Effects of Empowerment and Media Use by Women of Childbearing Age on Maternal Health Care Utilization in Developing Countries of Southeast Asia

Abstract

Despite its importance to maternal health, women’s empowerment in developing countries has yet to be adequately addressed. We investigated the effects of women’s empowerment and media use on maternal antenatal care in Southeast Asian countries. The data originate from the Demographic and Health Surveys conducted in Southeast Asia between 2011 and 2014 (n = 35,905). We conducted Poisson regression and meta-analyses to examine communication inequalities in the media use for the relationships between women’s empowerment and maternal health. Women who had decision-making authority for their own health care (incidence rate ratio [IRR] = 1.03, 95% CI = 1.01–1.05), household purchases (IRR = 1.02, 95% CI = 1.00–1.04), and visiting family or relatives (IRR = 1.05, 95% CI = 1.03–1.07) were more likely to receive health care than were study participants whose partners had the decision-making authority. When we added use of each type of media into the model, the women who read a newspaper daily (IRR = 1.10, 95% CI = 1.03–1.20), listened to the radio at least once a week (IRR = 1.02, 95% CI = 1.01–1.03), and watched television daily (IRR = 1.61, 95% CI = 1.55–1.67) were more likely to receive health care than those who did not use media at all. This study revealed that women’s empowerment and their use of media were related to better maternal health care.

Keywords

antenatal care women’s decisional authority media use Southeast Asia

Introduction

Approximately 300,000 maternal deaths are reported annually worldwide, with 99% representing preventable accidents in developing countries.¹ Although one of the Millennium Development Goals (MDGs) included reducing maternal mortality ratios (MMRs) to three fourths of 1990 levels by 2015, a drastic gap in MMRs persists between rich and poor countries.² Currently, millions of women in developing countries cannot receive appropriate antenatal care (ANC), including women who undergo natural childbirth without the help of well-trained midwives, further increasing MMRs.^3,4 This environment leads to complications before childbirth, which is the major cause of death and disabilities in women of childbearing age in developing countries.

Eight out of 10 deaths among women during childbirth in developing countries are related to their ability to receive emergency care from well-trained health and medical care experts.⁵ Consequently, increasing the rates of health and medical care utilization by women of childbearing age may prevent their death in childbirth.^6–8 ANC lowers MMRs by facilitating safe childbirth at medical facilities with assistance from well-trained midwives.^9,10 ANC also provides appropriate health information and services to mothers, empowering them and promoting their use of postnatal services, all of which have positive effects on the health of the fetus.¹¹ Consequently, the WHO recommends that pregnant women utilize ANC at least 4 times.^12,13

Factors that affect ANC utilization rates in developing countries include educational levels of both women in childbirth and their husbands, employment status of women in childbirth, household income, media use, number of childbirths, and medical history of obstetric complications.^14–18 The ANC utilization rates are also related to economic levels.¹⁸ However, as described by the “law of inverse care,” the healthy rich have the least need for medical services but receive more services than the sickly poor.^19,20 Lower-income mothers in developing countries who have significant health needs show low rates of actual care utilization.²¹ Consequently, efforts to strengthen mothers’ access to health care are important in reducing the health risks to both women in childbirth and newborn infants.²²

However, even with improvements in physical and economic access, which are related to the supplier side of maternal health care services, consumer utilization rates often do not match the expected levels because cultural practices related to pregnancy in developing countries often suppress mothers’ use of ANC.²³ Compared with the improvements in health care quality and access, the effects of social treatment of women on maternal health have been relatively neglected. When this problem is addressed from a consumer-centered rather than supplier-centered approach, it can be seen that the greater emphasis on mothers’ decision-making abilities, the higher the ANC utilization rates.^24–27 Consequently, to improve maternal health, it is necessary to raise mothers’ educational levels and extend women’s rights, creating environments that foster mothers’ preservation of their own health within patriarchal systems.²⁸ In other words, it is necessary to improve access to ANC and strengthen mothers’ health empowerment simultaneously.²³

