Empowerment of Women in Union is Associated with Improved Skilled Antenatal Care Attendance: A Pooled Cross-Sectional Analysis of DHS Data in West and Central Africa

Background: Maternal mortality remains unacceptably high in West and Central Africa. Skilled antenatal care (ANC) can prevent avoidable maternal and neonatal deaths, yet coverage remains unequal. Women’s empowerment may increase timely and adequate use of ANC, but comparable measurement has been challenging. Methods: We conducted a secondary analysis of the most recent Demographic and Health Surveys (2015-2021) from nine West and Central African countries with very high maternal mortality (Cameroon, Chad, The Gambia, Guinea, Liberia, Mali, Mauritania, Nigeria and Sierra Leone). The study included 46,759 women in union. The outcome was receipt of at least four ANC visits with a skilled provider (ANC4+). Women’s empowerment was measured using the Survey-based Women’s emPowERment index (SWPER) and categorized into quartiles. Weighted descriptive analyses and survey-adjusted logistic regression were used. Results: Overall, 58.68% of women reported ANC4+, ranging from 32.74% in Chad to 90.12% in Sierra Leone. Compared with women in the lowest empowerment quartile, the odds of ANC4+ increased progressively for women with medium (aOR = 1.14, 95%CI 1.02 - 1.27), high (aOR=1.50, 95%CI 1.34 - 1.68) and very high empowerment (aOR = 2.02, 95%CI 1.77 - 2.31), after adjustment for socio-demographic factors. Conclusion: Women’s empowerment is strongly associated with skilled ANC use in West and Central Africa. Empowerment-oriented, intersectoral actions should complement health-system efforts to accelerate progress toward SDG target 3.1.