Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia.

OBJECTIVE: To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre. METHODS: Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability. RESULTS: After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group. CONCLUSIONS: Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria.

Background: Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods: This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings: We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation: This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding: The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Examining reuse and replacement procedures for Ipas manual vacuum aspiration and cannulae in nine countries.

OBJECTIVE: To determine how many times Ipas manual vacuum aspiration (MVA) instruments are reused, for what reasons, when the instruments are replaced and/or discarded, and what the barriers are to replacing them. METHODS: We conducted a mixed-methods cross-sectional study of health care providers who provide MVA services and key stakeholders in the supply chain to understand reuse and replacement of Ipas MVA aspirators and cannulae. Qualitative interviews focused on procurement and replacement of Ipas MVA instruments. RESULTS: The authors interviewed 352 health care providers from nine countries from 2019 to 2021. Providers reported reusing MVA instruments an average of 34.4 times (standard deviation, 45). The reuse averages ranged from one time (Democratic Republic of the Congo) to 500 times (India), with figures varying between providers within the same country. Instrument malfunctioning rather than a specific number of uses drove reuse and subsequent replacement. The decision to replace was most commonly made by the provider during use. Half of the providers said that they knew of no issues with the supply chain, and 85% said they were always able to replace Ipas MVA instruments when needed. CONCLUSION: Tracking reuse of MVA instruments was uncommon at participating providers' health facilities. Providers' estimates revealed great variability in reuse frequency and tracking procedures.

The association of quality contraceptive counseling measures with postabortion contraceptive method acceptance and choice: results from client exit interviews across eight countries.

The availability of a variety of modern contraceptive methods is necessary but insufficient to provide a high-quality contraceptive service to postabortion clients. Women, especially young women, must be empowered to make informed choices about which methods they receive, including whether to use contraception following an abortion service. In this study, we conducted 2,488 client exit interviews with abortion clients after their induced abortion service or postabortion care visit in Ipas-supported health facilities in eight countries: Argentina, Bolivia, Ethiopia, Kenya, Mexico, Nepal, Nigeria, and Uganda. We evaluated the quality of postabortion contraceptive counseling across two domains of contraceptive counseling: information exchange and interpersonal communication. We measured the association between these quality elements and two outcomes: 1) client-perceived choice of contraceptive method and 2) whether or not the client received a modern contraceptive method. We examined these relationships while adjusting for sociodemographic and confounding variables, such as the client feeling pressure from the provider to accept a particular method. Finally, we determined whether associations identified differ by age group: under 25 and 25+. Information exchange and interpersonal communication both emerged as important counseling domains for ensuring that clients felt they had the ability to choose a contraceptive method. The domain of information exchange was associated with having received a contraceptive method for all abortion clients, including young abortion clients under 25. Nearly 14% of clients interviewed reported pressure from the provider to accept a particular contraceptive method; and pressure from the provider was significantly associated with a client's perception of not having a choice in selecting and receiving a contraceptive method during her visit to the facility. Improving interpersonal communication, strengthening contraceptive information exchange, and ensuring clients are not pressured by a provider to accept a contraceptive method, must all be prioritized in postabortion contraceptive counseling in health facilities to ensure postabortion contraceptive services are woman-centered and rights-based for abortion clients.

Community-based intervention improves abortion knowledge and reduces abortion stigma among women in Oromia, Ethiopia: a quasi-experimental mixed methods evaluation.

