Background
As of the 2021 Census, approximately 66.8% of India’s population resides in rural areas. (Ministry of Health & Family Welfare, 2023). With an estimated population of 1.4 billion in 2023, approximately 963 million people live in rural areas, and women comprise nearly half of this population—around 480 million rural women. The autonomy of these women in making decisions related to their sexual and reproductive health is crucial, not only for their individual well-being but also for the broader societal development. However, significant barriers prevent many rural women from exercising full autonomy in their sexual and reproductive health decisions, and data indicates that substantial gaps exist in achieving this goal (UNFPA, 2020).
One of the key frameworks addressing these issues is Sustainable Development Goal (SDG) Indicator 5.6, which aims to ensure universal access to sexual and reproductive health and reproductive rights. This goal is critical because it emphasises the need for informed decision-making in sexual and reproductive health, a fundamental aspect of gender equality and women’s empowerment (UNFPA, 2019). In India, the urgency of this goal is underscored by the high rate of unintended pregnancies and unsafe abortions. Approximately 16 million abortions occur annually in India, representing about 77% of the 48.5 million unintended pregnancies each year (Ministry of Health & Family Welfare, 2023). Unfortunately, around 800,000 of these abortions are unsafe, contributing significantly to maternal mortality, despite the legal framework established by the Medical Termination of Pregnancy (MTP) Act (IIPS and ICF, 2021). This highlights the persistent barriers rural women face in accessing safe sexual health services, particularly due to inadequate healthcare infrastructure compared to urban areas (Kesterton et al., 2010). This indicator is a critical measure of gender equality and women’s empowerment, particularly in the context of sexual and reproductive health rights (SRHR) (UNFPA, 2019).
Why Focus on SDG 5.6.1 in Rural India?
Rural areas are often more vulnerable to healthcare infrastructure, limiting access to essential reproductive health services (Kesterton et al., 2010). Many rural health facilities are poorly equipped, and the availability of skilled healthcare providers is often sparse. This stark contrast between urban and rural healthcare access means that rural women are disproportionately affected by a lack of information, services, and support for their reproductive health needs (IIPS and ICF, 2021).
The patriarchal structures prevalent in rural communities tend to prioritise male decision-making, leaving women with a limited say in their own health choices. Often, husbands or elders make family planning decisions, reflecting a broader cultural expectation that women should not assert control over their reproductive lives (Osamor & Grady, 2016).
Sexual autonomy, singularly in rural India, is often conditional, shaped by external justifications rather than genuine personal choice (Osamor & Grady, 2016). Women may feel justified in refusing sex under specific circumstances, such as concerns about sexually transmitted infections, but this does not equate to full autonomy over sexual relations. The broader right to refuse sex based on personal comfort, mood, or simply the choice not to engage is rarely recognized or respected within traditional rural settings (Mistry et al., 2009).
Assessing Trends and Gaps in Autonomy
Persistent Gaps in Women’s Autonomy
Figure 4.2
The National Family Health Survey (NFHS) series consistently reveal troubling gaps. For instance, in Figure 4.1, NFHS-3 (2005-06) reported that only 27.1% of women could independently make decisions about their healthcare, a figure that decreased to 20% in NFHS-4 (2015-16) but slightly increased to 25.3% in NFHS-5 (IIPS and Macro International, 2007; IIPS and ICF, 2017; IIPS and ICF, 2021). However, a majority of healthcare decisions (56.5% in NFHS-5) are still made jointly with husbands, highlighting how traditional gender roles continue to dictate household dynamics, severely restricting women’s autonomy over their health.
Figure 4.3
For example, in figure 4.3, only 28.4% of women in NFHS-5 could independently make major household purchases, and just 30.1% could decide on visiting family alone (IIPS and ICF, 2021). These figures suggest that if women struggle to exercise autonomy over routine, non-intimate aspects of their lives, their autonomy in more critical areas, such as sexual and reproductive health, is likely to be even more constrained (Osamor & Grady, 2016).
