Women’s empowerment and

choice of family planning methods

Mai Do and Nami KurimotoDepartment of International Health and Development

Tulane University School of Public Health and Tropical Medicine

Women’s empowerment Women’s empowerment and their RH rights (1994 ICPD)

Much variation in definition, often encompasses Process of change

Agency

Resources

Achievement

Difficulty to measure because: A process

Multidimensional

Operationalizes at different levels

Study purposes

To examine associations between women’s empowerment and contraceptive use in selected African countries

Hypothesis: women who are more empowered are more likely to use female, as well as couple, methods of contraception

Explore different dimensions of women’s empowerment

Country selection Inclusion criteria:

Substantial contraceptive use

Sufficient sample of married and cohabiting women

Comparable questions on women’s empowerment

Last DHS conducted within the last 5 years

Samples: Ghana (2008): n = 2,902 cohabiting, non-sterilized women

Namibia (2006-07): n = 3,235

Uganda (2006): n = 5,193

Zambia (2007): n = 4,241

Swaziland (2006-07): n = 1,940

Analytical frameworkIndividual Characteristics

Age

Highest education level

Household wealth tertile

Religion

Number of living children

Exposure to FP messages

Contraceptive knowledge

Community Characteristics

Place of residence

Prevalence of contraceptive use in community

Women’s empowerment Household economy Social-cultural activities Health seeking behavior Perceived agreement on fertility preference Sexual activity negotiation Domestic violence attitudes

Current contraceptive use1. Non-use2. Female-only controlled

methods3. Couple-oriented methods

Outcome

Current use of contraceptives:

Non-use

Use of female methods: oral pills, IUDs, injectables, and implants.

Use of couple methods: male and female condoms, diaphragm, withdrawal, lactational amenorrhea method (LAM), and periodic abstinence.

Male and female sterilization users are excluded.

Prevalence of current contraceptive use (%)

12.4

35.7

30.4

14.1

20.2

9.713.9

17.1

7.0

19.4

0

10

20

30

40

50

Ghana ('08) Namibia ('06/07) Swaziland('06/07)

Uganda ('06) Zambia ('07)

Female methods Couple methods

Measure of women’s empowermentDimension* Questions asked in DHS

1. Household economy -Who earns more-Decision maker in how to spend wife’s earning, husband’s earnings, major household purchases, daily household purchases

2. Socio-cultural activities

Decision maker about visits to family and relatives

3. Health seeking behavior

Decision maker about health care for yourself (i.e. women themselves)

4. Perceived agreement on fertility preferences

Perceptions about husband’s desired number of children (same as wife’s, more or less)

5. Sexual activity negotiation

Can refuse sex or ask for condom use in a number of situations: tired, husband has STDs, husband has sex with other women, etc.

6. Domestic violence attitudes

Whether a husband is justified in hitting/beating wife in a number of situation: she goes out without telling him, neglects children, refuses sex, burns the food, etc.

* Adapted from Maholtra and Schuler (2005) and Maholtra, Schuler and Boender (2002)

Relative risk ratios of overall women’s empowerment

Ghana

‘08

Namibia

‘06/07

Uganda

‘06

Zambia

‘07

Female Couple Female Couple Female Couple Female Couple

Overall score 1.14

^

1.27

*

1.19

***

1.24

***

1.21

***

1.31

***

1.17

***

1.08

**

^ p<.10; * p<.05; ** p<.01; *** p<.001

Relative risk ratios of women’s empowerment dimensions

Ghana ’08 Namibia ‘06/07 Uganda ‘06 Zambia ‘07

Female Couple Female Couple Female Couple Female Couple

Household economy 1.10 ^ 1.02 1.09 ** 1.05 1.09 ** 1.09 * NS NS

Socio-Cultural activities

Others/husband alone

Joint/women alone

NS NS NS NS NS NS NS NS

Health seeking behavior

Others/husband alone

Joint/women alone

NS NS NS NS NS NS

1.00

1.21 ^

1.00

0.95

Perceived agreement on fertility preference

No agreement

Agreement

NS NS

1.00

1.48 ***

1.00

1.02

1.00

1.20 ^

1.00

1.60 ***

1.00

1.45 ***

1.00

1.31 *

Sexual activity negotiation 1.18 * 1.13 * NS NS NS NS 1.03 1.08 *

Domestic violence attitudes 0.95 1.11 ^ 0.99 1.11 * NS NS NS NS

^ p<.10; * p<.05; ** p<.01; *** p<.001Swaziland: non significant associations

Findings Positive association between women’s empowerment and

contraceptive use in all countries.

No exact same associations between contraceptive use and women’s empowerment dimensions across countries. No “one size fits all” strategies for Africa.

In most countries, several empowerment dimensions associated with contraceptive use. Exception is Swaziland.

Empowerment in household economy, fertility preference, and sexual activity negotiation most often related to contraceptive use.

Different strategies may be employed in different countries.

Limitations Endogeneity between women’s empowerment and

contraceptive use not tested or controlled for

Cross-sectional nature of DHS data

Measures of socio-cultural activities and health seeking behaviors might not be good measures of empowerment

Women’s responses to hypothetical questions on empowerment

Dual method use not captured by DHS

Next step: Analysis should employ couple-oriented perspectives.

Take home messages

Women’s empowerment is important

No universal strategies to increase women’s empowerment in order to promote FP practice

MEASURE Evaluation PRH is a MEASURE project funded by

the United States Agency for International Development

(USAID) through Cooperative Agreement GHA-A-00-08-00003-

00 and is implemented by the Carolina Population Center at

the University of North Carolina at Chapel Hill in partnership

with Futures Group International, Management Sciences for

Health, and Tulane University. Views expressed in this

presentation do not necessarily reflect the views of USAID or

the U.S. Government. MEASURE Evaluation PRH supports

improvements in monitoring and evaluation in population,

health and nutrition worldwide.