Women’s Empowerment as a Social Determinant of Adverse Pregnancy Outcomes in the Tigray Region of Ethiopia: A Prospective Follow‑up Study

Women’s Empowerment as a Social Determinant of Adverse Pregnancy Outcomes in the Tigray Region of Ethiopia: A Prospective Follow‑up Study | 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 Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Women’s Empowerment as a Social Determinant of Adverse Pregnancy Outcomes in the Tigray Region of Ethiopia: A Prospective Follow‑up Study Gebreamlak Gidey Abebe, Alemayehu Bayray Kahsay, Araya Abrha Medhanyie, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8895973/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 Introduction: Women’s empowerment and the promotion of positive pregnancy experiences are global public health priorities and key sustainable development goals. However, little is known about the relationship between women’s empowerment and adverse pregnancy outcomes in a conflict prone setting like Ethiopia. Therefore, we aimed to assess women’s empowerment as a social determinant of adverse pregnancy outcomes in the Tigray region of Ethiopia including estimating the magnitude of adverse pregnancy outcomes and examining its association with women’s empowerment. Methods A community based prospective study design was employed from August 2024 and May 2025. A multistage clustered sampling technique was used to select and study 1258 pregnant women. The relationship between the domains of women’s empowerment and adverse pregnancy outcomes was modeled using a multivariable modified Poisson regression method. Adjusted Relative Risks (aRR) with a 95% confidence interval (CI) and p -value are reported. Result The findings showed that the magnitude of adverse pregnancy outcomes was 19.0% (95% CI: 16.9%–23.3%), with maternal complication (10.7%), abortion (5.5%), still birth (2.6%), and congenital anomalies (1.6%) being the main adverse pregnancy outcomes. The overall composite women’s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. However, specific women’s empowerment domains such as being a member of social networking (aRR = 0.68; 95% CI, 0.49-.96) and household asset ownership (aRR = 0.52 95% CI, 0.29-.89) reduced the risk of adverse maternal outcomes. In contrast, women who accept wife beating by husband (aRR = 1.42;95% CI, 1.12–1.99), were more likely to experience adverse pregnancy outcomes. Conclusion One in five women reported adverse pregnancy outcomes during the study period. Our study provides evidence that supports women’s empowerment, as a modifiable social determinant, reduces the risk of adverse pregnancy outcomes. We recommend that efforts aligned with Sustainable Development Goal 5 (SDG 5), including achieving gender equality, strengthening women’s participation in social networking groups, such as leadership and political engagement, wealth accumulation through income generation and savings, and promoting asset ownership, may help reduce the burden of adverse pregnancy outcomes in the study area. Women’s Empowerment Tigray Adverse pregnancy outcome decision-making Figures Figure 1 Figure 2 Introduction Pregnancy is usually a happy time for most women and their families although it can also be a period of concern and anxiety, for some women lose their babies during early or late pregnancy and delivery earlier than the expected date or face low birth weight [ 1 , 2 ]. The term “pregnancy outcomes” describes the result of a pregnancy and varies from pregnancy to pregnancy [ 3 , 4 ]. Adverse pregnancy outcome is defined as any pregnancy outcome other than a normal live birth, including abortion, stillbirth, preterm birth, low birth weight, early neonatal death, congenital abnormalities, and maternal pregnancy-related complications [ 5 – 7 ]. Globally, adverse pregnancy outcomes (APOs) remain a major public health concern, with low- and middle-income countries (LMICs) bearing a disproportionate burden, particularly in settings affected by armed conflict [ 8 ]. Global evidence indicates that armed conflict is associated with increased adverse pregnancy outcomes, resulting in poor maternal health and impaired fetal development, largely driven by damage to health infrastructure and reduced access to antenatal and general healthcare services [ 9 ]. Despite progress in reducing APOs such as maternal and perinatal mortality and morbidities in the last two decades, a World Health Organization’s (WHO) report in 2020 showed the burden of adverse pregnancy outcomes was increasing [ 10 ]. Previous studies have also reported a high burden of APOs such as preeclampsia, pregnancy-related hemorrhages, low birth weight, still birth and preterm delivery in LMICs [ 10 ]. Efforts to reduce adverse pregnancy outcomes have appropriately focused on addressing immediate determinants, including preconception care, antenatal services, and intrapartum-related complications. [ 8 , 11 ] However, social and structural factors, such as gender equality and women’s empowerment (immediate causes), have received little attention [ 12 ]. Globally, empowering women and decreasing maternal mortality are key indicators of sustainable development [ 13 ]. The targets and indicators of the Sustainable Development Goals (SDGs) illustrate that health equity (SDG 3) is not a stand-alone goal and underlie the synergies between health outcomes and gender equality (SDG 5), economic opportunities (SDG 8), and ensuring peaceful societies (SDG 16), among other[ 14 ]. Therefore, the targets to reduce adverse pregnancy outcomes and the goal to achieve gender equality and women’s empowerment provide further impetus to investigate the connections between these important agendas. Women’s empowerment is defined as a “process of change by which those who have been denied the ability to make choices acquire such an ability’’ [ 15 , 16 ]. Women’s empowerment in their homes, communities, and societies at large have been shown, through direct and indirect pathways, to be associated with positive pregnancy experiences [ 14 ]. Women with low agency and resources may be limited in their ability to make choices regarding their own health and those of their children. Consequently, these circumstances can contribute to their own ill health and risk of mortality as well as that of their children[ 17 ]. Empowered women who possess greater decision-making autonomy[ 18 ], social independence [ 2 , 19 ], and resistance to gender-based violence [ 13 , 20 ] are more likely to seek higher-quality maternal health care services across the full continuum of care, from preconception through the postnatal period and improved positive pregnancy outcomes and reduced adverse pregnancy outcomes [ 21 , 22 ]. Furthermore, women’s empowerment in developing countries improves use and quality of maternal health care, which in turn reduces complications, morbidity and mortality for mothers and babies [ 18 , 23 ]. Conversely, the absence of women’s empowerment in decision-making results in delays and poor utilization of maternal health services and ultimately increased adverse pregnancy outcomes such as maternal and neonatal mortalities [ 24 ]. Although the Ethiopian government has developed strategies and plans to improve the well-being of mothers and children, adverse pregnancy outcomes remain a major public health problem[ 25 ]. Evidence shows a high national pooled prevalence of adverse fetal outcomes (26.9%))[ 26 ] ,and adverse maternal outcomes (15.68%) [ 27 ]. Once one of the relatively best performing health systems in Ethiopia, the Tigray health system is on the verge of collapse due to the war that began on 4 November 2020 [ 28 ]. The health system experienced severe disruption due to the armed conflict: Only 3.6% of all health facilities (n = 1007), 13.5% of all hospitals and health centers (n = 266), and none of the health stations (n = 741) are currently operational [ 29 , 30 ]. Tigray’s primary care model relied on Health Extension Workers (HEWs) plus community structures like the Women’s Development Army (WDA) networks, which worked with HEWs to mobilize women, promote maternal and child health and link households to facilities. These are now completely inactive due to the conflict [ 31 , 32 ]. As a result, adverse pregnancy outcomes (APOs) increased substantially, with maternal mortality surging to 840 deaths per 100,000 live births from a pre-war level of 186 [ 33 ] under-five mortality rate of 59 per 1000 live births, neonatal mortality rate of 28.2 deaths per 1,000 live births, and a neural tube defect rate of 29.51 per 1,000 live births [ 34 , 35 ] Similarly, during the war, the magnitude of maternal adverse pregnancy outcome such as severe preeclampsia significantly increased from 36.6 to 47.9%, obstructed labor from 2.0 to 4.4% ,and Intensive Care Unit (ICU ) admissions among mothers with potentially life-threatening complications from 3.5 to 6.1% [ 36 ]. Despite the evidence that women empowerment is protective, a gap still exists in understanding how multidimensional, context specific women’s empowerment index affects the adverse pregnancy outcomes in Tigray. In addition, the majority of the existing studies in the region are cross- sectional in design and facility-based surveys using statistical approaches that may have limitations in identifying factors at different levels and robust estimates of the association between women’s empowerment and adverse pregnancy outcomes. Thus, this study overcomes these limitations by employing robust epidemiological evidence and a community-based prospective follow-up design incorporating multidimensional, context-specific indicators of women’s empowerment. Therefore, this study aimed to investigate the magnitude of adverse pregnancy outcomes and examine the impact of women’s empowerment domains on adverse pregnancy outcome in Tigray. We intended to provide stronger empirical evidence on the role of women’s empowerment in improving positive pregnancy experiences in order to guide policymakers in designing more targeted, effective, and equitable health interventions that are in both SDG 3 (health) and SDG 5 (women’s empowerment and gender inequality) aligned with national and global sustainable development agendas. Methods and materials Study area This study was conducted in the Tigray region, northern Ethiopia. Tigray is bordered by Eritrea to the north, Sudan to the west, Amhara to the south, and Afar to the east. The region comprises 93 districts (36 urban and 57 rural) organized into seven administrative zones (Mekelle, Eastern, Southern, South-Eastern, North-Western, Western, and Central). The study was implemented in nine selected districts, namely Hintalo, Enderta, Rural Adwa, Laelay Maychew, Naeder, Aksum town, Laelay Koraro, Tahtay Koraro, and Shire Endasilassie town excluding the Western zone and selected districts from the Northwestern and Central zones due to security concerns. The regional health system includes two specialized comprehensive hospitals, 14 general hospitals, 24 primary hospitals, 232 health centers, and 743 health posts (Fig. 1 ). Study design and period A community-based prospective follow-up study was conducted from August 2024 to May 2025. Source and study population All pregnant women within the study areas during the time of the baseline survey were the source of population. Pregnant women enrolled at an early antenatal care visit (at or after 8 weeks of gestation) through a cluster sampling technique were included as study participants. The inclusion criteria comprised women who were permanent residents of the selected districts (living in the area for at least six months), had a confirmed pregnancy with a gestational age of 8 weeks or more, and registered as pregnant at either the health post or within the Women’s Development Army (WDA) structure. Sample size and sampling procedure This study was part of our larger project intended to investigate the effect of Women’s Empowerment in improving utilization of continuum of maternity care and positive pregnancy outcomes in Tigray region, Ethiopia. Accordingly, the sample size was estimated based on the specific objectives of the whole study using Epi-info stat Calc 7.2.5.0. The double population proportion formula was used with the assumption: the proportion of an outcome among exposed group was 34% (p1=.03), and among non-exposed group was 23.9% (p2 = 0.239) [ 37 ]; pooled population proportion (p = 0.193); r = 1:2 ratio of exposure to non-exposure; 5% significant level at α level (two- sided); 80% power, design effect 1.8 and 10 non-response rate. The study included 1258 women from the 1477 women who were part of a fixed cohort from antenatal care to postnatal care. The cohort of pregnant women enrolled for the follow-up study were identified using a multistage cluster sampling technique. First, three zones from the accessible 6 zones were randomly selected and 9 districts were also randomly selected from the accessible districts. Second, using a simple random sampling method (lottery), 43 Tabiyas (sub-districts) were selected from a total of 113. Third, 86 ‘kushets/sub village’ (the smallest administrative units) were randomly selected from each village. Finally, all households within the selected kushets (clusters) that had eligible pregnant women enrolled in the follow-up study were subsequently tracked for the interview and the selected women were interviewed to ascertain pregnancy outcomes for their most recent delivery during the study period. Data collection tools, techniques, and quality assurance The questionnaires were developed through a review of relevant literatures, including the validated Survey-based Women’s Empowerment Index (SWPER) Global 2017 tool. The Ethiopian Demographic and Health Survey (EDHS) and other context-specific tools from Ethiopia were adapted to ensure cultural appropriateness and maintain the validity of the instrument [ 38 , 39 ]. Data collectors and supervisors were trained for three days and five percent of the tools were pre-tested to ensure clarity, wording, logical sequence, and the relevance of the questionnaires. Furthermore, a smart mobile-based approach (KoboToolbox) was used to collect the data. The questionnaires were prepared in English, translated into Tigrigna (the local language), and then retranslated into English by people proficient in both languages to maintain consistency. During actual data collection, the principal investigator and supervisors frequently supervised and checked the work of data collectors, and provided clarification and directions to those in doubt. Measurement of outcomes and other variables Outcome variable Adverse pregnancy outcome was defined as the presence of at least one self-reported maternal or fetal/neonatal complication i.e., abortion, stillbirth, early neonatal death, congenital abnormality, hemorrhage, preeclampsia/eclampsia, obstructed labor/prolonged labor, anemia, linkage of urine and stool, puerperal sepsis, and maternal death [ 3 , 40 , 41 ]. Although low birth weight and preterm birth are important perinatal outcomes, they