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/v2

There is growing recognition of the importance of women's empowerment in achieving reproductive health goals. This study examined the relationships between various reproductive health outcomes and social independence using data from the 2018 Turkey Demographic and Health Survey. Social independence was measured by a modified form of the Survey-based Women's Empowerment (SWPER) Global Index's social independence domain. Adjusted prevalence ratios were calculated for the eight dependent variables by social independence quintiles. A total of 5,156 married women were analyzed. In the lower social independence quintiles, the prevalence ratios for having four or more births, having more children than the desired number, having an unwanted birth, using female-only contraceptive methods, induced abortions, and miscarriages were significantly higher than in the highest quintile. The study emphasizes the necessity of integrating women's empowerment into reproductive health policies by providing evidence that women's social independence is a strong predictor of numerous reproductive health outcomes.

Demographic health survey

Reproductive health

Social independence

Women’s empowerment

Turkey

Reproductive health is a state of complete physical, mental, and social well-being, beyond the mere absence of disease or infirmity, in all aspects of the reproductive system.¹ The unequal distribution of power between genders has a profound and pervasive impact on women’s lives, including their reproductive health, across a range of social, economic, and political contexts.² Promoting gender equality and women's empowerment is widely recognized as a pivotal pathway for advancing sustainable development and enhancing women's reproductive health outcomes. The fifth Sustainable Development Goal of the United Nations calls for achieving gender equality and empowering all women and girls, and Target 5.6 focuses on sexual and reproductive health and rights.³ Understanding the relationship between women's empowerment and reproductive health outcomes is critical for assessing progress toward Sustainable Development Goal 5 and formulating effective interventions to improve women’s reproductive health.

A substantial body of research on different aspects of empowerment shows a close link with reproductive health indicators such as fertility preferences,^4-6 contraceptive usage,^7-10 birth spacing,⁴ unintended pregnancy rates,⁴ maternal care,⁸ institutional delivery, and skilled birth attendance.⁹ However, due to the complex and multifaceted nature of empowerment, there are considerable variations in the conceptualization and measurement of empowerment across these studies,¹¹ thereby complicating comparisons between studies. To address the need for a standard tool to measure empowerment, the Survey-based Women's Empowerment (SWPER) index was developed using individual-level data from demographic and health surveys (DHSs). This index was initially developed for use in African countries¹² and subsequently extended to low- and middle-income countries, named SWPER Global.¹³ The preliminary studies indicate strong associations between the SWPER index’s domains (social independence, decision-making, and attitudes toward violence) and several reproductive and child health outcomes. Relationships have been identified between the social independence domain and childhood immunization coverage,^14,15 child nutrition outcomes (stunting,wasting, and underweight),¹⁶ maternal healthcare utilization,^17,18 institutional deliveries,¹² and the ideal number of children.¹⁹ Similarly, associations have been found between attitudes toward violence and modern contraceptive use,¹² the ideal number of children, and the ability to have the desired number of children.¹⁹ Additionally, studies have linked the decision-making domain to modern contraceptive use,¹² skilled birth attendance, postnatal care,¹⁸ the ideal number of children, the ability to have the desired number of children,¹⁹ and child nutrition outcomes.¹⁶ A recent study observed a positive correlation between the three dimensions of SWPER, particularly the social independence domain, and the composite coverage index (a summary measure of universal health coverage in reproductive, maternal, newborn and child health) scores of 62 countries.²⁰

A variety of studies have demonstrated the relationship between the socioeconomic status of Turkish women and some reproductive health indicators, such as contraceptive use,²¹ maternal health service utilization,²² fertility preferences, and rates of spontaneous and induced abortions.²³ However, to our knowledge, no study has examined the relationship between reproductive health outcomes and empowerment using a composite measurement tool at the national level in Turkey. The present study aimed to examine the relationship between several reproductive health outcomes and women's empowerment in terms of social independence, using data from the 2018 Turkey Demographic and Health Survey (TDHS-2018). For this purpose, we modified the social independence domain of the SWPER Global Index. This modified measurement tool has the potential to inform future research and contribute to efforts to empower women in Turkey. Additionally, this study will contribute to the existing evidence base in this area by providing a comprehensive evaluation encompassing a multitude of reproductive health outcomes.

