Examining the association between men's gender equitable attitudes and contraceptive outcomes in rural Maharashtra, India.

Background: Previous literature suggests that men reporting more gender-equitable attitudes are more likely to use condoms, but there is a paucity of data evaluating whether these attitudes are associated with contraceptive communication and use. The objective of this study is to test the hypothesis that men reporting more gender-equitable attitudes will be more likely to (a) engage in contraceptive communication with their wives and (b) that they and/or their wives will be more likely to use all forms of family planning, compared to men with less equitable attitudes. Methods: Using cross-sectional dyadic survey data from young married couples from rural Maharashtra, India (N = 989), we assessed the associations between men's gender role attitudes and a) spousal contraceptive communication and b) contraceptive use by type (none, traditional, condoms, pills, or IUD). The contraceptive use outcome is based on wives' report. We assessed these associations via bivariate t-test (communication outcome) or ANOVA test (contraceptive type outcome), as well as unadjusted and adjusted logistic (communication outcome) and multinomial logistic (contraceptive type outcome) regression models. Adjusted models included sociodemographic factors selected a priori based on established associations with gender-equitable attitudes and/or our assessed outcomes. Findings: Men with more gender-equitable attitudes were more likely to discuss family planning with their wives (AOR = 1·05, 95%CI 1·03-1·07, p < 0·001) and to use condoms (ARRR = 1·03, 95%CI 1·00-1·06, p = 0·07). There was no association between gender-equitable attitudes and use of other types of contraception. Interpretation: While gender-equitable attitudes among men may facilitate condom use and family planning communication in marriage, they do not appear to be linked with greater likelihood of use of more effective types of contraceptive use. This suggests that males supportive of gender equity may take greater responsibility for family planning vis a vis a less effective contraceptive, condoms, in the absence of more effective short-acting contraceptives for men. Funding: The National Institutes of Health [Grant number 5R01HD084453-01A1] and the Bill & Melinda Gates Foundation, Seattle, WA [grant number INV-002967].

Understanding feasibility and acceptability of implementation of linking delivery of family planning and infant vaccination care in rural Maharashtra, India: a qualitative study.

BACKGROUND: Linking family planning with infant vaccination care has the potential to increase contraceptive use among postpartum women in rural settings. We explored the multilevel factors that can facilitate or impede uptake of contraception at the time of infant vaccination among postpartum women and couples in rural Maharashtra, India. METHODS: We conducted 60 semi-structured interviews with key stakeholders including: postpartum married women (n = 20), husbands (n = 10), and mothers-in-law (n = 10) of postpartum women, frontline healthcare workers (auxiliary nurse midwives (ANMs) and Accredited Social Health Activists (ASHAs), (n = 10), and community leaders (physician medical officers and village panchayat leaders) (n = 10). We sought to assess the feasibility and acceptability of delivering community-based postpartum family planning care in rural India at the time of infant vaccination. The Consolidated Framework for Implementation Research (CFIR) was used to design a structured interview guide and codebook. Data were analyzed via directed content analysis. RESULTS: Three major themes emerged: (1) Social fertility and gender norms including son preference and male control over contraceptive decision-making influence postpartum contraceptive access and choice. (2) Linking contraceptive care and infant vaccination is perceived as potentially feasible and acceptable to implement by families, health workers, and community leaders. The intervention provides care to women and families in a convenient way where they are in their community. (3) Barriers and facilitators to linked infant postpartum contraception and infant vaccination were identified across the five CFIR domains. Key barriers included limited staff and space (inner setting), and contraceptive method targets for clinics and financial incentives for clinicians who provide specific methods (outer setting). Key facilitators included convenience of timing and location for families (intervention characteristics), the opportunity to engage husbands in decision-making when they attend infant vaccination visits (participant characteristics), and programmatic support from governmental and community leaders (process of implementation). CONCLUSIONS: Linked provision of family planning and infant vaccination care may be feasible and accessible in rural India utilizing strategies identified to reduce barriers and facilitate provision of care. A gender-transformative intervention that addresses gender and social norms has greater potential to impact reproductive autonomy and couples' contraceptive decision-making.

Validation of the Fertility Norms Scale and Association with Fertility Intention and Contraceptive Use in India.

