Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges

Abstract

Background: The balance between increasing men's participation in family planning and rights-based initiatives favoring women's empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low-and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women's decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women's choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries. Methods: Women aged 15-49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women's and girls' empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes. Results: Findings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure.

From non-use to covert and overt use of contraception: Identifying community and individual factors informing Nigerian women’s degree of contraceptive empowerment

“…When couples negotiate reproductive outcomes, this is done against the backdrop of normative values, and if they disagree, whether this is real or perceived, there needs to be some form of conflict resolution [6]. As a result of the outcome of couple communication, or the absence of any communication, women may decide on their own to use a family planning method, even if this means using a method covertly [2,5,[8][9][10].…”

“…Moreover, a man's suspicion that his partner is using a contraceptive method covertly may be raised due to side effects, such as heavy bleeding, weight gain or loss, and lack of libido, or due to a delay in her becoming pregnant. Such suspicions, and the tension they cause may lead to disclosure by some women, ultimately bringing about improvement in communication between partners [10]. On the other hand, it has been reported that if a male partner discovers on his own that a woman is using a method without his approval, he may feel betrayed [5,10] and could report her to her parents, accuse her of infidelity, stop having sex with her, start an extramarital affair, physically abuse her, marry another wife, withdraw economic support, or even divorce her, all in a bid to "punish" and "disgrace" her for her actions [5,[8][9][10]12,13].…”

Prevalence and Determinants of Covert Contraceptive Use in Kenya: a Cross-Sectional Study

“…However, the study in Ghana included both married and unmarried women using contraceptives [28]. The practice of CCU could be due to societal perception of women using contraceptive as being promiscuous [6,14,28,29], patriarchy [9,29], fear of intimate partner violence [13,30,31], disagreement on the number of children [29], religious beliefs [14] and limited male involvement [6,32]. CCU could re ect women empowerment and autonomy in decision making [31] but could also indicate male dominance in decision making and create a barrier to increasing contraceptive coverage [9].…”

“…Similar to previous studies in Ethiopia [27], Ghana [28], Kenya [1,15] and Nigeria [5], injectables and implants were the commonest methods of contraceptives used overtly and covertly by married women. Injectables and implants are easy-to-use, effective, concealable [31], modern reversible contraceptives lasting three months, and three or ve years, respectively [3]. Injectables are also widely available and accessible in most health facilities and pharmacies hence promote CCU [31].…”

“…Injectables and implants are easy-to-use, effective, concealable [31], modern reversible contraceptives lasting three months, and three or ve years, respectively [3]. Injectables are also widely available and accessible in most health facilities and pharmacies hence promote CCU [31].…”