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RESEARCH ARTICLE
Associations of intimate partner violence and
reproductive coercion with contraceptive use
in Uttar Pradesh, India: How associations
differ across contraceptive methods
Shweta TomarID
1,2
*, Nabamallika Dehingia
1,2
, Arnab K. Dey
1,2
, Dharmendra Chandurkar
3
,
Anita Raj
1
, Jay G. Silverman
1
1Division of Global Public Health, Center on Gender Equity and Health, University of California, San Diego
School of Medicine, La Jolla, CA, United States of America, 2Joint Doctoral Program, San Diego State
University/University of California San Diego, San Diego, CA, United States of America, 3Sambodhi
Research and Communications Pvt. Ltd., Noida, Uttar Pradesh, India
*stomar@health.ucsd.edu
Abstract
Intimate partner violence (IPV) and reproductive coercion (RC)–largely in the form of pres-
suring pregnancy—appear to contribute to low use of contraceptives in India; however, little
is known about the extent to which these experiences differentially affect use of specific con-
traceptive methods. The current study assessed the association of IPV and RC with specific
contraceptive methods (Intrauterine Devices [IUDs], pills, condoms) among a large popula-
tion-based sample of currently married women (15–49 years, n = 1424) living in Uttar Pra-
desh. Outcomes variables included past year modern contraceptive use and type of
contraceptive used. Primary independent variables included lifetime experience of RC by
current husband or in-laws, and lifetime experiences of physical IPV and sexual IPV by cur-
rent husband. Multivariate logistic regression models were developed to determine the
effect of each form of abuse on women’s contraceptive use. Approximately 1 in 7 women
(15.1%) reported experiencing RC from their current husband or in-laws ever in their life-
time, 37.4% reported experience of physical IPV and 8.3% reported experience of sexual
IPV by their current husband ever in their lifetime. Women experiencing RC were less likely
to use any modern contraceptive (AOR: 0.18; 95% CI: 0.9–0.36). Such women also less
likely to report pill and condom use but were more likely to report IUD use. Neither form of
IPV were associated with either overall or method specific contraceptive use. Study findings
highlight that RC may influence contraceptive use differently based on type of contraceptive,
with less detectable, female-controlled contraceptives such as IUD preferred in the context
of women facing RC. Unfortunately, IUD uptake remains low in India. Increased access and
support for use, particularly for women contending with RC, may be important for improving
women’s control over contraceptive use and reducing unintended pregnancy.
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PLOS ONE | https://doi.org/10.1371/journal.pone.0241008 October 16, 2020 1 / 12
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OPEN ACCESS
Citation: Tomar S, Dehingia N, Dey AK,
Chandurkar D, Raj A, Silverman JG (2020)
Associations of intimate partner violence and
reproductive coercion with contraceptive use in
Uttar Pradesh, India: How associations differ
across contraceptive methods. PLoS ONE 15(10):
e0241008. https://doi.org/10.1371/journal.
pone.0241008
Editor: Laura Schwab-Reese, Purdue University,
UNITED STATES
Received: June 7, 2020
Accepted: October 6, 2020
Published: October 16, 2020
Copyright: ©2020 Tomar et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The dataset
supporting the conclusions of this article is
available in the Harvard Dataverse, doi: https://doi.
org/10.7910/DVN/ENRF4J.
Funding: This study was funded by the Bill and
Melinda Gates Foundation Grant No. OPP1083531
(Monitoring and Evaluating the Uttar Pradesh
Technical Support Unit) and INV-002967
(EMERGE-FP measures project). The funder
Introduction
Women and girls in India have over 48 million pregnancies per year, around half (48%) of
which are reported to be unintended [1]. These unintended pregnancies are associated with
reduced maternal healthcare utilization [2–4] and consequent poor maternal and child health
outcomes [5,6]. Lack of modern contraceptive (including contraceptive pills, intrauterine
devices [IUD], injectable contraception, male condoms, subdermal implants, diaphragms, lac-
tational amenorrhea, and emergency contraceptive pills) use is the proximal causal factor
behind unintended pregnancies worldwide [7,8]. A study conducted in 35 low- and middle-
income countries (LMICs) found that use of modern contraceptives could prevent 5 million
unintended pregnancies occurring across these countries annually [9]. The National Family
Health Survey (NFHS) 2015–16 found that less than half (48%) of the married women of
reproductive age in India were using any form of modern contraceptive at the time of survey
[10]. Increasing the use of modern contraceptives among women is therefore an important
step towards reducing unintended pregnancies and related negative health outcomes. Further,
contraceptive use is an important part of the Sustainable Development Goal (SDG) including
Goal 3 on guaranteeing good health and well-being for all and Goal 5 on promoting equality
and empowerment of women and girls [11].
