The effect of women’s bargaining power within couples on contraceptive use in Cameroon

Dimitri Tchakounté Tchuimi; Benjamin Fomba Kamga

doi:10.12688/gatesopenres.13100.1

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Research Article

The effect of women’s bargaining power within couples on contraceptive use in Cameroon

[version 1; peer review: 2 approved with reservations, 1 not approved]

Dimitri Tchakounté Tchuimi ¹, Benjamin Fomba Kamga¹

PUBLISHED 10 Feb 2020

Author details Author details

¹ Faculty of Economics and Management, University of Yaounde II, Yaounde, Centre, Po. Box 1792, Cameroon

Dimitri Tchakounté Tchuimi
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Benjamin Fomba Kamga
Roles: Funding Acquisition, Project Administration, Resources, Supervision, Writing – Original Draft Preparation

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the International Conference on Family Planning gateway.

Abstract

Background: The prevalence of contraception among married women, evaluated at 23%, is low in Cameroon. Maternal death rates, estimated at 782 deaths per 100,000 live births, are very worrying. The National Strategic Plan for Reproductive, Maternal, Newborn and Child Health (2015-2020) focuses on increasing contraceptive prevalence as a means to reduce maternal death. This paper identifies women’s bargaining power as a factor that may stimulate contraceptive use. The objective of this study is to measure the effect of women's bargaining power within couples on contraceptive use.
Methods: The data used come from the Demographic and Health Survey and Multiple Indicators (DHS-MICS) conducted in 2011. Women’s bargaining power within couples is measured by a Woman Bargaining Power Composite Index (WBPCI) built through a multiple correspondence analysis. Descriptive statistics (frequency distribution, cross tabulation, chi-square test) and the probit model were used to analyze the relationship between WBPCI and contraceptive use. Additionally, since the target population for this study is couples in which women were not pregnant, a Heckman probit model was also estimated to address the potential selection bias.
Results: The results of the descriptive statistics show that women's bargaining power is higher among women who use contraception than for those who do not. The results of the probit model show that women's bargaining power significantly increases the probability of contraceptive use by 3.4%. In addition, the probability of using contraception also increases with the education of women. The estimation of the Heckman probit model illustrates that the effect of women's bargaining power on the probability of contraceptive use remains virtually unchanged.
Conclusions: To reduce high maternal death rates in Cameroon, public health policies should not only focus on the health system itself but should also focus on social policies to empower women in the household.

Keywords

Women’s bargaining power, Contraceptive use, Couple, Maternal death, Probit model, Cameroon

Corresponding author: Dimitri Tchakounté Tchuimi

Competing interests: No competing interests were disclosed.

Grant information: This research was supported 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: © 2020 Tchakounté Tchuimi D and Kamga BF. 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: Tchakounté Tchuimi D and Kamga BF. The effect of women’s bargaining power within couples on contraceptive use in Cameroon [version 1; peer review: 2 approved with reservations, 1 not approved]. Gates Open Res 2020, 4:20 (https://doi.org/10.12688/gatesopenres.13100.1) First published: 10 Feb 2020, 4:20 (https://doi.org/10.12688/gatesopenres.13100.1) Latest published: 29 Jul 2024, 4:20 (https://doi.org/10.12688/gatesopenres.13100.3)

Introduction

Improving maternal health is one of the key priorities of public health policies in the world in general, especially in developing countries. Defined in 2000 as the fifth Millennium Development Goal (MDG-5), the reduction of maternal deaths was renewed in 2015 as a target of the third Sustainable Development Goal (SDG-3). For a woman, pregnancy is a period of the life cycle during which her health is particularly vulnerable. In fact, the complications observed throughout this period seem to be the main cause of maternal deaths in developing countries (Haider et al., 2017). The use of reproductive health care services, particularly in relation to the use of contraception to control fertility and to prevent early and unwanted pregnancies, appears to be an investment to ensure good health for the mother. Thus, access to reproductive health care is an effective weapon for limiting the risk of maternal morbidity and death (Hou & Ma, 2013).

In developing countries, several factors may be associated with the use of reproductive health care services. The 1994 International Conference on Population and Development (ICPD) in Cairo already emphasized the role of women's economic empowerment. Moreover, as it is recognized that decisions that lead women to use reproductive health care services occur in the sphere of marriage, the household or the family (Becker, 1996), much literature has suggested that appreciation of women's bargaining power¹, while at the same time reducing gender inequalities in the couple, is an important driver for the use of reproductive health care services (Blanc, 2001; Chapagain, 2006; Haque et al., 2012; Kamiya, 2011). It is generally recognized that women's bargaining power over resource allocation and decision-making is assessed through so-called modern factors, such as education, income, possession of property, legislation prohibiting violence against women and the freedom to move about (Adjiwanou et al., 2018; Allendorf, 2007; Beegle et al., 2001; Habibov et al., 2017). However, the power of women is hardly indissociable from the channel of social and cultural norms on the allocation of resources in the household and the role of women in the organization of the household and the couple; in most cases, these standards restrict women in decision-making both for themselves (decisions about the use of adequate health care, among others) and their children. As a result, since women's traditional values may hinder the positive impact of their modern values, the mechanisms by which women's bargaining power can influence the use of reproductive care appear delicate and ambiguous (Westeneng & D'Exelle, 2015), drawing our attention to the specificity of the context in which the study is conducted.

In Cameroon, the assessment of the use of reproductive health care is of particular importance since maternal death levels increased considerably between 2004 and 2011, from 669 to 782 deaths per 100,000 births. Current government policy on reproductive health focuses on facilitating access to reproductive care (with a focus on assessing modern contraceptive prevalence) as a means of reducing these high rates of maternal mortality. However, it is becoming increasingly clear that issues related to reproductive health are more of a joint behavior in a couple than an individual choice. Indeed, in Africa, marriage remains the privileged place of procreation (Noumbissi & Sanderson, 1999) and where the decision to use adequate reproductive health care results from the ability of each partner expressing preferences through negotiation (Nikiema et al., 2008).

This paper aims to evaluate the effect of women's bargaining power within couples on contraceptive use in Cameroon. The contribution of this study is at three main levels. First, information from work linking women's bargaining power in the couple and reproductive health is fairly abundant in countries with a strong tendency to conserve patriarchal cultures. However, this type of investigation is particularly rare in Cameroon, a country not bordering on the prevalence of asymmetrical gender relations and power imbalances between spouses. This study will fill the gap related to this information scarcity. Secondly, this study aims to provide an effective tool for achieving the goal of reducing maternal death rates of the current health policy in the horizon of 2020². Thirdly, it incorporates the idea that there is a potential sample selection bias due to the fact that the study focuses on non-pregnant women at the time of survey.

Methods

Ethical statement

Permission to use the datasets for this research was obtained prior to the study from the Demographic and Health Surveys (DHS) Program. Ethical approval was not required for this study because it used anonymized DHS data only. The IRB-approved procedures for DHS public-use datasets do not in any way allow respondents, households, or sample communities to be identified.

Data

The data come from the fourth DHS conducted jointly with the Multiple Indicator Cluster Survey in Cameroon (DHS-MICS) in 2011. This survey was conducted by the National Institute of Statistics (INS) in collaboration with the Ministry of Public Health and financial support from the United States Agency for International Development (USAID), United Nations Population Fund (UNFPA) and UNICEF. As in other developing countries, this survey has collected information on household characteristics, reproductive and sexual health/AIDS, children's health, STD/AIDS knowledge, attitudes and behaviors, and the bargaining power of women in households. Three questionnaires permitted us to collect the data in this survey: the women's questionnaire, the men's questionnaire and the household questionnaire. These different questionnaires generated five modules: the child, woman, man, household and couple modules. As part of this analysis, we will use the couple (monogamy) module within which the answers to the questions were reported by women aged 15 to 49 who reported being married or living in a union with a partner.

