Contraceptive autonomy with structural changes – UWPRC Small Grants Projects

UWPRC staff recently sat down with Dr. Leigh Senderowicz, one of our 2020 Small Grants recipients, to learn more about her project Understanding structural barriers to contraceptive autonomy among low-income Black African women in the Global South: An exploratory study.

Contraceptive autonomy — a person’s ability to decide for themself what they want in regards to contraceptive use, and then to realize that decision — is an essential element of maternal and reproductive health equity, but this multidimensional construct has been difficult to define and measure. This study uses qualitative methods (in-depth interviews and focus group discussions) to generate a nuanced understanding of contraceptive autonomy among low-income Black African women of reproductive age living in a Global South setting.  The analysis will focus on multiple dimensions of choice and access to rights-based reproductive health care.

Photo of Leigh Senderowicz

Change on a structural level

The project aims to intervene at a high level – academics, researchers, and donors whose work is associated with contraceptive autonomy. It is aimed at program designers and implementers, e.g., how does a program designer for an NGO (Non-Governmental Organization) develop a monitoring and evaluation (M&E) plan to see how successful their program is? Dr. Senderowicz likened the M&E plan to how exams and grades influence what students focus on when they are studying. If a professor tells students what content is going to be on their exam, that is what the students focus on. Similarly, family planning programs and providers focus on meeting the expectations set by their funders, evaluators, and other people who decide whether their grant will be renewed. Dr. Senderowicz wants to intervene at that level and change the way that we evaluate such programs – shifting the focus from contraceptive uptake to person-centered outcomes. “For the most part, no one wants to actively do harm – everyone is trying to navigate the structures and systems. When harm is being caused, it’s really important to look at the structural issues that are causing people to act in a certain way as opposed to looking at individual behaviors,” Dr. Senderowicz said.

Re-thinking incentives in family planning programs

Dr. Senderowicz’s work focuses on the concept of contraceptive autonomy – informed choice, free choice, and full choice in decision-making around contraceptive use and non-use. Family planning is an important part of reproductive health in a number of ways. However, the way that we have been measuring family planning in the past has led to incentives that encourage programs to pursue coercion in order to look good on paper. For example, if a program pressures someone into using an IUD (Intrauterine Device), they measure the use of the IUD but no one measures whether any coercion was used in the process.

In her past work, Dr. Senderowicz has found that measuring contraceptive uptake without measuring contraceptive autonomy creates perverse incentives to promote coercion. Her current work explores the concept of contraceptive autonomy and creating new measures that reflect person-centered, rights-based care essential to prevent contraceptive coercion. She hopes to do this by changing the incentives around what matters in reproductive health.

“When I think about prevention, I think about the concept of positive health as opposed to negative health. The WHO definition of health is not merely the absence of disease but this holistic understanding of well-being. We don’t put that into practice very often. We still tend to be focused on disease outcomes or their prevention, or prevention of illness” – Dr. Leigh Senderowicz

Relevance to the US and to Wisconsin

While the data for the current project comes from the Global South, Dr. Senderowicz says that the issues of reproductive autonomy affect populations in the Global North as well, including the US and Wisconsin. The issues around stratified reproduction – whose reproduction is valued or not, the way that race and gender impact family planning programs – might manifest differently in the Global North but the core issue of certain racial or ethnic groups being marginalized or their reproduction being limited is something we see in the US as well. There are shocking health disparities in terms of family planning in the state of Wisconsin and throughout the US. Dr. Senderowicz believes that this indicator would be helpful in shining a light on these.

Progress and next steps

Dr. Senderowicz has hired four project assistants (three graduate and one undergraduate student) to code the data – focus group interviews in French. All four students are fluent in French so their training focused on becoming familiar with the subject matter and cultural contexts. Dr. Senderowicz hopes that this unique experience will be valuable to the students. Once coding is complete, the next step for the project is synthesizing and analyzing the code. After that, it will be ready to be published into research papers as well as policy briefs targeted towards stakeholders.