Women's Agency and Contraception Use: A Cross-National Comparison of Nationally Representative Survey Data in India and Kenya

Purpose: Despite increased efforts to improve women’s health, maternal deaths are alarmingly high in Sub-Saharan Africa and Southeast Asia. Maternal mortality rate (MMR) in Kenya and India are 590 and 560 deaths/100,000 live-births respectively, placing them among the top-twenty nations with high MMRs.  Family-planning methods decreases number of births, and can effectively prevent pregnancy-related complications including death.  To reduce pregnancy rates, thereby decreasing MMR, World Health Organization recommends consistent and correct use of modern contraception.  The United Nations’ Millennium Development Goals (MDG) envisages “Improving Maternal Health” (MDG #5) by achieving universal access to reproductive health.  MDG#5 recognizes use of modern contraception is lowest among women living in poverty and those without education.  Guided by Amartya Sen’s Capability Approach of development as an expansion of freedoms necessary to achieve well-being, and Andersen’s Behavioral Model of Health Service Utilization, this cross-national study examines relationship between women’s autonomy and contraception decision-making.

Methods: Using nationally representative sample from Demographic and Health Survey, this study analyzed household women’s responses from Kenya (n=8444) and India (n= 12,4385).  Autonomy was measured by joint participation (yes/no) in decisions pertaining to her own healthcare, big household purchases, daily household purchases, visiting family and relatives, on spending money.  Contraception use was measured as using modern contraception (yes/no); contraception decision making measured as a joint decision between partners over all others. Control variables included aspects influencing predisposition, enabling and need factors.  Weighted univariate and bivariate analyses for survey data and binary logistic regressions reporting adjusted odds ratios were implemented for data analysis.  

Results: Women in India and Kenya reported high rates of joint contraception decision making at 84% and 61% respectively.  Use of modern contraception among women was prevalent among 70% Kenyan and 45% Indian participants.  Almost 100% of women in Kenya were aware of HIV/AIDS and sexually-transmitted infections (STIs), while 33% and 39% women in India reportedly never heard of an STI and HIV/AIDS, respectively.  At the bivariate level, literacy and autonomy on spending money was significantly associated with contraception decision-making in both countries.  Autonomy in spending money (India: OR:1.92, 95% CI:1.75–2.15; Kenya: OR:2.03, 95% CI:1.65– 2.50) and household purchases (India: OR:1.12, 95%CI:1.02–1.23; Kenya: OR:1.35, 95% CI:1.05–1.72) were significant predictors of contraception decision-making. Additionally, Indian women with autonomy in health-related decisions and visiting family were more likely to make contraception decisions jointly.  In both countries increased likelihood of using contraception was predicted by autonomy in spending money, increased age, literacy, and dominant religious group (Hindu and Christian in India and Kenya).  Compared to the poorest, women from wealthier households were more likely to report contraception use in both countries: six folds in Kenya (OR:6.33, 95%CI: 4.58–8.73) and more than three folds in India (OR:3.68, 95%CI: 3.44–8.73).  

Implications:  Both contraception decision making and use continues to be low among the poorest and illiterate women and those with little autonomy over household finances.  To improve women’s health, development programs and policies need to translate into greater economic independence and equal participation in financial decision making for women.