BACKGROUND: Since liberalization of the Ethiopian abortion law, there have been significant improvements in the availability and utilization of facility-based abortion services in the country. However, nearly half of abortions still take place outside of health facilities, where the quality of procedures remains unknown. Abortion stigma is one reason that unsafe abortion persists. This study aims to evaluate the effect of community interventions conducted from 2016 to 2019 on the level and manifestation of abortion stigma and knowledge in a community in Oromia region, Ethiopia. METHODS: The study is a quasi-experimental mixed methods evaluation including intervention and comparison communities. Two cross-sectional structured household surveys with independent samples, participatory evaluation wheels, and participatory impact diagrams were conducted with women of reproductive age (15-49) living in the communities. The baseline was conducted in 2016 and the endline in 2019. Difference-in-differences analysis was used to estimate the effect of the intervention on abortion knowledge and Stigmatizing Attitudes, Beliefs, and Actions Scale (SABAS) scores in the intervention community. RESULTS: One thousand five hundred fifty-five women participated in the household survey and 28 women participated in participatory evaluation meetings. Over one-third (37%) of women surveyed in the intervention community were exposed to the intervention activities. Knowledge of one or more indications of legal abortion increased from 21 to 85% in the intervention community, compared to an increase from 30 to 57% in the comparison. Mean SABAS scores decreased by 9.3 points in the intervention community and increased by 5.3 points in the comparison community. Differences-in-differences models indicate that exposure to the intervention resulted in decreased stigma scores (coefficient = - 9.33, p < 0.001) and increased knowledge (coefficient = 0.26, p < 0.001). CONCLUSIONS: This is one of the first studies to measure changes in community-level abortion stigma and knowledge over time in Ethiopia using a mixed method, quasi-experimental design. The results indicate that the community-based intervention improved abortion knowledge and reduced abortion stigma.

An examination of the characteristics and contraceptive acceptance of post-abortion clients in Ethiopia.

This national study examined the socio-demographic, health facility, and provider characteristics associated with the use of postabortion contraception in Ethiopia in 2014. We used data from a Prospective Morbidity Survey (PMS) conducted in Ethiopia in 2014 to measure abortion incidence and morbidity nationally. Data were collected on the presentation, care and treatment of 5,604 women who sought abortion services in 365 health facilities over 30 days. Descriptive and multivariate logistic regression analysis were used to examine postabortion contraceptive uptake. Nearly 75% of abortion clients received postabortion contraception. The majority received short-acting methods, around one-third chose a long-acting or permanent method. Most women sought abortion services at public health centers (61.8%) and were cared for by midlevel providers (82.5%). Multivariate regression results showed that women who sought services during the first trimester (odds ratio/OR = 1.44; 95% confidence interval/CI 1.06, 1.95), for induced abortions (OR = 3.55; 95% CI 2.52, 4.99), from public sector facilities, and those served by midlevel providers, had greater odds of receiving postabortion contraception. We conclude that providing strong contraceptive services postabortion in government facilities, including long-acting methods in the method mix, and providing this care by midlevel providers could further reduce unmet need for contraception and repeat abortions.

Drug Seller Provision Practices and Knowledge of Misoprostol in Bangladesh.

CONTEXT: In Bangladesh, prior to the availability of the approved combination regimen of mifepristone and misoprostol for menstrual regulation (MR), drug seller provision of misoprostol-only regimens for MR without a prescription was widespread but service quality was poor. Examining provider practices relating to misoprostol-only provision in Bangladesh may increase understanding of misoprostol use and provision in other low-resource, legally restrictive settings. METHODS: In 2013-2014, a countrywide cross-sectional knowledge, attitudes and practice survey was conducted among 777 randomly selected drug sellers; data were analyzed descriptively. Logistic regression was used to test the associations between exposure to three interventions designed to improve drug seller practice (nongovernmental organization [NGO]-led training, a call center and in-shop training from pharmaceutical company representatives) and correct knowledge of the misoprostol-only MR regimen. RESULTS: Almost all (97%) of the drug sellers reported providing medications intended for MR; misoprostol-only was more commonly sold than the combination regimen (96% vs. 26%). Nine percent had received NGO-led training, 62% had received in-shop training from a pharmaceutical company representative and 27% had used the call center. Overall, 19% of drug sellers knew the correct misoprostol-only MR regimen, and 74% wanted more information about this regimen. Correct regimen knowledge was positively associated with receipt of NGO training and call center utilization (odds ratios, 2.0 and 1.9, respectively). CONCLUSIONS: NGO-led training and call centers should be considered in other settings in which misoprostol alone is provided off-label for pregnancy termination.

