By Author
  By Title
  By Keywords

April 2004, Volume 54, Issue 4

Original Article

Facilitating Inter-Spousal Communication for Birth Spacing - a feasibility study of Pakistani Couples for Policy Implications

S. Saleem  ( Department of Community Health Sciences, The Aga Khan University, Karachi )
M. A. Isa  ( The Asia Foundation, Islamabad. )

Abstract

Objective:
To test three practices introduced to couples for adaptation of a non-permanent modern method of family planning and the role that each partner played during the process.
Setting: Urban and sub-urban areas of Karachi, Lahore, and Quetta.

Methods:
'Behavioral trials' was conducted which is a formative research method in which researcher and participants negotiate behavior(s) that the participant agrees to try for a specific amount of time. Interviews were conducted on 72 married couples (144 men and women) living in urban and sub-urban areas of Karachi, Lahore and Quetta. Study participants were either non-users of modern methods of family panning, or using traditional methods. The three behaviors negotiated were: a) Discuss benefits of birth spacing with spouse; b) discuss specific methods of family planning and decide on the most appropriate one and c) initiate use of a modern temporary method of family planning.

Results:
After the introduction of first practice, of 72 couples 38 reported failure to initiate the discussion with their spouse. Where women initiated the discussion the response from spouse was not as favorable as where men initiated the discussion. After introduction of second practice 28 couples were successful in discussing about selection of a family planning method. Twenty-four couples finally selected and used a method. Traditional users were more likely to adopt a modern method than non-users, especially those with 3-5 children.

Conclusion:
Strategies to cultivate a culture of inter-spousal communication on use of family planning methods should be developed as a component of family planning programs. (JPMA 54:182;2004.

Introduction



Over the years, the concept of men's involvement in family planning (FP) has been extensively explored, evaluated, and questioned especially in developing countries. Some considered use of condoms, or practicing withdrawal and abstinence as men sharing the responsibility for family planning while, others regarded women using contraception as an indicator of men's participation for allowing their women to use contraceptives.1-3
With more access to information on causes of high unmet need for family planning4-6 the concept of sharing responsibilities took more in-depth meaning, and focus turned over to the significance of fostering inter-spousal communications not only for family planning but also for other reproductive health needs of both partners.7-9
In traditional patriarchal societies, of which Pakistan is also a member, initiating discussion on sensitive topics by women still remains difficult. Male dominance prevents women to express their desire for sexual needs, use of contraception, or to decide for number of children.3,10 Men considered use of contraception by women as a tool for infidelity, and a challenge to their power and manly status.11-13 Pakistan's family planning program lacks communication and educational services for men hence the supportive role of men remains wanting for effective use of family planning methods. There is a dearth of information on couple studies from Pakistan, especially in family planning method use.
This paper presents the results of three practices introduced to couples for adaptation of a non-permanent modern method of family planning and the role that each partner played during the process.

Methods



'Behavioral trials (trials of improved practices or TIPs)' was conducted, which is a formative research method in which researcher and participants negotiate behavior(s) that the participant agrees to try for a specific amount of time. Behaviors are then assessed through periodic interviews. Such trials are conducted on a small number of participants selected purposively on categories considered relevant to the program within the chosen population segments.
This study was conducted in collaboration with three partner NGOs The Lyari Community Development Project (LCDP), Karachi; Maternity and Child Welfare Association of Pakistan (MCWAP), Lahore and Mehac Trust for Community Welfare and Development, Quetta, from July to October, 2000 mainly in the urban and peri-urban areas of Karachi, Lahore and Quetta.
The three practices negotiated were:
a) Discuss benefits of birth spacing with spouse b) discuss specific methods of family planning and decide on the most appropriate one c) initiate use of a modern temporary method of family planning.
Special interview guides were prepared and pre tested in the similar situation as of study populations. An information booklet (with illustrations) regarding appropriate use of various methods of family planning, their efficacy and side effects was prepared in consultation with experts to facilitate couples to discuss and select a most appropriate method. The book and referral cards with the address of the nearby family planning center were provided to the study participants as part of second and third practice.
A screening process was carried out to identify eligible men and women. The eligibility criteria to participate in the study was to be either a user of a traditional method or a non-user of a family planning method, belonging to one of the major ethnic groups of the study area, and having up to 5 children. Screening and enrollment was stopped once the sample size of 12 men (idex husbands) and 12 women (Index wives) was completed from each site (Karachi, Lahore and Quetta). Informed consent was obtained from each person contacted for the assessment of eligibility before enrollment in the study.
As a first practice, Index husbands and Index wives were counseled for the benefits of three years of spacing and were asked to initiate discussion with their spouses on the same. A week later during second interview, information on the experience of initiating discussion with the spouse on spacing was obtained separately from husbands and wives.
As a second practice, along with FP counseling information booklet with illustrations was provided to index respondents. A third interview was scheduled two weeks later with couples together to gain information on the experience of discussing use of family planning methods with each other. As a last practice couples were provided with the information about the available FP services in the area along with referral cards and approximate cost of each method. Last interview was scheduled after four weeks with couples to gain information on their experiences on use of family planning methods (Figure). Data was analyzed by using both qualitative and qualitative methods of analysis.

