Is women’s social independence a strong determinant for the reproductive health-related outcomes of the Turkish population?

doi:10.21203/rs.3.rs-3701025/v1

Background

Women's empowerment is increasingly recognized as a crucial factor in achieving reproductive health goals and gaining related rights. This study analyzed the relationship between women’s social independence and various reproductive health-related outcomes.

Methods

The study used data from the nationally representative 2018 Turkey Demographic and Health Survey. We analyzed data from 5156 married women. The study included eight dependent variables: 1) a total number of births; 2) an ideal number of children; 3) women’s ability to have just the desired number of children; 4) unplanned births; 5) needs for modern family planning methods; 6) contraceptive category (female-only or couple contraceptive methods); 7) induced abortions; and 8) miscarriages. The main predictor of outcome variables was women’s social independence, which was measured using a modified form of the social independence domain of the survey-based women's empowerment (SWPER) index. Principal component analysis was used to estimate the factor loadings of the items and calculate individual standardized scores. Social independence scores were classified into 20% quintiles as lowest, lower, middle, higher, and highest. The relationship between the dependent and independent variables was explored by calculating prevalence ratios and corresponding 95% confidence intervals (PRs, 95% CI) using a robust Poisson regression analysis. PRs were adjusted by age, household wealth quantiles, residence, and region.

Results

Women with the lowest levels of social independence had higher PRs than those with the highest social independence in the following categories: number of births of four or more [PR = 16.0 (7.2–25.3)], ideal number of children of four or more [PR = 1.9 (1.6–2.2)], more children than the ideal number [PR = 5.7 (3.3–8.1)], having an unplanned birth [PR = 2.3 (1.6–2.9)], the use of female-only contraceptive methods [PR = 1.7 (1.4–1.9)], induced abortions [PR = 1.9 (1.5–2.4)], and miscarriages [PR = 1.7 (CI 1.3-2.0)]. As women's social independence levels decreased, there was a consistent and gradual increase in negative reproductive health outcomes.

Conclusion

The study indicates that higher social independence levels are strongly associated with better reproductive health outcomes, emphasizing the need for women's empowerment in social independence for reproductive health policies.

Demographic health survey

Reproductive health

Social independence

Women’s empowerment

Turkey

Reproductive health is the state of complete physical, mental, and social well-being, beyond the mere absence of disease or infirmity, in all aspects of the reproductive system. Reproductive health implies a satisfying and safe sexual life with the freedom to decide when, how, and how often to reproduce [1]. The 1994 International Conference on Population and Development (ICPD) in Cairo was a milestone in the development of reproductive health rights. The ICPD marked a transition from a demographic approach to a comprehensive approach focusing on women's empowerment and gender equality in reproductive rights and health care. One year later, The Fourth World Conference on Women in Beijing, China, re-affirmed the decisions made at the ICPD. Since the ICPD, several countries have placed a greater emphasis on reproductive health and worked to create better policies and improve access to information and services. However, progress remains uneven across countries and different components of reproductive health. Reproductive health problems continue to be the leading cause of morbidity and mortality for women of childbearing age, especially in developing countries. Beyond the biological reasons that explain some of the observed differences between men's and women's health, power dynamics, resource distribution, social norms, and social values put women at a disadvantage in fulfilling their reproductive intentions and accessing relevant health services [2]. With a view to reducing the burden posed by reproductive health problems, the United Nations declared ‘achieving universal access to sexual and reproductive health care, reducing global maternal death rates, and ending the AIDS epidemic by 2030’ as a sustainable goal (Goal 5) [3].

