Health care providers’ perspectives about modern contraceptive use among eligible couples in a tribal area of Palghar district, Maharashtra: a qualitative study

INTRODUCTION

Family planning is key to slowing unsustainable population growth and the resulting negative impacts on the economy, environment, and national and regional development efforts. Globally, among women who want to avoid pregnancy, 77 per cent used modern contraceptive methods in 2021. Intrauterine device (IUD) is the most common contraceptive method used (18.6 per cent of women rely on this method), followed closely by male condom (17.0 per cent) in 14 countries, particularly in Central Asia and Eastern Asia.¹ Investing in family planning enables faster economic growth in nations by reducing fertility and changing the age structure and dependency ratio of a given population.²

The arduous path of the family planning program in India has witnessed a shift in approaches from population control to population stabilization and is now visualized through the lens of maternal and child health outcomes.³ In India, unmet need for family planning is greatest among 15–19-year-olds, among the less educated and in the poorest households. The choice of the contraceptive method, however, is influenced by a host of interdependent demographic, cultural, economic, and social factors. The modern contraceptive prevalence rate in India, as per the NFHS-5 report (2019-21), is 56.5% among married women aged 15-49. The total fertility rate for the scheduled tribe was 2.5. Thus, there is still a substantial unmet need for contraception among tribals in India.⁴ The most common modern spacing methods used by currently married women in Maharashtra are condoms (10%), followed by pills and IUDs or PPIUDs (2%) each.

As per NFHS 5 for Palghar district of Maharashtra, India, the current use of family planning methods for currently married women between the ages of 15 and 49 for any method was 71.8%. The total unmet need was 8.2%, while unmet need for spacing was 4%. Previous studies have also shown that among tribal communities, the foremost reasons for not using contraception consist of fear of adverse effects, lack of knowledge, and phobia of adverse health outcomes.⁵

Various studies conducted in India among tribal couples found low contraceptive usage and high unmet need for family planning among tribals. Also, though research on health providers’ perspectives has been done, research to identify barriers and facilitating factors for contraceptive use in a tribal community in this region has been lacking.

The study explores health care workers’ perspectives about the use of modern contraceptive methods among eligible couples in tribal areas. This information can be used to enhance the capacity building of health care workers to improve uptake and utilization of contraceptives by eligible couples, thus addressing the unmet need for contraception in tribal areas.

Objectives

The objective of this study was to understand healthcare providers’ perspectives regarding the use of modern contraceptive methods among eligible couples.

METHODS

The present qualitative study was conducted in subcentres of Ashaghad PHC, Palghar district, Maharashtra. The PHC provides health care services to about 44,000 people. There are five subcentres under the PHC. There are three CHOs, 47 ASHAs and seven ANMs under this PHC. Among the health care workers, three CHOs, five ANMs and nine ASHAs willing to participate were selected for the study. Hence, 17 participants were selected for the study. Participants were selected by the purposive sampling method. There was no non-participation or drop-out. A semi-structured questionnaire guide was developed and used to collect information.

Face-to-face in-depth interviews using a semi-structured questionnaire with each study participant were conducted. The participants interacted before the interview, and the researcher informed them about the purpose of doing this research. The participants were asked about the convenient place for the interview, which could be either a nearby healthcare facility or their homes. Participants mentioned that the health care facilities where they are working will be convenient for them. Hence, interviews were conducted in subcentres. Interviews were conducted by a public health expert who was trained in qualitative research.

Participants’ privacy and confidentiality were maintained by interviewing in a secluded area within the subcentre where only the researcher and participant interacted. The average duration of each interview was 30 to 45 minutes. IDIs were audio recorded after obtaining written consent from all study participants. The audio recordings of IDIs were first transcribed in Marathi (the local language) and then translated into English. No repeat interviews were carried out.

All participants were told that participation in the study was voluntary. They were informed that they could withdraw at any time during the study. Also, if they refuse, there would be no penalty. They were informed that there were no financial gains if they participated in this research. Data were analyzed manually using deductive thematic analysis. The most noteworthy quotes noticed in the transcript were picked to support the themes.

