Introduction
Since 2000, maternal mortality has declined globally, although less than expected when the Millennium Development Goals (MDGs) were agreed [
1]. Moreover, the burden of maternal morbidity remains high. In 2015, an estimated 27 million morbidity episodes occurred for the five most common direct obstetric complications, including eclampsia, pre-eclampsia, postpartum haemorrhage, puerperal infection, and abortion [
2]. These estimates have raised awareness of the many women who survive complications in pregnancy or childbirth with morbidities. As a result, a woman-centred approach to health and empowerment was embedded in the Sustainable Development Goals (SDGs), Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), and framework for the WHO Maternal Morbidity Working Group [
1,
3,
4].
A growing body of evidence suggests that women’s empowerment influences other SDGs [
5], including outcomes related to women’s sexual and reproductive health (SRH) [
6‐
10]. These relationships, however, may vary across contexts, SRH outcomes, and dimensions of women’s empowerment [
10‐
12]. Women’s empowerment is a multidimensional construct [
13‐
15] capturing the process by which women claim enabling
resources to enhance their
agency, or ability to make strategic life choices in a context of social constraints [
16].
Human resources may entail schooling or skills-based training;
economic resources may entail work, income, property, or other assets; and
social resources may entail relational networks that offer connectedness and support.
Intrinsic agency—akin to the concept of
thin relational autonomy [
17]—involves a consciousness of one’s capabilities, rights, and aspirations.
Instrumental agency involves strategic action to pursue one’s aspirations; and
collective agency involves the identification of group goals and joint actions to pursue those goals [
18].
The United Nations’ mandate to prioritize women’s empowerment—in its own right [
19] and as a driver of other SDGs [
20] has mobilized scientific efforts to conceptualize and to validate measures for women’s empowerment across groups [
21], countries [
18], and time [
22]. Recent efforts confirm our capacity to monitor the progress of nations toward advancing women’s empowerment using comparable measures. Still, women’s empowerment may, in some ways, be context-specific [
14,
16,
23,
24], involving some variation in relevant dimensions and related measures. In some contexts, for example, a woman’s expanded freedom of movement may reflect instrumental agency because of prevailing gender norms about postnatal confinement [
25]. Elsewhere, a woman who is not subject to these gender norms may not be said to have expanded agency in this domain [
21]. Efforts to validate
cross-context measures of empowerment may have eclipsed efforts to develop
contextual measures in special populations and lifecycle stages, such as during pregnancy and perinatal periods across the reproductive lifecycle [
26].
Measures of women’s empowerment—and agency—that may apply across the reproductive life cycle are lacking. The Sexual Pressure Scale [
27,
28] and Sexual Assertiveness Scale [
29] focus on empowerment/disempowerment with respect to
sexual activity. The Sexual Relationship Power Scale (SRPS) assesses agency with respect to
HIV risk and condom use in an intimate relationship [
30]. The Reproductive Autonomy
1 Scale focuses on the ability
to prevent pregnancy, and two of the four dimensions have weak psychometric properties [
31]. The Reproductive Empowerment Scale focuses on women’s ability
to use contraception [
32,
33]. The Pregnancy-Related Empowerment Scale assesses women’s empowerment
during pregnancy [
34] and has been adapted for use in Sub-Saharan Africa [
35]. None of these scales measure pregnancy- and non-pregnancy-specific agency and have unclear relevance in classic patriarchal settings, where women’s influence in household decisions and capacity to move freely may affect their choices about pregnancy- and non-pregnancy-related care.
Here, we developed and validated the Reproductive Agency Scale 17 (RAS-17) to measure women’s agency among diverse pregnant women of reproductive age. The RAS-17 is grounded in concepts of intrinsic and instrumental agency [
16,
36,
37] and integrates pregnancy- and non-pregnancy-specific items derived from qualitative research and prior surveys of Arab women of reproductive age. We collected primary data from 684 pregnant women attending prenatal visits at the Women’s Hospital of Hamad Medical Corporation (HMC) in Doha, Qatar, a high-income setting in the classic patriarchal belt where maternal mortality is low and the identification and prevention of perinatal morbidity is prioritized [
38,
39]. Foreign nationals comprise about 86% of the resident population, and 90% of foreign nationals are in the working ages (15–64 years). About 10% of foreign workers are non-Qatari Arab nationals from Egypt as well as Syria, Sudan, Lebanon, Jordan, and Palestine [
40].
We performed exploratory then confirmatory factor analyses (EFA/CFA) in random split-half samples to identify a final scale with adequate measurement properties [
41,
42]. We then used multiple-group CFA to assess the scale’s measurement invariance across pregnant Qatari and non-Qatari Arab women varying in age, trimester, gravidity, and parity and living in Qatar [
43,
44]. Evidence of cross-group comparability supports the scale’s use with diverse Arab women in Qatar and sending countries. Findings permit comparison of the RAS-17 with agency measures administered to Arab women of reproductive age but lacking pregnancy-specific items. Findings clarify the salience of developing contextual measures of women’s reproductive agency capturing pregnancy- and non-pregnancy-specific experiences that are valid in pregnancy and the perinatal period in diverse women of reproductive age, and that may apply across the reproductive lifecycle.
Women’s empowerment and definitions of agency
Women’s empowerment entails three interrelated processes: 1) claims on new
resources, which may 2) enhance
agency, and thereby, 3) facilitate the
achievement of desired life goals [
16,
45]. Human resources (like schooling and training), economic resources (like work, earnings, and property), and social resources (like peer networks), typically are observable. Agency, however, is a multidimensional construct that involves internal states of being, ways of acting, and ways of acting jointly with others [
16,
46].
Intrinsic agency—or
power within—entails an awareness of one’s own rights, confidence in one’s own capabilities, and motivation to pursue self-defined goals and aspirations.
