Multilevel analysis of women’s empowerment and maternal high-risk fertility behavior in Sub-Saharan Africa, 2011–2022

BACKGROUND: High-risk fertility behaviors remain a persistent public health challenge in sub-Saharan Africa, where maternal mortality and fertility rates are high. Women's empowerment is an essential factor in understanding and addressing high-risk fertility behaviors. However, previous studies have often focused on singular aspects of empowerment, such as education or decision-making authority. This study adopts a multidimensional approach to examine the association between women's empowerment and high-risk fertility behaviors across sub-Saharan Africa. METHODS: We used Demographic and Health Survey data from 29 sub-Saharan African countries collected between 2011 and 2022 (n = 179,430). Women's empowerment was measured using principal component analysis to derive three dimensions of empowerment (decision-making, attitudes toward violence, and social independence). High-risk fertility behaviors were assessed based on childbirth before age 18, short birth intervals (< 24 months), and high birth parity (≥ 4 births). We used multilevel regressions to examine the association between empowerment dimensions and high-risk fertility behaviors while accounting for country-specific effects and controlling for potential determinants and risk factors. RESULTS: Across the study population, substantial variation in women's empowerment dimensions was observed across countries and population subgroups. Multilevel analyses showed significant associations between each empowerment dimension and reduced probabilities of engaging in high-risk fertility behaviors. For example, a one standard deviation increase in social independence was associated with lower odds of early childbirth (OR = 0.534; CI = 0.502-0.567), short birth intervals (OR = 0.796; CI = 0.761-0.832), and high birth parity (OR = 0.560; CI = 0.532-0.590). Similar negative associations were observed for the decision-making and attitudinal dimensions. These associations appeared strongest for high-risk behaviors occurring earlier in women's reproductive lives. CONCLUSIONS: The findings highlight the importance of women's empowerment in reducing high-risk fertility behaviors across multiple dimensions and life stages, providing insights for potential policy interventions targeted at gender-based factors contributing to high-risk fertility behaviors to improve the region's maternal and child health outcomes.