Men, The Missing Link In Gender-equitable Family Planning: A Scoping Review

Objectives and defining the scope of the review

The aim of this evidence review is to provide a synthesis of learnings on best approaches to identify and engage young men in FP in order to achieve couples’ collaborative and equitable engagement in FP. Further, the synthesis also throws light on pathways to decision-making for couples, and points to where there are opportunities to tilt the gender equitability quotient in favor of more collaborative family planning decision-making processes.

The review aimed to synthesize the existing evidence to answer the following research questions:

•  What are the motivations and barriers for young men to participate in equitable family planning decision-making and contraceptive uptake?

•  How does the interplay of gender norms influence couple dynamic and their FP choices?

•  What is the evidence that discusses the characteristics and processes of identifying young men who support family planning and contraceptive uptake?

Data sources and search strategy

We examined peer-reviewed research published in two electronic databases, PubMed and JStor, and customized search strategies based on the research questions and key areas of enquiry. A preliminary search of keywords was first conducted in January 2019 (KS) to test the search terms and it was validated with the larger research team. These search terms included but were not limited to: family planning, engaging men in family planning, spousal communication, decision-making, contraceptive uptake, gender norms and family planning, contraception.

The PubMed search strategy was carried out using medical subject headings (MeSH) while the terms used in JSTOR were chosen from a more sociological lens. Along with this, a manual search of reference lists of the identified studies was also undertaken to comprehensively cover the literature. All these searches were conducted between January to March 2019. The search strategy is presented as underlying data. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for Scoping Reviews⁴. The PRISMA checklist is presented as underlying data.

Eligibility criteria

In order to ensure a relevance to concept and context, we adopted the following criteria for inclusion of articles:

Articles were not selected if:

Study selection and quality appraisal

We present a flow diagram to showcase the study selection (Figure 1). References for all studies were entered into the EndNote (Version 9.3.1) library and this was also used for the overall organization of search results.

Figure 1. PRISMA-ScR flowchart of study selection.

Authors (KS, AS) removed duplicates and undertook initial screening of titles and abstracts to remove those clearly outside the scope of the review. The full-text papers, which met the inclusion criteria, were reviewed and included in the final analysis. An article was assessed by considering whether the article reported directly on:

The overall quality assessment of “high”, “medium”, or “low” was based on the evaluation by two reviewers and active discussion until consensus was reached in the case of rating discrepancies. The final list of included articles was approved by all authors.

Charting of key information: Data extraction, synthesis and coding

The data extraction sheet consisted of a breakup of the key areas of enquiry. To detail the key areas thoroughly, both the reviewers (KS and AS) read the first two articles together and detailed the data extraction sheet, it consisted of domains such as: study settings and demographics, study objectives, data collection and methods, themes around contraception uptake, barriers and motivations of engagement of men, other themes, conclusion. Each extraction column on the sheet was defined elaborately to diminish any potential subjectivity that the reviewers may’ve introduced and to ensure inter-assessor reliability.

After the data from both PubMed and Jstor were extracted, it was synthesized using a thematic synthesis approach⁵. This approach uses a step-by-step method to code text, develop descriptive themes based on the codes and generate analytical findings based on the themes. For this, the domains of the extraction sheet were clustered together thematically to further condense and assimilate data. In this too, each clustered domain was defined in detail. Following this, the data were coded based on the occurrence of concepts, and cell numbers were assigned to each concept and the frequency of the data noted. This process was conducted to understand the data in a comprehensive manner, and also the recurring data points. It has been presented in the data synthesis sheet⁶ which has been included as underlying data.

Data analysis and conceptual framework

The synthesized and coded data was further analyzed according to the conceptual framework adapted from the ecological systems framework⁷ for unpacking male engagement in family planning. This conceptual framework was chosen as it captures the complexity that exists within the space of health behaviors and the nature of its inextricable relationship with the social environment. It depicts social interactions amongst various stakeholders at different levels of the ecosystem, and the role of social position in health inequities, making a strong case for the role of power, which exists in all structural and social spheres. We adapted this framework for the purpose of our analyses (Figure 2), comprising, norms at play, the health system, community and family, the couple and the “man” at the centre of it all. We adopt the same schema to present our findings in this paper.

