Background
Achieving universal access to sexual and reproductive health and rights is a key component to achieving Sustainable Development Goals (SDGs) 3 and 5, which aim to ensure healthy lives and wellbeing for all as well as gender equality [
1]. In sub-Saharan Africa, the modern contraceptive prevalence rate doubled among all married women of reproductive age (MWRA), from 14.7% in 2000 to 27.9% in 2019 [
2]. However, only 52% of those in need of family planning used modern methods. Consequently, 14 million unintended pregnancies are recorded each year, leading to unsafe abortions, maternal deaths and socioeconomic loss [
3,
4].
Despite investment in family planning programs and an increase in education attainment, African women are disproportionally deprived of the means to meet their family planning needs [
5]. Economic, cultural and geographical disparities that hinder the promotion of family planning also prevent modern contraceptive decisions [
6,
7]. Evidence shows that increasing women’s access to resources and rights has the potential to empower them to make decisions to use modern contraceptives and reduce fertility [
8]. Contraceptive decision-making is primarily made in marital relationships, but it is also influenced by community norms about gender roles and relationships [
9,
10].
In 2015, the SDGs introduced an indicator of family planning performance, i.e., the percent of demand for family planning satisfied with modern methods (mDFPS), with the goal of achieving at least 75% mDFPS by 2030 [
11]. A major difference between the proportion of mDFPS and the previously measured modern contraceptive prevalence rate is that this new measure only targets women who need family planning, therefore explicitly recognizes women’s right to control their own fertility and their autonomy to decide on effective modern methods [
12]. To date, among low- and middle-income countries (52.9%), West and Central Africa (32.9%) lag behind other areas in terms of mDFPS [
13]. In particular, Burkina Faso, a West African country, has seen the highest increase in the proportion of MWRA unable to meet their reproductive needs, from 26.5 in 1990 to 30.2 in 2010 [
14]. As a result, the proportion of mDFPS was only 40% in 2010, and projections estimate that it will reach 52% by 2030, which is only two-thirds of the proposed target in the SDGs [
15].
Until recently, research in Africa has focused on women’s socioeconomic status and family planning services as major determinants of contraceptive use [
16,
17]. For instance, in Burkina Faso, women’s modern contraceptive use was found to be positively associated with wealth, educational attainment, asset ownership, smaller ideal family size, monogamy, the presence of a living son, and the presence of a child younger than 1 year [
18‐
20]. In addition, living in a more urbanized location, living near a health facility and having been visited by a community health worker were significant factors related to a higher odd of modern contraception [
21‐
24]. Nevertheless, these studies did not adequately consider both women’s ability to make reproductive decisions and the community gender norms that affect these decisions [
24‐
26]. Recently, the literature has reported that a greater division in gender roles and relationships affects women’s autonomy and decreases their ability to obtain effective contraception [
9,
10]. Metheny and Stephenson [
27] found that women who lived in communities with greater men’s educational attainment, lower female employment, higher justification of domestic violence, a higher ideal number of children, and lower wealth were less likely to use contraceptives. Furthermore, SDG 5 outlined structural targets to achieve gender equality and empower all women and girls, including ending all forms of violence and discrimination against women and ensuring their access to rights and opportunities [
1]. Despite this evidence, few studies have simultaneously addressed the influence of gender on communities and individuals as well as modern contraceptive use in the African context [
25,
28]. Additionally, there is a lack of knowledge on systematic measures of imbalanced marital relationships and community-level gender inequality that may affect the process of empowerment for modern contraceptive use among women who need family planning.
Our theoretical framework drew on socioecological theory, which recognizes the key influence of factors at the individual, household and community levels on health behaviors [
29,
30]. In the context of gender inequality, the traditional division of gender roles and relationships based on sex limits women’s ability to access resources and use modern contraceptives, even though they need family planning [
28]. These limits may translate into violence against women, deprivation of the rights and opportunities enjoyed by women in communities, and an imbalance in marital relationships. In fact, the process of women’s empowerment is about gaining the ability to make free choices, autonomous decisions and achieve desired outcomes despite deep-seated limits [
31]. Women’s empowerment is commonly conceptualized as resources, agency and achievements [
32]. Resources are material and non-material assets to the enhancement of agency then the transformation of choices into achievements. Agency, as a central part of the process, refers to women’s ability to define one’s goals and act upon them. For instance, improving women’s access to resources through gender equality would not lead to empowerment unless women act as agents of change rather than mere recipients. Nevertheless, the exercise of agency become meaningful when it contributes to achieve women’s well-being either through a social struggle or a shift in gender relationships [
33,
34].
