UCLA

Background. Maternal mortality remains unacceptably high in lower- and middle-income countries, with 289,000 women dying every year due to causes related to pregnancy and childbirth. Although the vast majority of deaths are preventable, progress in reducing maternal deaths has stagnated, especially in sub-Saharan Africa. The use of a Skilled Birth Attendant (SBA) at childbirth has been identified as a key intervention to prevent maternal deaths, yet SBA use continues to be limited in Africa.

Method. This study examined the mechanisms and complex pathways linking women's status and power to SBA use in the two distinct African countries - Senegal and Tanzania. This study used the Demographic and Health Survey Datasets in 2010, and conducted regression analysis, mediation analysis, and structural equation modeling. The study sample included all births occurred in the last five years (weighted n=10,688 in SN; 6,748 in TZ) to currently married women (weighted n=7,033 in SN; 4,445 in TZ). Women's education is examined as a proxy of women's status. The structure and multiple dimensions of power were identified in both countries as: age at first marriage, household decision-making power, perceptions of gender norms against violence, and perceptions for sex negotiation.

Results. Overall, there is a significant relationship of SBA use with women's status and power, yet the results demonstrated the disparate influences of women's education on SBA use - directly and indirectly in Tanzania, and indirectly in Senegal. Multiple dimensions of power influence SBA use as a direct and mediating determinant. However, the significant dimensions differ by country: decision-making in Tanzania; perceptions of gender norms against violence and for sex negotiation and age at first marriage in Senegal. The influence of sociodemographic characteristics (e.g., employment, household wealth) also showed variations across settings.

Discussion. This study provides valuable insights in to the potential causal pathways and mechanisms by which women's status and power influence SBA use. Moreover, this study confirms the importance of identifying and using analytic techniques to appropriately model the multidimensional and contextual nature of women's status and power. The results highlighted the need for culturally and contextually tailored policy and program interventions to support advancements in gender equity and women's empowerment, as a means of improving maternal health in Africa.