The 12 participants recruited for this research were married adults from the Gulberg town, 6 males and 6 females, whose diverse demographic details are stated in Tables 1 and 2 (Supplementary Information), respectively. The data analysis generated two themes: Peripheral roots (factors observable by the society) affecting FP decisions and Taproots (deep factors hidden from society) for gender roles and responsibilities in explaining FP decisions. The first theme has three main categories; interpretation of FP, awareness about FP, and couple as representative of FP decision making whereas the second theme has five categories; roles and responsibilities of men in the family, roles and responsibilities of women in the family, women autonomy, mind the gap or taming the women, and way forward (Fig. 1 in Supplementary Information).
Category 1: Interpretation of FP
The participants stated that FP decisions affect both partners and for most, FP meant the gap between children and having an ideal family size, for which the couple can choose a method of contraception. In fact, some believed that financial constraints and its impact on a child's upbringing are paving the way for couples to rethink their ideal family size and to use FP to curtail their expenses associated with more children.
“A child is born with empty hands in this world. He/she needs everything including good education, food, and clothing etc…If parents will keep on producing children, they will not be able focus on all the needs of each child.” (Participant 09)
Additionally, educated participants thought that FP is beneficial for women's physical and mental health, as it provides a sufficient gap between the births of children, thus making her haemoglobin and nutritional reserves appropriate for healthy pregnancy and thereby preventing issues associated with unplanned pregnancy and abortion. Female respondents, being more concerned about their health, were motivated to use FP so that they can regain their health.
As per participants’ general opinion, the pressure on newly married women to prove their fertility leads to younger couples avoiding the use of FP methods. Women also felt that men are concerned about FP only when there is a threat of maternal mortality. Moreover, they believe that the number of children signifies the love of a wife towards her husband.
Furthermore, some participants believed a male child is a source of income for poor uneducated individuals, a concept leading to multiple pregnancies until the desired number of male children is achieved. Some uneducated participants also strongly felt that children are a gift from God, having more children pleases God and in-laws and so they should not control their birth. Uneducated participants reported,
"My husband says that this is God given. He is merciful on us; He has given us the blessing of children."(Female participant 11 from the lower middle SES)
"FP is against nature... It is interference with nature." (Male participant 05 from the lower middle SES)
Both genders believed that modern FP methods lead to side effects like weakness, infection, blood clots during menstruation, mental illness, cancer, infertility, and even death in the long run. While male respondents verbalized the ring method causing problems for them during sexual intercourse, female participants regarded the use of pills and injections as less reliable because they caused weight gain and skin darkening, hence affecting their appearance. Furthermore, an uneducated woman verbalized the old perception that pregnancy will make a female look aged before time and thus the use of FP may help them preserve their youth.
"She (mother-in-law) used to fight with me and said that you (participant) do not produce children because you want to stay young, as delivering babies will make a woman aged before time. She asked that am I an old woman, because I have been using FP?" (Uneducated female participant 12 from the lower middle SES)
As per uneducated participants, the lack of time and knowledge about FP, and the myth regarding condoms causing Acquired Immune Deficiency Syndrome (AIDS) and Tuberculosis (TB) were also factors inhibiting couples from using FP decisions.
Category 2: Awareness about FP
Generally, participants verbalized that due to information sources like education by health care professionals, media (TV channels), and NGO (Non-Governmental Organization) workers, they have some awareness about methods including pills, condoms, ring, coil, injection, withdrawal, and sterilization. Female participants from the upper middle SES regarded lady doctors as a source of information for them on FP while uneducated participants from the lower middle SES acquired information on FP from elders of the same gender amongst their family and friends Among physical methods, condoms were considered comparatively better for use among male participants, but also decreased their pleasure and needed to be used with consistency. Participants with spouses from the health care field were more likely to make informed decisions. An educated participant, whose wife was a midwife by profession, favoured condoms because it has no side effects, prevents STIs and because using condoms does not require seeking medical assistance as demanded by other methods. Regarding chemical methods, women preferred pills, ring, and injections due to their effectiveness. However, few women also prioritized natural methods because they have fewer side effects than other available methods. Furthermore, when the couple was certain of having achieved their desired family size, participants preferred Hysterectomy and other surgical procedures over operation because it is a permanent method. While many participants verbalized lack of authentic and culturally sensitive information sources about FP, some communities, having access to health centres, were found arranging lectures at the community level to disseminate health messages so that these may be passed from one generation to the other.
"You cannot talk openly on this matter [FP]. Ladies talk amongst themselves and so do gents and then they learn from experiences of each other and try it [FP methods]." (Participant 02)
Category 3: Couple as a Representative of FP Decision Making
Educated participants particularly felt that a couple should rear and nurture their children and that they should take equal and mutual decisions regarding FP as it is their personal concern and affects the reproductive systems of both the partners. The perceived role of a couple in FP decisions was deeply linked to dynamics of gender norms of males and females, as identified in the study findings. Furthermore, as highlighted by male participants only, giving children proper attention, time, and providing for their education, food, and other necessities makes participants rethink their FP decisions, particularly about ideal family size. The participants informed that many couples follow FP methods in a sequential manner, which begins from condoms, then use of Emergency Contraceptive Pills (ECPs), and later abortion. Thus, the participants had a fixed pattern of decision making on FP methods determined by the couple and strengthened by the duration of marriage. They shared that in case of any FP method failure (unplanned pregnancy), it was the couple's decision to continue the pregnancy or not. As per female participants, mutual decision making becomes easier if a man, being less egoistic, does not demand his wife to be a follower of decisions he takes without her active involvement on the matter.
