Gendered power dynamics and threats to sexual and reproductive autonomy among adolescent girls and young adult women: A cross-sectional survey in three urban settings

A qualitative exploration of reproductive coercion experiences and perceptions in four geo-culturally diverse sub-Saharan African settings

Reproductive coercion (RC) is any intentional behavior that interferes with another's reproductive decision-making or pregnancy outcome. This study aims to qualitatively examine RC experiences and perceptions among women and men in Ethiopia, Nigeria (Kano and Anambra States), and Uganda. This is a secondary analysis utilizing qualitative data from the Women's and Girls' Empowerment in Sexual and Reproductive Health study. Across sites, focus group discussions (38 groups; n=320 participants) and in-depth interviews (n=120) were conducted, recorded, and transcribed. Transcripts were loaded into Atlas.ti, and quotes describing experiences of reproductive control or abuse were coded as "reproductive coercion." RC quotes were input into a matrix for thematic analysis. Emergent RC themes included indirect reproductive pressures, direct family planning interference, concurrent experiences of violence, and responses to RC. Indirect reproductive pressures included tactics to both promote and prevent pregnancy, while direct interference centered on pregnancy promotion. Women who were not compliant with their partners' reproductive demands were often subjected to violence from multiple actors (i.e., parents, in-laws, community members) in addition to their partners. Despite concurrent forms of violence, women across sites resisted RC by using contraceptives covertly, choosing to abort, or leaving their abusive partnerships. Women and men across sites indicated that men were highly influential in fertility. RC behaviors were a mechanism of control over desired reproductive outcomes, which were often rooted in perceptions of childbearing as social status. Findings indicate a need for more nuanced community interventions targeting social norms, as well as improved RC screening and response within health services.

A Scoping Review of Nonconsensual Condom Removal ("Stealthing") Research

Nonconsensual condom removal (NCCR; also known as "stealthing") involves the removal of a condom before or during sexual intercourse without a partner's sexual consent. Within the past several years, nations across the globe have codified NCCR as a form of sexual violence penalized by civil and/or criminal penalties. Given the recent legal attention to this behavior, we performed a scoping review of the peer-reviewed, empirical, English-language studies conducted on NCCR in order to summarize the current state of this field of research. Our scoping review yielded 27 articles meeting study inclusion criteria. Data on NCCR victimization and perpetration prevalence rates and correlates, as well as perceptions of NCCR, were extracted. The majority of the reviewed studies were conducted within the past 5 years and pertained to NCCR victimization. Rates of NCCR victimization ranged from 7.9% to 43.0% for women and 5.0% to 19.0% for men who have sex with men; rates of NCCR perpetration ranged from 5.1% to 9.8% for men and 0% for women. NCCR correlates included sociodemographic variables, relationship type, psychological factors, and sexual health concerns. Perceptions of NCCR were largely negative. The nascent field of NCCR research provides empirical evidence from several countries regarding concerning rates of NCCR. Building upon this foundation, continued research regarding NCCR is imperative. Studies that further delineate NCCR prevalence, risk factors, and outcomes would provide critical information beneficial to the development of evidence-based prevention and intervention programs targeting reductions in NCCR.

Intersection of reproductive coercion and intimate partner violence: cross-sectional influences on women's contraceptive use in Burkina Faso, Côte d'Ivoire and Kenya

OBJECTIVES

Among nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women's contraceptive use outcomes, including current contraceptive use, method type and covert use.

DESIGN

The present analysis uses cross-sectional female data collected in Burkina Faso (December 2020-March 2021), Côte d'Ivoire (October-November 2021) and Kenya (November-December 2020).

SETTINGS

Burkina Faso, Côte d'Ivoire and Kenya PARTICIPANTS: Analytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390).

PRIMARY AND SECONDARY OUTCOME MEASURES

The exposures of interest-past-year emotional IPV, physical/sexual IPV and RC-were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments.

RESULTS

Across sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)).

CONCLUSIONS

Across settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women's reproductive health.

Prevalence and characteristics of covert contraceptive use in the Performance Monitoring for Action multi-country study

Objectives

A more nuanced understanding of contributors to covert contraceptive use remains critical to protecting covert users and reducing its necessity. This study aimed to examine the overall prevalence of covert use, and sociodemographic characteristics associated with covert vs overt use across multiple geographies in sub-Saharan Africa and Asia.

Study Design

Performance Monitoring for Action (PMA) is one of the few nationally representative surveys that measures covert use across socially diverse contexts via a direct question. Utilizing PMA 2019-2020 phase 1 data from Burkina Faso, Côte D'Ivoire, Kenya, Democratic Republic of Congo (DRC; Kinshasa and Kongo Central regions), Uganda, Nigeria (Kano and Lagos), Niger, and Rajasthan, we estimated overall prevalence of covert use. We conducted bivariate analyses and multivariate logistic regressions for 6 sites, comparing the odds of covert use with overt use among users of contraception by sociodemographic characteristics.

Results

Covert use ranged from 1% in Rajasthan to 16% in Burkina Faso. Marital status was the only sociodemographic characteristic consistently associated with type of use across sites. Specifically, polygynous marriage (compared to monogamous) increased odds of using covertly, ranging from adjusted odds ratio (aOR) of 1.8 [95% confidence interval (CI) 1.2-2.7] in Burkina Faso to 6.2 [95% CI 2.9-13.3] in Kinshasa. Unmarried women with partners or boyfriends were also more likely to be using covertly compared with their monogamously married counterparts in all sites (aORs ranged from 2.2 [95% CI 1.0-4.7] in Uganda to 4.4 [95% CI 1.7-11.0] in Kinshasa).

Conclusion

Understanding factors associated with covert use has programmatic and policy implications for women's reproductive autonomy.

Implications

Covert use is a common phenomenon across most sites, representing a small but programmatically important contingent of users. Family planning providers and programs must protect access to and maintain privacy of reproductive services to this population, but should also focus on creating interventions and environments that support overt use.