Conceptualizing Contraceptive Agency: A Critical Step to Enable Human Rights-Based Family Planning Programs and Measurement

We propose a detailed framework for contraceptive agency to serve as a rights-based guide for centering individuals’ ability to make and act on their own contraceptive choices, regardless of what those choices are, in program design and evaluation.

Despite widespread agreement on the importance of a human rights-based approach to contraception programming, a gap exists between the principle of valuing individual choice and what programs are held accountable for in practice.This gap is reflected in the increasingly recognized need for new rights-based measures.
n We discuss 6 opportunities for conceptual and measurement innovation and propose a framework for the construct of "contraceptive agency"-the ability of an individual to make and act on decisions related to whether to do something to avoid or delay pregnancy and what, if anything, to do when they are not actively trying to become pregnant.
n The contraceptive agency framework can serve as a guide for centering individuals' ability to make and act on their own contraceptive choices, regardless of what those choices are, in contraception program design and evaluation.

BACKGROUND
T he human right to control one's own childbearing requires that individuals can both make and act on reproductive decisions. 11][12][13] In this commentary, we review these frameworks and measures and argue that there remains a need for innovation in the conceptualization and measurement of the degree to which individuals have agency related to contraception.][16] In this commentary, we delineate specific conceptual gaps we seek to fill before presenting a detailed framework for the construct of contraceptive agency.Consistent with Donald et al.'s multidisciplinary definition of agency as the ability to define one's goals and act on them 17 and Sato et al.'s definition of agency as an individual's ability to produce an effect in pursuit of goals and values, 18 we define contraceptive agency as the ability of an individual to make and act on decisions related to whether to do something to avoid or delay pregnancy and what, if anything, to do when they are not actively trying to become pregnant.This definition draws attention to the degree of agency one has related to using or not using contraception to avoid or delay pregnancy and is agnostic to the decision itself (to use or not use contraception) in acknowledgment of the fact that there are legitimate reasons why people may make empowered decisions not to use contraception even when they also do not want to be pregnant. 9Note that agency related to other medical uses of contraception, such as management of acne or heavy periods, is beyond the scope of this definition.
After presenting the contraceptive agency framework, we discuss how the framework can be applied in the context of program design and evaluation, drawing on our experience with the Innovations for Choice and Autonomy (ICAN) project.ICAN's focus is developing and testing approaches to implementing the self-injectable contraceptive technology in a way that meets women's self-defined needs.As part of this work, we have used the contraceptive agency framework to guide development of self-injection programming and are developing and testing a new measure of contraceptive agency that we will use to evaluate the success of ICAN's programming.Our team includes members from Nigeria, Uganda, and the United States, with diverse disciplinary backgrounds, expertise, and lived experiences that we have leveraged to collectively develop this contraceptive agency framework and our forthcoming contraceptive agency measure.

OVERVIEW OF FRAMEWORKS AND MEASURES RELATED TO CONTRACEPTIVE AGENCY
The Reproductive Autonomy Scale (14 items), published in 2014, was groundbreaking in providing a measure of "the power to decide about and control matters associated with contraceptive use, pregnancy, and childbearing." 10Although this measure captures influence from in-laws or others, the authors focused primarily on relationships between women and their male partners, with items related to partner relationships in 3 domains: freedom from coercion, communication, and decision-making.
In 2018, the International Center for Research on Women (ICRW) Conceptual Framework for Reproductive Empowerment defined agency as the capacity of individuals to take deliberate actions to achieve their reproductive desires and preferences in 3 domains: voice, choice, and power. 11he authors note that the implication of this definition is that: individuals should be able to express their childbearing desires to their partners, providers, and others; meaningfully participate in communication and decisionmaking with partners, with providers, and within their communities; and shape desired outcomes related to marriage, the conditions of sexual intercourse and the use of contraception.To be clear about one's personal values related to doing or not doing something to avoid or delay pregnancy 2. To have information and support in accordance with one's preferences to make choices about doing or not doing something to avoid or delay pregnancy 3. To be conscious of the right to contraceptive choice, including:

