Objectives: Gender roles and cultural norms affect many aspects of women s life including their

Abstract Objectives: Gender roles and cultural norms affect many aspects of women s life including their health. This study examines the association between women s autonomy over their health and their access to obstetric healthcare services in Egypt. The hypothesis is that women with positive autonomy indicators are more likely to use obstetric health services which include antenatal care, place of delivery, and postnatal care. Methods: The study included currently married women ages 15 to 49 years old from the 2014 Egypt Demographic Health Survey data. The analysis included bivariate regression and three multiple regression models for each service utilization indicator. Results: Multiple regression models showed that autonomy indicators retained some of their significance even after adjusting for age, education, work, residency, wealth, and birth order. Conclusions: A woman s autonomy over her health affects her access to obstetric health service. 2

Table of Contents Introduction... 4 Conceptual model... 6 Methods... 9 Results... 11 Discussion... 16 Limitations... 19 Future Research... 19 Conclusion... 20 Acknowledgment... 20 References... 21 3

Introduction Gender is a set of cultural and social roles that influence the lives of men and women in society. 1 These roles are shaped by social forces to define the persona of a man or a woman in a community. 1 Gender inequality means a difference in power distribution between men and women. Usually, women end up being less fortunate and having more limited authority than men. 1 These roles influence women s education, work, and even their health and the health of their families. 1 A woman s position in the family affects her access to health services and knowledge which in turn impact her ability to seek healthcare for herself and her family. 1 These social factors mean that population and development programs are most effective when they incorporate gender into their program design. 2 The International Conference on Population Development (ICPD) in 1994 in Cairo emphasized gender as a crucial influencer of reproductive health and demographic trends. 2 Chapter IV in the ICPD program of action focused on gender equity and women s empowerment to highlight their importance in sustainable development. 2 Women s autonomy is one dimension of women s empowerment and gender equity. 3 When women have more autonomy, maternal and child health tend to improve, fertility and childhood mortality tend to decline, and population growth slows. 1 Empowerment cannot be narrowed to legal rights and economic power, because it has personal and cultural dimensions related to social disparities. 4 Unequal power distribution within the family limits reproductive health discussions between partners which impedes women access to the healthcare they need. 3 Family structure and gender dynamics are an example of such disparities. Prior research showed that women in extended family structures have higher autonomy compared to those who live in a nuclear household. 5 4

The Egyptian family is characterized by classic patriarchy, similar to other countries in the middle east and north Africa region. 6 In this family design, power distribution is based on gender and age with the highest authority for the oldest man. 7 The new young bride is expected to obey not only her husband but also other men in the family and older women particularly her mother in law. 6 These social and cultural factors affect women s health by impeding women from seeking care. Delay in seeking health care is the first of three delays recognized by the WHO that substantially increase maternal mortality. 8 Egypt made a substantial decrease in its Maternal Mortality Ratio (MMR) between 1990 and 2008 from about 195 to 43 death per 100,000 live births with a yearly decrease of 8.4%. 9 While Egypt has done a great deal to improve MMR, the country is still facing challenges especially concerning women s autonomy. 10 In 2006, a household survey in Egypt showed that of all women included in the study 27% of women could not go to the doctor/health unit by themselves, 44% said they need permission to go, and only 7% said that they could go without permission. 7 The same study indicated that 23% of the women said that someone else has the final say on whether they need to get medical care or not. In fact, Egypt ranked 135 out of 159 countries on the 2015 Gender Inequality Index (GII) which measures gender discrimination in three major aspects of human development; reproductive health, empowerment, and economic status. 11 Egypt scored 0.57 while the average of the Arab states was 0.54 with higher scores indicating more gender disparities. 11 Egypt was able to achieve some of the Millennium Development Goals (MDGs) indicators included in goal three for gender equity and goal five for Maternal Mortality but much is left to be done. 12 During the Sustainable Development Goals (SDG) era, Egypt needs to expand efforts to achieve goal three for health and well-being and goal five for gender equity. 13 5