Today, women’s empowerment is considered a critical component of achieving reproductive health goals and related rights. Empowerment is defined as a process by which women can increase their self-efficacy, make life-enhancing decisions, and gain control over resources [4]. Women’s empowerment, which has a complex and multidimensional nature, requires women’s access to public services such as education, health, and employment, as well as a developed capacity for autonomy, decision-making, and actions taken in line with their decisions [4]. There is a close link between empowerment and reproductive health outcomes. Studies conducted on various components of empowerment indicate a relationship between women’s empowerment and lower fertility [5, 6], use of contraceptives [7, 8], longer birth intervals [9], lower unintended pregnancy rates [9], and better access to maternal care [7]. The main limitation of these studies is the lack of a standard measurement tool that is comprehensive at the individual level, allowing cross-country comparisons. To meet this need, the survey-based women's empowerment (SWPER) index was developed in 2017 using demographic and health surveys (DHSs) in 34 African countries [10]. The index was later expanded to low- and middle-income countries under the name of SWPER Global [11]. The SWPER Global Index assesses women’s empowerment in three dimensions: social independence, decision-making, and attitudes toward violence. This index is a valuable tool for monitoring progress toward gender equality and empowering women and girls as part of the fifth United Nations Sustainable Development Goal. It is also useful for nationwide and cross-country comparisons [11].

Analyses based on DHSs data from various countries show strong associations between dimensions of the SWPER index and reproductive, maternal, and child health outcomes. Relationships exist between the dimension of social independence and outcomes including childhood immunization coverage [12, 13], child nutrition outcomes [14], and maternal health services, including institutional births [10], antenatal care, delivery assisted by a skilled birth attendant, and postnatal care [15, 16]. There are similar connections between the dimension of attitudes toward violence and outcomes including use of modern contraceptives [10] and excess fertility [16]; likewise, the dimension of decision-making is associated with delivery assisted by a skilled birth attendant and postpartum care [16] and child nutrition outcomes [14]. In a study by Everling et al. (2021), using data from 62 countries, a positive relationship was found between the three dimensions of SWPER and the composite coverage index (a summary measure of reproductive, maternal, newborn, and child health universal health coverage) scores of the studied countries, and the strongest relationship was identified in the domain of social independence [17]. The common feature of the preliminary studies using the SWPER index is that they indicate a strong relationship with several outcome variables, particularly in the domain of social independence.

In Turkey, the status of women has changed significantly due to the modernization process, socioeconomic transformations, and changing population policies since the establishment of the republic in 1923. The marriage age has advanced, the fertility rate has decreased, and women's education level and participation in the labor force have increased [18, 19]. Nevertheless, the Islamic patriarchal lifestyle is still prevalent in society, which is reflected in the social position of women. Gender inequalities are common in Turkey, where women live in a sociocultural environment where modern and traditional attitudes and behaviors coexist [20]. According to the 2022 Gender Gap Report, Turkey ranks 124th among 146 countries with a relatively low score (0.639) [21]. Domestic studies show that as the status of women increases, reproductive health indicators such as use of contraceptives [22], access to maternal health care [23], and the accessibility of induced abortion [24] improve. These studies generally focus on a single or a few reproductive health outcomes. The absence of a composite measurement tool in these studies complicates the understanding of the relationship between various aspects of women's empowerment and reproductive health outcomes.

In this study, we aim to evaluate the relationship between women's empowerment and various reproductive health outcomes in the 2018 Turkey Demographic and Health Survey (TDHS-2018) by focusing on the social independence domain of the SWPER Global Index, which evaluates several variables related to women’s status. We also aim to contribute to the evaluation of the effectiveness of reproductive health programs in Turkey through the incorporation of the SWPER Global Index.

Data source

We used the data from the TDHS-2018, a nationally representative household-based survey conducted every five years. The DHSs are standardized questionnaire-based surveys that gather comprehensive data on health and population in developing countries. The TDHS-2018 sample was selected with a multistage, stratified cluster sampling approach. In total, 7345 women aged 15–49 were interviewed using a standard DHS questionnaire [18]. The data for currently married women were analyzed in this study (n = 5156). All analyses were weighted, so the number of currently married women was represented as 4820 in the tables.

Measures

Dependent variables

The dependent variables of the study are explained below. The classifications of dependent variables and study populations are also listed in Table 1.

