Examining the Impact of Social

Norms on Reproductive
Decision-Making for Married Women
in India

Aditi Prabhu

Anoushka Vashisth

Navya Saluja

Shireen Banerjee

Srushti Panwar

Tara Nair Kapil

Written for

Project Concern International

 CONTENTS
1. Introduction

1.1 Sociological Context

1.2 Relationship between social norms and reproductive decision making

2. Social Structures

2.1 Role of Family & Community Expectations

2.2 Impact of Gender Roles & Patriarchy

2.3 Impact of the Caste System

3. Influence of Social Norms on Reproductive Decision Making

3.1 Age of Marriage

3.2 Son Preference

3.4 Stigma against contraceptive use

4. Analysis of Government & Organizations’ efforts

4.1 Past Government Efforts/Actions

4.2 Effectiveness of Civil Organization Efforts

4.3 Recommendations for Improvement

5. Conclusion & Path forward

1.Introduction

Marriage can be defined as “The legally or formally recognized union of two people as partners in
a personal relationship”1. The very existence of this union is founded in decision-making, starting
with the mutual decision made by two people to enter it. In the course of married life, people
proceed to decide upon a plethora of financial, familial and livelihood-related matters etc. This
process is complex and requires cooperation and a mutual acknowledgement of each partner’s
interests.

This decision making process also plays a prominent role in achieving certain milestones of
married life which are often societal expectations, one such expectation is to have children. While
the burden of making reproductive decisions falls on both partners, as the partner on whom befalls
the ‘child-bearing responsibility’ in a heterosexual marital union, women play a more prominent
role in the process. Reproductive decision-making is a wide concept that involves decisions
centered around the use of contraceptives, the various aspects of parenthood, fertility, reproductive
health etc. This includes decisions like mutually agreeing to use contraceptives, what type of
contraceptive is to be used (hormonal, mechanical, surgical etc.), whether both partners in a
relationship are ready to be parents, when to have children and the spacing between them, seeking
fertility treatments or other medical help in conception etc.2

1.1 Sociological Context

A number of these decisions have a profound impact on women’s physical and mental health and
also on the socio-economic conditions of the family unit as a whole. For these reasons, such
decisions require careful deliberation and knowledge about reproductive health as well as the
possible consequences and repercussions of such decisions. Greater autonomy for women in this
process is integral to gender equality, and access to sexual and reproductive health and rights3.

However, marriage exists within a social context and thus, the decisions made within it are
influenced by several variables. One of the most pressing variables is ‘social norms’. While there
is little agreement about how to define social norms, for the purpose of our paper, the definition
put forth in the Stanford Encyclopedia of Philosophy is the most apt; “social norms are the
informal rules that govern behavior in groups and societies”4. Often, several discriminatory norms
limit women’s autonomy in reproductive decision making.

1
Oxford University Press, “Marriage” Oxford English Dictionary, July 2023,
https://www.oed.com/dictionary/marriage_n?tab=meaning_and_use-paywall#38146529
2
Willan S, Gibbs A, Petersen I, Jewkes R, Exploring young women's reproductive decision-making, agency and social
norms in South African informal settlements, 29 April 2020,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190118/#pone.0231181.ref001
3
UNFPA India, Analytical Paper Series 3: Women’s Ability to Decide about Sexual Relations, Contraceptive Use and
Reproductive Health Care in India (SDG Indicator 5.6.1), 19 September 2022
https://india.unfpa.org/sites/default/files/pub-pdf/analytical_series_3_-_decision_making_by_women_on_sexual_relatio
ns_contracpetive_use_and_reproductive_health_care_in_india_-_revised.pdf
4
Bicchieri, Cristina, Ryan Muldoon, Alessandro Sontuoso, Edward N. Zalta (ed.), "Social Norms", The Stanford
Encyclopedia of Philosophy (Winter 2018 Edition), https://plato.stanford.edu/entries/social-norms/
1.2 Relationship between social norms and reproductive decision making

Generally, societal norms expressed as the opinions of parents, friends and relatives all play a role
in the reproductive choice of an individual or a couple.

You often find that in India, women are encouraged to get married and have children very young.
Child marriages are not as common as they were in the past, but they are still observed in some
communities. Male children are preferred over female children, and this,even today, is quite
common in India. This can lead to unhealthy reproductive practices such as having many children
until a boy is born. There is a stigma attached to contraceptive use, and this can limit an individual
to make informed reproductive decisions. There is a strong preference for larger families in India,
frequently due to family and social pressure. This is to continue the family lineage and provide
support in old age.

Many of these choices are made by couples without considering the economic factors, physical
health, and preferences of the couple themselves. Family planning has now recently become more
encouraged in India, due to steps taken by the people and government to educate the new
generations about reproductive health and choices.

It is crucial to recognize that social norms are not fixed and can change over time due to various
factors, including education, economic development, and cultural shifts. As societies evolve, the
influence of social norms on reproductive decision-making may also undergo transformations,
allowing for more individual autonomy and informed choices.

