DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2017 No. 129

Susy K. Sebayang

Ferry Efendi

Erni Astutik

July 2017

This document was produced for review by the United States Agency for 

International Development.

Women’s Empowerment and the Use of Antenatal Care 

Services in Southeast Asian Countries

Women’s Empowerment and the Use of Antenatal Care 

Services in Southeast Asian Countries 

Susy K. Sebayang1

Ferry Efendi2

Erni Astutik3

ICF 

Rockville, Maryland USA 

July 2017 

1

 Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Airlangga, Banyuwangi 

Campus, Indonesia 

2

 Department of Mental Health and Community Nursing, Faculty of Nursing, Universitas Airlangga, Surabaya, 

Indonesia 

3

 Department of Epidemiology, Faculty of Public Health, Universitas Airlangga, Banyuwangi Campus, Indonesia 

Corresponding author: Susy K. Sebayang, Department of Biostatistics and Population Studies, Faculty of Public 

Health, Universitas Airlangga, Banyuwangi Campus, Indonesia; email: sksebayang@fkm.unair.ac.id 
Acknowledgments

We would like to thank Wenjuan Wang and Shireen Assaf as mentors, and Bwalya Bupe Bwalyaa 

as a co-mentor, of the 2017 DHS Fellows Program for providing technical support and insights on 

the analysis. We also would like to thank Ramu Bishwakarma for his valuable comments. The 

DHS Fellows Program is funded by USAID and implemented by ICF. 

Editor: Bryant Robey 

Document Production: Joan Wardell 

The DHS Working Papers series is a prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried 

out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#AID-OAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and 

evaluate population, health, and nutrition programs. For additional information about The DHS 

Program, contact DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. 

Phone: +1 301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 

Recommended citation: 

Sebayang, Susy K., Ferry Efendi, and Erni Astutik. 2017. Women’s Empowerment and the Use of 

Antenatal Care Services in Southeast Asian Countries. DHS Working Paper No. 129. Rockville, 

Maryland, USA: ICF.
iii

Abstract

This study assessed the relationship between women’s empowerment and the use of antenatal care 

(ANC) services in five Southeast Asian (ASEAN) countries. The data used in the study are from 

the most recent Demographic and Health Surveys (DHS) conducted in Cambodia (2014), 

Indonesia (2012), Myanmar (2016), the Philippines (2013), and Timor-Leste (2009). 

The focus of the analysis was on currently married women who gave birth within the last 5 years 

before the survey. The two main outcomes were the number of ANC visits they made (four or 

more compared with none to three), and the timing of the first ANC visit (within the first trimester 

or later in the pregnancy). Four composite women’s empowerment variables were created from 17 

indicators: (1) labor force participation; (2) disagreement with reasons for wife beating; (3) 

decision-making power over household issues; and (4) knowledge level (based on education and 

media exposure). Analysis used logistic regression with adjustment for complex sampling design. 

Overall, results differed among the five countries. Labor force participation was significantly 

associated with number of ANC visits in Cambodia, Philippines, and Timor-Leste. Disagreement 

with reasons for wife beating and women’s knowledge level were each independently associated 

with number of ANC visits in Cambodia, Indonesia, and Myanmar. Women’s decision-making 

power was associated with number of ANC visits in Cambodia and Indonesia. 

The association of women’s empowerment variables with timing of the first ANC visit was not as 

evident as the association with number of visits. Labor force participation was significantly 

associated with attending ANC in the first trimester in Cambodia and Philippines. Disagreement 

with reasons for wife beating was significantly associated with early ANC visit only in TimorLeste. Women’s knowledge level was associated with early first ANC visit only in Cambodia, and 

women’s decision-making power was associated with early first ANC visit only in Philippines. 

There was no difference between adult and adolescent mothers in the association between 

women’s empowerment and use of ANC, except in two cases. In Cambodia, adolescent mothers 

with medium knowledge had lower odds of attending four or more ANC visits compared with 

adult mothers with poor knowledge; and in Myanmar, adolescent mothers with high labor force 

participation had higher odds of attending the first ANC visit early compared with the reference 

group of adult mothers with low labor force participation. 

Keywords: Antenatal care, women’s empowerment, labor force participation, decision-making 

power, women’s disagreement toward wife beating, knowledge level. 

1

1 Introduction

1.1 Background 

Improving reproductive, maternal, neonatal, and child health (RMNCH) outcomes remains a 

challenge in most of the developing world, including Southeast Asia. Of six Southeast Asian 

(ASEAN) countries joining the Countdown to 20151, only two (Cambodia and Indonesia) achieved 

the MDG 4 target to reduce child mortality, and only two (Cambodia and Lao Republic) achieved 

the MDG 5 target to reduce maternal mortality (Victora et al. 2016). Extra effort will be needed to 

achieve the new child and maternal mortality targets established as Sustainable Development 

Goals (SDGs) for 2030. Today only Cambodia has the current reduction rate above 7.5% required 

to achieve the SDG target of maternal mortality (Alkema et al. 2016). To improve ability to achieve

these targets, antenatal care (ANC) in the region must improve (UN-ESCAP, ADB, and UNDP 

2014).

