Women’s autonomy in health care decision-making in developing countries: a synthesis of the literature

Figures & data

Figure 1 Summary of search strategy.(/P)(P)Note: Based on the PRISMA statement template from Moher D et al.⁴⁷

Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1 Characteristics of reviewed articles

Author(s), year of publication	Setting	Study objective	Study design	Sample size	Data source
Acharya et al, 2010^Citation10	Nepal	Explored the links between women’s sociodemographic characteristics and their autonomy in decision-making about health care	Survey	n=8,257 ever-married women	Nepal Demographic Health Survey (NDHS) 2006
Allendorf, 2007^Citation26	Nepal	Compared women’s and their spouses’ reports of women’s autonomy and its association with health decisions and outcomes in Nepal	Survey	n=8,726 ever-married women	Data for this analysis come from the 2001 Nepal Demographic and Health Survey (NDHS)
Al Riyami et al, 2004^Citation11	Oman	Defined baseline data on ever-married women empowerment in Oman and the correlates of women’s empowerment on the unmet need for modern contraception	Survey	n=2,037 ever-married women	National Health Survey (NHS), 2000; a community-based survey by the Department of Research and Studies in the Omani Ministry of Health
Bloom et al, 2001^Citation6	North Indian city	Investigated the influence of women’s autonomy on use of care during pregnancy and child birth	Survey	n=330 women who had delivered a child within 3 years of the date of interview	Primary data
Dharmalingam and Morgan, 1996^Citation12	South India	Examined use of birth control among currently married women who reported that they want no more children	Survey	n=522 currently married women	Primary data
Fotso et al, 2009^Citation16	Kenya	Examined possible influences of the extent of women’s autonomy on their use of maternity services	Survey	n=1,927 women who had a pregnancy outcome	Data were from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya
Haque et al, 2012^Citation29	Bangladesh	Explored women’s decision-making autonomy as a potential indicator of the use of contraception	Survey	n=1,778 currently married women	National Survey (2007 Bangladesh Demographic Health Survey [BDHS])
Kamiya, 2011^Citation17	Tajikistan, Central Asia	Examined whether or not and how women’s autonomy within the household affects the use of reproductive health care	Survey	n=4,860 women aged 15–49 years	National survey (Tajikistan Living Standards Survey [TLSS] 2007)
Mistry et al, 2009^Citation15	Rural India	Assessed whether decision-making autonomy, permission to go out, and financial autonomy were associated with use of prenatal, delivery, and postnatal care	Survey	n=21,465 currently married rural women who had at least one singleton birth in the 3 years prior to the interview	National Survey (population-based 1998–1999 National Family Health Survey)
Nigatu et al, 2014^Citation18	Goba District, Ethiopia	Assessed the level of women’s autonomy and predictors of autonomy regarding their own and their under-five children’s health care utilization	Survey	n=759 women who had under-five child	Primary data collection
Rahman et al, 2014^Citation7	Bangladesh	Explored women’s decision-making autonomy as a potential indicator of the use of contraception	Survey	n=8,456 currently married and nonpregnant women	National data (2007 Bangladesh Demographic Health Survey [BDHS])
Rominski et al, 2014^Citation27	Ghana	Explored the role of female autonomy in reported abortion-seeking	Survey	4,916 women aged 15–49 years	2008 Ghana Demographic and Health Survey (DHS)
Senarath and Gunawardena, 2009^Citation25	South Asia Bangladesh, India, and Nepal	Investigated women’s autonomy in decision-making on their own health care, and the factors that are associated with the autonomy in three South Asian countries	Survey	Bangladesh (n=10,582), Nepal (n=8,728), and India (n=89,199)	Nepal Demographic and Health Survey (NDHS) 2001, Bangladesh DHS 2004, and National Family Health Survey India 1998–1999
Saleem and Bobak, 2005^Citation28	Pakistan	Investigated the relationship between women’s autonomy and contraceptive use and the extent to which women’s autonomy mediates the association between education and contraception use	Survey	n=6,579 ever married women	2000 Pakistan Reproductive Health and Family Planning Survey (PRHFPS)
Thapa and Niehof, 2013^Citation13	Four rural villages in Nepal	Assessed the relationship between women’s autonomy and husbands’ involvement in maternal health care	Survey, IDI and FGD	n=341 women who delivered a child a year prior to survey	Primary data collection
Wado, 2013^Citation14	Ethiopia	Examined the association between women’s autonomy and reproductive health care-seeking behavior of women in Ethiopia	Survey	n=14,070 women aged 15–49 years	2005 Ethiopian Demographic and Health Survey (EDHS)
Woldemicael and Tenkorang, 2009^48	Ethiopia	Examined the effect of women’s autonomy on their health-seeking behavior during pregnancy and delivery	Survey	n=5,560 currently married women	Data from the 2005 Ethiopian Demographic and Health Survey (EDHS)