Data source

This study utilized data from the TDHS-2018, a nationally representative, household-based survey conducted every five years. The TDHS-2018 conducted interviews with 7,345 women aged 15–49 using a standard DHS questionnaire. We analyzed data from currently married women (n = 5,156) in this study. To ensure the representativeness of the sample, all analyses were weighted. As a result, the tables show a total of 4,820 currently married women.

Dependent variables

The study included eight dependent variables, as described below. Table 1 also shows the classification of these variables and the number of women examined for each variable.

1) Total number of births: It describes the total number of children ever born to women.

2) Ideal number of children: This refers to the number of children women desire to have, regardless of their current family size. In cases where women provided non-numerical responses regarding their ideal number of children (n = 30), the mean ideal number of children (3.0) was assigned.^6,24

3) Having more children than the desired number: This variable indicates the difference between the woman's actual number of living children and her ideal number of children. It was calculated by subtracting the ideal number of children from the number of living children. If the difference was greater than zero, the woman was regarded as having more children than her desired number. Given that younger women are less likely to achieve their fertility goals, only married women aged 35 and above were included in the analysis.^6,24

4) Unwanted birth: This variable was used to determine whether the most recent child born within the previous five years was wanted or unwanted (wanted later or not wanted at all).

5. Demand for family planning satisfied with modern methods: This variable refers to the proportion of women using modern contraceptive methods compared to the total number of women with a demand for family planning (the sum of women with unmet needs for family planning and women using any method).²⁵

6) Contraceptive category: Contraceptive methods were divided into female-only methods (female sterilization, pills, injectables, intrauterine devices and implants) and couple methods (condoms, withdrawal and periodic abstinence). The main distinction between the two categories is that couple methods necessitate a certain level of awareness, support, involvement, or cooperation from the husband.²⁶

7) Induced abortion: It refers to whether the woman has ever had a pregnancy terminated by induced abortion.

8) Miscarriage: It refers to whether the woman has ever had a pregnancy terminated by miscarriage.

Table 1. The classification of the dependent variables and the number of women analyzed in the study

Dependent variables	Classification	Study population (weighted)
1. Total number of births	0-3; ≥ 4	Currently married women (n=4820)
2. Ideal number of children	0-3; ≥ 4	Currently married women (n=4820)
3. Having more children than the desired number	Yes; No	Currently married women aged ≥35 (n=2693)
4. Unwanted birth	Wanted at that time; Wanted later; Not wanted at all	Women who gave birth to a child in the last five years (n= 2002)
5. Demand for family planning satisfied with modern methods	Yes; No	The total number of women with a demand for family planning (n= 3924)
6. Contraceptive category	Couple methods; Female-only methods	Married women currently using any contraceptive method (n= 3358)*
7. Induced abortion (at least one)	Yes; No	Currently married women (n=4820)
8. Miscarriage (at least one)	Yes; No	Currently married women (n=4820)

* Women using the folkloric method (n= 8) were not included.

Explanatory variable

The study's main independent variable was women's social independence, which was measured using the SWPER Global Index. The SWPER index has three domains: 1) attitudes toward violence, 2) decision-making, and 3) social independence. We excluded the attitudes toward violence domain because a relatively low proportion of women (approximately 10%) endorsed statements about violence in the TDHS-2018. We also excluded the decision-making domain because the TDHS-2018 only asked questions about one of its three items. As a result, we included the social independence domain, as the TDHS-2018 encompassed all items within it. The original social independence domain comprises six items designed to identify the prerequisites for women to achieve their goals and the components that contribute to agency and autonomy. We found 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. Subsequently, we decided to use the modified form, adding these two items (Table 2). In the TDHS-2008, 7.1% of currently married women had never given birth. Their age at first birth was imputed through hot-deck imputation.¹² Principal component analysis was employed to estimate the factor loadings of the items, and individual standardized scores were calculated accordingly (Supplementary file 1). Social independence scores were divided into quintiles, with the lowest 20% of scores representing the least empowered women and the highest 20% representing the most empowered women.

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; less than once a week = 1; at least once a week and more = 2	Not at all = 0; less than once a week = 1; at least once a week and more = 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 to spend by herself	-	No= 0, Yes= 1

Covariates

These variables included women's age, place of residence (rural/urban), region (west, south, central, north, east), and household wealth categories (poorest, poorer, middle, wealthier, wealthiest). To maintain focus on the study's primary objective, we excluded the associations between these variables and reproductive health outcomes from the tables.