Sexual and Reproductive Health Autonomy
Figure 4.4
According to NFHS-4, as shown in figure 4.4, approximately 36% of rural women reported that they could decide whether to have sexual relations with their husbands or partners (IIPS and ICF, 2017). NFHS-5 data show that only 54% of rural women could decide on contraceptive use either alone or jointly with their partners, and 87.2% felt justified in refusing sex if their husbands had a sexually transmitted disease (STD) (IIPS and ICF, 2021).
Further, in terms of contraception use, according to NFHS-3, 54% of women used some form of contraception, with 37% opting for modern methods. This figure remained largely similar in NFHS-4 and only slightly improved in NFHS-5, where 54.5% of women used contraception, with 48.6% using modern methods. The unmet need for family planning remains significant; NFHS-3 reported that 56% of women wanted to avoid or delay pregnancy but did not use contraception, which improved to 22% in NFHS-4 and further to 19.8% in NFHS-5. Many women face pressure to conform to traditional family structures that prioritise childbearing and view contraception as a deviation from their expected roles.
The available data does not capture the complexity of women’s autonomy in terms of fundamental aspects of true sexual autonomy. The right to say no at any time, without needing a health-related justification, reflects genuine empowerment and respect for personal boundaries, which are still largely missing from rural women’s experiences as documented by current surveys.
This gap highlights that while some progress, quantitatively, has been made in merely acknowledging women’s right to protect their sexual health, it falls short of recognising their broader autonomy over their bodies and decisions based on personal preference, comfort, or desire—critical elements of true gender equality.
This challenge is compounded by the high prevalence of domestic violence in rural areas; NFHS-4 reports that 29.3% of rural women have experienced physical violence, and 14.3% have faced sexual violence, making the assertion of sexual autonomy particularly difficult and risky. The threat of domestic violence severely limits women’s ability to refuse sexual intimacy purely based on their mood or personal desire, as doing so could escalate into violence or further abuse.
This torpidity is attributed to several persistent barriers: inadequate healthcare services, lack of comprehensive family planning education, cultural resistance, and socio-economic constraints. Many rural health facilities are understaffed, lack essential supplies, and are located far from women’s homes, making access to contraceptives difficult. Additionally, misinformation and fears surrounding contraceptive side effects continue to deter usage.
Barriers to Menstrual Hygiene Management
Menstrual hygiene management remains a pressing issue for rural women in India, with substantial barriers that hinder access to hygienic menstrual products. NFHS-3 data revealed that 62% of rural women used cloth for menstrual hygiene, while only 36% used sanitary napkins (IIPS and Macro International, 2007). This situation has seen minimal improvement over the years, with NFHS-5 data showing that 67% of women still rely on cloth and only 29.5% use sanitary napkins (IIPS and ICF, 2021). The high cost of sanitary products makes them unaffordable for low-income women, who often resort to cheaper, less hygienic alternatives like cloth. This economic disparity underscores the need for subsidised or free sanitary products to ensure equitable access.
NFHS-5 data highlights that a lack of prior awareness contributes significantly to poor menstrual hygiene, as women are often uninformed about the health benefits of using sanitary products. Only 12% of menstruating women in India use sanitary pads, with over 88% relying on alternatives like unsanitised cloth, ashes, and husk sand. (Sinha, 2011). This knowledge gap perpetuates traditional methods, which lead to health complications.
The stigma attached to purchasing sanitary napkins, especially from male shopkeepers, pushes women towards using more discreet but less hygienic methods like cloth. Cultural attitudes often view menstruation as something to be hidden, further limiting access to modern menstrual products. The availability of proper sanitation facilities greatly impacts menstrual hygiene practices. NFHS data shows that 65% of young women with access to flush toilets at home use hygienic methods, compared to just 28% of those without proper toilet facilities. This stark difference emphasizes the importance of basic sanitation infrastructure in promoting better menstrual health.
Decline in Institutional Deliveries
Institutional delivery rates, a crucial indicator of maternal health services, have shown troubling trends in rural India. There was a marked increase in institutional deliveries from 38% in NFHS-3 to 78% in NFHS-4, but this figure dropped sharply to 45.6% in NFHS-5 (IIPS and Macro International, 2007; IIPS and ICF, 2017; IIPS and ICF, 2021). Similarly, the reliance on government facilities decreased from 62% in NFHS-4 to 34.8% in NFHS-5.
