Associations between women's empowerment, care seeking, and quality of malaria care for children: A cross-sectional analysis of demographic and health surveys in 16 sub-Saharan African countries

Background Fever and malaria are highly prevalent among children under five across sub-Saharan Africa, but utilization and quality of care for febrile illness remain insuffi-cient. Many studies examine socioeconomic and demographic determinants of care seek-ing; however, few assess how women's empowerment influences care seeking and quality. We examine associations of women's empowerment with: a) care utilization for children with fever and malaria and b) the quality of that care in 16 sub-Saharan African countries. Methods This cross-sectional study used data from Demographic and Health Surveys conducted between 2010 and 2018. We constructed indices for economic, educational, sociocultural, and health-related empowerment and calculated the proportion of chil-dren with fever and malaria who sought care and received a range of recommended clin-ical actions. We used multivariable Poisson hurdle models to assess associations between empowerment, utilization, and number of components of quality care, controlling for socioeconomic and demographic factors. Results Our sample consisted of 25 871 febrile children, 4731 of whom had malaria di-agnosed by rapid diagnostic test. Empowerment among mothers of children with fever was 0.50 (interquartile range, 0.38-0.63). In both the fever and malaria groups, over 30% of children were not taken for care. Among care seekers, febrile children received on av-erage 0.47 (SD = 0.37) of components of quality care, and children with malaria received 0.38 (SD = 0.34). Multidimensional women's empowerment was significantly associated with care seeking and quality among febrile children, and with quality among children with malaria. Associations persisted after adjustment for socioeconomic and demograph-ic characteristics. Conclusions Results demonstrate substantial gaps in women's empowerment and poor utilization and quality of care for fever and malaria among children. Increased women's empowerment is associated with seeking care and, separately, obtaining high-quality care. To improve health outcomes, consideration of how empowering women can promote care seeking and extract quality from the health system is warranted.