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The European Journal of Contraception & Reproductive
Health Care
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iejc20
Women’s autonomy and modern contraceptive
use in Ghana: a secondary analysis of data from
the 2014 Ghana Demographic and Health Survey
Martin Nyaaba Adokiya, Michael Boah & Timothy Adampah
To cite this article: Martin Nyaaba Adokiya, Michael Boah & Timothy Adampah (2021): Women’s
autonomy and modern contraceptive use in Ghana: a secondary analysis of data from the 2014
Ghana Demographic and Health Survey, The European Journal of Contraception & Reproductive
Health Care, DOI: 10.1080/13625187.2021.1910234
To link to this article: https://doi.org/10.1080/13625187.2021.1910234
Published online: 19 Apr 2021.
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RESEARCH ARTICLE
Women’s autonomy and modern contraceptive use in Ghana: a secondary
analysis of data from the 2014 Ghana Demographic and Health Survey
Martin Nyaaba Adokiya
a,b
, Michael Boah
b
and Timothy Adampah
c
a
Department of Global and International Health, School of Public Health, University for Development Studies, Tamale, Ghana;
b
Department of Epidemiology, Biostatistics, and Disease Control, School of Public Health, University for Development Studies, Tamale,
Ghana;
c
Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University,
Harbin, China
ABSTRACT
Objective: Women’s empowerment and autonomy have been proven to promote women’s use of
modern contraceptives. This study examined women’s autonomy as a potential factor for modern
contraceptive use among Ghanaian women in a union.
Method: We conducted a secondary analysis of data from the 2014 Ghana Demographic and
Health Survey. The main outcome measure was current modern contraceptive use from women’s
self-report. Three composite indices were used to assess women’s autonomy: household decision-
making, attitudes towards wife-beating, and property ownership.
Results: A total of 4772 non-pregnant women aged 15–49 years in a union were included in the
analysis. The mean age was 34.2(±7.97) years, 53.6% received at least secondary education, 87.7%
were employed, and 76.5% received family planning information within the last 12 months. The
prevalence of modern contraceptive use was 24.8% (95% CI: 22.9–26.7). Women’s autonomy was
independently associated with modern contraceptive use. Compared with women with low auton-
omy, women with moderate (AOR¼1.26, 95% CI: 1.02–1.55, p¼0.034) and high autonomy (AOR
¼1.34, 95% CI: 1.01–1.79, p¼0.044) had increased odds of modern contraceptive use. Maternal
age, education, number of living children, employment, region, and exposure to family planning
information were also strongly associated with modern contraceptive use.
Conclusions: The findings from this study support the assertion that women’s autonomy may be
vital in promoting the use of modern contraceptives among women in a union in Ghana and other
low-income and middle-income countries and should be considered in family planning programs.
ARTICLE HISTORY
Received 17 December 2020
Revised 17 March 2021
Accepted 24 March 2021
KEYWORDS
Women’s autonomy;
contraceptives; demo-
graphic; health survey;
maternal health; Ghana
Introduction
Globally, nearly all the maternal deaths occur in low and
middle-income countries (LMICs) [1]. Modern contraceptive
use minimises the risks of maternal deaths and improves
child health and survival through birth spacing and nutrition
[2]. Globally, 27, 2040 maternal deaths are prevented due to
contraceptive use [3]. Moreover, it is estimated that mater-
nal mortality would decline by 30% if women with no inten-
tion of giving birth used modern contraception [4].
Furthermore, the increase in contraceptives use has contrib-
uted to a decline in fertility in low and middle-income coun-
tries. An estimated 230 million births are prevented annually
due to contraception [3]. The use of modern contraceptives
is, therefore, a key intervention to reduce maternal deaths,
ensuring women’s and children’s health as well as promot-
ing economic development [5].
Despite the numerous advantages that modern contra-
ceptives provide to women, families, communities, and
nations, their use among married women is generally low,
particularly in sub-Saharan Africa. In 2017, modern contra-
ceptives were used by 45.7% of women in a union in the
world’s poorest countries to prevent unwanted pregnancies
[6]. In the same year, 28.5% of African women in union
used modern contraceptives. Furthermore, the 2017 Ghana
Maternal Health Survey (GMHS) found that, despite the
almost universal contraceptive awareness among Ghanaian
women, only 25% of women in a union use a modern
method of contraception to prevent unwanted pregnancies
[7]. Consequently, more than half of Ghanaian women in a
union are at risk of unwanted pregnancies [8]. Promoting
the use of modern contraceptives by Ghanaian women in a
union is thus vital for maternal health.
