Identifying the association of women’s empowerment with reproductive and maternal health practices using a cross-sectional study in the context of self-help groups in rural India

Introduction

The United Nation’s Sustainable Development Goals identify gender equality as a key development indicator achieved if men and women enjoy equal rights, opportunities, and freedoms (European Institute for Gender Equality. Concepts and definitions. Vilnius, Lithuania: European Institute for Gender Equality; 2019). However, women continue to be disproportionately disempowered in terms of freedoms, power dynamics, and autonomy¹. A growing body of literature acknowledges the nuances and complexities in measuring women’s empowerment as a key measure of gender equality². Dimensions of equality vary in significance according to local contexts, which evolve at their own pace³. Research strongly indicates the need to bridge gaps between theoretical constructs and empirical research to better understand the association of women’s empowerment with health and other development outcomes^3,4. This paper identifies key domains of women’s empowerment and measures their associations with reproductive and maternal health practices in a rural Indian context and thereby contributes to bridging those gaps.

Recent literature synthesizes existing evidence on the various measures of women’s empowerment^3–7. Mandal et al., acknowledge that women’s empowerment can be measured at household, service delivery, and community levels⁷. Huis et al., categorize women’s empowerment within three dimensions: micro, referring to personal empowerment; meso, capturing relational empowerment; and macro, measuring empowerment within societies³. A review of empirical evidence reveals over nineteen domains that have measured women’s empowerment in sixty studies⁴, ranging from individual characteristics such as age, education, household wealth, and employment, to constructs such as decision-making, freedom of movement and mobility, financial autonomy, gender attitudes, and self-efficacy; the two most common constructs of women’s empowerment being women’s participation in household decision-making and their mobility. Different combinations of questions in each of these studies measured women’s empowerment.

Literature also documents the association of empowerment with the health and wellbeing of women and their children. An analysis of India’s 1998–1999 National Family Health Survey-2 shows that increased mobility and decision-making, opposition to spousal violence, and financial autonomy were associated with a higher number of antenatal care visits, utilization of postnatal care, and institutional deliveries; the results were further substantiated by more recent studies in Ethiopia and Nepal^8–11. Another study in Nepal shows that increased household decision-making is associated with improved postnatal care but not antenatal care¹². Studies have also established associations of various measures of women’s empowerment with family planning method use^13–17. Generally, women’s empowerment in these studies is linked to increased method use. Women are more likely to use family planning services if they enjoy increased mobility, greater financial autonomy, freedom from violence, better spousal communication, and increased decision-making autonomy for various aspects of their individual and familial lives^13,15–22. In addition to these studies, three recent extensive literature reviews examining the relationship between women’s empowerment, and maternal and child health practice show that increased household decision-making, lack of exposure to spousal violence, financial autonomy, and increased mobility are associated with correct healthy behaviors such as antenatal care, skilled attendance at birth, contraceptive use, and reduced maternal mortality^17,23,24.

Women’s empowerment and its impact on health practices has been captured by two measures at the aggregate/community level. First, some studies aggregate individual characteristics of women within communities, showing that communities with higher-than-average education or employment among women are more likely to exhibit healthy behaviors than communities with lower-than-average education or employment among women^10,25. Second, few other studies acknowledge the role of women’s microfinance collectives, called self-help groups (SHGs), in increasing women’s individual empowerment or improving health practices^26–32. SHGs organize 10 to 12 women within a community to attend regular meetings and save small amounts of funds every week; the funds are used for mutual lending. Groups also facilitate bank loans at small interest rates for family emergencies and entrepreneurial activities. SHGs also engender social cohesion among members, encouraging them to demand their rights and services while developing a support structure that women and their families can rely upon in times of need. SHGs are also considered a means through which various health-related interventions or activities can be integrated to improve the practice of healthy behaviors among member households^26,28,31,32.

Evidence on the effect of women’s collectives or SHGs in improving women’s authority and resources in their own lives or supporting their individual practice of healthy behaviors is limited, with variation among studies^27,29,30,33. A systematic review showing that SHG membership increased women’s individual empowerment for financial autonomy and mobility did not show consistent good health practices³⁰. A recent Ethiopian study examining the effect of SHGs on women’s health and wellbeing showed that SHGs helped increase women’s awareness of their rights, as a collective, but with no increased access to services or greater financial autonomy within their households²⁷. In other studies, interventions through SHGs increased antenatal care coverage and institutional delivery but without other health benefits or increased individual empowerment^26,34–36.

Aggregating the individual characteristics of women in communities and examining the characteristics of SHGs may need to be performed separately. Aggregated values of individual characteristics represent the general condition of women in that community, while the characteristics of women’s SHGs represent the support structures and social networks women create among themselves that they can utilize in times of need. There remains a great deal to learn about the interplay of women’s collective empowerment through SHGs and women’s individual empowerment within their own homes and personal lives, and particularly how these expressions of empowerment are affected by SHG membership, further associated with access to health services, and improved maternal and child health practices.

