Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence

Reproductive coercion (RC) is a type of abuse where a partner asserts control over reproductive health trajectories—through interfering with pregnancy planning or a pregnancy outcome—despite the other partner’s pregnancy intentions [1‐3]. The term “RC” was coined by Miller et al. based on facility-based interviews with adolescents in the United States [4], corroborated in adult populations [2, 5], and later attributed to behaviors indicative of reproductive abuse globally [6‐12]. While this terminology was adopted based on findings from the United States, literature in low- and middle-income countries (LMICs), particularly in sub-Saharan Africa and South Asia, has long described the fertility pressures that women face and emergent tensions should fertility desires within a couple conflict [13, 14]. A more recent emergent research base highlights that RC is prominent in LMICs, but existing studies are limited by sample size [6, 8] and generalizability (i.e., among IPV survivors or married adolescents) [9, 15]. Despite heterogeneity in contexts, study populations, and measures, the evidence is clear that RC incurs considerable harm to women’s health via increasing risk for unintended pregnancy [1, 5, 11, 16].

To date, the most comprehensive measurement for RC is the RC Scale, developed in the United States [17, 18]. While the original RC Scale is not inclusive of all RC behaviors, specifically coercive control of pregnancy outcomes [3], it captures a range of pregnancy promoting behaviors with specified coercive intent. In sub-Saharan Africa, where condoms are more widely used for HIV prevention than pregnancy prevention, a modified version of this scale focused on pregnancy coercion has been recommended [9, 15].

Despite these measurement innovations, RC measurement at the national level remains sub-optimal. In 2018, the Demographic and Health Surveys (DHS) began including a single item on RC within their Phase 8 Model Women’s Questionnaires [“Has your (husband/partner) or any other family member ever tried to force or pressure you to become pregnant when you did not want to become pregnant?”] [19]. Given the phased approach to DHS roll-out, countries collect data at different timepoints, limiting comparability; further, to date, few countries have released public data on RC, limiting potential for cross-site analyses. Moreover, this single item may miss the range of abusive behaviors women face when seeking to control their fertility. In line with best practices for violence-related research, multi-item behavioral assessments may be preferable [20].

Moreover, understanding factors that may put women at risk for RC is critical for prevention and response, however, research on correlates of RC (i.e., risk factors) is limited given the dearth of quantitative data specific to RC in LMICs. One study, in Cote d’Ivoire, focused on RC and in-law abuse and found that in-law perpetrated RC was associated with ethnicity and marriage [8]. More recent research among intimate partner violence (IPV) survivors in Nairobi, Kenya found significant positive correlations between past 3-month RC and not wanting their last child at all, partner’s concurrent partnership, and inconvenient contraceptive method use; the same study found that increased couple communication was protective against RC [21]. Withstanding these few studies among specific sub-populations, large gaps remain in understanding who is most vulnerable to this unique form of abuse, as well as who may be protected. Further, insight is needed into how risk factors differ across cultural, geographic, and political contexts.

Given the lack of national data on RC, across ten LMIC sites (eight countries), this study aimed to: (1) validate the RC Scale; (2) calculate the prevalence of RC and specific behaviors; (3) assess correlates of RC in order to understand commonalities and divergence of risk and protective factors across contexts.

These nationally or regionally representative results deem that the modified RC Scale is a reliable measure across ten settings in sub-Saharan Africa and South Asia. Moreover, these results present important nuances when examining RC by setting, indicating a need for site-specific screening and response that accounts for cultural variation in pregnancy pressures. Specifically, prevalence of past-year RC varied substantially by geography, ranging from one in five women in Kongo Central, DRC (20.3%) to 3.1% in Niger. Two countries provided estimates within multiple regions/states rather than at the national level; DRC estimates widely varied across regions (20.3% Kongo Central vs. 11.9% Kinshasa), however, were more stable across Nigerian states (5.7% Kano vs. 5.0% Lagos). Correspondingly, few correlates were consistent across sites—such risk factors were focused at the partner dyad level, including polygynous relationships and living with a partner. Accordingly, sexual and reproductive health (SRH) providers must be alert to potential partner interference and factors that may increase susceptibility to RC, while seeking to understand norms that continue to perpetuate these harmful constraints on women’s reproductive autonomy.

Foremost, these results have important measurement implications for quantifying RC in LMICs and its burden on women’s SRH. Overall, the modified RC scale showed moderate internal consistency across settings (Cronbach’s alphas range: 0.66_{Cote d’Ivoire}–0.89_{Kinshasa,DRC/Lagos,Nigeria}), with other fit statistics corroborating goodness of fit. Notably, some item modification has been made since the original RC Scale was published by Miller et al. [4, 17]. Specifically, one item from the original Miller RC Scale was divided into two separate items for the sub-Saharan African context based on formative work in Niger, with intent was more clearly outlined [10, 15]: “made you feel bad or treated you badly for wanting to use a family planning method” and “tried to force or pressure you to become pregnant.” Across diverse sites, the post-hoc sensitivity analyses indicated up to 5% of women exclusively reported each of these behaviors (i.e., reported item 1 but not item 2 and vice-versa). Given these distinctions, future surveys should continue to differentiate such RC behaviors.

