Demographic and Health Surveys (DHS) are a reliable source of individual level information on socioeconomic characteristics, health, and development indicators in the context of LMICs. Since 1999, these surveys have been incorporating questions on women’s empowerment that potentially allows for comparisons within and between countries using an intersectional lens. We used data from the latest available DHS since 2000 for all available countries. For Mozambique, data from the 2011 survey was used because the 2015 survey lacked information on partner´s age and education. Six countries with a DHS were dropped because not all necessary items were available (Colombia, Turkey, Vietnam, Jordan, Yemen and Congo Brazzaville). Thus, 62 countries – 34 of which were already included in the SWPER for Africa [10] – were included in the analyses (Table 1), with a total sample of 662 835 partnered women.

The same three domains identified in the SWPER for Africa were observed in the global analyses: attitude to violence, social independence and decision making. The cross-country consistency among items composing each domain of the SWPER Global can be assessed through Table 1, where we present items with a loading of 0.3 or more (henceforth referred to as high loadings). All countries presented the exact same pattern of items identified in the attitude to violence domain, which included all the questions related to the woman’s opinion on whether a husband is justified in beating the wife in five different circumstances. Items composing the decision-making domain was also consistent across countries with higher loadings for the three questions related to the women´s involvement in household decisions, with only four countries presenting high-loading items that were not related to participation in household decisions. Three of them were from Latin America (Honduras and Peru, that also included woman’s education; and Guatemala, that included education and frequency of reading newspaper or magazine) and one from Europe & Central Asia (Tajikistan, that also included woman’s education and education difference between the woman and her husband). For the social independence domain, a greater variability in the patterns of items identified was observed. Countries from Africa and South Asia were the most stable in terms of the patterns for this domain (composed by the frequency of reading newspaper/magazine, women’s education, age the first birth, age at first cohabitation, and age and education differentials in relation to the partner). In the other four regions of the world, most countries presented low loadings for the frequency of reading newspapers or magazines. Education showed low loadings in only five countries (Azerbaijan, Tajikistan, Afghanistan, Cambodia and Honduras). The items related to pivotal events (age at first birth and at first cohabitation) presented high loadings in all countries. Age differentials to the partner had high loadings in three Europe and Central Asia countries (Armenia, Azerbaijan and Moldova) and education differentials to the partner in 12 out of the 62 countries, but without a clear pattern.

In Table 3 we present the correlations between the three SWPER domain scores calculated separately using principal component analyses in each country, and the global scores calculated using the pooled data. Cells are colored from yellow to dark green cells showing the strength of the correlations. Even though the item patterns presented in Table 1 were not entirely consistent for some countries (ie, all items presenting loading ≥0.3 in the same empowerment domain), the correlations between the country-specific and the SWPER Global scores were very high, equaling 0.89 or more. All countries presented correlations greater than 0.91 for all three SWPER domains, except for Gabon and Liberia where the correlations for social independence were 0.89 and 0.90, respectively.

Figure 1 shows scatter plots of the country ranks for the three SWPER domains against the country ranks for the GDI and the GII, providing evidence on the external validity of the SWPER. The correlation coefficients with the GDI (upper graphs) were 0.74, 0.72 and 0.67 for social independence, decision-making and attitude to violence, respectively. In the lower graphs, the SWPER rankings are plotted against the GII rankings. In this case, the Spearman correlations were 0.81, 0.67 and 0.44, respectively. Figure 1 shows that Latin America & Caribbean and Europe & Central Asia tend to present higher ranks in all empowerment domains while West & Central Africa, Eastern & Southern Africa and some countries from South Asia presented the lowest rankings.

Figure 1.  Scatter plot showing the SWPER domains ranking against the Gender Development Index and the Gender Inequality Index rankings with the Spearman correlation (r) indicated in the bottom right of each plot.