Inadequate ANC can threaten the life of newborns (Lincetto et al. 2006; Titaley et al. 2008). In 

Cambodia, the neonatal death rate among women who did not attend any ANC visits was more 

than six times as high as that of women who made four or more visits (Hong et al. 2017). The 

World Health Organization (WHO) recommends a minimum of four ANC visits as part of the 

global agenda (World Health Organization 2016b).

Women’s empowerment should be considered an important element, as it corresponds with 

indicators of maternal health (Furuta and Salway 2006; Osamor and Grady 2016; Sado, Spaho, 

and Hotchkiss 2014; Yesudian 2009). A review of 67 studies in developing countries showed a 

positive association between women’s empowerment and use of health services (Pratley 2016). A 

study using data from the most recent Demographic and Health Surveys (DHS) in 31 countries 

showed that women with the highest empowerment status were more likely to use modern 

contraception, attend four or more ANC visits, and have a skilled attendant at birth compared with 

women with lower empowerment status (Ahmed et al. 2010). An analysis of the 2007 Bangladesh 

DHS showed that women with high economic power and employment level, women with high 

disagreement with reasons to justify wife beating, women with decision-making power over 

familial health care and family planning, and women who had secondary or higher education had 

greater odds of attending at least four ANC visits (Haque et al. 2012). A study among Nepalese 

women found that a high level of autonomy was associated with more use of maternal health 

services (Adhikari 2016). Studies using DHS data from Indonesia and Timor-Leste found that 

women with little education were less likely to attend at least four ANC visits, although these 

 

1 Countdown to 2015 was a global agenda to achieve the targets of Millenium Development Goals 

(MDGs) for accelerating and ending preventable maternal, newborn, and child deaths. 
2

studies did not examine other indicators of women’s empowerment (Khanal et al. 2015; Titaley, 

Dibley, and Roberts 2010).

The decision-making power of adolescent mothers may differ from that of older mothers and thus 

may affect health-related decisions made by or for these adolescent mothers. In 2015, 5 of the 10

countries in ASEAN (Cambodia, Indonesia, Lao Republic, Philippines, and Thailand) reported an 

adolescent birth rate exceeding the global rate of 44.1 (Victora et al. 2016; World Health 

Organization 2016a). A study using data from the 2012 Indonesia Demographic and Health Survey 

(DHS) showed that 23% of teenage mothers reported their husbands or others made decisions for 

their health care (Utomo and Utomo 2013). In all ASEAN countries, the majority of people live in 

patriarchal systems (Niaz and Hassan 2006; Sue, Rasheed, and Rasheed 2015), and age determines 

social status. Adolescents are considered low in societal position, and this may impair their 

decision-making power.

There have been some improvements in Southeast Asia over the last 3 decades, both in women’s 

education level and male-female power balance (Booth 2016), but women’s poor social status, 

especially among adolescent mothers, may still have a negative impact on their use of health 

services. The preceding evidence suggests that the focus on women’s empowerment among 

adolescent and adult mothers needs to be assessed to understand their potential contribution to 

improving RMNCH in ASEAN countries. Rightfully, the issues of women’s empowerment and 

gender equality remain top priorities of the ASEAN governments (ASEAN 2016).

Too little attention, however, has been paid in ASEAN countries to finding evidence of the impact 

of women’s empowerment on their reproductive health. Studies in the region on women’s 

empowerment and its association with health care are limited. A recent study in four ASEAN 

countries suggested four components—labor force participation, household decision-making, 

family planning, and education—are important indicators for women’s empowerment (Phan 

2015). Our study modified this framework to investigate the association between women’s 

empowerment and use of ANC in five ASEAN countries with recent DHS surveys: Cambodia, 

Indonesia, Myanmar, the Philippines, and Timor-Leste. 

1.2 Conceptual Framework 

To assess the association between women’s empowerment and use of ANC, the analysis used two 

outcomes: the number of ANC visits and the timing of the first ANC visit. In our conceptual 

framework (Figure 1), we modified Phan’s framework for women’s empowerment (Phan 2015) 

and used four empowerment components as the variables of interest: women’s labor force 

participation; women’s disagreement with reasons to justify wife beating, women’s decisionmaking power over household issues, and women’s knowledge level. We adjusted for other 

covariates known to be correlated with ANC (Dahiru and Oche 2015; Khanal et al. 2015; Titaley, 

Dibley, and Roberts 2010). These covariates include age difference between the woman and her 
3

husband, husband’s education, employment, and place of residence, household wealth, household 

size, and child’s birth order. We also adjusted for women’s age at birth and tested whether the 

association between ANC use and women’s empowerment differs between adolescent and adult 

mothers. 

Figure 1. Conceptual framework of the association between women’s empowerment and antenatal 

care 

1.3 Research Question 

This study attempts to answer the following research questions:

1. Are there any associations between women’s empowerment variables and the use of 

ANC as measured by women’s number of ANC visits and by timing of the first ANC 

visit after pregnancy?

