Social and Logistical Barriers to the Use of Reversible Contraception among Women in a Rural Indian Village

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ABSTRACT

Women in a small coastal village in western India were asked to explain their preference for female sterilization over modern reversible contraceptive methods. Married women aged 19+ years were interviewed in six focus groups (n=60) and individually (n=15) regarding contraceptive methods and their use and side-effects. Women publicly denied contraceptive use but privately acknowledged limited use. They obtained contraceptive information from other village women and believed that modern reversible methods and vasectomy have high physical and social risks, and fertility goals could be achieved without their use. Women felt that reversible contraception is undesirable, socially unacceptable, and usually unnecessary, although the achievement of fertility goals is likely due to the use of female sterilization with abortion as a back-up method. Economic migration of village men may also play a role. Although women with high social capital can effectively disseminate correct knowledge, the impact on the uptake of reversible method is uncertain.

Key words: Beliefs; Contraception; Contraception, Reversible; Contraceptive methods; Family planning; Women; India

INTRODUCTION

Female sterilization is the most prevalent form of contraception in India, accounting for 76% of all use among women (1). Use rates of temporary modern contraceptive methods are very low. Previous studies have identified barriers to contraceptive use, which include the monetary and time costs of obtaining contraception (2,3), the social stigma of using contraceptives in an unsupportive setting (4,5), lack of knowledge (6,7), desire for more children (8- 10), the costs of acquiring additional information (11), and worry over possible side-effects and fears that reversible methods are ineffective (4,7,8,12). Historically, Indian health providers have emphasized female sterilization; this may also limit the uptake of reversible contraception (8,12,13).

This paper explores beliefs of women regarding reversible contraception in a context where women are able to achieve their fertility goals using sterilization and periodic abstinence with abortion as a back-up method (14). The study was conducted in a rural Indian village where stigma regarding sexual immoderation and myths and misconceptions regarding side-effects of reversible contraception and vasectomy also contribute to the conviction of women that sterilization is superior. Unlike many other rural areas, the study area women had access to modern methods from a health clinic, a hospital, and pharmacies nearby. A greater understanding of the contraceptive decision-making process has the potential to inform programmes that seek to increase the uptake of temporary contraceptive methods in rural India.

An estimated 75% of all contraceptive users (84% of those who use a modern contraceptive method) in India rely on female sterilization, while vasectomy is used by just 2% of contracepting couples (10). For many women, female sterilization is the first and the only contraceptive method they use (15). The median age at sterilization is 25.7 years; this, however, varies from a low of 23.6 years in Andhra Pradesh in southern India to 30.5 years in Manipur in eastern India (16). In 2001, an estimated 15.8% of currently-married Indian women of reproductive age had an unmet need for contraception, i.e. they desired to space or limit pregnancies but were not using contraceptive methods to do so (7). The contraceptive prevalence rate of reversible methods has remained low; while supplies of reversible contraceptives are available free of charge to women in some areas, demand has been weak (12). In Maharashtra, although 60.9% of women are using contraception, only 7.6% are using reversible methods for spacing (17). Birth intervals of <36 months, which have been linked to increased maternal and child morbidity and mortality (18-22), are more common among women who do not use spacing methods. …