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Empowerment, Contraceptives, Sustainable Development Goals
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Ansong JK, Otupiri E, Apenkwa J and Kuma Aboagye P. Women’s empowerment and contraceptive use: a community-based survey in peri-urban Kumasi, Ghana [version 1; peer review: 3 not approved]. Gates Open Res 2019, 3:1512 (https://doi.org/10.12688/gatesopenres.13025.1)
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Research Article
Women’s empowerment and contraceptive use: a community-based survey in peri-urban Kumasi, Ghana
[version 1; peer review: 3 not approved]
PUBLISHED 23 Jul 2019
This article is included in the International Conference on Family Planning gateway.
Abstract
Corresponding author:
Judith Kyei Ansong
Competing interests:
No competing interests were disclosed.
Grant information:
Funding was provided by The School of Medical Sciences, Kwame Nkrumah University of
Science and Technology and the Bill and Melinda Gates Institute for Population and Reproductive Health, John Hopkins Blumberg School of Public Health Project. Publication of this study was funded by the Bill and Melinda Gates Foundation (OPP1181398).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2019 Ansong JK et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Ansong JK, Otupiri E, Apenkwa J and Kuma Aboagye P. Women’s empowerment and contraceptive use: a community-based survey in peri-urban Kumasi, Ghana [version 1; peer review: 3 not approved]. Gates Open Res 2019, 3:1512 (https://doi.org/10.12688/gatesopenres.13025.1)
First published: 23 Jul 2019, 3:1512 (https://doi.org/10.12688/gatesopenres.13025.1)
Latest published: 23 Jul 2019, 3:1512 (https://doi.org/10.12688/gatesopenres.13025.1)
Science and Technology and the Bill and Melinda Gates Institute for Population and Reproductive Health, John Hopkins Blumberg School of Public Health Project. Publication of this study was funded by the Bill and Melinda Gates Foundation (OPP1181398).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
The measure of women’s empowerment varies among different regions in the world and within countries. Most studies reviewing women’s empowerment used secondary data, mostly from demographic and health surveys of countries, which usually present national data, and may considerably mask lower level differentials (Kishor & Subaiya, 2008; Saraswati & Mukherjee, 2012; Yihunie Lakew et al., 2011). This study provided household level data in peri-urban Kumasi to show various categories of empowerment, such as economic security and contribution to family, freedom from family domination, and mobility. These three categories together could influence a woman’s use of contraception. The results of the study would be essential for health planning and management, particularly in resource-poor settings such as the Ashanti Region. The findings can also be used to guide programs that could lead to an overall improvement in the reproductive health status of women.
The International Conference on Population and Development which took place in Cairo, Egypt in 1994 decided on a programme of action which emphasised that: “the empowerment and autonomy of women and the improvement of their political, social, economic and health status is both a highly important end in itself and necessary for the achievement of sustainable human development.” It mentions that: "Advancing gender equality and equity, and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women's ability to control their own fertility are priority objectives of the international community." (UNFPA, 1995) As a result of this, women empowerment is a significant factor to promote female access to family planning.
Unfair gender and social norms grant control of women’s needs to others in the family, limit their potential to take part in decision-making, limit their mobility and their permission to use family resources, and give them minimal reason to expect good-quality and well-mannered healthcare services. It has also been observed that there is a power change when inequitable gender and social norms are directly addressed, and people are helped to think differently about their roles and rights as women and men to make informed decisions about their reproductive choices. The primary requirement for women to control their fertility is to empower them. The basic requirement for women’s health, wellbeing, and rights is to empower them with the ability to manage their fertility. Women’s empowerment also overcomes barriers at family and community levels and increases women’s ability to make decisions about their family size or spacing of pregnancies (Grown et al., 2005; Klugman et al., 2014).
Women’s empowerment is defined as: “an expansion in the range of potential choices available to women so that actual outcomes reflect the particular set of choices which the women value” (Kishor & Subaiya, 2008). Empowerment itself is described as the process by which the powerless gain greater control over their lives, gaining power not over others but to achieve goals and ends (Gupta & Yesudian, 2006; Kishor & Subaiya, 2008). According to Malhotra, even though the empowerment process is applicable to both sexes, it is more relevant for women. This is because disempowerment of women is more prevalent and difficult to understand because household and inter-family relationships are a major source of women’s powerlessness (Malhotra & Schuler, 2005).
