Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges

Simon P S Kibira,Elizabeth Omoluabi,Caroline Moreau,Celia Karp,Hadiza Galadanci,Fredrick E Makumbi,Assefa Seme,Shannon N Wood,Selamawit Desta,Amy Tsui,Solomon Shiferaw

doi:10.1186/s12889-020-08977-y

Abstract

BackgroundThe balance between increasing men’s participation in family planning and rights-based initiatives favoring women’s empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women’s decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women’s choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries.MethodsWomen aged 15–49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women’s and girls’ empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes.ResultsFindings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure.ConclusionsResults indicate that while covert use of contraception is common, continued covert use is challenging, especially when side effects manifest. Covert use may further suggest women taking independent action, symbolizing some level of empowerment. Results underscore the importance of disentangling unique reasons for covert use and the severity of repercussions of disclosure.

Highlights

The balance between increasing men’s participation in family planning and rights-based initiatives favoring women’s empowerment is highlighted with the issue of covert use of contraception
The practice of covert use and reasons for using covertly Covert use of contraception was evoked by men and women across sites, suggesting that clandestine use of family planning methods was a common practice
Covert use was facilitated by the diffusion of concealable female-controlled methods, such as the injectable and implant, other methods, such as oral contraceptive pills or emergency contraception, were mentioned, for young women whose partners opposed family planning: “Once the man really wants to fail you, you can stealthily take pills or go for an injection since it is not a scar, which can be noticed” (Female Focus group discussion (FGD) participant, Married, Rural Uganda)

Summary

Introduction

The balance between increasing men’s participation in family planning and rights-based initiatives favoring women’s empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women’s decision-making processes, actions, and potential consequences of discreet contraceptive use. Couple-based reproductive health programs seem a promising approach to improving acceptability and use of contraception in patriarchal societies; yet, they may undermine women’s rights to control their own bodies, including women's free choice to use or not use contraception [12]. The delicate balance between pragmatic couplebased approaches and a rights-based perspective favoring women’s empowerment is brought to the fore with the issue of covert use of contraception (i.e. the practice of using contraception without one's partner’s knowledge [12,13,14])

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Conclusion