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

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.