23 Volume 38, Number 1, March 2012

Mai Do is assistant
professor, and Nami
Kurimoto was a
doctoral candidate
at the time of this
study, both in the
Department of Global
Health Systems and
Development, Tulane
University School of
Public Health and
Tropical Medicine,
New Orleans,
Louisiana, USA.
Since the 1994 International Conference on Population
and Development, womens empowerment has been rec-
ognized as important to their access to reproductive health
services, including family planning. Womens lack of pow-
er restricts their ability to make decisions about family
planning practice, as well as to have an open discussion
with their partners about it.
1,2
The purpose of this study was to identify associations
between womens empowerment and the use of contra-
ceptives in selected African countries. Specically, we ex-
amined whether womens empowerment was associated
with the likelihood that a couple used either a female or a
couple method of contraception. In this study, female-only
methods included the pill, IUD, injectable and implant;
couple methods included male and female condoms, the
diaphragm, foam, jelly, withdrawal, the lactational amen-
orrhea method and periodic abstinencethat is, methods
that require at least the awareness of and a certain degree
of support and cooperation from husbands. We hypoth-
esized that women who are more empowered would be
more likely to use any method, as well as female-only
methods, compared with women who are not empowered.
We also hypothesized that some empowered women may
be more likely to involve their husband in family planning
and, therefore, be more likely to use couple methods. In
addition, we explored the inuence of different dimen-
sions of womens empowerment on contraceptive use,
which generally has not been explicitly examined.
WOMENS EMPOWERMENT
Denitions and Measurements
To date, there is considerable variation in the denition
and conceptualization of womens empowerment.
35
The
World Bank denes empowerment as the expansion of
freedom of choice and action to shape ones life.
6
This
denition encompasses two features of womens empow-
erment: process of change (through which a woman gains
power in making decisions) and agency.
7,8
Kabeer denes
womens empowerment as a process by which those who
have been denied the ability to make strategic life choices
acquire such an ability.
9(p. 435)
This denition involves
resources and achievements, in addition to process of
change and agency, all of which are interrelated. A com-
mon underlying feature of these denitions is the recogni-
tion that household and interfamilial relations are central
aspects of womens empowerment. Cutting-edge empiri-
cal research often incorporates analyses of empowerment
that use data aggregated from individual and household
levels or direct measures at the community and societal
levels.
7,1012
The measurement of womens empowerment is dif-
cult: rst, because it is a process; second, because it is
CONTEXT: It is generally believed that womens lack of decision-making power may restrict their use of modern
contraceptives. However, few studies have examined the different dimensions of womens empowerment and
contraceptive use in African countries.
METHODS: Data came from the latest round of Demographic and Health Surveys conducted between 2006 and
2008 in Namibia, Zambia, Ghana and Uganda. Responses from married or cohabiting women aged 1549 were
analyzed for six dimensions of empowerment and the current use of female-only methods or couple methods.
Bivariate and multivariate multinomial regressions were used to identify associations between the empowerment
dimensions and method use.
RESULTS: Positive associations were found between the overall empowerment score and method use in all coun-
tries (relative risk ratios, 1.11.3). In multivariate analysis, household economic decision making was associated
with the use of either female-only or couple methods (1.1 for all), as was agreement on fertility preferences (1.31.6)
and the ability to negotiate sexual activity (1.11.2). In Namibia, womens negative attitudes toward domestic
violence were correlated with the use of couple methods (1.1).
CONCLUSIONS: Intervention programs aimed at increasing contraceptive use may need to involve different ap-
proaches, including promoting couples discussion of fertility preferences and family planning, improving womens
self-efcacy in negotiating sexual activity and increasing their economic independence.
International Perspectives on Sexual and Reproductive Health, 2012, 38(1):2333, doi: 10.1363/3802312
By Mai Do and
Nami Kurimoto
Womens Empowerment and Choice of Contraceptive
Methods in Selected African Countries
Womens Empowerment and Choice of Contraceptive Methods
International Perspectives on Sexual and Reproductive Health 24
indelity, as well as challenge his authority.
31
In Africa, evi-
dence of the relationship between domestic violence and
contraceptive use remains scarce, with the exception of
Alio et al., who found that women who had experienced
intimate partner violence were more likely than others to
report contraceptive use.
32
Finally, in areas where wives
decision making is limited, family planning is not wide-
spread, and there are differences in husbands and wives
fertility preferences, as well as reports of substantial clan-
destine use of contraception.
2,3335
METHODS
Country Selection
Countries were selected using the following criteria: sub-
stantial contraceptive use among married or cohabiting
women (prevalence of 20% or more); an adequate sample
of married or cohabiting women; comparable questions
on six dimensions of womens empowerment that may be
associated with contraceptive use; and a Demographic and
Health Survey (DHS) conducted within the last ve years
(i.e., 2006 or later). Five countriesGhana, Namibia, Ugan-
da, Zambia and Zimbabwemet these criteria. Zimbabwe
was later excluded because most contraceptive users relied
on the pill (72% of all married women using a method),
and the use of couple methods was too limited (only 4%)
to allow meaningful analyses.
36
Country Settings
The four countries included in this study have several
similarities and differences. First, their family planning
programs and activities began decades ago, when popula-
tion growth and high fertility rates were recognized by the
respective governments as a development issue. With the
exception of Uganda, where the governments support for
family planning began later than in other countries and re-
mains limited, the other governments have a strong com-
mitment to lowering fertility and increasing contraceptive
use.
