Male involvement in family planning; an often neglected determinant of contraceptive prevalence in Sub-Saharan Africa

INTRODUCTION

Although the world population is estimated to be over seven billion with an almost equal number of women as men, the place of women in the society has not improved much over the years especially in low and medium-income countries.¹ This is largely because of the patriarchal nature of our society.^1,2 The need for male involvement was brought to the front burner on a global scale at the International Conference on Population and Development (ICPD) plan of action, Cairo 1994.² There is sufficient evidence that involving men (and indeed the couple) in family planning and reproductive health issues generally results in improved health outcomes.^2,3 From time immemorial, efforts to improve information, counseling, and access to family planning have been focused mainly on women while neglecting the men, but it is becoming increasingly clear that offering counseling and information to the couple is more effective in terms of improving uptake and continued use of the chosen contraceptive method.^2,4 Although women bear children and most modern contraceptives are female centred, male involvement in family planning as used in this context not only imply the number of males using condoms or who had vasectomy but more importantly men who encourage and support their partners to choose and use a particular form of contraceptive for the purpose of family planning.

The Cairo International Conference on Population and Development (ICPD) programme of action (1994) urged that ‘special efforts should be made to emphasize men’s shared responsibility and promote their active involvement in responsible parenthood, sexual and reproductive behaviour including family planning, prenatal, maternal and child health, prevention of sexually transmitted diseases including HIV, prevention of unwanted and high risk pregnancies, shared control and contribution to family income, children’s education, health and nutrition, recognition and promotion of equal value of children of both sexes’.^2,4 This declaration emphasizes that men should have a central role in both family planning and the reproductive health issues of their partners and by so doing improve the overall well-being of the family in particular and the society at large. Failure to involve men in family planning and reproductive health programmes can have adverse implications. Indeed male responsibilities in family life must be included in the education of children from the earliest ages.

Family planning is considered a key component of basic health services and it benefits the health and wellbeing of the family and the community at large. According to the World Health Organization (WHO), family planning allows individuals and couples to anticipate and attain their desired number of children, the spacing and the timing of their births. It is achieved through the use of contraceptives and the treatment of involuntary infertility.⁵ Other terms used synonymously with family planning include birth control, fertility control, birth planning, these are all semantics. A woman’s ability to space and limit her pregnancies has a direct impact on her health and wellbeing as well as on the outcome of each pregnancy. This ability to decide on the number, spacing and timing of her pregnancies and childbirth is greatly influenced by the male partner especially in our culture where the patriarchal system of family life appears to be the accepted culture.

WHAT HAS BEEN SAID?

Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples.⁵ In Sub-Saharan Africa, the burden of unintended pregnancies is still high and the uptake of modern contraceptive is constrained by limited access, weak service delivery, poverty, religious and socio-cultural influences including opposition from the male partner.^6-8 In this part of the world, major family decision such as number of children to have and the timing of their birth appear to lie heavily with the husband.

In 1999, the centres for disease control and prevention identified family planning as one of the 10 great public health achievements in the United States during the 20^th century.⁹ Access to family planning and contraceptive services was cited for social, economic, and health benefits obtained through smaller family size, and longer interval between the birth of children, increased opportunities for pre-conception counseling and screening, fewer infant, child, and maternal mortalities. The use of barrier contraceptives not only prevent pregnancy but also control the transmission of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and other sexually transmitted infections.^9-11 Despite these overwhelming benefits, our story in the West African sub-region is that of poor gains mainly due to non-involvement of male partners or their lack of interest or outright ignorance. Recent findings suggest that if provided adequate information and counseling, male partners of potential female contraceptive users are more likely than not, to support its uptake and sustained use.¹¹ Statistics show that in some developed countries, the figure rose from 14% in the mid 60’s to 62% in 2008 thereby protecting between 70 million to 600 million women from unintended pregnancies.^12,13 Even in countries as diverse as Thailand, Iran, Egypt and Colombia, there has been significant increase in the acceptance of contraception between 1980 to 2004.¹⁴ The picture in the Sub-Saharan African region is that of modest uptake, this is worsened by lack of access and ineffective government policies and programmes as it concerns family planning, a clear case of misplaced priorities.

