The institutional review board of Georgetown University at Washington, DC approved all aspects of treatment of human subjects of the study design.
Study setting
Unmet need for contraception was declining in India and it reached 13% in 2005–2006. Jharkhand, a state in Northeastern India, has been described as more patriarchal than Southern states in India[21]. In Jharkhand, according to the latest National Family Health Survey (NFHS-3), conducted in 2005–2006[22], only 37 percent of married women of reproductive age are literate and 60 percent are not exposed to any media. The NFHS-3 found that 35.7 percent of married women of reproductive age used contraception, including 28.2 percent in rural areas of the state. Female sterilization dominates the method mix, with 23.4 percent of Jharkhand’s married women of reproductive age using that method, followed by the pill (3.8%), the condom (2.7%), and scant use of other modern methods. Less than 5 percent of women use a traditional method. The method mix in rural areas mirrors that in the state. The public health system in these areas consists of subcenters reporting to a primary health center. In each sub-center, one auxiliary nurse midwife provides services to an average of five villages.
Intervention
The family planning intervention that was designed to reduce women’s unmet need for contraception[11] was undertaken in three rural blocks in Jharkhand in 2004–2007. It was comprised of strengthening family planning generally and introducing a new family planning method, and was carried out in the Ormanjhi block, encompassing 89 villages and about 76,000 inhabitants. Burmu, encompassing 101 villages and about 77,000 inhabitants, served as a control site for the study. A third block that also received the intervention, Kanke, was excluded from the analysis in this paper, given its more urban structure than the other two blocks. Krishi Gram Vikas Kendra (KGVK), a nongovernmental organization (NGO) that works in Jharkhand and manages six subcenters in Ormanjhi, coordinated the intervention.
To strengthen family planning in the experimental villages, an NGO specializing in street theatre and puppet shows was hired to provide information about contraceptive methods, couple communication and decision making related to family planning and women’s reproductive rights. Public and private providers posted signs announcing that they offered various family planning methods. Wall paintings in public areas also informed village residents about the availability of a range of contraceptive methods, and providers conducted health fairs in villages. Providers were trained to offer family planning information and services which took into consideration gender power dynamics. No individual contraceptive method was stressed in the messages and information.
The second component of the intervention introduced a relatively new method, the Standard Days Method® (SDM), to public health centers run by the Ministry of Health and sub-centers run by NGOs. SDM is appropriate for women with cycles that usually range 26–32 days. It identifies days 8 to 19 of the menstrual cycle as the fertile window, i.e., the days when pregnancy is most likely. To prevent pregnancy, the couple avoids unprotected intercourse during the 12-day fertile window, which is identified by using a visual aid representing the menstrual cycle, a color-coded string of beads called Cyclebeads®. SDM efficacy rates, established in a clinical trial, are comparable to those of male condoms, the failure rate being less than 4 per 100 women years of correct use. Adoption of this method requires agreement by the couple rather than the wife alone. Providers were trained in SDM counseling; service delivery points were supplied with Cyclebeads®, the visual tool that supports correct use of SDM, and with simple leaflets presenting the method as a new family planning option in the context of informed choice. Anganwadi workers (community health workers) and village animators were also trained to offer information on family planning including SDM, and to provide SDM. The community health workers in particular were encouraged to reach out to men and couples. The intervention was not designed to address women’s empowerment broadly, but its emphasis on empowering women to know about and use family planning, and its promotion of couples’ joint decision-making concerning family planning use, were relevant to women’s empowerment in the intervention site. Furthermore, given that SDM is a couple method, and that it was being introduced as a new method of family planning in the intervention area, special care was taken to ensure that men were reached through the IEC [information, education and communication] efforts. In the control villages in Burmu, women had access to family planning through regular service channels; however, no special information was provided about availability of services nor was SDM offered in those villages.
Data
Married women ages 15–49 who lived in these blocks had an equal opportunity to participate in the study. A research firm in New Dehli conducted the baseline and endline community surveys. The former was conducted in both blocks in late 2004-early 2005, three months before the intervention started in Ormanjhi, and the latter was conducted after the intervention had been in place for close to three years (2007). The pretest and posttest surveys were independent of each other. To minimize the number of randomly selected households lost due to addresses not found, the final sampling frame was obtained after thorough physical inspection of addresses. All married women of reproductive age were eligible to be interviewed within each selected household. Up to three repeat visits were undertaken early in the morning or late in the evening, to minimize the number of respondents not found at home.