Social norms related to fertility may be driving pregnancy desire, timing and contraceptive use, but measurement has lagged. We validated a 10-item injunctive Fertility Norms Scale (FNS) and examined its associations with family planning outcomes among 1021 women and 1020 men in India. FNS captured expectations around pronatalism, childbearing early in marriage and community pressure. We assessed reliability and construct validity through Cronbach's alpha and exploratory factor analysis (EFA) respectively, examining associations with childbearing intention and contraceptive use. FNS demonstrated good reliability (α = 0.65-0.71) and differing sub-constructs by gender. High fertility norm among women was associated with greater likelihood of pregnancy intention [RRR = 2.35 (95% CI: 1.25,4.39); ARRR = 1.53 (95% CI: 0.70,3.30)], lower likelihood of delaying pregnancy [RRR = 0.69 (95% CI: 0.50,0.96); ARRR = 0.72 (95% CI: 0.51,1.02)] and greater ambivalence on delaying pregnancy [RRR = 1.92 (95% CI: 1.18,3.14); ARRR = 1.99 (95% CI: 1.21,3.28)]. Women's higher FNS scores were also associated with higher sterilization [RRR = 2.17 (95% CI: 1.28,3.66); ARRR = 2.24 (95% CI: 1.32,3.83)], but the reverse was noted for men [RRR = 0.61 (95% CI: 0.36,1.04); ARRR = 0.54 (95% CI: 0.32,0.94)]. FNS indicated better predictive value among women compared to men for key reproductive outcomes. This measure may be useful for social norms-focused evaluations in family planning and warrants cross-contextual study.

Association of traditional marital practices with contraceptive decision-making, couple communication, and method use among couples in rural Maharashtra, India.

In India, traditional social practices around marriage, such as non-involvement of prospective brides in choice of partner and timing of marriage, child/early marriage, dowry and purdah, compromise women's agency at the time of marriage and may also affect contraceptive practices in marriage. This paper examines the associations between traditional marital practices and contraceptive behaviours, including women's control over contraceptive decision-making, couples' communication about contraception, and ever use of contraceptives, among married women aged 18-29 years (N = 1,200) and their husbands in rural Maharashtra, India. Multivariable logistic regression was used to examine the association between these marginalising social practices and family planning behavioural outcomes, adjusting for demographic and parity confounders. Wives who were the primary decision-makers on who to marry had higher odds of ever having communicated with their husband on pregnancy prevention (AOR 1.76, 95% CI 1.16-2.68), and ever using modern contraceptives (AOR 2.19, 95% CI 1.52-3.16). Wives who were the primary decision-makers on when to marry also had higher odds of ever having used modern contraceptives (AOR 1.86, 95% CI 1.21-2.93). Women's involvement in marital choice may facilitate couples' engagement related to family planning, possibly via the establishment of better communication between partners.

Understanding quality of contraceptive counseling in the CHARM2 gender-equity focused family planning intervention: Findings from a cluster randomized controlled trial among couples in rural India.

OBJECTIVES: The CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) intervention engages health care providers to deliver gender-equity and family planning sessions to couples using a person-centered shared decision-making approach for contraception counseling. We previously showed that the intervention improved contraceptive use at 9-month follow-up. We sought to assess whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use. STUDY DESIGN: This is a planned secondary analysis of the effect of the CHARM2 intervention on 1201 married couples in rural Maharashtra, India in a cluster randomized controlled trial completed between 2018 and 2020. We assessed the effect of CHARM2 on perceived quality of care as measured by the Interpersonal Quality of Family Planning (IQFP) scale using a difference-in-differences linear regression approach including a mixed-effects model with nested random effects to account for clustering. We assessed whether the association between CHARM2 and modern contraceptive use was mediated by quality of family planning care. RESULTS: Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, SD 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% CI 0.07-0.50). CONCLUSION: Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve women's perceived quality of care. Effects on quality of care mediate observed effects of the intervention on contraceptive use. IMPLICATIONS: Contraceptive interventions should focus on improving person-centered outcomes, such as quality of care, rather than contraceptive use targets. By focusing on improving person-centered care, interventions will improve contraceptive use among those who desire a method while meeting the holistic reproductive health needs of clients and couples.

Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India: Evidence from a cross-sectional study.