Inequality in women’s use of health care services during childbirth is related to individual economic, educational, and empowerment status (3Es).²⁸ These 3Es are indispensable for realizing the MDGs, because undesirable social environments can weaken the effects of public health interventions and consolidate inequality.²⁹ In developing countries, a diverse set of delays (e.g., obtaining medical services, arriving at medical institutions, and providing medical services) can adversely affect mothers’ health.³⁰ Delays related to health and medical care directly contribute to maternal mortality, which is related to the level of 3Es. Despite its importance to maternal health, women’s empowerment in developing countries has yet to be adequately addressed. Here, we use the term to refer to both women’s rights to access and use medical services in relation to maternal health and their ability to make their own decisions.³¹ The objective of this study was to determine the effects of women’s empowerment and media use on maternal health care in Southeast Asian countries.

Methods

Study Sample

For the study, we used data derived from the Demographic and Health Surveys (DHS; http://dhsprogram.com/) conducted in Southeast Asia between 2011 and 2014. The data were collected nationally via period representative surveys of 5,000 to 30,000 households in low- and middle-income countries. These surveys were based on multistage stratified sampling of households in census enumeration areas in urban and rural villages. The sample size of each country was calculated in proportion to the country’s urban and rural populations and gender ratio. In all households, women aged between 13 and 49 years were eligible to participate, and women aged 15 to 59 years in subsamples were also eligible. The DHS data, including demographic characteristics, women’s empowerment, mass media use, and utilization of maternal health services, were obtained through face-to-face interviews. The response rates were higher than 90% among all DHS participants in the surveyed countries. The data used for this study were pooled from 6 Southeast Asia countries (Bangladesh, 2011; Cambodia, 2014; Indonesia, 2012; Nepal, 2011; Pakistan, 2012; and the Philippines, 2013), with different survey years based on country-specific conditions. After excluding responses with missing values, we used a total of 35,905 women from 6 South and Southeast Asian countries in the final analysis.

Study Design

We designed a cross-sectional study to examine the effect of women’s empowerment on their use of maternal health services during their most recent pregnancies, with mass media use as a potential moderator (Figure 1).

Figure 1.

A framework of this study.

Measures

Dependent variables

The outcome variable in the study was the women’s use of maternal health services during their most recent pregnancies, which was assessed using the following question: “How many times did you receive antenatal care during this pregnancy?” The responses included the total numbers of health service visits for antenatal care.

Independent variables

The 2 independent variables included women’s empowerment and their media use, which affected maternal health.

Women’s Empowerment

We assessed women’s empowerment issues based on 2 dimensions: their decision making in daily life and their attitudes toward partner violence. We originally included these responses based on the available DHS data. We analyzed the women’s daily decision-making ability using the following 3 questions: “Who usually makes decisions about health care for you?” “Who usually makes decisions about major household purchases?” and “Who usually makes decisions about visits to your family or relatives?” The responses were grouped into 3 categories: (1) partner’s decision, (2) joint decision of partner and woman, and (3) woman’s decision. Regarding attitudes toward partner violence, the following question was asked: “In your opinion, is a husband justified in hitting or beating his wife in the following situations?” (1) goes out without telling him, (2) neglects children, (3) argues with him, (4) refuses to have sex, and (5) burns food, and all responses were yes or no. We conducted confirmatory factor analysis of the 9 total questions to assess the women’s empowerment issues under multiple dimensions.³² The factors used to construct the empowerment index presented eigenvalues greater than 1 and factor loadings greater than 0.40. The first factor, decision making in daily life, accounted for 24.7% of the total variance (Cronbach’s alpha = 0.733). This factor comprised 3 of the 9 empowerment variables: “decisions about your health care”; “decisions about major household purchases”; and “decisions about visits to your family or relatives.” A second factor, freedom from domination, explained 24.1% of the total variance (Cronbach’s alpha = 0.816) and encompassed “goes out without telling him” and “neglects children.” The third factor, self-assertion, explained 23.2% of the total variance (Cronbach’s alpha = 0.763) and comprised the remaining 3 empowerment variables: “argues with her husband”; “refuses to have sex”; and “burns food.” We transformed these factors into scores by aggregating the women’s responses to the relevant sub-questions.

