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Associations of women’s empowerment with neonatal, infant and under-5 mortality in low- and /middle-income countries: meta-analysis of individual participant data from 59 countries
  1. David T Doku1,2,
  2. Zulfiqar A Bhutta3,4,
  3. Subas Neupane2
  1. 1 Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
  2. 2 Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Pirkanmaa, Finland
  3. 3 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  4. 4 Centre for Global Child Health, Sick Kids Foundation, Toronto, Ontario, Canada
  1. Correspondence to Dr David T Doku, Department of Population and Health, University of Cape Coast, Cape Coast, Ghana; dokudavid{at}


Background Child survival and women’s empowerment are global public health concerns and important sustainable development goals (SDGs). Low- and middle-income countries (LMICs) have the largest burden of both phenomena. The aim of this study is to investigate a measure of women’s empowerment at individual and population levels and its potential associations with neonatal, infant and under-5 mortality at national and regional levels in 59 LMICs.

Methods We used pooled population-based cross-sectional surveys from 59 LMICs (n=6 12 529) conducted from 2000 to 2015 using standardised protocols. We constructed individual-level women’s empowerment index (ILWEI) and population-level women’s empowerment index (PLWEI) for LMICs and investigated the potential associations of these measures with neonatal, infant and under-5 mortality using two-stage random-effect individual participant data (IPD) meta-analysis.

Results The pooled neonatal mortality rate was 24 per 1000 live births. Infant and under-5 mortality rates were 43 and 55/1000 live births, respectively. In the pooled sample, 61.6% and 19.9% of women had autonomy regarding their healthcare and household decision-making, respectively, whereas 56.0% rejected domestic violence against women for any reason. IPD meta-analysis showed that children of women with low ILWEI had a higher risk of neonatal (OR: 1.18, 95% CI 1.14 to 1.22), infant (OR: 1.12, 95% CI 1.08 to 1.17) and under-5 (OR: 1.12, 95% CI 1.07 to 1.18) mortality compared with children of high ILWEI. Similar relationships were found across most of the regions as well as between PLWEI and all the three outcomes.

Conclusions Women’s empowerment at individual and population levels is associated with neonatal, infant and under-5 mortality in LMICs. Our study underscores the importance of women’s empowerment in accelerating progress towards the attainment of the SDG targets for child survival in LMICs. Multi-sectoral and concerted efforts are necessary to eliminate preventable child mortality in these countries.

  • women’s empowerment
  • neonatal mortality
  • infant mortality
  • under-5 mortality
  • meta-analysis
  • low/middle-income countries

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  • Handling editor Dr Sanni Yaya

  • Correction notice This article has been corrected since it was published. The article type has been updated.

  • Contributors DTD and SN: developed the idea and the design of the study; analysed the data, contributed to the data interpretation and wrote the first draft of the manuscript. ZAB: reviewed the manuscript and provided direction for the intellectual content, additional analyses and context. All authors reviewed the draft manuscript and approved the final version for publication.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data are publicly available at Permission is required to use the data from Measure DHS.

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