Demissie et al.

BMC Public Health (2022) 22:837

https://doi.org/10.1186/s12889-022-13251-4

RESEARCH Open Access

Factors associated with decision‑making

power of married women to use family planning
in sub‑Saharan Africa: a multilevel analysis
of demographic health surveys
Getu Debalkie Demissie1*, Yonas Akalu2, Abebaw Addis Gelagay3, Wallelign Alemnew1 and Yigizie Yeshaw2,4

Abstract
Background: In sub-Saharan Africa, there are several socio-economic and cultural factors which affect women’s
ability to make decision regarding their own health including the use of contraceptives. Therefore, the main aim of
this study was to determine factors associated with decision-making power of married women to use family planning
service (contraceptives) in sub-Saharan Africa.
Methods: The appended, most recent demographic and health survey datasets of 35 sub-Saharan countries were
used. A total weighted sample of 83,882 women were included in the study. Both bivariable and multivariable multi-
level logistic regression were done to determine the associated factors of decision-making power of married women
to use family planning service in sub-Saharan countries. The Odds Ratio (OR) with a 95% Confidence Interval (CI) was
calculated for those potential variables included in the final model.
Results: Married women with primary education (AOR = 1.24; CI:1.16,1.32), secondary education (AOR = 1.31;
CI:1.22,1.41), higher education (AOR = 1.36; CI:1.20,1.53), media exposure (AOR = 1.08; CI: 1.03, 1.13), currently working
(AOR = 1.27; CI: 1.20, 1.33), 1–3 antenatal care visits (AOR = 1.12; CI:1.05,1.20), ≥ 4 ANC visits (AOR = 1.14;CI:1.07,1.21),
informed about family planning (AOR = 1.09; CI: 1.04, 1.15), having less than 3 children (AOR = 1.12; CI: 1.02, 1.23) and
3–5 children (AOR = 1.08; CI: 1.01, 1.16) had higher odds of decision-making power to use family planning.
Mothers who are 15–19 (AOR = 0.61; CI: 0.52, 0.72), 20–24 (AOR = 0.69; CI: 0.60, 0.79), 25–29 (AOR = 0.74; CI: 0.66, 0.84),
and 30–34 years of age (AOR = 0.82; CI: 0.73, 0.92) had reduced odds off decision-making power to use family plan-
ning as compared to their counterparts.
Conclusion: Age, women’s level of education, occupation of women and their husbands, wealth index, media expo-
sure, ANC visit, fertility preference, husband’s desire in terms of number of children, region and information about
family planning were factors associated with decision-making power to use family planning among married women.
Keywords: Decision-making power, Women, Family planning, Sub-Saharan Africa

Background
Sub-Saharan Africa (SSA) accounted for 66% of the
*Correspondence: [email protected] maternal deaths globally and had the highest Mater-
1
Department of Health Education and Behavioral Sciences, Institute nal Mortality Ratio (MMR) at 546 maternal deaths
of Public Health, College of Medicine and Health Sciences, University per 100,000 live births [1]. Unplanned pregnancy and
of Gondar, P. O. Box, 196 Gondar, Ethiopia
Full list of author information is available at the end of the article short inter-pregnancy spacing are the leading causes of

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Demissie et al. BMC Public Health (2022) 22:837 Page 2 of 9