2. If yes, do the associations differ between adolescent and adult mothers?

Outcome: Antenatal Care (ANC)

Number of ANC visits 

Time of first ANC visit

Women’s Empowerment:

Labor force participation 

Disagreement to justification toward wife beating

Decision-making power 

Women’s knowledge level 

Women’s Age at Birth:

Adolescent mother: <20 years 

Adult mother: 20+

Covariates:

Difference in age with husband 

Husband’s education 

Husband’s employment 

Place of residence 

Household wealth 

Household size 

Birth order 

5

2 Data and Methods

2.1 Data

Data from the latest Demographic Health Surveys (DHS) were used for analysis. DHS data were 

only available for five countries of the Southeast Asia region: Cambodia (2014), Indonesia (2012), 

Myanmar (2016), the Philippines (2013), and Timor-Leste (2009). Antenatal care (ANC) 

information for the most recent births of currently married women in the last 5 years preceding the 

survey were analyzed. 

2.2 Key Variables and Measurements 

Use of ANC was measured using two indicators: number of ANC visits and timing of the first 

ANC. Number of ANC visits was categorized into <4 visits or ≥4 visits (recommended number), 

and time of the first ANC was categorized into <4 months (recommended time of first ANC) and 

≥4 months of gestation. Women’s age at giving birth was categorized into adolescent birth (< age 

20) or non-adolescent birth (≥ age 20). 

As mentioned, women’s empowerment comprised four components, which were created from 17 

indicators using principal component analysis. The 17 indicators were selected based on a 

published framework that categorized women’s empowerment into labor force participation, 

decision-making, education, and knowledge of family planning. We excluded knowledge of family 

planning because it was reported to be unassociated with women’s empowerment in Southeast 

Asian countries (Phan 2015), but we added women’s disagreement with reasons to justify wife 

beating. 

Figure 2 shows the 17 indicators used in the analysis, grouped into the four components. Labor 

force participation is indicated by six aspects: work in the last 12 months (work or not), for whom 

women works (not working, work for family members, work for someone else, self-employed), 

women’s occupation (not working, unskilled labor, skilled labor, professional and self-employed), 

types of payment (not working, not paid, paid in cash and in-kind, paid in cash only), work all 

years (not working, work occasionally, work seasonally, work all year) and earn more than 

husband (not working or not paid in cash, earn less than husband, earn about the same as husband, 

earn more than husband). 

Women’s disagreement with reasons to justify wife beating was assessed in five areas: neglecting 

children; going out without husband’s permission; arguing with husband; refusing sex; and 

burning food. 

Decision-making power was evaluated with questions on who made decisions about women’s own 

health care, household purchases, visits to family members, and husband’s earnings. All decision 

components were categorized into a decision made by husband or other person, a decision made 
6

together with the woman, or a decision made by the woman only. The women’s knowledge 

component included formal educational level (no education, primary, secondary, and higher) and 

access to media (no access, access to some media, and access to all types of media). Principal 

component analysis of the 17 variables resulted in four different components representing labor 

force participation, disagreement with reasons to justify wife beating, decision-making power, and 

knowledge level. Each component was then divided into terciles of low, medium, and high level. 

For disagreement with reasons to justify wife beating, women were categorized as having high 

disagreement if they disagreed with all five reasons for wife beating, and as having low 

disagreement if they disagreed with the smallest number of reasons for wife beating. 

Other covariates included several variables, namely place of residence (rural-urban), household 

socioeconomic status (very poor, poor, middle income, rich, and very rich), household member 

(>4 or less), husband’s education (no education, primary, secondary, and higher), husband’s 

employment status (not working, agricultural labor, non-agricultural labor), age difference 

between husband and wife (wife older than husband, husband older by 0–4 years, husband older 

by 5-7 years, and husband older by >7 years), and birth order of the child (first, second, and third 

or more). 
7

Figure 2. Indicators of women’s empowerment 

2.3 Statistical Analysis 

Analysis of the association between the four components of women’s empowerment and the ANC 

outcomes was conducted using multiple logistic regression and adjusting for DHS sampling 

design. Interactions between each component of women’s empowerment and her age at birth were 

tested. Interaction is considered to occur if the p-value of the interaction was <0.05. All analysis 

was conducted using STATA 14.

Women’s 

empowerment

Labor force 

participation

Disagreement 

with reasons to 

justify wife 

beating

Decisionmaking 

power

Women’s 

knowledge level

Work the last 12 months

For whom women work 

Going out without husband’s permission

Household purchase

Own health care

Neglect children

Access to media

Types of paymentwomen get

Women’s occupation

Argue

Education level

Visitingf

Husband’s earning

amily

Refuse sex

Burn food

Work all years

Earn more than husband

9

3 Results

After exclusion of never-married and formerly married women, women who gave birth more than 

5 years preceding the survey, missing information on number of ANC visits and ANC timing, and 

missing covariates data, the weighted sample size ranged from 2,536 in Myanmar to 12,902 in 

Indonesia. The characteristics of women in the sample varied across the five countries. As Table 

1 shows, the percentage of women who gave birth as adolescents was lowest in Timor-Leste 

