RESEARCH ARTICLE
Women’s ep oduc i e heal h decision-
making: A mul i-coun y analysis o
demog aphic and heal h su eys in sub-
Saha an A ica
Eugene Ko uo Maa o Da ehID
1
*, Kwamena Sekyi Dickson
1
, Da id Teye Doku
1,2
1Depa men o Popula ion and Heal h, Uni e si y o Cape Coas , Cape Ghos , Ghana, 2Uni e si y o
Tampe e, Facul y o Social Sciences, Heal h Sciences and PERLA (Tampe e Cen e o Childhood, You h
and Family Resea ch), Uni e si y o Tampe e, Tampe e, Finland
*[email p o ec ed]
Abs ac
In oduc ion
Women’s abili y o make decisions ega ding hei ep oduc i e heal h has impo an impli-
ca ions o hei heal h and well-being. We s udied he socio-demog aphic ac o s a ec ing
ep oduc i e heal h decision-making among women in 27 sub-Saha a A ican coun ies.
Ma e ials and me hods
The s udy made use o pooled da a om cu en Demog aphic and Heal h Su ey (DHS)
conduc ed om Janua y 1, 2010 and Decembe 31, 2016 in 27 coun ies in sub-Saha a A i-
can. Bina y and mul i a ia e logis ic eg ession models we e used o in es iga e he associ-
a ions o women’s socio-demog aphic ac o s wi h decision-making ega ding sexual
ep oduc i e heal h.
Resul s
The p opo ion o women who can ask hei pa ne s o use a condom du ing sexual in e -
cou se anged om lowes in Mali (16.6%) o highes in Namibia (93.4%). Fu he mo e, he
p opo ion o women who can e use sex anged om 18.3% in Mali o 92.4% in Namibia.
O e all, app oxima ely e e y i e ou o en women can ask hei pa ne s o use a condom,
six ou en women could e use hei pa ne s sex and se en ou o en women could make
a leas 1 decision. Women om u al a eas (OR = 0.51, CI = 0.48–0.54), hose wi h no edu-
ca ion (OR = 0.11, CI = 0.10–0.12), Muslim women (OR = 0.29, CI = 0.27–0.31), women no
wo king (OR = 0.53, CI = 0.51–0.56) and women whose pa ne s had no educa ion (OR =
0.17, CI = 0.16–0.19) we e less likely o make a decision on hei ep oduc i e heal h.
Conclusion
Residence, age, le el o educa ion, eligion, occupa ion and pa ne ’s educa ion we e ound
o be associa ed wi h women’s decision-making abou sexual in e cou se, condom use and
PLOS ONE | h ps://doi.o g/10.1371/jou nal.pone.0209985 Janua y 9, 2019 1 / 12
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OPEN ACCESS
Ci a ion: Da eh EKM, Dickson KS, Doku DT
(2019) Women’s ep oduc i e heal h decision-
making: A mul i-coun y analysis o demog aphic
and heal h su eys in sub-Saha an A ica. PLoS
ONE 14(1): e0209985. h ps://doi.o g/10.1371/
jou nal.pone.0209985
Edi o : Mellissa H. Wi he s, USC Keck School o
Medicine, Ins i u e o Global Heal h, UNITED
STATES
Recei ed: May 23, 2018
Accep ed: Decembe 14, 2018
Published: Janua y 9, 2019
Copy igh : ©2019 Da eh e al. This is an open
access a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License, which
pe mi s un es ic ed use, dis ibu ion, and
ep oduc ion in any medium, p o ided he o iginal
au ho and sou ce a e c edi ed.
Da a A ailabili y S a emen : All ele an da a is
a ailable o he public a h ps://dhsp og am.com/
da a/a ailable-da ase s.c m. The au ho s con i m
hey had no special p i ileges o access o he da a.
Funding: The au ho s ecei ed no speci ic unding
o his wo k.
Compe ing in e es s: The au ho s ha e decla ed
ha no compe ing in e es s exis .
ep oduc i e heal h decision-making index. This s udy con ibu es o he discou se on ep o-
duc i e heal h decision-making in A ica. Policies and in e en ion a ge ed a imp o ing
women’s au onomy and empowe ing hem o ake cha ge o hei sexual and ep oduc i e
heal h issues should be ocused on hese ac o s.
In oduc ion
Sexual and ep oduc i e heal h may e e o indi iduals being able o eely make decisions
abou hei sexual ac i i y, ha is, choose when, whe e, and wi h whom o ha e sexual in e -
cou se [1]. Rep oduc i e heal h and igh s o women became o global in e es a e he In e -
na ional Con e ence on Popula ion De elopmen (ICPD) P og am o Ac ion in Cai o in 1994.
A o al o 179 coun ies a he ICPD in Cai o ad oca ed ha women should ha e he igh s o
eely decide on hei ep oduc i e heal h de oid o any disc imina ion [1]. This was u he
a i med by he ou h women con e ence in Beijing in 1995 [2].