The desire for more children, religious beliefs, fear of sex-
ual promiscuity on the part of women, fear of side effects,
and spousal objections are some key barriers to the use of
contraception by women in a union in sub-Saharan Africa
[9–11]. Furthermore, fear prevents married women from dis-
cussing contraception issues with their partners. For married
women who are able to discuss contraception with their
partners, their opinions sometimes diverge resulting in mis-
understandings between partners [9,10]. In most parts of
Africa, male partners are the final decision-makers on the
timing of pregnancy, family size, and choice of contracep-
tion [12]. However, women’s empowerment and autonomy
have been associated with positive health-seeking behav-
iour, including the use of contraceptives in developing
countries [13]. Crissman and his colleagues provided proof
CONTACT Michael Boah boahmichael@gmail.com, mboah@uds.edu.gh Department of Epidemiology, Biostatistics, and Disease Control, School of
Public Health, University for Development Studies, Tamale, Ghana
Supplemental data for this article can be accessed online at https://doi.org/10.1080/13625187.2021.1910234.
ß2021 The European Society of Contraception and Reproductive Health
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
https://doi.org/10.1080/13625187.2021.1910234
of this in their study among women in a union without
pregnancy desire when they reported that empowering
women sexually promoted their use of any form of contra-
ceptives [14]. We recognise that previous studies used vari-
ous composite indexes to measure women’s empowerment
and autonomy and contraceptive use in Ghana, which may
have influenced the existing results. For instance, a study
found only weak statistical evidence that women’s involve-
ment in household decision-making affected their use of
contraception [15]. Similarly, another study by Blackstone
found that women’s empowerment had a positive impact
on contraceptive indicators by measuring their attitude
towards intimate partner Violence and decision making [16].
However, using only women’s participation in household
decision-making or their participation in household deci-
sion-making and attitudes towards intimate partner violence
to measure autonomy limited spectrum of the relationship
between autonomy and contraceptive use. On this premise,
the present study included a third dimension—ownership
of property—to examine the relationship between women’s
autonomy, measured by women’s participation in house-
hold decision-making, attitudes towards wife-beating (intim-
ate partner violence), and ownership of property and
modern contraceptive use.
Materials and methods
Data source
Data for this study were drawn from the 2014 Ghana
Demographic and Health Survey (GDHS), particularly the
women’s file, a nationally representative study of the popu-
lation and health of Ghanaians. The GDHS methodology has
been described in detail elsewhere [17]. Briefly, the 2014
GDHS used a multistage stratified cluster sampling design
to select enumeration areas (EAs) and households. The
selection of EAs was dependent on the size of the popula-
tion. A total of 12,831 households were systematically
selected using an updated sampling frame from the 2010
Population and Housing Census in Ghana. The survey
included women aged 15–49 years. A total of 9396 women
(97% response rate) who were permanent residents or visi-
tors who passed the night preceding the survey in the
selected households completed the women’s questionnaire.
This study included only women who self-reported that
they were either married or cohabiting and not currently
pregnant at the time of the survey. Women who have
never been in a union (n¼2,954), women previously in a
union (n¼888), and currently pregnant women (n¼679)
were excluded from the study. These groups were
excluded because we believe their need for modern con-
traceptives may be minimal owing to their reduced risk of
unwanted pregnancy. Finally, a weighted sample of 4772
women in a union was included in this study. A weighted
sample was used to ensure the representativeness of the
sample due to the complex design used in the
Demographic and Health Surveys [18].
Outcome variable
Modern contraceptive use was the main outcome variable
in this study. It was measured by the number of women
who reported themselves or their partners as currently
using at least one modern contraceptive method. Modern
contraceptives in this study included male and female ster-
ilisation, vasectomy, injectables, intrauterine devices (IUDs),
implants, contraceptive pills, female and male condoms,
diaphragm, lactational amenorrhoea method, and emer-
gency contraception [19]. The outcome was in binary form
with ‘1’representing women using modern contraceptives
and ‘0’for non-users.
Main independent variable
The main independent variable was women’s autonomy. It
was estimated from 12 questions covering three dimen-
sions of women’s autonomy; women’s participation in
household decision-making, attitude towards wife-beating,
and ownership of property. A score of 1 point was given
when the woman participated in the questions regarding
household decisions and if she owned land alone or jointly.