were not included in the primary composite adverse pregnancy outcome due to their applicability only to live births and the substantial proportion of missing data, which could introduce differential misclassification or biases [ 42 , 43 ]. Excluding variables with large, potentially non‑random missingness like low birth weight, or gestational age can be preferable to including them and introducing bias. Abortion: Termination of pregnancy before 28 weeks of gestation or at less than 1,000 gm weight of conception. When a fetus passes away before 28 weeks of pregnancy without any intervention, spontaneous abortion, where the fetus passes away before 28 weeks of pregnancy due to medical intervention, is medically indicated abortion [ 44 ]. Stillbirth: If the infant died in the womb or during the intrapartum period after 28 weeks of gestation [ 45 ]. Early neonatal: A death as death occurring within 7days of birth [ 44 ]. Congenital anomalies: Defined as any abnormality of physical structure found at birth or during the first few weeks of life; or any irreversible condition existing in a child before birth in which there is sufficient deviation in the usually number, size, shape, location of any part, organ, and cell to warrant its designation as abnormal [ 40 ]. Main exposure variables This study examines women’s empowerment as the main independent variable using an index based on five dimensions: social independence, decision-making power, attitudes toward wife-beating by husbands, social networking, and asset ownership. Questionnaire items were adapted from the validated SWPER Global 2017 tool, the DHS, and relevant literature, with context-specific adjustments to meet the study objectives [ 38 , 39 ]. To assess social independence eight questions were asked on women’s completion of education, regular access to information, age at first birth, age at first marriage and cohabitation, age and educational difference with husband [ 46 , 47 ].. Women’s decision-making power was also assessed using four questions about women’s involvement in decisions regarding their own healthcare, household purchases, husband’s earnings and visits to family or relatives [ 38 , 39 ]. For the justification of wife-beating by husbands, respondents were asked five questions to determine whether they believed a man was justified in beating his wife under certain circumstances, such as burning food, arguing with her husband, going out without informing him, refusing sexual intercourse, and neglecting the children [ 46 , 47 ]. Social networking was assessed using four questions on women’s participation in health groups, leadership or political organizations, economic unions like saving and credit unions, and cultural or faith-based associations. Asset ownership was measured through four questions on ownership of land, housing, a mobile phone, and a bank account, either individually or jointly with a husband Table 1 summarizes the domains, indicators, cut-offs, and weights of the women’s empowerment multidimensional index. The index consists of five equally weighted domains (0.2 each), with indicator weights shared equally within domains. Empowerment scores were computed using weighted means, then standardized using the global SWPER mean and standard deviation, where zero reflects the average empowerment level in low- and middle-income countries [ 38 , 48 ] and other similar studies [ 49 ]. To standardize the score, the mean score was subtracted, and the results were divided by the respective standard deviation. Therefore, to examine the effect of each domain on adverse pregnancy outcomes at different levels of scores, women’s empowerment domains was divided into three groups: lower scores, medium scores and higher scores as per the previous literatures[ 50 , 51 ]. To examine the overall/composite effect women’s Empowerment multidimensional Index on APOs, women’s Empowerment multidimensional Index was divided into three groups: low for scores below 0.50, average for scores between 0.50 and 0.75, and high for scores of 0.75 or higher. [ 38 , 49 ]. Covariates: Sociodemographic variables (age, residency, marital status, education status, religion, and occupation, sex of household head, family structure, access to health facilities and community engagement).Obstetric variables (age at first marriage, contraceptive use, gravidity, previous bad obstetric history and domestic violence’s), and maternal health interventions received during the current pregnancy such as preconception care, antenatal care, postnatal care and key interventions like iron folic acid and tetanus toxoid vaccinations were included as a covariate variables during this study. Table 1 Dimensions, cut-offs and weights of women’s empowerment multidimensional Index, Tigray, and Ethiopia. Domains Indicators Empowered if a woman (cut-off) Weight (indicator) Weight (dimension) Social independence Women’s education Completed secondary or higher education 0.025 Frequency of reading newspapers/ magazines Read once a week or more 0.025 0.2 Frequency of watching television/listening to the radio Watch/listen once a week or more 0.025 Age of women at first birth Is of the age of 19 years or more 0.025 Age of women at first marriage Is of the age of 18 years or more 0.025 Age of women at first cohabitation Is of the age of 18 years or more 0.025 Age difference Less than five years younger than her husband 0.025 Educational differences has equal or higher education than her husband 0.025 Household decision-making Owns health care Takes decisions alone/jointly with her husband 0.05 0.2 Major household purchase Takes decisions alone/jointly with her husband 0.05 Family /relatives visits Takes decisions alone/jointly with her husband 0.05 Husband’s earnings Takes decisions alone/jointly with her husband 0.05 Attitude towards wife beating by husbands Wife beating justified: goes out without telling her husband Does not agree 0.04 0.2 Wife beating justified: neglects children Does not agree 0.04 Wife beating justified: argues with him Does not agree 0.04 Wife beating justified: refuses to have sex with husband Does not agree 0.04 Wife beating justified: burns the food Does not agree 0.04 Social networking membership Membership participation: in health-related group Yes 0.05 0.2 Membership participation: in leadership and politically based organizations Yes 0.05 Membership participation: in economically based unions, such as saving and credit unions Yes 0.05 Membership participation: cultural /faith-based organizations Yes 0.05 Asset ownership Owns land Owns alone/jointly with her husband 0.05 0.2 Owns house Owns alone/jointly with her husband 0.05 Owns mobile Yes 0.05 Owns bank account Yes 0.05 1 1 Data Management and Statistical Analysis After data files were downloaded from the server of the online Open Data Collection Kit (KoboToolbox) tool and saved as an Excel file, it was exported to SPSS version 27 for cleaning and then exported to STATA version 17 for further analysis. The frequency with percentages and mean with standard deviation were used to describe categorical and continuous variables respectively. A generalized linear model with a modified Poisson regression with a log link was fitted to estimate the aRR and 95% CI in order to examine the association between women’s empowerment and adverse pregnancy outcomes. A sequential backward model selection approach was used with preliminary bivariate analysis to identify the effect of each independent variable on the outcome variable and to control for possible confounding effects. Variables having a p value of less than 0.05 were included in the final model. We used Akaike’s information criteria (AIC) and Bayesian information criteria (BIC) (lower is better) to choose the final model. Results Socio-demographic characteristics A total of 1,477 women were enrolled in the study, with a 1258 (85.2%) response rate. The majority (68.2%) of women were aged 20–34 years old, with a mean age of 30.04 (+ 5.9 years). Those who attended primary education accounted for 42.37%. Forty-two percent (533) of the women reported that they have a primary level of education, 188 (14.9%) did not go to school and only 6.0% had secondary or tertiary or college and above. Most respondents were rural residents 1048 (83.3%) and most of the study participants, 1243(98.8%) were Orthodox Christians. Over three-fourths of the study respondents, 1004 (79.8%) belonged to the nuclear family structure. Women from house-holds with male heads were 1090 (86.6%). Furthermore, about 46.82% of the women have personal mobile phones, while only 5.8% of the women reporting having access to the internet ( Table-2 ). Table 2 Socio-demographic characteristics of the study participants n = 1258), Tigray, Ethiopia, August 2025 -May 2025 Variables Frequency/% Age of the mother < 20 Years 58(4.6%) 20–34 years 858(68.2%) ≥ 35 years 342(27.2%) Women’s Education No education 188 (14.9%) Primary (1–8) 533 (42.4%) Secondary (9–12) 462 (36.7%) College and above 75 (6.0%) Religion Orthodox Christian 1243(98.8%) Muslim 15(1.2%) Working in the last 12 months 182(14.47%) Residence Rural 1048(83.3%) Urban 210(16.7%) Sex of the Household head Female 168(13.4%) Male 1090 (86.6%) Have personal mobile phone 589(46.8%) Mobile phones for financial transactions (n = 589) 59(9.2%) Ever used the internet 73(5.8%) Family structure Extended 257(20.2%) Nuclear 1004 (79.8%) Husband education No education 392(31.2%) Primary (1–8) 429(34.1% ) Secondary ( 9–12) 347(27.6%) College and above 90(7.2%) Media Exposure 410 (32.6%) Model household 12 (1.0%) Walking time to nearest health facility (health center) <one hour 660 (52.5%) ≥one hour 598(47.5%) Walking time to nearest health facility (hospital) < 2 hours 436 (34.7%) 2–6 hours 671 (53.3%) ≥ 6 hours 151 (12.0%) Availability of public transport to the nearest health center/hospital 830(66.0%) Availability of ambulance services 451(35.9%) House enrolled in the Productive Safety Net Program (PNSP) 92(7.31) Being Insured for Community-Based health Insurance 133(10.6%) Availability of advocacy and sensitization on maternal health in the community 343(27.3%) Reproductive and Past Obstetric Characteristics Self-reported past obstetric history was assessed as follows: 425 (33.78%) women were married at age 18 or younger, with a mean age of marriage 18.59 ± 3.2. Approximately one-third 413 (32.8%) had five or more pregnancies. A total of 481 (38.2%) women had one or two live children. A history of stillbirth was reported by 108 (8.6%) women, 200 (15.9%) had a history of abortion, and 62 (4.9%) experienced early neonatal death ( Table-3 ). Table 3 Past reproductive and obstetric characteristics of the study participants n = 1258), Tigray, Ethiopia, August 2025 -May 2025 Variables Frequency/% Age at first marriage < 18 years-old 425(33.8%) ≥ 18 years-old 833 (66.2%) Ever use modern contraceptive? 910(72.3%) Common type of contraceptive ever use (n = 910) Pills 33(3.6%) Injectable 359 (39.5%) Implants 510(56.0%) Intrauterine contraceptive devise 8(0.9%) Gravidity (Number of pregnancy) Primigravida 150(11.9%) Multi gravida(2–4) 695 (55.3%) Grand multigravida (≥ 5) 413 (32.8%) Total number of alive Children no children 232(18.4%) 1–2 481(38.2%) 3–4 380 (30.2%) ≥ 5 165(13.1%) History of pregnancy loss(abortion) 200 (15.9%) History of still birth 108 (8.6%) History of early neonatal death 62(4.9%) History of preterm birth 51 (4.1%) Pregnancy related problems ever had for previous pregnancy 136(10.8%) Domestic violence 285(22.7%) Maternal health service utilization received during the current pregnancy Table 4 summarizes the utilization of preconception care, antenatal care (ANC), postnatal care (PNC), and selected maternal health interventions among the study participants. Only 92 (7.3%) of women reported receiving preconception care. At baseline, 1002 (79.7%) of participants were booked for antenatal care, while32.4% received postnatal or post-abortion care from a skilled health-care provider. The most received ANC interventions were iron–folic acid supplementation 1181 (93.9%) and at least one dose of tetanus toxoid (TT) vaccine 1019 (81.0%). Approximately 735(60.6%) of women received ultrasound screening during the current pregnancy. Early initiation of ANC was low: only 211 (16.8%) of women initiated their first ANC visit during the first trimester. In addition, nearly two-thirds of participants 855 (68.0%) were not adequately prepared for birth and complication readiness (Table 4 ). Table 4 Maternal health received during the current pregnancy among the study participants n = 1258), Tigray, Ethiopia, August 2025 -May 2025 Variables Frequency/% Preconception care received before the current pregnancy 92 (7.31%) Was antenatal care initiated at the time of the baseline assessment? 1,002 (79.65%) Women and families reached the birth preparedness and complication readiness plan Not well prepared 855 (67.97%) Well prepared 403 (32.03%) Time of initiation of first ANC in weeks (n = 1258) Not yes initiated 46 (3.7%) Within 12 weeks of pregnancy 211 (16.8%) 12–16 weeks of pregnancy 717 (57.0%) > 16 weeks of pregnancy 284 (22.6%) Ultrasound screening received during this pregnancy 735 (60.64%) Folic acid and iron intake during pregnancy 1181 (93.9%) Receive tetanus toxoid (TT) vaccine 1019 (81.0%) Postnatal/post abortion care received 408 (32.4%) Cultural factors that prevent her from attending MHS 216 (17.2%) Maternity services received at home by health care providers 193 ( 15.3%) Health care providers link to health facility in home visits 147 (8.5%) Magnitude of adverse pregnancy outcomes The magnitude of adverse pregnancy outcomes (APOs) among the study participants was 19.00% (95% CI: 16.87–21.28). Among the reported adverse outcomes, the most common were maternal complications 134 (10.7%), followed by abortion 69(5.5%), stillbirth 33(2.6%), and congenital anomalies 20 (1.6%) (Table 5 ). Table 5 Proportion of Adverse pregnancy outcomes in Tigray, Ethiopia, 2025 (n = 1258) Category of adverse pregnancy outcomes Frequency Percentage 95% CI Abortion 69 5.5 (4.3–6.9) Still birth 33 2.6 (1.8–3.7) Early neonatal death 11 0.9 (0.4 − 0.1.6) Perinatal mortality 44 3.5 (2.6–4.7) Birth defect/ congenital anomalies 20 1.6 (1.0-2.4) Maternal complications 134 10.7 (9.0-12.5) Overall adverse pregnancy outcomes 239 19.0 (16.9, 21.3) Maternal complications /adverse maternal outcomes The overall magnitude of adverse maternal outcomes was 10.7% (95%CI: 9.0%–12.49%) ((Table 5 ) . As shown in Fig. 2 , the most common adverse maternal outcome was a sign of severe headache/ visual problem (39.3%), followed by postpartum hemorrhage (33.7%). Among those who experienced an adverse maternal outcome, 24.3% a had severe abdominal pain and 22.4% antepartum hemorrhage The association between women’s empowerment and other factors associated with adverse pregnancy outcome In the bivariate analysis, the overall composite women’s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. However, the domains of attitudes toward violence, social networking, and asset