The mean age among the women in the quantitative part of the study was 25.3 years (SD 4.5). Eighty-five percent had some level of secondary or university education and one in ten was single at the time of data collection. Almost half (47.2%) described themselves as housewives and 26.4% were currently pregnant. Eight in ten reported that their last partner had some level of secondary or university education. Most of the participants (46 %) defined themselves as Catholics (Table 2).
Reproductive coercion prevalence
Ever RC prevalence was 17.4% (95% CI, 13.8-21.6) with similar proportions reporting ever experiencing PP (12.6%, 95% CI 9.4-16.3) or ever experiencing CS (11.8%, 95% CI 8.7-15.4). The prevalence of last twelve months RC was slightly lower (12.3%, 95% CI, 9.2-16.0) than above. Twelve months PP (7.4%, 95% CI 5.0-10.5) and CS (8.7%, 95% CI 6.1-12.0) were also similar.
The three most common ever RC behaviors experienced by women were threatening to leave partner if not pregnant (6.5%), forcing sex without a condom (6.2%), and removing condoms during sex (6%). Threatening to leave partner if not pregnant (6.4%), refusing to provide money for BC (4.4%), and removing condoms during sex (3.8%) were the three most common RC exposures in the last 12 months (Fig.1).
How was RC enacted?
The RC exercised by partners in the studied setting was seen to have different aims; to make the woman pregnant, but also to mainly control how or what kind of birth control to use. Our qualitative data allowed us to identify the pervasive and the subtle pathways by which RC behaviors were enacted. We found examples of contraceptive sabotage, pregnancy promotion, rape, forced sexual relations, humiliation and shaming, contraceptive refusal, threats of contraceptive sabotage, using better knowledge about contraceptives for manipulation and claiming that control is an expression of care, in the studied setting. For example, men’s PP acts, such as pressuring a woman to get pregnant, were continuous and persistent with a complete disregard of women’s motives to avoid a pregnancy.
When I finally got pregnant it was because of him, he told me ‘no’ he told me ‘you have to have a child, I want you to have a child, you have to have a child’ he nagged and nagged until I gave after. (Informant nr 6)
One of the subtle ways by which men exerted RC was framing it as a way of caring for their partners. This was expressed by men manipulating or withholding information on contraception to impose their own contraceptive choice to their partner’s. In one case, RC was not about imposing pregnancy, but by denying women’s agency to choose the contraceptive method to be used. Another manipulative tactic used by men to undermine women’s contraceptive self-efficacy was to question the woman’s ability to know whether she wanted a pregnancy or not.
Interviewer: In the beginning, when the two of you started to have a life together when you decided to live together, did you talk about family planning?
Respondent: Yes, but he always told me ‘no’, and that a woman isn’t with a man to use birth control, it’s for having children, but I said ‘no’, or like, in the beginning I didn’t want children right away, I wanted to have them later because I wanted to know him better, but no, he didn’t want to [use contraceptives]. (Informant nr 3)
Our interviews also showed that PP behaviors overlapped with emotional IPV. Men shamed and humiliated their partners who used contraception accusing them of infidelity. This situation often arose when women suspected their partners’ own infidelity and demanded them to use condoms. Our informants described how, having unprotected sex under those conditions was shameful in itself and perceived as forced sex. They also described how disagreements about contraceptives could result in rape.
[…] one day he came home in the morning and I remember I was always taking my contraceptives, my injections and yes, what he did was that he grabbed all those things the pills and he broke my family planning card. Then, he broke my pills and he hit me, right? He hit me eh…and then the accusations started and well as he had me there as if I was kidnapped, so I could not leave, right? And yeah sometimes he took, how do I say? He took me by force, and I did not like that, I did not like that […] (Informant nr 1)
Overlapping RC types
Overlapping RC types were common within the quantitative data. Four in ten women ever exposed to any form of RC were exposed to both PP and CS (three in ten among those reporting 12 months exposure to RC) (Fig. 2).
Our qualitative data also showed that women exposed to both PP and CS were the ones who were exposed to the most severe and explicit RC behaviors. In their narratives, PP was discussed more often than CS as well as the continuously nature of PP behaviors. For example, behaviors such as nagging the woman about having children, objecting when the woman was going to get her hormonal injection, or questioning that the woman should need any protection were discussed often. On the other hand, CS was described as happening occasionally. One of the informants told about how she repeatedly asked her partner if he had seen the card that she needed in order to get her free birth control at the HCC, he accused the children. When she found the card, tore apart and confronted him, he admitted that he took it and broke it and told her that she “couldn’t decide by herself”. Her partner kept obstructing her intent to use birth control alongside his different PP acts.
What factors were associated with RC?