maternal and child death in this region. In developing who had not [20, 21]. However, decisions for the use of
countries, more than 222 million women’s pregnancies contraceptives may be affected by unbalanced power
are unplanned [2]. The use of modern family planning relations between women and their partners, especially
methods after delivery is considered an important part of in more male-controlled societies and where cultural
interventional efforts [3, 4]. discrimination are practiced [22].
The 2030 Agenda for Sustainable Development Goal Furthermore, previous studies showed that decision-
(SDGs) includes relevant targets for using contraceptives making power of women to use family planning was
under the broader goals of health and well-being of the associated with education [2, 23–25], age [2, 25–28],
population and gender equality [5, 6]. Family planning knowledge about family planning [26, 29, 30], working
service contributes not only to the reduction of morbidity status of women [27, 28, 31], gender equality attitude
and mortality of mothers and children, but also prevents [29], number of living children [23, 27, 28], socio-eco-
the risk of unintended pregnancy and its adverse con- nomic status [24, 25, 31–33], residence [27, 28], husbands
sequence including HIV/AIDS and abortion and hence, desire in terms of number of children [30] and attitude
it has been used to improve the standard of living [7]. A towards family planning [26].
data from 51 surveys conducted between 2006 and 2013 Decision-making power of women to use family plan-
showed that although 30% of maternal deaths and 10% of ning service is a huge problem in SSA region. However, to
child death could be avoided by extending pregnancy [8], the best of our knowledge, there is no study that investi-
41% of women in SSA who intended to use modern con- gates the factors associated with decision-making power
traceptives were not using them [9]. Moreover, in 2010 to use family planning among married women in the
only 17% of married women are using contraceptives in region. Hence, this study was conducted to fill this gap by
SSA which is too low as compared to North Africa (50%), identifying the determinants of women decision- making
Middle East (39%), East Asia (76%) and Latin America power on the use of family planning service in the region.
(68%) [10, 11]. The finding of this study will be helpful to design appro-
A woman’s ability to choose the method of modern priate intervention measures that can increase the deci-
contraceptives is affected by her self-image and sense sion -making power of women to use family planning in
of empowerment. A woman who feels that she is una- the region.
ble to control other aspects of her life may be less likely
to feel that she can make decisions about fertility [12]. Methods
Independent or joint decision-making with partners Data source
on family planning use has a substantial contribution This study used the most recent appended demographic
to the improvement of maternal health [13]. Although and health survey (DHS) datasets of 35 sub-Saharan
women’s empowerment is the key to use contracep- countries which were conducted from 2009 to 2018.
tives, unfortunately, women’s position in all aspects of The DHS is a nationally representative survey, collected
decision-making, including the use of contraceptives, every 5 years, to provide population and health indi-
in developing countries is inferior to their husbands or cators at the national and regional levels. A pretested
partners [12, 14]. standard demographic and health survey questionnaires
Women often have less decision-making power due were used. The questionnaire was contextualized to the
to their political, economic, and sociocultural status different countries context and the data were gathered
and may not be in a position to protect themselves from by trained data collectors. The datasets of each sub Saha-
unwanted sexual intercourse and gender-based vio- ran country were obtained at https://​dhspr​ogram.​com/​
lence, which may predispose them to sexually transmit- data/​datas​et_​admin/​index.​cfm. Those countries with no
ted infections and other sexual and reproductive health data on decision-making power of women to use family
(SRH) problems [15]. planning were excluded from the analysis. In this study,
Women decision-making power has a great impact 83,882 women were included (Table 1).
on health care services utilization including fam-
ily planning service. Studies conducted in rural Nepal Variables of the study
[16], Pakistan [17] and Ghana [18] showed that wom- Dependent variable
en’s decision-making power plays an important role in The dependent variable for this study was decision-
determining uptake of maternal health services. One making power of married women to use family plan-
of the reasons for not using contraceptives is they have ning service. According to DHS, decision-making power
no power to decide on the use of these service [19]. Evi- of married women to use family planning was reported
dences showed that women who have decision-making in four categories (decision-making by women, partner,
power are more likely to use contraceptives than those joint and others). Hence, we dichotomized this variable
Demissie et al. BMC Public Health (2022) 22:837 Page 3 of 9

Table 1 List of sub-Saharan countries included, and their exposure, ANC visit, number of living children, fertil-
demographic and health surveys’ year ity preference of women, husband’s desire in terms of
Name of Country Year of survey Weighted number of children, information related to FP at health
sample size facility, residence and SSA region. Countries were cat-
(%) egorized in to sub-regions based on socioeconomic and
Angola 2015/16 1083 (1.29) geographical directions [34].
Burkina Faso 2010 2194 (2.62)
Benin 2017/18 1732 (2.06) Data analysis procedure
Burundi 2016/17 2792 (3.33) We used STATA 14 software to extract, recode and ana-
Cameroon 2018 1497 (1.79) lyze the data. The data were weighted before doing any
DR Congo 2013/14 2422 (2.89) statistical analysis to restore the representativeness of the
Chad 2015 710 (0.85) sample and to get a reliable estimate and standard error.
Comoros 2012 631 (0.75) The whole procedure of weighting and its rationale is
Congo 2011/12 2813 (3.35) found on the guide of DHS statistics [35].
Côte d’Ivoire 2011/12 1103 (1.32) Due to the correlated nature of DHS data, measures
Ethiopia 2016 3668 (4.37) of community variation/random-effects such as Median
Gabon 2012 1394 (1.66) Odds Ratio (MOR), Interclass Correlation Coefficient
Ghana 2014 1415 (1.69) (ICC), and Proportional Change in Variance (PCV) were
Gambia 2013 571 (0.68) calculated. Accordingly, the values of these measures
Guinea 2018 840 (1.00) were found out to be significant, and hence the use of
Kenya 2014 5035 (6.00) multilevel logistic regression model is more appropriate
Liberia 2013 1090 (1.30) than using ordinary logistic regression. To choose the
Lesotho 2014 2168 (2.58) best fitted model, first we developed four models and
Madagascar 2009 4807 (5.73) compared them with Deviance. These were: the null-
Mali 2018 1477 (1.76) model, a model with no independent variable; model I, a
Malawi 2015/16 9552 (11.39) model that has individual-level factors only; model II, a
Mozambique 2011 899 (1.08) model with community-level factors only and model III,
Nigeria 2018 4843 (5.77) a model that contains both community level and inde-
Niger 2012 1373 (1.64) pendent variables. Model III was selected as the best fit-
Namibia 2013 1721 (2.05) ted model as it had the lowest Deviance.
Rwanda 2014/15 3706 (4.42) Bivariable and multivariable multilevel logistic regres-
Sierra Leone 2016 2064 (2.46) sion was performed to determine the associated factors
Sao Tome and Principe 2009 607 (0.72)
of decision-making power of married women to use FP
Senegal 2011 1359 (1.62)
in SSA. All variables with a p value < 0.25 during bi-var-
Togo 2013 1231 (1.47)
iable analysis were entered into the multivariable logistic
Tanzania 2015/16 3149 (3.75)
regression model. In the final model, p value ≤0.05 was
Uganda 2016 4372 (5.21)
used to declare variables that are statistically significant.
South Africa 2016 1663 (1.98)
Zambia 2018 3794 (4.52) Results
Zimbabwe 2015 4107 (4.90) Sociodemographic characteristics of the respondents
The total weighted sample of 83,882 married women
were included in this study. Of these, 22.9% of the
respondents were in the age group of 25–29 years and
as: yes (if the women decide independently or together
more than half (60%) of them were rural dwellers. More
with their partner to use family planning) and no (if nei-
than one-third of both the respondents (39.9%) and their
ther the women decide independently nor jointly with
husbands (34.4%) had primary education. The majority
their partner to use family planning) [26].
of the respondents (73.3%) and their husbands (92.7%)
were currently employed. Similarly, the majority of the
Independent variables respondents (67%) had media exposure (Table 2).
Both individual and community level variables were
considered independent variables. The individual level Reproductive characteristics of the respondents
variables were age, level of education, wealth index, occu- Of the respondents, 47.6% of them had four or more
pational status of women and their husbands, media ANC visits. The majority of the respondents (69.2%) were
Demissie et al. BMC Public Health (2022) 22:837 Page 4 of 9

