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 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 ?; (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. 2000). Contrastingly, an analysis of DHS surveys from 6 sub-Saharan African (SSA) countries showed that women who experienced IPV were more likely to use contraception, compared to those who did not report any partner violence (Alio, et al. 2009a). A possible motivation for higher contraceptive use is the desire to prevent pregnancy in unfavorable conditions.

Previous studies have utilized two different approaches to estimate the prevalence of covert use. In the first approach, an indirect approach, one can compare reports of current modern contraceptive use between spouses. A woman who reports a female modern method but her partner does not report any modern method is simply assumed to be a covert user. In this vein, analysis of DHS data from 23 countries for all contraceptive methods showed major discrepancies between spouses’ reports of current use (Becker & Costenbader 2001).

However, in virtually all of those surveys, it was the husband who was more likely to report a method when the wife reported nonuse, and periodic abstinence was the modal method for his sole reports.

In the second approach, prevalence of covert use can be estimated from a question that directly asks a woman using contraception whether her partner knows that she is using a method. Compared to the first approach that may overestimate the prevalence of covert use – because his reporting nonuse when she reports a modern female method can be explained by other reasons than covert use (e.g. he forgot), the second approach is direct so may be more accurate. However, not all countries have included this question in their DHS surveys.

Recent national level estimates of covert use are not available. The present study therefore aims to describe the prevalence of covert use of modern contraception in selected DHS surveys, using the direct method. We also examine the association between various socio- demographic factors and covert use. Specifically, we hypothesize that women who: (1) are older and with higher parity; live in rural areas; attended school for fewer years; have shorter duration of marriage; are in a polygynous union; have a substantially older partner; attended school substantially fewer years than their partner; come from poorer families; want no more children; and who report violence perpetrated by their partners in the last 12 months are more likely to use contraception covertly while women who participate in household decision-making and do not justify spousal violence are less likely to be covert users; (2) injectable contraception is more prevalent among covert users than among open users; (3) couples in which the woman reported open use but the indirect method classified her as a covert user have demographic and socio-economic characteristics close to the group in which both direct and indirect estimates say the use is open.

METHODS

Survey Selection

We reviewed all DHS surveys from 2005 when the direct question was first introduced to determine which surveys had that question to a woman on whether her partner knows that she is using a method of family planning. If there were two surveys in a country with the question, the latest survey was selected up to the end of 2013. We estimated the level of covert use for 32 surveys that had at least 10 covert users. (***Three surveys—Maldives,

Armenia and Azerbaijan each had less than 10 covert users.) We compared the modern contraceptive method mix between open users and covert users for 22 surveys that had at least 50 covert users. Multiple regression analysis of individual surveys was performed for 8 surveys that had at least 140 covert users and had the four questions on household decision- making and five questions on attitudes toward spousal violence. (We used the rough rule that at least ten cases are needed per covariate.) We also included an indicator variable for polygyny and a variable for intimate partner violence (IPV) in the last 12 months in our analysis to assess their effects on covert use; however only a subset of the countries selected have both of these variables.

The data analysis was performed using Stata 14 (StataCorp, 2015). For analysis with sampling weights, we specify the woman’s weight and stratification scheme from each DHS using the svyset command. (***A slightly different weight was used for the analyses with the IPV variable since those questions were only asked of one sampled woman per household.)

Tabulations and logistic regression were done using the corresponding SVY commands. The couple data analyses were done with unweighted data as the individual weights for women or men include response rates for both single and in-union individuals so are not really appropriate for couples.

Variable definitions Covert use

Within each survey, we selected women reporting use of any female modern method of contraception. These methods were: female sterilization, the contraceptive pill, implant, injectable, intrauterine device (IUD), diaphragm/ foam/jelly, and the female condom. A woman using a female modern method was coded as a covert user if she answered “No” and as open user if she answered “Yes” to the question:“Does your husband/partner know that you are using a method of family planning?”. A small percentage (median of 1.3%) of women responded “Don’t know” to the question or refused to answer. These cases are treated as missing in the simple tabulations. However, for the regression analyses in eight countries

(see below) rather than delete them we chose to use an imputation procedure to assign them to open or covert use. Specifically, for those surveys, using the covariates described below, we first performed multiple logistic regression with the sample of women who answered definitively Yes” or “No” to the question. Then for those who reported “Don’t know” or refused, we obtained predicted probabilities of covert use from the regression equations. Next we chose the cutpoint of probabilities that maximized the percentage of correct classification and applied the cutpoint to predict whether each woman who answered “don’t know” or refused to answer the question should be classified as an open user or a covert user. These women were included in the final multiple logistic regressions presented below, and an evaluation of the results with and without these cases was done.