Our multivariable quantitative analysis showed that after adjusting for possible confounders, women’s higher education was a protective factor against ever and 12 months of exposure to any RC behaviors by a current or former partner (Table 3). In addition, it was a protective factor against exposure to any CS in the twelve months before the survey. No other variables were significantly associated with ever RC, ever PP, 12 months RC, 12 months PP, or 12 months CS (Table 3).
Women’s working status and their last partners’ education and working status were significantly associated with ever CS. Specifically, women whose last partner had university education had a 66% lower prevalence of ever CS than women whose partner had no education (APRR 0.34, 95% CI 0.11-0.99, Table 3). In addition, compared to women whose last partner was unemployed, women whose last partner was employed had a 51% lower prevalence of ever RC (APRR 0.49, 95% CI 0.27-0.88, Table 3). Finally, compared to women who were housewives, women who were studying had an 87% lower prevalence of ever CS (APRR 0.13, 95% CI 0.20-0.77).
Women try to cope, but rarely succeed
Our qualitative data showed that women use different strategies to cope with RC and that they do so continuously, although they rarely succeed to keep control over their reproduction over a longer time span. The coping strategies implemented depended on the type of RC and how the woman perceived it or how her partner framed it. It was also closely related to feelings as shame, fear, anger, and disappointment. We saw a broad spectrum of coping strategies in our data; acceptance, rationalization, laughter, resistance, sterilization, planning for adoption, threatening the partner, hiding contraceptives, relying on God, buying Hormonal Emergency Contraceptives (HEC), verbally objecting to RC, claiming to be in control and trying to control the partner.
Women coped with RC in different timely relation to the coercive act and those who had no way of coping at the time of the exposure, coped during the interview. If the RC was framed as an act of care, the women did not cope at the time of exposure. During the interview, the coercive acts, framed and understood as care, were explained with acceptance, rationalization, and humor. One interviewee laughed a lot during the interview, she openly discussed her relation and emphasized how her husband took care of her, for example when they started having sexual relations. She explained how he took care of her by finishing outside of her, so she did not need to use hormones. They never talked about condoms at the time.
Interviewer: Ok, so initially you did not use any kind of protection, did you?
I: And how did you talk about having sexual relations like that, with that method?
R: With that method? He took care of me. I did not know anything about sexuality, nothing, my mother never talked to me about sexuality or that I would have my period, it was scary. Imagine that I was fifteen when I got my period and nothing only the people in the street told me […] (Informant nr 5)
Some informants explained how their partners “cared” for them were rather framed as rational since the women often lacked basic knowledge about reproduction and birth control while the men had that knowledge.
[…] he went to the pharmacy and bought it because first, he told me “condoms”, but I told him “no with that you will hurt me” I did not know anything about that, I was a virgin and all, so he came back with a small box and told me “you will get injected”. I got so nervous that I fainted because I didn’t know what he would give me, until afterward, he knew more than me, then when he came he told me it was a one-month injection to not get pregnant. Then they had already, they gave it to me when I was unconscious [laughing] I did not even notice it… (Informant nr 2)
The informant nr2 stated that she got upset, that she felt betrayed by her partner and that she would have preferred if he had discussed birth control with her first. But, then she continued by explaining that she understood that he did what he did to protect both of them and laughed about the fact that he had that kind of knowledge while she did not.
Equality and mutual decision making within the relationship was seen to be an ideal within the study population and had an impact on the coping strategies that women used during the interviews. Some interviewees claimed to be in control of their reproduction although the RC was part of their narrative. For instance, one informant stop using oral contraceptives and became pregnant after her partner demanded not to use them.
Interviewer (I): So, if you would have decided, at what age would you have had your first child?
Respondent (R): I was deciding.
R: Because first I was looking after myself [by using contraceptives] and then I decided at what age I would have it [the child], or like, at the time I decided, “it’s fine, let’s have [a child]”
(Informant nr 6)
Not being able to control one’s reproduction and sharing stories of being pregnant although not really wanting it, created shame among the women. Some informants would make statements as “all children are a gift from God” or “it’s God’s decision if there is a child”. This further strengthens the interpretation that RC creates shame, and thus it could be easier to “blame” God instead of the person that one lives with.
The qualitative material shows that women are under a lot of pressure due to the lack of control that they impose over their reproduction. Planning to put an unborn and unwanted child for adoption, getting sterilized or a woman scaring her partner that she would abort the child if he made her pregnant against her will, are the more radical coping strategies used by the women exposed to RC in the studied setting.
Some informants knew that they would not be able to negotiate condom use with their partner, instead, they would make sure to have HEC at home to use after the sexual act. Thus, they coped before and after the sexual act but did not cope during the interview.