In total, a representative sample of 2,973 couples was constituted at the end of the survey. However, since we are interested in the use of contraception at the time of the DHS-MICS survey, the analysis is limited to couples in which women were not pregnant. The data comprised of a total of 461 couples where each woman was pregnant at that time was therefore excluded. Thus, the final sample consists of 2,512 couples.

Variable measurement

Dependent variable. The dependent variable of this paper is the use of contraception. It is measured by a variable that takes the value 1 if the woman uses a modern or traditional contraceptive method at the time of the survey, and 0 if not. The modern contraceptive methods include the pill, the intra-uterine device (IUD), the injection, the condom, the implant/Norplant, the female condom and sterilization. The traditional methods include periodic abstinence, withdrawal, breastfeeding, and amenorrhea.

Independent variables

The variable of interest, women’s bargaining power

The transition from the theoretical conception of the woman's bargaining power to her empirical measure is associated with many difficulties since the process of negotiation between the partners within a couple is unobservable (Beegle et al., 2001; Friedberg & Webb, 2006). Thus, to measure the bargaining power of women, it is essential to resort to proxies (Doss, 2006). A review of the literature reveals that several dimensions can be used to design it (Ewerling et al., 2017; Hanmer & Klugman, 2016; Lépine & Strobl, 2013; Mahmud et al., 2012).

In this research, women's bargaining power is apprehended through six specific dimensions: decision-making on key aspects of household life, control over financial resources, economic status/independence in the household, women's attitudes towards husband’s violence (a dimension to understand the contribution of cultural norms to the role of gender justifying the domination of the husband over the women), belonging to community groups/associations and the interruption of the interview by an adult (the husband, another man or a woman). A detailed description of each of these dimensions and their indicators is provided as Extended data (Table A1; Tchakounte, 2020). A multiple correspondence analysis (MCA) on the indicators that makes up each of these dimensions has permitted us to generate a Women Bargaining Power Composite Index (WBPCI) used in our investigations to measure the bargaining power of women. The results of this MCA are provided as Extended data (Table A2; Tchakounte, 2020)³.

Keeping the continuous values of the WBPCI has the relevance of avoiding ambiguities related to a categorization of this index in various modalities (Haider et al., 2017). As Richardson (2018) points out, using threshold values to categorize such an index is not appropriate as it is only a matter of value judgments and a subjective approach that sometimes may not reflect the context in which the study is conducted.

However, it should be noted that the WBPCI values obtained after the MCA are negative and positive (between -2.21 and 4.07), which may lead to ambiguities in the interpretation of this index and its likely effect on contraceptive use. Therefore, a normalization of the WBPCI will be made in order to make its values only positive (greater than or equal to zero). Thus, if Min_WBPCI is the minimum value of the WBPCI, then this normalization consists in applying the formula: WBPCI -Min_ WBPCI.

In addition, Cronbach's alpha coefficient is used to measure the internal consistency of the WBPCI. The closer the value of this coefficient is to 1, the more reliable the constructed index is (Aiken & West, 1991). Here, the value of Cronbach's alpha obtained is 0.716, which indicates the reliability of the WBPCI.

Control variables

Control variables are divided into three categories: socio-demographic, economic and cultural factors, media exposure factors, and intermediate variables of contraception. The first category of factors includes age, education, work status, religion, number of living children, household wealth and place of residence. Two factors of women’s exposure to the media are considered: exposure to television and exposure to radio. For the third category of factors, two intermediate variables of contraception are considered: the desire of the woman not to have an additional child and the husband's approval of family planning. Table 1 highlights the description, measurement and codes of control variables.

Table 1. Description, measurement and codes of control variables

Variables	Description and measurement
*Sociodemographic, economic and cultural factors*
Age of woman	Age (number of years) of the woman at the time of the survey.
Age of partner	Age (number of years) of the partner at the time of the survey.
Education of woman	The highest level of education attained by women measured by four dummy variables: uneducated, primary, secondary and higher level.
Education of partner	The highest level of education attained by partner measured by four dummy variables: uneducated, primary, secondary and higher level.
Status of occupation of husband	Measured by a binary variable taking the value 1 if the husband worked in the 12 months preceding the survey and 0 if not.
Religion of woman	Represents the religious affiliation of the woman measured by three dummy variables: Muslim, Christian and other religions.
Number of living children	Represents the number of living children of the couple.
Household wealth	Represents the household's living standard and measured using the wealth index, which categorizes household into five wealth quintiles: poorest, poor, average, rich and richest⁴.
Place of residence of household	Measured by a binary variable taking the value 1 if the household lived in a rural area and 0 if they lived in an urban area⁵.
*Factors of exposure to media*
Exposure to TV	Number of times the woman watched TV per week and measured by a dummy variable: 1 if at least once per week and 0 if not once.
Exposure to radio	Number of times the woman listened to the radio per week and measured by a dummy variable: 1 if at least once per week and 0 if not once.
*Intermediate variables of contraception*
Approval of family planning by husband	Measured by a dummy variable taking the value 1 if the husband approved family planning and 0 if not.
Desire of the woman to have no more children	Measured by a dummy variable taking the value 1 if the woman no longer wanted to have children and 0 if not.

Empirical methods

In addition to descriptive statistics (cross tabulation and chi-square tests), this paper also uses an econometric model. To this end, let us recall that the objective of the research is to measure the effect of women's bargaining power within couples on contraceptive use. Since contraceptive use is a dichotomous variable, a qualitative dependent variable model, and more specifically a probit model, is used.

Specification of probit model. The probit model can be formalized using the following equation:

C_{i}^{*} = β_{0} + β_{1} W B P_{i} + β_{2} X_{i} + ε_{i} [1]

Where

C_{i}^{*}

corresponds to the probability that the married woman of couple i use one contraceptive method. It’s the latent variable of contraceptive use, C_i, defined as:

C_{i} = {\begin{matrix} 1 if C_{i}^{*} > 0 \\ 0 if C_{i}^{*} \leq 0 \end{matrix}

The probability of using a contraceptive method is expressed as follows:

P (C_{i} = 1) = P (C_{i}^{*} > 0) = P (- ε_{1 i} \leq β_{0} + β_{1} W B P_{i} + β_{2} X_{i}) = 𝜑 (β_{0} + β_{1} W B P_{i} + β_{2} X_{i})

Where φ is the normal distribution function.

WBP_i corresponds to woman’s bargaining power of couple i and is measured by WBPCI. β is the coefficient which allows measurement of the effect of woman’s bargaining power on contraceptive use. X is the matrix of control variables, and γ is the vector of parameters which permits assessment of the effect on contraceptive use of control variables contained into X. ε is the error term, independently and identically distributed.

However, it should be noted that to analyze the effect of women's bargaining power on contraceptive use, we restricted the sample to women who were not pregnant at the time of survey and 461 women were excluded. Therefore, to provide a more robust analysis, it is relevant to address the potential selection bias that may exist as a result of the exclusion of pregnant women from the sample.