On the other hand, a score of 0 points was given if the
woman responded in the affirmative to questions regard-
ing justification of wife-beating. The final autonomy index
was created from the summation of the individual scores
covering the three dimensions of women’s autonomy (see
Table 2 and/or Supplementary Material S1 Table 1). The
final scores ranged from 0 to 12 (Cronbach’sa¼0.74).
Tertiles of women’s autonomy (low, moderate, and high)
were derived from a final autonomy index score to provide
a composite measure for women’s autonomy.
Control variables
The variables maternal age, educational level, religious
affiliation, region, region (combined)
1
, the setting of resi-
dence, number of living children, wealth group, employ-
ment status, knowledge about the ovulatory cycle and
exposure to family planning (FP) information were included
as potential confounders. Knowledge about the ovulatory
cycle was ‘Yes’if the woman responded that the fertile
period was ‘halfway between two periods’. Exposure to FP
information was ‘Yes’if the woman reported that she
received information on FP from at least one of the follow-
ing sources within the last 12 months: radio, television,
newspaper/magazine, visit by FP worker, or from FP facility.
Statistical analysis
Data analyses were carried out in STATA 13.0 for Windows
(StataCorp LP, College Station, Texas USA). Survey logistic
regression models were used in univariable and multivari-
able analyses to examine the association between the inde-
pendent variables and the outcome variable. The
association between the dimensions of women’s autonomy,
overall autonomy tertiles, and modern contraceptive use
was also investigated in the univariable analysis. All the
independent variables were included in the multivariable
analysis. Statistical significance was set at p<0.05. The vari-
able region (combined) was used in the multivariable
regression models instead of the region because of the
relatively small sample sizes in the selected regions and a
large number of regions. Multiple logistic regressions were
used to calculate the maximum likelihood estimates of the
2 M. N. ADOKIYA ET AL.
odds ratio (OR) and 95% confidence interval (CI). The fit of
the adjusted model was tested using the ‘svylogitgof’com-
mand [20]. There was no evidence of lack of fit of
the model.
Ethics
Written approval was obtained from the DHS program
before using the data. The ethical procedures of the DHS
program are published online at www.dhsprogram.com
Results
Descriptive analysis of the socio-demographic
characteristics of the sample population in this study
The mean age was 34(±7.9) years, 53.6% attained second-
ary or higher education, 77.0% were Christians, 87.7% were
employed, 61.8% had no knowledge of the ovulatory cycle,
and 76.5% were exposed to information on FP (Table 1).
Prevalence of modern contraceptive use and factors
associated with modern contraceptive use among
women currently in a union in Ghana
Overall, modern contraceptive use was 24.75% (CI:
22.90–26.69). In this study, age, education, region, region
(combined), the setting of residence, and exposure to FP
information were all statistically significantly associated
with modern contraceptive use (Table 1). Compared with
women aged 35–49 years, women aged 15–24 (OR ¼1.51,
p¼0.003) and 25–34 (OR ¼1.65, p<0.001) had higher
odds of modern contraceptive use. The crude odds for
modern contraceptive use was higher among women with
basic (OR ¼1.73, p<0.001) and secondary or higher (OR ¼
1.44, p<0.001) education relative to women with no
Table 1. Percentage of women in a union and crude odds ratio of modern contraceptive use by selected demographic variables
(N¼4772 unless indicated).
