Women’s covert use of contraception in 32 countries Ifta Choiriyyah and Stan Becker Ifta Choiriyyah is a graduate student and Stan Becker is a professor in the Department of Population, Family and Reproductive Health and the Johns Hopkins School of Public Health in Baltimore, Md. 21205. Their respective emails are: [email protected] and [email protected] Acknowledgments We are grateful for pilot project funding from Hopkins Population Center (NICHD R24HD042854). We would also like to thank Natalie Gasca and Caroline Moreau for helpful comments and two anonymous reviewers for suggestions for improvement. Key words contraception, covert use, Demographic and Health Surveys, couples Abstract Some proportion of women use contraception without informing their partners. However, most estimates of this practice to date have come from local studies. Using data from 32 DHS that asked women if their partners know of their use or not, we estimate covert use and its determinants. In addition we test the hypothesis that covert users are more likely to use injections than are open users. With data from couples an indirect estimate of covert use is also derived when the woman reports a modern female method and the partner reports nonuse or a traditional method. The direct estimate ranges from 0.7% (Egypt) to 20% (Sierra Leone) but the indirect estimates are much higher, reaching 74% in Sierra Leone. Polygyny, intimate partner violence and woman’s years of schooling have the strongest associations with covert use. In agreement with previous studies the level of covert use varies inversely with modern contraceptive prevalence. Implications for contraceptive programs are considered. BACKGROUND Researchers, policy makers, and programs have recognized the important role of men in couple’s efforts to prevent pregnancy and improve women’s reproductive health (Greene et al. 2006). It is known that some women in developing countries –particularly in sub-Saharan Africa- defer to their male partner’s wishes regarding family size and contraceptive use (Bogale et al. 2011; Mboane & Bhatta 2015; Mosha et al. 2013). Still, experimental studies in Ethiopia and Malawi have shown that family planning education, promotion of couple discussion on family planning, and encouragement from male peer motivators increase contraceptive uptake by couples (Shattuck et al. 2011; Tilahun et al. 2015); the mechanism suggested is through improved spousal communication (Hartmann et al. 2012). Most studies also suggest that many men respond positively to being engaged in such interventions (Sternberg & Hubley 2004). On the other hand, a worry is that male involvement may instead strengthen their control over women’s reproductive life, rather than support women’s empowerment. An experimental study among low-income married women in Lusaka, Zambia compared two conditions to provide vouchers for free access to modern contraceptives (Ashraf et al. 2014). In the “individual” study arm, the voucher was provided to women in private and required her signature only; while in the “couple study arm”, the voucher was handed to the husband in the presence of his wife and required both of their signatures. Compared to the women in the “individual” group, the women in the “couple group” were significantly less likely to redeem the voucher and more likely to give birth within two years of the intervention. Among women in the “individual group” who used the voucher, 11% reported that they did so without their husband’s knowledge. The result provides caution that interventions with men and couples could unintentionally disadvantage women who do not wish to have their partners involved in reproductive health decision-making. However, from the same study a follow-up of the women two years later found that “women in the Couples treatment [were] significantly happier and healthier than those in the Individual treatment group” (Ashraf et al. 2014 p. 3234). Despite widespread approval of contraception and some increase in male involvement, a number of women use contraceptives without their partner’s knowledge. Recent estimates of the prevalence of such covert use are mostly limited to specific methods. A survey among pill users in three cities of Bolivia found that 19% of the women hid their use from their partners (McCarraher et al. 2006). Another study among women participating in an HIV prevention trial using the diaphragm in South Africa and Zimbabwe showed that 9% of women at final follow-up had never told their partners that they were using the diaphragm (Sahin-Hodoglugil et al. 2009). A study in two districts in Uganda found that 5% of women were using contraceptives openly despite their partners’ disapproval while 15% did so without their partners’ knowledge (Blanc et al. 1996). The proportion of covert use was higher in rural areas (18%) than in urban areas (7%). Another study in four rural communities in Kenya showed that 20% of users of modern contraceptive methods were covert users (Watkins et al. 1997). This rural-urban differential suggests that where modern contraceptive