Table 2 Definition and measures of women’s autonomy

Author(s), year of publication	How autonomy is defined	How autonomy is measured
Acharya et al, 2010^Citation10	The ability – technical, social, and psychological – to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates (Dyson and Moore^Citation3)	DHS measures of autonomy Autonomy was measured in four areas of women’s decision-making: 1) in women’s own health care, 2) making major household purchases, 3) making purchase for daily household needs, and 4) visits to family or friends. Each of these questions had six responses that were recoded and grouped into two
Allendorf, 2007^Citation26	Study specific Women’s opportunity to make choice that affect their lives	DHS measures of autonomy Women’s autonomy was measured in the area of decision-making through five questions: 1) whether the woman has the final say on her health care, 2) making large household purchases, 3) making purchases for daily needs, 4) paying visits to family, friends, and relatives, and 5) choosing the food to be cooked each day
Al Riyami et al, 2004^Citation11	Definition of autonomy by Dyson and Moore: ^Citation3“the ability – technical, social, and psychological – to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates”	NHS indicators of empowerment Two indicators of empowerment were developed from women’s status module to measure women’s involvement in decision-making and freedom of movement. Women were asked “who has final say on eight decisions including family planning, what to cook, household expenditure, children’s clothes, children’s medicine and health care, problem solving, having another baby and visiting relatives”
Bloom et al, 2001^Citation6	The study used the term autonomy or interpersonal control as defined by these authors (Basu^Citation4; Dyson and Moore^Citation3; Miles-Doan and Bisharat^Citation22; Mason^49; Safilios-Rothschild^Citation23): “the capacity to manipulate one’s personal environment through control over resources and information in order to make decisions about one’s own concerns or about close family members” and “the ability to determine events in their lives, even though men and other women may be opposed to their wishes”	Study specific Assessed in three different areas: control over finances, decision-making power, and extent of freedom of movement. A composite measure for each area was created using the sums of equally weighted binary input variables. Women were scored 1 for answers to each factor that contributed to a higher degree of autonomy; otherwise they were scored 0
Dharmalingam and Morgan, 1996^Citation12	The ability – technical, social, and psychological – to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates (Dyson and Moore^Citation3)	Study specific The study focused on three measures of autonomy: perceived economic independence, freedom to move within, and between villages and spousal interaction, ie, whether the spouse discusses family finances and desired family size
Fotso et al, 2009^Citation16	The ability to make and execute decisions regarding personal matters of importance on the basis of the woman’s power over others, access to information, control over material resources, and freedom from violence by her husband or other men (Caldwell and Caldwell^50; Dyson and Moore^Citation3; Jejeebhoy and Sathar^51)	Study specific A PCA method was used to generate measures of autonomy. The authors extracted the first component from responses to nine questions as a “decision-making autonomy” variable, responses to an additional six questions created a “freedom of movement autonomy” variable, and all questions were used to generate an “overall autonomy” variable. Each measure of autonomy was then recoded as tertiles with categories labeled low autonomy, middle autonomy, and high autonomy
Haque et al, 2012^Citation29	No specific definition of female autonomy	DHS measures of autonomy Autonomy variables were based on the review of the literature (Bloom et al^Citation6; Furuta and Salway^52; Woldemicael^53) and on the structure of the BDHS data on the final say on own health, child health care, and family planning with partner
Kamiya, 2011^Citation17	The ability of women to make decisions within the household relative to their husband (Anderson and Eswaran^Citation9)	Proxy measure of autonomy Women’s decision-making power within the household was used as a proxy indicator to measure female autonomy. Three binary variables were used including whether or not female members make a decision on “children’s well-being”, “buying major items”, and “borrowing money”
