cross-national analysis of a model of reproductive health in developing countries

Social Science Research 35 (2006) 210–227

www.elsevier.com/locate/ssresearch

Cross-national analysis of a model of reproductivehealth in developing countries�

Vijayan K. Pillaia,¤, Rashmi Guptab

a School of Social Work, University of Texas at Arlington, Box 19129, Arlington, TX 76019, USAb India Association of North Texas, Dallas, TX 75080, USA

Available online 2 December 2004

Abstract

Current perspectives on reproductive health place strong emphasis on making steady pro-gress with respect to women’s reproductive rights (Mann, 1996, 1997) in developing countries.Reproductive rights are composed of abortion rights and personal rights such as rights ofequality of sexes during marriage. The purpose of this paper is to propose a model of repro-ductive health at the cross-national level. It is argued that improvements in gender equalityand levels of democracy are necessary and important for increasing reproductive health levels.Data from 129 developing countries are used to test the proposed model. It is found that as thelevel of democracy increases resulting in improvements in gender equality, the extent of per-sonal rights improves. Furthermore, advances in personal rights increase the level of reproduc-tive health. Theoretical implications and limitations of the study are discussed. 2004 Elsevier Inc. All rights reserved.

1. Introduction

Reproductive health is deWned as “a state of complete physical, mental, andsocial well-being, and not merely the absence of diseases or inWrmity, in all matters

� The authors thank Dr. Sanna Thompson, University of Texas at Austin, Mr. Ronald Swatzyna,University of Texas at Arlington, Dr. Kristine Ferguson at the University of Southern California, and thereviewers for their helpful comments.

* Corresponding author. Fax: +1 817 272 2046.E-mail address: [email protected] (V.K. Pillai).

0049-089X/$ - see front matter 2004 Elsevier Inc. All rights reserved.doi:10.1016/j.ssresearch.2004.08.003

mailto: [email protected]

mailto: [email protected]

V.K. Pillai, R. Gupta / Social Science Research 35 (2006) 210–227 211

relating to the reproductive system and to its functions and processes” (U.N. Doc.A/CONF. 171/13). The term “women’s reproductive health” is often associatedwith a satisfying and safe sex life, capacity to reproduce, and the freedom to decideif, when, and how to do so. Women’s reproductive health is determined by theextent of control one has over decisions such as marriage, when and with whom toengage in sexual relations, regulation of fertility by methods which are free fromunpleasant or dangerous side eVects of contraception, and access to informationon the prevention and treatment of reproductive illness and unsafe childbirth. Theability of women to make these crucial decisions depends on the extent of thereproductive rights they enjoy.

One-half of the world’s 2.6 billion women are now in their childbearingyears. Illnesses and deaths from complications of pregnancy, childbirth,unsafe abortion, diseases of the reproductive tract, and the improper use ofcontraceptive methods top the list of reproductive health threats to womenworldwide (Jacobson, 1991; United Nations, 1995; World Health Organization,1995).

The International Conference on Population and Development (ICPD) (1994)concluded that reproductive rights are human rights which ensure reproductivehealth, bodily integrity, and the security of the person. Wang and Pillai (2001)conceptualize reproductive rights as a constellation that includes abortionrights and personal rights. Reproductive rights embrace the human rights thatare already recognized in all national laws, international human rightsdocuments, and other consensus statements. These rights rest on thepresumption of the basic right of all couples and individuals to decide freely andresponsibly the number, and timing of their children; to have the information andmeans to do so; and the right to maintain the highest standards of sexual andreproductive health. It also includes their right to make decisions concerningreproduction; free of discrimination, coercion and violence, as expressed in exist-ing human rights documents. In the exercise of these rights, the needs of living andfuture children and one’s responsibility towards the community should be takeninto account.

Hendriks (1995) identiWes the 1980s as the turning point at which policy makers,scientists, and women’s health and rights activists began to acknowledge the intrin-sic relationship between health and human rights. Public health researchers suggestthat social, political, and structural factors must be addressed if reproductivehealth outcomes are to be improved (Bird and Bauman, 1995). A 1995 report bythe World Health Organization (WHO) and the International Women’s HealthCoalition suggests that improvements in women’s reproductive health inevitablyinvolve empowering women to have control over their own fertility and sexualityunder conditions of voluntary choice and minimum health risks. The purpose ofthis paper is to propose a model of reproductive health using data from 129 devel-oping countries. BrieXy, we argue that improvements in the level of democracy, andwomen’s socioeconomic parity with men, will generate a sociopolitical environ-ment of increased reproductive rights that will enhance women’s reproductivehealth levels.

