# Women and health workers’ conceptualisations of reproductive coercion and abuse: a comparative synthesis from Brazil, Nepal, Palestine, and Sri Lanka

## TL;DR

This study explores how reproductive coercion is understood and experienced by women and health workers in four countries, highlighting the need for better awareness and support in low- and middle-income regions.

## Contribution

The study provides a comparative, cross-cultural analysis of reproductive coercion in Brazil, Nepal, Palestine, and Sri Lanka, emphasizing local contexts and structural barriers.

## Key findings

- Reproductive coercion is recognized as a form of domestic violence across all four countries, involving pressure to control pregnancy.
- Cultural norms like son preference and restrictive health policies hinder women's reproductive autonomy in Nepal and Sri Lanka.
- Health workers face challenges addressing reproductive coercion due to religious beliefs and institutional constraints.

## Abstract

Reproductive coercion and abuse (RCA) is a hidden form of violence against women, involving controlling behaviours by a partner or family member to manipulate a woman’s reproductive autonomy, either to prevent or promote pregnancy. It correlates with partner violence, unintended pregnancy, contraceptive non-adherence, and poor sexual and reproductive health. However, research often oversimplifies RCA, treating it as a uniform phenomenon and neglecting its diverse manifestations. Additionally, there is scarce evidence on RCA in low- and middle-income countries. This study examines the conceptualisation and discourse surrounding reproductive coercion among health workers and women victims/survivors in Brazil, Nepal, occupied Palestinian Territories, and Sri Lanka. The main objectives include: 1) Investigating acts of reproductive coercion reported by women and health workers. 2) Exploring how health workers approach reproductive coercion in their practice. 3) Understanding the structural, institutional, and social barriers affecting victim/survivors encounters with reproductive coercion.

We conducted 62 qualitative interviews with health workers and domestic violence victims/survivors across the four countries, plus three focus groups with women in Nepal. Data were analysed thematically.

The findings reveal that reproductive coercion emerged as a form of domestic violence across all settings studied. Reported acts of coercion and violence by both women and health workers included attempts to force pregnancy against a woman's wishes and to hinder contraceptive use, driven by jealousy or the desire to promote pregnancy. Perpetrators, mainly husbands and family members (particularly in-laws in Nepal and Sri Lanka), employed various coercive behaviours such as pressure, decision-making control, threats (e.g., leaving the partner or violence), verbal harassment, and physical violence. The analysis also underscored broader structural and social challenges constraining women's reproductive choices and health workers' responses, encompassing religious beliefs surrounding contraception and abortion, cultural norms regarding son preference (notably in Nepal), and restrictive health policies concerning abortion and spousal consent for family planning (observed in Nepal and Sri Lanka).

The study emphasises the necessity for further research to comprehensively understand acts of reproductive coercion and abuse and guide health workers in effectively addressing this issue.

Reproductive coercion and abuse (RCA) is a hidden form of violence where someone controls a woman’s choices about having children, either by forcing her to become pregnant or preventing her from doing so. This can have serious consequences, like unintended pregnancies and poor reproductive health. However, RCA is often misunderstood and oversimplified in research, particularly in low and middle-income countries (LMICs), where the issue has not been studied enough. This study looks at how RCA is understood by health workers and women in four countries: Brazil, Nepal, occupied Palestinian Territories (oPT), and Sri Lanka. The study aims to identify the types of reproductive coercion experienced by women, understand how health workers deal with it, and explore the cultural, social, and structural barriers that make RCA difficult to address. Researchers conducted interviews with 62 health workers and victims/survivors of domestic violence and held group discussions with women in Nepal. The findings show that RCA is a form of domestic violence, with women being pressured by partners and family members, especially in-laws, to either become pregnant or stop using contraception. Women in Brazil reported facing pressure (sometimes described during clinical encounters) not to seek abortions. Cultural beliefs like a preference for sons, religious views on contraception, and strict health policies added to the difficulties women face in controlling their reproductive choices. The study concludes that RCA is a complex issue shaped by cultural, religious, and social factors. It calls for more research to help health workers better understand and address reproductive coercion, especially in LMICs.