Women’s Autonomy and Utilization of Family Planning Services in Three Eastern States of India

Lopamudra Ray Saraswati and Protap Mukherjee

Abstract

This article is an attempt to explore women’s autonomy and current use of contraception among married women of three eastern states, viz, Bihar, Orissa and West Bengal. The study was mainly based on the data from National Family Health Survey-2. In this present paper, the different measure of autonomy and uptake of contraception, which provides evidence of empowerment, is examined. For the present study bivariate and multi-variate analyses have been carried out. Although the majority of women participate in household decision; far fewer are final decision makers. The link of women’s education and mass media exposure with contraceptive use is found to be strong. Among direct indicators of autonomy, women with greater control over resources use contraception more than without control over resources. The study findings point to the importance of gender inequality being more broadly defined in determining fertility control behaviour.

International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088, India.

Introduction

Women autonomy in India is a much debated issue. Although almost all the social scientists and researchers agree with the fact that women in India are in a very low status in almost every region of this country; but there is a debate on the extent of its impact on various socio-cultural and demographic aspects. Because of their low autonomy, the women remained far behind than what they could have achieved in presence of a high autonomy. Since, India has a patriarchal society; men are placed in a more advantageous position than women here. The other things are the inheritance and succession practices, which tend to neglect women. Also, the family lineage and the living arrangements all are centred on men. Even the child rearing and caring practices also reflect the male supremacy. Access to nutrition, child care and education all favour boys over girls. From a very early age, a girl is socialized to give priority to the needs of the male members in the family. As a result of all these factors, men play a dominating role in every social aspect, keeping women with a very low autonomy and a low indeed self-esteem. Women’s empowerment is essentially an effort to rectify this imbalance and attain gender equity (Roy and Niranjan 2004).

In 2000 the UNDP has developed a gender-related development index based on a few macro level indicators like life-expectancy at birth, education and income. According to this index, the gender inequity in 1998 is substantially high in India a ranks a poor 108th out of the 143 countries for which the index value is available. The result is very obvious because there is a persistent gender gap in literacy in India. Although this gap is narrowing down day by day, there is still a very high differential in literacy between men and women in India. A similar pattern can be observed in case of the life expectancy. Where in most of the counties, female life expectancy is much higher than that of male, in case of India the phenomena is completely different. Although, in recent years female life expectancy has exceeded male life expectancy marginally, female child mortality remains much higher compared to males. There are studies which have highlighted the role of gender in understanding demographic diversities within the country. They suggest that women’s status is an important variable responsible for various demographic outcomes such as higher fertility levels etc and tried to predict the interplay of various factors behind it (Bardhan 1974). There are also studies which have investigated the impact of gender inequity on the north-south dichotomy in the demographic transition (Dyson and Moore 1983; Malhotra et. al. 1995).

Studies on women’s empowerment as such, are rare. There is a lack of knowledge regarding different dimensions of women’s autonomy and specific strategies to enhance it. Effective measures of women autonomy are required to carry on such studies. In the presence of appropriate measures of empowerment, commonly found measures like education and employment are generally used as surrogates. While these proxy measures are important and are ideally associated with empowerment, they may not capture all aspects of the multidimensional concept of empowerment (Joshi 1999). At the family/household level, gender inequity manifests itself in a weaker role for women in decision making, lesser control over resources and restrictions in physical movement. According to Jejeebhoy (1998), three most important dimensions related to women’s autonomy are decision making, mobility and access to economic resources, irrespective of regions or religions.

The National Family Health Survey collects information on a variety of aspects related to the status of women for understanding different dimensions of women’s autonomy in India. Using the data from the Round-II of this survey Roy and Niranjan (2004) examined the variation in the level of female autonomy in different socio-cultural settings. They have categorized the variables related to woman-autonomy in three groups. The first category is referred to as indirect indicators of empowerment and includes education, occupation, age difference between spouses and educational difference between spouses. The second group includes direct measures of empowerment and consists of indicators such as involvement in decision making, freedom of movement and access to money. The third set of indicators relates to the evidence of empowerment and is comprised of three indicators, namely, extent of self-esteem, favourable attitude towards girls’ education and practice of family planning. Their study is an attempt to identify the indirect and direct measures of empowerment. Their study reveals that both indirect and direct measures of empowerment have substantial impact on the evidences of women’s empowerment.