Media Use

We assessed media usage to identify other causal effects on the outcome variables, considering how often participants used the 3 mass media types (newspaper, radio, and television) and grouping their responses into 4 categories: (1) not at all, (2) less than once a week, (3) at least once a week, and (4) almost every day.

Covariates

Maternal health is affected by demographic characteristics.^33,34 Accordingly, we used mother’s age, educational attainment, household income, and location as the baseline independent variables. We grouped the participants into the following age categories: 13–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49 years. We categorized educational attainment of women into uneducated, elementary school/associate degree, middle school/associate degree, and high school/associate degree or higher status. We grouped household income into the following standard categories: the lowest 20% (first quartile), low 20%, middle 20%, high 20%, and the highest 20% (fifth quartile), and based on location into urban and rural categories. Lastly, religion was also a factor influencing maternal medical use; however, most of the 6 countries included in this study had state religions. Bangladesh and Indonesia contained 89% and 88% Muslim populations, respectively. In Cambodia, 95% of the population was Buddhist; 87% were Hindus in Nepal; 97% were Muslims in Pakistan; and 83% were Catholics in the Philippines.

Statistical Analyses

First, we described the general characteristics of the sample for each country in Southeast Asia, including the distribution of maternal health services utilized. Second, we conducted hierarchical multivariable Poisson regression analysis to correlate women’s empowerment factors with maternal health service utilization after adjusting for potential confounders. We used Poisson regression because the utilization-dependent variables were counted as measures with skewed nonparametric distributions compared with standard parametric approaches, such as linear regression, and were not statistically appropriate.³⁵ We also determined the association between women’s empowerment and maternal health service utilization stratified by the frequency of media use (newspaper, radio, and television). Finally, we conducted a meta-analyses of communication inequalities in media usage to determine the relationship between women’s empowerment and their maternal health. We performed all statistical analyses using STATA v. 14.0 (STATA, College Station, TX, USA).

Results

Sample Demographics

As detailed in Table 1, a total of 35,905 female participants were recruited for this study. The participants were derived from 6 countries, including Indonesia (36.96%), Bangladesh (16.40%), Cambodia (14.20%), Pakistan (12.66%), the Philippines (12.45%), and Nepal (7.33%) in East and Southeast Asia. By age, 28.33% of participants were 25–29 years old, and 23.30% were 30–34 years. Regarding educational attainment, most participants (41.79%) had middle school/associate degrees, followed by elementary school/associate degrees (28.90%), and the remainder were uneducated women (16.74%). With respect to household income, more participants were in the lowest (first) quartile (25.75%) than in the other groups. By location, one third (39.18%) of respondents reported residing in an urban area, and the rest (60.82%) hailed from rural areas.

Table 1.

General Characteristics of the Sample (n = 35,905).