One key factor behind low rates of modern contraceptive use is women’s low reproductive
autonomy i.e. power to decide and control contraceptive use, pregnancy, and childbearing
[12]. Research has shown that reproductive coercion (RC; partners/husbands and in-laws lim-
iting access to and use of contraceptives and pressuring women to become pregnant against
their will) in India is more prevalent in the context of physical and sexual violence against
women by their partners (intimate partner violence; IPV) [13]. Such Gender Based Violence
(GBV) is highly prevalent in India with lifetime experience of physical and sexual IPV among
ever married women reported at 30% and 6%, respectively [10] and lifetime experience of part-
ner and/or in-laws perpetrated RC reported by 12% of ever married women [14].
While the association of IPV with contraceptive use has been studied extensively, the results
from these studies have been found to be contradicting. In the Indian context, IPV has been
found to be associated with decreased likelihood of modern contraceptive use [15,16]. How-
ever, studies conducted in other settings have found that IPV and contraceptive use are posi-
tively associated [17]. Recent research has suggested that, considering the different method
mix (i.e. different contraceptive methods used by women) available in different contexts, these
contradicting findings may be due to IPV being associated with increased likelihood of
female-controlled method use (eg. Injectables, IUD etc.) but decreased likelihood of male-con-
trolled method use (eg. condoms) [15,16]. Associations between RC and contraceptive use has
been relatively less studied, particularly in LMIC settings [14]. One study conducted in India
found that RC is negatively associated with overall contraceptive use [14], but no studies to
date, in India or in any other LMIC context, have compared associations of both IPV and RC
with method-specific contraceptive use. Addressing this gap in knowledge can help in identify-
ing the type of contraceptive methods preferred by women facing IPV and RC.
The current study assesses the associations of use of different modern contraceptive meth-
ods with IPV and RC among a population-based sample of married women in Uttar Pradesh
(UP), the most populous state is India. Building on a previous study on prevalence of RC and
IPV and associations with overall contraceptive use [14], findings from the current study will
fill an important knowledge gap regarding whether method mix differs for women facing IPV
and RC as compared to those not reporting such abuse. This, in turn, may inform public health
programs (e.g. on family planning counselling) to better assist women facing IPV and RC in
the Indian context, as well as other LMIC settings. Models can be developed to provide
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provided support in the form of salaries for
authors, but did not have any additional role in the
study design, data collection and analysis, decision
to publish, or preparation of the manuscript. The
specific roles of these authors are articulated in the
‘author contributions’ section.
Competing interests: The authors have declared
that no competing interests exist. The commercial
affiliation of author does not alter our adherence to
PLOS ONE policies on sharing data and materials.
counseling around covert (without telling partner or in-laws) use of contraceptives, a typical
response of women coping with RC. Such models have already been successfully tested in high
income context [18,19].
