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Article reviewer (contract).

About the Role:

We’re looking for article reviewers to proofread articles about standardized exams and Study.com’s test prep products & services. You will collaborate with writers and provide helpful, actionable feedback to ensure we’re providing accurate, high-quality content.

As an Article Reviewer, you will:

• Independently choose work from a pool of available articles
• Proofread articles for factual accuracy, writing quality, and adherence to our guidelines
• Write and send detailed, helpful feedback to align writers to project expectations
• Collaborate with writers to create robust, useful informational content

As an Article Reviewer, you'll receive the following:

• Reliable Payments : Timely, reliable payments twice a month.
• Independence : No waiting, no assignments, and a library of articles for you to choose from
• Flexibility : Work from anywhere, at any time, completely online
• Supportive Staff : Access to a supportive in-house team to answer your questions

What we're looking for:

• You have experience copyediting content and providing helpful, actionable feedback
• You have excellent communication skills and are responsive and collaborative
• You have strong online research and English language skills
• You are detail-oriented and committed to providing high-quality, accurate information

Do you think you can be an Article Reviewer for Study.com? Click “ Apply Now ” at the bottom to fill out an application and submit your resume! You can view a step-by-step overview of the contract process here: How to Become a Freelancer with Study.com

About Study.com

At Study.com , our goal is to make education accessible and valuable. Over the last two decades, we’ve become the leading online education platform, delivering a personalized learning experience across a broad continuum of education for over 30 million students, instructors, and professionals every month.  

We help empower millions of learners to achieve their education and career goals. We focus on increasing access to education because we know information is the ultimate equalizer and that education is key to upward mobility. 

 Come review articles for the company that was ranked 10th on Virtual Vocations' top 25 list of best partners for remote work in 2021! Feel free to share this opportunity with any friends you think would be interested, too. 

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Blog – Posted on Tuesday, Sep 24

Get paid to read: 18 legitimate sites that pay reviewers.

Serious question: do you want to get paid to read? You might laugh it off at first, thinking that that sounds too good to be true, but it’s not. You can get paid for spending time on what you love: reading books. 

Of course, the key to this #hack is book reviewing, where you offer your personal opinion of a book after you’re done with it. (If you’d like to learn more, check out this post to discover how to write a book review .) Because books are constantly being published, book reviewers are generally always in demand. 

So whether you’re a voracious reader of nonfiction, genre fiction, classics, or indie books, there’s probably an outlet that’s willing to compensate you if you read (review) for them! Without further ado, here’s a definitive list of the 17 sites that will help you get paid to read. If you want to cut to the chase and find out which of them is the right fit for you, we recommend first taking this quick quiz:

Which review community should you join?

Find out which review community is best for your style. Takes 30 seconds!

Then read on for the full list of all of the ways to get paid while reading!

 1. Kirkus Media

💸 Pay: Freelance basis

👀 More information: Check here

If you’ve ever lingered on a book’s Amazon page before, you’ll have heard of Kirkus Reviews. It’s one of the most respected sources of book reviews out there, publishing many of the blurbs that you’ll see on Amazon, or on the cover of your favorite titles.

You have to wonder: where do all of these reviews come from? That’s where you come into the picture. Kirkus Media lists an open application for book reviewers. As of right now, they’re specifically searching for people who will review English and Spanish-language indie titles. Some of the qualities that they want in reviewers include: experience, a keen eye, and an ability to write about a 350-word review in two weeks’ time.

To apply, simply send your resume and writing samples! You can find out more about this opportunity here .

2. Reedsy Discovery

💸 Pay: Tip basis

A powerhouse in the world of indie books, Reedsy Discovery gives book reviewers the chance to read the latest self-published books before anyone else. You can browse through hundreds of new stories before picking one that piques your interest. And if you’ve built up a brand as a book reviewer on Reedsy Discovery, you can liaise with authors who contact you directly for a review.

Its application process is pretty simple: just complete this form to be selected as a book reviewer. Once you’re accepted, you can start looking through the shelves and reading immediately. One more thing: book reviewers can get tips for their book reviews. Readers can send $1, $3, or $5 as a token of appreciation (which, let’s be honest, all book reviewers deserve more of).

If this system intrigues you, you can “discover” more about how it works on this page .

3. Any Subject Books

Any Subject Books is a full-suite self-publishing service. More importantly for you, it hires book reviewers on a book-by-book basis to help them review new books.

They’re big on in-depth, honest, and objective reviews. No fluff here! They’re also happy to give you books in your preferred genres, so if you’re a voracious reader of war fiction, you won’t typically be asked to read the latest paranormal romance hit (or vice versa).

Sadly, Any Subject Books is not currently open to book reviewer applications, but check back again — this could change at any time.

4. BookBrowse

BookBrowse reviews both adult fiction and nonfiction, and some books for young adults. The site focuses on books that are not only enjoyable to read, with great characters and storylines, but that also leave the reader knowing something about the world they did not before. Reviewers also write a "beyond the book" article for each book they review.

5. Online Book Club

💸 Pay: $5 to $60

Online Book Club’s FAQ begins with a warning for all aspiring book reviewers: “First of all, this is not some crazy online get-rich-quick scheme. You won't get rich and you won't be able to leave your day job.”

That daunting reminder aside, Online Book Club’s setup is pretty reasonable, not to mention straightforward. You’ll get a free copy of the book and you’ll get paid for your review of that book. Moreover, it’s one of the few sites that’s transparent about their payment rates (anywhere between $5 to $60). To begin the sign-up process, simply submit your email here .

6. U.S. Review of Books

U.S. Review of Books is a nation-wide organization that reviews books of all kinds and publishes those reviews in a popular monthly newsletter. The way that it works for a book reviewer is simple: when a book title is posted, reviewers can request to read it and get assigned.

A typical review for U.S. Review of Books is anywhere between 250 and 300 words. They are looking particularly for informed opinions and professionalism in reviews, along with succinctness. To apply, submit a resume, sample work, and two professional references via email. But we’d recommend that you check out some previous examples of their book reviews here to first get a better sense of what they’re looking for.

7. Women’s Review of Books

💸 Pay: $100 per review

Women’s Review of Books is a long-running, highly-respected print publication that’s a part of Wellesley Centers for Women. This feminist magazine has been published for 36 years and is looking for more book reviewers to join their force.

If you plan on writing reviews for Women’s Review of Books , you should be aware that its reviews are published “in the service of action and consciousness.” Most of its writers are also academics, journalists, or book reviewers with some years of experience behind them. If you meet these qualifications and are accepted, you’ll be compensated $100 per review.

To pitch then a review, send them an email with a quick proposal. For more details, click here .

8. eBookFairs

eBookFairs primarily helps authors grow their author platforms, but it also has a Paid Book Reader program where readers can earn money by, you guessed it, reviewing the books listed on their site.

Note that they do have clear instructions on what qualifies as a review, so do read their guidelines carefully before applying to make sure you can meet them. For instance, the review must be at least 250 words, you must allow at least 3 days between reviews submitted, and it must provide helpful feedback for the author. There are also a limited number of paid reader positions available.

💸 Pay: Variable

If you’re a freelancer, you’re probably already familiar with Upwork! One of the biggest marketplaces for freelancers, Upwork has fingers in every industry’s pie. So it won’t be a surprise to learn that people who are looking for freelance book reviewers regularly post listings on its marketplace.

Because each job caters to an individual client, the requirements and qualifications will differ. It might be a one-time project, or the gig might turn into a long-running collaboration with the client. Generally, the listing will specify the book’s genre, so you’ll know what you’re getting before you agree to collaborate with the client on the other end.

To begin, you’ll need to sign up as a freelancer on Upwork. Find out more information on Upwork’s FAQ page!

10. Moody Press

💸 Pay: Free ARCs

Moody Press is a nonprofit publishing house of Christian titles and Bible study resources. If this is your niche, you’ll definitely be interested in Moody Press’ Blogger Review Program! As part of the program, you’ll get free copies of book published by Moody Press.

Like some of the other programs on this list, you won’t get paid for your review, but you will get a free book. Moody Press also asks you to write your honest review within 60 days of reading it. To get a feel for it, try joining the MP Newsroom Bloggers Facebook group , where you can directly interact with existing members of the program.

11. New Pages

💸 Pay: Variable 

Not interested in writing anything longer than 300 words? Are quick flash book reviews more your pace? If so, becoming a NewPages reviewer might be just your speed. NewPages.com is an Internet portal to small presses, independent publishers and bookstores, and literary magazines. More importantly, they’re looking for short book reviews (generally between 100 and 200 words) on any recent literary magazine or book that you’ve read.

If you’re already a fan of books from small presses or unknown magazines, even better: that’s exactly the kind of reviewer NewPages wants to work with. If you’d like to look through some of their past book reviews to see if your style matches, check out their book review archive here .

12. Publishers Weekly

Publishers Weekly is an online magazine focused on international book publishing and all that that entails. More pertinently, it regularly reviews both traditionally published and self-published books, which means that it does occasionally have a call for book reviewers. As of right now, it’s closed to applications — but if you check its Jobs page every once in a while, you might see an opening again.

13. Tyndale Blog Network

Tyndale Blog Network runs a program called My Reader Rewards Club, which is based on an innovative rewards system. If you join as a member, you can earn points for certain actions that you take on the site (for instance, inviting a friend to the program and sharing a direct link to MyReaderRewardsClub.com on Facebook each fetches you 10 points).