Results



There were no major socio-economic and demographic differences among the index men and women and their spouses. The mean age of index husbands was 32 ± 8 years, and their wives was 25±4 years. The mean age of index wives was 25 ±5 years, whereas mean age of their husbands was 30± 6 years. In both groups (men and women), men were more educated, though husbands of index women had an edge (83.3% vs 61.1% respectively). Moreover, where husbands initiated the discussion 61 % of the families were living in a nuclear set up as compared to where women initiated the discussion (41%). The mean duration of marriage was same between the two groups.
Of 36 index husbands, 19 were users of traditional methods (breast feeding, withdrawal, safe period and abstinence) and 17 were non-users of family planning methods. Of index wives 26 reported as users of traditional methods and 10 as non-users of family planning methods.
As first practice 36 men and 36 women were counseled for benefits of three years of spacing and were asked to initiate discussion with their spouses. Seventeen index husbands reported failure to initiate discussion: five each from Karachi and Lahore and seven from Quetta. Ethnically there were no major differences. The reasons for failure were: five men themselves and wife of one man refused discussion about spacing as they considered it against their religious beliefs or were not convinced for spacing; additionally three more men refused due to cultural reasons. Two wives disclosed their pregnancy status which was not known to the husbands earlier, one wife was taking oral pills secretly and disclosed this to her husband only when he initiated discussion on spacing, one man was in conflict with his wife so discussion did not occur, one wife wanted more children, one wife refused due to pressure from in-laws though her husband was supportive, one man was afraid of side effects and decided to decline from the study and one man and one wife was not available for the interview in spite of revisits and due to non-cooperation were dropped from the study.
There were 21 failures where women initiated the discussion, four from Karachi, nine from Lahore and eight from Quetta. In this group also no major ethnical differences were identified. After initial discussion with their husbands, 10 index women begged to be excused from the study due to their husbands' disapproval, four couples desired more children, two women disclosed their pregnancy status, and two reported pressure from in-laws to not to use family planning and were threatened for physical and verbal abuse. Further more, one wife was not available for the interview in spite of repeated visits, one did not initiate the discussion due to fear of disapproval from her husband, and one wife reported conflict with her husband and refused to further participate in the study.
Overall, where women initiated the discussion the response from spouse was not as favorable as where men initiated the discussion.Thirty-four couples that had conversation (19 where men initiated the discussion and 15 where women initiated the discussion) succeeded in doing so because of their mutual interest for the betterment of family and willingness to discuss spacing.
After the introduction of second practice to 34 couples, twenty-eight were successful in discussing about family planning methods. Of six failures; two wives missed their menses and were in doubt about their pregnancy status, three couples could not find time for discussion in given time and one wife became ill. Those couples that succeeded in discussing family planning, found the booklet very informative and helpful. Viewing the illustrations in their own timings and privacy was the main motivating factor for carrying out the discussion. Those men and women, who could not read consulted friends/doctor/younger sister to read to them of what was written in the booklet. Some of the comments made about the booklet were as follows:
"We felt embarrassed to talk to each other, this was the first time we had this kind of discussion; reading booklet was easy." One wife
One husband commented: "I already had information about pills and condoms but this booklet has given me information about other available methods for example Norplant, injections and IUCD."
The impeding factors during discussion which couples felt were religious and cultural constraints and fear of side effects of modern methods of family planning.
The couples generally did not involve any third person during the discussion and considered this as a personal issue.
Of 28 couples, 24 finally selected and used a method. Eleven of these couples were from Karachi, 9 from Lahore, and 4 from Balochistan. Of these, fifteen couples had 3-5 children and 9 had 1-2 children. Couples with 3-5 children reported discussing about spacing more often as compared to those with 1-2 children. The majority of couples opted for condoms (n=9) injections (n=7), pills (n=6), and IUCDs (n=2).
Four couples that did not adopt a method were either traditional users who were successful in having their desired spacing or those who ultimately decided to have more children.
Of 24 couples, which finally adopted modern methods, 17 were traditional users and 7 were non-users. In fourteen couples husbands were the initiators of discussion and in 10 couples women initiated the discussion. Nearly all couples made joint decisions for selecting a method. Husbands generally obtained condoms from chemists, while wives contacted family planning or MCH centers or lady health workers of the area to procure a method. The difficulties felt by the men and women in getting a method were; men felt embarrassed asking for condoms from chemists of their own areas who are generally known to them. Men also raised concerns for not being permitted in family planning clinics and MCH centers along with their wives to gain information. While women from Quetta had difficulty in obtaining a method due to restricted mobility. Both men and women were not satisfied by the quality of family planning care services as they were not satisfied by the counseling provided, and physical examination conducted. However all-24 couples showed intentions to continue with the method used in future.
The couples that completed all the three practices were demographically not different from those couples that refused to participate after the introduction of second and third practices except their education status as a couple. For those who finally accepted and chose a method 54 % of couples were educated (primary and above), where as in those couples that declined to further participate 43 % of both partners were educated (Table).