Measuring women’s empowerment remains challenging due to the latent and context-specific nature of agency. Using factor analysis, an explorative study on women’s agency identified multiple domains as follows participation in family decisions, freedom of movement, and vocalization of more gender equitable attitudes [
33]. However, mixed results have been found regarding these domains in association with modern contraceptive use, which has led to their relevance and consistency, especially in the African context, to be questioned [
35,
36]. In fact, the pronatalist nature of African societies prescribes strict gender roles and relationships that deprive women’s access to resources, rights, and opportunities to productive activities and confine them to reproductive roles [
6].
We study this issue in Burkina Faso, where not only are gender inequality indices among the worst in West Africa but MWRA are still unable to meet their needs for family planning [
14,
37].
The aim of this study is to first explore and identify relevant and consistent components of women’s agency in marital relationships, then assess community-level gender norms and relationships, and finally, examine their association with modern contraceptive use among MWRA in Burkina Faso. This approach allows a better description of how gender equality may influence women’s ability to make decisions about modern contraceptive use. This knowledge may help in designing comprehensive interventions to accelerate universal access to modern contraceptives, thereby aiding progress toward the SDGs.
Results
Sample characteristics
Overall, less than one-third (30.7%) of all 4714 MWRA who had family planning needs used modern methods. Meanwhile, two-thirds (66.9%) used no contraception at all, and 2.4% relied on traditional methods.
Dimensionality of women’s agency in marital relationships
In the exploration of the dimensionality of agency among married women, three components were retained. These three components matched the three sections of the DHS on participation in household decision-making, problems accessing healthcare and attitudes toward domestic violence; the eigenvalues were 1.7, 2.2, and 3.1, respectively. The evaluation of the internal consistency of each dimension yielded Cronbach’s alpha coefficients of 0.65, 0.83 and 0.70 for participation in household decision-making, problems accessing healthcare and attitudes toward domestic violence, respectively (Table
1). Following this analysis, we grouped each dimension into higher and lower levels of agency. For instance, women who solely or jointly participated in decision-making (regarding family visits, their own healthcare, or household purchases), had no substantial problems accessing healthcare (permission to go, money needed for treatment, distance to the health facility, or a desire to not go alone) or did not agree with domestic violence at all in any of the listed situations (the wife going out without telling her husband, neglecting the children, arguing with her husband, refusing sex, or burning food) were considered to have higher levels of agency (Table
2).
Table 1
Factor loadings of the dimensions of women’s agency in marital relationships before varimax rotation and the Cronbach’s alpha test
Participation in household decision-making | | | | 0.65 |
Family visits | 0.1586 | 0.6136 | 0.1564 | |
Own healthcare | 0.1500 | 0.5701 | 0.2019 | |
Household purchases | 0.0980 | 0.3495 | 0.2463 | |
Problems accessing healthcare | | | | 0.70 |
Needs permission to go | 0.0799 | −0.2277 | 0.4930 | |
Needs money for treatment | 0.0667 | −0.0601 | 0.3568 | |
Is prohibited by the distance to health facility | 0.0973 | −0.2318 | 0.4412 | |
Is not willing to go alone | 0.0913 | −0.1962 | 0.4984 | |
Attitudes toward domestic violence | | | | 0.83 |
If the wife goes out without telling her husband | 0.4440 | −0.0881 | −0.0951 | |