This paper focuses on the impact that social norms and the social structures that create them have
on reproductive decision making. It also talks about the policies being implemented and measures
being taken to break apart from these norms, and encourage good reproductive health and family
planning.
2. Social Structures

2.1 Role of Family & Community Expectations

In Indian societies, family members as well as other members of a community play a significant
role in influencing the reproductive decisions of women, both through the creation of social norms
as well as direct influence. Through a study by The Pew Research Centre in 2020 which surveyed
married women and other stakeholders, it was revealed that a primary expectation of society for
Indian women was to be an “ideal wife and mother”5, which was perceived as a duty to be fulfilled
after marriage. In conjunction with this, many of the married women who were surveyed stated
that it was an expectation to have a child immediately after marriage, with one of the reasons as
“proving womanhood” and to increase the respect shown by their families and others.

Moreover, “joint families”, where multiple generations live in the same home are common
throughout India. The norm is that sons would stay in his parents’ home, ensuring that they are
taken care of and looked after, while a daughter would live with her in-laws after marriage6.In
Indian society, the continuation of a family’s lineage is of a high importance, hence, a married
woman is likely to face pressure to reproduce and carry the family name7 . Participants of the
aforementioned study shared the intense pressure women face from her in-laws, most commonly,
her mother-in-law, especially in cases where the husband is not involved in the family planning8.
Such familial and community involvement in a woman’s reproductive decision making can
overpower her right to be involved in family planning as well as make decisions according to her
needs and preferences.

2.2 Impact of Gender Roles & Patriarchy

A patriarchal society denotes a system of values woven into political and socioeconomic systems
that promote gender inequality between men and women9. In this kind of society, the elder males
have absolute authority over a family, and the community as a whole. These patterns can be traced
to the marital roles that persist in Indian culture where women have been nurtured to behave
subordinately, and men to take on domineering roles. In fact, a late 2019 survey revealed that 9 out

5
Parsekar, Shradha S, et al. The Voice of Indian Women on Family Planning: A Qualitative Systematic
Review. Vol. 12, 1 Oct. 2021, pp. 100906–100906,
www.sciencedirect.com/science/article/pii/S2213398421002141?ref=cra_js_challenge&fr=RR-1,
https://doi.org/10.1016/j.cegh.2021.100906. Accessed 22 July 2023.
6
Asia Society. “Indian Society and Ways of Living.” Asia Society, 2023,
asiasociety.org/education/indian-society-and-ways-living.
7
Asia Society. “Indian Society and Ways of Living.” Asia Society, 2023,
asiasociety.org/education/indian-society-and-ways-living.
8
Parsekar, Shradha S, et al. The Voice of Indian Women on Family Planning: A Qualitative Systematic Review. Vol. 12,
1 Oct. 2021, pp. 100906–100906,
www.sciencedirect.com/science/article/pii/S2213398421002141?ref=cra_js_challenge&fr=RR-1,
https://doi.org/10.1016/j.cegh.2021.100906.
9
Parsekar, Shradha S. et al. "The Voice Of Indian Women On Family Planning: A Qualitative Systematic Review".
Clinical Epidemiology And Global Health, vol 12, 2021, p. 100906. Elsevier BV, doi:10.1016/j.cegh.2021.100906.
of 10 Indians affirm the belief that a wife should obey her husband, with 61% of the surveyed
women in support of this marriage structure10. In essence, the patriarchy provides a basis for the
persistence of these gender roles, thus, perpetuating the notion that the husband's choice holds
more weight than the wife's. Therefore, this causes the husband's reproductive decisions to be
prioritized over the wife's. Moreover, education in itself is not a right granted to Indian girls
around the country. The patriarchy dictates the idea that since birth, sons are more valuable, thus,
they are already provided with more resources such as an education11.

Social norms stemming from the patriarchy can only be overturned through holistic education and
awareness, both of which are evidenced to be compromised. Essentially, the patriarchy provides
the basis for the notion that boys are more valuable and dominant, hence, rise to these marriage
structures which assert distinctive roles for both men and women respectively. This, merged with
the educational limitations, precipitates conformity to the many social norms that the patriarchy
promotes to influence reproductive decision-making.

2.3 Impact of the Caste system

Women’s bodies, sexuality, and reproductive choices are linked to the ideological hegemony of the
caste–gender nexus in India, with marriage and sexual relations playing crucial roles in
maintaining caste boundaries12. Caste limits women's autonomy in decision making and controls
female sexuality to maintain caste purity, through endogamy and exogamy. Endogamy, which is
marriage within a specific caste as required by custom 13. It restricts women’s reproductive choices
by limiting the pool of martial partners. Exogamy, which is the custom of marrying someone from
outside your caste14, can lead to serious repercussions for women, as they will be the birth givers
and caretakers of ‘mixed/ impure’ children and have not conformed to their role as guardians of
lineage15. The allocation of livelihood on caste further perpetuates social norms and inequalities,
the upper caste women are confined to reproductive labor, while the lower caste women are
burdened with reproductive as well as manual labor, which is domestic unpaid work as well as
work in the labor market16.

