Influence of reproductive agency on modern contraceptive use and unwanted sex among young women in Burkina Faso: Findings from cross-sectional and longitudinal data

Influence of reproductive agency on modern contraceptive use and unwanted sex among young women in Burkina Faso: Findings from cross-sectional and longitudinal data | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of reproductive agency on modern contraceptive use and unwanted sex among young women in Burkina Faso: Findings from cross-sectional and longitudinal data Fiacre Bazié, Yentéma Onadja, Abdramane B. Soura This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9050274/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 Background Inconsistencies often observed between women's empowerment—or its various components—and young women's reproductive health can be attributed to several factors. These include gaps in defining autonomy through its context-specific determinants, methodological challenges in its measurement, and the frequent reliance on cross-sectional data, which fails to account for the multidimensional, contextual, and dynamic nature of empowerment. Methods This study uses both cross-sectional and longitudinal data from the Performance Monitoring for Action (PMA) research platform to assess the influence of young burkinabè women’s (ages 15–24) decision-making power on modern contraceptive use and the occurrence of unwanted sex. A multidimensional measure of agency was adapted to two domains of reproductive health: contraception and sexuality. For each domain, this measure comprises two sub-dimensions: motivation, defined as the ability to set reproductive goals, and self-efficacy, referring to the capacity to implement them. Results Our findings indicate that the influence of reproductive agency varies depending on the specific sub-dimension considered, the reproductive outcome assessed, and young women’s marital status. Within contraceptive agency, contraceptive motivation was positively and significantly associated with modern contraceptive use, but only among young women in union. Conversely, in the domain of sexual agency, sexual motivation was significantly linked to a lower risk of unwanted sex, but only among unmarried young women. Conclusions While reproductive agency is a key determinant of young women’s reproductive health, its assessment and the strategies aimed at strengthening it must account for its multidimensional and dynamic nature, with particular attention to young women’s marital status. Burkina Faso Reproductive agency modern contraception unwanted sex young women 1. Background Many individuals experience their first sexual and reproductive events during adolescence and early adulthood [ 1 ]. Young women go through these experiences at a critical stage of their psychological, social, cognitive, and physical development, making them more vulnerable to multiple sexual and reproductive health (SRH) issues [ 2 ]. SRH, including early and unintended pregnancies as well as forced sexual intercourse, represents a significant burden of morbidity, particularly for girls in developing countries [3; 4] In Burkina Faso, in 2021, nearly 31% of pregnancies and most recently reported births among adolescents were unintended [ 5 ]. During the same period, one in ten Burkinabe women (9.4%) experienced physical or sexual intimate partner violence [5; 7]. Data indicate that this rate was higher among younger cohorts. Indeed, younger women, due to significant age gaps with their partners combined with their psychological immaturity, are more exposed to various forms of violence in heterosexual relationships [ 8 ]. Early and unintended pregnancies and sexual violence among adolescent girls and young women have both short- and long-term consequences on their health and well-being, as well as on the health and well-being of their children and [9; 10]. Improving SRH among adolescents and young women, including access to contraception, not only meets immediate health needs but also enhances their future health trajectories while promoting the well-being of the next generation and its full contribution to development challenges. Unfortunately, many girls, facing a lack of choices and prospects or having restricted access to SRH services, are more likely not to use contraception, to experience forced sexual intercourse, and to become pregnant [ 11 ]. It is also recognized that beyond weak service provision, the factors underlying girls' SRH challenges in developing countries are primarily social and cultural, generally reflecting harmful gender norms and constraints faced by the majority of girls in these societies [12; 13; 14]. A significant body of research has highlighted the link between empowerment and improved sexual and reproductive health behaviors and outcomes among women and girls [ 15 ], including contraceptive use [16; 17; 15], prevention of unintended pregnancies [ 18 ], receipt of prenatal care [ 19 ], improvement in maternal dietary practices, delivery with a skilled birth attendant [ 20 ], and negotiation of sex [ 21 ]. Conceptual models, mostly based on Kabeer’s (1999) definition, distinguish three stages in the empowerment process: resources, also called preconditions [ 22 ] or opportunity structures [ 23 ]; agency, also referred to as autonomy [ 24 ]; and achievements, also termed outcomes [22; 23]. Agency is closely linked to empowerment, although empowerment is a broader concept generally associated with outcomes such as improved well-being in health, education, economic opportunities, public participation, and security [ 22 ]. Agency, on the other hand, is viewed as "the ability to define one’s goals and act upon them" [22; 25; 26]. This definition comprises two key components: (1) an individual’s capacity to define goals aligned with their values and preferences regarding a specific issue or decision, also called motivation or "motivational autonomy" [ 26 ]; and (2) their perception of their ability to act to achieve these goals, or self-efficacy [27; 26]. While empowerment includes elements such as resources (preconditions) and achievements (outcomes), agency is the process linking the former to the latter, serving as a mediator between resources and women's objectives [22; 25; 17]. Despite evidence on the links between women's empowerment, its various components, and reproductive health outcomes, numerous studies recognize the complexity of this relationship, often manifesting in negative or counterintuitive associations [28; 29; 15]. These ambiguous relationships between autonomy and health outcomes observed in the African context are often explained by gaps in defining autonomy based on its determinants within each context [25; 30; 31; 29; 15; 32; 33] and by methodological challenges in its measurement [34; 29; 15]. Another notable limitation in research on empowerment and its links to health outcomes is the widespread reliance on cross-sectional data. Cross-sectional perspectives consider empowerment as a static state rather than a dynamic process and provide little insight into the temporal links between empowerment and reproductive health [ 35 ]. In other words, commonly used cross-sectional data do not allow for determining whether empowerment improves reproductive health or vice versa. Considering this temporal dimension is particularly crucial for adolescent girls and young women to understand whether and how autonomy influences their reproductive behaviors throughout their maturation process. This study aims to use both cross-sectional and longitudinal data to employ a multidimensional index of agency adapted to reproductive health to explore the links between autonomy, contraceptive use, and unwanted sexual intercourse among adolescent girls and young women in Burkina Faso. This reproductive autonomy measure, developed in Sub-Saharan African contexts similar to Burkina Faso [36; 37; 38], incorporates two sub-dimensions of agency in two key SRH domains—sexuality and contraception—to capture the influence of women's decision-making power on reproductive behaviors. This measure considers the psychosocial processes of empowerment that link choices to individuals' actions, as defined in the World Bank’s empowerment framework [25; 26; 36]. Through these two sub-dimensions (motivation and self-efficacy) within each domain of reproductive agency (contraception and sexuality), this study will examine how each influences two SRH outcomes—modern contraceptive use and unwanted sexual intercourse—among adolescent girls and young women in Burkina Faso, both from a cross-sectional perspective and over time using longitudinal data. 2. Methods 2.1 Data This research utilizes data from the Performance Monitoring for Action (PMA) research platform in Burkina Faso. PMA is a platform for tracking reproductive health and family planning indicators, implemented in eight (08) countries across Sub-Saharan Africa and Asia, including Burkina Faso. In each country, PMA employs a multi-stage, stratified cluster sampling design to randomly select households and women of reproductive age (15–49 years). In Burkina Faso, the PMA survey sample is nationally representative and stratified by urban and rural residence. During the 2019–2021 period, in addition to the longitudinal survey design used, the platform introduced new thematic modules, including one on women's and girls' empowerment in reproductive health. This measure of women's reproductive autonomy, developed through collaboration between various country implementation teams, was initially piloted in Ethiopia, Uganda, and Nigeria between 2018 and 2019 using both qualitative and quantitative methodologies [36; 37; 38]. These studies led to the validation of a measure of reproductive autonomy in the domains of sexuality and contraception. Each domain of autonomy comprises two sub-dimensions: motivation and self-efficacy [ 36 ] Table 1 The items of the subdimensions of reproductive agency REPRODUCTIVE AGENCY Subdimensions Items Target population Response modalities Contraceptive Agency Contraceptive Motivation (5 items) Cronbach ‘s alpha = 0.78 If I use family planning, my husband/partner may seek another sexual partner. Adolescent girls and young women aged 15–24 who ever had sex 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) Cronbach’s alpha = N/A 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) Cronbach ‘s alpha = 0.72 If I refuse sex with my husband/partner, he may stop supporting me. Adolescent girls and young women aged 15–24 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) Cronbach ’s alpha = 0.70 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. 