Although the methods adopted may vary from region to region but the social and health benefits of family planning is evident across the globe in places where there is significant use of family planning services. The rapid reduction of global fertility rate in recent times from a total fertility rate (TFR) of 4.7 in early 1970’s to 2.6 in late 2000’s is predominantly credited to increased contraceptive use.^14,15 This much success may not have been achieved without involvement of men in family planning.

WHAT ARE THE ISSUES?

Many women of reproductive age in Sub-Saharan Africa do not use modern contraceptives due to numerous factors ranging from cost, side-effects, availability, influence of extended family and lack of spousal support.¹⁶ In Ghana, it was observed that resource constraints which placed the purchase of contraceptive supplies in competition with buying basic necessities for family survival became all the more acute and stressful when male partners objected to fertility regulation.¹⁷ Previous studies conducted in Ghana and Nigeria found that spousal communication predicts contraceptive use and available evidence show that women whose partners disapprove of modern contraceptive practice are unlikely to use or sustain its use.^18-20 In Ethiopia, barriers to women’s unmet need for family planning include their husbands opposition, religion, poor knowledge and lack of communication between spouses.²¹

Nigeria has a high total fertility rate (TFR) estimated to be between 5.5 and 5.7 children per woman of reproductive age with a low contraceptive prevalence rate of 15% among married reproductive age women.¹⁹ Understanding the role of men in their spouses contraceptive decision making could significantly contribute to efforts aimed at increasing uptake in Africa’s most populous nation. A study done in Enugu showed that more than half of the men in the study were aware of contraception and would support the use of contraceptive by their wives while about half of the female respondents equally expressed a desire to use contraceptive.¹⁷ Indeed the study also showed that over 65% of men would support the use of contraception if their partners desire to use them as well. This goes to show that spousal communication is indispensable to achieving a higher contraceptive prevalence.

Contraception plays a key role in decreasing maternal mortality. They provide significant protection for women by preventing unintended pregnancies, which often times end in unsafe abortions.^17,19 Fertility and family planning services have ignored men’s role in the past. Programs and policies focusing on women’s reproductive health services have been traditionally presented within the context of maternal and child health.¹⁸ Partner support is a significant predictor of the likelihood that women will attempt to use a contraceptive method. In this regard, male involvement refers to any activity that seeks to enhance the provision of reproductive health services including information provided through activities targeted at males of all ages, either individually or as part of a sexually active couple.^22-26 A study done in Ethiopia in 1993 showed that contraceptive use nearly doubled among couples that received husband-wife counseling compared to when women alone were counseled.²⁷ In China, husbands involvement in the counseling process contributed to reduced rates of unintended pregnancies and unsafe abortion among couples initially not using intrauterine devices.²⁸

Non marital birth rates among teens and young adults in the United States are high, particularly among low income and racial and ethnic minority populations. Increased contraceptive use is central to future reduction in non-marital births.²⁹ Exploring men’s reproductive health knowledge is particularly important in a developing country like Nigeria, where most women have limited control over their lives and completely dependent on husbands and older family members for making decisions regarding their health. Poor knowledge of reproductive health issues among men may pose barriers for women to seek care for health problems including access to and use of contraception.³⁰ A four-day workshop organized in India observed that men felt alienated, isolated and ridiculed when it comes to reproductive health since policy makers do not factor their input into such an important endeavour.³¹ The workshop suggested that giving men more opportunities to articulate their problems and get involved in family planning matters could make them more sensitive to women’s problems and ultimately support any decision that better the lot of the women folk. One major factor that appear to suggest male alienation in family planning is limited male contraceptive methods.²⁹ This narrative needs to change.

HOW DO WE CHANGE THE NARRATIVE?