Methods
Study design
Data for analysis were collected as part of an evaluation of Uttar Pradesh Technical Support
Unit (UP-TSU), an intervention targeted at improving the quality of public health facilities
and services in UP. The data used in current analyses were collected via a population-based
survey conducted from August to October 2016 that included items on socio-economic char-
acteristics, family planning practices, IPV and RC. The intervention did not focus on reducing
IPV or RC among women and hence did not influence the objective of this study. Of all the
districts (n = 75) in the state, the lowest 25 districts based on a composite index of health indi-
cators were designated as High Priority Districts (HPDs) [14]. This index included maternal
mortality ratio (MMR), percentage of institutional deliveries, infant mortality rate (IMR), per-
centage of children 12–23 months fully immunized, total fertility rate (TFR) and modern con-
traceptive prevalence rate (mCPR). A representative sample of currently married women of
reproductive age (15 to 49 years) was drawn using multi-stage sampling design from 49 dis-
tricts with an oversample from these 25 HPDs of UP. Further details of the research design has
been described elsewhere [14]. The current cross-sectional analyses utilizes the sub-sample of
women who were not sterilized or were not currently pregnant, and whose husbands were not
sterilized at the time of the survey (n = 1424). Study protocols were reviewed and approved by
the National Rural Health Mission of Uttar Pradesh, Public Health Service—Ethical Review
Board (PHS-ERB)—an independent ethical review board, and the Health Ministry Screening
Committee of the Indian Council for Medical Research. Informed written consent was
obtained by study participants and interviews were conducted in private space with only the
participant woman present.
Measures
The outcome variables included past year modern contraceptive use and type of contraceptive
method used in the same period. Any past year modern contraceptive use was defined as use of
any form of modern contraception (including contraceptive pills, intrauterine devices [IUD],
injectable contraception, male condoms, subdermal implants, diaphragms, lactational amen-
orrhea, and emergency contraceptive pills) in the 12 months preceding the survey. Type of
contraception used was captured using a categorical variable with nine categories—no modern
contraceptive method used and use of each of the eight forms of modern contraceptives speci-
fied above.
The primary independent variables in the analysis included lifetime experience of RC by
current husband or in-laws, and lifetime experience of physical IPV and sexual IPV by current
husband. Lifetime RC was captured using a composite index of eight equally weighted items
relating to coercion or force used by the husband or in-laws to limit women’s reproductive
autonomy. A woman was considered to have faced RC ever in her lifetime if she responded
“yes” to any of the following eight items: whether woman’s husband or in-laws ever stopped her
from going or refused to give permission for her to go to a clinic or community health event to get
family planning; destroyed,hidden,or taken a family planning method (such as pills) away from
her; told her that they would abandon her if she tried to prevent or delay getting pregnant; told
her that she would be beaten if she tried to prevent or delay getting pregnant; told her that it was
against their religion or culture to use family planning; told her that women who use family
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planning do this so that they can have sex with other men; told her that she could not use family
planning because she did not have any or enough sons; or not permitted her to use contraceptives.
Lifetime RC experience was dichotomized as yes or no based on ‘yes’ response to any of these
eight items. This measure was based on a previously published measure of RC adapted for the
Indian context and shown to have adequate reliability (Cronbach’s alpha = 0.73) [14].
Lifetime physical IPV was assessed through seven questions including whether the woman’s
current husband had ever slapped her,twisted her arm or pulled her hair; pushed her,shook her,
or threw something at her; tried to choke or burn her; kicked her,dragged her,or beat her up;
punched her with his fist or with something that could hurt her; or threatened or attacked her
with a knife,gun,or any other weapon. Lifetime physical IPV were dichotomized as yes or no
based on ‘yes’ response to any of these seven items. Similarly, woman’s experience of sexual
IPV was indicated by a positive response to whether the woman’s current husband ever done
any of the following:physically forced her to have sexual intercourse with him when she did not
want to; physically forced her to perform other sexual acts she did not want to; used threats or
other actions to make her perform sexual acts when she did not want to; forced her to do some-
thing sexual that she found degrading or humiliating; or she had sexual intercourse when she did
not want to because she was afraid of what her husband might do if she refused. Lifetime sexual
IPV were dichotomized as yes or no based on ‘yes’ response to any of these items. Both physi-
cal IPV and sexual IPV assessments were drawn from the WHO Multi-country Study on
Women’s Health and Domestic Violence [20].
Socio-demographic measures included caste, religion, household wealth status, woman’s
literacy, husband’s education, woman’s age, woman’s age at first marriage, and birth parity.