ownership were found to be statistically significant predictors of adverse pregnancy outcomes. In the multivariable analysis, several women’s empowerment domains and maternal health service–related factors were significantly associated with adverse pregnancy outcomes. These included household asset ownership, social networking membership, attitudes towards wife beating by husband, antenatal care booking at baseline, receipt of iron–folic acid supplementation, birth preparedness and complication readiness, and enrollment in the Productive Safety Net Program .Women’s empowerment domains of lower empowerment in attitude towards wife beating and women who accept wife beating by husbands had 42% (aRR = 1.42; 95% CI: 1.105–1.992) higher risk of adverse pregnancy outcomes than those who reject wife beating by husbands. Scores indicating medium empowerment in social networking reduced risk of adverse pregnancy outcome by 32% (aRR = 0.68; 95% CI: 0.49–0.96) relative to women who did not engaged in social networking. Regarding the empowerment domain of household asset, women from households with high asset ownership had a 48% (aRR = 0.52; 95% CI: 0.29–0.89) lower risk of adverse pregnancy outcome than their counter parts. Furthermore, women who booked antenatal care at baseline had 38% (aRR = 0.62; 95% CI: 0.47–0.83) lower risk of adverse pregnancy outcome than those who did not initiate timely for antenatal care. Women enrolled in Productive Safety Net Program had 1.55 times (ARR = 1.55; 95% CI: 1.02–2.37) higher risk of adverse pregnancy outcome than those who did not enroll. Moreover, women who took supplements (folic acid and iron during pregnancy) had 46% (aRR = 0.54; 95% CI: 0.37–0.79) lower risk of adverse pregnancy outcome than those who did not take supplements. Women who planned for birth and complications had 51% (ARR = 0.49; 95% CI: 0.35–0.69) lower risk of adverse pregnancy outcome than the counterparts. Table 6 Bivariate and modified Poisson regression analysis examining the association between women’s empowerment and other factors associated with Adverse pregnancy outcomes in Tigray, Ethiopia (n = 1258) Variables Adverse Pregnancy outcome Crude Adjusted Yes No RR (95% CI) RR (95% CI) Women’s empowerment domains Attitude towards wife beating by husband domain High empowerment (disagree) 67(16.5%) 339(83.5%) Ref. Medium empowerment 32(15.1%) 180(84.9%) 0.91(0.60–1.39) 1.07(0.69–1.64) low empowerment (Agree) 140(21.9%) 500(78.1%) 1.33(0.99–1.97) 1.42(1.05–1.92)* Being member of social networking domain Low empowerment 162(21.0%) 610(79.0%) Ref. Medium empowerment 45(13.0%) 302(87.0%) 0.62(0.44–0.86)* 0.68(0.49–0.96)* High empowerment 32(19.0%) 107(77.0%) 1.09(0.75–1.60) 1.26(0.84–1.90) Household asset ownership domain Low empowerment 148(21.3%) 548(78.7%) Ref. Medium empowerment 76(17.8%) 352(82.8%) 0.84(0.63–1.10) 0.89(0.66–1.19) High empowerment 15(11.2%) 119(88.8%) 0.53(0.31–0.89)* 0.52(0.29–0.89)* Over all women’s empowerment Low empowerment 17(19.9%) 666(80.1%) Ref. Medium empowerment 20(16.7%) 100(83.3%) 0.87(0.53–1.30) High empowerment 48(17.2%) 231(82.8%) 0.86(0.63–1.19) Booked for ANC at a time of baseline survey No 54(21.1%) 202(78.9%) Ref. Yes 185(18.5%) 817(81.5%) 0.64(0.49–0.85)* 0.62(0.47–0.83)* Distance to nearby health facility ( Hospital) < 2 hours 68(15.6%) 368(84.4%) Ref. 2–6 hours 155(23.1%) 516(76.9%) 1.48(1.11–1.97)* 1.31(0.96–1.78) ≥ 6 hours 16(10.6%) 135(89.4%) 0.68(0.39–1.17) 0.67(0.38–1.17) Regular media exposure No 189(20.5%) 735(79.6%) Ref. Yes 50(15.0%) 284(85.0%) 0.73(0.54–0.99)* 0.96(0.67–1.37) Productive Safety Net Program enrolment No 213(18.27%) 953(8.7%) Ref. Yes 26(28.3%) 66(71.7%) 1.55(1.03–2.32)* 1.55(1.02–2.37)* Folic acid and iron intake during pregnancy No 32(41.7%) 45(58.4%) Ref. Yes 207(17.5%) 974(82.5%) 0.42(0.29–0.61)* 0.54(0.37–0.79)* Birth preparedness and complication readiness plan Not well prepared 195(22.8%) 660(77.2%) Ref. Well prepared 44(10.9%) 359(89.1%) 0.48(0.35–0.66)* 0.49(0.35–0.69)* Discussion The main aim of this study was to examine the magnitude of pregnancy outcomes and explore the association between women’s empowerment and adverse pregnancy outcomes among the study participants in Tigray, Ethiopia. In this study the overall magnitude of adverse pregnancy outcomes was 19.0%. The most common adverse outcomes were maternal complications (10.7%), followed by abortion (5.5%), stillbirth (2.6%), and congenital anomalies (1.6%). These findings are higher than those reported in previous studies conducted in similar settings [ 44 , 52 ]. The relatively high magnitude observed in this study may be partly explained by the prolonged armed conflict in Tigray, which resulted in widespread destruction of health facilities, disruption of essential maternal health services, and reduced access to skilled care. These disruptions may have increased women’s vulnerability to preventable pregnancy complications. Another possible contributing factor is maternal undernutrition and food insecurity, which have been reported to be prevalent in the region following the conflict [ 53 ] Cultural practices such as prolonged fasting and dietary restrictions during pregnancy among Orthodox Christian women may further exacerbate nutritional deficiencies and increase the risk of adverse pregnancy outcomes [ 54 ]. In addition, the very low coverage of preconception care observed in this study may have limited opportunities for early risk identification and nutritional supplementation before pregnancy [ 55 ]. Comparatively, the magnitude of adverse pregnancy outcomes was less than the study conducted in Debre Berhan comprehensive specialized hospital, Northeast Ethiopia (28.3%) [ 3 ] and Limbe District, Cameroon (19%) [ 56 ]. This difference could be attributed to variation in the study populations, settings (community versus comprehensive specialized hospital), and criteria used for defining adverse pregnancy outcomes. For instance, the study in Northeast Ethiopia assumed adverse pregnancy outcome is the presence of at least one maternal or fetal/neonatal complication i.e., hemorrhage, preeclampsia, eclampsia, obstructed labor, low birth weight, stillbirth, prematurity, congenital malformation, puerperal sepsis, preterm delivery, and maternal death [ 3 ]. A study from Cameroon presumed adverse pregnancy outcome when mothers experienced at least one type of caesarean section, preterm, low birth weight and neonatal mortality [ 56 ]. The finding of the current study revealed that the overall composite women’s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. This findings replicate the previous studies findings by Taqwim [ 57 ] and Merrell & Blackstone [ 58 ] ,and Muluneh [ 40 ]. A possible explanations for this finding may be the dilution of effects, whereby combining multiple empowerment domains into a single composite index can obscure or mask the influence of specific empowerment domains on adverse pregnancy outcomes [ 59 ]. Further, contextual variations and measurement issues may also reflect differences, as composite indices often rely on broad survey indicators that may fail to capture nuanced, context-specific realities of women’s empowerment at the local level. [ 60 ]. Each domain of women’s empowerment may also have a distinct influence on adverse pregnancy outcomes, further suggesting that aggregating multiple domains into a single index can obscure important domain-specific effects [ 48 , 57 ]. Thus, our findings indicate that specific domains of women’s empowerment—particularly attitudes toward wife beating, participation in social networking groups or unions, and household asset ownership—were significantly associated with adverse pregnancy outcomes among the study participants. Lower empowerment of attitude towards wife beating by husband (women who accept wife beating) had higher risk of adverse pregnancy outcomes compared to those who disapprove wife beating. From the previous literatures, rejecting all justifications for wife beating was widely used as an empowerment indicator and proxy for women’s perceived status, rights, and autonomy [ 61 , 62 ]. This suggests that women who do not accept violence as normative may be more empowered in asserting their reproductive choices, controlling their fertility trajectories and improve positive pregnancy experiences. Although very few studies measure birth outcomes directly, there is consistent evidence that women’s empowerment in attitude towards wife beating by husband or disapproval of wife beating are linked to better reproductive health and care use, which are established pathways to reduced adverse pregnancy outcomes [ 57 ]. The possible reason for this relationship might be that if a women views wife beating as unjustifiable this may reflect higher self-esteem, awareness of rights, and decision-making power which might be associated with better reproductive, maternal and child health services and greater ability to seek contraception use, antenatal care by skilled health care provider, delivery and postnatal care by skilled health care provider, and the continuum of maternal health services which are the key precursors to reduce adverse pregnancy outcomes [ 63 , 64 ]. In the present study, women who had a medium empowerment score for social networking had a reduced risk of adverse pregnancy outcome relative to women who did not engage in social networking. Large trials conducted in South Asia and Africa support these findings, demonstrating that women who participated in social networking groups experienced a 23–33% reduction in fetal and neonatal complications and a 37–55% reduction in maternal complications [ 65 , 66 ]. Furthermore, a recent evaluation of federations of women’s groups in poor areas of India found that women exposed to meetings and health days had higher odds of timely first ANC initiation and ≥ 4 ANC visits, adequate dietary diversity and better water sanitation and hygiene access. These behaviors are known to lower risks of preterm birth, low birth weight and infection [ 67 ]. A study conducted in Ethiopia reported similar findings, demonstrating that stronger women’s participation in the Women’s Health Development Army was consistently associated with increased utilization of antenatal care, higher rates of facility-based delivery, child immunization, and lower maternal and perinatal complications, collectively indicating a reduced risk of severe adverse pregnancy outcomes [ 68 , 69 ]. Therefore, active membership in existing women’s groups or social networks—particularly participatory health-oriented groups such as the Women’s Development Army, women’s leadership, and savings groups—likely enhances social support, information sharing, collective efficacy, and timely health-seeking behaviors [ 69 ]. Thus, we believe that these mechanisms improve utilization of essential maternal health services, including antenatal care, facility-based delivery, and postnatal follow-up, which are strongly associated with reduced adverse maternal and neonatal outcomes and more positive pregnancy experiences. The household asset domain of women’s empowerment showed that women from households with high empowerment in asset ownership had a 48% lower risk of adverse pregnancy outcomes compared with their counterparts. Consistent with our findings, evidence from diverse settings indicates that women’s empowerment in asset ownership is associated with improved maternal nutrition, greater utilization of antenatal care services, reduced barriers to healthcare access, and a lower risk of adverse pregnancy outcomes [ 70 – 72 ]. Evidence from Cameroon similarly demonstrates that household asset endowments influence child health outcomes, highlighting a pathway through which asset-based empowerment enhances maternal health-seeking behavior and resource allocation for maternal and child health services, thereby reducing adverse pregnancy outcomes for both mothers and infants [ 73 ]. This association may be explained by the fact that women from households owning assets such as land or housing are more likely to be economically empowered/less financial constrained, have greater control over resources, decision making power, and possess increased autonomy to access services and exercise their life choices. A multicounty study across 18 countries in South Asia, the Middle East, and sub-Saharan Africa supports this justification, reporting that women who own assets are approximately 14% more likely to be empowered in decisions related to their own health, major household purchases, and social interactions compared with women who do not own assets [ 74 ]. Several health systems–related factors, including timely initiation of antenatal care, use of iron and folic acid supplementation during pregnancy, and adequate birth preparedness and complication readiness (BPCR), were significantly associated with a reduced risk of adverse pregnancy outcomes. In contrast, structural poverty—reflected by enrollment in the Productive Safety Net Program remained associated with a higher risk of adverse pregnancy outcomes, suggesting that social protection programs need to be strengthened and better integrated with existing maternal and child health interventions. Overall, the findings suggest that improving positive pregnancy outcomes /maternal and neonatal outcomes requires not only strengthening health service delivery (supply and demand) but also addressing structural and social determinants of health such as women’s empowerment. Strength and limitations This is the first study to utilize the Women’s Empowerment Multidimensional Index as to examine factors associated with adverse pregnancy outcomes or positive pregnancy experiences. Another strength of this study is it’s an application of modified Poisson regression to provide robust estimates of association for outcomes with women’s empowerment. Data were collected using a digital platform (Kobo Toolbox) with close supervision by trained field and database staff, minimizing missing data and enhancing data quality. Despite these strengths, several limitations should be acknowledged. The study sample may have limited representativeness, as unmarried women were not included, which restricts generalizability. In addition, some data, particularly socio-demographic and past obstetric history, were self-reported, raising the possibility of social desirability and recall bias, potentially underestimating the true prevalence of these experiences Conclusion and recommendation Despite substantial investments aimed at improving access to maternal and child health services, the magnitude of adverse pregnancy outcomes in the study area remained high at 19.0%. The findings indicate that several domains of women’s empowerment—particularly attitudes towards wife beating by husband, membership in social networks, and household asset ownership—were significant determinants of adverse pregnancy outcomes. Therefore, governments and policymakers should prioritize interventions that aligned with Sustainable Development Goal 5 (SDG 5)—to achieve gender equality and empower all