These efforts should include addressing the effect of gender and social power dynamics on women s access to and utilization of health services. This paper hypothesizes that there is a significant association between women s autonomy over their health and obstetric health service utilization behaviors including antenatal care (ANC), place of delivery, and postnatal care (PNC) and uses the 2014 Egypt Demographic Health Survey (EDHS) data to test this hypothesis. Findings from this paper aim to help policymakers in Egypt and countries with a similar cultural context in the Middle East and North Africa (MENA) region to acknowledge the role of women s autonomy and gender roles in improving women s health in the region. Conceptual Model This study s conceptual model is based on Andersen s Behavioral Model for access to medical care. 14 Andersen s model was first developed in 1968 to explain the variation in health care utilization by different families in the United States to help policymakers enable equitable services distribution. 15 Since then, the model has been updated four times to include extensive interaction with organizational factors. 16 This study analyzes the factors related directly to women without looking into Andersen s comprehensive health utilization model that includes quality of the health system such as availability of health personnel and distance to facilities and health beliefs. In this research, we examine three main groups of variables (figure 1); predisposing factors, enabling factors, and perceived need for care. 16 Andersen s model treats the relationships among the three clusters in sequential order. 16 Predisposing factors include the socio-cultural characteristics of the individual. 14 In this paper, the predisposing factors are age, education, work status, and area of residence (figure 1). As mentioned above, age has a significant effect on women s autonomy in the classic patriarchy family setting in which elders have more authority over themselves and others. 7 Education is the 6

second predisposing factor. Based on previous research, higher education is associated with better life quality, higher income, and finally better health for women. 17 Work affects women s socioeconomic status through income, expanding the network a woman has, and offering women freedom of movement. Also, the conceptual model includes the place of residence as one of the predisposing factors to control for the major difference in women s authority and roles in the family between rural and urban areas in Egypt. These differences are also associated with education, socioeconomic status (SES), and availability of health services in rural areas. The enabling factors include any lever that provides women with more resources to seek healthcare such as socioeconomic status and women s autonomy. 14 Enabling factors that are related to the health system function were excluded from the conceptual framework. Evaluating the perceived need represents a critical indicator of people's health status and their will to seek medical care. 16 For this study, the birth order of most recent pregnancy represents the perceived need based on the fact that women with more than three live children tend to have lower utilization of ANC services. 18 Other factors like fecundability and high-risk pregnancy were excluded due to limitations in the data. Different studies have defined women s autonomy using different indicators, but in general, most of the available research agrees on three main aspects which are; ability to participate in household decisions, ability to move without the husband s consent, and financial control over domestic resources. 3,5,7,19, 20,21 The use of health services was measured by woman s utilization of antenatal care (ANC), the place of delivery, and postnatal care (PNC) while she was pregnant with her youngest child during the five years period preceding the DHS survey. 19 It is important to mention that the arrows in the model do not mean that predisposing factors necessarily lead to the enabling factors. The independent variables have a correlation rather than 7

a causation relationship. The arrows in the conceptual model are based on the Andersen model which focuses on the health behavior relationship between the independent variables. 16 Predisposing Characteristics Enabling Resources Percieved Need Use of Health Services Antenatal Visits More than eight Age Education Work Autonomy SES Birth order Place of delivery Health facility Rural urban Postnatal care Within 48 hour Figure 1: Summery conceptual model decision making over health freedom of movement to go to health provider Woman Autonomy over health Need to ask for money to go to health provider Figure 2: Women s Autonomy over health indicators 8