RESUMEN Contexto: En Bangladesh, antes de que el régimen combinado de mifepristona y misoprostol fuera aprobado para la regulación menstrual (RM), la provisión sin receta de regímenes de misoprostol solo para RM por parte de vendedores de medicamentos estuvo muy generalizada, pero la calidad de servicio era deficiente. Examinar las prácticas de los proveedores relacionadas con la provisión de misoprostol solo en Bangladesh podría aumentar la comprensión sobre el uso y la provisión de misoprostol en otros entornos de bajos recursos restringidos legalmente. Métodos: Entre 2013 y 2014, se realizó una encuesta transversal de conocimientos, actitudes y prácticas en todo el país entre 777 vendedores de medicamentos seleccionados al azar; los datos fueron analizados descriptivamente. Se utilizó regresión logística para evaluar las asociaciones entre la exposición a tres intervenciones diseñadas para mejorar las prácticas de los vendedores de medicamentos (capacitación conducida por una organización no gubernamental [ONG], un centro de atención telefónica y capacitación en el negocio por parte de representantes de las compañías farmacéuticas), así como el conocimiento correcto del régimen de misoprostol solo usado para RM. Resultados: Casi la totalidad (97%) de los vendedores de medicamentos informaron que estaban vendiendo medicamentos para RM; que la venta de misoprostol solo era más común que el régimen combinado (96% vs 26%). El nueve por ciento había recibido capacitación impartida por ONG, el 62% había recibido capacitación en su negocio de un representante de una compañía farmacéutica y el 27% había utilizado el centro de llamadas. En general, el 19% de los vendedores de medicamentos conocía el régimen correcto de RM basado en misoprostol solo y el 74% quería más información sobre ese régimen. El conocimiento correcto del régimen se asoció positivamente con la recepción de capacitación de las ONG y la utilización del centro de atención telefónica (razón de probabilidades, 2.0 y 1.9, respectivamente). Conclusiones: La capacitación conducida por ONG y el uso del centro de atención telefónica deberían considerarse en otros entornos restringidos en los que el misoprostol solo se proporciona sin autorización para la interrupción del embarazo.

RÉSUMÉ Contexte: Au Bangladesh, avant la disponibilité du traitement homologué au mifépristone associé au misoprostol pour la régulation menstruelle (RM), la prestation par les vendeurs de médicaments des traitements de RM au misoprostol seul sans ordonnance était répandue, mais la qualité du service était faible. L'examen des pratiques de prestation relatives à la fourniture de misoprostol seul au Bangladesh peut aider à mieux cerner l'usage et l'offre de ce médicament dans d'autres contextes à faibles ressources soumis à des lois restrictives. Méthodes: En 2013­2014, une étude transversale sur les connaissances, les attitudes et les pratiques à l'échelle du pays a été menée auprès de 777 vendeurs de médicaments sélectionnés aléatoirement, pour analyse descriptive des données. La régression logistique a servi au test des associations entre l'exposition à trois interventions conçues pour améliorer la pratique des vendeurs de médicaments (formation sous la conduite d'organisations non gouvernementales [ONG], établissement d'un centre d'appels et formation par des représentants de laboratoires pharmaceutiques) et la connaissance correcte du traitement de RM à base de misoprostol seul. Résultats: Presque tous les vendeurs de médicaments (97%) ont déclaré vendre des médicaments destinés à la RM. Le misoprostol seul était vendu plus fréquemment que le traitement d'association (96% vs 26%). Neuf pour cent avaient bénéficié d'une formation par une ONG, 62% d'une formation locale assurée par un représentant de laboratoire pharmaceutique et 27% avaient eu recours au centre d'appels. Globalement, 19% des vendeurs avaient une connaissance correcte du traitement de RM à base de misoprostol seul et 74% désiraient plus d'information à ce sujet. La connaissance correcte du traitement était associée positivement à l'obtention d'une formation par une ONG et au recours au centre d'appels (RC, 2,0 et 1,9, respectivement). Conclusions: La formation sous la conduite d'une ONG et l'établissement d'un centre d'appels doivent être envisagés dans d'autres contextes sujets à une législation restrictive dans lesquels le misoprostol seul est proposé hors indication pour l'interruption d'une grossesse.

