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Family Planning, Fertility, and Women’s Empowerment in Low- and Middle-Income Countries

Alex Ezeh (Drexel University) served as moderator for this session, which focused on the relationships between family planning, fertility, and women’s empowerment specifically in the context of low- and middle-income countries.

THE INTERSECTIONS OF WOMEN’S ECONOMIC AND REPRODUCTIVE EMPOWERMENT

Yana van der Meulen Rodgers (Rutgers University) shared that this presentation was based primarily on a recent special issue of Feminist Economics, for which Rodgers was a co-editor. The intersections of women’s economic and reproductive empowerment were presented in a tri-level framework: micro-level intersections, such as decisions about contraceptive use and employment, meso-level intersections, such as social norms, labor marker practices, and informal sector employment, and macro-level intersections, such as the relationship between fertility, women’s LFP, and national or regional economic growth.¹ Research in this area examines the bidirectional effect of childbearing and access to reproductive health care on women’s decisions to work as well as the quality of work that is available to them and vice versa.

Rodgers outlined numerous economic benefits that result from investment in family planning or SRH. Women’s access to sexual and reproductive health and rights (SRHR) often manifests in higher maternal ages at first birth, lower fertility, and longer birth spacing. This access includes but goes beyond availability of contraception, incorporating the establishment of distribution networks for contraceptives, SRH education, and family planning counseling. The effects of SRHR access are important for women’s health and the economy, leading to lower costs for health systems as well as increased LFP, educational attainment, and lifetime earnings for women. Rodgers said that this research began in earnest with studies on the “power of the pill” and that similar findings have been obtained regarding the legalization of abortion.

Investment in family planning also has a positive effect on the well-being of children, Rodgers said. Lower fertility has been linked to improvements in children’s nutritional status, body-mass index (BMI), developmental progress, survival rates, and educational resources. Rodgers also noted evidence that parents will invest more in their daughters when they know that their daughters will have access to contraception and abortion.

The micro-level relationship between women’s economic and reproductive empowerment is described in an article from the recent special issue of Feminist Economics that examined the impact of quality of contraceptive

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¹ S. Gammage, J. Shareen and Y. Rodgers, The intersections of women’s economic and reproductive empowerment, Feminist Economics, 26(1), 1–22. (https://doi.org/10.1080/13545701.2019.1674451).

use on a woman’s ability to work, earn money, and contribute to family income in Ethiopia.² Quality of contraceptive use was measured by duration and method of contraception; the authors leveraged retrospective contraceptive use history and panel data to make these determinations. The study identified a causal link between consistent contraceptive use, on the one hand, and likelihood of employment and receipt of cash payments for work (as opposed to payments-in-kind or no payment), on the other hand. Rodgers noted that this study is one of few that have paid special attention to the challenge of endogeneity, in this case by using retrospective contraceptive use history as well as panel data. A study conducted in Turkey investigated this link in the opposite direction, asking, How does employment status affect contraceptive choice?³ That study found that employed women were more likely to use modern contraceptive methods over traditional methods, and that the effect was strongest for women who worked more secure jobs with stable incomes in the nonagricultural sector and had more access to social security and formal child care.

Rodgers shared a meso-level study that explored how the evolution of reproductive health services, social protections, and labor market institutions impact the type and quality of women’s employment in 45 low- and middle-income countries.⁴ The study authors identified a clear, positive relationship between unmet family planning needs and the percentage of women employed in the informal sector, as well as a similar correlation between higher rates of fertility and higher rates of informal employment. Countries that had sharp transitions in fertility did not necessarily have higher rates of women’s LFP. Instead, countries that invested in health care, education, labor market institutions, and social protections produced better labor market outcomes for women. Rodgers said these findings demonstrated a critical role for coordinated policy that addresses reproductive health needs, labor market institutions, and social protections to ensure positive economic outcomes for women.

Rodgers presented another meso-level study that reached similar conclusions regarding government investments in infrastructure and women’s reproductive health in India.⁵ The study’s mixed methods analysis of India’s

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² N.A. John, A.O. Tsui, and M. Roro, Quality of contraceptive use and women’s paid work and earnings in peri-urban Ethiopia, Feminist Economics 26(1), 23–43 (doi: 10.1080/13545701.2019.1632471).