2.2 Variables Explanatory variables The primary explanatory variables are the two sub-dimensions (motivation and self-efficacy) of each of the two reproductive agency domains (contraception and sexuality) among young women. For each sub-dimension, except for self-efficacy in contraception, a composite index was created using factor analysis and principal component analysis to retain the latent score. This score generally ranged from − 2.75 (for young women with low autonomy) to 1.07 (for women with high autonomy). For the self-efficacy in contraception sub-dimension, measured using two questions, an index was constructed based on a summative score corresponding to the sum of the average scores of both items. The self-efficacy scores ranged from 1 (low self-efficacy) to 5 (high self-efficacy). The same index calculation methods were applied for both the baseline and follow-up surveys. Terciles were used to categorize levels of autonomy: the first tercile represents young women with "low autonomy," the second tercile represents those with "moderate autonomy," and the third tercile represents those with "high autonomy." Our second explanatory variables are transition variables of contraceptive agency (transition in contraceptive motivation and self-efficacy). These two dichotomous variables pertain solely to contraceptive agency, the only domain of reproductive agency for which questions were asked in both survey phases (baseline and follow-up surveys). Using longitudinal data, a "transition" variable was constructed for each of the two subdimensions of contraceptive agency (motivation and self-efficacy). The transition variable captures year-over-year dynamics in contraceptive agency among young women. Transitions were measured based on observed changes in autonomy levels (low, moderate, and high) within each sub-dimension of contraceptive agency between the two surveys. A cross-tabulation was computed for each sub-dimension at both survey phases (as shown in the Table 1 in the supplementary material “Agency transition variable construction”). These dynamics are also illustrated in the Sankey diagram in the same supplementary material. To construct a dichotomous variable distinguishing positive from negative transitions, all nine (09) transitions were grouped into two categories: positive versus negative transition. A positive transition was defined as any shift from a lower autonomy category to a higher autonomy category from one year to the next. For instance, respondents who were in the "low autonomy" category in the baseline survey and moved to either "moderate autonomy" or "high autonomy" in the follow-up survey were classified as experiencing a "positive transition". Conversely, a "negative transition" occurred when a respondent moved from a higher autonomy category in the baseline survey to a lower category in the follow-up survey. For example, respondents initially in the "high autonomy" category who later shifted to "moderate autonomy" or "low autonomy" in the follow-up survey were classified as having undergone a "negative transition." Respondents whose autonomy level remained constant were treated differently: those who consistently remained in the "moderate autonomy" and "high autonomy" categories were classified as having a positive transition since they did not regress to lower categories. However, those who remained in the "low autonomy" category were considered to have experienced a "negative transition," as they remained among the least autonomous young women across both survey phases. Dependent Variables Our dependent variables are the two outcomes in two reproductive health domains: the use of modern contraception 1 (contraceptive domain) and the unwanted nature of the last sexual encounter (sexuality domain) among young women. The variable "use of modern contraception" was constructed based on the following question posed to sexually active young women who were not pregnant at the time of the survey: " Are you or your partner currently doing anything or using any method to delay or avoid pregnancy? " Response options included: Yes; No; No response. Those who answered "Yes" and reported using a modern contraceptive method were classified as modern contraception users (coded as 1). Others who did not use contraception were coded as 0. Women using traditional methods and those who selected "No response" were excluded from the analysis. The variable "unwanted sexual intercourse" was derived from the following question posed to young women who had engaged in sexual activity within the past twelve months: "The last time you had sex, did any of the following happen?" Response options included: 1- I did not want to have sex at that time, 2- My husband/partner pressured me to have sex, 3- I did not consent (I was forced) to have sex at that time, 4- I felt at risk of physical violence if I refused to have sex, 5- None of the above . Women reporting at least one of the first four responses were classified as having had an unwanted sex (coded as 1). Those who selected response 5 (None of the above) were classified as having had a volitional sex (coded as 0). The same variable construction method was applied to the follow-up survey. Other covariables In the explanatory models, key sociodemographic characteristics such as place of residence, marital status, age at last birthday, parity, education level, household wealth status, and employment 2 were used as covariables. 2.3 Analysis Cross-sectional analysis First, through a descriptive analysis, we measured the bivariate associations between the four sub-dimensions of agency and the two SRH outcomes in the same year. Next, we conducted explanatory analysis using several logistic regression models to evaluate the nature and degree of associations between women's autonomy and the two SRH outcomes. We anticipated that there may be a different and significant influence of reproductive autonomy on contraceptive use and unwanted sexual intercourse depending on whether the young woman is married or unmarried. Indeed, for young women in union, more regular exposure to their partner may differently influence the exercise of reproductive autonomy, as well as the occurrence of sexual intercourse and contraceptive use, compared to unmarried young women. Therefore, it is necessary to understand how young women's autonomy interacts with their marital status in the use of contraception and the occurrence of unwanted sexual intercourse. To account for these potential interactions between young women's autonomy and their marital status on the two SRH outcomes, the same logistic regression models were applied to three different samples: all young women, married young women, and unmarried young women. All models are adjusted for socio-demographic characteristics. Longitudinal Analysis In the second series of our analysis, we assessed, from a longitudinal perspective, the associations between young women's reproductive autonomy and SRH outcomes one year later. First, we examined how the reproductive agency of young women, measured one year prior, is associated with SRH outcomes one year later. As with the previous analysis, we began by evaluating the bivariate associations between the four sub-dimensions of reproductive agency measured in the baseline survey and the two SRH outcomes in the follow-up survey. Next, in explanatory models, we used multivariate logistic regression models to evaluate the odds ratios between each of the four sub-dimensions of reproductive agency and the two SRH outcomes one year later, to highlight the direction and strength of their relationships. As in the cross-sectional analysis, logistic regressions were performed on three different samples: all young women, married young women, and unmarried young women, to account for potential interactions between young women's autonomy and their marital status on the two SRH outcomes. All logistic regressions are adjusted for socio-demographic characteristics collected in the baseline survey. In these longitudinal analyses, although the SRH outcome in the baseline survey is not strongly correlated with the follow-up survey (for contraceptive use, corr = 0.38; for unwanted sexual intercourse, corr = 0.21), we observed that the SRH outcomes in the baseline survey strongly predicted the outcome in the follow-up survey (for contraceptive use, OR = 3.94; p < 0.001; for unwanted sexual intercourse, OR = 2.63; p < 0.001). Therefore, in each explanatory model predicting each SRH outcome in the follow-up survey, in addition to the socio-demographic characteristics, the sub-dimensions of agency were adjusted for the SRH outcomes in the baseline survey. Secondly, using the variable "contraceptive agency transition," we examined the relationships between contraceptive agency and SRH outcomes over time, while considering changes in the dynamics or trajectories of young women's autonomy between the two surveys. As before, a descriptive analysis was conducted to evaluate the bivariate associations between the two variables, "transition" or contraceptive agency dynamics, and SRH outcomes. Then, through multivariate logistic regression models, we assessed the net effects of the dynamics or "transition" in the two sub-dimensions of contraceptive agency on SRH outcomes the following year. Again, the analysis models were conducted separately on three samples (all young women, married young women, and unmarried young women). In each explanatory model, the "transition" or dynamics of the two sub-dimensions are adjusted (in addition to socio-demographic characteristics) with the corresponding SRH outcomes from the previous year. Our various explanatory models predict the conditions under which each of the two SRH outcomes (modern contraceptive use and unwanted sexual intercourse) occurs one year later. Cross-sectional analysess were weighted with the survey's cross-sectional weighting coefficients, and longitudinal analysis were weighted with the follow-up survey's weighting coefficients. All analysis were conducted using Stata 16. 3. Results 3.1 Results from cross-sectional analysis Table 3 presents the bivariate associations between the four sub-dimensions of reproductive agency, the use of modern contraception among sexually active young women, and unwanted sexual intercourse over the past twelve months. Chi-square tests show that the more autonomous young women were, the more likely they were to report using modern contraception. However, only contraceptive motivation was statistically associated with unwanted sexual intercourse. The higher the young women's level of contraceptive motivation, the less likely they were to report having experienced unwanted sexual intercourse in the past twelve months. Table 4 presents the results of the cross-sectional analysis, highlighting the odds ratios for the associations between reproductive agency and the two SRH outcomes. In the various adjusted models, there is generally a positive and significant association between contraceptive motivation and both the use of modern contraception and a lower risk of experiencing unwanted sexual intercourse over the past twelve months for all young women. Young women with high contraceptive motivation were nearly three times more likely to use contraception (OR = 2.89; p < 0.001) compared to those with low motivation. High contraceptive motivation reduced the risk of experiencing unwanted sexual intercourse by about 55% (OR = 0.45; p < 0.05). Among all young women, contraceptive self-efficacy was also positively and significantly associated with contraceptive use. This association was less consistent with unwanted sexual intercourse (significant only among young women with a medium level of self-efficacy). In the domain of sexual agency, motivation showed no significant relationship with either SRH outcomes for all young women. As for sexual self-efficacy, only a medium level of self-efficacy was positively associated with contraceptive use. There was no significant association between this sub-dimension and unwanted sexual intercourse among all women. It can also be observed that the different sub-dimensions of reproductive autonomy interact differently with marital status in predicting the two reproductive behaviors. Thus, in the domain of contraception, while married young women tend to use contraception less (compared to unmarried women), our results show that when they had high contraceptive motivation, they were four times more likely (OR = 4.41; p < 0.001) to use modern contraception compared to unmarried women, where the same level of motivation did not significantly affect contraceptive use. It can also be noted that contraceptive motivation, which has the greatest predictive power (among the four sub-dimensions) for modern contraceptive use among all young women, only influences decision-making power among married young women, both for contraceptive use and for reducing the risk of unwanted sexual intercourse. This sub-dimension has no influence on either SRH outcome among unmarried young women. In contrast, contraceptive self-efficacy strengthened contraceptive use among unmarried young women and was also an important factor in not experiencing unwanted sexual intercourse. In the domain of sexuality, unmarried young women are at higher risk of experiencing unwanted sexual intercourse compared to young women in union; however, when unmarried young women have high sexual agency (motivation and self-efficacy), this reduces the risk between 52% (motivation) and 62% (self-efficacy), compared to young women in union, where the same levels of autonomy were not significantly associated with a reduced risk of experiencing unwanted sexual intercourse. Moreover, sexual agency only influenced decision-making among unmarried young women, primarily for choices related to sexual intercourse. This domain of reproductive agency did not significantly influence freedom of choice regarding sexual intercourse (or the use of modern contraception) among married young women. 