Covariates

We evaluated the following socio-economic and demographic variables as possible predictors of covert use: woman’s age, number of children ever born (parity), number of years of schooling, duration of marriage (years), wealth quintile of the household, place of residence

(rural/urban), and difference in age and in number of years of schooling with her partner. A woman’s fertility preference was also examined as a possible predictor, determined from the question “Would you like to have (a/another) child, or would you prefer not to have any (more) children?”; women were coded as wanting another child or not wanting another child. Some women reported that they were undecided. Again, for the eight countries with the multiple regression analysis, we imputed values for these women. In SSA and Southeast Asian countries, women who reported that they were undecided about their intentions were put in the same category as those who wanted to have a/another child; but for the surveys in other regions these women were placed with those who did not want a/another child. This decision was based on a study of fertility intentions that found that the undecided in DHS surveys were more like the majority among those in the survey with stated desires (Becker & Sutradhar

2007). The percentages of women who were undecided ranged from 0% in Lesotho to 4.5% in

Zambia with mean and median of 1.8

Women’s participation in household decision-making was assessed based on their responses to four questions:“Who usually makes decisions about: (1) health care for yourself?; (2) making major household purchases?; (3) making purchases for daily household needs?; and (4) visits to your family or relatives?”. A woman received one point for each decision in which she decided alone or jointly with her partner. Attitudes toward spousal violence were assessed using five questions: “In your opinion, is a husband justified in hitting or beating his wife in the following situations: (1) If she goes out without telling him? (2) If she neglects the children? (3) If she argues with him? (4) If she refuses to have sex with him? (5) If the food is not properly cooked?”.

One point was given for each question to which a woman answered “No”.

Whether a woman is in a polygynous union was based on the question: “Does your husband/partner have other wives or does he live with other women as if married?”.

Regarding IPV, if there was more than one eligible woman in a household, one was randomly selected to answer the domestic violence module which asks about her experiences of emotional, physical, and sexual violence in her lifetime and in the last 12 months. The module specifically asks about three different types of spousal violence: (1) physical (push you, shake you, or throw something at you; slap you; twist your arm or pull your hair?; punch you with his fist or with something that could hurt you?; kick you, drag you or beat you up; try to choke you or burn you on purpose; threaten or attack you with a knife, gun, or any other weapon);

(2) sexual (physically force you to have sexual intercourse with him even when you did not want to; force you to perform any sexual acts you did not want to?); and (3) emotional (say or do something to humiliate you in front of others; threaten to hurt or harm you or someone close to you?; insult you or make you feel bad about yourself?). The WHO Multi-country Study on Women’s Health and Domestic found that women frequently consider emotional violence to be more devastating than physical violence. The study listed four specific acts of emotional abuse that were most frequently mentioned across cultures; three of which were also asked in DHS (WHO 2005). The binary variable for IPV was created to indicate whether a woman reported any violence (physical, sexual, or emotional) perpetrated by her husband/cohabiting partner in the last 12 months.

We performed simple logistic regression of covert use on each of the covariates described above for the 32 surveys that had at least 10 covert users. Since each covariate was statistically significant (p< 0.05) in at least 25% (n=8) of the surveys, we included all of them in the final multiple logistic regression model for the eight surveys that had at least 140 covert users (Kenya, , Uganda, Lesotho, Malawi, Zambia, India and Colombia). We compared the logistic regression that included the sample of women who provided a definitive answer “Yes” or “No” to the question on covert use with the logistic regression that included the additional women with predicted open or covert use. The coefficient estimates from both regressions were similar, i.e. the coefficients were all the same sign and roughly the same magnitude.

Weighted multiple logistic regressions were performed to evaluate predictors of covert use for the eight surveys. We present the adjusted odds ratios in the tables. Adjusted odds ratios of covert use for IPV as a covariate are presented separately because only a subset of surveys included the domestic violence module.

Indirect estimation of covert use

Indirect estimates of covert use are available from the data on in-union couples in all DHS surveys that sample females and males in the same households and ask about contraceptive use to each partner. (The DHS then creates a couple data file.) Since the direct question has only been asked in a limited set of surveys, it is important to determine how accurate the indirect estimates, from matched couples are. In the indirect method, the reports of contraceptive use by husbands are tabulated for women who report using a modern female method. The male questionnaire asked about use at last coitus: “The last time you had sex did you and your partner use any method (other than a male condom) to avoid or prevent a pregnancy?” and “What method did you or your partner use?”. An assignment to indirect covert use occurs when the husband reports nonuse or use of a traditional method. A man also could report condom use rather than a female modern method, and his partner’s contraceptive use would still be considered open since it may indicate dual method use for prevention of STIs.

We further must restrict the analyses to monogamous couples and those in which both partners reported that their last sexual intercourse was with the spouse, because in the man’s questionnaire the question about contraceptive use at last sex does not specify with which wife and outside partners are obviously not matched. The percentage of women who were in polygynous unions and thus dropped ranged from 1.2% in Guyana to 34.8% in Nigeria with a mean and median of 13%.

