|Year : 2017 | Volume
| Issue : 1 | Page : 3-8
Perceptions of nonsurgical permanent contraception among potential users, providers, and influencers in Wardha district and New Delhi, India: Exploratory research
Jennifer C Aengst1, Elizabeth K Harrington2, Pramod Bahulekar3, Poonam Shivkumar4, Jeffrey T Jensen5, BS Garg6
1 Adjunct Professor of Anthropology, Department of Anthropology, Portland State University, Portland, USA
2 Acting Instructor and Senior Fellow, Department of Obstetrics and Gynecology, Division of Family Planning, University of Washington, Seattle, Washington, USA
3 Social Scientist, Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
4 Professor, Head of Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences,Sevagram, Maharashtra, India
5 Professor, Reproductive and Developmental Sciences, Oregon National Primate Research Center; Leon Speroff Professor, Department of Obstetrics and Gynecology, Director of the Women's Health Research Unit, Center for Women's Health, Oregon Health and Science University, Portland, USA
6 Director, Dr. Sushila Nayar School of Public Health; Director and Professor of Community Medicine, Secretary, Kasturba Health Society, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
|Date of Web Publication||16-Feb-2017|
Jennifer C Aengst
6105 NE Garfield Ave., Portland, OR 97211
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: New permanent contraceptive methods are in development, including nonsurgical permanent contraception (NSPC). Objective: In the present study, perceptions of NSPC in India among married women, married men, mothers-in-law, providers, and health advocates in Eastern Maharashtra (Wardha district) and New Delhi were examined. Methods: We conducted semi-structured interviews with 40 married women and 20 mothers-in-law; surveys with 150 married men; and focus group discussions with obstetrics/gynecology providers and advocates. Transcripts were coded and analyzed using a grounded theory approach, where emerging themes are analyzed during the data collection period. Results: The majority of female respondents expressed support of permanent contraception and interest in NSPC, stating the importance of avoiding surgery and minimizing recovery time. They expressed concerns about safety and efficacy; many felt that a confirmation test would be necessary regardless of the failure rate. Most male respondents were supportive of female permanent contraception (PC) and preferred NSPC to a surgical method, as long as it was safe and effective. Providers were interested in NSPC yet had specific concerns about safety, efficacy, cost, uptake, and government pressure. They also had concerns that a nonsurgical approach could undermine the inherent seriousness of choosing PC. Advocates were interested in NSPC but had concerns about safety and potential misuse in the Indian context. Conclusion: Although perceptions of NSPC were varied, all study populations indicated interest in NSPC. Concerns about safety, efficacy, appropriate patient counseling, and ethics emerged from the present study and should be considered as NSPC methods continue to be developed.
Keywords: Contraceptive development, decision-making, nonsurgical permanent contraception, permanent contraception, sterilization
|How to cite this article:|
Aengst JC, Harrington EK, Bahulekar P, Shivkumar P, Jensen JT, Garg B S. Perceptions of nonsurgical permanent contraception among potential users, providers, and influencers in Wardha district and New Delhi, India: Exploratory research. Indian J Public Health 2017;61:3-8
|How to cite this URL:|
Aengst JC, Harrington EK, Bahulekar P, Shivkumar P, Jensen JT, Garg B S. Perceptions of nonsurgical permanent contraception among potential users, providers, and influencers in Wardha district and New Delhi, India: Exploratory research. Indian J Public Health [serial online] 2017 [cited 2018 Mar 23];61:3-8. Available from: http://www.ijph.in/text.asp?2017/61/1/3/200261
| Introduction|| |
Permanent contraception (sterilization) is widely used in high and low resource settings, yet is the only method that requires surgery., Currently, female permanent contraception requires abdominal, laparoscopic, or hysteroscopic surgery. This is resource intensive, as it requires surgical facilities and highly trained health care providers. Along with logistical challenges of surgery in rural areas, sterilization camps have led to public mistrust of family planning.,,
The present research group is investigating potential strategies for nonsurgical permanent contraception (NSPC) for women., NSPC could provide a new option for women considering sterilization with potential for enhanced safety (by avoiding surgery), improved access, and greater privacy.,, While providers and the public generally support the development of new contraception, there is little understanding of how women users, male partners, and health advocates would respond to NSPC., There is a need to better understand familial influences on contraceptive decision-making and the medical context for new methods.
The present study examined perceptions of permanent contraception and surgery, responses to new technology, and decision-making among married women, married men, mothers-in-law, obstetrics/gynecology providers, and health advocates in India. While this paper is focused on data from India, this research is part of a larger study examining permanent contraception in the United States.
| Materials and Methods|| |
This study was collaboration between investigators at the Mahatma Gandhi Institute of Medical Sciences (MGIMS) and Oregon Health and Sciences University (OHSU). Approval of human subjects' participation was obtained through the Institutional Ethics Committee at MGIMS and through the institutional review board at OHSU.