Methods The study is a secondary analysis of the Egypt 2014 Demographic Health Survey (EDHS) dataset downloaded from the Demographic Health Survey official website. The EDHS 2014 collected retrospective health information for the five years preceding the survey (2009-2014). 22 It was conducted under the Egyptian Ministry of Health and Population (EMHP) supervision. 22 The survey aims to help policymakers to evaluate health and population programs and implement new strategies that will improve the health of women and children in Egypt. 22 The design used complex stratified sampling to select a representative group of ever-married women 15 to 49 years old across Egypt. 22 The total number of respondents was 21,762. 22 This study included only currently married women, who had at least one child during the five-year period preceding the survey. This resulted in dropping 10,267 observations (unweighted number) from the sample. Observations with missing values on variables used in this study were also dropped from the dataset (339 observations). The final weighted sample size was 11,081 (unweighted sample size is 11,156). This study is guided by the conceptual model described earlier (figure 1). Age was categorized into four groups (15-19, 20-29, 30-39, and 40-49). Women were classified as workers (any occupation) and non-workers. The total number of births was recoded from a continuous variable into three categories; first birth, second or third birth, and fourth or higher order birth. This study is focusing on women autonomy over their health, and thus the following questions were chosen from the EDHS survey to represent the autonomy indicators(figure 2): 5,22 Decision making: Who is the person who usually makes the final decision on respondent s health needs? 9

Freedom of movement: Does getting permission to go to health services present a big problem for the respondent? Access to resources: Does asking for money to get medical care present a big problem for the respondent? The answers to those three questions are dichotomized to 0 and 1. The decision making question has six answers: 1. Respondent alone 2. Respondent and husband/ partner = 1 3. Respondent and another person 4. Husband/ partner alone 5. Someone else = 0 6. Others Any choice that included the respondent was marked as 1, and the rest were considered 0. The other two autonomy questions (getting permission to go to a health facility and asking for money to get medical care) have two response categories in the EDHS; a big problem, which indicates lower autonomy in the family, and not a big problem. A big problem was coded as 0 while the other as 1. Based on previous research, comprehensive obstetric care is defined as having the minimum number of ANC visits recommended by the WHO, delivering the baby at a health facility, and receiving PNC afterward. 19 Studies showed that deficiencies in any of those behaviors are associated with higher maternal mortality rates. 19 The 2016 WHO ANC model recommended a minimum of eight contacts with a trained professional for a positive pregnancy experience. 23 In this model, utilization of ANC is defined as a dichotomous variable whether the woman had at least eight ANC visits to skilled health care providers during the previous pregnancy or not. Place of delivery is also a dichotomous variable with institutional delivery versus home delivery. 10

The third dependent variable, utilization of PNC by skilled personnel within 48 hours of delivery, is defined as a yes or no variable. 19 This study used Stata for the analysis. Data were weighted based on the DHS weighting guidelines to adjust for the complex sample design. The individual sample weight variable (v005) was divided by 1,000,000, and the Svy command was used for the tabulation and the regression analysis throughout the analysis process. We ran cross-tabulations of independent variables with health service utilization indicators to calculate the association of each variable included in the conceptual model with the outcome indicators. To generate crude odd ratios, bivariate logistic regression models were estimated for each variable in the conceptual model, and all the dichotomized indicators of maternal health service use separately. Then three regression models for each of the three dependent variables were estimated using multivariate logistic regression. Finally, it is important to mention that the tables are cross-sectional, representing the experience of a mother s most recent pregnancy during the five year period preceding the survey rather than following the experience of a cohort of mothers over time. Results Table 1 shows the distribution of the sample by the demographic characteristics and the women s autonomy indicators. There were fewer women in the 15-19 and 40-49 age groups due to including currently married women with a recent birth exclusively in the sample. There is a tendency to postpone marriage until older ages in Egypt 22 and older women have low fertility. More than half of the women finished at least secondary education while 17.8% had no education and 16.1% have some form of higher education. These percentages are slightly different from the general population rates where around one-quarter of women have no education. 22 This is a result of choosing currently married women who had a birth during the 11

