Women's empowerment and short- and long-acting contraceptive method use in Egypt

Adaptation and psychometric assessment of a sexual and reproductive empowerment scale in Arabic among refugee and non-refugee adolescent girls

BACKGROUND

Sexual and reproductive empowerment (SRE) is an important determinant of women's and girls' health yet measuring it is complex due to cultural and domain-specific variations. This study describes the process of adapting an SRE scale consisting of four domains (self-efficacy; future orientation; social support; and safety) and testing its psychometric properties among Arabic speaking adolescent girls in Lebanon.

METHODS

An SRE scale developed in a Western context was adapted in four steps: (1) reviewing the scale and selecting culturally appropriate domains for translation to standard Arabic; (2) conducting cognitive interviews with 30 11-17-year-old adolescent girls in Lebanon; (3) administering the scale to 339 refugee adolescent girls who participated in an early marriage intervention; and (4) conducting confirmatory factor analysis (CFA) on the data to assess the scale's psychometric properties.

RESULTS

The original model for the 13-item, four-domain adapted scale demonstrated poor fit in CFA. After iteratively removing two items, scale properties were improved, albeit were not optimal. The validity and reliability results for the self-efficacy domain were acceptable. Cognitive interview data revealed that Arab adolescent girls understood self-efficacy in relational terms, recognizing that autonomous decision-making is not necessarily favored but is influenced by parents and family.

CONCLUSIONS

This study presents an effort to customize an SRE scale for use in studies on the health of adolescent girls in an Arab cultural context. Findings from cognitive interviews highlight the importance of taking into consideration relationality in adolescent sexual and reproductive decision-making. The self-efficacy domain in the adapted scale demonstrates acceptable psychometric properties and is recommended for use in health studies to capture SRE.

Kelly P. Reducing Violence Against Women and Girls in the Arab League: A Systematic Review of Preventive Interventions

The UN's Sustainable Development Goal #5 (Gender Equity) includes violence against women and girls (VAWG), considering it as a violation of the rights of women and girls. The variety of risk factors for VAWG in Arab countries suggests the need to identify effective interventions to guide practitioners and policy makers. A systematic review of preventive interventions across the Arab League examined the outcomes of VAWG. Authors registered the study on the prospective register of systematic reviews database. Authors conducted the search for evidence up to 2023. Database searching identified 1,502 studies and after application of the eligibility criteria, 17 studies remained for inclusion. Quality appraisal used the Mixed Methods Appraisal Tool. Evidence emerged from eight Arab countries. Interventions occurred at the primary, secondary, and tertiary levels of prevention. However, only two studies employed interventions using more than one level of prevention, which considered systems strengthening and the development of community solidarity networks. The evidence revealed a lack of clear evaluation and evidence for the effectiveness of interventions and prevention alongside reactive approaches, with no evidence as to how systems may reduce or prevent VAWG. One main issue is patriarchal dominance in Arab countries creating the lack of a collective female voice in any of the evidence. However, Arab countries can change with support. Achieving the UN's Sustainable Development Goal #5 by 2030 means interventions and programs need to include more than one prevention level, consider systems and include the collective female voice.

Contraceptive Adoption and Changes in Empowerment in Kenya, Nigeria, and Senegal

Women's empowerment and contraceptive use are critical to achieving gender equality. The positive association between more empowered women and higher rates of contraceptive use has been well-established by cross-sectional research. However, there remains a gap in understanding the longitudinal relationship between contraceptive adoption and changes to women's empowerment. This study represents a novel approach to understanding the relationship between contraceptive adoption and women's empowerment longitudinally, at the individual level. To the authors' knowledge, this is the first attempt to measure the relationship between contraceptive adoption and women's empowerment using more than one wave of panel data. We leverage the longitudinal design of the Urban Reproductive Health Initiative data to code empowerment items by change over time (e.g., more empowered, no change, less empowered). We use sparse principal component analysis to establish empowerment change domains and calculate individual scores standardized by country-level averages. We estimate mixed effects models on these change domains, to investigate the link between contraceptive adoption and empowerment. We find common themes in empowerment across contexts-but contraceptive adoption has both positive and negative effects on those domains, and this varies across context. We discuss the need for cohort studies to examine this relationship.

Women's sexual empowerment and utilization of long-acting reversible contraceptives in Ghana: evidence from the 2014 demographic and health survey

BACKGROUND

Long-Acting Reversible Contraceptives (LARC) contribute significantly to a decline in unintended pregnancies globally. However, not much is known about women's sexual empowerment and their utilization of Long-Acting Reversible Contraceptives in Ghana. The main objective of this study was to examine the association between women's sexual empowerment and LARC utilization in Ghana.