Figure 2. Conceptual framework based on a socio-ecological model for unpacking men's engagement in family planning.

Search results

Of 1,069 records initially identified through the database searches, 208 titles and abstracts were reviewed. Of these, 48 were eligible for inclusion (Figure 1). Articles other than these 48 have also been referenced in this review, mainly in the discussion section, to corroborate and support the findings. This also includes gray literature.

Study characteristics

Data were gathered from 48 articles spread across 26 countries covering vast geographical diversity. Many studies were multi-country and most were from South Asian countries including India, Nepal, Vietnam, Cambodia (31%, n=15) and Africa (70%, n=34) including Ghana, Tanzania, Nigeria. The majority of studies selected from South Asia were from India (23%, n=11).

Half of the studies used qualitative methods (50%, n=24) such as in-depth interviews, focus group discussions, key informant interviews and semi-structured questionnaires. Almost three quarters (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacies (22%, n=12)

Study participants included unmarried men (16%, n= 8), married men (19%, n= 9), married women (19%, n=9), married couples (25%, n =12) or more than two respondent categories (21%, n=10). The sample size ranged from 15 to about 50,000 men and women depending on the methodology of the study. The unit of analysis in these studies were largely men, whether married or unmarried, and couples. Many studies reported engagement of men and couples as opposed to engaging only men.

Studies included in the review were conducted mostly in urban areas (50%, n=24) while some were in rural areas (29%, n=14) and there were some studies (20%, n=10) that did not specify the area. For detailed characteristics of each study included in the synthesis, see Table 1.

Findings

Analysis of data suggests that engagement of men in family planning is influenced by an interplay of actors and factors lying at multiple levels of the ecosystem, aligned to the conceptual framework described above. Given the focus of the review, evidence on mens’ perspectives on FP, dynamics in the couple’s intimate space, their spousal communication and decision-making processes was more extensive. Based on the coding and synthesis and further analysis of data, four cross-cutting themes emerged.

The selected studies were mapped across these four themes, corresponding to our conceptual framework. See Table 2 for information on each of these sub-themes.

1)  Normative and systemic influences on family planning

Norms define the larger ethos of a social context, laying a set of rules for individuals to follow and assume a collective identity, and are reinforced, reinstated and reemphasized⁸ through various practices and customs. Conforming to norms is applauded by society, thus inspiring and to a large extent, enforcing adherence. Family planning is fraught with an interplay of social and gender norms at various levels: the intimate space, family, the community, at the policy and health system levels. Studies suggested that norms related to masculinities, marriage and sex, and fertility, and these are the factors that hold the most bearing on individual thought and action around FP.

Norms of masculinity

Notions of masculinity continue to reward men with a superior status when they adhere to them, while also pressuring them to constantly fulfil a range of expectations throughout their lives. One such example is engaging in risky sexual behaviours, where having multiple partners or engaging in sex without protection is considered a sign of male virility for young men^9,10 Peer pressure may make men who do not fulfil such expectations feel less “manly” and often induces distress and frustration¹¹. Gender-based violence, sexual abuse of women and homophobia in expressions of masculinity are some of the widely documented negative consequences^12–14.

In the studies, both women and men agree it is the main duty of a man to provide sufficiently for the family in their role as providers by maintaining a good standard of living¹⁵. Men also play the role of protectors by perceiving that it is their responsibility to uphold the honour of the women and the family²⁰. In doing so, they may resort to aggressive behaviour, and display strength to guard the sanctity of the family²⁰.

As pleasure givers, men tend to view themselves negatively if they are not able to create a pleasurable sexual experience for women. Sexual performance anxiety is closely tied to rigid notions of masculinity²¹.

Norms of marriage, fertility, and sex

The norms around marriage also vary contextually and are deeply intertwined with norms around sex and fertility. In South Asia, marriage is non-negotiable which culminates in childbearing²². Aspirations of young girls and boys are directed towards marriage from very early ages, and once married both women and men are expected to spend their life within a monogamous marital arrangement.

