|Year : 2014 | Volume
| Issue : 2 | Page : 139-146
Effect of conditional cash transfer on choice and utilization of contraceptives among newly married couples in Satara district
Asha K Pratinidhi1, Swapnil V Lale2
1 Director of Research, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra, India
2 Additional District Health Officer, Zilla Parishad, Satara, Maharashtra, India
|Date of Web Publication||4-Feb-2014|
Swapnil V Lale
A-4, Chintamani Vaibhav Apartment, Near Sanjeevan Hospital, Sadar bazzar, Satara - 415 002, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Satara district of western Maharashtra is in late expanding phase of demographic cycle. Postponement of first pregnancy with the use of reversible contraceptives is the need of the hour. Since 2007, Satara district is implementing a conditional cash transfer scheme second honeymoon package (SHP). Objectives: The objectives of this study are: (1) To find out the effect of conditional cash transfer on choice and utilization of contraceptives among participants of SHP. (2) To identify various barriers to the use of contraceptives. Materials and Methods: This was an evaluation study of a community based interventional program. Cases were the participants of SHP program while the controls were the couples residing in the same village as that of participants and married in the same year. Enquiries were made about their knowledge of contraceptives, reasons of postponement, choice of contraceptives, problems faced while using them, perceived benefits of participation, reasons for non-participation and non-use of contraceptives, etc. Results: This study has found out that 24.8% controls and 57.6% participant couples were having knowledge of contraception before their marriage. Amongst the participants of the scheme and controls, male condom was the most popular method used by 80.8% participants, followed by oral pills by 9.22% couples. Contraception prevalence rate among control couples was 17.6%, while that in participants was 91.8%. Resistance from family members, side-effects and failure of contraceptives were some of the barriers to their use. Conclusions: Conditional cash transfer has encouraged the use of contraceptives in acceptors of SHP. By participating in SHP and postponing first pregnancy 15.8% could complete their education, job/career betterment achieved by 16.4% and 19.3% adored marital pleasure.
Keywords: Conditional cash transfer, contraception, postponement of pregnancy
|How to cite this article:|
Pratinidhi AK, Lale SV. Effect of conditional cash transfer on choice and utilization of contraceptives among newly married couples in Satara district. Med J DY Patil Univ 2014;7:139-46
|How to cite this URL:|
Pratinidhi AK, Lale SV. Effect of conditional cash transfer on choice and utilization of contraceptives among newly married couples in Satara district. Med J DY Patil Univ [serial online] 2014 [cited 2019 Jul 23];7:139-46. Available from: http://www.mjdrdypu.org/text.asp?2014/7/2/139/126318
| Introduction|| |
Satara district of western Maharashtra is in late expanding phase of demographic cycle.  Postponement of first pregnancy with the use of reversible contraceptives is the need of the hour. Since 2007, Satara district is implementing a voluntary conditional cash transfer scheme second honeymoon package (SHP) with a corpus of Rs. 60 million from the National Rural Health Mission. If couples who had married after April 2007 and registered themselves with the zilla parishad and postponed having children for 2 years, they are promised an incentive of Rs. 5000. Couples who opted to wait a 3 rd year would earn Rs. 7500. SHP has been designed for postponement of pregnancy among newly married couples within few months of their marriage. By the time the couple is enrolled for the benefit of postponement of first pregnancy, their first honeymoon is already over. Their second honeymoon would commence after the desired period of postponement of first pregnancy. Hence the name SHP is given to the scheme. This paper examines the choice and utilization of contraceptives among participants of SHP and their controls in Satara district.
| Objectives|| |
- To find out the effect of conditional cash transfer on choice and utilization of contraceptives among participants of SHP scheme by comparing with their controls.
- To identify various barriers to the use of contraceptives.
- To find out various reasons for non-use of contraceptives.
- To get feedback about SHP from the participants.