212 V.K. Pillai, R. Gupta / Social Science Research 35 (2006) 210–227

2. A proposed model of reproductive health

Mann (1997) proposes two theoretical linkages between public health and humanrights. The Wrst relationship is based on the observation that human rights violationshave health consequences. The impact of rights violations, such as torture and rape,on physical and mental well-being has been adequately documented. The violation ofless obvious rights, such as the right to assembly, also has public health conse-quences. According to Mann (1997) in societies in which the right to assemble orassociate around health issues—such as drug use and non-heterosexual sex—publichealth programs suitable for the local culture, are less likely to emerge. Second, ahuman rights approach to public health appears to broaden the choices clients havewith regard to improving their health. This linkage was used as the basis for theagenda for women’s reproductive health at the 1994 Cairo ICPD conference.

A number of feminist scholars (Folbre, 1994; Hartmann, 1987; Vogel, 1987) haveargued that women face a number of threats to their physical (corporeal) and per-sonal integrity because they possess the capacity to reproduce. In developing coun-tries, women have few choices with regard to several aspects of the reproductiveprocess: intercourse, contraception, and gestation. These choices are often madeunder severe external pressure and threat. Many religious tenets delegate decisionsregarding marriage partners, family formation, and family size to women’s guard-ians. In addition, several religions hold strong and persistent views with regard to thereproductive roles of women (Lauren, 1998). In recent years, sub-populations such assex workers have been targeted for social exclusion for fear of the spread of HIV/AIDS (Pitin, 1991). On a broader scale, women’s small number of reproductivechoices strongly inXuences their ability to intervene and take appropriate action at anindividual level. Hartmann (1987) argues that reproductive rights are worthy of pur-suit in and of themselves and that these fundamental rights contribute to improve-ments in reproductive health.

In order to broaden women’s choices in all aspects of reproduction, the FourthWorld Conference for Women in Beijing (United Nations, 1995) strongly advocatedan empowerment approach. Empowerment refers to increasing women’s opportuni-ties to achieve a better quality of life as well as securing an overall improvement inrecognizing their contribution to the well-being of society (Batliwala, 1995). Empow-erment principles target improvement in gender equality as well as material well-being in order to enhance women’s ability to make choices and to set and achievegoals (Dixon-Mueller, 1993). Strengthening democratic processes facilitates desiredchanges in traditional institutions that have historically restricted women’s agencyand perpetuated gender inequality (Sim, 2000). In general, women’s empowermentprograms are closely linked to democratic civil liberties projects and evolving humanrights issues (McDaniel, 2002; Pimbert and Wakeford, 2002). The choices thatwomen make, with respect to reproductive health, can be broadened and realizedonly in the presence of a wide variety of reproductive rights (Mertus, 2000).

As gender equality improves, the amount of power that women exert collec-tively—to bargain and acquire desired resources—is likely to increase. Consider theinXuence of women’s increased power on societal institutions. In the Philippines,


women are enrolled at all levels of education; the percentage of women’s enrollmentin graduate schools is higher than that for men (Sutaria, 1981). At present, increasingproportions of women are found in all occupations and activities which were tradi-tionally considered to be preserved for men. Almost as a response to the growingpresence and inXuence of women in the labor market, there has been considerablemarket restructuring and an increase in catering to the demands by women for goodsand services. Furthermore, women have brought about revisions in legal documentssuch as the Family Code which traditionally accorded men more rights, authority,and privileges in keeping with social norms which sought compliance and deferencefrom women. A new Family Code of 1987 was legislated to correct most of the dis-criminatory practices.

The emergence of rights appears to be propelled by the growth of interest groups.Active social groups, rather than altruistic motivations or trans-national socializa-tion, shape rights agendas in the political arena (Moravcsik, 1998). As women gainpower, they are more likely to participate in extra familial and political activities andalso belong to organizations such as unions, clubs, what Durkheim calls ‘intermedi-ary associations’ (Durkheim, 1992). Political participation by women brings about anumber of opportunities to collectively organize and present a number of publicdemands to improve the availability and accessibility to various forms of capital. Inthe United States, for instance, left wing women’s organizations have played a crucialrole in passing laws to support women’s maternal roles (Heitlinger, 1993).

As women gain more power they will actively change their social environment byincreasing their social and personal choices. The pursuit of these choices involvesboth the demand for new rights and the dismantling of discriminatory legal practices.Improving gender equality as a means of empowering women is likely to result in asocial movement towards gaining the rights necessary to enjoying reproductivehealth (McDaniel, 1996). In sum, improving gender equality is likely to result inincreases in women’s rights in general and reproductive rights in particular.