In this mixed-methods qualitative study, we conducted semi-structured interviews with married women and mother-in-laws; focus groups discussions (FGDs) with providers and women's advocates; and surveys with married men. The study was conducted from January 2014 to February 2014 in Wardha district, Maharashtra, and New Delhi.
Female social workers recruited were parous or pregnant married women aged 18–45 years (n = 40) and mothers-in-law with at least one daughter-in-law (n = 20) from MGIMS outpatient waiting areas and from private homes in Wardha district [Box 1 [Additional file 2]]. Social workers conducted semi-structured interviews lasting between 45 and 60 min in Marathi or Hindi. Interview themes included perspectives on permanent contraception and surgery, new contraception, and family influence on decision-making. The sample size reflected the anticipated number of interviews needed to reach theoretical saturation., Interviews were audio-recorded, transcribed, and translated into English. Participants received 300 rupees as compensation.
Focus group discussions
Two FGD were conducted in Sevagram with practicing gynecologists from MGIMS (n = 12) and those working at Primary Health Centers and private practices (n = 8). These FGD focused on provider perceptions of surgical and NSPC. An additional FGD was conducted in New Delhi with health advocates (n = 5) involved in reproductive advocacy. Advocates were recruited through E-mail invitation using snowball sampling., This FGD addressed attitudes toward new contraceptive technology, permanent contraception, and NSPC. All FGDs were conducted in English, audio-recorded and transcribed. No compensation was provided.
Surveys were administered in Marathi by male social workers from MGIMS to 150 married men recruited from clinic and community settings. Participants had at least one child and were between the ages of 21 and 45 years. The survey assessed attitudes toward permanent contraception, surgery, and contraceptive decision-making. Men received 100 rupees in compensation.
Data were analyzed in an inductive manner, where observations led to the detection of patterns, which led to the formulation of general conclusions.,,, After reviewing the raw interview transcripts, two investigators identified themes, reached consensus on codes, created a codebook, and began coding in NVivo (QSR International, version 10, 2012, Doncaste, VIctoria, Australia). They compared their coding line-by-line, added additional codes as concepts emerged, and wrote up coding memos. FGD transcripts were manually coded, content was analyzed for themes, and the research team met frequently to discuss themes. Survey data were analyzed with descriptive statistics.
| Results|| |
A total of 40 women, 20 mothers-in-law, 150 men, 20 providers, and 5 advocates agreed to participate in the study. [Table 1] provides the demographic characteristics of married women and mothers-in-law (the survey instruments can be found in Appendix 1 [Additional file 1]).
Three themes emerged from interviews: (1) high family influence on contraceptive decision-making; (2) support for permanent contraception (surgical and nonsurgical) yet tempered by specific concerns; and (3) a desire for NSPC confirmation.
When asked with whom they discussed contraception, the majority listed husbands (38/40), followed by their mother-in-law (11/40). Half the women stated that contraception was their choice, while the other half explained that familial opposition would affect their use of contraception. One woman stated, “I will listen to my husband, I decided to fit a Copper-T but he opposed so I didn't fit it.” Respect for family members was frequently cited, as one woman said, “Because they are my family and I have to respect their decision.”Women were concerned about familial consequences of keeping contraception hidden from others. These impacts included tension, conflict, blame, abuse, and the potential of being driven from the home.
The majority was supportive of PC, planning to use it in the future, and described community attitudes toward PC as supportive. Women characterized nasbandi (female sterilization) as necessary, inevitable, and troublesome, with comments such as “anyhow, we have to do it” and “I don't have any alternative.” Support for PC was tempered by concerns about effectiveness, fear, and pain. Women had concerns about surgery, pain, and menstruation. One woman asked: “What will happen when my stomach gets cut? Will I get very much trouble? Somebody told (me) that if we make movement at the time of operation the death may occur. Yes I feel worry about regular period. May it cause death?” While there were concerns about sterilization, the majority still planned on getting the procedure done.
The majority expressed interest in NSPC. Their reasons included convenience, less pain, and the lack of cutting and anesthesia. One woman expressed: “Operation is avoided by the new process that is the best thing of it. Means after doing operation there is no bedrest so I can do, continue my daily routine. I can complete my day to day's work. And main thing is that there is no tension about home.” While there was interest in new methods, women were hesistant and concerned about safety and efficacy. Many stated the need for more information about a new method before accepting it. This led some women to state that they would prefer a method they already knew.
When asked about the importance of confirmation of tubal occlusion after NSPC, the majority stated a desire for confirmation for a new method. Their desire for confirmation remained consistent, whether the method was described as 99% or 90% effective. Some women linked confirmation with peace of mind, rather than numerical assurance of efficacy.