"He (husband) said to me that I can do what I feel is appropriate (referring to the use of coil method). I thought to try this (coil)... I have heard of its side effects and I have also seen girls suffering from side effects of medicines. Therefore, I was scared. I thought of not using medicines and my husband was also comfortable with the coil method." (Educated female participant 08)
Category 1: Role and Responsibilities of Men in the Family
Generally, majority of the participants stated that male roles and responsibilities were of “a son, father, husband, brother, and a father-in-law”, that any work outside the house is designated for them, that having the productive role gave them an upper hand in making FP decisions, that they are mostly rigid and are required to make all major family decisions involving money including schooling, investment, spending on furniture, job selection, and health expenditure as dictated by their forefathers, traditional societal norms, and social institutes. For some participants, even the selection of food menu was by the husband’s choice and an uneducated male participant also mentioned that in case of the father’s absence, the son takes the lead. However, female participants reported that these roles are given by the society and not by the “supernatural power” and that the decision-making process is unclear and affected by men's dominance. Even educated men thought that while considering doctors' opinion is important before taking major decisions, in case of any conflict, the husband should take FP decisions even if the wife was more educated than him and/or belonged to the health profession. The participants felt that masculinity means to have the ability to reproduce and to have power and ability to perform labour intensive tasks. However, women felt that a "good man" should be polite, fair, protective, a problem solver, brave, honest, responsible, confident and should not misuse his power, thereby acknowledging that men have more authority. While male participants, in particular, believed that a good son should be caring, and should give time and attention to his parents, participants, in general, perceived a good husband to be loyal, calm, liberal, and friendly, and a good father to be one who ensured a good environment for his children. "A good male should be fair, earning well, and should have good attitude". (Participant 02) In contrast, participants perceived a bad man to be one involved in substance abuse and misbehaviour with others, including his wife.
Category 2: Role and Responsibilities of Women in the Family
Generally, majority of the participants stated that female roles and responsibilities were of "a wife, sister, daughter-in-law, daughter, and a mother", that they are expected to perform all household chores, that they should rear children because they have delivered them (reproductive role), that they are not given a major role in making family decisions and that they, as mentioned particularly by female participants, are forced by societal values to follow traditional gender roles allocated to them while being supportive, passive, loyal, organized, gentle, loving, caring, selfless, obedient, soft-spoken, tolerant, and calm at all costs. In contrast, a bad woman, as mentioned by male participants, is boastful and abusive who compares her husband with others, is assertive and does not dress in a modest way. Male respondents also stated that an earning woman, being more aware of her rights, is assertive and outspoken and is socially recognized as one having no “Male protector and heir" (Male participant 04) at home.
"I do not favour that women should step out of house for earning because it will make her assertive... I will perceive that being outspoken is told/ taught to her on her job."(Uneducated male participant from the lower middle SES participant 05)
The participants informed that this situation creates conflict, as depicted by the media, with whose assistance women are now being involved in important family decisions, though still not as equally as men. While men generally emphasized that women can only decide on minor issues, like selecting the paint colour and house decoration, educated men, on the contrary, believed that women should be given a chance to speak in major decisions, and supported women in both a productive and community role. However, female participants also mentioned that in accepting the productive role, they cannot compromise on their reproductive role and thus must bear double the burden of responsibility. The uneducated women from the lower middle SES further mentioned that they are not always comfortable in negotiating the use of FP methods with their husbands and families. Nonetheless, their seemingly greater concern regarding the health and quality of their children’s lives makes them initiate discussion on FP decisions.
Category 3: Women Autonomy
The third category emerges only from the data of female participants.
As per female participants, inclusive of many who had shifted from an extended to a nuclear family system, while an extended family system disregards a woman’s autonomy, puts her under the pressure of conceiving a child soon after marriage, and deprives the couple of the privacy and time required for FP, a nuclear family system will not only provide the couple autonomy in their personal reproductive and professional lives but may also help her break the vicious cycle of gender discrimination in FP decisions by enabling her to train their children about gender equality with full freedom. A despaired woman mentioned:
"After (the birth of) my baby girl, when I used the injections my mother-in-law verbally abused me. She said that I am a woman of bad character, because I have used injections. She further said that I should produce as many children as she wants and that the use of FP will develop diseases in me that will lead to death. (Uneducated female participant 12 from the lower middle SES)
Female participants mentioned that the type of marriage has an impact on women’s autonomy. They shared that in arranged marriages, there was a lack of the required understanding in a couple about FP matters, regardless of the duration of their marriage. In arranged marriages, some participants were not given a chance to meet their would-be spouse, who after marriage would be their sexual partner. This may lead to lack of support for her from her husband, thus leading to a few female respondents feeling disempowered in FP decisions. Female participants mentioned that they used FP methods in secrecy because they were concerned about their health and their children's life, which hampered them from sharing things with their husbands since they felt that on doing so, they would be subjected to blame and suspicion and would have to face abuse from their in-laws and husbands.