women and girls by addressing social norms that condone wife beating, promoting women’s participation in social networks, and enhancing women’s ownership and control over household assets. Future research, including implementation-focused and qualitative studies, is warranted to further elucidate the pathways linking composite women’s empowerment domains with adverse pregnancy outcomes, particularly in high-burden settings such as Tigray. Abbreviations ANC Ante Natal Care APOs Adverse Pregnancy Outcomes EDHS Ethiopian Demographic Health Survey HEWs Health Extension workers SDGs Sustainable Development Goals SWPER Survey-based Women’s Empowerment Index WDA Women Developmental Army WHO World Health Organization. Declarations Ethical approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Board (IRB) at the College of Health Sciences, Mekelle University (reference number: MU-IRB 2632/2025 ). A support letter was obtained from the Tigray Health Bureau, and permissions were received from the selected districts and sub-districts. The objectives of the study, maintaining confidentiality, participants’ rights, potential risks, and the option to withdraw at any time were clearly explained to the participants. Thereafter, informed verbal consent was secured from the participating women. Finally, all collected data were anonymized, stored, and analyzed confidentially to ensure the participants’ privacy. Consent for publication : Not applicable Competing interests : The authors declare that they have no conflict of interest. Funding: No relevant funding was given for this research. Author Contribution GGA: Conceptualization, propagating tools, methodology, investigation, writing draft, writing review, editing, analysis, and administration of the project. AB, AAM, MG: Conceptualization of the research, methodology, supervision, writing-review and editing. TGG: conceptualization, methodology, mentorship and supervision, writing-review and editing. MAG: methodology, supervision, writing-review and editing. Finally, all the authors have read and approved the final manuscript. Acknowledgement We would like to thank Aksum and Mekelle University University for their valuable support. We also express our sincere gratitude to Sigma Theta Tau International, Alpha Zeta Chapter, for their invaluable support in funding data collectors, supervisors, and the women who participated in this study We also want to express our profound gratitude to Dr. GebreAb Barnabas who provided unrelenting guidance at all stages of the project, editing and incentivizing a deeper scrutiny of ourselves and our research experiences. We remain grateful to Mary Moran, and Dr. Feven Gebreegziabher for their financial and emotional support, without their assistance this work would not have been possible. Finally, we appreciate the help of Dr. Kebede Haile for his valuable contribution at all stages of the project. Data Availability All related data are presented fully within the paper, and available upon reasonable request to the lead author and the corresponding author. References Lawn JE, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? 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Journal of Demographic Economics; 2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Nursing","correspondingAuthor":false,"prefix":"","firstName":"Maureen","middleName":"","lastName":"George","suffix":""},{"id":592499474,"identity":"f4f216c6-3198-4359-b0c7-dc37b487cce6","order_by":5,"name":"Tesfay Gebregzeabher Gebrehiwet","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Tesfay","middleName":"Gebregzeabher","lastName":"Gebrehiwet","suffix":""}],"badges":[],"createdAt":"2026-02-16 20:09:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8895973/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8895973/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102904950,"identity":"4ebb1b5c-ee1e-4b22-b8c9-293dd76574e3","added_by":"auto","created_at":"2026-02-18 09:04:46","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":627840,"visible":true,"origin":"","legend":"\u003cp\u003eLocation of study districts in Tigray state, Ethiopia 2025\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8895973/v1/f67bb66813f9fb4f509288a8.jpeg"},{"id":102904949,"identity":"bcc04859-b18b-49d7-b732-b404498373dd","added_by":"auto","created_at":"2026-02-18 09:04:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35804,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of common maternal complications among the study participants in Tigray, Ethiopia (N = 107).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8895973/v1/2e1c19c0da53e9412ffec7ca.png"},{"id":103504286,"identity":"47ca49d1-10ea-41e1-9bf6-9cd2f1e83aa4","added_by":"auto","created_at":"2026-02-26 13:19:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2334573,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8895973/v1/44f502dc-9cd6-4323-8ce3-f548224d9bc4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Women’s Empowerment as a Social Determinant of Adverse Pregnancy Outcomes in the Tigray Region of Ethiopia: A Prospective Follow‑up Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy is usually a happy time for most women and their families although it can also be a period of concern and anxiety, for some women lose their babies during early or late pregnancy and delivery earlier than the expected date or face low birth weight [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The term \u0026ldquo;pregnancy outcomes\u0026rdquo; describes the result of a pregnancy and varies from pregnancy to pregnancy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Adverse pregnancy outcome is defined as any pregnancy outcome other than a normal live birth, including abortion, stillbirth, preterm birth, low birth weight, early neonatal death, congenital abnormalities, and maternal pregnancy-related complications [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, adverse pregnancy outcomes (APOs) remain a major public health concern, with low- and middle-income countries (LMICs) bearing a disproportionate burden, particularly in settings affected by armed conflict [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Global evidence indicates that armed conflict is associated with increased adverse pregnancy outcomes, resulting in poor maternal health and impaired fetal development, largely driven by damage to health infrastructure and reduced access to antenatal and general healthcare services [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite progress in reducing APOs such as maternal and perinatal mortality and morbidities in the last two decades, a World Health Organization\u0026rsquo;s (WHO) report in 2020 showed the burden of adverse pregnancy outcomes was increasing [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previous studies have also reported a high burden of APOs such as preeclampsia, pregnancy-related hemorrhages, low birth weight, still birth and preterm delivery in LMICs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEfforts to reduce adverse pregnancy outcomes have appropriately focused on addressing immediate determinants, including preconception care, antenatal services, and intrapartum-related complications. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] However, social and structural factors, such as gender equality and women\u0026rsquo;s empowerment (immediate causes), have received little attention [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Globally, empowering women and decreasing maternal mortality are key indicators of sustainable development [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The targets and indicators of the Sustainable Development Goals (SDGs) illustrate that health equity (SDG 3) is not a stand-alone goal and underlie the synergies between health outcomes and gender equality (SDG 5), economic opportunities (SDG 8), and ensuring peaceful societies (SDG 16), among other[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, the targets to reduce adverse pregnancy outcomes and the goal to achieve gender equality and women\u0026rsquo;s empowerment provide further impetus to investigate the connections between these important agendas.\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s empowerment is defined as a \u0026ldquo;process of change by which those who have been denied the ability to make choices acquire such an ability\u0026rsquo;\u0026rsquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Women\u0026rsquo;s empowerment in their homes, communities, and societies at large have been shown, through direct and indirect pathways, to be associated with positive pregnancy experiences [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Women with low agency and resources may be limited in their ability to make choices regarding their own health and those of their children. Consequently, these circumstances can contribute to their own ill health and risk of mortality as well as that of their children[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpowered women who possess greater decision-making autonomy[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], social independence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and resistance to gender-based violence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] are more likely to seek higher-quality maternal health care services across the full continuum of care, from preconception through the postnatal period and improved positive pregnancy outcomes and reduced adverse pregnancy outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, women\u0026rsquo;s empowerment in developing countries improves use and quality of maternal health care, which in turn reduces complications, morbidity and mortality for mothers and babies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConversely, the absence of women\u0026rsquo;s empowerment in decision-making results in delays and poor utilization of maternal health services and ultimately increased adverse pregnancy outcomes such as maternal and neonatal mortalities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although the Ethiopian government has developed strategies and plans to improve the well-being of mothers and children, adverse pregnancy outcomes remain a major public health problem[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Evidence shows a high national pooled prevalence of adverse fetal outcomes (26.9%))[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] ,and adverse maternal outcomes (15.68%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnce one of the relatively best performing health systems in Ethiopia, the Tigray health system is on the verge of collapse due to the war that began on 4 November 2020 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The health system experienced severe disruption due to the armed conflict: Only 3.6% of all health facilities (n\u0026thinsp;=\u0026thinsp;1007), 13.5% of all hospitals and health centers (n\u0026thinsp;=\u0026thinsp;266), and none of the health stations (n\u0026thinsp;=\u0026thinsp;741) are currently operational [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Tigray\u0026rsquo;s primary care model relied on Health Extension Workers (HEWs) plus community structures like the Women\u0026rsquo;s Development Army (WDA) networks, which worked with HEWs to mobilize women, promote maternal and child health and link households to facilities. These are now completely inactive due to the conflict [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs a result, adverse pregnancy outcomes (APOs) increased substantially, with maternal mortality surging to 840 deaths per 100,000 live births from a pre-war level of 186 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] under-five mortality rate of 59 per 1000 live births, neonatal mortality rate of 28.2 deaths per 1,000 live births, and a neural tube defect rate of 29.51 per 1,000 live births [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] Similarly, during the war, the magnitude of maternal adverse pregnancy outcome such as severe preeclampsia significantly increased from 36.6 to 47.9%, obstructed labor from 2.0 to 4.4% ,and Intensive Care Unit (ICU ) admissions among mothers with potentially life-threatening complications from 3.5 to 6.1% [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the evidence that women empowerment is protective, a gap still exists in understanding how multidimensional, context specific women\u0026rsquo;s empowerment index affects the adverse pregnancy outcomes in Tigray. In addition, the majority of the existing studies in the region are cross- sectional in design and facility-based surveys using statistical approaches that may have limitations in identifying factors at different levels and robust estimates of the association between women\u0026rsquo;s empowerment and adverse pregnancy outcomes. Thus, this study overcomes these limitations by employing robust epidemiological evidence and a community-based prospective follow-up design incorporating multidimensional, context-specific indicators of women\u0026rsquo;s empowerment.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to investigate the magnitude of adverse pregnancy outcomes and examine the impact of women\u0026rsquo;s empowerment domains on adverse pregnancy outcome in Tigray. We intended to provide stronger empirical evidence on the role of women\u0026rsquo;s empowerment in improving positive pregnancy experiences in order to guide policymakers in designing more targeted, effective, and equitable health interventions that are in both SDG 3 (health) and SDG 5 (women\u0026rsquo;s empowerment and gender inequality) aligned with national and global sustainable development agendas.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy area\u003c/h2\u003e \u003cp\u003eThis study was conducted in the Tigray region, northern Ethiopia. Tigray is bordered by Eritrea to the north, Sudan to the west, Amhara to the south, and Afar to the east. The region comprises 93 districts (36 urban and 57 rural) organized into seven administrative zones (Mekelle, Eastern, Southern, South-Eastern, North-Western, Western, and Central). The study was implemented in nine selected districts, namely Hintalo, Enderta, Rural Adwa, Laelay Maychew, Naeder, Aksum town, Laelay Koraro, Tahtay Koraro, and Shire Endasilassie town excluding the Western zone and selected districts from the Northwestern and Central zones due to security concerns. The regional health system includes two specialized comprehensive hospitals, 14 general hospitals, 24 primary hospitals, 232 health centers, and 743 health posts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and period\u003c/h3\u003e\n\u003cp\u003eA community-based prospective follow-up study was conducted from August 2024 to May 2025.