Taking into account the selection bias: specification of Heckman probit model. Indeed, if the probability of not being pregnant or having a child is correlated with the woman's bargaining power, this would lead to a potential source of sample selection bias. The results obtained from the probit model could then be biased. To produce results in accordance with the potential selection bias, the probit model with sample selection, or Heckman probit model, will be estimated. As specified in the equation [1], the probit model is written as: $C_{i}^{*} = β_{0} + β_{1} W B P_{i} + β_{2} X_{i} + ε_{i}$ where C is observed only for C* > 0.

The equation of selection is presented as follows:

O_{i} = β_{0} + β_{1} S_{i} + β_{2} W B P_{i} + β_{3} X_{i} + ϑ_{i} [2]

where O_i take the value 1 if the woman wasn’t pregnant at the time of the survey and 0 if not. S is an additional exogenous variable of the selection equation, corresponding to the ideal family size of the woman. ε_i~N(0,1), 𝜗_i~N(0,1) and ρ = corr(ε_i,𝜗_i), that is ε and 𝜗 are the error terms that follow a standard normal distribution and, the parameter ρ corresponds to their correlation. Nevertheless, as highlighted by Van de Ven & Van Pragg (1981), the probit model with sample selection assumes that dependent variable C for observation i is observed if O_i > 0. Thus, from the equation [2], to be certain of the existence or not of a selection bias, a likelihood ratio test on the null hypothesis H₀: ρ = 0 is performed. If this hypothesis is accepted, the error terms are independent and the equations [1] and [2] have no relation. In this case, there is no selection bias. On the other hand, if this hypothesis is refuted, the error terms are linked, which means that the probability of not being pregnant is correlated with the woman's bargaining power. In this case, there is a selection bias and the Heckman probit model would be more appropriate than the probit model.

Software

The software used to carry out the empirical analyzes of this study was STATA, version 15 (StataCorp, 2017).

Results and discussion

Results of descriptive statistics

The results of the descriptive statistics are divided into two parts: univariate and bivariate statistics.

Univariate statistics. Table 2 highlights the descriptive statistics of the variables of the study. It appears that among the non-pregnant women at the time of the survey, only 23% used one contraceptive method. Overall, women in a union have a low bargaining power within the couple since the average value of WBPCI is 2.301 (knowing that the maximum value is 6.26 and the minimum is 0). Looking at control variables, the average age of married women is 31, and 40 for their partner. Among these women, the most representative level of education is the primary level (41%), followed by the secondary level (29.5%), uneducated (27%) and the higher level (3%). In addition, most of partners have a primary level of education (36%), followed by secondary level (35%), uneducated (17.5%) and a higher level (7%). Almost all partners (99%) had an occupation in the 12 months preceding the survey. The most prevalent religion among married women is Christianity (71%), with 23% of Muslim religion. On average, couples had three living children. Regarding household wealth, 22% of households were poor, 21% very poor, 20% of average wealth, 19% very rich and 18% were rich. In addition, 60% of households lived in rural areas. Regarding media exposure variables, 55.5% of married women watched TV at least once a week and 33.5% listened to the radio at least once a week. Finally, for the intermediate variables of contraception, 33.5% of married women no longer wanted to have children and 36% said that their partner approved family planning.

Table 2. Descriptive statistic of variables

Variables	Mean/proportion	Std. Dev.	Min	Max
Contraceptive use	0.229	0.42	0	1
WBPCI	2.301	0.952	0	6.28
Age of woman	31.414	8.522	15	49
Age of husband	39.664	9.405	17	63
Education of woman
Uneducated	0.268	0.443	0	1
Primary education	0.411	0.492	0	1
Secondary education	0.295	0.456	0	1
Higher education	0.026	0.16	0	1
Education of partner
Uneducated	0.175	0.38	0	1
Primary education	0.36	0.48	0	1
Secondary education	0.348	0.477	0	1
Higher education	0.066	0.249	0	1
Occupation status of partner	0.989	0.103	0	1
Religion of woman
Muslim	0.226	0.418	0	1
Christian	0.708	0.455	0	1
Other	0.066	0.248	0	1
Number of living children	3.467	2.268	0	11
Household wealth
Poorest	0.207	0.406	0	1
Poor	0.223	0.417	0	1
Average	0.201	0.401	0	1
Rich	0.177	0.382	0	1
Richest	0.192	0.394	0	1
Place of residence: Rural	0.6	0.49	0	1
Exposure to TV	0.555	0.497	0	1
Exposure to Radio	0.495	0.5	0	1
Desire to have no more children	0.335	0.472	0	1
Approval of FP by husband	0.357	0.479	0	1

WBPCI, Woman Bargaining Power Composite Index; FP, family planning.

Bivariate statistics. Table 3 breaks down the values and modalities of the different explanatory variables by the use or not of contraception. As expected, focusing on the central variables of the study (Figure 1), it appears that women's bargaining power is higher among women who use contraception (their average WBPCI is 2.77) than for those who do not use it (their average WBPCI is 2.16). This means that women with high bargaining power are more likely to use contraception than women with low power.

Table 3. Cross tabulation between contraceptive use and the explanatory variables

	Contraceptive use
Variables	Yes		No
		Mean
WBPCI	2.77		2.162
Age of woman	32.254		31.164
Age of partner	40.127		39.526
Number of children	3.795		3.369
		Proportion
Education of woman
Uneducated	0.04***		0.336
Primary education	0.445*		0.401
Secondary education	0.466***		0.244
Higher education	0.049***		0.02
Education of partner
Uneducated	0.023***		0.22
Primary education	0.412		0.344
Secondary education	0.441***		0.321
Higher education	0.117***		0.051
Occupation status of partner: Employed	0.9895		0.9891
Occupation status of partner: Unemployed	0.0105		0.0109
Religion of woman
Muslim	0.068***		0.273
Christian	0.875***		0.658
Other	0.057		0.068
Wealth of household
Poorest	0.028***		0.261
Poor	0.139***		0.248
Average	0.214		0.197
Rich	0.268***		0.15
Richest	0.351***		0.145
Place of residence: Rural	0.442***		0.647
Place of residence: Urban	0.558		0.352
Exposure to TV: Yes	0.828***		0.474
Exposure to TV: No	0.172		0.525
Exposure to Radio: Yes	0.679***		0.441
Exposure to Radio: No	0.321		0.559
Desire to have no more children: Yes	0.453***		0.30
Desire to have no more children: No	0.546		0.699
Approval of FP by husband: Yes	0.742***		0.243
Approval of FP by husband: No	0.258		0.756

Significance of Chi-square test: *** p<0.01, ** p<0.05, * p<0.1.

WBPCI, Woman Bargaining Power Composite Index; FP, family planning.

Figure 1. Women’s bargaining power by contraceptive use.

The average age of women who use contraception is 32 years and 31 years for those who do not use it. Similarly, the spouses of women who use contraception are on average older (40 years) than those of women who do not use contraception (39 years).

Women who used contraception have on average more children than those who do not use contraception (four and three children, respectively). Regarding education, it is noted that among women who use contraception, the proportion of those who have a secondary level of education is the largest (46.6%), followed by primary level (44.45%), higher (4.9%) and those who are uneducated (4%). Conversely, among women who do not use contraception, the proportion of women at the primary level and without education is the highest (40.1% and 33.6%, respectively). The chi-square test reveals a significant relationship (at 1%) between education and contraceptive use. This suggests that as a woman increases further in education, she is more likely to use contraception. Similar findings were made regarding the women’s husbands; the more the husband is educated, the more likely it is that the woman uses contraception. On the other hand, the husband's occupation status is not related to the use of contraception based on the chi-square test result. Among women who use contraception, the proportion of Christians (87.5%) is very high compared to Muslims (6.8%).