In summary, our results suggest that husbands were more successful in initiating a discussion on spacing and selecting a method, though wives also played an important role and were supportive. Illustrative booklet was a useful source of disseminating information on family planning methods. Moreover, traditional users were more likely to adopt a modern method than non-users, especially those with 3-5 children. Couple education status was also helpful for the final selection and use of a method.
Discussion
Although NGOs and Government of Pakistan took initiatives in developing and implementing population and family planning program in early 1950's, involvement of men in family planning program remained wanting. In an attempt to make improvements in the program women were generally interviewed for their perceptions and practices about use of family planning methods.14-16 Men were ignored and no efforts were made to validate perceptions of women by interviewing men at the same time. There were only two surveys from Pakistan asking information on family planning from men as well.2,17 However, these surveys were conducted on a smaller sub sample of men making comparisons uncertain. A similar gap in information was identified from other countries where men were not involved in family planning programs and a need for information from couples were identified .5 This lack of male involvement has resulted in a slow rise in contraceptive prevalence rate in the country over the years. We introduced three practices to facilitate inter-spousal communications and assessed impact by interviewing husbands and wives separately and as a couple. An attempt was also made to assess factors that facilitate or hinder inter-spousal communication for future programmatic implications.
According to 1990-1991 Pakistan Demographic Health Survey, only 56% of husbands approved of family planning, and one third of Pakistani husbands had no idea what their wives thought of family planning. Only 39.7% of men mentioned discussing family planning with their wives. In our study, 63.3% of index men reported discussing spacing with their wives where as 41.2% of index women had discussion with their husbands. More than 55% of the refusals were from index women. From both groups, (index men and index women) the main reasons for refusals were husband's disapproval, and religious and cultural constraints. These findings are in agreement with findings from other developing countries.3,18 Our study has clearly identified that men's approval is an important factor for deciding to use a family planning method. This has important programmatic implications for a successful family planning program.
Studies from Africa and Pakistan have documented the fear of women in expressing their desire for use of family planning methods to their husbands or in-laws for dread of physical and verbal abuse.1,10 Several women in our study expressed similar apprehensions when they were requested to initiate the discussion with their husbands on benefits of spacing. Some of the comments made by women are self-explanatory:
"Husbands have their own minds. God knows how he will react. He will discuss it if he wants to."
"I do not know how he will react because last time I talked about family planning, he was very quiet."
"Talking about this topic is a sin."
"Husband will be very angry, but I will try."
However, where men initiated discussion, there was only one respondent who was not sure about his wife's reaction. A more recent national survey from Pakistan conducted on married women of reproductive age group gave insight into reasons for non-use of family planning methods; religion was not the main reason for non-use.13 We believe this differential in the responses from men and women in our study is a reflection of a traditional society where man is the decision maker and woman a follower rather than religious dogmas as a constraint for non-use of family planning methods. Information from Indonesia also support our results where cultural traditions and role of man as a decision maker over ruled any other reason for non-use of family planning methods.3 Pakistan has 33% of unmet need for family planning, in other words 33% of women with an expressed desire to limit or space children are not using contraceptives. Husband's disapproval is the third major cause mentioned by women for non-use of contraception.13 We suggest that culturally appropriate family planning programs with a focus on achieving approval of men should be developed in a way to draw on them as an agent of change, especially in Balochistan.
Appropriate information on family planning methods can increase contraceptive prevalence rate, reduce the chance of method failure and increase the likelihood of switching over from relatively less effective method to an effective one.19 In our study we provided couples with individual and couple counseling and an illustrative booklet with information on family planning methods. Couples were also provided with referral cards to the available family planning services in the area for further clarification and consultation. Though we do not have the direct evidence, but we believe that our informational booklet and interpersonal counseling played a major role in helping couples to choose a more effective methods of contraception.
In our study the couples that were the traditional users and those with 3-5 children were more prone to adopt a modern temporary method of family planning as compared to non-user or couples with 1-2 children. In order to achieve the ambitious national goals of reducing fertility through enhanced voluntary contraception to 4 births per woman by the year 2004 and to replacement level of 2.1 births per woman by 202020, we suggest that emphasis of national family planning program should be on young couples with 1-2 children, these couples should be provided with complete information on family planning methods with associated side effects and an initial contact with men is strongly recommended especially in communities with stronger cultural ties.
We recommend that for successful implementation of any family planning program especially in traditional societies, an initial contact with men should be emphasized. Appropriate information about family planning methods should be provided to couples for raising awareness and their use. Strategies to cultivate a culture of inter-spousal communication on reproductive health issues especially for use of family planning methods should be developed as a component of family planning programs. Furthermore, couples that are traditional users and those who have at least one child should be counseled about benefits of spacing.

