Reproductive Agency Research Articles

The state of postpartum contraceptive use in India: descriptive lessons from nationally representative survey data

BackgroundPostpartum contraception is a key tool to delay or prevent subsequent pregnancy after birth. Though prior research has demonstrated substantial dynamism in contraceptive use throughout the postpartum period, most measurement of postpartum contraception has focused on aggregate use of any method at a single time point. We sought to more thoroughly examine the continuum of postpartum contraceptive use amongst women in India.MethodsWe use 2019–21 National Family and Health Survey reproductive calendar data from n = 149,518 women with a birth in the one to five years prior to survey. We present estimates of postpartum contraceptive use by month postpartum, use of specific methods, initiation, duration, stopping, method switching, and subsequent pregnancy. We examine sociodemographic and birth factors associated with postpartum contraceptive use using multivariate logistic regression models. We also examine patterns of postpartum utilization for subpopulations of interest (adolescent mothers age 15–19 and first time mothers) and test whether conclusions are sensitive to a two-year rather than one-year postpartum time period definition.ResultsWe find that 59% of Indian women used a method of contraception within the first year postpartum, that condoms and female sterilization were the most commonly used methods, and that patterns of postpartum contraceptive use differed substantially by month, method, and subpopulation. Among postpartum contraceptive users, 9% switched methods, 19% stopped using contraception entirely, and 5% had another pregnancy within the first year postpartum. A number of sociodemographic and birth factors are associated with postpartum contraceptive utilization, and patterns of use differ meaningfully for adolescent and first-time mothers. Most findings were consistent when using a two-year rather than one-year time frame.ConclusionsThe dynamic nature of postpartum contraceptive use suggests limited value of static contraceptive uptake targets, whether for program planning or as measures of success, and bolsters the need to center and to improve reproductive agency, empowerment, and access throughout the postpartum period.

Constructive and destructive agency, regional path development and critical junctures: the case of cruise tourism in Nuuk, Greenland

ABSTRACT The literature on regional development paths and human agency has focused on a broad distinction between reproductive and change agency, and the actions of a relatively narrow range of stakeholders. This paper introduces a typology of path development that also distinguishes between constructive and destructive agency. Four overall types of path development are identified: continuation, transformation, decline and disappearance (CDTD). The CDTD typology is used to analyse a case of cruise tourism path development, focusing on why different path development goals are pursued by different stakeholders at a potentially critical juncture.

How do pro-social tendencies and provider biases affect service delivery? Evidence from the rollout of self-injection of DMPA-SC in Nigeria

BackgroundInconsistent provision of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) for self-injection (SI) undermines efforts to improve women’s reproductive health agency and access to self-care. In Nigeria, providers feel pro-social responsibility as frontline health workers to support their clients’ wellbeing. However, their pronatalist beliefs censure premarital sexual activity and inhibit access to contraceptives for young, unmarried women. How pro-social tendencies and provider biases interact to affect service delivery is a critical but underexplored question.MethodsWe conducted a mixed-methods study comparing stated pro-social tendencies and intentions to dispense DMPA-SC for SI (N = 81 in-depth interviews (IDIs)) with actual dispensing behavior during mystery client (MC) visits (N = 162 post-interaction surveys) across private and public facilities in Lagos, Enugu and Plateau. Qualitative analysis of providers’ pro-social tendencies, biases, and reasons for not offering DMPA-SC for SI complemented quantitative analysis exploring the associations between pro-social tendencies and dispensing behavior.ResultsProviders showed substantial levels of both pro-social tendencies and bias against young, unmarried women. High levels of stated intentions to dispense in IDIs (91% to older, married women vs 78% to young, unmarried women) did not translate to actual willingness to dispense in MC visits (30% to older, married women vs 27% to young, unmarried women). Young, unmarried actors were twice as likely to perceive differential treatment from providers (33%) relative to older, married women actors (17%). From IDIs, providers expressed biases about the appropriateness of family planning and SI specifically based on a client’s age, marital status, parity, and covert use. In some cases, pro-social tendencies reinforced bias when providers sought to uphold social norms as a gatekeeper; in other cases, pro-social tendencies on self-defined client needs helped overcome bias. Providers described other factors that deterred them from dispensing DMPA-SC for SI, including elements of self-care that posed risks to their practice or business.ConclusionsProvider biases may limit provision of DMPA-SC for SI, which could affect contraceptive equity and women’s control over their own fertility, especially for younger, unmarried women. Targeted interventions that effectively address provider biases against young, unmarried women, potentially leveraging providers’ underlying pro-social tendencies, may help ensure equity in client access to contraceptive self-care.