With regard to household wealth, the chi-square test leads to a significant relationship at 1% (except average wealth level) with contraception. Thus, the wealthier the household, the more likely the woman uses contraception, because the proportion of women who use contraception is higher among very rich households.

In terms of place of residence, there is also a significant 1% relationship with contraceptive use, and the proportion of women who access contraception is higher in urban areas (55.8%) than in rural areas (44.2%). Women's exposure to the media is significantly associated with contraception. Indeed, among women who use contraception, the proportion of women who are exposed to TV and radio is higher than those who are not exposed (82.8% and 67.9% against 2% and 32.1%, respectively). Finally, the intermediate factors of contraception (the desire to have no more children and the approval of family planning by the husband) are significantly related to the use of contraception.

Probit model results

Recall that the estimation of the probit model makes it possible to highlight the effect of the woman's bargaining power within the couple on contraceptive use. The results of this estimation are contained in the second column of Table 4. The interpretation of these results can be done from two angles: the effect of the woman's bargaining power and the other determinants of contraceptive use.

Table 4. Results of probit model and Heckman probit model.

	Probit	Heckman probit
Variables	dydx	dydx
WBPCI	0.0344***	0.0357***
	(0.00908)	(0.0105)
Age of woman	0.0119*	0.0133*
	(0.00673)	(0.00811)
Age squared	-0.000276***	-0.000325**
	(9.97e-05)	(0.000145)
Education of woman: Primary (Ref=uneducated)	0.0768***	0.0851**
	(0.0290)	(0.0368)
Education of woman: Secondary	0.0829**	0.0888**
	(0.0361)	(0.0424)
Education of woman: Higher	0.0411	0.0532
	(0.0626)	(0.0708)
Age of husband	0.000931	0.000820
	(0.00124)	(0.00136)
Education of husband: Primary (Ref=uneducated)	0.133***	0.140***
	(0.0372)	(0.0419)
Education of husband: Secondary	0.0840**	0.0896**
	(0.0375)	(0.0414)
Education of husband: Higher	0.0820	0.0832
	(0.0547)	(0.0582)
Occupation status of husband	0.0410	0.0565
	(0.0452)	(0.0608)
Religion of woman: Muslim	-0.121***	-0.137***
	(0.0214)	(0.0403)
Religion of woman: Christian	-0.0915**	-0.102**
	(0.0357)	(0.0442)
Household wealth: Poor (Ref=poorest)	0.110***	0.116**
	(0.0403)	(0.0461)
Household wealth: Average	0.164***	0.171***
	(0.0493)	(0.0526)
Household wealth: Rich	0.266***	0.277***
	(0.0627)	(0.0667)
Household wealth: Richest	0.326***	0.332***
	(0.0675)	(0.0700)
Place of residence (Ref=Urban)	0.0364**	0.0392*
	(0.0183)	(0.0218)
Number of children	0.0209***	0.0210***
	(0.00443)	(0.00526)
Exposure to TV	0.0650***	0.0690***
	(0.0196)	(0.0233)
Exposure to radio	0.00684	0.00756
	(0.0150)	(0.0168)
Desire to have no more children	0.0697***	0.0881**
	(0.0210)	(0.0415)
Husband approves FP	0.227***	0.244***
	(0.0198)	(0.0349)
N	2446	2,893
Prob>chi2	0.000	0.000
Pseudo R2	0.3089	-
Rho	-	-0.373
LR test (Rho=0): Prob>chi2	-	0.5548

*** p<0.01, ** p<0.05, * p<0.1. dydx, marginal effects; WBPCI, Women’s Bargaining Power Composite Index; FP, family planning; LR, likelihood-ratio.

The effect of the woman's bargaining power on contraceptive use. Table 4 shows that women's bargaining power positively and significantly affects (at 1%) the use of contraception. Indeed, an additional unit of the WBPCI leads to an increase in the probability of using contraception of 0.034. This result is coherent with the results of the bivariate statistics obtained. In the context of Cameroon, this can be explained by the fact that in developing countries, women are allocating more and more time and resources to income-generating activities and education. In fact, the DHS surveys show that the proportion of women at secondary and higher levels who are economically active increased between 2004 and 2011 from 39.1% to 46.2%, respectively. Thus, getting pregnant would be a hindrance to these ambitions. Therefore, if they have high bargaining power, and therefore a strong ability to influence decision-making in the desired direction, the likelihood that they will use contraception will be high. This outcome is similar to that found by Rwenge (2003); Klomegah (2006) and Patrikar et al. (2014). On the other hand, it is far from those of DeRose & Ezeh (2010) who found that the decision-making power of the woman (at the individual level) has no effect on the use of contraception in Uganda.

Other determinants of contraceptive use. Age, education, Muslim religion of the woman, household wealth, place of residence, number of living children, exposure to TV, approval of FP by husband and the desire of the woman to have no more children are the other determinants of contraceptive use. The woman's age significantly increases (at 1%) the probability of using contraception by 0.012.

Education of woman is also positively associated with the likelihood of using contraception. The higher the level of education, the higher the positive effect of education on the probability of contraceptive use increases, since the effect of primary education is 0.076 and the effect of secondary education is 0.082. This can be explained by the fact that relative to uneducated women, those who are educated clearly apprehend the importance of using contraception to control her fertility (through spacing or limitation) and to avoid unintended pregnancies. The challenge here is to focus on quality children, that is, children who can attend school and who can receive adequate health care. However, there is the unexpected result that higher education has no significant effect on contraceptive use. With regard to the religion of women, it appears that the Muslim religion negatively and significantly affects the probability of using contraception of 0.121. Indeed, this result can be justified since according to the report of the DHS-MICS 2011, the North Region is not only the area where we find the bulk of the Muslim population (67% in Adamawa Region, 47% in the Far North Region and 39% in the North Region), but it is also the part of the country where the total fertility rate is highest ( average of 5.2 in Adamawa Region, 6.8 in the Far North Region and 6.5 in the North Region). The Christian religion also negatively affects contraception by 0.07.

Household wealth has a positive and significant effect on the probability of contraceptive use, and this positive effect increases as household wealth increases. Compared to households living in urban areas, living in rural areas positively affects the probability of contraceptive use. This may reflect the fact that in rural areas, promotion and counseling campaigns for the use of contraceptive methods are increasingly reinforced and bear fruit. The higher the number of living children of a couple, the more likely the woman will use contraception to reduce the burden she may face. With regard to the exposure variables to the mass media, only exposure to the TV affects contraceptive use, which highlights the strong potential that TV has on an individual’s behaviors with regard to contraception. Finally, all intermediate variables of contraception positively affect the use of contraception. While the desire of a woman to have no more children has an effect of 0.069 on the probability of using contraception, the approval of family planning by husband has a much higher effect (0.239), which stresses the central role that the husband plays as a vector of contraceptive use.

Robustness checks

The third column of Table 4 also presents the results of the estimation of the probit model with sample selection (Heckman probit model) taking into account the existence of a potential selection bias. The results of the likelihood-ratio test suggest the absence of selection bias since the null hypothesis of a random selection of the sample is accepted (Prob> chi2 = 0.5548). Nevertheless, after controlling for selection bias, the effect of the woman's bargaining power (and other determinants) on the probability of contraceptive use remains virtually unchanged compared to those found in the probit model, which confirms the robustness of previously formulated analyzes. In the literature, Westeneng & D'Exelle (2015) also estimate the Heckman probit model for four equations: contraceptive use, prenatal visits, home delivery and delivery to specialized hospital/center. Regarding the equation of contraceptive use, their analysis also led to the absence of a selection bias.