3741
Second, in all four countries, knowledge of contracep-
tives was nearly universal,
38,4244
and ever-use of methods
was usually high. Eighty-four percent of married women
and 77% of married men had ever used any modern
method of contraception in Namibia;
42
the corresponding
proportions were 50% and 56% in Ghana,
43
68% and 67%
in Zambia,
44
and 38% and 39% in Uganda.
38
The current
use of contraceptives varied widely across countries. At
the time of the most recent DHS, the use of any method
(including sterilization) among married women was
24% in Ghana and Uganda, 41% in Zambia and 55% in
Namibia.
38,4244
Third, in the study countries, mens negative attitudes
toward contraceptive use have been documented. Forty-
three percent of Namibian men and 46% of Ghanaian
men believed that a woman who uses contraceptives may
become promiscuous (some women also opposed contra-
ception for fears of side effects or spousal disapproval).
42,43

Many men in Ghana and Zambia were concerned about
multidimensional; and third, because the concept oper-
ates at various levels.
13
Until recently, womens empower-
ment was often measured by proxies, such as education,
employment and knowledge. These characteristics are im-
portant but conceptually distant, and they do not always
reect empowerment.
7,12,1416
Among the many frameworks developed to measure
womens empowerment, that proposed by Malhotra,
Schuler and Boender,
17
and later by Malhotra and Schuler,
7

is one of the most comprehensive, in which empowerment
is measured in several dimensions and at different levels.
This framework suggests that womens empowerment
could be exercised in six different arenas: economic, so-
ciocultural, familial and interpersonal, legal, political and
psychological. Moreover, these arenas can be examined at
the household, community and broader societal levels by
a series of indicators within each category.
Empowerment and Contraceptive Use
A sizable body of literature exists on the relationships
between womens empowerment and contraceptive use.
Blanc
1
suggested that the balance of power in sexual rela-
tionships had an inuence on the use of health services,
which in turn could be linked to reproductive health out-
comes. She proposed a framework depicting the relation-
ships between power within sexual relationships and sex-
ual and reproductive health outcomes. Findings consistent
with that framework have been reported in a number of
studies examining contraceptive and condom use.
1821
A few studies have examined other dimensions of
womens empowerment, including decision making re-
garding household economy and family size, whether
women need permission to go out, coercion or control of
women by their spouse or family, womens political and
legal awareness, and their participation in public protests
and political campaigning.
11,22
Al Riyami, A and Mabry
23

found associations between womens unmet need for con-
traception and some measures of their involvement in
decision making and freedom of movement. In addition,
Govindasamy and Malhotra
24
found that among Egyptian
women, having freedom of movement, having at least
some control in household matters and budget decisions,
and being involved in family planning decision making
were all positively related to current use of contraceptives.
Other research has examined the relative weight of each
partners fertility preferences on contraceptive use.
25,26
An-
other study found that both spouses fertility intentions
were associated with fertility behavior, depending on the
number of children a couple already had.
27
Bankole and
Singh,
28
in a study of 18 developing countries, determined
that the use of modern contraceptives was highest when
both partners agreed to stop childbearing and lowest
when both wanted more children.
Fears of domestic and intimate partner violence have
been reported in many settings as a barrier to contracep-
tive use.
2931
The use of female methods of contraception,
such as the pill, may raise the male partners suspicion of
Volume 38, Number 1, March 2012 25
Data
Data came from the latest DHS conducted in each coun-
try: 20062007 for Namibia, 2007 for Zambia, 2008 for
Ghana and 2006 for Uganda. We included women aged
1549 who were currently married or cohabiting with
their partners. Women who had been sterilized or whose
husbands had been sterilized were excluded because the
series of questions on fertility, family planning negotiation
and choice at the time of the survey were not applicable,
as such sterilization may have taken place long before the
survey. The nal samples included 3,235 women in Na-
mibia, 4,241 women in Zambia, 2,902 women in Ghana
and 5,193 women in Uganda.
Variables
Following Becker and Costenbader,
55
we classied con-
traceptive use into three categories: nonuse, use of female-
only methods and use of couple methods (see earlier
denitions).
Womens empowerment was measured on the indi-
vidual level and along several dimensions as suggested
in earlier studies.
7,17
The rst two dimensionseconomic
and socioculturalwere similar to those used by Malhotra,
Schuler and Boender.
17
Economic empowerment was as-
sessed using ve questions related to a womans income
contribution relative to her husbands (1=less; 2=about
the same; 3=more), decisions about how each partners
income would be used (1=woman alone or joint decision;
0=other) and decisions about major and daily household
purchases (1=woman alone or joint decision; 0=other).
Principal components analysis was used to construct an
index of economic empowerment. Sociocultural empow-
erment was measured by asking women who decided
whether they could visit their family and relatives (1=wom-
an alone or joint decision; 0=other).
The familial and interpersonal dimensions of womens
empowerment are more complex than the rst two di-
mensions and can be measured by a number of indicators
related to domestic decision making, control over sexual
relations, marriage, fertility, contraception, health-seeking
behavior and attitudes regarding domestic violence.
17

Some of these components may be directly related to con-
traceptive use, while others may not. We examined four
of these dimensions of womens empowerment: health-
seeking behavior, agreement on fertility preferences, ne-
gotiation regarding sexual activity and attitudes toward
domestic violence.
