Factors Associated with Healthcare Decision-Making Autonomy among Pregnant Women in West Africa

Abstract Background Healthcare decision-making autonomy is central to women’s reproductive rights and maternal health. However, autonomy remains limited among many women in sub-Saharan Africa, particularly during pregnancy. This study examined factors associated with healthcare decision-making autonomy among pregnant women in West Africa. Methods This study used pooled, nationally representative Demographic and Health Survey data from 12 West African countries. The analytic sample included 7,330 pregnant women aged 15–49 years. Healthcare decision-making autonomy was categorized as no autonomy, joint autonomy, and complete autonomy. Descriptive statistics, Rao–Scott chi-square tests, and multivariable ordinal logistic regression were used to examine factors associated with higher levels of autonomy. Adjusted odds ratios and 95% confidence intervals were reported, accounting for the complex survey design. Results Overall, 62% of pregnant women reported no autonomy in healthcare decision-making, 28% reported joint autonomy, and 9.9% reported complete autonomy. In adjusted analyses, older age, higher education, current employment, unmarried status, and country of residence were significantly associated with greater autonomy. Compared with women aged 15–19 years, women aged 25–44 years had higher odds of being in a higher autonomy category. Education showed a graded association, with women who had higher education having more than twice the odds of greater autonomy compared with those with no formal education. Currently working women also had higher odds of greater autonomy, while rural residence was associated with lower odds. Substantial cross-country differences were observed, with higher autonomy in countries such as Ghana and Liberia and lower autonomy in Mali. Conclusion Healthcare decision-making autonomy among pregnant women in West Africa remains low. Interventions to improve maternal health should strengthen women’s education, economic empowerment, and rural access to supportive health systems while addressing household and sociocultural barriers that limit women’s participation in healthcare decisions.