Limitations of the study

This work is subject to two main limitations. Firstly, the couple module of the 2011 DHS-MICS data does not include the responses reported by husbands on decision-making in the household. This is why the paper focused on the responses reported by women only. This approach may be biased to the extent that these responses are likely to mask the reality of the couple's life and the true status of each spouse within the household. Secondly, women's bargaining power may be related to certain unobservable factors that also influence contraceptive use, suggesting the potential endogeneity of bargaining power. This aspect has been neglected in the analysis produced.

Conclusions

The objective of this paper was to assess the effect of women's bargaining power on contraceptive use based on Demographic and Health Survey and Multiple Indicators realized in 2011 in Cameroon. The bargaining power of women is measured by the WBPCI, constructed by a multiple correspondence analysis on the indicators that make up the six dimensions selected for its apprehension: the role in the decision-making on key aspects of household life, control over financial resources, economic position in the household, women's attitudes towards husband's violence, membership to associations and the interruption of the interview by an adult. Given the binary nature of contraceptive use, the probit model was used as the econometric method. The results obtained from bivariate statistics suggest that women's bargaining power is higher for women who use contraception than for women who do not use contraception. As for the econometric results, especially those of the probit model estimation, it appears that the increase of the woman's bargaining power in the couple significantly increases the probability of contraceptive use. In addition, education (primary and secondary), household wealth, exposure to TV media and intermediate variables of contraception are other determinants of contraceptive use.

Elsewhere, a robustness analysis was performed. To measure the effect of women's bargaining power on contraceptive use, women who were pregnant at the time of the survey had to be excluded, which suggests potential selection bias. Thus, a probit model with sample selection (Heckman probit model) was estimated to take into account the plausible selection bias of the sample. The outcome of the likelihood ratio test revealed the absence of selection bias. The results obtained from this Heckman probit model converge on the effect of women's bargaining power on contraceptive use, which is almost unchanged compared to that obtained from the probit model, which makes the conclusions of the probit robust.

Finally, this research is relevant in terms of economic policy implication. Indeed, the public health policy in force aims to significantly reduce the high maternal mortality rates by significantly increasing the number of women on contraception from 16.1% in 2011 to 30% by 2020. Firstly, since our findings postulate that women with high bargaining power are able to use the most appropriate reproductive health care, policy makers need to look at the social policies of status revitalization and women's empowerment within households with much acuity. Secondly, policy makers need to offer more opportunities and educational resources to encourage women to progress in education.

Data availability

Underlying data

The 2011 Cameroon Demographic and Health and Multiple Indicators Survey dataset used for this study is available online from the DHS website under the Couples’ Recode subsection:

https://dhsprogram.com/data/dataset/Cameroon_Standard-DHS_2011.cfm?flag=1. Data can be accessed by applying through the DHS website. Registration is required and access is granted for legitimate research purposes. Further information about data access can be found at: https://dhsprogram.com/data/Access-Instructions.cfm.

Extended data

Figshare: Extended data of the paper "The effect of women's bargaining power within couples on contraceptive use in Cameroon". https://doi.org/10.6084/m9.figshare.11719497 (Tchakounte, 2020)

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Software availability

Source code available from: https://github.com/DimitriTchakounte/Stata-Do-file.git

Archived source code at time of publication: https://doi.org/10.6084/m9.figshare.11371680.v2 (Tchakounte, 2019)

License: MIT

Footnotes

1 Bargaining power is defined as the ability of an individual to influence household decision-making. It is the amount of influence an individual has over other individuals in the household (Doss, 2013).

2 The current maternal health improvement policy is contained in the 2015–2020 National Family Planning Operational Plan with the primary goal of increasing the number of women on contraception from 16% in 2011 to 30% by 2020.

3 The six dimensions selected have a total of 31 indicators. After applying the principle of First Axis Ordering Consistency (FAOC) as prescribed by Asselin (2002), from the results of the first iteration of the MCA, it appears that three of these indicators (those of the interruption of the interview) are not appropriate for the construction of the WBPCI. They were thus subtracted from the second and last iteration.

4 The wealth index is generated by the DHS program using principal component analysis using data on a household’s ownership of selected assets, such as televisions and bicycles; materials used for housing construction; and types of water access and sanitation facilities.

5 According to the classification of the National Institute of Statistics, the urban area includes cities of at least 10,000 inhabitants and, the rural area includes small agglomerations of less than 10,000 inhabitants.

Faculty Opinions recommended

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Author details Author details

¹ Faculty of Economics and Management, University of Yaounde II, Yaounde, Centre, Po. Box 1792, Cameroon

Benjamin Fomba Kamga
Roles: Funding Acquisition, Project Administration, Resources, Supervision, Writing – Original Draft Preparation

Competing interests

No competing interests were disclosed.

Grant information

This research was supported 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.

Article Versions (3)

version 3

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Published: 29 Jul 2024, 4:20

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Published: 19 May 2021, 4:20

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https://doi.org/10.12688/gatesopenres.13100.1

© 2020 Tchakounté Tchuimi D and Kamga BF. 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.

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Tchakounté Tchuimi D and Kamga BF. The effect of women’s bargaining power within couples on contraceptive use in Cameroon [version 1; peer review: 2 approved with reservations, 1 not approved]. Gates Open Res 2020, 4:20 (https://doi.org/10.12688/gatesopenres.13100.1)

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 1

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Reviewer Report 06 Aug 2020

David K. Guilkey, Carolina Population Center, Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Approved with Reservations

https://doi.org/10.21956/gatesopenres.14260.r29213

This paper uses Demographic and Health Survey (DHS) data for Cameroon from 2011 to estimate a model of the determinants of contraceptive use. The key explanatory variable is an index for the strength of a woman’s bargaining power within couples which is constructed using multiple correspondence analysis. The main conclusion is that woman’s bargaining power has a positive and significant effect on contraceptive use and this result is robust to a selectivity correction used to control for dropping pregnant women from the contraceptive use equation.

Specific comments:

The multiple correspondence analysis (MCA) is not adequately described. For example, I assume that the authors used the first dimension from the MCA to construct their index but this is not clearly stated. It would also be useful to know what percent of the variation is explained by this first dimension.
It would be nice to know the breakdown of the methods that are included in the 22.9% contraceptive use. In particular, what is the percentage of traditional use? If it is large enough, it would be useful to see a multinomial logit model with three categories: non use, modern use, and traditional use since it may be the case that woman’s bargaining power could have different effects for modern versus traditional use.
The authors do not clearly state whether or not their model demonstrates causality or association. It is likely that their index could be considered endogenous to contraceptive use. It is also possible that exposure to radio and television as well as the desire for no more children are endogenous. If these possibilities are true, then the model is one of association.
It is not clear to me that the Heckman selection model is a useful addition. First of all, the identifying variable they use as an exclusion restriction from the contraceptive use equation is ideal family size and they state that this variable is exogenous. This is almost certainly not the case and it has been found to be a direct determinant of contraceptive use in other empirical work (see, for example, Cronin et al., 2018¹). Second, selection models tend to be unstable and not robust to minor variations in the model specification.
Therefore, I would recommend dropping the selection analysis and then switching to multinomial logit for the determinants of contraceptive use.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Cronin CJ, Guilkey DK, Speizer IS: The effects of health facility access and quality on family planning decisions in urban Senegal.Health Econ. 27 (3): 576-591 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Econometric Methods and program evaluation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 31 Jul 2020