Mistry et al,2009^Citation15	Adopted the definition of Dyson and Moore^Citation3 and Basu^Citation4: “[…] the capacity to manipulate one’s environment through control over resources and information for personal interests”	Study specific Women’s autonomy was measured across three dimensions: decision-making autonomy, permission to go out, and financial autonomy. Decision-making autonomy was measured based on responses to “who makes decisions in respondent’s household about”: “obtaining health care for yourself, purchasing jewelry or other major household items”, and “going and staying with parents or siblings”
Nigatu et al, 2014^Citation18	The extent of independent decision-making, freedom from constraint on physical mobility, and the ability to forge equitable power relationships within families	Study specific Women’s autonomy was measured by the composite index of the three constructs of women’s autonomy: control over finance, decision-making power, and extent of freedom of movement
Rahman et al, 2014^Citation7	The capacity to manipulate one’s environment through control over resources and information for personal interests (Dyson and Moore^Citation3; Basu^Citation4)	DHS measures of autonomy Women’s household decision-making autonomy was measured based on responses to individual questions regarding who makes decisions in the (respondent’s) household about: 1) obtaining health care, 2) large household purchases, 3) household purchases for daily needs, 4) visits to family or relatives, and 5) child health care
Rominski et al, 2014^Citation27	No specific definition of autonomy	DHS measures of autonomy Measured by a novel five-point scale created from existing DHS items: women’s freedom of movement, discretion over earned income, decision-making related to economic matters, freedom from violence or intimidation by husbands, and decision-making related to health care
Saleem and Bobak, 2005^Citation28	No specific definition of autonomy	Study specific Decision autonomy was estimated from nine questions on decision-making (eg, children’s health care, education, buying/selling property, and what to cook). Women were considered as “participating” in a decision if they made the decision alone or jointly with their husband or someone else
Senarath and Gunawardena, 2009^Citation25	The proportion of women who make the decision either alone or jointly with husband or someone else	Study specific Two dimensions of women’s autonomy were measured: decision autonomy and movement autonomy. With respect to decision-making, women were asked who in their family usually has the final say on making decisions on her own health care
Thapa andNiehof, 2013^Citation13	Definition of autonomy by Dyson and Moore: ^Citation3“the ability – technical, social, and psychological – to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates”	Study specific Measured in four dimensions: economic autonomy, domestic decision-making, movement autonomy, and intraspousal communication
Wado, 2013^Citation14	Definition of autonomy by Dyson and Moore: ^Citation3“the ability – technical, social, and psychological – to obtain information and to use it as the basis for making decisions about one’s private concerns and those of one’s intimates”	EDHS measures of autonomy Women’s autonomy was measured by women’s participation in domestic decision-making, attitude toward wife beating, attitude toward refusing sex with husband, and whether seeking permission to get medical help is a big problem
Woldemicael and Tenkorang, 2009^48	The capacity and freedom of a woman to act independently on her own and on the authority of others; for example, the ability to go to places alone, such as visiting health facilities or the market without asking anyone’s permission, making decisions regarding contraceptive use or household purchases (Basu^Citation4), and the ability of women to make and execute independent decisions pertaining to personal matters of importance to their lives and their families (Mason^Citation5)	DHS measures of autonomy Measured with four behavioral indicators that measure the degree of a woman’s autonomy using questions from the EDHS on who has the final say in making large household purchases, making household purchases for daily needs, and obtaining own health care

Abbreviations: BDSHS, Bangladesh Demographic and Health Survey; EDHS, Ethiopian Demographic and Health Survey; DHS, Demographic and Health Survey; NHS, National health Survey; PCA, principal component analysis.

