In western Guatemala, the more involved a woman feels in making household decisions, the greater her likelihood of reporting that in preparing for a recent birth, she and her husband developed a plan for addressing problems during the pregnancy, delivery and postpartum period.¹ A woman's sense of involvement in decision making is not, however, associated with two other behaviors that can ensure maternal and infant health. By contrast, the more a man feels that his wife plays a role in household decision making, the less likely she is to have delivered in a health facility. These findings, along with other results from a 2003 household survey, provide insight both into women's decision-making power in this part of Latin America and into the importance of including men in studies of relationships between couple dynamics and preventive health behaviors.

The survey, undertaken to measure the impact of the national Maternal and Neonatal Health Program, was conducted in three departments of western Guatemala. Interviewers surveyed all women aged 15–49 in selected households who were pregnant or had given birth in the previous 12 months, as well as the husbands of female respondents in every other household. Survey questions for women and men were similar, and covered demographic and socioeconomic characteristics; household decision making; and knowledge about, attitudes toward and behavior regarding maternal health.

To measure women's decision-making power, analysts constructed scores based on responses to four questions: who in the household made the final decisions on the purchase of household items, on what to do if a child became ill, on whether to buy medicine for a sick family member and on what to do if a pregnant woman in the household became very ill. Possible responses were woman only, man only, couple, father-in-law, mother-in-law, father, mother and other. For each decision, the response was scored 1 if the woman was involved (solely or with her husband) and 0 otherwise; the sum of the scores represented an overall index of a woman's decision-making power. Using logistic regression, the analysts examined the associations between these scores and three behavioral outcomes, measured among couples in which the wife had given birth within the previous 12 months: whether they had planned for an emergency during pregnancy, delivery and the postpartum period; where the baby had been born; and whether the mother and child had seen a health professional within four weeks after the birth.

Data were available for 546 couples, who made up the analytic sample. On average, the women were 27 years old and had had three children. Thirty-five percent had had no schooling, 44% a primary education and 20% a secondary or higher level of schooling; 22% worked for pay, and 53% reported a Mayan mother tongue. About half said that their household owned a means of transport, and about half reported that the household owned at least two of four specified items (radio, television, refrigerator and telephone). Of the 391 women who had recently given birth, 38% said that they had had a plan for emergencies related to the pregnancy or birth, 27% had delivered at a health facility and 37% had seen a health professional within four weeks after delivering.

For each type of decision explored in the survey, one or both spouses in the majority of couples (59–65%) said that the wife was involved in the final decision. In roughly half of these cases (29–34% of couples overall), both members of the couple reported that they made the decision jointly. Sole decision making by the wife was rarely reported by either spouse, but for each situation, about one-third of couples agreed that the husband made the decision alone. Couples' level of agreement about who made final decisions was high (64–74%). In three of the four specified situations, the proportion of couples in which both spouses reported that the wife participated in decision making increased with the woman's level of education and was higher if both partners were educated than if only one had been to school; in all four instances, it was greater among couples in which the wife was employed than among those in which she did not work outside the home. On average, both women and their husbands said that women were involved in two of the four types of decisions.

In multivariate analyses, women's self- reported decision-making role was positively associated with the likelihood that a couple had had a plan for addressing an emergency during pregnancy, delivery and the postpartum period: For every point that a woman scored on the decision-making index, her odds of this outcome increased by 32%. The odds of having delivered in a health facility and of having received professional care soon after giving birth were not associated with the number of decisions the woman reported playing a role in. Men's reports suggest a very different relationship between women's decision-making role and preventive behavior. Each one-point increase in the score reflecting a man's perception of his wife's participation in household decisions was associated with a 12% decline in the odds that she had given birth in a health facility.

In discussing their findings, the researchers comment on the lack of association between women's decision-making scores and two of three preventive behaviors. Data limitations, they suggest, may be partly responsible. However, they also contend that inadequate knowledge of the importance of skilled health care, documented in an earlier study, may prevent women in western Guatemala from obtaining appropriate care.

In the analysts' view, their findings yield important lessons about the role of men in decision making and in couples' health behavior. They observe that because spouses do not always agree on the wife's role in decision making, "to understand couple dynamics regarding household decisions, men need to be interviewed." Nevertheless, they conclude, the finding that couples often agreed that the husband was the main decision maker "can help program planners working on maternal health to include men as targets for maternal health interventions."—D. Hollander

REFERENCE

1. Becker S, Fonseca-Becker F and Schench-Yglesias C, Husbands' and wives' reports of women's decision- making power in western Guatemala and their effects on preventive health behaviors, Social Science & Medicine, 2006, 62(9):2313–2326.