	N (%)
Country^a
Bangladesh (2011)	5,888 (16.40)
Cambodia (2014)	5,097 (14.20)
Indonesia (2012)	13,272 (36.96)
Nepal (2014)	2,632 (7.33)
Pakistan (2012)	4,545 (12.66)
Philippines (2013)	4,471 (12.45)
Age (years)
13–19	1,679 (4.68)
20–24	7,799 (21.72)
25–29	10,172 (28.33)
30–34	8,367 (23.30)
35–39	5,053 (14.07)
40–44	2,237 (6.23)
45–49	598 (1.67)
Educational attainment
Uneducated	6,010 (16.74)
Elementary school/associate degree	10,378 (28.90)
Middle school/associate degree	15,004 (41.79)
High school/associate degree or higher	4,513 (12.57)
Household income
1st quintile (the lowest)	9,246 (25.75)
2nd quintile	7,325 (20.40)
3rd quintile	6,506 (18.12)
4th quintile	6,326 (17.62)
5th quintile (the highest)	6,502 (18.11)
Location
Urban	14,068 (39.18)
Rural	21,837 (60.82)
Decision-making (1) woman’s health care
Partner decides	7,291 (20.31)
Jointly	17,774 (49.50)
Woman decides alone	3,840 (30.19)
Decision-making (2) household purchases
Partner decides	8,067 (22.47)
Jointly	21,901 (61.00)
Woman decides alone	5,937 (16.54)
Decision-making (3) visiting to family or relatives
Partner decides	6,926 (19.29)
Jointly	23,503 (65.46)
Woman decides alone	5,476 (15.25)
Attitudes on partner violence (1) goes out without telling him
Yes	8,186 (22.80)
No	27,719 (77.20)
Attitudes on partner violence (2) neglects the children
Yes	9,591 (26.71)
No	26,314 (73.29)
Attitudes on partner violence (3) argues with him
Yes	5,577 (15.53)
No	30,328 (84.47)
Attitudes on partner violence (4) refuses to have sex
Yes	4,154 (11.57)
No	31,751 (88.43)
Attitudes on partner violence (5) burns food
Yes	2,309 (6.43)
No	31,751 (93.57)
Newspaper use
Not at all	22,632 (62.03)
Less than once a week	9,527 (26.53)
At least once a week	3,611 (10.06)
Daily	135 (0.38)
Radio use
Not at all	19,828 (55.22)
Less than once a week	9,108 (25.37)
At least once a week	6,873 (19.14)
Daily	96 (0.27)
Television use
Not at all	7,583 (21.12)
Less than once a week	5,295 (14.75)
At least once a week	21,035 (58.59)
Daily	1,992 (5.55)
Utilization of maternal health service^b	5.36 (3.81)

^aEach country’s survey year is represented.

^bMean and standard deviation.

Based on decision-making empowerment, only approximately 15% of the women reported making the sole decisions about household purchases or visits to family or relatives, and nearly 30% made the sole decisions about their health care. Regarding attitudes toward partner violence, over 20% of participants responded that their husbands were justified in hitting or beating them if they went out without telling them or neglected their children. By media use, across the 6 countries, over 50% of respondents did not use media at all. Based on type of media, 62.03% did not read newspapers and 55.22% did not listen to the radio. However, over 60% of participants reported watching television, at least once a week (58.59%) or daily (5.55%). For maternal health service use, the average number of utilizations during the most recent pregnancy was 5.4 ± 3.8 (range = 0–36).

Women’s Empowerment and Maternal Health

To determine the relationship between the women’s empowerment dimensions and their maternal health service utilization during the most recent pregnancy, we performed hierarchical Poisson regression analyses, and the results are presented in Table 2. After controlling for covariates, women who had decision-making authority for their own health care (incidence rate ratio [IRR, i.e., relative risk] = 1.03, 95% CI = 1.01–1.05), household purchases (IRR = 1.02, 95% CI = 1.00–1.04), and visiting family or relatives (IRR = 1.05, 95% CI = 1.03–1.07) were more likely to receive health care than were participants whose partners had exclusive decision-making authority. Regarding attitudes toward partner violence, women who disagreed that a partner was justified in hitting his wife if she went out without telling him (IRR = 1.03, 95% CI = 1.01–1.05), argued with him (IRR = 1.07, 95% CI = 1.05–1.09), or burned food (IRR = 1.06, 95% CI = 1.03–1.09) were more likely to utilize maternal health services during their pregnancies compared with those who agreed that the partner was justified for such violence. However, the association was not statistically significant between women’s attitudes towards justified violence for refusing to have sex and their utilization of maternal health services. Meanwhile, women who disagreed that a partner was justified in hitting his wife for neglecting children (IRR = 0.98, 95% CI = 0.97–0.99) were less likely to utilize health care services.