Gende inequali ies ha e e ec s on ep oduc i e heal h decision-making and i is a p inci-
pal componen o he social con ex o ep oduc i e heal h [3,4]. Women’s abili y o make
decision ega ding hei ep oduc i e heal h had been cu bed due o hei lack o au onomy
and powe ela ions wi h men being mo e in luen ial in decision-making [4]. Women’s au on-
omy is c i ical o he social, economic and sus ainable de elopmen o any coun y. In iew o
his, he sus ainable de elopmen goal (SDG) emphasizes gende equali y. I inc eases hei
ep oduc i e con ol, a i udes and abili y o nego ia e o sa e sex [5,6].
In he global comba agains HIV and AIDS, s udies had highligh ed he essence o commu-
nica ion be ween sexual pa ne s conce ning sa e sex [7,8]. Nego ia ion be ween sexual pa -
ne s abou condom use and sa e sex is associa ed wi h inc eased use o condoms [9]. S udies
ha e shown ha women’s au onomy is epea edly cons ained by educa ional, economic, cul-
u al and social condi ions [10,11,12,13].
In low- and middle-income coun ies, pa icula ly sub-Saha an A ica and Sou he n Asia,
he e a e se e al socio-economic and cul u al ac o s which a ec women’s abili y o make
decision ega ding hei own heal h and hose o hei dependen s, especially child en [14,15].
Ea lie s udies ha e ocused on some aspec s o ep oduc i e heal h, women au onomy and
decision-making, using sub-popula ions wi hin some coun ies in sub-Saha an A ica
[5,10,16,17,18,19,20]. As a as we know, no s udy has in es iga ed he subjec in mul iple
coun ies in he egion. We aim o p o ide na ional and egional es ima es o women’s au on-
omy in ep oduc i e heal h decision-making in 27 sub-Saha an A ican coun ies and we u -
he examine he ac o s associa ed wi h ep oduc i e heal h decision-making in hese
coun ies.
The concep o decision-making can be ca ego ized in h ee main ideas, hus, decision mak-
ing as a igh [21], as a choice [22] and as a p ocess [23]. Decision making is a p ocess ha
s a s wi h p oblem iden i ica ion, da a collec ion and ga he ing, analysis o da a, indings,
selec ing an app op ia e and mos sui able solu ion om he al e na i e solu ions and inally
e alua ion o he p ocess [23]. Socio-demog aphic cha ac e is ics such as le el o educa ion
[5], pa ne educa ional le el [5,10] and weal h s a us [10,16] ha e he po en ial o in luencing
an indi idual in making in o med decision. Exposu e o in o ma ion and knowledge and he
abili y o p o ide o one’s needs is a posi i e in luence on decision-making. By ex ension, a
woman’s decision making abou he sexual and ep oduc i e heal h will be e ec i ely accom-
plished based on he abili y o p o ide o he needs and he exposu e o knowledge.
Women’s ep oduc i e heal h decision making in sub-Saha an A ica
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None heless, he e a e possibili ies o o he backg ound cha ac e is ics such as eligious a ilia-
ion [10,16], place o esidence [23] and cul u al leanings [18,19,20] ha can ha e impac on
he decision-making p ocess [15]. In sub-Saha an A ica in pa icula , eligious a ilia ion, cul-
u al and social and place o esidence se ings also a ec women’s ep oduc i e heal h deci-
sion-making [10]. This a gumen is consis en wi h he P ed’s Beha iou al Ma ix [23].
Ma e ials and me hods
The s udy made use o pooled da a om cu en Demog aphic and Heal h Su ey (DHS) con-
duc ed om Janua y 1, 2010 and Decembe 31, 2016 in 27 coun ies in sub- Saha an A ica.
DHS is a na ionwide su ey collec ed e e y i e-yea pe iod ac oss low and middle-income
coun ies. DHS ocuses on ma e nal and child heal h by in e iewing women o ep oduc i e
age (15–49 yea s). DHS su eys ollow he same s anda d p ocedu es—sampling, ques ion-
nai es, da a collec ion, cleaning, coding and analysis—which allows o c oss–coun y compa -
ison. The su ey employs a s a i ied wo-s age sampling echnique. The i s s age in ol ed
he selec ing o poin s o clus e s (enume a ion a eas [EAs]). The second s age is he sys ema ic
sampling o households lis ed in each clus e o EA. All women in hei ep oduc i e age (15–
49) who we e usual o selec ed households o isi o s who slep in he households on he nigh
be o e he su ey we e in e iewed. The esponse a e a ied om 86.2% o 100.0%. Fo he
pu pose o his, only women who had in o ma ion on ep oduc ion heal h decision-making
we e used (N = 210,536), hus, women who we e ei he ma ied o li ing wi h a pa ne .
