003c/span\u003e section) shows the multinomial regression results with use of contraceptives as health indicator as used by Diop-Sidib\u0026eacute;, et al [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] in their study to understand the relationship between domestic violence and health outcomes in Egypt. To protect the rights of women, contraceptive use is very important to improve the quality of life of women in sub-Saharan Africa. Worldwide, the use of contraceptives act as a preventing tool to decrease the number of 2.7\u0026nbsp;million infant deaths [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The coefficients for contraception are positive and highly significant. The value of the coefficients increases from medium to high WEI. The results are consistent with the empirical findings of Corroon et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] in urban Nigeria where they concluded that high empowered women in general are more likely to use contraception measures and to use a health facility accessible to them.\u003c/p\u003e \u003cp\u003eThe multinomial logit results where health facility is the health variable is showing robust and positive health coefficient for both medium and high empowerment as compared to low empowerment that is the benchmark category. The individual characteristics as well are positive. Women empowerment is a powerful factor that help women use health facilities [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Holland et al [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] provide evidence that the level of women empowerment has a significant effect on the ability of women to have access to health care facilities. The results go in line with prevailing literature. Shibre et al [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] used the same variable to analyse women empowerment inequalities while using maternal health care services in Ethiopia, where they found that the use of health facilities available to women are more likely to occur when they know about their rights. Moreover, Tessema et al [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] found that health care access is only at 42.6 percent amongst women of reproductive age 15 to 49 years in 36 sub Saharan countries. Furthermore, the importance of health facility is undisputed in the study by Doctor et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] in trying to understand the challenges of health facility delivery in sub Saharan African countries. Their results show that women in the richest category of the wealth index are 68 percent more likely to give birth in health facilities provided to them. Likewise, women who are more educated are more likely to be empowered and use health facilities compared to women with no formal education.\u003c/p\u003e \u003cp\u003eMoreover, the health insurance as health indicator is used in analysing the effect of women empowerment on health outcomes of the respondent. The coefficients of the variable health insurance are positive for both medium and high level of empowerment as compared to the base outcome of low level of empowerment. Several measures have been put into practice to encourage health insurance coverage of women and it is viewed as improving the health outcomes of women. This is consistent with the study by Kawuki et al [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] in trying to understand the link between women empowerment and health insurance in Rwanda.\u003c/p\u003e \u003cp\u003eLastly, medical help from doctors and other medical professionals is used as indicator for health outcomes of women respondents of the DHS survey. The results are consistent and significant with existing literature. When the woman is more empowered as compared to low levels of empowerment, findings show a positive link between the medical help variable and medium and high level of empowerment compared to the base outcome of low levels of empowerment. These results go in line with the work of Hameed et al [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], when they tried to analyse the connection between women empowerment and contraceptive use.\u003c/p\u003e \u003cp\u003eThe results enrich the existing literature of women empowerment and women health. It illustrates positive link between medium and high level of empowerment with health outcomes of women in SSA. The access to healthcare services and ability for women to take economic and household decisions has improved the quality of living of many women in the SSA. However, the coefficient of education is negative, as it has been found that half of women in the sample are not educated.\u003c/p\u003e"},{"header":"6. Conclusion and Policy Recommendations","content":"\u003cp\u003eThe paper builds on a conceptual framework to analyse the relationship between women empowerment and women health in the 26 sub-Saharan countries of women to 15\u0026ndash;49 reproductive age. Based on the theoretical model by Muluneh et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], indicators are collected to conceptualise women empowerment using four different dimensions of women empowerment namely economic, social, psychological and legal/political and women health. The study adopts the multinomial logit regression approach to analyse the dynamic link between women empowerment and women health. It has been found that most women in the sample do not have access to healthcare services and are poorly educated. They lack resources to allow them to improve their standard of living. Countries with low level of empowerment have poor access to healthcare available to women. This leads to a high percentage of maternal mortality amongst these countries.\u003c/p\u003e \u003cp\u003eFrom the findings, we note that there is a need to revisit SSA\u0026rsquo;s countries policies to promote women health. Furthermore, there should be consistent and transparent reforms that will lead to efficiency in decision making and empower women who will create a positive impact in the economy as a whole. Investing in women health leads to a healthy population overall. Recognizing the health sector has an important role to play in preventing and responding to unequal access to healthcare services against women should be emphasised by policy makers. Greater involvement of non-governmental organisations and society-level interventions can better find solutions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Statement\u003c/h2\u003e \u003cp\u003eThis article is the authors' own original work, which has not been previously published elsewhere.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funds, grants, or other support was received\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interest\u003c/strong\u003e \u003cp\u003e \u003cb\u003e\u003c/b\u003eThere was no potential conflict of interest\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors reviewed the manuscript and made significant contribution in writing the paper.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e\n\u003ch2\u003eCode availability-Not applicable\u0026nbsp;\u003c/h2\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbreha, S. 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Women's Empowerment in Agriculture and Household-Level Health in Northern Ghana: A Capability Approach. \u003cem\u003eJournal of International Development\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 899\u0026ndash;918.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multidimensional, Women Empowerment Index, Health Outcomes, Sub Saharan Africa, Women’s Health","lastPublishedDoi":"10.21203/rs.3.rs-5281312/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5281312/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe study links up women empowerment to health and wellbeing outcomes of women in sub-Saharan Africa. Existing literature suggests that women empowerment influences reproductive health outcomes such as fertility, birth interval and contraceptive use. The evidence however remains mixed and tends to be country specific owing to the difficulties in measuring empowerment and health. The study links different dimensions of women empowerment to health outcomes of women in sub-Saharan African countries. Micro data from the Demographic Health Surveys for 26 sub-Saharan African countries from 2008 to 2020 is used to assess the link between women empowerment and health status. The Women Empowerment Index is built from four main dimensions namely economic, social, psychological and legal/political empowerment. Family planning use and maternal health are indicators used for women\u0026rsquo;s health. Women\u0026rsquo;s empowerment is hypothesised as a predictor of reproductive health outcomes. There is evidence of a positive link between women empowerment and women health.\u003c/p\u003e","manuscriptTitle":"Women Empowerment and Women Health in Sub Saharan Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-30 09:13:35","doi":"10.21203/rs.3.rs-5281312/v1","editorialEvents":[{"type":"communityComments","content":2}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"304f9ecb-ad0a-42b9-9977-87914b35a239","owner":[],"postedDate":"October 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-13T20:38:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-30 09:13:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5281312","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5281312","identity":"rs-5281312","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}