Table 2.

IRR and 95% CI of Women’s Empowerment and Media Use With Utilization of Maternal Health Services in the Last Pregnancy Among 6 South and Southeast Asian Countries in the DHS Data (n = 35,905).

	Model I		Model II
	IRR	95% CI	IRR	95% CI
Decision-making (1) woman’s health care
Partner decides	1		1
Jointly	1.03**	1.01–1.04	1.02*	1.00–1.04
Woman decides alone	1.03**	1.01–1.05	1.02**	1.01–1.04
Decision-making (2) household purchases
Partner decides	1		1
Jointly	1.03***	1.02–1.05	1.03***	1.01, 1.05
Woman decides alone	1.02*	1.00–1.04	1.01	1.00, 1.03
Decision-making (3) visiting to family or relatives
Partner decides	1		1
Jointly	1.06***	1.04–1.08	1.06***	1.04–1.08
Woman decides alone	1.05***	1.03–1.07	1.05***	1.03–1.07
Attitudes on partner violence (1) goes out without telling him
Yes	1		1
No	1.03***	1.01–1.05	1.03***	1.01–1.05
Attitudes on partner violence (2) neglects the children
Yes	1		1
No	0.98**	0.97–0.99	0.98*	0.97–1.00
Attitudes on partner violence (3) argues with him
Yes	1		1
No	1.07***	1.05–1.09	1.06***	1.04–1.08
Attitudes on partner violence (4) refuses to have sex
Yes	1		1
No	1.00	0.98–1.02	1.00	0.98–1.02
Attitudes on partner violence (5) burns food
Yes	1		1
No	1.06***	1.03–1.09	1.04**	1.01, 1.07
Newspaper use
Not at all			1
Less than once a week			1.05***	1.04–1.06
At least once a week			1.07***	1.06–1.09
Daily			1.10**	1.03–1.20
Radio use
Not at all			1
Less than once a week			1.00	0.99–1.01
At least once a week			1.02**	1.01–1.03
Daily			1.09	1.00–1.20
Television use
Not at all			1
Less than once a week			1.18***	1.16–1.20
At least once a week			1.23***	1.21–1.25
Daily			1.61***	1.55–1.67

Abbreviations: CI, confidence interval; IRR, incidence risk ratio.

IRR = adjusted country, age, educational attainment, household income, and location.

*P < .05; **P < .01; ***P < .001.

Upon addition of each media type into model II and controlling for the covariates, we found that women who read a newspaper daily (IRR = 1.10, 95% CI = 1.03–1.20), listened to the radio at least once a week (IRR = 1.02, 95% CI = 1.01–1.03), and watched television daily (IRR = 1.61, 95% CI = 1.55–1.67) were more likely to receive health care compared with those who did not use media at all.

We further analyzed the results of hierarchical Poisson regression to identify women’s empowerment and media usage following utilization of maternal health services in the last pregnancy by 6 South and Southeast Asian countries. Table 3 shows the detailed results. After controlling for the covariates, the Philippines, which was ranked eighth in the gender gap, did not show the effect of women's decision-making authority. By contrast, countries such as Nepal (105th) and Pakistan (148th) with a higher gender gap showed that women’s decision-making authority had a significant impact on medical service utilization by women. In Nepal, women who had decision-making authority for household purchases (IRR = 1.08, 95% CI = 1.02–1.16), and visiting family or relatives (IRR = 1.08, 95% CI = 1.00–1.16) were more likely to receive health care compared with participants whose partners had decision-making authority. In Pakistan, women who had decision-making authority for their own health care (IRR = 1.15, 95% CI = 1.07–1.22), visiting family or relatives (IRR = 1.10, 95% CI = 1.02–1.18), and women who disagreed that a partner was justified in hitting his wife for arguing with him (IRR = 1.10, 95% CI = 1.03–1.18) were more likely to utilize maternal health services during their pregnancies than were those who justified their partner’s violence.

Table 3.