This paper examines the association of women’s empowerment with their reproductive and maternal health practices, in relation to women’s SHGs. Women’s empowerment is captured in two broad dimensions: 1) collective empowerment, measured as women’s empowerment within SHGs for access to services, exercising of rights, and mutual support in times of need, and 2) individual empowerment, measured through women’s personal experiences and perceptions of support within their households and relationships. It is critical to consider both collective and individual empowerment simultaneously, as they do not change in isolation but represent a general trend of increased awareness of one’s rights and entitlements through increased access and utilization of opportunities, such as health services. We hypothesize that these two domains of empowerment – collective and individual – are correlated, and that greater levels of women’s empowerment are associated with improved health practices. This paper also examines the relationship between collective and individual empowerment and their association, independently as well as jointly, on selected health practices.

Methods

Results

The mean age of respondents was 28 years (Table 3). About 40% of respondents had no formal education, more than half were from scheduled castes or tribes, and were from low wealth index households. Only 11% of respondents were employed. About three quarters of women had been exposed to at least one health related SHG activity during their last pregnancy or following the birth of their youngest child. Approximately one-third of interviewed women belonged to SHGs that were not functioning optimally, while 41% belonged to stronger groups that met regularly for group activities. Most SHG members (84%) stated that their group had been formed more than three years ago, while around half reported that their group had conducted less than six meetings in the prior three months, less than half the expected number. Nearly all members (97%) saved money weekly as part of the group’s activities. A quarter of group members (26%) had taken out a loan through the group, and another 37% belonged to a group that had recently repaid or was currently repaying a bank loan. The Chi-square test of association suggests that formal education, household asset ownership, and exposure to SHG activities are positively associated with antenatal care, delivery preparation, postnatal care, and use of a family planning method (Table 3). Overall, over a third (39.6%) of the population interviewed had at least four antenatal care visits during their last pregnancy, around three-quarters (72.6%) had performed at least one delivery preparedness, a third (31.3%) had at least one postnatal care visit within seven days of delivery and 41.3% of respondents were using a family planning method at the time of the survey.

The correlation matrix of sub-domains of collective and individual empowerment shows that over 80% of the correlations noted were significantly associated with one another (Table 4). Collective efficacy was positively correlated with other sub-domains of collective empowerment such as social cohesion, collective agency and action, as well as the sub-domains of individual empowerment such as self-confidence, decision-making, self-esteem, and financial inclusion. Similarly, self-esteem was positively associated with all reported sub-domains of collective and individual empowerment. Financial inclusion was, however, negatively associated with sub-domains such as mobility, decision-making, collective agency, and collective action, signifying that women with assets and access to funds are less likely to engage in collective action and have limited ability to exercise freedom of movement or make decisions on their own. Freedom from violence is positively associated with social cohesion, collective efficacy, self-confidence, self-esteem, and financial inclusion, indicative that women who do not experience spousal violence are more likely to have trust in their group to support them in times of need, or to work together for positive change. Those women were also more likely to perceive their own worth positively, and own assets and resources.

Results from Model A of the logistic regression show that more empowered women were associated with four or more antenatal care visits during their last pregnancy (β = 0.02, SE = 0.004), preparation for their last delivery (β = 0.03, SE = 0.005), and a postnatal care visit within a week of delivery (β = 0.01, SE = 0.004) (Table 5). Findings from Model B show that antenatal care and postnatal care visits were primarily influenced by individual empowerment, while delivery preparedness was driven by collective support from SHGs, as well as individual empowerment. In Model C, where relationships between the outcome variables and each sub-domain were tested individually, collective efficacy, women’s self-confidence, freedom of mobility, self-esteem, and financial inclusion had positive and significant associations with antenatal care. Women’s preparedness for delivery during their last pregnancy was significantly associated with nearly all the sub-domains of collective and individual empowerment, except for freedom of mobility and freedom from spousal violence. Postnatal care within a week of delivery was positively associated with social cohesion, self-confidence, and financial inclusion. Generally, combined domains of collective and individual empowerment did not appear to affect family planning method use, but when we observed the specific sub-domains of empowerment, family planning method use was positively associated with collective agency, self-confidence, and experience of less spousal violence within the past 12 months.

Discussion

This paper measures empowerment extensively to describe both collective and individual empowerment among women in SHGs. Collective empowerment encompasses cohesion, whereby a member believes she will be supported by her SHG in time of need; efficacy, when a member believes her group can work together for positive change, agency indicates a group has assisted its members in seeking services, and action denotes that a respondent has herself participated in activities for social change. An extensive array of questions also relate to women’s individual empowerment within six domains: self-confidence in engaging with people of authority and new situations, freedom of mobility in leaving home for various activities, autonomy in decision-making within the household and in matters of the family’s and a woman’s own wellbeing, self-esteem as a measure of a woman’s perception of her own worth, access to financial resources and making those decisions independently, and freedom from experiences of violence, specifically spousal violence. This study’s findings reveal strong correlation between collective and individual empowerment among women who belong to SHGs, suggesting that collective empowerment and individual empowerment occur simultaneously for women in self-help groups. This supports previous research that suggests SHGs increase women’s abilities to access financial resources and opportunities, which further manifest as greater autonomy and propensity for autonomous decisions⁵⁸.

