Uncovering the Structural and Personal Barriers to Modern Family Planning

The Challenge

In Uttar Pradesh, India, men and women’s usage of modern family planning methods remains persistently low, despite years of investment by the Indian government and its partners in awareness, supply, and availability to encourage contraceptive use by couples who want to space or limit their family size.

Our Approach

We wanted to better understand why so few couples in Uttar Pradesh were using modern contraception methods to plan their families. Was it that they didn’t have access to commodities or were they afraid of side effects? Who was making and influencing these intimate decisions? To uncover these reasons, we took a mixed methods approach, examining three large quantitative data sets along with launching a new qualitative study where we interviewed husbands, wives, and other influencers such as mothers-in-law and frontline health workers. To analyze the issue, we employed CUBES, a behavioral framework, to holistically assess the potential behavioral and structural drivers influencing family planning decisions. The combination of qualitative and quantitative analysis generated novel insights about household decision making and influencers, and people’s drivers of family planning use.

Key Results

Our comprehensive research revealed a number of systematic and individual obstacles to increased use of modern family planning methods in Uttar Pradesh, including:

• Family planning decision making is complex and differs by method.
• Awareness of family planning is high, but that alone is not enough to increase usage. Building intention to use family planning is critical.
• Perceived access, age, education and other demographics partially predict intention to use family planning, but people’s internal beliefs and emotions strongly influence the forming of their intentions.
• The expectations of having a large family and at least one son contributed to feelings of shame about using family planning methods.
• While people saw little risk in unplanned, frequent, or early pregnancies, they reported significant concerns about the risks and side effects of modern contraceptive methods.
• Involving men is key, but their barriers may not be the same as their wives’. For example, men respond better to economic consequences than health arguments, and have greater exposure to outside information than their wives.

As countries around the world strive for sustainable development, they are encouraging family planning, which data shows leads to better health, educational, and economic outcomes for women and children alike. Yet many governments are finding that goal of increasing family planning to be surprisingly difficult, even with investments in access and awareness.

Thanks to our recent study of families in Uttar Pradesh, we are beginning to understand why. Family planning is a complex decision-making process for many families in India’s largest state, where big families are prized. Women are highly aware of contraceptive methods, and the vast majority (86%) say they want to space or limit their childbearing. However, their intention and actual use of a family planning method proved to be far lower.

This gap between awareness, intention, and action is the result of the numerous personal and systemic obstacles to family planning use that men and women both encounter. Couples who want to limit their family size or space their births may feel shame given social pressure to have a large family. Men and women alike may downplay the health and economic risks of pregnancy compared to common concerns about the side effects of family planning methods. Husbands and wives may assign responsibility for family planning to each other based on the method, leaving the other partner without a voice in the decision. 

Given the variety of behavioral drivers, supporting these couples in their family planning efforts will require a more targeted approach that helps them overcome real and perceived barriers to contraceptive use.