Governments and donor agencies working all over the world to improve women‘s access to economic resources, political, social and health status, reflect the fact that improvements in the condition of women, which are essential for achieving sustainable development, cannot be separated from advancements in women’s rights. One such focus area requiring gender-related action is the development and evaluation of ways that aim to promote positive reproductive health outcomes. Around the globe, women are restricted in their ability to make decisions or participate in decision-making concerning family planning or even to have open discussions with their partners about it due to lack of power (Blanc, 2001; Bawah et al., 1999). Cleland found out that the benefits of using contraception have been widely discussed, and the rise in its use in developing countries has been associated with a reduction in fertility, reduction of both child and maternal mortality, improvements in women empowerment, and poverty reduction among others (Cleland et al., 1996).
Ghana was one of the first countries to embrace a clear and all-inclusive population policy in sub-Saharan Africa. This policy, which was promulgated in 1969, aimed at reducing the growth rate of the population and offer individuals access to, and freedom to choose from, several family planning methods for spacing and limiting births. The policy was later reviewed in 1994 to take account of other emanated issues such as HIV/AIDS and to place a renewed emphasis on spacing and limiting births. It also aimed to reduce the total fertility rate through increased contraception (Ghana National Population Council, 1994). Since then, through the activities of many social organizations, family planning has become common in Ghana. The 2014 Ghana Demographic and Health Survey indicates that knowledge of contraceptive methods is universal in Ghana. In total, 98% and 99% of all men and all women, respectively, know at least one method of contraception. Among currently married women, knowledge of contraception is similar to that among all women, especially regarding level of knowledge. Of currently married women, 98% know at least one method of contraception or a modern method. Modern methods of contraception which are generally known in Ghana include condoms, sterilisation, the pill, the intrauterine device, injectable, implants, foam tablets and jelly (GSS/GHS/ICF International, 2015).
Despite this high level of awareness of contraception and the fact that family planning programmes have become well established in Ghana, progress on increasing utilization of contraception has not improved especially among married women. Between 2008 and 2014, the use of all methods of contraception marginally increased (from 24% to 27%), while the use of modern methods also increased (from 17% to 22%) among married women (GSS/GHS/ICF macro, 2009; GSS/GHS/ICF International, 2015). However, these figures are still much too low. The use of contraceptives among married women has nearly doubled in the past 20 years in Ghana. Past studies have indicated an increase in contraceptive use in the late 1980s and 1990s, from 13 to 22% among married women. However, over the past ten years, the changes have been unimpressive and sometimes negative. The prevalence rate for contraceptive use went up from 22% among currently married women in 1998 to 25% in 2003; it went down for five years until 2008, which was 24% but increased again to 34.3% in 2010. The overall picture has been one of inadequate progress made and missed targets (GSS/GHS/ICF macro, 2009; WHO, 2010).
Factors such as education, level of income, spousal consent, place of residence and religion determine contraceptive adoption and use among women (Chudasama et al., 2008; Kaggwa et al., 2008; Salway, 1994). Empowerment of women should not be ignored if satisfactory progress is to be made in increasing contraceptive utilization (GSS/GHS/ICF macro, 2009).
The benefit of empowering women is a pathway for achieving the Sustainable Development Goals: One (to end poverty in all its forms everywhere), Four (to ensure inclusive and quality education for all and promote lifelong learning) and Five (to achieve gender equality and empower all women and girls) (UNDP, 2015). Empowering women is a cornerstone of development because it helps build healthier, better-educated, and more peaceful and prosperous societies. There is a reduction in poverty, economies flourish, and the health of children and mothers improves when women are empowered in society. Additionally, women are able to make important decisions within the household and participate meaningfully and visibly in the society in which they live. Empowering women gives them the ability to make decisions about their body and their reproductive health, make better use of reproductive health and family planning information and services which enables them to achieve their desired family size (Srivastava, 2009).
