Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries

BACKGROUND

Women's empowerment has a direct impact on maternal and child health care service utilization. Large scope measurement of contraceptive use in several dimensions is paramount, considering the nature of empowerment processes as it relates to improvements in maternal health status. However, multicountry and multilevel analysis of the measurement of women's empowerment indicators and their associations with contraceptive use is vital to make a substantial intervention in the Sub-Saharan Africa context. Therefore, we investigated the impact of women's empowerment on contraceptive use among women in sub-Saharan Africa countries.

METHODS

Secondary data involving 474,622 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 32 Sub-Saharan Africa region was used in this study. Contraceptive use was the primary outcome variable. Multilevel analysis was conducted to examine the impact of women's empowerment on contraceptive use. Percentages were conducted in univariate analysis. Furthermore, multilevel logistic regression models were used to analyze the association between individual, compositional and contextual factors of contraceptive use.

RESULTS

Results showed large disparities in the number of women who reportedly ever use contraceptive methods; this range from as low as 6.7% in Chad and as much as 72% in Namibia. More than one-third of the respondents had no formal education and more than half were active labor force. Contraceptive use was significantly more common among respondents from the richest households (28.5% versus 18.9%). Various components of women's empowerment were positively significantly associated with contraceptive use after adjusting for demographic and socioeconomic factors. There was a significant variation in the odds of contraceptive use across the 32 countries (σ2= 1.12, 95% CrI 0.67 to 1.87) and across the neighbourhoods (σ2= 0.95, 95% CrI 0.92 to 0.98).

CONCLUSIONS

Our findings suggest that an increase in contraceptive use and by better extension maternal health care services utilization can be achieved by enhancing women's empowerment. Also, an increase in decision-making autonomy by women, their participation in labour force, reduction in abuse and violence and improved knowledge level are all key issues to be considered. Health-related policies should address inequalities in women's empowerment, education and economic status which would yield benefits to individuals, families, and societies in general.

A Web in the Patriarchal Clan System

Only recently has Japanese society come to realize the magnitude of domestic violence as a serious social problem. Using focus group methodology, this study investigated the function and the sociocultural reinforcements of male partner violence. The analysis of the participants’ accounts of various types of violence their partners perpetrated, which were accompanied by an elaborate collection of tactics to reinforce the effects of the violence, has led to the conceptualization of partners’ violence as a spider web. The Japanese patriarchal clan system and underlying ideology of male superiority fosters the maintenance of this web.

Reflections on human rights as a reality for women and midwives

We often speak of a woman's right to choose the way she wishes to give birth. This article discusses how 'real' that right is. Some of the legal background to human rights as they relate to childbirth is set out, centred on the 2010 European Court of Human Rights ruling in the home birth case, Ternovszky v Hungary. The limitations of this case point to why resorting to the law to achieve their rights about birth may not be the most fruitful remedy for women. Instead the argument is made for creating equality of voice in the clinical area to achieve a stronger collective voice for anchoring human rights in practice.

Violence prevention and municipal licensing of indoor sex work venues in the Greater Vancouver Area: narratives of migrant sex workers, managers and business owners

Using a socio-ecological, structural determinants framework, this study assesses the impact of municipal licensing policies and related policing practices across the Greater Vancouver Area (Canada) on the risk of violence within indoor sex work venues. Qualitative interviews were conducted with 46 migrant/immigrant sex workers, managers and owners of licensed indoor sex work establishments and micro-brothels. Findings indicate that policing practices and licensing requirements increase sex workers' risk of violence and conflict with clients and result in heightened stress, an inability to rely on police support, lost income and the displacement of sex workers to more hidden informal work venues. Prohibitive licensing and policing practices prevent sex workers, managers and owners from adopting safer workplace measures and exacerbate health and safety risks for sex workers. This study provides critical evidence of the negative public health implications of prohibitive municipal licensing in the context of a criminalised and enforcement-based approach to sex work. Workplace safety recommendations include the decriminalisation of sex work and the elimination of disproportionately high fees for licences, criminal record restrictions, door lock restrictions, employee registration requirements and the use of police as licensing inspectors.