Table 1

The classifications of the dependent variables and the study populations
Dependent variables	Classification in descriptive tables	Classification in Poisson regression analysis	Population (weighted)
1. Total number of births	None; 1–2; 3–4; ≥5	0–3 = 0 (reference category) ≥ 4 = 1	Currently married women (n = 4820)
2. Ideal number of children	None; 1–2; 3–4; ≥5	0–3 = 0 (reference category) ≥ 4 = 1	Currently married women (n = 4820)
3. Women’s ability to have the desired number of children	Fewer (number of living children minus the ideal number of children) < 0 Equal (number of living children minus ideal number of children) = 0 More (number of living children minus ideal number of children) > 0	Fewer and equal = 0 (reference category) More = 1	Currently married women aged ≥ 35 (n = 2693)
4. Unplanned birth	Wanted at that time; wanted later; not wanted at all	Wanted at that time = 0 (reference category) Unplanned (wanted later or not at all) = 1	Women who gave birth to a child in the last five years (n = 2002)
5. Needs for modern family planning method	Met need Unmet need No need	Met need = 0 (reference category) Unmet need = 1	Currently married women (n = 4820)
6. Contraceptive category	Couples methods (condom, withdrawal, periodic abstinence) Female-only methods (pill, injectable contraceptive, intrauterine devices, implant, female sterilization)	Couples methods = 0 (reference category) Female-only methods = 1	Married women currently using any family planning methods (n = 3358)*
7. Induced abortion (at least one)	No; Yes	No = 0 (reference category) Yes = 1	Currently married women (n = 4820)
8. Miscarriage (at least one)	No; Yes	No = 0 (reference category) Yes = 1	Currently married women (n = 4820)
* Women using the folkloric method (n = 8) were not included.

Total number of births

This variable describes the number of children that the women have given birth to.

Ideal number of children: The TDHS-2018 attempted to obtain a measure of fertility preferences that is less dependent on the woman’s current family size by inquiring about the respondent’s ideal number of children. In the survey, women with no children were asked ‘If you could choose the exact number of children to have in your whole life, how many would that be?’. Women who had children were asked: ‘If you could go back to the time when you did not have any children and could choose the exact number of children to have in your whole life, how many would that be?’ [18]. The mean ideal number of children found for the sample (3.0) was assigned to the women who answered the question without giving any numbers (n = 30) [6, 25].

Women’s ability to have the desired number of children

This variable provides information about the number of living children compared to the woman's ideal number of children. It is calculated by subtracting the ideal number of children from the number of living children. If the difference is zero, it means that the living and ideal number of children are equal; if it is less than zero, it means that the woman had fewer children than her ideal, and if it is larger than zero, it means that the woman had more children than her ideal. It is clear that women at a younger age are less likely to achieve the number of births they desire; thus, only married women aged 35 and over were examined in this study [6, 25].

Unplanned birth

This variable indicates whether the last child born in the last five years was wanted at that time, was wanted later, or was not wanted at all. The categories of wanted later and not wanted at all were classified as an unplanned birth.

Needs for modern family planning method: The following categories were determined: a) met need (women using modern contraceptive methods because they want to postpone their next birth for two or more years or stop childbearing altogether), b) no need (women who want pregnancy, who are nonfertile or in menopause), and c) unmet need. Unmet need for family planning is the proportion of women who i) are not pregnant, not postpartum amenorrhoeic, considered fecund and want to postpone their next birth for two or more years or stop childbearing altogether but are not using a modern contraceptive method, ii) have a mistimed or unwanted current pregnancy, or iii) are postpartum amenorrhoeic and their last birth in the last two years was mistimed or unwanted [18]. Modern methods include male and female sterilization, injectables, intrauterine devices (IUDs), contraceptive pills, implants, male and female condoms, lactational amenorrhea, and emergency contraception [18].

Contraceptive category

Contraceptive methods were categorized into female-only methods (the pills, injectables, IUDs, and implants) and couples methods (condom, withdrawal, and periodic abstinence). The main difference between the two categories is that couples methods require a certain degree of support, involvement, or cooperation or at least the awareness of the husband [8].

Induced abortion

This variable refers to whether the woman ever had a pregnancy that was terminated in an induced abortion.

Miscarriage

This variable refers to whether the woman ever had a pregnancy that was terminated in a miscarriage.