In certain contexts, and communities, marital unions are not socially imposed but are desirable. In Ghana, Kenya and in many other African countries, it was common for men to have multiple partners and in some cases even for women^24,26,64.

Within contexts where marriage is a norm, sex too is legitimized and is non-negotiable. Quick consummation of marriage, hence, is a signifier of a healthy and stable relationship. Women are expected to provide sex to their husbands as part of their marital duty^16,27. Men, too, display anxieties around ‘performance’ and adhere to the notion that ‘men always want sex’⁶⁵.

Fertility norms are stringent as pregnancies are considered unwanted if they occurred outside marriage/sanctioned norms of companionship and are subject to serious repercussions like community ostracization and violence²⁸. There is a perceived sense of “incompleteness” of home without children, which encourages couples to have children relatively quickly after marriage, mostly within the first year²⁹. An evaluation of the PRACHAR program implemented in rural Bihar, India, reveals the widespread fear that the capacity of childbearing may decline with age and village doctors along with traditional birth attendants also spread this misconception³⁰.

Systemic norms

The influence of context on individual behavior is exerted primarily through institutional and social factors¹⁶. Institutional factors, in the case of FP, are largely mediated through the health system, which can enable or constrain individual behavior. This is reflective of harmful gender norms significantly influencing the perspectives of all systemic actors from policy makers to last mile service delivery functionaries, such as ASHAs (Accredited Social Health Activists), in case of India³⁷. Further, with intermittent and inadequate training, health system actors themselves do not have consistent knowledge across the board and the ‘basket of choice’ is often not explained to the clients¹⁷. The community, familial, and peer networks are also intricately bound by community biases. Be it social demand on couples to have children or myths and misperceptions around FP use, they are percolated and become an exaggerated issue through community stakeholders. Fear of incurring community judgement for not bearing children and is relayed mostly through the mother-in-law^31,32 and preference to have a son also dominates fertility decisions and influences contraceptive use^33,34. Fertility norms hence play a significant factor in the choice of method use. Evidence reveals most couples complete their family size with the desired sex composition of children, and only then go in for female sterilization³⁵.

2)  Unpacking intimacies of couples and its influence on family planning and/or contraceptive uptake

The intimate space of a couple is also where many norms perpetuate and culminate, and hence, it is important to understand this in the context of FP. We present an analytical understanding derived from evidence reviewed, which primarily focusses on intimacies

Markers of ‘couple-making’

“Couple-making”, as suggested by literature, is a lifelong process but the initial years of couples’ relationships largely shape the relationship. These years define the extent to which they will apply gender based cultural scripts^39,40, and their influence^40,41 on sexual behaviour, expression and contraceptive choices. Couples look for windows of time to interact and share their emotional states “in the bedroom,” or when they were together “out in the evening,” in the absence of family members^29,38.

Studies are suggestive of various markers that determine the relationship dynamic between a couple which include their reproductive life course and the quality of their relationship. Reproductive stage refers to whether the individual has yet to start their childbearing, still wants or may want more children or has finished childbearing^{29,38,40,42,43}. Quality of relationships may be determined by levels of intimacy, emotional and physical, and quality of communication, hesitant and fearful or open and comfortable. Each of these have a clear linkage with the FP decision-making of couples.

In some African contexts, unmarried women may also use pregnancy as a way of solidifying their relationship and to convince their male partners to get married to them⁴³ and unmarried partners may resort to control and violence to ensure that women get pregnant and prove their fertility. In a study in India with urban men, clear linkages were found between mens’ attitudes on gender equality and how gender-sensitive is their decision-making around FP and contraceptive use⁴².

3)  Spousal communication around FP and the various initiations, negotiations and considerations

Our analysis suggests that negotiations are a critical feature and a daily element of a couple’s life, as documented in the articles reviewed. For FP related conversations, norms and unequal power relations^33,54 between men and women have serious implications- often making it intimidating for women to have direct communication with their husbands. Women may wait for their male partners to bring up FP, while men think that women should initiate and take responsibility for FP as they “bear the burden” of pregnancy, childbirth, and the care of young children³³.