3.2 Results from longitudinal analysis Table 5 presents the bivariate associations between the four sub-dimensions of reproductive agency measured one year prior and the two SRH outcomes. These bivariate analyses show that in the domain of contraception, neither of the sub-dimensions (motivation and self-efficacy) were significantly associated with the use of modern contraception one year later. However, both sub-dimensions were negatively and significantly associated with unwanted sexual intercourse one year later. In the domain of sexuality, both sub-dimensions of sexual agency were positively and significantly associated with modern contraceptive use, and negatively and significantly associated with unwanted sexual intercourse. The results of the explanatory analysis in Table 6 show different relationships between the variables compared to the descriptive analysis. In the domain of contraception, both sub-dimensions were not significantly associated with the use of modern contraception among all young women one year later. Furthermore, while contraceptive motivation did not significantly influence unwanted sexual intercourse among all young women, it paradoxically seemed to increase the risk of exposure to unwanted sexual intercourse one year later among unmarried young women (OR = 2.83; p < 0.05). Meanwhile, contraceptive self-efficacy, in addition to being associated with a lower risk of experiencing unwanted sexual intercourse one year later among all young women, was an important factor in preventing exposure to unwanted sexual intercourse among unmarried young women, who remain more exposed to unwanted sexual activity (compared to married women one year later). In the domain of sexual agency, both sub-dimensions were generally associated with a lower risk of experiencing unwanted sexual intercourse one year later among all young women. Contraceptive motivation was the sub-dimension that had the most influence on young women's ability to avoid unwanted sexual intercourse over time, compared to self-efficacy (OR = 0.46; p < 0.01 and OR = 0.62; p < 0.1, respectively). Additionally, while high motivation further decreased the risk of experiencing unwanted sexual intercourse among married young women (OR = 0.39; p < 0.01), self-efficacy seemed to be a significant risk factor in the same group (married young women) (OR = 1.69; p < 0.05) and at the same time, a factor preventing exposure among unmarried young women (OR = 0.43; p < 0.1). Moreover, sexual self-efficacy was also associated with contraceptive use one year later, particularly among unmarried young women. Tables 7 and 8 present respectively the descriptive and explanatory results of the relationships between the type of contraceptive agency dynamics and SRH outcomes one year later. As a reminder, these analyses, which focus only on the domain of contraceptive agency while still considering the two SRH outcomes one year later, also consider the changes in the dynamics or trajectories of autonomy among young women over the year through the "transitions" variables in the two sub-dimensions of this domain of agency. From the chi-square tests in Table 7 , we see that there was greater use of contraception and less unwanted sexual intercourse one year later among young women who experienced a "positive transition" in the motivation sub-dimension. This same trend was observed among those who experienced a positive transition in the contraceptive self-efficacy sub-dimension, although these associations were not statistically significant. These same results are confirmed with the explanatory analysis (Table 8 ). Indeed, it can be noted that a positive transition in the contraceptive motivation sub-dimension was associated with a higher chance of using modern contraception (OR = 1.39; p < 0.1) and a lower risk of experiencing unwanted sexual intercourse one year later among young women (OR = 0.63; p < 0.1). Moreover, just like in the cross-sectional results, married young women who experienced a positive dynamic in their autonomy trajectory over a year (positive transition) in motivation had a significantly higher chance of using contraception (OR = 1.57; p < 0.05), compared to unmarried young women, where a positive dynamic did not significantly affect the chances of using contraception the following year. Also, a positive dynamic in the contraceptive motivation sub-dimension further reduced the risk of experiencing unwanted sexual intercourse among married young women in the following year (OR = 0.47; p < 0.05) and at the same time was an important factor in preventing exposure to unwanted sexual intercourse among unmarried young women. A positive dynamic in the self-efficacy sub-dimension was only associated with a lower risk of experiencing unwanted sexual intercourse among unmarried young women one year later (OR = 0.57; p < 0.1). These results, which account for autonomy trajectories in the domain of contraception, primarily show that the motivation sub-dimension is a significant factor for SRH, particularly for young women in union. A positive trajectory in this sub-dimension was associated with higher chances of using modern contraception over time and a lower risk of experiencing unwanted sexual intercourse within this group of young women. 4. Discussion This study aimed to use a multidimensional index of measurement adapted to the context of Sub-Saharan Africa to examine the influence of reproductive autonomy on the SRH of adolescent girls and young women in Burkina Faso. The use of this measure, which focuses on two relevant domains of reproductive life, addresses the common use of inappropriate measures to capture the influence of women’s decision-making power over their reproductive lives [17; 15; 32; 29; 44]. Additionally, through the longitudinal approach, this study captures the influence of autonomy over time on the reproductive behaviors of adolescents and young women, a group still undergoing physiological and psycho-cognitive maturation and, therefore, more exposed to SRH issues [45; 14]. Our results show that while this association varies over time, each sub-dimension of this measure was significantly associated with the outcome in each domain of SRH considered. Thus, in the domain of contraceptive autonomy, cross-sectional analyses show that motivation and self-efficacy were positively associated with the use of modern contraceptive methods among young women. Similar results were observed in the domain of sexual autonomy when considering the influence of motivation and self-efficacy on sexual decision-making a year later. While our focus here is on adolescent girls and young women, our results are generally similar to those found by Moreau et al. (2020) [ 36 ]in other Sub-Saharan African contexts such as Uganda and Ethiopia. Locally, our results also align with other studies conducted in the context of Burkina Faso, which have shown a positive association between women’s decision-making autonomy and certain SRH outcomes, including contraceptive use [ 47 ] and fertility intentions [ 48 ]; however, the majority of these previous studies have relied on women’s decision-making power over household matters as a measure of autonomy. In our various analyses, autonomy in contraception shows stronger associations with the use of modern contraception in cross-sectional data and weaker associations in longitudinal data (without accounting for dynamics). Conversely, autonomy in sexuality shows stronger relationships with unwanted sexual intercourse in longitudinal data and weaker associations in cross-sectional data. We believe that these differences in the relationships between these two dimensions of reproductive autonomy and each SRH outcome can be explained by the temporal difference between the two outcomes. Indeed, while contraceptive use generally reflects a current situation (at the time of the survey), sexual intercourse has more of a retrospective character (even though we considered sexuality over the past twelve months). In this sense, for sexual intercourse, the exercise of decision-making power over the experience may not necessarily be related to the current level of autonomy, particularly among adolescent girls and young women. Conversely, the decrease in the influence of contraceptive autonomy on the use of modern contraception observed in the same longitudinal analysis (without considering dynamics of autonomy trajectories) highlights the non-linear nature of the empowerment process [25; 46; 49]. As a dynamic process, previous research has shown that the trajectory of a woman's agency is also influenced by individual life-course factors such as age, union entry, parity, etc. [49; 50; 51]. Therefore, the importance of autonomy in improving SRH, especially among young women, cannot be fully understood without accounting for these dynamics. In our case, we observed that young women who maintained a positive trajectory in the sub-dimension of contraceptive motivation over a year were more likely to improve their SRH. Moreover, although reproductive agency was associated with both SRH outcomes, the different analytical models implemented suggest that for each domain, the sub-dimension of motivation had a greater influence on the outcome considered compared to self-efficacy. We can thus say that motivation, which measures whether individuals consider and develop well-defined goals for a given issue, and whether these goals derive from their own preferences [ 26 ], determines the exercise of reproductive choices by young women in Burkina Faso in both domains of contraception and sexuality. This observation also supports the idea that behaviors resulting from intrinsic motivation, i.e., those stemming from a sense of self (as opposed to those resulting from extrinsic motivation, which involves a sense of pressure), are by their nature self-determined and autonomous behaviors [ 52 ]. In the same vein, it is recognized in the psychosocial processes of empowerment that the ability to set goals—motivation—precedes the ability to implement them [26; 36]. Our results also suggest that this first component constitutes the engine of decision-making power in SRH in young women in Burkina Faso. Furthermore, by highlighting the important role that motivation plays in the exercise of decision-making power in SRH, this research shows that social expectations regarding procreation, fear of infertility, stigma around female sexuality, perceptions of men’s sexual rights, and fear of relational sanctions—key components of two sub-dimensions of motivation in this measure—remain important determinants of young women’s autonomy in RH in Burkina Faso. These results also reflect the vast gender inequalities within couples and society at large [ 53 ], which remain significant factors influencing modern contraceptive use and decision-making power regarding sexuality. Therefore, to promote reproductive autonomy among young women in Burkina Faso, it is necessary to address structural constraints such as gendered social norms that condition the internal and external motivations guiding young women’s reproductive goals [46; 29]. Moreover, our cross-sectional and longitudinal analysis (with consideration of contraceptive autonomy dynamics) showed that contraceptive motivation was the sub-dimension most strongly associated with both SRH outcomes. The greater influence of this sub-dimension further demonstrates the pivotal role of contraception and autonomy related to its use in the reproductive lives of young women. This result confirms the cross-sectional and multidimensional nature of family planning in general, showing that in addition to fertility issues, it also intersects with restrictive norms concerning sexuality, particularly in relation to contraception among unmarried young women [54; 55; 56; 57]. Additionally, our cross-sectional results show that marital status interacts with young women’s autonomy by either reinforcing or diminishing its effect depending on the domain of reproductive agency. While contraceptive agency, particularly the motivation sub-dimension, was found to be a significant factor in