Maternal and Child Health Journal

, Volume 20, Issue 1, pp 172–186 | Cite as

The Influence of Women’s Empowerment on Child Immunization Coverage in Low, Lower-Middle, and Upper-Middle Income Countries: A Systematic Review of the Literature

  • Sara ThorpeEmail author
  • Kristin VanderEnde
  • Courtney Peters
  • Lauren Bardin
  • Kathryn M. Yount



An estimated 1.5 million children under five die annually from vaccine preventable diseases, and 17 % of these deaths can be averted with vaccination. Predictors of immunization coverage, such as maternal schooling, are well documented; yet, preventable under-five mortality persists. To understand these patterns, researchers are exploring the mother–child relationship through an empowerment framework. This systematic review assesses evidence of the relationship between women’s agency as a component of empowerment and vaccine completion among children <5 years in lower-income countries.


We searched in Socindex, Pubmed, Web of Science and Women’s Studies International for peer-reviewed articles focused on two measures of women’s agency—decision-making and freedom of movement—and child vaccination. Our initial search identified 406 articles and abstracts for screening; 12 studies met the inclusion and exclusion criteria.


A majority (83 %) of studies revealed at least one positive association of measures for women’s agency with immunization coverage. These relationships varied by geographic location, and most studies focused on women’s decision making rather than freedom of movement. No included study came from Latin America or the Middle East.


Overall, women’s agency, typically measured by decision-making, was positively associated with the odds of complete childhood immunizations. Yet, the concept of agency was inconsistently defined and operationalized. Future research should address these inconsistencies and focus on under-represented geographic regions including Latin America and the Middle East.


Child immunization Vaccine coverage Vaccine preventable diseases Women’s agency Women’s empowerment 



This paper was developed in collaboration with a group of mentors and colleagues who the principal researcher would like to acknowledge and thank for their contributions. The authors acknowledge Emory University, Rollins School of Public Health, and the Hubert Department of Global Health for its continuous support in the advancement of global health research and public health professionals. The views expressed in this article do not necessarily reflect those of Emory University Rollins School of Public Health.