Data analysis

In the preliminary analyses, hot-deck imputation was initially applied for nulliparous women using R software, version 4.2.1. Principal component analysis was utilized to estimate the factor loadings of the items and individual standardized scores using Minitab 17 software. Chi-squared tests were used to compare the proportion of reproductive outcomes by social independence quintiles. 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 software. PRs were adjusted by the woman’s age, place of residence, region, and household wealth quantiles. The statistical significance of the results was accepted when p < 0.05 for all comparisons. All estimates were weighted using the weight variable provided by the TDHS-2018.

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

In the study, 1.2% of women were under the age of 20, and 35.1% were 40 years of age or older. According to the household wealth categories, 15.7% of women were in the poorest group, and 22.6% were in the wealthiest group. The majority of women were located in urban areas (77.7%) and in the western part of Turkey (43.5%) (Table 3).

Table 3. The descriptive characteristics of women

Variables	n	%
Age group
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
Household wealth category
Poorest	758	15.7
Poorer	914	19.0
Middle	994	20.6
Wealthier	1066	22.1
Wealthiest	1088	22.6
Place of residence
Urban	3743	77.7
Rural	1076	22.3
Region
West	2095	43.5
South	617	12.8
Central	1028	21.3
North	257	5.3
East	822	17.1
Total	4820	100.0

Table 4 shows the frequency of women's reproductive outcomes and their distribution across social independence quintiles. A total of 16.7% of women had given birth to four or more children. This proportion increased with a decreasing social independence quintile, from 1.2% in the highest quintile to 46.2% in the lowest quintile (p < 0.001). Almost a third (31.0%) of women had an ideal number of four or more children. As the level of social independence increased, the ideal number of children decreased (p < 0.001). Among women aged 35 and over, 18.6% had more children than they desired. This proportion was 4.5% in the highest quintile but increased to 38.7% in the lowest quintile (p < 0.001). During the preceding five-year period, a total of 27.9% of the most recent births were either unwanted at the time of birth or not at all. There was an inverse association between social independence levels and unwanted birth proportions (p < 0.001). The study found that 60% of women in need of family planning use modern contraceptives, with 54.8% and 65.3% in the lowest and highest social independence quintiles, respectively (p = 0.001). Most women (57.2%) utilized couple-based contraceptive methods. As social independence levels increased, these methods became increasingly preferred (p < 0.001). A total of 14.6% of women had experienced at least one induced abortion, while 22.6% had experienced at least one miscarriage. Similarly, the proportions of induced abortions and miscarriages decreased as social independence levels increased (p < 0.001) (Table 4).

Table 3. Frequency of women's reproductive outcomes and their distribution across social independence quintiles.

Dependent variables	Total		Social Independence Quintile					Chi-square test
	Total		Lowest	Lower	Middle	Higher	Highest
	n*	%**	%**	%**	%**	%**	%**
Total number of births (n= 4820)
0-3	4016	83.3	53.8	79.5	90.6	94.0	98.8	χ² = 893.294
≥4	804	16.7	46.2	20.5	9.4	6.0	1.2	p < 0.001
Ideal number of children (n= 4820)
0-3	3323	69.0	53.0	64.2	70.9	73.3	83.6	χ² = 231.557
≥4	1497	31.0	47.0	35.8	29.1	26.7	16.4	p < 0.001
Having more children than the desired number (n= 2693)
Yes	501	18.6	38.7	19.8	14.2	12.1	4.5	χ² = 248.564
No	2192	81.4	61.3	80.2	85.8	87.9	95.5	p < 0.001
Unwanted birth (n= 2002)
Wanted at that time	1443	72.1	60.2	70.1	71.2	75.7	80.2	χ² = 78.842
Wanted later	214	10.7	9.5	10.5	12.2	8.8	12.4	p < 0.001
Not wanted at all	345	17.2	30.3	19.4	16.6	15.5	7.4
Demand for family planning satisfied with modern methods (n= 3924)
Yes	2356	60.0	54.8	61.4	58.3	60.9	65.3	χ² = 19.496
No	1568	40.0	45.2	38.6	41.7	39.1	34.7	p = 0.001
Contraceptive category (n= 3358)
Couple methods	1921	57.2	47.4	50.2	55.2	62.6	71.5	χ² = 102.661
Female-only methods	1437	42.8	52.6	49.8	44.8	37.4	28.5	p < 0.001
Induced abortion (at least one) (n= 4820)
Yes	703	14.6	19.4	16.3	14.2	11.4	11.7	χ² = 34.261
No	4117	85.4	80.6	83.7	85.8	88.6	88.3	p < 0.001
Miscarriage (at least one) (n= 4820)
Yes	1088	22.6	28.0	26.5	22.7	20.6	15.0	χ² = 58.403
No	3732	77.4	72.0	73.5	77.3	79.4	85.0	p < 0.001