There are several categories of the matched responses for monogamous couples combining the woman’s response to the direct question about her partner’s knowledge of her use with the indirect estimate. (We dropped cases of “don’t know” and refusals to the direct question for the analysis of couple responses). Specifically, there are four categories: covert-covert; covert-open, open-covert and open-open where the first term refers to the direct report and the second refers to the indirect assignment for each couple. To investigate whether the covert-open and open-covert groups are more like the open-open or the covert-covert groups we tabulated five covariates for each group and compared them. The woman and couple covariates from the woman’s perspective were: her age, her years of schooling, her number of children every born, age difference from her spouse and difference in years of schooling from her spouse. RESULTS

The 32 surveys included, numbers of in-union women with completed interviews, the levels of female modern contraceptive use and the percentage of those women reporting covert use are presented in Table 1. The earliest surveys included were in 2005 and the most recent survey was in 2013/14. The female modern contraceptive prevalence (we will denote this by mCPRf) and the percentage of covert use vary widely within the SSA region but less so in the other regions. For example, Zimbabwe’s mCPRf was 56% while in Liberia, Nigeria, and Sierra

Leone the mCPRfs were less than 10%. Also in the SSA region, Zimbabwe had the lowest level of covert use (3%) and Sierra Leone and Uganda had the highest levels (20% and 19%, respectively). In seven of the sixteen countries in SSA, the levels of covert use were more than

10%. In contrast, the levels of covert use in all of the countries in other regions were less than

3% except for Bolivia (4%) and Haiti (6%). Figure 1 shows that higher levels of female modern contraceptive use are associated with lower levels of covert use.

[TABLE 1 AND FIGURE 1 ABOUT HERE]

Comparing the method mixes between open and covert users (Table 2) in all but four surveys, the percentage using injectables among covert users was higher than among open users – the percentage of covert users using injections ranged from 40% in Honduras to 79% in Malawi.

However, in Sao Tome & Principe and Zimbabwe the contraceptive pill was the modal method among covert users (54% and 51% respectively). The IUD accounted for less than 15% of covert use in all countries, except Bolivia (23%) and Egypt (43%). Implants and female sterilization were used less frequently by covert users than by open users, except in Sao Tome,

India, and Haiti where the proportion using female sterilization was higher among covert users than among open users. Female sterilization was the most commonly used method by covert users in India (87%), Colombia (53%), and the Dominican Republic (36%), although female sterilization is also the modal method among open users in these countries. Note that in the Dominican Republic the percentage using female sterilization was nearly twice as high in the open group as in the covert group.

[TABLE 2 ABOUT HERE]

Among covariates, years of schooling, wealth, and type of union (monogamous/polygynous) were most often significantly associated with covert use (Table 3). In three of the eight surveys, women with more years of schooling were significantly less likely to be covert users.

Women living in households in the top two wealth quintiles were less likely to be covert users in two surveys. Women in urban areas were slightly more likely to be covert users; however the association was significant only in Zambia and Colombia. These findings contradict the results of the previous study in the two districts in Uganda, which found that the prevalence of covert use was higher in rural areas than urban areas (Blanc et al. 1996). Women in polygynous unions were more likely to be covert users in all surveys in SSA; the odds ratios were much higher than those of other covariates. The proportion of women in polygynous union ranged from 2% in Madagascar to 27% in Uganda (not shown).

[TABLE 3 ABOUT HERE]

Higher parity was positively and significantly associated with covert use in Kenya, Uganda and India. Age, duration of marriage, and fertility preference were not significantly associated with covert use except in Uganda where older women were less likely to be covert users. In

Malawi, women with a longer duration of marriage were less likely to use covertly. The difference between partners in age and in number of years of schooling were not significant predictors of covert use generally though women who were 5 or more years younger than their partners were more likely to be covert users in Kenya.

We hypothesized that women’s participation in household decision-making and attitudes toward spousal violence would significantly affect covert use as those covariates have been considered as proxies for women’s empowerment (Malhotra et al. 2002). However, these covariates were only significant in two countries. Women with a higher household decision- making score (i.e. they decided for themselves or jointly with their partner on more matters) were less likely to be covert users in Madagascar, and women with higher scores on attitudes toward spousal violence (i.e. they more frequently disagreed that a husband is justified to beat his wife) were less likely to be covert users in Zambia.

In Table 4, we present the adjusted odds ratios for the association of women’s reports of IPV and covert use where IPV data were available. Women who reported any physical, sexual, or emotional violence perpetrated by their partners in the last 12 months were more likely to be covert users in all six surveys. (Under the null hypothesis of no association, the probability that all six would have a positive coefficient is 0.016). The association was significant in

Malawi, Zambia, and Colombia.

[TABLE 4 ABOUT HERE]

From the couple data, Table 5 gives the distribution of monogamous couples across the four categories of direct and indirect open and covert use. The percentages with covert use from the direct question are almost all below those given for the same survey in Table 1 because, as has been shown above, wives in polygynous unions are more likely to be using covertly. Note that the percentage of women who say their husband knows and he reports a modern method is less than 30% of couples in Liberia, Nigeria and Sierra Leone. Except for Sierra Leone and Uganda, all countries had 10% or less of women who gave a direct report of covert use. In five of the 23 countries over half of the couples were in the group “open-covert” where she said

“he knows” and he reported nonuse or a traditional method. In SSA the category of open- open varied from 21% of couples in Sierra Leone to 88% in Zimbabwe (median of 58%). The last column of Table 5 gives the total indirect estimate of covert use for these couples. It varies from a low of 3% in Nepal to a high of 75% in Liberia with a median of 43%. Clearly the indirect estimates are much higher than the direct estimates.