The wealthier upper caste women have better access to healthcare facilities, making them better
informed about decisions concerning reproductive choices, family planning methods, assisted

10
Mitchell, Travis. "How Indians View Gender Roles In Families And Society". Pew Research Center's Religion &
Public Life Project, 2022,
https://www.pewresearch.org/religion/2022/03/02/how-indians-view-gender-roles-in-families-and-society/.
11
Arora, Parthshri et al. "The Patriarchy In The Indian School System | Re:Set". Re:Set, 2020,
https://resetfest.com/why-are-indias-girls-being-enrolled-in-government-schools-boys-in-private/.
12
Rao, N. (2015). Marriage, Violence, and Choice: Understanding Dalit Women’s Agency in Rural Tamil Nadu. Gender
& Society, 29(3), 410–433.
https://doi.org/10.1177/0891243214554798https://journals.sagepub.com/doi/10.1177/0891243214554798
13
Merriam webster dictionary, “Endogamy”https://www.merriam-webster.com/dictionary/endogamy
14
Cambridge dictionary , “Exogamy” https://dictionary.cambridge.org/dictionary/english/exogamy
15
Safdar, M. R., Akram, M., Sher, F., & Rehman, A. (2021). Socioeconomic Determinants of Caste-based Endogamy: A
Qualitative Study. Journal of Ethnic and Cultural Studies, 8(2), 39–54. https://www.jstor.org/stable/48710302?seq=6
16
Anjalichauhan,(2021)https://feminisminindia.com/2021/07/26/how-the-caste-system-subordinates-the-lives-bodies-and
-agency-of-women/
reproductive technologies, etc17. Lower castes live on the periphery of the villages because of ritual
and occupational reasons, restricting their access to healthcare and non-traditional/new medical
procedures, limiting their reproductive choices18. Underprivileged communities often face caste
based harassments in hospitals, and this further limits their reproductive choices19.

The Caste's deep integration in Indian society affects various aspects of life, setting strict social
norms, including reproductive choices. Caste hierarchy relegates women as passive decision
acceptors than active decision makers, minimizing their control over their own bodies.

17
Raj, Papia, and Aditya Raj. “Caste Variations in Reproductive Health Status of Women: A Study of Three Eastern
States.” Sociological Bulletin, vol. 53, no. 3, 2004, pp. 326–46. JSTOR,https://www.jstor.org/stable/23620467?seq=19
18
Raj, Papia, and Aditya Raj. “Caste Variations in Reproductive Health Status of Women: A Study of Three Eastern
States.” Sociological Bulletin, vol. 53, no. 3, 2004, pp. 326–46. JSTOR,https://www.jstor.org/stable/23620467?seq=19
19
Karpagam S. Caste-washing the healthcare system will do little to address its discriminatory practices. Indian J Med
Ethics. 2021 Jan-Mar;VI(1):1-4. doi: 10.20529/IJME.2020.108. PMID:
34080995.https://pubmed.ncbi.nlm.nih.gov/34080995/
3. Influence of Social Norms on Reproductive Decision Making

3.1. Age of Marriage

With newfound knowledge on the social institutions that create norms, this section will cover the
influence of social norms on reproductive decision making.

The marriage age of women is affected by several factors: level of education, work status,
domicile, family structure, traditional beliefs, family pressures, income level etc. During the last
three decades, there has been a significant increase in the median age at marriage. For women in
the age group 20–49 years, the median age of marriage increased from 16.2 years in 1992–93 to
19.2 years in the year 2019–2120.

In the traditional Indian context, girls were married off to older men at a very young age (10-15
years old21), they continued living with their birth parents until they reached puberty. Reaching
puberty signifies that women are now capable of reproduction and can be valuable to their
husbands. The cornerstone of this was that women were most fertile between their late teens and
early twenties ie. 18-2422. Although child marriage is illegal in India, 12 million girls still marry
before turning 1823, despite continuous attempts by national and international bodies.
Early marriages can lead to extended fertility spans, contributing to higher birth rates. On the other
hand, when women marry at more mature ages, there is an increased sense of empowerment for
women in their reproductive choices22. Young married women often lack knowledge about
motherhood and access to proper maternal healthcare, leading to increased rates of infant and
maternal mortality, because of incomplete knowledge , lack of autonomy and naivete , they are
more likely to accept false information and obey whatever their husbands dictate24 . Liberal
societies where women are more independent are shown to have a higher age of marriage.
Conversely, in societies where patriarchal ideals are heavily enforced, women tend to marry
earlier19