(5.7%) and highest in Cambodia (10.1%). The percentage of women attending four or more ANC 

visits was highest in Indonesia and Philippines, at 92% and 88%, and lowest in Timor-Leste, at 

64%. The percentage of women who went for the first ANC visit in the first trimester was highest 

in Indonesia and Cambodia, at 84% and 83% respectively, and lowest in Myanmar, at 47%. 
10

Table 1. Weighted characteristics of currently married women who gave birth in the last 5 years preceding 

the survey in Cambodia, Indonesia, Myanmar, Philippines, and Timor-Leste

Cambodia 

2014

(N=5,112)

Indonesia 2012 

(N=12,902)

Myanmar

2015-2016

(N=2,536)

Philippines

2013

(N=4,336)

Timor-Leste

2009

(N=4,558)

Variables N % N % N % N % N %

Age at birth

Adult (≥20 years) 4,597 89.9 11,783 91.3 2,382 93.9 3,923 90.5 4,299 94.3

Adolescent (<20 years) 514 10.1 1,119 8.7 153 6.1 413 9.5 259 5.7

Number of antenatal visits

Fewer than four 1,035 20.3 1,066 8.3 793 31.3 527 12.2 1,649 36.2

Four or more 4,076 79.7 11,836 91.7 1,743 68.7 3,808 87.8 2,909 63.8

Time of 1st antenatal visit

4 months of gestation or 

more 874 17.1 2,093 16.2 1,356 53.5 1,511 34.8 2,188 48.0

Less than 4 months of 

gestation 4,238 82.9 10,809 83.8 1,179 46.5 2,825 65.2 2,369 52.0

Husband’s education

Incomplete primary 

education/none 2,241 43.8 1,191 9.2 810 31.9 708 16.3 1,913 42.0

Complete primary or some 

secondary 2,179 42.6 6,124 47.5 1,437 56.7 1,140 26.3 2,372 52.0

Complete secondary or 

higher 692 13.5 5,587 43.3 289 11.4 2,487 57.4 273 6.0

Residence

Urban 753 14.7 6,613 51.3 689 27.2 2,019 46.6 1,170 25.7

Rural 4,359 85.3 6,289 48.7 1,847 72.8 2,316 53.4 3,388 74.3

Household Member

<4 665 13.0 2,075 16.1 352 13.9 404 9.3 164 3.6

≥4 4,447 87.0 10,828 83.9 2,184 86.1 3,932 90.7 4,394 96.4

Birth order

First child 1,805 35.3 4,863 37.7 940 37.1 1,140 26.3 621 13.6

Second child 1,636 32.0 4,230 32.8 675 26.6 1,107 25.5 681 15.0

Third child or more 1,672 32.7 3,810 29.5 921 36.3 2,089 48.2 3,256 71.4

Husband’s occupation

Agricultural 2,428 47.5 2,657 20.6 614 24.2 1,230 28.4 2,474 54.3

Non-agricultural 2,684 52.5 10,245 79.4 1,921 75.8 3,106 71.6 2,084 45.7

Difference in age between 

man and woman

Woman older than man 1,369 26.8 1,982 15.4 819 32.3 1,235 28.5 787 17.3

Husband 0-4 years older 2,170 42.5 5,185 40.2 975 38.4 1,672 38.6 1,656 36.3

Husband 5-7 years older 877 17.2 3,025 23.4 386 15.2 731 16.9 832 18.3

Husband >7 years older 695 13.6 2,710 21.0 356 14.1 697 16.1 1,282 28.1

Table 2 shows that in all five countries the proportion of women attending four or more ANC visits 

increased as household wealth increased. Similarly, the proportion of women attending the first 

ANC in the first trimester (< 4 months) improved as wealth improved, except in Myanmar, where 

the distribution was similar across wealth quintiles, especially across the middle and richer 

quintiles. The proportion of women attending fewer than four ANC visits decreased as women’s 

participation in the workforce, women’s disagreement with reasons to justify wife beating, and 

women’s knowledge level increased, except in Timor-Leste, for disagreement with reasons to 

justify wife beating and women’s knowledge level. In all five countries the proportion of women 
11

attending the first ANC visit later than the first trimester was lower as the level of women’s 

disagreement to reasons to justify wife beating was higher. A similar pattern was observed for 

labor force participation in Indonesia and the Philippines. Except for Myanmar and Philippines, 

the proportion of women attending fewer than four ANC visits and the proportion attending after 

the first trimester declined as household wealth increased. A similar pattern was observed for 

women’s knowledge level in all countries except Timor-Leste. 

3.1 Number of ANC visits 

Table 3 shows that women’s labor force participation was significantly associated with the number 

of ANC visits in Cambodia, Philippines, and Timor-Leste. In Cambodia women with high 

participation in the labor force had 32% greater odds of attending the recommended number of 

ANC visits (four or more) compared with women with low participation. In Philippines women 

with medium and high labor force participation had 33% and 36% higher odds respectively of 

attending the recommended number of ANC visits compared with women with low participation. 

In Timor-Leste women with high labor force participation had 65% higher odds of attending the 

recommended number of four or more ANC visits compared with women with poor labor 

participation. 