Background: Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children. Methods: We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second-even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables. Findings: We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare. Interpretation: Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises. Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967.

Associations between Contraceptive Decision-Making and Marital Contraceptive Communication and use in Rural Maharashtra, India.

Women's contraceptive decision-making control is crucial for reproductive autonomy, but research largely relies on the Demographic and Health Survey (DHS) measure which asks who is involved with decision-making. In India, this typically assesses joint decision-making or male engagement. Newer measures emphasize female agency. We examined three measures of contraceptive decision-making, the DHS and two agency-focused measures, to assess their associations with marital contraceptive communication and use in rural Maharashtra, India. We analyzed follow-up survey data from women participating in the CHARM2 study (n = 1088), collected in June-December 2020. The survey included the DHS (measure 1), Reproductive Decision-Making Agency (measure 2), and Contraceptive Final Decision-Maker measures (measure 3). Only Measure 1 was significantly associated with contraceptive communication (adjusted odds ratio [AOR]: 2.75, 95 percent confidence interval [CI]: 1.69-4.49) and use (AOR: 1.73, 95 percent CI: 1.14-2.63). However, each measure was associated with different types of contraceptive use: Measure 1 with condom (adjusted relative risk ratio [aRRR]: 1.99, 95 percent CI: 1.12-3.51) and intrauterine device (IUD) (aRRR: 4.76, 95 percent CI: 1.80-12.59), Measure 2 with IUD (aRRR: 1.64, 95 percent CI: 1.04-2.60), and Measure 3 with pill (aRRR: 2.00, 95 percent CI: 1.14-3.52). Among married women in Maharashtra, India, male engagement in decision-making may be a stronger predictor of contraceptive communication and use than women's agency, but agency may be predictive of types of contraceptives used.

Qualitative Examination of the Role and Influence of Mothers-in-Law on Young Married Couples' Family Planning in Rural Maharashtra, India.

Unmet need for family planning (FP) continues to be high in India, especially among young and newly married women. Mothers-in-law (MILs) often exert pressure on couples for fertility and control decision making and behaviors around fertility and FP, yet there is a paucity of literature to understand their perspectives. Ten focus group discussions (FGDs) were carried out with MILs of young married women (aged 18-29 years) participating in a couple-focused FP intervention as a part of a cluster-randomized intervention evaluation trial (the CHARM2 study) in rural Maharashtra, India. FGDs included questions on their roles, attitudes, and decision making around fertility and FP. Audio-recorded data were translated/transcribed into English and analyzed for key themes using a deductive coding method. MILs reported having social norms of early fertility and son preference. They understood that family size norms are lower among daughters-in-law and that spacing can be beneficial but were not supportive of short-term contraceptives, especially before the first child. They preferred female sterilization, opposed abortion, had apprehensions around side effects from contraceptive use, and had misconceptions about the intrauterine device, with particular concerns around its coercive insertion. MILs mostly believed that decision making should be done jointly by a husband and wife, but that as elders, they should be consulted and involved in the decision-making process. These findings highlight the need for engagement of MILs for FP promotion in rural India and the potential utility of social norms interventions.

Evaluation of a gender synchronized family planning intervention for married couples in rural India: The CHARM2 cluster randomized control trial.