Financial, cultural, and logistical factors already influence institutional deliveries in rural India. The cost of delivery poses a significant barrier; public deliveries cost Rs. 230 (US$5.8), private Rs. 1,039 (US$26.1), and home births are just Rs. 160 (US$4.0). For many low-income families, even public facility costs can be prohibitive, pushing them toward home births (Kesterton et al., 2010).
Cultural perceptions also play a critical role. Many rural communities view public healthcare as substandard, lacking essential newborn care, and often see childbirth as a natural process not requiring medical intervention, especially in Northern regions (Kesterton et al., 2010).
Lastly, geographical accessibility is often outweighed by perceived poor quality, cultural beliefs, and financial constraints. Even women near healthcare facilities frequently choose home deliveries, indicating that proximity alone is insufficient to drive utilisation of institutional care (Kesterton et al., 2010).
These pre-existing factors were over and above exacerbated and led to the sharp decline in institutional deliveries in rural India, as observed between NFHS-4 (2015-16) and NFHS-5 (2019-21) during the COVID-19 pandemic. The limited access was further strained during the pandemic, as many rural hospitals and health centers were overwhelmed or repurposed to handle COVID-19 cases, leaving little capacity for other essential health services, including maternal care. Private healthcare facilities were either shut down, redirected their focus to COVID-19, or became even less accessible due to increased costs and financial strain on rural families, pushing many women away from institutional deliveries (Sundararaman & Ranjan, 2020, p. 8).
Chronic underfunding of the public health sector meant that rural health facilities were ill-prepared to manage the surge in patient loads during the pandemic. With limited resources, inadequate staffing, and a lack of essential medical supplies, rural healthcare systems struggled to provide safe and reliable care, leading many families to opt for home births instead. This lack of preparedness and the fear of contracting COVID-19 at healthcare facilities significantly deterred women from seeking institutional deliveries during this period (Sundararaman & Ranjan, 2020, p. 11).
The Need for a Holistic Approach and the Way Ahead
Addressing the superficial gains in women’s autonomy requires more than isolated policy changes or short-term initiatives. It calls for a holistic approach integrating economic empowerment, cultural transformation, and systemic improvements in healthcare access.
1 Localising Destigmatision Approaches
There are significant geographical disparities in the use of hygienic methods during menstruation among adolescent women in rural India. For instance, states like Kerala and Tamil Nadu had higher rates of hygienic method usage than states like Bihar and Uttar Pradesh, where the prevalence was notably lower. (Singh et al., 2022)
Localising the efforts of campaigns and reaching the correct target audience is of utmost importance; initiatives such as the Pavna Menstrual Hygiene Programme successfully reaped results in the Raigarh district of Chattisgarh due to its community-based folklore, slogan writing, street plays (nukkad natak) and radio messaging. (Pavna: A Unique Community-based Menstrual Hygiene Programme, n.d.) A specific and localised approach in terms usage of regional languages and connecting specific masses geographically can have a stronger impact than structural policies alone.
While measures such as the Menstrual Hygiene Management Scheme (MHS) under the Swachh Bharat Mission (SBM) are a step forward in the correct direction, it is important to have an inclusive approach to the problem. The women elders of the villages and families should be informed of the benefits of switching to modern methods of menstrual hygiene and should be encouraged to support the younger girls who might not have the direct autonomy to make this call for themselves.
2 Coherent Data Collection: Qualitative Psycho-Social Aspects
Current NFHS surveys are largely quantitative, failing to capture the complex psycho-social factors such as cultural norms, stigma, and interpersonal dynamics that influence women’s health decisions (Koneru et al., 2020).
Regular district-level qualitative assessments using interviews and focus group discussions are further classified into various age groups and genders for in-depth analysis that may vary in intersectionality. This will provide deeper insights into barriers and mental blocks women face. Sensitive interventions that go far beyond initial rapport formation and require extensive fieldwork by research experts are crucial for targeting deeply entrenched stereotypical notions.
The real answer as to why the uptake of healthcare services remains low despite multiple government initiatives like Ayushman Bharat- HWCs, Free Drugs, and Diagnostics Initiatives (Steps taken by Government of India, 2023) lies at understanding the root cause of psycho-social aspects of research and data collection that often gets overlooked.
