Discussion of results
Our study is one of the first to look at the place for female condoms in India’s Family Planning Program based on the views of a wide range of users/potential users and dispensers (high risk and low risk), from urban and rural villages in India. Our study also included the experiential views of female sex workers and their male partners who had a history of female condom use. In general, we found that participants viewed female condoms as a welcome addition to their current basket of contraceptive choices and believed that it could become popular among users and dispensers following targeted interventions. We discuss our results below according to the World Health Organisation’s ‘Acceptability, Availability (and affordability), Accessibility, and Quality’ (AAAQ) framework, which considers access to health care from a human rights perspective in settings such as India, while taking quality for granted in this study .
When questioned about the advantages of female condoms, the views of those we interviews aligned to a degree with the findings of Weeks et al. (2013), who found that female condoms are advantageous to women (particularly female sex workers) as they can use it with their regular, casual, and paying partners . Moreover, similarly to our findings, it has also been identified that female condoms are desirable as they provide protection for women without negatively affecting their hormones or having harmful side-effects . This is important because intrusive contraceptive devices may take a toll on women. For example, in India, 25.5% of women who used modern non-permanent contraceptives report discontinuation due to non-pregnancy/fertility related factors .
On the other hand, some of the perceived barriers voiced by participants are perhaps rooted in misconceptions due to inadequate exposure to female condoms. For instance, a concern expressed by 4 respondents was that female condoms are a symbol of infidelity. A study conducted by Bandewar et al. (2015) in India also found that if women insisted on using male condoms they would be questioned on their commitment to their regular partner as “love was seen as incompatible with condom use” . However, our study interestingly also found that this was a reservation held only by women interviewed at rural sites and not women interviewed at urban sites. This could be explained by the ‘diffusion of innovation’ theory, according to which rural populations are usually a part of the ‘late majority’ who are hesitant to adopt novel innovations compared to their urban counterparts who make up the ‘early majority’ . Hence, if many urban users and dispensers start utilising female condoms, it could lead to a city-to-rural diffusion of female condom uptake . Future investigations into the promotion of female condoms according to the ‘diffusion of innovation theory’ would be useful. Moreover, male condoms have come to be associated with infidelity because of the extensive community campaigns advocating their use to prevent transmission of the human immunodeficiency virus (HIV) . For the time being in India, female condoms are in a sense, ‘protected’ from this ‘notoriety’ as they are still widely unknown, and as a result, have the chance to be marketed to the public more as contraceptives that can prevent STIs, than vice-versa.
We have attempted to contribute novel insights to the wider scholarly discussion surrounding how to dismantle barriers and increase the uptake of female condoms by users. Based on the views of our interview respondents, we found that wider visibility of female condoms by making them available in public clinics and through various media might help familiarise women with the device and reduce user apprehensions . Additionally, family planning agencies in India should develop creative promotional materials in different mediums which showcase the full potential of the female condom, as a multipurpose prevention technology. As it was the urban users and dispensers who largely believed that female condoms would be accepted within India’s family planning contraceptive cafeteria, promotional and educational efforts should also be initially focussed on the urban districts of India, and then extended into rural villages for greater acceptance.
Affordability and Availability
Another perceived disadvantage mentioned by participants was that the higher cost of female condoms compared to male condoms, coupled with its limited availability, makes it inaccessible in resource constrained settings such as India. This was also a re-emerging theme presented by other researchers from Zambia and South Africa [6, 36–37]. Thus, although female condoms have been introduced in many countries, their supply and uptake in developing nations hardest hit by HIV, and with high rates of abortions is largely inadequate .
The ease of use, and consistent use can happen only if availability is perineal, and practice makes perfect . In our study, we found that while potential users and dispensers are willing and enthusiastic to make use of female condoms, the continued underutilisation of this vital female initiated dual-barrier contraceptive can be largely accounted for by a shortage of targeted publicity, availability, and educational programs, because they are not an option in India’s family planning cafeteria. In fact, Peters et al. (2010) critique the fact that female condoms have never been in the limelight since they were introduced in 1984, and their analysis revealed that the strong international potential of female condoms has been stymied mainly at the international policy levels rather than any obstacles from the users end . Compared to male condoms that have been widely promoted, female condoms are relatively unknown even though, like male condoms, India has also been domestically manufacturing and distributing female condoms since 2012. In fact, the country has even introduced a more affordable variation of the female condom made from natural rubber latex [39–40]. Thus, there should be no dearth in availability if India’s Family Planning Program were to offer it as an option as many participants in our study favoured the free provision of female condoms. Additionally, it is expected that widespread use may further drive down their costs.
While the recommendations of increasing stock and reducing prices have been commonly cited in other studies [41–42], we found that a marketing strategy to promote the use of female condoms in India should also address concerns linked to infidelity and embarrassment by assuring women-friendly spaces and anonymity. This would enable women to confidentially purchase female condoms. A more optimal and non-stigmatising way would be to offer female condoms routinely as an option in family planning clinics at various health centres that women visit, along with all other conventionally offered contraceptives.
Like participants in two other studies in India and Zambia [6, 35], a few of the women we interviewed were also hesitant to use female condoms, as they feared inserting it into their vagina. We found this to be largely articulated by women who had no prior experience using female condoms. Thus, to improve user knowledge and confidence, the features of female condoms which enable user comfort, such as pre-lubrication, and flexibility of the rings at each end of the female condom, need to be emphasised while counselling women for its use. Additionally, to dispel fears that arise due to unfamiliarity, there should be detailed demonstrations of how female condoms are inserted, and women should be offered the option to practice insertion on mannequins. Furthermore, based on the grassroot recommendation made by respondents, we found that community organised women-friendly meetings are more effective avenues to disseminate information on female condoms as opposed to top-down initiatives. Consequently, family planning agencies should collaborate with trusted grassroot clinics, NGOs, and female community leaders to organise local gatherings where women can discuss the benefits of female condoms amongst themselves and support each other when learning about how to use it.