Is the expansion of the basket enough to satisfy the contraceptive needs of women?
The power of options, the theme of World Contraception Day 2023, can be perceived as inspirational and aspirational. Research evidence also shows that increased choice reduces maternal and child mortality, accelerates fertility decline, and empowers individuals, including young people, to take control of their lives. Moreover, offering a basket of contraceptive choices helps to reduce unmet needs, increases method continuity, and reduces unintended pregnancies. Adding one new method to the available method mix can increase contraceptive prevalence by as much as %.
Although there is data to support that there has been a moderate increase in the uptake of reversible contraceptive methods, the method mix is still dominated by sterilization. In addition, a high proportion of the population, especially in rural areas, continues to suffer and die from unintended and mistimed pregnancy and childbirth complications. The recent statistics reflect that the unmet need had declined from 13% to 9.4%. However, diving deeper into the sub-groups indicates that the unmet need for spacing remains significantly high among women aged 15-24. Additionally, more than two-thirds of women in the 15-24 age group are not even using modern methods, instead resorting to traditional ways or not using any method. The dominance of a permanent method within a context of low prevalence and high unmet need shows the substantial opportunity to increase other methods by expanding the basket, particularly in young and low parity women.
With the growing importance of the expansion of basket and a focus on moving away from the emphasis on regulating the family size and reproductive behavior, the Government of India introduced three new contraceptive methods in 2016:
- a three-monthly injectable contraceptive called Antara DMPA-IM (Intramuscular depo-medroxyprogesterone acetate,
- a nonhormonal oral contraceptive pill called Chhaya (Centchroman), and
- progestin-only pills.
On the same line, and in keeping up with goals and commitments, the Government has further expanded the basket of choices by rolling out DMPA-SC injectable contraceptive (Subcutaneous Depot Medroxyprogesterone Acetate) at peripheral facilities and implants at the district level in 2023.
But, despite the introduction of new methods and interventions, there is an existing gap between a woman’s desired fertility and her ability to access family planning methods and services. The widening gap results from the deeply rooted social and cultural norms and the lack of proper counseling and informed choices for women. As a result, many women are unable to access the basket in a lot of places across the nation.
Women’s choices and contraceptive behaviors
In our society, women are the driving force behind the family planning vehicle, and everyone thinks it is a woman’s responsibility to avoid getting pregnant. Social norms, cultural beliefs, and societal pressures have played a significant role in shaping contraceptive needs.
Cultural expectations that women should bear children soon after marriage to prove their fertility and strong desire for sons limit the use of reversible contraceptives. The prevalent social norms of undermining women’s agency also restrict the use of an expanded basket of choices.
Lastly, the prevalent social norms and taboos attached to reversible contraceptives such as Injectable and IUCDs have been withholding women’s choice of contraceptives. These myths and misconceptions around reversible contraceptives and strong cultural norms result in the discontinuation of the contraceptive method by the woman. Adding on to this, there is still a dire lack of awareness regarding alternative and reversible methods and knowledge of the side effects of existing reversible methods, particularly among young and low-parity women (Suri, 2022). Studies across low- and middle-income countries observed that fear of side effects such as prolonged bleeding and irregular periods, particularly infertility, is a significant barrier to modern contraceptive use.
Family planning and sexual and reproductive health difficulties stem from long-standing social norms that cannot be uprooted overnight. Increased investment in social and behavior change (SBC) approaches to strategize norm shifting in young women and couples is crucial. Since, reproductive decision-making is often beyond the control of young women and their husbands, engaging other gatekeepers, including senior men and women in the family and influential people in the community, such as self-help groups and Panchayati Raj Institution (PRI), is necessary. In addition, to encourage the role of male engagement, an expanded reproductive health program focusing on men’s health needs and their shared responsibility as partners, husbands, and fathers should be promoted.
We know the reasons behind such trends in terms of statistics, but what we need to understand is how these translate on the ground in terms of behaviors exhibited by frontline workers. This, along with more suggestions, will be covered in the next part of this series of blogs on contraception and its access in India.
References
Hall, M. A. K., Stephenson, R. B., & Juvekar, S. (2008). Social and Logistical Barriers to the Use of Reversible Contraception among Women in a Rural Indian Village. Journal of Health, Population, and Nutrition, 26(2), 241–250.
International Institute for Population Sciences, & ICF. (2022). National Family Health Survey (NFHS-5), 2019-21 | India (Volume I; pp. 1–714). International Institute for Population Sciences. http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf
Ross, J., & Stover, J. (2013). Use of modern contraception increases when more methods become available: Analysis of evidence from 1982–2009. Global Health, Science and Practice, 1(2), 203–212. https://doi.org/10.9745/GHSP-D-13-00010
Suri, M. and S. (2022, April 7). India’s Family Planning Mission Puts Burden of Sterilisation on Women at the Cost of Their Health. ORF. https://www.orfonline.org/research/burden-of-sterilisation-on-women-at-the-cost-of-their-health/
Aayushi Rastogi – Senior Manager, Sambodhi
Shristy – Deputy Manager, Sambodhi