Writing a review for a Tyndale or NavPress book on Amazon or Barnes & Noble gets you 10 points, with a maximum limit of 50 points in 30 days. In turn, you can use your accumulated points to receive more books off of Tyndale’s shelves. If this sounds like something that may be up your alley, check out their FAQ here.

14. Booklist Publications

💸 Pay: $12.50 to $15 per review

Booklist is the American Library Association’s highly respected review journal for librarians. Luckily for freelance writers, Booklist assigns freelance book reviews that vary from blog posts for The Booklist Reader to published book review in Booklist magazine.

As the site itself suggests, it’s important that you’re familiar with Booklist Publication’s outlets (which include Booklist magazine, the quarterly Book Links , and The Booklist Reader blog) and its writing style. Reviews are generally very short (no longer than 175 words) and professionally written. You can discover more of its guidelines here — and an archive of previous Booklist reviews here .

To apply, contact a relevant Booklist editor and be prepared to submit a few of your past writing samples.

15. Instaread

💸 Pay: $100 per summary

Not interested in writing critical takes on the books that you read? Then Instaread might be for you. Instaread has an open call for book summaries, which recap “the key insights of new and classic nonfiction.”

Each summary should be around 1000 to 1500 words, which makes it a fair bit lengthier than your average flash book review. However, Instaread will compensate you heartily for it: as of 2019, Instaread pays $100 for each summary that you write. You can peruse Instaread’s recommended Style Guide on this page , or download Instaread from your App Store to get a better feel for the app.

16. NetGalley

If you’ve dreamt about becoming an influencer in the book reviewing community, you may want to give NetGalley a look. Put simply, NetGalley is a service that connects book reviewers to publishers and authors. Librarians, bloggers, booksellers, media professionals, and educators can all sign up to NetGalley to read books before they’re published.

How it works is pretty simple. Publishers put digital review copies out on NetGalley for perusal, where NetGalley’s members can request to read, review, and recommend them. It’s a win-win for both publisher and reviewer: the publisher is able to find enthusiastic readers to provide an honest review for their books, and the reviewer gets access to a vast catalog of books.

The cherry on top is that NetGalley membership is 100% free! Simply use this form to sign up. And if you’d like more information, you can dip into their FAQ here .

17. getAbstract

Are you an avid reader of nonfiction books? getAbstract is a site that summarizes 18,000+ nonfiction books into 10-minute bites. Their Career Opportunities page often includes listings for writers. At the time of this post’s writing, getAbstract is looking for science and technology writers who can sum up the latest magazine articles and books. They pay on a freelance basis, so apply through their website to get further details.

18. Writerful Books

💸 Pay: $10 to $50

Writerful Books is an author services company that provides everything from beta reading to (you guessed it) book reviewing. As such, they’re always on the lookout for book reviewers with fresh and compelling voices.  

One of the benefits of this gig is that you can review any book that you want for them (although they prefer contemporary award-winning American, Australian, British, Canadian, Irish, and New Zealand authors). Getting a regularly paid gig with Writerful Books isn’t a guarantee, but if you regularly publish quality reviews for them, they may contact you. 

To apply, you’ll have to be able to provide previous book review samples. Here’s the job listing if you’re curious to learn more about this role.

If you're an avid reader,  sign up to Reedsy Discovery  for access to the freshest new reads — or  apply as a reviewer  to give us  your  hot takes!

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General questions that Reviewers should keep in mind when reviewing articles are the following:

• Is the article of interest to the readers of YJBM ?
• What are the strengths and weaknesses of the manuscript?
• How can the Editors work with the Authors to improve the submitted manuscripts, if the topic and scope of the manuscript is of interest to YJBM readers?

The following contains detailed descriptions as to what should be included in each particular type of article as well as points that Reviewers should keep in mind when specifically reviewing each type of article.

YJBM will ask Reviewers to Peer Review the following types of submissions:

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Frequently asked questions.

These manuscripts should present well-rounded studies reporting innovative advances that further knowledge about a topic of importance to the fields of biology or medicine. The conclusions of the Original Research Article should clearly be supported by the results. These can be submitted as either a full-length article (no more than 6,000 words, 8 figures, and 4 tables) or a brief communication (no more than 2,500 words, 3 figures, and 2 tables). Original Research Articles contain five sections: abstract, introduction, materials and methods, results and discussion.

Reviewers should consider the following questions:

• What is the overall aim of the research being presented? Is this clearly stated?
• Have the Authors clearly stated what they have identified in their research?
• Are the aims of the manuscript and the results of the data clearly and concisely stated in the abstract?
• Does the introduction provide sufficient background information to enable readers to better understand the problem being identified by the Authors?
• Have the Authors provided sufficient evidence for the claims they are making? If not, what further experiments or data needs to be included?
• Are similar claims published elsewhere? Have the Authors acknowledged these other publications? Have the Authors made it clear how the data presented in the Author’s manuscript is different or builds upon previously published data?
• Is the data presented of high quality and has it been analyzed correctly? If the analysis is incorrect, what should the Authors do to correct this?
• Do all the figures and tables help the reader better understand the manuscript? If not, which figures or tables should be removed and should anything be presented in their place?
• Is the methodology used presented in a clear and concise manner so that someone else can repeat the same experiments? If not, what further information needs to be provided?
• Do the conclusions match the data being presented?
• Have the Authors discussed the implications of their research in the discussion? Have they presented a balanced survey of the literature and information so their data is put into context?
• Is the manuscript accessible to readers who are not familiar with the topic? If not, what further information should the Authors include to improve the accessibility of their manuscript?
• Are all abbreviations used explained? Does the author use standard scientific abbreviations?

Case reports describe an unusual disease presentation, a new treatment, an unexpected drug interaction, a new diagnostic method, or a difficult diagnosis. Case reports should include relevant positive and negative findings from history, examination and investigation, and can include clinical photographs. Additionally, the Author must make it clear what the case adds to the field of medicine and include an up-to-date review of all previous cases. These articles should be no more than 5,000 words, with no more than 6 figures and 3 tables. Case Reports contain five sections: abstract; introduction; case presentation that includes clinical presentation, observations, test results, and accompanying figures; discussion; and conclusions.

• Does the abstract clearly and concisely state the aim of the case report, the findings of the report, and its implications?
• Does the introduction provide enough details for readers who are not familiar with a particular disease/treatment/drug/diagnostic method to make the report accessible to them?
• Does the manuscript clearly state what the case presentation is and what was observed so that someone can use this description to identify similar symptoms or presentations in another patient?
• Are the figures and tables presented clearly explained and annotated? Do they provide useful information to the reader or can specific figures/tables be omitted and/or replaced by another figure/table?
• Are the data presented accurately analyzed and reported in the text? If not, how can the Author improve on this?
• Do the conclusions match the data presented?
• Does the discussion include information of similar case reports and how this current report will help with treatment of a disease/presentation/use of a particular drug?

Reviews provide a reasoned survey and examination of a particular subject of research in biology or medicine. These can be submitted as a mini-review (less than 2,500 words, 3 figures, and 1 table) or a long review (no more than 6,000 words, 6 figures, and 3 tables). They should include critical assessment of the works cited, explanations of conflicts in the literature, and analysis of the field. The conclusion must discuss in detail the limitations of current knowledge, future directions to be pursued in research, and the overall importance of the topic in medicine or biology. Reviews contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Is the review accessible to readers of YJBM who are not familiar with the topic presented?
• Does the abstract accurately summarize the contents of the review?
• Does the introduction clearly state what the focus of the review will be?
• Are the facts reported in the review accurate?
• Does the Author use the most recent literature available to put together this review?
• Is the review split up under relevant subheadings to make it easier for the readers to access the article?
• Does the Author provide balanced viewpoints on a specific topic if there is debate over the topic in the literature?
• Are the figures or tables included relevant to the review and enable the readers to better understand the manuscript? Are there further figures/tables that could be included?
• Do the conclusions and outlooks outline where further research can be done on the topic?

Perspectives provide a personal view on medical or biomedical topics in a clear narrative voice. Articles can relate personal experiences, historical perspective, or profile people or topics important to medicine and biology. Long perspectives should be no more than 6,000 words and contain no more than 2 tables. Brief opinion pieces should be no more than 2,500 words and contain no more than 2 tables. Perspectives contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Does the abstract accurately and concisely summarize the main points provided in the manuscript?
• Does the introduction provide enough information so that the reader can understand the article if he or she were not familiar with the topic?
• Are there specific areas in which the Author can provide more detail to help the reader better understand the manuscript? Or are there places where the author has provided too much detail that detracts from the main point?
• If necessary, does the Author divide the article into specific topics to help the reader better access the article? If not, how should the Author break up the article under specific topics?
• Do the conclusions follow from the information provided by the Author?
• Does the Author reflect and provide lessons learned from a specific personal experience/historical event/work of a specific person?

Analyses provide an in-depth prospective and informed analysis of a policy, major advance, or historical description of a topic related to biology or medicine. These articles should be no more than 6,000 words with no more than 3 figures and 1 table. Analyses contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Does the abstract accurately summarize the contents of the manuscript?
• Does the introduction provide enough information if the readers are not familiar with the topic being addressed?
• Are there specific areas in which the Author can provide more detail to help the reader better understand the manuscript? Or are there places where the Author has provided too much detail that detracts from the main point?

