How researchers in India are getting couples in rural areas to talk about family planning

In Jharkhand, in eastern India, the land is rich but the people are poor. It’s the second most resource-rich state in the country, but 39% of the population lives below the poverty line. In the capital, Ranchi, luxury hotels and retail shops crowd the main roads. Businesspeople travel to the city to deal in Jharkhand’s natural resources: iron ore, copper, uranium.

Once you leave Ranchi, it’s easier to get a grasp of Jharkhand’s landscape: sprawling fields, shady trees, and long, winding roads. Small, square ponds appear by the sides of the road, with steps that indicate they’re man-made  – an old-fashioned system for water preservation that’s currently going through a revival.

As we drive through one village on a sunny afternoon, a health care worker tells me that the people here are refusing all government services, including health care, as a form of protest. The people of Jharkhand frequently clash with the government over resources, protesting laws that make it easier to dole out land to corporations, or to mine it for uranium. Just 20 miles from the hotel bars and government chambers where these decisions are made, I’m heading to a very different kind of gathering.

In the village of Khunti, families meet periodically for Saas Bahu Pati Sammelan, which translates to “meeting of the mother-in-law, the daughter-in-law, and the husband.” These meetings, facilitated by the Jharkhand government, are intended to improve communication in rural Indian joint-family households. Traditionally, a bride will move into her new husband’s family home, where she’ll often be subjected to the demands of her new family, especially her mother-in-law. Family planning is often the mother-in-law’s purview, partly because open discussion of sex can be taboo in marital relationships in rural India.

The meeting area is a raised concrete platform covered in what appears to be felt, for comfortable seating; when I arrive, women of various ages are milling about, until Kanan Balan, the district programme manager, calls for them to be seated. A small group of young men are already sitting quietly on one side, smiling nervously. They’re less boisterous than the women, who will talk and laugh and interrupt  –  and at one point burst into song  – during my interviews.

The loudest of the women is Sunita Malhotra, one of the mothers-in-law, who teases me for not understanding dialect. “We don’t cuss out our daughters-in-law anymore,” she told me, smiling. “Before, we did it a lot. It was very abusive.” She told me that she now understands that daughters and sons need to be educated equally, and that it will be easier to take care of a family with fewer children. “We’ve all become very wise.”

When I speak with other, younger mothers, they talk about family planning with shy confidence, about how it will be easier to care for young children if their ages are spaced out a bit. But eventually, as I’m scanning the group to see who else I can speak with, I realise the men have all quietly left. Perhaps they would have been more comfortable if they hadn’t been so outnumbered  –  in a reflection of a national pattern, all of the health care workers present are women.

Changing the pattern

In India, the idea that open communication and male involvement are keys to improving family health is slowly gaining ground. The Sammelan, meant to encourage direct communication, is part of that. This solution may seem simple and intuitive, but men and women in rural India are suspicious of many of the contraceptive options the government has on offer.

Some experts chalk these doubts up to old-fashioned ideas, patriarchal culture, and poor education  – all of which are undoubtedly factors. But the Indian government has frequently failed to prioritise individual well-being when it comes to family planning. These broader structural challenges come on top of family dynamics that make communication difficult. In a 1997 study, Indian men identified “shyness” as the number one reason they were unwilling to speak about family planning in their relationships.

This means that the mother-in-law will often preside over family planning decisions. Generally, a mother-in-law’s priority is having grandsons, hopefully more than one. She’s also likely to encourage sterilisation as the only contraceptive  – and ideally a daughter-in-law should have as many sons as possible before she starts using contraception.

In a study conducted by Arundhati Char, Minna Saavala, and Teija Kulmalain in 2010, mothers-in-law also prefered sterilisation because they saw it as a more “decent method.” One mother-in-law told the researchers, “When I went to the hospital with my daughter-in-law during the delivery of her last child, the doctor showed me some condoms and suggested that I ask my son and daughter-in-law to use them. I refused to even hold one in my hands. I don’t want such dirty things in my house.” Another added, “When there is sterilisation, why talk about other methods? They all cause problems.”