Fraser (1996) suggests that equality is not possible until women are empowered torecognize their needs as democratic citizens. One of the most important precondi-tions for the growth of gender equality is the emergence of democracy (Mahajan,1996). Democracy, as a system of governance, provides a large number of options forthe preservation of human rights (Sanction, 1987; Sorensen, 1993). Howard (1995)suggests that political structures of social democracy are more likely to ensure adher-ence to universal human rights than are other types of state-centered political organi-zations. Social democratic systems attempt to ensure, through political processes, anumber of preconditions necessary to uphold universal values of human rights whileproviding a social identity of inclusiveness. The view of social democracy as amedium for dissemination of human rights Wnds support in the political philosophiesof Jurgen Habermas (1989), who has proposed a number of theories on democracy.

Ideally, the public domain is comprised of discoursing individuals whose social,economic, and gender identities seldom shape the course of the discourse (Habermas,1989). The assumption that all citizens are equal has been contested by several femi-nist scholars (Fraser, 1996; Pateman, 1988; Ryan, 1992). Eley (1992) reveals that thelanguage of public discourse is essentially masculine and rational. Male citizens often


use this to their advantage in public discourses in an attempt to mask women’s con-cerns. In addition, the exercise of civil and political rights may be severely compro-mised when citizens are illiterate and poorly fed and housed (Ginsburg and Rapp,1995; Howard, 1995). In spite of these constraints, Habermas (1989) suggests thatdemocracies provide a socio-political climate for the ongoing revision of social rights,as they relate to civil and political liberties. At a theoretical level, democratic institu-tions appear to be more likely to produce an environment conducive to addressingissues of gender inequality.

Democratic societies are more likely to seek reproductive health goals throughcooperative strategies (Sen, 1997). These may open up a number of avenues forwomen, in the presence of adequate power and inXuence to control health serviceavailability and accessibility, to maximize their reproductive health status basedupon their preferences and tastes. Vilas (1995) points out that democratizationimplies eVectively addressing economic inequalities and articulating the demands andperspectives of all socially mobilized sectors, including the realization of women’srights. Some research on Africa and Latin America indicates that the democratiza-tion process may co-opt a broader gender equality agenda (Jaquette and Wolchik,1998; Jensen, 1995; Philips, 1991; Walby, 2000) and open more avenues for women tonegotiate for independence and initiatives for social change (Luciak, 1999; Schild,2000).

In sum, we argue that in developing countries, levels of reproductive rights arepositively related to reproductive health, and are a function of gender equality.Improvements in gender equality tend to signiWcantly improve the levels of reproduc-tive rights and reproductive health. Gender equality is most likely to be valued andobtained in democratic settings which appear to be conducive to upholding the idealsof human rights. Thus, a human rights approach to reproductive health underlies theproposed reproductive health model.

2.1. Variables, methods, and measurement

The selection of variables for measuring women’s reproductive health is guided bya list of reproductive health scale items developed by the World Health Organization.The World Health Organization (WHO) convened two inter-agency meetings in 1996and 1997 on reproductive health and reproductive rights indicators for global moni-toring. At the second inter-agency meeting on Reproductive Health Indicators forGlobal Monitoring, the WHO adopted a set of 17 reproductive health indicators(WHO, 1997). These indicators were selected from a large list of variables using crite-ria such as usefulness, robustness, representativeness, and comprehensibility. How-ever, country level data were not available for nine indicators. The WHO recognizesthis problem and is currently in the process of launching several initiatives to gener-ate data at the country level (WHO, 1997).

Women’s reproductive health in this study is measured by the following 10 globalmonitoring indicators, eight of which are from the WHO list. The indicators are: (1)infant mortality rate—the number of infant death during the Wrst year of life per1000 total births; (2) total fertility rate—the average number of children that a


woman gives birth to in her lifetime, assuming that the prevailing birth rate for eachage category remains unchanged. High parity births have high risk of maternal mor-bidity and mortality; (3) percentage of adults living with HIV/AIDS; (4) percentage ofpregnant women who received prenatal care. It is the percentage of women who wereattended by a skilled health personnel at least once during pregnancy; (5) percentageof deliveries attended by skilled attendants; (6) maternal mortality ratio—the annualnumber of maternal deaths per 100,000 live births; (7) percentage of underweight chil-dren under Wve; (8) prevalence of anemia among pregnant women, measured as thepercentage of women of reproductive age (15–49) with hemoglobin levels below 110 g/L for pregnant women; (9) percentage of pregnant women immunized for tetanus(Wang and Pillai, 2000); and (10) births per 1000 women aged 15–19. Teenage moth-erhood results in several undesirable socio-economic outcomes which carry reproduc-tive health risks. Disadvantages experienced during adolescence have long termnegative consequences (Kamaara, 1999; Silberschmidt and Rasch, 2001; Wang andPillai, 2000). All the reproductive health indicators are continuous variables.

