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

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. Outline
• Background on
reproductive
empowerment
(RE)
• Goals and
objectives
• Methods
• Findings
• Next steps
• Conclusion

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
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