METHODS

We used data from 5116 sexually active women who participated in the 2014 Ghana Demographic and Health Survey. Women's sexual empowerment was defined as women's perception of their right to self-determination and equity in sexual relations, and their ability to express themselves in sexual decision-making. A sum of scores was created with four dichotomous items as sexual empowerment score (0 = low sexual empowerment; 1, 2, and 3 = medium sexual empowerment; and 4 = high sexual empowerment). Multivariable binary logistic regression analyses were performed to establish the association between women's sexual empowerment and the use of LARC. Pearson Chi-square test was used in data analysis. The results are presented as adjusted odds ratios (aOR), with their respective confidence intervals (CIs) at a statistical significance of p < 0.05.

RESULTS

The prevalence of LARC utilization among sexually active women in Ghana was 6%. Majority of the women had medium sexual empowerment (91%). Although not statistically significant, the likelihood of utilizing LARC was lowest among women with high level of sexual empowerment (aOR = 0.62; CI = 0.27-1.43). On the other hand, Utilization of LARC increased with an increase in age. Women with parity four or more had higher odds of utilizing LARC as compared to women with zero birth (aOR = 9.31; CI = 3.55-24.39). Across religion, women who belong to the Traditional religion (aOR = 0.17; CI = 0.04-0.71) and Islam religion (aOR = 0.52; CI = 0.36-0.76) had lower odds of LARC utilisation as compared to Christian women. Women who make health decisions with someone else (aOR = 1.52; CI = 1.12-2.09) had higher odds of LARC utilisation as compared to women who make health decision alone.

CONCLUSION

Age, health decision maker, parity and religion were found to have a significant relationship with LARC utilization. Specifically, uneducated women, unemployed women and women who practice traditional religion were less likely to utilise LARC. However, women's sexual empowerment did not have a significant relationship with LARC. There is therefore the need for planning interventions for LARC utilization in line with educating women on the benefits and potential side effects of LARC. Also, there is a need for interventions targeted at increasing access to LARC among sexually active women.

Women's empowerment and contraceptive use: Recent evidence from ASEAN countries

BACKGROUND

A fundamental element of gender equity are women's rights to reproductive choice. Women's empowerment is often linked to enabling decisions around contraceptive use and reduced fertility worldwide, although limited evidence is currently available around contraceptive use and decision making in ASEAN countries.

OBJECTIVE

To examine the association between women's empowerment and contraceptive use in five selected ASEAN member states.

METHODS

Data from the latest Demographic and Health Survey of Cambodia, Indonesia, Myanmar, The Philippines, and Timor-Leste were used. The main outcome was contraceptive use among married women (15-49 years) from these five countries. We considered four indicators of empowerment: labor force participation; disagreement with reasons for wife beating; decision-making power over household issues; and knowledge level.

RESULTS

Labor force participation was found to be significantly associated with contraceptive use in all nations. Disagreement with justification of wife beating was not significantly related to contraceptive use in any country. Decision-making power (higher) was only associated with contraceptive use in Cambodia, while higher knowledge levels were associated with contraceptive use in Cambodia, and Myanmar.

CONCLUSION

This study suggests women's labor force participation is an important determinant of contraceptive use. Policies designed to open the labor market and empower women through education should be implemented to enable women's participation. Gender inequality may also be tackled by engaging women in decision-making processes at national, community and family levels.

Is empowerment in sexual health measurable? A scoping review of definitions and measurement indicators

The concept of empowerment in sexual health is widely used in health promotion. This scoping review aims to identify how it is defined and measured. PubMed, Sage Journals, PsycInfo and the Web of Science are data sources. The inclusion criteria for studies were as follows: (1) an analysis of empowerment in sexual health, (2) quantitative evaluation and (3) publication in a peer-reviewed journal in French or English since January 1996. Data were extracted using a summary table of the definitions and indicators of empowerment in sexual health. Of the 2181 articles found, 29 met the inclusion criteria. Only 4 studies on 29 clearly defined empowerment in sexual health. Five dimensions emerged from the indicators used in the 29 studies in relation to sexual empowerment (social participation, participation in decision making, power to act, sexual health knowledge and gender norms), with two types of indicators: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Most studies concerned women and focused on individual empowerment, with a lack of measure of collective and structural levels of empowerment. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. This set could be systematically used in each study based on sexual empowerment concept, completed by supplementary indicators considering the specific context.

