Reproductive agency : Validation of a measure for women's autonomy in family planning and sexuality in Burkina Faso.

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Fiacre Bazié, Yentema Onadja, Abdramane B. Soura, Meagan E. Byrne, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6982590/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The links between women's empowerment and their reproductive health remains complex due to persistent challenges in defining empowerment and its various components, as well as the factors shaping it in different contexts. These difficulties also stem from the inability to conceptualize reproductive empowerment as an independent process that both reflects and shapes broader empowerment dynamics. This study, based on data from the Performance Monitoring for Action (PMA) research platform in Burkina Faso, aims to assess the validity of a multidimensional measure of agency specifically adapted to reproductive health in the Burkinabe context. This measure consists of two key dimensions: motivation —the ability to define reproductive goals—and self-efficacy —the ability to act on them. It explores women’s decision-making autonomy in two key areas of reproductive health: family planning and sexuality. The findings indicate that this measure demonstrates acceptable psychometric properties for use in Burkina Faso. Moreover, external validity analyses reveal that, across each domain of agency, the motivation dimension was more strongly associated with reproductive outcomes compared to self-efficacy. Finally, the results highlight that social expectations regarding fertility, fear of infertility, stigma surrounding female sexuality, perceptions of men's sexual rights, and fear of relational sanctions contribute to limiting women's autonomy in reproductive decision-making. Sexual & Reproductive Medicine Women Reproductive health Agency Burkina Faso 1. Background The promotion of gender equality and women’s empowerment are seen as key factors for improving health and achieving development goals (United Nations General Assembly, 2000 ; Kabeer, 2005). Women's empowerment, defined as the process by which women enhance their ability to make strategic life choices (Kabeer, 1999), is an intrinsic human rights objective. A low level of empowerment has significant consequences on women and their children’s well-being: it is linked to various negative economic and health outcomes for women (Yount et al., 2014; James-Hawkins et al., 2016; Upadhyay et al., 2014) and their children (Malhotra et al., 2014; Chakraborty and Anderson, 2011). In 2015, the United Nations set the achievement of gender equality and the empowerment of women and girls as the fifth of the 17 Sustainable Development Goals (United Nations General Assembly, 2015). In response to the 1994 International Conference on Population and Development (ICPD), the Millennium Development Goals (MDGs), and later the Sustainable Development Goals (SDGs), research and health programs have increasingly focused on women's and girls' empowerment. A significant body of research has explored the link between empowerment and reproductive health (RH) outcomes, particularly highlighting the association between women's empowerment and improved sexual and RH (SRH) behaviors and outcomes (Prata et al., 2017), including contraception use (James-Hawkins et al., 2016; Ewerling et al.,2017) prevention of unwanted pregnancies (Upadhyay and Hindin, 2005), receipt of prenatal care (Mistry et al., 2009), improvement in maternal dietary practices, delivery with a skilled birth attendant (Fotso et al., 2009), and negotiation of sex (Upadhyay et al., 2014). Despite the evidence of the links between women's empowerment in general and RH outcomes, numerous research findings recognize the complexity of this relationship, resulting in links that are often negative or counter-intuitive (Schatz & Williams, 2012; Edmeades et al., 2018, Prata et al., 2017). These ambiguous relationships between autonomy and health outcomes, particularly observed in the specific context of Africa, are often explained by, among other things, shortcomings in defining empowerment in terms of the factors that determine it in each context (Malhotra 2004 ; Edmeades, J et al., 2018, Prata et al., 2017, Richardson, 2018; Yount et al., 2018) and by methodological problems in measuring empowerment (Agarwala and Lynch 2006; Edmeades, J et al., 2018; Prata et al., 2017). Indeed, in the literature, women's empowerment is often confused with women's “status”, including level of education, employment, financial assets and women's ability to use these resources to achieve specific goals (Heckert & Fabic, 2013). Women's empowerment is also often associated with autonomy and/or agency 1 (Malhotra and Schuler, 2005; Yount et al., 2015). Also, in studies investigating the links between empowerment and RH, the finding that diversified measures are used in different contexts, ranging from general indicators such as educational attainment, employment or socio-economic status to more specific measures such as participation in household decision-making and women's mobility, which are mainly used in low- and middle-income countries, reveals the lack of a unified framework guiding research in this area and often results in inappropriate measures (Malhotra 2004; Edmeades et al., 2018, Prata et al., 2017, Richardson 2018; Karp et al., 2020).Questions related to decision-making autonomy, which are widely used in the literature as a measure of women's empowerment, are based on experiences in Asia and may not reflect the situation in African countries. For example, with regard to freedom of movement, which is always used as an indicator of women's autonomy, some research has shown that women in sub-Saharan Africa (SSA) are not restricted in their movements and naturally enjoy greater civil liberties (Heckert & Fabic, 2013; OECD, 2010). These varying definitions of women’s empowerment perpetuate ambiguity in the literature, making it challenging to understand its impact on RH outcomes and simultaneously highlighting the need for conceptual and operational refinement (Kabeer, 1999; James-Hawkins et al., 2018). As a result, the literature has remained limited in its ability to fully explore how autonomy is linked to RH outcomes (Edmeades et al., 2018; Richardson, 2018; Karp et al., 2020). Moreover, the use of varying definitions of empowerment to examine its links with women’s RH reflects a certain inability to treat reproductive empowerment as a distinct process that both reflects and shapes the broader processes involved in overall empowerment (Edmeades et al., 2018). One of the critical aspects of empowerment is its multidimensional nature (Malhotra & Schuler, 2005; Edmeades et al., 2018). Individuals can simultaneously experience high (or low) levels of autonomy across several distinct dimensions or domains. While Malhotra and Schuler (2005) proposed five domains of empowerment—economic, sociocultural, legal, political, and psychological—Pratley (2016) and Hanmer & Klugman (2016) argue that it is justified to consider RH as a distinct dimension in addition to the five outlined by Malhotra and Schuler. The pivotal role of reproduction in overall empowerment, particularly for women, and its influence on other dimensions of empowerment suggest that it should be treated as a separate domain, equivalent to the other domains identified in earlier literature (Pratley, 2016; Edmeades et al., 2018). Autonomy across all these domains is essential for achieving comprehensive women’s empowerment (Hanmer & Klugman, 2016). 2. Review of several measures of empowerment in RH. Although a growing body of research addresses the impact of women's empowerment on RH outcomes, it is only recently that RH empowerment has been explicitly distinguished as a full and distinct dimension of empowerment itself (Edmeades et al., 2017; Edmeades et al., 2018; Vizheh et al., 2021). Edmeades and colleagues (2018) proposed the following definition of reproductive empowerment according to a recently developed framework: “ 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 ” (Edmeades et al., 2018 ; p5). A review of the literature reveals that more targeted research has specifically examined the process of empowerment in RH using concepts such as sexual self-efficacy (Quinn-Nilas et al., 2016), sexual assertiveness (Morokoff et al., 1997), sexual power (Pulerwitz, Gortmaker, & DeJong, 2000), reproductive autonomy (Upadhyay et al., 2014; Upadhyay, 2021), and the sexual pressure scale (Jones & Gulick, 2009; Jones, 2006) to better understand the gender dynamics shaping women’s decisions and outcomes in sexuality and reproduction. This rich body of research, however, remains challenging to synthesize due to the lack of a comprehensive framework that connects these concepts. Furthermore, most studies, in addition to being predominantly focused on Western contexts, have generally concentrated on the power structures that constrain women’s capabilities in RH rather than the psychosocial processes that interact with these power structures to shape sexual and reproductive choices and preferences (Eerdewijk et al., 2017; Edmeades et al.,2017; Moreau et al., 2020; Wood et al., 2020; Vizheh et al., 2021). Finally, within this body of work, the few that have incorporated the psychosocial attributes of RH empowerment, including Upadhyaya et al., (2014 and 2021), still primarily apply to Western cultures and provide little insight into the expressions and processes of RH empowerment in other cultural contexts, particularly African ones. Specific contexts where sexuality and fertility attitudes and norms, as well as masculinity hegemonic norms, severely limit the negotiation power of women and girls (Wolff, Blanc and Gage 2000; Varga 2003), restrict their RH decision-making (Blanc 2001) and ultimately compromise their RH (Blanc 2001; Jewkes & Morrell, 2012). Efforts to conceptualize empowerment, primarily focused on low- and middle-income country contexts, have significantly contributed to theoretical advancements (Van Eerdewijk et al., 2017; Donald et al., 2017; Edmeades et al., 2018; Ewerling et al., 2017). Building on Kabeer’s foundational work on women’s empowerment in the early 2000s, the World Bank developed a framework that defines empowerment as the interaction between resources and agency, guiding the progression from the existence of a choice to the realization of a choice through its exercise (Kabeer, 1999; Malhotra et al., 2002; Malhotra & Schuler, 2005). While the World Bank framework clarifies the general process of empowerment by integrating psychosocial dimensions and development contexts, it does not specify how the empowerment model applies to specific domains of life, particularly RH decisions, actions and outcomes. Several institutions, including the KIT Royal Tropical Institute in collaboration with the Bill & Melinda Gates Foundation (BMGF) (Van Eerdewijk et al., 2017), and the International Center for Research on Women (ICRW) (Edmeades et al., 2018), have recently proposed two empowerment frameworks focusing on RH. In addition to recognizing choice as an essential component of empowerment, the KIT-BMGF and ICRW frameworks explicitly recognize the dimensions of voice and power as necessary conditions for women to achieve their goals by challenging gender inequalities. Building on the KIT-BMGF model, the ICRW framework emphasizes decision-making in RH across key behavioral domains (volitional sexual relations, control over fertility and life choices), leadership in RH (leadership roles in community decision-making processes related to RH), and collective action in RH (influence on policies/programs and advocacy efforts) (Edmeades et al., 2018). Unlike the World Bank model, the KIT-BMGF and ICRW frameworks place less emphasis on the psychosocial processes guiding individual-level choices, instead focusing more on programmatic and advocacy objectives necessary for advancing gender equality and women's empowerment at the societal level. The distinctive contribution of the World Bank model lies in its attention to the internalization of these power structures at the individual level, seeking to describe how they shape the formulation of individual and internal goals and actions. However, this approach does not place particular emphasis on RH, nor does it clearly elucidate how empowerment applies to this specific domain of women’s lives. Conversely, the contributions of the KIT-BMGF and ICRW models highlight gender inequality as an institutional and collective barrier to women’s well-being in RH. However, these latter approaches place less emphasis on the psychosocial processes that guide the translation of choices into actions at the individual level. In response to these shortcomings, Moreau et al., (2020) from the Performance Monitoring for Action (PMA) research platform, building on the World Bank model and the work of KIT-BMGF and ICRW, proposed a new conceptualization of sexual and reproductive empowerment. This measure was developed and anchored within a conceptual framework of women's sexual and reproductive empowerment. This framework acknowledges the multi-level environment influencing sexual and reproductive decisions, shaped by social and cultural norms, interactions with partners and family, as well as internal motivations. Drawing inspiration from prior work on agency by Donald et al., (2017), who define it as the “ability to set one’s goals and act accordingly” Moreau and colleagues identified two components of agency: the existence of choice and the exercise of choice. Existence of choice, or motivational autonomy , refers to the internal and external motivations underlying women’s sexual and reproductive choices and goals (Moreau et al., 2020; Karp et al., 2020). As for exercise of choice, or self-efficacy , this encompasses various skills, particularly women’s confidence in exercising their choices and their ability to make decisions (Moreau et al., 2020; Karp et al., 2020). This conceptual framework addresses some of the limitations of existing research by considering the internalization of exogenous factors by women that shape their individual preferences regarding RH (Alsop & Heinsohn, 2005; Edmeades, 2018). The questions for this measure, developed during mixed-methods exploratory studies across three countries (Uganda, Ethiopia, and Nigeria), were subsequently integrated into the standard questionnaires of the PMA research platform without prior validation in each context. However, such prior validation is particularly crucial when it comes to empowerment measures. As highlighted by Malhotra and Schuler (2005), one of the main challenges in measuring empowerment lies in the fact that behaviors and attributes signifying empowerment in one context often hold different meanings in another. In this case, while certain similarities between sociocultural, economic, and political contexts across sub-Saharan Africa are acknowledged, each context retains its unique characteristics. Experts strongly recommend validating empowerment measures before applying them in a new context where no prior validation has been conducted (James-Hawkins et al., 2018; Richardson, 2018; Yount et al., 2018). The objective of this study is to determine whether this measurement index, developed in other African contexts, possesses the internal and external characteristics required to serve as a tool for assessing women's autonomy in the reproductive domain in Burkina Faso. This is a context where not only are gender inequality indices among the highest in West Africa, with persistently high incidences of physical and sexual violence, but also where a significant proportion of women are still unable to meet their contraceptive needs (Alkema et al., 2015; UNDP, 2019; Decker et al., 2022). To date, the limited studies examining the relationship between women's empowerment and RH in Burkina Faso have predominantly used household decision-making participation as a proxy for women’s autonomy (Pambè, Gnoumou, & Kaboré, 2014; Atake & Gnakou Ali, 2019; Some, Pu, & Huan, 2021; Beaujoin et al., 2021). However, this measure has increasingly been criticized for its limitations in capturing decision-making power—and its effects on RH—in sub-Saharan contexts. Based on the two sub-dimensions of agency (motivation - the ability to define goals - and self-efficacy - the ability to implement one's goals) used in the previous validation, we will assess the internal and external properties of this measure to see whether it is appropriate in the context of Burkina Faso for use as an instrument to identify the autonomy of Burkinabe women in two areas of RH: sexuality and family planning. 