BOX. Detailed Definition of Contraceptive Agency Domains
a. Entitlement to use, not use, switch, or stop using contraception b.Right to have access to a wide range of contraceptive methods and to choose which method, if any, to use 4. To exercise critical reflection and be aware that intersecting social constructions can constrain or enhance individuals' ability to exercise the right to choices related to doing or not doing something to avoid or delay pregnancy (critical reflection construct from critical consciousness theory 23 ) 5. To believe one has control over decisions related to doing or not doing something to avoid or delay pregnancy, including who they would like to be involved in those decisions (perceived control construct from health behavior theory 31 ) 6. To have confidence in one's ability to form and act on preferences related to doing something or not doing something to avoid or delay pregnancy (self-efficacy construct from health behavior theory The ICRW framework resulted in both the Reproductive Empowerment Scale (20 items) 19 and the Reproductive Decision-Making Agency Measure (12 items), which captures the "degree to which individuals are meaningfully engaged in the decision-making process, and their level of satisfaction with their own influence over the decision itself." 15hortly after the ICRW framework was published, the Women's and Girls' Empowerment in Sexual and Reproductive Health (WGE-SRH) framework and WGE-SRH index (21 items) were published by the Performance Monitoring and Accountability project. 13,20The WGE-SRH framework outlines a 3-stage empowerment process comprising "existence of choice," "exercise of choice," and "achievement of choice," referring to "contraceptive use by choice" as one of the specific manifestations of sexual and reproductive health (SRH) empowerment. 13The resulting WGE-SRH index includes several subscales that capture each stage. 20n 2020, Senderowicz published a framework for another highly related construct, contraceptive autonomy, defined as "factors necessary for a person to decide for themselves what they want in relation to contraception and then to realize that decision" with subdomains of informed choice (covering individuals' knowledge of options), full choice (availability and affordability of method provision and removal services), and free choice (whether contraceptive use or nonuse is voluntary). 12n 2023, Harper and colleagues published a new measure of decision-making agency in the contraception clinical encounter; the measure was developed and validated in the U.S. context. 16he authors' review of the empowerment and patient-centered care literature led them to define 3 domains to guide item generation for this new measure: freedom from coercion, nonjudgmental care, and active decision-making.The resulting scale is unidimensional and composed of 7 items that capture agency in the clinical encounter.

OPPORTUNITIES FOR INNOVATION IN DEFINING AND MEASURING CONTRACEPTIVE AGENCY
These frameworks and measures have a common recognition of the importance of individuals' ability to make and act on SRH decisions.We agree this duality is critical to include in any conceptualization of contraceptive agency and other constructs related to fulfillment of sexual and reproductive rights, and we seek to build on these foundational efforts in our conceptualization of a new contraceptive agency framework.In reviewing these related efforts and considering gaps in our ability to measure contraceptive agency, our team collectively identified 6 opportunities for innovation.

Focus on Contraception-Specific Issues
The reproductive autonomy, ICRW, and WGE-SRH frameworks and tools are highly innovative in providing broader conceptualizations of empowerment-encompassing issues related to contraception, abortion, volitional sex, and pregnancy. 11,13his holistic vision is critical and provides a valuable approach for looking across sectors at how programs support SRH.At the same time, contraception-specific frameworks related to agency are lacking.Although Harper et al.'s agency scale is an important contribution to the field, it focuses specifically on contraceptive decision-making in the clinical encounter-only 1 component of agency related to contraceptive decisions and actions. 16Contraception-specific frameworks and resultant measures are arguably more actionable than broader reproductive empowerment-related frameworks as tools to promote rights-based family planning as they outline more specific contraception-related issues for intervention.

Shift Away From Equating Covert Use With Disempowerment
The ability to engage others in decision-making has been equated with empowerment in the family planning field, as illustrated by the dominance of items on support from others or whether one can share opinions with partners and health care providers in the ICRW and WGE-SRH measures. 19,20This approach assumes all individuals desire others' involvement in decision-making, which is not uniformly the case.Additionally, we argue that limited or no engagement from others does not inherently indicate lack of empowerment.The reproductive empowerment scale goes so far as to include items equating leveraging social support to convince partners to use contraception with empowerment, 19 leaving out the possibility that an empowered person could choose to use contraception without telling anyone.In fact, while we recognize that disempowering restrictive social and gender norms are often to blame for covert use, we argue that covert use can in some cases reflect higher levels of agency.Covert use under these circumstances could indicate one's assessment of the constraints in their environment and a deliberate In our conceptualization of a new contraceptive agency framework, we seek to build on existing frameworks' recognition of the importance of individuals' ability to make and act on SRH decisions.decision to counter expectations and norms to act in accordance with their goals, as prior research has documented that some women do. 21,22Therefore, there is a need to incorporate this perspective in measures of contraceptive agency to allow for individual preferences for involving others.Notably, the reproductive decision-making agency measure is innovative in taking into consideration not just whether one shares their opinion with a partner but whether they want to share that opinion and how satisfied they are with the outcome. 15

