HIPs

Economic empowerment is the ability to make and act on decisions that involve the control over and allocation of financial resources (Golla et al., 2011). Women’s influence over financial decisions is associated with increased use of preventive health services by children and women (Lagarde et al., 2009; Ahmed et al., 2010), including use of modern contraceptive methods (Ahmed et al., 2010; Do and Kurimoto, 2012). Thus, interventions that aim to increase the economic power of women and girls may improve reproductive health behaviors, including sustained use of modern contraception (see Figure 1), particularly when linked with investments that directly address reproductive health and family planning and/or gender norms. The barriers included in the illustrative theory of change shown in Figure 1 focus on those that are thought to be directly addressed through economic empowerment interventions. Although the theory of change is organized in a linear format, the mechanisms of action are likely bi-directional and more complex.

These potential relationships motivate the family planning community to find ways and opportunities to accelerate the transition toward greater economic equality between the sexes by increasing women’s access to and control over financial resources. Although our current toolbox of interventions is limited, the international community has learned a great deal over the last three decades from implementing these types of programs.

This brief summarizes the current evidence on interventions used by family planning programs that sought to improve women’s or girls’ economic empowerment and that measured key family planning outcomes. The interventions cluster in three primary focus areas:

• Vocational training includes training in the use of new technologies (e.g., computers), business processes, management of assets (e.g., care and use of livestock), and entrepreneurial skills. Such training may also address behaviors valued in the labor market, such as coming to work on time, which help people gain or maintain employment or build a small business. These activities are sometimes linked to broader health and education programs that focus on “life skills” education for adolescents to improve self-efficacy, decision-making, and risk perception.
• Microfinance provides financial services for low-income and poor women and girls, such as access to savings groups, savings and loans groups, insurance, and microcredit for their income-generating activities or micro-enterprises.
• Cash transfers involve the transfer of cash or other assets and are a form of social protection typically targeted to the poor. These transfers can be contingent on specific behaviors or provided without condition.

This brief does not cover employment or agricultural programs or address investments in literacy and numeracy without a specific focus on economic empowerment of women or girls as a primary outcome. In 2016, the Technical Advisory Group for High Impact Practices (HIPs) concluded at that time that “evidence on the relationship between economic empowerment interventions and improved contraceptive use or fertility behaviors is insufficient to meet the standards of a High Impact Practice for Family Planning.” However, the HIP initiative is making this brief available to share the evidence obtained thus far on the effect of economic empowerment initiatives on family planning outcomes and to share key research questions for identifying whether and under what conditions economic empowerment interventions contribute to more positive family planning outcomes. For more information about HIPs, see https://www.fphighimpactpractices.org/overview.

Women have limited economic opportunities in many countries. In many countries, women lag substantially behind men in their access to market opportunities, choice of occupation, and pay (World Economic Forum, 2015). Restrictive gender norms, enforced by both men and women, prescribe that women are primarily responsible for childrearing and household chores and are subordinate to men (e.g., women have less decision-making authority and fewer legal protections concerning marriage, inheritance, and property ownership than men) (Duflo, 2012). Economic exclusion and restrictive views about women’s roles, in turn, contribute to women’s limited mobility, bargaining power, and participation in household decision-making, including decisions about fertility and contraceptive use (Gupta, 2013). Women’s limited mobility and literacy may lead to reduced levels of information and knowledge about family planning as well as restricted access to services (Gupta, 2013).

Adolescent girls face limited educational and economic opportunities. Girls face pressure to marry early and begin childbearing with few alternatives such as continued and higher education and employment (Clark, 2004; Pettifor et al., 2004). Like women, girls lag behind boys in the formal labor market. Boys are more likely to have employment opportunities compared with girls, and when girls do work they tend to give most of their earnings to their families (Katz, 2013).

Economically empowered women are more likely to use contraception in some settings. Using Demographic and Health Survey (DHS) data, Do and Kurimoto (2012) attempted to quantify the relationship between economic empowerment and contraceptive use in four African countries (see Box). After controlling for individual and community characteristics, they found a positive and statistically significant relationship between economic empowerment and contraceptive use in Namibia and Uganda but no or marginal relationship in Ghana and Zambia. A meta-analysis examining the association between women’s empowerment and maternal health care using data from 31 countries found “the most pronounced association for women’s empowerment with modern contraceptive use. Women with the highest empowerment score has an 82% higher odds of using modern contraception than women with a zero empowerment score” (Ahmed et al., 2010).

