• Manipulation of a woman’s reproductive autonomy is domestic violence 
• Attempts to force pregnancy against wishes and to hinder contraceptive use
• The perpetrators are mainly husbands and family members 
• Decision-making autonomy and safety over male or family control required 

Reproductive coercion and abuse (RCA), to manipulate a woman’s reproductive autonomy either to prevent or promote pregnancy, is a form of domestic violence against women in Sri Lanka. Women and health workers in Sri Lanka report acts of coercion and violence including attempts to force pregnancy against a woman's wishes and to hinder contraceptive use, driven by jealousy or the desire to promote pregnancy. The perpetrators, mainly husbands and family members (particularly in-laws), employ various coercive behaviours such as pressure, decision-making control, threats (e.g., leaving the partner or violence), verbal harassment, and physical violence. It correlates with unintended pregnancy, contraceptive non-adherence, and poor sexual and reproductive health (RH). Broader structural and social challenges constraining women's reproductive choices and health workers' responses encompass religious beliefs surrounding contraception and abortion, cultural norms regarding son preference, and restrictive health policies concerning abortion and spousal consent for family planning (FP).

Therefore, structural changes within health systems; comprehensive training for healthcare workers in the form of in-service and pre-service education including for being culturally informed, and for interventions that prioritise women's right to RH agency; and decision making autonomy, and safety over male or family control including carefully designed community-based awareness activities engaging husbands and mothers-in-law, are required to address RCA.

These findings and recommendations were made in a research article on "Women and health workers’ conceptualisations of RCA: A comparative synthesis from Brazil, Nepal, Palestine, and Sri Lanka" which was authored by M. Colombini, A. Shaheen, P. Rishal, P. Siriwardhana (attached to the Rajarata University's Social Sciences Department, and the Peradeniya University's Medical Faculty), C. Garcia-Moreno, L.J. Bacchus, S. Morse, E. Hartman and A.F. d’ Oliveira, and published in the Reproductive Health journal's 22nd Volume.

RCA is a significant public health issue, disproportionately affecting younger women. RCA prevalence varies significantly. It involves behaviours that interfere with a woman's autonomy in making reproductive decisions, including contraceptive use and pregnancy choices. Coercive actions, often accompanied by physical violence, range from promoting pregnancy (e.g., sexual violence, contraception sabotage, or pressuring a woman to continue a pregnancy) to preventing pregnancy. Control, fear, and intent characterise these RCA actions. RC may result from macro health policies or from interpersonal relationships.

RCA is primarily perpetrated against women and young girls, mostly by their husband or partner. However, in some contexts, other family members, such as mothers-in-law, may also engage in it. RCA can occur independently, as a distinct form of violence against women, though it is often viewed as the mechanism connecting intimate partner violence (IPV) to negative RH outcomes, highlighting their close relationship. Perpetrators of IPV often attempt to control women’s fertility, significantly impacting their ability to negotiate safe sex, access and utilise contraception, and obtain FP services. For example, a Rwandan study with expectant couples and current parents revealed that women who experienced RC in the past year are approximately 2.5-four times more likely to report experiencing IPV.

Perceived motives for RCA behaviours are diverse and include son preference, control over women’s lives and decision-making, rigid gender roles, family pressure, family formation or dissolution, entrapment and self-interest, and a desire for domination and control.

Beyond its impact on women’s reproductive autonomy, RCA is also associated with a range of adverse health consequences that are detrimental to the RH and well-being of women and girls. These include the increased risk for sexually transmitted infections, poor mental health, post-traumatic stress disorder, the repeat use of emergency contraceptives, unintended pregnancies, and lower contraceptive self-efficacy. It has a complex impact on women’s experiences of mothering, with some women feeling detached, resentful, and guilty toward their children. Furthermore, RCA hinders broader achievements toward gender equality, economic prosperity, and sustainability.

RCA in SL

RCA is a pervasive issue across Sri Lanka, shaped by patriarchal norms, societal expectations, and cultural practices, with varying degrees of family or societal pressure influencing its prevalence. Yet, policy addressing the issue remains limited.

Sri Lanka is characterised by a high number of unwanted pregnancies, societal expectations, and restrictive abortion laws (Section 303 of the Penal Code, No.2 of 1883), shaping women’s reproductive choices, with limited attention given to coercion in policy. Sri Lankan health guidelines (the Health Ministry's Family Health Bureau's National Guideline for First Contact Point Health Care Providers) lack a comprehensive definition of RC though they stress the importance of providing women with information and options regarding contraceptive methods.