modern contraceptive use among married young women, it had no significant influence on this same outcome among unmarried young women. On the other hand, while sexual agency across both sub-dimensions was an important factor in avoiding unwanted sexual intercourse among unmarried young women, this domain of reproductive agency had no significant influence on the same SRH outcomes among married young women. Overall, we can say that contraceptive agency (through its most important sub-dimension) is associated with decision-making power regarding the use of modern contraception primarily among married young women. In contrast, sexual agency is associated with decision-making power regarding sexuality primarily among unmarried young women. The greater influence of contraceptive agency on modern contraceptive use among married young women indicates that despite constraints and sociocultural norms opposing its use [58; 59], young women’s autonomy is more expressed when they are in marriage. Indeed, we can consider that because of marriage, young women are more exposed to and experience the consequences of pregnancies or closely spaced births (compared to unmarried young women). This can lead to a better consideration of the comparative advantages of contraception and a stronger motivation to use it compared to unmarried women. Conversely, the lesser influence of sexual agency on sexual decision-making within the group of married young women (compared to unmarried women, where this agency is more expressed) reflects a decline in the influence of decision-making power over sexuality within marriage. This result shows that unmarried young women, when autonomous, are better able to exercise their decision-making power regarding sexuality and confirms the idea that women in occasional partnerships are more likely to have full control over their sexual decisions than those in stable or long-term partnerships [ 21 ]. The influence of autonomy on sexual decision-making diminishes when young women are in marriage. In couple relationships, due to certain sociocultural norms concerning sexuality, women exercise less power over sexual decisions, which generally depend much more on the male partner [59; 61]. These results ultimately show that, although marriage enables young women to express their autonomy more in contraceptive matters, sexuality, due to the ongoing influence of certain norms, remains a domain where the expression of decision-making power is still difficult. These results, showing inverse effects of marital status depending on the domain of agency, further demonstrate the diverse influences that life-course factors, including marriage, can have on women’s autonomy, sometimes improving it and sometimes reducing it [22; 25; 21; 17]. Furthermore, this result shows that women’s autonomy, particularly in SRH matters, must be understood within the context of their marital status, which proves to be an important determinant of its expression. This research is not without limitations. The first limitation concerns the different methods used in constructing the measurement sub-dimensions, particularly with regard to the subdimension "contraceptive self-efficacy," which, unlike the others, was constructed from a summative score rather than a latent score, due to the limited number of items. The construction of measurement scales based on latent scores is recommended by several authors to minimize measurement and impact biases that may arise from issues related to item weighting when using summative scores [33; 62]. This sub-dimension therefore needs to be strengthened with additional items drawn from the Burkina Faso context to ensure the reliability of its measurement and also to arrive at a standardized measurement method across all sub-dimensions of agency. Furthermore, in explanatory analyses, it is also important to acknowledge the problem of endogeneity of variables. The endogenous nature of explanatory variables and the effects of certain uncontrolled factors make it difficult to establish causal links between reproductive agency and the two SRH outcomes considered. This is why we can only establish associations and refrain from drawing causal inferences. Despite these limitations, this study also has notable strengths. To our knowledge, it is the first to use a measure of autonomy adapted to RH and developed in the Sub-Saharan African context to examine the influence of autonomy on reproductive behaviors among young women in Burkina Faso. Furthermore, by using components of agency, this measure highlights the psychosocial processes of empowerment and their differential influence on SRH outcomes for this group of adolescent girls and young women, who are at a critical point in their psychological, social, and cognitive development, wherein the pursuit of autonomy is a crucial aspect [ 2 ]. Finally, through its longitudinal perspective, this research also fills a knowledge gap in the field related to the lack of longitudinal data, which allows for understanding the influence of autonomy on reproductive outcomes over time [29; 17]. Conclusion The ability to make decisions regarding sexuality and reproduction is a fundamental condition for the empowerment of women. It is acknowledged that a woman who has control over her body is more likely to experience empowerment in other aspects of her life. Conversely, a woman or adolescent girl with limited bodily autonomy is less likely to have control over her domestic life, health, future, and is less likely to assert her rights and realize her potential [ 63 ]. Reproductive health interventions that explicitly address women's reproductive autonomy as a distinct dimension of their action plans are likely to be more effective in helping women achieve their reproductive and sexual intentions [ 21 ]. From a programmatic perspective, it is essential that reproductive health programs consider the reproductive agency of young women as a potentially significant dimension to improve their reproductive lives when designing interventions. This also requires the definition, application, and operationalization of an appropriate conceptual framework that enhances the understanding of how young women’s autonomy influences critical reproductive health outcomes. In this sense, this measure, adapted to the African and Burkinabe context, which has shown significant links between young women’s agency and their reproductive health, can serve as a guiding tool for directing the programs and interventions of various stakeholders in Burkina Faso. Finally, these results suggest that to truly understand the influence of young women’s autonomy on the improvement of their reproductive health, it is necessary to consider both the dynamics or trajectories of autonomy and the individual as well as contextual factors that influence these dynamics. Abbreviations RH Reproductive Health SRH Sexual and Reproductive Health DHS Demographic and Health Surveys ISSP Institut Supérieur des Sciences de la Population PMA Performance Monitoring for Action WHO World Health Organization Declarations 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. Authors' contributions: FB and YO contributed to the conceptualization and design of the study. FB led the primary analysis and drafted the paper. YO and ABS contributed to the critical review of this manuscript. The authors read and approved the final manuscript. Funding: The authors did not receive support from any organization for the submitted work Availability of data and materials: The datasets supporting the conclusions shared in this article are available upon request at: https://www.pmadata.org/data/available-datasets Ethics approval and consent to participate: The Comité d'Ethique pour la Recherche en Santé/Ministère de la Santé et de l’Hygiène Publique et Ministère de l'Enseignement Supérieur, de la Recherche Scientifique et de l'Innovation in Burkina Faso provided ethical approval for the study. All participants provided verbal informed consent before interviews. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. References Halpern CT, Haydon AA. Sexual timetables for oral-genital, vaginal, and anal intercourse: Sociodemographic comparisons in a nationally representative sample of adolescents. 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Footnotes The use of modern contraception includes only women who were using male or female condoms, the pill, injectables, IUDs, implants, or emergency contraception at the time of the survey Employment is reported for women who report having worked outside the household in the past seven days or the past twelve months and who are compensated either: 1) in cash, or 2) in kind and in cash. Tables Tables 3 to 8 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Agencytransitionvariableconstruction.pdf Tables3to8.docx 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. 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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-9050274","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602198035,"identity":"ce1c2109-d08b-4390-b1f4-8dd238508252","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":"","institution":"Université Joseph Ki-Zerbo","correspondingAuthor":true,"prefix":"","firstName":"Fiacre","middleName":"","lastName":"Bazié","suffix":""},{"id":602198036,"identity":"1bb564d3-23a3-4132-8c2e-89a1ec5ebc69","order_by":1,"name":"Yentéma Onadja","email":"","orcid":"","institution":"Université Joseph Ki-Zerbo","correspondingAuthor":false,"prefix":"","firstName":"Yentéma","middleName":"","lastName":"Onadja","suffix":""},{"id":602198037,"identity":"01f6ebd9-7374-45e1-831c-29b790acd075","order_by":2,"name":"Abdramane B. 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Background","content":"\u003cp\u003eMany individuals experience their first sexual and reproductive events during adolescence and early adulthood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Young women go through these experiences at a critical stage of their psychological, social, cognitive, and physical development, making them more vulnerable to multiple sexual and reproductive health (SRH) issues [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. SRH, including early and unintended pregnancies as well as forced sexual intercourse, represents a significant burden of morbidity, particularly for girls in developing countries [3; 4]\u003c/p\u003e \u003cp\u003eIn Burkina Faso, in 2021, nearly 31% of pregnancies and most recently reported births among adolescents were unintended [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. During the same period, one in ten Burkinabe women (9.4%) experienced physical or sexual intimate partner violence [5; 7]. Data indicate that this rate was higher among younger cohorts. Indeed, younger women, due to significant age gaps with their partners combined with their psychological immaturity, are more exposed to various forms of violence in heterosexual relationships [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly and unintended pregnancies and sexual violence among adolescent girls and young women have both short- and long-term consequences on their health and well-being, as well as on the health and well-being of their children and [9; 10].\u003c/p\u003e \u003cp\u003eImproving SRH among adolescents and young women, including access to contraception, not only meets immediate health needs but also enhances their future health trajectories while promoting the well-being of the next generation and its full contribution to development challenges.