Variable
Weighted
%
Using modern contraceptives
Weighted
%Crude odds (OR) 95% CI p-Value
All women in a union 24.75
Age (Years) mean ¼34.17 sd ¼7.97
15–24 12.7 27.7 1.51 1.15–1.97 0.003
25–34 38.3 29.5 1.65 1.38–1.97 <0.001
35–49 49.0 20.3 Ref
Education
No education 27.7 19.5 Ref
Basic education 18.7 29.5 1.73 1.37–2.19 <0.001
Secondary or higher 53.6 25.8 1.44 1.19–1.74 <0.001
Religious affiliation
No religion 3.4 23 Ref
Traditional 2.5 15.9 0.63 0.34–1.18 0.148
Islam 17.1 18.1 0.74 0.47–1.17 0.195
Christian 77.0 26.6 1.21 0.81–1.81 0.348
Region
Western 10.4 25.8 1.25 0.82–1.90 0.291
Central 9.9 30.8 1.60 1.10–2.31 0.013
Greater Accra 18.8 21.7 Ref
Volta 7.8 32.2 1.71 1.15–2.55 0.008
Eastern 9.3 28.8 1.46 1.00–2.12 0.050
Ashanti 18.5 22.8 1.06 0.70–1.61 0.765
Brong Ahafo 8.1 29.6 1.52 1.03–2.22 0.034
Northern 10.4 12.3 0.50 0.34–0.75 0.001
Upper East 4.0 26.6 1.30 0.91–1.86 0.143
Upper West 2.8 27.4 1.36 0.91–2.03 0.134
Region (Combined)
North 17.1 18.1 Ref
South 82.9 26.1 1.60 1.32–1.95 <0.001
Setting of residence
Urban 50.2 22 Ref
Rural 49.8 27.5 1.34 1.10–1.64 0.004
Number of living children
0 6.4 16.7 0.58 0.23–1.42 0.232
1–3 52.9 24.9 0.96 0.81–1.13 0.606
4þ40.7 25.8 Ref
Wealth group
Poorest 19.0 23.7 1.10 0.83–1.46 0.506
Poorer 18.2 27.7 1.36 0.96–1.91 0.080
Middle 18.7 26.9 1.30 0.97–1.76 0.083
Richer 20.9 24.1 1.12 0.87–1.45 0.368
Richest 23.2 22 Ref
Employment status (N¼4761)
Unemployed 12.3 21.9 Ref
Employed 87.7 25 1.19 0.92–1.54 0.190
Knowledge of the ovulatory cycle
No 61.8 25 Ref
Yes 38.2 24.5 0.97 0.81–1.15 0.696
Exposure to FP information
No 23.5 20.7 Ref
Yes 76.5 26 1.35 1.08–1.68 0.008
Row %: note, column total for each sub-group need not be 100%. Ref: Reference group, sd: standard deviation.
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 3
formal education and higher among women residing in
rural settings (OR ¼1.34, p¼0.004) compared with urban
settings. The crude odds for modern contraceptive use was
higher for women in the Central (OR ¼1.60, p¼0.013),
Volta (OR ¼1.71, p¼0.008) and Brong Ahafo regions (OR
¼1.52, p¼0.034) but lower for women in the Northern
region (OR ¼0.50, p¼0.001) compared with women in
Greater Accra region. The crude odds of women practicing
contraception in the South of Ghana was 1.60 (p<0.001)
times higher than that of women practicing contraception
in the North of Ghana. Women with exposure to informa-
tion on FP were 1.35 times (OR ¼1.35, p¼0.008) more
likely to use modern contraceptives relative to women
without exposure to FP information (Table 1).
Regarding the three dimensions of women’s autonomy
(Table 2), only women’s participation in household deci-
sion-making was statistically significantly associated with
modern contraceptive use. For each one-unit increase in
household decision-making score, the crude odds of mod-
ern contraceptive use increased by 11% (OR ¼1.11,
p¼0.008). Compared with women with low autonomy,
women with average (OR ¼1.28, p¼0.010) and high (OR
¼1.48, p¼0.010) autonomy had increased crude odds of
modern contraceptive use (Table 2).
Independent factors associated with modern
contraceptive use among women currently in a union
in Ghana
In the adjusted model, women’s autonomy, age, education,
number of living children, employment, region (combined),
and exposure to FP information remained statistically sig-
nificantly associated with modern contraceptive use (Table
3). Compared with women with low autonomy, women
with moderate and high autonomy had 1.26 times
(p¼0.034) and 1.34 times (p¼0.044) higher odds respect-
ively of modern contraceptive use. The adjusted odds of
modern contraceptive use was about two times across
women aged 15–24 (AOR ¼2.32, p<0.001) and 25-34
(AOR ¼2.00, p<0.001) years relative to women aged
35–49 years. Women with basic education (AOR ¼1.43,
p¼0.004) and secondary or higher education (AOR ¼1.30,
p¼0.020) were more likely to be using modern contracep-
tives compared with women without any formal education.
In addition, employed women had higher odds of modern
contraceptive use relative to unemployed women (AOR ¼
1.37, p¼0.021). The adjusted odds for modern contracep-
tive use was higher for women residing in the South (AOR
¼1.58, p¼0.001) and women exposed to information on
FP (AOR ¼1.31, p¼0.022) compared with their counter-
parts. On the other hand, compared with women with 4
and more living children, women with no living children
(AOR ¼0.39, p¼0.037) and women with 1–3 living chil-
dren (AOR ¼0.69, p<0.001) were less likely to be on a
modern contraceptive (Table 3).