\u003c/p\u003e\n\u003ch3\u003eSource and study population\u003c/h3\u003e\n\u003cp\u003eAll pregnant women within the study areas during the time of the baseline survey were the source of population. Pregnant women enrolled at an early antenatal care visit (at or after 8 weeks of gestation) through a cluster sampling technique were included as study participants. The inclusion criteria comprised women who were permanent residents of the selected districts (living in the area for at least six months), had a confirmed pregnancy with a gestational age of 8 weeks or more, and registered as pregnant at either the health post or within the Women\u0026rsquo;s Development Army (WDA) structure.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling procedure\u003c/h3\u003e\n\u003cp\u003e This study was part of our larger project intended to investigate the effect of Women\u0026rsquo;s Empowerment in improving utilization of continuum of maternity care and positive pregnancy outcomes in Tigray region, Ethiopia. Accordingly, the sample size was estimated based on the specific objectives of the whole study using Epi-info stat Calc 7.2.5.0. The double population proportion formula was used with the assumption: the proportion of an outcome among exposed group was 34% (p1=.03), and among non-exposed group was 23.9% (p2\u0026thinsp;=\u0026thinsp;0.239) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]; pooled population proportion (p\u0026thinsp;=\u0026thinsp;0.193); r\u0026thinsp;=\u0026thinsp;1:2 ratio of exposure to non-exposure; 5% significant level at α level (two- sided); 80% power, design effect 1.8 and 10 non-response rate. The study included 1258 women from the 1477 women who were part of a fixed cohort from antenatal care to postnatal care. The cohort of pregnant women enrolled for the follow-up study were identified using a multistage cluster sampling technique. First, three zones from the accessible 6 zones were randomly selected and 9 districts were also randomly selected from the accessible districts. Second, using a simple random sampling method (lottery), 43 Tabiyas (sub-districts) were selected from a total of 113. Third, 86 \u0026lsquo;kushets/sub village\u0026rsquo; (the smallest administrative units) were randomly selected from each village. Finally, all households within the selected kushets (clusters) that had eligible pregnant women enrolled in the follow-up study were subsequently tracked for the interview and the selected women were interviewed to ascertain pregnancy outcomes for their most recent delivery during the study period.\u003c/p\u003e\n\u003ch3\u003eData collection tools, techniques, and quality assurance\u003c/h3\u003e\n\u003cp\u003eThe questionnaires were developed through a review of relevant literatures, including the validated Survey-based Women\u0026rsquo;s Empowerment Index (SWPER) Global 2017 tool. The Ethiopian Demographic and Health Survey (EDHS) and other context-specific tools from Ethiopia were adapted to ensure cultural appropriateness and maintain the validity of the instrument [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Data collectors and supervisors were trained for three days and five percent of the tools were pre-tested to ensure clarity, wording, logical sequence, and the relevance of the questionnaires. Furthermore, a smart mobile-based approach (KoboToolbox) was used to collect the data. The questionnaires were prepared in English, translated into Tigrigna (the local language), and then retranslated into English by people proficient in both languages to maintain consistency. During actual data collection, the principal investigator and supervisors frequently supervised and checked the work of data collectors, and provided clarification and directions to those in doubt.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of outcomes and other variables\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eOutcome variable\u003c/strong\u003e \u003cp\u003eAdverse pregnancy outcome was defined as the presence of at least one self-reported maternal or fetal/neonatal complication i.e., abortion, stillbirth, early neonatal death, congenital abnormality, hemorrhage, preeclampsia/eclampsia, obstructed labor/prolonged labor, anemia, linkage of urine and stool, puerperal sepsis, and maternal death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Although low birth weight and preterm birth are important perinatal outcomes, they were not included in the primary composite adverse pregnancy outcome due to their applicability only to live births and the substantial proportion of missing data, which could introduce differential misclassification or biases [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Excluding variables with large, potentially non‑random missingness like low birth weight, or gestational age can be preferable to including them and introducing bias.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAbortion: Termination of pregnancy before 28 weeks of gestation or at less than 1,000 gm weight of conception. When a fetus passes away before 28 weeks of pregnancy without any intervention, spontaneous abortion, where the fetus passes away before 28 weeks of pregnancy due to medical intervention, is medically indicated abortion [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStillbirth: If the infant died in the womb or during the intrapartum period after 28 weeks of gestation [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly neonatal: A death as death occurring within 7days of birth [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCongenital anomalies: Defined as any abnormality of physical structure found at birth or during the first few weeks of life; or any irreversible condition existing in a child before birth in which there is sufficient deviation in the usually number, size, shape, location of any part, organ, and cell to warrant its designation as abnormal [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMain exposure variables\u003c/h3\u003e\n\u003cp\u003eThis study examines women\u0026rsquo;s empowerment as the main independent variable using an index based on five dimensions: social independence, decision-making power, attitudes toward wife-beating by husbands, social networking, and asset ownership. Questionnaire items were adapted from the validated SWPER Global 2017 tool, the DHS, and relevant literature, with context-specific adjustments to meet the study objectives [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. To assess social independence eight questions were asked on women\u0026rsquo;s completion of education, regular access to information, age at first birth, age at first marriage and cohabitation, age and educational difference with husband [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].. Women\u0026rsquo;s decision-making power was also assessed using four questions about women\u0026rsquo;s involvement in decisions regarding their own healthcare, household purchases, husband\u0026rsquo;s earnings and visits to family or relatives [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. For the justification of wife-beating by husbands, respondents were asked five questions to determine whether they believed a man was justified in beating his wife under certain circumstances, such as burning food, arguing with her husband, going out without informing him, refusing sexual intercourse, and neglecting the children [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Social networking was assessed using four questions on women\u0026rsquo;s participation in health groups, leadership or political organizations, economic unions like saving and credit unions, and cultural or faith-based associations. Asset ownership was measured through four questions on ownership of land, housing, a mobile phone, and a bank account, either individually or jointly with a husband Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the domains, indicators, cut-offs, and weights of the women\u0026rsquo;s empowerment multidimensional index. The index consists of five equally weighted domains (0.2 each), with indicator weights shared equally within domains. Empowerment scores were computed using weighted means, then standardized using the global SWPER mean and standard deviation, where zero reflects the average empowerment level in low- and middle-income countries [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and other similar studies [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo standardize the score, the mean score was subtracted, and the results were divided by the respective standard deviation. Therefore, to examine the effect of each domain on adverse pregnancy outcomes at different levels of scores, women\u0026rsquo;s empowerment domains was divided into three groups: lower scores, medium scores and higher scores as per the previous literatures[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. To examine the overall/composite effect women\u0026rsquo;s Empowerment multidimensional Index on APOs, women\u0026rsquo;s Empowerment multidimensional Index was divided into three groups: low for scores below 0.50, average for scores between 0.50 and 0.75, and high for scores of 0.75 or higher. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCovariates: Sociodemographic variables (age, residency, marital status, education status, religion, and occupation, sex of household head, family structure, access to health facilities and community engagement).Obstetric variables (age at first marriage, contraceptive use, gravidity, previous bad obstetric history and domestic violence\u0026rsquo;s), and maternal health interventions received during the current pregnancy such as preconception care, antenatal care, postnatal care and key interventions like iron folic acid and tetanus toxoid vaccinations were included as a covariate variables during this study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDimensions, cut-offs and weights of women\u0026rsquo;s empowerment multidimensional Index, Tigray, and Ethiopia.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmpowered if a woman (cut-off)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003cp\u003e(indicator)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003cp\u003e(dimension)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eSocial independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u0026rsquo;s education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCompleted secondary or higher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency of reading newspapers/ magazines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRead once a week or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency of watching television/listening to the radio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWatch/listen once a week or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge of women at first birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIs of the age of 19 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge of women at first marriage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIs of the age of 18 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge of women at first cohabitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIs of the age of 18 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLess than five years younger than her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducational differences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehas equal or higher education than her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHousehold decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwns health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTakes decisions alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMajor household purchase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTakes decisions alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily /relatives visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTakes decisions alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHusband\u0026rsquo;s earnings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTakes decisions alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAttitude towards wife beating by husbands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife beating justified: goes out without telling her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes not agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife beating justified: neglects children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes not agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife beating justified: argues with him\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes not agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife beating justified: refuses to have sex with husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes not agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife beating justified: burns the food\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoes not agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSocial networking membership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMembership participation: in health-related group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMembership participation: in leadership and politically based organizations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMembership participation: in economically based unions, such as saving and credit unions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMembership participation: cultural /faith-based organizations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAsset ownership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwns land\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOwns alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwns house\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOwns alone/jointly with her husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwns mobile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwns bank account\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData Management and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eAfter data files were downloaded from the server of the online Open Data Collection Kit (KoboToolbox) tool and saved as an Excel file, it was exported to SPSS version 27 for cleaning and then exported to STATA version 17 for further analysis. The frequency with percentages and mean with standard deviation were used to describe categorical and continuous variables respectively. A generalized linear model with a modified Poisson regression with a log link was fitted to estimate the aRR and 95% CI in order to examine the association between women\u0026rsquo;s empowerment and adverse pregnancy outcomes. A sequential backward model selection approach was used with preliminary bivariate analysis to identify the effect of each independent variable on the outcome variable and to control for possible confounding effects. Variables having a p value of less than 0.05 were included in the final model. We used Akaike\u0026rsquo;s information criteria (AIC) and Bayesian information criteria (BIC) (lower is better) to choose the final model.