Determinants of autonomy in sexual and reproductive health decision making among women: A mixed-effects multilevel analysis of the demographic and health survey in Ghana

Background: Women’s autonomy in sexual and reproductive health (SRH) decision making is essential for achieving sustainable development goals (SDGs) 3 (ensuring healthy lives and promoting well-being) and 5 (achieving gender equality and empowering all women and girls). However, SRH decision-making autonomy remains limited with disparities in low- and middle-income countries (LMICs), including Ghana. Hence, this study examined the determinants of women’s autonomy in SRH decision making in Ghana. Methodology: We analyzed data from the 2022 Ghana Demographic and Health Survey (DHS), a nationally representative cross-sectional dataset. The sample included 8,811 married or cohabiting women aged 15-49 years. A mixed-effect multilevel binary logistic regression model was used to identify the determinants of SRH decision-making autonomy, with results presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results: We found that 51.7% [CI=49.8,53.7] of Ghanaian women had autonomy in SRH decision-making. SRH decision-making autonomy was significantly high among women aged 35--39 years [aOR=2.06; CI=1.19,3.55], 45-49 years [aOR=2.76; CI=1.57,4.86], those with secondary education [aOR=1.65; CI=1.34,2.02], those with higher education [aOR=3.33; CI=2.31,4.80], those with media exposure [aOR=1.38; CI=1.11,1.70], those currently working [aOR=1.67; CI=1.33,2.09], and having a partner with secondary [aOR = 1.26; CI: 1.04,1.52] or higher education [aOR = 1.41; CI: 1.05,1.88], compared to their respective reference categories. Conversely, lower SRH decision-making autonomy was observed among Muslim women [aOR=0.72; CI=0.57,0.91] and rural residents [aOR=0.74; CI=0.59,0.91] compared to Christian women and urban resident women, respectively. Additionally, significant regional and ethnic disparities were evident, indicating important structural and sociocultural influences on women’s autonomy in SRH decisions. Conclusion: Nearly half of Ghanaian women lacked autonomy in SRH decision-making, significantly influenced by age, education, exposure to media, current work status, religion, ethnicity, and geographic region. Addressing these disparities requires targeted multilevel interventions that consider the unique cultural and socio-economic barriers faced by disadvantaged groups.