Leveraging women empowerment for better maternal health: using the SWPER index to identify key drivers of quality antenatal care in Southern Africa

Background Quality antenatal care (ANC) is essential for reducing maternal and neonatal mortality; however, access remains inequitable in Southern Africa. Women's empowerment is increasingly recognized as a key determinant of health-seeking behavior; however, its role in shaping ANC quality has not been adequately examined in the region. Methods This study used cross-sectional Demographic and Health Survey (DHS) data from 2015 to 2023 across seven Southern African countries ( n = 36,671). Women's empowerment was measured using the SWPER Global Index, which covers the domains of attitude toward violence, social independence, and decision-making. Quality ANC was defined as the receipt of four essential services: blood pressure measurement, urine testing, blood testing, and iron supplementation. Hierarchical models were fitted, and the measures of variation and model fit were evaluated. The significance level was set at p < 0.05, with a 95% confidence interval. Results Overall, 45.1% of the women received quality ANC, with wide variation between countries (27.4% in Malawi vs. 92.1% in South Africa). A high level of empowerment against violence and decision-making was observed among the women in most of the countries. Women with high social independence (aOR = 1.12, 95% CI: 1.01–1.24) and strong rejection of gender-based violence (aOR = 1.15, 95% CI: 1.05–1.26) were significantly more likely to receive high-quality ANC. Early ANC initiation, ≥8 visits, and doctor-led care were the most powerful predictors of quality ANC care. Conclusion Women's empowerment, particularly social independence and autonomy from violence, plays a critical role in improving the quality of ANC in Southern Africa. However, persistent socioeconomic and geographic inequities highlight the need for context-specific strategies. Policies that integrate gender equality frameworks with strengthened ANC service delivery, especially in rural and low-performing countries, are essential for achieving maternal health targets.