3. Methods 3.1 Data This research uses data from the PMA research platform in Burkina Faso. PMA is a platform for monitoring RH and family planning (FP) indicators implemented in eight countries in SSA and Asia, including Burkina Faso. In each country, PMA uses multi-stage stratified cluster sampling to select a random sample of households and women of reproductive age (15–49 years) representative at national and sub-national levels depending on the country. During the 2020–2021 period, the PMA platform introduced new survey themes, including a module on the empowerment of women and girls in RH. In Burkina Faso, as with the PMA platform's standard questionnaires, the data from this survey module is representative at the national level and of urban and rural areas. The survey covered 167 enumeration areas (EAs), 5,800 households and 6,500 women aged 15–49 years. The questions on contraceptive agency were asked of all women, while those on sexual agency were only asked of women who had already had sexual intercourse. The response rates were 98% for the household questionnaire and 95% for the women's questionnaire. Missing data, most of which were less than 3%, were excluded from the analyses. Table 1 shows the questions in the RH empowerment module implemented in Burkina Faso. Table 1 The items of the subdimensions of reproductive agency REPRODUCTIVE AGENCY Subdimensions Items Target population Response modalities FP Agency FP motivation (5 items) If I use family planning, my husband/partner may seek another sexual partner. All women aged 15–49 years Likert Scale (1-Strongly disagree to 5- Strongly agree) If I use family planning, I may have trouble getting pregnant the next time I want to. There could/will be conflict in my relationship/marriage if I use family planning. If I use family planning, my children may not be born normal. If I use family planning, my body may experience side effects that will disrupt my relations with my husband/partner. FP self-efficacy (2 items) I can decide to switch from one family planning method to another if I want to. I feel confident telling my provider what is important for me when selecting a family planning method. Sexual Agency Sexual motivation (4 items) If I refuse sex with my husband/partner, he may stop supporting me. All women aged 15–49 years who ever had sex Likert Scale (1-Strongly disagree to 5- Strongly agree) If I refuse sex with my husband/partner, he may force me to have sex. If I refuse sex with my husband/partner, he may physically hurt me. If I show my husband/partner that I want to have sex, he may consider me promiscuous. Sexual self-efficacy (4 items) I am confident I can tell my husband/partner when I want to have sex. I am able to decide when to have sex. If I do not want to have sex, I can tell my husband/partner. If I do not want to have sex, I am capable of avoiding it with my husband/partner. 3.2 Analysis Since the main objective of this study is to test the contextual validity of this measure of reproductive autonomy, the first step will be to ensure that the items selected to make up each of the four subdimensions do indeed represent the same construct in the context of Burkina Faso. For each group of variables comprising each of the sub-dimensions, we first carried out a principal component analysis to assess the proportion of the total variance explained by the first component and then a factor analysis to assess the factor loadings of each of the variables (items) to the first factor. This first step enables us to determine the extent to which the items used for each subdimension effectively summarize the same dimension and refer to the same latent construct. A proportion greater than 50% of the total variance explained by the first component is necessary to estimate that this component does indeed summarize all the information from the variables used (Streiner 1994) and a factor loading of more than 0.50 is necessary to estimate that each variable observed is well correlated with the latent construct (Guadagnoli & Velicer 1988) and therefore that this latent construct represents a reliable measure of each item. We then computed the Cronbach's alpha coefficients for each subdimension to assess the internal consistency of the construct. An alpha coefficient of at least 0.7 is generally required to attest to the internal consistency of a multi-item measure (De Vaus, 2002). After this step, and in accordance with our conceptual framework, which stipulates that these different subdimensions are conceptually distinct yet interrelated, we assessed the relationships between the four subdimensions using Pearson’s correlation coefficient. This statistical measure evaluates both the strength and direction of the association between two variables. This step also allowed us to identify potential multicollinearity issues in preparation for including these four variables simultaneously in explanatory models. For the construction of empowerment indices, latent scores were utilized to minimize issues related to the weighting of individual items. However, for the contraceptive self-efficacy index, a summative score was used due to the limited number of items (two). Following the internal validity assessment, we proceeded with external validation of the measure. The first stage of this validation aimed to identify individual characteristics associated with women’s reproductive autonomy for each subdimension of the measure. Linear regression models were used, with the dependent variables (continuous) representing each of the four subdimensions of autonomy, while the explanatory variables included sociodemographic characteristics such as place of residence, marital status, parity, age, education level, household wealth, and women’s employment 2 status. In all four regression models, the sociodemographic characteristics were adjusted to predict the conditions under which women experienced gains in autonomy. The second stage of the external validation involved examining associations between women’s autonomy and RH outcomes. For this analysis, we used multivariate logistic regression models to evaluate the magnitude and direction of the associations between the four subdimensions of reproductive agency (independent variables) and two RH outcomes (dependent variables): volitional use of modern FP (family planning domain) and the occurrence of an unwanted last sexual intercourse (sexuality domain) among women. To construct the categorical variables for "reproductive agency," terciles were used to define different levels of autonomy based on the scores for each subdimension. The first tercile represented women with low autonomy, the second tercile represented women with moderate autonomy, and the highest tercile represented women with high autonomy. Our first dichotomous dependent variable, "volitional use of modern FP" was derived from the following question posed to women currently using a modern contraceptive method 3 : Would you say the decision to use contraception was mostly yours, mostly your husband's/partner's, or a joint decision? The response options included: (1) Mostly mine, (2) Mostly my husband’s/partner’s, (3) Joint decision, (4) Other, and (5) No response . Women who reported making the decision alone or jointly with their husband/partner were categorized as voluntarily using modern contraception (coded as 1), while women who were not current users of a modern contraceptive method were coded as 0. The objective was to assess the influence of women’s autonomy on their ability to voluntarily engage in family planning. Women whose use of contraception was not volitional (responses 2 and 4) were excluded from this analysis. The second dichotomous dependent variable, "unwanted sexual intercourse," was derived from the following question posed to women who had ever had sexual intercourse: The last time you had sexual intercourse, did any of the following occur? The response options included: (1) I did not want to have sexual intercourse at that time, (2) My husband/partner pressured me to have sexual intercourse, (3) I did not consent (I was forced) to have sexual intercourse at that time, (4) I felt at risk of physical violence if I refused to have sexual intercourse, and (5) None of the above. Women who reported experiencing at least one of the first four scenarios were categorized as having experienced unwanted sexual intercourse (coded as 1), while those who selected response 5 were categorized as having had wanted sexual intercourse (coded as 0). Finally, two analytical models were used to evaluate the nature and degree of associations between our explanatory variables and the two RH outcomes. These models predict the conditions under which women voluntarily use modern contraception and experience unwanted sexual intercourse. In the first model (unadjusted), each subdimension of reproductive agency was associated individually with each of the two RH outcomes to measure the crude effect of each subdimension on RH outcomes. In the second model (adjusted), all four subdimensions were included simultaneously, along with sociodemographic characteristics (place of residence, marital status, age, parity, education level, household wealth, and employment 4 ), to evaluate the predictive differences between the four subdimensions across the two RH outcomes. All data were weighted using the available sampling weights, and analyses were conducted using Stata version 16. 4. Results 4.1 Characteristics of interviewed women Table 2 presents the characteristics of the surveyed women. Approximately 80% of these women resided in rural areas, and 76% were married or cohabiting with a partner. About four in ten women were adolescents or young adults. Nearly 80% had experienced at least one live birth, and around 26% were using a modern contraceptive method. Additionally, over 87% of the sample had engaged in sexual intercourse, and among them, slightly more than 37% reported that their most recent sexual intercourse was unwanted . Table 2 Sociodemographic characteristics of interviewed women (N = 6418) Sociodemographic characteristics % (Weighted) N (Unweighted) Place of residence Urban 22.9 3887 Rural 77.1 2531 Marital status Unmarried 24 2131 Married 76 4287 Age group 15–19 21.1 1393 20–24 17.3 1253 25–34 30.6 1936 35–49 31 1836 Parity Nulliparous 23.9 1938 One child 12.6 948 2–3 children 23.5 1590 4 or more 39.9 1927 Education level None 59.6 2808 Primary 17.7 1283 Secondary level 1 16.5 1504 Secondary level 2 or more 6.2 821 Household wealth Poorest 34 1134 Middle 32.7 1335 Wealthiest 33.3 3949 Employment No 67.6 3880 Yes 32.4 2538 Ever had sex No 12.9 962 Yes 87.1 5338 Last sex unwanted No 62.9 3496 Yes 37.1 1842 Using modern FP No 74.2 4431 Yes 25.8 1987 4.2 Links between items of reproductive agency subdimensions Table 3 summarizes key psychometric properties of the various items and subdimensions within this measure of reproductive autonomy. These include the proportion of total variance explained by the first component, factor loadings, and Cronbach's alpha coefficient for each subdimension. Our results indicate that, for each set of variables corresponding to the four subdimensions, the proportion of total variance explained by the first component exceeds 50%. This finding demonstrates that the first component (subdimension) effectively summarizes the information contained within the respective set of variables. Each group of variables used for a specific subdimension of reproductive agency aligns well with a single latent construct. The factor loadings for each item on the first factor further reveal the degree of correlation between individual items and the latent construct, illustrating how well the construct serves as a reliable measure for the variables used. The results show that, for each subdimension, the factor loadings are consistently above 0.50, indicating a strong correlation between individual items and the latent construct (Guadagnoli & Velicer, 1988). These factor loadings suggest that each latent construct (subdimension) provides a coherent and valid representation of the items included. Finally, Cronbach’s alpha coefficient, which ranges from 0 to 1, is commonly used to assess the internal consistency of a latent construct—specifically, the extent to which the items within a subdimension collectively form a reliable measure of the latent variable. Typically, a coefficient above 0.7 is considered adequate, while a coefficient below 0.5 is regarded as relatively weak and unreliable (De Vaus, 2002). For all three subdimensions evaluated, Cronbach's alpha is at least 0.7. Overall, our findings demonstrate satisfactory thresholds for the psychometric criteria used, confirming the internal validity of each of the four subdimensions of reproductive agency. Table 3 Psychometric characteristics of the subdimensions of reproductive agency among women aged 15–49 REPRODUCTIVE AGENCY Subdimensions Items Factor loadings FP Agency FP motivation (5 items) N = 6,418 % Variance Explained = 54.67 Cronbach’s Alpha = 0.78 Score Range: -2.75 to 1.21 Mean: 0.05 Median: 0.21 If I use family planning, my husband/partner may seek another sexual partner. 0.66 If I use family planning, I may have trouble getting pregnant the next time I want to. 0.75 There could/will be conflict in my relationship/marriage if I use family planning. 0.77 If I use family planning, my children may not be born normal. 0.75 If I use family planning, my body may experience side effects that will disrupt my relations with my husband/partner. 0.73 FP self-efficacy (2 items) N = 6,418 % Variance Explained = 71.98 Cronbach’s Alpha = N/A Score Range: 0.96 to 5 Mean: 4.33 Median: 4 I can decide to switch from one family planning method to another if I want to. 0.84 I feel confident telling my provider what is important for me when selecting a family planning method. 0.84 Sexual Agency Sexual motivation (4 items) N = 5,338 % Variance Explained = 56.34 Cronbach’s Alpha = 0.71 Score Range: -2.62 to 1.07 Mean: -0.05 Median: 0.15 If I refuse sex with my husband/partner, he may stop supporting me. 0.71 If I refuse sex with my husband/partner, he may force me to have sex. 0.84 If I refuse sex with my husband/partner, he may physically hurt me. 0.84 If I show my husband/partner that I want to have sex, he may consider me promiscuous. 0.55 Sexual self-efficacy (4 items) N = 5,158 % Variance Explained = 55.32 Cronbach’s Alpha = 0.70 Score Range: -2.19 to 1.33 Mean: -0.001 Median: 0.16 I am confident I can tell my husband/partner when I want to have sex. 0.77 I am able to decide when to have sex. 0.78 If I do not want to have sex, I can tell my husband/partner. 0.77 If I do not want to have sex, I am capable of avoiding it with my husband/partner. 