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics\u003c/h2\u003e \u003cp\u003eA total of 1,477 women were enrolled in the study, with a 1258 (85.2%) response rate. The majority (68.2%) of women were aged 20\u0026ndash;34 years old, with a mean age of 30.04 (+\u0026thinsp;5.9 years). Those who attended primary education accounted for 42.37%. Forty-two percent (533) of the women reported that they have a primary level of education, 188 (14.9%) did not go to school and only 6.0% had secondary or tertiary or college and above. Most respondents were rural residents 1048 (83.3%) and most of the study participants, 1243(98.8%) were Orthodox Christians. Over three-fourths of the study respondents, 1004 (79.8%) belonged to the nuclear family structure. Women from house-holds with male heads were 1090 (86.6%). Furthermore, about 46.82% of the women have personal mobile phones, while only 5.8% of the women reporting having access to the internet (\u003cb\u003eTable-2\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of the study participants n\u0026thinsp;=\u0026thinsp;1258), Tigray, Ethiopia, August 2025 -May 2025\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency/%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of the mother\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58(4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e858(68.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e342(27.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWomen\u0026rsquo;s Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e188 (14.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (1\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e533 (42.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (9\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e462 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthodox Christian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1243(98.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15(1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWorking in the last 12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e182(14.47%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1048(83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e210(16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex of the Household head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e168(13.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1090 (86.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave personal mobile phone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e589(46.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMobile phones for financial transactions (n\u0026thinsp;=\u0026thinsp;589)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59(9.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver used the internet\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73(5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily structure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e257(20.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1004 (79.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e392(31.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (1\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e429(34.1% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary ( 9\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e347(27.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90(7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedia Exposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e410 (32.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel household\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWalking time to nearest health facility (health center)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;one hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e660 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;one hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e598(47.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWalking time to nearest health facility (hospital)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e436 (34.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e671 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvailability of public transport to the nearest health center/hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e830(66.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvailability of ambulance services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e451(35.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHouse enrolled in the Productive Safety Net Program (PNSP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92(7.31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeing Insured for Community-Based health Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e133(10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvailability of advocacy and sensitization on maternal health in the community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e343(27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eReproductive and Past Obstetric Characteristics\u003c/h2\u003e \u003cp\u003eSelf-reported past obstetric history was assessed as follows: 425 (33.78%) women were married at age 18 or younger, with a mean age of marriage 18.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2. Approximately one-third 413 (32.8%) had five or more pregnancies. A total of 481 (38.2%) women had one or two live children. A history of stillbirth was reported by 108 (8.6%) women, 200 (15.9%) had a history of abortion, and 62 (4.9%) experienced early neonatal death (\u003cb\u003eTable-3\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePast reproductive and obstetric characteristics of the study participants n\u0026thinsp;=\u0026thinsp;1258), Tigray, Ethiopia, August 2025 -May 2025\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency/%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at first marriage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years-old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e425(33.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;18 years-old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e833 (66.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver use modern contraceptive?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e910(72.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommon type of contraceptive ever use (n\u0026thinsp;=\u0026thinsp;910)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33(3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjectable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e359 (39.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e510(56.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrauterine contraceptive devise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8(0.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGravidity (Number of pregnancy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimigravida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150(11.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulti gravida(2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e695 (55.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand multigravida (\u0026ge;\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e413 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal number of alive Children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e232(18.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e481(38.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e380 (30.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e165(13.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of pregnancy loss(abortion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e200 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of still birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of early neonatal death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62(4.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of preterm birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy related problems ever had for previous pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e136(10.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomestic violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e285(22.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMaternal health service utilization received during the current pregnancy\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the utilization of preconception care, antenatal care (ANC), postnatal care (PNC), and selected maternal health interventions among the study participants. Only 92 (7.3%) of women reported receiving preconception care. At baseline, 1002 (79.7%) of participants were booked for antenatal care, while32.4% received postnatal or post-abortion care from a skilled health-care provider. The most received ANC interventions were iron\u0026ndash;folic acid supplementation 1181 (93.9%) and at least one dose of tetanus toxoid (TT) vaccine 1019 (81.0%). Approximately 735(60.6%) of women received ultrasound screening during the current pregnancy. Early initiation of ANC was low: only 211 (16.8%) of women initiated their first ANC visit during the first trimester. In addition, nearly two-thirds of participants 855 (68.0%) were not adequately prepared for birth and complication readiness (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal health received during the current pregnancy among the study participants n\u0026thinsp;=\u0026thinsp;1258), Tigray, Ethiopia, August 2025 -May 2025\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency/%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreconception care received before the current pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (7.31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas antenatal care initiated at the time of the baseline assessment?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,002 (79.65%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWomen and families reached the birth preparedness and complication readiness plan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot well prepared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e855 (67.97%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell prepared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e403 (32.03%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime of initiation of first ANC in weeks (n\u0026thinsp;=\u0026thinsp;1258)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot yes initiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin 12 weeks of pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u0026ndash;16 weeks of pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e717 (57.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;16 weeks of pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e284 (22.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound screening received during this pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e735 (60.64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFolic acid and iron intake during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1181 (93.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceive tetanus toxoid (TT) vaccine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1019 (81.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostnatal/post abortion care received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e408 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural factors that prevent her from attending MHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternity services received at home by health care providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193 ( 15.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth care providers link to health facility in home visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMagnitude of adverse pregnancy outcomes\u003c/h2\u003e \u003cp\u003eThe magnitude of adverse pregnancy outcomes (APOs) among the study participants was 19.00% (95% CI: 16.87\u0026ndash;21.28). Among the reported adverse outcomes, the most common were maternal complications 134 (10.7%), followed by abortion 69(5.5%), stillbirth 33(2.6%), and congenital anomalies 20 (1.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProportion of Adverse pregnancy outcomes in Tigray, Ethiopia, 2025 (n\u0026thinsp;=\u0026thinsp;1258)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory of adverse pregnancy outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(4.3\u0026ndash;6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStill birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(1.8\u0026ndash;3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly neonatal death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(0.4\u0026thinsp;\u0026minus;\u0026thinsp;0.1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerinatal mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(2.6\u0026ndash;4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth defect/ congenital anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(1.0-2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(9.0-12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall adverse pregnancy outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(16.9, 21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMaternal complications /adverse maternal outcomes\u003c/h2\u003e \u003cp\u003eThe overall magnitude of adverse maternal outcomes was 10.7% (95%CI: 9.0%\u0026ndash;12.49%) ((Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the most common adverse maternal outcome was a sign of severe headache/ visual problem (39.3%), followed by postpartum hemorrhage (33.7%). Among those who experienced an adverse maternal outcome, 24.3% a had severe abdominal pain and 22.4% antepartum hemorrhage\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe association between women\u0026rsquo;s empowerment and other factors associated with adverse pregnancy outcome\u003c/h2\u003e \u003cp\u003eIn the bivariate analysis, the overall composite women\u0026rsquo;s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. However, the domains of attitudes toward violence, social networking, and asset ownership were found to be statistically significant predictors of adverse pregnancy outcomes.\u003c/p\u003e \u003cp\u003eIn the multivariable analysis, several women\u0026rsquo;s empowerment domains and maternal health service\u0026ndash;related factors were significantly associated with adverse pregnancy outcomes. These included household asset ownership, social networking membership, attitudes towards wife beating by husband, antenatal care booking at baseline, receipt of iron\u0026ndash;folic acid supplementation, birth preparedness and complication readiness, and enrollment in the Productive Safety Net Program .Women\u0026rsquo;s empowerment domains of lower empowerment in attitude towards wife beating and women who accept wife beating by husbands had 42% (aRR\u0026thinsp;=\u0026thinsp;1.42; 95% CI: 1.105\u0026ndash;1.992) higher risk of adverse pregnancy outcomes than those who reject wife beating by husbands. Scores indicating medium empowerment in social networking reduced risk of adverse pregnancy outcome by 32% (aRR\u0026thinsp;=\u0026thinsp;0.68; 95% CI: 0.49\u0026ndash;0.96) relative to women who did not engaged in social networking. Regarding the empowerment domain of household asset, women from households with high asset ownership had a 48% (aRR\u0026thinsp;=\u0026thinsp;0.52; 95% CI: 0.29\u0026ndash;0.89) lower risk of adverse pregnancy outcome than their counter parts.