Adverse health effects of spousal violence among women attending Saudi Arabian primary health-care clinics

This study aimed to investigate the frequency of spousal violence among Saudi women and document the related health effects and injuries, as well as their attitudes to gender and violence. Structured interviews were conducted with 200 ever-married women recruited from primary-care centres in Jeddah. Nearly half of the surveyed women (44.5%) reported ever experiencing physical violence from their spouse. Although 37 women (18.5%) had received violence-related injuries, only 6.5% had reported these injuries to a health-care provider. Victims of spousal violence had poor perceptions of their overall health, and reported pain or discomfort, antidepressant use and suicidal thoughts. Women mostly disagreed with the presented justifications for wife-beating. However, the association between gender attitudes and spousal violence was not significant. The results of this study support calls for integration of education about partner violence into health-care curricula to enhance the access and quality of services.

Effective gender-based violence screening tools for use in primary health care settings in Afghanistan and Pakistan: a systematic review

Health care providers have an important role to play in the prevention and response to violence against women. However, the existing tools for screening for gender-based violence have been mostly formulated in the context of developed countries. This paper assesses which violence screening tools designed for use as the primary health care level would be feasible for use in Afghanistan and Pakistan, countries characterized by limited resources, unsupportive institutional frameworks and gender and social norms that reinforce domestic violence. A systematic review was made of the literature to evaluate the different screening instruments. The Women's Experience with Battering Scale (short version) and the Ongoing Violence Assessment Tool were judged to be the most useful tools for screening for violence against women in Afghanistan and Pakistan because they are short, S easy to administer and to score and respond to health care provider identified barriers of time and knowledge constraints for conducting screening for intimate partner violence.

Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya

BACKGROUND

Increases in the proportion of facility-based deliveries have been marginal in many low-income countries in the African region. Preliminary clinical and anthropological evidence suggests that one major factor inhibiting pregnant women from delivering at facility is disrespectful and abusive treatment by health care providers in maternity units. Despite acknowledgement of this behavior by policy makers, program staff, civil society groups and community members, the problem appears to be widespread but prevalence is not well documented. Formative research will be undertaken to test the reliability and validity of a disrespect and abuse (D&A) construct and to then measure the prevalence of disrespect and abuse suffered by clinic clients and the general population.

METHODS/DESIGN

A quasi-experimental design will be followed with surveys at twelve health facilities in four districts and one large maternity hospital in Nairobi and areas before and after the introduction of disrespect and abuse (D&A) interventions. The design is aimed to control for potential time dependent confounding on observed factors.

DISCUSSION

This study seeks to conduct implementation research aimed at designing, testing, and evaluating an approach to significantly reduce disrespectful and abusive (D&A) care of women during labor and delivery in facilities. Specifically the proposed study aims to: (i) determine the manifestations, types and prevalence of D&A in childbirth (ii) develop and validate tools for assessing D&A (iii) identify and explore the potential drivers of D&A (iv) design, implement, monitor and evaluate the impact of one or more interventions to reduce D&A and (v) document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for replication at scale.

Reproductive rights approach to reproductive health in developing countries

BACKGROUND

Research on reproductive health in developing countries focuses mostly on the role of economic development on various components of reproductive health. Cross-sectional and empirical research studies in particular on the effects of non-economic factors such as reproductive rights remain few and far between.

OBJECTIVE

This study investigates the influence of two components of an empowerment strategy, gender equality, and reproductive rights on women's reproductive health in developing countries. The empowerment strategy for improving reproductive health is theoretically situated on a number of background factors such as economic and social development.

DESIGN

Cross-national socioeconomic and demographic data from a number of international organizations on 142 developing countries are used to test a model of reproductive rights and reproductive health.

RESULTS

The findings suggest that both economic and democratic development have significant positive effects on levels of gender equality. The level of social development plays a prominent role in promoting reproductive rights. It is found that reproductive rights channel the influences of social structural factors and gender equality on reproductive health.