0.62 4.3 Links between the different subdimensions of reproductive agency After validating the subdimensions, the next step involved examining their mutual correlations to understand the direction and strength of their relationships. To achieve this, Pearson’s correlation coefficients were used, adjusted with Bonferroni correction for significance levels. Pearson’s correlation coefficient measures both the strength and direction of an association, ranging from − 1 to + 1, with a value of 0 indicating no association. The closer the coefficient is to -1 or + 1, the stronger the relationship between the two variables, up to a perfect correlation. Our results indicate a positive and significant correlation between subdimensions within the same domain of reproductive agency, as well as between the four subdimensions across the two domains of reproductive agency. The strongest correlation (Corr = 0.38) was observed between the two motivation subdimensions (family planning and sexuality). However, these correlations are generally moderate (Corr < 0.40) or weak, confirming that the subdimensions of reproductive agency are conceptually distinct, even though they are interrelated. These findings suggest that the different subdimensions represent unique constructs, making it possible to include them in explanatory models without concerns about multicollinearity. Table 4 Correlation matrix illustrating the direction and strength of the relationships between the subdimensions of reproductive agency FP motivation FP self-efficacy Sexual motivation Sexual self-efficacy FP motivation 1 FP self-efficacy 0.1862*** 1 Sexual motivation 0.3810*** 0.0553** 1 Sexual self-efficacy 0.0738** 0.2115*** 0.2375*** 1 4.4 External validation of the measure 4.4.1 Individual characteristics associated with reproductive agency Table 5 presents the results of linear regressions examining differences in the levels of the four subdimensions of reproductive agency according to the individual characteristics of the surveyed women. As previously described, latent scores were treated as continuous dependent variables for three subdimensions, while a summative score was used as the continuous dependent variable for contraceptive self-efficacy. The findings indicate that, regardless of the subdimension or domain of reproductive agency, education level was a significant driver of differences in autonomy among the women surveyed. Higher levels of education consistently increased autonomy across all four subdimensions of reproductive agency, with the greatest increases observed among women with the highest education level (upper secondary or higher). The economic status of women, represented by household wealth and employment, had a limited and sometimes unexpected association with reproductive autonomy. Across the four subdimensions, having a job or living in a wealthy household did not generally enhance women’s reproductive autonomy. The exception was in the subdimension of self-efficacy in sexuality, where employed women exhibited a slight gain in autonomy (β = 0.07; p < 0.05) compared to unemployed women. Notably, household wealth was negatively and significantly associated with lower autonomy in the self-efficacy in sexuality subdimension. Similarly, employment was negatively associated with reduced autonomy in both motivation subdimensions (family planning and sexuality). Age emerged as a key differentiating factor for autonomy levels. In three of the four subdimensions of reproductive agency, older women displayed higher levels of autonomy, confirming that autonomy increases with age. This highlights adolescents as the group with the lowest levels of autonomy among women of reproductive age. Marital status was not significantly associated with differences in autonomy in any of the four subdimensions of reproductive agency. However, within the domain of contraceptive agency, having a higher number of live births and residing in rural areas were associated with greater autonomy. Conversely, rural residence was negatively associated with autonomy in the sexuality domain. Table 5 Beta coefficients from linear regressions predicting levels in the subdimensions of reproductive agency based on sociodemographic characteristics of women aged 15–49 Sociodemographic characteristics FP AGENCY SEXUAL AGENCY PF motivation (n = 6411) PF self-efficacy (6411) Sexual motivation (n = 5333) Sexual self-efficacy (5153) Coef (95% CI) Coef (95% CI) Coef (95% CI) Coef (95% CI) Place of residence (Ref.=Urban) Rural .11 (.02 − .19)** .11 (.03 − .19)** − .17 (-.27 - − .08)*** − .10 (-.19 - − .008)* Marital status (Ref.=Unmarried) Married .02 (-.06 − .11) 07 (-.00 − .16) .02 (-.07 − .12) − .03 (-.14 − .06) Education level (Ref.=None) Primary − .04 (-.11 − .03) .09 (.02 − .16)** − .10 (-.18 − .02)** .18 (.10 − .26)*** Secondary level 1 .18 (.10 − .27)*** .20 (.12 − .27)*** .11 (.01 − .21)* .43 (.33 − .53)*** Secondary level 2 or more .37 (.24 − .49)*** .33 (.21 − .45)*** .45 (.31 − .60)*** .64 (.49 − .78)*** Parity (Ref.=Nulliparous) One child .40 (.29 − .51)*** .19 (.08 − .29)** .07 (-.04 − .19) − .04 (-.16 − .07) 2–3 children .40 (.28 − .53)*** .21 (.10 − .33)** − .06 (-.19 − .05) − .02 (-.15 − .10) 4 or more .56 (.42 − .70)*** .23 (.10–36)** − .07 (-.21 − .06) − .05 (-.19 − .09) Household wealth (Ref.= Poorest) Middle .04 (-.01 − .11) .008 (-.04 − .06) − .03 (-.10 − .02) − .16 (-.23 - − .09)*** Wealthiest .05 (-.02 − .13) .02 (-.05 − .09) − .05 (-.14 − .03) − .30 (-.39 - − .21)*** Age (Ref.=15–19) 20–24 − .04 (-.15 − .05) .11 (.01 − .20)* .16 (.04 − .28)** .19 (.07 − .30)** 25–34 − .04 (-.16 − .07) .14 (.03 − .25)* .24 (.11 − .37)*** .23 (.10 − .37)*** 35–49 − .06 (-.19 − .06) .07 (-.04 − .19) .19 (.05 − .33)** .16 (.01 − .30)* Employment (Ref.= none) Yes − .05 (-.11 − .00)* .05 (-.00 − .10) − .09 (-.15 - − .03)** .07 (.01 − .13)* . *p < 0,05; **p < 0,01; ***p < 0,001. 4.4.2 Association between reproductive agency and reproductive outcomes Table 6 presents the odds ratios from logistic regression models illustrating the nature and strength of associations between the subdimensions of the two domains of agency (contraception and sexuality) and two RH outcomes: volitional use of modern FP and the occurrence of unwanted sexual intercourse among women. Overall, the results reveal minor variations in the nature and magnitude of associations between the explanatory variables and the two RH outcomes across crude (unadjusted) and adjusted models. Both explanatory models demonstrate that contraceptive agency is generally positively and significantly associated with volitional use of modern FP. In the unadjusted model, women with higher levels of motivation and self-efficacy in contraception were nearly twice as likely to use modern contraception voluntarily compared to those with lower levels (OR = 1.96 and OR = 1.81, respectively; p < 0.001). These trends remained consistent when adjusting for the four subdimensions alongside women’s sociodemographic characteristics. However, within the domain of contraceptive agency, motivation for family planning exhibited a stronger association with volitional contraception use than self-efficacy in both crude and adjusted models. In contrast, within the domain of sexual agency, motivation showed no significant association with volitional use of modern FP. Regarding the self-efficacy subdimension of sexuality, in the unadjusted model, medium and high levels of self-efficacy were positively associated with volitional contraception use. However, in the adjusted model, this association appeared inconsistent, as only women with medium levels of self-efficacy in sexuality had significantly higher odds of voluntarily using contraception. Regarding the association between sexual agency and the corresponding reproductive outcome, i.e., the occurrence of unwanted sexual intercourse, results from both explanatory models show that only the motivation subdimension of sexuality was significantly associated with this outcome. Women with higher levels of motivation were less likely to experience unwanted sexual intercourse. Specifically, a high level of motivation in sexuality reduced the likelihood of experiencing unwanted sexual intercourse by approximately 37% (OR = 0.63; p < 0.05). Self-efficacy in sexuality, however, showed no significant association with unwanted sexual intercourse. Within the domain of contraceptive agency, high levels of motivation were also inversely and significantly associated with unwanted sexual intercourse. Women with higher motivation in family planning were nearly twice as likely to avoid unwanted sexual intercourse (OR = 0.57; p < 0.05). This association between motivation in family planning and reduced risk of unwanted sexual intercourse was stronger than the association observed between motivation in sexuality and the same RH outcome (OR = 0.57 vs. OR = 0.63; p < 0.05). Finally, within the self-efficacy subdimension of family planning, only medium levels were significantly associated with a lower likelihood of experiencing unwanted sexual intercourse (OR = 0.65; p < 0.05). However, this relationship appears less consistent compared to the patterns observed in the motivation subdimensions. Table 6 Odds ratios from logistic regressions predicting two reproductive outcomes based on reproductive agency among sexually active women aged 15–49 (Reference category = lowest tercile) Using modern FP (n = 4809) Last sex unwanted (n = 5338) Crude effects (95% CI) aOR (95% CI) Crude effects (95% CI) aOR (95% CI) FP AGENCY Motivation Medium 1.82 (1.39–2.37)*** 1.76 (1.30–2.40)*** .68 (0.50–0.91)* .77 (0.58–1.03)† Higher 1.96 (1.42–2.72)*** 1.78 (1.25–2.53)** .58 (0.38–0.86)** . 57 (0.35–0.93)* Self-efficacy Medium 1.36 (0.96–1.93) 1.08 (0.75–1.54) . 67 (0.46 − .97)* . 65 (0.43 − .97)* Higher 1.81 (1.35–2.41)*** 1.55 (1.08–2.18)* .94 (0.65–1.35) 1.11 (0.76–1.64) SEXUAL AGENCY Motivation Medium 1.28 (0.99–1.65) 1.11 (0.85–1.46) .55 (0.37–0.83)** .64 (0.44 − .92)* Higher 1.20 (0.89–1.63) .85 (0.63–1.15) .54 (0.35–0.83)** .63 (0.41 − .95)* Self-efficacy Medium 1.66 (1.27–2.18)*** 1.40 (1.03–1.91)* .85 (0.58–1.24) .93 (0.63–1.36) Higher 1.39 (1.02–1.90)* 1.11 (0.79–1.58) .84 (0.54–1.28) .91 (0.60–1.39) †p < 0,1 ; *p < 0,05; **p < 0,01; ***p < 0,001. In the crude effects model, each subdimension is analyzed in a bivariate relationship with the RH outcome (unadjusted). In the adjusted model, all four subdimensions are simultaneously adjusted for the following sociodemographic characteristics: place of residence, marital status, education level, parity, age, household wealth, and women’s employment status. 5. Discussion This study aimed to test the validity of a measure of women's reproductive autonomy in the context of Burkina Faso. This instrument, initially developed in other African settings, reflects both the psychosocial processes that link choices to actions (as defined in the World Bank’s empowerment framework) and the power structures that shape goal-setting and individual actions (Malhotra, Schuler, and Boender, 2002; Edmeades et al., 2018; Moreau et al., 2020; Wood et al., 2020). Except for the contraceptive self-efficacy subdimension, where it was impossible to assess Cronbach's alpha due to the limited number of items, the other psychometric analyses showed acceptable results consistent with those of the previous study. Overall, this measure demonstrated internal reliability for use in Burkina Faso. Additionally, in line with recent studies, the analyses confirmed the relevance of maintaining the subdimensions as distinct components of agency. While interrelated, these subdimensions reflect conceptually different realities (Hanmer & Klugman, 2016; James-Hawkins et al., 2016; Donald et al., 2017; Yount et al., 2017). Regarding external validity, in the domain of contraception, the positive relationship between higher motivation and volitional contraceptive use aligns with previous findings from Uganda and Ethiopia (Moreau et al., 2020). However, this relationship was not significant in Nigeria. By contrast, the observed positive relationship between high contraceptive self-efficacy and volitional contraceptive use differs from the previous study, where no significant association was found. In the domain of sexuality, the results indicating a significant positive association between high motivation and a lower risk of unwanted sexual intercourse are consistent with findings from Ethiopia and Nigeria, though not with Uganda. In this study, the self-efficacy in sexuality subdimension was not significantly associated with unwanted sexual intercourse, a result similar to Uganda but different from Ethiopia and Nigeria, where high sexual self-efficacy was significantly linked to a lower risk of unwanted sexual intercourse among women. The similarities observed between the two studies are encouraging for the potential generalizability of this measure across different sub-Saharan contexts. On the other hand, the differences observed in certain results may reflect the contextual subtleties of empowerment (Kabeer, 1999; Malhotra & Schuler, 2005; Donald et al., 2017; Richardson, 2018). These differences remind us that behaviors and attributes signifying empowerment in one context may hold different meanings in another (Kabeer, 1999; Malhotra & Schuler, 2005; Donald et al.,2017). Although this measure showed acceptable psychometric properties in our study, these findings confirm the theoretical consensus on the necessity of validating empowerment measures within each context before use (Malhotra & Schuler, 2005; Yount et al., 2015; Donald et al., 2017; Richardson, 2018). Furthermore, by examining two subdimensions of agency, this study highlights their comparative effects on women’s decision-making power regarding contraception and sexuality. Our results show that, for each domain of agency, the motivation subdimension was more strongly associated with women's reproductive decision-making. This suggests that motivation is the driving force of decision-making power in RH for women in Burkina Faso. While existing conceptualizations of psychosocial processes in empowerment recognize that goal-setting (motivation) precedes self-efficacy (the ability to act) (Malhotra & Schuler, 2002; Donald et al., 2017; Moreau et al., 2020), our findings show that, in the Burkinabe context, women’s ability to set reproductive goals aligned with their preferences (motivation) is more decisive for exercising decision-making power in RH. Motivation, which reflects whether individuals think and set well-defined goals based on their own values and preferences (Donald et al., 2017), is thus essential for exercising choice. These findings emphasize the importance of what Ryan and Deci (2000), in their self-determination theory, describe as intrinsic motivation in characterizing autonomous behavior. According to Ryan and Deci, behaviors driven by intrinsic motivation (stemming from a sense of self, as opposed to extrinsic motivation accompanied by pressure) are inherently autonomous and self-determined. Understanding the underlying goals and preferences is thus crucial to determining whether observed behaviors correspond to genuine agency. As Manski (2004) notes, without knowing the goals and preferences driving an individual's actions, it is difficult to measure their level of agency, as choices and actions must align with specific expectations and preferences to reflect true individual decision-making. Similarly, Donald et al., (2017) argue that unless it is clear that individuals have well-defined, internally regulated goals when undertaking specific actions, one cannot determine the extent to which they are engaged in the process of agency. Therefore, it is logical to consider motivation as the primary component of agency. In addition, the significant influence of FP motivation on both volitional FP use and the reduction of unwanted sexual intercourse highlights the central role of FP in RH. This finding underscores that FP not only addresses fertility-related concerns but also challenges restrictive sexual norms, particularly for young, unmarried women (Caldwell et al., 1989; Addai, 2000; Manlove et al., 2006). Overcoming these norms to use contraception, often seen as a marker of sexual activity, increases women’s negotiation power in sexual relationships. These results demonstrate the dual benefit of promoting women's autonomy for FP use. From a conceptual standpoint, this measure of reproductive autonomy identifies the social expectations that motivate women to engage in or avoid sexual activity and modern contraceptive use. It reveals that stigmatization of female sexuality, perceptions of male sexual rights, and fear of relational sanctions are significant factors shaping women’s internal motivations and decision-making capacities in RH. These results highlight persistent gender inequalities within partnerships and society (Blanc, 2001). Moreover, social expectations regarding fertility, fears of infertility, and the risk of partner abandonment significantly affect women’s autonomy in contraception and sexuality. This study also reveals that traditional empowerment approaches, which focus predominantly on the ability to act or participate in decision-making, may fall short in fully capturing women’s decision-making autonomy, particularly in RH. This underscores the need for theoretical frameworks tailored to specific contexts to better reflect the multifaceted nature of empowerment and its subdimensions. Regarding individual characteristics, the results suggest that education is positively associated with reproductive agency and serves as an important resource for enhancing women’s autonomy in RH. However, its influence is more pronounced when women have at least a secondary education, highlighting the importance of sustained educational efforts to ensure more women surpass the primary level, which currently marks the end of schooling for most Burkinabe girls. Economic status, measured by employment and household wealth, did not consistently enhance reproductive agency and sometimes showed inverse relationships with autonomy. This finding indicates that economic status, often used as a proxy for empowerment, is not always a reliable or appropriate measure, as previously suggested (Hanmer & Klugman, 2016; James-Hawkins et al., 2016; Prata et al., 2017). Among