contraceptive products and contraceptive access provided privately, as well as life skills training, can increase contraceptive use, which can in turn translate into informed choices about sexual activity and, at times, later onset of sexual intercourse (Ashraf et al., 2014; Bandiera et al., 2020). A randomized controlled trial (RCT) in Mozambique found that introducing female condoms to women led to a substantial increase in the proportion of women who used female condoms, especially among women with lower bargaining power, who were previously having unprotected sex (rather than using male condoms; Cassidy et al., 2021).

RCTs evaluating family planning counseling and education interventions have shown significant impact on contraceptive use among women across multiple national settings and world regions (Mwaikambo et al., 2011; Nanvubya et al., 2022; Zakiyah et al., 2016). They have also proven cost effective (Zakiyah et al., 2016). More recent evidence indicated that gender-transformative family planning interventions (e.g., those that counter traditional gender norms by including male partners and centralizing women’s voice and choice) also showed significant positive effects on contraceptive use but primarily in the form of condom use (Ghanotakis et al., 2017; Raj et al., 2016, 2022). Bapolisi et al. (2020) provided a clear example of these gender-transformative sexual and reproductive health interventions engaging men, in the context of the Democratic Republic of the Congo. Using a longitudinal parallel mixed-methods approach combined with matching techniques, the study assessed the impact of the Mawe tatu program, an intervention linking village savings and loan associations for women with men-to-men sensitization, to transform gender-inequitable norms and behaviors. These two project arms were combined with an educational component about family planning and sexual and reproductive health. The authors found evidence of a positive effect of this combined intervention on the household economy, on child nutritional status, on the use of reproductive health services including family planning, and on reducing sexual and gender-based violence. Studies on gender-transformative family planning with married couples in India yielded similar findings regarding increased contraceptive use, male engagement in family planning, men’s reports of relationship quality, and women’s reports of satisfaction with family planning, as well as reductions in partner violence and traditional masculinity norms (Averbach et al., 2023; Chatterji et al., 2023; Fleming et al., 2018; Raj et al., 2016, 2022).

A quasi-experimental trial design by Ahmed et al. (2015) in rural Bangladesh examined the effect of integrating family planning with a community-based maternal and newborn health program on improving postpartum contraceptive use and reducing short birth intervals (< 24 months). The study found contraceptive prevalence rates in the intervention arm to be 15% higher than in the control arm at 12 months, and birth intervals of

less than 24 months to be significantly lower in the intervention arm. Similarly, Karra et al. (2022) conducted an RCT in Lilongwe, Malawi, to assess the causal impact of improved access to family planning on contraceptive use and pregnancy spacing. The intervention arm received four services over a two-year period: (a) up to six family planning counseling sessions, (b) free transportation to a clinic, (c) free family planning services at the clinic or financial reimbursement for services obtained elsewhere, and (d) treatment for contraceptive-related side effects. The authors found that contraceptive use after two years of intervention exposure increased by 5.9 percentage points, mainly through an increased use of contraceptive implants. Furthermore, the treatment group’s hazard of pregnancy was 43.5% lower 24 months after the index birth, suggesting longer birth spacing. Moreover, a recent study showed that providing personalized digital counseling to women regarding modern contraceptive methods may be as effective in increasing contraceptive use as providing subsidies (Athey et al., 2023).

Additional evidence comes from Naz and Acharya (2021), who evaluated the impact of the Family Advancement for Life and Health (FALAH) project, a family planning program implemented in 31 districts in Pakistan, using a quasi-experimental approach comparing outcomes of multiple children from the same mothers before and after the project. The study found that FALAH increased interbirth intervals by 2.4 months on average and reduced the proportion of short birth intervals by approximately 7.1 percentage points.

One relatively understudied aspect of access to family planning is access to infertility treatment. A recent systematic review and meta-analysis by WHO indicated that, globally, approximately one in six people have experienced infertility at some stage in their lives, equivalent to a lifetime prevalence of 17.5% and a period prevalence of 12.6% in 2022 (WHO, 2023). Availability and access to infertility treatment remain limited in low- and middle-income countries (LMICs), especially in Sub-Saharan Africa. We are not aware of any causal study examining the relationship between women’s empowerment or agency and uptake of infertility treatment. Conversely, correlational studies have shown that infertility is associated with various physical and mental health issues. Infertility can lead to social ostracization or divorce; intimate partner violence; and poor economic, mental, or other health indicators (Kiani et al., 2020, 2021; Polis et al., 2017).

