Does State-level Women's Autonomy Contribute to State-level Variation in Birth Outcomes in India?

India currently experiences the second-highest rate of low birth weight infants in the world. Lower levels of women’s autonomy at the individual-level have been associated with reduced prenatal health care use and increased risk of low birth weight. To date, however, the extent to which state-level differences in women’s autonomy is related to state-level variations in rates of low birth weight has not been explored, despite the existence of significant differences in rates of low birth weight across Indian states. Using data from a nationally-representative sample of 19,380 women in all 29 states, the current study investigates how state-level measures of women’s autonomy relate to variation in rates of low birth weight across India. Data on birth weight were provided by mothers.  Individual-level women’s autonomy was assessed by her participation in decisions regarding her own healthcare, daily household and large item purchases, and visiting her family or relatives, and state-level empirical Bayes estimates were calculated from individual responses. Multilevel logistic regression models were fit to estimate associations of women's autonomy and state-level social environmental factors with risk of low birth weight.  Women in states with higher levels of women’s autonomy experience lower odds of giving birth to a low birth weight infant OR = 0.49, 95% CI: 0.33, 073), after adjustment for individual-level autonomy, which also predicts lower odds of low birth weight (OR = 0.95, 95% CI: 0.91, 0.99) and other known household- and individual-level socio-demographic and behavioral risk factors. Moreover, this association persists after adjustment for state-level GDP, but is slightly attenuated after adjustment for state-level sex ratios (female to male), which also independently predict reduced risk of low birth weight (OR = 0.63, 95% CI: 0.47, 0.84).  Results suggest that the woman/girl-friendly context of a state may be directly embodied in better fetal development, even after accounting for individual- and household-level mediators of this relationship. Policies designed to make a state more woman/girl-friendly may help to reduce rates of low birth weight and the adverse health and developmental sequelae associated with lower birth weight.