use is newly introduced and not yet socially acceptable, women would be more likely to hide use from their partners. A survey in an urban district in Zambia found that 7% of women were using contraceptives covertly; women who thought that their partners disapproved of family planning were 3.7 times more likely to use contraceptives secretly. However, the strong effect of partners’ perceived disapproval on covert use was diminished once the two communication measures (ever discussed contraception and ease of discussing contraception) were considered (Biddlecom & Fapohunda 1998). In addition, women were asked hypothetically what they would do if their male partners disapproved of their using contraceptives; almost 60% said they would use contraceptives without their partner’s knowledge. A woman’s perception of her partner’s disapproval may make her forgo discussion and conceal her use without finding out her partner’s real attitudes toward contraception. While spousal miscommunication may contribute to covert use of contraception, a number of qualitative studies show that women decide to use contraceptives secretly for very serious reasons and they can face dire consequences if their partners discover their contraceptive use. In Zambia, both women and men cited partner’s neglect and ill treatment of children as a justification for covert use of contraceptives (Biddlecom & Fapohunda 1998). Also, a longitudinal qualitative study among new contraceptive users in Mali found that six of the 17 covert users compared with six of the 38 open users were in polygynous marriages; the author concluded that the wife’s concern about social and economic neglect were more common in polygynous unions (Castle et al. 1999). In many cultures, women are expected to be obedient to their husbands, to conceive soon after marriage, and to be sexually available to their husbands (Wilson-Williams et al. 2008; Henry et al. 2015). Some men do not approve of contraceptive use because they are concerned that it could encourage infidelity, could challenge their own fertility preference, or could undermine their authority as heads of household (Watkins et al. 1997). A review of 34 articles on determinants of unmet need for family planning among women in low and middle income countries found that husband’s opposition or his fear of infidelity were among reasons for non-use (Wulifan et al. 2016). Partner’s disapproval of contraceptive use drives women to hide their contraceptive use, fearing open use would generate marital discord, physical and/or sexual violence, or lead to the partner withholding affection (Bawah et al. 1999; Castle et al. 1999). Recent studies indicate that partner disapproval and violence (if the man discovered contraceptive use) persist even among young people (Wilson-Williams et al. 2008; Nalwadda et al. 2010). Intimate partner violence (IPV) is widespread in every country where Demographic and Health Survey (DHS) have asked about it, ranging from 17% of women who had ever experienced IPV in the Dominican Republic to 61% in Uganda (Bott et al. 2013; Diop-Sidibé et al. 2006; Alio et al. 2009a). With regard to contraception some studies have shown a negative relationship between use and IPV (Stephenson et al. 2013; Williams et al. 2008) and others a positive relationship (Alio et al. 2009a; Salazar et al. 2012) . Studies that directly examine the association between IPV and unintended pregnancy mostly come from developed country settings. A cross-sectional survey among women aged 16-29 years visiting five family planning clinics in California found that 35% of women reporting partner violence also reported pregnancy coercion or contraceptive sabotage, compared to only 15% of those who had never experienced partner violence. In that study, pregnancy coercion was assessed using six questions asking whether a woman’s dating partner ever (1) told her not to use any birth control?; (2) said he would leave her if she did not get pregnant?; (3) told her he would have a baby with someone else if she didn't get pregnant?; (4) hurt her physically because she did not agree to get pregnant?; (5) tried to force or pressure her to become pregnant?; and (6) whether she had ever have hidden birth control from a sexual partner because she was afraid he would get upset with her for using it. Birth control sabotage was assessed using five questions specific to acts of contraception interference. Pregnancy coercion and contraceptive sabotage within the context of partner violence can clearly lead to unwanted pregnancies (Miller et al. 2010). The most comprehensive research from a developing country setting used data from the 2000 Demographic and Health Survey (DHS) for Colombia (Pallitto & O’Campo 2004). That study also found a significant association between IPV and unintended pregnancy, even after adjusting for confounding factors. A review of published reports suggests that partner violence is probably part of the reason for contraceptive non-use because the threat of violence makes contraceptive negotiation difficult (Gazmararian et al.