Table 2 Sociodemographic characteristics of the respondents in sub-Saharan Africa

Variable Category Weighted frequency Percent (%)

Age (in years) 15–19 3215 3.8

20–24 13,693 16.0
25–29 19,210 22.9
30–34 17,890 21.0
35–39 15,016 17.9
40–44 9794 11.9
45–49 5063 6.5
Residence Urban 33,704 40.0
Rural 50,177 60.0
Region East Africa 37,713 44.7
West Africa 19,471 24.0
South Africa 15,430 18.6
Central Africa 10,534 12.7
Educational level of respondents No formal education 16,714 19.9
Primary 33,490 39.9
Secondary 28,100 33.5
Higher 5578 6.7
Education level of husbands No formal education 15,251 18.2
Primary 28,865 34.4
Secondary 30,280 36.0
Higher 9406 11.0
Respondents’ occupation Currently working 61,454 73.3
Currently Not working 22,428 26.7
Husbands occupation Currently working 77,741 92.7
Currently Not working 6141 7.3
Wealth index Poorest 10,934 13
Poorer 14,093 16.8
Middle 16,119 19.4
Richer 19,309 23
Richest 23,425 27.8
Media exposure Yes 56,269 67.0
No 27,585 33.0

told about family planning methods during their facility the presence of variation in the decision-making power of
visits. More than half of the respondents (56%) had fertil- women to use family planning between clusters. It means
ity preference to have more children. Regarding the use if we randomly select women from different clusters,
of contraceptive methods, 36.2% of the respondents used those women at the cluster with higher decision making
injections (Table 3). power of women to use family planning had 1.23 times
higher chance of decision-making power to use family
Random effect analysis planning compared to their counterparts. As you can see
The random-effects model result showed that there is sig- in Table 3 below, model III has the lowest Deviance value.
nificant clustering of decision-making power of women Hence, it was selected as the best fitted model (Table 4).
to use family planning across the communities (OR of
community level variance =0.07, 95% CI = 0.06–0.10). Factors associated with decision‑making power of women
The value of ICC in the null model revealed that 2.16% of to use contraceptives
the overall variation of decision-making power of women The odds of decision-making power to use fam-
to use family planning was attributed to cluster variabil- ily planning among married women with age 15–19,
ity. The 1.23 MOR value of the null model also indicated 20–24, 25–29 and 30–34 years was decreased by 39%
Demissie et al. BMC Public Health (2022) 22:837 Page 5 of 9

Table 3 Reproductive characteristics of the respondents in sub-Saharan Africa

Variables Category Frequency Percent (%)