It is against this background that this study set out and investigated the impact that women’s empowerment has on current and future contraceptive use, taking into account socio-economic, demographic and other factors.
Methods
Study background
This was a community-based cross-sectional study with a quantitative approach. Data were collected at one point in time from the study population. The study population was women aged 15–49 years who were married or cohabiting at the time of the study. The study used the sampling frame of the Family Health and Wealth Study (FHWS) in Asawase, Kumasi; details of the FHWS study approach has been published elsewhere (OlaOlorun et al., 2016). In short, the FHWS is a longitudinal open-cohort study in Asawase and Oforikrom sub-metropolitan area (peri-urban Kumasi) that is looking at the relationship between family size, wealth and health. The FHWS has been on-going since 2009 and it has had three rounds of data collection. Data for the current study were collected from four well-defined clusters (A, B, C, and D) between April and June 2014.
Study area and participant selection
The study area for the Family Health and Wealth Survey covered Oforikrom, which has 25 electoral areas, and Asawase, which has 100. There were eight electoral areas randomly selected from Oforikrom and 32 from Asawase, giving 40 electoral areas. A census of households and structures (listed and clearly identified with numbers) in these electoral areas was undertaken. Sampling frames of the eligible households and structures were developed for the study area in Oforikrom and the three study areas in Asawase giving four clusters (A, B, and C, D). Households were systematically selected. In the households with more than one eligible family (couple), one couple was randomly selected. In all, 20 families from each electoral area were selected, which summed up to 800 families for the FHWS (OlaOlorun et al., 2016).
Since the current study was nested in the FHWS, a sampling frame was constructed with the list of all the 800 FHWS households. One married/cohabiting woman aged 15–49 years, who was willing to be part of the study, was randomly sampled from each of the randomly selected households.
The 800 women in the households, captured under the FHWS round II, served as the study sample for the current study; 761 of the women who were randomly selected, consented to participate in the current study.
Survey questions
Each respondent was interviewed in the Ashanti Twi language. Before each interview, the objective of the research was communicated to the respondents in detail for them to understand and give their consent. Respondents were assured of anonymity and the confidentiality of their responses and all other information gathered. The inclusion criteria were: current contraceptive users (using contraceptive at the time of the study) or intended to use contraceptive in future, willing and able to give informed consent, aged between 15–49 years, married or living with a man (the study did not consider the type of marriage, once the woman reported that she was married or cohabiting she was eligible to be studied), and a resident of the study area for at least two years. At the end of each study, all questionnaires were checked for completeness and consistency. Women who were not using any method of contraception at the time of the study, and did not intend to use contraceptive in future were excluded.
The survey instrument included questions on age, religion, level of education, ethnicity, number of living children and how much they earned. Age in complete years was categorized as 24 years, 25–29 years, 30–34 years, 35–39years, 40–44 years and 45–49 years. Marital status was defined as married or cohabiting. Parity was defined as the number of living children and was grouped as 0–1, 2–3 and 4 or more. Education level was defined as no formal, primary, middle or Junior High School and Secondary or Higher. The secondary and tertiary education categories were collapsed due to the small percentage of women with tertiary education. Religion was also categorised as Catholic, other Christians, Muslim and Traditional or Spiritualist due to their varied beliefs on contraceptive use.
The survey instrument had two major components: family planning and empowerment. A screening question on contraceptive use inquired whether a respondent was currently using (use at the time of the survey) or had the intention to use any family planning method in future. There were two questions that probed reproductive control, namely if she had decided to have more children and if she intends to use contraceptives after having a child. Questions used to determine empowerment focused on economic security and contribution, freedom from family domination, and mobility.
The empowerment questions were developed based on an empowerment scale, which was adopted from Maholtra and Schuler (Malhotra & Schuler, 2005). Specifically, for mobility, we asked whether respondents required permission from their husbands/partners to attend an organizational meeting, visit parents, travel outside the home, see a health care worker or to access family planning. Every respondent was given a single point for each place she had visited, a single point if she had ever gone there alone and an additional point if she went without the husband’s/partner’s approval. The scale ranged from 0 to 12 and was treated as a continuous variable. For the purposes of this study, a score from 1 to 6 was considered as not empowered and a score from 7 to 12 was considered as empowered for easy analysis.
