Conceptions and Measurement of Contraceptive Autonomy

Abstract

This dissertation uses mixed methods to understand women’s perspectives on contraceptive access and provision, and to create and test a new population-based quantitative indicator that measures various dimensions of autonomy in family planning. The introduction to the dissertation charts the intellectual history of the contemporary family planning movement to elucidate how we arrived at the present moment with the existing tools in our measurement toolbox. The first paper develops a novel concept called “contraceptive autonomy,” which is defined as the various factors are necessary for a woman to decide for herself what she wants as it relates to contraceptive use, and then to realize that decision. This paper then proposes an algorithm to operationalize the measure of the three subdomains of contraceptive autonomy (free choice, full choice and informed choice) into two population-based indicators: the stand-alone autonomy score and the autonomy-adjusted contraceptive prevalence rate. The second paper uses qualitative methods to explore women’s subjective experiences with barriers to contraceptive autonomy in a sub-Saharan African country. The analysis is based on 49 in-depth interviews with women of reproductive age and 3 key-informant interviews with health system administrators. Findings include a spectrum of coercive experiences ranging from the subtle to the overt, as well as the importance of systemic and structural causes of contraceptive coercion. The final paper is an analysis of quantitative data collected from household surveys in rural Burkina Faso to generate a proof-of-concept of the contraceptive autonomy algorithm. This analysis tests and applies the concepts and methods described in Paper 1 to a random sample of women ages 15-49 (n=2654). Findings show that lack of informed choice is the largest contributor to contraceptive non-autonomy in this setting. Logistic regression models show that predictors of contraceptive autonomy in this setting include education, nulliparity, and being married. By creating new tools that can be used by those who implement, and evaluate contraceptive programs to better gauge the extent to which these programs respect women’s autonomy, as well as furnish an improved understanding what the major barriers to autonomy are, the ultimate goal of this dissertation is to contribute to an improved respect for women’s choices within global family planning programs.