Number of ANC visits 0 24,679 29.4

1–3 19,255 23
≥4 39,948 47.6
Number of living children <3 32,908 39.2
3–5 38,515 45.9
>5 12,458 14.9
Fertility preference Unable to have children 5100 6
Do not want another children 31,887 38
Want to have another children 46,895 56
Information about FP at health facility Yes 25,844 30.8
No 58,037 69.2
Husband’s desire in terms of number of children Same as spouse 37,187 44
Husband wants more 39,023 46.5
Husband wants fewer 7671 9.5
Type of contraceptive used Pill 12,892 15.4
IUD 2292 2.73
Injections 30,380 36.2
Male condom 7236 8.6
Female sterilization 4305 5
Periodic abstinence 6703 8
Withdrawal 3777 4.5
Implants /Norplant 12,311 14.7
Lactation amenorrhea (LAM) 1776 2.2
Other methods (including traditional 2205 2.7
method)

Table 4 Comparison of models and result of random effect analysis

Parameters Null model Model I Model II Model III

Community level variance 0.07 (0.06–0.10) 0.07 (0.06–0.10) 0.07 (0.05–0.09) 0.07 (0.05–0.09)
ICC 2.16% 2.14% 2.00% 2.02%
MOR 1.29 1.29 1.28 1.28
PCV Ref 0.69% 7.42% 6.60%
Model fitness
Deviance 54,592.124 53,855.498 53,915.178 53,310.886

(AOR = 0.61; CI: 0.52, 0.72), 31% (AOR = 0.69; CI: Women who are currently working were 1.27
0.60, 0.79), 26% (AOR = 0.74; CI: 0.66, 0.84), and 18% (AOR = 1.27; CI: 1.20, 1.33) times more likely to have
(AOR = 0.82; CI:0.73, 0.92) as compared to their coun- decision-making power to use contraceptive as compared
terparts, respectively. The odds of decision-making to women who were not currently working. Women who
power to use family planning among married women had media exposure were 1.1 (AOR = 1.08; CI: 1.03, 1.13)
whose education level was primary, secondary and times more likely to have decision-making power on fam-
higher was about 1.24 (AOR = 1.24; CI:1.16,1.32), ily planning use as compared to those women who did
1.31 (AOR = 1.31; CI:1.22,1.41) and 1.36 (AOR = 1.36; not have media exposure.
CI:1.20,1.53) times higher compared to those who did Similarly, the odds of decision-making power on family
not have formal education. planning among participants who had 1–3 and ≥ 4 ANC
Demissie et al. BMC Public Health (2022) 22:837 Page 6 of 9

visit was increased by 12%(AOR = 1.12; CI:1.05,1.20) and families than others and hence have a stronger motiva-
14% (AOR = 1.14;CI:1.07,1.21) than those who had no tion to practice contraceptives [39].
ANC visit, respectively. Besides, the odds of decision- This study also showed that those women and their
making power on family planning among respondents husbands who were currently working contribute to
who were informed about family planning was increased decision-making power of women to use FP. This finding
by 9% (AOR = 1.09; CI: 1.04, 1.15) than their counter- is similar with other studies in Malawi [40], Ethiopia [2],
parts. Women whose husbands desired fewer children Nigeria [41] and South Asia [42]. Women who have occu-
had a 14% (AOR = 0.86; CI: 0.79, 0.93) reduced chance pations may have power and resources, consequently
of decision- making power for family planning than their leading to increased independence. Therefore, they do
counterparts. not have to depend on their spouses for resources to
Women who had less than 3 and 3–5 children were make decisions and buy contraceptives. Besides, women
1.12 (AOR = 1.12; CI: 1.02, 1.23) and 1.08 (AOR = 1.08; whose husbands had occupation may improve the fam-
CI: 1.01, 1.16) times higher odds of decision-making ily life generally and this may contribute to women’s deci-
power to use family planning than women who had > 5 sion-making power to use FP indirectly.
children, respectively. Women who did not have children Similarly wealth index was positively associated with
had 48% reduced odds of decision-making power to use decision-making power of women. Those women from
FP than women who want to have children (AOR = 0.52; the richest wealth index had higher chance of decision-
CI: 0.47–0.58). Moreover, the odds of decision-making making power to use FP than the poorest ones. This find-
power to use FP was increased by 1.10 (AOR = 1.10; CI: ing is in line with other previous studies which explain
1.04, 1.17) times among respondents who do not want that women’s economic status impacts their health and
other children than those who want to have other chil- decision-making power on contraceptive usage [32, 43,
dren (Table 5). 44]. Women who had more income may have had access
and exposure to mass media about contraceptives and
Discussion hence it increases the likelihood of women’s decision-
The main aim of this study was to determine associated making power to use it. Furthermore, in this study, media
factors of decision-making power to use family planning exposure was associated with women’s decision-making
among married women in sub-Saharan Africa. Accord- power to use FP which is in line with other previous stud-
ingly, in this study age, level of education of women, ies [28, 41]. This is due to the fact that mass media helps
women and their husbands’ occupation, wealth index, to increase the decision-making power of women to use
region, media exposure, ANC visit, fertility preference of contraceptives [29].
women, husbands’ desire in terms of the number of chil- In the present study we observed that women who had
dren and information about family planning were factors more children were less likely to have decision-making
associated with decision-making power of women to use power on the use of contraceptives as compared to those
family planning. who had fewer children. This finding seems odd and in
As this study showed, older women were more likely to contrast with other studies [23, 27]. This might be related
decide to use family planning service than the younger to some religions which teach their followers not to use
ones. This finding is similar to a study conducted in any modern family planning methods. On the other
Ethiopia [28], Mozambique [19] and Bangladesh [36]. A hand, in this study we also found out those women whose
possible explanation is that when women get older, they husbands had higher desire for more number of children
may feel more confident to deal with their husband and had poor decision-making power to use FP. This finding
to decide on family planning use [37]. On the other hand, was similar to a study conducted in Honduras [45] and
young women might not be expected to argue with their Ethiopia [30]. This could be related to husbands’ strong
older husbands and are required to respect their opin- influence on women not to use FP, particularly in devel-
ions which may lead to the low decision-making power of oping countries [46, 47].
younger women to use FP. In this study, women who were informed about FP
The present study revealed that educational status of at a health facility had more decision-making power to
women was associated with decision- making power of use FP as compared to their counterparts. This finding
women to use FP. Consistently, other studies also showed is consistent with other studies [46, 48]. The implication
that educated women had higher odds of decision-mak- of this finding is those women who have information
ing power to use family planning [2, 27, 37, 38]. Educa- and knowledge about family planning could help them
tion improves women’s control over their reproductive to discuss about the use of contraceptives and influence
choices by increasing their position within the family their husbands. Similarly this study showed that those
and educated women are more likely to desire smaller women who attended ANC visits were more likely to
Demissie et al. BMC Public Health (2022) 22:837 Page 7 of 9