Households were categorized into three social categories using caste and religion, from most
to least marginalized; they were 1) Non-Muslim Scheduled Caste or Scheduled Tribe (SC/ST),
2) Muslim, and 3) neither SC/ST nor Muslim. Household wealth status was assessed using
Standard of Living Index (SLI) which is a proxy for the economic status of the household [21]
and is widely used in national Demographic and Health Surveys, including the India NFHS
[10]. The households were categorized into 4 groups ranging from poorest (1) to wealthiest (4)
based on SLI scores of 0 to 25, 26 to 50, 51 to 75, and 76 to 100 (range 0–100). A woman was
considered to be literate if she reported being able to both read and write in at least one lan-
guage. Husband’s education was dichotomized based on whether or not he had completed pri-
mary school. The legal age of marriage for women in India (i.e. 18 years) was used as a cut-off
to create two categories- women married at age below 18 years and women married at age of
18 years or above.
Analysis
Association of demographics with each outcome variable (any past year modern contraceptive
use and type of contraceptive used) and predictors (lifetime RC, lifetime physical and sexual
IPV) was assessed using chi-square test. Specific contraceptive methods used by 5 or fewer par-
ticipants were collapsed into “other modern methods”. This grouping was not subject to fur-
ther analysis. Chi-square tests were also used to test associations between the predictors and
outcome variables. Logistic regression adjusted for socio-demographic variables was used to
further assess the relationship (adjusted odds ratio [aOR] and 95% Confidence Interval [CI])
between any past year modern contraceptive use and predictors. Multinomial logistic regres-
sion models described similar relationships (adjusted relative risk ratio [aRRR] and 95% CI)
between predictors and type of contraceptive used. Multiple iterations of the multinomial
model were performed with different base outcomes to test the risk ratio of each type of con-
traceptive relative to different base category. Multivariate logistic regression models (binomial
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for any modern contraceptive use and multinomial for type of method used) including all
three predictors—RC, physical IPV, and sexual IPV along with demographics were developed
to determine independent effect of each form of abuse on women’s contraceptive use. We
tested covariates for multicollinearity prior to model construction. We found no collinearity,
so all covariates were included in our models. Appropriate sample weights based on the multi-
stage sampling procedure were used in all analyses. Data were analyzed using STATA 16.0
software (StataCorp, USA).
Results
Approximately 1 in 4 (22.8%) women reported use of any modern contraceptive in the 12
months preceding the survey, with 6.7% reporting use of contraceptive pills, 1.4% reporting
use of an IUD, and 13.3% reporting use of male condoms (Table 1). Women in higher wealth
categories were more likely to report use of any modern method of contraception, specifically
pills, as compared to those in lower wealth categories. Literate women were more likely than
illiterate women to report use of any modern contraceptive, specifically male condoms.
Women whose husbands had completed primary education (vs lower than primary) were
more likely to report condom use. The proportion of women reporting IUD use was higher
among women who got married as minors (less than 18 years) as compared to those who were
married at 18 years of age or later (all p values<0.05).
Approximately 1 in 7 women (15.1%) reported ever experiencing RC from their current
husband or in-laws (Table 2). More than 1 in 3 women (37.4%) reported ever experiencing
physical IPV and 8.3% reported ever experiencing sexual IPV from their current husband.
RC was found to be associated with overall modern method of contraception. In logistic
models (binomial and multinomial with different base outcome) adjusted for demographics
(Table 3), women who had experienced RC were less likely to report use of any modern con-
traceptive (aOR 0.18; 95% CI, 0.09–0.36) in past 1 year. Findings from multinomial models
indicate that women who face RC were less likely to use pills as compared to using no method
(aRRR 0.02; 95% CI, 0.00–0.07). In the model with pills as base outcome, women who faced
RC were more likely to use IUDs than pills (aRRR 63.74; 95% CI, 7.42–547.20) and condoms
than pills (aRRR 13.9; 95% CI, 2.89–67.30). Neither physical nor sexual IPV by current hus-
band were associated with any past year modern contraceptive use or type of contraceptive
used.