Abortion Ecologies in Southern African Fiction: Transforming Reproductive Agency by Caitlin E. Stobie (review)

Abortion Ecologies in Southern African Fiction: Transforming Reproductive Agency by Caitlin E. Stobie (review)

Diya: coerced abortion and reproductive autonomy in India

ABSTRACT Coerced abortion: a forced/coerced termination of pregnancy against the will of a woman is medico-legally classified as an offense because it is conceived as a violation of reproductive rights. However, legal empowerment does not corroborate with Indian women’s lived realities. The movie—Diya, directed by A. L. Vijay—dramatizes these structural and ideological concerns that delimit the reproductive decision-making of woman. The paper critiques the movie’s prioritization of patriarchal norms and its consequent failure to address the crux of women’s reproductive autonomy. It argues that Diya reveals the hauntological presence of the patriarchal ideologies governing reproductive agency in Indian society. This article draws on the interrelated theories of Bourdieu’s symbolic violence, Galtung’s cultural violence, the notion of structural violence, Derrida’s hauntology, and the concepts of reproductive coercion and trauma to underscore the movie’s oversimplification of the complicated experientiality.

Reproductive agency and the acceptability of divorce, abortion, and homosexuality among migrants from the Middle East and Africa living in Sweden–a cross-sectional analysis

BackgroundSweden has a longstanding history of promoting sexual reproductive health and rights. Reproductive decision-making is a fundamental right, but an individual’s decision-making power differs across contexts. We examined self-reported reproductive agency and the acceptability of divorce, abortion and homosexuality among migrants in Sweden originating from the Middle East or North Africa (MENA) and Sub-Saharan Africa (SSA).MethodsThis cross-sectional study used face-to-face interview data from the 2018–2019 Migrant World Values Survey (MWVS) and included individuals 18–49 years old who migrated to Sweden from MENA or SSA. Partial proportional odds models were used to estimate adjusted odds ratios (aOR) and corresponding confidence intervals (CI) of associations between sociodemographic factors and two outcomes: 1) reproductive agency (decision-making power on when, with whom, and how many children to have), measured on a 10-point scale categorized as low (1–4), moderate (5–7), and high (8–10); and 2) the Choice Sub-Index (CSI), a composite index of the acceptability of divorce, abortion, and homosexuality, categorized as 0- < 0.4 (low), 0.4- < 0.7 (moderate), and 0.7–1.0 (high).ResultsBetween September 2018 and November 2019, 7991 participants responded to the MWVS, of whom 4669 met the inclusion criteria. Almost 3/4 (73%) of respondents expressed a high degree of reproductive agency, but less than five per cent of respondents had a high value on the CSI. Living in Sweden ≥ 4 years was associated with higher values on the CSI (aOR 1.76, 95% CI 1.15–2.67), while identifying as Muslim was associated with having a low value on the CSI (aOR 0.44, 95% CI 0.32–0.63). Neither duration of time in Sweden nor identifying as Muslim were associated with reproductive agency. Age and reason for migration (family reunification or as a refugee) were not associated with either outcome.ConclusionOur study found that migrants from MENA and SSA expressed a high degree of reproductive agency. Migrants had low values of a combined measure of the acceptability of divorce, abortion and homosexuality; however, acceptance increased with time spent in Sweden. Understanding factors associated with migrants’ sense of reproductive agency and their values and how these change over time in Sweden provides a foundation for working towards equitable sexual and reproductive health and rights.