other characteristics, adolescents (15–19 years) were found to have lower levels of autonomy in three of the four subdimensions. These results underscore the need to focus on empowering adolescents and young women to improve their RH. This study is not without limitations. The first limitation lies in the fact that the items used to construct the subdimensions were developed in other contexts which, although sharing certain similarities with Burkina Faso, have distinct socioeconomic and cultural specificities. As a result, while all subdimensions demonstrated acceptable internal validity, it cannot be guaranteed that different and more locally relevant items would not have emerged had exploratory studies for measure development been conducted specifically in Burkina Faso. The second limitation concerns the differing methods used to construct the measurement subdimensions, particularly the contraceptive self-efficacy subdimension. Unlike the others, it was constructed using a summative score rather than a latent score due to the limited number of items. The use of latent scores for constructing multidimensional measures is recommended by several authors to minimize measurement and impact biases arising from item-weighting issues in summative scoring (Yount et al., 2017; Steele & Goldstein, 2006). This subdimension requires additional items tailored to the Burkinabe context to ensure its reliability and to standardize the index construction method across all subdimensions. Finally, the retrospective nature of sexual intercourse data could influence both the degree and nature of their relationships with the explanatory variables, particularly the self-efficacy in sexuality subdimension, which showed no significant association with unwanted sexual intercourse. A longitudinal perspective on the associations between the different domains of agency and RH outcomes could provide more coherent results. Despite these limitations, to our knowledge, this is the first study to use a measure specifically adapted to RH to assess the effect of autonomy on key reproductive outcomes such as contraceptive use and sexual decision-making among women in Burkina Faso. This measure of reproductive agency, validated using a nationally representative sample and grounded in RH domains relevant to women—volitional FP and volitional sexual intercourse—, can be used to measure Burkinabe women’s reproductive autonomy and to examine its effects on other important areas of their lives. Conclusion With the recognition of the multidimensional nature of agency (Malhotra & Schuler, 2005; Upadhyay, 2014), there is a growing interest in developing frameworks and measurement tools tailored to relevant domains of development. This conceptual framework of empowerment, which focuses on two critical domains of RH—contraceptive use and sexuality—aims to better capture this specific dimension of autonomy in RH. Unlike other measures of women’s empowerment, the reproductive autonomy measure used in this study focuses more directly on interpersonal power and the power structures influencing decisions related to family planning and sexuality. This measure, which has shown consistent relationships with RH outcomes, can therefore serve as a tool for assessing women’s reproductive autonomy across various African contexts. From a programmatic perspective, this study highlights that gender inequalities and other gender-specific norms related to sexuality and fertility remain significant barriers to women’s decision-making autonomy and, more broadly, their RH. Improving RH must include initiatives aimed at transforming these harmful norms to enhance women’s decision-making power in Burkina Faso. Declarations Authors' contributions: Conceptualization : Fiacre Bazié; Methodology : Fiacre Bazié; Formal analysis : Fiacre Bazié; Writing - original draft preparation : Fiacre Bazié; Writing - review and editing : Fiacre Bazié, Yentema Onadja, Abdramane B. Soura, Meagan Byrne, Fernand B. Bationo. All authors read and approved the final manuscript. Ethics approval and consent to participate: As this study uses secondary datasets that have been de-identified and are openly available through the Performance Monitoring for Action (PMA) website (www.pmadata.org ), ethics approval and informed consent were not required. Acknowledgements: The authors would like to acknowledge the PMA Burkina Faso central staff and interviewers for their invaluable contribution to this work, as well as the respondents for their participation in this study. The authors also acknowledge The Bill and Melinda gates Foundation for funding the PMA’s surveys in Burkina Faso (grant number OPP1163880). The funding body had no role in the design of the study, data collection, analysis, and interpretation of data and in writing of the manuscript. Funding: The authors did not receive support from any organization for the submitted work. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. 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The Lancet Global Health, 6 (1), e29. Yount, K. M., VanderEnde, K. E., Dodell, S., & Cheong, Y. F. (2016). Measurement of women’s agency in Egypt: A national validation study. Social indicators research, 128 , 1171-1192. Footnotes Agency (or autonomy) is part of the more global process of empowerment, which also includes resources and achievements (Kabeer 1999). Employment is defined for women who report having worked outside the household within the past seven days or the past 12 months and are compensated either: 1) in cash, or 2) both in cash and in-kind. The use of modern contraception includes only women who were using male or female condoms, the pill, injectables, the IUD, implants, or emergency contraception at the time of the survey. Employment is defined for women who report having worked outside the household within the past seven days or the past 12 months and are compensated either: 1) in cash, or 2) both in cash and in-kind. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6982590","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":476830307,"identity":"8033ea7f-2068-4324-a459-3b7a4575532b","order_by":0,"name":"Fiacre Bazié","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBACAyA+wGAjAWIzPgCxITRBLWlgLcwGEC0gmoAWBoY0MMkmQZQWc/bjDw98SLCQ5599+Fg1T80dOX4GZrYP+LRY9iQkHJyRIGE441xa2m2eY8+MJRuYmWfgddiBhAOHeX9IMG7g4TG7zcN2OHHDAf7D+P1y/mHD4T8JEvYbePi/FfP8A2lhZsav5UYyw2GGBIlEoC1szLxtRGixnPGM4WBPgkTyjDNsxpJz+w4bSzYT0GLOn/74w4+EOtv+HuaHH958OyzHz96MXwsKYOIBkSRoAKaUH6SoHgWjYBSMghEDAPc9SnVKcGX2AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-7556-6266","institution":"Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso","correspondingAuthor":true,"prefix":"","firstName":"Fiacre","middleName":"","lastName":"Bazié","suffix":""},{"id":476830308,"identity":"37bb3b1c-d09f-4500-8956-4896d9792194","order_by":1,"name":"Yentema Onadja","email":"","orcid":"","institution":"Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso","correspondingAuthor":false,"prefix":"","firstName":"Yentema","middleName":"","lastName":"Onadja","suffix":""},{"id":476830309,"identity":"38c1b00e-149a-406f-96df-a1bd48cf0018","order_by":2,"name":"Abdramane B. Soura","email":"","orcid":"","institution":"Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso","correspondingAuthor":false,"prefix":"","firstName":"Abdramane","middleName":"B.","lastName":"Soura","suffix":""},{"id":476830310,"identity":"c892a66b-6f03-4b94-a296-7f49de56bfb6","order_by":3,"name":"Meagan E. Byrne","email":"","orcid":"","institution":"Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA","correspondingAuthor":false,"prefix":"","firstName":"Meagan","middleName":"E.","lastName":"Byrne","suffix":""},{"id":476830311,"identity":"1d5ba0c0-ec9f-4745-b0ea-5b361f0f4924","order_by":4,"name":"Fernand B. Bationo","email":"","orcid":"","institution":"Département de Sociologie, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso","correspondingAuthor":false,"prefix":"","firstName":"Fernand","middleName":"B.","lastName":"Bationo","suffix":""}],"badges":[],"createdAt":"2025-06-26 10:44:41","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6982590/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6982590/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85543514,"identity":"8a80d2e2-f9b1-4c28-87e8-95b4a8cccff9","added_by":"auto","created_at":"2025-06-27 07:27:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1857595,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6982590/v1/68958ba4-f6c6-4155-b8f7-21441e8d3976.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eReproductive agency : Validation of a measure for women's autonomy in family planning and sexuality in Burkina Faso.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe promotion of gender equality and women\u0026rsquo;s empowerment are seen as key factors for improving health and achieving development goals (United Nations General Assembly, 2000 ; Kabeer, 2005). Women's empowerment, defined as the process by which women enhance their ability to make strategic life choices (Kabeer, 1999), is an intrinsic human rights objective. A low level of empowerment has significant consequences on women and their children\u0026rsquo;s well-being: it is linked to various negative economic and health outcomes for women (Yount et al., 2014; James-Hawkins et al., 2016; Upadhyay et al., 2014) and their children (Malhotra et al., 2014; Chakraborty and Anderson, 2011). In 2015, the United Nations set the achievement of gender equality and the empowerment of women and girls as the fifth of the 17 Sustainable Development Goals (United Nations General Assembly, 2015). In response to the 1994 International Conference on Population and Development (ICPD), the Millennium Development Goals (MDGs), and later the Sustainable Development Goals (SDGs), research and health programs have increasingly focused on women's and girls' empowerment. A significant body of research has explored the link between empowerment and reproductive health (RH) outcomes, particularly highlighting the association between women's empowerment and improved sexual and RH (SRH) behaviors and outcomes (Prata et al., 2017), including contraception use (James-Hawkins et al., 2016; Ewerling et al.,2017) prevention of unwanted pregnancies (Upadhyay and Hindin, 2005), receipt of prenatal care (Mistry et al., 2009), improvement in maternal dietary practices, delivery with a skilled birth attendant (Fotso et al., 2009), and negotiation of sex (Upadhyay et al., 2014).\u003c/p\u003e \u003cp\u003eDespite the evidence of the links between women's empowerment in general and RH outcomes, numerous research findings recognize the complexity of this relationship, resulting in links that are often negative or counter-intuitive (Schatz \u0026amp; Williams, 2012; Edmeades et al., 2018, Prata et al., 2017). These ambiguous relationships between autonomy and health outcomes, particularly observed in the specific context of Africa, are often explained by, among other things, shortcomings in defining empowerment in terms of the factors that determine it in each context (Malhotra 2004 ; Edmeades, J et al., 2018, Prata et al., 2017, Richardson, 2018; Yount et al., 2018) and by methodological problems in measuring empowerment (Agarwala and Lynch 2006; Edmeades, J et al., 2018; Prata et al., 2017). Indeed, in the literature, women's empowerment is often confused with women's \u0026ldquo;status\u0026rdquo;, including level of education, employment, financial assets and women's ability to use these resources to achieve specific goals (Heckert \u0026amp; Fabic, 2013). Women's empowerment is also often associated with autonomy and/or agency\u003csup\u003e1\u003c/sup\u003e (Malhotra and Schuler, 2005; Yount et al., 2015). Also, in studies investigating the links between empowerment and RH, the finding that diversified measures are used in different contexts, ranging from general indicators such as educational attainment, employment or socio-economic status to more specific measures such as participation in household decision-making and women's mobility, which are mainly used in low- and middle-income countries, reveals the lack of a unified framework guiding research in this area and often results in inappropriate measures (Malhotra 2004; Edmeades et al., 2018, Prata et al., 2017, Richardson 2018; Karp et al., 2020).Questions related to decision-making autonomy, which are widely used in the literature as a measure of women's empowerment, are based on experiences in Asia and may not reflect the situation in African countries. For example, with regard to freedom of movement, which is always used as an indicator of women's autonomy, some research has shown that women in sub-Saharan Africa (SSA) are not restricted in their movements and naturally enjoy greater civil liberties (Heckert \u0026amp; Fabic, 2013; OECD, 2010).\u003c/p\u003e \u003cp\u003eThese varying definitions of women\u0026rsquo;s empowerment perpetuate ambiguity in the literature, making it challenging to understand its impact on RH outcomes and simultaneously highlighting the need for conceptual and operational refinement (Kabeer, 1999; James-Hawkins et al., 2018). As a result, the literature has remained limited in its ability to fully explore how autonomy is linked to RH outcomes (Edmeades et al., 2018; Richardson, 2018; Karp et al., 2020).\u003c/p\u003e \u003cp\u003eMoreover, the use of varying definitions of empowerment to examine its links with women\u0026rsquo;s RH reflects a certain inability to treat reproductive empowerment as a distinct process that both reflects and shapes the broader processes involved in overall empowerment (Edmeades et al., 2018). One of the critical aspects of empowerment is its multidimensional nature (Malhotra \u0026amp; Schuler, 2005; Edmeades et al., 2018). Individuals can simultaneously experience high (or low) levels of autonomy across several distinct dimensions or domains. While Malhotra and Schuler (2005) proposed five domains of empowerment\u0026mdash;economic, sociocultural, legal, political, and psychological\u0026mdash;Pratley (2016) and Hanmer \u0026amp; Klugman (2016) argue that it is justified to consider RH as a distinct dimension in addition to the five outlined by Malhotra and Schuler. The pivotal role of reproduction in overall empowerment, particularly for women, and its influence on other dimensions of empowerment suggest that it should be treated as a separate domain, equivalent to the other domains identified in earlier literature (Pratley, 2016; Edmeades et al., 2018). Autonomy across all these domains is essential for achieving comprehensive women\u0026rsquo;s empowerment (Hanmer \u0026amp; Klugman, 2016).\u003c/p\u003e"},{"header":"2. Review of several measures of empowerment in RH.","content":"\u003cp\u003eAlthough a growing body of research addresses the impact of women's empowerment on RH outcomes, it is only recently that RH empowerment has been explicitly distinguished as a full and distinct dimension of empowerment itself (Edmeades et al., 2017; Edmeades et al., 2018; Vizheh et al., 2021). Edmeades and colleagues (2018) proposed the following definition of reproductive empowerment according to a recently developed framework: \u0026ldquo;\u003cem\u003eBoth 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\u003c/em\u003e \u0026rdquo; (Edmeades et al., 2018 ; p5).\u003c/p\u003e \u003cp\u003eA review of the literature reveals that more targeted research has specifically examined the process of empowerment in RH using concepts such as sexual self-efficacy (Quinn-Nilas et al., 2016), sexual assertiveness (Morokoff et al., 1997), sexual power (Pulerwitz, Gortmaker, \u0026amp; DeJong, 2000), reproductive autonomy (Upadhyay et al., 2014; Upadhyay, 2021), and the sexual pressure scale (Jones \u0026amp; Gulick, 2009; Jones, 2006) to better understand the gender dynamics shaping women\u0026rsquo;s decisions and outcomes in sexuality and reproduction. This rich body of research, however, remains challenging to synthesize due to the lack of a comprehensive framework that connects these concepts. Furthermore, most studies, in addition to being predominantly focused on Western contexts, have generally concentrated on the power structures that constrain women\u0026rsquo;s capabilities in RH rather than the psychosocial processes that interact with these power structures to shape sexual and reproductive choices and preferences (Eerdewijk et al., 2017; Edmeades et al.,2017; Moreau et al., 2020; Wood et al., 2020; Vizheh et al., 2021).