past five years which excludes older women who have lower levels of education. Most women were living in rural areas. More women are included in the middle wealth quantile than in the poorest and richest ones. The majority of currently married women age 15 to 49 had no job. Half of the women had between two to three children at the time of the survey. Table 1: Sample characteristics of currently married women who had at least one birth between 2009-2014, Egypt. Socio-demographic Category Frequency Percentage characteristics Age 15-19 20-29 30-39 40-49 344 6110 4091 536 3.1 55.1 36.9 4.8 Education No education Primary Secondary Higher 1971 960 6370 1779 17.8 8.7 57.5 16.1 Place of residence Rural Urban 7556 3525 68.2 31.8 Wealth Poorest Poorer Middle Richer Richest 1898 2138 2763 2371 1910 17.1 19.2 24.9 21.4 17.2 Work Not working Working 9645 1435 87.1 13.0 Total children ever born First pregnancy 2 to 3 4 and more 2502 6014 2565 22.6 54.3 23.2 Autonomy over own health: Decision making not participate participate 1971 9109 17.8 82.2 Permission to go Big problem Not a problem 871 10210 7.9 92.1 Asking for money Big problem Not a problem 1156 9925 10.4 89.6 Total 11,081 100% Note: All numbers are weighted Regarding autonomy indicators, most of the women age 15 to 49 reported that they have autonomy over their health; 82.2% of women participated in decisions regarding their health, 92.1% had the freedom to go to a health facility, and 89.6% said that asking for money for 12

healthcare is not a big problem (Table 1). For the dependent variables, 58.1% had at least eight ANC visits during their last pregnancy, 87.4% delivered at a health facility, and 82.4% had PNC within 48 hours of delivery (Table 2). Table 2: Coverage (percentage) of maternal health services for the last birth among currently married women who had at least one birth between 2009-2014 by background characteristics, Egypt. Category ANC > 8 Delivery in a Facility PNC Total Age 15-19 20-29 30-39 40-49 64.2 59.4 57.0 48.6 87.9 88.3 86.3 84.8 P= 0.04 8 83.3 81.3 80.6 P= 0.12 344 6110 4091 536 Education No education Primary Secondary Higher 39.8 45.5 60.4 77.2 72.7 83.9 89.7 97.4 P= 0.00 67.0 77.7 84.9 93.1 P= 0.00 1971 960 6370 1779 Residence Rural Urban 53.1 69.0 0 84.2 94.2 P= 0.00 78.7 90.4 P= 0.00 7556 3525 Wealth Poorest Poorer Middle Richer Richest 70.7 73.3 82.8 88.9 95.4 76.3 79.7 88.5 93.7 97.6 70.7 73.3 82.8 88.9 95.4 1898 2138 2763 2371 1910 Work Not working Working 57.5 62.6 P=0.01 87.3 88.2 P=0.46 82.1 84.5 P=0.10 9645 1435 Total children ever born First pregnancy 2 to 3 4 and more 73.6 57.5 44.5 93.7 88.7 78.2 89.0 83.8 72.6 2502 6014 2565 Autonomy over own health: Decision not participate participate 48.0 60.3 81.8 88.6 75.6 83.9 1971 9109 Permission to go Big problem Not a problem 49.3 58.9 81.5 87.9 71.4 83.3 871.3 10210 Asking for money Big problem Not a problem 46.5 59.5 8 88.1 74.0 83.4 1156 9925 Total 58.1 87.4 82.4 11,081 Note: ANC: Antenatal care, PNC: Postnatal care within 48 hours; All numbers are weighted. 13