Four main themes were identified in advance. These 4 major themes were contraceptives affect partners’ health, family members are the decision-makers, role of tribal culture in family planning and better health education methods are keys for promoting modern contraceptives.

RESULTS

Table 1 describes the health care providers' characteristics. A total of 17 health care providers participated in this study. The age of the participants ranged from 22 to 54 years. The mean age was 40 years.

Out of the total participants, 7 (41%) participants had work experience of more than 10 years, 4 (23%) participants had work experience between 5 and 10 years, while 6(36%) participants had work experience of less than 5 years. The 14 (82%) participants had undergone training in family planning, while 3 (18%) did not receive any training.

Thematic findings

Theme 1- contraceptives affect partner’s health

Health care providers were asked about the prevailing misconceptions about family planning methods in their area. Health care providers highlighted that a plethora of misperceptions were prevalent in the area, as these were deeply rooted in that community.

The following misconceptions among couples were mentioned by CHOs.

“I don’t advise my partner to use pills, as pills will stop the birth. (3 years’ experience)”

“We don’t prefer CuT as a contraceptive as it will lead to pus formation (1-year experience).”

The ANMs cited the following misconceptions as told by couples –

“I don’t prefer IUCD as it will remain inside the uterus and it is difficult to remove. Also, it is heard that one cannot lift weights when cuT is inside the uterus. Hence, it is better not to use it” (4 years’ experience).

“CuT remains inside the uterus, and it also affects fertility. Hence, I don’t support my partner in using it” (14 years’ experience).

The ASHA workers reported the following misconceptions about contraceptives among eligible couples –

“Antara will stop childbirth, OC pills cause burning micturition, and if I use cuT, I will not be able to work as there is abdominal pain due to it” (14 years’ experience).

Theme 2 - family members, the decision makers

The health care providers were asked about the difficulties they faced while counselling couples regarding spacing methods in their area. Difficulties faced by healthcare workers were expressed by them as –

“Mostly decisions are taken by family members, usually the husband and the mother-in-law, about the use of contraceptives (ANM 5 years’ experience)”.

“Usually, wives among eligible couples are illiterate; hence, they listen to family members rather than health care providers” (ANM 14 years’ experience).

“Wives among eligible couples are illiterate; hence, mostly decisions are taken by husbands. It is very difficult to convince a husband, especially when the husbands are alcoholics and they don’t listen to us” (ASHA 6 years’ experience).

Theme 3- role of tribal culture in family planning

Health care providers were asked about the prevailing customs regarding contraceptive use in their area. These were highlighted as-

“Illiterate couples don’t listen to us; instead, they listen to quacks. Couples don’t consider family planning as an important issue” (CHO 1 year of experience).

“Use of jungle herbal medicines is common here and is an alternative to modern contraceptives” (ANM 12 years’ experience).

“In a few families, the mother-in-law tells us that no problem arises even if too many children are born with less spacing to me. So, there is no need for couples to adopt family planning methods by couples” (ASHA 6 years’ experience).

Theme 4 - better health education methods are key in promoting modern contraceptives

The health care providers were asked about the facilitating factors regarding spacing methods by eligible couples in this area.

Facilitating factors reported by health care workers where culturally appropriate street plays at the community level can be effective, use of IEC materials to explain the importance of contraceptives for better maternal and child health is required, health education of students above 13 years at residential tribal schools, i.e. Ashram schools, is required, community-level camps involving mother-in-law and husband in promoting use of contraceptives are essential and involvement of gram panchayat members in promoting the use of contraceptives will enhance the faith and thus uptake of contraceptives.

DISCUSSION

The present study is unique as such to explore perspectives of the health care providers regarding uptake and use of modern contraceptives, was not been done previously among the tribal community in this region. The research done at the national and international levels shows that there is a need for effective couple counselling for the uptake and use of modern contraceptives. The study highlighted that there is still a lack of awareness about contraceptive use in tribal areas due to illiteracy and related ignorance. The factors for unmet need for family planning among women in this study can be enumerated as the role of family members as pillars in decision making and choice of contraceptive, misconceptions about contraceptives, tradition of listening to community members &quacks and custom to use jungle herbs as contraceptives without knowing their effectiveness as contraceptives.