Two themes emerged from interviews: (1) mothers-in-law have high household influence; and (2) mothers-in-law support PC (surgical and nonsurgical), yet had specific concerns.
The majority described themselves as the most influential family member. They acknowledged their status and power in the household and many noted that compliance underscored their relationships with others. One simply stated, “Everyone listens and obeys me.” Compliance, demeanor, and a lack of misbehavior were singled out as important traits of a good daughter-in-law. They spoke of the influence mothers-in-law have over fertility decision-making (i.e., encouragements to have more children; demands that daughters-in-law undergo sterilization).
The majority had undergone PC, described personal and community attitudes of PC positively, and felt it was the best choice for their daughters-in-law. There was some hesitance to discuss PC, with a few noting “We don't discuss these things” or “Elder ladies don't talk about it but girls or ladies in the city discuss about it.” While their main concerns were the “troublesome” aspects postsurgery (i.e., rest period and dietary changes), most reacted positively toNSPC, citing the desirability of avoiding an operation and postsurgery recovery.
The majority of survey participants (87/150) did not desire additional children. Very few men (10/150) reported having undergone vasectomy, while a quarter (34/150) reported their partners had undergone tubal sterilization. Among men whose partners were at risk for pregnancy, most (120/150) were considering female PC for the future. Although over one-half (59/100) reported being uncomfortable with PC for their partners due to the need for surgery, most (135/150) responded favorably to the statement, “I would support my partner's decision to undergo surgical sterilization.” Most men (127/150) reported a preference for NSPC over surgery if the new method was safe and effective.
Three themes emerged from FGDs: (1) providers believed use and acceptance of PC differ among rural women and highly educated women; (2) providers are concerned about government pressure related to population control; and (3) providers are interested in NSPC but have concerns.
Providers presented rural women as having no fear of surgery and a desire for invasive procedures. As one expressed, “There is (such a) strong association with the surgical method, they are not accepting another surgical method at all. Even with laproligation or other, the mindset is so strong, they want more invasive procedure.” Providers contrasted this with highly educated women, who they characterized as hesitant to use PC and less likely to accept new technology.
Providers had concerns about government consequences related to PC, such as pressure to follow norms and concerns about being held accountable for complications. They were concerned about recruiting women for sterilization and the pressure to meet government targets. One provider said, “In the government setup they will have some targets, how many tubal ligations are done. So if that target has not been achieved, some action will be taken against him… like promotion and raises will stop.”
Providers were interested in NSPC because it would be efficient, noninvasive, and not require postoperative recovery. Their concerns included the following: (a) medical (i.e., effectiveness, complications, failure, backup contraceptive coverage); (b) cost and government role; (c) implementation (i.e., delivery, training); and (d) possible ethical violations. They felt the procedure should only be done by an obstetrics/gynecology provider and that there would be a need for extensive education about howNSPC differed from surgical sterilization.
When presented with the scenario of NSPC requiring contraceptive coverage as tubal occlusion develops, providers discussed the merits and challenges of the 3-month injectable method, depo-medroxyprogesterone acetate (DMPA). Many noted that DMPA is not widely used or supported in India. They felt women would be more likely to accept DMPA if it was limited to one injection and the government covered the cost.
Providers felt that if NSPC were 99% effective, there would be no need for a test confirming tubal occlusion. Providers were not sure how they could confirm NSPC unless it was with a hysterosalpingogram, a radiologic imaging procedure for tubal patency. As most gynecologists do not perform this procedure, they were unsure of how meaningful or necessary confirmation would be, especially as most surgical sterilization techniques do not require a confirmation test. They felt that a confirmation test would make the method less acceptable to women, as onestated, “If they have to come back for a test, they will think the providers don't have faith in the method.”
In discussing ethical issues, providers were concerned whether marginalized women would be targeted in current research or future clinical trials (clinical trials of NSPC are intended to begin in the United States). They felt that an easily available method could be misused, citing the example of unmarried women's access to misoprostol for medical abortion. Thus, providers felt that NSPC should require additional documentation for access. A further concern was that unmarried girls could be sterilized unknowingly, especially as there would not be any scar. One provider said, “Because there is no scar, so something can be done. So they want to misuse women, it can be done. It can be done on vulnerable women, because there is no scar.” This generated another question: How could a provider prove the procedure had been done? One doctor asked, “Suppose someone is complaining that 'you have not done my tubal' what evidence do you have against that? Proof that it has been done. What is the method that this has been done? There must be confirmation at 2–3 months that the procedure is done and working complete.”
FGD with advocates revealed that they had significant concerns about a new contraceptive method, particularly around issues of safety and coercion.