Psychiatric Gaslighting: The Surveillance of Mental Illness during Pregnancy

Abstract Women living with mental health symptoms face the dilemma of continuing psychotropic medication when pregnant or breastfeeding. Based on two years of observations in a mental health clinic focusing on reproductive health, we examine how patients living with mental health conditions exert reproductive agency during meetings with psychiatrists; how these clinicians respond to this engagement; and the consequences of this advocacy for medical decision-making. We find that psychiatrists psychologize patient advocacy by interpreting it as a manifestation of untreated mental pathology. This psychologization moves beyond imposing a professional vision on the interaction and beyond a paternalistic communication style to psychiatric gaslighting: patient engagement is invalidated and subverted under psychiatric professional vision to double-down on psychotropic medication. Psychiatric gaslighting is a sociological and institutional phenomenon; operating through cultural scripts about how both gender and mental illness shape credibility, incentive structures in medical practice, lingering epistemic problems in psychiatry, and psychiatry’s struggle for professional legitimacy. Within an unequal power relationship between health professionals aiming to safeguard their authority and a stigmatized population, patients are disempowered by psychiatric concepts that link mental health to good mothering. We conclude that the biomedical management of vulnerable populations serves professional interests.

Intersection of medicalization and reproductive autonomy: Challenging the barriers faced by women with disabilities

This paper explores the medicalization of disability and its detrimental effects on the reproductive autonomy of women with disabilities. Medicalization frames disability as a medical condition that requires intervention, often leading to the assumption that disabled individuals are incapable of making informed reproductive decisions. Drawing on case studies of women with disabilities, including those with muscular dystrophy, cerebral palsy, and psychiatric conditions, the paper highlights how medicalized views result in coercive reproductive practices such as forced sterilization, limited access to assisted reproductive technologies (ART), and the pathologization of pregnancy. These practices are rooted in harmful stereotypes about disabled women’s ability to parent and a lack of understanding within healthcare systems. By analyzing these issues, the paper critiques how medicalization reinforces discriminatory attitudes and institutional barriers, restricting disabled women’s Reproductive rights. It calls for a shift toward a rights-based, inclusive approach to reproductive healthcare that upholds the autonomy of women with disabilities, advocating for policy reforms to ensure informed consent, equitable access to reproductive services, and the dismantling of medicalized frameworks that undermine disabled women’s reproductive agency.

‘Having children is like rain, as they say in our region’: exploring refugees’ reproductive agency

Migrants with refugee backgrounds in the Netherlands face significant reproductive health challenges, including higher rates of unintended pregnancies and limited access to contraception. This study explores how post-migration realities affect the reproductive agency of refugees from Afghanistan, Somalia, Eritrea and Syria. Utilising a participatory approach, eight peer researchers from these communities conducted eight focus-group discussions and 118 in-depth interviews, involving four migrant grassroots organisations and two Dutch non-governmental organisations. The findings reveal that refugees must navigate multiple tensions: (1) adapting to a new country, including securing housing, employment and adjusting to social norms and gender dynamics; (2) navigating cultural norms and family expectations; and (3) obtaining resources such as knowledge and contraception, within a healthcare system that may lack cultural sensitivity and reflect broader societal stigma. These challenges may require strategies that differ from Dutch notions of individualistic reproductive choices. Reproductive services must be sensitive to this complex navigation and adopt a culturally sensitive approach, focusing on refugees’ strengths and agency rather than solely on issues like cultural taboos, lack of knowledge, low literacy or language barriers.

Attitudes toward sexual and reproductive health and rights and their associations with reproductive agency: a population-based cross-sectional study in Ethiopia, Kenya, and Zimbabwe

We investigated the association between values and attitudes toward sexual and reproductive health and rights (SRHR) and gender equality, with reproductive agency in Ethiopia, Kenya, and Zimbabwe. Using 2020-21 World Values Survey (WVS) data (n = 3096), we utilised the SRHR Support Index including five subindices to gauge SRHR attitudes, the WVS Equality Index for gender equality values, and the perceived level of freedom of choice and control over whether, when, and how many children to have as a proxy for reproductive agency. Descriptive statistics, bivariate, and multivariable logistic regressions were used to analyse how values and attitudes differed between respondents of high vs low reproductive agency using the median as cut-off, stratified by country and sex. Country, education, subjective social class, and religion were associated with reproductive agency. Adjusted analyses indicated associations between supportive values and attitudes towards equitable masculinity norms, SRHR interventions and gender equality, with high reproductive agency. Associations varied more between countries than by sex. Findings suggest an association between SRHR and gender equality values and attitudes and the level of reproductive agency, and underscore the importance of addressing values and attitudes in context-specific interventions. Measures of SRHR progress should be critically reviewed and complemented with self-assessed – as opposed to researcher-ascribed – items to support the successful implementation of global SRHR agendas.