The programs included in this synthesis aimed to improve economic empowerment and included a research component that measured key family planning outcomes. Although some of these programs did not aim to increase contraceptive use directly, they were included in the synthesis if they measured other key family planning outcomes including improvements in unintended pregnancy, fertility, delay of marriage, birth spacing, or breast feeding. Most of the studies did not include complete implementation details, such as duration and content of the intervention.

Vocational Training
Programs in Bangladesh, the Dominican Republic, Malawi, and Uganda assessed the effect of vocational training on family planning outcomes, including contraceptive use, teenage pregnancy, and age at marriage (Population Council, 2016; Bandiera et al., 2012; Ibarraran et al., 2012; Cho et al., 2015; Rotheram-Borus et al., 2012). All these programs targeted youth, ages 10–24 years old, and were designed to provide skills needed to enter the workforce. Two programs, in Bangladesh and Uganda, targeted adolescent girls only (Population Council, 2016; Bandiera et al., 2012), whereas others included both boys and girls (Ibarraran et al., 2012; Cho et al., 2015; Rotheram-Borus et al., 2012).

The intensity of training varied. In Bangladesh, girls received 44 hours of life-skills training plus 100 hours of either education, gender-rights awareness, and/or livelihoods training over 18 months, whereas the program in the Dominican Republic consisted of 225 hours of training (Population Council, 2016). Sample sizes ranged from 100 to 10,000 among the five studies. Only two programs included health components; one focused on increasing knowledge (for example, about HIV and pregnancy) and reducing risky behaviors such as sex without condoms and forced sex (Bandiera et al., 2012) and the other included an HIV prevention component (Rotheram-Borus et al., 2012). Three of the five studies measured condom use. The two programs in Uganda, which included a health component, documented an increase in condom use (Bandiera et al., 2012; Rotheram-Borus et al., 2012) as well as other positive effects. The program in Malawi found no significant effects on condom use (Cho et al., 2015).

A program in the Dominican Republic that focused on professional training documented a 5 percentage-point reduction in the pregnancy rate among participants ages 16–19. The authors attributed the difference to the program’s positive impact on youth’s expectations for their future (Ibarraran et al., 2012).

The Bangladesh program aimed to increase the age at marriage. In communities where girls received livelihoods training in entrepreneurship, mobile phone repair, photography, and basic first aid, girls were 23% less likely to be married as children at endline than girls in the control communities. Girls in intervention arms that focused on education or gender-rights awareness were 31% less likely than girls in the control communities to be married as children (Population Council, 2016).

Conclusion: Although youth programs commonly invest in vocational training, few programs measure the effects of these investments on contraceptive or fertility outcomes. Inclusion of sexual and reproductive education appears to be critical to improving contraceptive use. Future employment expectations may also play an important role in influencing the sexual behavior of adolescents.

Microfinance
Two randomized controlled trials of multi-component programs that included microfinance and other activities, such as reproductive health education and life skills, found limited effects on use of condoms or other contraceptives (Dunbar et al., 2014; Desai and Tarozzi, 2011).

In Zimbabwe, at 24 months post-intervention, contraceptive use was the same among female orphans ages 16–19 who were randomized to participate in a combined microcredit, HIV education, life skills education, and social support program and those in the comparison group who received HIV education and life skills only. Within-group changes in condom use (from baseline to endline) were statistically significant for the intervention group (odds ratio [OR]=1.79, confidence interval [CI]=1.23 to 2.62) but not for the comparison group (OR=1.29, CI=0.86 to 1.95) (Dunbar et al., 2014).

In Ethiopia, communities were randomly assigned to receive a microcredit program only, a reproductive health program only, both programs, or no program. Differences in contraceptive use by women in each community group were not statistically significant in models that adjusted for demographic and family characteristics (Desai and Tarozzi, 2011).

Randomized evaluations of village savings and loan programs in Ghana, Malawi, and Uganda found no impact on utilization of health services among beneficiaries (Karlan et al., 2012).

