Women’s decision-making autonomy and early antenatal care initiation in Ghana: a propensity score-matched analysis

Abstract

Women’s decision-making autonomy is widely recognized as an important determinant of maternal health behaviors such as the timing of antenatal care (ANC) initiation in low- and middle-income countries. However, empirical evidence from Ghana on this relationship, particularly using causal inference approaches, remains limited. This study investigates the effect of women’s decision-making autonomy on the early initiation of ANC visits in Ghana. Data were sourced from the 2022 Ghana Demographic and Health Survey (GDHS), including 4,314 women aged 15–49 years with a birth in the preceding three years before the survey. Autonomy was measured as a composite index from household decision-making participation. Propensity Score Matching (PSM) was used to match women with High and None/Low autonomy, based on covariates like age, education, wealth, and residence. The average treatment effect on the treated (ATT) was estimated to assess the impact of high autonomy on early ANC initiation (within the first trimester), compared to the counterfactual scenario in which the same women lacked such autonomy. Among the women included in the study, 25.3% reported high decision-making autonomy, and 66.4% initiated ANC early. Women with high autonomy were more likely to be older (30–49 years), educated (secondary or higher), married, employed, Christian, insured, urban residents, and from wealthier households. After matching on socio-demographic covariates, no statistically significant effect of high autonomy on early ANC initiation was observed [-0.029; 95% CI: -0.081 to 0.022]. Women’s decision-making autonomy, when measured through household decision-making participation and within the Ghanaian context, does not independently drive early ANC initiation, suggesting that broader structural and contextual barriers may constrain the translation of autonomy into early care-seeking.