Evaluation of a Gender Synchronized Family Planning Intervention for Married Couples in Rural India: The CHARM2 Cluster Randomized Control Trial

"The CHARM2 intervention offers a scalable model to improve contraceptive use, communication, and agency and possibly decrease unplanned pregnancies for couples in rural India."

Research suggests that gender equity (GE) in family planning (FP) interventions is important to support women's reproductive choice and agency and to increase modern contraceptive use, particularly in contexts where traditional gender norms prevail. FP services in India emphasise and incentivise female sterilisation, and many women report never receiving counseling on other contraceptive methods. Implemented in the rural Pune district of Maharashtra, India, CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital equity) builds upon a prior 3-session male engagement intervention (see Related Summaries, below) by integrating female-focused sessions emphasising women's choice and agency (i.e., gender synchronisation). This cluster randomised controlled trial (RCT) evaluated the impact of CHARM2, relative to standard of care, on modern contraceptive use, marital contraceptive communication and joint decision-making, women's contraceptive agency, and pregnancy.

Despite the demonstrated effectiveness of the original CHARM intervention, and high male participation in it, impact on contraception was largely limited to condoms, and only half of women participated in couple sessions. Inadequate focus on women may have impeded their participation and uptake of female-controlled reversible contraceptive methods. CHARM2 was a 5-session GE+FP counseling intervention that added 2 female-only sessions (delivered by an auxiliary nurse midwife - ANM) in parallel with the 2 male-only sessions provided in the original CHARM intervention, followed by a joint session for the couples. CHARM2 offered a broader array of contraceptives (e.g., intrauterine devices (IUDs) and oral contraceptive pills) directly to women by a gender-matched provider across the multiple sessions.

CHARM2 providers, including ANMs and both allopathic and non-allopathic (ayurvedic and homeopathic) doctors, received a 2-day training on GE issues, person-centred FP, and the CHARM2 intervention in addition to receipt of standard government FP training. The researchers gave all providers in the intervention clusters a visual flip chart covering the themes of CHARM2 content and cards with FP methods to facilitate counseling sessions inclusive of contraceptive choice.

CHARM2's person-centred care approach emphasises women's role in FP decision-making and female reproductive agency in order to ensure the intervention does not just focus as heavily on male engagement. In line with that approach, for women, CHARM2 sessions assessed reproductive coercion from partners or family and made women's choice and fertility goals central to contraceptive decision-making, including discussion about the potential for covert contraceptive use. For men, counseling emphasised the importance of male engagement and respectful communication with wives. Content for both spouses included exploration of fertility goals and counseling on contraceptive options to achieve these goals, as well as skills training and practice related to contraceptive communication and joint decision-making. GE elements of the programme included dialogue on the importance of respect for women and girls, risks of social norms related to son preference, and the effect male dominance and marital violence can have on healthy and positive marital dynamics and the health of women and children.

For the 2-armed cluster RCT, 40 geographic clusters in rural Maharashtra, India, defined based on the catchment areas of subcentre health facilities, were randomised to control (n = 20) and intervention (n = 20). Eligibility criteria included wife aged 18-29, couple residing together for at least 6 months with no plan for migration, and neither spouse sterilised or infertile. The researchers collected data from couples at 3 time points: baseline (September 2018 - June 2019), 9-month (July 2019 - March 2020), and 18-month (June-December 2020) follow-up. There was a gap between the follow-up surveys due to the COVID-19 pandemic and statewide shutdowns.

Six hundred intervention and 601 control couples were included in outcome analyses. 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% confidence interval (CI) 1.03-2.3; 18-month AROR 0.8, 95% CI 0.4-1.4). 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).

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. However, there was no sustained intervention effect on women's perceptions they had an equal right to decide what contraceptive to use, which was seen at 9-month follow-up but lost at 18-month follow-up. This loss of effect may indicate need for a booster session to sustain intervention effects, but may also be due to the COVID-19 pandemic, which resulted in gender-regressive practices in households that reinforced male dominance and authority while impeding mobility and contraceptive access for women.

In short, this study found "significant short-term impacts on contraceptive use, communication, and agency, as well as some longer-term positive impacts on contraceptive communication and agency in the form of contraceptive self-efficacy and a possible effect on unplanned pregnancies". The researchers suggest that the dissipation of the impact of CHARM2 on modern contraceptive use (especially condoms) by the 18-month follow-up may again be explained by the COVID-19 pandemic, when access to the public health system, including FP services may have been constrained. A further note: The emphasis on condom use among CHARM2 participants may be due, at least in part, to the intervention's original focus on male engagement but also reflects the fact that condoms remain the most common method of reversible contraception in the country and state.

The researchers reflect more broadly on some of the null or unsustained intervention effects, observing that "male engagement efforts may be more easily achieved and sustained than are women's agency impacts for these types of GE interventions. Further data is needed to understand how to create and sustain gendered impacts in gender-synchronized FP interventions with regard to women's contraceptive behaviors independent of their male partners."

That said, the researchers found high intervention participation and satisfaction with the CHARM2 intervention, a receptivity among the population to the programme that "support[s] sustainability and scale-up of the CHARM2 intervention. Further indicating support for scale up are responses from key stakeholders in the community, including leadership in the health system and community leaders," as seen in a report on stakeholder interviews and mapping of local providers that is available in Supplemental Document 2 of the paper. "These providers and stakeholders indicated that the local system and communities could manage the program and that they believe it should be continued."

In conclusion: "the gender synchronized GE+FP CHARM2 intervention supports women's reproductive agency, joint contraceptive decision-making, and contraceptive use among young married couples in rural Maharashtra...[although] effects can be tenuous in the context of crisis such as the COVID-19 pandemic."