If the wife neglects the children | 0.4536 | −0.0946 | −0.1087 | |
If the wife argues with her husband | 0.4552 | −0.0581 | −0.1306 | |
If the wife refuses sex | 0.4087 | −0.0345 | −0.1354 | |
If the wife burns food | 0.3701 | −0.0859 | −0.0664 | |
Eigen values | 3.1 | 1.7 | 2.2 | |
Variance explained (%) | 25.7 | 18.5 | 14.0 | |
Table 2
Demand for family planning satisfied with modern methods (mDFPS) in relation to marital relationships, gender inequality in communities, and socioeconomic characteristics
Contraceptive prevalence |
Modern methods | | | 30.7 | |
Traditional methods | | | 2.4 | |
Women’s agency | N (4, 714) | | | |
Participation in household decision-making | | | | 0.0001 |
No: No participation (0) | 1, 903 | 39.1 | 26.5 | |
Yes: Maybe (1–3) | 2, 811 | 60.9 | 33.5 | |
Problems accessing healthcare | | | | 0.0001 |
Yes: Maybe (0–3) | 3, 639 | 77.7 | 27.8 | |
No: No problems (4) | 1, 075 | 22.3 | 41.0 | |
Attitudes toward domestic violence | | | | 0.0001 |
Agree: Maybe agree (0–4) | 2, 040 | 43.9 | 26.0 | |
Opposed: Do not agree (5) | 2, 674 | 56.1 | 34.4 | |
Community-level of gender equality | N (573) | | | |
Violence and discrimination against women |
Acceptance of domestic violence | | | | 0.0001 |
Low | 283 | 49.4 | 35.7 | |
High | 290 | 50.6 | 25.7 | |
Early marriage | | | | 0.0001 |
Low | 285 | 49.7 | 38.5 | |
High | 288 | 50.3 | 23.8 | |
Female genital mutilation | | | | 0.0025 |
Low | 282 | 49.2 | 33.8 | |
High | 291 | 50.8 | 27.6 | |
Unpaid work | | | | 0.0001 |
Low | 287 | 50.1 | 35.3 | |
High | 286 | 49.9 | 26.1 | |
Fertility expectations | | | | 0.0001 |
Low | 287 | 49.7 | 38.7 | |
High | 286 | 50.3 | 22.0 | |
Access to opportunities and resources for women |
Asset ownership | | | | 0.0692 |
Low | 286 | 49.9 | 32.6 | |
High | 287 | 50.1 | 28.9 | |
Secondary education | | | | 0.0001 |
Low | 284 | 49.6 | 21.5 | |
High | 289 | 50.4 | 40.0 | |
Exposure to family planning messages | | | | 0.0001 |
Low | 285 | 49.7 | 22.8 | |
High | 288 | 50.3 | 40.0 | |
Contact with family planning health worker | | | | 0.7080 |
Low | 287 | 50.1 | 31.1 | |
High | 286 | 49.9 | 30.4 | |
Socioeconomic factors |
Wealth | | | | 0.0001 |
Poor | 1516 | 33.9 | 19.2 | |
Middle | 906 | 19.0 | 21.8 | |
Rich | 2292 | 47.1 | 42.7 | |
Residence | | | | 0.0001 |
Urban | 1522 | 27.3 | 48.2 | |
Rural | 3192 | 72.7 | 24.2 | |
Women’s age | | | | 0.0471 |
15–24 | 1162 | 25.0 | 27.5 | |
25–39 | 1900 | 40.7 | 32.0 | |
40–49 | 1652 | 34.3 | 31.6 | |
Women’s education level | | | | 0.0001 |
No education | 3596 | 76.7 | 25.3 | |
Primary | 674 | 13.7 | 40.5 | |
Secondary & Higher | 444 | 9.6 | 60.4 | |
Use of modern contraceptives in relation to women’s agency, community-level gender equality, and socioeconomic factors
Overall, 61% of MWRA participated in some family decisions, and 22% of them had no problems accessing healthcare, while 56% did not agree with domestic violence at all. All three dimensions were positively associated with mDFPS. With respect to the community-level indicators of gender equality, there were lower proportions of mDFPS in communities with high levels of acceptance of domestic violence, early marriage, female genital mutilation, unpaid work, fertility preferences, and asset ownership. In contrast, a higher proportion of mDFPS was reported in communities with a high level of secondary education and exposure to family planning messages. For socioeconomic factors, there was a higher proportion of mDFPS reported among women living in wealthier households, women living in urban areas, older women, and more educated women (Table
2).
Multilevel analysis of predictors of mDFPS
In our regression strategy, we sequentially added components of women’s agency in marital relationships (Model 1), community-level indicators of gender equality regarding discrimination and access to opportunities for women (Model 2), and socioeconomic factors (Model 3). The results are displayed in Table
3.