Self-efficacy and Unwanted Sexual Intercourse: 'Reproductive Health Education Programme for High-school Students in Vojvodina'

Introduction

Studies have shown the importance of self-efficacy in the domain of risky sexual behaviour. The aim of this study was to examine the association of unwanted sexual intercourse among secondary-school students with socio-demographic factors and perceived self-efficacy, and to assess the effectiveness of the programme on reproductive health.

Methods

The study involved 5,026 second-grade students in 72 high schools in the Province of Vojvodina, Serbia (APV). They were surveyed before and after the implementation of the extracurricular 'Reproductive health education programme for secondary-school students in APV'. A questionnaire consisting of 57 questions (socio-demographic characteristics, knowledge, attitudes, and behaviour of students regarding reproductive health, and a general self-efficacy scale) was used as the research instrument.

Results

One quarter of students had engaged in unwanted sexual intercourse on one or more occasions. Students with poor material status were twice as likely to engage in unwanted sexual intercourse (ОR=2.01; 95%CI=1.07-3.75) as students with average or good material status. Students who did not engage in unwanted sexual intercourse had a higher self-efficacy score than students who who did (t=2.903; p<0.01). After the programme was completed, there was an increase in general self-efficacy.

Conclusion

Poor material status is a predictor of unwanted sexual intercourse. Students who have a higher level of self-efficacy engaged to a lesser degree in unwanted sexual intercourse. The programme is effective in terms of increasing general self-efficacy, and can be applied to encourage responsible sexual behaviour.

A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa

Volitional sex is central to the sexual health and well-being of women and girls globally. To date, few studies have examined women's empowerment and its application to sexual health outcomes, including volitional sex. The aim of this study was to explore the relevance of a sexual and reproductive empowerment framework to volitional sex across four geographically and culturally diverse contexts in sub-Saharan Africa. Qualitative data were collected between July and August 2017 in four sites: Ethiopia, Nigeria (Anambra and Kano states) and Uganda. A total of 352 women aged 15-49 and 88 men aged 18 and older were interviewed through 120 in-depth interviews and 38 focus group discussions (n = 440 total participants). Results describe the substantial barriers restraining women's sexual choices, particularly norms that stigmatise women's requests for sex, even within marriage. Results further highlight women's internal sexual motivations, particularly related to the enjoyment of sex and the role of sex in strengthening partner relationships. Future empowerment research and measurement should focus not only on sexual constraints, but also integrate internal motivations, in order to fully understand the factors that shape women's sexual health outcomes.

Women’s Agency in Egypt, Jordan, and Tunisia: The Role of Parenthood and Education

Women in Middle Eastern and North African countries continue to report low levels of agency, despite their increasing educational attainment and declining fertility rates. We address this paradox by considering how women’s agency is linked to parenthood in Egypt, Jordan, and Tunisia and how this association is moderated by their level of education. We study three dimensions of instrumental agency: involvement in decision-making, financial autonomy, and freedom of movement using data for married women aged 18–49 from the Integrated Labor Market Panel Surveys: Egypt 2012 (n = 7622), Jordan 2016 (n = 4550), Tunisia 2014 (n = 1480). Results from multivariate regression models of these different dimensions demonstrate that married women who are mothers generally exhibit higher levels of agency than their counterparts who are childless, though this does not hold for every dimension and the strength of the association between parenthood and agency differs by dimension and country. We find a notable exception to this pattern of positive association in the Egyptian sample: parenthood decreases agency among Egyptian women with post-secondary education. Our results suggest that parenthood may only increase women’s agency in settings with deeply entrenched patriarchal norms that imply little education for women.

Factors associated with early long-acting reversible contraceptives discontinuation in Ethiopia: evidence from the 2016 Ethiopian demographic and health survey

Background

Ethiopia is struggling to achieve the 2020 family planning target. But the current contraceptive prevalence uptake is low and dominated by short-acting methods. Contraceptive discontinuation rate is also high. This analysis was done to identify the reasons and factors associated with long-acting and reversible contraceptives (LARC) discontinuation in Ethiopia.

Methods

The unit of analysis was LARC-use episodes in the 5 years preceding the survey, generated from the 2016 Ethiopian Demographic and Health Survey data. A total of 1385 LARC episodes were included. Data analysis was done using STATA 15. The event file generated from the contraceptive calendar was merged to the original data set to identify factors associated with LARC discontinuation. Univariate, bivariate and inferential analyses were done for 12 months LARC discontinuation.