Profiles describe a notable person in the fields of science or medicine. These articles should contextualize the individual’s contributions to the field at large as well as provide some personal and historical background on the person being described. More specifically, this should be done by describing what was known at the time of the individual’s discovery/contribution and how that finding contributes to the field as it stands today. These pieces should be no more than 5,000 words, with up to 6 figures, and 3 tables. The article should include the following: abstract, introduction, topics (with headings and subheadings), and conclusions.

• Does the Author provide information about the person of interest’s background, i.e., where they are from, where they were educated, etc.?
• Does the Author indicate how the person focused on became interested or involved in the subject that he or she became famous for?
• Does the Author provide information on other people who may have helped the person in his or her achievements?
• Does the Author provide information on the history of the topic before the person became involved?
• Does the Author provide information on how the person’s findings affected the field being discussed?
• Does the introduction provide enough information to the readers, should they not be familiar with the topic being addressed?

Interviews may be presented as either a transcript of an interview with questions and answers or as a personal reflection. If the latter, the Author must indicate that the article is based on an interview given. These pieces should be no more than 5,000 words and contain no more than 3 figures and 2 tables. The articles should include: abstract, introduction, questions and answers clearly indicated by subheadings or topics (with heading and subheadings), and conclusions.

• Does the Author provide relevant information to describe who the person is whom they have chosen to interview?
• Does the Author explain why he or she has chosen the person being interviewed?
• Does the Author explain why he or she has decided to focus on a specific topic in the interview?
• Are the questions relevant? Are there more questions that the Author should have asked? Are there questions that the Author has asked that are not necessary?
• If necessary, does the Author divide the article into specific topics to help the reader better access the article? If not, how should the author break up the article under specific topics?
• Does the Author accurately summarize the contents of the interview as well as specific lesson learned, if relevant, in the conclusions?

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4 Ways a Settlement Could Change the Housing Industry

The influential National Association of Realtors agreed to make several changes to its policies to settle class-action lawsuits brought by home sellers who say they were forced to pay inflated commissions to real estate agents.

By Debra Kamin

In the early hours of Friday morning, the National Association of Realtors agreed to a global settlement deal that would resolve several lawsuits against the trade group.

A group of Missouri home sellers sued N.A.R. over their policies on agent compensation, arguing that a N.A.R. rule requiring home sellers to pay commissions to their agents and the agents of their buyers led to inflated fees and price fixing. The lawsuit also called into a question another rule requiring agents to list homes on N.A.R.-affiliated databases in order to sell them. In October, a jury agreed that both practices were anticompetitive, and a judge ordered damages of at least $1.8 billion.

More than a dozen copycat cases, all accusing N.A.R. of stifling competition and violating antitrust laws, have followed.

With the settlement agreement, N.A.R. will pay $418 million in damages , but more important, it has agreed to rewrite a number of rules that have long been central to the U.S. housing industry. Here’s how things stand to change, pending court approval.

Home prices will drop.

In the United States, most agents specify a commission of 5 or 6 percent, paid by the seller. That means that someone with a $1 million home should expect to spend up to $60,000 on real estate commissions alone, with $30,000 going to his agent and $30,000 going to the agent who brings a buyer. Even for a home that costs $400,000 — close to the current median for homes across the United States — sellers are still paying around $24,000 in commissions, a cost that is baked into the final sales price of the home.

With the settlement agreement, sellers’ agents will no longer be required to make offers of commission to buyers’ agents, a practice called decoupling. This will save homeowners billions.

“Decoupling will allow commissions to be removed and negotiated down, lowering both housing prices and overall consumer costs,” said Steve Brobeck, the retired executive director of the Consumer Federation of America. Mr. Brobeck said that Americans spend about $100 billion a year in real estate commissions, and with the settlement, that number is expected to dip by at least $20 billion and up to $50 billion.

Since commissions are tacked onto the price of a home, “Over time, both sellers and buyers will force rates down through negotiation and comparison shopping in a more price-transparent marketplace,” he said.

The 6 percent commission will cease to be the norm.

The lawsuits argued that N.A.R., and brokerages that required their agents to be members of N.A.R., had set rules that led to an industrywide standard commission of 5 or 6 percent — one of the highest rates in the world. Without that guaranteed rate, agents will now most likely be forced to lower their commissions to compete for business.

“U.S. commissions are unlikely to decline to the 1 or 2 percent rate level in England, where only one agent and an attorney are usually involved in a home sale. But they certainly will decline substantially, and commissions will also increasingly reflect the competence and efforts of agents on sales,” Mr. Brobeck said in an email.

Steering — the practice of agents directing buyers to more expensive houses — will be less common.

Most of the databases where homes are listed for sale in the United States are restricted to dues-paying members who belong to N.A.R., a dominance that has led to antitrust allegations against N.A.R.

One N.A.R. rule demands that a listing agent, when posting a home on the database, clearly state the amount of compensation that a buying agent will receive should they bring a buyer. This is a practice that critics say has long led to “steering,” in which buyers’ agents direct their clients to pricier homes in a bid to collect a bigger commission check.

Under the settlement, any fields displaying broker compensation will be eliminated entirely, which will help damper the practice.

About one million real estate agents could leave the profession.

The number of real estate agents swelled during the pandemic, when mortgage rates plummeted and the housing market boomed. In 2020 and 2021, more than 156,000 people got their real estate licenses, and membership in the National Association of Realtors hit a peak of 1.6 million members in 2022.

A lot of that growth was predicated on the idea of easy money.

But now a lot of those agents are struggling, and a reduction in commission rates will only increase the pain. Half of the agents in the country sold one house — or no house s at all — last year. With the industry now staring down a massive overhaul, veteran agents predict their less experienced peers will leave the field all together.

Some analysts predict a mass departure. One widely cited report from investment banking firm Keefe, Bruyette & Woods projects 1 million agents leaving the field as shared commissions vanish.

“Veteran agents have built strong relationships, established reputations and extensive networks. Newer real estate agents may struggle,” said Jen McDonald, who leads LPT Realty in Reno, Nev., and has spent 24 years in the industry. “Without established reputations or strong clients bases, they are going to find it challenging to retain clients or attract new ones.”

Debra Kamin reports on real estate, covering what it means to buy, sell and own a home in America today. More about Debra Kamin

U.S. Consumers Pay Average of $61 per Month for Video Streaming Services: Study

By Todd Spangler

Todd Spangler

NY Digital Editor

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Streaming video services continue to face challenges like high costs, high churn rates and competition from other media — while a good chunk of U.S. audiences still questions whether the price of their subscriptions is worth it.

On average, Americans households that subscribe to streaming video entertainment services said they spend $61 per month for four services, according to Deloitte ’s 18th annual Digital Media Trends report. That’s up 27% from $48 per month on last year’s survey .

According to Deloitte’s latest report, churn has softened a bit but still remains high: 40% of consumers said they canceled any subscription VOD service in the previous six months down from 44% last year. The survey found that 67% of respondents want a streaming bundle to be able to search for content across all multiples services; 63% want a bundle of services that they can customize each month. About 47% of consumers surveyed said they would spend more time on streaming video platforms if content was easier to find. More than half of Gen Z and millennial consumers say they get better recommendations for content to watch from social media than from streaming services themselves.

“Streaming services have reached a pivotal moment,” said Jana Arbanas, vice chair at Deloitte and U.S. telecom, media and entertainment sector leader. “Delivering great content is no longer enough — curating a more personalized experience designed to better match content with personal preferences and interests is the next step.”

She added, “it’s important to recognize that social media is the primary way people discover and get excited about entertainment. For content to resonate and drive engagement with consumers, streaming video providers should work to ensure their content connects with their diverse audiences and fosters a sense of community and social connectivity.”

Other findings from the Deloitte report:

• 42% of those surveyed said generative AI and humans can both deliver entertaining content; 70% of those surveyed say they would rather watch a TV show or movie written by a human — while 22% said generative AI could produce content that was more interesting than human creators.
• Among Gen Z and millennial respondents, 49% watch TV shows and movies after hearing about them from creators online and 55% find out about new game titles from live-streamers and content creators on social media. In addition, of this group, 54% said ads on social media influence them the most.
• 60% of Gen Zs prefer watching UGC videos because they do not have to spend time searching for what to watch.
• Nearly 70% of Black consumers surveyed — and more than half of Asian, multiracial and Hispanic consumers — say it’s important to them that TV shows and movies are written and produced by diverse creative teams.
• About 42% of those surveyed said videos on social media are “much more” diverse than TV shows and movies; that figure is 60% among Gen Zs and over 50% among multiracial (57%), Black (56%), LGBT (55%) and Hispanic (53%) respondents.
• About 60% of those surveyed spend an average of nine hours per week playing video games; 30% of men who play games consider bullying to be part of the experience, but only 19% of women gamers surveyed feel the same way.

Deloitte’s 18th annual Digital Media Trends survey was fielded by an independent research firm in October 2023 among 3,517 U.S. consumers 14 and older. More info on the report is available at this link . The report’s generational definitions are as follows: Generation Z (born 1997-2009), millennial (1983-1996), Generation X (1966-1982), boomers (1947-1965) and matures (1946 and prior).

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Research Roundup: How the Pandemic Changed Management

• Mark C. Bolino,
• Jacob M. Whitney,
• Sarah E. Henry

Lessons from 69 articles published in top management and applied psychology journals.

