At a glance…

  • To increase male participation in family planning decision-making, the Urban Health Initiative (UHI) in Agra, India met with over 10,000 male rickshaw pullers to educate, engage and empower them.
  • As of 2012, an estimated 1,000 rickshaw pullers in Agra shared information with their passengers, families and communities about the benefits of contraception and how to access services.

In many facets of Indian life, including fertility, men are the primary decision makers. The vast majority of women interviewed for the 2010 MLE Baseline Survey for the Urban Health Initiative said they needed their husband’s or family’s permission to use family planning. More than 90 percent of women reported that they decided together with their spouses what type of contraceptive method to use. Many men prefer that their wives undergo sterilization rather than using a hormonal or barrier method or undergoing a vasectomy themselves. Although vasectomies are very safe and medically simpler than female sterilization, misconceptions about loss of virility resulting from male sterilization persist among many men.

A slum resident buying condoms from a traditional outlet. Image Credits: © Urban Health Initiative, 2012

Many men living in the slums of Agra, Uttar Pradesh make their living as rickshaw pullers. Therefore, the Urban Health Initiative (UHI) decided that engaging rickshaw pullers to be family planning behavior change communicators within their communities would help to involve men in family planning, improve communication between husbands and wives and address myths and misconceptions related to vasectomy and other contraceptive methods. UHI first approached the rickshaw stand owners and president of the rickshaw union to build buy-in and support for the initiative. Then, field workers employed by nongovernmental organizations partnering with UHI approached the rickshaw pullers individually. The rickshaw pullers who were interested were then educated in groups about health issues, including the benefits of family planning.

The trained rickshaw pullers help link men in their communities with resources, educational materials and family planning services, including men’s group meetings, fixed service days, interactive educational events on no-scalpel vasectomy (NSV) and focused drives to provide NSV services. Social marketing materials and free contraceptive supplies are available at event sites. Men who express an interest in receiving family planning are registered and receive follow-up visits in their homes by peer educators.

At baseline, preference for female sterilization was far more pronounced among the poorest residents of Agra, where 64 percent of women using a modern contraceptive method chose female sterilization, in contrast to the richest residents, among whom 40 percent chose female sterilization. Among Agra’s richest citizens, only 0.4 percent of men underwent sterilization; none of Agra’s poorest citizens received vasectomies. This gap was the impetus for this UHI intervention’s focus on no-scalpel vasectomy.

The rickshaw pullers promote family planning within their families and communities, using their rickshaws to share information about family planning service delivery sites and to spread awareness of the benefits of family planning by displaying banners and tin plates with family planning messages on their rickshaws. Behavior change communication materials featuring different family planning methods are also available throughout slums and various gathering places.

A rickshaw puller sits with his wife and their first baby. Image Credits: M. Hussain, FHI360, 2010

These activities have not only addressed common contraceptive misconceptions—particularly about NSV—and increased family planning awareness and use by the rickshaw pullers and their customers, but they have also empowered the rickshaw pullers to form collectives which are supported by local organizations and the American India Foundation. These collectives empower members to open bank accounts and access financial institutions for loans to meet their family’s expenses and help rickshaw pullers by ensuring their passengers pay them fare prices based on market regulations. Rickshaw pullers use the collectives as a way to organize to attain their rights; for example, the rickshaw pullers of Azampada slum approached the mayor to demand the removal of the water loggings in their community through the installation of a proper drainage system and road in order to reduce the number of dengue cases in their community.

The success of the program is evident in the fact that 15 to 20 percent of the rickshaw pullers who were exposed to the UHI program opted to undergo no-scalpel vasectomy.

As of 2012, 1,000 rickshaw pullers were working to educate and link passengers and community members with family planning services. The benefits extend beyond these rickshaw pullers and their families. Rickshaw pullers who are satisfied with their choice of NSV then champion the method to their peers, spreading awareness and acceptance of this simple, safe and highly effective permanent contraceptive method.

This story was originally written by the Measurement, Learning & Evaluation Project, which evaluated the Urban Reproductive Health Initiatives (UHRIs) in Kenya, Senegal, Nigeria and India. The Challenge Initiative is charged with expanding access to the proven solutions and successes developed under the UHRIs.