Table 5 Multilevel regression analysis of decision-making power to use family planning among married women in sub-Saharan Africa
Decision-making power Odds Ratio
Variables Yes, No (%) No, No (%) COR(95%CI) AOR(95%CI)

Age (years)
15–19 2797 (87) 418 (13) 0.76 (0.66–0.87) 0.61 (0.52–0.72)*
20–24 12,167 (88.9) 1526 (11.1) 0.91 (0.81–1.00) 0.69 (0.60–0.79)*
25–29 17,144 (89.3) 2066 (10.7) 0.96 (0.87–1.07) 0.74 (0.66–0.84)*
30–34 16,092 (89.9) 1799 (10.1) 1.04 (0.94–1.05) 0.82 (0.73–0.92)*
35–39 13,506 (89.9) 1510 (10.1) 1.06 (0.95–1.17) 0.89 (0.79–1.00)
40–44 8798 (89.8) 996 (10.2) 1.01 (0.91–1.13) 0.92 (0.82–1.02)
45–49 4527 (89.5) 536 (10.6) 1 1
Residence
Urban 30,082 (89.3) 3622 (10.7) 1 1
Rural 5229 (10.4) 44,949 (89.6) 1.01 (0.97–1.06) 1.02 (0.96–1.08)
Region
East Africa 34,861 (92.4) 2853 (7.6) 1 1
West Africa 17,302 (85.6) 2901 (14.4) 0.52 (0.49–0.53) 0.52 (0.49–0.56)*
South Africa 13,895 (90.1) 1536 (9.9) 0.76 (0.71–0.81) 0.76 (0.71–0.82)*
Central Africa 8973 (84.2) 1561 (14.8) 0.51 (0.48–0.55) 0.51 (0.47–0.55)*
Educational level of respondents
No education 14,423 (86.3) 2291 (13.7) 1 1
Primary 30,266 (90.4) 3224 (9.6) 1.51 (1.42–1.59) 1.24 (1.16–1.32)*
Secondary 25,250 (89.9) 2851 (10.1) 1.40 (1.32–1.49) 1.31 (1.22–1.41)*
Higher 5093 (91.3) 485 (8.7) 1.66 (1.49–1.85) 1.36 (1.20–1.53)*
Respondents’ occupations
Working 55,489 (90.3) 5965 (9.7) 1.35 (1.29–1.42) 1.27 (1.20–1.33)*
Not working 19,542 (87) 2886 (13) 1 1
Husband’s occupation
Working 69,705 (89.7) 8035 (10.3) 1.24 (1.15–1.35) 1.17 (1.08–1.27)*
Not working 5326 (86.7) 816 (13.30 1 1
Wealth index
Poorest 9656 (88.3) 1277 (11.7) 1 1
Poorer 1558 (11.1) 12,535 (88.9) 1.06 (0.98–1.18) 1.01 (0.93–1.09)
Middle 1736 (11) 14,383 (89) 1.09 (1.01–1.18) 1.01 (0.94–1.09)
Richer 2071 (10.3) 17,239 (89.3) 1.12 (1.04–1.20) 1.02 (0.94–1.11)
Richest 2208 (9.4) 21,217 (0.6) 1.28 (1.19–1.38) 1.13 (1.03–1.23)*
Media exposure
Yes 50,675 (90.1) 5594 (10.9) 1.19 (1.14–1.26) 1.08 (1.03–1.13)*
No 24,335 (88.2) 3251 (11.8) 1 1
ANC visit
No ANC visit 21,972 (89) 2708 (11) 1 1
1–3 ANC visit 1964 (10.2) 17,291 (89.8) 1.08 (1.02–1.51) 1.12 (1.05–1.20)*
  