Independent dimensions include women’s reproductive rights, gender equality, anddemocracy rating. Wang and Pillai (2000) found a two sub-dimensional model forwomen’s reproductive rights: the right to legal abortion and personal marriage and divorcerights. The right to legal abortion is measured by the variable “grounds on which abortionis permitted.” Eight categories are assigned, based on the conditions where abortion is per-mitted: (1) illegal with no exception; (2) to save the woman’s life, (3) to preserve physicalhealth; (4) to preserve mental health; (5) rape or incest; (6) fetal impairment; (7) economicor social reasons; and (8) on request. Illegal with no exception is coded as 0. On request iscoded as 7 because in countries where abortion is permitted on request, it is also permittedon other grounds. For countries where abortion is either “not illegal” or “available onrequest,” the number of conditions under which abortion could be performed is counted.

The second sub-dimension of women’s reproductive rights, personal marriage anddivorce rights, is indicated by four variables: (1) personal rights to interracial, inter-religious, or civil marriages (interracial); (2) personal rights of equality of sexes dur-ing marriage and for divorce proceedings (divorce); (3) singulate mean age at mar-riage for women (marriage); and (4) maternal beneWts (beneWt).1 The values of twovariables, personal rights to interracial, inter-religious, or civil marriages and per-sonal rights of equality of sexes during marriage, range from 0 to 3. Zero indicatessevere violation of rights, 1 indicates frequent violation of rights, 2 represents occa-sional breaches of the rights, and 3 represents full respect for the rights. Singulatemean age at marriage refers to the mean age at Wrst marriage over the historicalperiod among women who ever married in the age group 15–50.

Gender equality is measured by: (1) percentage of women’s share of second levelschool enrollment; (2) percentage of seats held by women in the national parliament;(3) political and legal equality for women; and (4) social and economic equality forwomen. Discrete values ranging from 0 to 3 are used to code political and legal equal-ity for women, and social and economic equality for women. Zero indicates severe

1 Maternal beneWt is an additive measure of two scales: proportion of wages in the covered period, andthe number of days of maternity leave permitted divided by 150 days (maximum days).


violation of rights, 1 indicates frequent violation of rights, 2 represents occasionalbreaches of rights, and 3 represents full respect for rights.

Democracy in this study is measured by three variables: (1) human rights rating—a continuous variable ranging from 0 to 100 with 100 indicating the highest level ofhuman rights rating and (2) political rights and civil liberty. This variable is an addi-tive measure of two variables. One is political right; the other is civil liberty. The mea-sure ranges from 1 to 14 with 1 representing the highest degree of freedom. (3)Political terror scales (PTS)—a graded ordinal scale for measuring human rights vio-lation.2 In their discussion of PTS as a measure of democracy, Poe et al. (1999) con-clude that it is the “best currently available,” although the measure may be biasedtoward those countries that abuse human rights. Fig. 1 presents the empirical modelof reproductive health to be tested.

2.2. Data

Data sources for all the variables in the model are presented in Table 1. Theunits of analysis in this study are nations identiWed by World Bank (2000/2001) asdeveloping. Data necessary for testing the proposed model of reproductive healthare obtained for 129 developing nations. A list of all nations is presented in Fig. 2.Sources of data for this study are from a number of organizations under theUnited Nations. The United Nations staV continually review the data they publishfor reliability and validity3. However, the diWnitions and methodology underlyingindicators vary, sometimes signiWcantly, from country to country. The magnitudeof bias present in the data is not fully known. In general, the data on indicatorsprovided by United Nations and the World Bank are considered useful for identi-fying broad trends and diVerences (World Bank, 2000/2001).

A number of variables in the model suVer from the problem of missing data. Ofthe 27 variables utilized in this study, only 10 variables had information for allcountries. The remaining 17 variables had more than 10% cases with missing data.This problem was addressed by using the method of “hot decking.” When there aremissing observations, many of the standard statistical analyses such as maximum

2 The variable is coded in the following way: 1 D under a secure rule of law, people are not impris-oned for their views, and torture is rare or exceptional. Political murders are extraordinarily rare.2 D There is a limited amount of imprisonment for non-violent political activity. However, few areaVected, torture and beatings are exceptional. Political murder is rare. 3 D There is extensive politicalimprisonment, or a recent history of such imprisonment. Execution or other political murders and bru-tality may be common. Unlimited detention, with or without trial, for political views is accepted.4 D The practices of level 3 are expanded to larger numbers. Murders, disappearances, and torture are acommon part of life. In spite of its generality, on this level of violence aVects primarily those who inter-est themselves in politics or ideas. 5 D Level of violence (torture, murders) has been extended to thewhole population. The leaders of these societies place no limits on the means or thoroughness withwhich they pursue personal or ideological goals.