Hildegard of Bingen's Embryology: Enabling Women's Reproductive Power without Seed.

This paper examines Hildegard of Bingen's embryological theory within the intricate landscape of medieval medicine and religion. It situates Hildegard's understanding of conception within ongoing historical debates surrounding the roles of male and female reproductive substances, particularly the concept of seed or semen. By analyzing her conceptual framework against prevailing classical and medieval reproductive theories, the research illuminates Hildegard's distinctive contribution to understanding conception as a holistic bodily process. Classical embryological discourse predominantly oscillated between Aristotle's one-seed theory-which positioned men as sole generative agents-and Galen's two-seed theory, which marginally acknowledged female reproductive participation. While technically aligning with Aristotelian principles by denying female semen, Hildegard diverged significantly by valorizing women's reproductive agency. she argued that women produced a foam essential for new life, just as essential as the man's semen. Also, the female reproductive body played a crucial role in purifying and nurturing the defective male semen, enabling conception. This conceptualization subtly challenged contemporary gender hierarchies, presenting reproduction as a complex, interdependent physiological mechanism with theological resonances, making the parallels of the woman's reproduction and God's creation. In conclusion, Hildegard's embryological theory presents a sophisticated intellectual intervention that reimagined female reproductive potential within medieval scientific and religious frameworks.

Contraceptive and Pregnancy Decision-Making Autonomy and Health Care Experiences Among Women With Intellectual Disabilities.

There is currently limited research exploring the extent to which women with an intellectual disability experience autonomy over contraception, pregnancy timing and pregnancy outcome decisions. Previous studies have highlighted inequities in sexual and reproductive health outcomes. However, barriers and facilitators of reproductive autonomy for women with an intellectual disability across the reproductive journey, including health care experiences, are poorly described; this is the focus of the current study. Ten women with intellectual disabilities participated in focus groups or individual interviews where they discussed their experiences of accessing sexual and reproductive health services and making reproductive health decisions. Data were analysed using reflexive thematic analysis. Three themes elucidate how a lack of sexual and reproductive health information and violence impacted many participants' ability to control timing of conception and make informed pregnancy outcome decisions. The first theme describes contraceptive literacy as a barrier to reproductive autonomy. Most participants received no contraception or reproductive health education prior to their first pregnancy. While most women were aware of common forms of contraception and pregnancy options, their contraceptive knowledge was incomplete or incorrect. The second theme explores how most participants experienced agency over pregnancy outcome decisions, though informed decision-making was hampered by reproductive coercion and abuse, delayed pregnancy detection and insufficient information about all pregnancy options. The third theme identifies health professionals as pivotal in empowering reproductive agency and facilitating informed decision-making. Women with intellectual disabilities demonstrate the willingness and the ability to make informed and autonomous reproductive health decisions when appropriately supported with care and information. However, they face reproductive coercion and abuse and are often required to overcome numerous systemic challenges to assert their reproductive rights. Significant efforts are needed to better understand and address barriers to informed reproductive decision-making.

Accelerating Progress in Women's Sexual and Reproductive Health and Rights Decision-Making: Trends in 32 Low- and Middle-Income Countries and Future Perspectives.