Gender differences in treatment outcomes among participants in a mixed-gender substance abuse aftercare program

This study examined gender and gender-related predictors in multiple outcomes of substance abuse aftercare treatment among 78 females and 141 males enrolled in a mixed-gender aftercare program in Massachusetts from 1994 to 1996. Female participants entered the program with higher needs than their male counterparts, showing a worse condition in almost all baseline characteristics, of which many are statistically significant. The generalized estimating equations (GEE) model revealed significant gender differences in the two treatment outcomes of employment income and illegal activity days. Also, many significant gender-related predictors and interaction variables were found.

Battered mothers speak out: participatory human rights documentation as a model for research and activism in the United States

This article describes the work of the Battered Mothers' Testimony Project, a multiyear effort that documented human rights violations against battered women and their children in the Massachusetts family court system. This article (a) presents the Battered Mothers' Testimony Project's participatory human rights methodology as an alternative model for research and activism on violence against women and children in the United States, (b) summarizes the authors' findings and human rights analysis of how the Massachusetts family courts handled custody and visitation in specified cases involving partner and child abuse, and (c) discusses U.S. obligations under international human rights law and the value of a human rights approach to violence against women and children in the United States.

The critical path of women affected by family violence in Latin America: case studies from 10 countries

This research examined the critical path followed by women from 10 Latin American countries who suffer family violence. It identified the personal and social processes women experience as a result of their help-seeking actions and the kinds of responses found at local services. The study used an action-oriented qualitative methodology with a standard research protocol that was translated and adapted for the various ethnic groups. The results provided community actors with an understanding of the barriers women face in overcoming the obstacles, humiliation, and inadequate responses they encounter along their critical paths.

Domestic violence at the intersections of race, class, and gender: challenges and contributions to understanding violence against marginalized women in diverse communities

This article provides a comprehensive review of the emerging domestic violence literature using a race, class, gender, sexual orientation intersectional analysis and structural framework fostered by women of color and their allies to understand the experiences and contexts of domestic violence for marginalized women in U.S. society. The first half of the article lays out a series of challenges that an intersectional analysis grounded in a structural framework provides for understanding the role of culture in domestic violence. The second half of the article points to major contributions of such an approach to feminist methods and practices in working with battered women on the margins of society.

Malawi Women and HIV: Socio-Cultural Factors and Barriers to Prevention

Heterosexually transmitted HIV/AIDS continues to devastate the health and economy of sub-Saharan African countries. In Malawi, 15.4% of 15-49 year olds are infected with HIV and 18-26% of pregnant women are living with HIV. Research has shown that sociocultural factors, especially gender roles and relationships, play a significant role in the transmission of HIV in Africa but little is known about Malawi women's perspective on HIV/AIDS. What do Malawi women say about the impact of HIV/AIDS on their lives, their role in prevention, and the barriers they face in trying to stem the spread of the disease? To answer these questions, three focus groups with Malawi women were conducted and analyzed for themes. The purpose of this paper is to describe one emergent theme captured in the statement, "We are just vessels for our husbands." This theme is explicated through discussions of women's and men's images, women's roles, gender/power relationships, disempowerment, role models and empowerment. Evident in this theme are interrelated messages for those involved in HIV/AIDS prevention. Health education alone is insufficient to stem the tide of HIV in Malawi. A multidisciplinary, systematic approach that includes women's education and economic empowerment as well as modifying legal and social structures that contribute to the spread of HIV/AIDS in Malawi is suggested as necessary additions to HIV and AIDS intervention programs. Only through forging partnerships between health, education, women's development groups, and political and social leaders will we be able to reduce the impact of HIV/AIDS in Malawi.