\u003c/p\u003e \u003cp\u003eFinally, within this body of work, the few that have incorporated the psychosocial attributes of RH empowerment, including Upadhyaya et al., (2014 and 2021), still primarily apply to Western cultures and provide little insight into the expressions and processes of RH empowerment in other cultural contexts, particularly African ones. Specific contexts where sexuality and fertility attitudes and norms, as well as masculinity hegemonic norms, severely limit the negotiation power of women and girls (Wolff, Blanc and Gage 2000; Varga 2003), restrict their RH decision-making (Blanc 2001) and ultimately compromise their RH (Blanc 2001; Jewkes \u0026amp; Morrell, 2012).\u003c/p\u003e \u003cp\u003eEfforts to conceptualize empowerment, primarily focused on low- and middle-income country contexts, have significantly contributed to theoretical advancements (Van Eerdewijk et al., 2017; Donald et al., 2017; Edmeades et al., 2018; Ewerling et al., 2017). Building on Kabeer\u0026rsquo;s foundational work on women\u0026rsquo;s empowerment in the early 2000s, the World Bank developed a framework that defines empowerment as the interaction between resources and agency, guiding the progression from the existence of a choice to the realization of a choice through its exercise (Kabeer, 1999; Malhotra et al., 2002; Malhotra \u0026amp; Schuler, 2005). While the World Bank framework clarifies the general process of empowerment by integrating psychosocial dimensions and development contexts, it does not specify how the empowerment model applies to specific domains of life, particularly RH decisions, actions and outcomes.\u003c/p\u003e \u003cp\u003eSeveral institutions, including the KIT Royal Tropical Institute in collaboration with the Bill \u0026amp; Melinda Gates Foundation (BMGF) (Van Eerdewijk et al., 2017), and the International Center for Research on Women (ICRW) (Edmeades et al., 2018), have recently proposed two empowerment frameworks focusing on RH. In addition to recognizing choice as an essential component of empowerment, the KIT-BMGF and ICRW frameworks explicitly recognize the dimensions of voice and power as necessary conditions for women to achieve their goals by challenging gender inequalities.\u003c/p\u003e \u003cp\u003eBuilding on the KIT-BMGF model, the ICRW framework emphasizes decision-making in RH across key behavioral domains (volitional sexual relations, control over fertility and life choices), leadership in RH (leadership roles in community decision-making processes related to RH), and collective action in RH (influence on policies/programs and advocacy efforts) (Edmeades et al., 2018). Unlike the World Bank model, the KIT-BMGF and ICRW frameworks place less emphasis on the psychosocial processes guiding individual-level choices, instead focusing more on programmatic and advocacy objectives necessary for advancing gender equality and women's empowerment at the societal level. The distinctive contribution of the World Bank model lies in its attention to the internalization of these power structures at the individual level, seeking to describe how they shape the formulation of individual and internal goals and actions. However, this approach does not place particular emphasis on RH, nor does it clearly elucidate how empowerment applies to this specific domain of women\u0026rsquo;s lives. Conversely, the contributions of the KIT-BMGF and ICRW models highlight gender inequality as an institutional and collective barrier to women\u0026rsquo;s well-being in RH. However, these latter approaches place less emphasis on the psychosocial processes that guide the translation of choices into actions at the individual level.\u003c/p\u003e \u003cp\u003eIn response to these shortcomings, Moreau et al., (2020) from the Performance Monitoring for Action (PMA) research platform, building on the World Bank model and the work of KIT-BMGF and ICRW, proposed a new conceptualization of sexual and reproductive empowerment. This measure was developed and anchored within a conceptual framework of women's sexual and reproductive empowerment. This framework acknowledges the multi-level environment influencing sexual and reproductive decisions, shaped by social and cultural norms, interactions with partners and family, as well as internal motivations. Drawing inspiration from prior work on agency by Donald et al., (2017), who define it as the \u003cem\u003e\u0026ldquo;ability to set one\u0026rsquo;s goals and act accordingly\u0026rdquo;\u003c/em\u003e Moreau and colleagues identified two components of agency: the existence of choice and the exercise of choice. Existence of choice, or \u003cem\u003emotivational autonomy\u003c/em\u003e, refers to the internal and external motivations underlying women\u0026rsquo;s sexual and reproductive choices and goals (Moreau et al., 2020; Karp et al., 2020). As for exercise of choice, or \u003cem\u003eself-efficacy\u003c/em\u003e, this encompasses various skills, particularly women\u0026rsquo;s confidence in exercising their choices and their ability to make decisions (Moreau et al., 2020; Karp et al., 2020).\u003c/p\u003e \u003cp\u003eThis conceptual framework addresses some of the limitations of existing research by considering the internalization of exogenous factors by women that shape their individual preferences regarding RH (Alsop \u0026amp; Heinsohn, 2005; Edmeades, 2018). The questions for this measure, developed during mixed-methods exploratory studies across three countries (Uganda, Ethiopia, and Nigeria), were subsequently integrated into the standard questionnaires of the PMA research platform without prior validation in each context. However, such prior validation is particularly crucial when it comes to empowerment measures. As highlighted by Malhotra and Schuler (2005), one of the main challenges in measuring empowerment lies in the fact that behaviors and attributes signifying empowerment in one context often hold different meanings in another. In this case, while certain similarities between sociocultural, economic, and political contexts across sub-Saharan Africa are acknowledged, each context retains its unique characteristics. Experts strongly recommend validating empowerment measures before applying them in a new context where no prior validation has been conducted (James-Hawkins et al., 2018; Richardson, 2018; Yount et al., 2018).\u003c/p\u003e \u003cp\u003eThe objective of this study is to determine whether this measurement index, developed in other African contexts, possesses the internal and external characteristics required to serve as a tool for assessing women's autonomy in the reproductive domain in Burkina Faso. This is a context where not only are gender inequality indices among the highest in West Africa, with persistently high incidences of physical and sexual violence, but also where a significant proportion of women are still unable to meet their contraceptive needs (Alkema et al., 2015; UNDP, 2019; Decker et al., 2022). To date, the limited studies examining the relationship between women's empowerment and RH in Burkina Faso have predominantly used household decision-making participation as a proxy for women\u0026rsquo;s autonomy (Pamb\u0026egrave;, Gnoumou, \u0026amp; Kabor\u0026eacute;, 2014; Atake \u0026amp; Gnakou Ali, 2019; Some, Pu, \u0026amp; Huan, 2021; Beaujoin et al., 2021). However, this measure has increasingly been criticized for its limitations in capturing decision-making power\u0026mdash;and its effects on RH\u0026mdash;in sub-Saharan contexts.\u003c/p\u003e \u003cp\u003eBased on the two sub-dimensions of agency (motivation - the ability to define goals - and self-efficacy - the ability to implement one's goals) used in the previous validation, we will assess the internal and external properties of this measure to see whether it is appropriate in the context of Burkina Faso for use as an instrument to identify the autonomy of Burkinabe women in two areas of RH: sexuality and family planning.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Data\u003c/h2\u003e \u003cp\u003eThis research uses data from the PMA research platform in Burkina Faso. PMA is a platform for monitoring RH and family planning (FP) indicators implemented in eight countries in SSA and Asia, including Burkina Faso. In each country, PMA uses multi-stage stratified cluster sampling to select a random sample of households and women of reproductive age (15\u0026ndash;49 years) representative at national and sub-national levels depending on the country.\u003c/p\u003e \u003cp\u003eDuring the 2020\u0026ndash;2021 period, the PMA platform introduced new survey themes, including a module on the empowerment of women and girls in RH. In Burkina Faso, as with the PMA platform's standard questionnaires, the data from this survey module is representative at the national level and of urban and rural areas. The survey covered 167 enumeration areas (EAs), 5,800 households and 6,500 women aged 15\u0026ndash;49 years. The questions on contraceptive agency were asked of all women, while those on sexual agency were only asked of women who had already had sexual intercourse.\u003c/p\u003e \u003cp\u003eThe response rates were 98% for the household questionnaire and 95% for the women's questionnaire. Missing data, most of which were less than 3%, were excluded from the analyses. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the questions in the RH empowerment module implemented in Burkina Faso.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe items of the subdimensions of reproductive agency\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eREPRODUCTIVE AGENCY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubdimensions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTarget population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResponse modalities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eFP Agency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFP motivation (5 items)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my husband/partner may seek another sexual partner.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eAll women aged 15\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eLikert Scale (1-Strongly disagree to 5- Strongly agree)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, I may have trouble getting pregnant the next time I want to.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThere could/will be conflict in my relationship/marriage if I use family planning.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my children may not be born normal.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my body may experience side effects that will disrupt my relations with my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFP self-efficacy (2 items)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI can decide to switch from one family planning method to another if I want to.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI feel confident telling my provider what is important for me when selecting a family planning method.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eSexual Agency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSexual motivation (4 items)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may stop supporting me.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eAll women aged 15\u0026ndash;49 years who ever had sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eLikert Scale (1-Strongly disagree to 5- Strongly agree)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may force me to have sex.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may physically hurt me.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I show my husband/partner that I want to have sex, he may consider me promiscuous.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSexual self-efficacy (4 items)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI am confident I can tell my husband/partner when I want to have sex.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI am able to decide when to have sex.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I do not want to have sex, I can tell my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I do not want to have sex, I am capable of avoiding it with my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Analysis\u003c/h2\u003e \u003cp\u003eSince the main objective of this study is to test the contextual validity of this measure of reproductive autonomy, the first step will be to ensure that the items selected to make up each of the four subdimensions do indeed represent the same construct in the context of Burkina Faso. For each group of variables comprising each of the sub-dimensions, we first carried out a principal component analysis to assess the proportion of the total variance explained by the first component and then a factor analysis to assess the factor loadings of each of the variables (items) to the first factor. This first step enables us to determine the extent to which the items used for each subdimension effectively summarize the same dimension and refer to the same latent construct. A proportion greater than 50% of the total variance explained by the first component is necessary to estimate that this component does indeed summarize all the information from the variables used (Streiner 1994) and a factor loading of more than 0.50 is necessary to estimate that each variable observed is well correlated with the latent construct (Guadagnoli \u0026amp; Velicer 1988) and therefore that this latent construct represents a reliable measure of each item. We then computed the Cronbach's alpha coefficients for each subdimension to assess the internal consistency of the construct. An alpha coefficient of at least 0.7 is generally required to attest to the internal consistency of a multi-item measure (De Vaus, 2002).\u003c/p\u003e \u003cp\u003eAfter this step, and in accordance with our conceptual framework, which stipulates that these different subdimensions are conceptually distinct yet interrelated, we assessed the relationships between the four subdimensions using Pearson\u0026rsquo;s correlation coefficient. This statistical measure evaluates both the strength and direction of the association between two variables. This step also allowed us to identify potential multicollinearity issues in preparation for including these four variables simultaneously in explanatory models.\u003c/p\u003e \u003cp\u003eFor the construction of empowerment indices, latent scores were utilized to minimize issues related to the weighting of individual items. However, for the contraceptive self-efficacy index, a summative score was used due to the limited number of items (two).\u003c/p\u003e \u003cp\u003eFollowing the internal validity assessment, we proceeded with external validation of the measure. The first stage of this validation aimed to identify individual characteristics associated with women\u0026rsquo;s reproductive autonomy for each subdimension of the measure. Linear regression models were used, with the dependent variables (continuous) representing each of the four subdimensions of autonomy, while the explanatory variables included sociodemographic characteristics such as place of residence, marital status, parity, age, education level, household wealth, and women\u0026rsquo;s employment\u003csup\u003e2\u003c/sup\u003e status. In all four regression models, the sociodemographic characteristics were adjusted to predict the conditions under which women experienced gains in autonomy.\u003c/p\u003e \u003cp\u003eThe second stage of the external validation involved examining associations between women\u0026rsquo;s autonomy and RH outcomes. For this analysis, we used multivariate logistic regression models to evaluate the magnitude and direction of the associations between the four subdimensions of reproductive agency (independent variables) and two RH outcomes (dependent variables): volitional use of modern FP (family planning domain) and the occurrence of an unwanted last sexual intercourse (sexuality domain) among women.\u003c/p\u003e \u003cp\u003eTo construct the categorical variables for \"reproductive agency,\" terciles were used to define different levels of autonomy based on the scores for each subdimension. The first tercile represented women with low autonomy, the second tercile represented women with moderate autonomy, and the highest tercile represented women with high autonomy.