Bivariate tabulation of the independent variables with the health services utilization outcomes was statistically significant in the majority of the cases with some exceptions (Table 2). Working women were more likely to have at least eight ANC visits, but there was no association between work status and either facility delivery or PNC. Younger women (15-19) are more likely to have more than eight ANC visits than older women. Women with higher education are almost twice as likely to have eight or more ANC visits than those with no education. Rural area residents have lower services utilization compared to urban area residents. Women with at least four children are less likely to use obstetric health services in general than prim gravida women. Among women who do not participate in making decisions regarding their health, 48% had at least eight ANC visits compared to 60% among those who have authority over their health. The pattern is similar for the other two autonomy variables (asking for permission to visit a health center or for money for healthcare). In general, there was a 6.4 to 13.0 percentage point difference in obstetric health service utilization outcomes between women who have a positive autonomy indicator and those who do not (Table 2). It is important to note that obstetric health service utilization outcomes are associated with each other, as shown in Table 3. Seventy-nine percent of women who had less than eight ANC visits delivered at a hospital compared to 93.6% for those who had more than eight ANC visits. The association between place of delivery and PNC was highly significant where only 12.4% of women who delivered outside a health facility had PNC within 48 hours of delivery versus 92.5% for those who delivered at a health facility. 14

Table 3: Association between the obstetric health services utilization indicators. Facility delivery % PNC % ANC NO Yes Facility delivery No Yes < 8 21.3 78.7 No 87.6 12.4 >= 8 6.4 93.6 Yes 7.5 92.5 Total 12.6 87.4 17.6 82.4 Notes: ANC: Antenatal Care, PNC: Postnatal Care within 48 hours. All numbers are weighted. Table 4: Crude Odds Ratios OR and Confidence Intervals (CI) ANC Place of delivery PNC Age 15-19 20-29 30-39 40-49 OR 95% CI OR 95% CI OR 95% CI 0.82 0.74 0.53 0.63-7 0.56-0.97 0.38-0.72 4 0.86 0.77 0.68-1.58 0.57-1.30 0.47-1.26 1.17 3 0.98 0.84-1.65 0.73-1.43 0.65-1.47 Education No education Primary Secondary Higher 1.27 2.31 5.14 6-1.51 2.05-2.61 4.29-6.17 1.96 3.26 13.93 1.56-2.48 2.71-3.91 9.61-20.20 1.71 2.76 6.63 1.39-2.11 2.37-3.22 5.07-8.67 Place of residence Rural Urban 1.97 1.72-2.26 3.04 2.42-3.81 2.54 2.12-3.04 Wealth Poorest Poorer Middle Richer Richest 1.33 1.91 2.89 5.42 1.14-1.55 1.66-2.20 2.45-3.42 4.48-6.56 1.21 2.38 4.57 12.41 2-1.45 1.90-2.98 3.34-6.26 8.51-18.11 1.14 2.00 3.33 8.59 0.95-1.37 1.61-2.47 2.56-4.34 6.36-11.60 Work Not working Working all categories 1.24 6-1.44 9 0.87-1.38 1.19 0.97-1.47 Total children ever born First pregnancy 2 to 3 4 and more 0.48 0.29 0.43-0.54 0.25-0.33 0.53 0.24 0.43-0.66 0.19-0.31 0.64 0.33 0.54-0.75 0.28-0.39 AUTONOMY: Decision making Do not participate Participate 1.65 1.46-1.86 1.73 1.46-2.05 1.68 1.45-1.95 Permission to go to healthcare Big problem Not a big problem 1.48 1.24-1.76 1.64 1.32-2.04 2.00 1.67-2.40 Ask for money to get healthcare Big problem Not a big problem 1.69 1.45-1.97 1.74 1.44-2.10 1.76 1.49-2.08 ANC: Antenatal Care, PNC: Postnatal Care, OR: Odds Ratio, CI: Confidence Interval 15