Instrumental agency involves the
power to make one’s own strategic life choices, to act to pursue one’s goals, and to affect change in one’s life. Instrumental agency may be enacted, for example, in household decisions, movement in public spaces, and the expression of views that oppose prevailing norms [
21,
47,
48].
Collective agency represents the development of group goals and joint actions to achieve shared goals [
46,
49,
50]. These three types of agency—
intrinsic,
instrumental, and
collective—can arise in all domains of life, including at home, in the labor market, and in informal and formal political spaces. Women’s agency can be restricted by the normative environment or can challenge restrictive, gendered expectations of roles, responsibilities, and rights [
46]. These types of agency also can evolve across lifecycle stages.
Measurement of women’s agency
Despite agreement that women’s agency is multidimensional [
16,
51,
52], its measurement has had notable limitations. First, many researchers have used a single question or summative scale, capturing limited dimensions of women’s agency, often related to decision-making, freedom of movement,
or financial autonomy [
7,
53‐
57]. A consistent, multidimensional measure of women’s agency still is needed. Second, researchers have paid limited attention to context-specificity in measures of women’s agency [
24]. A common practice has been to rely on empowerment measures from multi-country surveys administered to women of reproductive age. The Demographic and Health Survey (DHS) [
58,
59] and other multi-country surveys [
60,
61] have included questions on intrinsic agency, such as women’s attitudes about physical violence against wives. The DHS and other surveys [
61] also have included questions on instrumental agency, such as women’s influence in household decisions and, in some regions, women’s freedom of movement. Although the
dimensions of intrinsic and instrumental agency are widely relevant, the ways in which these forms of agency manifest may vary [
18,
51,
61,
62], and salient local aspects of women’s intrinsic and instrumental agency may be missed.
Third, researchers have tended to create scales of agency that separate pregnancy-specific and non-pregnancy-specific experiences, missing changes and fluctuations across the reproductive lifecycle. One practice has been to focus on non-pregnancy-specific, socio-economic measures of agency among all (ever-married) women of reproductive age, typically 15–49 years. While this group of women is important demographically, their experiences of agency (or non-agency) are diverse, and salient reproductive experiences may not be captured. The Pregnancy-Related Empowerment Scale (PRES), developed in the United States [
34], has been used to assess whether group prenatal care improves pregnancy-related empowerment in Malawi and Tanzania [
35]; however, the scale has not been validated cross-culturally, including in Arab populations, and cannot track women’s agency
outside of pregnancy because it includes only pregnancy-specific items. The Reproductive Empowerment Scale of the DHS does not align conceptually with dimensions of women’s intrinsic and instrumental agency and focuses only on
pregnancy prevention [
32,
33]. Women’s agency may change across stages of the reproductive lifecycle [
7,
63,
64] and may fluctuate, for example, during menstruation, pregnancy, and the perinatal period [
25,
65]. Capturing these changes and fluctuations requires a scale that includes
pregnancy- and
non-pregnancy-specific items that can apply to women across the reproductive life cycle.
Finally, validations of women’s agency scales have, only recently, tested for
measurement invariance, or dimensional and statistical comparability across groups [
21], countries [
18], and time [
22]. Women from different Arab countries, for example, may have different levels of intrinsic or instrumental agency
and different interpretations of agency-related questions [
66]. Variability across groups of women in the measurement properties of an agency scale may preclude comparisons of mean group differences in agency using the same scale [
21].
Women’s agency in the Arab Middle East
In the Arab Middle East, qualitative studies have suggested that women’s intrinsic and instrumental agency are salient and variable across contexts [
67,
68]. In one study of women receiving micro-credit in Egypt, women with intrinsic agency in mobility—who felt able to leave the home unaccompanied—felt better able to augment their own well-being [
67]. Another study of spousal conflict in Egypt concluded that women valued instrumental agency—or influence in how household earnings were allocated [
68]. Among never-married women in Palestine, however, participation in general household decisions was related to experiences of physical and psychological domestic violence [
69]. Among agricultural workers in northwest Syria, women have gained some agency without challenging men’s power and privilege in the household [
70].
Quantitative studies in the Arab Middle East have assessed the associations of general dimensions of women’s agency with their reproductive health. In Oman, women’s education was a better predictor of contraceptive use than their instrumental agency in household decisions and freedom of movement [
71]. In Egypt, women’s decision-making autonomy (a term used by the author) was associated with women’s contraceptive use [
72]. In national longitudinal data for Egypt, women’s intrinsic agency (more gender-equitable attitudes) partially mediated a negative relationship between women’s schooling and fertility; however, the mediating role of women’s instrumental (decision-making) agency was more complex [
12]. Also, in Egypt, the influences of women’s first birth on their empowerment confirmed the salience of motherhood for women’s empowerment [
65]. Finally, in a comparative analysis of the DHS, 23 countries were ranked on
empowerment sources (such as education and employment) and
empowerment setting (such as age at marriage) [
73]. Jordan and Morocco ranked fourth and twenty-first, respectively, suggesting wide variation in women’s empowerment across Arab countries. In Jordan, the percentage of women making independent decisions ranged from 61.4 for healthcare to 10.5 for major household purchases; whereas, in Morocco, relatively few women reported making independent decisions about purchases for daily household needs (15.4%) and travelling to friends’ homes (8.6%) [
73].
Despite these examples, most research on women’s agency has occurred outside the Arab Middle East [
21]. Moreover, despite attention to conceptualizing women’s empowerment in the region [
74‐
77], the conceptualization and measurement of women’s
agency remains limited. To date, no researchers have developed and validated a measure of women’s reproductive agency in the Arab region that is multidimensional, includes pregnancy- and non-pregnancy-specific experiences, and is comparable across a diverse groups of women of reproductive age.