The role of women’s autonomy and empowerment in maternal health decision making: Implications on the implementation process of a service delivery reform in Kenya. A qualitative exploratory study

Abstract Background A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya. Women's voice, agency, and autonomy are critical aspects of gender equality and women's empowerment since women’s ability to make decisions alone or in consultation with others in the household is an important determinant of access and utilization. As part of the process evaluation, this study sought to understand women’s process of decision-making in seeking maternal health care and how these affect women’s ability to access and use these services. Methods We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment that combines the interrelated concepts of “female autonomy”, and “women’s agency” with the latter incorporating ‘voice’, ‘choice’ and ‘power’. We conducted key informant interviews, in-depth interviews, and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, and women attending post-natal clinics. A thematic analysis approach was used to analyze the data in NVivo 12. Results The results revealed significant findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare. Conclusions Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. By identifying specific determinants within each dimension, this study provides valuable insights that can provide guidance for the ongoing implementation of an innovative service delivery redesign model by emphasizing the critical need for developing holistic and context-specific strategies to promote women's voices to ensure acceptability and sustained use.