³ D. Pekkurnaz, Employment status and contraceptive choices of women with young children in Turkey. Feminist Economics 26(1), 98–120. (doi: 10.1080/13545701.2019.1642505).

⁴ S. Gammage, S. Joshi, and Y. van der Muelen Rodgers, The intersections of women’s economic and reproductive empowerment, Feminist Economics 26(1), 1–22 (doi: 10.1080/13545701.2019.1674451).

⁵ R.P. Pande, S. Namy, and S. Malhotra, The demographic transition and women’s economic participation in Tamil Nadu, India: A Historical Case Study, Feminist Economics 26(1), 179–207 (doi: 10.1080/13545701.2019.1609693).

historical demographic transitions showed that declining fertility rates correlated with higher educational attainment and employment rates for women in their peak productive and reproductive years. Rodgers pointed out that even as fertility rates declined in this setting, women on average still devoted their time to motherhood; the study authors argued that a shift in focus had occurred from childbearing to child rearing.

At the macro level, Rodgers highlighted a study that examined fertility and LFP among immigrants and their descendants in the United States.⁶ Through the use of Current Population Survey data, the study showed that the gender norms and traditions of an immigrant’s home country influenced their employment and reproductive health experience in the United States, in that the fertility rate and women’s LFP in the source country were associated with immigrant fertility rate and LFP in the United States. This association declined across generations, which Rodgers highlighted as evidence that gender norms are mutable and that women’s LFP plays a critical role in changing these norms.

Rodgers also presented some of her own macro-level work based on DHS data from women’s reproductive health diaries on abortion from 51 low- and middle-income countries.⁷ Her study focused on the impact of the U.S. Global Gag Rule (renamed in 2017 as “Protecting Life in Global Health Assistance”), a policy that restricts funding for reproductive health services abroad if the recipient NGO provides abortion services, counseling, or referrals, or advocates for abortion law reform. Policies of this type have been rescinded by every Democratic president and restored by every Republican president since the Reagan administration.

Through logistic regression analysis of data collected during the George W. Bush administration, Rodgers found that countries affected by the Global Gag Rule saw increases in abortion rates—by a factor of three in Latin American and the Caribbean and a factor of two in sub-Saharan Africa—despite the stated intention of the policy to decrease abortion rates. These low- and middle-income countries have restrictive legal regimes of their own surrounding abortion, which the analysis showed was associated with higher total fertility rates, unsafe abortions, maternal mortality, and adolescent birth rates. Unsafe abortion accounts for nearly 8 percent of maternal mortality globally and as much as 10 percent in sub-Saharan Africa, Latin America, and the Caribbean. These relationships may be the result of income effects but could also be a causal result of restrictive

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⁶ F.M. Muchomba, N. Jiang, and N. Kaushal, Culture, labor supply, and fertility across immigrant generations in the United States, Feminist Economics 26(1), 154–178 (doi: 10.1080/13545701.2019.1633013).

⁷ Y. Rodgers, The Global Gag Rule and Women’s Reproductive Health: Rhetoric versus Reality (New York: Oxford University Press, 2018).

abortion laws. Rodgers therefore concluded that the Global Gag Rule “does not protect life at all” and that a potentially more constructive and cost-effective approach would be to integrate contraceptive care and safe abortion into the full range of reproductive health services rather than “marginalize women and their reproductive health with funding restrictions that are based purely on ideology,” as she put it.

Ushma Upadhyay inquired about the effects of the U.S. Global Gag Rule in Latin America. Rodgers identified reduced access to contraception—resulting from forced closures and staff or supply shortages among clinics affected by the U.S. Global Gag Rule—as the key mediating factor that drove higher rates of both unintended pregnancies and abortions in the region.

WOMEN’S EMPOWERMENT AND FAMILY PLANNING IN SUB-SAHARAN AFRICA: REVIEW OF THE LITERATURE

Yohannes D. Wado (African Population and Health Research Center) said that an overall consensus regarding the benefits of family planning and SRH services is reflected in the United Nations Sustainable Development Goals (SDGs), which call for universal access to SRHR in accordance with the International Conference on Population and Development Programme of Action and the Beijing Platform for Action.