Explanatory variable

The main predictor for dependent variables was women’s social independence, measured using the SWPER Global Index, a validated measure of women’s empowerment for low- and middle-income countries based on DHS data. The SWPER index has three domains: 1) attitudes toward violence, 2) social independence, and 3) decision-making. Since nearly 10% of the women approved the statements related to violence in the TDHS-2018, the violence domain was not included in the study. In addition, the decision-making domain was also excluded since only one of the three items of that domain was inquired about in the TDHS-2018. Therefore, we included the social independence domain of the SWPER index, as all items in this domain were available in the TDHS-2018. The original social independence domain includes six items meant to identify the prerequisites that allow women to accomplish their goals and components that contribute to agency and autonomy. It was seen that two items, ‘internet usage’ and ‘do you have money that you can spend by yourself?" were highly correlated with the items of the original social independence domain in the SWPER index. Later, we decided to use a modified social independence domain in the SWPER index adding these two variables (Table 2). In the study, 7.1% of women had never given birth. Their age at first birth was imputed through hot-deck imputation [10]. Principal component analysis was used to estimate the factor loadings of the items, and individual standardized scores were calculated accordingly (see Additional file 1). Social independence scores were classified into 20% quintiles as the lowest, lower, middle, higher, and highest.

Table 2

Items and code/units of the original and modified social independence domains
	The original social independence domain of the SWPER Global Index	The modified social independence domain
Items	Code/unit	Code/unit
1. Frequency of reading a newspaper or magazine	Not at all = 0; <once a week = 1; ≥once a week = 2	Not at all = 0; less than once a week = 1; at least once a week = 2; almost every day = 3 Recode: Not at all = 0; <once a week = 1; ≥once a week = 2
2. Woman’s education in completed years of schooling	Years	Years
3. Age of woman at first birth	Years	Years
4. Age at first cohabitation	Years	Years
5. Age difference: woman’s minus husband’s age	Years	Years
6. Education difference: woman’s minus husband’s years of schooling	Years	Years
7. Internet usage	-	No = 0; irregularly = 1; regularly = 2
8. Whether the woman has money that she can spend by herself	-	0 = No, 1 = Yes

Potential confounders

Potential confounding variables of the study were age (the current age of the respondent in completed years), place of residence (rural/urban), region (west, south, central, north, east), and wealth index (poorest, poorer, middle, wealthier, wealthiest). The wealth index is a composite measure of a household's cumulative living standard and is derived from readily available data on household ownership of specific assets, housing construction materials, and access to water and sanitation facilities [18]. The associations between covariates and reproductive health outcomes were not included in the tables to avoid deviation from the study's main objective. However, these relationships are well known to researchers [7, 26].

Data analysis

In the initial analyzes, hot-deck imputation was initially applied for nulliparous women with R software version 4.2.1, and principal component analysis was performed using Minitab 17 software. The descriptive characteristics of the women were summarized as frequency and percentage distributions. The chi-square test was used to examine the relationship between women's sociodemographic and reproductive characteristics and social independence quintiles (Additional file 2). Prevalence ratios and corresponding 95% confidence intervals (PRs, 95% CI) were estimated to explore the relationship between dependent variables and social independence quintiles using robust Poisson regression analysis with R. PRs are more interpretable than odds ratios from logistic regression and account for overdispersed variance [27]. PRs were adjusted by the woman’s age, household wealth quantiles, residence, and region. Statistical significance was accepted when p < 0.05 for all comparisons. All estimates were weighted using the weight variable provided by TDHS-2018.

Table 3 shows the sociodemographic and reproductive characteristics of the women surveyed. In the study, 1.2% of women were under 20 years old, and 35.1% were 40 years of age or older. In terms of the distribution of women’s household wealth index, 15.7% of women were in the poorest category, and 22.6% were in the wealthiest category. Most members of the study group resided in urban areas (77.7%) and in the western part of Turkey (43.5%). Approximately half (54.4%) of the women had one or two children, while 7.1% had no children and 7.4% had five or more children.