For economic security and contribution, the respondent was asked whether she required permission from her husband/partner to earn money, own a property in her name, have a savings account, and own any productive asset, and what proportion of her total household expenses was met through her own earnings. Two variables were used in this analysis, economic security and contribution to family support. Economic security was based on a scale from 0 to 4. One point was assigned for each of the following: if a woman owned her house or land, owned any productive asset, had her own cash savings and if her savings were ever used for business or money lending or treasury bills. A woman with a score of 2 or higher was classified as empowered for easy analysis. Contribution to family support measured if the respondent said she provided all, most, half, or some of her family’s support, as opposed to very little or none.
For freedom from family domination, the respondent was asked if her husband had ever prevented her from: using her own money, visiting her parents, working outside the home, accessing family planning services or taken her money when she didn’t want him to. If she answered ‘no’ to all these she was classified as “empowered” and coded 1; the group “not empowered,” was coded as 0.
Data analysis
The items on the scales were collapsed into two categorical variables, empowered and not empowered, for chi-square analysis. Based on the empowerment scale, the women were empowered or not empowered in terms of economic security and contribution to family support, freedom from family domination scores and mobility (Nanda, 2011).
Double data entry into a pre-designed electronic database record form using EPI Info version 7 was done and later exported into STATA version 12 for analysis. Bivariate regression analyses were run to investigate the relationships between current contraceptive use, categorical and continuous independent variables. Multivariate logistic regression was used to determine associations between the various category of women’s empowerment, and current or future contraceptive use. Categorical variables (binary, ordinal and nominal) were presented in proportions and ratios with their 95% confidence intervals. The continuous variables were presented as means with their ranges and standard deviations. For multivariate analyses chi-square was used to establish any difference in proportions. The relationships between the empowerment dimensions and contraceptive use or intention to use were analysed and presented as odds ratios and adjusted odds ratios with 95% confidence interval and p-values. P≤0.05 was considered to indicate statistical significance.
Ethical considerations
The Committee of Human Research, Publications and Ethics of the Kwame Nkrumah University of Science and Technology/Komfo Anokye Teaching Hospital approved the study. The Kumasi Metropolitan Directorate of Health Services and leaders of the various communities provided administrative clearance.
Written informed consent with respondents’ anonymity, privacy and confidentiality assured was obtained from all participants. The respondents’ autonomy was protected and there was no coercion of any sort. All information collected in this study was given code numbers and no name was recorded so that the reports cannot be easily linked with their names.
Results
Demographic information
Almost two-thirds (62%) of the respondents were less than 35 years of age. The mean age of the respondents was 34.2 years with a range of 18 to 49 years. More than 74% were married. A little over 60% of respondents were Christians. More than 26% had only primary education, with 23% having had secondary education or higher. Akan accounted for the largest proportion of respondents by ethnic groupings (50%). Of the respondents, 16% had not received any formal education. A little under half (47%) of the respondents earned less than 200 Ghanaian Cedis monthly, equivalent to 50 US dollars. Nearly half (49%) of the respondents have two or three living children (Table 1). Responses to each question of the survey from each participant are available as Underlying data (Ansong et al., 2019).
Table 1. Socio-demographic characteristics.
Contraceptive use and women’s empowerment
In total, 46% of the women sampled were using contraceptives at the time of the survey as compared to 54% who intended to use a contraceptive method in future.
Based on the three scales used in the study, 218 (29 %) of the respondents were empowered in all the three categories. A total of 255 (34%) of the respondents were empowered in two out of the three categories of empowerment measure, and 220 (29%) were empowered in only one category of the empowerment measure but 68 (9%) of them were not empowered in any of the categories (Figure 1).
Figure 1. Distribution of the overall level of empowerment.