Knowledge barriers

More than half the studies in the review directed knowledge as the most significant factor^13,45,66 influencing the process of constructive spousal communication. Women and men may possess dissimilar knowledge as a result of their different experiences, exposure and position within the society⁴⁶. In patriarchal settings, where mobility of girls is highly surveilled and school dropout rate is high, the social distribution of knowledge is lopsided. It is understood as the information derived from people’s practical experiences of the world which vary as per contexts too. In contexts like India, schools contribute very little in informing girls or boys about sexuality and reproduction⁴⁷ and couples enter marriages without foundational knowledge about sexual issues and FP. Many newly married couples express a great need for information during their courtship or engagement period²⁵.

Power relations and communication barriers

Conversations were found to be easier if both partners were knowledgeable on the topic of FP⁴⁸. A study in Madhya Pradesh, India, revealed that men’s knowledge of temporary methods is mostly limited to their names and they had fewer platforms to engage on the issue in comparison to women⁴⁹. Men may consider FP if they are informed about it in formal settings, preferably at a facility, by trained providers. Given unequal power relations, comparatively more knowledge by women (even when incomplete), is not taken well by men. They perceive it as their own inadequacy and do not like being educated by their female partners³⁸. While sensing tension, women often hesitate to argue for a method with incomplete information, while this makes it easier for men to dismiss it¹⁰. Along with multiple myths and misperceptions⁵² around side-effects, this limits the couple’s ability to communicate equitably and effectively. This impedes their ability to translate their idea of FP from intention, to active and informed contraceptive choice.

Some studies show that, in the absence of direct discussion, women may often assume that their male partners are against use of FP⁵⁰. One spouse’s perception of the other spouse’s approval is more likely to be correct if they have discussed FP, than if they have not³.

Opportunities for negotiation between men and women

Communication about sex and sexuality maybe initiated by men but women make efforts to accommodate their own expressions⁵¹. Acceptability of women articulating views on sex and desire is higher for urban men⁶³ who are also desirous of greater sexual access and hence encourage these conversations and they seem to want more engagement from their wives, which increases their sexual access. Communication about sex, both verbal and non-verbal, provides women with resources and agency (ibid) over men to draw on, even on other matters of their relationship and family life. This provides an opportunity for further exploration to tap into inducing contraceptive use as sexual negotiations often precede contraceptive negotiations

4)  Influences and pathways to collaborative decision-making around FP

The data suggest that there are a range of factors that couples consider before taking FP decisions, which may lie and play beyond the couples’ intimate space^29,38,40,43.

Economics of method use

Evidence suggests that financial motivations have a crucial role to play and drive couple’s interest in FP. In fact, economic hardships are a standard response for self-use by men, especially in case of vasectomy acceptance³⁸. On the surface, men might be willing to accept women’s contraceptive use but they are unwilling to bear the costs and perceived risks of FP on women. In such cases, they may push or convince women to have unprotected sex⁶⁷. Side-effects experienced by women due to use of FP methods, is a significant deterrent to use for men³⁶. Expenditure on treatment of side effects of their partners as well as loss of agricultural participation^3,53 was seen to put a financial burden on men and make them apprehensive about contraceptive use⁵⁴.

Increased expenses related to care-taking and the need to provide adequate food, shelter, education, and opportunities to succeed for their children^3,26,29,40. Educating one’s children emerges as a significant reason, especially for men, to rethink their fertility aspirations. Studies in Vietnam, India, Tanzania suggest that educating children was felt as a necessity by both women and men, and with smaller family size they can send their children to school, which in turn will allow them to advance in life^3,29,55.