Each of the rst two dimensions was measured by a sin-
gle question: who made decisions about health care for the
woman (1=woman alone or joint decision; 0=other), and
whether the woman thought she and her partner wanted
the same number of children (1=yes; 0=no or dont know).
While the latter is not a perfect measure, perceived agree-
ment in desired fertility can be an indication of spousal
discussion and negotiation related to fertility.
The last two dimensions of womens empowerment
were measured by a series of yes-or-no questions. For ne-
control over their wives reproductive behavior, and hence
the achievement of their own desire for a large family.
2,33
In
addition, some men (as well as women) were concerned
that the availability of contraceptives could encourage neg-
ative sexual behaviors, such as early sexual initiation and
adultery.
45
In Uganda, Wolff et al.
46
found that mens op-
position to contraception was associated with an increase
in womens unmet need, as well as increased reliance on
traditional methods instead of modern ones.
A fourth similarity among the included countries is
that, as elsewhere in Sub-Saharan Africa, contraceptive use
is strongly inuenced by mens opinions and couple dy-
namics. In Zambia, according to Susu et al.,
47
two in ve
women who were not practicing family planning said their
husbands disapproval was a reason for not using contra-
ceptives. Another study found that covert contraceptive use
among women was strongly associated with difculties in
spousal communication about contraception.
33
Ezeh
48
also
found that husbands disapproval was a common reason
for married women in Ghana to not use a method for fear
that they would lose his affection. Other studies in Ghana
have suggested that the promotion of family planning can-
not be successful without addressing gender-related fac-
tors, and mens attitudes toward contraception, which are
rooted in the society.
2,4850
Even in Namibia, where studies
on family planning and fertility are limited, a multicoun-
try study found that approval of family planning by both
spouses was signicantly associated with womens use of
any modern method.
51
In addition, many Ghanaian women who used contra-
ceptives feared physical abuse and reprisals not only from
their husband, but also from members of their extended
family.
2,4850
One of these studies reported that men thought
it was acceptable to beat their wife if she adopted family
planning.
48
In Uganda, mens disapproval of family plan-
ning was cited as a reason for not using contraceptives
by some women.
52
Hence, experience with domestic and
intimate partner violence is also an important factor that
may prevent women from practicing contraception. In
one Uganda study, many participants agreed that violence
against women should be expected if womens use of con-
traceptives was identied or even suspected.
53
Another
study in this country reported that more women than
men (27% vs. 22%) justied domestic violence if a woman
adopted a contraceptive method without her husbands
approval.
54
Despite these similarities, these countries vary widely in
contraceptive prevalence. Namibia had the highest contra-
ceptive prevalence (55%), as well as the highest level of
modern contraceptive use (53%), of the study nations.
42

Ghana and Uganda had the lowest contraceptive preva-
lence (24%); the use of traditional methods was also more
common there.
38,43
The inclusion of these countries, there-
fore, allows us to draw different inferences and implica-
tions from any observed associations of womens empow-
erment with the use of different methods within different
contraceptive use settings.
Womens Empowerment and Choice of Contraceptive Methods
International Perspectives on Sexual and Reproductive Health 26
were used in this study: Three were continuous indices
and three were categorical. An overall empowerment in-
dex was constructed from the six measures using principal
components analysis.
Reliability coefcients for the different empowerment
measures and the overall score ranged from 0.60 to 0.86,
indicating reasonable to high levels of correlation among
components.
Sample Characteristics
The individual and community characteristics of these
samples are presented in Table 1. Individual-level vari-
ables included age, educational level, household wealth,
religious afliation, number of living children, exposure
to family planning messages in mass media (newspapers,
radio and TV) and knowledge of modern contraceptives
(number of methods known). Community-level variables
included rural versus urban residence and the prevalence
of contraceptive use in the community; the latter was cal-
culated by aggregating information from individual wom-
en (regardless of union status) in each community, exclud-
ing respondents. This measure was included as a proxy for
contraceptive use norms, which have been shown to be
associated with individual contraceptive behavior;
56,57
in
addition, as posited by social network theory, a womans
contraceptive use may be associated with the normative
behaviors in her community.
5659
Analysis
Bivariate multinomial regression was used to examine
relationships between current contraceptive use and cat-
egorical as well as continuous independent variables. Mul-
tivariate multinomial regression was employed to identify
associations between womens empowerment, its various
dimensions and current contraceptive use, with and with-
out controlling for individual- and community-level vari-
ables that may affect the outcome. An svy set of commands
was used in the Stata 11 package
60
to account for the DHS
cluster sampling design and to obtain standard errors of
estimates that were adjusted for this design.
COUNTRY FINDINGS
Namibia
Half of Namibian women were using a contraceptive
method at the time of the survey36% were using a fe-
male method, and 14% a couple method (not shown).