In 1994, the International Conference on Population and Development (ICPD) Programme of Action established the empowerment and autonomy of women as fundamental to achieving sustainable economic and social progress. Three decades later, significant strides have been made in enhancing sexual and reproductive health and rights (SRHR). However, deep-rooted gender inequality continues to impede substantial progress for many. We assess the advancements made under the Sustainable Development Goals, specifically through indicator 5.6.1, which measures women's SRHR decision-making. Using data from 76 Demographic and Health Surveys and 1 Multiple Indicator Cluster Survey in 32 low- and middle-income countries from 2006 to 2022, the study analyzed trends in women's SRHR decision-making and its subcomponents of autonomy on reproductive health care, contraceptive use, and sexual relations-among married or in-union women aged 15-49 years currently using contraception. The analysis also examined trends in decision-making disparities related to household wealth quintiles, women's education levels, and area of residence, using disaggregated population-weighted percentages. Analysis revealed a generally positive trend in women's SRHR decision-making, with gains observed in Eastern and Southern Africa and notable declines in West and Central Africa. Subindicator disparities showed variations in autonomy across health care, contraception, and the ability to refuse sex. An inequality analysis highlighted that while some countries saw a narrowing wealth gap in decision-making, others faced growing disparities. Educational and urban-rural divides also shifted, reflecting a complex landscape of progress and challenges in improving women's SRHR decision-making. The analysis underscores a patchwork of progress in women's SRHR decision-making while also exposing deep disparities. These data suggest a critical need for interventions tailored to cultural and socioeconomic contexts, particularly in countries and subnational areas lagging behind. Forward-thinking strategies must prioritize enhancing women's reproductive agency, ensuring interventions are informed by community-tailored priorities and global human rights standards.

The Maiden’s Tower of Femininity

This paper examines portrayals of femininity within “Maiden in the Tower” tales. It analyzes the means by which maturation, sexuality, reproduction, and female agency contribute to the shaping of femininity. Via Petrosinella by Giambattista Basile, Rapunzel by the Brothers Grimm, and Tangled by Disney, the paper explores how variations portray historically unique interpretations of ideal, female traits that defy common assumptions. The evolution of perspectives across “Maiden in the Tower” tales help us grasp how gender ideologies are communicated and how women are socialized.

Experience, access and utilisation of fertility care for infertile men within the biomedical sector in urban Bangladesh: protocol for a qualitative study

IntroductionOne in six people of reproductive age experience infertility in their lifetime throughout the world, often with devastating consequences. Men are often invisible in infertility research and services, yet masculinity...

Undermining Japan's Pro-Natal Expectations and Practices: Re-Examining Reproduction and Pregnancy in Mieko Kawakami's Breasts and Eggs

The declining birthrate in Japan and consequent pro-natalist discourse and policies invoke traditional gender roles, such as those connected to the Meiji Japan ‘good wife, wise mother’ ideal, which places womanhood as synonymous with motherhood. This article examines Mieko Kawakami’s Breasts and Eggs (2020) as a critique of these reproductive pressures faced by contemporary women, specifically focusing on the depiction of reproductive agency. The characters of Midoriko and Natsuko highlight the novel’s critique of Japan’s revitalized ‘good wife, wise mother’ ideology and I argue that Kawakami’s work exposes the limitations of these selective pro-natalist policies and calls for a reimagining of motherhood and womanhood.

Sexual choking/strangulation and its association with condom and contraceptive use: Findings from a survey of students at a university in the Midwestern United States.

Consensual sexual choking has become prevalent among young United States (US) adults. In sex between women and men, women are overwhelmingly the ones choked, perhaps reproducing traditional heteronormative power dynamics. No research has examined the relationship between being choked during consensual sex and the use of external condoms and other contraceptives. We administered a cross-sectional campus-representative survey to 4989 undergraduate students at a large public Midwestern US university. Half of respondents (n = 1803) had ever been choked during sex. Having been choked was associated with a significantly lower likelihood of event-level condom use (OR = 0.32 [0.19, 0.54] for >5 times lifetime choking among men and OR = 0.35 [0.27, 0.45] for >5 times lifetime choking among women compared to those with no choking experiences) and in the past 6 months (OR = 0.42 [0.24, 0.72] for >5 times lifetime choking among men and OR = 0.59 [0.43, 0.81] for >5 times lifetime choking among women compared to those with no choking experiences). Also, having ever been choked was associated with a significantly greater likelihood of having used an implant/intra-uterine device in the past 6 months (OR = 1.85 [1.28, 2.68] for >5 times lifetime choking compared to those with no choking experiences). Recognition that sexual choking is prevalent among young people has only recently emerged and educational programs are lacking. Study findings could be used to engage people in discussions about choking in relation to gender, power, and reproductive health agency.