But there’s evidence that this dynamic has been changing. In the same study, Char et al. found that a couple could subvert the authority of the mother-in-law by using temporary methods  – like the pill  – without telling her. The researchers write:

“With regard to the sons in this study, even though they paid heed to their mothers, they regarded decisions concerning use of reversible methods as their own. Although most daughters-in-law felt they were not in a position to be sterilised against their mother-in-law’s will, they saw any interference from her in the use of reversible methods as unjustified.”

Priya Jha, who has worked in the past as India’s country director at the Institute for Reproductive Health, said that couples are also able to subvert traditional family hierarchies using aspirational arguments. Jha has spent a lot of time working in Jharkhand, the location of the Sammelan, and said that she’s observed young families who can now see the advantages of having a dual-income household with fewer children.

Couples “are more empowered to listen to what their parents are asking them, but also to be able to give them economic reasons why they want to use certain contraceptives,” she said. “They want a good life for themselves, they want certain facilities, they’re aspirational about owning a house, getting a TV, buying a motorbike, rather than having like three children in one go and not having enough resources to supplement and feed them and take them to a good school.”

Innovative routes

Subversion and direct communication may seem like opposite approaches to shifting the contraceptive conversation. The scenario that Jha described, in which young couples communicate with their families and make economic arguments for controlling their reproductive futures, is more in line with the goals of the Sammelan than is the scenario in the 2010 study, in which women and couples simply hide their contraceptive methods from their families.

But there are advocates in India who promote both strategies. According to Kanan Balan, the district program manager in Jharkhand who helps organise the Sammelan, health workers will sometimes give women birth control pills knowing that their husbands will remain unaware the wives are taking them. Proponents of injectable contraceptive methods for women often cite as a benefit the fact that recipients can easily hide them from their husbands.

But hiding a contraceptive method can backfire. Balan said that in Jharkhand, doctors won’t insert an IUD unless a woman’s husband has also agreed to use the device. “If he notices something in his wife’s cervix, he might wonder why she did this without asking,” she told me. “He might think she doesn’t want to get pregnant because she’s being unfaithful. It happens.”

Balan sees a mother-in-law’s wish to know her children’s contraceptive habits as natural. “She lives in the house and she’s the oldest, so she thinks she ought to be informed about what’s going on,” Balan said. “As a mother, I would also want to know, what is my son doing? What is he eating, what is he drinking, where is he going?...So [the Sammelan] is a good way for families to bond, when we know one another well.”

Another recent contraceptive intervention in Jharkhand followed similar logic. From 2007 to 2016, the Jharkhand government worked with Georgetown University’s Institute for Reproductive Health to offer CycleBeads as a free contraceptive option in all of the state’s districts. CycleBeads are strings of beads, or malas, that are used to track fertility according to the Standard Days Method. Glow-in-the-dark white beads represent “unsafe days,” when women are likely to get pregnant if they have unprotected sex.

In order for this method to work, all channels of communication must be strong: health care workers must be able to accurately communicate how the method works, and spouses must also be able to communicate effectively with each other so that they abstain or use condoms on “unsafe days.”

This means that men must be involved in the process. “We find men to be very interested in CycleBeads,” said Jha, who facilitated the CycleBeads scale-up. “We had so many instances where we found men to be actually using CycleBeads. It wasn’t the women. And they were the ones deciding when to go and buy condoms.”

Subhadra Tiwari, a social worker who began using CycleBeads herself after promoting them, said she has a discussion with her husband every time they have sex: “‘Are you sure that we’re on the safe days?’ he asks. ‘If it’s unsafe, then I’ll use a condom!’”

The CycleBeads program has led to an increased use of condoms in certain Jharkhand villages. According to Sanjay Paul, who also worked on the scale-up, men were more willing to use condoms once they understood that they didn’t have to use them all the time. Women who used CycleBeads also reported feeling more confident when communicating about sex with their partners.

By many measures, the Jharkhand program was a success. Both the couples who used CycleBeads and the health care workers who promoted it reported that they were happy with the method, and found it effective. And there were positive social consequences as well: couples were communicating better about their reproductive lives.

