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Developing Measures of Women’s Reproductive Empowerment in Sub-Saharan Africa for Rigorous Evaluations


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Presented by Carolina Mejia, Mahua Mandal, and Abby Cannon at the 2016 AEA conference.

Published in: Health & Medicine
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Developing Measures of Women’s Reproductive Empowerment in Sub-Saharan Africa for Rigorous Evaluations

  1. 1. Developing Measures of Women’s Reproductive Empowerment in Sub-Saharan Africa for Rigorous Evaluations Carolina Mejia, PhD, MPH Mahua Mandal, MPH, PhD Abby Cannon, MSW, MPH MEASURE Evaluation University of North Carolina October 26, 2016 AEA Conference, Atlanta, GA
  2. 2. Outline • Background on reproductive empowerment (RE) • Goals and objectives • Methods • Findings • Next steps • Conclusion
  3. 3. Background • Over the last two decades, women's empowerment has become a focus for development efforts. • Empowerment is commonly defined as “the expansion in people’s ability to make strategic life choices in a context where this ability was previously denied to them.” (Kabeer, 2001) • Distinguishing between different types of empowerment is of particular importance because empowerment within one dimension does not necessarily translate into empowerment in other dimensions or facets of women’s lives.
  4. 4. Background (2) • Reproductive empowering women is one dimension of empowerment and has been viewed as a critical factor for family planning, reproductive, and sexual health. • Numerous studies have found a positive association between women’s empowerment and reproductive outcomes, including lower fertility, longer birth intervals, use of contraception, and lower rates of unintended pregnancy. • Obstacles exist in defining and measuring reproductive empowerment and other gender-related concepts.
  5. 5. Reproductive empowerment Definition “The expansion of people’s ability to make and act upon informed decisions about whether and when to get married; have sex; have children and how many.”
  6. 6. IMPROVED SRH OUTCOMES • Decreased sexual violence and coercion • Decreased child marriage • Improved HTSP • Decreased unmet need for FP • Decreased HIV/STI • Decreased unintended or unplanned birth Individual Agency Relational Agency Enabling Environment • SRHR knowledge • Body literacy • Fertility awareness • Critical reflection about social norms and attitudes related to SRHR • Self-efficacy to express, negotiate, and carry out one’s sexual and reproductive desires and intentions • Couple communication and negotiation • Healthy and pleasurable relationships • Shared sexual and reproductive decision making • Freedom from violence and coercion • Culture norms • Supportive legal/policy frameworks • Quality SRH services • Comprehensive SRH education • Expanded method mix • Supportive social networks and family members • Equitable norms • Economic opportunities INFORMED CHOICE Conceptual framework
  7. 7. Overall goal Assess the existing literature on quantitative measures of reproductive empowerment and develop culturally-specific measures grounded on a new conceptual model of RE.
  8. 8. Study aims • Conduct a systematic literature review of studies seeking to measure reproductive empowerment, family planning, and reproductive health outcomes. • Conduct focus groups to explore issues related to cultural norms, values, beliefs about reproductive and sexual health. • Develop culturally-appropriate measures of RE.
  9. 9. Methods: Literature review (1) • Databases: PubMed, CINAHL, and Web of Science • Search terms: marriage, reproductive, fertility, birth spacing, family planning, contraception, abortion, empowerment, power, personal autonomy, auonomy, decision making, coercion, choice, gender norms, measure/scales/survey. • Geographic region: Any • Language: English • Publication date: 1/1/94 and 2/1/16 Search strategy
  10. 10. Reproductive Empowerment Flowchart for Literature Search Duplicates Records Removed n= 2211 Methods: Literature review (2) Inclusion criteria • Topic areas • Family planning • Fertility/reproduction, abortion • Sexual or romantic relationship, marriage • Gender-based violence • Concepts/Domains • Empowerment, autonomy, power dynamics • Gender norms • Coercion/controlling behaviors • Couples communication/negotiation/decision making
  11. 11. Full Articles Excluded Based on Eligibility Criteria n= 361 Reproductive Empowerment Flowchart for Literature Search Records from PubMed, Web of Science & CINAHL identified N= 8058 Titles and Abstracts Excluded n= 5441 Full Articles Reviewed for Eligibility n= 406 Articles Included in the Review (of quantitative measures of RE) n= 45 Duplicates Records Removed n= 2211 Methods: Literature review (3) Flowchart Title and Abstracts Screened n= 5847
  12. 12. Findings: Literature review (1) • Studies represent diverse geographical areas, including 23 countries. • Common domains measured were: • Decision making • Sexual coercion and violence • Gender norms and attitudes 3 2 2 3 23 3 9 Reproductive Empowerment Measures by Region (n=45) East Asia and Pacific Europe and Central Asia Latin America and Caribbean Middle East and North Africa North America South Asia Sub-Saharan Africa