Table 4 presents the result of simple logistic regressions of each variable included in the conceptual model on the service utilization indicators. Simple logistic regression showed that women who have autonomy over their health have better obstetric health service utilization outcomes. Odds ratios ranged from 1.48 to 2.00 for the association between the autonomy measures and a positive utilization indicator (table 4). Table 5 shows the adjusted odds ratios from three multiple regression models for each health services utilization outcome. Women s autonomy variables retained some of their significance even after adjusting for all the independent variables included in the conceptual model. Women who make a decision regarding their health were more likely to have more than eight ANC visits (odds ratio 1.24, 95% confidence interval 8-1.41) and to get PNC within 48 hours of delivery (odds ratio 1.18, 95% confidence interval 1-1.38). Women who said that asking for permission to go to healthcare provider was not a big problem were more likely to have PNC within 48 hours than those who had a big problem asking for money (odd ratio 1.35, 95% confident interval 6-1.72). Also, women who had no problem asking for money to get healthcare were more likely to have more than eight ANC visits than women who reported that it was a big problem to ask for money (odd ratio 1.25, 95% Confidence Interval 1.4-1.50). Running the three multiple regression models repeatedly while excluding one independent variable each time had no major effect on the significance of autonomy indicators. Discussion Gender roles and cultural barriers faced by women in developing countries have an effect that extends beyond economic growth and political participation to health and well-being. Studies that demonstrate that women s autonomy influences their health help to explain the impact the ICPD had on women s health by encouraging international organizations to become 16

more gender aware and integrate gender roles and cultural barriers in their reproductive health programs. 24 These barriers and cultural norms can be hard to change since they are embedded deeply in family structures; however, accounting for them while designing new public health programs is critical for success. Table 5: Adjusted Odds Ratios OR and Confidence Intervals (CI) ANC Place of delivery PNC Age 15-19 20-29 30-39 40-49 OR 95% CI OR 95% CI OR 95% CI 7 1.31 1.16 0.81-1.40 0.98-1.76 0.81-1.65 1.43 1.83 2.33 0.89-2.29 1.13-2.96 1.32-4.12 1.45 1.78 2.32 2-2.06 1.24-2.55 1.47-3.66 Education No education Primary Secondary Higher 5 1.57 2.36 0.87-1.27 1.38-1.79 1.93-2.88 1.70 2.09 5.52 1.33-2.18 1.72-2.54 3.67-8.32 1.49 1.85 2.72 1.19-1.87 1.58-2.17 2.02-3.67 Place of residence Rural Urban 0.84 0.69-2 4 0.75-1.43 0.94 0.72-1.22 Wealth Poorest Poorer Middle Richer Richest 1.23 1.45 2.21 3.91 5-1.44 1.24-1.69 1.81-2.70 3.02-5.06 6 1.59 2.68 5.45 0.89-1.26 1.27-2.00 1.79-4.03 3.42-8.70 1.42 2.25 4.96 0.84-1.19 1.15-1.74 1.62-3.13 3.38-7.26 Work Not working Working all categories 0.98 0.84-1.14 0.78 0.63-0.98 0.93 0.75-1.14 Total children ever born First pregnancy 2 to 3 4 and more 0.48 0.36 0.42-0.54 0.30-0.42 0.54 0.31 0.43-0.68 0.24-0.41 0.64 0.40 0.54-0.76 0.32-0.49 AUTONOMY: Decision making Do not participate Participate 1.24 8-1.41 1.18 0.99-1.42 1.18 1-1.38 Permission to go to healthcare Big problem Not a big problem 0.92 0.74-1.14 0.96 0.72-1.29 1.35 6-1.72 Ask for money to get healthcare Big problem Not a big problem 1.25 4-1.50 ANC: Antenatal Care, PNC: Postnatal Care, OR: Odds Ratio, CI: Confidence Interval 1.14 0.88-1.48 5 0.84-1.33 This study provides a glimpse of how gender inequalities can affect a woman healthcare 17