Researchers recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic that were published between March 2020 and July 2023 in top journals in management and applied psychology. The review highlights the numerous ways in which employees, teams, leaders, organizations, and societies were impacted and offers lessons for managing through future pandemics or other events of mass disruption.

The recent pandemic disrupted life as we know it, including for employees and organizations around the world. To understand such changes, we recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic. These papers were published between March 2020 and July 2023 in top journals in management and applied psychology.

• Mark C. Bolino is the David L. Boren Professor and the Michael F. Price Chair in International Business at the University of Oklahoma’s Price College of Business. His research focuses on understanding how an organization can inspire its employees to go the extra mile without compromising their personal well-being.
• JW Jacob M. Whitney is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at Kennesaw State University. His research interests include leadership, teams, and organizational citizenship behavior.
• SH Sarah E. Henry is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at the University of South Florida. Her research interests include organizational citizenship behaviors, workplace interpersonal dynamics, and international management.

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Public Health

How bad is maternal mortality in the u.s. a new study says it's been overestimated.

Selena Simmons-Duffin

The new analysis of death certificates says the U.S. maternal mortality rate is in line with other wealthy countries, contradicting an earlier report from the CDC. muratkoc/Getty Images hide caption

The new analysis of death certificates says the U.S. maternal mortality rate is in line with other wealthy countries, contradicting an earlier report from the CDC.

This story has been updated to include additional comment from the Centers for Disease Control and Prevention.

The CDC's National Center for Health Statistics' most recent report put the U.S. maternal mortality rate at a whopping 32.9 deaths per 100,000 births. That number garnered a great deal of attention, including being covered by NPR and other news outlets.

A new study suggests the national U.S. maternal mortality rate is actually much lower than that: 10.4 deaths per 100,000 births.

The widely reported issue of racial disparities in U.S. maternal mortality persists, even with the lower overall rate. Black pregnant patients are still three times more likely to die than white patients, according to data in the study published in the American Journal of Obstetrics and Gynecology on Wednesday.

"We have to prevent these deaths," says K.S. Joseph , a physician and epidemiologist in the OB-GYN department of the University of British Columbia. Joseph is the lead author of the peer-reviewed paper. "Even if we say that the rate is 10 per 100,000 and not 30 per 100,000, it does not mean that we have to stop trying."

The fact that the rate of maternal mortality in the U.S. seems to have been significantly inflated may be disconcerting. Experts NPR spoke with about the data explain that measuring maternal deaths is complex, and that CDC was not intentionally misleading the public. They also emphasize that most maternal deaths are preventable .

Shots - Health News

Health department medical detectives find 84% of u.s. maternal deaths are preventable.

The trouble with the data started about 20 years ago, when the national death certificate was updated to include a pregnancy checkbox that the person certifying someone's death could tick. This checkbox created problems, which CDC analysts have acknowledged in their own papers , and changes were made in 2018 to CDC's methods for calculating maternal deaths. But Joseph and other researchers suspected the data was still not reliable.

"We felt that the pregnancy checkbox was misclassifying a lot of such deaths and adding them to maternal deaths," he explains.

In the new paper, Joseph and colleagues redid the CDC's National Center for Health Statistics analysis of data from 1999-2002 and 2018-2021, skipping over years when the data was in flux. Then they disregarded the deaths with only the pregnancy checkbox ticked. "We would only consider deaths to be a maternal death if there was a pregnancy-related cause mentioned by the physician who was certifying the death," he explains. "There are several lines in the certificate where a pregnancy-related cause can be mentioned, and if any of those lines mentioned a pregnancy-related cause, we would call it that."

That approach yielded a rate of 10.4 per 100,000. It also showed that the rate did not change much between 1999 and 2021. That rate is much closer to those reported in other wealthy countries , although Joseph warns that every country uses a different process and so international comparisons are unreliable.

"I think it's a very important study – I was happy to see it," says Steven L. Clark , an OB-GYN at Baylor College of Medicine who was not involved in the research. "It confirms statistically what most of us who actually deal with critically ill pregnant women on a regular basis thought for years. We are bombarded with these statistics saying how horrible maternal care is in the United States, and yet we just don't see it."

Clark does not blame the CDC for putting the maternal mortality rate so high. "They can only analyze the data that they're provided with, and that data starts at the individual hospitals and individual places in the United States," Clark says. "CDC gets these numbers, and I think they probably do a great job – I don't think there's any conspiracy here to hide anything from the public."

Joseph agrees. "The point I would like to make is that, yes, the [National Vital Statistics System] is overestimating rates and that's because of the pregnancy checkbox," Joseph says. "But this issue of assessing the actual maternal mortality rate is not a simple issue."

Deciding what time frame to consider, which conditions to include, and more, makes the task challenging. Joseph's study does not count suicides in the post-partum period, for instance.

The CDC's National Center for Health Statistics declined NPR's initial request for comment on the study. After publication, a spokesperson for the agency emailed a written statement. "CDC disagrees with the findings," the statement reads, and goes on to assert that the methods used by the researchers "are known to produce a substantial undercount of maternal mortality." The CDC declined to provide anyone for an interview.

Dr. Veronica Gillispie-Bell is an OB-GYN and the medical director of Louisiana's maternal mortality review committee. She also was not involved in the study. She says the findings do not surprise her – her committee finds checkbox errors all the time. "When we're validating the cases, it's very common that a 70 year old man – somebody checked the pregnancy checkbox and it will appear that that was a pregnancy-associated death when it was more of a clerical error."

She says in committees like hers in states all over the country – supported and funded by CDC – experts are looking closely at each of these maternal deaths and validating them. "We don't just look at the numbers," she says. "We review cases to determine, first of all, was this death pregnancy-related or not? Was this death preventable? And if so, what could we have done to prevent the death?"

She worries this new study will encourage some to dismiss the issue. "Anybody that was doubting is going to be like, 'I knew it wasn't that bad of a problem.'" She thinks the study should instead be a "call to action" to support state review committees like hers that validate the data and investigate each death.

Dr. Louise King , an OB-GYN and bioethicist at Harvard Medical School, agrees. "It's really important to dig down into this," she says. "Maternal deaths may be related to poor health coming into pregnancy, but that's still on us."

King notes that maternal mortality rates are still too high in the U.S., and the disproportionate effect on Black patients "is just plain scary," she says.

Joseph agrees that the racial disparities in the data make clear that there's a long way to go before the problem of maternal mortality is addressed. He adds, "this study does not mean that you can take your eye off the ball."

• maternal mortality
• death certificates

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Seller is highly motivated and will include all of the candidate's family members, his impressive portfolio of 90+ criminal indictments and a $50 gift certificate for his mar-a-lago resort gift shop..

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Is Trump a billionaire? Maybe not. Rich-guy Donald Trump can't find money for bond. How about a MAGA bake sale?

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Experience includes: Being the best Republican president in American history, even better than Abraham Lincoln ; forging close, admiring relationships with notorious dictators ; and almost-successfully overthrowing a RIGGED presidential election.

Trump's affinity for autocrats: Trump keeps praising dictators like Hitler and Kim Jong Un. Will Republicans ever care?

This one-of-a-kind, pristine Trump model comes complete with legions of authoritarian-curious supporters who are easily convinced to trade their money for cheap red hats and unkept promises, as well as an array of New York real-estate assets the candidate very much does not want the state to seize to pay for a recent $454 million business fraud judgment .

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Please contact: John Barron , 1-800-LUV-MAGA.

Follow USA TODAY columnist Rex Huppke on X, formerly Twitter,  @RexHuppke  and Facebook  facebook.com/RexIsAJerk

• Open access
• Published: 19 March 2024

Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study

• Easter Olwanda 1 ,
• Kennedy Opondo 2 ,
• Dorothy Oluoch 1 ,
• Kevin Croke 2 ,
• Justinah Maluni 1 ,
• Joyline Jepkosgei 1 &
• Jacinta Nzinga 1  

BMC Women's Health volume  24 , Article number:  181 ( 2024 ) Cite this article

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Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women’s ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women’s processes of decision-making in seeking maternal health care and how these affect women’s ability to access and use antenatal, delivery, and post-natal services.

We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of “female autonomy”, and “women’s agency” with the latter incorporating ‘voice’, ‘choice’ and ‘power’. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.

The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.

Conclusions

Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women’s decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women’s voices for sustained use.

Peer Review reports

Globally, the provision of health care is evolving towards providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions [ 1 ]. Patient-centered care, in relation to clinical decision-making, is grounded in concepts of intrinsic values, personal preferences, and partnership [ 2 ]. A patient-centered approach, empowers women by involving them in decision-making processes and respecting their choices [ 3 ]. Women’s empowerment, in turn, enhances their autonomy and ability to seek appropriate and timely maternal health care [ 4 ], ultimately affording women agency for their overall well-being. When women are not empowered or lack autonomy, they may face barriers to accessing quality care, resulting in adverse maternal health outcomes [ 5 ].

Research on patient-centered care for women shows that women’s autonomy (i.e., the freedom of women to exercise their judgment in order to act for their own interests) influences reproductive, maternal, and child health outcomes [ 6 , 7 , 8 , 9 , 10 , 11 ]. Conversely, the absence of women’s autonomy in decision-making results in delays and poor utilization of maternal health services and ultimately increased maternal morbidity and mortality [ 12 ]. Thus, empowered women can make informed decisions about their reproductive health, including family planning, timing and spacing of pregnancies, and the type of care they receive during pregnancy and childbirth [ 13 , 14 , 15 , 16 ].

