MEASUREMENTS OF WOMEN’S AUTONOMY IN REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES: A LITERATURE REVIEW

Background: The autonomy associated with the essence of decision-making in the field of reproductive health, including about fertility, pregnancy, and the utilization of health services. The research has shown that autonomy occurred in poor countries and growing. This literature is intended to explore autonomy measures and policies related to reproductive health programs. Methods: Review of the literature search some databases such as the Online Public Access Catalog (OPAC) and Pubmed Medical Center (PMC). Twenty-two articles that met the criteria for discussion included articles dominated by South and Southeast Asia and parts of Africa, as well as one European region. Most of the literature defines women's autonomy using theories from previous literature. Results: the study proves that there is a link between autonomy and utilization of health services, family planning and fertility. Autonomy measurement is done by using direct and indirect dimensions. Dimensions direct connect participation in decision making related to the economy, household and mobility. The other dimension is to assess women's attitudes toward domestic violence. Dimensions are indirectly related to proxies that affect women's status such as employment, education or media exposure. Conclusion: Potential policies and programs related to reproductive health in developing countries basically recommend the integration of women's empowerment in health programs.


INTRODUCTION
The reproductive health rights become one of the international agenda in 1994, the International Conference of Population Development (ICPD) conference in Cairo emphasis about humanism approach and human rights in looking at population and development issues and on the role of empowering women in reproductive behavior. The reproductive health also become a priority program to improve the women roles7, 23. Autonomy assessment is an indicator in increasing the role of women16. Dason and Moore (1983) explain autonomy as a person's ability to participate in the environment, be able to access information freely and be involved in decision making. Married women have increased autonomy so they can make decisions in the household and have power over personal rights such as household affairs and financial arrangements28,36.
Socio-economic and social is one dimension of autonomy. Countries with patriarchal ideas such as Bangladesh, India, including Indonesia have the same problem in autonomy. This understanding puts men in a more powerful position than women. Haque's (2012) study in Bangladesh and Widyastuti (2017) in Indonesia show that autonomy affects women's decisions in using ANC. Likewise, research in India shows that there is a link between women's autonomy and the use of health services and the improvement of reproductive health32. Other studies have shown that women with higher status may control fertility and reproductive health25.
Gender dynamics related to sexual and reproductive health began to be encouraged after the ICPD Conference in 1994. Based on the facts, there are limitations for women to participate in decisions in the household and family environment12. This continues to deepen the international agenda, MDG's 2015, SDG's, and the World Bank's world development report 2012, which places the main program on issues of women's rights and gender.
Based on the concept of Kabeer (1999; reproductive health is associated with women's autonomy. therefore, research is needed to support the theory by measuring autonomy. Specifically, the objectives of this study are 1) To identify the linkages between autonomy and various reproductive health outcomes, 2) to examine indicators of measuring autonomy with various reproductive health outcomes.

Search Strategy and Study Inclusions
Searches were initially carried out on all literature sites such as Pubmed, Elseiver, Bmj, Biomed, Science direct and others .However, there is no literature on the measurement of autonomy. The search for literature sources is done by electronic online databases with Online Public Access Catalog (OPAC) and Pubmed Medical Centre (PMC). The addition of sources of information is done using Google Scholar, and relevant articles are also used as references. The selection process is described in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework in Figure 1. Inclusion criteria consist of 1) English and Indonesian 2) Assessing the links between autonomy and at least one of the reproductive health outcomes.
3)Describe clearly the measurement of autonomy 4)Describe associations, not opinions or literature 5) limitation of 2000-2020.The exclusion criteria were articles with the keywords above, however 1) targeting the general population (not married women) 2) did not address women's autonomy. 3) articles other than English and Indonesian.. Publications with primary and secondary data are included when discussing autonomy and one of the effects of reproductive health, so that the remaining 29 articles with full texts will be assessed and then 7 articles are released because they only contain reviews and opinions. And at the end of the search, 22 articles were included in the selection for review. The evaluation of the quality of articles was not carried out in this study because the purpose of the synthesis of the literature was to summarize the assessment of the effect size of the review article ( Figure  1) Most studies are conducted in parts of South Asia, ten in parts of Africa and two in parts of Southeast Asia and Europe. All studies used quantitative methods for data collection, dominated by secondary data with a Demographic Health Survey (DHS), the rest using primary data.
Autonomy and various effects of reproductive health Most of the literature defines female autonomy using theory from previous literature. Another study combines the definition of female autonomy by Dyson and Basu as the capacity to manipulate the environment related to controlling resources and information for personal desires. Dominant studies discuss the relevance of autonomy with the use of reproductive health services, six articles discuss Family Planning, five publications suggesting pregnancy, and the rest link autonomy with fertility and sexual activity.
Autonomy measurement indicator Measurement of autonomy is carried out using direct and indirect dimensions. The direct dimension links participation in decision making related to the economy, household and mobility. Another dimension is assessing women's attitudes towards domestic violence. The dimensions are indirectly related to proxies that affect women's status such as employment, education or media exposure. So that causes gender differences between men and women. Various literature uses these dimensions singly or in combination. Most of the literature uses dimensions of participation in decision making in households for measuring autonomy.
On a single basis, participation in the household was used in the research of Hindin