WOMEN’S EMPOWERMENT AND ACCESS TO ABORTION

Comprehensive abortion care, which includes information provision, abortion management, and post-abortion care, is an integral component of women’s sexual and reproductive health. In 2020, WHO included comprehensive abortion care in its published list of essential healthcare services.

The WHO Abortion Care guideline released in March 2022 strives to facilitate evidence-based decision making for quality abortion care that is effective, efficient, accessible, acceptable, person-centered, equitable, and safe (WHO, 2022).

Clarke and Mühlrad (2021) examined the impact of progressive and regressive legislation targeting access to abortion services on women’s health in Mexico using a two-way fixed-effects approach. While the Federal District of Mexico decriminalized and subsidized early-term elective abortion (progressive), other states increased sanctions on “illegal” abortions (regressive). On the progressive end, the authors documented sharp declines in maternal morbidity, especially due to hemorrhage in early pregnancy, suggesting considerable improvements in health outcomes flowing from legal access to abortion. On the regressive end, small or null impacts on women’s health were observed in the states that increased sanctions. It is important to note that when women are denied legal access to abortion, some will seek other means to terminate a pregnancy (e.g., Scrimshaw, 1985).

In the context of India, Rastogi and Sharma (2022) explored whether legal restrictions on prenatal discrimination against females led to shifts by parents toward postnatal discrimination. Leveraging the same cross-temporal and cross-spatial variation described in Nandi (2015), they also documented an increase in female births, yet this was accompanied by less human capital investment in those children, providing evidence of postnatal discrimination. Specifically, females born in states affected by the ban were 2.3, 3.5, and 3.2 percentage points less likely, respectively, to complete grade 10, complete grade 12, and enter university. The study found these effects to be primarily concentrated among the poorest households that had no resources to evade the ban.

WOMEN’S EMPOWERMENT AND WOMEN’S ACCESS TO HEALTHCARE AND SERVICE UTILIZATION

Beyond family planning, associations between women’s empowerment and health-related knowledge, behaviors, care access, and service utilization in LMIC contexts are well documented, particularly in relation to sexual and reproductive health (e.g., HIV), maternal health (antenatal/postnatal), and newborn/early child health services. A multitude of studies have conducted secondary analyses of Demographic and Health Surveys (DHS) data across various countries and settings globally. For example, Htun et al. (2021) analyzed Myanmar DHS data to identify barriers to accessing healthcare among 7,779 married women aged 15–49 years. This study focused on women’s decision-making power and disagreement with justification of wife-beating, which are described in the study as indicators of women’s empowerment but could also be considered indicators of women’s

agency. Barriers to healthcare access include not getting permission to go to the doctor, not being able to get the money needed for advice or treatment, long distances to a health facility, and not wanting to go alone. Using logistic regression, the authors found that women with high empowerment scores experienced fewer barriers when accessing healthcare services generally when compared to married women with low or middle empowerment scores. Barriers to healthcare access were also reduced among women residing in urban areas and those with a higher level of education, fewer children, and richer households. Reviews of the literature involving LMICs show similar predictors of women’s control over decision making to seek healthcare for themselves, including women’s education and employment; husbands’ education and employment; and household wealth (Idris et al., 2023; Osamor & Grady, 2016).

In an analysis of Nepal DHS data, Khatiwada et al. (2020) identified significant associations between various dimensions of women’s empowerment, which they defined as including education, occupation, owning a bank account, media exposure, internet use, and access to skilled birth attendants during delivery. These findings were consistent with those of a prior analysis of DHS data from 31 countries where data on women’s empowerment were available, 21 of which were African countries (Ahmed et al., 2010). That study found that women experiencing empowerment inequities were less likely to utilize health services. Empowerment was measured based on five questions, with a possible score of 0–5, asking women about their involvement in decisions related to their own healthcare, large household purchases, daily household needs purchases, visits to their family or relatives, and daily meal preparation. Women with the highest empowerment scores were found to be significantly more likely to have attended four or more antenatal care visits and to have had a skilled birth attendant than were women with the lowest empowerment scores.