*Weighted number of women **Column percentage

For almost all variables, the PRs for adverse reproductive health outcomes demonstrated a consistent and gradual increase as social independence quintiles decreased. In the lowest quintile, the prevalence of having four or more births was up to 16.0 times higher than in the highest quintile. Similarly, the lowest quintile had higher PRs for having an ideal number of four or more children (PR = 1.9), having a greater number of children than the desired number (PR = 5.7), and having an unwanted birth (PR = 2.3) compared to the highest quintile. The PRs for induced abortion and miscarriage in the lowest quintile were about twice as high (PR=1.9 and 1.7, respectively) as those in the highest quintile. The demand for family planning satisfied by modern methods was the only variable whose PRs were not significant by social independence quintiles (Table 4).

Table 4. Prevalence ratios of reproductive outcomes by social independence quintiles

	Social Independence Quintile
Dependent variables	Lowest	Lower	Middle	Higher	Highest
	PR (95% CI)	PR (95% CI)	PR (95% CI)	PR (95% CI)	ref
Total number of births
0-3 (ref)	1,0	1,0	1,0	1,0
≥4	16.0 (7.2-25.3)	9.7 (4.3-15.1)	5.6 (2.4-8.7)	3.7 (1.5-5.8)	1.0
Ideal number of children
0-3 (ref)	1.0	1.0	1.0	1.0
≥4	1.9 (1.6-2.2)	1.7 (1.4-1.9)	1.5 (1.2-1.7)	1.4 (1.2-1.7)	1.0
Having more children than the desired number
No (ref)	1.0	1.0	1.0	1.0
Yes	5.7 (3.3-8.1)	3.6 (1.9-4.8)	2.5 (1.4-3.6)	2.2 (1.2-3.2)	1.0
Unwanted birth
Wanted at that time (ref)	1.0	1.0	1.0	1.0
Unplanned (wanted later or not at all)	2.3 (1.6-2.9)	1.6 (1.2-2.1)	1.6 (1.2-2.0)	1.1 (0.8-1.4)	1.0
Demand for family planning satisfied with modern methods
Yes (ref)	1.0	1.0	1.0	1.0
No	0.99 (0.9-1.1)	0.9 (0.8-1.0)	1.0 (0.9-1.2)	1.0 (0.9-1.2)	1.0
Contraceptive category
Couple methods (ref)	1.0	1.0	1.0	1.0
Female-only methods	1.7 (1.4-1.9)	1.6 (1.4-1.9)	1.5 (1.2-1.7)	1.2 (1.0-1.4)	1.0
Induced abortion (at least one)
No (ref)	1.0	1.0	1.0	1.0
Yes	1.9 (1.5-2.4)	1.6 (1.3-2.1)	1.3 (1.1-1.7)	1.0 (0.7-1.2)	1.0
Miscarriage (at least one)
No (ref)	1.0	1.0	1.0	1.0
Yes	1.7 (1.3-2.0)	1.7 (1.4-2.0)	1.5 (1.2-1.8)	1.3 (1.1-1.6)	1.0

PR: Prevalence ratio adjusted for woman’s age, wealth index, region, and place of residence ref: Reference category

This study analyzed the relationship between the reproductive health outcomes of married women and their social independence based on the TDHS-2018 data. The study provided a standard measure of Turkish women’s empowerment using a modified form of the social independence domain of the SWPER Global Index, which includes items reflecting gender-related barriers to achieving reproductive health goals. The study’s results indicated that higher social independence levels for women were strongly associated with a reduced prevalence of poor reproductive health outcomes. These findings underscore the importance of achieving gender equality and women's empowerment as a means of simultaneously overcoming many reproductive health problems.

