Individual- and community-level women's empowerment and complete use of maternal healthcare services: A multilevel analysis of 34 sub-Saharan African countries

Background: Current literature on women's empowerment (WE) and maternal healthcare use is limited to individual-level analysis, with a focus on single components of maternal healthcare services. As gender-related community contexts may importantly shape women's ability to seek healthcare services, we examined how both individual- and community-level WE are associated with complete use of maternal healthcare services in sub-Saharan Africa (SSA). Methods: We analyzed Demographic and Health Surveys conducted between 2011 and 2022 across 34 SSA countries (N = 194,740 women aged 15–49 years old). Complete care was defined as utilizing four or more antenatal care contacts, facility delivery, and any postnatal care. Based on a globally validated survey-based WE index (SWPER), a composite variable was constructed for individual- and community-level WE for each domain of attitude to violence, social independence, and decision-making: low-low (reference), low-high, high-low, and high-high. Multilevel linear probability models were used adjusting for key sociodemographic factors. Results: About one-third of women (35.4%) utilized complete care. Women with high empowerment at both individual- and community-levels demonstrated the highest probability of complete care (b = 0.058; 95% CI = 0.051,0.066 for attitude to violence; b = 0.116; 95% CI = 0.108,0.124 for social independence; b = 0.070; 95% CI = 0.063,0.078 for decision-making). Women with low empowerment but living in high empowerment communities (low-high) were more likely to utilize complete care than their counterparts (high-low group), which was particularly evident in the social independence domain. Conclusion: We found a strong contextual effect of WE on complete utilization of maternal healthcare services. Alongside efforts to enhance individual WE, interventions to advance gender equality at the community-level are crucial to facilitate timely access to maternal healthcare in SSA.