The effects of a community-based intervention on women's knowledge and attitudes about safe abortion in intervention and comparison towns in Oromia, Ethiopia.

The aim of this post-intervention assessment was to measure the effects of community intervention on the knowledge and attitudes of women regarding safe abortion in Ethiopia. In 2014, following implementation of an educational intervention on sexual and reproductive health from December 2012 to December 2013, 800 women were interviewed about their knowledge, attitudes, and practices regarding abortion. Multivariate regression analyses of respondents' demographics, sources of abortion information, knowledge, and attitudes about safe abortion were conducted. More women in the intervention community knew safe abortion was available in the community (76 percent vs. 57 percent; p < 0.001). Women in the intervention community had greater odds of feeling that women should have access to safe abortion services (adjusted odds ratio [aOR]: 1.55, 95 percent confidence interval [CI]: 1.06, 2.28) after adjusting for socio-demographic characteristics. They had significantly greater odds of feeling comfortable and confident talking to a healthcare provider (aOR: 2.44, 95 percent CI: 1.55, 3.84) and/or her partner (aOR: 2.47, 95 percent CI: 1.58, 3.85) about abortion. Increased mobilization of community networks in disseminating sexual health and abortion information was followed by increased knowledge of abortion services in the intervention community and improved reproductive choices for women.

Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study.

OBJECTIVE: To assess the feasibility of following up women who purchase mifepristone+misoprostol or misoprostol-only from pharmacies in order to measure the safety and effectiveness of self-administration of menstrual regulation. STUDY DESIGN: A prospective cohort study followed women purchasing mifepristone+misoprostol or misoprostol-only from pharmacies in Bangladesh. Participants were recruited by pharmacy workers either in person or indirectly via the purchaser of the drugs. End users were contacted by phone 2 weeks after recruitment, screened and interviewed. RESULTS: Study recruitment rates by pharmacy workers were low (30%, 109 of 642 women informed about the study), but 2-week follow-up rates were high (87%). Of the 109 end users interviewed, 87 purchased mifepristone+misoprostol and 20 misoprostol-only, while 2 women did not know what drugs they had purchased. Mean self-reported number of weeks of pregnancy was 5.7 weeks. Information provision by pharmacy workers was inadequate (40.4% received none, 8.7% received written information or pictures). A total of 80.5% of mifepristone+misoprostol users were sold the correct regimen versus 9 out of 20 misoprostol-only users. A total of 68.8% did not report experiencing any complications (70.0% misoprostol-only; 69.0% mifepristone+misoprostol users, p=1.0). A total of 94.3% of mifepristone+misoprostol users and 75% of misoprostol-only users reported that they were not pregnant at day 15 (p=.020). However, 7.3% of all users sought additional treatment. CONCLUSIONS: Challenges in assessing outcomes of self-managed menstrual regulation medications purchased from pharmacies must be overcome through further development of this methodology. Interventions are urgently needed to ensure that women have access to correct dosages, accurate information and necessary referrals. IMPLICATIONS: This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

Improving health worker performance of abortion services: an assessment of post-training support to providers in India, Nepal and Nigeria.