[TABLE 5 ABOUT HERE]

Regarding characteristics of women in the open-covert and open-open groups, there were some significant differences (p<0.10) but nothing that held across most surveys. For example, in ten of the 23 surveys (Ethiopia, Lesotho, Nigeria, Swaziland, Tanzania, Uganda, Zambia,

Bolivia, the Dominican Republic and Guyana) women in the open-covert group had significantly less schooling than women in the open-open group (for example, women in

Ethiopia in the first group had 2.9 years while women in the open-open group had 4.1 years

(p<0.05)). But in Kenya and India the significant difference was in the opposite direction (e.g.

5.5 years and 4.8 years in the respective groups in India). Mean children ever born was significantly higher among the open-covert group in a somewhat different group of ten countries (Ghana, Lesotho, Namibia, Nigeria, Sao Tome and Principe, Sierra Leone, Swaziland,

Zambia, Zimbabwe and Dominican Republic) and the significant difference was in the reverse direction in India (3.0 and 3.2 children ever born in the respective groups).

With regard to methods reported by women, because of small sample sizes, we could only compare the open-covert and open-open groups (not shown). Most differences between the method mixes of the two groups were small. Pill use was significantly higher among women in the open-open group than among those in the open-covert group in four of the 23 countries

(Zimbabwe, Kenya, Bolivia and Dominican Republic). In contrast, sterilization was significantly higher in the open-covert group than in the open-open group in four of these countries–Zambia, Zimbabwe, Kenya and the Dominican Republic. But in the opposite direction, sterilization was significantly higher in the open-open group in India.

DISCUSSION

Using the 32 DHS surveys that included a direct question to the woman on whether her partner knows that she is using contraception or not, we estimated the percentage using covertly among users of female modern methods. Compared to the other regions, SSA countries had higher prevalences of covert use; the highest was 20% in Sierra Leone. Outside the region, only Haiti – whose mCPRf was the lowest in the Latin America & Caribbean region

– had a noteworthy proportion of covert users (6%). The estimates were similar to the findings summarized by Biddlecom and Fapohunda (1998) that 7 to 20% of modern contraceptive users were covert users (direct) and that the percentage of covert use (indirect) is lower where the modern contraceptive prevalence is higher (Figure 1).

The percentages of covert users in SSA countries also tend to be higher than those in countries in other regions with a similar level of modern contraceptive use. With the exception of Kenya, Malawi, Rwanda, and Zimbabwe, the mean numbers of children desired by men in SSA are higher than five. Except for Rwanda where the men desired a lower number of children than the women; the difference between men’s and women’s desired number of children ranged from 0.5 in Kenya to 5.6 in Chad (Westoff 2010). This gap in the desired family size probably contributes to higher prevalence of covert use in SSA.

Our finding that covert use was quite strongly associated with both polygynous union and with IPV suggests an important reason why women use contraception covertly. Polygyny is still commonly practiced in many countries in East and West Africa (Tertilt 2005). Among our country surveys, Sierra Leone and Uganda, which have the highest prevalence of covert use

(20% and 18% respectively), also have the highest percentage of polygynous unions among women using female modern contraceptives (25% and 27% respectively). Polygyny has been associated with a higher incidence of HIV (Brahmbhatt et al. 2002), higher levels of child mortality (Strassmann 1997), and of female depression (Adewuya et al. 2007); and it probably contributes to the higher percentage of covert users in SSA. A woman in a polygynous union concerned about her children’s welfare may be afraid of neglect because she has to compete for resources and affection with co-wives – a concern also raised by the respondents in a study by Castle et al. (1999). But she is also afraid to create marital conflict if she uses contraception openly. Also, because the husband is dividing his time between wives, a woman in a polygynous union will have fewer opportunities to discuss contraception with her husband than do her monogamous counterparts and thus she may decide to use contraception without her husband’s knowledge.

A number of studies have linked domestic violence to various reproductive health problems including miscarriage and induced abortion (Silverman et al. 2007; Pallitto et al. 2013), HIV and other STIs (Jewkes et al. 2010), and adverse maternal and infant outcomes (Han &

Stewart 2014). Our analysis found that women experiencing IPV were more likely to be covert users in all of the surveys where IPV data were available; the effect of IPV on covert use was next strongest (after polygyny) among covariates. Repeated intimate partner violence could prompt a woman to use contraception surreptitiously to prevent unwanted pregnancy in such unfavorable conditions. Indeed, women who had experienced intimate partner violence in 6

SSA countries (Cameroon, Kenya, Malawi, Rwanda, Uganda, and Zimbabwe) were more likely to use contraception (Alio et al. 2009a), and they might do so covertly to avoid threat and possible contraceptive sabotage.

Women experiencing IPV have limited autonomy over their reproductive choices and potentially face difficulties in accessing family planning services. Covert contraceptive use seems to be one of the strategies used by a woman wishing to avoid pregnancy when she is not able to overtly exercise her autonomy. On the other hand, covert use could aggravate men’s fears and anger because they might perceive covert use as a threat to their authority or a sign of infidelity (Biddlecom & Fapohunda 1998). Therefore, covert users might be more likely to use contraception inconsistently or discontinue use.

