Objectives: The purpose of this study was to examine women’s autonomy and contraceptive use by using women’s decision-making power, a dimension of women’s status, as a proxy marker. Our aim was to examine the interaction between reproductive and non-reproductive (domestic) decision-making powers and their ultimate effect on contraceptive use. Additionally, through linking qualitative and quantitative data, the study provided a socio-cultural context of these factors and perceived gender roles in family planning within couples.
Methods: Quantitative and qualitative data were derived from the Pregnancy and STI (sexually transmitted infection) Avoidance Study conducted in a rural Malawi district between June 2000 and May 2002. Among the 11 traditional authorities, three areas were selected by probability proportional to size (PPS) procedures. In each area, four villages were enumerated and a total of 1,296 households were recruited by a systematic sampling method. All female residents between the ages of 15 and 34 and male residents between the ages of 20 and 44 were invited to participate. From the study, selected household survey data of currently married women were analyzed with the Statistical Package for Social Science (SPSS). Focus group discussions (FGDs) were conducted in the same study areas in May 2002 to complement previous quantitative data collection. Four FGDs on men’s and women’s attitudes toward pregnancy avoidance were analyzed and combined with the results from the household survey.
Results: Both quantitative and qualitative data revealed women’s low status and the predominance of men’s decision-making power at the household and community levels. Of particular note, women were least likely to have decision-making power regarding their own health care. Although none of the decision-making areas had significant association with ever use of modern contraceptive methods, domestic decision-making power and family planning decision-making power were significantly associated. Basic socio-demographic factors such as educational level, parity, and desired number of children had significant associations with ever use of modern contraceptive methods. Women’s decision-making power was shaped by various socio-cultural factors including religion and tribe, education, cash employment, and marital structure. FGD data added richness to the quantitative data, especially regarding men’s perceptions toward women’s low status, barriers to modern contraceptive use, couple’s opinions on condom use, and recommendations toward current family planning services.
Conclusion: This study suggests that the theory of women’s autonomy and contraceptive use is formed by various components including socio-demographic factors, fertilityrelated factors, and decision-making powers. Moreover, the study showed that all areas of domestic decision-making power were significantly related to family planning decision-making power. This suggests that women’s empowerment in reproductive health cannot be separately addressed from that of domestic issues. An empowerment program should prioritize improving women’s decision-making power in their own health care, an area which women have the least power. For all areas, women’s decision-making power did not have any significant associations with contraceptive use. Factors such as agreement on fertility preference within couples, spousal communication about family planning, and other dimensions of women’s autonomy may mediate this relationship. Given the multi-dimensional nature of women’s autonomy, further studies are necessary to determine the pathway through which women’s status affects eproductive health behavior and outcomes.