\u003c/p\u003e \u003cp\u003eFurthermore, women who booked antenatal care at baseline had 38% (aRR\u0026thinsp;=\u0026thinsp;0.62; 95% CI: 0.47\u0026ndash;0.83) lower risk of adverse pregnancy outcome than those who did not initiate timely for antenatal care. Women enrolled in Productive Safety Net Program had 1.55 times (ARR\u0026thinsp;=\u0026thinsp;1.55; 95% CI: 1.02\u0026ndash;2.37) higher risk of adverse pregnancy outcome than those who did not enroll. Moreover, women who took supplements (folic acid and iron during pregnancy) had 46% (aRR\u0026thinsp;=\u0026thinsp;0.54; 95% CI: 0.37\u0026ndash;0.79) lower risk of adverse pregnancy outcome than those who did not take supplements. Women who planned for birth and complications had 51% (ARR\u0026thinsp;=\u0026thinsp;0.49; 95% CI: 0.35\u0026ndash;0.69) lower risk of adverse pregnancy outcome than the counterparts.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate and modified Poisson regression analysis examining the association between women\u0026rsquo;s empowerment and other factors associated with Adverse pregnancy outcomes in Tigray, Ethiopia (n\u0026thinsp;=\u0026thinsp;1258)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAdverse Pregnancy outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCrude\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAdjusted\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWomen\u0026rsquo;s empowerment domains\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude towards wife beating by husband domain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh empowerment (disagree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67(16.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e339(83.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180(84.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91(0.60\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.07(0.69\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elow empowerment (Agree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140(21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e500(78.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33(0.99\u0026ndash;1.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42(1.05\u0026ndash;1.92)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBeing member of social networking domain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e162(21.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e610(79.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(13.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e302(87.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62(0.44\u0026ndash;0.86)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68(0.49\u0026ndash;0.96)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(19.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107(77.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09(0.75\u0026ndash;1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.26(0.84\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold asset ownership domain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148(21.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e548(78.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76(17.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e352(82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84(0.63\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89(0.66\u0026ndash;1.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15(11.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119(88.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53(0.31\u0026ndash;0.89)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.52(0.29\u0026ndash;0.89)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver all women\u0026rsquo;s empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17(19.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e666(80.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20(16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100(83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.87(0.53\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48(17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e231(82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86(0.63\u0026ndash;1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBooked for ANC at a time of baseline survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54(21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e202(78.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e185(18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e817(81.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.64(0.49\u0026ndash;0.85)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62(0.47\u0026ndash;0.83)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance to nearby health facility ( Hospital)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68(15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e368(84.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e155(23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e516(76.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.48(1.11\u0026ndash;1.97)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.31(0.96\u0026ndash;1.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16(10.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e135(89.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68(0.39\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67(0.38\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular media exposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189(20.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e735(79.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50(15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e284(85.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73(0.54\u0026ndash;0.99)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96(0.67\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProductive Safety Net Program enrolment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e213(18.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e953(8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26(28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66(71.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.55(1.03\u0026ndash;2.32)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.55(1.02\u0026ndash;2.37)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFolic acid and iron intake during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45(58.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e207(17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e974(82.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42(0.29\u0026ndash;0.61)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.54(0.37\u0026ndash;0.79)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth preparedness and complication readiness plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot well prepared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e195(22.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e660(77.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell prepared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44(10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e359(89.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48(0.35\u0026ndash;0.66)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.49(0.35\u0026ndash;0.69)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main aim of this study was to examine the magnitude of pregnancy outcomes and explore the association between women\u0026rsquo;s empowerment and adverse pregnancy outcomes among the study participants in Tigray, Ethiopia. In this study the overall magnitude of adverse pregnancy outcomes was 19.0%. The most common adverse outcomes were maternal complications (10.7%), followed by abortion (5.5%), stillbirth (2.6%), and congenital anomalies (1.6%).\u003c/p\u003e \u003cp\u003eThese findings are higher than those reported in previous studies conducted in similar settings [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The relatively high magnitude observed in this study may be partly explained by the prolonged armed conflict in Tigray, which resulted in widespread destruction of health facilities, disruption of essential maternal health services, and reduced access to skilled care. These disruptions may have increased women\u0026rsquo;s vulnerability to preventable pregnancy complications. Another possible contributing factor is maternal undernutrition and food insecurity, which have been reported to be prevalent in the region following the conflict [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] Cultural practices such as prolonged fasting and dietary restrictions during pregnancy among Orthodox Christian women may further exacerbate nutritional deficiencies and increase the risk of adverse pregnancy outcomes [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In addition, the very low coverage of preconception care observed in this study may have limited opportunities for early risk identification and nutritional supplementation before pregnancy [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Comparatively, the magnitude of adverse pregnancy outcomes was less than the study conducted in Debre Berhan comprehensive specialized hospital, Northeast Ethiopia (28.3%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Limbe District, Cameroon (19%) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. This difference could be attributed to variation in the study populations, settings (community versus comprehensive specialized hospital), and criteria used for defining adverse pregnancy outcomes. For instance, the study in Northeast Ethiopia assumed adverse pregnancy outcome is the presence of at least one maternal or fetal/neonatal complication i.e., hemorrhage, preeclampsia, eclampsia, obstructed labor, low birth weight, stillbirth, prematurity, congenital malformation, puerperal sepsis, preterm delivery, and maternal death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A study from Cameroon presumed adverse pregnancy outcome when mothers experienced at least one type of caesarean section, preterm, low birth weight and neonatal mortality [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe finding of the current study revealed that the overall composite women\u0026rsquo;s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. This findings replicate the previous studies findings by Taqwim [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] and Merrell \u0026amp; Blackstone [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] ,and Muluneh [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A possible explanations for this finding may be the dilution of effects, whereby combining multiple empowerment domains into a single composite index can obscure or mask the influence of specific empowerment domains on adverse pregnancy outcomes [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Further, contextual variations and measurement issues may also reflect differences, as composite indices often rely on broad survey indicators that may fail to capture nuanced, context-specific realities of women\u0026rsquo;s empowerment at the local level. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Each domain of women\u0026rsquo;s empowerment may also have a distinct influence on adverse pregnancy outcomes, further suggesting that aggregating multiple domains into a single index can obscure important domain-specific effects [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Thus, our findings indicate that specific domains of women\u0026rsquo;s empowerment\u0026mdash;particularly attitudes toward wife beating, participation in social networking groups or unions, and household asset ownership\u0026mdash;were significantly associated with adverse pregnancy outcomes among the study participants.\u003c/p\u003e \u003cp\u003eLower empowerment of attitude towards wife beating by husband (women who accept wife beating) had higher risk of adverse pregnancy outcomes compared to those who disapprove wife beating. From the previous literatures, rejecting all justifications for wife beating was widely used as an empowerment indicator and proxy for women\u0026rsquo;s perceived status, rights, and autonomy [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This suggests that women who do not accept violence as normative may be more empowered in asserting their reproductive choices, controlling their fertility trajectories and improve positive pregnancy experiences. Although very few studies measure birth outcomes directly, there is consistent evidence that women\u0026rsquo;s empowerment in attitude towards wife beating by husband or disapproval of wife beating are linked to better reproductive health and care use, which are established pathways to reduced adverse pregnancy outcomes [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. The possible reason for this relationship might be that if a women views wife beating as unjustifiable this may reflect higher self-esteem, awareness of rights, and decision-making power which might be associated with better reproductive, maternal and child health services and greater ability to seek contraception use, antenatal care by skilled health care provider, delivery and postnatal care by skilled health care provider, and the continuum of maternal health services which are the key precursors to reduce adverse pregnancy outcomes [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, women who had a medium empowerment score for social networking had a reduced risk of adverse pregnancy outcome relative to women who did not engage in social networking. Large trials conducted in South Asia and Africa support these findings, demonstrating that women who participated in social networking groups experienced a 23\u0026ndash;33% reduction in fetal and neonatal complications and a 37\u0026ndash;55% reduction in maternal complications [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Furthermore, a recent evaluation of federations of women\u0026rsquo;s groups in poor areas of India found that women exposed to meetings and health days had higher odds of timely first ANC initiation and \u0026ge;\u0026thinsp;4 ANC visits, adequate dietary diversity and better water sanitation and hygiene access. These behaviors are known to lower risks of preterm birth, low birth weight and infection [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. A study conducted in Ethiopia reported similar findings, demonstrating that stronger women\u0026rsquo;s participation in the Women\u0026rsquo;s Health Development Army was consistently associated with increased utilization of antenatal care, higher rates of facility-based delivery, child immunization, and lower maternal and perinatal complications, collectively indicating a reduced risk of severe adverse pregnancy outcomes [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Therefore, active membership in existing women\u0026rsquo;s groups or social networks\u0026mdash;particularly participatory health-oriented groups such as the Women\u0026rsquo;s Development Army, women\u0026rsquo;s leadership, and savings groups\u0026mdash;likely enhances social support, information sharing, collective efficacy, and timely health-seeking behaviors [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Thus, we believe that these mechanisms improve utilization of essential maternal health services, including antenatal care, facility-based delivery, and postnatal follow-up, which are strongly associated with reduced adverse maternal and neonatal outcomes and more positive pregnancy experiences.