Male involvement in reproductive health is a complex process of social and behavioural change that is needed for men to play more responsible role in reproductive health. It not only implies contraceptive acceptance but also the need to change the attitude and behaviour of men towards women’s health, make them more supportive of women using health care services and sharing child bearing responsibilities. Participation of men in reproductive health issues leads to a better understanding between the husband and wife, reduces unwanted pregnancies and the unmet need for family planning.²⁹ In India for instance, a dismal picture of male participation in family planning is reflected in the wide gender disparity in contraceptive usage especially that of female sterilization. It was shown that for every hundred women only three men undergo sterilization.^30,31 Although the percentage of women using a contraceptive method increased from 40.6% to 48.2%, the share of male method reduced to only about 21%. This emphasizes the need to design strategies to involve men in reproductive health issues. Spousal communication can improve family planning use and continuation.^32-34 However in countries with high fertility rates and unmet needs for family planning, Nigeria inclusive, men have often been regarded as unsupportive of their partner’s use of modern family planning methods.³⁴ This may not be entirely true. A study done in Mpigi Uganda found that even though men were of aware of the health benefits of family planning, their major fears where based on known or perceived side effects of female contraception which they claimed could reduce sexual pleasure, infertility, excessive bleeding which could lead to female fatigue and reduced interest in sexual activities with their spouses.³⁵ This was seen as a precursor to having extra-marital affair which they claimed they would rather oppose the use of contraception by their partners than indulge in such act. From the same study it was observed that men were not comfortable with the two common available mode of male contraception; condom and vasectomy. They believe that condom use significantly reduce sexual pleasure while vasectomy would lead to losing one’s masculinity, hence they were both unacceptable to the majority of male respondents in that study. Other perception of men regarding their views on family planning as gathered from this study are the erroneous believe that large family size was a social symbol in the society and fear of sexual promiscuity on the part of the female partner, since the fear of extra-marital pregnancy will be eliminated by the use of a contraceptive method.³⁵ Appropriate male counseling and provision of relevant information will disabuse their mind and dispel such misconceptions. This should equally be backed up with relevant government policies and programmes meant to encourage male participation in family planning as shared responsibility.

A pre-requisite for the use of contraceptives is adequate knowledge about the various methods available. For a high rate of contraceptive usage to be achieved, the population needs to be very familiar with at least one of the methods of contraception. A study done in Southwest Nigeria showed that about 65% of the male respondents knew at least one modern method of contraception with condom been the most popular amongst them, 88.1%. Knowledge of some traditional methods like abstinence and withdrawal methods were equally high among them.³⁶ Sadly, despite this high knowledge of modern contraceptive methods, only 32% where actually using it, albeit inconsistently. Interestingly, it was found that more men than women (63% compared with 35.7%) would approve the use of family planning. Only about 50% of women and 38.1% of men had discussed the issue of family planning with their spouses. More than half of the respondents were of the opinion that men should take decisions regarding family size, child spacing, contraceptive choices and other health related decisions.³⁶ A culture that is widespread in Nigeria. Men in the developing world, Nigeria included are often the primary decision-makers about family size and use of family planning.^36,37 A considerable discordance between couples on issues of family planning and desired family size is common place in most developing countries. It is evident that male involvement in family planning and reproductive health would enhance equality in gender relation, promote better relationship between couples and hence improve their sexual and reproductive well-being.^37,38

Male income/social status also appears to be an important factor in their consideration and support for the use of family method by themselves or their wives. A study has shown that men who are high income earners are more likely to use contraception.³⁹ Interestingly, recognition is growing on a global scale that male involvement in reproductive health policy and service delivery offers both men and women important benefits.⁴⁰ On a wider scale, such involvement could lead to decreased maternal mortality, increased contraceptive prevalence, reduce overall prevalence of HIV/AIDS, an outcome only possible if men are involved not just as clients of reproductive health care but also as partners, service providers, policy makers, teachers and project managers.^36-40