Table 3
Multilevel logistic modeling of women’s empowerment and demand for family planning satisfied using modern methods adjusting for socioeconomic characteristics
Participation in household decision-making (No) |
Maybe participation | 1.30** | [1.11–1.53] | 1.20* | [1.03–1.41] | 1.09 | [0.93–1.28] |
Problems accessing healthcare (Maybe) |
No problems | 1.62*** | [1.36–1.93] | 1.45*** | [1.22–1.73] | 1.27** | [1.06–1.51] |
Attitudes toward domestic violence (Agree) |
Opposed | 1.36*** | [1.16–1.60] | 1.23* | [1.04–1.46] | 1.13 | [0.95–1.35] |
Community-level of gender equality |
Violence and discrimination against women | | | 1.0 | [0.63–1.59] | 0.91 | [0.58–1.44] |
Acceptance of domestic violence |
Early marriage | | | 0.91 | [0.42–1.96] | 0.99 | [0.45–2.16] |
Female genital mutilation | | | 2.59*** | [1.60–4.18] | 2.46*** | [1.52–3.99] |
Unpaid work | | | 0.84 | [0.61–1.16] | 0.85 | [0.61–1.19] |
Fertility expectations | | | 0.70*** | [0.60–0.82] | 0.75*** | [0.64–0.87] |
Women’s rights and opportunities |
Asset ownership | | | 1.67* | [1.10–2.53] | 1.72* | [1.13–2.61] |
Secondary education | | | 4.91*** | [2.08–11.55] | 1.98 | [0.76–5.20] |
Exposure to family planning messages | | | 2.95*** | [1.83–4.74] | 2.68*** | [1.64–4.36] |
Contact with family planning health workers | | | 1.40 | [0.75–2.63] | 1.43 | [0.77–2.66] |
Socioeconomic factors |
Wealth (Poor) |
Middle | | | | | 1.09 | [0.87–1.35] |
Rich | | | | | 1.68*** | [1.35–2.08] |
Residence (Rural) |
Urban | | | | | 0.87 | [0.65–1.16] |
Women’s age (15–24) |
25–39 | | | | | 1.25* | [1.03–1.52] |
40–49 | | | | | 1.38** | [1.11–1.71] |
Women’s education level (No education) |
Primary | | | | | 1.26* | [1.17–1.85] |
Secondary & Higher | | | | | 1.38** | [1.11–1.72] |
Model statistics |
Log likelihood | | − 2783.11 | | − 2682.2 | | − 2659.6 |
Chi-square | | 60.4 | | 276.9 | | 335.6 |
Comparison to previous model |
Chi-square | | | | 201.7*** | | 110.9*** |
Degrees of freedom | | | | 9 | | 7 |
Random variance |
ICC Null = 0.20 95% CI [0.16–0.24] | 0.17 | [0.14–0.22] | 0.08 | [0.06–0.12] | 0.07 | [0.05–0.12] |
Variance between clusters Null: 0.82 95% CI [0.64–1.05] | 0.70 | [0.54–0.91] | 0.29 | [0.19–0.44] | 0.28 | [0.19–0.43] |
PVC (%) | 15 | | 65 | | 66 | |
Model 1 showed significant positive associations of all three components of agency with mDFPS. The odds of mDFPS increased by 30, 62 and 36% for women who participated in some family decisions, faced no problems accessing healthcare, and were opposed any type of domestic violence, respectively. In Model 2, the addition of community-level indicators decreased the estimates in Model 1; however, the significance and directionality remained. Women in communities with higher prevalence of female genital mutilation (OR: 2.59; 95% CI [1.60–4.18]), were significantly more likely to report mDFPS. In contrast, living in communities with higher fertility expectations (OR: 0.70; 95% CI [0.60–0.82]) lowered the odds of reporting mDFPS. In parallel, residing in a community with higher average access to secondary education (OR: 4.91; 95% CI [2.08–11.55]) and exposure to family planning messages (OR: 2.95; 95% CI [1.83–4.74]) was positively associated with mDFPS. Finally, when socioeconomic factors were added in Model 3, the effect size and the statistical significance of agency components were greatly reduced, but the directionality remained the same. Although opposition to domestic violence and participation in family decisions lost their significance, they were still marginally and positively associated with mDFPS. In contrast, previous estimates of community-level indicators remained essentially unchanged in their significance and directionality, except for secondary education. Furthermore, household wealth, as well as women’s age and education, were positively associated with mDFPS.
The comparison of the three models showed substantial variations in community-level indicators compared to those of the null model (σ2 = 0.82, 95% CI 0.64 to 1.05). For instance, the log likelihood test found that model 2 had a better fit than model 1 [χ2 (9) = 201.7; p < 0.001] and that model 3 had a better fit than model 2: [χ2 (7) = 110.9; p < 0.001]. Furthermore, the modeling process showed that the proportions of variance change (PVCs) from the null model were 15, 65 and 66% for models 1, 2, and 3, respectively.
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