Journal Article

Association between self-reported gender-based discrimination and maternal mortality rates: results of an ecological multi-level analysis across nine countries in Sub-Saharan Africa

Quentin, Wilm, Faye, Adama, Mohammed, Shafiu, Sisimayi, Chenjerai, Niangaly, Hamidou, Waitzberg, Ruth, Chitah, Bona, Fonn, Sharon, Dossou, Jean-Paul, Elwange, Charlestine Bob, Orduhan, Clara, De Allegri, Manuela, Kambala, Christabel

2025

Overview

Background Sub-Saharan Africa suffers from the highest maternal mortality ratio (MMR) in the world, with 542 deaths per 100,000 live births in 2017, relative to a global ratio of 211. Reducing gender-based discrimination (GBD) and increasing the empowerment of women and girls have recently been recognized as prerequisites for improving maternal health. Previous studies have shown GBD to result in low utilization of maternal health services and poorer quality of care. However, limited research is available on the relationship between GBD and maternal mortality in Sub-Saharan Africa (SSA). Therefore, the objective of this study was to assess whether GBD is associated with maternal mortality in SSA. Methods We investigated the association between self-reported GBD and maternal mortality in an ecological study. We used data from two surveys: the Demographic and Health Surveys (DHS) and the Afrobarometer. Data refer to 78 sub-national regions, located in nine Sub-Saharan African countries (Benin, Malawi, Mali, Nigeria, Senegal, South Africa, Uganda, Zambia, and Zimbabwe). Data were analyzed using a two-level linear regression model with random intercept. The regression controlled for covariates at region- and country-level. Results The proportion of women who reported experiencing GBD varied between 0% in several regions in Benin, Mali, Senegal, South Africa, and Zimbabwe and 24·7% in Atacora, Benin. We identified a positive association between the proportion of women who reported experiencing GBD in a region in the past year and MMR (β 0.88, CI [0.65; 1.12]). A 1% increase in the proportion of women experiencing GBD resulted in an increase of the MMR by nearly two, meaning, an additional two more maternal deaths per 100,000 live births. This association was even more pronounced after adjusting for region-level covariates, but did not change with the inclusion of country-level covariates (β 1.95, CI [1.71; 2.19]). Conclusions The study’s findings show that the rate of self-reported GBD is associated with maternal mortality in a region, even after controlling for other factors that are known to influence maternal deaths. However, our model does not rule out endogeneity. Further research is needed to unravel causal pathways between GBD and maternal mortality.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Analysis / Biostatistics / Births / Data / Deaths / Discrimination / Domestic violence / Ecological studies / Ecological study / Economic aspects / Empowerment / Environmental Health / Epidemiology / Family planning / Fatalities / Fertility / Folkhälsovetenskap, global hälsa och socialmedicin / Gender / Gender discrimination / Health / Health aspects / Health services / Health services utilization / Health status / Health surveys / Inequality / Maternal & child health / Maternal and child access to health and healthcare / Maternal characteristics / Maternal health services / Maternal mortality / Medical care / Medicine / Medicine & Public Health / Mortality / Mortality rates / Mothers / National security / Patient outcomes / Polls & surveys / Public Health / Public Health, Global Health and Social Medicine / Quality management / Quality of care / Regions / Regression models / Reproductive health / Self report / Sex discrimination / Sex ratio / Social aspects / Sub-Saharan africa / Surveys / Vaccine / Variables / Women