This study showed that women with lower empowerment levels had a high prevalence of unintended outcomes related to excess fertility, as reported in previous studies that used different empowerment measurements.^4-6,19,24,27 Compared with the highest social independence quintile, the PRs in the lowest quintile increased to 16.0 for four or more births, 2.3 for unwanted births, 5.7 for not having the desired number of children, 1.9 for induced abortions, and 1.7 for miscarriages. In addition, the ideal number of children gradually increased as social independence levels decreased. The tendency for excess fertility among women with lower social independence levels may be linked to the heightened adoption of patriarchal ideologies that promote early marriages and high fertility among these women. Lower social independence levels mean poorer access to formal education, younger marriage and childbearing, larger age and education gaps with spouses, less access to information, and greater economic dependence on spouses. All of these disadvantages are common characteristics of women living in male-dominated patriarchal societies. The cultural and social values society places on femininity and motherhood may have a greater influence on women growing up in such social structures, leading them to internalize these values and shape their preferences for excess fertility. These women can define themselves by their roles in domestic life and describe their social functions as mothers or wives.²⁸ Despite notable progress in the status of women in Turkey since the establishment of the Republic, a considerable influence of Islamic patriarchal elements persists in society.²⁹ Furthermore, the current government policies that emphasize women’s traditional roles serve to exacerbate existing gender inequalities, which poses a threat to women’s reproductive health and rights.³⁰

The higher prevalence of unfavorable outcomes among women with lower social independence may also indicate inadequate access to comprehensive reproductive health services throughout their lifespans in comparison to women in the highest empowerment quintile. The study demonstrated that there were no significant differences in the PRs of demand for family planning satisfied with modern methods across social independence quintiles. However, the elevated prevalence of unwanted births and induced abortions may suggest that unempowered women lack sufficient access to family planning services throughout their lives. The cross-sectional nature of the data analyzed in this study does not allow for a full explanation of these causal relationships. It's also possible that the Poisson regression analysis didn't find a significant relationship between the demand for family planning satisfied with modern methods and the social independence quintiles due to the multidimensional and complex nature of empowerment. The prior study demonstrated a link between modern contraceptive usage and the SWPER index's attitudes toward violence and decision-making domains.⁵

Women's empowerment brings about enormous changes 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 men's participation in family planning services. This study showed that women in higher social independence quintiles were more likely to prefer couple-based contraceptive methods, which reflect spousal cooperation in contraception. Couple methods include traditional methods that have limited contraceptive effects, including withdrawal and periodic abstinence. However, as seen in Table S2, the lower social independence quintiles utilized the withdrawal method at a roughly 7% higher proportion compared to the highest quintile. The utilization of long-acting and permanent modern contraceptive methods, including intrauterine devices and female sterilization, was more prevalent in lower empowerment quintiles, while higher quintiles were more likely to use male condoms (Supplementary file 2). These findings may suggest that women with lower social independence may be turning to long-acting and permanent female-only contraceptive methods that do not necessitate spousal involvement because they have either achieved or even surpassed their desired number of children. Female-only contraceptives are effective methods promoted by family planning programs, but they also reflect that the primary responsibility for contraception falls on women. Ideally, couples should be able to make decisions together in family planning and all aspects of their lives. In Pakistan, a study found that empowerment measures for couples' joint decision-making are a significant determinant of contraceptive use, particularly in favor of couple methods.²⁶

Limitations

Our study has some limitations. Firstly, the study's analyses, which relied on cross-sectional data, cannot prove causality. A second limitation is that the analysis included the social independence domain of the SWPER Global Index; thus, the dimensions of attitude toward violence and decision-making remain unexamined. Finally, the study's results can only be generalized to currently married women, as four of the eight items used to measure social independence were only suitable for these women.

This study clearly demonstrates the strong relationship between women's reproductive health outcomes and their social independence levels. Women in the lower social independence quintiles had a significant disadvantage in various reproductive health outcomes, including excess fertility, unwanted births, pregnancies resulting in induced abortion and miscarriage, failure to reach fertility goals, and assuming sole responsibility for birth control. In contrast, women in the highest social independence quintile had the best outcomes for all examined variables. These results suggest that women's empowerment is necessary for long-term gains in reproductive health. To achieve this, planned interventions must extend beyond the health sector to address the underlying structural inequalities and social determinants of health. In the short term, reproductive health services should be strengthened for women with lower empowerment levels. We need longitudinal studies that include all dimensions of the SWPER Global Index to gain further insight into the causal relationship between women's empowerment and reproductive health.

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The authors declare no competing interests.

SupplementaryMaterial.docx

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

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Abstract

Introduction

Methods

Results

Discussion

Conclusion

References

Additional Declarations

Supplementary Files

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