Women’s disagreement with reasons to justify wife beating was significantly associated with 

number of ANC visits in Cambodia, Indonesia, and Myanmar. In Cambodia and Indonesia women 

with medium disagreement with reasons to justify wife beating had 39% and 38% greater odds 

respectively of attending the recommended number of ANC visits compared with women with low 

disagreement, and in Myanmar women with medium disagreement had 46% greater odds. In 

Myanmar women who had high disagreement with reasons to justify wife beating had 33% greater 

odds, and in Cambodia 43% greater odds, of attending the recommended number of ANC visits 

compared with women with low disagreement. 

Decision-making power was significantly associated with number of ANC visits in Cambodia and 

Indonesia. In Indonesia women with a medium level of decision-making power had 32% greater 

odds of attending the recommended number of ANC visits, and in Cambodia 47% greater odds, 

compared with women with low decision-making power. Women’s knowledge level was 

associated with the number of ANC visits in Cambodia, Indonesia, and Myanmar. In Myanmar 

women with a medium level of knowledge had 37% greater odds of attending the recommended 

number of ANC visits compared with women with low knowledge. Similarly, in Myanmar women 

with a high level of knowledge had 44% greater odds, and in Indonesia 70% greater odds, of 

attending the recommended number of ANC visits compared with women with low knowledge. 

Table 3 also shows a significant association between women’s knowledge level and mother’s age 

in Cambodia. In this country adolescent mothers with a medium level of knowledge had 56% lower 

odds of attending the recommended number of ANC visits compared with adult women with a low 

level of knowledge (the reference group). 
12

Table 2. Distribution of number of ANC visits and timing of first ANC visit by women’s socioeconomic and emp

Cambodia, Indonesia, Myanmar, Philippines, and Timor-Leste

Cambodia (N=5,112) Indonesia (N=12,902) Myanmar (N=2,536) Philippines (N=4,336) 

Variables N

visits

<4

a

(%)

≥4 

months

b

(%) N

visits 

<4

a

(%)

≥4 

months

b

(%) N

visits 

<4

a

(%)

≥4 

months

b

(%) N

visits 

<4

a

(%)

≥4 

months

b

(%) 

Wealth quintile

Lowest 1,087 31.5 23.5 2,377 20.6 28.3 598 49.3 56.5 1,076 21.4 45.8 

Second 1,048 26.2 22.8 2,444 9.9 20.0 538 37.6 52.8 963 13.9 40.4 

Middle 973 19.8 16.8 2,606 5.9 15.6 442 31.2 56.2 881 9.3 33.1 

Fourth 940 12.3 11.2 2,863 4.2 12.2 497 24.0 56.4 784 8.3 30.6 

Highest 1,063 10.3 10.4 2,611 2.3 6.7 461 8.3 44.6 633 2.5 15.4 

Labor force 

participation

Low 1,807 22.1 20.0 4,510 9.7 18.7 816 31.7 55.0 1,355 16.9 41.1 

Medium 1,690 24.6 20.7 4,028 8.7 16.7 755 36.0 51.8 1,487 10.0 34.8 

High 1,615 13.7 10.0 4,364 6.3 13.2 965 27.2 53.5 1,493 10.0 29.2 

Disagreement 

with reasons to 

justify wife 

beating

Low 1,628 26.4 20.8 4,066 10.5 18.1 832 38.3 55.4 1,292 17.0 39.1 

Medium 1,817 19.6 17.4 4,282 9.1 17.4 897 30.6 52.6 1,458 12.0 33.9 

High 1,668 14.9 13.2 4,554 5.5 13.4 807 24.7 52.5 1,586 8.4 32.2 

Decision-making 

power

Low 1,468 23.9 18.2 4,224 9.9 18.2 922 31.2 52.3 1,406 12.3 33.3 

Medium 1,790 18.2 17.9 4,318 6.5 14.2 831 28.9 52.7 1,482 11.7 33.8 

High 1,853 19.4 15.4 4,361 8.5 16.3 782 33.9 55.7 1,448 12.4 37.5 

Women's 

knowledge 

level

Low 1,801 25.5 23.1 4,183 13.0 21.5 775 44.5 57.1 1,354 17.7 40.8 

Medium 1,752 20.8 16.7 4,353 7.7 15.7 850 29.5 55.6 1,418 11.6 35.6 

High 1,559 13.6 10.6 4,366 4.4 11.8 911 21.7 48.5 1,563 7.8 29.0 

a ANC visits took place < 4 times during the pregnancy.

b The first ANC visit was at ≥4 months of gestation.
13

Table 3. Adjusted odds ratios of the association between women’s empowerment indicators and number of 

covariates

Cambodia Indonesia Myanmar Philippines 

Variables AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% C

Age at birth

Adult (Ref.) 1 1 1 1 

Adolescent 0.96 0.56 - 1.64 0.64** 0.47 - 0.88 0.44*** 0.27 - 0.70 0.83 0.58 - 1.

Labor force participation

Low (Ref.) 1 1 1 1 

Medium 1.14 0.91 - 1.42 1.00 0.80 - 1.23 0.92 0.70 - 1.20 1.33* 1.02 - 1.