Contraception: A gendered burden? A mixed methods exploration of experiences around contraception responsibility

Initially designed to promote sex-reproductive autonomy, contraception has historically focused on the bodies of women and people who can become pregnant (PBP), resulting in an unequal distribution of pregnancy prevention responsibilities between the sexes, now referred to as the “contraceptive burden.” This article explores two aspects of this burden from the PBP perspective: the sharing of contraceptive responsibilities between intimate partners, and the emancipation of gender scripts in fertility management. Mixed data from two separate research projects included an online questionnaire (quantitative component; n = 367) and focus groups (qualitative component; 34 people in 12 small groups). Targeting PBP aged 18 to 35 with diverse sexual orientations and relationship statuses, recruitment for both samples spanned posts on our lab’s and our partners’ social media pages (Facebook, Instagram), and postings in university and local Montreal businesses, encouraging a varied socio-demographic sample. Descriptive and reflexive thematic analyses were carried out. The quantitative results indicate a gap between the egalitarian values of PBPs and the reality of their contraceptive work, highlighting the complexity of power dynamics in intimate relationships. Qualitative findings bring out a sense of injustice linked to this disproportionate burden, influenced by systemic factors such as the gender imbalance in contraceptive options. The discussion focuses on the tensions in the distribution of contraceptive responsibilities between PBPs and their partners, with their economic and social implications. The article calls for a more holistic approach to the problem of contraceptive burden, integrating interpersonal and societal perspectives. It stresses the importance of reproductive agency and invites us to reflect on people’s satisfaction with the management of their fertility. Recommendations in the areas of education, awareness-raising, diversity, and accessibility of contraceptive options are put forward, aiming to improve conditions of gender justice.

“The ones at the bottom of the food chain”: structural drivers of unintended pregnancy and unsafe abortion amongst adolescent girls in Zambia

BackgroundAccess to safe abortion care is highly unequal and fundamentally rooted in socioeconomic inequalities which are amplified by restrictive social norms and legal systems. We analyse these inequalities along the reproductive health continuum amongst adolescent girls in Zambia.MethodologyThis paper draws from 20 focus group discussions conducted in 2021 with community members (young/adult) in five urban, peri urban, and rural sites in Zambia. Data was analysed using thematic analysis.ResultsAdolescent pregnancy in the community was reported to be very common across the communities with girls from poorer families being disproportionately affected. Parents were reported to be complicit in facilitating their daughter’s sexual-economic exchanges which emerged as a key driver of pregnancies. Young age and unmarried status meant adolescent girls could face triple stigma: stigma around accessing contraception to prevent a pregnancy, stigma in experiencing an unintended pregnancy and stigma around terminating an unintended pregnancy. There were clear socioeconomic differences in adolescent girl’s exposure to community and health provider censure and/or acceptance of their pregnancy, and in their ability to conceal an abortion. Having the means to pay for health care allows some adolescents to seek terminations earlier and to access private health facilities while poorer adolescent girls face greater exposure to community censure through their embeddedness within the community. Abortions in this group attracts greater visibility through complications arising from their constrained choice for safe abortion methods. Stigmatising attitudes of community members also undermined adolescents’ reproductive agency and mental health. For adolescents who choose to keep an unintended pregnancy, reintegration into school was highly challenging despite a national policy in place, with marriage being viewed as the only future option for poorer teenage mothers.ConclusionThe embeddedness of adolescent pregnancies within community structures of economic insecurity and gendered and age-related power relations highlight the importance of introducing community level approaches to tackle unintended pregnancies and unsafe abortion. Understanding teenage pregnancy as a community issue creates opportunities for community level support to young girls especially when they return to school.

(031) SEXUAL HEALTH AND REPRODUCTIVE EMPOWERMENT OF YOUNG ADULT ASIAN AMERICAN WOMEN

(031) SEXUAL HEALTH AND REPRODUCTIVE EMPOWERMENT OF YOUNG ADULT ASIAN AMERICAN WOMEN