Background: Despite calls for gender transformative family planning interventions to increase male engagement and female reproductive agency, there is limited research involving rigorous evaluation of the integration of these approaches. CHARM2 (counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) builds upon a prior three-session male engagement intervention by integrating female-focused sessions emphasizing women's choice and agency (i.e., gender synchronization). We hypothesized that CHARM2 participants will be more likely to report marital contraceptive use and communication and women's contraceptive agency, and less likely to report unintended pregnancy, relative to participants in the control condition. Methods: We conducted a two-armed cluster randomized controlled trial evaluating the effects of CHARM2 on marital contraceptive use, communication, decision-making; women's contraceptive agency, and pregnancy among young married couples in rural Maharashtra, India (ClinicalTrials.gov #NCT03514914, complete). 40 geographic clusters, defined based on the catchment areas of subcenter health facilities (the most proximal level of community health care within India's public health system) were randomized to control (n = 20) and intervention (n = 20). We assigned all participants within that geographic cluster to the corresponding cluster treatment condition; participants, investigators, and study staff were not masked to treatment assignment. Eligibility criteria included wife aged 18-29, couple residing together for at least six months with no plan for migration, and neither spouse sterilized or infertile. The CHARM2 intervention included five provider-delivered sessions on gender equity and family planning, two delivered in parallel to husbands and wives separately by gender-matched providers, and one final joint session, delivered within the four months subsequent to baseline survey. We conducted surveys and pregnancy testing at baseline and 9-month and 18-month follow-up. We used difference-in-differences multilevel mixed effects logistic regressions to assess CHARM2 effects on marital contraceptive use and communication, and women's contraceptive agency; we used single time point mixed effects logistic regressions for pregnancy outcomes. All analyses used an intention-to-treat approach. Findings: 1201 couples were recruited between September 2018 and June 2019; 600 intervention and 601 control. All couples were included in outcome analyses. Full couple retention was 90·2% (n = 1083) at 9-month follow-up and 90·5% (n = 1087) at 18-month follow-up. Modern contraceptive use was higher among intervention participants at 9-month but not 18-month follow-up (9-month adjusted ratio of odds ratio [AROR] 1·5, 95% CI 1·03-2·3; 18-month AROR 0·8, 95% CI 0·4-1·4). Communication (9-month AROR 1·9, 95% CI 1·0-3·6; 18-month AROR 2·7, 95% CI 1·5-4·8) and agency (9-month AROR 5·1, 95% CI 1·2-22·4; 18-month AROR 8·1, 95% CI 1·4-48·2) both improved at both time points. There was no significant difference in pregnancy between groups over the 18-month period (AOR 0·8, 95% CI 0·7-1.1) However, for women who expressed fertility ambivalence at baseline, unintended pregnancy was marginally less likely among intervention participants (47% vs 19%) (p = 0·07). There were no reported adverse events. Interpretation: The CHARM2 intervention offers a scalable model to improve contraceptive use, communication, and agency and possibly decrease unplanned pregnancies for couples in rural India.

COVID-19-Related Financial Hardship, Job Loss, and Mental Health Symptoms: Findings from a Cross-Sectional Study in a Rural Agrarian Community in India.

Several countries, including India, imposed mandatory social distancing, quarantine, and lockdowns to stop the spread of the SARS-CoV-2 virus. Although these measures were effective in curbing the spread of the virus, prolonged social distancing, quarantine, and the resultant economic disruption led to an increase in financial stress and mental health concerns. Prior studies established a link between the first lockdown and an increase in mental health issues. However, few studies investigated the association between post-lockdown financial hardship, job loss, and mental health. In this study, we examined the association between COVID-19-related financial hardship, job loss, and mental health symptoms approximately nine months after the end of the first nationwide lockdown in India. Job loss was associated with higher reporting of mental health symptoms among men (aIRR = 1.16) while financial hardship was associated with poor mental health symptoms among women (aIRR = 1.29). Conversely, social support and government aid were associated with better mental health symptoms among women. Our findings highlight the need for financial assistance and job creation programs to aid families in the recovery process. There is also an urgent need for improving the availability and affordability of mental health services in rural areas.

Male-female concordance in reported involvement of women in contraceptive decision-making and its association with modern contraceptive use among couples in rural Maharashtra, India.

OBJECTIVE: Women's involvement in contraceptive decision-making increases contraceptive use and reduces unmet need, but study of this has been limited to women's self-reports. Less research is available examining couple concordance and women's involvement in contraceptive decision-making as reported by both men and women. STUDY DESIGN: We carried out a cross-sectional study using data from rural India (N = 961 young married couples). Using multivariable regression we examined the association between concordance or discordance in spousal reports of wife's involvement in contraceptive decision-making and modern contraceptive use, adjusting for demographics, intimate partner violence, and contraceptive use discussion. RESULTS: More than one third (38.3%) of women reported current modern contraceptive use. Report of women's involvement in contraceptive decision-making showed 70.3% of couples agreed that women were involved, jointly or alone (categorized as Concordant 1), 4.2% agreed women were not involved (categorized at Concordant 2), 13.2% had women report involvement but men report women were uninvolved (categorized as Discordant 1), and 12.2% had women report uninvolvement but men report that women were involved (categorized as Discordant 2). Discordant 2 couples had lower odds of modern contraceptive use relative to Concordant 1 couples (adjusted RR = 0.61, 95% CI 0.45-0.83). No other significant differences between Concordant 1 couples and other categories were observed. CONCLUSION: One in four couples indicated discordance on women's involvement in contraceptive decision making, with Discordant 2 category having lower odds of contraceptive use. Couples' concordance in women's involvement in contraceptive decision-making offers a target for family planning research and interventions to better meet their needs. Trial registration ClinicalTrial.gov, NCT03514914. https://clinicaltrials.gov/ct2/show/NCT03514914.