What is violence against women? Defining and measuring the problem: a response to Dean Kilpatrick

This article discusses (a) the relationship between the reemergence of the women's movement in the 1970s and the current field of violence against women; (b) the role voluntary associations and social activism play in shaping social institutions, including the institution of academic scholarship; (c) the need to broaden our definition of violence against women to include nonviolent acts, such as stalking and emotional abuse; (d) the need to study the interrelationships among various forms of violence and abuse, including violence and abuse experienced as a minor and violence and abuse experienced as an adult; (e) the importance of using precise language when reporting research findings; (f) the importance of using a multiple definition/measurement approach when conducting research on violence against women; and (g) the need for comprehensive research on violence against women that takes into account the various types of violent and abusive behaviors experienced by women over their lifetimes.

Dilemmas and opportunities for an appropriate health-service response to violence against women

This article is an overview of the role of health services in secondary and tertiary prevention of intimate partner violence. In it, I review the evidence, which comes mostly from developed countries, on the effectiveness and limitations of in-service training programmes to identify and care for women who have experienced intimate partner violence. I also discuss recent initiatives in developing countries to integrate concerns on gender-based violence into health-care services at different levels, some of the dilemmas and challenges posed by the current approaches to intimate partner violence, and recommendations for future interventions.

If anthropology is global, then so are its ethical dilemmas

This paper reviews three personal situations of the author as a student: an NGO activist in the women's movement and a UN official working on women's health and tobacco. Each situation, the kinds of ethical issue posed and lessons for the future direction of ethics in anthropology are outlined. The paper argues that applied anthropology is embedded in the position of the field of anthropology within the politics of the State and that this defines the parameters of individual choice. Contradictions in ethical situations and decision-making are posed by changing from the distant observer to active involvement and these may not be resolved by logic alone. Furthermore, governance and defining global ethical standards such as for the behavior of the tobacco multinational corporations is a fascinating new realm for anthropological ethical resolve.

Spousal Abuse/Homicide: A Current Issue in Health Risk Management

Domestic homicides shocked Calgary in 1995. As the year drew to a close, statistics revealed that 5 of the city's 18 murders were at the hands of an abusive spouse, former spouse, or boyfriend. This prompted women across the city to campaign for more protection for women. Press conferences were held in which Calgary's most prominent women's groups called for tougher action against violent offenders. With 1996 over the halfway mark, one case of spousal homicide has occurred. Although statistics are down from this time last year, it is an event that should not have occurred. Although public awareness and pressure led to more women's shelters and programs, these results were tertiary measures. This level of prevention deals with "after the crisis response" to the event and is reactive in its approach. Proactive or primary measures which reduce the risk of the problem starting are now being called for. Throughout history, health care professionals have been called upon to assist the legal system in the prosecution of cases where patient care overlaps with the law, or where the law and physiological realities collide. However not until recently have nurses had the opportunity to study within the field in a formal, organized manner (Lynch, 1995). The shift toward community-based rather than institutional care brings health care professionals in direct contact with cases of abuse and neglect in their natural settings. Early warning signs and symptoms of interpersonal violence will go unreported until nurses are taught to include these in their observations. Nursing programs now prepare nurses for this new specialty practice. Although calls for changes to the restraining orders and greater police protection for women in volatile situations are perfectly understandable, no one pretends they are the answer. The solution begins with spreading the very basic understanding throughout society that women are not property to be exploited or targets for venting anger. To effect change, spousal abuse must be viewed as a primary health care issue that affects us all, as well as being a social and human rights issue. It would benefit our society to become as incensed over spousal abuse as we are over drunk driving. Spousal abuse is a criminal offense and should be treated as such. Ending spousal abuse will require a significant reevaluation of human relationships, a much decreased public tolerance of violence and its depiction, and economic and political conditions that promote equality and a greater ability to control one's own life, but not others (MacLeod, 1994). This analysis of Calgary's response to the domestic homicides of 1995 is a risk-management approach of how the city dealt with this critical problem. With a greater focus on risk management strategies, along with public education and a greater interface with law enforcement agencies, forensic nurses will help reduce the sequelae of human violence; specifically, the fatalities of spousal abuse.