Discussion
Findings and interpretation
This study sought to examine the relationship between
women’s autonomy, measured by three composite indexes,
including their participation in household decision-making,
attitudes towards wife-beating, and ownership of property
and modern contraceptive use. The findings showed that
about a quarter (24.7%) of the women were currently using
a modern contraceptive method. In this study, the percent-
age of women currently using a modern contraceptive
method is comparatively lower than the 39% and 69% that
have been reported elsewhere [10,21]. However, the results
are consistent with findings (25%) from the most recent
maternal health survey conducted in Ghana [7].
This study explained that women’s autonomy was
strongly associated with modern contraceptive use after
adjusting for potential confounders. Women with moderate
and high autonomy were more likely than women with
low autonomy to report currently using a modern method
of contraception. This finding is consistent with results
from a national study conducted in Bangladesh [22].
Table 2. Percentage of women in a union and crude odds ratio of modern contraceptive use by the dimensions of women’s autonomy (N¼4772).
Autonomy variable
Weighted
%
Using modern contraceptives
Weighted
%Crude odds (OR) 95% CI p-Value
Participation in household decisions making scores
0(No autonomy) 3.6 23.0 1.11 1.03–1.20 0.008
1 6.3 21.3
2 10.6 18.5
3 20.3 24.1
4 34.1 25.1
5(Highest autonomy) 25.1 28.6
Attitude towards wife-beating scores
0(No autonomy) 5.1 23.6 1.02 0.97–1.08 0.442
1 4.1 25.5
2 5.9 19.8
3 6.7 26.1
4 8.0 24.4
5(Highest autonomy) 70.2 25.1
Ownership of property scores
0(No autonomy) 57.6 24.2 1.08 0.97–1.20 0.151
1 25.3 24.1
2(Highest autonomy) 17.1 27.7
Women’s autonomy (tertiles)
Low 31.0 21.3 Ref
Moderate 52.6 25.6 1.28 1.06–1.54 0.010
High 16.4 28.5 1.48 1.10–1.99 0.010
Row %: note, column total for each sub-group need not be 100%. Ref: Reference group.
4 M. N. ADOKIYA ET AL.
Indeed, measuring women’s autonomy is complex. Men
and women do not have the same understanding of the
dimensions used to measure women’s status. Therefore,
the degree of autonomy is depends on who responds to
the questions [23]. This is an important limitation of this
study since women were the main respondents to the
questions on the dimensions of autonomy used in this
study. However, our findings support the assertion that
women’s autonomy, particularly their participation in
household decision-making, may be vital in promoting
modern contraceptive use among women in a union in
Ghana and other LMICs. Nevertheless, we acknowledge
that women’s participation in household decision-making
may not necessarily reflect their reproductive autonomy.
For instance, evidence from Nigeria suggests that males
are the final decision makers regarding the use of contra-
ceptives [12]. In Ghana, one in four women could not
demand the use of condoms by their male partners during
sexual intercourse [24]. Often, Ghanaian women in a union
are stripped of their sexual autonomy because the tradi-
tions give more power to males over females when it
comes to female reproductive health issues [25].
The other factors that were statistically significantly
associated with modern contraceptive use in this study
should be given attention. Similar to a previous study
involving 32 sub-Saharan Africa countries [26], this study
found an association of younger age (<35 years) with mod-
ern contraceptive use. Younger women are in the early
stages of their reproductive course, thus their motivation
to use contraception stems from their un-readiness to have
children, desire to space births and prevent unwanted
pregnancies [27,28]. Moreover, age-specific fertility in
Ghana peaks around 25–29 years and declines from 30 to
34 years, at which age, a sizeable percentage of women,
become menopausal and may have no need for contracep-
tion [17].
The findings also revealed that women with some for-
mal education were more likely to use modern contracep-
tives compared with women without formal education,
which is consistent with previously published reports
[22,29,30]. The speculated reasons for the high use of mod-
ern contraceptives among educated women are that edu-
cation enhances women’s knowledge on contraception,
improves access to contraceptives, and strategically reposi-
tions them within the family. This is achieved through the
building of their confidence and power to participate in
decision making on reproductive health issues within the
family [5]. A positive link between increased maternal
knowledge and decision-making power, and increased use
of modern contraceptives has been suggested by other
studies from sub-Saharan Africa [26].
Additionally, employed women were more likely to use
contraceptives, which has been explained elsewhere that
this is probably due to their higher exposure to media. This
enhances their knowledge on the benefits of modern
contraceptive use [22]. As revealed in this study, exposure
to information on FP was statistically significantly associ-
ated with contraceptive use. On the other hand, women in
the South of Ghana had higher odds of modern contracep-
tive use. This may be one of the explanatory factors for the
low fertility and desire for a fewer number of children by
women in the South relative to women in the North [17].