BACKGROUND: Health worker performance has been the focus of numerous interventions and evaluation studies in low- and middle-income countries. Few have examined changes in individual provider performance with an intervention encompassing post-training support contacts to improve their clinical practice and resolve programmatic problems. This paper reports the results of an intervention with 3471 abortion providers in India, Nepal and Nigeria. METHODS: Following abortion care training, providers received in-person visits and virtual contacts by a clinical and programmatic support team for a 12-month period, designed to address their individual practice issues. The intervention also included technical assistance to and upgrades in facilities where the providers worked. Quantitative measures to assess provider performance were established, including: 1) Increase in service provision; 2) Consistent service provision; 3) Provision of high quality of care through use of World Health Organization-recommended uterine evacuation technologies, management of pain and provision of post-abortion contraception; and 4) Post-abortion contraception method mix. Descriptive univariate analysis was conducted, followed by examination of the bivariate relationships between all independent variables and the four dependent performance outcome variables by calculating unadjusted odds ratios, by country and overall. Finally, multivariate logistic regression was performed for each outcome. RESULTS: Providers received an average of 5.7 contacts. Sixty-two percent and 46% of providers met measures for consistent service provision and quality of care, respectively. Fewer providers achieved an increased number of services (24%). Forty-six percent provided an appropriate postabortion contraceptive mix to clients. Most providers met the quality components for use of WHO-recommended abortion methods and provision of pain management. Factors significantly associated with achievement of all measures were providers working in sites offering community outreach and those trained in intervention year two. The number of in-person contacts was significantly associated with achievement of three of four measures. CONCLUSION: Post-training support holds promise for strengthening health worker performance. Further research is needed to compare this intervention with other approaches and assess how post-training contacts could be incorporated into current health system supervision.

A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014.

BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. METHODS: This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. RESULTS: There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. CONCLUSION: Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Using a harm reduction lens to examine post-intervention results of medical abortion training among Zambian pharmacists.

Despite broad grounds for legal abortion in Zambia, access to abortion services remains limited. Pharmacy workers, a primary source of health care for communities, present an opportunity to bridge the gap between policy and practice. As part of a larger operations study, 80 pharmacy workers, both registered pharmacists and their assistants, participated in a training on medical abortion in 2009 and 2010. Fifty-five of the 80 pharmacy workers completed an anonymous, structured training pre-test, treated as a baseline questionnaire; 53 of the 80 trainees were interviewed 12-24 months post-training in face-to-face interviews to measure the retention of information and training effectiveness. Survey questions were selected to illustrate the principles of a harm reduction approach to unsafe abortion. Bivariate analysis was used to examine pharmacy worker knowledge, attitudes and dispensing behaviours pre-training and at follow-up. A higher percentage of pharmacy workers reported referring women to a health care facility between surveys (47% to 68%, p = 0.03). The number of pharmacy workers who reported dispensing ineffective abortifacients decreased from baseline to end-line (30% to 25%) but the difference was non-significant. However, study results demonstrate that Zambian pharmacy workers have a role to play in safe abortion services and some are willing to play that role.

Women's empowerment and generalized anxiety in Minya, Egypt.

Gender disparities in mental health are global, with women experiencing higher rates than men of anxiety disorders, mood disorders, and attempted suicide. Women's low social status may partly explain these disparities, yet evidence from Arab and Middle Eastern settings is limited. We assessed whether women's empowerment - or acquisition of enabling resources, and in turn, enhanced agency - was associated with their lower generalized anxiety. For 539 ever-married women 22-65 years who participated in the 2005 Egypt Demographic Health Survey (EDHS) and a 2012 follow-up survey in rural Minya, we estimated linear reduced-form and mediation regression models to assess the associations of women's premarital enabling resources with their generalized anxiety in 2012, overall and through measures of their marital agency in 2005. Women's higher schooling attainment, premarital economic activity, later age at first marriage, and greater proximity to natal (or birth) family had significant, adjusted associations with lower generalized anxiety. Measures of women's agency in marriage had mixed associations with generalized anxiety, but their inclusion modestly reduced the coefficients for premarital resources. Parallel qualitative findings confirmed nuanced associations between women's exclusive decision-making and their mental health. Efforts to enhance women's education and premarital economic activity might be combined with efforts to delay first marriage and ensure women's extra-marital social support to maximize their empowerment and its mental-health benefits.