\u003c/p\u003e \u003cp\u003eUnfortunately, many girls, facing a lack of choices and prospects or having restricted access to SRH services, are more likely not to use contraception, to experience forced sexual intercourse, and to become pregnant [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is also recognized that beyond weak service provision, the factors underlying girls' SRH challenges in developing countries are primarily social and cultural, generally reflecting harmful gender norms and constraints faced by the majority of girls in these societies [12; 13; 14]. A significant body of research has highlighted the link between empowerment and improved sexual and reproductive health behaviors and outcomes among women and girls [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], including contraceptive use [16; 17; 15], prevention of unintended pregnancies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], receipt of prenatal care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], improvement in maternal dietary practices, delivery with a skilled birth attendant [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and negotiation of sex [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConceptual models, mostly based on Kabeer\u0026rsquo;s (1999) definition, distinguish three stages in the empowerment process: resources, also called preconditions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] or opportunity structures [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]; agency, also referred to as autonomy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]; and achievements, also termed outcomes [22; 23]. Agency is closely linked to empowerment, although empowerment is a broader concept generally associated with outcomes such as improved well-being in health, education, economic opportunities, public participation, and security [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Agency, on the other hand, is viewed as \u003cem\u003e\"the ability to define one\u0026rsquo;s goals and act upon them\"\u003c/em\u003e [22; 25; 26]. This definition comprises two key components: (1) an individual\u0026rsquo;s capacity to define goals aligned with their values and preferences regarding a specific issue or decision, also called motivation or \"motivational autonomy\" [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]; and (2) their perception of their ability to act to achieve these goals, or self-efficacy [27; 26]. While empowerment includes elements such as resources (preconditions) and achievements (outcomes), agency is the process linking the former to the latter, serving as a mediator between resources and women's objectives [22; 25; 17].\u003c/p\u003e \u003cp\u003eDespite evidence on the links between women's empowerment, its various components, and reproductive health outcomes, numerous studies recognize the complexity of this relationship, often manifesting in negative or counterintuitive associations [28; 29; 15]. These ambiguous relationships between autonomy and health outcomes observed in the African context are often explained by gaps in defining autonomy based on its determinants within each context [25; 30; 31; 29; 15; 32; 33] and by methodological challenges in its measurement [34; 29; 15].\u003c/p\u003e \u003cp\u003eAnother notable limitation in research on empowerment and its links to health outcomes is the widespread reliance on cross-sectional data. Cross-sectional perspectives consider empowerment as a static state rather than a dynamic process and provide little insight into the temporal links between empowerment and reproductive health [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In other words, commonly used cross-sectional data do not allow for determining whether empowerment improves reproductive health or vice versa. Considering this temporal dimension is particularly crucial for adolescent girls and young women to understand whether and how autonomy influences their reproductive behaviors throughout their maturation process.\u003c/p\u003e \u003cp\u003eThis study aims to use both cross-sectional and longitudinal data to employ a multidimensional index of agency adapted to reproductive health to explore the links between autonomy, contraceptive use, and unwanted sexual intercourse among adolescent girls and young women in Burkina Faso. This reproductive autonomy measure, developed in Sub-Saharan African contexts similar to Burkina Faso [36; 37; 38], incorporates two sub-dimensions of agency in two key SRH domains\u0026mdash;sexuality and contraception\u0026mdash;to capture the influence of women's decision-making power on reproductive behaviors. This measure considers the psychosocial processes of empowerment that link choices to individuals' actions, as defined in the World Bank\u0026rsquo;s empowerment framework [25; 26; 36].\u003c/p\u003e \u003cp\u003eThrough these two sub-dimensions (motivation and self-efficacy) within each domain of reproductive agency (contraception and sexuality), this study will examine how each influences two SRH outcomes\u0026mdash;modern contraceptive use and unwanted sexual intercourse\u0026mdash;among adolescent girls and young women in Burkina Faso, both from a cross-sectional perspective and over time using longitudinal data.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data\u003c/h2\u003e \u003cp\u003eThis research utilizes data from the Performance Monitoring for Action (PMA) research platform in Burkina Faso. PMA is a platform for tracking reproductive health and family planning indicators, implemented in eight (08) countries across Sub-Saharan Africa and Asia, including Burkina Faso. In each country, PMA employs a multi-stage, stratified cluster sampling design to randomly select households and women of reproductive age (15\u0026ndash;49 years). In Burkina Faso, the PMA survey sample is nationally representative and stratified by urban and rural residence. During the 2019\u0026ndash;2021 period, in addition to the longitudinal survey design used, the platform introduced new thematic modules, including one on women's and girls' empowerment in reproductive health. This measure of women's reproductive autonomy, developed through collaboration between various country implementation teams, was initially piloted in Ethiopia, Uganda, and Nigeria between 2018 and 2019 using both qualitative and quantitative methodologies [36; 37; 38]. These studies led to the validation of a measure of reproductive autonomy in the domains of sexuality and contraception. Each domain of autonomy comprises two sub-dimensions: motivation and self-efficacy [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\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\u003eContraceptive Agency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eContraceptive Motivation (5 items)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCronbach \u0026lsquo;s alpha\u0026thinsp;=\u0026thinsp;0.78\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\u003eAdolescent girls and young women aged 15\u0026ndash;24 who ever had sex\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 \u003cp\u003eCronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;N/A\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 \u003cp\u003eCronbach \u0026lsquo;s alpha\u0026thinsp;=\u0026thinsp;0.72\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\u003eAdolescent girls and young women aged 15\u0026ndash;24 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 \u003cp\u003eCronbach \u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.70\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=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Variables\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eExplanatory variables\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe primary explanatory variables are the two sub-dimensions (motivation and self-efficacy) of each of the two reproductive agency domains (contraception and sexuality) among young women. For each sub-dimension, except for self-efficacy in contraception, a composite index was created using factor analysis and principal component analysis to retain the latent score. This score generally ranged from \u0026minus;\u0026thinsp;2.75 (for young women with low autonomy) to 1.07 (for women with high autonomy). For the self-efficacy in contraception sub-dimension, measured using two questions, an index was constructed based on a summative score corresponding to the sum of the average scores of both items. The self-efficacy scores ranged from 1 (low self-efficacy) to 5 (high self-efficacy). The same index calculation methods were applied for both the baseline and follow-up surveys. Terciles were used to categorize levels of autonomy: the first tercile represents young women with \"low autonomy,\" the second tercile represents those with \"moderate autonomy,\" and the third tercile represents those with \"high autonomy.\"\u003c/p\u003e \u003cp\u003eOur second explanatory variables are transition variables of contraceptive agency (transition in contraceptive motivation and self-efficacy). These two dichotomous variables pertain solely to contraceptive agency, the only domain of reproductive agency for which questions were asked in both survey phases (baseline and follow-up surveys). Using longitudinal data, a \"transition\" variable was constructed for each of the two subdimensions of contraceptive agency (motivation and self-efficacy). The transition variable captures year-over-year dynamics in contraceptive agency among young women. Transitions were measured based on observed changes in autonomy levels (low, moderate, and high) within each sub-dimension of contraceptive agency between the two surveys. A cross-tabulation was computed for each sub-dimension at both survey phases (as shown in the Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e in the supplementary material \u0026ldquo;Agency transition variable construction\u0026rdquo;). These dynamics are also illustrated in the Sankey diagram in the same supplementary material. To construct a dichotomous variable distinguishing positive from negative transitions, all nine (09) transitions were grouped into two categories: positive versus negative transition. A positive transition was defined as any shift from a lower autonomy category to a higher autonomy category from one year to the next. For instance, respondents who were in the \"low autonomy\" category in the baseline survey and moved to either \"moderate autonomy\" or \"high autonomy\" in the follow-up survey were classified as experiencing a \"positive transition\". Conversely, a \"negative transition\" occurred when a respondent moved from a higher autonomy category in the baseline survey to a lower category in the follow-up survey. For example, respondents initially in the \"high autonomy\" category who later shifted to \"moderate autonomy\" or \"low autonomy\" in the follow-up survey were classified as having undergone a \"negative transition.\" Respondents whose autonomy level remained constant were treated differently: those who consistently remained in the \"moderate autonomy\" and \"high autonomy\" categories were classified as having a positive transition since they did not regress to lower categories. However, those who remained in the \"low autonomy\" category were considered to have experienced a \"negative transition,\" as they remained among the least autonomous young women across both survey phases.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eDependent Variables\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOur dependent variables are the two outcomes in two reproductive health domains: the use of modern contraception\u003csup\u003e1\u003c/sup\u003e (contraceptive domain) and the unwanted nature of the last sexual encounter (sexuality domain) among young women. The variable \"use of modern contraception\" was constructed based on the following question posed to sexually active young women who were not pregnant at the time of the survey: \"\u003cem\u003eAre you or your partner currently doing anything or using any method to delay or avoid pregnancy?\u003c/em\u003e\" Response options included: Yes; No; No response. Those who answered \"Yes\" and reported using a modern contraceptive method were classified as modern contraception users (coded as 1). Others who did not use contraception were coded as 0. Women using traditional methods and those who selected \"No response\" were excluded from the analysis. The variable \"unwanted sexual intercourse\" was derived from the following question posed to young women who had engaged in sexual activity within the past twelve months: \u003cem\u003e\"The last time you had sex, did any of the following happen?