Findings from the multivariate models adjusted for both demographics and inclusive of all
three forms of abuse (Table 4) were identical, with women reporting lifetime experience of RC
less likely to use any modern contraceptive (aOR 0.19; 95% CI, 0.10–0.38), less likely to use
pills than using no method (aRRR 0.02; 95% CI, 0.00–0.07) more likely to use an IUD than
pills (aRRR 69.41; 95% CI, 9.35–515.45) and more likely to use a condom than pills (15.00;
95% CI, 3.01–74.79). Additionally, women who faced RC were less likely to use a condom as
compared to no contraceptive use (aRRR 0.24; 95% CI, 0.12–0.49) in the models inclusive of
all forms of violence.
Discussion
More than 1 in 7 (15%) women are affected by RC in this population-based sample of ever
married women. As discussed earlier, previous study in UP reported an RC prevalence rate of
12% among ever-married women in reproductive age [14]. The current study was based on
the same sample but excluded women who may not need contraceptives at the time of study
i.e. women who were sterilized, whose husbands were sterilized and who were pregnant at the
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Table 1. Frequencies of sample demographics by outcomes of interest.
Total Past year FP use-any Pills IUD Condom
Unwtd.
N
% (95%
CI)
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Total 1770 362 22.8%
(19.9–
25.9)
87 6.7%
(5.2–8.5)
23 1.4%
(0.7–2.8)
230 13.3%
(10.9–
16.1)
Background characteristics
Age
15–19 4 0.6%
(0.2–1.8)
0 0.00% 0.683 0 0.00% 0.675 0 0.00% 0.227 0 0.00% 0.213
20–24 192 11.5%
(9.1–14.5)
47 21.8%
(14.2–
32.0)
9 4.0%
(1.3–12.0)
4 0.8%
(0.2–2.3)
30 15.7%
(9.4–24.9)
25–29 314 20.3%
(17.2–
23.9)
84 21.5%
(15.9–
28.2)
18 6.5%
(3.7–11.1)
2 0.1%
(0.0–0.4)
62 14.3%
(9.5–21.0)
30+ 914 67.6%
(64.0–
71.0)
231 23.5%
(19.8–
27.7)
60 7.2%
(5.3–9.8)
17 1.9%
(0.9–4.0)
138 12.7%
(9.9–16.2)
Age at marriage
<18 1264 87.4%
(84.1–
90.1)
321 22.7%
(19.4–
26.3)
0.906 77 6.6%
(4.9–8.7)
0.785 22 1.6%
(0.8–3.2)
0.006 201 13%
(10.5–
15.9)
0.13
18+ 160 12.6%
(9.9–15.9)
41 23.3%
(15.1–
34.2)
10 7.4%
(3.4–15.1)
1 0.1%
(0.0–1.0)
29 15.4%
(8.7–26)
Wealth Quintile
1 (poorest) 302 19.3%
(15.4–
23.9)
66 20.9%
(15.4–
27.7)
0.049 17 6.3%
(3.8–10.3)
0.01 6 1.4%
(0.5–3.8)
0.259 37 9.0% (5.4–
14.8
0.142
2 557 37.2%
(32.2–
42.5)
128 19.6%
(15.6–
23.9)
40 5.7%
(3.6–8.8)
6 0.7%
(0.3–1.8)
70 11.9%
(8.6–15.8)
3 466 34.9%
(30.2–
39.9)
135 24.1%
(18.3–
31.1)
19 5.4%
(3.2–9.1)
11 2.4%
(0.9–6.5)
101 16.0%
(11.9–
21.1)
4 (wealthiest) 99 8.6%
(6.1–12.0)
33 35.1%
(25.2–
46.5)
11 16.8%
(8.9–29.5)
0 0.00% 22 18.3%
(9.5–32.4)
Literacy
Illiterate 957 66.2%
(62.5–
69.6)
218 20.2%
(16.9–
24.0)
0.025 56 6.1%
(4.4–8.4)
0.423 13 1.5%
(0.6–3.7)
0.679 131 10.7%
(8.1–14.0)
0.0083
Literate 467 33.8%
(30.4–
37.5)
144 27.8%
(22.4–
33.9)
31 7.8%
(4.9–12.2)
10 1.2%
(0.5–2.5)
99 18.4%
(13.9–
24.0)
Spouse literacy
Illiterate 469 33.4%
(29.2–
37.8)
99 20.0%
(16.0–
24.9)
0.195 27 6.0%
(3.7–9.5)
0.609 7 1.4%
(0.5–4.4)
0.937 56 10.3%
(7.0–14.9)
0.012
Literate 955 66.6%
(62.3–
70.8)
263 24.1%
(20.3–
28.4)
60 7.0%
(5.1–9.5)
16 1.4%
(0.5–3.4)
174 14.8%
(11.9–
18.3)
Caste/religion
(Continued)
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time of study. Thus, RC appears to be pervasive among women in LMIC settings, especially
among women who may have a need for contraceptives.
