A Conceptual Framework for Reproductive Empowerment: Empowering Individuals and Couples to Improve their Health

Authors for the Background Paper: Jeffrey Edmeades, Carolina Mejia, Jennifer Parsons, and Meroji Sebany
Authors for the Brief: Jeffrey Edmeades, Laura Hinson, Meroji Sebany, and Lydia Murithi

"At the core of the model is an understanding that while reproductive empowerment is fundamentally an individual concept, it is expressed through relationships at multiple levels that interact with each other in a variety of ways."

With funding from the United States Agency for International Development (USAID) and in partnership with MEASURE Evaluation, the International Center for Research on Women (ICRW) has developed a conceptual framework for reproductive empowerment, with the ultimate goal of supporting provision of the evidence needed to develop programmes that enhance reproductive empowerment and improve the lives of women, men, and their families.

There are 2 connected documents available with the same title that articulate the framework:

• A 76-page Background Paper that was created in advance of a joint ICRW and MEASURE Evaluation technical convening of MEASURE Evaluation held in November 2016 that: briefly reviews the ways in which empowerment has been conceptualised across various fields of enquiry, focusing on key concepts that are relevant to reproductive empowerment; introduces the conceptual framework for reproductive empowerment; explores how reproductive empowerment has been measured through a detailed review of recent literature and highlights a series of validated measurement approaches; and examines how these measures compare to the key concepts and relationships identified in the conceptual framework; and
• A 12-page Brief that defines reproductive empowerment and presents the conceptual framework of reproductive empowerment, based on the literature review and consultations with experts in the fields of sexual and reproductive health (SRH), rights-based family planning (FP), and women's empowerment.

As the reader learns, the right of individuals to freely make decisions about their reproductive lives has been a cornerstone of SRH programming since at least the 1994 United Nations Conference of Population and Development. However, it is only recently that researchers have explicitly considered the reproductive sphere as a distinct dimension of empowerment itself. Thus, there is a lack of clarity about what might be considered reproductive empowerment, what its key components are, and how best to measure it.

The definition of reproductive empowerment proposed is this: "Both a transformative process and an outcome, whereby individuals expand their capacity to make informed decisions about their reproductive lives, amplify their ability to participate meaningfully in public and private discussions related to sexuality, reproductive health and fertility, and act on their preferences to achieve desired reproductive outcomes, free from violence, retribution or fear."

"In the context of family planning, this implies that individuals should be able to express their childbearing desires to their partners, providers, and others; meaningfully participate in communication and decision-making with partners, with providers, and within their communities; and shape desired outcomes related to marriage, the conditions of sexual intercourse and the use of contraception."

There are 6 key components of the framework, which entail an understanding of:

1. Agency, which is the capacity of individuals to take deliberate actions to achieve their reproductive desires and preferences. Agency is understood to be shaped by the characteristics of individual relationships or interactions in which an individual is engaged. Agency includes the elements of:
   • Voice, which is the ability of individuals to actively advocate for their reproductive interests, articulate their opinions and desires related to their reproductive lives, shape and share in discussions related to reproduction and demand change when not satisfied with the status quo);
   • Choice, which may be constrained by either a lack of real and viable alternatives or by high social, economic, or emotional costs associated with specific alternatives; and
   • Power, which is present in all social interactions and is therefore a crucial enabler of both voice and choice.

   On the framework, the empowered individual has agency at 3 levels:

   • Individual-level agency: the ability of individuals to conceptualise and define reproductive desires and goals, develop plans for utilising available resources in pursuit of these goals, and confidently exercise voice to demand meaningful engagement in decision-making processes;
   • Immediate relational agency: the ability of individuals to exercise choice and voice with regard to their reproductive desires and preferences in their interactions with peers, family members and romantic/marital partners; and
   • Distant relational agency: the ability of individuals to exert voice, choice, and power in their interactions with actors atat the community, regional, or national level.
2. Individuals as embedded in a wide range of social structures, including friends, family, and the state.
3. Agency and empowerment as inherently relational concepts, experienced and expressed in relationships at different social levels.
4. Empowerment as a process that fluctuates over the lifecourse, as individuals pass through various life stages.
5. Resources as "enabling factors" that act as catalysts for empowerment at each level of agency, from the individual to the distant relational. They may be financial assets or intangible assets, such as correct knowledge of which contraceptive methods are most effective, the awareness an individual has of the social structures influencing their situation, or the level of emotional intimacy and trust in the relationship.
6. The expression of reproductive agency in 3 ways: SRH decision-making, leadership, and collective action.

As noted above, the inconsistency in conceptualising reproductive empowerment has resulted in the use of a wide range of tools and approaches for measurement. MEASURE Evaluation, with support from ICRW, conducted a literature review between February and July 2016. The most commonly used and validated scales measuring sub-domains of reproductive empowerment found during the literature review were:

• Gender-Equitable Men (GEM) Scale, which measures men's and women’s equitable and inequitable attitudes around gender roles related to sexual power dynamics, childcare, housework, and other areas. Its focus is on broader gender equity issues rather than empowerment.
• Reproductive Autonomy Scale, which measures reproductive autonomy, defined as women's ability to achieve their reproductive intentions through 14 items measuring 3 sub-domains. Its application in international settings has yet to be psychometrically tested.
• Sexual Assertiveness Scale for Women, which includes sub-scales for initiation and refusal of sex, as well as assertiveness for pregnancy and sexually transmitted infection (STI) prevention.
• Revised Conflict Tactics Scale (CTS2), which has 5 sub-scales: negotiation; psychological aggression; physical assault; sexual coercion; and injury.
• Women's Empowerment–Multidimensional Evaluation of Agency, Social Capital & Relations Scale (WE-MEASR), which measures domains of women's agency; social capital; and relations and includes numerous scales within each domain, including support for traditional gender roles (male dominance); self-efficacy to discuss and use family planning and; self-efficacy to refuse sex.

The review of the literature points to several gaps in measurement that future research should seek to address, according to ICRW and MEASURE Evaluation. For example, although WE-MEASR and other approaches attempt to measure social or community norms, which is an advance on approaches focused on individuals, more needs to be done to effectively capture and include the influence of meso-level influences.

Looking ahead, the brief offers several considerations:

For researchers:

• Consider stepping back from traditional outcomes of interest, such as contraceptive use, and reframing in terms of enhancing reproductive empowerment and meeting reproductive goals.
• Develop measures that capture the core components of empowerment more directly. Measures of reproductive empowerment must consider the ways that voice, choice, and power influence reproductive behaviours, and directly measure these alongside the key expressions of reproductive empowerment (SRH decision-making, leadership and collective action).
• Understand reproductive empowerment as a dynamic process and incorporate this understanding into measures of reproductive empowerment.

For programme implementers:

• Focus on empowering people to achieve their reproductive goals, as they define them. In some cases, this may mean choosing not to use family planning. Instead, programming aimed at achieving specific reproductive goals should focus on enhancing empowerment and changing norms around specific behaviours.
• Aim to enhance empowerment through shaping relationships. This can include focusing on couple communication, facilitating dialogue between individuals and institutions, enhancing public voice of women, or finding ways to build the resources that help achieve greater agency (e.g., building self-efficacy) within relationships.

Click here for the 76-page Background Paper in PDF format.
Click here for the 12-page Brief in PDF format.