Evidence on women's involvement in decision-making are limited to women's self reports and often not specific to contraceptive decision-making. This study uses couples dyadic data to assess male­female concordance on women's involvement in contraceptive decision-making and contraceptive use outcomes. Couple's concordance on women's involvement in contraceptive decision-making is associated with contraceptive use. There is potential in couple-focused family planning counseling that enhances women's contraceptive decision-making agency to improve women's contraceptive use.

The PROMISES study: a mixed methods approach to explore the acceptability of salivary progesterone testing for preterm birth risk among pregnant women and trained frontline healthcare workers in rural India.

INTRODUCTION: India has an overall neonatal mortality rate of 28/1000 live births, with higher rates in rural India. Approximately 3.5 million pregnancies in India are affected by preterm birth (PTB) annually and contribute to approximately a quarter of PTBs globally. Embedded within the PROMISES study (which aims to validate a low-cost salivary progesterone test for early detection of PTB risk), we present a mixed methods explanatory sequential feasibility substudy of the salivary progesterone test. METHODS: A pretraining and post-training questionnaire to assess Accredited Social Health Activists (ASHAs) (n=201) knowledge and experience of PTB and salivary progesterone sampling was analysed using the McNemar test. Descriptive statistics for a cross-sectional survey of pregnant women (n=400) are presented in which the acceptability of this test for pregnant women is assessed. Structured interviews were undertaken with ASHAs (n=10) and pregnant women (n=9), and were analysed using thematic framework analysis to explore the barriers and facilitators influencing the use of this test in rural India. RESULTS: Before training, ASHAs' knowledge of PTB (including risk factors, causes, postnatal support and testing) was very limited. After the training programme, there was a significant improvement in the ASHAs' knowledge of PTB. All 400 women reported the salivary test was acceptable with the majority finding it easy but not quick or better than drawing blood. For the qualitative aspects of the study, analysis of interview data with ASHAs and women, our thematic framework comprised of three main areas: implementation of intervention; networks of influence and access to healthcare. Qualitative data were stratified and presented as barriers and facilitators. CONCLUSION: This study suggests support for ongoing investigations validating PTB testing using salivary progesterone in rural settings.

Validation of the Interpersonal Quality of Family Planning Scale in a rural Indian setting.

OBJECTIVES: The provision of high-quality family planning (FP) counseling can both enhance clients' experience of care and improve their ability to make and act on their contraceptive decisions. The Interpersonal Quality of Family Planning (IQFP) scale measures FP counseling quality and has been validated in the United States. We aimed to explore whether it remains appropriate for use in a low-/middle-income country (LMIC). STUDY DESIGN: We surveyed 1201 nonsterilized married women ages 18-29 in Maharashtra, India, between September 2018 and June 2019. Respondents rated their FP provider from "poor" (1) to "excellent" (5) across 11 IQFP items. We assessed scale reliability via Cronbach's α test and used exploratory factor analysis to evaluate unidimensionality and regression models of plausibly related outcomes to assess construct validity. RESULTS: Five hundred four women (42%) had seen an FP provider within the past year, 491 (97%) of whom answered all items. Mean IQFP score was 2.62 out of 5 (SD 0.94, range 1-5). Scale reliability was high (α = 0.97). Exploratory factor analyses support unidimensionality (all factor loadings > 0.4). A 1-point increase in average IQFP score was associated with nearly double the odds of current modern contraceptive use (adjusted odds ratio = 1.73, 95% confidence interval = 1.36-2.19). CONCLUSIONS: The IQFP scale shows good reliability and construct validity in this context, and its use in LMIC settings should be broadly considered. A higher IQFP score was associated with greater odds of contraceptive use. The reported FP counseling quality was low, so future public health efforts should aim to increase counseling quality to better meet the needs of women in low-resource settings like rural India. Measurement tools like IQFP can support success evaluation of the quality of care provided by family planning programs. IMPLICATIONS: The Interpersonal Quality of Family Planning scale is a useful tool in rural India, a different context than the one in which it was developed. Use of the IQFP scale should be considered in other low-/middle-income countries to better measure the quality of family planning care provided.

