Conceptualizing Contraceptive Agency: A Critical Step to Enable Human Rights-Based Family Planning Programs and Measurement

"The contraceptive agency framework can be applied as a practical resource to guide program design and evaluation."

Ensuring a rights-based approach to contraception involves supporting individuals and couples to make and act on their own choices, regardless of what they choose. This commentary proposes a framework for the construct of "contraceptive agency", the ability of an individual to make and act on decisions related to whether to do something to avoid or delay pregnancy and what, if anything, to do when they are not actively trying to become pregnant. The paper draws on the authors' experience with the Innovations for Choice and Autonomy (ICAN) project. ICAN's focus is developing and testing approaches to implementing the self-injectable contraceptive technology in a way that meets women's self-defined needs.

The commentary begins with an overview of existing frameworks and measures related to contraceptive agency. These frameworks and measures have a common recognition of the importance of individuals' ability to make and act on sexual and reproductive health (SRH) decisions. However, the authors argue for the need for contraception-specific frameworks and resultant measures. Further, they argue that limited or no engagement from others does not inherently indicate lack of empowerment. A measure should also take into consideration not just whether one shares their opinion with a partner but whether they want to share that opinion and how satisfied they are with the outcome.

Another concern the authors articulate is that agency in SRH decision-making tends to be narrowly conceptualised and measured with a focus on involvement and influence of others, yet "agency in decision-making relies on a broader set of internal processes related to the formation of values-based preferences that have been understudied in the SRH field....[I]t is important for contraception-related frameworks and measures to include the extent to which individuals recognize what their rights are and what societal injustices, such as gender inequities and poverty, may be constraining them." In addition, existing programmes and measures primarily focus on partners as a key source of interference in women's contraceptive agency. "However, there is a need to expand acknowledgment of other sources of social influence, particularly among adolescents for whom parental involvement is often more salient and people who live with extended family, including in-laws."

Innovation is also needed, per the authors, in response to calls that have been made for more attention to sexual and reproductive health and rights among men and gender nonbinary people. Currently, however, measures of empowerment and rights fulfillment in the SRH field are predominantly developed for women only. There is also a need to shift away from equating contraceptive use with empowerment.

Based on that assessment of what is lacking in current frameworks and measures related to reproductive empowerment and autonomy, the authors advance a contraceptive agency framework to serve as a guide for centring individuals' ability to make and act on their own contraceptive choices, regardless of what those choices are, in contraception programme design and evaluation. On this framework, Domain 1 covers constructs related to decision-making (e.g., to have information and support in accordance with one's preferences to make choices about doing or not doing something to avoid or delay pregnancy), and Domain 2 covers constructs related to acting on decisions (e.g., to have control over who and to what extent others are involved in and aware of one's preferred actions related to avoiding or delaying pregnancy). These 2 theoretically informed domains cover the range of psychosocial constructs necessary for an individual who is not actively trying to get pregnant to have full agency over what (if anything) they decide to do related to avoiding or delaying pregnancy. A person of any gender with high levels of each of the 8 constructs is considered to have high contraceptive agency, whether or not they decide to use contraception and regardless of what method they choose.

The authors recognise the inherent risk that defining individual-level constructs in this way will primarily motivate behavioural rather than social or structural interventions. Thus, they situate contraceptive agency within the broader context of influences on individual decisions and actions, drawing on the Integrated Behavioral Model and the Social Ecological Model. (See figure above.)

The paper draws out implications for practice and measurement. "For example, through the theoretically informed constructs of consciousness of the right to contraceptive choice and critical reflection about constraints to contraceptive choice, programming can be implemented to make sure individuals are aware of their rights and the conditions that constrain them in acting on those rights. The structural and social factors depicted in the framework as patterning uneven opportunities for agency based on social position will also guide program designers to recognize that agency is impacted by social influences at family, peer, partner, and community levels and that programs should strive to help individuals navigate these social and structural factors as much as is feasible without relying solely on individual-level solutions."

In the ICAN project, the authors used the contraceptive agency framework to guide a human-centred design process in Uganda toward solutions that would first and foremost support agency in making and acting on one's own decisions rather than promoting uptake of self-injection. The resulting community-based programme entails leveraging peer social support to support women in making and acting on their own contraceptive decisions, while also diffusing information about the option of self-injection and having peers offer moral support for those interested in self-injecting. Specific constructs from the contraceptive agency framework were used in the design of programme materials. For example, peer support training materials discuss the importance of making sure women know their rights, are confident in their ability to make a choice, and have the level of support and information that they themselves desire.

In conclusion: "Programmatic and measurement innovations resulting from the contraceptive agency framework will be critical to help move the family planning field toward implementing - and holding ourselves accountable for - progress toward rights-based principles that are widely agreed upon in practice but less often operationalized and measured."