Freedom of mobility, participation in household decision-making, and self-efficacy are key dimensions of women’s empowerment [ 17 , 18 ]. Empowering women to make their own decisions, pursue goals, and control their lives and resources is a crucial aspect of Sustainable Development Goal (SDG) 5, which seeks to attain gender equality and empower all women and girls [ 19 ]. Moreover, empowering women in reproductive and sexual matters is crucial, as intimate relationships often involve significant power imbalances that can limit women’s ability to negotiate with their partners on sexual issues [ 20 ].

The International Centre for Research on Women (ICRW) has developed a conceptual framework for reproductive empowerment merging “female autonomy” and “women’s agency”, which includes ‘voice’, ‘choice’, and ‘power’. This framework is relevant to women’s autonomy in Kakamega as it provides a comprehensive approach to understanding the factors influencing women’s agency and empowerment, informing targeted interventions and policies in the region. Women’s individual agency involves expressing opinions, making decisions about their lives, and pursuing their aspirations, which empowers them to assert their voices and seek personal and professional growth. Immediate relational agency focuses on the influence of close relationships such as family, friends, and intimate partners on an individual’s agency [ 21 ]. These relationships can either support or restrict a woman’s ability to exercise her voice, make choices, and pursue empowerment. Supportive relationships enable women to exercise their agency freely, while oppressive ones may limit their ability to make decisions and assert their voice, hindering empowerment. Distant relational agency refers to the broader social, cultural, and institutional influences that shape women’s agency and empowerment [ 22 ]. Societies that prioritize gender equality, offer legal protections, ensure access to education and healthcare, and promote women’s participation in decision-making enhance women’s agency. Conversely, gender inequalities and limited opportunities hinder women’s agency and empowerment.

The relationship between individual, immediate, and distant relational agency is complex and interconnected, with individual agency influenced by both immediate and distant relational agency. Supportive immediate relationships and equitable social structures can enhance individual agency, enabling women to exercise their voice and make choices while repressive immediate relationships and restrictive social structures can limit women’s agency [ 23 ]. Aligning all three levels of agency positively leads to women’s voice, choice, power, and empowerment. These concepts are illustrated in Fig.  1 below.

Borrowed from the Conceptual Framework of Reproductive Empowerment by the International Center for Research on Women (ICRW)

Evidence suggests that increasing women’s mobility can empower them to exercise greater control over their lives by increasing their access to healthcare, education, markets and information [ 6 , 24 ]. Additionally, women with strong sense of self-efficacy have the potential to anticipate different success scenarios, persevere in the face of obstacles, take action against the existing social norms [ 25 ], and navigate complicated healthcare contexts to receive care [ 26 ]. Relative to maternal and child health, increased postpartum maternal self-efficacy been has associated with improved functional status in the postpartum period [ 27 ]. Furthermore, women’s control over resources and decision-making within a household plays a crucial role in enhancing healthcare-seeking behaviors and maternal and child health outcomes [ 28 ]. Changes in women’s intra-household bargaining power, also increases a woman’s status and impacts her decision-making ability [ 29 , 30 ]. All these are key considerations in determining the implementation process and success of maternal and child health interventions and reforms. Existing literature primarily emphasizes the impact of women’s choice and agency on health decision-making and service use, but there is limited documentation on how women’s autonomy experiences can inform the implementation of improved maternal and child health interventions.

The implementation context

Kakamega County was selected due to its high maternal mortality rate of 316 per 100,000 live births and neonatal mortality rate of 19 per 1,000 live births, alongside approximately 70,000 births in 2018, distributed with 35% at home, 28% in primary care facilities, and 37% in hospitals. Part of recommendations from the Lancet Global Health Commission on High Quality Health Systems for improving quality of care is the implementation of “Service Delivery Redesign for Maternal and Newborn Health”, (SDR) reform. Kakamega County started the phased implemention of SDR in 2021 and is currently in its improvement phase.

During the SDR implementation period, improvements were made to health facilities, including the commissioning of a new Maternity wing and an increase in bed capacity at Malava. The Linda Mama health scheme provides affordable maternal and child health services, and Malava sub-county hospital increased its claims from 34 to 79%. Additionally, a newborn unit was constructed, and the facility currently has a resident pediatrician, surgeon and gynecologist supported by nurses, clinicians, and medical officers.

Similarly, Lumakanda sub-county hospital has reorganized its infrastructure at the maternity wing and the newborn unit, introduced emergency evacuation services, implemented pseudo-facility improvement fund (FIF) disbursements, enhanced accountability and visibility of blood resources through a blood tracker dashboard, enrolled women for pregnancy care text prompts, and provided Emergency obstetric and newborn care (EmONC) training to its staff while also training health workers from primary health care facilities. A summary of the SDR related implementation activities can be found in the Supplementary file 1 .

This paper aimed at examining how women’s processes of decision-making in seeking maternal and neonatal health care both influences and is influenced by the implementation of SDR in Kakamega county. It is anticipated that the learning from this paper will inform the implementation of SDR by highlighting patient voice in reforming delivery of MCH services.

Study setting

The study took place in Malava and Lumakanda sub-County hospitals which are maternity centers of excellence where the Kakamega Service Delivery Redesign (SDR) is being implemented. The Kakamega maternal and child health Service Delivery Redesign (SDR) is a structural reform that aims to reorganize the maternal and newborn health services by shifting deliveries for all women to advanced facilities that offer definitive care for complications. The reform is now being implemented by the Kakamega County government with the aim of improving the quality of antenatal, delivery and postnatal care. It purposes to ensure that all women can give birth in safe environments, with skilled providers that have the tools and competencies to care for women during uncomplicated birth and who can detect and deal with complications if and when they occur [ 31 ].

Study design

This was a cross-sectional exploratory study using qualitative research methods with purposively selected participants. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. In this context, small group interviews involved a small group of individuals, allowing for in-depth exploration of individual perspectives within a group setting, while focus group discussions were conversations guided by a moderator, emphasizing interactions among 8–10 participants to explore shared perspectives and group dynamics.

The FGDs had an average of 8 individuals while the small group discussions had an average of 4 individuals. For the FGDs demographic dynamics such as gender and age were managed through the selection of participants to ensure diverse representation within the groups. We formed homogeneous groups based on specific demographic criteria, to foster open and comfortable discussions among participants with shared characteristics. In this case we had FGDs specifically for younger women, another for older women, and lastly with the men separately. Conversely, for small groups, we intentionally chose participants representing various demographic profiles to capture a range of perspectives and experiences. The FGDs lasted between 45 and 60 min, the IDIs lasted between 30- 45 min and the KII lasted an average of 45 min.

See the Table  1 below.

The pre-set inclusion criteria included willingness to consent and to participate in the study, and good knowledge or understanding of the areas of inquiry. We employed purposeful participant selection to include diverse demographic characteristics, experiences, and perspectives in relation to the research topic.

Data collection

Data collection took place in November 2022 and in March 2023. Participants were recruited from the antenatal, delivery and post-natal clinics in Lumakanda and Malava sub-County hospitals. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men using guides with questions developed in English and then translated into Swahili.

The interviews covered three broad topics of interest (1) factors that affect women’s autonomy and decision-making power in the household, (2) the process of decision-making at the family level in seeking maternal health care during pregnancy, delivery, and the postpartum period, and (3) how the decision-making process affects women’s ability to access and use maternal health services. Interviews were audio-recorded for participants who consented. During the interviews, detailed descriptive field notes were written covering interactions between the interviewer and respondent, non-verbal communication, environment, and reflections from interview content. All interviews were transcribed verbatim in Swahili and translated to English then cross-checked to ensure appropriate data and its quality before data analysis. Interviews were conducted to the point of theoretical saturation through iterative data analysis of emerging themes which was done alongside data collection. Iterating between data collection and analysis enabled the research team to be mindful of their own biases and actively worked to mitigate them, thus contributing to the robust representation of opinions. A total of 27 interviews including the IDIs, KIIs and FGDs lasting 30-60 min were conducted sequentially.

Data analysis

A thematic analysis approach was adopted. The English transcripts were read several times to develop familiarity with the raw data. Open coding was done to identify women’s expressions highlighting their autonomy; axial coding then followed to relate and label codes with shared concepts, dimension, and properties. Finally selective coding was done to delimit coding to the identified core concepts from the data [ 32 ]. See Table  2 below. E.O independently coded the data in the first phase of analysis. This was then followed by discussions between E.O and J.N, comparing emerging codes and developing a consensus on a final coding framework that was used to code and analyze the data in NVIVO 12.

This section presents the findings from an in-depth exploration of women’s agency and autonomy. Several key themes and sub-themes emerged, providing valuable insights into the complex dynamics surrounding women’s agency and autonomy. These findings contribute to a deeper understanding of the challenges and opportunities women face in asserting their rights, making choices, and navigating their social and cultural environments. The results further reveal the multifaceted nature of women’s agency and autonomy, encompassing individual, immediate relational, and distance relational factors and shed light on the interplay between these factors and uptake and utilization of maternal and child health services.