  13. 13. Author and country Scale Items Ansara & Hindin (2009) • Philippines 1. Modified conflict tactics scale Physical aggression - Did they or their husband ever: • Throw something at their partner? Ansara & Hindin (2010) • Canada 1. Conflict tactics scale 2. Emotional and financial abuse Did partner perpetrate any of the following acts? • Threaten to hit you with his/her fist or anything else that could have hurt you? Mohammadkhani et al. (2009) • Iran 1. Personal and relationships profile 2. Marital attitude survey Sexual coercion scale items • Made my partner have sex without a condom • Insisted on sex when my partner did not want to (but did not use physical force) Common measures
  14. 14. Author and Country Scale Items Morokoff et al. (1997) • USA Sexual Assertiveness Scale (SAS) Initiation: I begin sex with my partner if I want to. Nanda, Schuler, and Lenzi (2013) • Tanzania 1. GEM Scale 2. Household decision-making scale 3. Attitudes towards wife refusing sex scale 4. Attitudes toward wife scale GEM Scale examples: (agree or disagree) • There are times a woman deserves to be beaten • A woman’s role is taking care of her home and family HH Decision-making Scale: Attitudes towards wife refusing sex Attitudes towards wife beating Pulerwitz et al. (2002) • USA Sexual Relationship Power Scale (SRPS) Relationship Control • If I asked my partner to use a condom, he would get violent.
  15. 15. Findings: Literature review (2) • Measures of enabling factors such as social networks and policies around SRH are not commonly included in RE. • No studies focused on: • Never-married women • Women in other types of relationships (e.g., with multiple partners or women in plural marriages). • Very few scales directly measure the partner’s perspective. • Lack of age-appropriate RE measures for adolescent girls and boys. Our review yielded three studies of girls and/or boys as young as 13 years of age. Gaps in measuring RE
  16. 16. Methods: Focus groups (1) • Purposive sampling strategies • Goal: • 10 FGs with women in Zambia (five rural and five urban areas) • Four FGs with men • FG recruitment is currently in progress Sampling and recruitment Females Chipata (Rural) n=5 Lusaka (Urban) n=5 no children children no children children 15-17 year old n/a 1 n/a 1 18-24 year old n/a 2 1 1 25-49 year old 1 1 1 1 Numbers in bold indicated that FG has been completed.
  17. 17. Methods: Focus groups (2) • The conceptual model guided development of the discussion guide topics and themes such as: relationship control; decision-making power or dominance; coercion; autonomy; and self-efficacy. • Themes were explored through FP and reproductive health topics at various levels of gender-related power dynamics (e.g., partners, households, service providers, communities). • Discussion topics were presented in case study scenarios tailored by age group and sex of participants. Discussion topics
  18. 18. Preliminary findings (1) • Communication and decision-making about FP • Women mentioned feeling responsible for making decisions about FP but several reported hiding contraceptive use from their husbands. Focus groups with women • Negotiating sex with partner • The majority of the women expressed the belief that women have the obligation to have sex whenever their husband desires. The only time women are not obligated to have sex is soon after giving birth or when they are on their menstrual cycle. • Women expressed fear of what would happened if they withheld sex from husband (e.g., husband being unfaithful or wife being sent back to her parent’s village.)
  19. 19. Preliminary findings (2) • Others influence on decision making • Participants mentioned if negotiations about FP failed with husbands, then they would turn to a “Nkhoswe” or “clan-representative” who is the family adviser, advocate, and arranger of the most important life affairs. • Use and access to FP services • Women with children reported receiving the majority of information about FP from health clinics after giving birth. • Women with no children mentioned receiving information about FP from friends who already have children and from the media. Focus groups with women
  20. 20. Next steps • Complete analyses of full focus group data to generate RE measures. • Consult with RE experts on measures for content-validity. • Conduct cognitive interviews with women to establish face-validity of measures. • Finalize RE measures and add measures to a health survey for validation.
  21. 21. Conclusion Understanding RE and measures will help future research and program planning and/or improve reproductive health/FP outcomes. This study provides a starting point for assessing the existing literature on quantitative measures of RE and moving forward to developing culturally-specific measures grounded on a current conceptual model of RE.
  22. 22. Acknowledgments • Lara Lorenzetti, PhD (candidate), and Christopher Bernie Agala, PhD (candidate), MEASURE Evaluation • Diana Santillan and Preeti Dhillon (formally at ICRW). • Trinity Mwale and Stanley Santula, Zambia.
  23. 23. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government.