Women ga e o al and w i en consen . E hical app o al o DHS is usually ob ained om he
e hics egula o y boa ds o he coun ies o which he s udies a e conduc ed and by ICF In e -
na ional’s ins i u ional e iew boa d. Pe mission o use he da a se was so om MEASURE
DHS. Da a se is a ailable o he public a h ps://dhsp og am.com/da a/a ailable-da ase s.c m
(da a was no collec ed o owned by he au ho s; po en ial use s would be gi en access once a
concep no e is sen o MEASURE DHS)
De ini ion o a iables
Ou come a iables. The h ee main ou come a iables used we e: (1) decision-making on
sexual in e cou se, (2) decision-making on condom use, and (3) ep oduc i e heal h decision-
making index. Fo he i s a iable, women we e asked i hey can e use hei pa ne sex. Fo
he second a iable (i.e. decision-making on condom use), women we e asked i he can ask
hei pa ne s o use condoms. The esponse ca ego y o hese a iables we e: 1 = “yes”, 2 =
“no” and 3 = “don’ know/ no su e”. This esponse was ca ego ized as 0 = “no and don’
know” and 1 = “yes” (see Da eh e al. [10]). The hi d ou come a iable, ep oduc i e heal h
decision-making index, is gene a ed om he combina ion o he decision-making on sexual
in e cou se and he decision-making on condom use a iables. This was ca ego ized as 0 = no
decision and 1 = a leas 1 decision.
Explana o y a iables. The explana o y a iables consis o : esidence, age, weal h s a us,
educa ion, eligion, occupa ion and pa ne ’s educa ion. Residence was ca ego ized as u ban
and u al. Age was g ouped in 5 –yea in e al: 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–
49. Weal h s a us was de i ed om he owne ship o a a ie y o household asse s and ca ego-
ized as poo es , poo e , middle, iche and iches . Le el o educa ion and pa ne ’s educa ion
was cap u ed as no educa ion, p ima y, seconda y and highe educa ion. Religion was
eco ded as Ch is ian, Muslims and O he s. Religion was no a ailable o Nige . Occupa ion
was ca ego ized as no wo king, wo king.
Women’s ep oduc i e heal h decision making in sub-Saha an A ica
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S a is ical analysis
All da a se s om he 29 coun ies downloaded om MEASURE DHS we e me ged and
appended as one da a se be o e he analysis was done. Desc ip i e and in e en ial s a is ics
we e used. Desc ip i e igu es a e epo ed in pe cen ages by coun ies. Bina y and mul i a i-
a e logis ic eg ession models we e used o in es iga e he ela ionship be ween he explana o y
a iables and he ou come a iables. Two models we e used o assess he p edic o s o wom-
en’s decision-making on sexual in e cou se, decision-making on condom use, and ep oduc-
i e heal h decision-making index. Model I looked a a bi a ia e analysis be ween each o he
p edic o a iables and he ou come a iable. Model II was i ed o in es iga e he associa ion
be ween he independen a iables and he ou come a iables (decision-making on sexual
in e cou se, decision making on condom use, and ep oduc i e heal h decision-making
index). All equency dis ibu ions we e weigh ed whils he su ey command in S a a was
used o adjus o he complex sampling s uc u e o he da a in he eg ession analyses. All
esul s o he logis ic analyses we e p esen ed as odds a ios (ORs) wi h 95% con idence in e -
als (CIs).
Resul s
Table 1 shows selec ed in o ma ion om women om 27 coun ies in sub-Saha an A ica.
The p opo ion o women who could ask hei pa ne o use a condom du ing sexual in e -
cou se anged om 16.6% in Mali o 93.4% in Namibia. P opo ion o women who could
e use sex anged om 18.3% in Mali o 92.4% in Namibia. The p opo ion o women who
could make a leas 1 o he ep oduc i e heal h decisions anged om 25.5% in Mali o 97.2%
in Namibia. O e all, app oxima ely e e y i e ou o en women could ask a pa ne o use a
condom, six ou en women could e use hei pa ne s sex and se en ou o women could
make a leas 1 decision.
Table 2 p esen s he odds o making a decision on sexual in e cou se, condom use and
ep oduc i e heal h among women in 29 sub–Saha an A ican coun ies. Residence, age,
weal h s a us, educa ion, eligion, occupa ion and pa ne ’s educa ion s ongly p edic ed deci-
sion-making on sexual in e cou se and condom use among women in he 29 sub–Saha an
A ican coun ies. Women om u al a eas we e less likely o decide on sexual in e cou se
(OR = 0.58, CI = 0.55–0.61), condom use (OR = 0.54, CI = 0.51–0.57) and o e all decisions on
ep oduc i e heal h (OR = 0.51, CI = 0.48–0.54), compa ed o hose om u ban a eas. The
e ec s o women’s age on hei abili y o ake decision a ied and we e mainly posi i e. Fo
ins ance, women aged 20–24 yea s we e 1.07 imes mo e likely o decide o ha e sex o no
(CI = 1.02–1.12), 1.54 imes mo e likely o decide o use condom o no (CI = 1.47–1.62) and
1.20 imes mo e likely o decide on hei ep oduc i e heal h (CI = 1.14–1.26), compa ed o
women aged 15–19 yea s. The ela ionship be ween weal h s a us and women’s abili y o make
decision was mainly nega i e. Women wi h poo es weal h s a us we e 0.44 imes less likely o
decide o ha e sex o no , 0.32 imes less likely o decide o use condom o no and 0.33 imes
less likely o decide on hei ep oduc i e heal h, compa ed o women wi h iches weal h
s a us.