In model 1 the three categories of empowerment were modelled as the main covariates against contraceptive use in a bivariate logistic regression model. Economic security and contribution empowerment (p=0.001) and mobility empowerment (p=0.016) were statically significant with current or future contraceptive use even though economic security and contribution had higher odds (odds ratio (OR)=1.91; 95% confidence interval (CI)=1.33, 2.73) than mobility empowerment (OR=1.07; 95% CI=1.01, 1.13) (Table 2).
Table 2. Logistic regression on the categories of empowerment and contraceptive use.
| Variables | Model 1 | Model 2 | ||
|---|---|---|---|---|
| OR | p-value (95%CI) | AOR | p-value (95%CI) | |
| Economic security and contribution | ||||
| Not empowered (ref) | 1.00 | |||
| Empowered | 1.91 | 0.001* (1.33,2.73) | 1.76 | 0.027* (1.06,2.93) |
| Freedom from family domination | ||||
| Not empowered (ref) | 1.00 | |||
| Empowered | 0.92 | 0.624 (0.69,1.24) | 0.93 | 0.707 (0.65,1.32) |
| Mobility | ||||
| Not empowered (ref) | 1.00 | |||
| Empowered | 1.07 | 0.016* (1.01,1.13) | 1.34 | 0.096 (0.94,1.90) |
Economic security and contribution (adjusted OR (aOR)=1.76; 95% CI= 1.06, 2.93) was found out to be statistically significantly associated with contraceptive use (p=0.027), whereas freedom from family movement (aOR= 0.93; 95% CI = 0.65, 1.32) and mobility (aOR= 1.34; 95% CI = 0.94, 1.90) were not significantly associated with contraceptive use (Table 2). The odds of empowered women using contraceptives was 1.76 times the odds of women who are not empowered as indicated in the aOR from the table.
Discussion
As a result of the International Conference on Population and Development, which took place in Cairo, Egypt in 1994, women empowerment has been a significant factor in promoting female access to family planning (UNFPA, 1995). Empowering women gives them the ability to make decisions about their body and their reproductive health and make better use of reproductive health and family planning information and services, which enables them achieve their desired family size (Srivastava, 2009). The measure of women’s empowerment varies among different regions in the world and within countries.
Based on the three scales used in the study, less than a third of the respondents were empowered in all the three categories. More than 35% of the respondents were empowered in two out of the three categories of empowerment measure, and 29% were empowered in only one category of the empowerment measure but about 1 in 10 of them was not empowered in any of the categories. This paper also confirmed the fact that even though knowledge and awareness of family planning methods are almost universal in Ghana, utilisation has been less than desired. This study found that 46% of the respondents were current contraceptive users; this is higher than the national figure reported by the 2014 GDHS. The NGO-funded family planning promotion that was on-going at the time of the study could be responsible for the seemingly high figure.
This study is limited by the fact that women’s empowerment and contraception are controversial topics and respondents may have given socially desirable answers. An additional limitation of this study was its cross-sectional nature, which makes it difficult to determine the temporal relationship between variables. However, despite these limitations, the study used random sampling with a well-established sampling frame and also used questions that were context-sensitive. The study also found a statistically significant association between economic security and contribution empowerment and current and future contraceptive use.
Conclusions
This study has highlighted key issues on the relationships between women’s empowerment and contraceptive use in a peri-urban setting in Sub-Saharan Africa. It is also one of the few attempts to provide an overview of a quantitative evidence-based study. Economic security and contribution to family empowerment was identified in this study as having an association with a woman’s current or future use of contraceptives. It can be concluded that women’s empowerment plays a significant role in the utilization of family planning services.
Data availability
Underlying data
Open Science Framework: Women’s empowerment and contraceptive use; a community-based survey in peri-urban Kumasi, Ghana. https://doi.org/10.17605/OSF.IO/JHPR5 (Ansong et al., 2019).
This project contains the dataset in DTA and CSV formats.
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
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Ansong JK, Otupiri E, Apenkwa J and Kuma Aboagye P. Women’s empowerment and contraceptive use: a community-based survey in peri-urban Kumasi, Ghana [version 1; peer review: 3 not approved]. Gates Open Res 2019, 3:1512 (https://doi.org/10.12688/gatesopenres.13025.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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