Voluntary Use of Contraception among Older Adolescents and Young Adults

What norms contribute to this behavior?

Social norms are the perceived, informal rules that define acceptable, appropriate, and obligatory actions within a given group or community. Some social norms are specific to a particular context, while others may be broad enough to span multiple contexts; even seemingly contradictory norms may exist in the same context.¹

The following examples represent social norms relevant to voluntary use of contraception for older adolescents and young adults (ages 15-25) that emerged from across the literature. They are not meant to be a comprehensive list of all relevant social norms or norms relevant in all contexts. 

• Large families are desirable in many communities, meaning young couples may be reluctant to use contraception.^2–13 Son preference norms within communities may impact family spacing and size, as couples try to achieve an ‘ideal’ family composition.^14–17 Delayed marriage and therefore delayed childbearing can result in shorter birth intervals, indicating a desire to “catch up” to develop a large family size.¹⁸
  Meta-Norms: Gender Ideology; Protection; Social Status

• Child spacing is viewed as acceptable in many religious communities, though not always through modern methods.^{5,7,8,13,19,20} Some communities have protective norms against having children too close together–for example, norms against getting pregnant while still breastfeeding.^5,8,21 However, child spacing may also be seen as unacceptable in other religious communities.¹²
  Meta-Norms: Gender Ideology; Protection; Social Status

• Norms associated with femininities, such as women must prove they can get pregnant, and that they prove womanhood through large families, are associated with deciding to use –or not use– contraception to space pregnancies.^{2–5,12,13,20,21}
  Meta-Norms: Gender Ideology; Protection; Social Status

• Norms that promote men as the head of the household discourage shared decision-making regarding the timing of births and family size and can lead husbands to impose control over contraception –either forcing or prohibiting its use.^9,11,22–25
  Meta-Norms: Authority; Control and Violence; Gender Ideology; Social Status

• Couples may feel pressure to conceive soon after they get married to allay concerns about infertility, leading to a delay in contraceptive uptake.^12,26 Because of this pressure, contraceptive use and even discussion may be seen as appropriate only after a first child.^{6,13,20,21,27}
  Meta-Norms: Control and Violence; Gender Ideology; Social Status

• Child spacing is seen as improving quality of life and health of families in communities.^{2,5,6,8,12,19}
  Meta-Norms: Gender Ideology; Protection; Social Status

• Women are considered responsible for contraceptive use, including for child spacing,^4,15,28 but often lack the agency or household decision-making power to practice it.^2–6,8,13 Women may see it as common or acceptable to covertly use family planning methods to space pregnancies.^5,29
  Meta-Norms: Gender Ideology; Privacy; Social Status

• Norms associated with social hierarchies between medical providers and young couples, especially young women, may impact contraceptive use. Due to the power hierarchy inherent in the relationship, young women may not feel comfortable discussing sexual and reproductive health with their medical provider. ^13,30–32
  Meta-Norms: Gender Ideology; Protection; Social Status

• Seeking or discussing family planning may be considered taboo, creating barriers to contraceptive use, due to the perception that it promotes promiscuity and infidelity among women,^{4,21,24,28,29,33} that it is a private matter,¹³  or that communicating about contraception is inappropriate or taboo.^7,24,30
  Meta-Norms: Gender Ideology; Protection; Social Status

• Norms related to the uncleanness of menstrual blood may prohibit women from using contraception for fear of irregular bleeding as a side effect.^21,29
  Meta-Norms: Gender Ideology; Protection; Social Status

What other factors affect this behavior?

Family planning use among older adolescents, especially for delaying first birth and spacing births, depends on a number of factors. For example, these may include the following:

Individual

• Nomadic pastoralist women vs semi-nomadic pastoralist women¹

Interpersonal

• Couple and Community Education^2–5
• Polygamy^3,6–9
• Couple and Community Socio-economic Status^4,5,10
• Migrant vs resident husbands^11,12

Community

• Religion^1,3,11
• Post-conflict Settings^10,13
• Geographic Setting (Urban and Rural)^7,10,14–19

Who influences this behavior?

Certain groups or individuals influence young people to use family planning methods, including their partners, friends, and peers, as well as local and religious leaders. Families, especially parents and in-laws, are also important reference groups depending on the context.

• Intimate partners^1–8
• Healthcare providers^2,5,9–12
• Peers and friends^{1–3,5,7,8,13–17}
• Family, including Parents, In-laws, and Siblings^{1,2,4,7,9,12,13,15,18–21}
• Traditional, Religious and Community Leaders^{2,7,9,18,22,23}
• Community Members^4,17,18,24

Selected interventions addressing norms and behaviors

• Girl Power-Malawi (GPM) was implemented by UNC Project-Malawi from February 2016 to August 2017 across four health clinics in Lilongwe, Malawi. The project aimed to improve care-seeking and reduce sexual risk behaviors among adolescent girls and young women. Major intervention components included youth-friendly healthcare, empowerment sessions and cash transfers. Youth-friendly care consisted of health clinics with a separate space for integrated sexual and reproductive health care, provided by staff who had received training for confidential, non-judgmental care. 12 monthly, group-based, interactive empowerment sessions were offered by a trained counselor, addressing romantic relationships, financial concepts, and skills like problem-solving and communication. Finally, conditional cash transfers were provided to girls after attending each empowerment session. The intervention was evaluated through a multi-arm study to evaluate the effectiveness of the intervention activities alone and in combination. Findings showed improvements in young women’s communication with others including their partners about contraception and family planning method use. Young women in the empowerment sessions had positive associations with using contraception, a relationship mediated by communicating about contraception.^1,2

• Masculinité, Famille, et Foi, part of the Passages Project, was implemented by Tearfund in Kinshasa, DRC, between 2015-2020. The program sought to reduce gender-based violence and increase family planning use among newly married couples and first-time parents through creating protective normative religious environments and working with religious leaders as agents of change. The intervention consisted of engaging faith leaders, building capacity of mentors (called Gender Champions), hosting community dialogues, conducting organized diffusion, and fostering an enabling service environment. Faith leaders and Gender Champions received gender transformative training before organizing and leading regular group discussions, including service linkages to local health clinics. Community mobilization included stories of change, and supportive sermons to the entire congregation. Researchers used factor analysis to measure how social norms influenced participant intentions to use modern family planning, which showed that women were concerned about social sanctions resulting from contraceptive use whereas men were influenced by perceptions of contraceptive use among their peers. An evaluation of the intervention using baseline and endline surveys found an increase in family planning acceptability for first-time parents including increased use, personal attitudes, self-efficacy, perceived social norms and couple communication around modern contraception. First-time parents also reported reduced experience and perpetration of violence to discourage modern contraception use.^3,4