In multinomial regression analysis, the overall score for
womens empowerment was strongly associated with
contraceptive use: A one-point increase in the score was
related to a 19-percent increase in the likelihood that they
had used a female method rather than no method, and to
a 24-percent increase in the likelihood of using a couple
method instead of none (Table 2, model 1). Several em-
powerment dimensions were also related to method use: A
one-point increase in the economic measure was positively
associated with use of both female and couple methods
as opposed to use of no method (relative risk ratios, 1.2
gotiation of sexual activity, we used a series of six ques-
tions on whether the woman herself felt she was able to
refuse to have sex with her partner and to ask him to use
a condom in various circumstances, or whether a woman
was justied in doing so (1=yes; 0=no; only ve questions
were used in Uganda). Womens attitudes regarding do-
mestic violence were measured using ve questions about
whether they believed it was justiable for a man to beat
his wife or partner in specic situations. For example, Is a
[husband/partner] justied in beating his [wife/partner] if
she goes out without telling him? A woman who respond-
ed no was considered to have a negative attitude toward
domestic violence. It should be noted that these questions
asked about womens attitudes toward such beatings, rath-
er than their actual experience of domestic violence. We
used principal components analysis to construct indices
for the negotiation of sexual activity and domestic violence
measures. Thus, six indicators of womens empowerment
TABLE 1. Selected characteristics of married or cohabiting women aged 1549 in
four African countries, Demographic and Health Surveys, 20062008
Characteristic Namibia Zambia Ghana Uganda
(N=3,235) (N=4,241) (N=2,902) (N=5,193)
INDIVIDUAL
Age
1524 16.7 27.0 17.6 29.4
2539 60.1 56.6 58.9 54.0
4049 23.2 16.4 23.5 16.6
Educational level
None 12.6 13.0 30.0 24.8
Primary 30.8 61.3 22.3 60.2
Secondary 47.6 21.7 44.2 11.8
secondary 9.1 4.0 3.6 3.2
Household wealth tertile
Poorest 33.1 40.9 31.9 35.7
Middle 30.4 31.5 34.0 36.9
Richest 36.5 27.6 34.0 27.4
Religion
Catholic 22.1 na 12.5 43.9
Protestant 74.9 78.6 na 33.3
Pentecostal na na 35.2 na
Other Christian na na 26.0 na
None/other 3.0 21.4 26.2 22.8
Mean no.of living children (range) 2.8 3.4 3.0 3.8
(012) (013) (011) (014)
Exposure to family planning messages in mass media
No 41.1 56.5 31.3 39.6
Yes 58.9 43.5 68.7 60.4
Mean no.of methods known (range) 5.1 6.1 6.4 5.0
(09) (010) (010) (08)
COMMUNITY
Residence
Rural 52.1 65.6 57.9 87.0
Urban 47.9 34.4 42.2 13.0
Contraceptive prevalence (range), 41.4 27.9 17.5 15.7
(7.582.1) (0.061.5) (5.525.8) (0.051.7)
Includes the pill, IUD, injectable, implant, male and female condoms, diaphragm, foam, jelly, withdrawal,
the lactational amenorrhea method and periodic abstinence. Among all women in the community
aged 1549, regardless of union status. Notes: All gures are percentages unless noted otherwise. na=not
applicable.
Volume 38, Number 1, March 2012 27
Zambia
Nearly 40% of women in the Zambian sample were using
a contraceptive at the time of the survey; the proportions
using female and couple methods were roughly the same
(not shown). In regression analysis, positive associations
were found between the overall empowerment score and
the use of both female and couple methods as opposed
to no method (relative risk ratios, 1.2 and 1.1, respective-
lyTable 3, model 1). Among the various empowerment
dimensions, spousal agreement regarding fertility prefer-
ence, ability to negotiate sexual activities and negative
attitudes toward domestic violence were related to meth-
od use, as each of these measures was positively associ-
for eachmodel 2), while agreement on fertility preference
was correlated only with use of female methods (1.6), and
a one-point increase in the score for womens attitudes
toward domestic violence was related to increased use of
couple methods (1.2).
When all individual and community characteristics
were controlled for, Namibian womens economic em-
powerment and agreement on fertility preference were
positively associated with the use of female methods rather
than no method (relative risk ratios, 1.1 and 1.5, respec-
tivelymodel 3). The use of couple methods, however, was
related only to womens negative attitudes toward domes-
tic violence (1.1).
TABLE 2. Relative risk ratios (and standard errors) from multinomial regression analysis to identify associations between
empowerment measures and the use of female or couple contraceptive methods, versus no use, Namibia, 20062007
Measure Model 1 Model 2 (unadjusted) Model 3 (adjusted)
Female Couple Female Couple Female Couple
Overall score 1.19 (0.03)*** 1.24 (0.05)*** na na na na
Economic na na 1.15 (0.03)*** 1.16 (0.06)** 1.09 (0.04)** 1.05 (0.06)
Sociocultural activities
Others/partner alone (ref) na na 1.00 1.00 1.00 1.00
Joint/woman alone na na 1.22 (0.16) 1.06 (0.19) 1.15 (0.15) 0.96 (0.18)
Health-seeking behavior
Others/partner alone (ref) na na 1.00 1.00 1.00 1.00
Joint/woman alone na na 1.13 (0.16) 0.87 (0.17) 1.15 (0.17) 0.89 (0.19)
Agree on fertility preference
No (ref)
Yes
na
na
na
na
1.00
1.61 (0.14)***
1.00
1.20 (0.15)
1.00
1.48 (0.13)***
1.00
1.02 (0.15)
Sexual activity negotiation na na 1.04 (0.03) 1.09 (0.05) 1.00 (0.03) 1.02 (0.05)
Domestic violence attitudes na na 1.04 (0.03) 1.20 (0.05)*** 0.99 (0.03) 1.11 (0.05)*
*p<.05. **p<.01. ***p<.001. p<.10. Model 3 controls for all individual and community characteristics. Notes: Female-only methods include the pill, IUD,
injectable and implant; couple methods include male and female condoms, the diaphragm, foam, jelly, withdrawal, the lactational amenorrhea method and
periodic abstinence. na=not applicable. ref=reference group.
