Perceptions of reversible and permanent contraception in India (POPI)
Awarded 2014
Complex Family Planning Fellowship Research
Neha Bhardwaj, MD
University of New Mexico Health Sciences Center

In 1951 India became the first country to launch a national family planning program focused on promoting reversible and permanent contraception including financial incentives for both method acceptors and providers. Despite governmental provision of the copper intrauterine device (IUD), oral contraceptive pills (OCP) and condoms at no cost, most Indian women choose permanent sterilization after completing childbearing. There also exists a history of forced sterilization in India during The Emergency from 1975-1977, however permanent contraception in India for women may simply be the preferred contraceptive method due to ease and permanence. Whether the predominance of sterilization stemmed from Indian men and women’s desire for permanent contraception, from deficient knowledge and access to reversible methods, from public health messages and established norms, or from coercion in the form of incentives is unknown.
The primary objective of this study is to understand the perceptions, attitudes and beliefs towards reversible and permanent contraception among Indian women and men in an urban Indian setting. The secondary objective is to determine the extent of interest in potential non-surgical forms of permanent contraception.
This cross-sectional study used qualitative data collection methods (focus groups). The sampling frame included subgroups of married women, married men, mothers-in-law and women’s health advocates. Thematic saturation was achieved after three focus groups per subgroup with 9-14 participants per focus group. The discussion guide was developed and modified iteratively to illicit the perceptions, attitudes and beliefs towards family spacing, contraceptive decision making and contraception method preference. Two independent coders analyzed the qualitative data using modified grounded theory. Participants completed a baseline survey containing demographic information, brief obstetric history, and contraceptive use and knowledge.
All subgroups expressed concern about contraceptive side effects and risks, with a preference for non-hormonal methods (female sterilization and condoms). Male sterilization was considered unacceptable by the vast majority of participants in all four subgroups, and perceived as causing a physical weakness that diminishes their ability to work. Among the married women, married men, and mothers-in-law subgroups, male sterilization failure, evidenced by a wife’s pregnancy, implies a wife had an extra-marital affair. Women’s health advocates believed that women desired a reversible contraceptive method. Many women’s health advocates and married women believed that female sterilization was reversible.
Married women and advocates expressed a strong preference for a highly effective reversible and side-effect free method of contraception.  As the age of sterilization decreases in India while the infant mortality stagnate, there is a concern for non-intentional contraceptive coercion among women’s health advocates, including physicians, as some believe female sterilization is not an irreversible method of contraception. Women of lower socioeconomic statuses are also more affected as they rely on sterilization more than other methods such as the IUD or condoms.
Counseling and consent for female sterilization, the dominant contraceptive method, must emphasize the irreversibility of the procedure. While additional reversible methods should be developed, if new permanent methods are developed, their permanence must be stressed.