There is also growing research specific to the role of expanding information and communication technologies such as mobile phones, be they simple-feature phones or smartphones enabling full internet connectivity. With technology maturation and expansion of mobile data networks, mobile phone capabilities have expanded from enabling communication to provision of information and delivery of services (Aker & Mbiti, 2010). The increased affordability of mobile phones has also translated into enhanced financial independence and better labor market prospects, especially for women (Suri & Jack, 2016); food security and dietary quality (Bhandari, 2017; Sekabira & Qaim, 2017); better educational outcomes (Aker et al., 2012); and more decision-making power for women in domestic and public domains such as care work (Wekwete, 2014) and politics (Abubakar & Dasuki, 2018; Varriale et al., 2022). One influential study leveraging

a natural experiment suggested that access to the Kenyan mobile money system M-PESA increased per capita consumption levels and lifted 2% of Kenyan households out of poverty. This study also documented more pronounced impacts for female-headed households, which seemed to be driven by changes in financial behavior (e.g., higher saving) and labor market outcomes such as occupational choice, especially for women who moved out of agriculture and into business (Suri & Jack, 2016).

A large-scale study covering over 200 countries found that the expansion of mobile phones was associated with lower gender inequalities, higher contraceptive use, and lower maternal and child mortality, with particularly strong associations among the poorest countries and communities (Rotondi et al., 2020). By complementing macro-level information with micro-level data and quasi-experimental techniques, the study also showed that ownership of mobile phones narrowed the information gap about reproductive and sexual health and increased women’s independent decision making (Rotondi et al., 2020). Some of this evidence is consistent with a correlational study from India suggesting that women’s mobile phone use is positively associated with women’s physical mobility, nonsurgical contraceptive use, and higher community connectivity among women (Rajkhowa & Qaim, 2022). Associational evidence even suggests that benefits may transmit intergenerationally. For instance, using DHS data from 29 countries, Pesando and Qiyomiddin (2023) found that infants born to women owning mobile phones fare consistently better in terms of birth weight. Identified mechanisms are consistent with the idea of broader knowledge and access to healthcare services, and associations were found to be stronger in countries where infant health is poorer, yet mobile phone diffusion is higher, highlighting the comparatively higher potential of the mobile phone diffusion for global development in the poorest contexts.

Focusing on experiences of intimate partner violence, some evidence indicates that mobile phones may help women overcome physical boundaries, especially women who are separated from support networks and are bound within their husbands’ social spheres. A recent study covering 10 low-income countries and employing instrumental-variable and nonparametric matching techniques found that women’s independent (e.g., independent of women’s male partners) ownership of mobile phones was associated with a 9–12% lower likelihood of emotional, physical, and sexual violence over the previous 12 months, even after controlling for characteristics proxying for socioeconomic status, household resources, and local development within the community (Pesando, 2022). The study also showed that mobile phone ownership was positively associated with women’s decision-making power within the household and male partners’ lower acceptability of intimate partner violence. Importantly, this was not observed in all countries, with Angola emerging as an exception—here, women’s mobile phone

ownership was associated with higher likelihood of experiencing intimate partner violence. This evidence is consistent with the idea that, in some contexts—especially where digital gender gaps are still wide, independent device use is limited, and shared device use is still the norm—mobile phones may serve as “disempowering” devices: independent (or even concealed) use of mobile phones may in fact trigger violent reactions from male partners, who feel threatened by “new” status imbalances within the household unsettling norms of male dominance. Large-scale comparative studies (McDougal et al., 2019) as well as qualitative research in selected low-income countries support this possibility (Mpiima et al., 2019; Uduji & Okolo-Obasi, 2018). In line with the above disempowering scenario, technology and media may also spread gender-traditional ideas and strengthen gender stereotypes, thus reinforcing backlash effects, as shown by Forsyth and Ward (2022) in Honduras and Gray (2014) in Malawi.

A comprehensive overview of the implications of mobile phone expansion for dynamics of gender equality in areas such as health, agriculture, education, food security, labor markets, business, and participation in politics can be found in Pesando and Rotondi (2020). One central tenet of this expanding scholarship is that the full potential of mobile phone technology cannot be reached if digital divides by gender persist. Women are still far less likely to own mobile phones on their own, use them less often when they have access, and have poorer information and communication technology skills compared to men, thus creating second-level (skill-related) digital divides on top of first-level (access-related) divides (Blumenstock & Eagle, 2010; Fatehkia et al., 2018), and therefore highlighting a key area for policy intervention.

Access to healthcare has also been found to be a significant contributor to women’s empowerment and agency, illustrating the reciprocal nature of empowerment and healthcare access. Asaolu et al. (2018) analyzed DHS data from 19 countries in Sub-Saharan Africa, defining women’s empowerment as attitudes toward violence, labor force participation, education, and access to healthcare. In this study, access to care was described as the distance to health facilities, ability to afford services, and the permission to access services. The study concluded that removing healthcare barriers can empower women by providing resources that allow women to exercise their agency.

