2025 Theses Doctoral

Advancing the Science on Measurement, Determinants, and Outcomes of Pregnancy and Abortion Coercion in Global Settings: A Mixed Methods Study

Liang, Mengjia

Background
Reproductive coercion, which includes behaviors that undermine an individual’s autonomy in reproductive decision-making, is increasingly recognized as a critical issue within sexual and reproductive health and rights (SRHR). However, evidence remains limited, particularly in low- and middle-income countries (LMICs), where structural and sociocultural factors shape reproductive agency in distinct ways. This dissertation seeks to advance a comprehensive understanding of reproductive coercion by examining its prevalence, determinants, and consequences, as well as the policy and programmatic responses addressing it. Through a mixed-methods approach, this research aims to generate evidence that informs interventions and policies to enhance reproductive autonomy, particularly in LMICs. Specifically, it comprises three interrelated studies: (1) a global scoping review synthesizing existing evidence on reproductive coercion; (2) a quantitative analysis of Cambodia Demographic and Health Survey (CDHS) data to identify factors associated with reproductive coercion and its health consequences; and (3) a qualitative study exploring policy and programmatic responses to reproductive coercion in LMICs through key informant interviews (KIIs) with global and regional experts.

Methods
A systematic scoping review was conducted to synthesize global evidence on reproductive coercion, including its measurement, determinants, and consequences. The quantitative component utilized nationally representative data from the 2021-2022 CDHS, employing logistic regression models to assess associations between reproductive coercion, demographic and social factors, and reproductive health outcomes such as intimate partner violence (IPV), contraceptive use, unintended pregnancy, and sexually transmitted infections (STIs). The qualitative component consisted of 17 KIIs with academics, policymakers, health practitioners, and civil society actors engaged in reproductive coercion interventions and policy advocacy across LMICs. Thematic content analysis was used to identify key challenges, opportunities, and best practices in addressing reproductive coercion at policy and programmatic levels.

Results
The scoping review reveals that reproductive coercion remains inconsistently defined and measured, with most research originating from high-income countries and limited evidence from LMICs. While existing studies indicate strong associations between reproductive coercion, IPV, and adverse reproductive health outcomes, gaps remain in understanding contextual variations and intervention effectiveness in LMIC settings.

The quantitative analysis of Cambodia highlights that 4.4% of married or in-union women report experiencing pregnancy coercion, while 36.3% experience reproductive coercion when incorporating broader SRHR decision-making constraints (SDG 5.6.1). Younger age, lower education, economic disadvantage, limited social connectedness, and attitudes justifying domestic violence are significant predictors. Reproductive coercion is associated with higher risks of IPV and STIs, underscoring its intersection with gender-based violence. However, no significant associations were found with modern contraceptive use or unintended pregnancy, suggesting complex pathways between coercion and reproductive behaviors.

The qualitative findings indicate that while reproductive coercion is increasingly recognized within global and regional policy discussions, dedicated interventions remain scarce. Most LMIC policies address reproductive coercion indirectly within family planning and IPV frameworks, often without clear implementation guidance. Innovative interventions, such as the ARCHES model and gender-transformative community programs, have shown promise, yet face challenges related to policy fragmentation, limited provider training, social norms, and funding constraints. Experts emphasize the need for multi-sectoral strategies that integrate reproductive coercion responses into SRHR and GBV services, engage men and communities in norm change, and ensure sustainable financing beyond donor-driven initiatives.

Conclusion
This research underscores reproductive coercion as a complex, multi-faceted issue requiring coordinated responses across legal, health, and social systems. While Cambodia provides a case study of reproductive coercion’s prevalence and health implications, broader LMIC policy and programmatic responses remain underdeveloped. Strengthening measurement frameworks, expanding evidence-based interventions, and fostering cross-sector collaboration are critical for advancing reproductive autonomy and reducing coercion globally. Future research should focus on context-specific programmatic evaluations, policy integration strategies, and mechanisms to sustain reproductive coercion interventions within national health and gender equity agendas.