High 1.32* 1.03 - 1.69 1.12 0.89 - 1.41 1.1 0.84 - 1.45 1.36* 1.05 - 1.

Disagreement with reasons 

to justify wife beating

Low (Ref.) 1 1 1 1 

Medium 1.39** 1.12 - 1.73 1.38** 1.10 - 1.73 1.46* 1.09 - 1.96 1.20 0.94 - 1.

High 1.43** 1.12 - 1.83 1.18 0.91 - 1.52 1.33* 1.01 - 1.75 1.37 0.99 - 1.

Decision-making power

Low (Ref.) 1 1 1 1 

Medium 1.47*** 1.18 - 1.84 1.32* 1.06 - 1.64 1.18 0.92 - 1.51 0.89 0.71 - 1.

High 1.24 0.98 - 1.56 1 0.80 - 1.25 1.09 0.84 - 1.40 0.87 0.68 - 1.

Women's knowledge level

Low (Ref.) 1 1 1 1 

Medium 1.14 0.89 - 1.47 1.22 0.97 - 1.54 1.37* 1.07 - 1.75 1.01 0.79 - 1.

High 1.38** 1.09 - 1.76 1.66*** 1.28 - 2.16 1.44* 1.05 - 1.97 1.06 0.77 - 1.

Difference between adolescent 

vs. adult mothers with low 

knowledge (Ref.) 1

Difference between adolescent 

mothers with medium 

knowledge and adult mothers 

with low knowledge 0.44* 0.22 - 0.89

Difference between adolescent 

mothers with high knowledge 

and adult mothers with low 

knowledge 0.83 0.43 - 1.59

Number of observations 4,899 12,869 2,680 4,408 

Population size 5112 12902 2536 4336 

*** p<0.001, ** p<0.01, * p<0.05
14

3.3 Timing of First ANC Visit 

Table 4 shows that women’s labor force participation was significantly associated with attending 

the first ANC visit in the first 4 months in Cambodia and Philippines. In Philippines women with 

high participation in the labor force had 29% higher odds of attending the first ANC visit in the 

first trimester, and in Cambodia 80% higher odds, compared with women with low labor force 

participation. Disagreement with reasons to justify wife beating was significantly associated with 

early ANC visits only in Timor-Leste, where women with a medium level of disagreement had 

30% greater odds, and women with high disagreement had 39% greater odds, of attending the first 

ANC in the first trimester compared with women with low disagreement with reasons to justify 

wife beating. 

Women’s decision-making power was associated with early ANC visit only in Philippines, where 

women with high decision-making power had 20% lower odds of attending the first ANC in the 

recommended first 4 months of gestation compared with women with low decision-making power. 

Women’s knowledge level was associated with early first ANC visit only in Cambodia, where 

women with a high level of knowledge had 75% greater odds of attending the first ANC visit early 

compared with women with low knowledge. 

As Table 4 shows, we found a significant interaction between labor force participation and 

mother’s age at birth in Myanmar. In this country, adolescent mothers with high labor force 

participation had 3.5 times greater odds of attending the first ANC early compared with the 

reference group of adult mothers with low labor force participation. 
15

Table 4. Adjusted odds ratios of the association between women’s empowerment indicators and timing of first 

covariates

Cambodia Indonesia Myanmar Philippines 

Variables AOR 95% CI AOR 95% CI AOR 95% CI AOR 95% CI 

Age at birth

Adult (Ref.) 1 1 1 1 

Adolescent 0.64* 0.44 - 0.92 0.65*** 0.51 - 0.82 0.55 0.25 - 1.18 0.64** 0.48 - 0.84 

Labor force participation

Low (Ref.) 1 1 1 1 

Medium 1.25 0.98 - 1.60 1.03 0.86 - 1.22 1.06 0.82 - 1.38 1.07 0.89 - 1.3

High 1.84*** 1.41 - 2.41 1.16 0.97 - 1.38 0.92 0.73 - 1.16 1.29** 1.08 - 1.5

Disagreement with reasons to 

justify wife beating

Low (Ref.) 1 1 1 1 

Medium 1.24 0.99 - 1.56 1.14 0.96 - 1.37 1.11 0.90 - 1.38 1.06 0.90 - 1.2

High 1.22 0.96 - 1.53 1.02 0.86 - 1.21 1.05 0.82 - 1.35 1.09 0.87 - 1.3

Decision-making power

Low (Ref.) 1 1 1 1 

Medium 1.09 0.88 - 1.35 1.19 0.99 - 1.43 1.00 0.79 - 1.25 0.93 0.77 - 1.1

High 1.20 0.92 - 1.56 1.04 0.88 - 1.23 0.97 0.74 - 1.26 0.80* 0.67 - 0.9

Women's knowledge level

Low (Ref.) 1 1 1 1 

Medium 1.27 0.98 - 1.64 1.10 0.92 - 1.32 1.03 0.82 - 1.31 0.96 0.80 - 1.14 

High 1.75*** 1.33 - 2.30 1.19 0.96 - 1.48 1.23 0.92 - 1.65 1.02 0.82 - 1.2

Difference between adolescent 

vs. adult mothers with low 

labor force participation (Ref.) 1

Difference between adolescent 

mothers with medium labor 

force participation vs. adult 

mothers with low labor force 

participation 1.40 0.54 - 3.64

Difference between adolescent 

mothers with high labor force 

participation vs. adult mothers 

with low labor force 

participation 3.52* 1.29 - 9.58

Number of observations 4,899 12,869 2,680 4,408 

Population size 5112 12902 2536 4336 

*** p<0.001, ** p<0.01, * p<0.05

17

4 Discussion and Conclusions

4.1 General Findings 

We found that type of women’s empowerment associated with using ANC services differed across 