3 At a broad level we could give international data some validity if hypotheses for which we have strongtheoretical reasoning are supported—for example, the negative relationship between women’s status andinfant mortality rates in developing countries. This and similar hypotheses have been successfully testedusing United Nations data by cross national researchers (Shen and Williamson, 2001).


likelihood can result in biased estimation (Liang and Zeger, 1986). Several imputa-tion methods such as overall mean, class mean, regression, hot deck, and multipleimputations have now been developed to minimize the bias resulting from missingdata. Among these methods, hot deck imputation is relatively simpler than othersand is widely used. In this method, missing values are obtained by identifying acase which is similar in selected characteristics to the missing data case. The valueof the variable from the identiWed case is substituted for the missing value. In thisstudy, similar cases for missing value imputation were randomly identiWed as beingin the same region to which the missing case belonged. This strategy produces vari-ation consistent with a range of possible values from complete records within theregion. Hot deck imputation method assumes that data are missing at random(MAR) (Little and Rubin, 1987). Data are missing at random when the missingvalue of a case related to a variable is not dependent on the value of the missingcase itself but may depend upon values of other variables in the data set. Since thevalue imputed for missing observation is that of a case similar in selected charac-

Fig. 1. The hypothetical model of women’s reproductive health. Variables: X, human rights rating; X2,political rights and civil liberty; X3, political terror scale; Y1, percentage of women’s share of second levelschool enrollment; Y2, percentage of seats held by women in national parliament; Y3, political and legalequality for women; Y4, social and economic equality for women; Y5, grounds on which abortion is per-mitted; Y6, singulate mean age at marriage; Y7, maternity beneWts; Y8, personal rights to interracial,interreligious, or civil marriages; Y9, personal rights of equality of sexes during marriage and for divorceproceedings; Y10, infant mortality rate; Y11, total fertility rate; Y12, birth per 1000 women aged 15–19;Y13, percentage of adults living with HIV/AIDS; Y14, percentage of pregnant women who received pre-natal care; Y15, percentage of deliveries attended by skilled attendants; Y16, maternal mortality ratio;Y17, percentage of under-5 children under weight; Y18, prevalence of anemia among pregnant women;Y19, percentage of pregnant women immunized for tetanus. Gen, Gender equality; Dem, the extent ofdemocracy; PRR, personal reproductive rights; WRH, women’s reproductive health.


Table 1Variables and data sources

Variable Source

Democracy (DEM)X1: Human rights rating Humana, Charles. 1992. World Human Rights GuideX2: Political rights and civil liberty Freedom House. 1998. Annual Survey of Freedom

Country Scores 1998–1999X3: Political terror scale Amnesty International. 1999. Annual Report on Country

Human Rights Practices. www.ippu.purdue.edu/info/gsp/governance/terrorscale.html

Gender equality (GEN)Y1: Percentage of women’s share of second level

school enrollmentUnited Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y2: Percentage of seats held by women in national parliament

United Nations Development Fund for Women. 2001. Progress of the World’s Women 2000

Y3: Political and legal equality for women Humana, Charles. 1992. World Human Rights GuideY4: Social and economic equality for women Humana, Charles. 1992. World Human Rights Guide

Legal abortion right (ABR)Y5: Grounds on which abortion is permitted United Nations Development Programme. 2000. World

Abortion Policies 1999

Personal reproductive rights (PRR)Y6: Singulate mean age at marriage for women United Nations Statistics Division. 2001. The World’s

Women 2000: Trends and StatisticsY7: Maternity beneWts United Nations Statistics Division. 2001. The World’s

Women 2000: Trends and StatisticsY8: Personal rights to interracial, interreligious,

or civil marriagesHumana, Charles. 1992. World Human Rights Guide

Y9: Personal rights of equality of sexes during marriage and for divorce proceedings (WRH)

Humana, Charles. 1992. World Human Rights Guide

Y10: Infant mortality rate United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y11: Total fertility rate United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y12: Births per 1000 women 15–19 United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y13: Percentage of adults living with HIV/AIDS United Nations Development Fund for Women 2001. Progress of the World’s Women2000

Y14: Percentage of pregnant women who received prenatal care

United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y15: Percentage of deliveries attended by skilled attendants

United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y16: Maternal mortality ratio United Nations Statistics Division. 2001. The World’s Women 2000: Trends and Statistics

Y17: Percentage of under-5 children under weightUnited Nations Children’s Fund. 2001. The Progress of Nations 2000

Y18: Prevalence of anemia among pregnant women

Population Action International. 2001. World of DiVerence: Sexual and Reproductive Risks

Y19: Percentage of pregnant women immunized for tetanus

World Resources Institute. 1999. World Resources 1998–1999

http://www.ippu.purdue.edu/info/gsp/governance/terrorscale.html




teristics, hot deck imputation tends to underestimate the variability in the variablewith missing values. This is likely to increase the likelihood of Type-I error.