IRR and 95% CI of Women’s Empowerment and Media Use With Utilization of Maternal Health Services in the Last Pregnancy by 6 South and Southeast Asian Countries in the DHS Data (n = 35,905).

	Bangladesh (2011)		Cambodia (2014)		Indonesia (2012)		Nepal (2014)		Pakistan (2012)		Philippines (2013)
	IRR	95% CI	IRR	95% CI	IRR	95% CI	IRR	95% CI	IRR	95% CI	IRR	95% CI
Decision-making (1) woman’s health care
Partner decides	1		1		1		1		1		1
Jointly	0.99	0.94–1.04	1.05	0.98–1.12	1.01	0.99–1.03	0.99	0.93–1.05	1.06*	1.01–1.12	1.05	0.98–1.12
Woman decides alone	0.97	0.91–1.04	1.02	0.96–1.09	1.01	0.99–1.04	1.00	0.93–1.08	1.15***	1.07–1.22	1.02	0.96–1.09
Decision-making (2) household purchases
Partner decides	1		1		1		1		1		1
Jointly	1.04	0.99–1.09	1.02	0.98–1.06	1.00	0.98–1.03	1.05*	1.01–1.15	1.06	1.00–1.11	1.02	0.98–1.06
Woman decides alone	1.08	0.98–1.18	1.00	0.96–1.04	0.98	0.96–1.00	1.08*	1.02–1.16	0.99	0.91–1.07	1.00	0.96–1.04
Decision-making (3) visiting to family or relatives
Partner decides	1		1		1		1		1		1
Jointly	1.10***	1.04–1.15	0.99	0.94–1.04	1.05***	1.03–1.08	1.05	0.98–1.12	1.02	0.97–1.08	0.99	0.94–1.04
Woman decides alone	1.11**	1.03–1.20	0.98	0.93–1.04	1.02	0.99–1.04	1.08*	1.00–1.16	1.10*	1.02–1.18	0.98	0.93–1.04
Attitudes on partner violence (1) goes out without telling him
Yes	1		1		1		1		1		1
No	1.05	0.99–1.12	1.08***	1.04–1.12	1.02*	1.01–1.05	0.89	0.49–1.61	0.96	0.90–1.03	1.05	0.98–1.12
Attitudes on partner violence (2) neglects the children
Yes	1				1		1		1		1
No	1.03	0.97–1.09	1.01	0.97–1.05	0.98*	0.96–1.00	1.24	0.73–2.10	1.01	0.94–1.08	1.01	0.97–1.05
Attitudes on partner violence (3) argues with him
Yes	1		1		1		1		1		1
No	1.07*	1.01–1.13	1.00	0.93–1.08	1.03	1.00–1.06	1.70	0.50–5.79	1.10**	1.03–1.18	1.00	0.93–1.08
Attitudes on partner violence (4) refuses to have sex
Yes	1		1		1		1		1		1
No	0.92*	0.84–1.00	1.02	0.97–1.07	0.97*	0.95–0.99	3.05	0.44–21.12	1.05	0.99–1.11	1.17**	1.05–1.30
Attitudes on partner violence (5) burns food
Yes	1		1		1		1		1		1
No	1.37***	1.20–1.56	1.02	0.97–1.07	1.02	0.98–1.07	0.51	0.20–1.28	0.99	0.93–1.06	1.12*	1.02–1.24
Newspaper use
Not at all	1		1		1		1		1		1
Less than once a week	1.11***	1.06–1.17	1.03	1.00–1.06	1.05***	1.03–1.07	1.04	0.98–1.11	1.02	0.97–1.06	1.03*	1.00–1.06
At least once a week	1.28***	1.21–1.36	1.02	0.98–1.05	1.08***	1.06–1.11	1.09*	1.00–1.18	1.00	0.91–1.10	1.02	0.98–1.05
Daily									0.95	0.88–1.03
Radio use
Not at all	1		1		1		1		1		1
Less than once a week	1.07	0.99–1.15	1.04	1.00–1.08	1.02*	1.00–1.03	1.03	0.97–1.09	0.96	0.92–1.01	1.04*	1.00–1.08
At least once a week	1.03	0.96–1.12	1.08*	1.04–1.11	1.05***	1.03–1.07	1.02	0.96–1.08	1.02	0.89–1.18	1.08***	1.04–1.11
Daily									1.07	0.97–1.17
Television use
Not at all	1		1		1		1		1		1
Less than once a week	1.12***	1.05–1.19	1.15*	1.10–1.20	1.14***	1.10–1.19	1.12**	1.05–1.19	1.19***	1.13–1.26	1.17***	1.11–1.24
At least once a week	1.25*	1.19–1.31	1.14*	1.10–1.19	1.20***	1.16–1.25	1.14**	1.06–1.23	1.13*	1.01–1.27	1.24***	1.18–1.30
Daily									1.37***	1.30–1.44