TABLE 3. Relative risk ratios (and standard errors) from multinomial regression analysis to identify associations between
empowerment measures and the use of female or couple contraceptive methods, versus no use, Zambia, 2007
Measure Model 1 Model 2 (unadjusted) Model 3 (adjusted)
Female Couple Female Couple Female Couple
Overall score 1.17 (0.03)*** 1.08 (0.03)** na na na na
Economic na na 1.10 (0.03)** 1.01 (0.03) 1.03 (0.03) 1.02 (0.03)
Sociocultural activities
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
0.99 (0.12)
1.00
0.80 (0.09)
1.00
1.01 (0.13)
1.00
0.97 (0.12)
Health-seeking behavior
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
1.20 (0.11)
1.00
0.90 (0.10)
1.00
1.21 (0.12)
1.00
0.95 (0.11)
Agree on fertility preference
No (ref)
Yes
na
na
na
na
1.00
1.75 (0.16)***
1.00
1.31 (0.15)*
1.00
1.45 (0.14)***
1.00
1.31 (0.15)*
Sexual activity negotiation na na 1.10 (0.03)** 1.11 (0.04)** 1.03 (0.03) 1.08 (0.03)*
Domestic violence attitudes na na 1.06 (0.03)* 1.09 (0.03)* 0.99 (0.03) 1.02 (0.03)
*p<.05. **p<.01. ***p<.001. p<.10. Model 3 controls for all individual and community characteristics. Notes: Female-only methods include the pill, IUD,
injectable and implant; couple methods include male and female condoms, the diaphragm, foam, jelly, withdrawal, the lactational amenorrhea method and
periodic abstinence. na=not applicable. ref=reference group.
Womens Empowerment and Choice of Contraceptive Methods
International Perspectives on Sexual and Reproductive Health 28
methods was associated with womens negative attitudes
toward domestic violence (1.2).
When individual and community characteristics were
controlled for in model 3, womens ability to negotiate
sexual activity remained strongly associated with both
contraceptive use outcomes: An increase of one point in
this empowerment score was correlated with an 18% in-
crease in the likelihood of using a female method instead
of no method, and a 13% increase in the likelihood of us-
ing a couple method instead of no method. In this model,
economic empowerment was only marginally related to
use of female methods, and the association between nega-
tive attitudes toward domestic violence and use of couple
methods also lost signicance.
Uganda
The majority (79%) of Ugandan women were not using
any contraceptives at the time of the survey; use of female
methods was twice that of couple methods (14% and 7%,
respectivelynot shown). Regression analysis found that
the overall score of womens empowerment had a strong
relationship with contraceptive use: An increase of one
point in the score was associated with a 21% increase in
the relative risk of using female methods as opposed to
no method, and a 31% increase in the likelihood of using
couple methods instead of no method (Table 5, model 1).
Four of the empowerment dimensions were shown to be
associated with contraceptive use. Womens economic em-
powerment was related to both female and couple method
use (relative risk ratios, 1.2 for eachmodel 2). In addition,
women who reported spousal agreement on fertility pref-
erences were more likely to use female or couple methods
rather than no method (1.4 and 2.0, respectively), as were
those who scored higher on the scale of negative attitudes
ated with the use of female (1.11.8) and couple methods
(1.11.3) in model 2. In addition, womens involvement
in household economic decisions was related to use of fe-
male methods (1.1).
When individual- and community-level characteristics
were controlled for, however, the associations between
use of female methods and economic empowerment
and negotiation over sex disappeared, as did those be-
tween domestic violence attitudes and use of either type
of method (model 3). Only perceived agreement on fertil-
ity preferences remained signicant for both female and
couple method use: Compared with women who said
their partner wanted a different number of children (or
who did not know their partners preference), those who
reported agreement were 45% more likely to use a female
method rather than no method, and 31% more likely to
use a couple method instead of none. Finally, the correla-
tion between womens ability to negotiate sexual activity
and their use of couple methods remained signicant: A
one-point increase in this scale was associated with an 8%
increase in the likelihood of using a couple method.
Ghana
More than three-quarters of women in the Ghana sample
were not using any contraceptives at the time of the survey;
only 12% were using female methods and 10% were us-
ing couple methods (not shown). The regression analysis
found that the overall empowerment score was associated
with the use of couple methods rather than no method
(relative risk ratio, 1.3Table 4, model 1). Female and
couple method use were each related to womens empow-
erment in negotiating sexual activity (1.3 for eachmodel
2). In addition, the use of female methods was associated
with economic empowerment (1.1), and the use of couple
TABLE 4. Relative risk ratios (and standard errors) from multinomial regression analysis to identify associations between
empowerment measures and the use of female or couple contraceptive methods, versus no use, Ghana, 2008
Measure Model 1 Model 2 (unadjusted) Model 3 (adjusted)
Female Couple Female Couple Female Couple
Overall score 1.14 (0.07) 1.27 (0.11)* na na na na
Economic na na 1.14 (0.07)* 1.11 (0.10) 1.10 (0.05) 1.02 (0.09)
Sociocultural activities
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
1.13 (0.17)
1.00
0.94 (0.16)
1.00
1.17 (0.16)
1.00
0.97 (0.18)
Health-seeking behavior
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
0.98 (0.19)
1.00
0.79 (0.15)
1.00
1.00 (0.22)
1.00
0.82 (0.15)
Agree on fertility preference
No (ref)
Yes
na
na
na
na
1.00
1.05 (0.13)
1.00
1.17 (0.20)
1.00
1.04 (0.11)
1.00
1.06 (0.14)
Sexual activity negotiation na na 1.26 (0.09)** 1.28 (0.07)*** 1.18 (0.07)* 1.13 (0.05)*
Domestic violence attitudes na na 0.96 (0.05) 1.21 (0.07)** 0.95 (0.04) 1.11 (0.06)
*p<.05. **p<.01. ***p<.001. p<.10. Model 3 controls for all individual and community characteristics. Notes: Female-only methods include the pill, IUD,
injectable and implant; couple methods include male and female condoms, the diaphragm, foam, jelly, withdrawal, the lactational amenorrhea method and
periodic abstinence. na=not applicable. ref=reference group.