Aurélia Lépine, Institute for Global Health, University College London, London, UK

Not Approved

https://doi.org/10.21956/gatesopenres.14260.r29255

This paper has several issues that would need to addressed before indexing:

The authors infers causality in the abstract and in other sections of the paper (method, result, discussion) between women's bargaining power and contraceptive use while the

This paper has several issues that would need to addressed before indexing:

The authors infers causality in the abstract and in other sections of the paper (method, result, discussion) between women's bargaining power and contraceptive use while the analysis cannot say anything about a causal relationship.
There is not enough information on the MCA and on the variables included in the women's bargaining power index. Also authors do not discuss potential issues in relying on self-report. In this context I see two main issues 1) social desirability bias and 2) the fact that women who have disproportionate power in the household in context in which this clashes with social norms may actually be more a sign of woman's neglection by her husband or conflict between spouses rather than women's bargaining power.
The sample excluded pregnant women but it is not clear if it excluded women who were not sexually active. In addition, given that it seems that several measures of women's power captured decision-making in the couple it was not clear why the analysis did not focus on married women or women living with their partner.
The dependent variable should have been coded 0 if the woman was using a traditional contraceptive method.
Bivariate analysis does not add anything to the multivariate analysis result and should be removed. In fact, the relationship between women's bargaining power and contraceptive is driven by confounding factors.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health economics.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Reviewer Report 27 Apr 2020

Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada

Approved with Reservations

https://doi.org/10.21956/gatesopenres.14260.r28708

This study is important to show the importance of women's decision-making autonomy over their use of contraception, which still remains at fairly low levels in Cameroon. The analyses are well-conducted with particular attention to possible problems of sample selection bias. This study has been conducted several times in different contexts and this study does not innovate enough in this direction.

That said, there are some corrections to be made to the article.

The construction of the independent variable: the authors used the "multiple correspondence analysis" approach to build their autonomy indicator. Then, they subtracted the minimum of the indicator values to have positive values. The problem with this construction is that it is difficult to interpret it as such, and the difficulty of comparing it between countries (which obviously is not the case here). The change of axis is to allow a good interpretation of the intercept in a regression, otherwise, I don't see the importance of this change.
The argument of the threshold to use to cut the indicator is a problem, but one can easily proceed as in the construction of poverty quintiles by dividing the indicator into 5 parts (like in the dhs). It can still be used as a quantitative variable in regressions.
Too much emphasis is placed on maternal mortality, we have to put this into perspective a little and look at the primary role of contraception which is to limit fertility level of for birth spacing.
The authors limited their analysis to couples. I do not see the relevance of this limitation here especially since the partner information that is used is the same that is available for married women with a larger sample. It is better to justify the choice of the sample, otherwise, it is more important to work on all married women I think.
In terms of results, the bivariate analysis is not properly conducted. It reversed the place of the dependent and independent variable. For example, in Figure 1, the authors show that the autonomy index is higher for women who use contraception than for other women who don’t. The opposite reasoning is the way to go; that contraceptive use is higher among women who have a high index. But the problem is precisely that with a categorical dependent variable and a continuous independent variable, there is no (simple) way to make a bivariate description.
The results presented in Table 3 are therefore poorly presented. To find out, for example, whether a woman's level of education is associated with the use of contraception, the frequencies must be presented in row and not in the column as shown in the table.
The Heckman model uses an exogenous variable. In this study, the exogenous variable used is “ideal family size of the woman”. A condition of the exogenous variable is that it does not explain the dependent variable of the second equation (here contraception). However, it is obvious that this variable influences the use of contraception. The ideal number of children is an important variable in the woman's decision to use contraception.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Demography, quantitative methods, sub-Saharan Africa

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Author Response 27 Sep 2021

Dimitri TCHAKOUNTE, Faculty of Economics and Management, University of Yaounde II, Yaounde, Po. Box 1792, Cameroon

27 Sep 2021

Author Response

Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have ... Continue reading Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have thus introduced in the revised paper most of his corrections.

Comment 1: I agree with this comment since in the new version, the values of the Woman Bargaining Power Composite Index (WBPCI) are now comprising between -2.79 and 1.586.

Comment 2: We do not affirm that an index should not be categorized (as you explained, the DHS program use such a method), but we refer on the argument suggested by Richardson (2018) to justified why our Index has not been categorized.

Comment 3: As the reviewer suggested, the emphasis has been placed on the primary role of contraception rather than maternal mortality.

Comment 4: We follow the instruction of the reviewer concerning this comment. That is why in the revised paper, the study considers only married women or women living in a union with a partner.

Comment 5: The reviewer is right. We removed the bivariate analysis in the revised paper.

Comment 6: Effectively, ideal family size of the woman seems to be an inadequate exogenous variable. We thus removed this analysis from the revised paper as also suggested by David K. Guilkey.
Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have thus introduced in the revised paper most of his corrections.

Comment 1: I agree with this comment since in the new version, the values of the Woman Bargaining Power Composite Index (WBPCI) are now comprising between -2.79 and 1.586.

Comment 2: We do not affirm that an index should not be categorized (as you explained, the DHS program use such a method), but we refer on the argument suggested by Richardson (2018) to justified why our Index has not been categorized.

Comment 3: As the reviewer suggested, the emphasis has been placed on the primary role of contraception rather than maternal mortality.

Comment 4: We follow the instruction of the reviewer concerning this comment. That is why in the revised paper, the study considers only married women or women living in a union with a partner.

Comment 5: The reviewer is right. We removed the bivariate analysis in the revised paper.

Comment 6: Effectively, ideal family size of the woman seems to be an inadequate exogenous variable. We thus removed this analysis from the revised paper as also suggested by David K. Guilkey.
Competing Interests: No competing interests were disclosed. Close
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Author Response 27 Sep 2021

Dimitri TCHAKOUNTE, Faculty of Economics and Management, University of Yaounde II, Yaounde, Po. Box 1792, Cameroon

27 Sep 2021

Author Response

Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have ... Continue reading Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have thus introduced in the revised paper most of his corrections.

Comment 1: I agree with this comment since in the new version, the values of the Woman Bargaining Power Composite Index (WBPCI) are now comprising between -2.79 and 1.586.

Comment 2: We do not affirm that an index should not be categorized (as you explained, the DHS program use such a method), but we refer on the argument suggested by Richardson (2018) to justified why our Index has not been categorized.

Comment 3: As the reviewer suggested, the emphasis has been placed on the primary role of contraception rather than maternal mortality.

Comment 4: We follow the instruction of the reviewer concerning this comment. That is why in the revised paper, the study considers only married women or women living in a union with a partner.

Comment 5: The reviewer is right. We removed the bivariate analysis in the revised paper.

Comment 6: Effectively, ideal family size of the woman seems to be an inadequate exogenous variable. We thus removed this analysis from the revised paper as also suggested by David K. Guilkey.
Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have thus introduced in the revised paper most of his corrections.

Comment 1: I agree with this comment since in the new version, the values of the Woman Bargaining Power Composite Index (WBPCI) are now comprising between -2.79 and 1.586.

Comment 2: We do not affirm that an index should not be categorized (as you explained, the DHS program use such a method), but we refer on the argument suggested by Richardson (2018) to justified why our Index has not been categorized.

Comment 3: As the reviewer suggested, the emphasis has been placed on the primary role of contraception rather than maternal mortality.

Comment 4: We follow the instruction of the reviewer concerning this comment. That is why in the revised paper, the study considers only married women or women living in a union with a partner.

