Increases in women’s autonomy and in men’s involvement in maternal health care—two social trends that may contribute to improved maternal health outcomes—do not necessarily occur in tandem, according to a recent study conducted in rural Nepal.¹ Instead, the researchers find that aspects of women’s autonomy bear both positive and negative relationships to a husband’s involvement in pregnancy care. For example, women’s autonomy in making economic and domestic decisions is negatively associated with the likelihood that they had discussed their health with their husband during pregnancy and that the husband had attended antenatal care visits (odds ratios, 0.5–0.8). However, women who report higher levels of spousal communication on community, health and reproductive issues—another measure of autonomy—have elevated odds of having discussed their health with their husband during pregnancy (2.0), and of their husband having prepared for (1.6) and attended (1.3) the birth.

The data come from a mixed-methods study fielded in four rural villages in Kailali district in 2011. The researchers interviewed 275 married women, randomly selected from local health records, who had had a live birth in the previous year and had lived with their spouse at the time of pregnancy, delivery and the survey. To assess husbands’ involvement in four aspects of maternal health, the researchers asked women whether their spouse had discussed her health during her most recent pregnancy, made preparatory arrangements for the birth, accompanied her to antenatal care visits and attended the delivery. They also evaluated four types of women’s autonomy: economic and domestic autonomy, each measured in terms of whether certain household decisions were made by the women (either alone or jointly with their husbands); movement autonomy, defined by whether women needed permission to go to the market, the local health facility, group meetings, friends’ or relatives’ houses, and religious institutions; and spousal communication, defined as speaking with one’s husband about community affairs, money, desired family size, health and use of family planning. Positive responses to the autonomy questions were summed to create five-point scales. In addition, women were asked to provide social and demographic information, including ethnicity, marriage type (love or arranged), and education levels for themselves and their husband.

The researchers also conducted 16 in-depth interviews with married women and men, mothers-in-law and members of the health service community, as well as two focus group discussions (one with women and one with men).

Themes emerging from the qualitative data included perceptions that social norms were gradually changing to accept greater male involvement in maternal health care, although participants indicated that some men who offer assistance to their pregnant wives experience stigmatization. Husbands were perceived to provide social support and advice to their pregnant wives, but were generally said to be absent during antenatal visits; husbands participating in the study, however, expressed interest in increasing their involvement in their wives’ care.

On average, women who took part in the quantitative survey were 23 years old, had married at age 18 and had had their first child just over a year later. Some 53% reported being in a love marriage, rather than an arranged one, and 75% lived in a household that included family members other than their spouse and children. During their most recent pregnancy and delivery, 97% of women had had at least one antenatal care visit, 72% had delivered with the assistance of a skilled provider and 69% had given birth in a health facility.

More than four-fifths of women reported that their husband had discussed their health with them during the pregnancy and prepared for the birth (e.g., by saving money or arranging for transportation). Some 78% indicated their husband had been present at delivery, though this proportion was lower among those delivering in a health facility (59%), and a substantial minority of women (41%) said their husband had attended antenatal care appointments. On the five-point autonomy scales, women scored lowest on economic (1.7) and movement (2.3) autonomy; mean scores were higher for domestic decision making (4.0) and spousal communication (4.5).

A bivariate analysis showed that women’s autonomy and other characteristics were associated with husbands’ involvement in maternal health care. Women’s economic autonomy and domestic autonomy were both negatively associated with couples having discussed the woman’s health during pregnancy (odds ratios, 0.8 and 0.6, respectively), and women’s domestic decision-making autonomy and movement autonomy were negatively associated with husbands’ presence during antenatal care (0.8 and 0.7). Women’s domestic and movement autonomy and spousal communication were positively associated with husbands’ birth preparedness (1.2–1.8); spousal communication was also positively associated with both discussion of the wife’s health during pregnancy (1.8) and the husband’s presence at delivery (1.6). Arranged marriage was a strong predictor of having discussed maternal health (3.4), and husbands were generally more likely to have been involved in pregnancy care if they or their wives had at least a secondary education (1.8–4.8) or if the woman had been exposed to the radio, television or print media in the past week (2.4–3.3).

In a multivariate analysis that controlled for other social and demographic covariates, the relationships between women’s autonomy and men’s involvement in maternal health care were generally similar to those in the bivariate analysis. The likelihood of having discussed the woman’s health during pregnancy remained negatively associated with wives’ involvement in economic and domestic decision making (odds ratios, 0.8 and 0.5, respectively), and positively related to spousal communication (2.0). Both domestic and movement autonomy were negatively associated with husbands’ presence during antenatal care (0.7 and 0.6), while spousal communication was positively associated with husband’s birth preparedness and presence at delivery (1.6 and 1.3).

According to the authors, these findings suggest that communication between spouses may enhance both women’s autonomy and men’s involvement in maternal health care. The negative relationship between other forms of autonomy and men’s involvement presents a mixed picture, however, and suggests that a rise in women’s autonomy may not be accompanied by greater spousal involvement in maternal care. The authors recommend that policies to improve maternal health "combine a continuous effort to enhance women’s autonomy through education and economic support with stimulating husbands’ involvement in their wives’ health care."—H. Ball

REFERENCE

1. Thapa DK and Niehof A, Women’s autonomy and husbands’ involvement in maternal health care in Nepal, Social Science & Medicine, 2013, Vol. 93, pp. 1–10.