Include the Extent to Which People Are Conscious of Their Rights and Societal Injustices
Agency in SRH decision-making tends to be narrowly conceptualized and measured with a focus on involvement and influence of others, as with the reproductive autonomy, reproductive empowerment, reproductive decision-making, and WGE-SRH frameworks, 10,19,20 or a focus on knowledge and information, as with the contraceptive autonomy construct. 12In fact, agency in decisionmaking relies on a broader set of internal processes related to the formation of values-based preferences that have been understudied in the SRH field. 17Critical reflection is an important construct relevant to agency in decision-making.Borrowed from critical consciousness theory, critical reflection describes how people become aware of systemic social injustice as a precursor to taking action toward liberation. 23This suggests that it is important for contraception-related frameworks and measures to include the extent to which individuals recognize what their rights are and what societal injustices, such as gender inequities and poverty, may be constraining them.Though some previous efforts have engaged with the concept of critical consciousness in describing empowerment-related constructs, existing measures to capture those constructs lack items about critical consciousness as a part of decision-making-for example, critical consciousness is part of the reproductive empowerment framework but not the measure. 11,19

Broaden Acknowledgment and Measurement of Sources of Interference
Existing programs and measures primarily focus on partners as a key source of interference in women's contraceptive agency.5][26] However, there is a need to expand acknowledgment of other sources of social influence, particularly among adolescents for whom parental involvement is often more salient and people who live with extended family, including in-laws.Regarding measurement, the reproductive decision-making and WGE-SRH measures rely heavily on questions related to partner influence, making these measures not applicable for individuals without partners who may still face constraints to their contraceptive agency.The reproductive empowerment and reproductive autonomy measures include items assessing who makes the final decision about contraceptive use and include other family members and an "other" option in addition to partners, but these 2 measures rely heavily on partner-related items. 10,19In contrast, the agency in a contraceptive decisionmaking measure recently developed in the United States focuses exclusively on provider influence. 16

Develop Universally Applicable Measures
Measures of empowerment and rights-fulfillment in the SRH field are predominantly developed for women, given their childbearing capabilities and the inequitable gender norms that have been shown to limit women's rights and agency.][29][30] Inclusive concepts and measures that are not gender specific can support sexual and reproductive health and rights for all.This is particularly important as we experience a cultural shift toward recognizing shared responsibility for pregnancy prevention and family planning and the need for contraceptive methods that work for different bodies.

Shift Away From Equating Contraceptive Use With Empowerment
Existing empowerment frameworks acknowledge that acting in accordance with one's goals is the aim of contraceptive access efforts, yet measures resulting from these frameworks tend to rely on items that equate contraceptive use specifically with empowerment.For example, the reproductive empowerment measure subscale on social support includes 3 items about the extent to which individuals could convince an unsupportive partner to let them use contraception and no items about support for decisions not to use contraception. 19One notable exception is the contraceptive autonomy framework, which explicitly makes clear that items should assess whether contraceptive use is desired and removals for long-term methods are accessible. 12ere is a need to expand acknowledgment of other sources of social influence, particularly among adolescents for whom parental involvement is often more salient and people who live with extended family.

CONTRACEPTIVE AGENCY FRAMEWORK
Considering the aforementioned opportunities for conceptual innovation, we drew on interdisciplinary theoretical constructs related to agency, 17 health behavior, 31 and critical consciousness 23 to develop a framework delineating 8 specific constructs comprising contraceptive agency.Domain 1 covers constructs related to decision-making, and Domain 2 covers constructs related to acting on decisions (Box).These 2 theoretically informed domains cover the range of psychosocial constructs necessary for an individual who is not actively trying to get pregnant to have full agency over what (if anything) they decide to do related to avoiding or delaying pregnancy.A person of any gender with high levels of each of the 8 constructs is considered to have high contraceptive agency whether or not they decide to use contraception and regardless of what method they choose.
We recognize the inherent risk that defining individual-level constructs such as this one will primarily motivate behavioral rather than social or structural interventions.Thus, in the Figure, we situate contraceptive agency within the broader context of influences on individual decisions and actions, drawing on the Integrated Behavioral Model 31 and the Social Ecological Model. 32On the left, we acknowledge the historical, political, economic, and cultural environment that influences and interacts with donors', governments', and nongovernmental organizations' priorities related to family planning.Here, we also account for individual characteristics, such as religion, age, and ethnicity.Together, these individual, structural, and systemic factors form the context in which individuals make and act on decisions related to avoiding or delaying pregnancy.The contraceptive care environment (access to and quality of services including the accessibility, structure, and process of care 33,34 ) and the social environment (including influence from community members, household and other family members, peers, partners, and the media 32 ) are depicted on the top and bottom, respectively, as directly influencing contraceptive agency.In accordance with the Integrated Behavioral Model, we depict that the degree of how salient avoiding or delaying pregnancy is within the broader context of an individual's life and priorities also can play a role in acting on one's preferred approach (which may include using any form of contraception or not, even when one does not desire pregnancy). 31

