Picture of provider at urban clinic in Nairobi, Kenya counseling a patient on ARCHES. ARCHES includes education on strategies some women employ to covertly use contraceptive methods without partner interference.
Jasmine Uysal, Research Coordinator February 9, 2018
Globally, over 214 million in low-income countries who want to delay or
limit their pregnancies report not using an effective contraceptive
method.1 This unmet need contributes to poor reproductive health
outcomes for mother and child including high rates of maternal
mortality.2 Male partner objection to or interference with
contraceptive methods is one of the major barriers that women face to
successfully using contraceptive methods, and is prevalent in sub-Saharan
Africa.3-6 Reproductive coercion (RC) is the expression of
this opposition, and refers to a specific set of behaviors to control women's
fertility and contraceptive use. These behaviors include using force or threats
to pressure women to become pregnant against her will, and direct interference
with women's contraceptive use or ability to access contraceptive
While recent research has focused on the prevalence of reproductive
coercion and its connection to intimate partner violence (IPV), one area left
relatively unexplored is how women respond to these controlling behaviors and
attempt to maintain their reproductive autonomy.
Covert contraceptive use (CCU), the use of contraceptives without a male
partner's knowledge, is a strategy many women report utilizing when they do not
want to become pregnant but are not able to openly use contraceptives due to RC
and other coercion or restrictions from family or their community.11
One participant from a recent focus group in Nairobi, Kenya described why she
used contraceptives covertly:
"When I gave birth to my first child, it was via a
C-section. So when I told my husband that I needed time before having another
child, he would take nothing of that kind, so I was forced to get the family
planning method that I was using secretly."
- Family planning client,
Across the small number of studies assessing the prevalence of
CCU, estimates range from approximately 25% to 35% among clinic and
community-based samples of female contraceptive users.12-14 CCU may
be especially prominent in sub-Saharan Africa where acceptability of
contraceptives is still low especially for unmarried women, married and
unmarried adolescents, and nulliparous women. A recent study in Ghana among 300
women attending family planning clinics found that unmarried Muslim, and
traditionalist women were significantly more likely to report CCU than their
Preliminary results from a Center on Gender Equity and Health
(GEH) study among a representative sample of married adolescents and their
husbands (n = 1100 dyads) in rural Niger are consistent with these findings. GEH
has found that one in every three married adolescent contraceptive users reports
that they have done so without their husband's knowledge, with covert use
particularly common among adolescents who had not had children. Supporting the
hypothesis that women resort to CCU in contexts in which their partners attempt
to restrict and interfere with their contraceptives with their husband's
knowledge to report experiencing reproductive coercion.13
In Kenya, preliminary findings from another GEH study among
contraceptive users at community-based clinics in urban Nairobi indicate that 1
in 4 women reported ever using contraception covertly.14 Findings
from focus groups of women from these same clinics illustrate the strategies
some women use to use contraception without their male partners knowing so as to
maintain their reproductive autonomy. Here women, described going to clinics
when their partner was away, switching contraceptive methods to one that can be
better concealed from their partner (i.e. injection, IUD, implant), and
employing support networks of other women both access contraceptives and hide
them outside their homes. Women described using methods covertly and
successfully for several months to years.15
"I am even the one who keeps the pills for [my friend]
because she cannot keep the pills in her house, as she is not yet married. She
is seeing men [sexually active], but she doesn't want to get pregnant, so I have
advised her to use pills and condoms."
- Family planning client, Kenya
Covert contraceptive use is a prevalent yet understudied
phenomenon that represents an important form of women's resistance to male
partner opposition to and interference with pregnancy prevention, as well as a
promising strategy for intervention. Women who report having increased control
over their reproductive decision-making are more likely to use modern
contraceptives.16 Covert contraceptive use is a behavior that allows
women to maintain autonomy regarding their reproductive health and decisions,
even in the presence of barriers from partners, family or others attempting to
control if and when they will become pregnant. Further study of CCU should be
prioritized as one strategy to promote both gender equity and health.
GEH is currently developing and evaluating ARCHES (Addressing
Reproductive Coercion in HEalth Settings), a model that provides education and
empowerment to increase women's reproductive autonomy, including support of CCU
among women who are coping with reproductive coercion. Because women in
different cultural and geographic contexts may employ different education on CCU
strategies that women from their local communities report successfully
using.17,18 Currently, ARCHES is being adapted for the Kenyan and
Bangladeshi contexts by GEH's Jay Silverman and local implementing partners.
Results from evaluations of these adaptations of ARCHES will inform ongoing
efforts to support clinical providers to promote reproductive autonomy for
women, including use of CCU.
Guttmacher. Adding it up: Investing in Contraception and
Maternal and Newborn Health, 2017. Guttmacher Institute 2017.
Saiffuddin Ahmen QL, Li Liu, Amy Tsui. Maternal deaths averted
by contraceptive use: an analysis of 172 countries. The Lancet.
Izale K, Govender I, Fina JP, Tumbo J. Factors that influence
contraceptive use amongst women in Vanga health district, Democratic Republic of
Congo. African journal of primary health care & family medicine.
Muanda MF, Ndongo GP, Messina LJ, Bertrand JT. Barriers to
modern contraceptive use in rural areas in DRC. Culture, Health &
Ajah LO, Dim CC, Ezeqwui HU, Iyoke CA, Uqwu EO. Male partner
involvement in female contraceptive choices in Nigeria. Journal of
obstetrics and gynaecology: the journal of the Institute of Obstetrics and
Okigbo CC, McCarraher DR, Gwarzo U, Vance G, Chabikuli O. Unmet
need for contraception among clients of FP/HIV integrated services in Nigeria:
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Miller E, Silverman JG. Reproductive coercion and partner
violence: implications for clinical assessment of unintended pregnancy.
Expert review of obstetrics & gynecology. 2010;5(5):511-515.
Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence
against adolescent girls and associated substance use, unhealthy weight control,
sexual risk behavior, pregnancy, and suicidality. Jama.
Silverman JG, Raj A. Intimate Partner Violence and Reproductive
Coercion: Global Barriers to Women's Reproductive Control. PLoS Medicine.
Miller E, Jordan B, Levenson R, Silverman JG. Reproductive
Coercion: Connecting the Dots Between Partner Violence and Unintended Pregnancy.
Biddlecom AE, Fapohunda BM. Covert contraceptive use:
prevalence, motivations, and consequences. Studies in family planning.
Baiden F, Mensah GP, Akoto NO, Delvaux T, Appiah PC. Covert
contraceptive use among women attending a reproductive health clinic in a
municipality in Ghana. BMC Women's Health. 2016;16(1):31.
Niger evaluation on married adolescents The Center on Gender
Equity and Health; 2017.
Results from ARCHES Kenya baseline. 2018.
Silverman J, Boyce S, Challa S, Carter N. ARCHES: Reducing
Adolescent and Adult Unintended Pregnancy and Partner Violence in Kenya
Formative Research Report. San Diego, CA: The Center on Gender Equity and
Loll D, Bauermeister J, Ela E, et al. Reproductive autonomy and
contraceptive use among adolescent and young adult women in Ghana.
Miller E, Decker MR, McCauley HL, et al. A family planning
clinic partner violence intervention to reduce risk associated with reproductive
coercion. Contraception. 2011;83(3):274-280.
Tancredi DJ, Silverman JG, Decker MR. et al. Cluster randomized
controlled trial protocol: addressing reproductive coercion in health settings
(ARCHES). BMC Women's Health. 2015;15(1):57.