1. Women’s empowerment and choice of family planning methods Mai Do and Nami Kurimoto Department of International Health and Development Tulane University School of Public Health and Tropical Medicine

2. 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

3. 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

4. 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

5. Analytical framework Individual 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 use 1.Non-use 2.Female-only controlled methods 3.Couple-oriented methods

6. 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.

7. Prevalence of current contraceptive use (%)

8. Measure of women’s empowerment Dimension*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)

9. Relative risk ratios of overall women’s empowerment Ghana ‘08 Namibia ‘06/07 Uganda ‘06 Zambia ‘07 FemaleCoupleFemaleCoupleFemaleCoupleFemaleCouple 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

10. Relative risk ratios of women’s empowerment dimensions Ghana ’08Namibia ‘06/07Uganda ‘06Zambia ‘07 FemaleCoupleFemaleCoupleFemaleCoupleFemaleCouple Household economy 1.10 ^1.021.09 **1.051.09 **1.09 *NS Socio-Cultural activities Others/husband alone Joint/women alone NS Health seeking behavior Others/husband alone Joint/women alone NS 1.00 1.21 ^ 1.00 0.95 Perceived agreement on fertility preference No agreement Agreement 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 1.031.08 * Domestic violence attitudes 0.951.11 ^0.991.11 *NS ^ p<.10; * p<.05; ** p<.01; *** p<.001 Swaziland: non significant associations

11. 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.

12. 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.

13. Take home messages  Women’s empowerment is important  No universal strategies to increase women’s empowerment in order to promote FP practice

14. 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.