Andersen (Taylor), Margo
Women’s Autonomy and the Effect on Family Planning in Nepal
Faculty Mentor: Scott Sanders, Renata Forste
In 2010, maternal death rates globally reached as high as 210 per 100,000 (United Nations, 2013) and resulted in part from a lack of maternal health services. Maternal health services like family planning play a critical role in improving women’s reproductive health in developing countries (Bhatia and Cleland, 1995). Today there are an estimated 225 million women in developing countries that would choose to delay or stop childbearing but are not using any method of contraception (World Health Organization [WHO], 2015). Linked to low contraceptive use, women in these regions also have low levels of autonomy. These male-dominated regions place little value in women and their health. To further examine the link between women’s autonomy and family planning, I model women’s empowerment and contraceptive use in Nepal. In Nepal, there is a low rate of contraceptive usage and a large percentage of women who would like to have access but don’t. In 2006, 25% of married women expressed an unmet need for family planning (Adanu, 2008). Despite increases in family planning throughout Asia, Nepal still lacks in terms of the availability and usage of family planning.
The outcome variable is a binary indicator of currently using contraception in the past 12 months or not. My original hypothesis uses bivariate analysis to see the association of increased autonomy and the effects it has on contraceptive usage. I add control variables to my original model which makes the analysis a multivariate analysis dealing with a dichotomous dependent variable, one independent variable and eight control variables. My models are thus estimated using binary logistic regression. The results are presented as odds ratios, which represent the increase or decrease in the odds of contraceptive use versus no use associated with a unit or category change in the independent variables. I model the relationship between autonomy and contraceptive use with controls. I continue the analysis by adding interactions of key variables, urban and religion, with autonomy.
The multivariate results are presented in the table. The first model presents the odds for the association between autonomy and contraceptive usage. For every one point increase on the autonomy scale, the odds of contraceptive use increase 19% (model 1. When women have a greater ability to have a say in their own health care, spending, household purchases, and ability to visit friends and relatives, they are more likely to use contraception. Each additional household decision women have a say in increases the odds of current contraceptive use by 7% (model 2).
The odds of contraceptive use increase by 6% for every year increase in age. Urban residency plays an important role in contraceptive usage; those who live in urban areas are 15% more likely than those who live in rural areas to currently be using contraceptive methods. The ecological zones of mountain and terai have very similar rates of contraceptive usage, but the hill ecological zone has an 11% reduction in the odds of using contraceptives. To further understand how autonomy affects contraception, I tested interactions between autonomy and urban residency. The interaction between rural residency and low autonomy is positive and significant (OR =1.32), which indicates that the likelihood of low autonomy is associated more closely with rural residency. The effects are most significant between urban and rural when there is no reported autonomy. After a woman is autonomous in at least one aspect of the scale the interaction begins to disappear. (see Graph 1)
Interactions were also tested between autonomy and religion. Graph 2 shows the religions plotted to show interactions with autonomy and contraceptive use. Overall Buddhists are more likely to use contraception than any other religion. Buddhists also are more likely to use contraceptive methods when they have lower autonomy. Hindus are experiencing greater levels of contraceptive usage than the other religion category. Other religions have low variability in their contraceptive use despite changes in autonomy (see Graph 2).
The interactions of autonomy and urban residency as well as religion show that autonomy is not just
a simple idea that can be applied across the population. Autonomy has variability based on religious
principles as well as geo-spacial location.
An important indicator to see if change in family planning is happening is to see the extent to which nonusers plan or are able to use contraception in the future. Based on the literature and the proximate
determinants of fertility theory, I hypothesized that increased autonomy, characterized by decision making, and would influence contraception. Though autonomy did increase the likelihood of women using
contraception there are other factors that influence contraceptive usage.
A Limitation to my research consist of lacking a concreate definition of autonomy. Autonomy is a term that has many implications but no set factors to determine whether a woman is autonomous. Autonomy is broad and has many influencing factors. I propose that autonomy should be expanded to more than just four decision making factors. Based on my interaction with autonomy and religion we see that religion also influences autonomy levels. This implies that autonomy is not a simple concept and needs further research to develop a stronger concept concerning women’s autonomy.
The current program for family planning included in Nepal Health Sector Program Implementation Plan is
based on media programs that are broadcasted on TV as well as in print (NPC, 2011). These current
programs seem to unintentionally focus on those people who have access to these media outlets. These
current media outlets focus on those who have a TV, normally those who are in urban residencies, and those who can read, who generally have higher education. The trend in the literature show that women who have more education should also be more autonomous and have higher contraceptive usage (Riyami, 2004). Increasing women’s autonomy, as well as continuing maternal health goals such as increasing family planning need to continue. These are necessary for Nepal to further develop as a country.