Tolerance toward IPV has been associated with a history of IPV experience (Yount & Li 2009;

Lawoko 2006), suggesting that these attitudes cannot be simply interpreted as a reflection of a woman’s own values but rather an internalization from her experience. In this vein, a study in Uganda found that more women than men (27% versus 22%) justified spousal violence if a woman used contraception without her husband’s approval (Koenig et al. 2003). A study among contraceptive pill users in Bolivia showed that fear of being hit was most strongly associated with covert use (McCarraher et al. 2006). Fear of violence might create conditions in which women are unable to advocate and assert their personal wishes, leading to covert use or even nonuse of contraception. However, in our study the attitude toward spousal violence is not a significant predictor of covert use, nor was household decision-making power. We suggest that the result - that household decision-making power did not predict covert use--is due to the fact that one empowered woman may be able to negotiate contraceptive use with her partner so she can use openly, but another empowered woman could decide to use contraception on her own without her partner’s knowledge. These two effects are in opposite directions and could possibly explain why the variable was not a significant predictor.

Women’s socioeconomic status and level of schooling have been shown to be predictors of contraceptive use (e.g. Ainsworth et al. 1996; Creanga et al. 2011). Our study shows that these two covariates are also important predictors of covert use in some countries. Women's education may give her improved status in the household so that she can assert and communicate her wish to use contraception with her partner. Educational attainment and socioeconomic status are closely related, as most women in the lowest wealth quintiles only possess limited years of schooling compared to their wealthier counterparts. With her education and resources, women in higher socioeconomic status households are better able to seek family planning services and use contraception openly.

Similar to what is observed among open users, covert users mostly use injectables in the majority of surveys. Injectable use was higher among covert users than among open users in eight of 16 surveys where injectables were the modal method. Injectables are easily concealable, are good for three months, and do not require lengthy or complicated medical procedures. Pills are more inconvenient to use since a woman has to take one daily and needs to hide the packet. However, a nontrivial proportion of covert users do use pills. The IUD might be preferable among covert users due to its concealment and long term protection but a man can sometimes feel the string with his penis during sexual intercourse. Interestingly, covert users use female sterilization more frequently than implants. Implant rods (or the single rod that is now used) can be quite easily seen under the skin upon close inspection compared to female sterilization which leaves no scar at all with the transcervical approach.

Indirect estimates

How accurate is the indirect estimate of covert use for surveys that did not include the direct question? Table 5 showed large differences between the two estimates and obviously one or both estimates are wrong. Does the direct question lead to an underestimate or is the indirect estimate an overestimate or possibly some combination of both?

Though convincing evidence is lacking from our analyses, it appears clear that the indirect method leads to an overestimate. The reasons that the male partner would say nonuse when the woman reports a modern female method can be categorized as: 1) she is using the method covertly; 2) she told him of her use and he wasn’t paying attention or forgot; 3) in response to the question on contraceptive use at last coitus he thinks more of coitus-dependent methods such as condoms and less about female controlled non-coital methods, e.g. he usually uses a condom but did not use it at last coitus so he reports nonuse; 4) she reports use but her report is false, i.e. his report of nonuse is correct. In our analyses we have assumed that her report of a female modern method use is correct. But to what extent is her report valid? Some evidence for this comes from the question in DHS to pill users to show the pill packet to the interviewer. In 21 surveys where this was tabulated, the mean percentage of women who could produce the packet was 78% (Becker and Costenbader 2001, Table 2). Thus it is possible that social desirability bias may lead some women to falsely report contraceptive use.

The DHS data from Zimbabwe perhaps illustrate the third reason-- there was a significantly higher percentage of women using sterilization in the open-covert group than in the open- open group, i.e. if the partner does not mention female sterilization when the wife does and says that he knows, then the couple falls in the open-covert group. Though they are far apart in estimated levels, there is nevertheless some consistency between the direct and indirect estimates in that pill use was shown in some countries to be significantly higher in the open- open groups than in the open-covert groups, i.e. it seems that men whose partners are using the pill are more likely to recall it than are partners of women using other methods.

A plausible argument can also be made that the direct estimate is an underestimate.

Estimates of covert use of less than 6% of married and Zambia and of

1.2% in India seem implausibly low but again this cannot be definitely demonstrated from our analyses. However, there is a simple argument for this: Among women who have not told their partners of their contraceptive use, a certain proportion probably would not want to share this fact with a interviewer who is a stranger; in this case, responses to the direct question would lead to underestimates.

Strengths and Limitations

To our knowledge this is the first study to document covert use from representative samples in over thirty countries around the world, thanks to the inclusion of the relevant question in these DHS surveys. We were also able to compare the direct and indirect estimates of covert use which is novel. In addition we were able to compare the modern method mixes that were reported by women in the open and covert groups. Furthermore, with regard to IPV, while previous studies have examined the relationship to contraceptive use and nonuse, we were able to document that among users, those who reported IPV were significantly more likely to use covertly than those who did not report IPV.