Other studies show an association between women’s empowerment and antenatal and postnatal service utilization. In an analysis of four rounds of Ethiopia DHS data of 61,635 women ages 15–49 years from 2000–2016, Shibre et al. (2023) found that highly empowered women used more antenatal and postnatal care services than poorly empowered women did. This study utilizes empowerment, defined as decision making, social independence, and attitudes toward violence, as an equity stratifier to assess

inequalities in the uptake of maternal child health (MCH) services, including early antenatal care and four or more antenatal care and postnatal care services. Similarly, a cross-sectional study with 200 women in Bangladesh aimed to identify the patterns between women’s empowerment, in terms of mobility and decision making, and health-seeking behavior (Mainuddin et al., 2015). This study found that only 12% of women were empowered or had the agency to make their own decisions about seeking healthcare, and that women’s empowerment could enhance decision-making authority related to health-seeking behavior. Additional studies using DHS data from LMICs showed that enhanced decision making could increase chances of attending antenatal care visits during pregnancy, receiving skilled antenatal care, making the first prenatal visit during the first three months of pregnancy, and delivery in a hospital (Fawole & Adeoye, 2015; Mokam & Zamo Akono, 2022; Sripad et al., 2019).

An analysis of DHS data in Bangladesh evaluated dimensions of women’s empowerment alongside the continuum of care (CoC) for maternal health (including pregnancy, delivery, and postpartum care) among 4,942 married women of reproductive age who had at least one live birth in the past three years (Rahman et al., 2021). After adjusting for individual-, household-, and community-level variables, women with higher social independence were found to have more antenatal care visits, higher retention of skilled birth attendants, and higher completion of full CoC than women with low social independence. Indicators under the social independence domain, including frequency of reading newspapers or magazines, education, age at first cohabitation, and age at first birth, were found to be important predictors of CoC.

Finally, Nieuwenhuijze and Leahy-Warren (2019) systematically reviewed 97 primary research articles (qualitative, quantitative, and mixed methods) from LMICs and high-income countries, focused on empowerment in the areas of birth experience, maternal and newborn health outcomes, use of maternity services, participation in care, and satisfaction with care. This review identified four consequences of women’s empowerment in pregnancy and childbirth, finding that women’s empowerment based on decision-making indicators during pregnancy and childbirth could increase women’s satisfaction with the birth experience, deeming it positive, exuding a sense of accomplishment, and providing an opportunity to heal from a previous traumatic birth. Empowerment was also found to contribute to the woman’s overall health as well as the health of her baby and family, enhancing self-confidence and emotional well-being, increasing self-advocacy in terms of more assertive interactions with providers, and contributing to a sense of control over choice and decision making.

women with more intrinsic agency, measured by attitudes about domestic violence, had taller and heavier children; women with greater instrumental agency, measured by influence over household decisions, had children who were less anemic (Jones et al., 2020a). Other studies focused on concordance in spouses’ reports of who makes household decisions. For example, a study of 26 African countries found that children were less likely to have low height-for-age, low weight-for-height, or incomplete vaccination status when their mothers and fathers agreed that the mother had at least equal say in household decisions or when their mothers claimed more power than their fathers (Annan et al., 2021). Other studies focused on the distinction between community- and individual-level agency. For example, a study of 12 African, Latin American, and South Asian countries found that women’s decision-making power predicted children’s immunization status, nutritional status, and survival more consistently across communities than across women within communities (Desai & Johnson, 2005).

India stands out for having especially large and statistically significant associations between women’s decision-making power and children’s health across all outcomes and all levels of analysis (Desai & Johnson, 2005). As seen for research on women’s agency and women’s health, India also provides a great deal of insight into the relationship between women’s positioning in the family and child health. In joint Indian households, in which multiple adult brothers live in the same household, the children of lower-ranking wives were shown to have higher neonatal mortality and lower height-for-age (Coffey et al., 2022).

Lower fertility can also improve children’s health and mortality if, due to smaller family size, parents can invest more in each child’s health and development. Yount et al. (2014) examined how fertility decline affected girls’ well-being and gender gaps in children’s well-being in poor countries, using several years of DHS data. They found that fertility decline and women’s later first birth were associated with gains in girls’ survival at ages 1–4 years, vaccination coverage at ages 12–23 months, and nutrition at 0–36 months. The study demonstrated that the gender gaps in child health reduced as women’s median age at first birth increased.

