Proposed changes to framework to assess contraceptive autonomy based on phased in-depth interviews in northwest Tanzania

Le résumé fourni par la source

Access to sexual and reproductive healthcare is internationally regarded as an essential human right. Use of modern contraception is typically selected as a key indicator of women’s reproductive rights. However, there is a growing consensus that measuring rates of modern contraceptive use may not provide a full picture of women’s reproductive autonomy. A novel framework to investigate contraceptive autonomy, which includes broader indicators to reflect knowledge, justice, and volition, has been recently proposed. We conducted in-depth interviews in three phases in eight rural communities in northwest Tanzania with users and non-users of contraceptives using open-ended questions derived from the proposed contraceptive autonomy framework. Trained female interviewers performed one-on-one interviews in Kiswahili to explore women’s perspectives and knowledge about family planning (FP), decision-making, and experiences. Interviews were digitally recorded, transcribed verbatim, translated into English, and independently coded by two investigators. A total of 72 women were interviewed. Women had a median age of 29.5 years [interquartile range, 24–38] and a median of 4 [2–5] children. Those using modern contraception (75%) had been doing so for 1.9 [0.75–4.0] years. In the informed choice domain of contraceptive autonomy, most women could correctly name at least 3 contraceptive methods and summarize benefits and side-effects; women described risks and some benefits of non-use. In the full choice domain, health facilities had multiple contraceptives, although some stockouts were noted. In the free choice domain, nearly all women reported being free to choose to use, discontinue, or refuse FP. Many also described strong external influences that affected their decision-making about FP that were not captured by the proposed contraceptive autonomy framework. Both users and non-users of FP in our study demonstrated many components of contraceptive autonomy. Their experiences have shaped our suggestions for ways to increase comprehensiveness in measuring contraceptive autonomy. These suggestions likely have broad applicability that extends beyond rural Tanzania to many other regions. Integrating assessment of external influences into evaluations of contraceptive autonomy will further expand global capacity to evaluate both access to, and autonomy about, contraceptive use as a fundamental human right. The United Nations has established an international goal of ensuring access to sexual and reproductive healthcare for all people by 2030. One way that this is often assessed is by measuring the number of women who use contraception. Recently, there has been a growing recognition that this approach risks overlooking issues of women’s autonomy in contraceptive decision-making. A new proposed model to measure contraceptive autonomy details key aspects of contraceptive understanding and choice that could be assessed to provide a fuller picture of the information, breadth of options, and freedom with which women use contraception. In this study, our goal was to apply this model of assessing contraceptive autonomy among women living in rural northwest Tanzania. We conducted interviews to understand women’s views of and experiences with family planning and analyzed these interviews to uncover common themes. We found that many women had knowledge of multiple methods by which to plan their families, were able to access a variety of contraceptive options, and were free to choose to use, discontinue, or reject family planning. Notably, many women described experiencing strong influences from others in their families and communities that affected their decision-making about family planning. These influences were not captured by this framework. We propose modifications to the framework that we believe will increase its comprehensiveness and further strengthen its utility for assessing women’s autonomy and promoting health equity globally.

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