Use of Contraceptives, Empowerment and Agency of Adolescent Girls and Young Women: A Systematic Review and Meta-analysis

"This review highlights the impact of empowerment on adolescent and young adult contraceptive use, boosting uptake and decision-making."

Globally, lack of access to contraceptives contributes to unintended pregnancies, which significantly affect the health of adolescent girls and their offspring, particularly in low- and middle-income countries (LMICs). Such pregnancies can also threaten adolescents' community status, increase violence risk, and hinder education, employment, and independence opportunities - diminishing their agency. Empowerment entails women's control over resources, self-reliance, decision-making, and choice. This control can be defined in terms of earnings and expenditures, self-reliance, decision-making and choice, with women having the final say in various issues. This systematic review assesses the use of contraceptives in empowering and strengthening agency - and vice versa - among adolescents and young women.

Definitions used in the study:

• Contraceptive use: modern contraceptives like pills, implants, and condoms;
• Interventions: education, promotion, and provision of these contraceptives through community, school, and technological platforms, involving teachers, parents, peers, and community/outreach workers; and
• Empowerment: resources (encompassing material and human assets facilitating choice), agency (defining and pursuing goals by employing diverse strategies like bargaining, negotiation, deception, manipulation, subversion, and resistance, individually and collectively), and achievements (combining resources and agency to result in capabilities that drive achievements).

With no date or language restrictions, the researchers searched 6 electronic databases (final search date: October 20 2023), assessed the methodological quality of studies, and performed meta-analysis. Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). Of 40 studies, 34 provided sexual and reproductive health (SRH) empowerment with behavioural skills, and 6 provided multidimensional empowerment. The delivery platforms included school, community, digital, and clinic

The results from RCTs show a significant effect of SRH empowerment in increasing ever use of contraception (relative risk (RR) 1.22; 95% confidence interval (CI) 1.02, 1.45; n=9; I²=77%; GRADE: very low) and an insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: very low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: very low). The low-GRADE certainty is due to high risk of bias, statistical heterogeneity, and precision in the studies. Despite these issues, there is suggestive evidence that empowerment may be positively associated with improved contraceptive uptake.

None of the studies assessed impact of contraceptive use on empowerment. The review also did not report any long-term impact of empowerment on contraceptive use. Furthermore, studies have not consistently defined or measured empowerment.

Reflecting on the findings, the researchers reiterate the review's finding that empowerment interventions primarily targeted SRH with limited focus on multidimensional empowerment. However, they point out, interventions aimed at changing societal norms, building capacity, and financial means are crucial for enhancing contraceptive use among younger populations. Strengthening economic and health domains is integral to empowerment, but only one study targeted both.

Along these lines, while school-based programmes are effective in empowering adolescents in SRH, including the use of contraceptives, the literature also suggests that the effectiveness of school-based empowerment is amplified when these efforts are linked to communities. Community-based SRH empowerment strategies should be prioritised over school-based ones, as the World Health Organization (WHO) defines adolescent-friendly services as accessible, acceptable, equitable, appropriate, and effective for various youth subpopulations (not just those in schools).

Looking ahead, the researchers suggest that tailored programmes and policies for LMIC youth are crucial. Increased accessibility to empowerment programmes is crucial for enhancing contraceptive use in resource-limited settings, especially for out-of-school adolescents. Future research should focus on long-term outcomes, agency, and achievement-related measures. In particular, assessing agency outcomes can inform informed decision-making. Most studies in the review focused on Africa and the Americas, so further research is necessary in South Asia, the Gulf, and Europe.

In conclusion: "Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required."