Volume 38, Number 1, March 2012 29
use. The observed difference between female and couple
method use could be a result of the efforts of such pro-
grams over several decades.
Second, in all countries but Ghana, womens overall
empowerment score was positively associated with both
female and couple method use. In three of the countries,
we also found that two or three empowerment dimensions
were associated with contraceptive use in the multivariate
analyses: economic decision making, negotiation of sexual
activity and perceived agreement on fertility preferences.
In several cases, one of these dimensions of empowerment
was related to use of both female and couple methods. In
Namibia, which had the highest contraceptive prevalence
and the greatest difference between the types of methods
used, contraceptive use was associated with three of the
six dimensions. Furthermore, this was the only country
in which both economic empowerment and agreement
on fertility preferences were related to use of female-only
methods.
In none of the countries was the sociocultural or health-
seeking dimension associated with contraceptive use. It is
possible that in these African countries, womens mobil-
ity is not as limited as it is in some Asian settings;
61
this
is one of the limitations of current questions on womens
empowerment in the standard DHS questionnaire, which
were based on a conceptual framework developed mainly
from experience in Asia.
62
Hence the question used to
measure this aspect of empowerment may not accurately
capture this dimension in Africa, and questions related to
other types of mobility restrictions may be more relevant.
Additional qualitative research is needed to understand
the specic context surrounding womens mobility and
to identify appropriate indicators for this measure, as sug-
gested by Schatz and Williams.
62
toward domestic violence (1.2 for each). Empowerment in
negotiating sexual activity was related only to the use of
couple methods (1.1).
When all background characteristics were adjusted for,
womens economic empowerment remained associated
with contraceptive use: A one-point increase in the em-
powerment score was related to a 9% increase in the rela-
tive risk of using either female or couple methods instead
of no method (model 3). However, the domestic violence
measure was no longer associated with use of either type
of method, and the association between womens ability to
negotiate sexual activity and use of couple methods also
lost signicance. Finally, women who reported spousal
agreement on fertility preferences were 60% more likely
to use couple methods than to use no method, while the
association with use of female methods disappeared.
DISCUSSION
Most studies of womens empowerment and family plan-
ning have examined only a single or a few aspects of
empowerment, a complex concept that is often difcult
to measure. This study is unique in that it measured six
dimensions of empowerment and identied associations
between these dimensions and contraceptive practice in
four African countries.
Associations between method use and the different di-
mensions of empowerment varied across countries, yet
some ndings were consistent across two or more coun-
tries. First, female-only methods were much more com-
monly used than couple methods in Namibia and Uganda.
It should be noted that all female methods in this study
were modern methods, which are more likely to be pro-
moted by family planning programs than traditional meth-
ods, whose use made up the majority of couple method
TABLE 5. Relative risk ratios (and standard errors) from multinomial regression analysis to identify associations between
empowerment measures and the use of female or couple contraceptive methods, versus no use, Uganda, 2006
Measure Model 1 Model 2 (unadjusted) Model 3 (adjusted)
Female Couple Female Couple Female Couple
Overall score 1.21 (0.03)*** 1.31 (0.06)*** na na na na
Economic na na 1.20 (0.03)*** 1.20 (0.05)*** 1.09 (0.03)** 1.09 (0.04)*
Sociocultural activities
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
1.12 (0.13)
1.00
1.17 (0.17)
1.00
1.11 (0.14)
1.00
1.11 (0.17)
Health-seeking behavior
Others/partner alone (ref)
Joint/woman alone
na
na
na
na
1.00
0.91 (0.09)
1.00
1.01 (0.14)
1.00
1.07 (0.12)
1.00
1.13 (0.16)
Agree on fertility preference
No (ref)
Yes
na
na
na
na
1.00
1.40 (0.14)**
1.00
1.99 (0.22)***
1.00
1.20 (0.12)
1.00
1.60 (0.18)***
Sexual activity negotiation na na 1.09 (0.05) 1.13 (0.06)* 0.97 (0.04) 1.02 (0.05)
Domestic violence attitudes na na 1.16 (0.03)*** 1.21 (0.06)*** 1.03 (0.03) 1.07 (0.05)
*p<.05. **p<.01. ***p<.001. p<.10. Model 3 controls for all individual and community characteristics. Notes: Female-only methods include the pill, IUD,
injectable and implant; couple methods include male and female condoms, the diaphragm, foam, jelly, withdrawal, the lactational amenorrhea method and
periodic abstinence. na=not applicable. ref=reference group.