Table 3

The sociodemographic and reproductive characteristics of women
Variables	n	%
Age group (n = 4820)
15–19	56	1.2
20–24	411	8.5
25–29	737	15.3
30–34	923	19.1
35–39	1002	20.8
40–44	910	18.9
45–49	781	16.2
Wealth quintile (n = 4820)
Poorest	758	15.7
Poorer	914	19.0
Middle	994	20.6
Wealthier	1066	22.1
Wealthiest	1088	22.6
Place of residence (n = 4820)
Urban	3743	77.7
Rural	1076	22.3
Region (n = 4820)
West	2095	43.5
South	617	12.8
Central	1028	21.3
North	257	5.3
East	822	17.1
Total number of births (n = 4820)
None	342	7.1
1–2	2622	54.4
3–4	1501	31.1
≥ 5	356	7.4
Ideal number of children (n = 4820)
None	84	1.7
1–2	1857	38.5
3–4	2505	52.0
≥ 5	375	7.8
Woman’s ability to have the desired number of children (n = 2693)
Fewer	1242	46.1
Equal	951	35.3
More	502	18.6
Unplanned birth (n = 2002)
Wanted at that time	1443	72.1
Wanted later	214	10.7
Not wanted at all	345	17.2
Needs for modern family planning methods (n = 4820)
Met need	2356	48.9
Unmet need	1568	32.5
No need	896	18.6
Contraceptive category (n = 3358)
Couple methods	1921	57.2
Female-only methods	1437	42.8
Induced abortion (at least one) (n = 4820)
No	4117	85.4
Yes	703	14.6
Miscarriage (at least one) (n = 4820)
No	3732	77.4
Yes	1088	22.6

In the study, 1.7% of the women stated that the ideal number of children is zero, whereas 7.8% mentioned five or more children. Among women who were 35 years of age and older, 18.6% had more children than their desired number. Regarding births during the past five years, 27.9% were the result of unplanned pregnancies (wanted later or not at all). The percentage of unmet needs for modern family planning methods was 32.5%. The majority of women used couples-based contraceptive methods (57.2%). According to the study, 14.6% of women experienced at least one induced abortion, while 22.6% experienced at least one miscarriage (Table 3). A significant relationship was observed between social independence quintiles and all variables (Additional file 2).

Table 4 shows the relationship between reproductive health outcomes and the social independence quintiles. Lower quintile groups of social independence had more negative outcomes than higher quintile groups. The prevalence of having four or more births was as often as 16.0 times higher in the lowest quintile than in the highest quintile. Similarly, the lowest quintile group had a higher PR for having an ideal number of four or more children (PR = 1.9), having more than the desired number of children (PR = 5.7), and having an unplanned birth (PR = 2.3) than the highest quintile. The PRs of having induced abortions and miscarriages in the lowest quintile were approximately two times higher (PR = 1.9 and 1.7, respectively) than the PRs in the highest quintile. For nearly all variables, PRs for adverse reproductive health outcomes increased consistently and gradually when social independence quintiles decreased (Table 4).