Individual agency

Independent women with strong self-trust were more likely to exercise their agency with greater adaptability and confidence in decision-making. Such strong inherent trust mediated power within which consequently shaped women’s individual agency and their ability to make decisions regarding maternal care.

“In my life, I’ve always been very independent and doing things on my own. I’ve never really encountered those challenges where I was told that someone else had to speak for me. Most of the time, I just do my own thing.”-ANC2

Conversely, the perception of shame, and insignificance among young pregnant girls diminished their agency in seeking services.

“For some, some are just afraid, especially those of young age. They are scared of coming to the clinic, so they try to hide the pregnancy because it brings them shame.” FGD men

The power within was also influenced by other factors including social support and past experiences. Supportive social networks provided women with the necessary resources, information, and support to develop their power within and exercise agency. Our findings indicate that social networks played a crucial role in shaping women’s individual agency in maternal healthcare decisions as they provided women with information, knowledge, and resources that enhanced their agency. Women sought input from their social networks including, family members, friends, community health volunteers (CHVs), and birth companions. Some elements such as finances, relational trust, and experiences of people were considered before a social network was chosen to aid with the decision-making.

“At times, the husband will help in decision making because it could be a place that is far and needs transport, he will be the one to decide whether I will go to Malava or not. The decision comes from him.”-PNC 1

The contacts drawn from social networks also shared their previous birthing experience with women fostering a sense of agency. Negative birth experiences raised awareness of potential challenges and helped women make more informed decisions while choosing the best options for the next birthing experience. In such instances, while the objective was to look for quality, the previous experiences of others as well as social relationships with health workers constituted the yardstick in making the final choice as the experiences of some participants revealed:

“That time I heard negative views about this place, and I didn’t feel the need to come. I heard that in Lumakanda they are very harsh and I told myself that “let me get used to Turbo”, I never set foot here. But in 2014, I said no, let me try the local facility.”-PNC 3

“Number one, etiquette of these nurses towards these pregnant women. You know you can go somewhere else, and the nurse just shouts at you. It’s like she carries all her stress to the hospital. But here in Lumakanda, I have not faced anything. So, that’s why I decided to come all the way.”-ANC 2

Additionally, health literacy had a great influence on women’s individual agency through the knowledge, attitudes, and beliefs acquired through health education and media exposure. Collectively, we saw how health education, media exposure, and health-seeking behavior significantly impacted women’s individual agency and decision-making for maternal care. With improved knowledge, women were more empowered to actively participate in decision-making processes, assert their preferences, and access appropriate healthcare services. Of note, is how health and financial literacy empowered women by increasing their understanding and enabling them to actively participate in decision-making processes.

“Maybe the media can broadcast that, mothers with children, and pregnant women, need to go to the hospital to get health services. They need to understand that they will benefit from going there. They need to hear it for themselves.”-PNC 3

Additionally, m edia exposure had a substantial impact on shaping women’s perceptions and attitudes toward maternal care. Our findings show that access to accurate and reliable information through various media channels can contribute to informed decision-making and empower women to seek appropriate maternal care. The respondents identified and recognized the value of health literacy in gaining autonomy and control over their health and well-being as corroborated in the quote below.

“Through media, newspapers, radios, councils, through these open places, many mothers have now discovered their rights and they have power now”-CHV.

Immediate relational agency

We found that women’s immediate relationships were also linked to household decision-making and freedom of movement. Our findings demonstrated that when women had their own source of income, it often led to increased empowerment and decision-making power within the household. Conversely, women who did not participate in income generation could hardly participate in decision-making in the house as recounted by this respondent.

“The only thing affecting my ability to make decisions, it’s because I’m not working. I do see those who are working, have the ability to decide, they can do their own things, as they wish. Even if there are obstacles from the husband, she can decide, let me do this. But for someone like me, it’s difficult.”-PNC 3

Health-related decisions, including seeking medical treatment, had financial implications. The costs associated with treatment impacted decision-making, particularly if they were substantial or necessitated long-term financial obligations. In such cases, decisions were made, considering the financial impact and available resources.

“Our clients depend on their husbands and their mothers-in-law as decision-makers. Since they depend on them especially the husbands to give them transport to go to the facility, they (husbands) are the key decision makers on where they seek their service.”-NO-IC

Spousal communication allowed for open dialogue, negotiation, and compromise, leading to decisions that consider the needs and preferences of both partners. Couples who trusted each other navigated power over each other by considering each other and providing a morale boost that facilitated decision-making in the household.

“It’s my husband whom I confide in the most. I feel comfortable talking to him, especially during my pregnancy, when I had a lot of complications like high blood pressure, and even had to undergo an operation. He’s my husband, so I talk to him, and he’s the one who helps me.”-PNC 3

Freedom of movement also influenced women’s immediate rational agency. Household structures were mostly patriarchal, where men held dominant roles and women’s mobility and decision-making power was limited. The traditional role of men as heads of households mandated a restricted life for women as they were expected to be submissive and show respect towards male partners.

“You find in some cultures a woman cannot say anything in front of the husband. The man is the one who speaks. In some areas, you are told “When you get here you follow what the husband, the mother or the father says”. -ANC 1

In contrast, single/separated women had complete freedom of movement and were able to decide alone. This was evidenced by one of the respondents, who shared that.

“When it comes to decision-making, I don’t think anyone can influence me because I make decisions myself. Even if someone discourages me, I know what I’m doing and what I’m looking for.”-ANC 2

Engaging in domestic tasks restricted women’s mobility outside the home. The demands of household chores meant that women could not move freely. Their social functioning was largely restricted to the household, the fields, and tending to children.

“Well, there are hindrances, at times I am alone at home without a house help, and I need to go somewhere. There are cows to take care of and children who may have gone to school waiting for me to make lunch. You see, there are hindrances, and you cannot just leave like that until you plan yourself.”-PNC 3

Mistrust within the household also undermined women’s freedom of movement and decision-making. These restrictions were reinforced by societal expectations and gender norms that prescribe women’s roles as primarily confined to the private sphere. Women’s ability to move about was sometimes constrained due to trust issues between spouses.

“You know, sometimes I come here in the morning and leave at two or three. He thinks it’s not just the hospital, he doesn’t understand, but I only come to the hospital. That’s one of the things he considers that and regulates my time out.”-PNC 3

Distance relational agency

Finally, social-cultural, and health systems factors presented various influences and circumstances that affected women’s ability to exercise agency and make choices in their lives. In this context, religious norms limited women’s access to evidence-based maternal care. Some respondents acknowledged that some religions challenged the idea of seeking healthcare in health facilities.

“In terms of decision-making, the church does not hinder anyone, but our church believes in not taking medication. We believe that if I am sick and you come to pray for me, I will be healed. However, it also says that if you know that your faith is not strong enough, you can go and seek medical treatment. But after you have received treatment, don’t come back to the church until you have finished whatever you need to do. Then, you can call on the elders to come and pray for you before returning to the church.”-CHV

Patriarchal structures including male dominance also limited women’s ability to exercise agency and make decisions independently. Most respondents emphasized men’s cultural role in decision-making regarding seeking MCH care. They acknowledged that increasing the engagement of men would yield considerable health benefits and provide an important avenue for giving men information which would also foster trust between spouses.

“Well, I would really wish to bring him along so he can see for himself how busy it is, from here to there. If he doesn’t see it for himself, he won’t understand.”-PNC 3

However, there were instances where male involvement was recognized as enabler for agency, as evidenced by men accompanying their spouses for clinics.

“You see, for instance, today my husband accompanied me, and he needed to go to work, so he brought me and went to work, and he finished what he was doing, and now he is calling me because we have been waiting here for a long time.”-PNC 1

Additionally, gender norms affected women’s ability to make decisions at the household level. Several women had partial control of their households’ finances but also kept financial secrets from their partners. This could be attributed to the feeling of being disempowered and the belief that financial secrets would give them a sense of autonomy. Interestingly, even after saving this money secretly, some women still needed their spouse’s approval to spend.

“They (women) also fear, even after saving they still can’t use the money without getting approval from the husband because they cannot do anything. It is mandatory, the husband has to know.”-MCH in charge

Women also stressed the need for securing the buy-in of the decision makers through community units, the nyumba kumi initiative, counselors, and healthcare providers.

“If we can find partners like you, we can go to the assistant chief’s council through the community health volunteers (CHVs). We can invite men to attend, and even if not all of them will come, we can create a network by telling a friend who tells another friend. This is like politics, but if we can use this network to spread the importance of maternal healthcare, it will be beneficial.”-CHV.

Health system factors such as facility workload, wait times, staff availability, and distance to health facilities also impacted women’s agency. The healthcare facilities were often overwhelmed with a high patient load, leading to longer waiting times, and delays in receiving care which can reduce women’s agency in seeking timely healthcare and may force them to delay or forgo necessary care. Women’s ability to make decisions about their own health was compromised when they had limited choices or faced barriers to accessing services. It also created a burden on women who had additional responsibilities, such as caregiving or work, as they struggled to find time to visit busy healthcare facilities.

“The health workers here are often overworked and have many patients to attend to. This leads to longer waiting times, which can sometimes make the patients frustrated.”-CHV

“Because of the staff shortage, we have only 2 staff in the ANC area. So, if one goes on leave, the one who is there serves both sides, the ANC and the other clients, the immunization side. So, the long queues and the long waiting time affect them, they don’t like it. I think that demotivates them even just to come to seek the services” -NO IC.