In sub-Saharan Africa, the use of contraception remains low, and the need for family planning and SRH services is often unmet despite recent improvements. Wado said that gender-based power imbalances are pervasive across every factor in the causal framework for unmet family planning needs, including social norms that encourage large families and early marriage, opposition to contraception by partners, low engagement of men in contraceptive efforts, and a lack of informed choice at the health services level that leads to misconceptions about contraceptive side effects.

Literature on women’s empowerment and family planning in sub-Saharan Africa conceptualizes empowerment as a multidimensional and multilevel process of change that encompasses elements of agency, resources, and achievements; two commonly cited definitions of empowerment in the literature include those popularized by Naila Kabeer (London School of Economics and Political Science)⁸ and the World Bank.⁹ Studies generally include

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⁸ “The expansion of people’s ability to make strategic life choices in a context where this ability was previously denied to them” (N. Kabeer, Resources, agency, and achievements: Reflections on the measurement of women’s empowerment, Development and Change 30(3), 435–464.)

⁹ “The process of enhancing individuals or group’s capacity to make purposive choices and to transform those choices into desired actions and outcomes” (R. Alsop and N. Heinsohn, Measuring Empowerment in Practice: Structuring Analysis and Framing Indicators [World Bank, 2005] [doi: 10.1596/1813-9450-3510]).

one or more dimensions of empowerment: economic (e.g., women’s control over income, access to and control of family resources); sociocultural (e.g., freedom of movement, lack of discrimination against daughters); familial or interpersonal (e.g., participation in domestic decision-making, control over sexual relations, freedom from domestic violence); legal (e.g., knowledge of rights, domestic support for exercising rights); political (e.g., political awareness, access, voting rights); or psychological (e.g., self-esteem, self-efficacy, well-being).

Wado examined the correlation between a country’s aggregate-level gender inequality index and contraceptive prevalence. The index captures reproductive health, empowerment, and status, with a higher index indicating greater disparity between males and females. Many countries in sub-Saharan Africa have a high gender inequality index (>0.5) that correlates with low contraceptive use. Only Rwanda, Namibia, and South Africa have gender inequality indices below 0.5, and all three countries have higher rates of contraceptive use. Wado noted that some countries where contraceptive use is high, including Zimbabwe, still have high gender inequality indices. In an analysis of DHS indicators of women’s empowerment and reproductive health outcomes, a moderate correlation was observed between contraceptive use and the percentage of married women who participate in household decision making.

Wado presented findings from several studies that show differing degrees of relationship between women’s empowerment and contraceptive use. A meta-analysis that collected DHS data on women’s empowerment and contraceptive use in 33 developing countries, 19 of which are in sub-Saharan Africa,¹⁰ revealed a positive and significant relationship between women’s decision-making autonomy and contraceptive use. It found that women with higher empowerment scores were more likely to use modern contraception in 8 of these 19 sub-Saharan African countries. Another study that leveraged DHS data from five African countries generated empowerment scores based on six dimensions of empowerment indicators and found a strong association between overall empowerment scores and contraceptive use; however, Wado noted that only countries with high contraceptive prevalence were included in that study.¹¹ In a third study that aggregated DHS data from 34 sub-Saharan African countries, three dimensions of women’s empowerment (attitude toward violence, social independence, and decision making) were developed using principal component

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¹⁰ S. Ahmed, A.A. Creanga, D.G. Gillespie, and A.O. Tsui, Economic status, education and empowerment: implications for maternal health service utilization in developing countries, PLOS ONE 5(6), e11190 (doi: 10.1371/journal.pone.0011190).

¹¹ M. Do and N. Kurimoto, Women’s empowerment and choice of contraceptive methods in selected African countries, International Perspectives on Sexual and Reproductive Health 38(1), 23–33 (doi: 10.1363/3802312; PMID: 22481146).

analysis based on 15 items from the DHS Empowerment Module and other status indicators.¹² The analysis showed that attitudes toward violence and decision making were more consistently associated with modern contraceptive use than social independence. In the fourth and final study that Wado cited, pooled DHS data based on multi-level empowerment indicators from 32 sub-Saharan African countries indicated that decision-making autonomy and LFP were positively associated with contraceptive use in all examined countries, and that the rates of contraceptive use were higher in countries with a moderate score on the human development index.