Among women experiencing RC, less than 1 in 15 (6.4%) reported use of any modern con-
traceptive in the last 1 year; similar to previous research [14], these women were significantly
less likely to use modern contraceptives as compared to women who had not experienced RC,
after adjusting for effect of IPV and demographics. Similar to the earlier study among this pop-
ulation, overall contraceptive use was not found to be associated with IPV. These findings
show that, similar to other contexts [22–24], RC among women in Uttar Pradesh reduces their
ability to successfully use modern contraceptive method.
The model for method specific contraceptive use shows that experience of RC was associ-
ated with decreased likelihood of pill and condom use but not IUD. The findings on reduced
condom use are consistent with previous studies in India demonstrating that men perpetrating
IPV are less likely to use condoms [25–27]. However, the finding on reduced likelihood of pill
use based on RC would appear to contradict the hypothesis that female-controlled methods
Table 1. (Continued)
Total Past year FP use-any Pills IUD Condom
Unwtd.
N
% (95%
CI)
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Unwtd.
N
% (95%
CI)
p-
value
Total 1770 362 22.8%
(19.9–
25.9)
87 6.7%
(5.2–8.5)
23 1.4%
(0.7–2.8)
230 13.3%
(10.9–
16.1)
Neither SC/ST
nor Muslim
847 58.2%
(53.2–
63.1)
233 24.6%
(20.5–
29.3)
0.197 62 7.6%
(5.5–10.5)
0.424 16 1.7%
(0.7–4.1)
0.513 142 14.6%
(11.2–
18.7)
0.154
SC/ST 320 21.8%
(18.0–
26.2)
79 22.6%
(17.2–
29.0)
16 5.8%
(3.4–9.9)
4 0.9%
(0.3–3.2)
54 14.4%
(10.6–
19.4)
Muslim 257 20.0%
(15.3–
25.7)
50 17.5%
(12.3–
24.3)
9 4.8%
(2.2–10.0)
3 0.8%
(0.2–3.4)
34 8.4% (5.1–
13.7)
Parity
0 211 14.9%
(12.0–
18.4)
53 22.9%
(15.4–
32.5)
0.541 12 5.7%
(2.8–11.6)
0.876 4 0.9%
(0.2–3.6)
0.175 35 15.9%
(9.6–25.1)
0.022
1 148 9.2%
(7.0–11.8)
43 28.3%
(19.6–
38.9)
12 7.0%
(3.1–15.3)
1 0.2%
(0.0–1.2)
29 20.2%
(12.1–
31.7)
2 229 14.9%
(12.6–
17.5)
63 25.3%
(17.8–
34.7)
7 5.2%
(1.8–14.0)
4 0.8%
(0.2–2.4)
49 19.0%
(12.7–
27.5)
3+ 836 61.1%
(57.4–
64.6)
203 21.3%
(17.8–
25.2)
56 7.2%
(5.2–9.8)
14 1.8%
(0.8–4.2)
117 10.3%
(7.8–13.4)
https://doi.org/10.1371/journal.pone.0241008.t001
Table 2. Prevalence of reproductive coercion, husband IPV and in-law IPV.
