Comprehensive contraceptive transition theory, Shireen J. Jejeebhoy and Zeba Sathar argue, must prioritize women’s agency and gender roles, particularly the ability of women and girls to make independent contraceptive choices, including about preferred methods, for achieving reproductive rights.
Traditionally, family structures have been authoritarian and age- and gender-stratified, with norms ensuring that power, authority and control rest with men and keep women in a subordinate position, whether in terms of property or of inheritance rights (Harper et al. 2020). Even where laws exist, fragile family support may inhibit women from claiming their legal rights, and compromise their reproductive rights. However, as societies modernize and become more egalitarian, women play an increasingly powerful role in choosing their partners and the type of union they enter, refusing sex or initiating sex, and deciding which contraceptive method to use, if any.
Context matters: families and societies
Across low- and middle-income countries (LMICs), certain regions broadly conform to traditional hierarchical kinship structures (in particular South Asia and MENA – Middle East and North Africa), others are mixed (sub-Saharan Africa), and yet others are more modern and egalitarian (East and South-East Asia, Latin America). These structures play a strong role in determining the mores around women’s behavior, including in reproduction.
We thus argue that contextual influences, whether represented by sub-national, national or regional affiliations, are associated with particular kinship structures, marriage systems, inheritance and other laws and norms. These, in turn, shape social norms surrounding female agency and empowerment, and directly affect reproductive choices available to women and girls. While countervailing influences may exist, societies that grant more equal status and agency to women and men are more likely than others to also offer an environment that gives greater reproductive choices to women.
Women’s agency – community and individual influences
In a recent paper (Jejeebhoy and Sathar 2024), we reviewed 61 studies comprising 80 distinct sub-studies that explored relationships between women’s agency – decision-making, freedom of movement, control over resources, partner power balance and gender role attitudes – and contraceptive behavior (Figure 1). Most of them (67/80) support a positive association between indicators representing at least one domain of women’s agency and contraceptive outcomes after controlling for confounding factors.
While fewer studies have explored inter-country-level or community-level associations between female agency and contraceptive practice, and just a few of these have explored both of these effects together with individual-level associations, our findings are illuminating. Plotting the association between one key measure of agency, namely decision-making around three major household items, and contraceptive use for 69 LMICs drawn from DHS surveys in countries in every region for which data were available reveals a strong positive correlation (Figure 2).
Multi-country, country, and sub-national studies that go beyond the individual level and incorporate community-level information have corroborated the importance of community-level over and above individual-level factors in explaining the links between gender norms and roles and contraceptive outcomes (Metheny and Stephenson 2017; Mejía-Guevara et al. 2020). For example, they have highlighted that the decision to adopt a modern contraceptive was strongly influenced by perceptions about community reactions or community decision-making patterns, reflecting prevailing cultural norms surrounding the expected roles of women (Stephenson et al. 2007; DeRose and Ezeh 2010); or that, irrespective of personal beliefs, living in neighbourhoods with equitable attitudes or perceptions about community approval of family planning were positively associated with contraception (Okigbo et al. 2018; Dynes et al. 2012). Evidence, although not abundant, is sufficient to support the proposition that both individual and community level factors can influence women’s agency and contraceptive behaviour.
Transformative factors
Individual countries and societies are in flux, transitioning from more traditional to more modern patterns, and this affects women’s agency and gender roles. Transformative factors include changes in female educational attainment and opportunities for paid work outside the home, along with greater mass and social media exposure, and membership in women’s movements. While the links between education and contraceptive use are positive in most studies, contraceptive programs have an even greater effect on the uptake of contraception (Bongaarts and Hardee, 2019). Pathways of influence can also be indirect – clearly, women with agency will take the lead in adopting contraception, with or without a contraceptive/ family planning program. In settings with weak programs and restricted access to services, women’s agency can play an especially strong role in enhancing contraception (e.g. Brazil, Cavenaghi and Alves 2019). Conversely, a strong program endorsed at the state level can act as an equalizer and empower even the most disadvantaged women by expanding the reach of information and services to them (e.g. Iran, Abassi et al., 2009).