\u003c/p\u003e \u003cp\u003eOur first dichotomous dependent variable, \"volitional use of modern FP\" was derived from the following question posed to women currently using a modern contraceptive method\u003csup\u003e3\u003c/sup\u003e: \u003cem\u003eWould you say the decision to use contraception was mostly yours, mostly your husband's/partner's, or a joint decision? The response options included: (1) Mostly mine, (2) Mostly my husband\u0026rsquo;s/partner\u0026rsquo;s, (3) Joint decision, (4) Other, and (5) No response\u003c/em\u003e. Women who reported making the decision alone or jointly with their husband/partner were categorized as voluntarily using modern contraception (coded as 1), while women who were not current users of a modern contraceptive method were coded as 0. The objective was to assess the influence of women\u0026rsquo;s autonomy on their ability to voluntarily engage in family planning. Women whose use of contraception was not volitional (responses 2 and 4) were excluded from this analysis.\u003c/p\u003e \u003cp\u003eThe second dichotomous dependent variable, \"unwanted sexual intercourse,\" was derived from the following question posed to women who had ever had sexual intercourse: \u003cem\u003eThe last time you had sexual intercourse, did any of the following occur? The response options included: (1) I did not want to have sexual intercourse at that time, (2) My husband/partner pressured me to have sexual intercourse, (3) I did not consent (I was forced) to have sexual intercourse at that time, (4) I felt at risk of physical violence if I refused to have sexual intercourse, and (5) None of the above.\u003c/em\u003e Women who reported experiencing at least one of the first four scenarios were categorized as having experienced unwanted sexual intercourse (coded as 1), while those who selected response 5 were categorized as having had wanted sexual intercourse (coded as 0).\u003c/p\u003e \u003cp\u003eFinally, two analytical models were used to evaluate the nature and degree of associations between our explanatory variables and the two RH outcomes. These models predict the conditions under which women voluntarily use modern contraception and experience unwanted sexual intercourse.\u003c/p\u003e \u003cp\u003eIn the first model (unadjusted), each subdimension of reproductive agency was associated individually with each of the two RH outcomes to measure the crude effect of each subdimension on RH outcomes. In the second model (adjusted), all four subdimensions were included simultaneously, along with sociodemographic characteristics (place of residence, marital status, age, parity, education level, household wealth, and employment\u003csup\u003e4\u003c/sup\u003e), to evaluate the predictive differences between the four subdimensions across the two RH outcomes.\u003c/p\u003e \u003cp\u003eAll data were weighted using the available sampling weights, and analyses were conducted using Stata version 16.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Characteristics of interviewed women\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the characteristics of the surveyed women. Approximately 80% of these women resided in rural areas, and 76% were married or cohabiting with a partner. About four in ten women were adolescents or young adults. Nearly 80% had experienced at least one live birth, and around 26% were using a modern contraceptive method. Additionally, over 87% of the sample had engaged in sexual intercourse, and among them, slightly more than 37% reported that their most recent sexual intercourse was \u003cem\u003eunwanted\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of interviewed women (N\u0026thinsp;=\u0026thinsp;6418)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% (Weighted)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (Unweighted)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3887\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1936\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNulliparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e948\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3 children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2808\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level 2 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e821\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold wealth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoorest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWealthiest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver had sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e962\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5338\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLast sex unwanted\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1842\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsing modern FP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Links between items of reproductive agency subdimensions\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes key psychometric properties of the various items and subdimensions within this measure of reproductive autonomy. These include the proportion of total variance explained by the first component, factor loadings, and Cronbach's alpha coefficient for each subdimension. Our results indicate that, for each set of variables corresponding to the four subdimensions, the proportion of total variance explained by the first component exceeds 50%. This finding demonstrates that the first component (subdimension) effectively summarizes the information contained within the respective set of variables. Each group of variables used for a specific subdimension of reproductive agency aligns well with a single latent construct. The factor loadings for each item on the first factor further reveal the degree of correlation between individual items and the latent construct, illustrating how well the construct serves as a reliable measure for the variables used. The results show that, for each subdimension, the factor loadings are consistently above 0.50, indicating a strong correlation between individual items and the latent construct (Guadagnoli \u0026amp; Velicer, 1988). These factor loadings suggest that each latent construct (subdimension) provides a coherent and valid representation of the items included.\u003c/p\u003e \u003cp\u003eFinally, Cronbach\u0026rsquo;s alpha coefficient, which ranges from 0 to 1, is commonly used to assess the internal consistency of a latent construct\u0026mdash;specifically, the extent to which the items within a subdimension collectively form a reliable measure of the latent variable. Typically, a coefficient above 0.7 is considered adequate, while a coefficient below 0.5 is regarded as relatively weak and unreliable (De Vaus, 2002). For all three subdimensions evaluated, Cronbach's alpha is at least 0.7.\u003c/p\u003e \u003cp\u003eOverall, our findings demonstrate satisfactory thresholds for the psychometric criteria used, confirming the internal validity of each of the four subdimensions of reproductive agency.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePsychometric characteristics of the subdimensions of reproductive agency among women aged 15\u0026ndash;49\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eREPRODUCTIVE AGENCY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubdimensions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFactor loadings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eFP Agency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eFP motivation (5 items)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6,418\u003c/p\u003e \u003cp\u003e% Variance Explained\u0026thinsp;=\u0026thinsp;54.67\u003c/p\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.78\u003c/p\u003e \u003cp\u003eScore Range: -2.75 to 1.21\u003c/p\u003e \u003cp\u003eMean: 0.05\u003c/p\u003e \u003cp\u003eMedian: 0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my husband/partner may seek another sexual partner.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, I may have trouble getting pregnant the next time I want to.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThere could/will be conflict in my relationship/marriage if I use family planning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my children may not be born normal.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I use family planning, my body may experience side effects that will disrupt my relations with my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFP self-efficacy (2 items)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6,418\u003c/p\u003e \u003cp\u003e% Variance Explained\u0026thinsp;=\u0026thinsp;71.98\u003c/p\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;N/A\u003c/p\u003e \u003cp\u003eScore Range: 0.96 to 5\u003c/p\u003e \u003cp\u003eMean: 4.33\u003c/p\u003e \u003cp\u003eMedian: 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI can decide to switch from one family planning method to another if I want to.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI feel confident telling my provider what is important for me when selecting a family planning method.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eSexual Agency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSexual motivation (4 items)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;5,338\u003c/p\u003e \u003cp\u003e% Variance Explained\u0026thinsp;=\u0026thinsp;56.34\u003c/p\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.71\u003c/p\u003e \u003cp\u003eScore Range: -2.62 to 1.07\u003c/p\u003e \u003cp\u003eMean: -0.05\u003c/p\u003e \u003cp\u003eMedian: 0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may stop supporting me.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may force me to have sex.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I refuse sex with my husband/partner, he may physically hurt me.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I show my husband/partner that I want to have sex, he may consider me promiscuous.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eSexual self-efficacy (4 items)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;5,158\u003c/p\u003e \u003cp\u003e% Variance Explained\u0026thinsp;=\u0026thinsp;55.32\u003c/p\u003e \u003cp\u003eCronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.70\u003c/p\u003e \u003cp\u003eScore Range: -2.19 to 1.33\u003c/p\u003e \u003cp\u003eMean: -0.001\u003c/p\u003e \u003cp\u003eMedian: 0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI am confident I can tell my husband/partner when I want to have sex.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI am able to decide when to have sex.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I do not want to have sex, I can tell my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I do not want to have sex, I am capable of avoiding it with my husband/partner.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Links between the different subdimensions of reproductive agency\u003c/h2\u003e \u003cp\u003eAfter validating the subdimensions, the next step involved examining their mutual correlations to understand the direction and strength of their relationships. To achieve this, Pearson\u0026rsquo;s correlation coefficients were used, adjusted with Bonferroni correction for significance levels. Pearson\u0026rsquo;s correlation coefficient measures both the strength and direction of an association, ranging from \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1, with a value of 0 indicating no association. The closer the coefficient is to -1 or +\u0026thinsp;1, the stronger the relationship between the two variables, up to a perfect correlation. Our results indicate a positive and significant correlation between subdimensions within the same domain of reproductive agency, as well as between the four subdimensions across the two domains of reproductive agency. The strongest correlation (Corr\u0026thinsp;=\u0026thinsp;0.38) was observed between the two motivation subdimensions (family planning and sexuality). However, these correlations are generally moderate (Corr\u0026thinsp;\u0026lt;\u0026thinsp;0.40) or weak, confirming that the subdimensions of reproductive agency are conceptually distinct, even though they are interrelated.\u003c/p\u003e \u003cp\u003eThese findings suggest that the different subdimensions represent unique constructs, making it possible to include them in explanatory models without concerns about multicollinearity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation matrix illustrating the direction and strength of the relationships between the subdimensions of reproductive agency\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFP motivation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFP self-efficacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSexual motivation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSexual self-efficacy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFP motivation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFP self-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1862***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual motivation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3810***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0553**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual self-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0738**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2115***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2375***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.4 External validation of the measure\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e4.4.1 Individual characteristics associated with reproductive agency\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the results of linear regressions examining differences in the levels of the four subdimensions of reproductive agency according to the individual characteristics of the surveyed women. As previously described, latent scores were treated as continuous dependent variables for three subdimensions, while a summative score was used as the continuous dependent variable for contraceptive self-efficacy.\u003c/p\u003e \u003cp\u003eThe findings indicate that, regardless of the subdimension or domain of reproductive agency, education level was a significant driver of differences in autonomy among the women surveyed. Higher levels of education consistently increased autonomy across all four subdimensions of reproductive agency, with the greatest increases observed among women with the highest education level (upper secondary or higher). The economic status of women, represented by household wealth and employment, had a limited and sometimes unexpected association with reproductive autonomy. Across the four subdimensions, having a job or living in a wealthy household did not generally enhance women\u0026rsquo;s reproductive autonomy. The exception was in the subdimension of self-efficacy in sexuality, where employed women exhibited a slight gain in autonomy (β\u0026thinsp;=\u0026thinsp;0.07; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to unemployed women. Notably, household wealth was negatively and significantly associated with lower autonomy in the self-efficacy in sexuality subdimension. Similarly, employment was negatively associated with reduced autonomy in both motivation subdimensions (family planning and sexuality). Age emerged as a key differentiating factor for autonomy levels. In three of the four subdimensions of reproductive agency, older women displayed higher levels of autonomy, confirming that autonomy increases with age. This highlights adolescents as the group with the lowest levels of autonomy among women of reproductive age. Marital status was not significantly associated with differences in autonomy in any of the four subdimensions of reproductive agency. However, within the domain of contraceptive agency, having a higher number of live births and residing in rural areas were associated with greater autonomy. Conversely, rural residence was negatively associated with autonomy in the sexuality domain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBeta coefficients from linear regressions predicting levels in the subdimensions of reproductive agency based on sociodemographic characteristics of women aged 15\u0026ndash;49\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSociodemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFP AGENCY\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSEXUAL AGENCY\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePF motivation (n\u0026thinsp;=\u0026thinsp;6411)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePF self-efficacy (6411)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSexual motivation (n\u0026thinsp;=\u0026thinsp;5333)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSexual self-efficacy (5153)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoef (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoef (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoef (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoef (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence (Ref.