"My husband wants to have more children, but I do not favour it. It is because I know it is my duty that I have to (manage) everything, which will not be possible for me if there are more children... I use ECP secretly to prevent (pregnancy). I have not shared this with him, otherwise he will misunderstand me. That's why I am using FP (in secrecy)! He does not like injections, tablets, and all other things (FP methods). As I am a working woman, he may think what am I doing when I am not at home?" (Educated, working woman 09)
However, a few women also mentioned in-laws being supportive by covering up their daughter-in-law’s mistakes in arranged marriages, as opposed to in a love marriage.
Category 4: Mind the Gap/Taming the Women
Generally, participants felt that although a woman looks towards her spouse to avoid maltreating her, her compromising and passive nature contrasted with her spouse’s superior, influential, masculine, and dominant nature prevents her from refusing him the pleasure of unprotected sex because doing so would go against his ego, thus labelling the assertive woman as shameless. This causes a woman to lose control of her body and hence prevents her from negotiating and communicating her wishes regarding FP decisions to her husband and in-laws, thus creating gender disparity in our society. Moreover, girls getting married at an early age are not mature enough which makes them suppressed and dependent on others so that by the time they gain maturity, decision making on FP matters is heavily influenced by others in the family. Female participants shared that being financially dependent on husbands suppresses their decision making, that a woman is discriminated against and also has fewer reproductive rights with more roles and responsibilities to perform, such as fulfilling household chores even during pregnancy and in the post-partum period without receiving any recognition for it. A 40-year-old female participant stated:
"A wife is not a machine who will keep on producing children. He (husband) does not allow me to use FP methods. If he (husband) has his way, then I would be pregnant right now. But, it is me who tries to be cautious." (Female participant with six para, from lower middle SES 12)
The participant shared that the blame of side effects of FP methods, baby’s gender, unplanned pregnancy, and infertility, is mostly passed on to a woman who alone is held accountable. However, some participants mentioned that some husbands, who care for their wives, allow them to use FP methods. While educated participants from the upper middle SES emphasized that girls are not given their rights since childhood, young educated men mentioned that men can compromise on their pleasure and use condoms to care for their wives’ health. Some educated male participants also hinted at upcoming egalitarian gender dynamics by sharing that in some communities, modern gender roles can be observed. Both male and female participants verbalized that due to gender inequality regarding FP decisions, women have experienced not only verbal, but also physical, emotional, sexual, and psychological violence.
"I asked her to have medicine as I forgot to get condoms for intercourse. She refused and we had an argument. Thus, I got short tempered and slapped her; then we slept apart." (Male uneducated participant 06)
While male participants mentioned that they execute their anger and frustration on someone less powerful, like children and women in the family, females mentioned that having an extramarital affair with other women has been a usual way to taunt, blame, and abuse a woman. Females shared that in an eastern society, women accused of ruining the harmony in a family are divorced and so they, being concerned about a disturbed family’s impact on the academic performance and mental health of their children, do not speak up for their rights.
"She has to agree with it (husband's decisions on FP) whether it is right or not. I believe that if a woman disobeys her husband, she will be at a loss. If she will not agree, the husband will fulfil his desires through other means. The benefit is of the husband and the loss is of the wife. She is at loss if she does not follow the husband's decision and does not obey him. I think that if a person is not getting anything at home he will get that from outside. For example, if I want to have a burger and it is not cooked at home; definitely I will go outside to have it." (Uneducated male participant 05 from lower middle SES)
Moreover, an example of lack of awareness leading to misuse/overuse of FP methods was that the husband of a young female participant pressurized her for hysterectomy in her reproductive age to prevent her from remarrying in case of any uncertainty. Afterwards, she became aware that hysterectomy is a permanent procedure and her husband began to use emotional violence by threatening her with divorce if she did not follow his orders. Lastly, while female participants verbalized that women are human and thus should be treated in a humane manner, one of the male participants interestingly mentioned that females can also be violent towards their husbands. Apparently, some couples do take mutual decisions on FP matters, but the common finding of this study was that women are bound to agree to men's decision, regardless of their willingness and knowledge about FP.
Category 5: Way Forward
Most participants mentioned that empowering women through education and financial liberty can facilitate in solving problems of gender discrimination. This can give equal reproductive rights to both genders. "Being educated makes women in a position to stand for themselves." (Educated male participant 03) Educated young male participants emphasized the pronounced role of the print and electronic media while educated women pointed out the critical role of parents in raising children to create a society where gender equality is respected. Along with that, the role of NGOs, government, community awareness lectures, and telephonic assistance, were also highlighted to encourage people to avail FP services.