title: Autonomy dimensions and care seeking for delivery in Zambia; the prevailing importance of cluster-level measurement.
abstract: It is widely held that decisions whether or when to attend health facilities for childbirth are not only influenced by risk awareness and household wealth, but also by factors such as autonomy or a woman's ability to act upon her own preferences. How autonomy should be constructed and measured - namely, as an individual or cluster-level variable - has been less examined. We drew on household survey data from Zambia to study the effect of several autonomy dimensions (financial, relationship, freedom of movement, health care seeking and violence) on place of delivery for 3200 births across 203 rural clusters (villages). In multilevel logistic regression, two autonomy dimensions (relationship and health care seeking) were strongly associated with facility delivery when measured at the cluster level (OR 1.27 and 1.57, respectively), though not at the individual level. This suggests that power relations and gender norms at the community level may override an individual woman's autonomy, and cluster-level measurement may prove critical to understanding the interplay between autonomy and care seeking in this and similar contexts.
authors.affiliation: Ruprecht-Karls-Universität Heidelberg, Institute of Public Health.
authors.forename: Sabine
authors.initials: S
authors.lastname: Gabrysch
authors.affiliation: Ruprecht-Karls-Universität Heidelberg, Institute of Public Health.
authors.forename: Shannon A
authors.initials: SA
authors.lastname: McMahon
authors.affiliation: Ruprecht-Karls-Universität Heidelberg, Institute of Public Health.|London School of Hygiene &Tropical Medicine, Faculty of Epidemiology and Population Health.
authors.forename: Katja
authors.initials: K
authors.lastname: Siling
authors.affiliation: London School of Hygiene &Tropical Medicine, Faculty of Epidemiology and Population Health.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Kenward
authors.affiliation: London School of Hygiene &Tropical Medicine, Faculty of Epidemiology and Population Health.
authors.forename: Oona M R
authors.initials: OM
authors.lastname: Campbell
mesh_terms: D000293:Adolescent; D000328:Adult; D016000:Cluster Analysis; D005260:Female; D005610:Freedom; D006801:Humans; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011336:Probability; D055815:Young Adult; D015024:Zambia