20
Singh M, Shekhar C, Shri N. Patterns in age at first marriage and its determinants in India: A historical perspective of
last 30 years (1992-2021). SSM Popul Health. 2023 Feb 10;22:101363. doi: 10.1016/j.ssmph.2023.101363. PMID:
36852378; PMCID:
PMC9958403.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9958403/#:~:text=During%20the%20last%20three%20d
ecades,in%20the%20year%202019%E2%80%9321.
21
Mansi jaswal, 2022
https://www.livemint.com/news/india/increasing-legal-age-of-marriage-to-21-is-it-a-boon-or-a-bane-for-indian-women-international-wo
men-s-day-11646540444993.html
22
American college of obstetricians and gynecologists
,https://www.acog.org/womens-health/faqs/having-a-baby-after-age-35-how-aging-affects-fertility-and-pregnancy#:~:tex
t=A%20woman%27s%20peak%20reproductive%20years,getting%20pregnant%20naturally%20is%20unlikely.

23
IIPS and Macro International under the Ministry of Health and Family Welfare, India Demographic health survey for
india , https://ipc2021.popconf.org/uploads/211100

24
Dixit, A., Bhan, N., Benmarhnia, T. et al. The association between early in marriage fertility pressure from in-laws’
and family planning behaviors, among married adolescent girls in Bihar and Uttar Pradesh, India. Reprod Health 18, 60
(2021). https://doi.org/10.1186/s12978-021-01116-9
https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01116-9#:~:text=Adolescent%20girls%20who%20
marry%20early,and%20communication%20with%20their%20husbands
Moreover, early marriages pose health risks due to early sexual debut and pregnancy19, as young
minds may struggle to handle societal and familial pressures along with domestic and sexual labor.
Adolescent brides often face limited educational and work opportunities, as they are forced to have
children right after marriage, becoming dependent on their husbands and in-laws, which restricts
their decision-making autonomy21. As a result, they become vulnerable to poor reproductive health
outcomes due to an amalgamation of low contraception use and lack of communication with their
husbands21. Further, for women who receive an education, balancing educational and familial
responsibilities can be challenging, adding to the pressure to have children early.

In summary, the concept of marriage has evolved from its traditional purpose, but child marriage
continues to be a persistent issue with far-reaching consequences for women's health and
autonomy. Addressing these challenges requires efforts to promote education, empower women in
decision-making, and raise awareness about the negative impacts of early marriages on
reproductive health and population growth.

3.2 Son Preference

Son preference refers to preference of a male child over a girl child. In the context of reproductive
decision making in India, the existence and consequent impact of the son preference norm is
extensive. Son preference is itself grounded in several other discriminatory social norms and
practices, thus having a profound impact on women’s reproductive decisions. In this subsection,
we shall be focusing on how this norm impacts contraceptive use and number of children.

In the 2019-21 National Family Health Survey (NFHS), 15% of Indian women ages 15 to 49
reported wanting to have more sons than daughters, while just 3% said they wanted more
daughters than sons25. It is also important to note that while son-preference in India is very
prevalent, it is not universal, or without its exceptions and regional variations as well as disparities.
For example, studies have shown that son preference is less prevalent in south India as compared
to north26. The norm is influenced by several other determinants like the sex of the existing
children or the older siblings27. Some reasons behind son preference in the context of Indian
society are:

● Sons are viewed as an asset, as they will continue to live with the parents, take care of
them in their old age and provide for the family in terms of income and other economic

25
Yunping Tong, Changes in son preference, ultrasound use and fertility Pew research center
https://www.pewresearch.org/religion/2022/08/23/changes-in-son-preference-ultrasound-use-and-fertility/
26
Abhishek Singh, Ashish Kumar Upadhyay, Kaushalendra Kumar, Ashish Singh, Fiifi Amoako Johnson, Sabu S.
Padmadas, Spatial heterogeneity in son preference across India’s 640 districts: An application of small-area estimation,
Demographic Research Volume 47 Article 26,
https://www.demographic-research.org/volumes/vol47/26/default.htm#:~:text=Son%20preference%20is%20highest%20
in,%2C%20Kerala%2C%20and%20Tamil%20Nadu.
27
A-H. El-Gilany, E. Shady, Determinants and causes of son preference among women delivering in Mansoura, Egypt,
Eastern Mediterranean Health Journal, Vol. 13, No. 1, 2007,
https://applications.emro.who.int/emhj/1301/13_1_2007_119_128.pdf
 resources28. Daughters on the other hand are considered to be a part of the family only
until their marriage. They are often viewed as lacking economic potential and are not
expected to go out and earn in order to be able to contribute to the family’s income.
Furthermore, the dowry system wherein the bride’s family has to give several gifts and
money to the groom’s family upon marriage also contributes to their perception as a
liability.
● Traditionally in Indian society, giving birth to a son is viewed as increasing the family’s
social standing by providing them with an heir to carry on the familial legacy as well to
defend their honor. On the other hand, as women are traditionally subjected to harsher and
more restrictive social norms as well as greater social scrutiny, the possibility of
challenging any one of these norms contributes to the vulnerability of the daughter’s social
standing or honor and by extension, that of the family29. Son preference also has causes
rooted in religious traditions and practices such as funeral rituals30.

