Women’s empowerment as a social determinant of adverse pregnancy outcomes in the Tigray region of Ethiopia: a prospective follow‑up study

Women’s empowerment and the promotion of positive pregnancy experiences are global public health priorities and key sustainable development goals. However, little is known about the relationship between women’s empowerment and adverse pregnancy outcomes in a conflict prone setting like Ethiopia. Therefore, we aimed to assess women’s empowerment as a social determinant of adverse pregnancy outcomes in the Tigray region of Ethiopia including estimating the magnitude of adverse pregnancy outcomes and examining its association with women’s empowerment. A community based prospective study design was employed from August 2024 and May 2025. A multistage clustered sampling technique was used to select and study 1258 pregnant women. The relationship between the domains of women’s empowerment and adverse pregnancy outcomes was modeled using a multivariable modified Poisson regression method. Adjusted Relative Risks (aRR) with a 95% confidence interval (CI) and p -value are reported. The findings showed that the magnitude of adverse pregnancy outcomes was 19.0% (95% CI: 16.9%–23.3%), with maternal complication (10.7%), abortion (5.5%), still birth (2.6%), and congenital anomalies (1.6%) being the main adverse pregnancy outcomes. The overall composite women’s empowerment score and some specific empowerment domains (such as social independence, and decision-making) did not show significant associations with adverse pregnancy outcomes. However, specific women’s empowerment domains such as being a member of social networking (aRR = 0.68; 95% CI, 0.49-0.96) and household asset ownership (aRR = 0.52 95% CI, 0.29-0.89) reduced the risk of adverse maternal outcomes. In contrast, women who accept wife beating by husband (aRR = 1.42;95% CI, 1.12–1.99), were more likely to experience adverse pregnancy outcomes. One in five women reported adverse pregnancy outcomes during the study period. Our study provides evidence that supports women’s empowerment, as a modifiable social determinant, reduces the risk of adverse pregnancy outcomes. We recommend that efforts aligned with Sustainable Development Goal 5 (SDG 5), including achieving gender equality, strengthening women’s participation in social networking groups, such as leadership and political engagement, wealth accumulation through income generation and savings, and promoting asset ownership, may help reduce the burden of adverse pregnancy outcomes in the study area.