The distance between women’s residences and healthcare facilities also impacted their agency due to challenges related to transportation, time constraints, and financial resources required for travel.

“Most of them I’ve seen prefer the rural facilities, that is health centers or dispensaries instead of coming back to Lumakanda. I think the issue affecting them is transport.”-MS.

“At night, for a car, you’ll spend Ksh. 2,000 and if it’s a motorcycle, you’ll give him Ksh.800 shilling.”-FGD-BC

In some cases, where improved road networks existed, there were reports of women being able to access hospitals easily without difficulties.

“They come to Lumakanda because the road is tarmacked, so, if it’s a pregnant woman, she will not be spun in potholes.”-FGD Men

Our results indicate that individual agency, immediate relational agency, and distance relational agency influence women’s agency and autonomy. In terms of individual agency, factors such as self-stigma, trust in oneself, social networks, and previous birthing experiences emerged as important determinants of women’s decision-making power and control over their lives. Immediate relational agency, on the other hand, highlighted the significance of household decision-making dynamics, including aspects like control of household finances, respect between couples, and spousal communication. These factors played a crucial role in shaping women’s ability to exercise agency within their immediate relationships. Furthermore, distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Factors such as facility workload, staff availability, and religious norms were found to significantly influence women’s decision-making power and freedom of movement. Overall, these findings underscore the importance of recognizing and addressing various dimensions of agency and autonomy in order to empower women and promote gender equality.

Our work highlights a myriad of factors that influenced decision-making among women attending ANC, delivery, and PNC clinics during the early days of implementing a service delivery reform aimed at shifting all delivery to hospitals in a rural county in Kenya. Women’s autonomy and agency is still limited despite it being a crucial determinant of the use of maternal healthcare services. In our case, literacy was a pointer when analyzing women’s individual agency and decision-making capacity in engaging with MCH interventions and reforms. Our work revealed how, women with limited health literacy were unaware of their options in regarding participation in decision-making over their own reproductive health. Respondents reported the positive contribution of mass media in enhancing the household decision-making capacity. Similarly, Seidu et al. [ 33 ] demonstrated that women who watched television almost every day had a higher capacity to take household decisions, compared to those who did not watch television at [ 33 ] all. Mass media influences women empowerment, including their ability to take household decisions [ 34 ] by changing some socio-cultural norms such as gender stereotyping [ 35 ] suggesting that interventions to promote shared decision-making may be particularly important for patients with limited health literacy.

When women had individual agency, they reported having informed and better financial choices for themselves, and their families. Thus, individual agency elevated perceived self-efficacy in their decision making. Choices about individual women’s reproductive pathways and decision-making for care seeking therefore depended their perception of self; the self in relation to social environment and reflection on risks associated with the decision to seek care or not [ 36 ]. Social identity influences decision-making practices of individuals emphasizing the importance of deliberately embracing diversity and promoting inclusion future in the design of interventions and reforms with a focus on. This involves acknowledging and valuing different social identities, creating spaces that are safe and accessible for all individuals, and actively involving them in decision-making processes [ 37 ].

Women’s autonomy can also be better understood from a relational perspective since individual autonomy often fails to incorporate social reality. Relational autonomy posits that persons are socially embedded and that their identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants and health system determinants [ 38 ]. We found that in both joint and nuclear families, women who have better spousal communication with their husbands have greater agency. The role of immediate relational agency is therefore mediated through the family context and the quality of relationships the women have which consequently influences their agency. Male heads of households were central in health decisions, and in some instances discussing health issues with their wives before final decisions were made [ 39 , 40 ]. While joint and constructive communication leads to psychological well-being and protect against stressors during pregnancy [ 41 ] the process for decision-making often becomes delayed, consequently mothers’ ability to receive professional health care and other obstetric interventions on time.

Freedom of movement is also an important determinant of immediate relational agency, as the household structure affects women’s freedom of movement, since women residing in joint households are less likely to have decision-making power and need permission more often from other household members to execute some routine household activities [ 42 ]. Women require the permission of a husband or another male to pursue activities outside the home due to trust issues, social norms, and religious norm. This subsequently limited women’s ability to access and use skilled maternal health services including attending antenatal clinics or giving birth at a health facility. However, women who worked outside the home were more mobile, and women who were independent in the social sphere were also confident in their ability to negotiate independent mobility [ 40 ]. Additionally, it has been shown that husbands’ out-migration promotes women’s freedom of movement [ 43 ].

In summary, there is need for deliberate efforts towards empowering women’s autonomy in reproductive matters. Men might also benefit in the empowerment process through enlightenment and through effective implementation of male engagement interventions that leverage men’s power within households and promote women’s autonomy in decision making. Notably, women who receive male engagement education report making joint decisions (such as contraceptive choices, purchases of daily needs, and whether or not to work out of the home) compared to those who do not received such education [ 44 ].

The strength of this study includes the comprehensive exploration of agency across multiple dimensions, providing insights into the influence of factors such as previous birthing experiences, self-esteem, social support, financial control, respectful communication, and health system barriers on women’s agency. Although the challenge of establishing causality between the identified factors and women’s agency pose a challenge, the findings offer compelling descriptive explorations of the often undermined voice of women in shaping maternal and child health interventions policies and practices.

The study findings underscore the limited autonomy of women in Kakamega County, emphasizing the importance of considering women’s decision-making in the successful implementation of the SDR. Moving forward, it is crucial for SDR implementation strategies to recognize and promote women’s autonomy, engaging decision-makers to understand the significance of women’s choices regarding delivery in higher-level facilities. This calls for a concerted effort to enhance women’s autonomy in reproductive healthcare through initiatives such as male involvement, women’s empowerment programs, access to resources, and institutional support. Additionally, MCH programs should prioritize health and financial literacy, freedom of movement, gender equality, and media access to counter cultural and religious barriers to women’s autonomy.

Availability of data and materials

The data that supports the findings of this study are available in the article and its supplementary material.

Abbreviations

Antenatal clinics

Community Health Volunteers

Emergency obstetric and newborn care

Facility Improvement Fund

Focus Group Discussions

International Centre for Research on Women

In-depth interviews

Key Informant Interviews

Newborn Unit

National Health Insurance Fund

Sustainable Development Goal

Service Delivery Redesign

Crossing the quality chasm: a new health system for the 21st century - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/25057539/ . Cited 2020 Jul 25.

Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med. 2011;9:100–3.

Article   PubMed   PubMed Central   Google Scholar  

Ells C, Hunt MR, Chambers-Evans J. Relational autonomy as an essential component of patient-centered care. IJFAB. 2011;4(2):79–101.

Google Scholar  

Prata N, Tavrow P, Upadhyay U. Women’s empowerment related to pregnancy and childbirth: introduction to special issue. BMC Pregnancy Childbirth. 2017;17(2):1–5.

Imo CK. Influence of women’s decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018. BMC Pregnancy Childbirth. 2022;22(1):141.

Bloom SS, Wypij D, Das GM. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography. 2001;38:67–78.

Article   CAS   PubMed   Google Scholar  

Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190.

Article   ADS   PubMed   PubMed Central   Google Scholar  

Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009;69(6):926–33.

Article   PubMed   Google Scholar  

Thapa NR. Women’s autonomy and antenatal care utilization in Nepal: a study from Nepal demographic and health survey 2016. MOJ Women’s Heal. 2019;8(4):1–7.

MathSciNet   Google Scholar  

Vedam S, Stoll K, McRae DN, Korchinski M, Velasquez R, Wang J, et al. Patient-led decision making: measuring autonomy and respect in Canadian maternity care. Patient Educ Couns. 2019;102(3):586–94.

Gagliardi AR, Dunn S, Foster A, Grace SL, Green CR, Khanlou N, et al. How is patient-centred care addressed in women’s health? A theoretical rapid review. BMJ Open. 2019;9(2):e026121.

Sadiq UA. Women autonomy and the use of antenatal and delivery services in Nigeria. MOJ Public Heal. 2017;6(2):273–7.

Prata N, Fraser A, Huchko MJ, Gipson JD, Withers M, Lewis S, et al. Women’s empowerment and family planning: a review of the literature. J Biosoc Sci. 2017;49(6):713–43.

Corroon M, Speizer IS, Fotso J-C, Akiode A, Saad A, Calhoun L, et al. The role of gender empowerment on reproductive health outcomes in urban Nigeria. Matern Child Health J. 2014;18:307–15.

Do M, Kurimoto N. Women’s empowerment and choice of contraceptive methods in selected African countries. Int Perspect Sex Reprod Health. 2012;38(1):23–33.

Adhikari R. Effect of women’s autonomy on maternal health service utilization in Nepal: a cross sectional study. BMC Womens Health. 2016;16(1):1–7.

Article   Google Scholar  

Rominski SD, Gupta M, Aborigo R, Adongo P, Engman C, Hodgson A, et al. Female autonomy and reported abortion-seeking in Ghana, West Africa. Int J Gynecol Obstet. 2014;126(3):217–22.

Jejeebhoy SJ. Women’s autonomy in rural India: its dimensions. In: Determinants and the influence of context, IUSSP seminar paper on Female Empowerment and Demograpi, ic c’roce. 2000.

SDG Indicators. SDG indicators. Available from: https://unstats.un.org/sdgs/metadata/ . Cited 2023 Jan 6.

