Reproductive Autonomy and Sexual and Reproductive Health Outcomes among Young Women in Ghana

Abstract

Background: Women’s empowerment is a powerful outcome of, as well as a pathway through which to improve, sexual and reproductive health (SRH) and wellbeing. Prior research suggests associations between women’s empowerment and SRH outcomes. However, there is variability in how researchers measure empowerment and proxies are frequently used. This dissertation will examine the construct of reproductive autonomy (RA), a specific domain of empowerment defined as “having the power to decide about and control matters associated with contraceptive use, pregnancy, and childbearing” (Upadhyay, Dworkin, et al. 2014). RA has not yet been studied in a Sub-Saharan African context nor among young women. This dissertation examines the following three relationships in a sample of young Ghanaian women: 1) demographic, reproductive and social factors associated with RA; 2) associations between RA and modern contraceptive use; and 3) associations between RA and pregnancy decision-making, an understudied SRH outcome reflecting who had the most say in the outcome of the last pregnancy. Methods: The RA items and original research questions here were prospectively embedded into a larger parent study focused on stigma toward SRH among adolescents. This study sampled 1,080 young Ghanaian women ages 15 to 24 from facility and community-based sites in Accra and Kumasi, Ghana. Decision-making RA and communication RA measures were created as summative scales using items adapted from the validated scale and ranged from 3 (low RA) to 12 (high RA). In Paper 1, I tested associations between each RA sub-scale and sociodemographic, reproductive history, and social context variables of interest using bivariate statistics (student’s t-tests and ANOVA, where appropriate) and multivariable linear regression models. For Paper 2, I used bivariate statistics (chi-square and t-tests) and multivariable logistic regression models to examine the associations between the RA sub-scales and modern contraceptive use at last sex. For Paper 3, I used bivariate statistics (chi-square and ANOVA) and multinomial regression models to examine associations between the RA sub-scales and pregnancy decision-making (who made the decision about the outcome of the last pregnancy). Results: Regarding Paper 1, I found that a different set of factors were significantly associated with decision-making RA as compared to communication RA. Ethnic group, religion, frequency of religious attendance, and previous pregnancy were significantly associated with decision-making RA, while educational attainment, ethnic group, and social approval for adolescent SRH were associated with communication RA (p-values < 0.05). In Paper two, I found that after adjusting for socio-demographic factors of interest, decision-making RA was associated with modern contraceptive use at last sex among young Ghanaian women (Adjusted Odds Ratio [aOR]: 1.12; 95% CI: 1.01-1.24); communication RA was not significantly associated (aOR: 1.03; 95% CI: 0.88-1.19). In paper three, I found that higher levels of decision-making RA were associated with a decreased relative risk of a woman’s partner having the most say about the pregnancy decision as compared to her having the most say (Adjusted Relative Risk Ratio: 0.79; 95% CI: 0.66-0.93). Conclusions: The results of this dissertation demonstrate that RA may be an important construct to consider when addressing SRH among young Ghanaian women. Additional research should continue to explore the importance of social context for more robust conceptualization and measurement of RA. Public health interventions may benefit from incorporating gender transformative approaches to increase RA among young women, thereby improving SRH outcomes including modern contraceptive use and pregnancy decision-making.