Causal evidence for this so-called “quantity-quality” tradeoff is lacking, however—it is unclear whether factors that cause delayed childbearing (e.g., greater education) also cause improvements in child health, or whether health improvements stem from lower/delayed fertility itself. However, earlier work on child survival, birth spacing, and birth order for nearly 3,000 low-income women in Ecuador demonstrated the negative impact of high birth order and closely spaced births on the survival of infants and young children (Wolfers & Scrimshaw, 1975).

5,128 following the intervention (Harris-Fry et al., 2016). They found that women’s participatory groups could significantly improve women’s health knowledge, including improvements in women’s dietary diversity scores and participation in healthcare decision making, as well as knowledge regarding contraception, treatment and prevention of sexually transmitted infections, nutrition, and anemia prevention. Other interventions aimed at mitigating domestic violence (Krishnan et al., 2012), improving community health and nutrition (Pradhan et al., 2023), and addressing upstream causes of food insecurity all showed promise in enhancing women’s empowerment and reducing negative health outcomes.

Using a clustered RCT design, Handa et al. (2014, 2015, 2017) evaluated a national poverty program named Kenyan Cash Transfer for Orphans and Vulnerable Children, an unconditional transfer of US $20 per month to eligible households. The program aimed to positively affect sexual and reproductive health outcomes and socioeconomic development of women, girls, and their families by improving household-level economic stability, investing in educational opportunities, promoting equitable household and community gender norms, and increasing young women’s life aspirations and reproductive agency. The program reduced the odds of early initiation of sexual activity by 31%, yet it had no effects on outcomes such as condom use, number of partners, and transactional sex. Additional findings indicated that, while the program reduced the likelihood of pregnancy by 5 percentage points, there was no significant impact on likelihood of early marriage. Program impacts on pregnancy appeared to work through increasing the enrollment of young women in school, financial stability of the household, and delayed age at first sexual encounter. Another randomized cash transfer, conditional on girls’ monthly high school attendance in South Africa, decreased the risk of physical intimate partner violence by delaying girls’ sexual initiation and reducing the number of sexual partners (Kilburn et al., 2018).

SUMMARY AND CONCLUSIONS

As described in this chapter, a significant body of largely descriptive and associational survey research exists to support relationships between women’s empowerment and healthcare access, service utilization, and outcomes. The areas that received the greatest attention (and that have causal evidence) include interventions and programs designed to improve sexual and reproductive health access, family planning use, antenatal health, and infant to young child health outcomes, in part by affecting women’s agency or also by affecting indicators of socioeconomic development. Notably, interventions designed to address educational and economic opportunities and social capital have shown positive effects on family planning outcomes

(e.g., decreased early marriage, older age at sexual debut, reduced unintended pregnancy, and improved healthcare access) in LMICs, most notably in Sub-Saharan Africa. This work has mainly focused on measuring agency at the individual level and through indicators of self-efficacy, reproductive autonomy, and householding decision making.

Beyond the RCT and quasi-experimental designs cited in this chapter, a larger portion of the existing work has relied upon DHS data and/or secondary analyses of cross-sectional data, has been conducted in limited and specific geographical and clinical settings, and has used empowerment indicators based on somewhat narrow definitions or unidimensional measures. As noted in Chapter 4, associations between health outcomes, women’s empowerment, and socioeconomic development are often bidirectionally framed in the literature. As such, our new conceptual framework considers health fundamental to population dynamics and socioeconomic development. Finally, the greatest body of work reviewed focused on individual-level conceptualizations and targets for empowerment, with less overall evidence existing for measurements and interventions designed to affect agency and subsequently the health of women and girls at community and societal levels.

Overall, future research is warranted to expand the evidence base, to further illuminate causal associations between women’s empowerment and health and healthcare access using primary data collection, longitudinal and prospective designs, quasi-experimental RCTs, and mixed-methods policy-evaluation approaches. Studies are warranted using a broader range of multidimensional measures of both empowerment indicators and priority outcomes that relate to patient-/woman-/community-centered health and healthcare experiences, importantly of quality and respectful care and both within and outside the formal healthcare sectors. Additionally, studies focused on a holistic set of physical, mental, reproductive, and behavioral health conditions most salient to women and their families and communities, across the life course (including beyond reproductive and economically productive years) and across generations, are critically important.

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