Son preference has in the past led to a skewed sex ratio, high rates of female Infant Mortality Rate
(number of infant deaths per thousand live births), as well as nutritional neglect of daughters. To
curb female foeticide wherein a child is aborted simply because she is a girl, the government has
banned prenatal sex determination and implemented strict action against those who try to violate
this as under the PC-PNDT laws. The positive impact of these measures is evidenced through
statistics like India’s Sex ratio in 2023 being 1020 females per 1000 males as per the National
Family Health Survey, 2020-21 (NFHS-5).31 In 2022, the female IMR also dropped drastically and
nearly equaled the male IMR although in 16 states the IMR remained higher for females as
compared to males32. This norm affects women’s reproductive decision making in the following
ways:

1) Contraceptive use- There is increased use of temporary contraceptives in families with

mostly sons as compared to families with mostly daughters. Sterilization, which is the
most popular method of contraception in India, is also utilized mostly when the family has
achieved its desired number of sons. This is accompanied by decreased use of
contraceptives in families where there are mostly daughters, as it limits the woman’s
capacity to have more children thereby limiting the possibility of having a son33.

28
UNFPA, Son Preference and Daughter Neglect in India, Pg 3
https://www.unfpa.org/sites/default/files/resource-pdf/UNFPA_Publication-39764.pdf
29
UNFPA, Son Preference and Daughter Neglect in India, Pg 3
https://www.unfpa.org/sites/default/files/resource-pdf/UNFPA_Publication-39764.pdf
30
Aparna Mitra, Department of Economics University of Oklahoma, SON PREFERENCE IN INDIA: IMPLICATIONS
FOR GENDER DEVELOPMENT, Pg 8 https://www.academia.edu/download/43400722/seg_1.pdf
31
Ministry of Health and Family Welfare, Press Information Bureau Delhi, Update on Child Sex Ratio,
https://pib.gov.in/PressReleasePage.aspx?PRID=1782601
32
The Times of India, Rema Nagarajan, India’s female IMR drops to same level as males,
http://timesofindia.indiatimes.com/articleshow/94629223.cms?utm_source=contentofinterest&utm_medium=text&utm_
campaign=cppst
33
Jeffrey Edmeades, Rohini Prabha Pande, Tina Falle, Suneeta Krishnan, Son preference and sterilization use among
young married women in two slums in Bengaluru city, India,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101305/#:~:text=Son%20preference%20and%20the%20use,with%20s
ons%20(Hussain%20et%20al.
 2) Number of children and Inter-pregnancy Interval (IPI)- In India, social norms
historically favored large families due to high mortality risks and the belief in strength
through numbers. Efforts to improve education, healthcare, and access to family planning
can empower women to make informed choices about family size and reproductive
decisions, potentially leading to a shift in these traditional norms over time. Son
preference also influences the number of children, families continue to have children and
that too in quick succession until they reach the desired number of sons. Shorter IPI can
lead to undernutrition due to prolonged periods of breast-feeding34, postpartum
hemorrhage, anemia35, as well as an increase in maternal mortality36. The risk of
malignancies like cervical cancer is also more common in women who have children at
small intervals37 38.

While there is a dearth of information on the comparative prevalence of son preference between
men and women, it is important to note the increased violence against women whose first child is a
girl39. The threat of violence can have a heavy influence on women’s tendency for son preference
while also limiting their autonomy in making the decision to have a sex-selective abortion.

3.4 Stigma Against Contraceptive Use

Contraception involves any action taken to prevent pregnancy and is offered in various forms
ranging from immediate and reversible measures (such as condoms and birth control medication)
to irreversible surgical methods, such as (vasectomies and tubal ligation, which is the act of
removing or clipping the fallopian tubes)40. Contraception is often offered in more urban areas,
such as cities, but the stigma surrounding it hinders its usage, limiting the reproductive decision
making of married women.. In a study conducted by the Pew Research Centre, where married
women around India were surveyed about their thoughts on social norms regarding family
planning and marriage, it was revealed that one of the sources of stigma against contraceptives was
the religions married women belonged to. An example is that contraceptives are forbidden by
Islam, as they believe that the decision of how many children to bear and when is the decision of
God41. Furthermore, since contraception prevents pregnancies, it opposes the preference for more