\"\u003c/em\u003e Response options included: \u003cem\u003e1- I did not want to have sex at that time, 2- My husband/partner pressured me to have sex, 3- I did not consent (I was forced) to have sex at that time, 4- I felt at risk of physical violence if I refused to have sex, 5- None of the above\u003c/em\u003e. Women reporting at least one of the first four responses were classified as having had an unwanted sex (coded as 1). Those who selected response 5 (None of the above) were classified as having had a volitional sex (coded as 0). The same variable construction method was applied to the follow-up survey.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eOther covariables\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the explanatory models, key sociodemographic characteristics such as place of residence, marital status, age at last birthday, parity, education level, household wealth status, and employment\u003csup\u003e2\u003c/sup\u003e were used as covariables.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eCross-sectional analysis\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eFirst, through a descriptive analysis, we measured the bivariate associations between the four sub-dimensions of agency and the two SRH outcomes in the same year.\u003c/p\u003e \u003cp\u003eNext, we conducted explanatory analysis using several logistic regression models to evaluate the nature and degree of associations between women's autonomy and the two SRH outcomes. We anticipated that there may be a different and significant influence of reproductive autonomy on contraceptive use and unwanted sexual intercourse depending on whether the young woman is married or unmarried. Indeed, for young women in union, more regular exposure to their partner may differently influence the exercise of reproductive autonomy, as well as the occurrence of sexual intercourse and contraceptive use, compared to unmarried young women. Therefore, it is necessary to understand how young women's autonomy interacts with their marital status in the use of contraception and the occurrence of unwanted sexual intercourse. To account for these potential interactions between young women's autonomy and their marital status on the two SRH outcomes, the same logistic regression models were applied to three different samples: all young women, married young women, and unmarried young women. All models are adjusted for socio-demographic characteristics.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eLongitudinal Analysis\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the second series of our analysis, we assessed, from a longitudinal perspective, the associations between young women's reproductive autonomy and SRH outcomes one year later.\u003c/p\u003e \u003cp\u003eFirst, we examined how the reproductive agency of young women, measured one year prior, is associated with SRH outcomes one year later. As with the previous analysis, we began by evaluating the bivariate associations between the four sub-dimensions of reproductive agency measured in the baseline survey and the two SRH outcomes in the follow-up survey.\u003c/p\u003e \u003cp\u003eNext, in explanatory models, we used multivariate logistic regression models to evaluate the odds ratios between each of the four sub-dimensions of reproductive agency and the two SRH outcomes one year later, to highlight the direction and strength of their relationships. As in the cross-sectional analysis, logistic regressions were performed on three different samples: all young women, married young women, and unmarried young women, to account for potential interactions between young women's autonomy and their marital status on the two SRH outcomes. All logistic regressions are adjusted for socio-demographic characteristics collected in the baseline survey. In these longitudinal analyses, although the SRH outcome in the baseline survey is not strongly correlated with the follow-up survey (for contraceptive use, corr\u0026thinsp;=\u0026thinsp;0.38; for unwanted sexual intercourse, corr\u0026thinsp;=\u0026thinsp;0.21), we observed that the SRH outcomes in the baseline survey strongly predicted the outcome in the follow-up survey (for contraceptive use, OR\u0026thinsp;=\u0026thinsp;3.94; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; for unwanted sexual intercourse, OR\u0026thinsp;=\u0026thinsp;2.63; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Therefore, in each explanatory model predicting each SRH outcome in the follow-up survey, in addition to the socio-demographic characteristics, the sub-dimensions of agency were adjusted for the SRH outcomes in the baseline survey.\u003c/p\u003e \u003cp\u003eSecondly, using the variable \"contraceptive agency transition,\" we examined the relationships between contraceptive agency and SRH outcomes over time, while considering changes in the dynamics or trajectories of young women's autonomy between the two surveys. As before, a descriptive analysis was conducted to evaluate the bivariate associations between the two variables, \"transition\" or contraceptive agency dynamics, and SRH outcomes. Then, through multivariate logistic regression models, we assessed the net effects of the dynamics or \"transition\" in the two sub-dimensions of contraceptive agency on SRH outcomes the following year. Again, the analysis models were conducted separately on three samples (all young women, married young women, and unmarried young women). In each explanatory model, the \"transition\" or dynamics of the two sub-dimensions are adjusted (in addition to socio-demographic characteristics) with the corresponding SRH outcomes from the previous year.\u003c/p\u003e \u003cp\u003eOur various explanatory models predict the conditions under which each of the two SRH outcomes (modern contraceptive use and unwanted sexual intercourse) occurs one year later.\u003c/p\u003e \u003cp\u003eCross-sectional analysess were weighted with the survey's cross-sectional weighting coefficients, and longitudinal analysis were weighted with the follow-up survey's weighting coefficients.\u003c/p\u003e \u003cp\u003eAll analysis were conducted using Stata 16.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Results from cross-sectional analysis\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents the bivariate associations between the four sub-dimensions of reproductive agency, the use of modern contraception among sexually active young women, and unwanted sexual intercourse over the past twelve months. Chi-square tests show that the more autonomous young women were, the more likely they were to report using modern contraception. However, only contraceptive motivation was statistically associated with unwanted sexual intercourse. The higher the young women\u0026apos;s level of contraceptive motivation, the less likely they were to report having experienced unwanted sexual intercourse in the past twelve months.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents the results of the cross-sectional analysis, highlighting the odds ratios for the associations between reproductive agency and the two SRH outcomes. In the various adjusted models, there is generally a positive and significant association between contraceptive motivation and both the use of modern contraception and a lower risk of experiencing unwanted sexual intercourse over the past twelve months for all young women. Young women with high contraceptive motivation were nearly three times more likely to use contraception (OR\u0026thinsp;=\u0026thinsp;2.89; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to those with low motivation. High contraceptive motivation reduced the risk of experiencing unwanted sexual intercourse by about 55% (OR\u0026thinsp;=\u0026thinsp;0.45; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among all young women, contraceptive self-efficacy was also positively and significantly associated with contraceptive use. This association was less consistent with unwanted sexual intercourse (significant only among young women with a medium level of self-efficacy).\u003c/p\u003e\n \u003cp\u003eIn the domain of sexual agency, motivation showed no significant relationship with either SRH outcomes for all young women. As for sexual self-efficacy, only a medium level of self-efficacy was positively associated with contraceptive use. There was no significant association between this sub-dimension and unwanted sexual intercourse among all women.\u003c/p\u003e\n \u003cp\u003eIt can also be observed that the different sub-dimensions of reproductive autonomy interact differently with marital status in predicting the two reproductive behaviors. Thus, in the domain of contraception, while married young women tend to use contraception less (compared to unmarried women), our results show that when they had high contraceptive motivation, they were four times more likely (OR\u0026thinsp;=\u0026thinsp;4.41; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) to use modern contraception compared to unmarried women, where the same level of motivation did not significantly affect contraceptive use. It can also be noted that contraceptive motivation, which has the greatest predictive power (among the four sub-dimensions) for modern contraceptive use among all young women, only influences decision-making power among married young women, both for contraceptive use and for reducing the risk of unwanted sexual intercourse. This sub-dimension has no influence on either SRH outcome among unmarried young women. In contrast, contraceptive self-efficacy strengthened contraceptive use among unmarried young women and was also an important factor in not experiencing unwanted sexual intercourse.\u003c/p\u003e\n \u003cp\u003eIn the domain of sexuality, unmarried young women are at higher risk of experiencing unwanted sexual intercourse compared to young women in union; however, when unmarried young women have high sexual agency (motivation and self-efficacy), this reduces the risk between 52% (motivation) and 62% (self-efficacy), compared to young women in union, where the same levels of autonomy were not significantly associated with a reduced risk of experiencing unwanted sexual intercourse. Moreover, sexual agency only influenced decision-making among unmarried young women, primarily for choices related to sexual intercourse. This domain of reproductive agency did not significantly influence freedom of choice regarding sexual intercourse (or the use of modern contraception) among married young women.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Results from longitudinal analysis\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e presents the bivariate associations between the four sub-dimensions of reproductive agency measured one year prior and the two SRH outcomes. These bivariate analyses show that in the domain of contraception, neither of the sub-dimensions (motivation and self-efficacy) were significantly associated with the use of modern contraception one year later. However, both sub-dimensions were negatively and significantly associated with unwanted sexual intercourse one year later. In the domain of sexuality, both sub-dimensions of sexual agency were positively and significantly associated with modern contraceptive use, and negatively and significantly associated with unwanted sexual intercourse.\u003c/p\u003e\n \u003cp\u003eThe results of the explanatory analysis in Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e show different relationships between the variables compared to the descriptive analysis. In the domain of contraception, both sub-dimensions were not significantly associated with the use of modern contraception among all young women one year later. Furthermore, while contraceptive motivation did not significantly influence unwanted sexual intercourse among all young women, it paradoxically seemed to increase the risk of exposure to unwanted sexual intercourse one year later among unmarried young women (OR\u0026thinsp;=\u0026thinsp;2.83; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Meanwhile, contraceptive self-efficacy, in addition to being associated with a lower risk of experiencing unwanted sexual intercourse one year later among all young women, was an important factor in preventing exposure to unwanted sexual intercourse among unmarried young women, who remain more exposed to unwanted sexual activity (compared to married women one year later).