The study further showed that there were misconceptions about contraceptives, mainly IUCD, about its side effects, mainly related to menstrual bleeding, abdominal pain and subsequent infertility. Thus, fear about contraceptives was a major determinant of non-acceptance of contraceptives among tribal couples. These findings are supported by a previous qualitative study by Memon et al.⁶

The study findings revealed a few barriers regarding the promotion of modern contraceptives by health care workers among eligible couples. The study participants mentioned that the major barrier was illiteracy. As the couples were illiterate, they were not able to decide on contraceptive use singly or jointly. The couple depends upon family members to decide on contraceptive use. The study also highlighted the complex situations, as some of the husbands were alcoholics and they disapproved of the wife’s decision to accept contraceptive methods. Thus, the unmet need for contraceptives among tribal women in this region was unacceptably high compared to other parts of the state. The mother-in-law plays a dominant role in deciding about contraceptive use as the head of the family. Her decision depends upon the number of children the couple has and is mainly driven by son preferences. Similar findings were claimed by El Weshahi et al.⁷

Moreover, the study findings suggest that the health care providers were worried about the tribal culture and its impact on the tribal community. The tribals are isolated and live far away from non-tribal communities. These tribal communities have their own different set of cultural and traditional practices. The community follows these practices, and it serves as significant obstacles in family planning adoption among eligible couples. The family planning program suffers setbacks due to various myths about contraceptives in communities. The study also highlighted the role of community members and quacks as influencers of couples’ decisions to use contraceptives. These findings were similar to Ochako et al.⁸

According to the health care providers, better health education using effective IEC materials will definitely enhance awareness about family planning. As the eligible couples are mostly illiterate or less educated, with the use of effective IEC materials, it will become easy for health care workers to make couples understand and to take informed decisions about modern contraceptives. The community awareness about contraceptives can be raised by street plays and by displaying banners about contraceptives at strategic places in these areas. This will, in turn, be effective in reducing fear and increasing use of modern contraceptives. The health care workers also reported that there is a practice of early marriages in tribal areas; hence, health education about family planning should be given in tribal schools. The health care workers also mentioned that conducting effective counselling during the house visits by health care workers will significantly enhance the use of modern contraceptives despite widespread fear about contraceptive side effects. The health care workers insisted that during community gatherings for immunization sessions, there is ample opportunity to provide health education as mothers are accompanied by family members or mothers-in-law. This will help to emphasize the benefits of contraceptive use to couples, families and the community at large. These findings are similar to other qualitative studies by Takyi et al, Dixit et al, and Cordero et al.^9-11

CONCLUSION

The study provides qualitative evidence that the understanding of misconceptions in the tribal community and barriers and facilitating factors by health care workers among eligible couples are essential to gain insights and thus to facilitate better delivery of contraceptives and their sustainability in the tribal area. Eligible couples need knowledge about contraceptives and assertiveness for making safer fertility decisions. Added focus should be given on information, education and awareness among eligible couples on aspects of sexual and reproductive health. Broader strategies, including community-level actions, are needed to address socio-cultural practices that confront damage to the family planning program. Fostering sustained behaviour change in community members appropriate to local needs and using a culturally sensitive approach will greatly enhance family planning intentions. Strengthening these community-level interventions will definitely enhance uptake and better utilisation of modern contraceptives by eligible couples in the tribal community.

Further, implementation research is required to generate a more effective approach to address community-level barriers and make use of existing skilled staff to meet the unmet need of family planning in tribal areas.

ACKNOWLEDGEMENTS

Authors would like to thank Dr. Geetanjali Sachdeva, Director, ICMR-National Institute for Research on Women’s Health (formerly ICMR-National Institute for Research in Reproductive and Child Health for her extended cooperation and support for conducting the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Ethical Approval was obtained from Institutional Ethics Committee, ICMR- National Institute for Research on Women’s Health Mumbai. (Formerly ICMR- National Institute for Research in Reproductive and Child Health)

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