To our knowledge, this is the first study to explore the impact of women’s empowerment on mDFPS, both within marital relationships and in communities in Burkina Faso. As expected, the proportion of mDFPS was suboptimal among MWRA; however, in addition to conventional approaches such as improving accessibility to health services, progress can be made by empowering women and promoting gender equality. Meanwhile, in communities, promoting women’s access to productive means (assets and family planning information) rather than emphasizing reproductive roles (high fertility expectations) may also increase the mDFPS. One finding that was incompatible with the general description above was that living in communities with a higher prevalence of female genital mutilation was associated with increased odds of mDFPS.
Suboptimal demand for family planning satisfied with modern methods
Less than one-third of MWRA who had family planning needs were able to use modern methods. In Burkina Faso, Choi et al. [15] found 40% of mDFPS, but the pace of the growth was three times slower than that required to reach 75% by 2030.
Substantial effect of women’s agency on mDFPS
Similar to previous research, we found that participation in household decision-making, a lack of problems accessing healthcare, and negative attitudes toward domestic violence constituted separate components of women’s agency [33, 41]. Moreover, the variables for each component were fairly consistent within our study population. In addition, three-fifths of the MWRA either were able to participate in household decisions or held negative views on domestic violence, while only one-fifth had no problems accessing healthcare. According to Wayack-Pambe, few married women in Burkina Faso are empowered; only 59% of them participate in decision-making, while 61% live under psychological pressure [42]. Furthermore, we found that the odds of mDFPS increased with the presence of each component of women’s agency, especially the freedom to access healthcare. The associations between women’s agency and contraception have been studied fairly extensively and seem to be mostly positive [35, 36]. However, no study has systematically accounted for the dimensionalities and consistency of indicators of agency as related to mDFPS. Considering these parameters in our study not only strengthened the results but also revealed the struggle that MWRA have undergone to avoid unintended pregnancies. In addition, our study may have identified freedom in accessing healthcare as a contextually salient component in the relationship of women’s agency with mDFPS. However, previous conceptualizations of empowerment have considered women’s freedom of movement to be unlimited in the sub-Saharan African context [43, 44]. In fact, heath-seeking behavior is not trivial for married women, as it requires financial independence and more equal spousal power dynamics. In Burkina Faso, previous research found that married women with home ownership or bargaining power were more likely to meet their healthcare needs that were less obvious to husbands, including contraception [19, 45]. It should be noted that these components of agency are also influenced by levels of inequality in communities [42].
Adding community-level of gender equality reduced the influence of women’s agency on mDFPS especially participation in household decision-making and attitudes toward domestic violence. Previous research suggested that in communities that emphasized on traditional gender norms and relationships, perceived benefit gained from using family planning diminish [46]. In fact, it is possible that women who participate in household decisions and have equitable gender norms may more carefully consider, beyond the health risks, the social costs of losing their independence due to modern contraceptive adoption. In contrast, the lack of significant reduction on the effect of women’s access to healthcare may indicate that there is a weaker control of community gender norms and relationships on women’s health seeking behavior [47]. Conversely, Yaya et al. found in sub-Saharan Africa that women who have high decision making power and medium acceptance of wife beating still have increased odds of ever use of contraception, after controlling for community and country levels of socioeconomic factors [26]. However, the authors focused on past experience of contraception regardless of the type of methods. This approach may have overlooked the effects of contraceptive past experience on the process of empowerment. In addition, seeking modern and traditional methods of contraception may involve different levels of empowerment. Furthermore, our findings emphasized on the need to consider the effects of gender equality in communities rather than that of crude socioeconomic factors in relation with modern contraceptive use.
Beneficial effects of gender equality in communities on mDFPS
Consistent with socioecological theories, community-level gender inequality also shaped mDFPS. Previous studies found that discrimination against women negatively impacted modern contraceptive use, while greater opportunity for women had the opposite effect [10, 27, 28]. We found substantial variation in mDFPS across communities. Women in communities with higher fertility expectations were significantly less likely to address their family planning needs with modern methods. This finding points to African pronatalism as the most common and salient obstacle to modern contraception, as it prioritizes women’s reproductive roles and denies women the choice to limit their fertility [9, 48]. Through social conformity, women may adhere to the prevailing fertility expectations and refrain from using modern contraceptives.
