This study is the first to investigate the association between women’s autonomy and modern contraception use among partnered women in Zambia. Of the 6727 partnered women analysed in this study, only 8.8% of women were currently using a modern method of contraception. Women with moderate and high autonomy levels were significantly associated with modern contraception use, although over 70% had low levels of autonomy. Other factors related to increased modern contraception use included increased level of education, age and increased wealth. Our result differs from the 2018 ZDHS report, where modern contraception use was reported to be 43%. The difference between our findings and the ZDHS findings could be due to the differing variables used in the data analysis. Nevertheless, both results obtained are still lower than the set target of 50% as stipulated in the 2017 National Health Strategic Plan [3, 4].
Other studies evaluating women’s autonomy and modern contraception use have similarly used demographic health surveys to explore this question [10, 18,19,20]. Women with high or moderate autonomy were more likely to be assertive enough to make independent choices regarding modern contraception than those with low autonomy [15, 21, 22]. In reaching women’s autonomy and level of education, women’s autonomy could bear more influence on contraception use, as seen from a Pakistan study which found that women’s decision-making autonomy was more significantly associated with contraception use than education [16]. Other cultural factors, such as those that promote men as heads of relationships, may influence decision-making in women who are educated [23,24,25]. All these issues are essential indicators of gender equality and are women’s rights issues [26].
Formal education improves women’s understanding of sexual and reproductive health, including modern contraception use and women’s decision-making, as was found in another study in Zambia [10]. However, most women in Zambia still do not have formal education, which can partly explain the low contraception use among partnered women [19]. Age was another feature associated with contraception use and reflects findings reported in similar studies [20]. Like other sub-Saharan African countries, Zambia has a lower fertility age; the median age at first birth in Zambia is 19.2 among those aged between 20 and 49 [4]. Desire to delay pregnancy owing to younger age and to wanting a longer birth interval could be additional factors as to why modern contraception use was higher among younger women. Wealthy women were more likely to report modern contraception use than those in the poorest category; this result is similar to findings from studies undertaken in Ghana, which showed wealthy women had a higher likelihood of using modern contraceptives [21, 22, 31, 32]. The poverty level in Zambia stands at 88%, with about 60% of its population living below the poverty line of less than $1 US per day [19, 33, 34].
Based on the findings in this study, women’s autonomy was significantly associated with modern contraception use among partnered women in Zambia. Although we did not analyse wife-beating as an independent factor, other studies have found that women subjected to domestic violence or intimate partner violence are less likely to use contraception or access health care [35,36,37].
Our findings show that modern contraception use among partnered women in Zambia is low. This could explain the high maternal mortality rate due to unplanned pregnancies [4]. To achieve the sustainable development goals (SDG 3 and 5), programs and policies that encourage women to get involved in decision-making must be promoted. Women were empowered to take up leadership roles at all levels of society [1, 2, 5]. Women must be given some degree of independence in decision-making regarding sexual and reproductive health.
The findings of this study highlight the importance of gender equality in decision making by affirming the evidence finding that enhancing women’s autonomy improves the uptake of contraception use [24, 25].
Strategies to improve women’s autonomy include improving women’s socioeconomic status, enhancing their education and dismantling of cultural laws that support gender inequality [14, 26]. Increasing the socio-economic status of women is one of the most powerful tools that impacts significantly on reproductive choice [26].
Women’s autonomy could also be improved by enhancing women’s level of education [16]. This can improve self-awareness and enhance knowledge enabling women to learn more about self-value through interactions with others [27]. The Zambian government developed an education policy allowing pregnant girls to continue their education to reduce early marriages and retain girls in schools [28]. Nevertheless, more targeted policies that would promote already married women, particularly in rural areas, to have access to a basic level of education are required [29]. Male involvement, particularly in sexual and reproductive health, is another strategy that could enhance women’s autonomy [9, 30, 38, 39]. It promotes confidence and enhances morale towards positive decisions, consequently improving the uptake of sexual reproductive health services such as contraception [30, 40, 41]. Traditional norms and cultural beliefs are barriers that inhibit women’s autonomy [23]. Therefore, abolishing certain practices, such as patriarchal norms, that inhibit women’s participation in households would empower women to participate in decision-making [23, 38, 39].
Limitations and strengths of the study
Limitations of this study include the use of current women’s contraception use status, which may not reflect past and future contraception choices. In addition, autonomy was only measured using women’s responses without involving responses from their partners and made the assumption that all partners were male. Moreover, the study was cross-sectional, used secondary data for analysis, could only explore associations, and could not infer causality. This means that results must be interpreted with caution. A longitudinal study design may be able to better study the relationship. Despite the limitations, this study’s strengths included using a large representative sample from a reputable source, the DHS, that uses sound sampling methods with a high response rate. In addition to this, previously validated measures were used in this study [31, 32].