Two recent studies documented a positive effect of microfinance on contraceptive use. A study in rural Uttar Pradesh, India, assessed the impact of integrating family planning information and referrals within a microfinance program. Post-intervention, the study documented a 5 percentage-point increase in modern contraceptive use and an additional 24 percentage-point increase in periodic abstinence among members of the microfinance program (FHI 360, 2013). In Nigeria, researchers found a significant difference in modern contraceptive use among women living in communities with access to microfinance compared with those in comparison communities (30% vs. 21%, respectively) (Abdu-Aguye et al., 2015). A number of important methodological considerations are of note in both studies. For example, in the Nigeria study there were a number of important differences between the intervention and control samples, and the intervention included improvements in service delivery and demand generation activities that were not available to the control sites.

Conclusion:  Current research is limited and does not support a direct link between microfinance programs and contraceptive use as measured in existing studies. However, these groups might offer a platform to reach key beneficiaries with family planning and reproductive health messaging.

Cash Transfers
Conditional and unconditional cash transfers generally improve girls’ access to school as well as their retention and progression in school, as summarized in the Educating Girls HIP Brief. Identifying the appropriate beneficiaries—the populations most in need and grade levels where dropouts are most likely to occur—is a critical factor in the effectiveness of these interventions. Some theorize that benefit programs which pay cash incentives may have the unintended consequence of increasing birth rates. A review of social safety net programs by the World Bank concluded that there is little or no evidence of increased fertility rates as a consequence of social safety net transfers, and the transfers do not appear to influence the ability of the woman to decide on using contraception (World Bank, 2014).

Conditional cash transfers often include features meant to discourage fertility such as the inability to add more children to the beneficiary roster and information workshops. These findings are consistent with evaluations of a large-scale conditional cash transfer program in Mexico: of the four evaluations of this program, three demonstrated no effect on fertility or pregnancy rates (Darney et al., 2013; Feldman et al., 2009; Stecklov et al., 2007), while one found modest effects on contraceptive use among young adult women but not among youth (Lamadrid-Figueroa et al., 2008). The young adult women were required to attend promotional talks whereas youth were not.

A conditional cash transfer program in India encouraging facility delivery documented an increase in postpartum contraceptive use among beneficiaries (OR= 1.31) (Zavier and Santhya, 2013). In Kenya, an unconditional cash transfer program for female orphans ages 15–24 demonstrated a reduction in pregnancy, even after controlling for schooling, but not early marriage (Handa et al., 2015). Interviews with beneficiaries indicate the girls used cash for food, health, and clothing. In the absence on the cash transfer, beneficiaries may have resorted to transactional sex to obtain these goods.

Conclusion: Cash transfers may be particularly important for youth who have limited access to financial resources. However, cash transfers focused more generally on social protection (i.e., welfare safety net for poor) without a specific link to reproductive health information are unlikely to have an effect on fertility rates or reproductive behavior.

Multi-Component Economic Empowerment plus Health Activities
Some programs incorporate multiple economic empowerment approaches combined with health education and promotion activities. We found three studies that examined the effects of these combined programs on family planning outcomes. The programs combined savings and credit (microfinance), vocational and/or business training, and sexual and reproductive health education.

In Ethiopia, married adolescents in all four study arms of an economic empowerment and reproductive health program reported increased contraceptive use:

1. Those who received economic empowerment information and guidance only (9 percentage-point increase);
2. Those who received sexual and reproductive health education only (27 percentage-point increase);
3. Those who received both economic empowerment and sexual and reproductive health education (15 percentage-point increase); and
4. The control group (no intervention) (5 percentage-point increase).

Although differences between each intervention group and the control group were statistically significant, the sexual and reproductive health content may have been the critical component for improving contraceptive use among the married adolescent girls. The evaluation attributed the increase in contraceptive use to the improvement in the attitudes about contraception among husbands of enrolled girls (Edmeades and Hayes, 2014).

In Kenya, unmarried adolescents exposed to an intervention combining microfinance, vocational training, sexual and reproductive health education, and mentoring were somewhat more likely to use condoms than non-participants (52.1% vs 44.3%, respectively), but the difference was not statistically significant (Erulkar and Chong, 2005).