Abbreviations: CI, confidence interval; IRR, incidence risk ratio.

IRR = adjusted age, educational attainment, household income, and location.

*P < .05; **P < .01; ***P < .001.

Meta-Analyses of the Relationships Between Women’s Empowerment and Maternal Health

After adjusting for mass media use, the correlations were significant between women’s empowerment (decision making in daily life, freedom from domination, and self-assertion) and maternal health service utilization except in Indonesia (Figure 2). This finding suggested profound inequalities in health communication not only among individuals but also within countries and regions, despite the presence of mass media maternal health campaigns in these countries.

Figure 2.

Utilization of maternal health services during last pregnancy.

Discussion

In the developing countries of Southeast Asia, the use of antenatal care by pregnant women is extremely low. In Nepal, the ratio of women in childbirth who had received ANC on 4 or more occasions was lower than 3 out of 10, with 1 out of 4 never receiving ANC.³ These statistics were not even half of the average levels for developing countries.³⁶ The extremely low rates may be attributed partly to inadequate or deficient administrative capacities in these countries compared with their health needs. Based on their 3Es, women’s socioeconomic status was deeply related in their use of health care services during childbirth in developing countries,^28,37 and expansion of quality maternal health care services may motivate women to utilize these services.^38,39 Consequently, to lower the developing countries’ MMRs, it is necessary to mitigate ANC-related health inequality via maternal health care policies targeting the poor.⁴⁰

Policies that focus solely on this issue from a health care provider standpoint are likely to be limited in effectiveness because family structures and cultural factors play an important role in the overall low ANC utilization rates in developing countries. According to studies in Southeast Asian and Islamic countries, women received support from their natal families, husbands, and husbands’ families depending on both ANC frequency and greater overall utilization of maternal health care services.^41,42

Our results show that maternal health care is significantly associated with women’s empowerment and media use. First, we found that women who had decision-making authority and opposed domestic violence were more likely to use maternal health services. Specifically, Nepal and Pakistan, which show higher gender gap, showed significant effects of women's decision-making power on the use of medical care.⁴³ In the developing countries of Southeast Asia, physical abuse and domestic violence toward women increased the risks of illness and death in newborn infants.⁴⁴ Ultimately, enhancing women’s health-related empowerment and social status fundamentally increased the ANC utilization rates and improved their general health.⁴⁵ Therefore, activities that extend women’s rights and institutionalize gender equality throughout societies are needed.

Second, media use is positively associated with the utilization of maternal health services; specifically, newspaper and television use were significantly associated with better maternal health. A few studies focused on the patient role as the crucial factor in the management of their own health, which indicated that the patient had a more critical role compared with the health-care provider in controlling the patient’s own health. It suggested that more attention is needed to address the issues of health literacy, improving the relationship between physician and patients as well as enhance community awareness, whether through health promotion programs or media for the optimum use of available resources.⁴⁶ Therefore, reducing communication inequalities to encourage mothers may also contribute to improved maternal health in developing countries.

