Women's empowerment programs focus primarily on increasing the decision-making power of women, while male involvement/couple-friendly programs emphasize communication and negotiation within couples in making decisions. In-depth-interviews and focus group discussions were conducted to investigate patterns of household decision-making and the context of male involvement behaviors in Katmandu, Nepal. A questionnaire focusing on household decision-making and husbands’ roles during pregnancy was administered to 592 pregnant women receiving antenatal services at a large maternity hospital. Multivariate regression techniques were used to compare male involvement behaviors across varying levels of women's autonomy, represented by different decision-making patterns. Higher women's autonomy, as measured by her sole final decision-making power, was associated with significantly lower male involvement in pregnancy health. After adjustment for other covariates, each additional decision in which a woman had final say was associated with a significantly lower likelihood of her husband accompanying her to antenatal care (OR=0.70, p<0.01). Conversely, joint decision-making between the husband and wife was associated with significantly higher levels of male involvement in pregnancy health. For each additional decision made jointly with husbands, women were more likely to discuss health with their husbands (OR=1.47, p<0.001), to make birth preparations (OR=1.19, p<0.05), and to experience a high level of male involvement (OR=1.29, p<0.05). The positive associations between joint decision-making and male involvement imply that couple communication and shared negotiation strategies can improve health practices. These results indicate that programs intended to increase women's empowerment and/or women's health must consider the dynamics and ramifications of including or excluding males in their efforts. Involving husbands and encouraging couples’ joint decision-making in reproductive and family health may provide an important strategy in achieving both women's empowerment and women's health goals.