Limitations of the study also deserve discussion. First, the percentage of women who reported “don’t know” or refused to answer the question about whether the partner knows or not, was about 4% in quite a few countries and was a very high 18% in Sierra Leone, though in the surveys used for multivariate analysis the maximum was 2% and the mean percentage was 1.3%. While we imputed values for these cases from a multivariate model, exploration of the reasons for these responses/refusals would be important for future qualitative research.

Furthermore, if the woman responds ‘no’ to the question “Does your husband/partner know that you are using a method of family planning?” this does not correspond exactly with hidden use. For example, she may have attempted to discuss the matter with him and he possibly said something like “whatever you decide is fine with me” so he technically does not know of her use but she is not consciously hiding her use either.

Also social desirability bias could be a major problem with these data. It could help explain the large difference between the direct and indirect estimates. To be specific, women may respond that yes, he knows when that is not the case but they do not want to admit that their husbands do not know of their use in a context where there may be an expectation that husbands would know such things. Regarding the indirect estimates, since the question to the woman was about ‘current use’ of contraception but the question to the man was about use at last coitus, the indirect estimate could be too high simply because he may be less likely to think of long-acting and permanent methods in responding to the question.

With regard to the analyses, small numbers of covert users in some surveys made it impossible to do the multivariate analyses for those surveys. Also as usual with cross- sectional data, associations do not establish causation. However, there may be an exception: with regard to the relationship of covert use with IPV, since the women are current contraceptive users and the violence occurred during the past 12 months, it seems clear that the violence was not due to the current contraceptive use itself, as it is covert!

To what extent can we generalize from the findings from the multivariate analyses of eight surveys. To partially assess this we did combine surveys for several countries in the same region that had similar levels of mCPRf and covert use (from univariate analyses) but small numbers of covert users. We used the same multivariate model with unweighted data (not shown) and found that the relationships with covariates were similar (e.g. years of schooling continued to be a significant predictor).

CONCLUSION

High covert use in SSA is associated with low contraceptive use there. Of the 16 countries in

SSA only Zimbabwe had less than 4% covert use but of the 16 countries in other regions, only

Haiti had covert use of more than 4%. In the other regions contraceptive use is much higher and thus more socially accepted. Our results suggest that polygyny and intimate partner violence challenge women’s ability to use contraceptive methods openly, particularly in SSA.

Covert contraceptive use might benefit her (i.e. she can prevent unwanted fertility), but it can negatively affect other aspects of her welfare as suggested from the study by Ashraf and colleagues (Ashraf et al. 2014). There is a need to address IPV in family planning services provision where IPV is common and contraceptive use is not yet the norm. In a confidential and non-judgmental manner service providers need to inquire of women about their partners’ attitudes and behaviors regarding contraceptive use, whether they have difficulties discussing contraception with their partners, and whether they want to involve their partners at all. In countries where polygyny is still common, providers should ask a woman’s type of marriage since women in polygynous unions may have interspousal communication problems. This information will help providers counsel such women in selecting methods that best meet their needs. While involving men in family planning programs is important and encouraging couple communication can be beneficial, such communication is sometimes impossible due to a threat of violence and some women would only be able to use contraception covertly. The challenges faced by these women deserve careful consideration in developing policies and programs aiming to improve male involvement.

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Figure 1: Percent of users of modern female methods who are using covertly, by modern female contraceptive prevalence for 32 DHS surveys 2015-2013 SL 20 UG 15

ST SZ LS GH NG 10 TZ KE LR ET

Covertuse (%) HT ZM

5 MG MW NM BO MD ZW TL UA PE GY HN PH IN CO DO KH NPJO EG 0

0 20 40 60 80 Modern female contraceptive prevalence(%) For country labels, see Table 1

Table 1. Number of women, modern female contraceptive prevalence rate and percent of users of modern female methods who report using covertly in selected DHS surveys

