In India, the burden of contraception still falls on women

A mother of two, Seema Devi, 36, from Barauli village in Barabanki district of Uttar Pradesh, is quite clear she does not want a third child. But the onus of avoiding an unwanted pregnancy is on her. Her husband refuses to use any method of contraception.

“The problem is mine, so I have to take precautions,” said Seema Devi, a homemaker. “It is best that I keep taking the [contraceptive] pills, it saves us from hassles and arguments in the house. When have men cared about the troubles of a woman’s body?”

India’s family planning campaigns, run by both its public health systems and civil society programmes, mirror Seema’s thinking: they are focussed almost entirely on women, found a recent study by International Center for Research on Women. The result is that women have greater awareness about contraception and bear its entire burden while men, who actually control decision-making in most homes, remain ill-informed and resentful about family planning practices, said the study.

The study conducted across six sites in Uttar Pradesh and Bihar aimed to understand the barriers to male engagement in contraceptive use and family planning. The findings are published in a report titled “It’s on him too: Pathways to engage men in family planning”.

This imbalance, along with pressures of having to play the role of a provider and a procreator for men, leads to hasty, indecisive and sometimes violent outcomes for the couples, the study concluded.

Men continue to shirk the use of family planning methods, according to the fourth round of the National Family Health Survey (2015-16). Three in eight men believe that “contraception is women’s business and that men should not have to worry about it”. Nearly 20% of men also believe contraception could make a woman “promiscuous”.

So while men get to decide the method of contraception, it is women who have to use it and deal with the consequences of its usage. Female sterilisation continues to be the preferred mode of family planning among Indian couples between the ages of 15 and 49, with 36% of couples opting for it. Male sterilisation is an option used by only 0.3% of couples, according to the survey. In the decade to 2015-16, male sterilisation rates dipped from 1% to 0.3%.

The power dynamic in Indian households is decided by age, gender and ownership of resources – all factors that usually favour men. “With power comes decision-making authority – men decide when and how many children to have,” said Kuhika Seth, technical specialist, International Center for Research on Women. “Family planning is fraught with the interplay of social and gender norms.”

Seema Devi is a homemaker with little education – she has studied up to Class 8 – and is married into an agricultural family where she shares her home with eight others. Entrenched gender roles, the lack of literacy and social factors place the burden of family planning entirely on her, and this is a story common across India.

To ensure increased adoption of contraceptives among men, the study suggested that couples be encouraged to talk to each other and that community spaces be created to discuss the myths around family planning. Male-targeted family planning campaigns, a wider range of male contraceptives and the deployment of male health workers to deal with men could alter the existing skew, said experts.

Limited options for men

Most campaigns are targeted at women and families, as we said, excluding young men. “[T]here is a dearth of male-targeted campaigns and contraceptive options for men, and this also hampers their adoption of contraceptive methods,” said VS Chandrashekar, chief executive officer, Foundation for Reproductive Health Services, India.

More than 90% of women discussed family planning with their husbands, but only 18% of them had a say in the final decision, IndiaSpend’s 2017 survey in Bihar, India’s most fertile state by children per woman, had found.

Up to 54% of men said that their wives could not use contraception without their permission and one-fifth believed that it is a woman’s responsibility to avoid pregnancy – 31% of women agreed with this – said a study on masculinity conducted by International Center for Research on Women and United Nations Population Fund in 2014. The study surveyed 9,205 men and 3,158 women, aged 18-49, across seven states – Uttar Pradesh, Rajasthan, Punjab, Haryana, Odisha, Madhya Pradesh and Maharashtra.

Most methods of modern contraception like intra-uterine contraceptive devices are targeted at women while there are only two primary methods of contraception for men – vasectomy and condoms, which are underpromoted – said Chandrashekar.

“Historically, in the ’60s and ’70s, vasectomy was the most popular method of contraception,” Chandrashekar said. “There were two factors that changed it – the excesses during Emergency and the popularisation of the laparoscopic method of tubectomy for women.”

In the five years leading up to the national Emergency in 1975, when civil liberties were suspended, the Indira Gandhi-government had led an aggressive sterilisation campaign and there were reports of men being forcibly sterilised.

These two developments shifted the onus of family planning totally onto women and nothing was done to amend this skew, explained Chandrashekar.

‘We do not discuss contraception’

Shivdevi (53), an Accredited Social Health Activist worker in Gosaiganj block in Uttar Pradesh’s Lucknow district, has supervised two villages for the last 15 years, and she has yet to see a man getting a vasectomy done. “Husbands expect women to shut up and follow instructions,” said Shivdevi. “She will be thrashed if she even suggests a vasectomy.”