Wado explained that data on covert use of contraception are also of interest to empowerment research because they have implications for decision-making autonomy. Studies dating to the 1990s show that covert use of contraceptives is a common practice. A recent study currently under review leveraged two rounds of PMA data collected in Kenya and showed that 12.2 percent of women were engaging in covert use of contraception.¹³ This practice was more common among older women (ages 35–49) and in individuals of low socioeconomic status. Injectables and implants were among the most common contraceptive methods used covertly, and these methods are also the ones driving the rise in contraceptive use in sub-Saharan Africa.

Wado concluded his presentation by underscoring the challenges inherent in conceptualizing empowerment for research and measurement, pointing to a limited set of qualitative studies that describe what empowerment means in different contexts and noting that the common method of aggregating or pooling data from different countries may mask contextual variations. Wado echoed the call for programming that engages both men and women in efforts to expand contraceptive use in sub-Saharan Africa.

In the discussion, Nancy Birdsall commented that there is no question about the high association between empowerment and contraceptive use, as well as between education and formal employment and contraceptive use, in sub-Saharan Africa. Birdsall then asked whether the ultimate cause of these relationships is known. Wado noted that his review focused on empowerment and family planning outcomes, but acknowledged that education and employment are key variables. Rates of education and modern-sector employment in sub-Saharan Africa are low, although Wado pointed out that relationships between contraceptive use and employment are more inconsistent than associations with educational attainment, possibly because

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¹² F. Ewerling, J.W. Lynch, C.G. Victora, A. van Eerdewijk, M. Tyszler, and A.J.D. Barros, The SWPER index for women’s empowerment in Africa: development and validation of an index based on survey data, Lancet Global Health 5(2017), e916–e923.

¹³ C. Akoth, J.O. Oguta, and S.M. Gatimu, (under review), Prevalence and determinants of covert contraceptive use in Kenya: A cross-sectional study.

conceptualizations of “employment” (e.g., formal vs. informal) may distort the observable relationship between employment and contraceptive use in the region. Wado said that the causes of low education and employment levels are complex and related to the level of development in sub-Saharan Africa as well as political commitments to education, women’s employment, and family planning. In francophone Africa in particular, wars and conflicts in the region further weaken this political commitment.

FAMILY PLANNING, FERTILITY, AND WOMEN’S EMPOWERMENT

Zeba A. Sathar (Population Council) said that it is time to challenge some of the theoretical frameworks, such as the Demographic Transition Theory, that assume that a shift from higher fertility to replacement-level fertility rates will result in a lasting equilibrium between fertility intentions and outcomes as well as improvements to the welfare of women and girls. The “demographic dividend”—the economic growth potential that can result from shifts in a population’s age structure¹⁴—is often cited as one explanation for how fertility decline can have a beneficial impact on women, children, and household welfare: in this model, that decline promotes women’s LFP and household savings. However, Sathar posited that fertility decline does not predict other aspects of women’s welfare. For example, sex-selective abortion and gender violence continue even in contexts of low fertility.

In addition, Sathar said, the relationship between empowerment and fertility may require closer examination. Individual-level measurements of women’s empowerment and autonomy have operated relatively well for decades, and women’s empowerment does correlate strongly with contraception and fertility (with positive and negative correlations, respectively). However, Sathar noted, the factors that influence the outliers in these data are unclear. Why do some countries, such as Nepal and Bangladesh, demonstrate higher levels of contraceptive use and lower fertility rates than their levels of women’s empowerment would predict, while other countries, such as Afghanistan and Pakistan, show the opposite deviation from the model?

Several other correlations between contraceptive use and specific empowerment measures may be useful in further analyzing this relationship. For example, contraceptive use correlates strongly with female adult literacy rates and freedom from physical or sexual violence. In addition, a strong direct correlation exists between the total fertility rate and gender violence, including physical and sexual violence. A weaker correlation exists between contraceptive use and women’s LFP—perhaps due to variation in types of employment.