Concordance in sexual and fertility desires

Where fertility desires of women and men are more aligned and communicated,^54,56,57, couples are also able to resist external pressure^38,58 and take up FP. While women are more open to aligning their choices with men, men are reluctant to change their position⁵⁹. A study conducted in Nigeria concluded that men's preferences carry more influence, particularly when the couple has few children⁶⁰. The fertility intentions of a couple may also be triggered by son preference and until the desired sex composition is achieved. The couple may not opt for a modern method⁴² and may also switch to traditional methods of FP. Evidence suggests that men actively support their partner's method use; for instance, reminding their partner to take her pill sourcing and paying for contraceptives increases the likelihood of correctly and consistent method use²⁹.

Men look at maintaining sexual frequency

Couples’ sexual desires also determine their contraceptive use and in turn their ability to fulfill their fertility desires. While infrequent sexual intercourse is often cited as a reason to not use a method⁵⁷, methods which pose a barrier to the frequency and pleasure in sex are also cited as a reason for non-use. In case of condoms, reduced sexual pleasure, oily substance decreasing sexual strength, ‘interrupts foreplay’, ‘ruins the mood’ are often cited reasons^18,36. For long term methods, especially male sterilization, decreased sexual libido and sex drive were seen a hurdle to use. Male sterilization is not considered to be a tenable option due to a range of reasons from poor knowledge and understanding of the method, rumours, and availability of a skilled provider³⁸. A couple who has achieved their family size and wants to maintain sexual frequency may opt for female sterilization and not depend on any reversible method. For other women-centric methods such as pills, injectables – vaginal dryness, irregular or prolonged bleeding were standard responses^3,23.

Matters get further complicated in contexts where multiple partnerships are common. In Sub-Saharan Africa, men may rely on one partner to use a female method, while using condoms with a second, and no method with a third²⁴. This is also representative of the difference in contraceptive-use reporting between men and women and there is evidence which shows that men tend to over-report contraceptive use and provide socially desirable answers^19,68.

Decision-making approaches

Depending on the communication and couple dynamics, decision-making patterns tend to take three main approaches: joint decisions, male-dominated decisions, and female-dominated decisions²⁶. Evidence across Uganda, Nigeria, Vietnam, India and Nepal^52,61–63 points strongly that traditional gender norms elevate men as primary and mostly sole decision-makers. At times, at best, men inform their partners about the decision being taken and women are expected to accept it.

Truly joint and collaborative decision-making remains aspirational, especially when it comes to issues around contraceptive use and family planning. There is not sufficient evidence to suggest that couples who take household decisions together will also display the same equitability when it comes to FP communication and decisions⁵⁷. Even while controlling for household economic status and women’s education, young women have a higher likelihood of receiving appropriate pregnancy care when they reported autonomy in terms of household decision making and access to money¹⁶.

Studies conducted in Kenya, South Africa and Tanzania suggest that economic hardship and widespread unemployment reduce the opportunity for young men to exert their traditional masculine identity as providers and protectors of the family as they used to^{24,28,38,44,50,64}. With higher rural to urban migration, higher costs of living, with women playing a larger role in the labour market and more nuclear family structures the ways in which couples traditionally functioned is slowly changing. It could also potentially apply to decisions around FP as women gather more say in the household but existing literature does not explore this strand.

Limitations of the review

The literature available for the key areas of enquiry were sparse, highlighting the need for this review. To make sense of the data, review team undertook multiple rounds of synthesis. This review provides an analytical synthesis of literature around many domains, but most importantly, around couple’s intimate space and relationship dynamics, thus, making an addition to the research base on family planning.

Given the nature of the review, it may not be possible to draw linear linkages between various concepts and data points and but these are suggested to be seen in a continuum. Since the review focusses on specific domains, especially the communication and decision-making space of the couples, it may not cover all the supply side factors in the FP domain.

Most of the key themes presented in the review were common across studies based out of LMICs and the findings are representative of insights from all geographical locations but they need to be interpreted with reference to context. Thus, caution is needed with generalization of the results.

Underlying data

Harvard Dataverse: Underlying data for ‘Men, the missing link in gender-equitable family planning: A scoping review’. https://doi.org/10.7910/DVN/ETOVRG⁶