\u003c/p\u003e\n \u003cp\u003eIn the domain of sexual agency, both sub-dimensions were generally associated with a lower risk of experiencing unwanted sexual intercourse one year later among all young women. Contraceptive motivation was the sub-dimension that had the most influence on young women\u0026apos;s ability to avoid unwanted sexual intercourse over time, compared to self-efficacy (OR\u0026thinsp;=\u0026thinsp;0.46; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and OR\u0026thinsp;=\u0026thinsp;0.62; p\u0026thinsp;\u0026lt;\u0026thinsp;0.1, respectively). Additionally, while high motivation further decreased the risk of experiencing unwanted sexual intercourse among married young women (OR\u0026thinsp;=\u0026thinsp;0.39; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), self-efficacy seemed to be a significant risk factor in the same group (married young women) (OR\u0026thinsp;=\u0026thinsp;1.69; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and at the same time, a factor preventing exposure among unmarried young women (OR\u0026thinsp;=\u0026thinsp;0.43; p\u0026thinsp;\u0026lt;\u0026thinsp;0.1). Moreover, sexual self-efficacy was also associated with contraceptive use one year later, particularly among unmarried young women.\u003c/p\u003e\n \u003cp\u003eTables \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e present respectively the descriptive and explanatory results of the relationships between the type of contraceptive agency dynamics and SRH outcomes one year later. As a reminder, these analyses, which focus only on the domain of contraceptive agency while still considering the two SRH outcomes one year later, also consider the changes in the dynamics or trajectories of autonomy among young women over the year through the \u0026quot;transitions\u0026quot; variables in the two sub-dimensions of this domain of agency.\u003c/p\u003e\n \u003cp\u003eFrom the chi-square tests in Table \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e, we see that there was greater use of contraception and less unwanted sexual intercourse one year later among young women who experienced a \u0026quot;positive transition\u0026quot; in the motivation sub-dimension. This same trend was observed among those who experienced a positive transition in the contraceptive self-efficacy sub-dimension, although these associations were not statistically significant.\u003c/p\u003e\n \u003cp\u003eThese same results are confirmed with the explanatory analysis (Table \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e). Indeed, it can be noted that a positive transition in the contraceptive motivation sub-dimension was associated with a higher chance of using modern contraception (OR\u0026thinsp;=\u0026thinsp;1.39; p\u0026thinsp;\u0026lt;\u0026thinsp;0.1) and a lower risk of experiencing unwanted sexual intercourse one year later among young women (OR\u0026thinsp;=\u0026thinsp;0.63; p\u0026thinsp;\u0026lt;\u0026thinsp;0.1). Moreover, just like in the cross-sectional results, married young women who experienced a positive dynamic in their autonomy trajectory over a year (positive transition) in motivation had a significantly higher chance of using contraception (OR\u0026thinsp;=\u0026thinsp;1.57; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), compared to unmarried young women, where a positive dynamic did not significantly affect the chances of using contraception the following year. Also, a positive dynamic in the contraceptive motivation sub-dimension further reduced the risk of experiencing unwanted sexual intercourse among married young women in the following year (OR\u0026thinsp;=\u0026thinsp;0.47; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and at the same time was an important factor in preventing exposure to unwanted sexual intercourse among unmarried young women. A positive dynamic in the self-efficacy sub-dimension was only associated with a lower risk of experiencing unwanted sexual intercourse among unmarried young women one year later (OR\u0026thinsp;=\u0026thinsp;0.57; p\u0026thinsp;\u0026lt;\u0026thinsp;0.1).\u003c/p\u003e\n \u003cp\u003eThese results, which account for autonomy trajectories in the domain of contraception, primarily show that the motivation sub-dimension is a significant factor for SRH, particularly for young women in union. A positive trajectory in this sub-dimension was associated with higher chances of using modern contraception over time and a lower risk of experiencing unwanted sexual intercourse within this group of young women.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to use a multidimensional index of measurement adapted to the context of Sub-Saharan Africa to examine the influence of reproductive autonomy on the SRH of adolescent girls and young women in Burkina Faso. The use of this measure, which focuses on two relevant domains of reproductive life, addresses the common use of inappropriate measures to capture the influence of women\u0026rsquo;s decision-making power over their reproductive lives [17; 15; 32; 29; 44]. Additionally, through the longitudinal approach, this study captures the influence of autonomy over time on the reproductive behaviors of adolescents and young women, a group still undergoing physiological and psycho-cognitive maturation and, therefore, more exposed to SRH issues [45; 14].\u003c/p\u003e \u003cp\u003eOur results show that while this association varies over time, each sub-dimension of this measure was significantly associated with the outcome in each domain of SRH considered. Thus, in the domain of contraceptive autonomy, cross-sectional analyses show that motivation and self-efficacy were positively associated with the use of modern contraceptive methods among young women. Similar results were observed in the domain of sexual autonomy when considering the influence of motivation and self-efficacy on sexual decision-making a year later. While our focus here is on adolescent girls and young women, our results are generally similar to those found by Moreau et al. (2020) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]in other Sub-Saharan African contexts such as Uganda and Ethiopia. Locally, our results also align with other studies conducted in the context of Burkina Faso, which have shown a positive association between women\u0026rsquo;s decision-making autonomy and certain SRH outcomes, including contraceptive use [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and fertility intentions [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]; however, the majority of these previous studies have relied on women\u0026rsquo;s decision-making power over household matters as a measure of autonomy.\u003c/p\u003e \u003cp\u003eIn our various analyses, autonomy in contraception shows stronger associations with the use of modern contraception in cross-sectional data and weaker associations in longitudinal data (without accounting for dynamics). Conversely, autonomy in sexuality shows stronger relationships with unwanted sexual intercourse in longitudinal data and weaker associations in cross-sectional data. We believe that these differences in the relationships between these two dimensions of reproductive autonomy and each SRH outcome can be explained by the temporal difference between the two outcomes. Indeed, while contraceptive use generally reflects a current situation (at the time of the survey), sexual intercourse has more of a retrospective character (even though we considered sexuality over the past twelve months). In this sense, for sexual intercourse, the exercise of decision-making power over the experience may not necessarily be related to the current level of autonomy, particularly among adolescent girls and young women.\u003c/p\u003e \u003cp\u003eConversely, the decrease in the influence of contraceptive autonomy on the use of modern contraception observed in the same longitudinal analysis (without considering dynamics of autonomy trajectories) highlights the non-linear nature of the empowerment process [25; 46; 49]. As a dynamic process, previous research has shown that the trajectory of a woman's agency is also influenced by individual life-course factors such as age, union entry, parity, etc. [49; 50; 51]. Therefore, the importance of autonomy in improving SRH, especially among young women, cannot be fully understood without accounting for these dynamics. In our case, we observed that young women who maintained a positive trajectory in the sub-dimension of contraceptive motivation over a year were more likely to improve their SRH.\u003c/p\u003e \u003cp\u003eMoreover, although reproductive agency was associated with both SRH outcomes, the different analytical models implemented suggest that for each domain, the sub-dimension of motivation had a greater influence on the outcome considered compared to self-efficacy. We can thus say that motivation, which measures whether individuals consider and develop well-defined goals for a given issue, and whether these goals derive from their own preferences [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], determines the exercise of reproductive choices by young women in Burkina Faso in both domains of contraception and sexuality. This observation also supports the idea that behaviors resulting from intrinsic motivation, i.e., those stemming from a sense of self (as opposed to those resulting from extrinsic motivation, which involves a sense of pressure), are by their nature self-determined and autonomous behaviors [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In the same vein, it is recognized in the psychosocial processes of empowerment that the ability to set goals\u0026mdash;motivation\u0026mdash;precedes the ability to implement them [26; 36]. Our results also suggest that this first component constitutes the engine of decision-making power in SRH in young women in Burkina Faso. Furthermore, by highlighting the important role that motivation plays in the exercise of decision-making power in SRH, this research shows that social expectations regarding procreation, fear of infertility, stigma around female sexuality, perceptions of men\u0026rsquo;s sexual rights, and fear of relational sanctions\u0026mdash;key components of two sub-dimensions of motivation in this measure\u0026mdash;remain important determinants of young women\u0026rsquo;s autonomy in RH in Burkina Faso. These results also reflect the vast gender inequalities within couples and society at large [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], which remain significant factors influencing modern contraceptive use and decision-making power regarding sexuality. Therefore, to promote reproductive autonomy among young women in Burkina Faso, it is necessary to address structural constraints such as gendered social norms that condition the internal and external motivations guiding young women\u0026rsquo;s reproductive goals [46; 29].\u003c/p\u003e \u003cp\u003eMoreover, our cross-sectional and longitudinal analysis (with consideration of contraceptive autonomy dynamics) showed that contraceptive motivation was the sub-dimension most strongly associated with both SRH outcomes. The greater influence of this sub-dimension further demonstrates the pivotal role of contraception and autonomy related to its use in the reproductive lives of young women. This result confirms the cross-sectional and multidimensional nature of family planning in general, showing that in addition to fertility issues, it also intersects with restrictive norms concerning sexuality, particularly in relation to contraception among unmarried young women [54; 55; 56; 57].