MoherDLiberatiATetzlaffJAltmanDGThe PRISMA GroupPreferred reporting items for systematic reviews and meta-analyses: the PRISMA statementPLoS Med200966e100009719621072

 PubMed Web of Science ®Google Scholar

AcharyaDRBellJSSimkhadaPvan TeijlingenERRegmiPRWomen’s autonomy in household decision-making: a demographic study in NepalReprod Health201071520630107

 PubMed Web of Science ®Google Scholar

AllendorfKCouples’ reports of women’s autonomy and health-care use in NepalStud Fam Plann2007381354617385381

 PubMed Web of Science ®Google Scholar

Al RiyamiAAfifiMMabryRMWomen’s autonomy, education and employment in Oman and their influence on contraceptive useReprod Health Matters2004122314415415242223

 PubMed Web of Science ®Google Scholar

BloomSSWypijDDas GuptaMDimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian cityDemography2001381677811227846

 PubMed Web of Science ®Google Scholar

DharmalingamAPhilip MorganSWomen’s work, autonomy, and birth control: evidence from two south Indian villagesPopul Stud1996502187201

 Google Scholar

FotsoJCEzehACEssendiHMaternal health in resource-poor urban settings: how does women’s autonomy influence the utilization of obstetric care services?Reprod Health20096919531235

 PubMedGoogle Scholar

HaqueSERahmanMMostofaMGZahanMSReproductive health care utilization among young mothers in Bangladesh: does autonomy matter?Womens Health Issues2012222e171e18021968029

 PubMed Web of Science ®Google Scholar

KamiyaYWomen’s autonomy and reproductive health care utilisation: empirical evidence from TajikistanHealth Policy20111022–330431321592608

 PubMed Web of Science ®Google Scholar

MistryRGalalOLuMWomen’s autonomy and pregnancy care in rural India: a contextual analysisSoc Sci Med200969692693319656604

 PubMed Web of Science ®Google Scholar

NigatuDGebremariamAAberaMSetegnTDeribeKFactors associated with women’s autonomy regarding maternal and child health care utilization in Bale Zone: a community based cross-sectional studyBMC Womens Health2014147924990689

 PubMed Web of Science ®Google Scholar

RahmanMMMostofaMGHoqueMAWomen’s household decision-making autonomy and contraceptive behavior among Bangladeshi womenSex Reprod Healthc20145191524472384

 PubMed Web of Science ®Google Scholar

RominskiSDGuptaMAborigoRFemale autonomy and reported abortion-seeking in Ghana, West AfricaInt J Gynaecol Obstet2014126321722224920181

 PubMed Web of Science ®Google Scholar

SenarathUGunawardenaNSWomen’s autonomy in decision making for health care in South AsiaAsia Pac J Public Health200921213714319190000

 PubMed Web of Science ®Google Scholar

SaleemSBobakMWomen’s autonomy, education and contraception use in Pakistan: a national studyReprod Health20052816242030

 PubMedGoogle Scholar

ThapaDKNiehofAWomen’s autonomy and husbands’ involvement in maternal health care in NepalSoc Sci Med20139311023906115

 PubMed Web of Science ®Google Scholar

WadoYWomen’s Autonomy and Reproductive Healthcare-seeking Behavior in EthiopiaCalverton, MDUnited States Agency for International Development [USAID]2013

 Google Scholar

DysonTMooreMOn kinship structure, female autonomy, and demographic behavior in IndiaPopul Dev Rev1983913560

 Web of Science ®Google Scholar

BasuAMCulture, the Status of Women, and Demographic Behaviour: Illustrated with the case of IndiaOxford, UKClarendon Press1992

 Google Scholar

Miles-DoanRBisharatLFemale autonomy and child nutritional status: the extended family residential unit in Amman, JordanSoc Sci Med19903177837892244220

 PubMed Web of Science ®Google Scholar

Safilios-RothschildCFemale power autonomy and demographic change in the Third WorldLondonCroom Helm1982117132

 Google Scholar

AndersonSEswaranMWhat determines female autonomy? Evidence from BangladeshJ Dev Econ2009902179191

 Web of Science ®Google Scholar

MasonKGender and Demographic Change: What do we KnowLiege, BelgiumInternational Union for the Scientific Study of Population1995331

 Google Scholar