Region and country Year of No of Modern % Covert (abbreviation) survey married female CPR contraceptiv women (mCPRf )* e use Sub-Saharan Africa Ghana (GH) 2008 2950 14.1 10.9 Liberia (LR) 2007 4508 8.7 7.8 Nigeria (NG) 2008 23954 5.7 10.2 Sao Tome & Principe (ST) 2008/09 1754 28.2 12.6 Sierra Leone (SL) 2008 5373 5.5 20.2 Ethiopia (ET) 2005 8644 13.6 8.2 Kenya (KE) 2008/09 5041 37.1 9.0 Madagascar (MG) 2008/09 11903 27 4.7 Tanzania (TZ) 2010 6310 23.7 8.7 Uganda (UG) 2006 5362 16 18.8 Lesotho (LS) 2009 4129 36.3 11.5 Malawi (MW) 2010 15445 39.8 5.2 Namibia (NA) 2006/07 3575 42.5 4.9 Swaziland (SZ) 2006/07 2069 34.5 12.8 Zambia (ZM) 2013/14 9649 39.9 5.4 Zimbabwe (ZW) 2005/06 5118 56.4 2.6 North Africa/West Asia/ Europe Egypt (EG) 2005 18134 55.5 0.7 Jordan (JO) 2007 10360 35.6 0.6 Moldova (MD) 2005 4892 35.2 2.8 Ukraine (UA) 2007 4195 23.8 2.5 South & Southeast Asia India (IN) 2005/06 87925 42.3 1.1 Nepal (NP) 2006 8244 33.1 0.9 Cambodia (KH) 2005 10309 24.1 0.6 Philippines (PH) 2008 8564 31.3 0.9 Timor Leste (TL) 2009/10 7877 20.8 2.3 Latin America & Caribbean Guyana (GY) 2005 3006 26.8 1.6 Bolivia (BO) 2008 10188 29.8 3.8 Colombia (CO) 2010 27396 62.3 1.5 Dominican Republic (DO) 2007 15872 67.6 1.1 Haiti (HT) 2005/06 6376 18.2 6.2 Honduras (HN) 2011/12 13178 59.2 1.9 Peru (PE) 2010 13626 38.7 2.1 * Modern female methods include: pill, IUD, injectables, implant, female sterilization, female condom, diaphragm, and emergency contraceptives

Table 2. Contraceptive method mix among open users vs. covert users – selected DHS surveys with more than 50 covert users

All Region and female country Type of No. of modern Pill IUD Injectable Implan Female use wome methods s t sterilization n a Sub-Saharan Africa Nigeria Open 960 100.0 29.5 19.2 42.7 0.6 7.5 Covert 110 100.0 25.9 10.5 57.9* 2.4 2.9 Sao Tome & Open 408 100.0 53.4 1.6 40.4 0.0 4.6 Principe Covert 71 100.0 54.2 0.0 39.9 0.0 5.9 Sierra Leone Open 212 100.0 41.2 3.9 54.5 0.0 0.4 Covert 75 100.0 42.1 6.9 51.1 0.0 0.0 Ethiopia Open 1159 100.0 22.4 1.6 73.2 1.3 1.4 Covert 97 100.0 31.7 2.3 64.0 0.8 1.3 Kenya Open 1471 100.0 20.3 4.6 56.4 5.2 13.4 Covert 169 100.0 12.3 0.3 71.3* 5.0 11.1 Madagascar Open 2885 100.0 21.9 1.4 66.5 4.1 6.1 Covert 150 100.0 29.1 1.4 66.5 2.8 0.2 Tanzania Open 1212 100.0 29.4 2.4 42.2 10.3 15.7 Covert 113 100.0 21.2 0.6 70.2* 2.8 5.1 Uganda Open 647 100.0 17.5 1.0 62.3 2.3 16.9 Covert 146 100.0 19.1 0.9 71.7* 1.4 7.0 Lesotho Open 1190 100.0 35.2 5.2 52.5 0.2 6.4 Covert 175 100.0 29.3 4.1 61.3 0.6 4.7 Malawi Open 5611 100.0 6.3 0.7 64.1 3.5 25.2 Covert 310 100.0 5.9 0.5 79.4* 1.3 12.9 Namibia Open 1283 100.0 20.3 3.2 50.4 0.2 25.3 Covert 75 100.0 28.4 0.0 61.9 0.0 8.8 Swaziland Open 583 100.0 27.5 4.2 49.2 0.5 18.3 Covert 91 100.0 31.0 5.3 52.3 0.0 11.4 Zambia Open 3531 100.0 29.7 2.7 48.6 4.9 13.8 Covert 204 100.0 27.2 9.2 46.6 0.9 15.0 Zimbabwe Open 2753 100.0 76.8 0.5 17.0 2.1 3.5 Covert 80 100.0 51.2 0.4 37.2 3.5 7.8 North Africa/West Asia/ Europe Egypt Open 9620 100.0 17.8 66.0 12.5 1.5 2.1 Covert 84 100.0 26.4 42.5 25.9 1.6 3.7 South & Southeast Asia India Open 35565 100.0 7.1 4.0 0.2 0.0 88.6 Covert 433 100.0 6.8 5.5 1.3 0.0 86.5 Latin America & Caribbean Bolivia Open 3071 100.0 11.2 28.6 37.2 22.7 0.0 Covert 120 100.0 12.9 22.6 55.0* 8.9 0.0 Colombia Open 16374 100.0 12.1 12.0 14.6 5.1 56.1 Covert 267 100.0 16.5 10.1 17.2 2.8 53.4 Dominican Rep. Open 10625 100.0 19.6 3.1 6.0 0.8 70.5 Covert 125 100.0 34.6 9.3 19.6 0.3 36.2 Haiti Open 1060 100.0 18.5 0.1 59.6 12.3 0.1 Covert 76 100.0 19.0 0.0 75.1 2.9 3.0 Honduras Open 7375 100.0 20.1 11.6 30.4 0.0 38.0 Covert 141 100.0 24.5 11.7 40.3* 0.0 23.4 Peru Open 5315 100.0 21.4 8.4 44.9 0.3 24.2 Covert 123 100.0 21.8 7.9 58.2* 0.0 12.1 a Percentages do not add to 100% for some countries because other modern methods (female condom, diaphragm, foam, jelly, emergency contraceptive) are not shown. These percentages were <1% in all surveys except for Haiti and Zambia. (In Haiti and Zambia 9.4% and 1.2% respectively of users were using female condom.) * The percentage of women using injectables is significantly higher among covert users than among open users (p< 0.05). Table 3. Adjusted odds ratios for selected covariates from multiple logistic regressions predicting covert use of modern female contraceptive methods, by region and country

