Men's Attitude Towards Contraception and Sexuality, Women's Empowerment, and Demand Satisfied for Family Planning in India

"Here we emphasize the potential role of women's equality as a precondition for securing wellbeing and prosperity for populations, and its catalytic effect on contraceptive provision and use..."

Research shows that, in India, the burden of family planning continues to fall on women due to persistent gender restrictive norms and inequalities, as well as kinship structures and other contexual factors. These gender-related socio-cultural factors have contributed to the stagnation observed in the prevalence of modern contraceptive use and unmet need for family planning in the country. This study examines the extent to which men's attitudinal norms towards contraception and sexuality influence women's ability to satisfy their demand for contraception, and whether various forms of women's empowerment can neutralise or offset potential negative effects of those norms.

Data for this study are from the 2015-16 National Family Household Survey (NFHS), which is a nationally representative survey from India that provides comprehensive data on fertility preferences, family planning, and other demographic characteristics and health outcomes for women of reproductive age (15-49) and their under-5 year-old children. For the purposes of this study, the sample size was reduced to 57,341. The analysis relies on information from 640 districts.

As a proxy for men's attitudinal norms, the researchers aggregated men's perceptions regarding contraception (contraception is women's business, women who use contraception may become promiscuous) and control over their wife (if his wife refuses to have sex, men have the right to deny financial support, have sex with another woman, or beat wife) at district level. Using a 3-level random intercepts model, they assessed individual and contextual-level associations of men's attitudinal norms and met need for contraception among sexually active women with any demand for family planning, while adjusting for women's empowerment indicators (education, job status, and adult marriage) and individual demographic factors.

Select results of the descriptive analysis:

• In India, 19.4% of married women with any demand for family planning had unmet need: 8.5% for spacing and 10.9% for limiting the number of children. Among the other 80.6% of women who reported using contraception, the large majority were using modern contraceptives (71.8%), with 54.2% of them using female sterilisation (associated with cultural factors), as opposed to traditional/folkloric methods (8.8%).
• The most prevalent norms expressed by 36.1% of men was the attitude that contraception use is women's business, followed by the belief that women who use contraception are promiscuous (19.8%).
• While a large percentage of women (56%) reported being married at an adult age, less than 30% have completed secondary/higher education or were currently working - perhaps reflective of the pervasive influence of gender norms.

The results of the multi-level analysis indicate that men's attitudinal norms are negatively associated with women's contraceptive use. For instance, a 1-standard deviation increase in the proportion of men who believe that contraception is women's business was associated with a 12% reduced likelihood of contraceptive use (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.82-0.95). Similar associations remained or were stronger after considering only modern methods, or when excluding female sterilisation. Furthermore, the contextual effects analysis revealed that women's higher education or wealth did not improve contraceptive uptake in communities with strong attitudinal norms, but working women or women married as children were more likely to use contraception in those communities.

In short, the study found men's attitudinal norms may be dominating over women's empowerment regarding family planning choices among reproductive age women. However, employment appeared to play a strong protective role associated with women's contraceptive use. "Thus, approaches to prevent, monitor and mitigate harm to women need to be implemented alongside employment promotion as a means to empower women, especially where restrictive norms are strong and women's labor force participation is low."

Various avenues for future research are outlined - for example, research to:

• Explain the mechanisms of the protective effects of job status on contraceptive uptake in the presence of strong gender restrictive norms;
• Study the role of female sterilisation, the dominant method of contraception in India, in the stagnation of met need, "as it may potentially be inhibiting the use of other forms of contraception across regions, and cultural norms around sterilization may be dominating women's reproductive autonomy and holding women back from realizing the benefits of broader empowerment initiatives";
• Understand the impact of differences in gender egalitarian attitudes (e.g., exploring male and female attitudes and the differences between then) and family planning; and
• Consider the supply side of the problem.

In conclusion: "It is important for gender transformative programs to be inclusive of men and to jointly address gender egalitarian norms. Successful programs should be holistic, address multiple sectors and shareholders, take multiple approaches, and can be initiated by leveraging through more community-based and programmatic efforts..."