Generally, Europe & Central Asia and Latin America & Caribbean show the higher mean scores in the three empowerment domains (Table 4). The African regions and South Asia presented the lower mean scores, with West & Central Africa showing the lowest average scores in all three empowerment domains. East Asia and Pacific presented high mean scores for social independence and decision making but scored below the average for attitude to violence.

We explored whether a slightly modified version of the original SWPER, previously validated for African countries [10], could be used as an indicator of women´s empowerment across LMICs. 14 items identified from the previous version, that allow the assessment of empowerment in three dimensions (attitude to violence, social independence, and decision-making), were pre-selected for the SWPER Global validation process. The PCA analysis, showed consistency across countries in terms of patterns of components retained and item loadings for the attitude to violence and decision-making domains. For the social independence domain, we found more variability in terms of the item loadings. In particular, women’s education had low loadings in regions with higher educational levels, and therefore less variability in educational levels. Notwithstanding, the correlation between the country-specific and the SWPER Global scores were above 0.89 for all three empowerment domains in all 62 countries included in the analysis.

Two important changes from the previous version of the SWPER were made based on the workshop held with experts on women’s empowerment. The first was to remove the women’s working status as it was agreed that there are many reasons why women work, which are not necessarily related to their own choices. Also, work may not be empowering, depending on the working conditions, and on whether or not women are formally employed, are entitled to maternity leave, are paid for their work, and are able to decide what to do with their earnings. Our preliminary analyses (results not shown) showed that in several countries the work item had negative loadings in the PCA, suggesting that working could be indicative of lower empowerment levels. This inconsistent behavior has also been demonstrated in the literature. For example, women who were working and paid in cash in Egypt were at lower risk of experiencing intimate partner violence, while in India, Peru and Iran their risk was higher [24,25]. The second change in the SWPER Global was to give equal weights to women´s involvement in household decisions, whether they were taken only by the women or jointly with her the partner. In the original version of the SWPER, a decision made by the woman alone was given a higher score than a joint decision with the partner. However, there was consensus among experts that joint decisions on household issues such as purchases and visits to family or friends were thought to be a potential reflection of gender equality [26]. These content modifications were essential to refine and expand the index to a global context including all LMICs.

Our findings show the SWPER Global is a suitable common measure of women’s empowerment for LMICs, addressing the need for a single consistent survey-based indicator of women´s empowerment that allows to track progress over time and across countries at the individual and country levels. The external validity assessment showed overall strong correlations between country rankings in the SWPER Global with their rankings in the GDI and the GII which capture distinct aspects of gender inequalities at the country level. Construct validity of the SWPER was also previously assessed at the individual level, through its positive association with modern contraceptive use, institutional delivery, stunting [10] and, more recently, with child developmental outcomes [27] and neonatal, infant and under-5 mortality [28]. In the current manuscript, we chose not to present associations between the SWPER Global and health outcomes as other recently published studies have already shown its positive associations with the coverage of reproductive, maternal, newborn and child health interventions [29]; and negative association with experience of psychological and physical or sexual violence. [30]These results reassure the internal validity of the SWPER Global and its potential to widen the research on the effects of women’s empowerment on health interventions and outcomes.

After the first version of the SWPER was published in 2017, other similar measures of women´s empowerment in the context of Africa have been proposed in the literature. In 2018, Asaolu et al. [31], using DHS from nineteen countries across Sub-Saharan Africa, identified attitude towards violence, labor force participation, education, and access to health care as valid domains of empowerment although some variations between sub-regions were observed (eg, in East Africa education was surprisingly not a relevant component of women´s empowerment) [31]. Also in 2018, Miedema et al. [15] tested the cross-national invariance of women´s empowerment using DHS data from five countries in East Africa and identified three domains of women´s empowerment capturing women´s human/social assets, attitudes related to wife abuse, and women´s participation decision applicable across countries, very similar to what was presented in the original SWPER paper [10]. These other efforts highlight the importance of the topic and how different approaches can lead to different but similar results. Also, how diverse priorities also lead to different approaches. In our case, we compromised on country specificity to obtain an indicator that allows for comparative analysis and monitoring across a large array of countries.

