Background. Although decision-making authority is associated with maternal healthcare utilisation, the evidence on the relative importance
of individual-level v. community-level decision-making participation for child survival in sub-Saharan Africa is limited.
Objectives. To assess the net effects of individual- and community-level measures of decision-making involvement (DMI) on under-5
mortality in Nigeria.
Methods. Data on a nationally representative sample of 31 482 children in the 2013 Nigeria Demographic and Health Survey were analysed.
Mothers who reported involvement in decision-making on own healthcare, major household purchases and visits to friends and relatives
were categorised as having high DMI. Community-level measures of DMI were derived by aggregating the individual measures at the
cluster level. Kaplan-Meier estimates of childhood mortality rates were computed. Multilevel discrete-time hazard models were employed
to investigate the net effect of individual- and community-level DMI on childhood mortality.
Results. Childhood mortality, at 59 months, was higher among children of women with low DMI (120 per 1 000) compared with those
with high DMI (84 per 1 000). The full multilevel model showed that there was no difference in the risk of childhood death between
children whose mothers had high v. low DMI (hazard ratio (HR) 1.01, CI 0.90 - 1.12). However, mortality risk was found to be lower among
children in communities with medium DMI (HR 0.84, CI 0.74 - 0.96). Maternal age at child’s birth, education, household wealth index and
preceding birth interval were significantly associated with under-five mortality.
Conclusion. Besides socioeconomic and biodemographic characteristics, community- and not individual-level DMI was associated with
under-5 mortality. Women’s empowerment programmes targeting maternal and child health outcomes should also focus on communities.