In India, use of modern methods of contraception is suspected to be greatly influenced by women’s autonomy as the other demographic aspects. There is lack of study which examines the impact women’s autonomy on the couple’s contraceptive use behaviour. Uptake of contraception is at the initial stage in India, in spite of a number of strategies and policies taken by the government. Three eastern states of India, namely Bihar, Orissa and West Bengal, are situating in three different levels in terms of modern contraceptive use. The predicting factors are different for the three states. The causes of not using also vary in a number of ways. Women from these three states have different levels of autonomy. Also the interplay of the autonomy indicators and the contraceptive use behaviour are expected to show different phenomena for these three states. So, we have selected these three eastern states to study the contraceptive use behaviour among the couples of these states and to predict the influence of women’s autonomy on it. We have also studied the reasons behind not using modern contraceptive methods and the main barriers to use it.

Barriers to family planning service use

The influence of physical access on the utilization of family planning services is well-founded, with many studies demonstrating the greater use of services among women who live in relative proximity to a service (Tsui and Ochoa 1992). Research into the barriers faced in accessing reproductive health services, however now recognizes that problems of access extend beyond physical access to services and include issues of economic, administrative, cognitive and psychosocial access (Bertrand et. al. 1995; Foreit et. al. 1978). Furthermore, the barriers to family planning service use are seen as extending beyond factors operating at the individual and household levels, to include characteristics of the social and cultural environment and the health service infrastructure. This view of access recognizes the importance of attributes of the health system in shaping an individual’s ability to seek health care, highlighting the importance of the supply environment on health care utilization. This conceptualization of access incorporates factors operating at the individual, household and community level to influence an individual’s ability to utilize a health service, thus framing his/her access to services in terms of the socio-economic, cultural and service supply context in which he/she lives (Stephenson and Hennink 2004).

Previous studies of the use of reproductive health services have been largely focused on factors operating at the individual and household levels, broadly categorized as demographic, socio-economic, cultural and health experience factors. Demographic factors that have been shown to increase the likelihood of using reproductive health services are low parity (Magadi et. al. 2000; Kavitha and Audinarayana 1997) and younger maternal age (Bhatia and Cleland 1995). Socio-economic factors, however, have been shown to be of greater importance in determining health service utilization than demographic factors (Obermeyer and Potter 1991). While demographic factors may shape the desire to use services (e.g. younger women may have more modern attitudes towards health care use) the socio-economic status of an individual and the household in which they live determines the economic ability to utilize health services (Foreit et. al. 1978). In terms of socio-economic factors, the most consistently found determinant of reproductive health service utilization is a woman’s level of educational attainment (Addai 1998; Bhatia and Cleland 1995; Magadi et. al. 2000). It is thought that increased educational attainment operates through a multitude of mechanisms in order to influence service use, including increasing female decision making power, increased awareness of health services, changing marriage patterns and creating shifts in household dynamics (Obermeyer 1993). Cost has often been shown to be barrier to service utilization (Griffiths and Stephenson 2001) and also influences the choice of service provider. Socio-economic indicators such as urban residence (Addai 1998), household living conditions (Magadi et. al. 2000) and household income (Kavitha and Audinarayana 1997) have also proven to be strong predictors of a woman’s likelihood of utilizing reproductive health services.

Both demographic and socio-economic determinants of reproductive health service utilization are mediated by cultural influences on health service behaviour (Basu 1990). The health care behaviour of individuals is often mediated by community beliefs and norms, such that individual behaviour is influenced by community perceptions of individual actions (Foreit et. al. 1978). Although individual demographic and socio-economic may shape an individual’s desire and ability to use a service, the cultural environment in which he/she lives exerts a strong influence on the extent to which these factors actually lead to service utilization. Stephenson and Hennink (2004) have taken all the five dimensions of access to health care, namely economic, cognitive, psychosocial, administrative and physical, in their studies on the Pakistan-data to predict the major barriers to the utilization of contraceptive services.

Objectives

The main objective of the present study is to assess the relation between women’s autonomy and contraceptive use behaviour in three eastern states of India, that is, Bihar, Orissa and West Bengal. The specific objectives are set as:

  • To explore the current use of contraception among married women of these three states by their various background characteristics.
  • To study the prevalence of modern contraceptive method use among women with different levels of autonomy.
  • To find out the main predicting factors behind the use of a modern contraception and to measure the influence of women autonomy on it.
  • To examine the major barriers to the utilization of family planning services.