Table 4

The relationship between the reproductive outcomes and social independence quintiles of women
		Social Independence Quintile
Dependent variables	n	Lowest %*	Lower %*	Middle %*	Higher %*	Highest %*
Total number of births
0–3 (ref)	4015	53.8	79.5	90.6	94.0	98.8
≥ 4	804	46.2	20.5	9.4	6.0	1.2
PR (95% CI)**		16.0 (7.2–25.3)	9.7 (4.3–15.1)	5.6 (2.4–8.7)	3.7 (1.5–5.8)	ref
Ideal number of children
0–3 (ref)	3323	53.0	64.2	70.9	73.3	83.6
≥ 4	1497	47.0	35.8	29.1	26.7	16.4
PR (95% CI)**		1.9 (1.6–2.2)	1.7 (1.4–1.9)	1.5 (1.2–1.7)	1.4 (1.2–1.7)	ref
Woman’s ability to have the desired number of children
Fewer or equal (ref)	2192	61.3	80.2	85.3	87.9	95.5
More	501	38.7	19.8	14.2	12.1	4.5
PR (95% CI)**		5.7 (3.3–8.1)	3.6 (1.9–4.8)	2.5 (1.4–3.6)	2.2 (1.2–3.2)	ref
Unplanned birth
Wanted at that time (ref)	1443	60.2	70.1	71.4	75.7	80.2
Unplanned (wanted later or not at all)	558	39.8	29.9	28.6	24.3	19.8
PR (95% CI)**		2.3 (1.6–2.9)	1.6 (1.2–2.1)	1.6 (1.2-2.0)	1.1 (0.8–1.4)	ref
Needs for modern family planning method
Met need (ref)	2356	54.8	61.4	58.3	60.9	65.3
Unmet need	1568	45.2	38.6	41.7	39.1	34.7
PR (95% CI)**		1.0 (0.9–1.1)	0.9 (0.8-1.0)	1.0 (0.9–1.2)	1.0 (0.9–1.2)	ref
Contraceptive category
Couple methods (ref)	1921	47.4	50.2	55.2	62.6	71.5
Female-only methods	1437	52.6	49.8	44.8	37.4	28.5
PR (95% CI)**		1.7 (1.4–1.9)	1.6 (1.4–1.9)	1.5 (1.2–1.7)	1.2 (1.0-1.4)	ref
Induced abortion (at least one)
No	4117	80.6	83.7	85.8	88.6	88.3
Yes	704	19.4	16.3	14.2	11.4	11.7
PR (95% CI)**		1.9 (1.5–2.4)	1.6 (1.3–2.1)	1.3 (1.1–1.7)	1.0 (0.7–1.2)	ref
Miscarriage (at least one)
No	3732	72.0	73.5	77.3	79.4	85.0
Yes	1087	28.0	26.5	22.7	20.6	15.0
PR (95% CI)**		1.7 (1.3-2.0)	1.7 (1.4-2.0)	1.5 (1.2–1.8)	1.3 (1.1–1.6)	ref
ref: Reference category Column percentage *Adjusted woman’s age, wealth index, region, and place of residence

The social independence of women was not statistically associated with the unmet need for modern family planning methods. However, the percentage of unmet needs for modern family planning methods increased as the social independence quintile decreased (Table 4).

Table 5 displays the distribution of family planning methods used by women across different social independence quintiles. The use of traditional methods, mainly withdrawal, was nearly 5% higher in the lower social independence quintiles than in the highest quintile. The use of IUDs and female sterilization was more prevalent in lower quintiles, while male condoms were more commonly used in higher quintiles (Table 5).

Table 5

Distribution of family planning methods used by women according to social independence quintiles
		Social Independence Quintile
		Lowest	Lower	Middle	Higher	Highest	Total
Family planning methods	n	%	%	%	%	%	%
Withdrawal	984	31.9	28.6	31.8	30.1	23.5	29.2
Male condom	919	15.3	21.3	23.4	31.5	45.8	27.3
Intrauterine device	660	23.6	23.7	20.1	16.8	13.4	19.6
Female sterilization	500	21.6	18.0	16.3	12.3	5.7	14.8
Pills	230	5.9	6.6	7.3	6.7	7.7	6.8
Injections	48	1.4	1.4	1.0	1.5	1.8	1.4
Periodic abstinence	19	0.0	0.0	0.1	0.9	1.8	0.6
Other traditional (folkloric methods)	8	0.3	0.4	0.0	0.3	0.2	0.2
Modern methods	2356	67.8	70.9	68.2	68.8	74.4	70.0
Traditional methods	1009	32.2	29.1	31.8	31.2	25.6	30.0
Total	3368	100.0	100.0	100.0	100.0	100.0	100.0

This study analyzed the relationship between the reproductive health outcomes of Turkish married women and their social independence based on the TDHS-2018 data. We define the social independence levels of Turkish women using a modified form based on the social independence domain of the SWPER Global Index, a standard composite measurement tool, and our findings highlight the critical importance of women's empowerment for improving reproductive health. The study reveal that as women's social independence decreases, reproductive health problems such as excess fertility, unplanned births, induced abortions, miscarriages, and failure to achieve fertility goals increase. These dose‒response relationships between social independence and reproductive health indicators imply that this relationship might be causal.

