Disentangling the associations between women's decision-making power dynamics and maternal and child health outcomes in 35 sub-Saharan African countries.

BACKGROUND: Prior research has typically treated women's sole and joint decision-making as equivalent components of women's empowerment. This paper explores how different forms of women's decision-making power relate to maternal and child health (MCH) in sub-Saharan Africa (SSA). METHODS: We used the most recent data from Demographic and Health Surveys conducted in 35 SSA countries (2012-2023), with outcome-specific samples ranging from 60,866 to 307,862 mother-child pairs. Women's decision-making power in healthcare, household purchases, and family visits was categorized as any decision by husband/others (reference), decisions usually by women alone, and joint decisions usually with husbands. Logistic regressions with country and survey-year fixed effects were estimated separately for seven MCH outcomes: antenatal care (≥4 visits), facility deliveries with skilled attendants, any postnatal care, low birth weight (<2.5 kg), stunting (height-for-age z-score < -2 SD), full immunization coverage, and any child morbidity (diarrhea, fever, or acute respiratory infection). RESULTS: Most women reported any decision by husbands/others (59.1%), followed by joint decisions with husbands (32.6%) and decisions by women alone (8.3%). Joint decisions were consistently associated with more favorable MCH outcomes, including lower odds of child morbidity compared with decisions by women alone (aOR = 0.80, 95% CI = 0.77-0.83) and any decision by husband/others (aOR = 0.77, 95% CI = 0.76-0.79), after adjusting for sociodemographic characteristics. CONCLUSIONS: Shared household decision-making, rather than women's autonomy alone, may be an important pathway to better maternal and child health in SSA. Interventions that promote mutual respect and shared responsibility in household decisions can improve the health and well-being of women and children in SSA.