IMPLICATIONS FOR PRACTICE AND MEASUREMENTS
The contraceptive agency framework can be applied as a practical resource to guide program design and evaluation.In the design phase, the 8 contraceptive agency constructs from the framework can serve as a menu of areas where programs can choose to intervene to improve agency.The framework will encourage programming that innovates beyond the common focus on knowledge and self-efficacy in many social and behavior change approaches 35,36 toward a fuller set of activities that can promote contraceptive agency.For example, through the theoretically informed constructs of consciousness of the right to contraceptive choice and critical reflection about constraints to contraceptive choice, programming can be implemented to make sure individuals are aware of their rights and the conditions that constrain them in acting on those rights.The structural and social factors depicted in the framework as patterning uneven opportunities for agency based on social position will also guide program designers to recognize that agency is impacted by social influences at family, peer, partner, and community levels and that programs should strive to help individuals navigate these social and structural factors as much as is feasible without relying solely on individuallevel solutions.
Depending on objectives and resource constraints, programs will understandably prioritize specific constructs within the framework without needing to intervene with all elements.Indeed, the framework should serve as an aspirational guide and ensure donors and programs contend with the range of approaches necessary to comprehensively support and hold programs accountable for contraceptive agency.The framework can also be used as a tool to advocate for taking a rightsbased approach by giving programs a concrete path toward prioritization of agency rather than other non-rights-based end goals, such as reducing fertility.We note that the framework is meant to complement rather than replace other tools to aid in program planning, such as those required for inventory planning or ensuring high-quality, rights-based service delivery. 37n the ICAN project, we used the contraceptive agency framework to guide the design of new programs to support diffusion of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC).Recognizing the complexity and inherent tension in focusing on a single method while upholding informed choice, we used the contraceptive agency framework to guide our human-The framework will encourage programming that innovates beyond the common focus on knowledge and self-efficacy toward a fuller set of activities that can promote contraceptive agency.centered design process in Uganda toward solutions that would first and foremost support agency in making and acting on one's own decisions rather than promoting uptake of self-injection.Our new community-based program entails leveraging peer social support to support women in making and acting on their own contraceptive decisionswhatever those decisions may be-while also diffusing information about the option of selfinjection and having peers offer moral support for those interested in self-injecting (results forthcoming).Specific constructs from the contraceptive agency framework were used in the design of program materials.For example, peer support training materials discuss the importance of making sure women know their rights, are confident in their ability to make a choice, and have the level of support and information that they themselves desire.Self-injection is positioned as a method women should be aware of and supported to use if they desire, but the contraceptive agency framework helped us prioritize agencyrelated programming over an approach that prioritized promoting contraceptive uptake.Our forthcoming contraceptive agency measure (discussed next) will be used in the evaluation phase to gauge the success of these programs in upholding or promoting women's agency, regardless of how many choose self-injection.
Related to measurement, the 8 constructs in the framework can serve as a guide for what programs should measure to ensure they promote agency related to contraceptive decision-making (Domain 1) and actions (Domain 2) and that they are doing no harm in those same areas.Our team is developing a new scale to measure contraceptive agency (results from research in Uganda, Nigeria, and the United States are forthcoming).The item pool for the new scale was developed based on formative research with women and the aforementioned gaps in other measures, such as a lack of items on the degree of support for decisions not to use contraception and the predominance of items that equate contraceptive nonuse or covert use with disempowerment.Recognizing that contraceptive agency is complex and that the resulting scale will likely be multidimensional, we envision that this new measure will be particularly well suited for application in program evaluations and other special studies.Subscales that comprise the measure can be applied alone or in tandem with other subscales, depending on program priorities, and we also plan to create a short form to facilitate the measure's integration into regular program monitoring and, eventually, population-based surveys.Efforts to improve the measurement of complex constructs, such as quality of care and fulfillment of reproductive intentions, have required careful contextualization and direction. 38,39Thus, we recognize that publication of the new contraceptive agency scale will necessitate guidance on its application for a range of different contexts, including cross-sectional studies, program monitoring, and longitudinal studies.

CONCLUSION
The contraceptive agency framework can compleexisting rights-based program planning tools 37 by helping programs prioritize intervention components that will support individuals' ability to make and act on decisions related to avoiding or delaying pregnancy-regardless of what they choose.Our review of related frameworks confirms this is a novel contribution to the literature.][7][8][9]

Domain 1 :
Agency in Decision-Making Related to Avoiding or Delaying Pregnancy 1.

FIGURE.
FIGURE.Contraceptive Agency Framework: Constructs Constituting and Influencing Agency