Items of the social independence domain of the SWPER index, such as women’s education, early marriage or childbearing, access to information (e.g., reading a newspaper or internet usage), age, and education differences between women and their husbands, may serve as gender-related barriers to achieving reproductive health goals [12]. These items might affect each other, possibly changing the state of reproductive health. For example, early marriages and early childbearing are more common among less educated women. More importantly, if women have weaknesses in multiple items, negative reproductive outcomes may be higher than those implied by their additive effects. The total completed years of schooling attained by women, which is a good indicator of women's status, represent women's access to a formal education. Education offers professional development, an occupation and/or a job, a stable income, better access to information and health services, and a better lifestyle for women. Educated women may have more opportunities to gain control over their fertility and reproductive decisions [26]. Education is also an important determinant of age at marriage. Early marriages, which are common in communities where more traditional norms and values are adopted, are another factor leading to early childbearing and an increase in the possibility of excessive fertility [28, 29]. Larger age and education differences between spouses mostly reflect male dominance in domestic power relations and gender inequalities, which in turn may affect reproductive health behaviors [11].

We found that women with lower social independence display worse reproductive health levels. Among the women in the lowest social independence quintiles, percentages of excess fertility, preferences toward excess fertility, having more children than the desired number, unmet need for modern family planning methods, and using female-only contraceptives are as high as nearly 50 percent. These negative outcomes are less common in higher social independence quintiles. For example, the percentages for excess fertility and having more children than the desired number are only 1.2% and 4.5%, respectively, for the women in the highest quintile. As a result of enormous differences in reproductive health indicators between different social independence groups, lower social independence quintiles have quite high-risk increases of unintended outcomes.

The strong relationship between low social independence and high fertility can be explained by women's fertility preferences. Girls who grow up in a family that has adopted a patriarchal social order define their roles as mothers and/or wives. Even women who grew up in a patriarchal society can defend the patriarchal social order, define themselves by their roles in domestic life, and describe their social functions as mothers and/or wives [30]. Having grown up in social groups with common gender inequalities, these women may argue that men are superior to women and that women should not benefit equally from opportunities such as education and employment. They may even tend to justify violence against women. In the TDHS-2018, women aged 15–49 were asked if they agreed that a husband is justified in hitting or beating his wife under the following five circumstances: she burns the food, she argues with him, she goes out without telling him, she neglects the children, and she refuses to have sex with him. Overall, 9% of women accepted at least one of these cases as a justification for physical violence [18]. The results related to excess fertility and unintended pregnancies for the women in lower social independence quintiles may be due to a lack of access to reproductive health services. Social norms and gender inequalities are often the root causes of health neglect among disadvantaged groups [31].

There are no reasonable differences in terms of unmet needs for family planning across social independence groups based on survey data collection time. However, women in the highest empowerment group might have better access to family planning services during their lifetime than women in lower empowerment groups since they have less excess fertility and fewer unintended pregnancies. Current data also indicate that higher social independence groups more commonly utilize couples-based contraceptive methods and abortion services. Induced abortions indirectly depict the quality of family planning services. Induced abortions are common in cases where family planning services are not accessible, or consultations and follow-ups are not delivered effectively. We may have found a nonsignificant relationship between social independence and the unmet need for modern contraceptive methods in this study due to the multidimensional and complex nature of the concept of empowerment. Attitudes toward violence and the decision-making domains of SWPER are reported as significant determinants of modern contraceptive usage [10]. Longitudinal studies, including other dimensions of empowerment, are needed to better understand the relationship between contraceptive use, the unmet need for family planning and empowerment.