the five ASEAN countries in the study. Labor force participation was associated with making the 

recommended number of ANC visits in Cambodia, Philippines, and Timor-Leste. Disagreement 

with reasons to justify wife beating and women’s knowledge level each were associated with 

number of ANC visits in Cambodia, Indonesia, and Myanmar. Women’s decision-making power 

was associated with number of ANC visits in Cambodia and Indonesia. 

Early first ANC visit was associated with women’s empowerment only in Philippines. Labor force 

participation was associated with early first ANC visit in Cambodia and Philippines. Disagreement 

with reasons to justify wife beating was associated with early first ANC visit only in Timor-Leste, 

while women’s knowledge level was associated with early first ANC visit only in Cambodia. 

Unlike the other women’s empowerment indicators that showed a positive association with early 

first ANC visit, decision-making power showed a significant negative association with early first 

ANC visit in Philippines. 

Adolescent mothers generally attended fewer ANC visits and came for the first ANC visit later 

compared with adult mothers. There was no age difference in the association between women’s 

empowerment and number of ANC visits except in Cambodia, where adolescent mothers with a 

medium knowledge level had lower odds of making four or more ANC visits compared with the 

reference group of adult mothers with low knowledge. Also in Myanmar, adolescent mothers with 

a high level of labor participation had higher odds of attending first ANC early in the pregnancy 

compared with the reference group of adult women with low labor force participation. 

4.2 Comparison with Other Studies 

Generally, our study supports the findings from a review of 67 studies in developing countries that 

women’s empowerment is positively associated with the use of health care services (Pratley 2016). 

Similar to our findings, a study in India reported that younger women were less likely to have 

adequate ANC (Singh and Singh 2014). 

Specifically, our study found that women with high labor force participation had 32%-65% higher 

odds of attending four or more ANC visits in Cambodia, Philippines, and Timor-Leste. Our results 

were similar to an analysis of the 2007 Bangladesh DHS showing that women with a high level of 

employment and economic decision-making power had 56% greater odds of attending four or more 

ANC visits (Haque et al. 2012). 

Women who had high disagreement with all reasons for wife beating had 18%-43% higher odds 

of attending four or more ANC visits in Cambodia, Indonesia, and Myanmar. This estimate is 
18

similar to that of the study in Bangladesh, which reported 19% greater odds of making the 

recommended number of ANC visits among women with high disagreement with reasons for wife 

beating (Haque et al. 2012). 

Differing from our results, data from the Tajikistan Living Standards Survey 2007 showed that 

women’s decision-making on household financial issues had a negative association with the 

probability of attending four or more ANC visits, while it was positively associated with the 

likelihood of attending at least one ANC visit (Kamiya 2011). We could not compare our estimate 

directly with the study from Bangladesh (Haque et al. 2012), which combined women’s decisionmaking power of family health care and family planning. However, the difference between women 

with medium and low decision-making power in our study (32% versus 47%) was similar to the 

difference between women with high and low familial health care and family planning decisionmaking power in Bangladesh, which showed 43% greater odds of attending a sufficient number of 

ANC visits among women with a high level of decision-making power compared with those with 

low-level decision-making power (Haque et al. 2012). 

Our estimates for the association between women’s knowledge level and number of ANC visits 

were lower (38%-66%) compared with a pooled analysis of DHS data from 33 developing 

countries reporting that women with complete primary education had almost three times greater 

odds of attending four or more ANC visits compared with women with less or no education 

(Ahmed et al. 2010). In rural India adolescent mothers who had high school or higher education 

had nearly three times higher odds of having full ANC (attending four or more ANC visits, had 

tetanus toxoid injection, and received iron-folic acid) compared with illiterate adolescent mothers 

(Singh et al. 2012). Our finding was closer to the study in Bangladesh, where women who attended 

secondary or higher education had 5.4 times greater odds of attending four or more ANC visits 

(Haque et al. 2012). In Timor-Leste, women who did not have any formal education had 54% 

greater odds of making fewer than four ANC visits (Khanal et al. 2015), which is within the range 

of our estimates. Although we could not directly compare our results with another study using 

DHS data in Indonesia, the direction of the association was similar to our findings. The study found 

that women in Indonesia in the poorest households who had only primary education or no 

education had nearly nine times greater odds of not attending the recommended four ANC visits 

compared with women in the wealthiest households who had completed secondary education or a 

higher level (Titaley, Dibley, and Roberts 2010). 