Comment 5: The reviewer is right. We removed the bivariate analysis in the revised paper.

Comment 6: Effectively, ideal family size of the woman seems to be an inadequate exogenous variable. We thus removed this analysis from the revised paper as also suggested by David K. Guilkey.
Competing Interests: No competing interests were disclosed. Close
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Vissého Adjiwanou, Université du Québec à Montréal (UQAM), Montréal, Canada
Aurélia Lépine, University College London, London, UK
David K. Guilkey, University of North Carolina at Chapel Hill, Chapel Hill, USA
Patrick O. Asuming, University of Ghana, Accra, Ghana
Abiodun Adanikin, Coventry University, Coventry, UK
Manini Ojha, O. P. Jindal Global University, Sonipat, India

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6 Views

06 Aug 2024 | for Version 3

Manini Ojha, O. P. Jindal Global University, Sonipat, Haryana, India

6 Views Cite this report Responses(0)

Not Approved

Most of my previous comments have not been addressed by the authors in the version I have received. I cannot approve the manuscript for indexing with those comments and suggestions unaddressed.

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Applied microeconometrics, empirical development economics, economics of the households, health, gender and education

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10 Views

23 Jul 2024 | for Version 2

Manini Ojha, O. P. Jindal Global University, Sonipat, Haryana, India

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Approved With Reservations

Referee Report
The effect of women’s bargaining power within couples on contraceptive use in Cameroon

The paper uses DHS data to address whether women’s bargaining power within couples plays a role in modern contraceptive use in Cameroon. This is an important question worthy of research, especially since there is a gap in the literature as far as Cameroon is concerned.

I have now read the paper with great interest and in detail. However, I have certain reservations about the paper and I provide detailed comments on what can be done to improve the paper. I recommend a major revision and resubmission for the paper.

Page 3, “Moreover, as it is recognized……..health care service (Blanc, 2001…..)” This sentence is long winding and awkward. This needs to be rephrased.
Data: the study utilizes only married women or women living in a union with a partner. I’m curious to know whether these women are married only once or more than once. It would be good to see the results for the sample of women married only once to ensure that responses are for the current union only.
The authors’ outcome variable is contraceptive use defined as a binary taking value 1 if she uses modern contraceptive and 0 if she uses traditional or no contraception at all. However, traditional forms of contraception are also methods of contraception. I would be interested in seeing the analysis if the author code the contraceptive use variable as 1 for modern contraceptive vs 0 for no contraceptives; 1 for modern contraceptive & 0 for traditional contraceptives; 1 for modern & traditional contraceptives & 0 for no contraceptives. I advise the authors to add this analysis for sensitivity checks.
It would be useful for the authors to explain in simple words how to interpret the WBPCI that is constructed through MCA.
Why does the analysis not include any information on the woman’s husband characteristics? I believe as robustness, additional controls including the husband’s characteristics – atleast his employment, age, education ought to be included. The “descriptive statistics” show some summaries for partner characteristics but it is not clear if these are included in the regressions from the section on “Control variables”. In addition, DHS has information on whether the husband desires additional kids or not. This ought to be included in the regression as well as use of contraception may be a joint decision as explained by the authors.
I believe there is some information available in the DHS about women’s health care utilization. It would be interesting to see the results upon inclusion of some of these variables – doctor’s visit, distance to health facility and so on. Such variables also belong to the model that determines use of contraception.
On Page 5, under the “specification of logistic regression model”, there is a typo “?” while describing the error term.
Why have the controls like age and number of living children been converted to dummy variables for different age categories. It would be good to see the results with age and number of living children as a continuous variable. Similarly years of education is available for both the woman and the man. The authors could include years of education as a continuous variable in their regression as well.
Page 6, typo “This Table have two models…”. It should be “This Table has two models….”
The authors claim in the discussion section that WBPCI is significantly associated with women’s contraceptive use. This is contentious. The result is only significant for the unadjusted model, where the authors do not control for any additional explanatory variables. Once additional variables are included, the effect of WBPCI disappears, thus suggesting that women’s bargaining power is no longer an important determinant of modern contraceptive use once you control for exposure to radio & newspaper, desire for more kids, education, number of existing children, husband’s occupation and so on. The authors need to include this as the discussion rather than suggest that WBPCI does play a significant role in determining the log odds of using modern contraception. There is only one line explaining this result in the discussion at the end while most of the discussion pertains to the unadjusted model without any controls. This could be misleading.
Women’s age interpretation can be simplified if a continuous variable for age is utilized (information is available as continuous variable in DHS). This way it is easier to interpret if with age, the capacities of procreation decline and whether the data does in fact suggest this. As I have mentioned before, the authors can change the measurement of some of these variables and estimate an alternative model for sensitivity analysis and check.
I would like to see some discussion on what could explain the result that husband’s occupational status is associated with lower odds of using contraception?
In the limitations section, the authors mention that women’s bargaining power may be related to certain unobservable factors that also influence contraceptive use suggesting potential endogeneity of WBPCI. However, the authors are not claiming causality and as such this is not a big concern. The paper is concluding only associations.
I have reservations about the policy implications the authors make in the conclusion. The authors mention that “findings postulate that women with high bargaining power are able to use the most appropriate reproductive health care, policymakers need to look at the social policies of status revitalization and women’s empowerment within households with much acuity.” This finding is only accurate in the model with no controls and as such cannot be used as a policy suggestion. Once controls are included in the model, women’s bargaining is no longer significant. In fact, the effects of other variables considered are significant and the policy conclusions needs to be derived from those variables.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Applied microeconometrics, empirical development economics, economics of the households, health, gender and education

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13 Views

22 Jul 2024 | for Version 2

Abiodun Adanikin, Coventry University, Coventry, England, UK

13 Views Cite this report Responses(0)

Not Approved

Thank you for requesting my assessment of this manuscript, analysing women's bargaining power and modern contraceptive use in Cameroon. The manuscript was generally well written, but there are some concerns regarding data interpretation. The adjusted WBPCI was not significant, with a value of 0.996 (0.918 – 1.081), and I am curious as to whether the basis for the interpretation and conclusion of the manuscript can solely rely on the unadjusted analysis in this case, as all other variables have been interpreted using adjusted methods. This could potentially indicate bias in the interpretation. Furthermore, the interpretation of the impact of higher education and poor household wealth on modern contraceptive use in Table 3 is incorrect.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

maternal and child health epidemiology, social statistics and demography

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8 Views

19 Jul 2024 | for Version 2

Patrick O. Asuming, University of Ghana, Accra, Greater Accra Region, Ghana

8 Views Cite this report Responses(0)

Approved With Reservations

The paper investigates the effect of women's bargaining power on the use of modern contraceptives in Cameroon. The paper uses data from the 2018 Demographic and Health survey and analysis data for 6546 women who were married or in union. The authors created an index of women's bargaining power from a series of indicators and run a logistic regression model to identify the association between bargaining power and contraceptive use. The authors conclude that woman's bargaining power within the household increases the likelihood of contraceptive use.
Overall, I think the paper addresses a very important issue. It is generally well written.
My main concern is that the author's main conclusion is based on the crude model (model without covariates) but not on the full model. It is normally expected that the conclusions should be based on the full model, which in this case suggests that women's bargaining power has no influence on the likelihood of use of modern contraceptive. It is not just that the Odds-Ratio (OR) losses significance. Indeed, the OR declines substantially from the crude model to the full model to the extent that it changes signs. This probably suggests that the bargaining power of the women is probably captured by some of the covariates used. I suggest that the authors modify their conclusion accordingly to be more reflective of the full model.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health systems research, development economics, health economics.