The empowerment of women causes an enormous change in gender relations and women’s roles in the family and society. These changes can improve a couple’s ability to make decisions together by increasing the participation of men in family planning services. This study implies that women in higher social independence quintiles prefer couples-based family planning methods by cooperating better with their husbands due to their higher education levels as well as the less-pronounced difference in either age or education. Among the couples methods, the male condom is more prevalent in the higher quintiles, while withdrawal, which is the least effective family planning method [32] is more common in the lower quintiles. Once the women in lower social independence groups experience undesirable fertility-related consequences (excess fertility, unplanned births, pregnancies resulting in abortion and miscarriage, and failure to reach fertility goals), they are likely to turn to female-only methods that do not require spousal cooperation. Ideally, couples should be able to make decisions together not only in reproductive health but also in all areas of life. In Pakistan, Hameed et al. (2014) found that there is not a significant relationship between utilizing couples-based methods and the empowerment of women in household decision-making, physical mobility, and economic decisions. However, they found that couples-based methods are more common when the couples have the habit of making their decisions together [8].

Limitations

Our study has some limitations. First, because the analyses of the study were based on cross-sectional data, cause-and-effect relationships are not quite clear. Thus, the data do not yield any temporal relationships between women’s empowerment and reproductive health outcomes. Longitudinal studies are needed to better understand the women's empowerment process and causal mechanisms as well as to determine the impact of social independence on reproductive health outcomes and other empowerment components. The second limitation is that the analyses only include the social independence domain of the SWPER Global Index, and the dimensions of attitude toward violence and decision-making cannot be evaluated. Further studies on the impact of other dimensions of empowerment on reproductive health outcomes are needed. Another limitation is that four of the eight items used in the summary measurement of social independence are only for currently married women, so the analyses are limited to this study group. Therefore, the results of the study can only be generalized to married women. Despite these limitations, our study clearly demonstrates the strong relationship between reproductive health outcomes and women's social independence.

The study results show that women who are within low social independence quintiles have a significant disadvantage in terms of excess fertility, unplanned births, pregnancies resulting in abortion and miscarriage, and failure to reach fertility goals. In addition, women with low social independence prefer contraception methods that put the burden on the woman. The women in the highest quintile have the best outcomes in all reproductive health outcomes. There is a dose‒response relationship between women’s social independence and reproductive health outcomes. These results suggest that women's empowerment is necessary for long-term gains in reproductive health. In the short term, reproductive health services should be strengthened for women in lower social independence quintiles. Interventions to be planned in this area should go beyond the health sector by addressing structural inequalities and the social determinants of health. The social independence measurement used in this study, together with the two variables added to the social independence domain of the SWPER Global Index, has serious potential for directing research and action plans for women's empowerment in Turkey.

CI: Confidence interval

DHS: Demographic and health survey

ICPD: International Conference on Population and Development

IUD: Intrauterine device

PR: Prevalence ratio

SWPER: The survey-based women's empowerment

TDHS-2018: The 2018 Turkey Demographic and Health Survey

Ethics approval and consent to participate

Ethical approval for the collection of TDHS-2018 data was granted by the Hacettepe University Ethics Commission to the Hacettepe University Institute of Population Studies, which carried out the survey. The dataset analyzed in this study was anonymized and made publicly available. Permission for the use of data was obtained through the website of the Hacettepe University Institute of Population Studies (https://hips.hacettepe.edu.tr/en/menu/demographic_and_health_survey_serie-101).

Consent for publication

Not applicable

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The study received no specific grant from any funding agency in the public, private, or not-for-profit sectors.

Authors' contributions

RÖ and GDH conceptualized and contributed to the design of the study. RÖ analyzed the data. RÖ and GDH interpreted the results. RÖ wrote the first draft of the manuscript, with contributions from GDH. Both authors critically revised and approved the final manuscript.

Acknowledgements

We would like to thank Prof. Aluisio J D Barros for his contribution to modifying the social independence domain of SWPER Global Index and for valuable feedback.

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No competing interests reported.

Additionalfiles.docx

Is women’s social independence a strong determinant for the reproductive health-related outcomes of the Turkish population?

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Abstract

Background

Methods

Results

Conclusion

Background

Methods

Data source

Measures

Dependent variables

Explanatory variable

Potential confounders

Data analysis

Results

Discussion

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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