choice and even her life expectancy. This research highlights the relationship between women s autonomy over their health and health-seeking behaviors in Egypt. Specifically, we found that women s autonomy is related to obstetric health care utilization even after controlling for other social and individual variables. These results demonstrate the critical role of women s autonomy in shaping women s health. An interesting finding is that although 13% of women in the sample work, working does not have a positive effect either on the place of delivery or PNC. In Egypt women often do not work unless they are in great need or live below the poverty line. Similar findings can be seen in Pakistan and India where labor force participation has a negative association with prenatal care and institutional delivery since only low socioeconomic status women work. 26,27 The association found between the obstetric health service utilization is consistent with what has been found in previous research. 28 In general, women who have better ANC during their pregnancy tend to have institutional delivery and better outcome. 28 The strong connection between health facility delivery and PNC reflects a common policy in developing countries in which a doctor or a nurse provides a quick checkup for every woman in the delivery room before discharging them within 24 hours of giving birth. Results from the DHS Egypt final report demonstrated a decrease in the percentage of women who participate in decision making over their health compared to prior years. In 2008, 86.8% of ever-married women 15 to 49 years old said they participated in making decisions over their health, with 25.6% making the decision alone. In 2014, 82.7% of similar women said they participated in making decisions over their health, and only 14.6% said they made the decision independently. 22,25 This means that Egypt is moving in a negative direction regarding women s autonomy with potential negative implications for women s health. The significant association 18

between women s autonomy over their health and use of obstetric health services found in this study indicates that husbands play major roles in their wives health and thus maternal health in general. The fact only 14.6% women make decisions about their health care alone without consulting anyone else illustrates the effect of family structure in shaping future healthcare programs. Even with the considerable progress, Egypt made during the past decades regarding maternal mortality; the country is still straggling to accomplish equitable power distribution between men and women. 9,11 The most recent data indicated that Egypt is on the red list on the SDGs dashboard for goal three for health and well-being and goal five for gender equity; being on the red list means that the country is seriously far from achieving the goal. 13,29 Achieving the more ambitious agenda included in the SDGs might be impossible without addressing gender issues faced by Egyptian women that affect their ability to get the healthcare they (or their children) need. Limitations The time taken to conceive, previous miscarriages, and other medical health conditions during pregnancy that might increase women s utilization of obstetric health services were also excluded because the relevant information was not available. Finally, the study did not account for other determinants of health service utilization such as the quality of care and proximity to facilities which are included in the fourth and final phase of the Andersen model. 16 Future Research The United Nations described the gender gap in the MENA and South Asia regions as the highest globally 30, yet the research to identify the underlying factors and the implications of gender inequality on women s and children health is still limited, particularly in the MENA 19

region. Further research can try to apply the comprehensive version of Andersen s model including the health system service quality and health behavior. Future studies should also focus on linking women s autonomy to maternal and under-five mortality. Research that looks for interventions that can be used to decrease the gender gap is critical for changing the policies in Egypt and the MENA region. Conclusion Findings from this paper provide insights into the association between women s autonomy and obstetric health service utilization in the Middle East cultural context. Results from this study should encourage policymakers in Egypt to focus on empowering women to be able to get the healthcare they need. Gender transforming programs that include men and women are essential for addressing the critical effect a husband has on his wife s health and life expectancy. Acknowledgment I would first like to thank my thesis advisor Professor Siân Curtis a faculty at the University of North Carolina- Chapel Hill. The door to Professor Curtis s office was always open whenever I had a question about my research or writing. She consistently inspired me to do more and steered me in the right the direction whenever she thought I needed it. I would also like to acknowledge Professor Ilene Speizer a faculty at the University of North Carolina- Chapel Hill as the second reader of this thesis, and I am grateful for her valuable comments. 20