≥ 4 ANC visit 4179 (10.5) 35,769 (89.5) 1.06 (1.01–1.12) 1.14 (1.07–1.21)*
Number of living children
  < 3 29,429 (89) 3749 (11) 1.06 (0.99–1.13) 1.12 (1.02–1.23)*
3–5 34,552 (89.7) 3964 (10.3) 1.09 (1.02–1.17) 1.08 (1.01–1.16)*
  > 5 11,050 (88.7) 1408 (11.3) 1 1
Fertility preference
Who did not have children 4300 (84.3) 800 (15.7) 0.68 (0.63–0.74) 0.52 (0.47–0.58)*
Do not want other children 29,101 (91.3) 2786 (8.7) 1.29 (1.23–1.36) 1.10 (1.04–1.17)*
Want to have other children 41,630 (88,8) 5265 (11.2) 1 1
Demissie et al. BMC Public Health (2022) 22:837 Page 8 of 9

Table 5 (continued)
Decision-making power Odds Ratio
Variables Yes, No (%) No, No (%) COR(95%CI) AOR(95%CI)

Women who are told FP at health facility

Yes 23,291 (90.1) 2553 (9.9) 1.13 (1.08–1.19) 1.09 (1.04–1.15)*
No 51,739 (89.2) 6298 (10.8) 1 1
Husbands’ desire in terms of number of children
The same with spouse 33,656 (90.5) 3531 (9.5) 1.22 (1.17–1.28) 0.99 (0.94–1.04)
Husbands who wants more 34,518 (88.5) 4505 (11.5) 1 1
Husbands who wants fewer 6856 (89.4) 815 (10.6) 1.07 (0.98–1.16) 0.86 (0.79–0.93)*
*P-value≤0.05

have decision-making power to use family planning. Acknowledgments

We would like to express our thanks to the MEAUSRE DHS Program for provid-
This finding was also consistent with other studies [24, ing the dataset for this study.
36]. One explanation is that women go to health facili-
ties for ANC services where they are receiving health Authors’ contributions
GDD and YY designed the study, analyzed the data and drafted the manu-
information including family planning. script. YA, WA and AAG were involved in the analysis of the data and critically
One strength of this study is the use of a representa- reviewed the article. All authors read and approved the final manuscript.
tive dataset that includes 35 sub-Saharan countries,
Funding
making the findings of this study generalizable to There was no funding for this study.
the region. The other strength of the study is the use
of multilevel modeling, a model that accounts for the Availability of data and materials
All the data related to the study were included in the manuscript. The DHS datasets
nested/hierarchical nature of the demographic and analyzed for this study are available in the DHS repository with its website upon
health survey to get reliable estimates. However, the reasonable request. (https://​dhspr​ogram.​com/​data/​datas​et_​admin/​index.​cfm).
study has also limitations. Because of the secondary
nature of the study, there were some ambiguous meas- Declarations
urement of variables in the data that we could not cor-
Ethics approval and consent to participate
rect at this level which remains as amorphous and we Since we used a secondary DHS data, obtaining ethical approval was not
can also only determine associations; no causality as it needed. However, we have received a permission letter to download and use
is an observational study. The other limitation of this the data files from DHS Program. The protocol was performed in accordance
with the relevant guidelines and regulations.
study is because of we used DHS conducted in different
years, it is impossible to accurately compare results. Consent for publication
Not applicable.
Conclusions Competing interests
Age, women’s level of education, women and their hus- All the authors declare that they have no competing interests.
bands’ occupation, wealth index, media exposure, ANC
Author details
visit, fertility preference, husband’s desire for more number 1
Department of Health Education and Behavioral Sciences, Institute of Public Health,
of children, region and information about family planning College of Medicine and Health Sciences, University of Gondar, P. O. Box, 196 Gondar,
were factors associated with decision-making power to use Ethiopia. 2Department of Human Physiology, School of Medicine, College of Medi-
cine and Health Sciences, University of Gondar, P. O. Box, 196 Gondar, Ethiopia.
family planning among married women. Behavior change 3
Department of Reproductive health, Institute of Public Health, College of Medicine
interventions including health education and promotion in and Health Sciences, University of Gondar, P. O. Box, 196 Gondar, Ethiopia. 4Depart-
this region should target young married women, women ment of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine
and Health Sciences, University of Gondar, P. O. Box, 196 Gondar, Ethiopia.
who are not educated, women who are not currently work-
ing and whose husbands’ desire to have is more number of Received: 27 January 2021 Accepted: 12 April 2022
children thereby to improve the decision-making power of
women to use family planning.
Abbreviations
ANC: Antenatal Care; DHS: Demographic and Health Surveys; FP: Family Plan- References
ning; MMR: Maternal Mortality Ratio; SRH: Sexual Reproductive Health; SSA: 1. WHO. Trends in Maternal Mortality:1990–2015, Estimates by
Sub-Saharan Africa; WHO: World Health Organization. WHO,UNICEF,UNFPA: The World Bank and the United Nations Popula-
tion Division. Geneva: World Health Organization; 2015a.
Demissie et al. BMC Public Health (2022) 22:837 Page 9 of 9

