Gender Norms, Contraceptive Use, and Intimate Partner Violence: A Six-country Analysis

"Gender inequality is complex, multidimensional, and evolving, and thus requires multiple, multi-level interventions to effect positive change."

What evidence, if any, is there that specific gender norms are associated with both contraceptive use and reduced intimate partner violence (IPV) experience? To address this question, the researchers selected a diverse group of countries in terms of population size, geographical location, and culture to test whether the associations between gender attitudes and the outcomes of interest were similar or different in these contexts. The goal of this analysis was to inform social and behaviour change (SBC) programmes designed to enhance contraceptive use, reduce IPV, and expand gender equity.

The study draws upon Connell's theory of gender and power, a sociological theory that addresses structural factors that affect gender dynamics and has been applied to studies in multiple low- and middle-income countries. This theory posits that gender is inherently relational, not individual. According to this theory, women are socialised to: rely on men for economic support as part of the broader gendered, unequal division of labour; acquiesce to men's sexual demands and other expressions of power; and tolerate - even justify - emotionally fraught partnerships ("cathexis") that result in negative outcomes, including with respect to health. This study explores couples’ decision-making and women's self-reported experience of IPV as proxies for unequal power, and women's and men's justification for violence as a proxy for emotional attachment within the couple (cathexis).

The study relies on analysis of Demographic and Health Survey (DHS) couples' datasets from Mali, Nigeria, Nepal, Pakistan, Tanzania, and Zambia that were collected in/after 2015 and include the DHS Domestic Violence Module for female respondents. To examine the associations between couple concordance regarding household decision-making or justification of violence (wife beating) and women's use of modern contraceptives or experience of violence, bivariate and multivariate logistic regression models were fit using Stata15.

Selected key findings:

• Joint decision-making about large household purchases was significantly positively associated with modern contraceptive use in all study countries, as well as with reduced odds of IPV experience in adjusted models in Tanzania and Zambia. For instance, couples in which at least one person said that major household purchases were made jointly had between a 1.17 and a 2.02 times increased odds of women reporting current use of a modern contraceptive method.
• In Nigeria, women's justification for violence was negatively associated with contraceptive use.
• Compared to couples where neither partner said that violence was justified, couples where both partners reported violence to be justified in at least one instance had between 1.49 and 2.97 times increased odds of the woman experience violence compared to couples where neither partner said that violence was justified.
• Wealth and educational attainment were broadly associated with increased odds of contraceptive use and, in Nigeria and Pakistan, with decreased odds of IPV experience.
• Husband's alcohol consumption, positively associated with contraceptive use in Nepal and Nigeria, was a major risk factor for IPV experience across countries included in this study.

These findings point to the protective role of dyadic cooperation in decision-making, reflecting some degree of power sharing. Compassionate, trusting dyadic relationships, as posited in Connell's notion of cathexis, are protective with respect to IPV. However, the quantitative investigation shared here is incomplete, say the researchers, without phenomenological inquiry designed to understand action from the perspective of the actors themselves.

In proposing areas for future research directions, the researchers suggest, for example, that adding and validating new measures of gender norms, decision-making variables, and power differentials to broadly applied tools such as the DHS could contribute to both the scholarship and practice of SBC. For cross-national studies, gender norms should not be limited to individual-level normative beliefs but also be measured by asking respondents about their beliefs regarding what others in their community do (descriptive norms) and about what they think others in their community would approve (injunctive norms) regarding how men and women do or should act.

Thus, the evidence suggests that:

• Family planning programmes should support joint decision-making, as it was positively associated with contraceptive use across the six countries and is a proxy for shared economic power within the household.
• IPV reduction and prevention programmes should also consider encouraging joint decision-making, and programmes should enable participants to interrogate attitudes regarding justifying violence against female partners and propose approaches to avoid IPV.
• Approaches to address men's alcohol use should be context specific and should be tackled intentionally, if cautiously, while planning for potential unintended consequences.