The ela ionship be ween eligion and women’s abili y o make decision was mainly nega-
i e. Muslim women we e 0.39 imes less likely o decide o ha e sex o no , 0.30 imes less
likely o decide o use condom o no and 0.29 imes less likely o decide on on hei ep oduc-
i e heal h, compa ed o Ch is ian women. Women who we e no wo king we e 0.58 imes
less likely o decide o ha e sex o no , 0.69 imes less likely o decide o use condom o no
and 0.54 imes less likely o decide on hei ep oduc i e heal h, compa ed o women wo king
ou side hei home. On he o he hand, women who wo k a home we e 1.33 imes mo e like
Women’s ep oduc i e heal h decision making in sub-Saha an A ica
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o decide o ha e sex o no , 2.56 imes mo e likely o decide o use condom o no and 1.89
imes mo e likely o decide on hei ep oduc i e heal h, compa ed o women wo king ou side
hei home. Women wi h no educa ion we e 0.19 imes less likely o decide o ha e sex o no ,
0.12 imes less likely o decide o use condom o no and 0.11 imes less likely o decide on
hei ep oduc i e heal h, compa ed o women wi h highe educa ion.
In he inal mul i a ia e model, he s a is ical associa ions be ween all he exposu es and he
h ee ou comes we e e ained, al hough mos o he odds we e a enua ed (Table 3). The only
excep ion is ha he associa ions o decision-making on sexual in e cou se wi h age and weal h
s a us los hei s a is ical signi icance.
Discussion
This pape examined he p e alence o ep oduc i e heal h decision-making and he ac o s
ha de e mine women’s decision-making on ep oduc i e heal h issues in 27 sub-Saha an
A ican coun ies. The s udy ound ou ha he e we e wide a ia ions in he p opo ion o
Table 1. Backg ound cha ac e is ics o sampled women in 27 sub–Saha an A ican coun ies.
Coun y Weigh ed N�% can ask pa ne
o use a condom
% can e use sex Rep oduc i e heal h decision index
No Yes No Yes No decision A leas 1
Benin, 2011–2012 11,045 61.6 38.4 47.2 52.8 41.9 58.1
Bu undi, 2011 5,424 33.7 66.3 39.4 60.6 19.6 80.4
Came oon, 2011 4,682 42.7 57.3 25.4 74.6 19.9 80.1
Chad, 2014–2015 4,553 82.6 17.4 55.6 44.4 51.8 48.2
Como os, 2012 3,087 54.4 45.6 55.7 44.3 43.5 56.5
Congo, 2011–2012 6,259 34.4 65.6 29.4 70.6 14.9 85.1
Congo DR, 2013–2014 12,119 60.1 39.9 33.8 66.2 25.8 74.2
Co e d’ oi e, 2011–2014 6,290 58.0 42.0 42.9 57.1 35.3 64.7
E hiopia, 2011 10,225 63.2 36.8 47.0 53.0 38.0 62.0
Gabon, 2012 4,383 18.2 81.8 18.4 81.6 8.3 91.7
Gambia, 2013 6,763 55.7 44.3 47.7 52.3 39.6 60.4
Ghana, 2014 5,382 33.3 66.7 26.1 73.9 17.8 82.3
Guinea, 2012 6,727 75.8 24.2 59.9 40.1 39.6 60.4
Kenya, 2014 8,679 25.6 74.4 25.7 74.3 14.3 85.7
Leso ho, 2014–2015 1,662 7.9 92.1 24.6 75.4 3.2 96.8
Libe ia, 2013 5,382 43.7 56.3 15.4 84.6 12.7 87.3
Malawi, 2010 15,577 22.4 77.6 25.1 74.9 12.3 87.7
Mali, 2012–2013 7,509 83.4 16.6 81.7 18.3 74.5 25.5
Mozambique, 2011 9,337 61.1 38.9 51.2 48.8 44.9 55.1
Namibia, 2015 3,090 6.6 93.4 7.7 92.3 2.8 97.2
Nige ia, 2013 27,749 61.9 38.1 38.7 61.3 33.7 66.3
Rwanda, 2014–2015 6,962 16.7 83.3 17.3 82.7 6.9 93.1
Sie a Leone, 2013 10,800 67.4 32.6 31.4 68.6 28.8 71.2
Senegal, 2010–2011 10,390 69.9 30.1 71.0 29.0 58.2 41.8
Togo, 2013–2014 6,298 39.8 60.2 28.1 71.9 21.7 78.3
Zambia, 2013–2014 9,837 24.2 75.8 30.4 69.6 15.4 84.6
Zimbabwe, 2015 6,155 29.2 70.8 28.2 71.8 14.1 85.9
All Coun ies ( o al) 210,536 50.2 49.8 39.3 60.7 30.7 69.3
�Numbe o women wi h da a on ep oduc i e heal h decision
h ps://doi.o g/10.1371/jou nal.pone.0209985. 001
Women’s ep oduc i e heal h decision making in sub-Saha an A ica
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Table 2. Logis ic eg ession model showing he ela ionship (Odds a io) be ween backg ound cha ac e is ics and women’s decision-making on sexual in e cou se,
condom use and ep oduc i e heal h decision-making index in 27 sub-Saha an A ican coun ies, 2010–2016.