The qualitative side of data collection would help unfold and unlock overlooked norms of toxic femininity that restrict growth and moving forward to modern ideas within women’s circles. Toxic femininity manifests through behaviors that reinforce patriarchal structures, such as policing other women’s choices, promoting submissive roles, or enforcing traditional gender norms that limit autonomy. (Snider, 2018)
This approach enables targeted, culturally to address deeply rooted norms and empower women in their reproductive choices (Osamor & Grady, 2016). Enhanced qualitative data collection will build a stronger evidence base for policies that genuinely reflect and address women’s needs in rural settings.
3 Upskilling Community Health Workers (CHWs)
Community Health Workers (CHWs) are often the first point of contact for women in these communities, and their training needs to go beyond medical knowledge to include effective communication and culturally sensitive approaches that respect women’s autonomy. Only 4% of women report receiving high-quality counselling, highlighting the need for enhanced training to ensure interactions are respectful, informative, and supportive (Osamor & Grady, 2016). By improving counselling skills, CHWs can bridge knowledge gaps, dispel myths about contraceptive use, and empower women to make informed decisions. Deploying more CHWs and establishing mobile health clinics can address the significant service delivery gaps in rural and underserved areas, where only 22% of women reported receiving family planning counselling (Mondal et al., 2020). Mobile clinics can deliver essential reproductive health services directly to communities, reducing travel, time, and cost barriers. Integrating these services within existing community structures and tailoring them to local needs can ensure broader access to resources.
4 Infrastructural Preparedness
According to the National Health Accounts (NHA) estimates, public health expenditure in India has historically been low compared to other countries. As of 2017-18, public health expenditure was approximately 1.28% of GDP, significantly lower than the World Health Organization’s recommendation of at least 5% for developing countries to ensure adequate healthcare services. The National Health Policy 2017 aimed to increase public health expenditure to 2.5% of GDP by 2025, but progress towards this goal has been slow.
The impact of this under-financing has been reflected through the state of the rural healthcare system and its unpreparedness for the challenges posed by COVID-19, which included an increased demand for healthcare services, disruptions in regular medical care, and a reallocation of resources away from routine health services. There is a dire need for rural healthcare systems to be adequately resourced to handle both routine and emergency health needs. This can be done through means like (Sundararaman & Ranjan 2020):
- Building new healthcare facilities, upgrading existing ones, and ensuring they are equipped with essential medical supplies and technology. This also involves improving transportation networks to facilitate access to healthcare services, especially for remote communities
- Need for increased financial resources allocated to public health systems. Increased investment can help recruit and retain healthcare professionals, improve training programs, and enhance the quality of care provided
- Many existing insurance plans do not cover outpatient services, leading to high out-of-pocket costs that can drive families into poverty. Expanding coverage to include preventive care, outpatient treatments, and essential medications can alleviate the financial burden on rural households
- Deploying mobile health units, telemedicine services, and community health workers who can provide care in underserved areas. Affordability can be enhanced by implementing sliding scale fees based on income, subsidising costs for low-income families, and ensuring that essential medications are available at low or no cost
- Training healthcare workers in emergency response protocols, establishing stockpiles of essential medical supplies and creating communication strategies to disseminate information quickly during a crisis. Preparedness also involves conducting regular drills and simulations to ensure that healthcare systems can respond efficiently to outbreaks or pandemics
- Need for better sanitary disposal systems in rural areas, such as setting up incinerators, waste bins for sanitary products
- Conclusion: A Comprehensive Path to Empowerment
The path to empowering rural women in India and enhancing their reproductive health and sexual autonomy is multifaceted and requires a coordinated approach. By improving healthcare accessibility, enhancing counselling quality, engaging communities, and addressing socio-cultural barriers, we can create an environment that supports women’s autonomy. Empowerment programs, educational opportunities, economic development, and strong health infrastructure are crucial to this comprehensive strategy. Continuous monitoring, evaluation, and advocacy will ensure these initiatives remain responsive and effective, ultimately fostering a society where rural women can make informed and independent decisions about their health and well-being.