Data and Methodology

For the present study the data have been taken from the National Family Health Survey undertaken in 1998-99 in India at the state level. In this paper three eastern states of India have been chosen for analysis; those are Bihar, Orissa and West Bengal. The analysis is based solely on the currently married women.

In the survey, each woman was asked questions to measure their autonomy directly. The questions include whether the respondent has decision making power regarding buying jewelry, accessing to health care, staying with relatives or friends etc.; whether she has freedom for physical mobility; and whether she has control over economic resources. Based on these questions the direct indicators of the woman’s autonomy have been measured. The woman is considered to have high decision making power if she has involvement in taking decision about all the three aspects: buying jewelry, accessing health care and staying with relatives. She is assigned moderate decision making power if she has involvement in any of these decision makings; and is assigned low decision making power, if she has involvement in none of these three. The decision making about cooking food, although asked in the survey, has been excluded in the present study, because it is expected that almost every woman can take decision about at least this matter, and practically it was showing a very high frequency. In the survey, the question of physical movement was asked regarding two things: whether she needs permission to go to market and to go with friends. As similar to the decision making variable, this variable also has been assigned to have three values: complete freedom of movement, if she needs permission neither to go to market nor to go with friends; incomplete freedom of movement, if she needs permission in any one of these; and no freedom, if she needs permission or is not at all allowed to go in both of these two. Control over resources has been calculated based on the question that asks whether the respondent is allowed to set some money aside. If she is allowed so then she is thought to have control over economic resources, otherwise not. These all are considered as the direct measures of autonomy. Among the indirect measures of autonomy, education of the woman, occupational status of the woman, differences of her age with her husband and her education in comparison with her husband’s education have been considered.

Bi-variate analyses have been performed to see the uptake of modern contraceptive methods among the sampled women in various autonomy groups. Percentages of women using any modern contraceptive method have been calculated for the women showing various levels of autonomy. Multivariate analysis has been done to predict the contributing factors in using any modern contraceptive method. In the binary logistic regression analysis the dependent variable is taken as the current use of any modern contraceptive method. Three models have been fitted to predict it. In the baseline model only the direct indicators of autonomy have been taken as the explanatory variables. In the second model, the indirect indicators also have been taken with these. In the final model, we have controlled for some important socio-demographic variables to see the change in the indicators of autonomy. The analysis has been carried out separately for the three states.

Then we concentrated on why the respondents are not using the modern methods of family planning. A direct question was asked in the survey to the women who were not using any contraceptive method at the time of the survey, regarding the main reason for what the respondent was not using any modern family planning method. The responses are divided into four categories: Psychosocial (religious opposition, opposition of the husband, respondent’s own opposition etc.); Cognitive (lack of knowledge of family planning services or methods); Administrative (poor services, fear of bad experience regarding services or methods and all other method related problems); and, Economic (cost). Then the percentage distributions of women in various autonomy groups by the cause of not using, have been observed. This analysis also is done differently for the three states.

Discussion of the main findings:

Table-1 reports the percentages of women using any modern contraceptive method by the direct and indirect indicators of autonomy. It shows that in total the uptake of modern contraceptive method use is the highest in West Bengal (44.1 percent) among these three states. Orissa is not far behind the West Bengal. Total 37.8 percent currently married women use some modern contraceptive method in Orissa. But Bihar remains far behind – only 21.2 percent currently married women use some modern contraceptive method. Decision making power does not show any consistent relationship with the use of contraception. Freedom of movement seems to have a significant impact on the use of contraception in case of Bihar. Percentages of users are higher for women having complete and incomplete freedom of movement than those having no freedom. But in case of the other two states freedom of movement does not seem to have much impact on the utilization of the family planning services. Women in Orissa and Bihar, who have control over economic resources are found to be using modern contraceptive methods more in percentage than those of not having control. But in West Bengal control over economic resources does not make any change in the utilization of the family planning.

Among the indirect measures of autonomy, woman’s education is showing to have a positive impact on the utilization in Bihar and Orissa. As the education increases, the use of modern method also increases. Occupational status of the woman is showing different phenomenon for different states. Use of contraception is very low among the paid-employees in Bihar and Orissa, but it is high in case of West Bengal. Most probably, this is because in Bihar and Orissa women generally work in very low paid jobs and subsequently have very low status. On the other hand, women in West Bengal work in comparatively highly paid jobs. In case of Orissa and West Bengal, women who have either very little or very big age-difference with husband, show similar patterns in using contraception. Percentage of women using any modern method is higher for the women who have education less than their husband.