References



1. Pakistan Demographic and Health Survey-1990-91.
2. Mohamad JR, Andrew BL, Ubudi. Husband's approval of contraceptive use in metropolitan Indonesia: program implications. Stud Fam Plan 1988;3:162-8.
3. Kiani KFM. Understanding men's role in family planning in Pakistan. In: Pakistan's Population Issues in the 21st Century. Proceedings of First annual conference of Population Association of Pakistan; Oct 24-26 2000, Karachi; pp. 83-100.
4. Bankole A, Singh S. Couples fertility and contraceptive decision making in developing countries: hearing the man's voice. Intel Fam Plann Persp 1998;24:15-23.
5. Bongaarts J, Bruce J. The causes of unmet need for contraception and the social content of services. Stud Fam Plan 1995;26:57-75.
6. Becker S. Measuring unmet need: wives, husbands or couples?. Intel Fam Plann Persp 1999;25:172-80.
7. Wells E. Involving men in reproductive health. Out look 1997;14:1-7.
8. Blaney CL. Involving men after pregnancy. Network 1997;17:22-25.
9. Johansson A, Nga NT, Huy TQ, et al. Husbands' involvement in abortion in Vietnam. Stud Fam Plan 1998;29:400-13.
10. Casterline BJ, Sathar A Z, Haque M. Obstacles to contraceptive use in Pakistan. New York Population Council New York, 1998.
11. Bawah AA, Akweongo P, Simmons R, et al. Women's fears and men's anxieties: the impact of family planning on gender relations in Northern Ghana. Stud Fam Plann 1999;30:54-66.
12. Bankole A. The role of mass media in family planning promotion in Nigeria, DHS working papers Calverton, MD, USA: Macro International, 1994, No. 11.
13. Mustufa MA, Mumford SD. Male attitudes towards family planning in Khartoom, J Biosoc Sci 1984;16:437-50.
14. Hakim A, Cleland J and Bhatti M. Pakistan Fertility and Family Planning Survey (1996-97). National Institute of Population Studies, Islamabad and Center for population studies. London: School of Hygiene and Tropical Medicine, 1998.
15. Pakistan Contraceptive Prevalence Survey (1994-95). The Ministry of Population Welfare and the Population Council. September, 1995.
16. Hakim A, Sultan M, ud din F. Pakistan Reproductive Health and Family Planning Survey (2000-1). National Institute of Population Studies, Islamabad. July 2001 (Preliminary report).
17. National Impact Survey 1968-69.
18. Petro-Nustas W. Men's knowledge and attitudes toward birth spacing and contraceptive use in Jordan. Intl.Fam Plann Persp 1999;25:181-5.
19. Bulut A. Acceptance of effective contraceptive methods after induced abortion. Stud Fam Plann. 1984:15;281-4.
20. Population Policy of Pakistan. A Document of the Ministry of Population Welfare, Government of Pakistan, 2002.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: