Norms and values as barriers and enablers to global sexual and reproductive health and rights

Abstract

Background: Sexual and reproductive health and rights (SRHR) are interdependent and framed as universal rights as per the 2018 Guttmacher- Lancet Commission's (GLC) definition, yet their realisation remains uneven and context-dependent. Social norms, gender inequality, and structural factors (e.g. policy, laws, resources etc) shape whether rights on paper become rights-in-practice. Perceived reproductive agency - the capacity to decide if, when, and how many children to have - offers a person-centred lens linking rights to lived experience. This research is important in sub-Saharan Africa given that the region has experienced important SRHR gains and changes in the past three decades while both urgent and complex needs still remain. Also, most country-comparative analyses of unintended pregnancy and abortion focus on legislation alone, leaving out social norms - which differentiates the formal environment (what should be available) from the lived environment (what is socially acceptable and practically attainable) - underexplored. To address these gaps, we (i) developed a comprehensive SRHR & Gender Module aligned with the GLC SRHR definition; (ii) constructed population-level indices for SRHR-supportive attitudes; (iii) analysed their associations with perceived reproductive agency and subjective well-being (SWB); and (iv) examined how abortion norms and laws relate to rates of unintended pregnancy and abortion among women who do not want to be pregnant across countries and over time.Aim: To improve the understanding of norms and values toward SRHR and gender equality, and study how these serve as barriers or enablers to SRHR outcomes globally, with a particular focus on individual perceptions and country-level outcomes.Methods: Together with the World Values Survey (WVS), we developed and piloted an SRHR and Gender Module to capture a broad range of SRHR domains in line with the GLC definition. The module was piloted in Nigeria (2017-2018), then fielded in a revised version in Ethiopia, Kenya, and Zimbabwe during WVS Wave 7 (2017-2021; N = 4,948) in nationally representative samples. Study I (Ethiopia, Kenya, Zimbabwe; n = 3,711) used exploratory factor analysis of 58 module items to derive five subscales and an overall SRHR Support Index. Adjusted regression models examined sociodemographic correlates of the index, stratified by country and sex. Study II (Ethiopia, Kenya, Zimbabwe; n= 3,096) assessed how SRHR attitudes (Index and subindices) and gender-equality values (WVS Equality Index) related to perceived reproductive agency measured by respondents rating their level of freedom of choice and control over their family planning (i.e. if, when and how many children to have) using a 1-10 Likert scale with higher numbers representing higher agency. We compared values and attitudes among respondents of high vs. low perceived agency (using the median as a cut-off) using descriptive statistics, bivariate tests, and multivariable logistic regression, stratified by country and sex. Study III (all four countries; N = 4,302) examined associations between perceived reproductive agency and SWB captured by four items where respondents rated their life satisfaction (Likert scale; 1-10), overall life agency (Likert scale; 1-10), health status (Likert scale; 1-5), and happiness (Likert scale; 1-4). Using bivariate and multivariable logistic regressions, we analysed how SWB differed among respondents of high vs. low perceived reproductive agency stratified by country and sex. Study IV combined WVS and European Values Survey data on population level abortion norms with country-year measures of abortion legislation (restrictive: prohibited altogether/save life/preserve health; vs. broadly legal: on request/broad socioeconomic grounds) and Guttmacher Institute estimates of unintended pregnancy and abortion rates per 1,000 women wanting to avoid pregnancy, and percent of unintended pregnancies ending in abortion (88 countries; 1990-2019). We conducted five country case analyses of major policy changes (Poland, South Africa, Spain, Uruguay, India) to contextualise quantitative patterns.Results: In study I, a 23-item, five-factor solution captured norms toward: (1) sexual and reproductive rights, (2) neighbourhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. The sub-indices performed well across countries and subgroups and were combined into a comprehensive SRHR Support Index (1-100 scale; mean = 39.19, SD = 15.27; a = 0.80), with higher scores indicating more supportive SRHR attitudes. Mean scores for the Index were highest in Kenya, then Ethiopia and lowest in Zimbabwe, with different scores for the sub-indices. Higher education and being single were associated with more supportive attitudes (except Ethiopia). Younger age and urban residence were associated with higher support among men only. In study II, we found that, respondents rated their reproductive agency high (median =9, IQR=6-10). Country, education, subjective social class, and religion were associated with reproductive agency. Adjusted analyses indicated associations between supportive attitudes towards Equitable Masculinity Norms, SRHR Interventions Norms and Gender Equality, with high reproductive agency. In study III, we found that among the 4,302 respondents, 55% perceived their reproductive agency as high, 66% reported high life satisfaction; 51% high overall life agency, and 75% rated themselves healthy and happy. Higher perceived reproductive agency was associated with higher overall life agency and among women greater life satisfaction. In study IV, we found that more supportive norms toward abortion and lower rates of unintended pregnancy and abortion were found in countries where abortion was broadly legal. By contrast, low public support for abortion clustered with higher rates of unintended pregnancy and abortion. The share of unintended pregnancies ending in abortion was highest in countries where abortion was liberal in law but low in public support. Country case analyses showed that shifts in policy, norms, and outcomes are highly context-specific.Conclusions: Norms and values toward SRHR are associated with SRHR outcomes, examined at both the individual and country levels. In addition to legislation and policies, SRHR supportive norms and gender equitable values appear crucial to ensuring that people - particularly women, can exercise their sexual and reproductive rights and realise not only better sexual and reproductive health, but well-being at large.List of scientific papersI. Svallfors S*, Båge K*, Ekström AM, Dessie Y, Wado YD, Fagbemi M, Larsson EC, Litorp H, Puranen B, Sundewall J, Uthman OA, Kågesten AE. Support for sexual and reproductive health and rights in Sub- Saharan Africa: a new index based on World Values Survey data. Reprod Health. 2024 Jun 25;21(1):90. PMID: 38918832; PMCID: PMC11197335. https://doi.org/10.1186/s12978-024-01820-2II. Båge K, Kågesten A, Uthman O, Salazar M, Puranen B, Svallfors S, Ekström AM, Litorp H. Attitudes toward sexual and reproductive health and rights and their associations with reproductive agency: a population-based cross-sectional study in Ethiopia, Kenya, and Zimbabwe. Sex Reprod Health Matters. 2024 Dec;32(1):2444725. Epub 2025 Feb 21. PMID: 39803831; PMCID: PMC11849024. https://doi.org/10.1080/26410397.2024.2444725III. Båge K, Kågesten A, Fagbemi M, Uthman O, Arunda M. O, Puranen B, Ekström AM, Litorp H. Is reproductive agency associated with subjective well-being? A population-based cross-sectional study among men and women in four sub-Saharan African countries using the World Values Survey. Critical Public Health. 2026 36(1). https://doi.org/10.1080/09581596.2025.2604450IV. Båge K, Bearak J, Cleeve A, Larsson EC, Puranen B, Gemzell- Danielsson K, Ekström AM, Litorp H, Svallfors S, Kågesten AE. Variations in abortion attitudes and reproductive outcomes by abortion legislation globally: an ecological analysis. [Submitted]*Shared first author</p