Furthermore, women may conform to the prevailing fertility norms to gain social approval and avoid violence. Consistent with previous research, we did not find significant relationship between violence justification at the community level and modern contraceptive use [10]. Despite an overall negative association between acceptance of domestic violence and modern contraceptive use in African communities, within countries disparities may still exist [9]. In fact, the impact of both acceptance and experience of violence on women’s contraceptive behavior is complex to capture due to stigma which may lead to under-reporting. Further work is needed to develop tools that can capture specific and reliable elements of violence in communities.
Unexpectedly, a higher practice of female genital mutilation in the community was positively associated with the use of modern contraception. We ruled out the possibility of the ecological fallacy (Additional file 3) by controlling for individual-level genital mutilation status. As female genital mutilation is seen as an indicator of the violation of women’s rights, we expected to find a negative association with modern contraception [49]. Although the practice of female genital mutilation is discriminatory against women, women may have undergone the procedure as an act of conformity, and there is even a sense of pride in the practice in many African societies, including Burkina Faso [50, 51]. Therefore, female genital mutilation may not necessarily deter a household from using modern contraceptives. On the other hand, it is possible that in communities where the practice of female genital mutilation is widespread, the complications of pregnancies and childbirths are better understood and may have encouraged women to adopt more effective contraceptive measures [52]. Further research is required to examine the impact of other community-level influences that may mediate the association between female genital mutilation and modern contraceptive use.
Unsurprisingly, our findings on the association between community-level access to rights and resources for women and mDFPS were consistent with the current literature [9, 10, 27]. In particular, we found that greater access to assets and exposure to family planning messages in the community was also associated with higher odds of mDFPS. Our results indicate independent effects of community-level rights and opportunities for women as well as violence and discrimination against women on mDFPS. Therefore, the expansion of mDFPS should take into account both community factors, such as political changes, and cultural barriers regarding gender equality [53]. In addition, women’s access to rights and resources relative to those of men should also be considered. In fact, an increased male-to-female ratio may reflect higher gender inequality and privileging of the reproductive over the productive roles of women [27].
Limitations and strengths
This study used a socioecological framework, a systematic analytical strategy, and rigorous statistical methods to assess mDFPS and its link to women’s empowerment. Nonetheless, we acknowledge several limitations. Due to a lack of data, we were unable to control for the community-level of access to family planning, which remains unexplained. Additionally, most of the empowerment indicators in the DHS questionnaire were developed in South Asia [54]. Therefore, the empowerment indicators may not adequately reflect the Burkina Faso context. Future research may examine ethnographic evidence and use more appropriate variables. However, our results are consistent with those of previous studies in a similar context. Moreover, as a cross-sectional study, this analysis does not support any inferences about causality in the relation between women’s empowerment and modern contraceptive use. A longitudinal study may enhance our understanding of the dynamic interactions between the dimensions of empowerment and socioeconomic factors. Last, community-derived gender inequality indicators are based on physical boundaries, which may not fully represent the concept of community in terms of sociocultural entity [55].
Despite the limitations, this study also has strengths. First and foremost, the nationwide survey with representative sampling allowed multilevel analyses, which provided a more comprehensive outline for understanding the influence of gender inequality on women’s reproductive behavior, especially in resource-constrained countries. This study conceptualized power dynamics at multiple levels and further identified multiple and relevant components of women’s agency in the Burkina Faso context. Such results could be useful in the future conceptualization, measurement and interpretation of empowerment. As the study population was limited to those with some interest in family planning per the selection criteria, we might have neglected the need for family planning in the non-selected sub-population. We therefore compared woman’s agency, empowerment and socioeconomic indicators between the selected and non-selected groups (Additional file 4). We found that non-selected married women of reproductive age reported significantly lower levels of participation in household decision-making, freedom in accessing healthcare and opposition of domestic violence. Moreover, we also found significantly higher proportion of non-selected women living in communities with high levels of acceptance of domestic violence, early marriage, female genital mutilation, unpaid work and fertility expectations. In contrast, non-selected women more frequently lived in communities with low levels of secondary education, and exposure to family planning messages. Women in the non-selected group were also significantly poorer, younger, less educated and more concentrated in rural areas. It is possible that these women had not perceived family planning as desirable or possible, and therefore the need for empowering women and promoting gender equality may be greater than the results of this study suggest. Last, this study provided insight into the need to adopt a multilevel and comprehensive approach to addressing socioeconomic development, gender inequality and sexual and reproductive rights.