Communication within families facilitates the use of ANC.^47,48 However, in Bangladesh and Pakistan, the important role played by mothers-in-law is a barrier to accessing ANC.^49–52 In most Asian countries, including Nepal, the mothers-in-law made the decisions for their sons’ wives in accordance with patriarchal systems.^53,54 Although husbands support their wives in conflicts with their mothers, the role of Asian men in ANC and childbirth is very limited.^55,56 Consequently, informing mothers-in-law of the benefits of ANC by increasing health education is important in raising the ANC utilization rates of women in Southeast Asia.^47,57,58

Developing countries in Southeast Asia are undergoing significant changes. First, investments in improving women’s education attainment are underway. Young educated women are more active in utilizing health and medical services because of their higher health literacy.^16,50,59 Second, efforts are ongoing to mitigate social inequality through economic growth. It is generally accepted that increased gross national income per capita translates to increased life expectancy as well.^60–62 Health and medical service needs are met as economies develop and household incomes increase.^63–65 However, current efforts to elevate women’s social status remain insufficient. As noted earlier, strengthening the decision-making power of women by providing access to education as well as efforts to reduce social inequality from a national perspective will facilitate consumer-centered medical care for women in developing countries. A study from India clearly revealed that women showed lower health care utilization than men, despite worse self-rated health and higher disease burden. Empowerment such as economic independence of women reduces the gender difference, which cannot be explained by demographics (e.g., education, income level, etc.) and the variation in the burden of medical conditions.⁶⁶ Access to media exposure such as TV and Internet may be an effective way to educate women on their rights and encourage the preventive use of medical care during pregnancy. Women’s empowerment will improve the maternal health care indices and decrease obstetric complications and infant mortality rates.

The present study has a number of limitations. First, we used cross-sectional data to analyze only correlation, not causation. Although the data used random-effects models to explain heterogeneity among countries, it was impossible to totally control qualitative heterogeneity among the 6 nations studied, which might have resulted in bias involving the estimated coefficients of the research model. Although the DHS data were interstate and collected and analyzed through standardized questionnaires and methods, the interpretation of the results was based on investigations conducted over 4 years (2011–2014) and selected representative populations in the developing countries. Second, a recall bias may have existed in women’s responses about their past pregnancies and childbirths because these data were self-reported. Third, this study did not include the recent debate on empowerment in depth because we used secondary data. Empowerment, especially when referred to in the context of development, may be a contested terminology.⁶⁷ The critique of empowerment emphasizes how this concept was used as a rhetoric by a neoliberal development model to justify the reduction of the role of the state in welfare programs.

In conclusion, to improve maternal health care management, it is necessary to create supportive environments that promote ANC services for women. In the present study, women’s empowerment and media use were related to improved maternal health care. Consequently, for maternal health care in developing countries in Southeast Asia, measures that assist families and local communities in promoting women’s health empowerment need to be contemplated. Empowered women can give birth to healthy fetuses by utilizing appropriate ANC, leading to populations that reproduce more healthily, which ultimately improves the economic and human capital of developing countries.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2016R1C1B1008131; PI: Prof. Dr. Minsoo Jung).

Author Biographies

Minsung Sohn, MPH, PHD, is an assistant professor in the Department of Health and Care Administration at the Cyber University of Korea. She has research interests in 3 areas: (1) health care systems, (2) quality of health services, and (3) medical expenditure and utilization with quantitative and qualitative approaches. She is investigating the impact of long-term care insurance on suicide as well as the lifetime medical costs of the elderly with dementia, funded by the National Research Foundation of South Korea.

Minsoo Jung, DrPH, is an associate professor in the Department of Health Sciences, Dongduk Women’s University. His main research interests are health sociology, health communication, and community-based health promotion with emphasis on hierarchical linear models and social network analysis. He has more than 100 professional publications as well as major research grants (e.g., from the National Research Foundation of Korea). He will be awarded a 2020 fellowship to serve as a visiting professor at Harvard University.

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