To conclude, women’s autonomy is independently asso-
ciated with modern contraceptive use among women in a
union in Ghana. The findings of this study affirm the expe-
riences from other low- and middle-income countries. It
indicates a favourable relationship between women’s
household decision-making power and education with
improved use of modern contraceptives. Family planning
promotion programs should take into account women’s
autonomy, specifically their household decision-making
power regarding their own health.
Differences and similarities in relation to other studies
The present study is similar to other studies, which exam-
ined women’s autonomy and contraceptive use [15,21,31].
It also shares similarities in relation to other studies, which
used nationally representative data in the analysis [22,26].
However, there are also some notable differences. First, this
study differs in relation to other studies with regard to the
dimensions used to measure women’s autonomy and
internal consistency as evidenced by the high Cronbach
alpha value. The most frequently used domain of women’s
autonomy employed in most studies is their participation
in household decision-making [32]. For instance, a similar
study in Ghana measured women’s autonomy as a
Table 3. Adjusted odds ratio for multivariable logistic regression models
predicting modern contraceptive use by selected variables.
Variable
Adjusted
odds (AOR)
95% Confidence
Interval p-Value
Women’s autonomy
Low Ref
Moderate 1.26 1.02–1.55 0.034
High 1.34 1.01–1.79 0.044
Age
15–24 2.32 1.12–1.82 <0.001
25–34 2.00 1.66–2.42 <0.001
35–49 Ref
Education
No education Ref
Basic education 1.43 1.12–1.82 0.004
Secondary or higher 1.30 1.04–1.61 0.020
Religious affiliation
No religion Ref
Traditional 0.77 0.41–1.43 0.405
Islam 0.94 0.61–1.45 0.770
Christian 1.21 0.81–1.80 0.342
Number of living children
0 0.39 0.16–0.95 0.037
1–3 0.69 0.56–0.84 <0.001
4þRef
Employment status
Unemployed Ref
Employed 1.37 1.05–1.79 0.021
Wealth group
Poorest 1.44 0.96–2.14 0.075
Poorer 1.22 0.78–1.91 0.381
Middle 1.11 0.79–1.57 0.529
Richer 1.08 0.84–1.37 0.553
Richest Ref
Region (Combined)
North Ref
South 1.58 1.21–2.07 0.001
Setting of residence
Urban Ref
Rural 1.27 0.94–1.70 0.114
Exposure to information on FP
No Ref
Yes 1.31 1.04–1.65 0.022
Knowledge of the ovulatory cycle
No Ref
Yes 0.97 0.81–1.16 0.730
Ref: Reference group.
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 5
composite of domestic decision-making concerning house-
hold economics and self-efficacy [15]. It is worth mention-
ing that the said study did not only use only women’s
participation in household decision- making as a measure
of autonomy, but the internal consistency as shown by the
Cronbach alpha value was comparatively lower (0.63) , a
common feature among many studies which used house-
hold decision-making as the only dimension of women’s
autonomy [33,34].
Strengths and weaknesses
In this study, the strengths include the use of relatively
high-quality data from the DHS. In addition, the study is
nationally representative and used a large sample for the
analyses to produce reliable estimates. However, due to
the cross-sectional design used by the DHS, only statistical
associations and not causal linkages can be deduced.
Furthermore, the women provided responses to their cur-
rent decision making patterns which may not reflect their
past patterns. Similarly, the duration of modern contracep-
tives use was not investigated. The results of this study
should, therefore, be interpreted with caution taking into
consideration these notable limitations.
Relevance of the findings: implications for clinicians
and policy-makers/health care providers
The findings of this study demonstrate that women should
be active players in decision-making regarding their own
reproductive health and should be involved in decisions
concerning their reproductive health. Moreover, there is
evidence pointing to the conclusion that current use of
contraceptives is increased when women participated in
household decision–marking regarding family plan-
ning [31].
Additionally, the low use of effective contraception
among women in a union identified in this study may be
impacting negatively on population growth, socioeconomic
development, and achieving the Sustainable Development
Goals (SDGs) relating to maternal health. The non-use of
contraceptives has been associated with unplanned preg-
nancies, which are precursors of maternal mortality as they
can result in complicated pregnancies or unsafe abortions
[35,36]. It calls for integrated efforts to promote the use of
effective contraception among women in a union, particu-
larly those who want to delay pregnancy.