Explana o y ac o s P opo ions
N = 210,536
Decision-making on sexual in e cou se Decision-making on condom use Rep oduc ion heal h decision-making index
Model I
Odds Ra io (OR) 95% CI
Model I
Odds Ra io (OR) 95% CI
Model
Odds Ra io (OR) 95% CI
Residence
U ban 73,097 Re Re Re
Ru al 137,439 0.58���(0.55–0.61) 0.54���(0.51–0.57) 0.51���(0.48–0.54)
Age
15–19 16,259 0.75���(0.70–0.79) 1.05���(0.98–1.11) 0.79���(0.74–0.84)
20–24 39,968 1.07��(1.02–1.12) 1.54���(1.47–1.62) 1.20���(1.14–1.26)
25–29 51,524 1.11���(1.06–1.16) 1.54���(1.47–1.62) 1.23���(1.17–1.29)
30–34 43,210 1.14���(1.09–1.19) 1.49���(1.43–1.56) 1.25���(1.19–1.31)
35–39 36,717 1.10���(1.05–1.16) 1.39���(1.33–1.46) 1.19���(1.32–1.25)
40–44 25,567 1.04(0.99–1.09) 1.21���(1.15–1.28) 1.08��(1.03–1.14)
45–49 20,075 Re Re Re
Weal h s a us
Poo es 42,002 0.44���(0.42–0.47) 0.32���(0.30–0.34) 0.33���(0.31–0.35)
Poo e 42,981 0.53���(0.50–0.56) 0.41���(0.39–0.44) 0.42���(0.39–0.45)
Middle 41,850 0.58���(0.55–0.62) 0.49���(0.46–0.51) 0.47���(0.45–0.51)
Riche 42,003 0.72���(0.68–0.75) 0.64���(0.60–0.67) 0.63���(0.59–0.67)
Riches 41,680 Re Re Re
Educa ion
No educa ion 88,230 0.19���(0.17–0.21) 0.12���(0.11–0.13) 0.11���(0.10–0.12)
P ima y 66,581 0.45���(0.41–0.49) 0.40���(0.36–0.43) 0.34���(0.30–0.38)
Seconda y 47,764 0.65���(0.60–0.72) 0.56���(0.52–0.61) 0.56���(0.50–0.63)
Highe 7,961 Re Re Re
Religion
Muslims 76,621 0.39���(0.36–0.40) 0.30���(0.29–0.32) 0.29���(0.27–0.31)
Ch is ians 121,473 Re Re Re
O he s 12,442 0.54���(0.50–0.59) 0.41���(0.38–0.45) 0.40���(0.37–0.44)
Occupa ion
No wo king 64,520 0.58���(0.56–0.60) 0.67���(0.65–0.70) 0.53���(0.51–0.56)
Wo king 146,016 Re Re Re
Pa ne ’s educa ion
No educa ion 72,118 0.25���(0.23–0.27) 0.18���(0.17–0.19) 0.17���(0.16–0.19)
P ima y 59,380 0.56���(0.53–0.61) 0.58���(0.55–0.62) 0.51���(0.47–0.55)
Seconda y 62,269 0.80���(0.75–0.86) 0.73���(0.69–0.78) 0.75���(0.70–0.81)
Highe 16,769 Re Re Re
Coun y
Benin 11,045 Re Re Re
Bu undi 5,424 1.55���(1.44–1.65) 3.40���(3.18–3.65) 3.24���(3.00–3.50)
Came oon 4,682 2.73���(2.53–9.94) 2.40��(2.24–2.57) 3.08���(2.84–3.34)
Chad 4,553 0.65���(0.61–0.70) 0.29���(0.27–0.32) 0.62���(0.57–0.66)
Como os 3,087 0.76���(0.70–0.82) 1.56���(1.44–1.69) 1.05���(0.97–1.14)
Congo 6,259 1.80���(1.70–1.89) 1.00(0.94–1.05) 2.05���(1.95–2.17)
Congo DR 12,119 2.47���(2.31–2.63) 2.83���(2.66–3.02) 4.52���(4.18–4.89)
Co e d’ oi e 6,290 1.09��(1.03–1.16) 1.10��(1.04–1.18) 1.24���(1.16–1.32)
E hiopia 10,225 1.06�(1.00–1.11) 0.98(0.92–1.03) 1.18���(1.11–1.24)
Gabon 4,383 4.55���(4.18–4.94) 6.55���(6.04–7.10) 7.74���(6.96–8.61)
(Con inued)
Women’s ep oduc i e heal h decision making in sub-Saha an A ica
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women making decisions on sexual in e cou se (18%-92%), condom use (16%-93%) and
ep oduc i e heal h decision-making index (25%-97%) ac oss he egion.