References 1. Riley NE. Gender power and population change. Population Bulletin. 1997;52:1. 2. United Nations Population Fund. Programme of Action: Adopted at the International Conference on Population and Development, Cairo. UNFPA. 1994. 3. Acharya DR, Bell JS, Simkhada P, van Teijlingen ER, Regmi PR. Women s autonomy in household decision-making: a demographic study in Nepal. Reproductive Health. 2010;7:15. 4. Presser H, Sen G. Women s Empowerment and Demographic Processes: Moving beyond Cairo. Population Council. 2000;27:371-373. 5. Nigatu D, Gebremariam A, Abera M, Setegn T, Deribe K. Factors associated with women s autonomy regarding maternal and child health care utilization in Bale Zone: a community based cross-sectional study. BMC Womens Health. 2014;14:79. 6. Kandiyoti D. Bargaining with Patriarchy. JSTOR. 1988; 2: 274-290. 7. Yount KM, VanderEnde KE, Dodell S, Cheong YF. Measurement of women s agency in egypt: A national validation study. Soc Indic Res. 2016;128: 1171-1192. 8. Calvello EJ, Skog AP, Tenner AG, Wallis LA. Applying the lessons of maternal mortality reduction to global emergency health. Bulletin of World Health Organization. 2015;93:417-423. 9. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010;375:1609-1623. 10. Sarker I, Saadat S, Cortez R, Abdel-Hamid AM. Achieving MDGs 4&5: Egypt s Progress on Maternal and Child Health. Achieving MDGs 4&5: Egypt s Progress on Maternal and Child Health. THe World Bank. 2014. 11. Human Development Reports. Gender Inequality Index [Internet]. [Cited May 14, 2018]. Available from: http://hdr.undp.org/en/composite/gii. 12. United Nations Development Programme (UNDP), the Ministry of Planning, Monitoring and Administrative Reform in Egypt. Egypt s Progress Towards Millennium Development Goals. UNDP. 2015. 13. 2017 Sustainable Development Goals Index & Dashboards. Egypt's Country Profiles [Internet]. [Cited June 11, 2018]. Available from: https://www.dropbox.com/sh/yvgzn5o4t19xigc/aacatlucxuwae46z7mj7igg8a?dl=0&p review=egypt-country-profile.pdf. 14. Andersen RM. Andersen and Newman Framework of Health Services Utilization. Journal of Health and Social Behavor. 1995;36:1-10. 15. Andersen RM. A behavioral model of families use of health services. 1968;25:111. 16. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavor. 1995;36:1-10. 17. Jejeebhoy, Shireen J. Women s Education, Autonomy, and Reproductive Behaviour: Experience from Developing Countries. OUP Catalogue. 1995. 18. Adhikari T, Sahu D, Nair S, Saha KB, Sharma RK, Pandey A. Factors associated with utilization of antenatal care services among tribal women: A study of selected States. Indian Journal of Medical Research. 2016;144:58-66. 19. Haider MR, Qureshi ZP, Khan MM. Effects of women s autonomy on maternal healthcare utilization in Bangladesh: Evidence from a national survey. Sexual and Reproductive 21

Healthcare. 2017;14:40-47. 20. Taukobong HFG, Kincaid MM, Levy JK, Bloom SS, Platt JL, Henry SK, et al. Does addressing gender inequalities and empowering women and girls improve health and development programme outcomes? Health Policy and Planning. 2016;31:1492-1514. 21. Jejeebhoy SJ. Convergence and divergence in spouses perspectives on women s autonomy in rural India. Studies in Family Planning. 2002;33:299-308. 22. Ministry of Health and Population/Egypt, Associates/Egypt, El-Zanaty and Associates/ Egypt, International ICF. Egypt Demographic and Health Survey 2014. DHS. 2015. 23. World Health Organization WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: WHO; 2016. 24. Feldman-Jacobs C, Yeakey M, Avni M. A summary report of new evidence that gender perspectives improve reproductive health outcomes. Popline. 2011. 25. Ministry of Health and Population/Egypt, El-Zanaty F, Way A. Egypt Demographic and Health Survey 2008. DHS. 2009. 26. Hou X, Ma N. The effect of women s decision-making power on maternal health services uptake: evidence from Pakistan. Health Policy and Planning. 2013;28:176-184. 27. Mistry R, Galal O, Lu M. Women s autonomy and pregnancy care in rural India: a contextual analysis. Social Science & Medicine. 2009;69:926-933. 28. Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy and Childbirth. 2013;13:40. 29. Sustainable Development Goals Index & Dashboards Report: Global Responsibities, International spillover in achieving the goals. 2017. 30. United Nations Department of Economic and Social Affairs. The World s Women 2015. Trends and Statistics. New York: UN; 2015. 22