Women who had no need for family planning, because they desired more children soon or were not at risk of pregnancy, were excluded from the analyses for this study, which focused directly on women with a need for contraception. Also, given the very small number of followers of religions other than Hinduism and Islam, only Muslim women were selected for comparison with Hindu women, who were the majority in the sample.
Variables
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Women’s Decision-making Power. In this study, women’s decision-making power was measured though normative beliefs concerning whether women should be involved in various household decisions. The questionnaire included a 5-item question on household decision-making, consistent with questions in the DHS: “In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife, or both equally?” The decisions were: making large household purchases; making small daily household purchases; deciding what to do with the money she earns for her work; deciding when to visit family, friends, or relatives; and deciding how many children to have and when to have them. The few cases choosing the response options “Don’t know/depends” were excluded from analysis. Implementing the participation model in the measurement of normative beliefs, 1 point was assigned to Wife and Both equally, and 0 points were assigned to Husband only.
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Need for Contraception. To determine eligibility for inclusion in the analysis, a score of 1 was assigned to: (a) pregnant women who had wanted their last child later or had not wanted more children at all, (b) nonpregnant women who were using any family planning method, and (c) nonpregnant women who were not using family planning despite their not wanting a child in the next two years and being at risk of pregnancy (or did not respond whether she wanted the child). A score of 0 was assigned if (a) a pregnant woman said that the child was intended, or (b) a nonpregnant woman was not using family planning because she wanted to have children in the next two years or was not at risk of pregnancy (infecund, menopausal, postpartum amenorrhea, not sexually active).
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Met Need. A score of 1 was assigned to the woman in need of contraception if she said that she was using any modern family planning method and a 0 if she was pregnant, was using a traditional method, or was using no method.
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Age. The woman’s age was calculated considering her birth date and the date of the interview. Two questions were asked: “In which month and year were you born?” and “What age did you reach in your last birthday?” Inconsistencies were corrected where possible.
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Children. Women were asked how many living children they had.
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Literacy. Women were asked, “Have you ever gone to school?” and, “What was the highest year of studies you attained?” Women who responded “Primary instruction” or less were given a card with a sentence and asked to read it. To translate educational attainment into a single score, the two variables were combined and produced the following scale: 0 = unable to read, whether the woman had formal education or not (70.8%) and 1 = reads part or all the sentence and/or has primary, secondary, or higher education (29.2%).
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Work. The woman was asked whether she worked at the time of the interview and whether she had worked in the past 12 months. (“As you know, some women work for a pay in cash or in kind. Others sell things, have small businesses, or work family land or in family enterprises. Are you currently doing any of these jobs? Have you worked in the past 12 months?”) Her responses were coded 0 = did not work and 1 = worked and/or is working now, regardless of whether she received payment or not, and the type of payment.
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Religion. Women were asked whether they were Hindu, Muslim, Christian, Sikh, Jain, or Buddhist. Muslims received a score of 0, Hindus a score of 1, and the others a missing value.
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Listening to Radio. Women were asked if they listened to radio and frequency of radio listening: never (0), less than once a week (1), at least once a week (2), or almost every day (3).
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Watching Television. Women were asked if they watched television and frequency of television watching: never (0), less than once a week (1), at least once a week (2), or almost every day (3).
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Visited Health Center. Women who had visited a health center in the past 12 months were given a score of 1. Those who did not received a 0.
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Received Visit. Similar scores were assigned to women who in the past 12 months had received the visit of anyone who talked about family planning.
Analyses
Chi-square (χ2) and the t-test for independent samples were employed to analyze simple pre-post data, and the following generalized linear model evaluated the effects of the intervention on women’s decision-making power:
(1)
where λ is the decision-making power measure and β and ϵ are the regression coefficients and the error term. The main target of the analysis was the δ x π interactive effect on decision-making power, where δ is a fixed-effects treatment factor defined as 1 = Burmu pretest, 2 = Ormanjhi pretest, 3 = Burmu posttest, and 4 = Ormanjhi posttest and π is a fixed-effects literacy factor with two levels (literate, illiterate). The other component of Equation 1, ξ
k
, is a set of main-effect covariates that includes age, religion, children, radio, TV, and work. A similar model, but with the focus on the 3-way treatment x literacy x decision-making power interaction and having met need for contraception as the dependent variable (γ) was employed to assess the moderating roles of women’s literacy and decision-making power in the intervention process:
(2)