=Urban)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.11 (.02 \u0026minus;\u0026thinsp;.19)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.11 (.03 \u0026minus;\u0026thinsp;.19)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.17 (-.27 - \u0026minus;\u0026thinsp;.08)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.10 (-.19 - \u0026minus;\u0026thinsp;.008)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status (Ref.=Unmarried)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.02 (-.06 \u0026minus;\u0026thinsp;.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e07 (-.00 \u0026minus;\u0026thinsp;.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.02 (-.07 \u0026minus;\u0026thinsp;.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.03 (-.14 \u0026minus;\u0026thinsp;.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level (Ref.=None)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.04 (-.11 \u0026minus;\u0026thinsp;.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.09 (.02 \u0026minus;\u0026thinsp;.16)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.10 (-.18 \u0026minus;\u0026thinsp;.02)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.18 (.10 \u0026minus;\u0026thinsp;.26)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.18 (.10 \u0026minus;\u0026thinsp;.27)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.20 (.12 \u0026minus;\u0026thinsp;.27)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.11 (.01 \u0026minus;\u0026thinsp;.21)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.43 (.33 \u0026minus;\u0026thinsp;.53)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level 2 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.37 (.24 \u0026minus;\u0026thinsp;.49)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.33 (.21 \u0026minus;\u0026thinsp;.45)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.45 (.31 \u0026minus;\u0026thinsp;.60)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.64 (.49 \u0026minus;\u0026thinsp;.78)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity (Ref.=Nulliparous)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.40 (.29 \u0026minus;\u0026thinsp;.51)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.19 (.08 \u0026minus;\u0026thinsp;.29)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.07 (-.04 \u0026minus;\u0026thinsp;.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.04 (-.16 \u0026minus;\u0026thinsp;.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3 children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.40 (.28 \u0026minus;\u0026thinsp;.53)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.21 (.10 \u0026minus;\u0026thinsp;.33)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.06 (-.19 \u0026minus;\u0026thinsp;.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02 (-.15 \u0026minus;\u0026thinsp;.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e.56 (.42 \u0026minus;\u0026thinsp;.70)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.23 (.10\u0026ndash;36)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.07 (-.21 \u0026minus;\u0026thinsp;.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.05 (-.19 \u0026minus;\u0026thinsp;.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold wealth (Ref.= Poorest)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.04 (-.01 \u0026minus;\u0026thinsp;.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.008 (-.04 \u0026minus;\u0026thinsp;.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.03 (-.10 \u0026minus;\u0026thinsp;.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.16 (-.23 - \u0026minus;\u0026thinsp;.09)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWealthiest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.05 (-.02 \u0026minus;\u0026thinsp;.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.02 (-.05 \u0026minus;\u0026thinsp;.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.05 (-.14 \u0026minus;\u0026thinsp;.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.30 (-.39 - \u0026minus;\u0026thinsp;.21)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Ref.=15\u0026ndash;19)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.04 (-.15 \u0026minus;\u0026thinsp;.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.11 (.01 \u0026minus;\u0026thinsp;.20)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.16 (.04 \u0026minus;\u0026thinsp;.28)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.19 (.07 \u0026minus;\u0026thinsp;.30)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.04 (-.16 \u0026minus;\u0026thinsp;.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e.14 (.03 \u0026minus;\u0026thinsp;.25)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.24 (.11 \u0026minus;\u0026thinsp;.37)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.23 (.10 \u0026minus;\u0026thinsp;.37)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.06 (-.19 \u0026minus;\u0026thinsp;.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.07 (-.04 \u0026minus;\u0026thinsp;.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.19 (.05 \u0026minus;\u0026thinsp;.33)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.16 (.01 \u0026minus;\u0026thinsp;.30)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment (Ref.= none)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.05 (-.11 \u0026minus;\u0026thinsp;.00)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.05 (-.00 \u0026minus;\u0026thinsp;.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.09 (-.15 - \u0026minus;\u0026thinsp;.03)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.07 (.01 \u0026minus;\u0026thinsp;.13)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e. \u003cem\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0,05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0,01; ***p\u0026thinsp;\u0026lt;\u0026thinsp;0,001.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e4.4.2 Association between reproductive agency and reproductive outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the odds ratios from logistic regression models illustrating the nature and strength of associations between the subdimensions of the two domains of agency (contraception and sexuality) and two RH outcomes: volitional use of modern FP and the occurrence of unwanted sexual intercourse among women.\u003c/p\u003e \u003cp\u003eOverall, the results reveal minor variations in the nature and magnitude of associations between the explanatory variables and the two RH outcomes across crude (unadjusted) and adjusted models. Both explanatory models demonstrate that contraceptive agency is generally positively and significantly associated with volitional use of modern FP. In the unadjusted model, women with higher levels of motivation and self-efficacy in contraception were nearly twice as likely to use modern contraception voluntarily compared to those with lower levels (OR\u0026thinsp;=\u0026thinsp;1.96 and OR\u0026thinsp;=\u0026thinsp;1.81, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These trends remained consistent when adjusting for the four subdimensions alongside women\u0026rsquo;s sociodemographic characteristics. However, within the domain of contraceptive agency, motivation for family planning exhibited a stronger association with volitional contraception use than self-efficacy in both crude and adjusted models.\u003c/p\u003e \u003cp\u003eIn contrast, within the domain of sexual agency, motivation showed no significant association with volitional use of modern FP. Regarding the self-efficacy subdimension of sexuality, in the unadjusted model, medium and high levels of self-efficacy were positively associated with volitional contraception use. However, in the adjusted model, this association appeared inconsistent, as only women with medium levels of self-efficacy in sexuality had significantly higher odds of voluntarily using contraception.\u003c/p\u003e \u003cp\u003eRegarding the association between sexual agency and the corresponding reproductive outcome, i.e., the occurrence of unwanted sexual intercourse, results from both explanatory models show that only the motivation subdimension of sexuality was significantly associated with this outcome. Women with higher levels of motivation were less likely to experience unwanted sexual intercourse. Specifically, a high level of motivation in sexuality reduced the likelihood of experiencing unwanted sexual intercourse by approximately 37% (OR\u0026thinsp;=\u0026thinsp;0.63; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Self-efficacy in sexuality, however, showed no significant association with unwanted sexual intercourse.\u003c/p\u003e \u003cp\u003eWithin the domain of contraceptive agency, high levels of motivation were also inversely and significantly associated with unwanted sexual intercourse. Women with higher motivation in family planning were nearly twice as likely to avoid unwanted sexual intercourse (OR\u0026thinsp;=\u0026thinsp;0.57;\u003c/p\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This association between motivation in family planning and reduced risk of unwanted sexual intercourse was stronger than the association observed between motivation in sexuality and the same RH outcome (OR\u0026thinsp;=\u0026thinsp;0.57 vs. OR\u0026thinsp;=\u0026thinsp;0.63; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFinally, within the self-efficacy subdimension of family planning, only medium levels were significantly associated with a lower likelihood of experiencing unwanted sexual intercourse (OR\u0026thinsp;=\u0026thinsp;0.65; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, this relationship appears less consistent compared to the patterns observed in the motivation subdimensions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds ratios from logistic regressions predicting two reproductive outcomes based on reproductive agency among sexually active women aged 15\u0026ndash;49 (Reference category\u0026thinsp;=\u0026thinsp;lowest tercile)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUsing modern FP (n\u0026thinsp;=\u0026thinsp;4809)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eLast sex unwanted (n\u0026thinsp;=\u0026thinsp;5338)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude effects (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrude effects (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFP AGENCY\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMotivation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.82 (1.39\u0026ndash;2.37)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.76 (1.30\u0026ndash;2.40)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.68 (0.50\u0026ndash;0.91)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.77 (0.58\u0026ndash;1.03)\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.96 (1.42\u0026ndash;2.72)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.78 (1.25\u0026ndash;2.53)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.58 (0.38\u0026ndash;0.86)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.\u003cb\u003e57 (0.35\u0026ndash;0.93)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36 (0.96\u0026ndash;1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08 (0.75\u0026ndash;1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.\u003cb\u003e67 (0.46 \u0026minus;\u0026thinsp;.97)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.\u003cb\u003e65 (0.43 \u0026minus;\u0026thinsp;.97)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.81 (1.35\u0026ndash;2.41)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.55 (1.08\u0026ndash;2.18)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.94 (0.65\u0026ndash;1.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.11 (0.76\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSEXUAL AGENCY\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMotivation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.28 (0.99\u0026ndash;1.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11 (0.85\u0026ndash;1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.55 (0.37\u0026ndash;0.83)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.64 (0.44 \u0026minus;\u0026thinsp;.92)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20 (0.89\u0026ndash;1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.85 (0.63\u0026ndash;1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.54 (0.35\u0026ndash;0.83)**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.63 (0.41 \u0026minus;\u0026thinsp;.95)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.66 (1.27\u0026ndash;2.18)***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.40 (1.03\u0026ndash;1.91)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.85 (0.58\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.93 (0.63\u0026ndash;1.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.39 (1.02\u0026ndash;1.90)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11 (0.79\u0026ndash;1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.84 (0.54\u0026ndash;1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.91 (0.60\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger;p\u0026thinsp;\u0026lt;\u0026thinsp;0,1 ; *p\u0026thinsp;\u0026lt;\u0026thinsp;0,05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0,01; ***p\u0026thinsp;\u0026lt;\u0026thinsp;0,001. In the crude effects model, each subdimension is analyzed in a bivariate relationship with the RH outcome (unadjusted). In the adjusted model, all four subdimensions are simultaneously adjusted for the following sociodemographic characteristics: place of residence, marital status, education level, parity, age, household wealth, and women\u0026rsquo;s employment status.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis study aimed to test the validity of a measure of women's reproductive autonomy in the context of Burkina Faso. This instrument, initially developed in other African settings, reflects both the psychosocial processes that link choices to actions (as defined in the World Bank’s empowerment framework) and the power structures that shape goal-setting and individual actions (Malhotra, Schuler, and Boender, 2002; Edmeades et al., 2018; Moreau et al., 2020; Wood et al., 2020). Except for the contraceptive self-efficacy subdimension, where it was impossible to assess Cronbach's alpha due to the limited number of items, the other psychometric analyses showed acceptable results consistent with those of the previous study. Overall, this measure demonstrated internal reliability for use in Burkina Faso.\u003c/p\u003e \u003cp\u003eAdditionally, in line with recent studies, the analyses confirmed the relevance of maintaining the subdimensions as distinct components of agency. While interrelated, these subdimensions reflect conceptually different realities (Hanmer \u0026amp; Klugman, 2016; James-Hawkins et al., 2016; Donald et al., 2017; Yount et al., 2017).\u003c/p\u003e \u003cp\u003eRegarding external validity, in the domain of contraception, the positive relationship between higher motivation and volitional contraceptive use aligns with previous findings from Uganda and Ethiopia (Moreau et al., 2020). However, this relationship was not significant in Nigeria. By contrast, the observed positive relationship between high contraceptive self-efficacy and volitional contraceptive use differs from the previous study, where no significant association was found.\u003c/p\u003e \u003cp\u003eIn the domain of sexuality, the results indicating a significant positive association between high motivation and a lower risk of unwanted sexual intercourse are consistent with findings from Ethiopia and Nigeria, though not with Uganda. In this study, the self-efficacy in sexuality subdimension was not significantly associated with unwanted sexual intercourse, a result similar to Uganda but different from Ethiopia and Nigeria, where high sexual self-efficacy was significantly linked to a lower risk of unwanted sexual intercourse among women.