Associations between Contraceptive Decision‐Making and Marital Contraceptive Communication and use in Rural Maharashtra, India

Abstract

Women's contraceptive decision-making control is crucial for reproductive autonomy, but research largely relies on the Demographic and Health Survey (DHS) measure which asks who is involved with decision-making. In India, this typically assesses joint decision-making or male engagement. Newer measures emphasize female agency. We examined three measures of contraceptive decision-making, the DHS and two agency-focused measures, to assess their associations with marital contraceptive communication and use in rural Maharashtra, India. We analyzed follow-up survey data from women participating in the CHARM study (n = ), collected in June-December . The survey included the DHS (measure ), Reproductive Decision-Making Agency (measure ), and Contraceptive Final Decision-Maker measures (measure ). Only Measure  was significantly associated with contraceptive communication

Is the Decision Not to Use Contraception an Indicator of Reproductive Agency?

“…If one considers the variable “marital status” for example, “currently married” is generally the standard reference group to draw conclusions about those who respond as being “separated/divorced” or “widowed.” For contraceptive decision‐making, there is no widely accepted reference group “norm.” That lack of consensus is with good reason, as demonstrated by the work of Nazarbegian and colleagues (Nazarbegian, Averbach, Bhan, et al. 2022) who conducted a review of various reference groupings used in contraceptive decision‐making analyses using data from DHS and non‐DHS surveys in papers published between 2011 and 2021. They found that most ( n = 8) papers use “joint” decision‐making as the reference group to draw conclusions about women's unilateral decision‐making or mostly unilateral husband/partner decision‐making.…”

“…Donald et al note that joint decisionmaking encompasses situations of both mutual agreement as well as resolution following a conflict (Donald et al 2020). Similarly, Nazarbegian and colleagues explore distinctions in contraceptive decision-making measures focused on perceptions of control versus behavior and postulate that joint contraceptive decision-making may be more representative of male engagement and the power associated therewith than it is of female agency (Nazarbegian, Averbach, Johns, et al 2022). Further, as Gram and colleagues describe in their synthesis of the organizing concepts of "women's empowerment," indicator choice is laden by fact-, theory-, and value-based distinctions (Gram, Morrison, and Skordis-Worrall 2019).…”

“…Beginning in the mid-1990s, DHS began collecting data on contraceptive decision-making, asking married women reporting current contraceptive use who was "mainly responsible" for the decision to use contraception (El-Zanaty et al 1999). The scientific literature pertaining to contraceptive decision-making largely relies on data collected through DHS, with findings across a range of country and cultural contexts revealing that women's engagement in decision-making to use contraceptives is associated with other indicators of women's agency (Nazarbegian, Averbach, Bhan, et al 2022;Prata et al 2017;Upadhyay et al 2014;James-Hawkins et al 2018;Mandal, Muralidharan, and Pappa 2017).…”

“…(1) one's perceptions of their capacity to act on choice (can); (2) one's behaviors to advance choice (act); and (3) one's continued action even in the face of barriers or backlash (resist) (Raj 2020;Raj, Dey, and Lundgren 2021). In the measurement of reproductive agency, women's engagement in contraceptive decision-making is a key indicator of the "act" mechanism of agency (Hameed et al 2014;Yaya et al 2018;Nazarbegian, Averbach, Bhan, et al 2022). The indicator has, however, been limited to women's decision-making to use contraception, with little to no attention paid to women's decision-making not to use contraception.…”

“…Either type of a decision, if self-determined, represents agency. This shift in perspective as to what  constitutes "success" is key for recognizing the priority of individual choice and rights, and one in which the family planning community has more actively been engaging (Bhan and Raj 2021;Bhan et al 2022;Speizer, Bremner, and Farid 2022;Senderowicz 2020). In this spirit, and with recognition that decision-making questions should include inquiry into women's engagement in the decision not to use contraception as well as to use contraception, The DHS Program added a question on decision-making not to use contraception as a result of the DHS-7 core questionnaire revision process of 2014.…”