The development of a global common measure of women´s empowerment, however, represents a huge challenge, given its complex and multidimensional constructs as well as their variability across different societies with contextually specific gender vulnerabilities. As a result, the SWPER Global has limitations, some already previously recognized and discussed in our previous publication [32]. Empowerment is not primarily an outcome, but a process that includes critical consciousness, aspiration, voice, choice, and change [33,34]; and as such, there are elements enabling or limiting it that have not been considered in the SWPER [32]. Decision-making assesses control but not choice, nor risk for sanctions or backlash based on choices made. Inclusion of aspects such as personal ownership of assets, economic participation, and opportunities and participation in governance processes were also pointed in the expert workshop as important measures of empowerment that are not captured by the SWPER. Some of these items are not available in DHS surveys and would require different data sources. However, there is a growing number of measures related to assets, opportunity and agency that are being added to DHS with potential to be incorporated in future updates of the SWPER Global. These include mobile phone ownership, internet access, bank accounts, and decision-making on how to spend personal earnings. As these are only available for a few recent surveys, their inclusion in the SWPER at this point would markedly reduce the number of countries for which the index could be calculated. Also, more items are needed to capture additional domains of women’s empowerment, especially in contexts with higher socioeconomic development, including (but not being restricted to) economic empowerment, sexual and reproductive empowerment, power relations outside marriage including political engagement or influence, social and occupational leadership and positioning, and freedom of movement and safety at the individual level.

Another important limitation is that the index is limited to women married or in a union and therefore leaves out sizeable groups of women in some countries (Table S4 in the Online Supplementary Document). African and Asian countries tend to have higher proportions of married adolescent girls, which may affect comparisons of empowerment levels across world regions and require age-stratified analyses. The development and validation of a measure that includes both partnered and unpartnered women, however, would require a very different approach, which is beyond the scope of the proposed indicator based on national health surveys for which most of the relevant information are only available for women that are married or in a union. Lastly, it is important to note that due to data availability, the countries included in our analysis represent 48% of all LMICs, ranging from over 70% of the countries from South Asia, West and Central Africa and Eastern and Southern Africa to 14% of the countries from Middle East and North Africa (Table S5 in the Online Supplementary Document). Given the little difference found in the behavior of the SWPER between the original version for Africa and the current, including all available LMICs, it is unlikely that the inclusion of more countries would lead to relevant changes to the indicator we proposed.

Acknowledging the current limitations of the SWPER Global, particularly in light of the recommendations from the expert workshop, efforts must continue to improve the indicator. We commend the DHS efforts to include questions related to women’s empowerment in the surveys, but having more information will be fundamental to advance in this direction either capturing other domains of women’s empowerment or improving the ones already measured with the SWPER. Several measures related to assets, opportunity and agency are already being added to the most recent DHS and will potentially be incorporated in future updates of the SWPER Global. However, more items related to domains like economic empowerment, sexual and reproductive empowerment, power relations outside marriage, leadership and positioning, and freedom of movement should be considered for inclusion in the surveys to provide a more robust measure of women’s empowerment, consistent with the SDG5 agenda. Another future challenge will be to develop another indicator that includes unpartnered women and enables comparison with the partnered ones, as well as the evaluation of inequalities between subgroups of women. Nevertheless, the SWPER Global is a pioneer indicator of women´s empowerment based on individual-level survey data from LMICs, which enables comparability between countries from all world regions and over time. It represents an advance over other global gender and development indices by including a domain on attitudes towards violence against women, a prevalent form of human rights violation as well as an important universally recognized aspect of gender inequality worldwide. Use of the SWPER Global will contribute to monitoring the progress towards SDG5, in terms of gender equality and empowerment at the national and sub-national levels. It also allows quantification of the role of empowerment in terms of health, nutrition and developmental outcomes of women and children worldwide.