Another program in Ethiopia sought to increase the age at marriage among adolescent girls by providing access to literacy, numeracy, and livelihood training; financial support for school; and a goat for the girl and her family if her parents did not arrange for her to marry. The program also worked with community leaders around child marriage norms. An endline comparison of participants and non-participants showed that, compared with their counterparts in the comparison communities, 10–14-year olds in the intervention community were less likely to be married, 15–19-year olds in the intervention community were more likely to be married, and girls in the intervention community were more likely to use condoms (Erulkar and Muthengi, 2009).
Conclusion: Interventions with multiple economic empowerment approaches combined with sexual and reproductive health education may have modest effects on family planning-related outcomes. One evaluation, in particular, highlights the importance of sexual and reproductive health education to contraceptive use.

Economic Empowerment and Gender-Based Violence
Experts raise concerns about the potential that women’s empowerment programs, particularly economic empowerment programs, may increase intimate partner violence if men respond negatively when family roles are first challenged. Two literature reviews attempt to describe the relationship between women’s empowerment programs, including economic empowerment programs that specifically address gender-based violence (GBV) and those that do not, and risk for domestic violence (Heise 2011; Mejia et al., 2014). Mejia and colleagues (2014) identified 19 economic empowerment interventions, of which 15 specifically addressed gender norms and/or gender-based violence. Of the 15 programs that addressed gender, 8 reported a GBV outcome (i.e., attitudes about or experience with GBV): 3 of the 8 reported a decrease in experience of GBV, 5 reported no change in experience, and none reported an increase. Rigorous evaluations of economic empowerment programs, whether they specifically address GBV or not, should assess women’s experience of GBV as an unintended consequence among program participants.

A Review of Approaches and Methods to Measure Economic Empowerment of Women and Girls aims to inform agencies commissioning evaluations on how to ensure women’s economic empowerment dimensions are captured and to help those designing interventions to ensure these support positive transformation in the lives of women and girls. Available from: http://www.tandfonline.com/doi/pdf/10.1080/13552074.2014.920976

Understanding and Measuring Women’s Economic Empowerment: Definition, Framework and Indicators lays out a fundamental concepts measurement framework and illustrative indicators to guide the design, implementation, and evaluation of women’s economic empowerment programs. Available from: http://www.icrw.org/wp-content/uploads/2016/10/Understanding-measuring-womens-economic-empowerment.pdf

Economic Empowerment Strategies for Adolescent Girls: A Research Study Conducted for the Adolescent Girls’ Advocacy and Leadership Initiative identifies key findings on economic empowerment strategies for adolescent girls and provides recommendations to inform future program development. Available from: http://agaliprogram.org/eng/wp-content/uploads/2009/05/AGALI-Economic-Empowerment-Report-2013-.pdf

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This document was originally drafted by Kimberly Ashburn, Joan Kraft, Shefa Sikder, Reena Shukla, and Shawn Malarcher. Critical review and helpful comments were provided by Afeefa Abdur-Rahman, Gifty Addico, Moazzam Ali, Michal Avni, Myra Betron, Vicky Boydell, Clarissa Lord Brundage, Venkatraman Chandra-Mouli, Wade Channell, Peggy D’Adamo, Rani Deshpande, Ellen Eiseman, Madeleine Short Fabic, Mychelle Farmer, Mario Philip Festin, Allison Annette Foster, Kate Gray, Rehana Gubin, Gwyn Hainsworth, Jane Hutchings, Sandra Jordan, Niranjala Kanesathasan, Eugene Kongnyuy, Camille Collins Lovell, Erin Mielke, Dani Murphy, Constance Newman, Saiqa Panjsheri, May Post, Shannon Pryor, Heidi Quinn, Minal Rahimtoola, Suzy Sacher, Nisha Sarpal, Amy Setig, Ritu Shroff, Preethi Sundaram, Linda Sussman, Caitlin Thistle, and Caroll Vasquez.

This brief is endorsed by: Abt Associates, Bill & Melinda Gates Foundation, CARE, Chemonics International, EngenderHealth, FHI 360,  FP2020, Georgetown University/Institute for Reproductive Health, International Planned Parenthood Federation, IntraHealth International, Jhpiego, John Snow, Inc., Johns Hopkins Center for Communication Programs, Management Sciences for Health, Marie Stopes International, Options, Palladium, Pathfinder International, Population Council, Population Reference Bureau, Population Services International, Save the Children, United Nations Population Fund, University Research Co., LLC, and the U.S. Agency for International Development.

For more information about HIPs, please contact the HIP team at USAID.