Bring a friend: Leveraging financial and peer support to improve women’s reproductive agency

In the second of two articles about women’s fertility and family planning, S Anukriti et al. highlight findings which reveal that women are more likely to avail of family planning services if they are accompanied by one of their peers to the clinic. They suggest that peer support could also reduce social isolation, enable greater mobility, and overcome the resistance from mothers-in-law and other family members, with the findings of this intervention having broader implications for women’s empowerment.

Reproductive agency is a cornerstone of women's wellbeing, significantly impacting their health, education, and career prospects. However, despite its importance, many women worldwide still lack the autonomy to decide and control their contraceptive use, pregnancy, and childbearing. Globally, an estimated 270 million women of reproductive age (ages 15-49) have an unmet need for family planning, that is, they want to space or limit pregnancy, but are not using a contraceptive method.

In a recent paper (Anukriti et al. 2022), we examine women’s reproductive agency in rural India, a setting where women face a number of barriers to accessing health care, including limited physical mobility, low personal autonomy, and opposition to contraceptive use from household members such as mothers-in-law. These constraints in turn contribute to low utilisation of reproductive health services and minimal social engagement related to accessing family planning. We find that making family planning services more affordable for women, combined with encouragement to engage with their female peers for support, can empower women to seek reproductive health care and use modern contraception if they so desire.

The study

We conducted a randomised controlled trial with a sample of 671 married women aged 18-30 in Jaunpur district of India’s most populous state, Uttar Pradesh. Following a baseline survey in 2018, women in our study were randomly assigned to either a control group or a voucher group. Women in the voucher group were offered a voucher package for subsidised family planning services at a local clinic for their own personal use, including reimbursements for transportation to the clinic, for a ten-month period. In addition, a subset of voucher recipients – the “Bring-a-Friend” group – could offer the same voucher package to peers of their choice, if these peers accompanied them to the clinic at least once. In this way, women in this subgroup were further enabled to leverage peer support for healthcare seeking.

Findings

We found that vouchers, especially when combined with vouchers for a friend, increased reproductive healthcare-seeking behaviour among women whose mothers-in-law are opposed to family planning. Compared to women in the control group, voucher recipients were 68-86% more likely to have visited a clinic for family planning services in the last ten months and were 44-49% more likely to be using modern contraception at the time of the endline survey.

However, for women who perceived their mothers-in-law to be opposed to their modern contraceptive use at baseline, receiving a voucher only for one’s own use was ineffective – it is only when we combined a voucher for a woman’s own use with a voucher that encouraged a woman’s peers to participate, that we observed improvements in family planning outcomes. This finding suggests that peer support can enable women to seek family planning services by overcoming potential resistance from their mothers-in-law. Voucher recipients did not receive any backlash from their family members, even when their husbands or mothers-in-law were opposed to family planning.

The importance of peer support

Enabling women to jointly seek family planning services reduced their social isolation. At the baseline, women in our study area had only interacted with a few individuals besides their husbands and mothers-in-law about issues related to family planning and reproductive health. By enabling women to invite others to and subsequently visit the clinic with them, our Bring-a-Friend intervention made women less socially isolated. Women in the Bring-a-Friend group were more likely than other sample women to have female peers from outside their household with whom they discussed family planning-related issues. In addition, they were more likely to have at least one peer from outside their household who accompanied them to a health facility and advised them to use family planning. Consequently, women also experienced a reduction in their fear regarding the stigma of family planning use.

Our study provides valuable insights into how we can improve women's reproductive agency and social interactions when they lack freedom of movement. Commonly used policy tools that require women to “cross the boundary”, such as vouchers for family planning services whose utilisation is contingent on women travelling outside their homes, may not work when women cannot access public spaces alone and are socially isolated. Therefore, in addition to making family planning services affordable, it is crucial to enable women to form connections and leverage the support of these connections to overcome physical and social mobility barriers.

Conclusion

Well-intended interventions that exclusively target women may be ineffective in settings where other household members, such as women’s mothers-in-law, play a key role in decision-making. Policies and programmes, therefore, need to consider how to effectively engage mothers-in-law, and potentially other household members who hold significant decision-making power, to improve women’s welfare, especially if preferences and incentives between women and these household members are misaligned.

Our results also extend beyond the Indian and South Asian settings to other contexts where women face similar socioeconomic and mobility barriers. The relevance of our findings also extends beyond family planning and reproductive autonomy to domains such as female education and labour force participation, where women’s inability to access public spaces, combined with restrictions imposed by their family members, are key barriers to utilisation, and where peer support can make a substantive difference.

The first article on the effect that mothers-in-law have on accessing family planning services ('Convincing the Mummy-ji: Improving mother-in-law approval of family planning in India') can be read here.