Decision-making autonomy and depressive symptoms among women in Lesotho: Rural–urban differences

Objectives To assess the association between depressive symptoms and decision-making autonomy with rural urban inequalities, and mapped province-level spatial disparities in depression prevalence in ever-married women in Lesotho. Methods This study used cross-section data of 3297 women aged 15–49 years from the 2023–24 Lesotho Demographic and Health Survey (LDHS). Depression was measured using the Patient Health Questionnaire-9 (PHQ-9 ≥ 10). Women’s decision-making autonomy was measured using a composite empowerment index based on participation in five household decision-making domains. Survey-weighted multivariable logistic regression models were fitted at the national level and stratified by place of residence. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Spatial analyses were conducted to examine district-level variation in depression prevalence and autonomy. Results Overall, 7.4% (95% CI: 6.3–8.7) of women reported moderate-severe depressive symptoms. Women with decision-making autonomy showed lower odds of depression nationally (AOR = 0.63; 95% CI: 0.39–0.98), with a stronger effect in rural areas (AOR = 0.44; 95% CI: 0.27–0.74). Depression prevalence was highest in central–northern districts (Maseru, Berea, Leribe, Butha-Buthe) and lower levels of autonomy observed in southern and south-western provinces. Conclusions Women’s decision-making autonomy is significantly associated with lower odds of depressive symptoms in Lesotho, particularly among rural women. The observed rural–urban and spatial inequalities highlight the need for context-specific mental health and reproductive health interventions that incorporate women’s empowerment as a core component.