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11 Views

19 May 2021 | for Version 2

David K. Guilkey, Carolina Population Center, Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

11 Views Cite this report Responses(0)

Approved

No further comments.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Econometric Methods and program evaluation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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21 Views

06 Aug 2020 | for Version 1

David K. Guilkey, Carolina Population Center, Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

21 Views Cite this report Responses(0)

Approved With Reservations

The multiple correspondence analysis (MCA) is not adequately described. For example, I assume that the authors used the first dimension from the MCA to construct their index but this is not clearly stated. It would also be useful to know what percent of the variation is explained by this first dimension.
It would be nice to know the breakdown of the methods that are included in the 22.9% contraceptive use. In particular, what is the percentage of traditional use? If it is large enough, it would be useful to see a multinomial logit model with three categories: non use, modern use, and traditional use since it may be the case that woman’s bargaining power could have different effects for modern versus traditional use.
The authors do not clearly state whether or not their model demonstrates causality or association. It is likely that their index could be considered endogenous to contraceptive use. It is also possible that exposure to radio and television as well as the desire for no more children are endogenous. If these possibilities are true, then the model is one of association.
It is not clear to me that the Heckman selection model is a useful addition. First of all, the identifying variable they use as an exclusion restriction from the contraceptive use equation is ideal family size and they state that this variable is exogenous. This is almost certainly not the case and it has been found to be a direct determinant of contraceptive use in other empirical work (see, for example, Cronin et al., 2018¹). Second, selection models tend to be unstable and not robust to minor variations in the model specification.
Therefore, I would recommend dropping the selection analysis and then switching to multinomial logit for the determinants of contraceptive use.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Econometric Methods and program evaluation

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26 Views

31 Jul 2020 | for Version 1

Aurélia Lépine, Institute for Global Health, University College London, London, UK

26 Views Cite this report Responses(0)

Not Approved

This paper has several issues that would need to addressed before indexing:

The authors infers causality in the abstract and in other sections of the paper (method, result, discussion) between women's bargaining power and contraceptive use while the analysis cannot say anything about a causal relationship.
There is not enough information on the MCA and on the variables included in the women's bargaining power index. Also authors do not discuss potential issues in relying on self-report. In this context I see two main issues 1) social desirability bias and 2) the fact that women who have disproportionate power in the household in context in which this clashes with social norms may actually be more a sign of woman's neglection by her husband or conflict between spouses rather than women's bargaining power.
The sample excluded pregnant women but it is not clear if it excluded women who were not sexually active. In addition, given that it seems that several measures of women's power captured decision-making in the couple it was not clear why the analysis did not focus on married women or women living with their partner.
The dependent variable should have been coded 0 if the woman was using a traditional contraceptive method.
Bivariate analysis does not add anything to the multivariate analysis result and should be removed. In fact, the relationship between women's bargaining power and contraceptive is driven by confounding factors.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health economics.

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35 Views

27 Apr 2020 | for Version 1

Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada

35 Views Cite this report Responses(1)

Approved With Reservations

The construction of the independent variable: the authors used the "multiple correspondence analysis" approach to build their autonomy indicator. Then, they subtracted the minimum of the indicator values to have positive values. The problem with this construction is that it is difficult to interpret it as such, and the difficulty of comparing it between countries (which obviously is not the case here). The change of axis is to allow a good interpretation of the intercept in a regression, otherwise, I don't see the importance of this change.
The argument of the threshold to use to cut the indicator is a problem, but one can easily proceed as in the construction of poverty quintiles by dividing the indicator into 5 parts (like in the dhs). It can still be used as a quantitative variable in regressions.
Too much emphasis is placed on maternal mortality, we have to put this into perspective a little and look at the primary role of contraception which is to limit fertility level of for birth spacing.
The authors limited their analysis to couples. I do not see the relevance of this limitation here especially since the partner information that is used is the same that is available for married women with a larger sample. It is better to justify the choice of the sample, otherwise, it is more important to work on all married women I think.
In terms of results, the bivariate analysis is not properly conducted. It reversed the place of the dependent and independent variable. For example, in Figure 1, the authors show that the autonomy index is higher for women who use contraception than for other women who don’t. The opposite reasoning is the way to go; that contraceptive use is higher among women who have a high index. But the problem is precisely that with a categorical dependent variable and a continuous independent variable, there is no (simple) way to make a bivariate description.
The results presented in Table 3 are therefore poorly presented. To find out, for example, whether a woman's level of education is associated with the use of contraception, the frequencies must be presented in row and not in the column as shown in the table.
The Heckman model uses an exogenous variable. In this study, the exogenous variable used is “ideal family size of the woman”. A condition of the exogenous variable is that it does not explain the dependent variable of the second equation (here contraception). However, it is obvious that this variable influences the use of contraception. The ideal number of children is an important variable in the woman's decision to use contraception.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Demography, quantitative methods, sub-Saharan Africa

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Author Response

27 Sep 2021

Dimitri TCHAKOUNTE, Faculty of Economics and Management, University of Yaounde II, Yaounde, Po. Box 1792, Cameroon

Responses on the report of Vissého Adjiwanou, Department of Sociology, Université du Québec à Montréal (UQAM), Montréal, QC, Canada.

The corrections suggested by the reviewer are very useful. We have thus introduced in the revised paper most of his corrections.

Comment 1: I agree with this comment since in the new version, the values of the Woman Bargaining Power Composite Index (WBPCI) are now comprising between -2.79 and 1.586.

Comment 2: We do not affirm that an index should not be categorized (as you explained, the DHS program use such a method), but we refer on the argument suggested by Richardson (2018) to justified why our Index has not been categorized.

Comment 3: As the reviewer suggested, the emphasis has been placed on the primary role of contraception rather than maternal mortality.

Comment 4: We follow the instruction of the reviewer concerning this comment. That is why in the revised paper, the study considers only married women or women living in a union with a partner.

Comment 5: The reviewer is right. We removed the bivariate analysis in the revised paper.

Comment 6: Effectively, ideal family size of the woman seems to be an inadequate exogenous variable. We thus removed this analysis from the revised paper as also suggested by David K. Guilkey.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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The effect of women’s bargaining power within couples on contraceptive use in Cameroon

Abstract

Keywords

Introduction

Methods

Ethical statement

Data

Variable measurement

Table 1. Description, measurement and codes of control variables

Empirical methods

Software

Results and discussion

Results of descriptive statistics

Table 2. Descriptive statistic of variables

Table 3. Cross tabulation between contraceptive use and the explanatory variables

Figure 1. Women’s bargaining power by contraceptive use.

Probit model results

Table 4. Results of probit model and Heckman probit model.

Robustness checks

Limitations of the study

Conclusions

Data availability

Underlying data

Extended data

Software availability

Footnotes

References

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The effect of women’s bargaining power within couples on contraceptive use in Cameroon

Abstract

Keywords

Introduction

Methods

Ethical statement

Data

Variable measurement

Table 1. Description, measurement and codes of control variables

Empirical methods

Software

Results and discussion

Results of descriptive statistics

Table 2. Descriptive statistic of variables

Table 3. Cross tabulation between contraceptive use and the explanatory variables

Figure 1. Women’s bargaining power by contraceptive use.

Probit model results

Table 4. Results of probit model and Heckman probit model.

Robustness checks

Limitations of the study

Conclusions

Data availability

Underlying data

Extended data

Software availability

Footnotes

References

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Open Peer Review

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Reviewer Reports

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