The Individual and Community Level Women Empowerment and Utilization of Maternity Care Services in Afghanistan: A Multilevel Cross-Validation Study

Abstract

Abstract Background: No study has ever reported on the impact that women's empowerment could have on the utilization of maternity care services in Afghanistan using a country-specific scale. This study aimed to explore the relationship between women empowerment and utilization of maternity care for married Afghan women aged 15-49 years in Afghanistan, assessing the convergence validity of the survey-based women empowerment index in Afghanistan (SWEI-A). Methods: We conducted a cross-sectional study using secondary data from Afghanistan demographic health survey 2015. The utilization of the maternity continuum of care was measured by three indices including antenatal care, institutional delivery, and postnatal care. Women empowerment was measured using the country-specific index; namely, SWEI-A across seven suggested domains. The association of different domains with the utilization of maternity care was estimated by multilevel Poisson regression at both individual and community levels. Results: In general, the results showed that the utilization of maternity services is considerably higher among women with high scores as compared to those with low scores in almost all domains of SWEI-A, except for property-owning in which women with high scores appeared to have lower rates of utilization of such service as compared to those with low scores. Although the rate of adequate ANC, institutional delivery, and PNC appeared to be higher in women with high scores as compared to those with low scores at the individual level; at the community level, the communities with high participation of women in the labor force were less likely to have adequate ANC, institutional delivery, and PNC. Likewise, for the literacy domain, individual-level literacy was associated with higher utilization of ANC, institutional delivery, and PNC contrary to community-level literacy. Conclusion: Except for property-owning, the high score in almost all other domains was associated with higher utilization of maternity care which indicates an acceptable level of convergence validity for the developed index (SWEI-A) in measuring women empowerment among married Afghan women aged 15-49 years. The index could inform future policies and interventions regarding women empowerment dimensions in the country and guide future studies to produce comparable results.