Three Ways to Support Women’s Contraceptive Decision Making
By Elisabeth Rottach and Rahal Saeed
Historically, family planning programs have placed significant effort on increasing uptake of contraceptives. But less emphasis has been placed on helping individuals to continue using the method of their choice. Yet choosing to use a contraceptive method — be it short- or long-acting — is not a single decision made in one moment of time. External forces, such as social pressures and unequal gender norms, are continually at play.
For example, every day a woman takes an oral contraceptive pill, or every three months when she travels to the health facility to get an injection, she is deciding to continue using that method. Every time she is asked by a mother-in-law or neighbor when she is going to have her first child, or her next child, she must reaffirm her decision to use contraception. Every time an unmarried adolescent girl has to go to the pharmacy to pick up a new pack of pills, she has to decide whether she is willing to endure the stigma and discrimination that she faces from the provider so that she can continue her method. And every time a woman uses contraceptives in secret because of an unsupportive partner, she decides to risk conflict, and sometimes violence, to continue using family planning. Each time her decision is questioned, either directly or indirectly, she may be tempted to give in and stop using contraception.
Numerous studies document how social pressure, reproductive coercion , stigma and discrimination, and lack of spousal support negatively influence contraceptive uptake and continuation. Many of these barriers are rooted, in part, in unequal gender norms and narrowly defined roles for women that place high value on their reproductive roles. Thus, is it vital to create a supportive environment for individuals to continue using contraception. A key strategy for creating that environment is to change norms around gender and youth, as well as finding ways to engage men and boys more effectively in family planning.
Policy and Programs Solutions
Below are three actions that family planning policymakers and programmers can take to foster social and gender norms that support users to continue using contraception.
1.Strengthen gender transformative policies and structures. Transforming unequal gender norms requires addressing power dynamics in broader systems and institutions. However, many family planning programs tend to focus on individual and community-level change, limiting the scale, sustainability, and effectiveness of these programs. Advocates and decisionmakers should focus on designing, funding, and implementing policies that transform those norms that restrict women’s autonomy and reproductive decision making. For example, policies could incorporate actions to strengthen the decision-making power of women in their choice and use of family planning, like how Mali’s Costed Implementation Plan for Family Planning incorporated a strategy to organize meetings with influential leaders to change norms and attitudes towards women’s participation in decision making. Efforts are also needed to establish accountability mechanisms to ensure that gender transformative policies are adequately implemented and monitored, including increasing family planning budgets and ensuring the hiring of more women at senior leadership levels within governments. When combined with individual and community-level interventions, this holistic approach can create a sustainable enabling environment that supports women to make their own contraceptive decisions.
2. Expand women’s life opportunities through cross-sectoral collaboration. Gender inequality cannot be solved by the family planning sector alone. It requires a whole-of-system approach. We need to find ways to leverage partnerships across sectors to address underlying gender barriers to sustained family planning use, as Palladium’s USAID-funded NPI EXPAND project is doing in Kenya. This could happen by strengthening partnerships between education and health sectors to promote girls’ education and implement gender-transformative comprehensive sexuality education in schools, which could also help to reduce stigma. We could connect workforce development and family planning programs to change norms around women’s leadership and participation in the labor workforce, increase their professional skills, and provide them with the resources to control their fertility. Cross-sectoral policies and programs have huge potential to accelerate both gender equality and sector-specific goals, such as contraception continuation.
3. Institutionalize male engagement policies and services. Standing up to community pressure can be even more difficult for a woman if she does not have her partner’s support — an often-cited reason for discontinuing contraceptives. However, family planning policies and programs still do a poor job of engaging men. We need to stop focusing policies and programs exclusively on women. This posture not only reinforces women’s reproductive role and limits their opportunities, but it excludes men from accessing information and services that are important for their lives too and exonerates them from family planning responsibility and ownership. Family planning programs must protect women’s autonomy and decision making. That is not negotiable. But policymakers and programmers should design and implement better policy and program approaches to engage men and boys in family planning, such as those identified in the HP+ Male Engagement Policy Framework, to create a more supportive and equitable environment for contraceptive decision making.
Individuals can be both enabled and constrained by their surrounding environments. Gender plays a big role in determining individuals’ realities and choices, including around continued use of contraceptives. In contexts where gender, social, and community norms are unsupportive, trying to sustain contraceptive use can feel unattainable. Policymakers and programmers need to better understand this reality and design policies and programs that will create an environment for all people to make and act on their own reproductive decisions, free from coercion.
Elisabeth Rottach is a senior technical advisor for health at Palladium. Rahal Saeed, also with Palladium, is a senior program manager and the former country director for Health Policy Plus Pakistan.