No Yes
Unwtd. N % (95% CI) Unwtd. N % (95% CI)
Reproductive coercion 1218 84.9% (80.9–88.1) 206 15.1% (11.9–19.1)
Husband physical IPV 887 62.6% (56.8–68.0) 537 37.4% (32.0–43.2)
Husband sexual IPV 1302 91.8% (88.6–94.1) 122 8.3% (5.9–11.4)
https://doi.org/10.1371/journal.pone.0241008.t002
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will be positively associated with forms of GBV, as pills are typically considered as female-con-
trolled contraceptives that can be used without the knowledge of male partners. However, a
recent study on GBV and contraceptive methods posited that contraceptive pill use should
only be considered truly female-controlled in cases where it is feasible for women to both con-
ceal the pill package, and to take the pill unobserved [28]. This is likely not the case in this set-
ting, as this study was conducted in rural areas of Uttar Pradesh where the average household
size is over five, approximately half (44%) of households include women’s in-laws [10], and
women generally live in close-quarters with other family members, with each room occupied
by an average of three family members [29]. This close proximity to other family members
may make it difficult for women facing RC to conceal and use pills without knowledge of hus-
band or in-laws, making pills use less likely in cases of RC.
Table 3. Logistic (binomial and multinomial) adjusted for demographics.
Method used vs no contraceptive use Method wise comparison
Any modern method vs
no modern method
Pills vs no
modern method
IUD vs no
modern method
Condom vs no
modern method
IUD vs Pills Condom vs
Pills
Condom vs
IUD
aOR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95%
CI)
Reproductive
coercion
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.18��� (0.09–0.36) 0.02��� (0.00–
0.07)
1.07 (0.21–5.46) 0.23 (0.12–0.47) 63.74��� (7.42–
547.20)
13.92��� (2.89–
67.30)
0.22�(0.04–
1.32)
Husband physical
IPV
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.72�(0.51–1.02) 0.83 (0.43–1.59) 0.72 (0.15–3.39) 0.67�(0.43–1.02) 0.87 (0.16–
4.63)
0.81 (0.37–
1.74)
0.93 (0.18–
4.85)
Husband sexual
IPV
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.62 (0.33–1.16) 0.61 (0.25–1.51) 0.32 (0.04–2.51) 0.69 (0.32–1.50) 0.52 (0.06–
4.53)
1.14 (0.38–
3.38)
2.17 (0.28–
16.66)
�Trend towards statistical significance (p <0.1)
��� Statistically significant at p <0.01
https://doi.org/10.1371/journal.pone.0241008.t003
Table 4. Multivariate logistic (binomial and multinomial) adjusted for demographics and inclusive of different forms of violence.
Method used vs no contraceptive use Method wise comparison
Any modern method vs
no modern method
Pills vs no
modern method
IUD vs no
modern method
Condom vs no
modern method
IUD vs Pills Condom vs
Pills
Condom vs
IUD
aOR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95% CI) aRRR (95%
CI)
Reproductive
coercion
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.19��� (0.10–0.38) 0.02��� (0.00–
0.07)
1.12 (0.27–4.68) 0.24��� (0.12–0.49) 69.41��� (9.35–
515.45)
15.00��� (3.01–
74.79)
0.22�(0.04–
1.05)
Husband physical
IPV
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.86 (0.60–1.23) 1.08 (0.53–2.18) 0.80 (0.18–3.56) 0.76 (0.50–1.17) 0.74 (0.15–
3.69)
0.71 (0.31–
1.60)
0.96 (0.20–
4.66)
Husband sexual
IPV
No Ref Ref Ref Ref Ref Ref Ref
Yes 0.64 (0.32–1.24) 0.52 (0.20–1.41) 0.37 (0.03–4.21) 0.76 (0.33–1.74) 0.70 (0.05–
9.15)
1.45 (0.46–
4.60)
2.08 (0.18–
24.03)
�Trend towards statistical significance (p <0.1)
��� Statistically significant at p <0.01
https://doi.org/10.1371/journal.pone.0241008.t004
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Association of IPV and RC with contraceptive use
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In contrast, experience of RC increased the likelihood of IUD usage, both in comparison to
pills and condoms. Earlier research has also found that women find IUDs easier to use covertly
than the oral contraceptive pills [30]. While insertion of IUD is a one-time activity which can
be done when husband or in-laws are not around, pills need to be consumed regularly and
therefore, involve a higher risk of detection. However, the results from NFHS, 2015 show that
only 1.5% women in India and 1.2% in Uttar Pradesh use IUD [10]. One possible reason
behind this low IUD use is the lack of commitment from national and state government to
take steps required for increasing awareness of and access to IUDs [31]. This may be a partial
explanation for the most commonly used method among women facing RC being condoms.