| Materials and Methods|| |
Institutional ethics committee has given clearance vide its letter dated 12 th October 2010. This was an evaluation study of a community based interventional program. Cases were the participants of SHP program while the controls were the couples residing in the same village as that of participants and married in the same season or year. Participants were selected by stratified random sampling. The strata being considered is Taluka (smaller administrative unit of the district). In the state of Maharashtra, there are 33 districts. In Satara district, there are 11 Talukas. Sample size was calculated using the formula N = 4σ2 (Zcrit+Zpwr) 2 /D 2 . The minimum required sample size was 1,157 participants and the same number of controls. Considering the population of various Talukas in 2001 census, proportionate weightage was given to the acceptors and non-acceptors from each Taluka. Considering 10 to 15% possible drop outs and Taluka wise population, adequate sample size was selected. The controls were taken from the same area as that of acceptors, married in the same year irrespective of their age, literacy; socio-economic status etc. The aim of the study was to find out the profile of acceptors and non-acceptors. Matching of all the characteristics determining the decision making of accepting SHP would have masked the characteristics responsible for decision making. Pre-tested semi open data collection schedule was filled up by duly trained auxiliary nurse midwife (ANM) and multipurpose male health workers (MPW). ANM and MPW were required to visit each house as a pair. MPW interviewed husbands and ANM interviewed the wives preferably in separate rooms. Enquiries were made about their knowledge of contraceptives, reasons of postponement, choice of contraceptives, problems faced while using them, perceived benefits of participation, reasons for non-participation and non-use of contraceptives etc., Data collection was performed during November 2010 to June 2012 period. Statistical analysis was performed using STATA; (StataCorp LP, 4905 Lakeway Drive, College Station, Texas 77845-4512, USA) version 12 statistical software.
| Results|| |
After the announcement of SHP scheme and getting information of the scheme; a total of 5589 couples opted for the scheme. Out of 1355 participant couples selected for this study; all women and 1303 men could be contacted. Out of 1350 control couples 1267 men could be contacted while all women were interviewed. Females were more accessible than males. All females could be contacted whereas 52 male participants (3.8%) and 83 male controls (6.8%) could not be contacted in spite of repeated attempts. Most were out of station due to job related reasons, some had moved away due to marital discords, etc. In this paper, an effort is made to assess prior knowledge of acceptors of SHP and their controls regarding contraceptives before their marriage.
[Table 1] shows the age wise and literacy wise distribution of knowledge about contraceptives before marriage. Female controls in less than 20 years age group had better knowledge of contraceptives before marriage as compared to female participants in the same age group. Male controls in less than 25 years age group were having better knowledge as compared with male participants in the same age group. Female participants in less than 7 years of schooling group and more than 12 years of schooling group had better knowledge than female controls in the same literacy range.
[Table 2] shows the use of contraceptives by participants and controls. 1244 (91.8%) participants of SHP were using modern methods of contraception against 237 (17.55%) controls using the same. Male condoms were the most commonly used contraceptives by participants (88.02%) and controls (76.37%) followed by oral pills by 10.05% participants and 10.55% controls.
[Table 3] shows various reasons for postponing child birth and reasons for participation in this scheme. Here only main reasons were included. When the main reason is taken they become mutually exclusive groups and Chi-square test can be applied. P value states that the reasons quoted by male and female partners were significantly different. Husband and wife are different individuals. They may be having different goals, aspirations, viewpoints, motives, perceptions, understanding or physical problems. Same decision may be taken by different individuals for different reasons. Most of the controls couples were undecided about postponing child birth and purposefully did not adopt any family planning method. Hence they were not compared with the study group in relation to reasons for postponing of child birth. Two hundred fifty-three female participants and 229 male participants reserved their opinion/could not tell specific reasons for postponement. This response may be of either partner. Spouse has decided to postpone child birth, while respondent may be submissive.
[Table 4] shows the reasons for selection of male condom as a contraceptive. Participants seemed to be well-versed with various advantages and benefits of male condoms; such as ease of use, its convenience, time of action along with few other reasons. This might be the result of better counseling offered to acceptors of SHP.
[Table 5] shows the reasons why some users have chosen oral pills as a method of contraception. There was no difference in the reasons given for choosing oral pills by the participants and controls (P = 0.43, NS).
[Table 6] shows the problems faced while using contraception. Majority of the users did not face any difficulties. Significantly more number of controls (both male and female) reported domestic problems when compared with male and female participants. Failure and side-effects of contraceptives were reported predominantly by participants when compared with their controls.
[Table 7] shows the opinion of parents/in laws regarding participation in the SHP scheme. Majority experienced support or neutral attitude by the elders. Significantly more number of female participants got support from parents/in-laws when compared with male participants. Significantly more number of male participants faced resistance or mixed response from the elders.
|Table 7: Opinion of parents/in-laws regarding postponement of first pregnancy|
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[Figure 1] shows the perceived benefits of participation in the SHP scheme. Majority experienced marital pleasure, educational and job betterment and improvement in wealth.
|Figure 1: Perceived benefits of participation in second honeymoon package|
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[Table 8] shows various reasons why controls have not participated in SHP. Resistance from parents/in-laws was the predominant reason for non-participation; followed by "want of child." Lack of information was quoted by 366 females and 245 males. This made it evident that the program failed to reach up to one forth eligible couple. Nine could not participate because their age was less than required by the program. This package was only available to those couples where wife was more than 18 years and husband more than 21 years of age at the time of marriage (i.e., legal age of marriage).
