Women’s Empowerment and Choice of Contraceptive Methods in Selected African Countries

This 12-page report shares findings from a study to identify associations between women's empowerment and the use of contraceptives in selected African countries. The study, supported by the MEASURE Evaluation Population and Reproductive Health Project, funded by the United States Agency for International Development, examined whether women's empowerment was associated with the likelihood that a couple used either a female or a couple method of contraception. It was concluded that intervention programmes designed to increase contraceptive use may need to involve different approaches, including promoting couples' discussion of fertility preferences and family planning, improving women's self-efficacy in negotiating sexual activity, and increasing their economic independence.

Data for the study came from the Demographic and Health Surveys conducted between 2006 and 2008 in Namibia, Zambia, Ghana, and Uganda. Responses from married or cohabiting women aged 15 to 49 were analysed for six dimensions of empowerment and the current use of female-only methods or couple methods. In this study, female-only methods included the pill, IUD, injectable and implant; couple methods included male and female condoms, the diaphragm, foam, jelly, withdrawal, the lactational amenorrhea method, and periodic abstinence - methods that require at least the awareness of and a certain degree of support and cooperation from husbands.

Associations between method use and the different dimensions of empowerment varied across countries, yet some findings were consistent across two or more countries. First, female-only methods were much more commonly used than couple methods in Namibia and Uganda. Second, in all countries but Ghana, women's overall empowerment score was positively associated with both female and couple method use. In three of the countries, the study also found that two or three empowerment dimensions were associated with contraceptive use - economic decision making, negotiation of sexual activity, and perceived agreement on fertility preferences. In Namibia, which had the highest contraceptive prevalence and the greatest difference between the types of methods used, contraceptive use was associated with three of the six dimensions of empowerment. This was the only country in which both economic empowerment and agreement on fertility preferences were related to use of female-only methods.

In none of the countries was the sociocultural or health-seeking dimension associated with contraceptive use. This finding was unexpected. The authors propose that it is plausible that there is truly no association between this aspect of decision making and contraceptive use, because health-seeking behaviour may not necessarily involve interactions with their partners, whereas method use does. It was not clear whether women were empowered to make decisions regarding their health care, or whether they simply lived in households in which husbands or partners contributed little to issues that were not directly related to themselves.

Despite some limitations, the study concludes that there are important associations between several dimensions of women’s empowerment and the choice of contraceptive methods, and these findings have a number of significant implications. More research is needed to understand the mechanisms of the associations between empowerment and contraceptive use in settings with different contraceptive prevalence rates. Future studies need to take into account women's empowerment from men's perspective to better capture couples’ decision-making dynamics. Finally, more research is needed to gain insight into the meaning and functioning of women’s empowerment in African settings.

The authors suggest that different strategies could be employed to promote family planning in these countries. For example, in Zambia, one strategy to increase overall contraceptive use could be promoting couples’ discussions about their fertility desires and involving men in decision making related to fertility and contraception. Another strategy may be to improve women’s self-efficacy and attitudes related to the negotiation of sexual activity; since this dimension was related only to couple method use, it may be an effective strategy in settings where the availability of modern contraceptives, with the exception of condoms, is limited. Programmes designed to increase women's ability to negotiate sexual activity may be particularly important in Ghana, where family planning practice is not widespread. Such programmes may need to be coupled with efforts to increase contraceptive availability to meet the potential for increased demand for modern methods.

In Uganda, programmes designed to improve women’s independent earnings and contribution to household finances may be more important than those designed to increase couples’ discussions of fertility. Other programmes in Uganda may need to consider costs related to family planning supplies and transportation to health facilities, which could be an important factor in the use of female methods, many of which require periodic resupplies or assistance from medical professionals. It is possible that women who have some control in financial matters have better access to these services than women who have little or no control. Finally, in Namibia, the findings that women’s empowerment regarding household finances and fertility preferences were associated with female methods and not couple methods may suggest that many Namibians still perceive family planning practice as a woman's responsibility. Overall, the study suggests that although women’s empowerment in general is associated with increases in contraceptive use, a "one-size-fits-all" strategy for contraceptive promotion in Africa is unlikely to be effective.

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