Developing and testing measures of reproductive decision-making agency in Nepal.

Laura Hinson,Lydia Murithi,Jeffrey Edmeades,Mahesh Puri

doi:10.1016/j.ssmph.2019.100473

Abstract

Conceptual ambiguity in how we define reproductive empowerment has left the field with inconclusive evidence of its relationship to key reproductive outcomes. Our study aimed to develop and test a measure of reproductive decision-making agency, which is a critical component of reproductive empowerment, in a sample of married women from two Nepalese districts. Initial measures were developed based on theory and previous literature. Next, we used cognitive interviewing techniques to explore local meanings of reproductive empowerment and decision making through eight focus group discussions and 24 in-depth interviews. This process resulted in four core questions used to assess decision making across three domains of reproductive behavior: when to have children, whether to use family planning, and which family planning method to use. We combined these questions to develop an overall assessment of decision-making agency. These measures were included in a quantitative survey conducted with 1000 women, split evenly between the two districts. The combined measure of overall reproductive decision-making agency was internally consistent across the three domains examined (Cronbach's alpha = 0.6416), performed well across a range of validity assessments, including those aimed at assessing construct and criterion validity, and was predictive of a range of reproductive outcomes, particularly those related to feelings of reproductive control. The results suggest that the measures developed here provide insight into the nuances of joint versus sole decision making beyond those provided by standard measures. With better measures of reproductive agency, we can better design interventions for men and women, to meet their reproductive needs.

Highlights

In recent decades, the development field has increasingly recognized the role that women’s empowerment plays in shaping reproductive outcomes, in areas of the world where women are more disempowered than men
We explored the degree to which the measure was predictive of a range of key reproductive outcomes, focusing in particular on three different measures of feelings of reproductive control: how hopeful participants were about their ability to have control over how many children they have and when; how hopeful participants were about their ability to control fertility using a method of contraception if and when they want to; and if participants felt able to achieve their desires about when to have children up to that point in their lives, including when to stop having children
Because the Performance Monitoring and Accountability 2020 (PMA2020) survey does not ask questions about each of the domains we identified for reproductive empowerment, the wording and response categories used for the question on contraceptive use were adapted to each domain

Summary

Introduction

The development field has increasingly recognized the role that women’s empowerment plays in shaping reproductive outcomes, in areas of the world where women are more disempowered than men. Edmeades, Mejia, and Sebany (2018) propose a conceptual frame work for reproductive empowerment that address some of these chal lenges through positioning reproductive empowerment as a distinct dimension of overall empowerment, building on, among others, con ceptual frameworks of women’s empowerment (see, for example, van Eerdewijk et al, 2017; Kabeer, 2001) Within this approach, reproduc tive empowerment results from the interaction of three interrelated, multilevel processes: voice, the capacity of individuals to assert their interests, articulate their opinions and desires, and meaningfully participate in decision-making processes related to their reproductive lives; choice, the ability of individuals to meaningfully contribute to reproductive decisions; and power, the ability of individuals to shape reproductive decision-making processes by exerting influence over others, which acts as a key enabler of both voice and choice.

Methods

Results

Discussion

Conclusion