Note
1. The North comprised of Upper East region, Upper West region
and Northern region. The remaining seven administrative regions
constituted the South.
Author contributions
MNA, MB, and TA conceptualised and designed the study, MB ana-
lysed the data. All authors interpreted the results. MB and TB wrote
the draft manuscript, MNA reviewed the draft manuscript, all authors
critically reviewed and approved the final manuscript for submission.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
Martin Nyaaba Adokiya http://orcid.org/0000-0003-0167-5512
Michael Boah http://orcid.org/0000-0002-5660-2292
Timothy Adampah http://orcid.org/0000-0002-1691-1752
Data availability statement
The dataset used for this study is publicly available at www.dhspro-
gram.com/data/available-datasets.cfm with approval from the DHS
program. The authors do not have the authority to share the dataset
with any researcher without approval from the DHS program.
References
[1] World Health Organization, United Nations Children’s Fund,
United Nations Population Fund, World Bank Group, United
Nations. Trends in maternal mortality: 1990 to 2015: estimates
by WHO, UNICEF, UNFPA, World Bank Group and the United
Nations Population Division. Geneva: World Health
Organization; 2015.
[2] Ahmed S, Choi Y, Rimon JG, et al. Trends in contraceptive
prevalence rates in sub-Saharan Africa since the 2012 London
Summit on Family Planning: results from repeated cross-sec-
tional surveys. Lancet Glob Heal. 2019;7(7):e904–e911.
[3] Ahmed S, Li Q, Liu L, et al. Maternal deaths averted by contra-
ceptive use: an analysis of 172 countries. Lancet. 2012;
380(9837):111–125. Elsevier Ltd.
[4] Cleland J, Conde-Agudelo A, Peterson H, et al. Contraception
and health. Lancet. 2012;380(9837):149–156.
[5] Emina JBO, Chirwa T, Kandala NB. Trend in the use of modern
contraception in sub-Saharan Africa: does women’s education
matter? Contraception. 2014;90(2):154–161.
[6] Cahill N, Sonneveldt E, Stover J, et al. Modern contraceptive
use, unmet need, and demand satisfied among women of
reproductive age who are married or in a union in the focus
countries of the Family Planning 2020 initiative: a systematic
analysis using the Family Planning Estimation Tool. Lancet.
2018;391(10123):870–882.
[7] Ghana Statistical Service, Ghana Health Service, ICF. Ghana
Maternal Health Survey 2017 [Internet]. Accra, Ghana; 2018.
Available from: www.dhsprogram.com/publications/publication-
fr340-other-final-reports.cfm.
[8] Johnson FA, Madise NJ. Targeting women at risk of unintended
pregnancy in Ghana: should geography matter? Sex Reprod
Healthc. 2011;2(1):29–35.
[9] Bald
e MD, Diallo BA, Compaor
e R, et al. Men’s behavior sur-
rounding use of contraceptives in Guinea. Int J Gynecol Obstet.
2016;135(S1):S16–S19.
[10] Nagase T, Kunii O, Wakai S, et al. Obstacles to modern contra-
ceptive use among married women in southern urban
Maldives. Contraception. 2003;68(2):125–134.
[11] Aryeetey R, Kotoh AM, Hindin MJ. Knowledge, perceptions and
ever use of modern contraception among women in the Ga
East District, Ghana. Afr J Reprod Health. 2010. 14: 26–31.
http://www.ncbi.nlm.nih.gov/pubmed/21812195.
[12] Akaba G, Ketare N, Tile W. A community-based, mixed-methods
study of the attitudes and behaviors of men regarding modern
family planning in Nigeria. Int J Gynaecol Obstet. 2016;135(1):
86–90.
[13] Pratley P. Associations between quantitative measures of wom-
en’s empowerment and access to care and health status for
mothers and their children: a systematic review of evidence
from the developing world. Soc Sci Med. 2016;169:119–131.
[14] Crissman HP, Engmann CE, Adanu RM, et al. Shifting norms:
pregnant women’s perspectives on skilled birth attendance and
facility –based delivery in rural Ghana. Afr J Reprod Health.
2013;17(1):15–26.
6 M. N. ADOKIYA ET AL.
[15] Atiglo DY, Codjoe SNA. Meeting women’s demand for contra-
ceptives in Ghana: Does autonomy matter? Women Health.
2019;59(4):347–363.
