1 2 ACKNOWLEDGMENTS The authors would like to acknowledge the United States Agency for International Development (USAID) for its support of this research. We are grateful to the following people for their vital assistance throughout this study: Mahua Mandal, Abby Cannon, Janine Bardon O’Fallon, Sarah Treves- Kagan, Bernard Agala, and Lara Lorenzetti at MEASURE Evaluation, and our local consultants Trinity Mwale and Stanley Santula. Also, we wish to thank Amani Selim, Joan Kraft, and Michal Avni in the Office of Reproductive Health at USAID for their support of and commitment to this study. 3 CONTENTS ABBREVIATIONS ..................................................................................................................................................... 6 EXECUTIVE SUMMARY ........................................................................................................................................ 7 Background .............................................................................................................................................................. 7 Purpose ..................................................................................................................................................................... 7 Methods .................................................................................................................................................................... 8 Findings .................................................................................................................................................................... 8 Recommendations and Next Steps ...................................................................................................................... 9 BACKGROUND ...................................................................................................................................................... 10 INTRODUCTION ................................................................................................................................................... 11 Reproductive Empowerment Definition and Conceptual Framework ........................................................ 11 Expressions of Empowerment ........................................................................................................................... 12 Levels of Agency and Resources ........................................................................................................................ 13 Measurement of Reproductive Empowerment ................................................................................................ 14 RESEARCH GOALS ............................................................................................................................................... 16 Country Setting ...................................................................................................................................................... 16 METHODS ................................................................................................................................................................ 17 Study Design .......................................................................................................................................................... 17 Study Location and Population ........................................................................................................................... 17 Sample and Eligibility ........................................................................................................................................... 17 Data Collection ...................................................................................................................................................... 17 Data Processing, Coding, and Analysis ............................................................................................................. 18 Ethical Review ....................................................................................................................................................... 19 FINDINGS ................................................................................................................................................................. 20 Participant Characteristics .................................................................................................................................... 20 Decision Making about Sexual and Reproductive Health .............................................................................. 20 Levels of Agency and Resources ........................................................................................................................ 23 Indicators for Measurement of Reproductive Empowerment ...................................................................... 27 DISCUSSION ............................................................................................................................................................ 34 Sexual and Reproductive Health Decision Making ......................................................................................... 34 Limitations .............................................................................................................................................................. 36 Recommendations and Next Steps .................................................................................................................... 37 CONCLUSION ......................................................................................................................................................... 39 REFERENCES .......................................................................................................................................................... 40 APPENDIX A. FOCUS GROUP GUIDE SAMPLE ....................................................................................... 44 APPENDIX B. CODEBOOK FOR FOCUS GROUPS .................................................................................. 48 4 Developing Measures of Reproductive Empowerment APPENDIX C. FOCUS GROUP CHARACTERISTICS ................................................................................ 50 APPENDIX D. FOCUS GROUP PARTICIPANT DEMOGRAPHICS, BY GENDER ......................... 51 FIGURES Figure 1. Conceptual framework of reproductive empowerment ..................................................................... 13 TABLES Table 1. Number and stratification of focus groups by location ....................................................................... 17 Table 2. Reproductive empowerment domains, illustrative quotes, and corresponding scale items ........... 28 Table 3. Sexual and reproductive health decision making ................................................................................... 29 Table 4. Sexual and reproductive health norms .................................................................................................... 31 Table 5. Social support for sexual and reproductive health ................................................................................ 32 Table 6. Partner communication ............................................................................................................................. 32 Table 7. Critical consciousness ................................................................................................................................ 33 Table 8. Family planning program implications .................................................................................................. 38 Developing Measures of Reproductive Empowerment 5 ABBREVIATIONS CC critical consciousness CCU covert contraceptive use FGD focus group discussion RE reproductive empowerment SRH sexual and reproductive health USAID United States Agency for International Development ZDHS Zambia Demographic and Health Survey 6 Developing Measures of Reproductive Empowerment EXECUTIVE SUMMARY Background Women’s empowerment has been a major focus of development work for decades. The lack of women’s empowerment in social, political, and economic contexts is linked to poor health outcomes. However, the relationship between women’s lack of empowerment and their sexual and reproductive health is unclear. Researchers have recently begun to look at reproduction as a distinct aspect of women’s empowerment, known as reproductive empowerment (RE). MEASURE Evaluation—funded by the United States Agency for International Development (USAID)— undertook research to develop measures of RE to improve evaluations of interventions aimed at increasing RE. Our research is part of a three-phased activity to conceptualize and develop better measurement tools to accurately assess RE. During the first phase of this project, together with the International Center for Research on Women (ICRW), we created a conceptual framework based on definitions of empowerment and the socioecological model (Sallis, Owen, & Fisher, 2015). Through this framework, we defined RE as the outcome of a transformative process of change whereby individuals expand their capacity to make informed decisions about their reproductive lives, amplify their ability to participate meaningfully in public and private discussions related to reproduction, and act on their preferences and choices to achieve desired reproductive outcomes, free of violence, retribution, or fear. We emphasize that RE is a dynamic process in which women and