2. Belay A, Mengesha Z, Woldegebriel M, Gelaw Y. Married women’s decision 28. Edossa Z, Debela T, Mizana B. Women’s decision on contraceptive use
making power on family planning use and associated factors in Mizan-Aman, in Ethiopia: multinomial analysis of evidence from Ethiopian demo-
South Ethiopia: a cross sectional study. BMC Womens Health. 2016;16(1):12. graphic and health survey. Health Serv Res Managerial Epidemiol.
3. Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, 2020;7:1–7.
trends, and outcomes. Stud Fam Plan. 2010;41:241–50. 29. Bogale B, Wondafrash M, Tilahun T, Girma E. Married women’s decision
4. Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in making power on modern contraceptive use in urban and rural south-
subSaharan Africa: magnitude of the problem and potential role of ern Ethiopia. BMC Public Health. 2011;11:342.
contraceptive implants to alleviate it. Contraception. 2008;78:73–8. 30. Alemayehu B, Kassa G, Zeleke L, Abajobir A, Alemu A. Married Women’s
5. United Nations General Assembly. Transforming our world: the 2030 Agenda decision-making power in family planning use and its determinants in
for Sustainable Development: General Assembly Resolution 70/1; 2015. Basoliben, Northwest Ethiopia. J Contracept. 2020;11:43–52.
6. United Nations (2017a). The sustainable development goals report. 31. Alem S. Cross sectional study on decision-making power of working
New York: United Nations. 2017. and nonworking women in family planning and reproductive health
7. World Health Organization (WHO). Department of health and human and rights in Gombak. Malaysia Article in J W J Womens Health Issues
services. Office of Population Affairs. 2010;2010. Care. 2014;3(2).
8. Rutstein SO. “Effects of preceding birth intervals on neonatal, infant 32. Becker S, Fonseca-Becker F, Schenck-Yglesias C. Husbands’ and wives’
and under-five years mortality and nutritional status in developing reports of women’s decision-making power in Western Guatemala
countries: evidence from the demographic and health surveys,” Int J and their effects on preventive health behaviors. Soc Sci Med.
Gynecol Obstet,. 2005;89:pp. S7-S24. 2006;62(9):2313–26.
9. Sedgh G, Hussain R. Reasons for contraceptive nonuse among women 33. Grady W, Klepinger D, Billy J, Cubbins L. The role of relationship power
having unmet need for contraception in developing countries. Stud in couple decisions about contraception in the US. J Biosoc Sci.
Fam Plan. 2014;45(2):151–69. 2010;42(3):307–23.
10. Ahman E, Shah I. Unsafe abortion: global and regional estimates of the 34. Hashan MR, Das GR. Differences in prevalence and associated factors
incidence of unsafe abortion and associated mortality in 2008. J Obstet of underweight and overweight/obesity according to rural-urban
Gynaecol Can. 2011;31(12):1149–58. residence strata among women of reproductive age in Bangla-
11. Bremner J, Frost A, Haub C, Mather M, Ringheim K, Zuehlke E. World desh: evidence from a cross-sectional national survey. BMJ Open.
population highlights: key findings from PRB’s 2010 world population 2020;10(2):e034321.
data sheet. Popul Bull. 2010;65(2):1–12. 35. Croft T, Marshall A, Allen C, Arnold F, Assaf S, Balian S. Guide to DHS
12. Do M, Kurimoto N. Women’s empowerment and choice of contracep- statistics. Rockville: ICF; 2018.
tive methods in selected African countries. Int. Perspect Sex Reprod 36. Haque S, Rahman M, Mostofa M, Zahan M. Reproductive health care
Health. 2012:23–33. utilization among young mothers in Bangladesh: does autonomy mat-
13. Wado Y. Women’s autonomy and reproductive healthcare-seeking ter? Womens Health Issues. 2012;22(2):e171–e80.
behavior in Ethiopia. Calverton: ICF International; 2013. 37. Patrikar S, Basannar D, Sharma M. Women empowerment and use of
14. Bourey C, Stephenson R, Bartel D, Rubardt M. Pile sorting innovations: contraception. Med J Armed Forces India. 2014;70:253–6.
exploring gender norms, power and equity in sub-Saharan Africa. 38. Tilahun T, Coene G, Luchters S, Kassahun W, Leye E, Temmerman M,
Global public health. 2012;7(9):995–1008. et al. Family planning knowledge, attitude and practice among mar-