Result

Approximately 82% of LARC episodes were implants. About 45% of intrauterine device (IUD) and 61% of implant episodes were discontinued by 36 months. Side effects and the desire to become pregnant were the main reasons for discontinuation. Women aged 25–34 (HR = 0.26; 95% CI: 0.20–0.35) and those aged 35–49 (HR = 0.17; 95%CI: 0.11–0.26), women who participated in decision-making partially (HR = 0.53; 95%CI: 0.37–0.78), or fully (HR = 0.55; 95%CI: 0.40–0.74) and primiparous women (HR = 0.53, 95%CI: 0.33–0.86) had a lower hazard of discontinuing LARCs. On the other hand, women who had only primary education (HR = 1.32; 95%CI: 1.02–1.72) and women who were not sure about their fertility intention (HR = 2.11; 95%C: 1.28–3.46) had a higher likelihood of discontinuing these methods.

Conclusion

Majority of LARC episodes were discontinued early, mainly due to the desire for pregnancy or experience of side effects. Older women, particularly those involved in household decision-making, and primipara were less likely to discontinue LARC. Women with only primary education and those uncertain about their fertility intention had a higher likelihood of discontinuation. Family planning service providers should focus on fertility intention and side effects when counseling women for contraceptive choice. Improving women’s participation in household decision-making may decrease LARC discontinuation in Ethiopia.

Contraceptive use in Cambodia: does household decision-making power matter?

In Cambodia, the growth of family planning services and socio-economic development have resulted in a spectacular rise in contraceptive prevalence rate and an equally remarkable reduction in contraceptive use differentials. With rising educational levels and increased participation in the modern labour market, Cambodian women are playing an increasingly pivotal role in household decision-making. This study used data from three rounds of Cambodia Demographic and Health Surveys to elucidate trends and patterns of contraceptive use. It then examined the determinants of contraceptive use through the use of logistic regression. The central hypothesis to be tested was whether or not women's involvement in household decision-making affected contraceptive use. Multivariate analysis showed that apart from the number of living children, women's work status and education of both men and women had a more significant impact on contraceptive use, as compared to women's power in household decision-making. More effort is needed to empower women in all aspects in order to reduce the socio-economic differentials in contraceptive use and improve their reproductive health, in line with the goal of the global agenda of the sustainable development goals (SDGs) to leave no one behind.

Factors associated with reported modern contraceptive use among married men in Afghanistan

BACKGROUND

Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples.

METHODS

Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis.

RESULTS

Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not.

CONCLUSIONS

Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.

Regional variations of contraceptive use in Bangladesh: A disaggregate analysis by place of residence

This study advances current knowledge on contraceptive use in Bangladesh by providing new insights into the extent of regional variations in contraceptive use across rural and urban areas of Bangladesh. We examined the regional variations in contraceptive use among 15,699 currently married women ages 15-49 years using data from the 2014 Bangladesh Demographic and Health Survey (BDHS). Multivariate logistic regression models of contraceptive use were calibrated with sociodemographic attributes and cultural factors. Based on the aggregate sample (i.e., rural and urban combined), we found significant regional variations in contraceptive use across the administrative divisions in Bangladesh. Based on a disaggregate sample (i.e., rural and urban separately), we found that there were significant differences in divisional variations in contraceptive use in rural areas. In contrast, no significant variation in contraceptive use across divisions in urban areas of Bangladesh was found. More specifically, among women living in rural areas, the Rajshahi and Rangpur divisions had higher odds of contraceptive use than the Barisal division, whereas the Chittagong and Sylhet divisions had much lower odds of contraceptive use even after adjusting for selected sociodemographic attributes and cultural factors. A separate analysis of the divisional variations in usage of modern methods of contraception also revealed similar findings with only one exception. Findings of this study provide an evidence-based direction for adapting a pragmatic approach to reducing the divisional disparity of contraceptive use in rural areas of Bangladesh.

Women's empowerment in Egypt: the reliability of a complex construct

Women’s empowerment, defined as the process where women acquire enabling resources that enhance their agency, is a strategy employed to improve women’s reproductive health. Agency is conceptualised as the ability to define life choices. However, measures of women’s agency, such as household decision-making, are thought to be unreliable. Null and negative associations between women’s empowerment and reproductive health are often attributed to weak measures of empowerment that are perceived to lack validity and reliability. This study uses the 2006 and 2012 Egyptian Labor Market Panel Survey and the 2008 and 2014 Egyptian Demographic and Health Survey to examine the reliability of measures of women’s agency by considering the effects of women’s individual and household characteristics on women’s agency. Both surveys are nationally representative, from similar time periods and include the same measures of agency – household decision-making and attitudes towards intimate partner violence (IPV). Negative binomial regression models of individual and household determinants of agency demonstrate the degree to which the measures secure consistent results upon repeated application. Results show that the same individual, household, and spousal characteristics were consistently associated with decision-making and attitudes towards IPV in the two surveys. Findings support the conceptualisation of women’s empowerment as household decision-making and attitudes towards IPV in Egypt. This also offers promising evidence for use of these measures in reproductive health research, in women's health programmes, and as part of strategies to improve women’s empowerment.