[16] Blackstone SR. WOMEN’S EMPOWERMENT, HOUSEHOLD STATUS
AND CONTRACEPTION USE IN GHANA. J Biosoc Sci. 2017;49(4):
423–434.
[17] Ghana Statistical Service, Ghana Health Service, ICF
International. Ghana Demographic and Health Survey, 2014.
Rockville (MD): Ghana Statistical Service, Ghana Health Service,
ICF International; 2015.
[18] Demographic and Health Survey. Guide to DHS statistics.
Demographic and health surveys methodology. Rutstein SO,
Rojas G, editors. Calverton (MD): Demographic and Health
Surveys, ORC Macro; 2006.
[19] Festin MPR, Kiarie J, Solo J, et al. Moving towards the goals of
FP2020 - classifying contraceptives. Contraception. 2016;94(4):
289–294.
[20] Archer KJ, Lemeshow S. Goodness-of-fit test for a logistic
regression model fitted using survey sample data. Stata J. 2006;
6(1):97–105. doi:https://www.stata-journal.com/sjpdf.html?arti-
clenum=st0099
[21] Patrikar SR, Basannar DR, Seema Sharma M. Women empower-
ment and use of contraception. Med J Armed Forces India.
2014;70(3):253–256.
[22] Rahman MM, Mostofa MG, Hoque MA. Women’s household
decision-making autonomy and contraceptive behavior among
Bangladeshi women. Sex Reprod Healthc. 2014;5(1):9–15.
[23] Ghuman SJ, Lee HJ, Smith HL. Measurement of women’s auton-
omy according to women and their husbands: results from five
Asian countries. Soc Sci Res. 2006;35(1):1–28.
[24] Darteh EKM, Doku DT, Esia-Donkoh K. Reproductive health
decision making among Ghanaian women. Reprod Health.
2014;11:23.
[25] Dodoo ND, Atiglo DY, Biney AAE, et al. Does financial auton-
omy imply reproductive and sexual autonomy? Evidence from
urban poor women in Accra, Ghana. Afr Stud. 2019;78(4):
477–495.
[26] Yaya S, Uthman OA, Ekholuenetale M, et al. Women empower-
ment as an enabling factor of contraceptive use in sub-Saharan
Africa: a multilevel analysis of cross-sectional surveys of 32
countries. Reprod Health. 2018;15(1):214.
[27] Achana FS, Bawah AA, Jackson EF, et al. Spatial and socio-
demographic determinants of contraceptive use in the Upper
East region of Ghana. Reprod Health. 2015;12:29.
[28] Apanga PA, Adam MA. Factors influencing the uptake of family
planning services in the Talensi District, Ghana. Pan Afr Med J.
2015;20:1–9.
[29] Ba DM, Ssentongo P, Agbese E, et al. Prevalence and predictors
of contraceptive use among women of reproductive age in 17
sub-Saharan African countries: a large population-based study.
Sex Reprod Healthc. 2019;21:26–32.
[30] Adanu RM, Seffah JD, Hill AG, et al. Contraceptive use by
women in Accra, Ghana: results from the 2003 Accra Women’s
Health Survey. Afr J Reprod Health. 2009;13:123–133. Available
from: http://www.bioline.org.br/pdf?rh09011
[31] Haile A, Enqueselassie F. Influence of women’s autonomy on
couple’s contraception use in Jimma town, Ethiopia. Ethiop J
Heal Dev. 2006;20:145–151.
[32] Prata N, Fraser A, Huchko MJ, et al. WOMEN’S EMPOWERMENT
AND FAMILY PLANNING: A REVIEW OF THE LITERATURE. J
Biosoc Sci. 2017;49(6):713–743.
[33] Upadhyay UD, Gipson JD, Withers M, et al. Women’s empower-
ment and fertility: a review of the literature. Soc Sci Med. 2014;
115:111–120.
[34] Do M, Kurimoto N. Women’s empowerment and choice of
contraceptive methods in selected African countries. Int
Perspect Sex Reprod Health. 2012;38(1):23–33.
[35] Moronkola OA, Ojediran MM, Amosu A. Reproductive health
knowledge, beliefs and determinants of contraceptives use
among women attending family planning clinics in Ibadan,
Nigeria. Afr Health Sci. 2006;6(3):155–159.
[36] Bankole A, Keogh S, Akinyemi O, et al. Differences in unin-
tended pregnancy, contraceptive use and abortion by HIV sta-
tus among women in Nigeria and Zambia. Int Perspect Sex
Reprod Health. 2014;40(1):28–38.
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE 7