The s udy ound ou ha abou 1 in 2 women could no eques hei pa ne s o use con-
dom whils wo ou o i e could no e use hei pa ne s sexual in e cou se when hey
eques . Th ee ou o en women could no make decision ega ding hei ep oduc i e heal h.
Simila esul s we e seen by Da eh and collegues in 2014 [10] They epo ed ha one- i h o
sampled Ghanaian women could no e use hei pa ne s’ eques o sexual in e cou se whils
one ou o ou could no demand he use o condoms by hei pa ne s. Residence, women’s
educa ion, eligion, occupa ion and pa ne s’ educa ion we e independen ly associa ed wi h
bo h decision-making on sexual in e cou se, condom use as well as he ep oduc i e heal h
decision-making index while age and weal h we e independen ly associa ed wi h decision-
making ega ding condom use and he ep oduc i e heal h index. This is e iden in ea lie
wo ks o Exa e y e al. [5]; Rahman e al. [13], Hammed e al.[24] and Suja h and Reddy[6].
Olde women we e seen o be mo e likely o make decision on sexual in e cou se, condom
use and ep oduc i e heal h decision-making index, compa ed o he younge ones. This ind-
ing a i ms he s udy by Hameed e al. [24] and Da eh e al. [10] who ound ha women wi h
inc eased age end o ge highe decision-making powe . In mos A ican coun ies, younge
women a e no expec ed o a gue wi h olde pe sons and a e equi ed o espec hei opinions
a all ime. The e a e also aces o in e gene a ional sexual ela ionships and age mixing
be ween younge women and olde men in a sexual ela ionship. The e is also e idence o
ea ly ma iage by younge women which is being used as a s a egy o economic su i al [25].
Table 2. (Con inued)
Explana o y ac o s P opo ions
N = 210,536
Decision-making on sexual in e cou se Decision-making on condom use Rep oduc ion heal h decision-making index
Model I
Odds Ra io (OR) 95% CI
Model I
Odds Ra io (OR) 95% CI
Model
Odds Ra io (OR) 95% CI
Gambia 6,763 0.86���(0.81–0.91) 1.19���(1.12–1.26) 1.00(0.94–1.07)
Ghana 5,382 2.64���(2.46–2.84) 3.29���(3.08–3.53) 3.35���(3.10–3.62)
Guinea 6,727 0.66���(0.62–0.70) 0.58���(0.54–0.62) 0.69���(0.65–0.74)
Kenya 8,679 2.31���(2.18–2.45) 3.61���(3.40–3.83) 3.38���(3.17–3.61)
Leso ho 1,662 2.69���(2.38–3.04) 26.14���(21.07–32.43) 20.06���(15.29–26.33)
Libe ia 5,382 4.79���(4.42–5.18) 2.12���(1.99–2.26) 4.90���(4.61–5.33)
Malawi 15,577 2.92���(2.78–3.08) 6.45���(6.11–6.81) 5.96���(5.60–6.33)
Mali 7,509 0.22���(0.21–0.23) 0.37���(0.34–0.39) 0.29���(0.27–0.31)
Mozambique 9,337 1.13���(1.06–1.19) 1.41���(1.33–1.49) 1.58���(1.51–1.65)
Namibia 3,090 9.99���(8.80–11.34) 21.60���(18.84–24.75) 22.30���(18.39–27.04)
Nige ia 27,749 1.55���(1.48–1.62) 1.06�(1.01–1.11) 1.58���(1.51–1.65)
Nige 9,866 0.44���(1.48–1.62) 0.55���(0.52–0.58) 0.54���(0.52–0.57)
Rwanda 6,962 4.46���(4.15–4.79) 8.45���(7.85–9.10) 10.36���(9.27–11.46)
Sie a Leone 10,800 2.11���(1.99–2.23) 0.93�(0.88–0.98) 1.94���(1.83–2.05)
Senegal 10,390 0.34���(0.32–0.37) 0.64���(0.60–0.67) 0.49���(0.46–0.51)
Togo 6,298 2,28���(2.01–2.60) 2.10���(1.97–2.23) 2.28���(2.13–2.44)
Uganda 7,125 3.31���(3.10–3.54) 2.92���(2.74–3.10) 4.20���(3.90–4.52)
Zambia 9,837 2.28���(2.16–2.42) 5.72���(5.38–6.08) 4.58��(4.28–4.90)
Zimbabwe 6,155 2.50���(2.34–2.67) 4.37���(4.09–4.68) 4.78���(4.40–5.19)
�p<0.05
�� p<0.01
���p<0.001
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Table 3. Mul i a ia e logis ic eg ession model showing he ela ionship (Adjus ed odds a io) be ween backg ound cha ac e is ics and women’s decision-making
on sexual in e cou se, condom use and ep oduc i e heal h decision-making index in 27 sub–Saha an A ican coun ies, 2010–2016.