  1. 1.
    Harris, J., Gacic-Dobo, M., Eggers, R., Brown, D., & Sodha, S. (2014). Global immunization data (pp. 1–4). Geneva: WHO.Google Scholar
  2. 2.
    Harahap, J. (2000). Factors affecting childhood immunization in North Sumatra Province, Indonesia (pp. 1–63). Master of Arts Thesis, Mahidol University.Google Scholar
  3. 3.
    World Health Organization (WHO). (2011). Global Vaccine Action Plan 20112020 (NLM classification: WA 115). Geneva: WHO Press.
  4. 4.
    Burton, A., Monasch, R., Lautenbach, B., Gacic-Dobo, M., et al. (2009). WHO and UNICEF estimates of national infant immunization coverage: Methods and processes. Bulletin of the World Health Organization, 87, 535–541.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Kamau, N., & Esamai, F. O. (2001). Determinants of immunization coverage among children in Mathare Valley, Nairobi. East African Medical Journal, 78(11), 590–594.PubMedCrossRefGoogle Scholar
  6. 6.
    Mutua, M. K., Kimani-Murage, E., & Ettarh, R. R. (2011). Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated? BMC Public Health, 11, 6.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Corsi, D. J., Bassani, D. G., Kumar, R., Awasthi, S., et al. (2009). Gender inequity and age-appropriate immunization coverage in India from 1992 to 2006. BMC International Health and Human Rights, 9(1), S3.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Chowdhury, A. M., Bhuiya, A., Mahmud, S., Abdus Salam, A. K., et al. (2003). Immunization divide: Who do get vaccinated in Bangladesh? Journal of Health, Population and Nutrition, 21(3), 193–204.Google Scholar
  9. 9.
    Antai, D. (2012). Gender inequities, relationship power, and childhood immunization uptake in Nigeria: A population-based cross-sectional study. International Journal of Infectious Diseases, 16(2), e136–e145.PubMedCrossRefGoogle Scholar
  10. 10.
    Fatiregun, A. A., & Okoro, A. O. (2012). Maternal determinants of complete child immunization among children aged 12–23 months in a southern district of Nigeria. Vaccine, 30(4), 730–736.PubMedCrossRefGoogle Scholar
  11. 11.
    Babirye, J. N., Rutebemberwa, E., Kiguli, J., Wamani, H., et al. (2011). More support for mothers: A qualitative study on factors affecting immunisation behaviour in Kampala, Uganda. BMC Public Health, 11, 723.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Fadnes, L. T., Nankabirwa, V., Sommerfelt, H., Tylleskär, T., et al. (2011). Is vaccination coverage a good indicator of age-appropriate vaccination? A prospective study from Uganda. Vaccine, 29(19), 3564–3570.PubMedCrossRefGoogle Scholar
  13. 13.
    Pande, R. P., & Yazbeck, A. S. (2003). What’s in a country average? Wealth, gender, and regional inequalities in immunization in India. Social Science and Medicine, 57(11), 2075–2088.PubMedCrossRefGoogle Scholar
  14. 14.
    Jamil, K., Buhiya, A., Streatfield, K., & Chakrabarty, N. (2005). The immunization program in Bangladesh: Impressive gains in coverage, but gaps remain. Health Policy and Planning, 1(14), 49–58.Google Scholar
  15. 15.
    Parashar, S. (2005). Moving beyond the mother–child dyad: Women’s education, child immunization, and the importance of context in rural India. Social Science and Medicine, 61(5), 989–1000.PubMedCrossRefGoogle Scholar
  16. 16.
    Topuzoğlu, A., Ay, P., Hidiroglu, S., & Gurbuz, Y. (2007). The barriers against childhood immunizations: A qualitative research among socio-economically disadvantaged mothers. European Journal of Public Health, 17(4), 348–352.PubMedCrossRefGoogle Scholar
  17. 17.
    Kabeer, N. (1999). Resources, agency, achievements: Reflections on the measurement of women’s empowerment. Development and Change, 20(3), 435–464.CrossRefGoogle Scholar
  18. 18.
    Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(6), e1000097. doi: 10.1371/journal.pmed1000097.Google Scholar
  19. 19.
    Rahman, M., & Obaida-Nasrin, S. (2010). Factors affecting acceptance of complete immunization coverage of children under five years in rural Bangladesh. Salud Publica de Mexico, 52(2), 134–140.PubMedCrossRefGoogle Scholar
  20. 20.
    Mahapatro, S. R. (2012). Utilization of Maternal and child health care services in India: Does women’s autonomy matter? The Journal of Family Welfare, 58(1), 22–33.Google Scholar
  21. 21.
    Singh, L., Rai, R. K., & Singh, P. K. (2011). Assessing the utilization of maternal and child health care among married adolescent women: Evidence from India. Journal of Biosocial Science, 44(1), 1–26.PubMedCrossRefGoogle Scholar
  22. 22.
    Babalola, S. (2009). Determinants of the uptake of the full dose of diphtheria–pertussis–tetanus vaccines (DPT3) in Northern Nigeria: A multilevel analysis. Maternal and Child Health Journal, 13(4), 550–558.PubMedCrossRefGoogle Scholar
  23. 23.
    Singh, K., Haney, E., & Olorunsaiye, C. (2012). Maternal autonomy and attitudes towards gender norms: Associations with Childhood immunization in Nigeria. Maternal and Child Health Journal, 17(5), 837–841.CrossRefGoogle Scholar
  24. 24.
    Agarwal, S., & Srivastava, A. (2009). Social determinants of children’s health in urban areas in India. Journal of Health Care for the Poor and Underserved, 20(4 Suppl), 68–89.PubMedCrossRefGoogle Scholar
  25. 25.
    Vikram, K., Vanneman, R., & Desai, S. (2012). Linkages between maternal education and childhood immunization in India. Social Science and Medicine, 75(2), 331–339.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Abuya, B. A., Onsomu, E. O., Kimani, J. K., & Moore, D. (2011). Influence of maternal education on child immunization and stunting in Kenya. Maternal and Child Health Journal, 15(8), 1389–1399.PubMedCrossRefGoogle Scholar
  27. 27.
    Pandey, S., & Lee, H. N. (2012). Determinants of child immunization in Nepal: The role of women’s empowerment. Health Education Journal, 71(6), 642–653.CrossRefGoogle Scholar
  28. 28.
    Singh, K., Bloom, S., & Brodish, P. (2013). Gender equality as a means to improve maternal and child health in Africa. Health Care for Women International, 36(1), 57–69.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Upadhyay, U. D. & Karasek, D. (2010). Women‘s empowerment and achievement of desired fertility in Sub-Saharan Africa (DHS Working Papers No. 80). Calverton, Maryland, USA: ICF Macro.Google Scholar
  30. 30.
    Yount, K. M., VanderEnde, K., Dodell, S., & Cheong, Y. F. (2015). Measurement of women’s agency in Egypt: A National Validation Study. Social Indicators Research. doi: 10.1007/s11205-015-1074-7.Google Scholar
  31. 31.
    Agarwala, Rina, & Lynch, Scott M. (2006). Refining the measurement of women’s autonomy: An international application of a multi-dimensional construct. Social Forces, 84(4), 2077–2098.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Sara Thorpe
    • 1
    Email author
  • Kristin VanderEnde
    • 1
  • Courtney Peters
    • 1
  • Lauren Bardin
    • 1
  • Kathryn M. Yount
    • 1
  1. 1.Emory UniversityAtlantaUSA

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