In India, frontline workers – ASHAs, anganwadi workers or auxiliary nurse midwives – who are responsible for disseminating information on family planning, are almost entirely female. They interact mostly with women since their mandate is to serve the health and nutrition needs of women and children.

Men get their information on contraception mostly from informal sources and not the health system.

“Insufficient resources are invested in promoting male contraceptive methods, patriarchy makes this shift even harder, hence, asking for a greater investment of resources, but that is not happening,” said Chandrashekar.

“We can not discuss condoms and sterilisation with the men from our village – we are supposed to maintain a respectable distance from them,” said Shivdevi. “Men anyway think that we are misleading their women [by encouraging them to use contraception].”

Not enough is being done to convince men, especially the young, of the ease of contraception, Chandrashekar said. “No one talks to young men directly about family planning or explains how hassle-free vasectomy could be,” he said. “There is a lack of proper house-reach for men.”

Focus on female contraception

Among women, those who have the least exposure to family planning messages tend to have a particular profile – older, from rural areas, with little or no schooling and belonging to Muslim families or scheduled tribes and the two lowest wealth quintiles, the survey found. But men from similar backgrounds do not have this disadvantage, the study said.

The high uptake of female sterilisation is also because 80% of the funds available for family planning is directed towards terminal methods (surgical and mostly non-reversible) of preventing conception, specifically female sterilisation, a 2019 study by Population Foundation of India had found.

Not just husbands, members of the family who are older or command more resources in the family also often make these decisions for the couple, the evidence review found. Living with the mother-in-law restricts a daughter-in-law’s access to health services and family planning methods, IndiaSpend reported in December 2019.

“Mostly when women come to ask us for an oral contraceptive because they do not want another child, they come alone,” said Shalini (she uses only one name), a gynaecologist at the community health centre in Lucknow’s Gosaiganj block. “If a woman does not want a child, she is supposed to take care of it, men do not care. But in several cases when the husband rapes his wife, we do not even expect him to bother with a condom.”

Men find contraceptives ‘invasive’

Condom use in India has declined 52% over eight years to 2016 and vasectomies have fallen by 73% – indicating greater reluctance among men to use birth control – according to Health Management Information System data. But the use of emergency contraceptive pills among women increased during the same period by over 100%.

Despite a few campaigns and financial incentives for vasectomy (higher than for tubectomy), men continue to believe old myths around it. “They feel their physical strength will decline, their libido will decrease or they will not be able to ejaculate – they will become the laughing stock of the community,” said Abinav Pandey, an activist working on family planning with Pandit Govind Ballabh Pant Institute of Studies in Rural Development, Lucknow.

Nearly 75.4% of married men in India currently use no method of contraception, as per the National Family Health Survey. Upto 73.3% of men do not use contraception during intercourse with their wives and 69.4% do not when they are with their live-in partners/girlfriends.

Among unmarried men, 52.9% use no contraception. Christian men form the highest percentage of men resistant to using contraception (77.3%), whereas 75% of Hindu men and 72.4% Muslim men use no contraception.

“I constantly spoke for months with a man in our village to convince him to get a vasectomy done. Very unwillingly he agreed, but before going through with the procedure he backed out because the villagers told him that he will lose all physical strength and will not be able to earn anything,” said Sarita Verma, an ASHA worker in Lucknow’s Samnapur village.

The study reiterated what is a known fact – that men believe male sterilisation reduces sexual prowess, weakens the body and affects the ability to work and earn. There are similar misconceptions around condoms too. This makes men uncomfortable even talking about contraception.

Engaging men in family planning

Young men need to be convinced that male contraception is safer and simpler than female sterilisation, said Chandrashekar, adding that more male health-workers must be assigned to this campaign for this purpose.

Young boys should be taught about these methods in sex education at school and targetted mass media campaigns featuring public figures and celebrities should be deployed, he said. However, sex education in India is only available in some urban schools and is still a taboo elsewhere.

More contraceptive options for men must be made available – such as the gel that is currently being researched, which should be fast-tracked – said Chandrashekar.

“Utilising masculine ideals of provider (economic motivation), protector (instilling pro-feminist ideas for community activism) and pleasurer (direct messaging on gender equity and sexuality) in innovative ways” can change gender-skewed attitudes to contraception, said the study.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.