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Women in Ethiopia, Nigeria and Uganda are often pressured by family and through societal expectations to have more children, but commonly resort to covert or indirect means of contraception to maintain some reproductive autonomy. This is a central finding from a cross-country study led by researchers at the Johns Hopkins Bloomberg School of Public Health.

The findings were presented at the fifth International Conference on Family Planning (ICFP) taking place Nov. 12 to 15, 2018 in Kigali, Rwanda. The 2018 ICFP was co-hosted by the Bill & Melinda Gates Institute for Population and Reproductive Health, which is based at the Johns Hopkins Bloomberg School of Public Health, and the Ministry of Health of the Republic of Rwanda.

For the qualitative study, Celia Karp and Shannon Wood, Ph.D. candidates in the Bloomberg School's Department of Population, Family and Reproductive Health, collaborated with their in-country Performance Monitoring and Accountability 2020 (PMA2020) colleagues to conduct 120 in-depth interviews and 40 focus group discussions with376 and 64 men across four communities in Ethiopia, Nigeria and Uganda from July to August 2017.

The investigations were part of a larger project known collectively as the Women's and Girls' Sexual and Reproductive Empowerment (WGE-SRH) study, which was designed to explore the motivations and constraints women experience and the choices they make concerning sex, contraception and pregnancy. Ultimately, the researchers have used their findings to construct a cross-cultural index to measure sexual and reproductive empowerment.

In one analysis of the WGE-SRH, Karp and colleagues found that women's motivations to become pregnant were not only based on their own values, but also shaped by external pressures from husbands, families and communities.

"Women were often expected to bear children very soon after marriage, whereas premarital childbearing was negatively sanctioned. These expectations constrained women's autonomy about if and when to get pregnant," Karp says. "In northern Nigeria, motivations to bear more children were particularly prevalent in polygamous families, where wives secured their influence and children's inheritance through childbearing."

Misconceptions and fears about contraception, such as concerns that its use would harm the womb or cause infertility, also limited women's ability to prevent unintended pregnancy or achieve their desired number of pregnancies, Karp notes.

"Reproductive choice for and childbearing: Where does women's empowerment fit in? Findings from a three-country qualitative study" was presented by Celia Karp on Thursday, Nov. 15.

Indirect Strategies As Empowerment

In a closely related analysis, Wood and colleagues found that both male and female respondents tended to consider sex principally a marital obligation and a means of procreation. Sexual pleasure was often an afterthought, and sex outside of marriage was seen as wasteful—except in Uganda, where married men frequently pursued extramarital partners and even married women could do so without sanction if their husbands failed to support them. financially. However, even men and women reporting multiple partners considered faithful monogamous relationships the ideal.

Most of the female respondents in the study, including married ones, indicated that they had a limited ability to either initiate or avoid sex. Culturally, it was considered inappropriate for a woman to voice her own sexual desire directly—or to resist her husband's advances. Women, therefore, often resorted to indirect strategies for asserting their choice to have or avoid sex. "These strategies included non-verbal cues, such as singing or cooking their husband's favorite meal when they wanted to have sex, or faking menstruation or illness when they wanted to avoid sex," Wood says.

"The exploration of sexual health outcomes through the application of a Women's and Girl's Sexual and Reproductive Health Empowerment Framework across four settings" were presented by Shannon Wood on Wednesday, Nov. 14.

Covert Use of Contraception

Similarly, in a third analysis, the WGE-SRH team found evidence of widespread covert use of contraception, including long-acting injectable contraceptive methods, among women who felt that they could not voice their reproductive choices directly. For some women, covert use of contraception resulted from disagreements with their husbands over having more children. For others, it was a strategy to delay commitment to a new partner or distance themselves from a failing relationship.

The WGE-SRH team has used the results of the WGE-SRH study to develop a cross-cultural quantitative index of women's empowerment in the realm of sex, planning and pregnancy. "One aspect our study results highlight," Wood says, "is that women's confidence in directly telling partners what they want is only a partial measure of their real self-efficacy—we also need to take into account the non-verbal and covert strategies to which they commonly resort."

"Covert use of family planning among sub-Saharan African women—reasons, challenges and consequences" was presented by Simon Kibira one of the lead investigators from Makerere University School of Public Health in Uganda on Wednesday, Nov. 14.