However, this does not explain the increased likelihood of condom use as compared to pills
among women facing RC. A context-specific explanation for greater use of condoms as com-
pared to pills is perpetration of such coercion by family members other than husband. As
reported in the previous study, in-laws were the sole perpetrator in almost half of all RC cases
[14] in this sample. For women facing RC by in-laws but not by husband, i.e., where husbands
are not attempting to coerce her to become pregnant, condom use may well be the most feasi-
ble method of contraception. Future studies investigating the connection of use if specific
methods based on source of RC will be important to clarify these findings. While the current
study collected data on perpetrator of RC, multivariate analysis for different RC perpetrators
could not be conducted due to small cell sizes (small strata), particularly regarding IUD use.
The current results add to the building consensus that screening for RC should be included
in confidential contraceptive counselling, as this experience appears to be a significant factor
in women’s choices and needs regarding type of contraceptive methods. Enabling women fac-
ing RC to successfully use contraceptives can help in reducing unintended pregnancies [14,
32] and related adverse health consequences [5,6,14,33]. Models of clinic-based intervention
found to successfully address RC and to reduce pregnancy among women seeking contracep-
tives [18,19] should be considered for adaptation and implementation in rural UP and similar
contexts. Since IUD prevalence is very low in India and the current study found it to be a pre-
ferred method of contraception among women facing RC, improving awareness about and
access to IUDs by the Indian government may both increase overall contraceptive use in the
country, and also better help women to preserve their reproductive autonomy.
Limitations
While the current findings provide important insights into the type of contraceptives used by
women facing RC, there are several limitations related to the study design that are worth not-
ing. The data used include lifetime RC and IPV but past 12 months contraceptive use. Data to
assess current desire to become pregnant, an important factor behind contraceptive use
among women, was not collected. The study also has limitations in the sample size within the
strata of types of contraceptive which yields small cell sizes, making it difficult to detect differ-
ences by group. This is reflected in the large confidence intervals obtained for use of IUDs
which have a very low prevalence. A larger sample and greater representation across con-
traceptive types may present clearer findings. As contraceptive use and particularly IUDs and
other less commonly used forms of contraceptive use increase under FP2020 activities, further
research could help provide greater clarity into these issues. Also, we interpret study findings
to indicate that the positive association between RC and IUD use may be because of women’s
control and potentially even the possibility of women’s covert use of this method. Further
research should assess the quantitative association between RC and covert contraceptive use
more directly and can also delve into the qualitative reasons for type of contraceptive used
among women contending with RC to provide more insight into these findings. Data used in
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Association of IPV and RC with contraceptive use
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the study is cross-sectional and therefore causality cannot be inferred. Lastly, the study used
self-reported data which might have introduced social desirability and recall bias.
Conclusion
Reproductive coercion is prevalent and critical barrier to overall use of contraceptive methods
among women in Uttar Pradesh. Among women facing RC, IUD is the most preferred con-
traceptive method, and pills, the most commonly used female controlled method used in
India, may be more difficult to use for these women. Although, further research is warranted,
these findings suggest that confidential identification of women facing RC by community
health workers and health facility-based providers may result in increased contraceptive use,
especially as new female-controlled contraceptives (injectables and implants) are currently
being introduced in UP and other Indian states.
Author Contributions
Conceptualization: Shweta Tomar, Dharmendra Chandurkar, Jay G. Silverman.
Formal analysis: Shweta Tomar, Nabamallika Dehingia.
Methodology: Shweta Tomar.
Writing – original draft: Shweta Tomar.
Writing – review & editing: Shweta Tomar, Arnab K. Dey, Anita Raj, Jay G. Silverman.
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