Explana o y ac o s P opo ions
N = 210,536
Decision-making on sexual in e cou se Decision-making on condom use Rep oduc ion heal h decision-making index
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Residence
U ban 73,097 Re Re Re
Ru al 137,439 0.89���(0.86–0.91) 0.83���(0.81–0.85) 0.81���(0.81–0.86)
Age
15–19 16,259 0.93���(0.88–0.97) 1.35���(1.28–1.41) 0.99(0.94–1.05)
20–24 39,968 1.04�(0.99–1.07) 1.53���(1.46–1.59) 1.14���(1.10–1.20)
25–29 51,524 1.04��(1.00–1.08) 1.49���(1.44–1.66) 1.16���(1.11–1.20)
30–34 43,210 1.06��(1.02–1.10) 1.41���(1.36–1.47) 1.15���(1.03–1.20)
35–39 36,717 1.02(0.98–1.06) 1.32���(1.27–1.38) 1.10���(1.05–1.14)
40–44 25,567 0.99(0.95–1.03) 1.16���(1.11–1.21) 1.02(0.97–1.07)
45–49 20,075 Re Re Re
Weal h s a us
Poo es 42,002 0.74���(0.71–0.77) 0.59���(0.57–0.62) 0.61���(0.58–0.64)
Poo e 42,981 0.80���(0.76–0.83) 0.69���(0.66–0.72) 0.69���(0.66–0.72)
Middle 41,850 0.82���(0.78–0.85) 0.74���(0.71–0.77) 0.72���(0.69–0.75)
Riche 42,003 0.88���(0.95–1.03) 0.81���(0.78–0.84) 0.81��(0.77–0.84)
Riches 41,680 Re Re Re
Educa ion
No educa ion 88,230 0.49���(0.45–0.53) 0.34���(0.32–0.37) 0.37���(0.34–0.41)
P ima y 66,581 0.66���(0.61–0.71) 0.52���(0.48–0.55) 0.54���(0.50–0.51)
Seconda y 47,764 0.83���(0.77–0.88) 0.72���(0.67–0.77) 0.78���(0.71–0.85)
Highe 7,961 Re Re Re
Religion
Muslims 76,621 0.60���(0.59–0.62) 0.76���(0.74–0.78) 0.60���(0.58–0.62)
Ch is ians 121,473 Re Re Re
O he s 12,442 0.89���(0.85–0.93) 0.82���(079–0.85) 0.84���(0.81–0.88)
Occupa ion
No wo king 64,520 0.78���(0.76–0.80) 0.82���(0.80–0.83) 0.72���(0.70–0.74)
Wo king 146,016 Re Re Re
Pa ne ’s educa ion
No educa ion 72,118 0.74���(0.70–0.78) 0.60���(0.57–0.63) 0.65���(0.61–0.68)
P ima y 59,380 0.92��(0.88–0.97) 0.75���(0.71–0.79) 0.84���(0.79–0.89)
Seconda y 62,269 0.99(0.95–1.04) 0.91���(0.87–0.95) 0.95(0.90–1.01)
Highe 16,769 Re Re Re
Coun y
Benin 11,045 Re Re Re
Bu undi 5,424 1.20���(1.12–1.30) 2.88���(2.68–3.10) 2.48���(2.28–2.69)
Came oon 4,682 2.01���(1.85–2.18) 1.52���(1.40–1.64) 2.10���(1.92–2.29)
Chad 4,553 0.86���(0.80–0.93) 0.33���(0.30–0.35) 0.82���(0.76–0.88)
Como os 3,087 0.86��(0.79–0.94) 1.26���(1.15–1.39) 1.06(0.97–1.16)
Congo 6,259 1.10��(1.04–1.16) 0.54���(0.51–0.57) 1.10��(1.04–1.17)
Congo DR 12,119 1.45���(1.35–1.56) 1.68���(1.56–1.80) 2.42���(2.22–2.64)
Co e d’ oi e 6,290 1.18���(1.11–1.26) 1.10��(1.03–1.18) 1.32���(1.23–1.41)
E hiopia 10,225 1.15���(1.09–1.22) 0.96(0.90–1.02) 1.30���(1.23–1.38)
(Con inued)
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Women wi h poo es , poo e , middle and iche weal h s a us we e less likely o make deci-
sion on sexual in e cou se, condom use and ep oduc i e heal h decision-making index, com-
pa ed o women wi h iches weal h s a us simila o hose ound by [5,10,18,21]. Weal h may
lead o au onomy and independence and is ela ed o occupa ion and educa ion. Weal h could
also be associa ed wi h sel -es eem and con idence and his may ha e e ec s on he abili y o
make decision ega ding ep oduc i e heal h issues.
