Abstract
INTRODUCTION: Extensive evidence suggests that family planning programs are second only to education in providing returns on dollars spent with improvements in long-term maternal and child health outcomes. However, no current research synthesis to date has robustly examined whether use of family planning results in increased empowerment and greater agency of women, despite theoretical, but not empirical, support that family planning influences this outcome as well. Our objective was to conduct a systematic review of the evidence on how women's access to and/or use of family planning methods impacts their agency and empowerment, including mechanisms and effect modifiers important to this relationship. METHODS: We searched 20 global and regional databases for interventional and observational research published from January 2000 through January 2022 which reviewed the relationship between family planning use and subsequent women's empowerment. Titles/abstracts and full-text articles were screened in duplicate, and key data were extracted using a standardized form. We evaluated risk of bias using the Newcastle-Ottawa Scale and rated the certainty of evidence for four outcomes (decision-making, labor force participation, wages, and schooling) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Findings were analyzed and summarized in both tabular and narrative format. RESULTS: We identified 3,170 articles after de-duplication, of which 14 quantitative and three qualitative studies met inclusion criteria. Studies were in both high income and low- and middle-income countries, with the largest proportion being from South Asia. Studies ranged from randomized controlled trials of programs at the community level to quasi-experimental studies of policies. The GRADE framework yielded low and very low confidence in the findings. Outcomes were categorized into domains using Kabeer's framework of Resources, agency and achievements. Most studies measured the impact of family planning on resources or agency. Combining measures across all domains of empowerment, 47% had positive, 39% null, and 14% negative results. DISCUSSION: Overall, this systematic review suggests that family planning access has a positive impact on a variety of empowerment measures across different domains of empowerment. However, the quality ratings indicate that while our synthesis suggests potential benefits of family planning for women's empowerment, the current evidence base provides limited confidence for definitive conclusions. One of the main challenges in understanding the impact of family planning on empowerment is the diversity of conceptualizations and measures of empowerment used. In addition, the geographic coverage of studies was limited to few countries, with only one study from Latin America. Further research using a process-oriented measure of empowerment comparable across contexts could add to our understanding. In addition to being a fundamental human right, investing in family planning likely contributes to women's empowerment in multiple domains.