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¹⁴ United Nations Population Fund. http://unfpa.org/demographic-dividend.

Sathar more specifically examined anomalous data regarding family planning in Asia, a region that shows wide variation in family planning effort (FPE) indices across countries. Proper measurement of these efforts would require incorporation of more gender-related indicators into data collection and analysis. Nonetheless, the classic correlation patterns exist between contraceptive use or total fertility rate and the FPE index (i.e., FPE is highly correlated with contraceptive use and inversely correlated with total fertility rate, although the latter correlation is weaker). However, marriage patterns in Asian countries represent an anomaly. Although countries with higher rates of contraceptive use and lower total fertility rates may be expected to also have higher ages at first marriage, this expectation is not always born out.

In Bangladesh, more than half of women are married by age 18 despite high contraceptive use and low fertility, while in Pakistan, a country with relatively low rates of contraceptive use and high fertility, only 18 percent of women are married by the same age. Similarly, other indicators of women’s empowerment, such as domestic violence rates, fail to follow expected correlations with total fertility rates and contraceptive use. Sathar emphasized that the field needs to understand the regional drivers of marriage patterns and commonly used empowerment measures through more nuanced and qualitative studies to understand what these sorts of indicators mean for women’s empowerment and autonomy.

Sathar suggested that theoretical frameworks evolve toward a multidimensional perspective, one that encompasses changes in fertility and contraceptive use alongside variation in women’s and girls’ autonomy or welfare. Furthermore, she cautioned against placing greater value on reaching a demographic state-of-replacement fertility than on reaching an ideal equilibrium of women’s and girls’ welfare as it relates to fertility intentions and outcomes. Some aspects of family planning programs can be modified now based on existing data, such as the power relationships between women and providers as well as the incorporation of domestic violence prevention. Finally, Sathar asked workshop attendees to agree on a minimum number of agency measures that are necessary to achieve autonomy and resist family and societal pressure toward negative outcomes, such as unwanted sex, pregnancy, marriage, or violence.

In the discussion, Ann Blanc (Steering Committee Chair, Population Council) asked Sathar to elaborate on how the burdens of caring for children and the elderly mediate the relationship between LFP and childbearing. Sathar referenced a study conducted in India in which women’s LFP declined in spite of lower fertility rates, and identified child care as a mediating factor in this complicated relationship. She noted that childcare duties, as well as care for older parents, often fall to women and subsequently decrease women’s LFP.

FERTILITY, FAMILY PLANNING, AND EMPOWERMENT: THE CASE OF ADOLESCENTS

Ndola Prata (University of California, Berkeley) described adolescence as an important time during which people experiment with independence, forge new relationships, develop new social skills, and learn new behaviors. It is therefore important to engage adolescents in meaningful ways—including through support for SRH—that may encourage healthy transitions to adulthood.

According to the United Nations, adolescent birth rates have declined since 1990, although variation throughout the world is considerable and rates remain high in many low- and middle-income countries. The decline in adolescent birth rate has also been slower than the decline in the total fertility rate in some areas. Prata underlined that although early marriage is a strong underlying factor, not all childbearing among married adolescents is intended and sexual initiation before marriage is almost universal. High levels of adolescent fertility are associated with a high proportion of unsatisfied demand for family planning, and longer duration of schooling—particularly for girls—has been linked to lower levels of adolescent fertility.

The United Nations Population Division has reported that the governments of low- and middle-income countries have increasingly recognized adolescent fertility as a major concern.¹⁵ However, comprehensive SRH education is not universally available and contraceptive use in low- and middle-income countries is low, despite evidence that access to contraception is a key element in reducing adolescent fertility. A recent review estimated that approximately 23 million girls (ages 15–19) in low- and middle-income countries have an unmet need for contraception.¹⁶ Prata said that meeting this need would decrease the number of unwanted pregnancies and unsafe abortions as well as improve overall reproductive health outcomes.