[Table 9] enumerates various reasons why newly married couples in the control group did not use contraceptives. Want of a child was a predominant reason quoted by 297 female and 311 male controls. Felt the need of contraceptives differed between female and male controls.
| Discussion|| |
This study has found out that 24.8% controls and 57.6% participant couples are having knowledge of contraception before their marriage. Participants and controls were newly married couples. Controls were selected without matching for age, income, education etc., to find out which factors influence participation in SHP. More educated, rich women participated in SHP. Those who were ignorant about contraception were also illiterate and prefer not to opt for incentives under SHP. This study was conducted 3 years after the introduction of SHP. We wanted to know the profile of participants and we have found out the practice of contraceptive use as the end point of the study. Similarly, various studies have reported that 55.2% to 75.7% couples knew at least one method of contraception. ,,, Balaiah et al. observed that the majority of tribal men not only have had no concept of family spacing, but have not even taken any initiative to improve their knowledge or acceptance of condom. Men who are aware of contraceptive methods have had little knowledge of their correct use.  Mohsin note that though 82.2% women have been aware of the existence of a contraceptive method, only 44.2% have ever used one. , Nguyen et al. found that condoms and pills have been known by almost all young people. However, their knowledge of condoms and pills has been inadequate.  Olaseha et al. found that 45% had fair, 34.5% poor and 22.5% good knowledge of contraceptives. A large majority (70%) have had never used any contraceptives.  These findings agree with those in the present study.
Amongst the participants of the scheme and controls, condom was the most popular method. 80.81% participants used it, followed by oral pills by 9.22% couples. Various studies across geographies have found that most commonly used contraceptive was condom (34.5% to 54%). ,,,,,, These findings agree with those in the present study. Joesoef et al. note that the levels of contraceptive use varied among cities, ranging from 34.2% to 56.5%.  Piccinino found that female sterilization, the pill and male condom to be the most widely used methods in USA in 1995. This observation differs from that in the present study. This may be because their study was not confined to newly married couples. 
The use of contraceptives would have been theoretically similar to the proportion seen in the control group. As the acceptors were enrolled immediately after marriage, the use of contraceptives before accepting SHP could not be ascertained. Special efforts were taken on the acceptors by the health workers on counseling of use of contraceptives, which was part of the SHP and is not performed routinely in the services rendered to the population at large. Hence the higher proportion of use of contraceptives could be attributed to the services given under SHP. The incentive money is promised after enrolment as acceptor, but is disbursed only after the lapse of pregnancy free period of 2-3 years as per desire of the couples (Rs. 5000/- for 2 years of postponement and Rs. 7500/- for 3 years of postponement). Similar to present study, which provides monetary incentives to promote the use of contraceptives; Sharma et al. note that the methods accepted by the tribals of Rajasthan appear to be those that have some monetary incentive attached to them. 
In the present study, 28 participants quoted the problems with other contraceptives as a reason of selecting condoms. Similarly, Frost note that use of a method chosen mostly out of dislike of other methods is positively associated with condom use.  This study employed an open ended questionnaire, where the perceptions and opinions of the participants were found out for use of particular contraceptive. (1) When there are more family members, there is no privacy to use contraceptives like male condoms. Consumption of oral pills in such condition is more acceptable. More family members were perceived by the users of oral pills as a problem in use of other contraceptives which require privacy. In a joint family there are many family members around. Use of oral pills does not need such privacy as is required for disposal of condoms. (2) Population control by use of oral pills was considered appropriate method in the opinion of some of the participants. (3) Advertisement on television (TV) - Some women were motivated by advertisement on TV and hence written advertisement on TV as a reason for choosing oral pills. Barber et al. demonstrate that exposure to the mass media is related to child bearing behavior and to the preference for smaller families, weaker son preferences and tolerance of contraceptive use.  Frost et al. in United States note that use of oral pills is mostly due to its selective preference and not due to dislike of other methods. 