Crissman HP, Adanu RM, Harlow SD. Women’s sexual empowerment and contraceptive use in Ghana. Stud Fam Plann. 2012;43(3):201–12.

Burkitt I. Relational agency: relational sociology, agency and interaction. Eur J Soc Theory. 2016;19(3):322–39.

Ahinkorah BO, Dickson KS, Seidu A-A. Women decision-making capacity and intimate partner violence among women in sub-Saharan Africa. Arch Public Health. 2018;76(1):1–10.

Tesha J, Fabian A, Mkuwa S, Misungwi G, Ngalesoni F. The role of gender inequities in women’s access to reproductive health services: a population-level study of Simiyu Region Tanzania. BMC Public Health. 2023;23(1):1–9.

Fernando P, Porter G. Bridging the gap between gender and transport. In: Balanc load women, Gend Transp. 2002. pp. 1–14.

Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175.

Merrell LK, Blackstone SR. Women’s empowerment as a mitigating factor for improved antenatal care quality despite impact of 2014 Ebola Outbreak in Guinea. Int J Environ Res Public Health. 2020;17(21):8172.

Mirghafourvand M, Bagherinia M. Relationship between maternal self-efficacy and functional status four months after delivery in Iranian primiparous women. J Psychosom Obstet Gynecol. 2018;39(4):321–8.

Kadengye DT, Atahigwa C, Kampire P, Mucunguzi S, Kemigisha E, Nyakato VN, et al. Effect of women’s intra-household bargaining power on postnatal and infant healthcare in rural Uganda-results from a cross sectional survey in Kyenjojo district. Midwifery. 2020;84:102665.

Field E, Pande R, Rigol N, Schaner S, Moore CT. On her account: Can strengthening women’s financial control boost female labor supply? Growth labour markes low income. In: Ctries Program Work Pap. 2016(32).

Heath R, Tan X. Intrahousehold bargaining, female autonomy, and labor supply: theory and evidence from India. J Eur Econ Assoc. 2020;18(4):1928–68.

Croke K, Gage A, Fulcher I, Opondo K, Nzinga J, Tsofa B, et al. Service delivery reform for maternal and newborn health in Kakamega County, Kenya: study protocol for a prospective impact evaluation and implementation science study. BMC Public Health. 2022;22(1):1727.

Strauss A, Corbin J. Basics of qualitative research techniques. 1998.

Seidu A-A, Ahinkorah BO, Hagan JE Jr, Ameyaw EK, Abodey E, Odoi A, et al. Mass media exposure and women’s household decision-making capacity in 30 sub-Saharan African countries: analysis of demographic and health surveys. Front Psychol. 2020;11:581614.

Jensen R, Oster E. The power of TV: cable television and women’s status in India. Q J Econ. 2009;124(3):1057–94.

Dasgupta S. Impact of exposure to mass media on female empowerment: evidence from India. Int J Dev Issues. 2019;18(2):243–58.

SolnesMiltenburg A, van Pelt S, Lindskog B, Sundby J, Meguid T. Understanding women’s decision-making process for birth location in Tanzania based on individual women’s reproductive pathways: a life-course perspective. Glob Health Action. 2022;15(1):2040149.

Scott J, Onyango MA, Burkhardt G, Mullen C, Rouhani S, Haider S, et al. A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo. BMC Pregnancy Childbirth. 2018;18(1):1–9.

Osamor PE, Grady C. Autonomy and couples’ joint decision-making in healthcare. BMC Med Ethics. 2018;19:1–8.

Chace Dwyer S, Mathur S, Kirk K, Dadi C, Dougherty L. “When you live in good health with your husband, then your children are in good health….” A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger. BMC Public Health. 2022;22(1):1–9.

Raman S, Srinivasan K, Kurpad A, Ritchie J, Razee H. “We have to ask and only then do”: unpacking agency and autonomy in women’s reproductive health in urban India. Health Care Women Int. 2016;37(10):1119–37.

Dakura J, Yidana A, Kuganab-lem R. Spousal communication in decision making during pregnancy in Northern Ghana. Public Health Res. 2022;12(3):69–77.

Debnath S. The impact of household structure on female autonomy in developing countries. J Dev Stud. 2015;51(5):485–502.

Ghimire D, Zhang Y, Williams N. Husbands’ migration: increased burden on or more autonomy for wives left behind? J Ethn Migr Stud. 2021;47(1):227–48.

Japhet P, Maluka S. Effects of male engagement interventions on women’s autonomy in decision making in Iringa Region, Tanzania. Tanzania J Dev Stud. 2021;19(1).

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Acknowledgements

We would like to express our gratitude to the Kakamega County Government for granting us permission to conduct the study and for providing the essential preliminary information that facilitated our research. Furthermore, we would like to convey our sincere appreciation to the study participants for their invaluable cooperation throughout the course of this study.

This study is funded by the Bill and Mellinda Gates Foundation grant number # 263771.5119872. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Easter Olwanda, Dorothy Oluoch, Justinah Maluni, Joyline Jepkosgei & Jacinta Nzinga

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JN conceptualized the study, EO conducted the interviews, JN and EO undertook the analysis, EO developed the first draft of the manuscript. KO, KC, DO, JM, and JJ contributed to subsequent drafts and all authors approved this version of the manuscript for publication.

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Olwanda, E., Opondo, K., Oluoch, D. et al. Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study. BMC Women's Health 24 , 181 (2024). https://doi.org/10.1186/s12905-024-02965-9

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Opinion The case for a 32-hour workweek with no loss in pay

Bernie Sanders, an independent, represents Vermont in the U.S. Senate. Shawn Fain is president of the United Auto Workers.

Although it is rarely discussed in the media, the Senate overwhelmingly passed legislation to establish a 30-hour workweek in 1933. While that legislation ultimately failed because of intense opposition from corporate America, a few years later President Franklin D. Roosevelt signed the Fair Labor Standards Act into law and a 40-hour workweek was established in 1940.

Unbelievably, 84 years later, despite massive growth in technology and worker productivity, nothing has changed.

Today, American workers are more than 400 percent more productive than they were in the 1940s. And yet, despite this fact, millions of our people are working longer hours for lower wages. In fact, 28.5 million Americans now work over 60 hours a week, and more than half of full-time employees work more than 40 hours a week.

The sad reality is, Americans work more hours than the people of most other wealthy nations. In 2022, U.S. workers logged 204 more hours a year than employees in Japan, 279 more hours than those in the United Kingdom and 470 more hours than those in Germany.

Despite these long hours, the average worker in America makes almost $50 a week less than he or she did 50 years ago, after adjusting for inflation.

Let that sink in for a moment. In a 1974 office, there were no computers, email, cellphones, conference calling or Zoom. In factories and warehouses, there were no robots or sophisticated machinery, no cloud computing. In grocery stores and shops of all kinds, there were no checkout counters using bar codes.

Think about all the incredible advancements in technology — computers, robotics, artificial intelligence — and the huge increase in worker productivity that has been achieved. What have been the results of these changes for working people? Almost all the economic gains have gone straight to the top, while wages for workers are stagnant or worse.

While CEOs are making nearly 400 times as much as their average employees, many workers are seeing their family lives fall apart, missing their children’s birthday parties and Little League Baseball games, as they are forced to spend more time at work. What stresses them out even further is that many still do not have enough money to pay rent, put food on the table and send their kids to college without going deeply into debt.

This should not be happening in the United States of America in 2024. It’s time for a 32-hour workweek with no loss in pay.

Let’s be clear. This is not a radical idea: Belgium has already adopted a four-day workweek. Other developed countries are moving toward this model, such as France (35-hour workweek and considering reducing to 32) and Norway and Denmark (roughly 37-hour workweeks). In 2019, Microsoft tested a four-day workweek in Japan and reported a 40 percent increase in productivity.

Last year, the United Kingdom conducted a four-day workweek pilot program of 3,000 workers at more than 60 companies, and it was a huge success for both workers and employers. Over 73 percent of workers who participated in this program reported greater satisfaction with their work. Businesses that participated in this program saw a 35 percent average increase in revenue, and 91 percent of businesses opted to continue a four-day workweek after the study concluded.

Studies have shown that workers are either equally or more productive during a four-day workweek — one study found that worker productivity rose , with 55 percent saying their ability at work increased after companies adopted this new schedule. In addition, 57 percent of workers in companies that have moved to a four-day workweek have indicated that they are less likely to quit their jobs.

Moreover, at a time when so many of our people are struggling with their mental health, 71 percent of workers in companies that have moved to a four-day workweek report feeling less burnout, 39 percent reported feeling less stress and 46 percent reported feeling less fatigued .

Even Bill Gates, the founder of Microsoft, and Jamie Dimon, CEO of JPMorgan Chase, predicted last year that advancements in technology could lead to a three- or 3½-day workweek.

The question is: Who will benefit from this transformation? Will it be the billionaire class or workers? In our view, the choice is obvious. At a time of massive income and wealth inequality and huge increases in productivity, the financial gains from new technology must go to workers, not just to the people on top.

As part of their historic contract negotiations with the Big Three automakers — General Motors, Ford Motor Co. and Stellantis (formerly Chrysler) — the United Auto Workers called for the introduction of a four-day, 32-hour workweek at the same rate of pay and overtime pay for anything beyond that.

Despite significant gains for workers in their new contract, they were not successful in winning that demand. The struggle continues.

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