Prata presented an analytic framework to study adolescent reproductive health that identifies the key drivers of adolescent fertility as unsafe sexual practices, specifically lack of contraception, and harmful practices, such as child marriage and female genital mutilation. The framework also outlines the underlying causes or social determinants that contribute to these drivers to highlight potentially effective areas of programmatic intervention. These underlying causes include poverty, attitudes that prevent safe sexual practices, lack of education, health system bottlenecks, and gender discrimination. Prata noted that these drivers may not contribute equally in all regions to reproductive outcomes, such as unsafe abortion and sexually

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¹⁵ United Nations Department of Economic and Social Affairs, Population Division, World Population Policies (2013).

¹⁶ J. Deitch and L. Stark, Adolescent demand for contraception and family planning services in low- and middle-income countries: a systematic review, Global Public Health 14(9), 1316–1334 (doi: 10.1080/17441692.2019.1583264; Epub 2019 Feb 22; PMID: 30794484).

transmitted infections (STIs), or to individual, household, or community-level consequences, such as maternal morbidity and mortality, adolescent offspring mortality, and increasing poverty. For example, harmful practices are less common in Angola than in Niger, but both countries have high fertility driven by a lack of contraceptive use.

Prata introduced a second framework to conceptualize the adolescent contraceptive journey. This framework recognizes documented differences in contraceptive access and utilization among adolescents depending on whether they are unmarried, married without children, or married with children. The framework is designed to identify opportunities at the micro, meso, and macro levels across these three important subgroups. For example, the norms of a community may dictate very different contraceptive access for an adolescent who is unmarried than for one who is married (e.g., based on norms surrounding sexual activity), or even for two married adolescents when one does and the other does not already have children (e.g., access to contraception once desired family size has been met).

Different approaches employed to improve adolescent empowerment have focused on areas such as asset building, attitudes and capabilities, conditions and opportunities, and economic assistance. Prata focused on youth participation in SRH policies and programs, citing the United Nations’ recognition of adolescent participation in matters that concern them directly or indirectly as a fundamental right. Four essential and interconnected features of meaningful adolescent participation have been outlined by the United Nations: space (i.e., safe and inclusive opportunity to form and express views), voice (i.e., expression of views facilitated freely in a medium of choice), audience (i.e., listening to adolescent views), and influence (i.e., appropriate action based on adolescent views). Prata highlighted three categories of participation as it relates to empowerment: empowerment within (e.g., self-efficacy, dignity, recognition of entitlement), empowerment with (e.g., building partnerships, solidarity), and empowerment to (e.g., challenging violations, influencing decisions, realizing rights, and holding duty bearers accountable). Prata emphasized that the empowerment to category of participation is especially important for adolescent SRH.

Outcomes for meaningful participation can be aggregated into three groups: consultative, collaborative, and adolescent-led. Prata said that ideally the voice and agency features of adolescent participation in SRH matters would be adolescent-led, but noted work by the United Nations Children’s Fund (UNICEF) to develop consultative and collaborative strategies for adolescents of both genders to participate in the prevention of child marriage.

Increased availability of contraception to adolescents represents an economic opportunity for low- and middle-income countries. Improved contraceptive access empowers healthier and more educated young adults

and decreases fertility, alleviating rapid population growth and poverty. Furthermore, this access allows low- and middle-income countries to harness the demographic dividend. Prata said a great deal of evidence supports interventions that will help low- and middle-income countries to reduce adolescent fertility, including longer duration of education, comprehensive sex education, universal health care for adolescent SRH (including wide contraceptive access), adolescent empowerment, abolition of harmful practices, and promotion of gender equity.

In the discussion, Caroline Kabiru (African Population and Health Research Center) asked how SRH services and rights differ for adolescent girls and young women, including by marital status, commenting that the association between early marriage and contraceptive use in Bangladesh, for example, may not be surprising because it is perhaps more acceptable for a married (rather than unmarried) adolescent girl to use contraception. Prata confirmed that married adolescents, regardless of age, in sub-Saharan Africa and South Asia have relatively better access to SRH service than unmarried adolescents. However, adolescent girls are pressured to have multiple children after marriage. Education on the importance of birth spacing to the health of mothers and children has increased use of contraception by young married mothers, but Prata said that in countries with high fertility rates and low contraceptive prevalence, such as Angola and Niger, young women will sometimes have four or five children before seeking family planning counsel.