The present study has identified various barriers to the use of contraception. Similarly, many studies have reported that lack of agreement between partners; want of a male baby, husband's (decision maker's) attitude, undesirable side effects, wife's education, inadequate knowledge of contraceptives, negative traditional practices, unavailability of contraceptive supplies and opposition from family members as barriers to the use of contraceptives. ,,,,,,,, These findings agree with those in the present study. Catherine studied why pregnant adolescents say they have not used contraceptives prior to conception. The most frequent cited reasons have been "I don't mind getting pregnant (20%) and I want to get pregnant (17.5%)." This observation agrees to that of the present study.  Dennis note that barriers to contraceptive access encourage non-use and gaps in use, which contribute to the high prevalence of unintended pregnancies in the United States.  These findings differ from those in the present study. This may be because of the health system in US is operated by health insurance industry, while that in India is admix of private and public enterprise and a role of health insurance is limited.
In the present study, 19% of participants have experienced marital pleasure and got time for preparing oneself mentally for the parenthood. This would help to improve mutual understanding and reduce marital discord. Nearly, 16% participants reported educational betterment. Female education is known to be associated with various factors such as total fertility rate, infant mortality rate, maternal morbidity rate etc., 2% participants have been able to avoid teenage pregnancies. Due to health improvement of prospective mothers birth-weight of babies may improve, this may reduce infant mortality rate. Many couples apart from above mentioned benefits weighed prize money as an important benefit for ensuring betterment and future of their would be born child. Improvement in economic status will perpetuate by means of the diffusion process. However, after having opted for postponement for 2 years; 482 participants did not follow use of contraceptives and had their first child before the stipulated period of 2-3 years. These couples have not attached much expectation to the program and got frustrated due to typical government employee attitude and demanding too much paperwork and submission of documents at the time of enrolling the couples. It may also be related to their socio-cultural miliu in which in-laws and other relatives expect birth of a baby within a couple of years of their marriage. Perceived benefits of postponement of first child all over the world appear to be related to similar considerations as in the present study apart from some differences related to the socio-cultural factors such as gender, equity and housing conditions. ,,,
Guttmacher institute has observed that on average, 85% of women gave only one reason for non-use and the average number of reasons per respondent was just 1.1. This finding agrees with that in the present study. They have further stated that more than a third of women in South East Asia were not using contraceptives because they do not believe they were at risk of getting pregnant. Although 11-12% women have cited opposition to family planning methods. 
In the present study, contraception prevalence rate among control couples was 17.6%, while that in participants was 91.8%. This study was confined to newly married couples. It is observed that social and religious norms support demonstration of fertility soon after marriage. Motherhood may be one of the few ways in which a young married woman can affirm her value and identity to herself and her community.  Family planners may be influenced by social norms and not target or serve young married couples.  Studies in the middle East have found that societal attitudes determine that newlyweds should not approach any form of family planning until they have at least one child, which may deter providers from serving them. Moreover, family planning programs are not influencing men, who may control fertility decisions, especially in couples where the wife is an adolescent.  Individuals may not want to use contraceptives until a desired level of fertility is achieved. For example, a study in India has found that family planning methods are often first used after two sons are born.  Chandhick et al. reported overall contraceptive prevalence of 45.2%. They have found that there has not been any concept of using family planning method for either postponing the first conception after marriage or spacing between the two child births. A large majority of women (70.5%) have used a family planning method for the first time only after completing their desired family size.  Ajayi et al. noted that a majority of adolescents appear to have received information on reproductive health, but the quality of information is low. Nearly, 89% have never used contraceptives. Many contradictions between attitudes and practices pose serious questions.  As compared with these studies contraception prevalence rate of participants of SHP is undoubtedly more. Conditional cash transfer offered under SHP in Satara has helped to increase the contraception prevalence rate among newly married couples.
| Conclusions|| |
This study has found out that 24.8% controls and 57.6% participant couples are having knowledge of contraception before their marriage. 1244 (91.8%) participants of SHP were using modern methods of contraception against 237 (17.55%) controls using the same (P < 0.0001). 314 female participants opted to delay the child birth to complete their education. 119 female participants postponed because the age is less. A total of 95 male participants did not want child early because of job or carrier opportunities. A total of 94 male participants participated for the prize money. Amongst the participants of the scheme and controls, condom was the most popular method, 1095 participants of SHP (88.02%) used it. Followed by oral pills (10.05%) couples, Safe period method was employed by 15-51 couples. Participants seemed to be well-versed with various advantages and benefits of condoms. Majority of contraceptive users experienced support or neutral attitude by the elders. Female and male participants received different treatment from parents and in-laws (P < 0.0001). Side-effects and failure of contraceptives were some of the barriers to their use. Control couples were not using contraceptives because of want of child (23.2%), absence of perceived need (5.5%), resistance from family members (4%), side-effects of contraceptives (1.2%) and refusal by spouse (0.46%).
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]