Conclusions
Even after adjusting for other factors, women’s agency has a strong influence on contraceptive outcomes. Contraceptive use is likely influenced by both individual- and community-level factors. Transformational factors, especially increased exposure to education and family planning programs have independent effects on contraceptive outcomes, at times even weakening or cancelling out the effects of women’s agency. Three key conclusions emerge. First, context matters; kinship structures and social norms influence both female agency and sexual relationships, a major basis of the reproductive choices available to women and girls. Second, as associations are complex and can be multidirectional, there is a need to unpack the pathways in the relationships between and across women’s agency and patterns of contraceptive use. And finally, contraceptive endpoints must shift from mere levels of contraceptive use to measures that reflect more completely women’s own intent about whether to practice contraception, and the timing and choice of specific contraceptive methods .
References
Abbasi-Shavazi M.J., McDonald P., Hosseini-Chavoshi M. 2009. The Fertility Transition in Iran: Revolution and Reproduction. Dordrecht: Springer Netherlands. https: //doi.org/10.1007/978-90-481-3198-3.
Bongaarts J., Hardee K. 2019. “Trends in Contraceptive Prevalence in Sub-Saharan Africa: The Roles of Family Planning Programs and Education.” African Journal of Reproductive Health 23 (3): 96–105. https://doi.org/10.29063/ajrh2019/v23i3.9.
Cavenaghi S., Alves J.E.D. 2019. “The Everlasting Outmoded Contraceptive Method Mix in Brazil and Its Legacy.” Revista Brasileira de Estudos de População 36 (December): 1–29. https://doi.org/10.20947/s0103-3098a0103.
DeRose L.F., Ezeh A.C. 2010. “Decision-Making Patterns and Contraceptive Use: Evidence from Uganda.” Population Research and Policy Review 29 (3): 423–39. https://doi.org/10.1007/s11113-009-9151-8.
Dynes M., Stephenson R., Rubardt M., Bartel D. 2012. “The Influence of Perceptions of Community Norms on Current Contraceptive Use among Men and Women in Ethiopia and Kenya.” Health & Place 18 (4): 766–73. https://doi.org/10.1016/j.healthplace.2012.04.006.
Harper C., Watson C., Kyomuhendo Bantebya G., Ghimire A., George R. 2020. “Historical Lessons on Gender-Norm Change, with Case Studies from Uganda and Nepal.” ALIGN.
Jejeebhoy S.J., Sathar Z. 2024. Revisiting Women’s Empowerment and Contraception. Population and Development Review supplement “Contraceptive Transitions: Explanations and Evidence” https://doi.org/10.1111/padr.12688
Mejía-Guevara I., Cislaghi B., Weber A., Hallgren E., Meausoone V., Cullen M.R., Darmstadt G.L. 2020. “Association of Collective Attitudes and Contraceptive Practice in Nine Sub-Saharan African Countries.” Journal of Global Health 10 (1): 10705. https://doi.org/10.7189/jogh.10.010705.
Metheny N., Stephenson R. 2017. “How the Community Shapes Unmet Need for Modern Contraception: An Analysis of 44 Demographic and Health Surveys.” Studies in Family Planning 48 (3): 235–51. https://doi.org/10.1111/sifp.12028.
Okigbo C.C., Speizer I.S., Domino M.E., Curtis S.L., Halpern C.T., Fotso J.C. 2018. “Gender Norms and Modern Contraceptive Use in Urban Nigeria: A Multilevel Longitudinal Study.” BMC Women’s Health 18 (1): 178. https://doi.org/10.1186/s12905-018-0664-3.
Stephenson R., Baschieri A., Clements S., Hennink M., Madise N.. 2007. “Contextual Influences on Modern Contraceptive Use in sub-Saharan Africa.” American Journal of Public Health 97 (7): 1233–40. https://doi.org/10.2105/AJPH.2005.071522.