34
Dr. Rachna Jain, Chhattisgarh Institute of Medical Sciences (CIMS), Interview
35
CC Onwuka, EO Ugwu1, SN Obi, CI Onwuka, CC Dim, GU Eleje, EC Ezugwu, PU Agu, UI Nwagha, BC Ozumba,
Effects of Short Inter‑Pregnancy Interval on Maternal and Perinatal Outcomes: A Cohort Study of Pregnant Women in a
Low‑Income Country, Pg 1, https://www.ajol.info/index.php/njcp/article/view/197712/186480
36
Mühlrad, H., Björkegren, E., Haraldson, P. et al. Interpregnancy interval and maternal and neonatal morbidity: a
nationwide cohort study. Sci Rep 12, 17402 (2022). https://doi.org/10.1038/s41598-022-22290-1
37
Dr. Rachna Jain, Chhattisgarh Institute of Medical Sciences (CIMS), Interview
38
Mukherjee BN, Sengupta S, Chaudhuri S, Biswas LN, Maiti P., A case-control study of reproductive risk factors
associated with cervical cancer. Int J Cancer, https://doi.org/10.1002/ijc.2910590408
39
Annamaria Milazzo, Why are adult women missing? Son preference and maternal survival in India, Journal of
Development Economics Volume 134, Pg 467-484,
https://www.sciencedirect.com/science/article/abs/pii/S030438781830508X
40
Better Health Channel. “Contraception - Choices.” Vic.gov.au, 2020,
www.betterhealth.vic.gov.au/health/healthyliving/contraception-choices.
41
Parsekar, Shradha S., et al. The Voice of Indian Women on Family Planning: A Qualitative Systematic Review. Oct.
2021, pp. 100906–6, https://doi.org/10.1016/j.cegh.2021.100906.
children and therefore is often discouraged. Defiance of these norms can result in social ridicule
and estrangement, which is often why they are still in existence.

However, in cases where contraception is less frowned upon, the responsibility of using it often
falls upon the married woman, rather than her husband. Evidence of this is the response given by
several women in the study by the Pew Research Centre, which is that men sometimes resist the
use of condoms and other contraception, leaving the women to take the appropriate measures, such
as using birth control medication. One reason behind this is that there is a disapproval of
permanent contraception for men, as it implies “a loss of vitality and impotency” (Parsekar et al.).
In fact, a study conducted by the National Library of Medicine revealed that sterilization in women
is the most common form of contraception in India42, which emphasizes this point. In addition to
this, a study conducted by the RAND Corporation in 2019 revealed that India had 31 million
women with an “unmet need” for contraception43. Especially in rural India, many institutions and
pharmacies do not offer contraception, leaving women to use unsafe methods which can cause
harm.

The most important measure that can be taken to destigmatize contraception would be to increase
educational programs regarding sexual education for both married women and men, which would
increase the bodily autonomy of married women and reduce the responsibility on women to
maintain contraception usage. Furthermore, an increase in pharmacies and gynecology
departments in government hospitals would increase married women’s access to contraception, as
well as for her husband.

42
Hall, Mary Ann Kirkconnell, et al. “Social and Logistical Barriers to the Use of Reversible Contraception among
Women in a Rural Indian Village.” Journal of Health, Population, and Nutrition, vol. 26, no. 2, 2008, pp. 241–50,
www.ncbi.nlm.nih.gov/pmc/articles/PMC2740665/.
43
Green, Hannah Harris . “Rural Women in India Struggle to Access Contraception. These People Are Trying to Change
That.” The World from PRX, Feb. 2019,
theworld.org/stories/2019-02-01/rural-women-india-struggle-access-contraception-these-people-are-trying-change.
4. Analysis of Government & Organizations’ efforts

4.1 Past Government Efforts/Actions

In the past several decades, the Indian government has been relatively committed to instating
policies and other programs targeting family planning and other educational campaigns. Through
thorough analysis, this subsection will detail the three key efforts made by the Indian government
within the scope of this issue, and reveal the gaps that remain for each.

1. National Programme for Family Planning 1952

In 1952, the Indian government launched its national family planning program with the
core goals being population growth and reducing maternal, infant, and child mortality44.
Despite great investments put towards family planning, the program actually enforced the
‘small family’ norm33. Essentially, the concept that a small family is more favorable for
India’s socioeconomic status in itself limits a woman’s autonomy to make reproductive
decisions as she would be denied the right to choose how many children she would want
to have. Therefore, it is clear that the priorities of this program lay in bolstering India’s
socioeconomic health rather than promoting female empowerment33.

2. “Beti Bachao, Beti Padhao (BBBP)_” (Save Girl Child, Educate Girl Child) 2015

Unlike the aforementioned program, the “Beti Bachao, Beti Padhao (BBBP)” scheme was
introduced in 2015 with the core focus to ensure women's empowerment through
encouraging education and improving the child sex ratio34. Driven by the patriarchal son
preference social norm, the United Nations revealed that India “is one of the countries
with the most skewed child sex ratio” between 2000 and 202045. As a result, the BBBP
scheme has proactively dealt with gender-based discrimination against the girl child
through increasing female literacy rates and raising awareness of the issue of son
preference46. However, the lack of implementation and representation from
community-level workers disallowed the program to make substantial progress towards
empowering female reproductive-decision making.