Despite the pervasiveness of RC among women and girls seeking FP services, it remains overlooked in health interventions. Global guidance on how FP health workers can identify and respond to RC is relatively new (the World Health Organisation's [WHO] "Caring for women subjected to violence: A WHO curriculum for training health-care providers").

Most health interventions targeting RCA – though limited — have been implemented in FP clinics. The most well-known intervention to address RC - Addressing RC in Health Settings (ARCHES) - is being adapted for low- and middle-income country (LMIC) settings. ARCHES is a brief, clinician-delivered universal education and counselling intervention in FP clinics aimed at reducing IPV, RC and unintended pregnancies. However, effective models for addressing RC and IPV within other clinical services in LMICs have yet to be identified.

Furthermore, although health workers are essential in identifying and responding to RCA, there remains a significant gap in understanding how these health workers and other non-health professionals address RCA. Additionally, contextual differences in how healthcare workers perceive and respond to coercive acts related to RCA also remain underexplored.

Methodology 

SL

In Sri Lanka, the research involved urban public health facilities, including hospitals in Colombo. Sri Lanka also uses One Stop Crisis Centres for referrals. These Centres are crisis management facilities for victims of violence, providing integrated health, legal, and psychosocial support. 

Participants sampling, study tools and data collection methods

A purposive sample of 62 qualitative interviews, and three focus group discussions were considered. Health workers were purposively selected based on their experience in providing care to women affected by IPV, while victims of IPV were identified through existing services at the study site. Female community volunteers were purposively selected based on their ability to reflect on community experiences with IPV. Interviews were conducted from June 2019 to August 2020, and November 2019 to February 2022. 

Results

While some RCA related perceptions and responses are unique to specific contexts, several commonalities emerge. These include the normalisation of male control over FP, the limited recognition of RCA as abuse, and the lack of training.

Most women were aged between 20–45 years, predominantly married, and with children. Health workers include nurses and doctors. 

Perceived manifestations of RCA experienced by women

Two distinct categories of RCA emerged: coercive behaviours to promote pregnancy and coercive behaviours to prevent pregnancy Most were perpetrated by husbands, though, in some instances, in-laws were involved as well.

Manifestations of RCA 

RCA often involves husbands controlling their wives' use of contraception, sometimes motivated by jealousy or the suspicion of infidelity. The pressure to conceive more children is common, though not always recognised as coercive behaviour by healthcare workers.

Health workers’ awareness and perception of RCA 

Health workers showed limited awareness of RCA as a distinct issue. The choice of contraception was often viewed as a matter of couple decision-making, with the husband's consent playing a significant role.

Health workers’ responses to RCA 

Health workers attempted to advise women on the importance of using contraception and the health implications of repeated pregnancies. Some tried to discuss FP use with husbands, but, cultural norms limited the effectiveness of these interventions. There is a lack of systematic approaches to address RCA.

Coercion and abuse to promote pregnancy

Pregnancy coercion was the most frequently reported type of RCA. This form involves various pressures exerted on women to become pregnant or to continue pregnancies against their will. Women report emotional abuse, pressure, verbal threats, and physical abuse when they attempt to use contraception or express a desire not to conceive more children. 

The fear of retaliation led some women to conceal their contraceptive use.

RCA: coercion to prevent pregnancy and coercion to promote pregnancy. The perpetrators include husbands/partners who exhibit all related behaviours. Cultural and religious influences include societal fertility norms. Legal and policy influences include restrictive abortion laws, and policies requiring spousal consent for contraception.

"Some women here say that their husbands want more children, but, they (the women) don’t. They don’t call it violence; it’s just how it is," a Sri Lankan health worker said.

Extreme pressure to bear children is often rooted in cultural preferences for male children. Health workers report instances where women were either threatened or physically beaten by their husbands, either for being suspected of carrying a female child or for refusing to conceive again soon after childbirth.

One woman shared that her husband wanted her to be pregnant constantly, believing that it would keep her busy with the children while he pursued extramarital affairs. "He always asked to make a baby. There were economic issues also. They didn’t even matter to him. He had several other affairs with other women. That's why he wanted to have many children in order to keep me occupied at home all the time," a Sri Lankan woman said.

Coercion and abuse to prevent pregnancy

Conversely, in some situations, women are pressured – or forced – to use contraception (e.g. injection or tubal ligation) to prevent pregnancy by partners or in-laws. Coercive behaviours related to preventing pregnancy are reported by respondents (primarily health workers), but are less common than coercion to promote pregnancies. These include forcing contraceptive use by husbands and in-laws. 