Table 2 presents the mean values of all the variables before and after imputationfor missing data. For all the variables with mean substitution, the ratio of the meanvalues before and after mean substitution is about 1.

2.3. Analysis and results

In order to test the proposed reproductive health model, it is essential to obtainreliable and valid measures of all the latent concepts associated with the reproductive

Fig. 2. Nations included in the study.


health model. The conWrmatory factor analytic method provides a tool to assess thepsychometric properties of the latent concepts in the model. Table 3 presents the testresults of the measurement model.4

The Wt between the hypothesized covariance structure for each of the latent constructand the covariance structure obtained from the sample data are indicated by Wt indicessuch as goodness of Wt index (GFI) and adjusted goodness Wt index (AGFI).5 The GFIshows the amount of variance and covariance explained by the model. The AGFI diVers

4 Factor analytic models are estimated using the structural equation software, MPLUS. The structuralequation modeling software programs such as EQS and LISREL assume that all the indicators are contin-uous. However, Mplus, a structural equation modeling program developed by Muthen and Muthen(1998), allows for estimation of factor analytic models when some variables are measured at the continu-ous levels and others at the nominal. A few of the variables used in this study are categorical in nature in-Xuencing the choice of MPLUS package over other structural equation programs currently available. Inaddition the program accommodates the estimation of models that contain data missing completely atrandom, and missing at random.

5 Prior to conWrmatory factor analysis, the signs of a few indicators were reversed such that each indica-tor in the model theoretically loaded positively with the latent dimension it is associated with.

Table 2Comparison of the mean values of the variables before and after missing data imputation using the hotdeck method

Variable Variable label Mean before imputation

Mean after imputation

Human rights rating Human 54.192 53.070Political rights and civil liberty Liberty 8.246 8.246Political terror scale Terror 8.111 8.111Percentage of women’s share of second level school

enrollmentShare 44.784 44.380

Percentage of seats held by women in national parliament Seat 9.190 9.190Political and legal equality for women Legal 1.479 1.426Social and economic equality for women Social 1.205 1.209Grounds on which abortion is permitted Abortion 2.810 2.810Singulate mean age at marriage for women Marriage 22.368 22.202Maternity beneWts BeneWt 85.761 85.804Personal rights to interracial, interreligious, or civil

marriagesInterracial 2.370 2.364

Personal rights of equality of sexes during marriage and for divorce proceedings

Divorce 1.493 1.481

Infant mortality rate Infant 57.097 57.097Total fertility rate tfr 4.164 4.164Births per 1000 women aged 15–19 Teen 91.278 91.278Percentage of adults living with HIV/AIDS Aids 3.233 3.249Percentage of pregnant women who received prenatal care Care 72.361 72.945Percentage of deliveries attended by skilled attendants Attend 61.263 63.255Maternal mortality ratio Maternal 401.000 404.111Percentage of under-5 children under weight Weight 20.556 20.171Prevalence of anemia among pregnant women Anemia 3.989 3.853Percentage of pregnant women immunized for tetanus Tetanus 50.555 53.264


Table 3Measurement model parameters (standardized solution in parentheses)

* p < .05.** p < .01.

Latent Observed Slope R2 CFI (TLI)

VariablesDEM Human 1.000

(0.720)0.518 0.99 (0.98)

Liberty ¡0.480* (¡0.790)

0.624

Terror ¡0.220* (¡0.360)

0.130

GEN Legal 1.000 (0.603)

0.363 0.93 (0.89)

Social 0.445** (0.857)

0.735

Share 1.862* (0.382)

0.146

Seat 1.355* (0.380)

0.144

ABR Abortion 1.000 (0.949)

0.900

PRR Marriage 1.000 (0.215)

0.046 0.92 (0.89)

BeneWt 4.019 (0.169)

0.028

Interracial 0.745**

(0.745)0.555

Divorce 0.651**

(0.651)0.423

WRH Teen 1.000 (0.610)

0.370 0.89 (0.91)

Infant 0.870**

(0.680)0.470

tfr 0.040** (0.670)

0.453

Aids 0.040* (0.300)

0.090

Care 0.440* (0.720)

0.520

Attend 0.220* (0.530)

0.298

Maternal 9.360** (0.927)

0.859

Weight 0.754* (0.468)

0.219

Anemia 0.020* (0.650)

0.420

Tetanus 0.190* (0.290)

0.090


from GFI only in terms of the fact that it adjusts for the number of degrees of freedomin the model. The values of these indexes range from zero to one. The desirable range ofvalues for these two indexes, suggestive of good Wt between the model and data, isbetween .90 and 1. Values above .90 are considered indicative of good Wt. All the latentconstructs in this study have GFI values above .90. In addition, all the factor loadingsare positive as expected and signiWcant at the .05 levels. The slope values or factor load-ings are un standardized regression coeYcients that estimate the direct eVect of the fac-tors on the indicators. Most of the standardized factor loadings are above .30 except inthe case of the two indicators (marriage and beneWt) of personal reproductive rights.