Women wi h seconda y and lesse educa ion we e less likely o make decision on sexual
in e cou se, condom use and ep oduc i e heal h decision-making index, compa ed o
women wi h highe educa ion. Also, women whose pa ne s had no educa ion, p ima y and
seconda y educa ion we e less likely o make decision on sexual in e cou se, condom use and
ep oduc i e heal h decision-making index, compa ed o hose wi h highe educa ion. This is
consis en wi h p e ious s udies [5,10,16,20]. Educa ion empowe s women o be independen
and equip hem wi h he essen ial in o ma ion ega ding sexual in e cou se and condom use
ha may be impo an o making decisions ega ding hei ep oduc i e heal h isssues. How
well a pe son is in o med a ec s decsion making a e e y s age [26].
Ealie s udies had con i med ha one’s eligious a ilia ion may ha e some e ec s on he
decision-making wi h ega ds o ep oduc i e heal h. The s udy also ound ha Muslim
women and women om o he eligions we e less likely o make decision on sexual in e -
cou se, condom use and ep oduc i e heal h decision-making index, compa ed o Ch is ian
women. This inding is consis en wi h Da eh e al. [10] bu goes con a y o ha o Exa e y
Table 3. (Con inued)
Explana o y ac o s P opo ions
N = 210,536
Decision-making on sexual in e cou se Decision-making on condom use Rep oduc ion heal h decision-making index
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Model II
Adjus ed Odds Ra io (AOR) 95% CI
Gabon 4,383 2.79���(2.54–3.06) 3.64���(3.33–3.98) 4.12���(3.67–4.63)
Gambia 6,763 1.19���(1.11–1.27) 1.30���(1.21–1.39) 1.35���(1.26–1.45)
Ghana 5,382 1.94���(1.80–2.09) 2.25���(2.09–2.42) 2.29���(2.11–2.49)
Guinea 6,727 0.92�(0.86–0.99) 0.68���(0.63–0.73) 0.95(0.87–1.01)
Kenya 8,679 1.60���(1.50–1.71) 2.34���(2.20–2.50) 2.22���(2.06–2.49)
Leso ho 1,662 1.29���(1.14–1.47) 12.28���(9.83–15.32) 8.18���(6.19–10.81)
Libe ia 5,382 4.06���(3.74–4.41) 1.73���(1.61–1.85) 4.05���(3.71–4.42)
Malawi 15,577 2.09���(2.65–3.09) 4.58���(4.31–4.87) 4.00���(3.74–4.28)
Mali 7,509 0.34���(0.32–0.37) 0.46���(0.43–0.50) 0.44���(0.41–0.47)
Mozambique 9,337 2.09���(1.97–2.21) 1.02(0.95–1.09) 0.89���(0.84–0.95)
Namibia 3,090 5.98���(5.23–6.83) 12.40���(9.83–15.32) 12.32���(10.05–15.10)
Nige ia 27,749 1.52���(1.45–1.60) 0.78���(0.74–0.82) 1.49���(1.41–1.57)
Rwanda 9,866 2.86���(2.65–3.09) 5.73���(5.29–6.20) 6.12���(5.51–6.80)
Sie a Leone 6,962 2.73���(2.557–2.90) 0.99(0.93–1.05) 2.45���(2.30–2.61)
Senegal 10,800 0.55���(0.52–0.59) 0.84���(0.79–0.89) 0.78���(0.73–0.83)
Togo 10,390 1.67���(1.56–1.79) 1.70���(1.59–1.82) 1.83���(1.70–1.96)
Zambia 6,298 1.38���(1.30–1.47) 3.33���(3.12–3.56) 2.49���(2.31–2.68)
Zimbabwe 7,125 1.31���(1.22–1.41) 1.94���(1.80–2.09) 2.08���(1.90–2.27)
�p<0.05
�� p<0.01
���p<0.001
NB: Rep oduc i e heal h decision-making index is he combina ion o decision-making on sexual in e cou se and he decision-making on condom use
h ps://doi.o g/10.1371/jou nal.pone.0209985. 003
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