\u003c/p\u003e \u003cp\u003eAdditionally, our cross-sectional results show that marital status interacts with young women\u0026rsquo;s autonomy by either reinforcing or diminishing its effect depending on the domain of reproductive agency. While contraceptive agency, particularly the motivation sub-dimension, was found to be a significant factor in modern contraceptive use among married young women, it had no significant influence on this same outcome among unmarried young women. On the other hand, while sexual agency across both sub-dimensions was an important factor in avoiding unwanted sexual intercourse among unmarried young women, this domain of reproductive agency had no significant influence on the same SRH outcomes among married young women. Overall, we can say that contraceptive agency (through its most important sub-dimension) is associated with decision-making power regarding the use of modern contraception primarily among married young women. In contrast, sexual agency is associated with decision-making power regarding sexuality primarily among unmarried young women. The greater influence of contraceptive agency on modern contraceptive use among married young women indicates that despite constraints and sociocultural norms opposing its use [58; 59], young women\u0026rsquo;s autonomy is more expressed when they are in marriage. Indeed, we can consider that because of marriage, young women are more exposed to and experience the consequences of pregnancies or closely spaced births (compared to unmarried young women). This can lead to a better consideration of the comparative advantages of contraception and a stronger motivation to use it compared to unmarried women. Conversely, the lesser influence of sexual agency on sexual decision-making within the group of married young women (compared to unmarried women, where this agency is more expressed) reflects a decline in the influence of decision-making power over sexuality within marriage. This result shows that unmarried young women, when autonomous, are better able to exercise their decision-making power regarding sexuality and confirms the idea that women in occasional partnerships are more likely to have full control over their sexual decisions than those in stable or long-term partnerships [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The influence of autonomy on sexual decision-making diminishes when young women are in marriage. In couple relationships, due to certain sociocultural norms concerning sexuality, women exercise less power over sexual decisions, which generally depend much more on the male partner [59; 61]. These results ultimately show that, although marriage enables young women to express their autonomy more in contraceptive matters, sexuality, due to the ongoing influence of certain norms, remains a domain where the expression of decision-making power is still difficult.\u003c/p\u003e \u003cp\u003eThese results, showing inverse effects of marital status depending on the domain of agency, further demonstrate the diverse influences that life-course factors, including marriage, can have on women\u0026rsquo;s autonomy, sometimes improving it and sometimes reducing it [22; 25; 21; 17]. Furthermore, this result shows that women\u0026rsquo;s autonomy, particularly in SRH matters, must be understood within the context of their marital status, which proves to be an important determinant of its expression.\u003c/p\u003e \u003cp\u003eThis research is not without limitations. The first limitation concerns the different methods used in constructing the measurement sub-dimensions, particularly with regard to the subdimension \"contraceptive self-efficacy,\" which, unlike the others, was constructed from a summative score rather than a latent score, due to the limited number of items. The construction of measurement scales based on latent scores is recommended by several authors to minimize measurement and impact biases that may arise from issues related to item weighting when using summative scores [33; 62]. This sub-dimension therefore needs to be strengthened with additional items drawn from the Burkina Faso context to ensure the reliability of its measurement and also to arrive at a standardized measurement method across all sub-dimensions of agency.\u003c/p\u003e \u003cp\u003eFurthermore, in explanatory analyses, it is also important to acknowledge the problem of endogeneity of variables. The endogenous nature of explanatory variables and the effects of certain uncontrolled factors make it difficult to establish causal links between reproductive agency and the two SRH outcomes considered. This is why we can only establish associations and refrain from drawing causal inferences.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study also has notable strengths. To our knowledge, it is the first to use a measure of autonomy adapted to RH and developed in the Sub-Saharan African context to examine the influence of autonomy on reproductive behaviors among young women in Burkina Faso. Furthermore, by using components of agency, this measure highlights the psychosocial processes of empowerment and their differential influence on SRH outcomes for this group of adolescent girls and young women, who are at a critical point in their psychological, social, and cognitive development, wherein the pursuit of autonomy is a crucial aspect [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, through its longitudinal perspective, this research also fills a knowledge gap in the field related to the lack of longitudinal data, which allows for understanding the influence of autonomy on reproductive outcomes over time [29; 17].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe ability to make decisions regarding sexuality and reproduction is a fundamental condition for the empowerment of women. It is acknowledged that a woman who has control over her body is more likely to experience empowerment in other aspects of her life. Conversely, a woman or adolescent girl with limited bodily autonomy is less likely to have control over her domestic life, health, future, and is less likely to assert her rights and realize her potential [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Reproductive health interventions that explicitly address women's reproductive autonomy as a distinct dimension of their action plans are likely to be more effective in helping women achieve their reproductive and sexual intentions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a programmatic perspective, it is essential that reproductive health programs consider the reproductive agency of young women as a potentially significant dimension to improve their reproductive lives when designing interventions. This also requires the definition, application, and operationalization of an appropriate conceptual framework that enhances the understanding of how young women\u0026rsquo;s autonomy influences critical reproductive health outcomes. In this sense, this measure, adapted to the African and Burkinabe context, which has shown significant links between young women\u0026rsquo;s agency and their reproductive health, can serve as a guiding tool for directing the programs and interventions of various stakeholders in Burkina Faso.\u003c/p\u003e \u003cp\u003eFinally, these results suggest that to truly understand the influence of young women\u0026rsquo;s autonomy on the improvement of their reproductive health, it is necessary to consider both the dynamics or trajectories of autonomy and the individual as well as contextual factors that influence these dynamics.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRH Reproductive Health\u003c/p\u003e \u003cp\u003eSRH Sexual and Reproductive Health\u003c/p\u003e \u003cp\u003eDHS Demographic and Health Surveys\u003c/p\u003e \u003cp\u003eISSP Institut Sup\u0026eacute;rieur des Sciences de la Population\u003c/p\u003e \u003cp\u003ePMA Performance Monitoring for Action\u003c/p\u003e \u003cp\u003eWHO World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\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\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eFB and YO contributed to the conceptualization and design of the study. FB led the primary analysis and drafted the paper. YO and ABS contributed to the critical review of this manuscript. The authors read and approved the final 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\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\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\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe Comit\u0026eacute; d\u0026apos;Ethique pour la Recherche en Sant\u0026eacute;/Minist\u0026egrave;re de la Sant\u0026eacute; et de l\u0026rsquo;Hygi\u0026egrave;ne Publique et Minist\u0026egrave;re de l\u0026apos;Enseignement Sup\u0026eacute;rieur, de la Recherche Scientifique et de l\u0026apos;Innovation in Burkina Faso provided ethical approval for the study. All participants provided verbal informed consent before interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHalpern CT, Haydon AA. Sexual timetables for oral-genital, vaginal, and anal intercourse: Sociodemographic comparisons in a nationally representative sample of adolescents. 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UN DESA/POP/2022/TR/NO. 3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e The use of modern contraception includes only women who were using male or female condoms, the pill, injectables, IUDs, implants, or emergency contraception at the time of the survey\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Employment is reported for women who report having worked outside the household in the past seven days or the past twelve months and who are compensated either: 1) in cash, or 2) in kind and in cash.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 3 to 8 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","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":"Burkina Faso, Reproductive agency, modern contraception, unwanted sex, young women","lastPublishedDoi":"10.21203/rs.3.rs-9050274/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9050274/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInconsistencies often observed between women's empowerment\u0026mdash;or its various components\u0026mdash;and young women's reproductive health can be attributed to several factors. These include gaps in defining autonomy through its context-specific determinants, methodological challenges in its measurement, and the frequent reliance on cross-sectional data, which fails to account for the multidimensional, contextual, and dynamic nature of empowerment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study uses both cross-sectional and longitudinal data from the Performance Monitoring for Action (PMA) research platform to assess the influence of young burkinab\u0026egrave; women\u0026rsquo;s (ages 15\u0026ndash;24) decision-making power on modern contraceptive use and the occurrence of unwanted sex. A multidimensional measure of agency was adapted to two domains of reproductive health: contraception and sexuality. For each domain, this measure comprises two sub-dimensions: motivation, defined as the ability to set reproductive goals, and self-efficacy, referring to the capacity to implement them.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur findings indicate that the influence of reproductive agency varies depending on the specific sub-dimension considered, the reproductive outcome assessed, and young women\u0026rsquo;s marital status. Within contraceptive agency, contraceptive motivation was positively and significantly associated with modern contraceptive use, but only among young women in union. Conversely, in the domain of sexual agency, sexual motivation was significantly linked to a lower risk of unwanted sex, but only among unmarried young women.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhile reproductive agency is a key determinant of young women\u0026rsquo;s reproductive health, its assessment and the strategies aimed at strengthening it must account for its multidimensional and dynamic nature, with particular attention to young women\u0026rsquo;s marital status.\u003c/p\u003e","manuscriptTitle":"Influence of reproductive agency on modern contraceptive use and unwanted sex among young women in Burkina Faso: Findings from cross-sectional and longitudinal data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 03:46:05","doi":"10.21203/rs.3.rs-9050274/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":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T08:44:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 03:46:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9050274","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9050274","identity":"rs-9050274","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}