3. 2014 Rashtriya Kishor Swasthya Karyakram (RKSK)

In 2014, the Ministry of Health and Family Welfare launched the RKSK in order to gauge
male and female adolescents from a variety of circumstances, particularly marginalized
groups, to expand the scope of health programming47. Through involving parents and the
community, RKSK provides routine physical and mental health check-ups to meet the

44
Government of India. “Family Planning :: National Health Mission.” National Health Mission, 19 June 2023,
nhm.gov.in/index1.php?lang+1&level+2&sublinkid=821&lid=222.
45
Arora, Avni. “‘Beti Bachao, Beti Padhao’ Scheme: A Critical Analysis.” ORF, 19 Oct. 2022,
www.orfonline.org/expert-speak/beti-bachao-beti-padhao-scheme/.
46
IBEF. “Beti Bachao, Beti Padhao (BBBP) Scheme: IBEF.” India Brand Equity Foundation, 2022,
www.ibef.org/government-schemes/beti-bachao-beti-padhao.
47
“National Health Mission.” NHM Himachal Pradesh, nhm.hp.gov.in/rksk. Accessed 29 July 2023.
 service needs of adolescents37. The RKSK program can be seen to have targeted the ‘age
of marriage’ norm through its emphasis on adolescents, and empowering the younger
generation to maintain autonomy of their bodies. Further, its inclusion of male groups
facilitates the spread of awareness and education regarding reproductive health37.

Through these policies, it is clear that the Indian government has placed emphasis on caring for a
maternal figure. However, reproductive decision-making is not limited to just mothers but is also
inclusive to married women who don’t even want to have children to begin with. Therefore, while
substantial governmental progress has been made surrounding this issue, there are still gaps of
effective implementation and community engagement that remain.

4.2 Effectiveness of Civil Organization Efforts

Civil organizations, or NGOs, are crucial for civil society, promoting social welfare, human rights,
and sustainable development. They operate independently of governments, formed by passionate
individuals or groups to address specific issues. NGOs advocate for marginalized populations and
work towards positive social change. This section will address specific organizations that have
made contributions towards social norms and reproductive decision-making in India.

The Population Council is a non-profit organization that has been working in India for over 50
years to improve reproductive health and rights. The Council has a number of programs that focus
on improving reproductive decision-making in married women, including:

1. Janani Suraksha Yojana (JSY): This is a government-funded program that provides financial
incentives to women who deliver their babies in a health facility. The JSY has been shown to
increase the use of skilled birth attendants and reduce maternal mortality 48. This program has been
centrally sponsored to serve as a link between the government and pregnant women using
Accredited Social Health Activist (ASHA). Janani Suraksha Yojana (JSY) shifts social norms by
providing financial incentives for institutional deliveries (Institutional deliveries are childbirths in
healthcare facilities. Stigma involves negative perceptions, biases, and cultural norms favoring
home deliveries, discouraging women from seeking medical care, impacting maternal and child
health outcomes.), empowering women through awareness campaigns, and engaging community
health workers to challenge traditional childbirth practices.

2. Center for Reproductive Rights:The Center for Reproductive Rights was established in 1992
with a goal where every woman is free to decide whether or when to have children and whether to
get married; where access to quality reproductive health care is guaranteed; and where every
woman can make these decisions free from coercion or discrimination. 49 They work towards norm
change through various means, including education, access to health services, economic

48
Population Council. (2012). The sexual and reproductive health and rights of young people in India: A review of the
situation.
https://knowledgecommons.popcouncil.org/cgi/viewcontent.cgi?article=1018&context=departments_sbsr-pgy
49
Center for Reproductive Rights. (1992). About Us. https://reproductiverights.org/about-us/
empowerment, legislation, community mobilization, and leveraging mass media and popular
culture. 50

While these programs have been successful in improving reproductive decision-making in married
women in India by incentivizing, promoting and educating against social norms that hinder
reproductive health care and decision choices, there are still gaps and challenges that need to be
addressed to ensure equitable access to reproductive health services.

Firstly, the effectiveness of cash incentives in promoting institutional deliveries and shifting social
norms needs further evaluation. Research should explore how these incentives influence women's
decision-making and the cultural factors that impact their choice of delivery location. 51

Implementing the JSY scheme through ASHAs has its challenges. Finding ways to effectively
engage and empower ASHAs in challenging traditional childbirth practices and promoting
institutional deliveries is essential for the program's success. 52 Additionally, Ensuring equity in the
uptake of the JSY scheme is crucial. Evidence suggests that poorer women may face barriers in
accessing and benefiting from the program, highlighting the need to address these disparities and
ensure that all women, regardless of their socioeconomic status, can benefit from the incentives. 53