Womens Empowerment and Choice of Contraceptive Methods
International Perspectives on Sexual and Reproductive Health 30
More research
is needed to
understand the
mechanisms of
the associations
between em-
powerment and
contraceptive
use in settings
with different
contraceptive
prevalence rates.
In fact, it is possible that the use of female methods may re-
sult in increased perceived empowerment among these us-
ers; women could use female methods without any discus-
sion with or involvement of their partners. In Namibia, this
scenario cannot be ruled out: The pill and injectables were
the most commonly used methods, and there was a large
difference in the use of female and couple methods. Na-
mibia was also the only study country in which we found
positive associations between any dimension of empower-
ment and female method use only. In the other countries,
empowerment was related to couple method use only, or
to use of both types of method, which does not entirely
support the argument of reverse causality.
The study was also restricted to married or cohabiting
women, who accounted for between 36% (in Namibia)
and 63% (in Uganda) of the DHS samples. Our supple-
mentary analyses showed that women in the study sam-
ples were less educated and less wealthy than women who
were not included in this study (not shown). Because it is
possible that unmarried women may be more empowered
than married or cohabiting women, our results are gener-
alizable only to women who are married or living with a
partner in these four countries.
Finally, although our study employed the most recent
DHS data, changes in contraceptive availability and use
may have occurred in the last few years. For example,
Uganda has been promoting long-acting and permanent
family planning methods in some areas, and Zambia has
seen a shift in funding from family planning to HIV pre-
vention and treatment.
66,67
Although these changes are
unlikely to have led to shifts in contraceptive use within a
short time frame, in the long term these changes may lead
to increased use of long-acting methods, such as IUDs, or
of couple methods, such as male condoms; consequently,
the associations between empowerment and contraceptive
use observed in this study may also change.
Conclusions
Despite these limitations, our study found important as-
sociations between several dimensions of womens em-
powerment and the choice of contraceptive methods, and
these ndings have a number of signicant implications.
More research is needed to understand the mechanisms
of the associations between empowerment and contracep-
tive use in settings with different contraceptive prevalence
rates. For example, must a threshold of contraceptive
prevalence be reached before womens empowerment be-
gins to play a role in modern contraceptive use? And does
demand for family planning need to be established before
associations between empowerment and method use can
be observed? Other unanswered questions involve how
interactions between empowerment and access to family
planning services may inuence the use of contraceptives.
Furthermore, future studies need to take into account
womens empowerment from mens perspective to better
capture couples decision-making dynamics. Finally, as
mentioned earlier, more research is needed to gain insight
The nding that womens empowerment in their health-
seeking behavior was not linked to contraceptive use was
unexpected. It is plausible that there is truly no association
between this aspect of decision making and contraceptive
use, because health-seeking behavior may not necessarily
involve interactions with their partners, whereas method
use does. Again, qualitative research is needed to improve
our understanding of decision making within households:
For example, what issues are considered a household mat-
ter and should be decided jointly by couples, and which
are considered to involve women only? In our study, it
was not clear whether women were empowered to make
decisions regarding their health care, or whether they sim-
ply lived in households in which husbands or partners
contributed little to issues that were not directly related
to themselves. A recent qualitative study in Kenya sug-
gested marked differences in how individuals interpreted
the same questions on womens decision-making power.
63

Clearly, although the DHS includes standard questions
that allow cross-country comparisons, supplemental quali-
tative research would be helpful to better understand the
contexts surrounding womens empowerment.
In addition, this study is limited by the data available
to measure womens empowerment. Data came from
womens responses to questions about usual practices in
their household, as well as to several hypothetical ques-
tions. Hence, there is some risk of social desirability bias if
women gave responses that they thought were expected,
especially on sensitive issues related to sexual activity and
domestic violence. Moreover, for some dimensions of em-
powerment, such as agreement on fertility preferences, the
measure may not reect the true situation if partners do
not talk about the number of children that they want to
have, or if women agree to whatever their husbands wish.
Other studies have found that in settings with high gen-
der inequality, actual fertility preference agreement may
be lower than reported because societal norms may make
women less likely to voice their own fertility desires,
11,64,65

and women may also be more likely to agree with their
partners wishes.
Another limitation of this study is related to the cross-
sectional nature of DHS data. Because the data for womens
empowerment and contraceptive use were collected at the
time of the survey, the temporal relationship between the
two variables cannot be determined. It is also possible that
the same observed or unobserved factors may inuence
both empowerment and method use. We did control for
several factors that are theoretically related to contracep-
tive use but not to empowerment, such as the number of
methods known and the prevalence of contraceptive use
at the community level. Full testing and controlling for en-
dogeneity is desirable, but was beyond the scope of this
study.
Reverse causality between womens empowerment and
method use cannot be ruled out. It is plausible that some
women feel empowered because contraceptive use gives
them a sense of being capable of controlling their fertility.
Volume 38, Number 1, March 2012 31
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into the meaning and functioning of womens empower-
ment in African settings.
Our ndings suggest that different strategies could be
employed to promote family planning in these countries.
For example, in Zambia, one strategy to increase overall
contraceptive use could be promoting couples discus-
sions about their fertility desires and involving men in deci-
sion making related to fertility and contraception. Another
strategy may be to improve womens self-efcacy and atti-
tudes related to the negotiation of sexual activity; since this
dimension was related only to couple method use, it may
be an effective strategy in settings where the availability of
modern contraceptives, with the exception of condoms, is
limited. Programs that aim to increase womens ability to
negotiate sexual activity may be particularly important in
Ghana, where family planning practice is not widespread.