Women who were individually more empowered were more likely to seek four or more antenatal care visits, signifying that a pregnant woman who is more empowered will be more likely to express greater self-confidence and leave her home to interact with a frontline health worker, in addition to having greater access to financial resources for utilizing those services. Other studies employing a few individual empowerment measures separately found similar results^{9,11,23,24,34–36,59,60}.

Delivery preparedness was associated with both collective empowerment and individual empowerment. Women are more likely to prepare for their infant’s delivery if they express higher levels of empowerment related to self-confidence, decision-making, self-esteem, and financial autonomy. Collective support from fellow SHG members is also reflected in a positive association of social cohesion, and collective efficacy, agency and action. SHG members are more likely to assist fellow members in delivery preparations, and those women exercise their abilities to plan, save money, and consult with others in determining next steps.

Postnatal care was associated with higher levels of overall combined empowerment, primarily driven by greater association with individual empowerment. A woman received postnatal care if she visited a frontline worker or health facility, or if a frontline worker visited her at home. Literature suggests that domains of individual empowerment such as increased self-confidence and financial autonomy are associated with a postnatal care visit^9,11,12,59, which is substantiated by our findings. Our findings show association of increased social cohesion with postnatal care; other studies have not acknowledged the role of collective empowerment.

In this study, family planning is not found to be associated with any aggregate empowerment scores – overall or combined, collective or individual – but increased collective agency was positively associated with family planning use, reflecting women’s confidence in the group’s support. Individual self-confidence was positively associated with family planning use, reflecting a woman’s ability to exercise choice and will within her home. Family planning often serves as a proxy for inter-personal relationships and communication between couples; hence, women reporting lower experiences of spousal violence tend to use family planning methods more. This is corroborated by the literature^14,61–63. Changing behavior around family planning use takes time, and further effort is needed – through SHGs – to meet women’s need for comprehensive services. Programs working to address reproductive and maternal health behaviors through SHGs have an opportunity to focus on family planning messages, encourage discussions of family planning practice, and strengthen links with the health system to improve women’s access to family planning services. Our findings are consistent with other studies that note positive associations of certain elements of individual empowerment, such as self-confidence and freedom from violence and family planning use^{13,15,16,18–21,23,24,32,60}. Only one other study that looks at the association of SHG membership with family planning method use shows positive results⁶⁴. These studies neither account for collective empowerment nor capture a wide array of individual empowerment elements, and as a result our study contributes to the global body of literature by studying the association of collective empowerment and individual empowerment with family planning method use.

Limitations – A key limitation of this study is that the associations of empowerment with health practices in relation to SHGs are from one point in time. This prevents us from looking at changes in empowerment over time, how these changes affect uptake of reproductive and maternal health behaviors among SHG members and determining the interplay of the sub-domains of collective empowerment and individual empowerment with one another. Further longitudinal studies with SHGs are needed to observe change in empowerment patterns affecting reproductive and maternal health practices over time. In addition, exploring questions of collective empowerment with other women in a group would reduce bias from endogeneity. Adequate time and effort are needed to collect comprehensive information from respondents, through local, well-trained investigators. Our study acknowledges this need by using well-trained and experienced investigators to interview respondents in private settings.

Conclusions

Through the deployment of an extensive tool capturing women’s empowerment both collectively and individually, we found that collective and individual empowerment are correlated when associated with women’s SHGs. Furthermore, both collective and individual empowerment are independently and jointly associated with better reproductive and maternal health practices such as antenatal care, delivery preparedness, postnatal care, and current family planning use. These results suggest that SHGs are a powerful mechanism for increasing women’s realization of their rights and opportunities, enabling them to access services and improve the quality of their lives. While this study demonstrates an association of empowerment with better reproductive and maternal health practices, these results should be interpreted with caution. While these findings are not generalizable to non-SHG populations, they may be applicable to similar sociocultural contexts and settings within India and globally. Future interventions should utilize SHGs to share messages about reproductive and maternal health practices and programs specifically encouraging women to exercise their individual and collective expression within their homes and communities to accelerate these healthy behaviors. Further research on the multi-dimensional domains of collective and individual empowerment presented in this paper is necessary for achieving the maximal effectiveness of SHGs. As women have opportunities to join SHGs and lead healthier lives, through information and support gained in SHGs, societies will be able to achieve gender equality at an accelerated pace and reap the benefits of a more equitable society.

Data availability

Consent

Written informed consent for publication of the participants’ details was obtained from the participants.