A cross-sectional analysis of intimate partner violence and family planning use in rural India.

BACKGROUND: Intimate partner violence (IPV) has been shown to be associated differentially with contraceptive use based on type, with IPV more likely among pill users and less likely among condom users. Recent increases in IUD uptake allow consideration of this type of contraceptive. We assessed the association between self-reported IPV and self-reported contraceptive use, by type, among non-pregnant married women in rural India in a region with higher than average IUD use. METHODS: We assessed the association between past 12-month IPV (physical, sexual, or any) and past 3-month contraceptive use (condom, pill, IUD, or any modern method) using crude and adjusted multinomial logistic regression models. FINDINGS: Among the 1001 women included, 109 (10·9%) reported experiencing physical IPV and 27 (2·7%) reported experiencing sexual IPV in the past 12 months. Women experiencing physical IPV were significantly less likely to use condoms (adjusted relative risk ratio [RRR]: 0·54, 95% confidence interval [CI]: 0·30-0·98, p = 0·042) than women not experiencing violence. There was a trend towards increased IUD use among women experiencing physical IPV (adjusted RRR: 1·78, 95% CI: 0·91-3·41, p = 0·091) compared to those not experiencing physical IPV, but this did not reach statistical significance. INTERPRETATION: Our findings suggest that women who experience physical IPV in India are less likely to use condoms and may be more likely to use IUDs than women without exposure to IPV. This research expands on prior findings suggesting higher uptake of women-controlled contraceptives among women contending with IPV in India.

Masculine Gender Ideologies, Intimate Partner Violence, and Alcohol Use Increase Risk for Genital Tract Infections Among Men.

Masculine gender ideologies are thought to underlie alcohol use, intimate partner violence (IPV) perpetration, and sexual risk of HIV and other sexually transmitted infections (STIs). We extend on studies in the Indian context by examining the roles of masculine gender ideologies, alcohol use, and IPV on three outcomes of HIV risk (condom use, genital tract infection [GTI] symptoms, and GTI diagnosis). We applied logistic regression models to cross-sectional data of men and their wives in rural Maharashtra, India (n = 1,080 couples). We found that men with less masculine gender ideologies demonstrated greater odds of condom use (i.e., lower odds no condom use, odds ratio [OR] = 0.96, 95% confidence interval [CI] = [0.93, 0.98]). IPV perpetration was associated with increased odds of reporting ≥1 GTI symptom (adjusted OR [AOR] = 1.56, 95% CI = [1.07, 2.26]) and decreased GTI diagnosis (AOR = 0.28, 95% CI = [0.08, 0.97]). Moderate alcohol consumption was associated with increased odds of reporting ≥1 GTI symptom (AOR = 1.51, 95% CI = [1.01, 2.25]). Our findings have direct implications for men's and women's health in rural India, including targeted GTI diagnosis and treatment, integrated violence prevention in STI clinics, and targeted intervention on masculine gender ideologies.

A gender synchronized family planning intervention for married couples in rural India: study protocol for the CHARM2 cluster randomized controlled trial evaluation.