Such programs may need to be coupled with efforts to in-
crease contraceptive availability to meet the potential for
increased demand for modern methods.
In Uganda, programs aimed at improving womens in-
dependent earnings and contribution to household nanc-
es may be more important than those aimed at increasing
couples discussions of fertility. Other programs in Uganda
may need to consider costs related to family planning sup-
plies and transportation to health facilities, which could be
an important factor in the use of female methods, many of
which require periodic resupplies or assistance from medi-
cal professionals. It is possible that women who have some
control in nancial matters have better access to these ser-
vices than women who have little or no control. Finally,
in Namibia, the ndings that womens empowerment re-
garding household nances and fertility preferences were
associated with female methods and not couple methods
may suggest that many Namibians still perceive family
planning practice as a womans responsibility. If, indeed,
men have reservations about family planning, intervention
programs that involve them may be more useful than pro-
grams aimed at improving womens empowerment alone.
Overall, our study suggests that although womens em-
powerment in general is associated with increases in con-
traceptive use, a one-size-ts-all strategy for contraceptive
promotion in Africa is unlikely to be effective.
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voir de dcision des femmes peut limiter leur pratique de la
contraception moderne. Peu dtudes examinent cependant les
diffrentes dimensions de lautonomisation des femmes et de
leur pratique contraceptive dans les pays dAfrique.
Mthodes: Les donnes sont issues du dernier passage de
lEnqute dmographique et de sant, entre 2006 et 2008, en
Namibie, en Zambie, au Ghana et en Ouganda. Les rponses
des femmes de 15 49 ans maries ou en concubinage sont
analyses en fonction de six dimensions dautonomisation et
de la pratique actuelle de mthodes strictement fminines ou
de couple. Les associations entre les dimensions dautonomi-
sation et la pratique dune mthode sont identies par rgres-
sions multinomiales bivaries et multivaries.
Rsultats: Des associations positives sont observes entre la
cote dautonomisation globale et la pratique dune mthode
dans tous les pays (rapports de risques relatifs, 1,11,3). Dans
lanalyse bivarie, la prise de dcisions conomiques au sein
du mnage est associe lusage de mthodes strictement fmi-
nines ou de couple (1,1 pour tous), de mme que laccord sur les
prfrences de fcondit (1,31,6) et que la capacit de ngocia-
tion de lactivit sexuelle (1,11,2). En Namibie, les attitudes
ngatives des femmes lgard de la violence familiale sont en
corrlation avec la pratique des mthodes de couple (1,1).
Conclusions: Ladoption de diffrentes approches pourrait
tre utile aux programmes dintervention visant accrotre la
pratique contraceptive, notamment la promotion de la discus-
sion des couples sur les prfrences de fcondit et la plani-
cation familiale, lamlioration de lauto-efcacit des femmes
dans la ngociation de lactivit sexuelle et le renforcement de
leur indpendance conomique.
Acknowledgments
This research was supported by the MEASURE Evaluation Popula-
tion and Reproductive Health Project, funded by the U.S. Agency
for International Development through cooperative agreement as-
sociate award GPO-A-00-09-00003-00. The authors thank An-
astasia Gage and Janine Barden-OFallon for their comments
on earlier versions of this article.
Author contact: [email protected]
RESUMEN
Contexto: Hay la creencia generalizada de que la falta de
poder de toma de decisiones entre las mujeres puede restringir
su uso de anticonceptivos modernos. Sin embargo, son pocos
los estudios que han examinado las diferentes dimensiones del
empoderamiento de la mujer y el uso de anticonceptivos en los
pases africanos.
Mtodos: Los datos provinieron de la ms reciente ronda de
Encuestas de Demografa y Salud conducidas entre 2006 y
2008 en Ghana, Namibia, Uganda y Zambia. Se analizaron
las respuestas de mujeres casadas o viviendo en unin consen-
sual en edades de 1549, con respecto a seis dimensiones de
empoderamiento y el uso actual de mtodos exclusivos para
mujeres o mtodos para la pareja. Se usaron regresiones multi-
nomiales bivariadas y multivariadas para identicar las aso-
ciaciones entre las dimensiones de empoderamiento y el uso
de mtodos.
Resultados: Se encontraron asociaciones positivas entre el
puntaje general del ndice de empoderamiento y el uso de un
mtodo anticonceptivo en todos los pases (razones de riesgo
relativo, 1.11.3). En el anlisis multivariado, el hecho de que
la mujer tome decisiones econmicas en el hogar se asoci con
el uso de mtodos, ya sea de uso exclusivo de la mujer o de la
pareja (1.1 para ambos), as como con el acuerdo a nivel de
pareja en las preferencias de fecundidad (1.31.6) y con la
capacidad de negociar la actividad sexual (1.11.2). En Na-
mibia, las actitudes negativas de las mujeres hacia la violencia
intrafamiliar se correlacionaron con el uso de mtodos que no
sean exclusivamente femeninos (1.1).
Conclusiones: Las intervenciones dirigidas a aumentar el
uso de anticonceptivos pueden requerir el uso de diferentes
enfoques, entre ellos la promocin del dilogo en las parejas
sobre las preferencias de fecundidad y el uso de la planica-
cin familiar, el mejoramiento de la ecacia personal de las
mujeres para negociar la actividad sexual y el mejoramiento
de su independencia econmica.
RSUMS
Contexte: Il est gnralement admis que le manque de pou-