But the Indian national government did not choose to subsidise the method nationwide after the Jharkhand program ended in 2016. While none of the Jharkhand government employees or NGO workers I’ve spoken with are sure why, they have a guess  – the same reason that the Indian government tends to promote sterilisation over other methods. A newly introduced temporary form of contraception requires a huge structural investment to get people to understand and use the method correctly, and once they do, it’s still not as effective, in terms of the total number of unwanted pregnancies, as a method like sterilisation. (India’s Ministry of Health and Family Welfare did not respond to inquiries regarding the CycleBeads program.)

But Jha thinks that this choice should still be available, since many women fear the invasive nature or side effects of other methods. “Were they really offering them choices? Not very much,” she said.

Getting men on board

One of the key barriers to many contraceptive methods in India is a lack of knowledge. Jha said many couples don’t use methods that allow them to space their pregnancies  – like the pill –  simply because no one has properly educated them about these options. “Without good information sharing, counseling, unsustained use is very high with user-directed methods,” she explained. “So organisations push for methods where the user has to do nothing, which is an IUD or sterilisation.”

In the early 2000s, when Arundhati Char was working with the family planning organisation DKT International to find ways to improve India’s contraceptive prevalence rate  – the percentage of women using at least one method of contraception  – she noticed that education on various methods was lacking. Health care workers, she recalls, would go door to door and sometimes simply leave packets of contraceptive pills without explaining their usage or assessing women for risk factors. Even if women were taking the pills correctly, government supplies could be inconsistent. Given this kind of carelessness, it’s easy to understand why many women in India think contraceptive pills just don’t work that well.

Over the past three decades, Char has worked on getting men more involved in the contraceptive conversation. In her initial research, she found that men were often left out, in part because nobody was trying to reach them. Health care workers would visit homes while men were at work, and even when they did speak to the residents, usually only women were available. Char has since designed an intervention in which men are allowed to anonymously call a helpline and speak to male workers. When the program was implemented in 2012, it worked  – men were interested, and the contraceptive prevalence rate went up in the village in Maharashtra where the centre was based.

As advocates work to get men to merely participate in reproductive conversations, some Indian men are already willing to take on the contraceptive burden. RISUG, for example, is an injectable, reversible male contraceptive that has been in development for decades. (The acronym stands for “Reversible inhibition of sperm under guidance.”) Arvind Kumar, a staffer at the All India Institute of Medical Sciences, was one of the first trial subjects for RISUG. He said that he’s never felt the polymer gel that was injected into his vas deferens 18 years ago, and he’s never had to worry about his wife getting pregnant. But he was unable to convince his friends to get on board. “Why weren’t they interested, it’s very difficult to say this,” he told me. “They have their own way of thinking. That’s it.”

There’s evidence that this attitude is changing, but so far much of it is anecdotal. Heather Vahdat, who has worked with Family Health International to brainstorm possible contraceptive interventions, said that many of the men whom she and her colleagues interviewed expressed, unprompted, a desire for male methods  –  or methods that would require both partners to participate.

The design of Vahdat’s project can help explain why we don’t have more data on these attitudes  – it was intended specifically to find female methods, and to profile female users. “We didn’t sit down specifically and talk to men about contraception, but my experience tangentially on a bunch of different projects is it just keeps coming up,” she said. “I really feel like the tide is turning.” But there hasn’t been a parallel effort to figure out which men might be interested, or what their specific needs are.

RISUG is not yet available to the public, but both Char and Jha think that if it ever does become available, the organisations that introduce it will need to work hard to avoid the mistakes the Indian government has made when introducing other forms of contraception. RISUG’s inventor, Sujoy Guha, is hoping to do a secondary set of human trials to test the contraceptive’s viability specifically in the context of rural Indian health centers. That’s never been done in India, where methods have historically been imported from other countries without additional clinical testing. The medical community and the government will have to work to distribute this method to Indian men according to their needs. Otherwise, RISUG could go the way of the condom or birth control pills in India  – both of which are barely used.

This is the second instalment of Breaking the Cycle on How We Get To Next, a three-part series on the past, present, and future of reproductive health in India. Reporting and research was supported by the Pulitzer Center on Crisis Reporting.

This article first appeared on Medium’s How We Get To Next.