Healthcare workers’ recognition and understanding of RCA behaviours

The researchers distinguish here between the health workers’ recognition and understanding of RCA, and their actual responses in clinical settings. This separation allows to highlight a key gap between recognition and action.

The extent to which health workers encountered RCA varied. Many health workers did not directly associate these situations with abuse. Instead, they thought that husbands’ influence on contraceptive use was part of couple-decision making. "Here, it’s common for the husband to have a say in whether his wife uses contraception. It’s seen as part of couple decision-making," a Sri Lankan health worker said.

Perceptions of RCA varied noticeably, often shaped by local cultural norms and the policy context. In Sri Lanka for example, FP is often viewed as a decision requiring the husband’s consent and health workers felt that women are unable to act independently in these matters. Such a statement reflects deeply ingrained patriarchal attitudes and gender biases, which persist even when not supported by legal or clinical policy requirements. "Even if a woman wants to use FP, she can’t go against her husband’s wishes," a Sri Lankan health worker said.

Healthcare workers’ responses to RCA 

The responses of health workers to manifestations of RCA varied, often reflecting their limited awareness and understanding of the issue. Their actions ranged from expressing confusion about why women would not use contraception when they did not desire more children, to counselling husbands on contraception use.

In some cases, health workers attempt to engage with male partners directly to advocate for delaying pregnancies or allowing their wives to use contraception. However, these approaches involving male partners are often fraught with challenges including safety related concerns.

Organisational issues within healthcare systems also influence health workers’ responses. Some nurses refer women who report experiencing RCA — primarily being forced to forego contraception — to doctors for further guidance on FP, though this is not always effective. For instance, a Sri Lankan hospital nurse described difficulties in consulting a doctor for FP advice due to delays, which further complicated efforts to support women facing family pressure to discontinue contraception. "It’s hard to get through to the doctor for advice on FP. 

Discussion

RCA is a significant problem, driven by cultural, religious, and social norms, and perpetrated by husbands, with in-laws playing a role. RCA took two forms: coercion to either promote (pregnancy coercion) or prevent pregnancy, often involving verbal, emotional, or physical abuse when women resist. In Sri Lanka, jealousy and suspicions of infidelity led husbands to control contraception to ensure their wives’ fidelity.

The results highlight the complex and context specific nature of RCA, demonstrating that while forms of abuse may be similar, the underlying motivations and justifications vary significantly by cultural, religious, and social factors. Cultural drivers like son preference, religious and community norms, gender power imbalances, and organisational practices condone RCA and hinder women’s reproductive choices. Understanding the acts and perpetrators of RC is essential for shaping services that support women and health workers, as well as for reducing gender-based discrimination in countries where son preference is still prevalent.

Despite these differences, one common theme is the lack of training and preparedness among healthcare workers to know how to respond, leaving many feeling unequipped to intervene effectively. 

RCA is rarely acknowledged as a form of abuse, with health workers often viewing it through the lens of cultural and societal expectations and policy requirements that gave the male authority dominance in FP decisions. Therefore, it is critical to also consider health policy contexts that reinforce gender inequalities, such as requirements for the husband’s authorisation for certain RH services, including contraception and abortion. 

The importance of health provider interventions like listening, identifying coercive signs, discussing relational contexts, and creating a safe environment for disclosure are emphasised. However, challenges such as the lack of time, inappropriate settings, and inadequate training hinder effective intervention. These challenges are further compounded in LMICs by deeply entrenched gender norms and power imbalances, making it even harder to address RC behaviours.

Promising intervention strategies that adopt human rights and women centred approaches include ensuring private consultations with women, focusing on confidentiality, respecting autonomous choice, and building a supportive environment for disclosure. 

Tailoring intervention strategies to these unique contexts is essential to empower healthcare workers and support women in regaining control over their RH and rights. Healthcare systems should prioritise training and supporting healthcare workers to recognise signs and respond to RCA, and also educate women, discuss and offer strategies and resources to make informed reproductive choices.

Organisational practices that involve men in FP decision-making are important. However, mediation with husbands should be approached with caution, as this may increase safety risks to both women and health workers. Discreet contraceptive options, such as injectables, can help women navigate patriarchal control over their RH. Given the strong link between RCA and IPV, it is crucial that health workers in primary or maternal health are also trained to identify and respond to RCA.

Conclusion

The cultural specificity of RCA highlights how patriarchal, religious, and social norms shape RC. While the core manifestations of RCA — whether coercion to promote or prevent pregnancy— are consistent, the motivations and justifications for these actions vary widely.