Substantial clandestine contraceptive use (use without partners' knowledge) has been reported in areas where family planning is not yet widespread, such as sub-Saharan Africa. However, accurate quantitative data on this sensitive issue can be difficult to obtain. In two studies — one in urban Mali and another in urban Zambia — use of qualitative research methods revealed why a small subset of contraceptive users chose to keep their method use secret from their partners. This practice has programmatic implications: Even though some family planning services focus on "couples" as clients, an important role remains for provision of individual, confidential services to women.
In many parts of the world, family planning programs are shifting their focus to increase the participation and responsibility of men in family planning decisions. But in some cases, especially when husbands' and wives' fertility preferences differ and wives' influence on decision-making is limited, the advantages of hiding use from men may outweigh the disadvantages. Clandestine use may be in the best health interests of some women and their children, and it may allow some women to improve their financial independence and autonomy.
In the Mali study, conducted in Bamako from 1996 to 1998 by the Centre d'Etudes et de Recherche sur la Population pour le Développement and FHI's Women's Studies Project, 55 married women ages 18 to 43 years who were first-time contraceptive users were interviewed about their use shortly after a first consultation at a clinic. Forty-one of the women were interviewed again nine months later, and 33 were interviewed a third time at 18 months.1 The Zambian study, conducted in Ndola district by the Ndola-based Tropical Diseases Research Centre and the New York-based Population Council, obtained qualitative data from six focus group discussions (three with married women and three with married men) in 1996 to guide the design of a survey. More than 1,600 women ages 15 to 44 years (and the husbands of about half of the women) were then surveyed.2 Analyses of most data from both studies were limited to women who were using contraception because they wanted to delay their next birth or wanted to stop childbearing altogether.
Clandestine use in sub-Saharan Africa has been estimated between 6 percent and 20 percent.3 In the Mali study, 17 (31 percent) of 55 women initially reported that they were using contraceptives without their husbands' knowledge, although two of these women subsequently told their husbands. In Zambia, 53 (7 percent) of 765 surveyed women reported clandestine use.
Inadequate economic, health, and social support from husbands — especially when children's welfare was at stake — were reasons often cited to justify clandestine use. "You just observe what is happening at home; if there is no support, you start a pill secretly," said one woman during a focus group discussion in Zambia. According to qualitative data from both studies, many clandestine users also believed that their husbands would disapprove of contraceptive use. Some women from Mali, for example, anticipated disapproval because they thought their husbands wanted as many children as possible, believed that family planning was against their religion, or feared that contraception would make their wives promiscuous, ill, or infertile.
Although more than half of the clandestine users in Mali had discussed contraception with their husbands and knew that they disapproved, both studies found that many wives have difficulty approaching their husbands to discuss this issue. The Zambian study showed this to be the strongest determinant of clandestine use. "I would really like him to know that I use [it], and for us to agree about it; that's what I want, but I haven't been able to do it," said one woman from Mali who used an injectable contraceptive clandestinely.
Both studies showed that women feared that spousal detection of contraception could result in arguments, even divorce. Injectables, which do not come with packets or literature that might arouse a spouse's suspicion, were one of the most common contraceptive methods among clandestine users. However, not all users were prepared for the menstrual side effects they experienced, and some feared that side effects such as prolonged bleeding, spotting, or amenorrhea might be detected by their spouses.
Together, the two studies provide the following recommendations for the design and implementation of family planning programs in these settings:
-
To increase levels of contraceptive acceptability, service providers should continue to educate men about family planning, and — if appropriate — local religious leaders should reassure men and women that family planning is not prohibited by their religion.
-
In cases where efforts to increase men's acceptance of contraception are unsuccessful, providers need to assure contraceptive users of complete confidentiality.
-
Maternal and child health services could be integrated with family planning services to help women access services without arousing suspicions. In addition, a mix of methods should be available to help women minimize unwanted side effects and costs.
— Kerry L. Wright
References
- Castle S, Konate MK, Ulin PR, et al. A qualitative study of clandestine contraceptive use in urban Mali. Stud Fam Plann 1999;30(3):231-48.
- Biddlecom AE, Fapohunda BM. Covert contraceptive use: prevalence, motivations, and consequences. Stud Fam Plann 1998;29(4):360-72.
- Blanc AK, Wolff B, Gage AJ, et al. Negotiating Reproductive Outcomes in Uganda. Calverton, MD: Macro International Inc. and Institute of Statistics and Applied Economics [Uganda], 1996; Rutenberg N, Watkins SC. The buzz outside the clinics: conversations and contraception in Nyanza province, Kenya. Stud Fam Plann 1997;28(4):290-307; Watkins SC, Rutenberg N, Wilkinson D. Orderly theories, disorderly women. In Jones GW, Caldwell JC, Douglas RM, et al., eds. The Continuing Demographic Transition. Oxford: Clarendon Press, 1997.