The values of squared multiple correlation represent the proportion of varianceexplained in the variable by the latent construct. They point to the reliability of eachindicator with respect to its latent construct. An examination of the reliability esti-mates suggests that a few indicators have low reliability values. In particular, two ofthe four indicators of reproductive rights have low factor loadings. Among the repro-ductive health indicators, two have low values. These indicators are retained for sub-stantive grounds.6

Table 4 presents the results of the test of the model, using the Mplus structuralequation modeling approach (Muthen and Muthen, 1998), in the form of structuralparameter estimates. The structural equation modeling approach provides an ade-quate strategy for testing the proposed model of reproductive health which has anumber of causally related latent dimensions. Each dimension is measured by a num-ber of indicators. Unlike multivariate techniques such as regression analysis, it isassumed that the indicators contain measurement error. The reproductive health

6 To determine whether the presence of poor indicators result in changes in the values of the measure-ment model parameters, the measurement model was re-estimated after dropping four indicators, mar-riage, beneWt, HIV/AIDS, and tetanus. The values of the factor loadings and the R-squared values of thevariables in the two measurement models are similar.

Table 4Structural equation model of reproductive health: parameter estimates (standardized solutions in paren-theses)

DEM, Democracy; GEN, gender equality; ABR, abortion; PRR, personal reproductive rights; WRH,women’s reproductive health.

* p < .05.** p < .01.

Endogenous factors Exogenous factors

DEM GEN ABR PRR

DEMGEN 0.342* (0.280)ABR 0.082 (0.165)PRR 1.870* (0.135)WRH 1.818* (0.095) ¡3.919 (¡0.102) 28.487** (0.812)

CFI D 0.902TLI D 0.895


model developed in this study contains a number of latent factors that are causallylinked. Structural equation modeling approach facilitates the regression analysis ofcausal models where the independent and dependent variables are latent dimensions.

The eVect of democracy on gender equality is positive and signiWcant, supportingthe hypothesized relationship between gender equality and democracy. The genderequality level increases by approximately 32% per unit increase in the measure ofdemocracy. Improvement in gender equality is expected to result in signiWcantincreases in reproductive rights. Empirical support for the expected relationshipbetween gender equality and reproductive rights is mixed.

Reproductive rights were conceptualized as an inter-correlated two-dimensionalconstruct. The two dimensions being abortion rights and personal rights. The eVectof gender equality on abortion rights is insigniWcant. A positive eVect was hypothe-sized. As expected, the eVect of gender equality on the personal rights dimension ofreproductive rights is positive and signiWcant. Gender equality also has positive andsigniWcant inXuence on reproductive health as hypothesized.

The two components of reproductive rights, abortion rights and personal rights,were hypothesized to inXuence women’s reproductive health levels positively. How-ever, the eVect of abortion rights on reproductive health is found to be insigniWcant.The eVect of personal rights on reproductive health is positive and signiWcant ashypothesized. Thus, there is partial support for the hypothesized direct eVect ofreproductive rights on women’s reproductive health levels in developing countries. Indeveloping countries, increases in gender equality and the development of personalrights directly improve the levels of reproductive health. The reproductive healthmodel developed in this study appears to Wt the data well. The values of GFI andAGFI are .901 and .900, respectively. Both good of Wt indexes reach the suggestednormative value of .900 or above.

3. Conclusion and discussion

The last decade witnessed some of the greatest strides in promoting women’shealth globally. At the 1994 Cairo conference, it was resolved that globally, thedesired high levels of reproductive health, throughout a woman’s life, should rankequally in importance to the national aspiration for sustainable personal develop-ment and security. The conference also recognized the positive association betweenreproductive health, gender equality, and women’s empowerment. In spite of thesevalue shifts in favor of promoting reproductive health, progress toward achievingimprovements in women’s reproductive health in developing countries has been slow(Rosenfeld, 2001). For example, at the 1995 Beijing conference, all participant coun-tries were charged to reduce maternal mortality rate by 50% of the 1990 levels in theyear 2000. However, progress in this area remains slow (Rosenfeld, 2001).

The slow pace toward improving women’s reproductive health is associated withsocial structural barriers and ill-designed programs (Lieberman and Davis, 1992). Atthe program level, initiatives for improving reproductive health have been based onthe idea of women’s empowerment. In this paper we have argued that improvements


in gender equality, as well as reproductive rights in developing countries, provide twoimportant sources of empowerment for women in those countries. This perspective isconsistent with the 1995 Beijing Plan of action (United Nations, 1995) which pro-poses guarantees of fundamental freedoms and reproductive rights along with genderequality, leading to the improvement of women’s health in developing countries.