\u003c/p\u003e \u003cp\u003eThe household asset domain of women\u0026rsquo;s empowerment showed that women from households with high empowerment in asset ownership had a 48% lower risk of adverse pregnancy outcomes compared with their counterparts. Consistent with our findings, evidence from diverse settings indicates that women\u0026rsquo;s empowerment in asset ownership is associated with improved maternal nutrition, greater utilization of antenatal care services, reduced barriers to healthcare access, and a lower risk of adverse pregnancy outcomes [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Evidence from Cameroon similarly demonstrates that household asset endowments influence child health outcomes, highlighting a pathway through which asset-based empowerment enhances maternal health-seeking behavior and resource allocation for maternal and child health services, thereby reducing adverse pregnancy outcomes for both mothers and infants [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. This association may be explained by the fact that women from households owning assets such as land or housing are more likely to be economically empowered/less financial constrained, have greater control over resources, decision making power, and possess increased autonomy to access services and exercise their life choices. A multicounty study across 18 countries in South Asia, the Middle East, and sub-Saharan Africa supports this justification, reporting that women who own assets are approximately 14% more likely to be empowered in decisions related to their own health, major household purchases, and social interactions compared with women who do not own assets [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral health systems\u0026ndash;related factors, including timely initiation of antenatal care, use of iron and folic acid supplementation during pregnancy, and adequate birth preparedness and complication readiness (BPCR), were significantly associated with a reduced risk of adverse pregnancy outcomes. In contrast, structural poverty\u0026mdash;reflected by enrollment in the Productive Safety Net Program remained associated with a higher risk of adverse pregnancy outcomes, suggesting that social protection programs need to be strengthened and better integrated with existing maternal and child health interventions. Overall, the findings suggest that improving positive pregnancy outcomes /maternal and neonatal outcomes requires not only strengthening health service delivery (supply and demand) but also addressing structural and social determinants of health such as women\u0026rsquo;s empowerment.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eThis is the first study to utilize the Women\u0026rsquo;s Empowerment Multidimensional Index as to examine factors associated with adverse pregnancy outcomes or positive pregnancy experiences. Another strength of this study is it\u0026rsquo;s an application of modified Poisson regression to provide robust estimates of association for outcomes with women\u0026rsquo;s empowerment. Data were collected using a digital platform (Kobo Toolbox) with close supervision by trained field and database staff, minimizing missing data and enhancing data quality. Despite these strengths, several limitations should be acknowledged. The study sample may have limited representativeness, as unmarried women were not included, which restricts generalizability. In addition, some data, particularly socio-demographic and past obstetric history, were self-reported, raising the possibility of social desirability and recall bias, potentially underestimating the true prevalence of these experiences\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eConclusion and recommendation\u003c/h2\u003e \u003cp\u003eDespite substantial investments aimed at improving access to maternal and child health services, the magnitude of adverse pregnancy outcomes in the study area remained high at 19.0%.\u003c/p\u003e \u003cp\u003eThe findings indicate that several domains of women\u0026rsquo;s empowerment\u0026mdash;particularly attitudes towards wife beating by husband, membership in social networks, and household asset ownership\u0026mdash;were significant determinants of adverse pregnancy outcomes. Therefore, governments and policymakers should prioritize interventions that aligned with Sustainable Development Goal 5 (SDG 5)\u0026mdash;to achieve gender equality and empower all women and girls by addressing social norms that condone wife beating, promoting women\u0026rsquo;s participation in social networks, and enhancing women\u0026rsquo;s ownership and control over household assets. Future research, including implementation-focused and qualitative studies, is warranted to further elucidate the pathways linking composite women\u0026rsquo;s empowerment domains with adverse pregnancy outcomes, particularly in high-burden settings such as Tigray.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnte Natal Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdverse Pregnancy Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthiopian Demographic Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHEWs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Extension workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDGs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSWPER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSurvey-based Women\u0026rsquo;s Empowerment Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWomen Developmental Army\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval for this study was obtained from the Institutional Review Board (IRB) at the College of Health Sciences, Mekelle University (reference number: \u003cb\u003eMU-IRB 2632/2025\u003c/b\u003e). A support letter was obtained from the Tigray Health Bureau, and permissions were received from the selected districts and sub-districts. The objectives of the study, maintaining confidentiality, participants\u0026rsquo; rights, potential risks, and the option to withdraw at any time were clearly explained to the participants. Thereafter, informed verbal consent was secured from the participating women. Finally, all collected data were anonymized, stored, and analyzed confidentially to ensure the participants\u0026rsquo; privacy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent for publication\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cb\u003eCompeting interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo relevant funding was given for this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGGA: Conceptualization, propagating tools, methodology, investigation, writing draft, writing review, editing, analysis, and administration of the project. AB, AAM, MG: Conceptualization of the research, methodology, supervision, writing-review and editing. TGG: conceptualization, methodology, mentorship and supervision, writing-review and editing. MAG: methodology, supervision, writing-review and editing. Finally, all the authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank Aksum and Mekelle University University for their valuable support. We also express our sincere gratitude to Sigma Theta Tau International, Alpha Zeta Chapter, for their invaluable support in funding data collectors, supervisors, and the women who participated in this study We also want to express our profound gratitude to Dr. GebreAb Barnabas who provided unrelenting guidance at all stages of the project, editing and incentivizing a deeper scrutiny of ourselves and our research experiences. We remain grateful to Mary Moran, and Dr. Feven Gebreegziabher for their financial and emotional support, without their assistance this work would not have been possible. Finally, we appreciate the help of Dr. Kebede Haile for his valuable contribution at all stages of the project.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll related data are presented fully within the paper, and available upon reasonable request to the lead author and the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLawn JE, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009;107(Suppl 1):S5\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBessing B, Koray M, Baatiema L. \u003cem\u003eWomen's Empowerment and Quality Antenatal Care in Ghana: Analysis of the SWPER Global Index in the Ghana Demographic Health Survey.\u003c/em\u003e 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadese M, et al. 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PLoS ONE. 2023;18(2):e0281369.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMpolokeng L, Musekiwa A. \u003cem\u003ePrevalence and factors associated with adverse pregnancy outcomes in South Africa: Evidence from the 2016 Demographic and Health Survey.\u003c/em\u003e SAMJ: South African Medical Journal, 2024. 114(6B): pp. 14\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAyele E, et al. Prevalence of Undernutrition and Associated Factors among Pregnant Women in a Public General Hospital, Tigray, Northern Ethiopia: A Cross-Sectional Study Design. J Nutr Metabolism. 2020;2020(1):2736536.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesalegn BB, et al. Ethiopian orthodox fasting and lactating mothers: longitudinal study on dietary pattern and nutritional status in rural Tigray, Ethiopia. Int J Environ Res Public Health. 2018;15(8):1767.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebretsadik GG, et al. 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BMC Public Health, 2024. 24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnweh NV, Baye FM. The responsiveness of household asset endowment to child health outcomes in Cameroon: the role of women empowerment. Journal of Social and Economic Development; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmir-Ud-Din R, Naz L, Ali H. Relationship between asset ownership and women's empowerment: Evidence from DHS data from 18 developing countries \u0026ndash; CORRIGENDUM. Journal of Demographic Economics; 2023.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Women’s Empowerment, Tigray, Adverse pregnancy outcome, decision-making","lastPublishedDoi":"10.21203/rs.3.rs-8895973/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8895973/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eWomen\u0026rsquo;s empowerment and the promotion of positive pregnancy experiences are global public health priorities and key sustainable development goals. However, little is known about the relationship between women\u0026rsquo;s empowerment and adverse pregnancy outcomes in a conflict prone setting like Ethiopia. Therefore, we aimed to assess women\u0026rsquo;s empowerment as a social determinant of adverse pregnancy outcomes in the Tigray region of Ethiopia including estimating the magnitude of adverse pregnancy outcomes and examining its association with women\u0026rsquo;s empowerment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA community based prospective study design was employed from August 2024 and May 2025. A multistage clustered sampling technique was used to select and study 1258 pregnant women. The relationship between the domains of women\u0026rsquo;s empowerment and adverse pregnancy outcomes was modeled using a multivariable modified Poisson regression method. Adjusted Relative Risks (aRR) with a 95% confidence interval (CI) and \u003cem\u003ep\u003c/em\u003e-value are reported.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe findings showed that the magnitude of adverse pregnancy outcomes was 19.0% (95% CI: 16.9%\u0026ndash;23.3%), with maternal complication (10.7%), abortion (5.5%), still birth (2.6%), and congenital anomalies (1.6%) being the main adverse pregnancy outcomes. The overall composite women\u0026rsquo;s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. However, specific women\u0026rsquo;s empowerment domains such as being a member of social networking (aRR\u0026thinsp;=\u0026thinsp;0.68; 95% CI, 0.49-.96) and household asset ownership (aRR\u0026thinsp;=\u0026thinsp;0.52 95% CI, 0.29-.89) reduced the risk of adverse maternal outcomes. In contrast, women who accept wife beating by husband (aRR\u0026thinsp;=\u0026thinsp;1.42;95% CI, 1.12\u0026ndash;1.99), were more likely to experience adverse pregnancy outcomes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOne in five women reported adverse pregnancy outcomes during the study period. Our study provides evidence that supports women\u0026rsquo;s empowerment, as a modifiable social determinant, reduces the risk of adverse pregnancy outcomes. We recommend that efforts aligned with Sustainable Development Goal 5 (SDG 5), including achieving gender equality, strengthening women\u0026rsquo;s participation in social networking groups, such as leadership and political engagement, wealth accumulation through income generation and savings, and promoting asset ownership, may help reduce the burden of adverse pregnancy outcomes in the study area.\u003c/p\u003e","manuscriptTitle":"Women’s Empowerment as a Social Determinant of Adverse Pregnancy Outcomes in the Tigray Region of Ethiopia: A Prospective Follow‑up Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 09:04:41","doi":"10.21203/rs.3.rs-8895973/v1","editorialEvents":[{"type":"communityComments","content":0}],"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":"c309598a-b67b-4989-a7d8-da2396a2d171","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T12:39:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 09:04:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8895973","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8895973","identity":"rs-8895973","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}