Developing Measures of Women’s Reproductive Empowerment in Sub-Saharan Africa for Rigorous Evaluations
of Women’s Reproductive
Empowerment in Sub-Saharan
Africa for Rigorous Evaluations
Carolina Mejia, PhD, MPH
Mahua Mandal, MPH, PhD
Abby Cannon, MSW, MPH
University of North Carolina
October 26, 2016
AEA Conference, Atlanta, GA
• Background on
• Goals and
• Next steps
• 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.
• 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.
“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.”
• SRHR knowledge
• Body literacy
• Fertility awareness
• Critical reflection about
social norms and
attitudes related to
• Self-efficacy to express,
negotiate, and carry
out one’s sexual and
• Healthy and
• Shared sexual and
• Freedom from
violence and coercion
• Culture norms
• Supportive legal/policy
• Quality SRH services
• Comprehensive SRH
• Expanded method mix
• Supportive social
networks and family
• Equitable norms
• Economic opportunities
Assess the existing
literature on quantitative
measures of reproductive
empowerment and develop
grounded on a new
conceptual model of RE.
• Conduct a systematic literature
review of studies seeking to
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.
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
Flowchart for Literature Search
Methods: Literature review (2)
• Topic areas
• Family planning
• Fertility/reproduction, abortion
• Sexual or romantic relationship, marriage
• Gender-based violence
• Empowerment, autonomy, power dynamics
• Gender norms
• Coercion/controlling behaviors
• Couples communication/negotiation/decision making
Full Articles Excluded Based
on Eligibility Criteria
Flowchart for Literature Search
Records from PubMed, Web of
Science & CINAHL identified
Titles and Abstracts Excluded
Full Articles Reviewed for
Articles Included in the
Review (of quantitative
measures of RE) n= 45
Methods: Literature review (3)
Title and Abstracts
Findings: Literature review (1)
• Studies represent
areas, including 23
• Common domains
• Decision making
• Sexual coercion and
• Gender norms and
Reproductive Empowerment Measures by
East Asia and Pacific
Europe and Central Asia
Latin America and Caribbean
Middle East and North Africa
Ansara & Hindin
Physical aggression - Did they or their
• Throw something at their partner?
Ansara & Hindin
Did partner perpetrate any of the following
• Threaten to hit you with his/her fist or
anything else that could have hurt you?
et al. (2009)
1. Personal and
Sexual coercion scale items
• Made my partner have sex without a
• Insisted on sex when my partner did not
want to (but did not use physical force)
Morokoff et al.
I begin sex with my partner if I want to.
1. GEM Scale
3. Attitudes towards
wife refusing sex
4. Attitudes toward
GEM Scale examples: (agree or
• There are times a woman deserves to
• 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.
Power Scale (SRPS)
• If I asked my partner to use a condom,
he would get violent.
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
• 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
Gaps in measuring RE
Methods: Focus groups (1)
• Purposive sampling strategies
• 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.
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,
• Discussion topics were presented in case study
scenarios tailored by age group and sex of participants.
Preliminary findings (1)
• Communication and decision-making about
• 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.)
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
• Complete analyses of
full focus group data to
generate RE measures.
• Consult with RE experts
on measures for
• Conduct cognitive
interviews with women
to establish face-validity
• Finalize RE measures
and add measures to a
health survey for
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
• Lara Lorenzetti, PhD
(candidate), and Christopher
Bernie Agala, PhD
• Diana Santillan and Preeti
Dhillon (formally at ICRW).
• Trinity Mwale and Stanley
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.