BACKGROUND: Prior research from India demonstrates a need for family planning counseling that engages both women and men, offers complete family planning method mix, and focuses on gender equity and reduces marital sexual violence (MSV) to promote modern contraceptive use. Effectiveness of the three-session (two male-only sessions and one couple session) Counseling Husbands to Achieve Reproductive Health and Marital Equity (CHARM) intervention, which used male health providers to engage and counsel husbands on gender equity and family planning (GE + FP), was demonstrated by increased pill and condom use and a reduction in MSV. However, the intervention had limited reach to women and was therefore unable to expand access to highly effective long acting reversible contraceptives such as the intrauterine device (IUD). We developed a second iteration of the intervention, CHARM2, which retains the three sessions from the original CHARM but adds female provider- delivered counseling to women and offers a broader array of contraceptives including IUDs. This protocol describes the evaluation of CHARM2 in rural Maharashtra. METHODS: A two-arm cluster randomized controlled trial will evaluate CHARM2, a gender synchronized GE + FP intervention. Eligible married couples (n = 1200) will be enrolled across 20 clusters in rural Maharashtra, India. Health providers will be gender-matched to deliver two GE + FP sessions to the married couples in parallel, and then a final session will be delivered to the couple together. We will conduct surveys on demographics as well as GE and FP indicators at baseline, 9-month, and 18-month follow-ups with both men and women, and pregnancy tests at each time point from women. In-depth interviews will be conducted with a subsample of couples (n = 50) and providers (n = 20). We will conduct several implementation and monitoring activities for purposes of assuring fidelity to intervention design and quality of implementation, including recruitment and tracking logs, provider evaluation forms, session observation forms, and participant satisfaction surveys. DISCUSSION: We will complete the recruitment of participants and collection of baseline data by July 2019. Findings from this work will offer important insight for the expansion of the national family planning program and improving quality of care for India and family planning interventions globally. TRIAL REGISTRATION: ClinicalTrial.gov, NCT03514914 .

Health care providers' perspectives on delivering gender equity focused family planning program for young married couples in a cluster randomized controlled trial in rural Maharashtra, India.

Background: There is increasing programming and research on male engagement and gender-equity (GE) counselling in family planning (FP) services. However, there is a lack of data on healthcare provider's perspectives on delivering these interventions. The objective of the paper is to present providers' perspectives on delivering a GE-focused FP intervention, CHARM, to married couples in rural India. Methods:  In-depth interviews were carried out with 22 male village health care providers who were delivering a GE-focused FP intervention, CHARM, to 428 husbands (247 couples) rural Maharashtra, India. Providers were interviewed on their experiences and perspectives during delivery of CHARM. Major domains were identified during a thematic analysis. Results: Local male health providers are interested and can be engaged in delivering a GE-focused FP intervention. Providers believed that the CHARM intervention improves couples' communication, contraceptive use and strengthened their own capacity to provide FP services in accordance with national FP programmatic efforts. Providers found the low-tech flipchart including pictures and information helpful in supporting their service provision. Providers reported some challenges including lack of privacy and space for counselling, limited access to contraceptive options beyond pill and condom, numerous myths and misconceptions about contraceptives. Providers also reported persistent social norms related to expectancy of pregnancy early in marriage, and son preference. Conclusions: Providers in rural areas with high fertility and related maternal health complications are interested in and can successfully implement a GE-focused FP intervention. Future efforts using this approach may benefit from greater focus to support broader array of spacing contraceptives particularly among first time parents, none or one child parents. There is a need to better support engagement of wives possibly through female provider led sessions parallel to male programs, i.e. gender synchronized rather than couples' sessions. Trial registration: ClinicalTrials.gov  NCT01593943, May 8, 2012.

Rationale & design of the PROMISES study: a prospective assessment and validation study of salivary progesterone as a test for preterm birth in pregnant women from rural India.

BACKGROUND: In India, 3.6 million pregnancies are affected by preterm birth annually, with many infants dying or surviving with disability. Currently, there is no simple test available for screening all women at risk of spontaneous PTB in low income setting, although high resource settings routinely use cervical length measurement and cervico-vaginal fluid fetal fibronectin for identification and care of women at risk due to clinical history. In rural India, where the public health system has limited infrastructure, trained staff and equipment, there is a greater need to develop a low-cost screening approach for providing early referral, treatment and remedial support for pregnant women at risk of preterm birth. There is interest in the use of a salivary progesterone test as a screening tool preliminary evidence from India, Egypt and UK has shown promise for this type of test. The test requires further validation in a low resource community setting. METHODS: The Promises study aims to validate and test the feasibility of introducing a low-cost salivary progesterone preterm birth prediction test in two rural districts in India with high rates of prematurity. It is a prospective study of 2000 pregnant women recruited from Panna and Satna in Madhya Pradesh over approximately 24 months. Demographic and pregnancy outcome data will be collected, and pregnancies will be dated by ultrasound sonography. Saliva progesterone will be measured by ELISA in samples obtained between 24-28 weeks of gestation. The association between salivary progesterone and preterm birth will be determined and the utility of salivary progesterone to predict preterm birth < 34, as well as < 30 and < 37 weeks assessed. Additional qualitative data will be obtained in terms of acceptability and feasibility of saliva progesterone testing and knowledge of PTB. DISCUSSION: A validated cost-effective saliva test, which has potential for further adaptation to a 'point of care' setting will allow early identification of pregnant women at risk of preterm birth, who can be linked to an effective pathway of care and support to reduce preterm birth and associated adverse consequences. This will reduce both economic and emotional burden on the affected women and their families.