Utilization of services
Review studies show the dominance of autonomy related to the utilization of health services. ten studies conducted research to identify the relationship between autonomy and utilization of services, both for maternal health and for children. Eight studies were conducted in South Asian countries (Bangladesh, Nepal, India) and two others in African countries. Ghose (2017) shows the association between participation in decision making and the utilization of maternal health services for Bangladeshi women. The results showed that, compared to women who could make decisions, women in urban areas who had decided on their health care with their husbands / partners had 20% (95% CI 0.794 to 1,799) more likely to attend at least four antenatal visits and they settling in rural areas has 35% (95% CI 0.464 to 0.897) lower chances of attending at least four antenatal visits. This is supported by Haider (2017) which shows that every one increase in autonomy score, the utilization of maternal health services will increase by 0.14 for ANC, and 0.13 for PNC. Research in the same country was also carried out by Haque (2012), but with young female respondents (15-24 years) showing that young women who have a higher degree of autonomy are more likely to receive adequate ANC. Likewise, women with moderate autonomy were 1.40 times more likely to give birth assisted by trained personnel than women with low autonomy. Widyastuti (2017) also with the subject of Indonesian adolescents reveals that it is important for adolescents to have decision-making power in the family, especially during pregnancy.
Studies in another South Asian country in Nepal also showed that women with autonomy in health care were significantly more likely to attend ANC = 3 visits (OR = 1.69, 95% CI = 1.41-2.03) and had the opportunity to give birth in a health facility ( OR = 1.44 95% CI = 1.26-1.64)31. African countries such as Eritrea and Ethiopia also express the same thing that the strong positive influence of a woman's decision making enables them to participate in decisions. The percentage of women with high decision-making power has a positive relationship with antenatal care visits36. Furuta's (2006) study is slightly different from the others, because the results showed that although the relationship was not consistent across all indicators, husband and wife discussions about family planning were associated with an increased likelihood of receiving antenatal care and childbirth..

Family Planning
Blackstone (2017) in his study in African countries (Ghana) and regression analysis showed that women who are abused have a low chance to use contraception. In other African countries (Ethiopia) studies related to family planning autonomy associated with dimensions in household decisions and attitudes toward violence with the results showed there is a correlation between the two34. Renuka (2016) in Coimbatore also proves the alleged relationship with chi-square analysis which shows a strong relationship between decision-making power and contraceptive use and between indirect dimensions and educational indicators that have a strong relationship with contraceptive use. Samari (2017) in Egypt found that women with a high degree of autonomy tend to use the LARC method compared to shortacting ones. The same thing with research Patrikar (2014) in India found evidence that women with low levels of decision making has a higher degree of autonomy that allows the use of contraception. study in Bangladesh showing that women with a high autonomy scale of unwanted pregnancies were around 23%. Stojanovski (2017) also conducted research in roma which showed that women who are able to make decisions showed 1.4 times control unwanted pregnancy.
In another South Asian country, Nepal has shown a study that women who are literate are 39 percent less likely to die of infants than illiterate women. Likewise, women who are able to participate in decision making have a 26 percent lower likelihood of infant mortality than those who are not involved in the decision-making process4.

DISCUSSION
the concept of autonomy does not only concern social issues, but also develops in health sciences. The autonomy of women in making decisions, especially in terms of reproductive health, is very important for better maternal and child health18. From various factors that hinder women's access to reproductive health in developing countries, it proves that women's autonomy has an important role10.
The ability of women to participate in health decisions depends in part on autonomy13. People with low income have an impact on the status of women with limited autonomy and the ability to make decisions in every aspect of life30. This illustrates that a society with such conditions still has a strong social structure that rigidly defines the roles of men and women, usually coded in religious, ethnic and social traditions14.
R. Freedman in the 2012 IDHS Further Analysis, describes a model between fertility and social conditions with the prevailing norms. The results of further analysis of the 2012 IDHS show that social structures and norms have a significant effect on fertility. Previous research, located in Sehore, a district of Madhya Pradesh in India by Char et al (2010), showed that family and prevailing norms influence women to make decisions regarding the number of children and the use of contraception. According to Freedman, variables that directly affect fertility are basically also influenced by the norms prevailing in society.
In making decisions related to fertility, the relationship between family members is influenced, especially the relationship between husband and wife. Husband and wife relations are reflected in gender relations which are the construction of sociocultural values and norms at the community level2. The success of the Family Planning (KB) program is highly dependent on community participation. It is hoped that the high level of community participation in the family planning program can achieve the goals of the family planning program. One indicator of the success of the Family Planning (KB) program is the declining rate of population growth. Women's participation and empowerment in family planning programs is a potential strategy in increasing women's access and cultural transformation8.
Women's participation in the family planning program supports women's empowerment in making decisions for themselves and their families22. The sociocultural context that describes the relationship between women's characteristics at the individual level in decision-making and autonomy is the main mediator intervention between women's status and reproductive outcomes19. Gender inequality affects communication, thereby limiting women's decision making to access reproductive health3.
Reproductive health program and policy opportunities in developing countries are basically related to the integration of women's empowerment into health programs. Based on the literature study, the program strategy offered relates to contraceptive use through the promotion of women's empowerment, namely decision making and education. thus impacting women's ability to negotiate fertility decisions. Meanwhile, for the utilization of