\u003c/p\u003e \u003cp\u003eThe similarities observed between the two studies are encouraging for the potential generalizability of this measure across different sub-Saharan contexts. On the other hand, the differences observed in certain results may reflect the contextual subtleties of empowerment (Kabeer, 1999; Malhotra \u0026amp; Schuler, 2005; Donald et al., 2017; Richardson, 2018). These differences remind us that behaviors and attributes signifying empowerment in one context may hold different meanings in another (Kabeer, 1999; Malhotra \u0026amp; Schuler, 2005; Donald et al.,2017). Although this measure showed acceptable psychometric properties in our study, these findings confirm the theoretical consensus on the necessity of validating empowerment measures within each context before use (Malhotra \u0026amp; Schuler, 2005; Yount et al., 2015; Donald et al., 2017; Richardson, 2018).\u003c/p\u003e \u003cp\u003eFurthermore, by examining two subdimensions of agency, this study highlights their comparative effects on women’s decision-making power regarding contraception and sexuality. Our results show that, for each domain of agency, the motivation subdimension was more strongly associated with women's reproductive decision-making. This suggests that motivation is the driving force of decision-making power in RH for women in Burkina Faso. While existing conceptualizations of psychosocial processes in empowerment recognize that goal-setting (motivation) precedes self-efficacy (the ability to act) (Malhotra \u0026amp; Schuler, 2002; Donald et al., 2017; Moreau et al., 2020), our findings show that, in the Burkinabe context, women’s ability to set reproductive goals aligned with their preferences (motivation) is more decisive for exercising decision-making power in RH.\u003c/p\u003e \u003cp\u003eMotivation, which reflects whether individuals think and set well-defined goals based on their own values and preferences (Donald et al., 2017), is thus essential for exercising choice. These findings emphasize the importance of what Ryan and Deci (2000), in their self-determination theory, describe as intrinsic motivation in characterizing autonomous behavior. According to Ryan and Deci, behaviors driven by intrinsic motivation (stemming from a sense of self, as opposed to extrinsic motivation accompanied by pressure) are inherently autonomous and self-determined. Understanding the underlying goals and preferences is thus crucial to determining whether observed behaviors correspond to genuine agency. As Manski (2004) notes, without knowing the goals and preferences driving an individual's actions, it is difficult to measure their level of agency, as choices and actions must align with specific expectations and preferences to reflect true individual decision-making. Similarly, Donald et al., (2017) argue that unless it is clear that individuals have well-defined, internally regulated goals when undertaking specific actions, one cannot determine the extent to which they are engaged in the process of agency. Therefore, it is logical to consider motivation as the primary component of agency.\u003c/p\u003e \u003cp\u003eIn addition, the significant influence of FP motivation on both volitional FP use and the reduction of unwanted sexual intercourse highlights the central role of FP in RH. This finding underscores that FP not only addresses fertility-related concerns but also challenges restrictive sexual norms, particularly for young, unmarried women (Caldwell et al., 1989; Addai, 2000; Manlove et al., 2006). Overcoming these norms to use contraception, often seen as a marker of sexual activity, increases women’s negotiation power in sexual relationships. These results demonstrate the dual benefit of promoting women's autonomy for FP use.\u003c/p\u003e \u003cp\u003eFrom a conceptual standpoint, this measure of reproductive autonomy identifies the social expectations that motivate women to engage in or avoid sexual activity and modern contraceptive use. It reveals that stigmatization of female sexuality, perceptions of male sexual rights, and fear of relational sanctions are significant factors shaping women’s internal motivations and decision-making capacities in RH. These results highlight persistent gender inequalities within partnerships and society (Blanc, 2001). Moreover, social expectations regarding fertility, fears of infertility, and the risk of partner abandonment significantly affect women’s autonomy in contraception and sexuality.\u003c/p\u003e \u003cp\u003eThis study also reveals that traditional empowerment approaches, which focus predominantly on the ability to act or participate in decision-making, may fall short in fully capturing women’s decision-making autonomy, particularly in RH. This underscores the need for theoretical frameworks tailored to specific contexts to better reflect the multifaceted nature of empowerment and its subdimensions.\u003c/p\u003e \u003cp\u003eRegarding individual characteristics, the results suggest that education is positively associated with reproductive agency and serves as an important resource for enhancing women’s autonomy in RH. However, its influence is more pronounced when women have at least a secondary education, highlighting the importance of sustained educational efforts to ensure more women surpass the primary level, which currently marks the end of schooling for most Burkinabe girls. Economic status, measured by employment and household wealth, did not consistently enhance reproductive agency and sometimes showed inverse relationships with autonomy. This finding indicates that economic status, often used as a proxy for empowerment, is not always a reliable or appropriate measure, as previously suggested (Hanmer \u0026amp; Klugman, 2016; James-Hawkins et al., 2016; Prata et al., 2017). Among other characteristics, adolescents (15–19 years) were found to have lower levels of autonomy in three of the four subdimensions. These results underscore the need to focus on empowering adolescents and young women to improve their RH.\u003c/p\u003e \u003cp\u003eThis study is not without limitations. The first limitation lies in the fact that the items used to construct the subdimensions were developed in other contexts which, although sharing certain similarities with Burkina Faso, have distinct socioeconomic and cultural specificities. As a result, while all subdimensions demonstrated acceptable internal validity, it cannot be guaranteed that different and more locally relevant items would not have emerged had exploratory studies for measure development been conducted specifically in Burkina Faso.\u003c/p\u003e \u003cp\u003eThe second limitation concerns the differing methods used to construct the measurement subdimensions, particularly the contraceptive self-efficacy subdimension. Unlike the others, it was constructed using a summative score rather than a latent score due to the limited number of items. The use of latent scores for constructing multidimensional measures is recommended by several authors to minimize measurement and impact biases arising from item-weighting issues in summative scoring (Yount et al., 2017; Steele \u0026amp; Goldstein, 2006). This subdimension requires additional items tailored to the Burkinabe context to ensure its reliability and to standardize the index construction method across all subdimensions.\u003c/p\u003e \u003cp\u003eFinally, the retrospective nature of sexual intercourse data could influence both the degree and nature of their relationships with the explanatory variables, particularly the self-efficacy in sexuality subdimension, which showed no significant association with unwanted sexual intercourse. A longitudinal perspective on the associations between the different domains of agency and RH outcomes could provide more coherent results.\u003c/p\u003e \u003cp\u003eDespite these limitations, to our knowledge, this is the first study to use a measure specifically adapted to RH to assess the effect of autonomy on key reproductive outcomes such as contraceptive use and sexual decision-making among women in Burkina Faso. This measure of reproductive agency, validated using a nationally representative sample and grounded in RH domains relevant to women—volitional FP and volitional sexual intercourse—, can be used to measure Burkinabe women’s reproductive autonomy and to examine its effects on other important areas of their lives.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003eWith the recognition of the multidimensional nature of agency (Malhotra \u0026amp; Schuler, 2005; Upadhyay, 2014), there is a growing interest in developing frameworks and measurement tools tailored to relevant domains of development. This conceptual framework of empowerment, which focuses on two critical domains of RH—contraceptive use and sexuality—aims to better capture this specific dimension of autonomy in RH.\u003c/p\u003e\u003cp\u003eUnlike other measures of women’s empowerment, the reproductive autonomy measure used in this study focuses more directly on interpersonal power and the power structures influencing decisions related to family planning and sexuality. This measure, which has shown consistent relationships with RH outcomes, can therefore serve as a tool for assessing women’s reproductive autonomy across various African contexts.\u003c/p\u003e\u003cp\u003eFrom a programmatic perspective, this study highlights that gender inequalities and other gender-specific norms related to sexuality and fertility remain significant barriers to women’s decision-making autonomy and, more broadly, their RH. Improving RH must include initiatives aimed at transforming these harmful norms to enhance women’s decision-making power in Burkina Faso.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: Conceptualization\u003c/strong\u003e: Fiacre Bazi\u0026eacute;; \u003cstrong\u003eMethodology\u003c/strong\u003e: Fiacre Bazi\u0026eacute;; \u003cstrong\u003eFormal analysis\u003c/strong\u003e: Fiacre Bazi\u0026eacute;; \u003cstrong\u003eWriting - original draft preparation\u003c/strong\u003e: Fiacre Bazi\u0026eacute;; \u003cstrong\u003eWriting -\u003c/strong\u003e \u003cstrong\u003ereview and editing\u003c/strong\u003e: Fiacre Bazi\u0026eacute;, Yentema Onadja, Abdramane B. Soura, Meagan Byrne, Fernand B. Bationo. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eAs this study uses secondary datasets that have been de-identified and are openly available through the Performance Monitoring for Action (PMA) website (www.pmadata.org ), ethics approval and informed consent were not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge the PMA Burkina Faso central staff and interviewers for their invaluable contribution to this work, as well as the respondents for their participation in this study. The authors also acknowledge The Bill and Melinda gates Foundation for funding the PMA\u0026rsquo;s surveys in Burkina Faso (grant number OPP1163880). The funding body had no role in the design of the study, data collection, analysis, and interpretation of data and in writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data:\u0026nbsp;\u003c/strong\u003eThe datasets supporting the conclusions shared in this article are available upon request at: https://www.pmadata.org/data/available-datasets\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAddai, I. (2000). 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Social science \u0026amp; medicine, 60(11), 2641-2655. https://doi.org/10.1016/j.socscimed.2004.11.032\u003c/li\u003e\n\u003cli\u003eVarga, C. A. (2003). How gender roles influence sexual and reproductive health among South African adolescents. Studies in family planning, 34(3), 160-172. https://doi.org/10.1111/j.1728-4465.2003.00160.x\u003c/li\u003e\n\u003cli\u003eVan Eerdewijk, A., Wong, F., Vaast, C., Newton, J., Tyszler, M., \u0026amp; Pennington, A. (2017). White paper: A conceptual model on women and girls' empowerment.\u003c/li\u003e\n\u003cli\u003eVizheh, M., Muhidin, S., Behboodi Moghadam, Z., \u0026amp; Zareiyan, A. (2021). Women empowerment in reproductive health: a systematic review of measurement properties. \u003cem\u003eBMC women's health, 21\u003c/em\u003e(1), 1-13.\u003c/li\u003e\n\u003cli\u003eWolff, B., Blanc, A. K., \u0026amp; Gage, A. J. (2000). Who decides? Women's status and negotiation of sex in Uganda. Culture, health \u0026amp; sexuality, 2(3), 303-322 https://doi.org/10.1080/136910500422278\u003c/li\u003e\n\u003cli\u003eWood, S. N., Karp, C., Tsui, A., Kibira, S. P. S., Desta, S., Galadanci, H., . . . Seme, A. (2020). A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa. \u003cem\u003eCulture, Health \u0026amp; Sexuality\u003c/em\u003e, 1-18.\u003c/li\u003e\n\u003cli\u003eYount, K. M., Peterman, A., \u0026amp; Cheong, Y. F. (2018). Measuring women's empowerment: a need for context and caution. \u003cem\u003eThe Lancet Global Health, 6\u003c/em\u003e(1), e29.\u003c/li\u003e\n\u003cli\u003eYount, K. M., VanderEnde, K. E., Dodell, S., \u0026amp; Cheong, Y. F. (2016). Measurement of women\u0026rsquo;s agency in Egypt: A national validation study. \u003cem\u003eSocial indicators research, 128\u003c/em\u003e, 1171-1192.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Agency (or autonomy) is part of the more global process of empowerment, which also includes resources and achievements (Kabeer 1999).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Employment is defined for women who report having worked outside the household within the past seven days or the past 12 months and are compensated either: 1) in cash, or 2) both in cash and in-kind.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The use of modern contraception includes only women who were using male or female condoms, the pill, injectables, the IUD, implants, or emergency contraception at the time of the survey.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Employment is defined for women who report having worked outside the household within the past seven days or the past 12 months and are compensated either: 1) in cash, or 2) both in cash and in-kind.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Women, Reproductive health, Agency, Burkina Faso","lastPublishedDoi":"10.21203/rs.3.rs-6982590/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6982590/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe links between women's empowerment and their reproductive health remains complex due to persistent challenges in defining empowerment and its various components, as well as the factors shaping it in different contexts. These difficulties also stem from the inability to conceptualize reproductive empowerment as an independent process that both reflects and shapes broader empowerment dynamics.\u003c/p\u003e\n\u003cp\u003eThis study, based on data from the Performance Monitoring for Action (PMA) research platform in Burkina Faso, aims to assess the validity of a multidimensional measure of agency specifically adapted to reproductive health in the Burkinabe context. This measure consists of two key dimensions: \u003cstrong\u003emotivation\u003c/strong\u003e—the ability to define reproductive goals—and \u003cstrong\u003eself-efficacy\u003c/strong\u003e—the ability to act on them. It explores women’s decision-making autonomy in two key areas of reproductive health: family planning and sexuality.\u003c/p\u003e\n\u003cp\u003eThe findings indicate that this measure demonstrates acceptable psychometric properties for use in Burkina Faso. Moreover, external validity analyses reveal that, across each domain of agency, the motivation dimension was more strongly associated with reproductive outcomes compared to self-efficacy. Finally, the results highlight that social expectations regarding fertility, fear of infertility, stigma surrounding female sexuality, perceptions of men's sexual rights, and fear of relational sanctions contribute to limiting women's autonomy in reproductive decision-making.\u003c/p\u003e","manuscriptTitle":"Reproductive agency : Validation of a measure for women's autonomy in family planning and sexuality in Burkina Faso.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-27 07:11:20","doi":"10.21203/rs.3.rs-6982590/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0db2b158-5844-4604-8c1f-a867eb5058b6","owner":[],"postedDate":"June 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50635018,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2025-06-27T07:11:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-27 07:11:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6982590","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6982590","identity":"rs-6982590","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}