Region and country Marriage Attitude Difference Place of (number of users) Years of duration Decision on spousal Age in years of residenc Fertility Polygynous Age Parity schooling (yrs) making violence difference schooling e Wealth preference union > 5 years > 3 years Urban 40% Want highest another a Sub-Saharan Africa Kenya (n=1672) 0.97 1.17* 0.90* 0.99 0.93 0.97 1.72* 0.81 1.05 0.74 1.20 2.82** Madagascar (n=3109) 0.94 0.92 0.97 1.06 0.74** 0.97 0.67 1.23 1.60 0.54* 1.01 5.56** Uganda (n=809) 0.91* 1.20* 1.01 1.03 1.01 0.92 1.12 0.66 1.23 1.03 1.35 1.78* Lesotho (n=1376) 1.02 0.88 0.91* 1.01 1.06 1.05 1.30 0.65 1.78 0.46* 0.83 Malawi (n=6082) 1.02 1.11 0.90** 0.93* 1.06 0.98 1.23 0.71 1.49 0.90 1.02 2.75** Zambia (n=3725) 1.05 1.00 0.99 0.97 0.92 0.91* 1.29 1.20 1.64* 0.95 0.67 3.80** South & Southeast Asia India (n=36252) 1.02 1.12* 0.96 0.96 0.96 1.01 0.92 0.93 0.75 1.00 0.33** 0.55 Latin America & Caribbean Colombia (n=16380) 0.96 1.07 0.96 1.04 0.98 1.34 0.98 0.83 1.67* 0.79 0.91 - a In Sub-saharan African and South/Southeast Asian countries, women who are undecided about their next pregnancy are in the same category with women who want another child; while in Latin American & Caribbean countries, undecided women are in the same category with women who do not want another child * p <0.05 and ** p <0.01 for test of null hypothesis of odds ratio = 1.0 Table 4. Adjusted odds ratio of the effect of intimate partner violencea on covert use for six DHS surveys with data available*

Country Adjusted odds ratio Kenya 1.64 Malawi 1.20* Uganda 2.24 Zambia 1.95** India 1.30 Colombiab 1.70* * Adjusted for age, parity, years of schooling, marriage duration, place of residence, wealth, age difference with partner, difference in years of schooling with partner, polygyny, household decision making score, and attitude on domestic violence. a Report of any physical, sexual, or emotional violence in the last 12 months. b Experience on emotional violence was not asked in Colombia.

Table 5: Percentage distribution of monogamous couples in DHS surveys with women reporting a modern female method of contraception, by whether she directly reports that the husband knows she is using (open) or not (covert) and whether the husband reports a modern method (open) or not (covert).

Region and Number All Category of direct and indirect open or covert use (direct- Country of mono- categories indirect) gamous Direct covert report Direct open report All couples (“he does not know”) (“he does know”) indirec All direct covert- covert- All direct open- open- t reports of covert open reports of covert open* covert covert use open use use Sub-Saharan Africa Ghana 243 100 7 6 1 93 44 49 50 Liberia 162 100 10 7 3 90 65 25 72 Nigeria 302 100 9 7 2 91 63 28 70 Sao Tome & 255 100 12 10 2 88 37 51 47 Principe Sierra Leone 72 100 24 18 6 67 56 21 74 Ethiopia 434 100 7 6 1 93 26 68 32 Kenya 461 100 10 8 2 90 29 61 37 Madagascar 1223 100 3 2 1 97 27 69 29 Tanzania 251 100 8 5 3 92 30 62 35 Uganda 143 100 14 10 4 86 24 62 34 Lesotho 280 100 10 7 3 90 29 61 36 Malawi 1357 100 4 3 1 96 40 55 43 Namibia 332 100 4 3 1 96 39 57 42 Swaziland 244 100 7 3 4 93 38 55 41 Zambia 2653 100 4 2 2 96 23 73 25 Zimbabwe 1307 100 2 1 1 98 10 88 11 North Africa/West Asia/Europe Ukraine 306 100 4 4 0 96 29 67 33 South & Southeast Asia India 16,752 100 1 1 1 99 22 77 23 Nepal 900 100 1 1 0 99 2 97 3 Timor Leste 430 100 2 1 1 98 59 40 60 Latin America and Caribbean Bolivia 884 100 4 3 1 96 22 74 25 Dominican Rep. 7697 100 1 1 0 99 46 53 47 Guyana 446 100 3 2 1 97 57 40 59

* Couples in which she reported a modern female method and he reported condoms are included in the open-open group. Those refusing to answer or answered “don’t know” to the direct question were excluded from the tabl