The most prevalent item slightly differed across sites; “made you feel bad or treated you badly for wanting to use a family planning method” was most common in seven sites, whereas “tried to force or pressure you to become pregnant” was most prevalent in Lagos, Nigeria and Uganda, and “taken away your family planning or kept you from going to the clinic to get family planning” was the most common behavior in Rajasthan, India. Among women experiencing RC, one to two behaviors were experienced on average; therefore, focusing on only one of these items, similar to the DHS single-item [“Has your (husband/partner) or any other family member ever tried to force or pressure you to become pregnant when you did not want to become pregnant?”] could miss the range of RC behaviors women experience. Notably, the item most similar to the DHS single item (item 2) was not the most common across the majority of sites, suggesting that the single item currently in place in DHS may have low sensitivity and thus underestimate RC experience. Subsequent analyses are needed to understand how prevalence estimated based on this binary measure—created from the 5-item modified RC Scale—differ from the single-item measure included within the DHS once more RC data become available across contexts. Including assessment for this unique form of abuse within large-scale surveys is essential to inform prevention and response, as well as understand changes over time; future measurement refinement will seek to understand the minimal number of items needed to ensure comprehensive measurement.

This cross-site analysis emphasizes the importance of context specific factors when examining RC and pressures surrounding pregnancy, as few correlates for past-year RC were consistent across sites; the few commonalities observed across sites largely concentrated at the partner dyad level of the socioecological framework. Polygynous partnership, compared to monogamous partnership, was the most consistent correlate across sites. In Burkina Faso and Uganda, living with a partner, as opposed to marriage, significantly increased odds of past-year RC. Notably, significant differences were not seen across age groups and decreased odds for higher parity groups were only seen in Kongo Central and Kenya. While few studies have examined correlates of RC in LMICs, results are consistent with previous findings indicating that RC correlates and contributors were concentrated at the dyad level, including those related to concurrent partnerships [21]. Future research should seek to understand motivations for RC perpetration, including disentangling dyadic drivers rooted in power versus those driven by pronatalist social norms.

Some limitations exist specific to this measure for past-year RC. While the binary measure for past-year RC excludes item 6 (hurt you physically because you did not get pregnant) due to need for additional violence referrals to collect these data, less than 2% of women in the three sites that data were collected experienced this RC behavior and post hoc sensitivity analyses indicated large overlap of item 6 with other items, suggesting that these prevalence estimates are likely missing few RC cases. Notably, however, our analysis only examines pronatalist pregnancy coercion behaviors (i.e., partners seeking pregnancy and women seeking to avert pregnancy). Recent literature in sub-Saharan Africa [9, 25], however, has explored the potential for RC to act in the opposite manner, with women seeking pregnancy and men acting against their intentions to avert pregnancy (i.e. forced use of family planning). Among IPV survivors in Nairobi, an additional item was tested “forced you to use birth control;” while this item did not load in exploratory factor analyses, likely because it was measuring a unique form of RC, 13.5% of IPV survivors in urban settlements of Nairobi reported experiencing this form of RC in the past 3 months [9]. Additional research is needed to understand forced usage of family planning, rather than forced non-use, as a form of RC. Lastly, we recognize that while immense strides have been made in conceptualizing and measuring this form of abuse, this relatively narrow definition of RC excludes coercion surrounding reproductive outcomes, and specifically abortion coercion. Future work is needed to better understand the many ways that partners, and broader actors including family and community members, can counteract women’s reproductive intentions and outcomes.

Moreover, some further limitations exist specific to the present study design and analytical methods. Foremost, to understand risk of RC for women in need of contraception, this analysis excludes women who are currently pregnant. Notably, these women may be pregnant due to RC experience, leading to an underestimate of RC prevalence. Future longitudinal assessments aim to disentangle RC, contraceptive use, and pregnancy experiences to better quantify impact. All analyses are cross-sectional, limiting our understanding of temporality surrounding correlates of RC; however, the assessed correlates are largely demographic in nature and unlikely to change over the past-year period for RC assessment. Household-based data collection comprised all women ages 15–49 within the selected enumeration areas, however, in some sites (particularly Lagos and Kano, Nigeria) there were few young, nulliparous/primiparous women; as such, age and parity analyses were limited within these sites. Future research should oversample adolescents, who are at a critical stage in their life course trajectory, and may be prone to RC [25, 26]; comparison with adult populations can help disentangle possible risk associated with delayed childbearing. Similarly, duration of marriage and child sex preference should be explored at potential drivers of RC.

Local policymakers are well positioned to institute culturally appropriate programs to mitigate RC and its impact. Notably, some factors were found to be protective against RC, and further research should seek to understand their role in preventing RC perpetration. Specifically, in Kinshasa, DRC and Kano, Nigeria, RC experience declined with increasing household wealth tertile, and in Kenya and Kano partner education of secondary school or higher was protective against past-year RC; in Kano, odds of RC reduced by nearly 80% for those with a more educated partner. While continuing to institute programs to expand access to education and empower women and girls, these results speak to the need to simultaneously educate men, both generally and specifically to dismantle patriarchal norms that promote men as the ultimate decision-makers in household matters, including contraceptive use. Moreover, in high RC prevalence contexts, such as DRC and Uganda, screening for RC must be institutionalized within all SRH services, and specifically family planning services; protection against unintended pregnancy is imperative when nearly one in five women are experiencing this form of reproductive violence. Interventions such as Addressing Reproductive Coercion within Healthcare Settings (ARCHES) [27, 28] can provide a framework for training family planning providers on how to recognize, screen, and prevent recurrent RC; this intervention has been implemented in the United States, Kenya, and Bangladesh and may prove useful to other contexts if culturally adapted. Though RC prevalence and correlates vary across contexts, this form of abuse is ultimately rooted in power and control—counteracting harmful norms will require both empowering women and girls in their reproductive choices and bolstering men as supportive partners in reproductive decision-making.