While they valued having more contraceptive choices and the avoidance of surgery, they had concerns about safety and the introduction of new contraception in the Indian context. They described India as “a site of experimentation,” where marginalized people had been targeted and studies lacked transparency and oversight. One advocate explained, “There are women's groups and NGOs that are highly skeptical of any clinical trial of any new contraceptive but that's for good reason – due to this historical and contemporary trend of Indian people being used as guinea pigs… these groups aren't anti-clinical trial, they're not anti-vaccine or anti-increasing the basket of choice for women, but time after time these trials do not comport to the Drug Controller General of Indiaregulations, Indian Council of Medical Research regulations and basic ethics.”
When asked about challenges of introducing a new contraceptive method, advocates listed cultural attitudes (e.g., menstruation, male opposition, perceptions of infidelity); religious opposition; and provider bias (e.g., biases about rural and Muslim women; biases for permanent methods). One participant noted, “I've heard providers everywhere speak about women as if they're dogs, that you just need to get them in for sterilization… just the bias about women, and rural women is that… oh they're uneducated so they don't clean themselves.” Advocates were concerned about DMPA since it is controversial and not easily accessible. They stated that nonhormonal methods and less invasive procedures were more acceptable in India. Advocates felt strongly that women could only make reproductive choices freely in a context free of incentives.
Advocates felt that NSPC could be a good technology, yet were concerned about coercion. Advocates described the persistence of target setting mentality among government officials and providers, despite claims of discontinued quotas. An advocate explained, “They (providers) have to meet the targets otherwise they are punished. So they will go for the shortcuts, wherever they are able.”They expressed the viewpoint that a new method of PC would make it easier to sterilize women against their will. One advocate summarized this view: “The entire system is built around coercion and numbers, and it is never about respecting the woman and her choices, her dignity as a human being, her dignity as a rights-holder.”
| Discussion|| |
The present study showed that despite the high interest in NSPC, concerns about safety, efficacy, and ethics remain. Ethical concerns and hesitation of new methods were due to distrust of the government system. Participants emphasized the importance of effective counseling and insisted that only a provider should do the procedure. Controversial studies and methods significantly influence participants' perceptions and receptiveness to new contraception.,
While there was research on family influence on fertility decision-making, the role of mothers-in-law was influential.,, Cultural norms that link compliance with being “good” daughter-in-law, along with son preference, make it difficult for Indian women to make reproductive decisions free from family influence. It was found that PC was viewed differently from other contraceptive methods. When asked to list methods, women rarely included PC, yet described it as “inevitable.” That the majority stated they had already been sterilized or were planning to do so – along with the interchangeable use of “nasbandi” and “the operation” – indicates that sterilization was normalized., On a policy level, this points to the need for better contraceptive counseling, so that women were fully aware of their choices. All participants expressed support for NSPC, yet had concerns about safety and efficacy. NSPC confirmation was desired, yet patients and providers viewed confirmation differently. Married women desired confirmation for reassurance while providers explained confirmation as a way to be protected from legal repercussions. The context of sterilization in India continues to generate distrust of the government. Both providers and advocates had concerns about coercion and transparency. This impacted present study, as poorly handled studies, resulted in extensive questions about our motivations and an initial hesitation to participate.,,
Findings of the present study must be interpreted in light of several limitations. While present sample was not representative of married women, married men, and mothers-in-law, the sample size and methods were appropriate for reaching theoretical saturation.,,, Interview and survey translations may have missed subtle meanings. The use of social workers poses questions about the consistency of data collection. Participants were commenting on their perceptions of NSPC, a method not yet available. While questions were focused on traits of NSPC, some responses were hypothetical and did not generate meaningful data. Social desirability bias – the tendency of participants to want to please the researchers – may have affected present study findings, possibly resulting in more positive responses to NSPC.,,,
Qualitative research analyzes meanings rather than measuring data quantitatively., Concerns about reliability and validity were addressed through credibility, rigor, and trustworthiness. Validity was ensured through triangulation, which used three methods to verify research findings., While present findings cannot be widely generalized, they can be generalized beyond this specific study. The present study gives rich insight into perceptions of permanent contraception and contraceptive decision-making in India. Internal reliability was confirmed through data analysis procedures to ensure that present research team was coming to the same conclusions. While social settings cannot be “frozen” in time, researcher is confident that other researchers would have similar research findings if they replicated our study.
| Conclusion|| |
This study provides data on contraceptive decision-making, attitudes toward PC, and new contraception. Future research on NSPC should focus on religious perspectives on surgery, contraceptive trust in diverse population groups, and strategies for patient counseling – all of which will inform eventual clinical trials.
Financial support and sponsorship
Bill and Melinda Gates Foundation, USA.
Conflicts of interest
There are no conflicts of interest.
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