Improving gender equality is a socio-political process. Democratic processeswhich allow multiple political groups, including women’s groups, to participateand compete for scarce resources, are seen as a precondition for improving genderequality. The positive inXuence of democratic levels on gender equality supportsthe argument that gender relations are political and the context of political pro-cesses should not be ignored during the course of planning social empowermentprograms. As gender equality increases, women’s ability to negotiate power andenter into partnership with men, as recognized equals, increases. This ability isessential for ensuring the presence of a number of realistic choices women can exer-cise in order to achieve desired levels of reproductive health.

As gender equality increases, the level of personal reproductive rights increases.This study shows abortion rights to have no signiWcant relationship with genderequality levels. Therefore, it may be speculated that broader ideologies, related to themeaning of life and death, inXuence the conditions under which abortion is permit-ted. In particular, our results suggest that personal reproductive rights play a crucialrole in improving reproductive health levels in developing countries. Mann (1997)has theorized the role of reproductive rights in increasing reproductive health indeveloping countries. His suggestion Wnds empirical support in this study, reinforcingthe need to enhance the link between reproductive rights and reproductive health as aglobal strategy for improving reproductive health; as set forth at the 1994 Cairo Con-ference and the 1995 Beijing conference. Our results extend Mann’s thesis and sug-gest that the role played by the building of democratic institutions in developingcountries, as it aVects women’s reproductive health, may not be ignored.

A wide variety of social empowerment programs has been advocated for achievingreproductive health in developing countries. These programs vary in content andapproach toward achieving empowerment. This is because there is no universal deWni-tion of social empowerment. In this study, we describe women’s empowerment, in thecontext of reproductive health, as improving gender equality and promoting reproduc-tive rights. Given this limited deWnition of social empowerment, results indicate a posi-tive association between empowerment and reproductive health levels in developingcountries. In this regard, the personal component of women’s reproductive rights isfound to be more relevant than the abortion rights component. Social empowerment isa political process (Fukuda-Parr, 2003). Democratic practices which provide women’sgroups a forum to actively pursue women’s issues are more likely to address problemsof gender stratiWcation and gender discrimination in social and political spheres. Dem-ocratic institution building in developing countries is necessary in order for socialempowerment programs to succeed in improving their reproductive health levels.

In developing countries, the availability of reproductive health services may berestricted by a number of external factors. The following is an example that demon-strates how large, powerful donors and core states such as the United States inXuence


global reproductive health levels. In 2003, President Bush promised to spend $15 bil-lion on HIV/AIDS in developing countries over a period of Wve years. However, soonafter the announcement, the Bush Administration proceeded to apply the anti-abor-tion “global gag rule” to the terms of funding. The gag rule, also known as the “Mex-ico City Policy,” prohibits foreign, non-governmental organizations (NGOs) fromreceiving U.S. Agency for International Development (USAID) family planningfunds and from using their own funds to provide legal abortion services. In addition,these agencies are also prohibited from lobbying their governments for abortion lawreform. President Bush has now withdrawn his commitment, which results in adramatic international reduction in the budgeted outlay for HIV/AIDS prevention.The immediate victims of this course of action are women and girls (Bauman, 2003).

The role of democratic institutions and values, in improving levels of women’sreproductive health in developing countries, rests on at least two assumptions on thenature of democratic states. First, it is assumed that an appropriate unit of analysisfor examining democratic states is the nation state (Held, 1992). A second assump-tion is that the representative assembly, as the central nucleus of any democratic gov-ernment, is equipped to safeguard public interest and discourse (Evans, 2000).However, due to the forces of globalization, these assumptions do not always hold.The belief that the political boundaries of the state are insular and impermeable maynot be true (Held and McGrew, 1999). This is because powerful media and informa-tion technologies make it possible to transport public discourse from within the stateto non-citizens outside the state’s political boundaries. If non-citizens inXuence statepublic discourse, the appropriate unit of analysis may no longer be the state. Further-more, the nucleus of any democratic state, the representative assembly, may not beable to act independently and fully in the interests of its citizens.

The decline in state power stems from the growing prominence of internationalorganizations such as the United Nations and the World Trade Organization andtheir ability to prevail over national policies. A number of multinational organiza-tions have made heavy capital investments in emerging democracies so that they areable to negotiate terms and conditions with the state which may not be in the bestinterest of a signiWcant proportion of the local population (Gills et al., 1993). Therevision of these assumptions necessitates a more global formulation of democracyas a concept. Such reformulations may result in rethinking the unit of analysis forfuture studies as well as revising the magnitude of state level inXuences on women’sreproductive health.

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