Education and fertility in Egypt: Mediation by women's empowerment

In 2006, fertility in Egypt reached a two-decade low of 3 births per woman; however, by 2008, the demographic transition reversed, and fertility has remained higher at 3.5 births per woman. Low educational achievement is linked to high fertility. Education is also important in the process of women's empowerment, suggesting that educational achievement lowers fertility through gains in women's agency. However, no studies test this pathway, and evidence on the relationship between education and fertility in Middle Eastern settings is limited. Using longitudinal data from the 2006 and 2012 Egyptian Labor Market Panel Survey (ELMPS), a nationally representative sample of households in Egypt, for 4336 married women aged 15-49 years, this study estimates several linear and mediation regression models of number of births and considers whether women's empowerment explains the relationship between education and number of births. Women's empowerment is operationalized through three measures of instrumental agency: individual household decision making, joint household decision making, and mobility and one measure of intrinsic agency-gender beliefs and attitudes. Higher educational achievement has significant adjusted associations with lower fertility. However, measures of women's agency have mixed mediation associations for education and fertility. Greater individual household decision making and belief in egalitarian gender norms partially mediate the relationship between education and fertility, while greater joint decision making suppresses the relationship. Contrary to expectation, women who have more instrumental agency through more individual and joint household decisions have higher fertility than those who make fewer household decisions. However, women who demonstrate intrinsic agency through greater egalitarian gender beliefs have lower fertility than those who believe in inequitable gender norms. Empowerment programs should focus on improvements in women's education and changing women's intrinsic agency in Egypt, to lower fertility.

Longitudinal Determinants of Married Women's Autonomy in Egypt

This article explores determinants of women's autonomy in Egypt around the beginning of the 'Arab Spring' in 2011. We show that women's autonomy over time is a product not only of their individual characteristics, but also of the household and community environment in which they live. Using the 2006 and 2012 Egyptian Labor Market Panel Survey (ELMPS) and multilevel models, results demonstrate that women's autonomy changes over time. There are large and consistent variations in women's autonomy by household region of residence and wealth. For example, women in the rural and urban Upper Egypt region are less autonomous than women in the Cairo region, and women in wealthier households are less autonomous compared to the poorest households. Programs aiming to increase women's autonomy focus exclusively or primarily on women's own characteristics. These results indicate that strategies to improve women's autonomy should be mindful of the multiple dimensions of autonomy and have a programmatic focus on changing household and social environments.

First birth and the trajectory of women's empowerment in Egypt

BACKGROUND

Women's empowerment is often used to explain changes in reproductive behavior, but no consideration is given to how reproductive events can shape women's empowerment over time. Fertility may cause changes in women's empowerment, or they may be mutually influencing. Research on women's empowerment and fertility relies on cross-sectional data from South Asia, which limits the understanding of the direction of association between women's empowerment and fertility in other global contexts. This study uses two waves of a panel survey from a prominent Middle Eastern country, Egypt, to examine the trajectory of women's empowerment and the relationship between first and subsequent births and empowerment over time.

METHODS

Using longitudinal data from the 2006 and 2012 Egyptian Labor Market Panel Survey, a nationally representative sample of households in Egypt, for 4660 married women 15 to 49 years old, multilevel negative binomial, ordinary least squares, and logistic regression models estimate women's empowerment and consider whether a first and subsequent births are associated with empowerment later in life. Women's empowerment is operationalized through four measures of agency: individual household decision-making, joint household decision-making, mobility, and financial autonomy.

RESULTS

A first birth and subsequent births are significantly positively associated with all measures of empowerment except financial autonomy in 2012. Women who have not had a birth make 30% fewer individual household decisions and 14% fewer joint household decisions in 2012 compared to women with a first birth. There is also a positive relationship with mobility, as women with a first birth have more freedom of movement compared to women with no births. Earlier empowerment is also an important predictor of empowerment later in life.

CONCLUSIONS

Incorporating the influence of life events like first and subsequent births helps account for the possibility that empowerment is dynamic and that life course experiences shape women's empowerment. This and the notion that empowerment builds over time helps portray women's lives more completely, demonstrates the importance of empowerment early in the life course, and addresses issues of temporality in empowerment fertility research.