Spousal discordance on reports of contraceptive communication, contraceptive use, and ideal family size in rural India: a cross-sectional study.

BACKGROUND: Persistent low rates of spacing contraceptive use among young wives in rural India have been implicated in ongoing negative maternal, infant and child health outcomes throughout the country. Gender inequity has been found to consistently predict low rates of contraception. An issue around contraceptive reporting however is that when reporting on contraceptive use, spouses in rural India often provide discordant reports. While discordant reports of contraceptive use potentially impede promotion of contraceptive use, little research has investigated the predictors of discordant reporting. METHODS: Using data we collected from 867 couples in rural Maharashtra India as part of a men-focused family planning randomized controlled trial. We categorized couples on discordance of men's and women's reports of current contraceptive use, communication with their spouse regarding contraception, and ideal family size, and assessed the levels of discordance for each category. We then ran multinomial regression analyses to determine predictors of discordance categories with a focus on women's empowerment (household and fertility decision-making, women's education, and women's knowledge of contraception). RESULTS: When individuals reported communicating about contraception and their spouses did not, those individuals were also more likely to report using contraception when their spouses did not. Women's empowerment was higher in couples in which both couples reported contraception communication or use or in couples in which only wives reported contraception communication or use. There were couple-level characteristics that predicted husbands reporting either contraception use or contraception communication when their wives did not: husband's education, husband's familiarity with contraception, and number of children. CONCLUSIONS: Overall there were clear patterns to differential reporting. Associations with women's empowerment and contraceptive communication and use suggest a strategy of women's empowerment to improve reproductive health. Discordant women-only reports suggest that even when programs interact with empowered women, the inclusion of husbands is essential. Husband-only discordant reports highlight the characteristics of men who may be more receptive to family planning messages than are their wives. Family planning programs may be most effective when working with couples rather than just with women, and should focus on improving communication between couples, and supporting them in achieving concordance in their reproductive preferences. TRIAL REGISTRATION: Clinical Trials Number: NCT01593943 , registered May 4, 2012 at clinicaltrials.gov.

Associations between intimate partner violence and married women's condom and other contraceptive use in rural India.

Background The existing literature on the intersection between women's reports of spousal intimate partner violence (IPV) and contraceptive use in South Asia is conflicted. Results vary based on method of contraception use and form of violence (physical or sexual), and few examine the relationship between IPV and various methods of modern spacing contraceptive (MSC) use. This study examines associations between IPV and MSC use among a sample of married, not-currently pregnant couples in rural Maharashtra, India (n=861). METHODS: Multinomial logistic regression models assessed wives' physical and sexual IPV victimisation (for the past 6-months) in relation to the wives' past 3-month MSC use (categorised as condom use, other MSCs [oral pills, Intrauterine device (IUD)] and no MSCs). RESULTS: In terms of violence, 9% (n=78) and 4% (n=34) of wives reported recent physical and sexual IPV victimisation, respectively. The majority (72%; n=621) did not use any MSC method in the past 3 months; 14% (n=119) reported recent condom use, and the same proportion reported other MSC use. Recent physical IPV was associated with increased likelihood of recent condom use (AOR: 2.46, 95% CI: 1.20, 5.04), and recent sexual IPV was associated with increased likelihood of recent use of other MSC (AOR: 3.27, 95% CI: 1.24, 8.56). CONCLUSIONS: These findings reinforce the need for integration of counselling around IPV prevention and intervention programming into existing family planning services targeting married couples in rural Maharashtra, India.