Peer-supported clinic visits strengthen reproductive choices in rural India

Despite improvements in economic and social empowerment, women in many countries still have little control over their own fertility and reproductive health. A new study from the University of Illinois Urbana-Champaign explores a program reducing barriers to family planning by providing financial and peer support to women in Uttar Pradesh, India's most populated state.

Globally, around 270 million women have an unmet need for modern contraception, and this can be even more critical in places like rural Uttar Pradesh where our study takes place. This is a patrilineal and patrilocal society, where women live with their husbands and mothers-in-law, and they are very influenced by the social norms around family planning and fertility."

Catalina Herrera-Almanza, co-author, assistant professor in the Department of Agricultural and Consumer Economics, part of the College of Agricultural, Consumer and Environmental Sciences at Illinois

The study included married women between 18 and 35 who already had at least one child. One group of participants received vouchers to visit a local family planning clinic; another group received vouchers for themselves as well as an additional voucher they could use to invite a peer to join them. A third group served as a control group that received no vouchers.

These women would typically not travel to a clinic by themselves and would most likely be accompanied by their husband or mother-in-law. By encouraging them to bring another woman of childbearing age, the researchers hoped to provide social support for reproductive choices.

"Research shows that social networks can have a big impact on welfare outcomes, both beneficial and detrimental. Inviting a friend along to a family planning clinic may provide encouragement and help women overcome fears of stigma associated with being seen at the clinic," Herrera-Almanza said.

They found that women in the two voucher groups were equally likely to visit the clinic, but the women in the bring-a-friend group were more likely to bring a female peer. They often chose a sister-in-law, perhaps because it was more acceptable to their husbands and mothers-in-law if they brought a family member.

Women in the bring-a-friend group were more likely to start using modern contraception and less likely to fear social stigma, indicating that the opportunity to discuss family planning with peers could lead to stronger reproductive agency.

Importantly, there was no backlash when these women informed husbands and mothers-in-law of their decision to go to a clinic. In fact, the positive effects were stronger when the mother-in-law was opposed to using birth control prior to the study.

"All the women in the study had at least one child, because the social norms indicate that when you get married you have a child right away to prove fertility, and there is a strong preference for sons. The goal for these women isn't necessarily to have fewer children, but to be able to space out child births," Herrera-Almanza said.

The study results underscore that social mechanisms like peer support are important in a community with restrictive social norms. The sample women had very few peers with whom to discuss reproductive choices and encouraging them to bring a friend could be a way to expand their social network and build agency.

"Furthermore, it's important to consider the structure of the household. Decisions aren't just made between husbands and wives. In this patrilocal, patrilinear society, the mother-in-law is also a very important factor. Husbands often migrate for work and are frequently absent, giving the mother-in-law even more power in the household, and policies need to account for this context," Herrera-Almanza concluded.

The paper, "Bring a friend: Leveraging financial and peer support to improve women's reproductive agency in India," is published in the Journal of Development Economics [DOI:10.1016/j.jdeveco.2025.103706]. Authors include S. Anukriti, Catalina Herrera-Almanza, and Mahesh Karra.

This study was supported by a Northeastern University Tier-1 Grant and the Human Capital Initiative's Program for Women's Empowerment Research (POWER) through a grant from the William and Flora Hewlett Foundation (Grant 2020-1162). Supplemental funding was provided by the Global Development Policy Center and by the Institute of Economic Development at Boston University.