4.3 Recommendations for Improvement

1. Educational and Awareness Measures: The most important and effective strategy for
dispelling misguided social norms is raising awareness against them. Introducing an
unbiased sex-ed curriculum in school and helping educate young girls and women about
reproductive health and sexuality which helps them make well-informed decisions. Such
programmes in the past have suffered from limitations like backlash from the public, by
extending sex ed to adults and men, who are in a better position to enforce norm change.
Appointing people from within a community to educate and counsel them can be helpful
as people are much more comfortable and likely to listen to them rather than strangers, this
is similar to the role played by ASHAs (Accredited Social Health Activists) as a part of
the National Programme for Family Planning54. Another limitation is focusing only on the
biological aspect of sexuality which does little to change norms, the social aspect of such
topics such as consent also needs to be discussed. The curricula need to be drafted keeping

50
Caroline Harper, Rachel Marcus, Rachel George, Sophia M. D’Angelo, Emma Samman. (2020).
https://www.alignplatform.org/gender-power-progress
51
Lahariya C. (2009). Cash incentives for institutional delivery: linking with antenatal and postnatal care may ensure
'continuum of care' in India. Indian journal of community medicine : official publication of Indian Association of
Preventive & Social Medicine, 34(1), 15–18. https://doi.org/10.4103/0970-0218.45370
52
Vikaspedia. (2023). Janani Suraksha Yojana.
https://vikaspedia.in/health/nrhm/national-health-programmes-1/janani-suraksha-yojana
53
Thongkong, N., van de Poel, E., Roy, S.S. et al. How equitable is the uptake of conditional cash transfers for
maternity care in India? Evidence from the Janani Suraksha Yojana scheme in Odisha and Jharkhand. Int J Equity Health
16, 48 (2017). https://doi.org/10.1186/s12939-017-0539-5
54
Press Information Bureau, Ministry of Health and Family Welfare, Initiatives under the Family Planning Programme,
https://pib.gov.in/newsite/PrintRelease.aspx?relid=159064
 in mind the specific myths and misconceptions in the community rather than generalized
discriminatory norms.

2. Empowerment Measures: Empowerment of women through their economic upliftment

and by providing them with livelihood opportunities helps them gain financial
independence thus, increasing their autonomy in reproductive decision making. Some
strategies to tackle the norms against women working may include, introducing working
women role models for young girls to create a new norm, making the work environment
safer and more suited to women by introducing facilities like child care, more women in
leadership positions within the workplace, offer flexible work hours etc.

3. Healthcare Measures: Establishing clinics and community health care centers in rural
areas to help women gain easier and timely access to reproductive healthcare and also seek
a medical professional’s opinion about the physiological consequences of their
reproductive decisions. Providing monetary and economic incentives to women for
visiting clinics, increasing the number of female doctors and conducting meetings to
familiarize women with local medical professionals to increase the patients’ comfort is an
effective strategy to encourage women to access healthcare and subvert norms that
discourage women from seeking healthcare.

4. Restructuring research: Issues centered around reproductive decision making need to be

looked at through a gendered lens to be more effective. There needs to be increased focus
on distribution of autonomy and norm change at the grassroot level. Other pervasive social
variables like caste, regional disparity, rural/urban also need to be considered.

5. Integrated Programs through Gender-Lens: Improving women's reproductive

decision-making through integrated programs with a gender lens involves addressing
gender norms, power imbalances, and challenging traditional roles 55. Strengthening
women's reproductive agency is essential, empowering them to make informed choices
about their sexual and reproductive health through education and access to services. 56
Promoting open and equitable couple communication and decision-making fosters shared
responsibility. Additionally, investing in gender-equitable policies and decision-making
within the healthcare system ensures better access to reproductive health services,
fostering improved decision-making for women.

55
Bill & Melinda Gates Foundation. (2019). Gender Integration.
https://www.gatesfoundation.org/our-work/programs/gender-equality/gender-integration
56
Willan, S., Gibbs, A., Petersen, I., & Jewkes, R. (2020). Exploring young women's reproductive decision-making,
agency and social norms in South African informal settlements. PloS one, 15(4), e0231181.
https://doi.org/10.1371/journal.pone.0231181
5. Conclusion & Path Forward

From our thorough analysis, it is clear that the difficulty in empowering women to make
reproductive decisions lies in the prevalent social norms that exist. Education, on its own, also
cannot reverse these social norms.

The implications of this conclusion are extensive. For instance, policymakers can note the
significant impact social norms have on reproductive decision-making, thus leading to the
implementation of awareness campaigns. Furthermore, this paper also sheds light on the role of
gender inequality / patriarchal ideals in reproductive decision-making and how education is not a
one size fits all solution to this problem. Policymakers and the Indian government can then evolve
the educational system in a way that it would contribute to the reversal of social norms.

However, this paper is not without limitations. The research’s findings take into account both
urban and rural regions of India, thus, neglecting the diverse range of communities that exist in
India. Moreover, the sample sizes of the secondary data we derived for this paper is not always
consistent, disallowing for a completely unbiased conclusion. Despite these limitations, the
thorough analysis conducted utilizing a range of scholarly sources and stakeholder conversation
proves our findings substantial and relevant.