Involving men in family planning services is particularly challenging in countries whose culturally defined gender roles may hinder men’s participation. For example, in countries where communication between spouses is limited and manifestation of masculinity often involve violence against women, high risk sexual behaviour is common place. Involving men in such a setting could be difficult but could be achieved with long term public education and attitudinal change. A programme sponsored by United States Agency for International Development (USAID) in Cambodia found that Cambodia as at 2001 had 437/100,000 live births with one of the worst maternal mortality ratio in the world, a low contraceptive prevalence of 19%, one of the highest HIV prevalence in Asia at 1.9% and a high rate of unintended pregnancies.³⁹ But following a country wide intervention in the form of health education, counseling and promotion of reproductive health services as a couple driven affair, the indices have significantly improved.³⁹ This improvement was attributed to the impact of male involvement in both policy making and reproductive health services.

The importance of involving men in family planning activities cannot over stressed. Studies from several countries cited above has shown that reproductive health programmes are more likely to be more effective for women when men are actively involved and alienation of men ultimately leads to reduced uptake. Failure to involve men in family planning programmes can have negative outcome because even when the women are educated and motivated to practice contraception, they may not be able to do so.^6-8 Although the majority of married women in Nigeria are not currently using contraceptives and have no intention of doing do in the near future, the high level of awareness about contraception but very low level of use has been established in studies in Nigeria.^6,7 Lack of pragmatic intervention to disabuse the minds of the society regarding their perception of family planning and it’s benefits has not helped in this regard. In Nigeria, the high rate of population growth has been driven by high fertility rates, which have fallen much less rapidly than the crude death rate. This poor outlook could be due to poor accessibility of services, low status of women, high illiteracy rate among women, the patriarchal nature of the society and a general lack of involvement of men in family planning.

MEN AS PARTNERS

An approach that addresses men as partners reflects the view that men can improve women’s contraceptive use and reproductive health. These programmes view men as allies and resources in efforts to improve contraceptive prevalence rates and other reproductive health indices. While this focus of viewing men as partners is ongoing, efforts should also be made to address the gender inequities prevalent in our society which significantly favours men and puts women at a disadvantage.

MEN AS CLIENTS

This emphasizes the need to provide reproductive health services to men in much the same way that women receive these benefits. There is no doubt that men also have their own unmet reproductive health needs that ought to be addressed. It reflects a limited interpretation of male involvement if simply it advocates a remedial focus on men who have been excluded from traditional reproductive health services. This is clearly reflected in the ICPD Cairo declaration emphasizing that men should be involved in women’s sexual and reproductive health services as this largely guarantees success. Many interventions to offer men the opportunity to examine and question the gender norms that harm their health and that of their sexual partners should be instituted. This approach should emphasize how services are provided and looks to reinforce gender equity rather than specifying which reproductive health services should be provided and to whom, this is divisive. Although the interventions that involved men as agents of positive change are relatively few, they serve the interest of men as well as women by increasing men’s choices, their knowledge level and the overall well-being and survival of the entire family.

CONCLUSION

The international conference on population and development in Cairo changed the focus of family planning programs and research. Although women had historically been the focus of reproductive health services, research has shown the importance of involving men in family planning. Due to gender imbalance worldwide, men may hold the key to increased contraception use and reduced unmet need. By including men in family planning initiatives, studies consistently show that male knowledge about contraception will increase, as will communication between partners about the issue. These two factors will lead to positive male attitudes and behaviours regarding contraceptive use. Furthermore, as men become more educated about and less threatened by family planning, the dialogue occurring between couples may be lending contraception decision making power to women. However in order to more effectively include men in fertility regulation, the international reproductive health community must continue to determine the predictors of contraception use and unmet need.

Efforts must be made to re-conceptualise the role of men in family planning, this will necessarily involve changing long held beliefs about the meaning of masculinity, exercise of power by men as well as instilling a sense of what is meant to be a responsible and supportive sexual partner and father. The first step to accomplishing this goal is to continue researching on the specific reproductive health and family planning needs of men. Also, the international reproductive health community must continue to define the sexual and reproductive rights of men without infringing on the rights of women. Women’s feelings about their partners becoming more involved in contraceptive and reproductive decisions must always are considered for balance and synergy.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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