Voluntary and rights-based family planning for women: Observations from a community-based study in southern India

Family planning programmes globally emphasise voluntarism and rights in contraceptive provision, shifting the focus away from fertility regulation. With the intent of measuring the policy-practice gap, this study aims to determine access to voluntary rights-based family planning services among women of reproductive age.

Between November 2018 and January 2019, 390 married women aged 18 to 44 years residing in Kanchipuram, Tamil Nadu, were interviewed, after obtaining written informed consent from the participants. Agreement between intended and actual family size and spacing, perceived informed choice and contraceptive coercion during client-provider interaction were the primary outcomes studied. Univariate analysis using Pearson's or Trend chi square tests and multivariate logistic regression were used to analyse the factors associated with contraceptive coercion; adjusted odds ratios (AOR) with their 95% confidence intervals are reported.

Of the 390 most recent pregnancies, 114 (29%) were found to be unintended. Reported concurrence of intended versus actual family size and spacing among respondents was 76% (118/155) and 42% (121/287), respectively. During interaction with a healthcare provider, only 139 (36%) were offered a choice of two or more modern contraceptives; others were advised either tubectomy (69, 18%) or intrauterine devices (IUD) (50, 13%) as the sole option. In the past five years, 181 (46%) women reported adopting a modern method voluntarily, while 33 (8.5%) were forced and 8 (2.0%) were coerced to use modern contraception. Multivariate analysis revealed that women's employment status (AOR: 13.1[1.3,127.6], P=0.027), public healthcare facilities (AOR: 18.7 [1.8, 193.2], P=0.014), and long-acting reversible contraception (AOR: 30.5 [8.2, 112.6], P <0.001), IUD in particular, were strongly associated with contraceptive coercion.

Provider bias and coercion to use selective modern methods in a limited contraceptive choice setting leaves much to be desired. Expanding the basket of choices and mainstreaming indicators pertaining to informed decision making and rights-based care is imperative.