4.3 Possible Mechanism 

Labor force participation was not a significant factor for number of ANC visits in Indonesia and 

Myanmar, possibly because women might not necessarily use the cash they earned for maternal 
19

health care. Disagreement with reasons to justify wife beating was a significant factor for ANC 

visits in Cambodia, Indonesia, and Myanmar, but not in Philippines and Timor-Leste. The finding 

of non-significant association may be because the proportion of women in Philippines who 

disagreed with all reasons for wife beating was very high (84%), and in Timor-Leste very low 

(11%). 

The link between disagreement with reasons for wife beating and attending ANC visits may be 

similar to the link between experiencing domestic violence and attending ANC visits. In TimorLeste, for example, women who experienced combined physical, sexual, or emotional violence at 

home were likely to have fewer ANC visits compared with women who did not experience 

domestic violence (Taft, Powell, and Watson 2015). Similar to women who experienced domestic 

violence, women who have low disagreement with reasons to justify wife beating may have limited 

mobility to attend ANC due to partner’s control and thus be less likely to take part in activities 

outside of home (Nahrgang 2016). 

In Cambodia and Myanmar women’s decision-making power indicated that they were in a good 

position to decide for themselves whether to go for ANC. Women in other countries may be in the 

same position, but our findings were not statistically significant. In Cambodia, Indonesia, and 

Myanmar, women’s knowledge level, an indicator created from a combination of formal education 

and access to media, may indicate an understanding of the importance of ANC that could lead 

women with a high level of knowledge to attend ANC. In Philippines and Timor-Leste, however, 

women with a high level of formal education and good access to media may not have good 

knowledge of the importance of maternal health care, and thus did not become a significant factor, 

leaving labor force participation as the only significant empowerment factors for ANC in these 

two countries. 

Early first ANC visit was associated with a lower number of women’s empowerment factors in all 

countries. Early first ANC visit may be more affected by whether women were aware of their 

pregnancy early in the gestation. We could not offer any other possible explanation for the reason 

that women with high decision-making power in the Philippines had significantly lower odds of 

attending the first ANC early in the first trimester compared with women with a low decisionmaking power. 

The significant interaction between women’s age at birth and knowledge level in Cambodia for 

number of ANC visits, and women’s age at birth and labor force participation in Myanmar for 

ANC timing, suggests that there might be different mechanisms between the decisions to attend 

ANC for young mothers and for adult mothers. Compared with adult mothers, an increase in 

knowledge from a low to a medium level among adolescent mothers was associated with lower 

odds of making ANC visits in Cambodia. This could be because adolescent mothers might rely 

more on maternal health decisions made for them by their family members. Indeed, their pregnancy 

was likely to be their first experience, and thus their knowledge of maternal health-seeking 

behavior was not optimal.
20

4.4 Strengths and Weaknesses 

To our knowledge, this is the first study to report the association of women’s empowerment and 

ANC in the ASEAN region. We found significant associations between women’s empowerment 

indicators and number of ANC visits, even after adjustment for the effect of household wealth. 

The strength of the study is that we used the latest data from nationally representative surveys in 

five different ASEAN countries and thus can compare the findings between countries. We included 

four components of women’s empowerment (labor force participation, disagreement with reasons 

to justify wife beating, decision-making power, and knowledge level) that were derived from 17 

different variables. We included number of ANC visits and timing of the first to provide a broad 

perspective on use of ANC. We also compared adolescent and adult mothers to assess the possible 

differential association between ANC and women’s empowerment by women’s age. 

We excluded never-married women from the DHS datasets. As such, we may have underestimated 

the association between ANC and adolescent pregnancies. However, the number of births among 

never-married women excluded was low (0.1% in Indonesia, 3.4% in Philippines, and 0.06% in 

Timor-Leste), so we expect that the underestimation also was low. DHS did not assess a direct 

measure of maternal health knowledge. However, we were able to combine women’s level of 

education and access to media to create a proxy indicator for this factor. 

5. Conclusion

In conclusion, the type of women’s empowerment associated with ANC use is different across the 

five ASEAN countries studied. In general, women’s empowerment status is significantly 

associated with total number of ANC visits in more of the countries than is the case for timing of 

women’s first ANC visit. 

6. Policy Implication and Further Study

This study showed that use of ANC is associated with several factors related to women’s 

empowerment status, as well as to health care decision-making itself. Improving the prevalence of 

recommended number of ANC visits as well as early ANC visits requires multi-sectoral 

approaches. It is likely that improving women’s access to the labor force, such as creating job 

opportunities, providing incentives on women’s entrepreneurship, and providing specific policies 

to support women at work, especially in Cambodia, Philippines, and Timor-Leste, can improve 

use of ANC and thus achieve better maternal and child health in ASEAN countries. Other possible 

interventions to empower women include developing community-based women’s groups and 

improving women’s access to health information through the media, especially in Cambodia, 

Indonesia, and Myanmar. The issue of women’s empowerment and maternal health outcomes 

should be addressed in ASEAN to accelerate attainment of the SDG targets. We recommend 

further studies to assess the efficacy of such interventions in improving ANC and subsequent 

maternal and child health indicators in ASEAN countries. 
21

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