15. International Labour Organization. Global Employment Trends for ried couples in Jimma zone, Ethiopia. PLoS One. 2013;8(4):61335.
Women. 2009:43. 39. Beckman L. Communication, power, and the influence of social
16. Kamala L. Women’s autonomy and utilization of maternal health care networks in couple decisions on fertility. Determinants Fertil Dev
services in rural Nepal. Nepal Population Journal. 2018;18(17). Countries. 1983;2:415–43.
17. Xiaohui H, Ning M. The effect of women’s decision-making power on 40. Kinoshita R. Women’s domestic decision - making power and contra-
maternal health services uptake: evidence from Pakistan. Health Policy ceptive use in rural Malawi. Reprod Health. 2003;2(8).
Plan. 2013;28:176–84. 41. PAULINE O, CHRISTINE G. FACTORS ASSOCIATED WITH WOMEN’S
18. Edward K, Augustine T, Kwaku K, Joshua A. Women’s health decision- HEALTH CARE DECISION-MAKING AUTONOMY: EMPIRICAL EVIDENCE
making autonomy and skilled birth attendance in Ghana. Int J Reprod- FROM NIGERIA. J Biosoc Sci. 2018;50(1):70–85.
uct Med. 2016;9. 42. Senarath U, Gunawardena N. Women’s autonomy in decision
19. Mboane R, Bhatta M. Influence of a husband’s healthcare decision making for health care in South Asia. Asia Pac J Public Health.
making role on a woman’s intention to use contraceptives among 2009;21(2):137–43.
Mozambican women. Reprod Health. 2015;12(1):1–8. 43. Iyayi F, Igbinomwanhia R, Bardi A, Iyayi O. The control of Nigerian
20. Christine D, Kira L, Allison K, Kevin G. Women’s preferences for contra- women over their sexuality in an era of HIV/AIDS: a study of women in
ceptive counseling and decision making. Bone. 2008;23(1):1–7. Edo state in Nigeria. Int NGO J. 2012;6(5):113–21.
21. Bamiwuye S, Wet D, Adedini S. Linkages between autonomy, poverty 44. Osuafor G, Maputle S, Ayiga N. Factors related to married or cohabiting
and contraceptive use in two sub-Saharan African countries. Afr Popul women’s decision to use modern contraceptive methods in Mahikeng.
Stud. 2013;27(2):164–73. South Africa Afr J Prm Health Care Med. 2018;10(1).
22. Wahaga E. The gendered nature of productive and reproductive roles 45. Ilene S, Lisa C. Gender relations and reproductive decision making in
in the agricultural sector. Int J Dev Sustain. 2018;7(1):120–46. Honduras. Int Fam Plan Perspect. 2005;31:131–9.
23. Mussie A, Kiday H, Gebrezgabiher B, Gebremedhin G, Fitwi Tinsae A, 46. Eshete A, Adissu Y. Women’s joint decision on contraceptive use in
Yemane B. Married Women’s autonomy and associated factors on Gedeo zone, southern Ethiopia: a community based comparative
modern contraceptive use in Adwa town, northern Ethiopia. Sci J cross-sectional study. Int J Family Med. 2017.
Public Health. 2014;2(4):297–304. 47. Mason A, Badiani R, Van Nguyen T, Patrick K, Del Carpio X. Toward
24. Mohammad H, Zaina P, Khan MM. Effects of women’s autonomy on gender equality in East Asia and the Pacific. In: A companion to the
maternal healthcare utilization in Bangladesh: Evidence from a national world development report. World Bank East Asia Pacific Reg report.
survey. Sex Reprod Healthc. 2017;14:40–7. Washington DC: World Bank; 2012.
25. Pauline O, Christine G. Women’s autonomy in health care decisionmak- 48. Dabere N, Abebe G, Muluemebet A, Tesfaye S, Kebede D. Factors associ-
ing in developing countries: a synthesis of the literature. International ated with women’s autonomy regarding maternal and child health care
journal of Women’s. Health. 2016. utilization in bale zone: a community based cross-sectional study. BMC
26. Dinku D, Daniel B, Zenebe M, Sintayehu M. Decision-making power Womens Health. 2014;14:79.
of married women on family planning use and associated factors in
Dinsho Woreda. South East Ethiop J Contracept. 2020;11:15–23.
27. Acharya D, Bell J, Simkhada P, van Teijlingen E, Regmi P. Women’s Publisher’s Note
autonomy in household decision-making: a demographic study in Springer Nature remains neutral with regard to jurisdictional claims in pub-
Nepal. Reprod Health. 2010;7(15). lished maps and institutional affiliations.