African Population Studies
Union for African Population Studies
ISSN: 0850-5780
Vol. 10, Num. 1, 1995
African Population Studies/Etude de la Population Africaine, Vol. 10,
November/novembre
1995
Family
Planning in Africa:
Old Belief and New Perspective
Yanyi K.
Djamba
Code Number: ep95001
Abstract
This
article reviews the underlying assumption of most family planning programmes
in Africa. The results show that the hypothesis that African men oppose the
use of contraceptive methods is erroneous. Rather, current data reveal that
men want to learn more about birth control. Also, most men and women believe
that husbands are the primary decision-makers of reproductive and sexual
lives. A new perspective for men's involvement programmes is then provided
as a route to low fertility in Africa.
Résumé
Le
présent article passe en revue l'hypothèse de base de la
plupart des programmes de planification familiale en Afrique. Les résultats
montrent que l'hypothèse que les hommes en Afrique s'opposent à l'utilisation
des méthodes contraceptives modernes est erronée. Tout au
contraire, les données actuelles révèlent que les
hommes veulent en savoir davantage sur le contrôle des naissances.
Aussi, la plupart des hommes et des femmes pensent-ils que les maris (époux)
sont les premiers à prendre des décisions en ce qui concerne
la vie reproductive et sexuelle. Une nouvelle approche consistant à mettre
en oeuvre des programmes visant à impliquer les hommes semble constituer
la voie royale vers une baisse de la fécondité en Afrique.
INTRODUCTION
Family
planning programmes in Africa have traditionally concentrated on reaching
women through the maternal and child health services. Based on the conventional
wisdom that African men oppose family planning, this female-dominated structure
of most family planning programmes neglects men who in many African countries
usually make decisions in matters of sex and family size. The purpose of
this article is to show that this view which has reinforced the belief that
family planning is women's business is wrong, and that early programmes of
family planning missed a key ingredient for success: men.
Though
some men may be reluctant to practice birth control themselves, recent survey
data show that men are more conscientious users than are women when they
do accept family planning (Stokes, 1980). Men are also more likely than women
to persuade their friends to accept family planning. And when male family
planning acceptors select female methods, they are, compared to women, more
often able to get their partners to use them successfully (Brown et al. 1990).
As efforts to bring family planning to women are almost exhausted, now is
the time to include men in family planning campaigns.
After
reviewing data from different surveys, policy recommendations are presented
for increasing contraceptive use through men's involvement. The ultimate
aim is to reach a situation where it will no longer be necessary to develop
separate programs for men and for women, but programmes for couples in the
interest of the family as a social unit.
Do
African Men Really Oppose Family Planning?
Survey
findings do not support the assumption that African men are opposed to family
planning or that they have little interest in spacing and limiting births.
On the contrary, there is evidence that men are aware of family planning
and are open to learning more about it. In a Zimbabwean national survey of
men with reproductive-age wives, Adamchak and Mbizvo (1991) found that virtually
all men had received family planning information mainly from radio and personal
communications. Interestingly, nearly 85 percent of these Zimbabwean men
said that they would like to learn more about family planning.
A
1989 survey of married men in two suburbs of Accra revealed that men expressed
interest in using family planning services, both for themselves and their
wives (Armstrong and Onsei, 1989). Similarly, data from a 1982 survey of
male Khartoum residents show that three in five men with reproductive-age
wives wanted to use family planning, and more than half of the men wanted
to learn more about male and female sterilization (Mustafa and Mumford, 1984).
Cases
in which husbands oppose the use of family planning are usually negligible.
A study conducted in Dakar, for example, shows that only about six percent
of teachers oppose the use of family planning. This value represents the
highest rate across all employment categories; moreover, it does not appear
surprisingly high given the fact that teachers want relatively more children
than do other workers (Posner and Mbodji, 1989).
Table
1 shows national percentages of currently married women who are not using
a contraceptive method because of opposition from their husbands. These data
show that husband's opposition is not the most important reason for nonuse
of contraceptive methods. In fact, a majority of women who reported their
husbands as disapproving have never discussed family planning with them.
Thus, the perception of husband's opposition is associated with the lack
of communication: "ignorant of their spouses' views, women assume them to
be negative [...]" (Bongaarts and Bruce, 1994:23). In Kenya, for example,
the lack of communication between spouses proved to be a more common obstacle
to contraceptive use than male opposition (MacCauley et al. 1994:18).
Who
is the Decision-Maker?
Conjugal
relationships are largely defined in cultural terms. The relative power of
spouses in the making of fertility decisions involves their socialization
to specific roles and their interaction over the reproductive life span.
Although these relationships may vary from one culture or ethnic group to
another, there is evidence that many African men and women believe that husbands
should be the primary decision-makers regarding contraceptive use and marital
sexual activity.
Data
from a 1991 survey of five urban areas in Nigeria illustrate this pattern.
To discover which spouse is the most influential in family decisions, the
following question was asked to both husbands and wives: "In family decisions,
are you influenced more by your own views, the views of your spouse, or those
of your parents, relatives, and friends?" As shown in Table 2, about 88 percent
of married men and 78 of married women replied that husbands' views are more
influential in family decisions (Isiugo-Abanihe, 1994). Only seven percent
of husbands and 16 percent of wives said women are more influential.
Examining
both quantitative and qualitative data from Ghana, Ezeh (1993) found that
spousal influence regarding reproductive goals is an exclusive right exercised
only by the husband. A woman's characteristics do not affect her husband's
family planning attitude, but her contraceptive attitude largely depends
on her husband's characteristics. The author argues that this pattern operates
both through men's comparative advantage in mate selection and through cultural
norms which subjugate women to men. Further evidence of husband's role in
family decision matters is given in Table 3. Data in this table reveal that
a large majority of men and women agree that most often husbands make reproductive
decisions, decide whether or not to have sexual relations, decide upon the
duration of abstinence, and make choices about the practice of family planning.
In
a 1991 survey conducted in Kinshasa, Zaire, married men and married women
were asked to name the person who decided that contraceptives be used in
their marriages (Djamba, 1994). Results in Table 4 show that among users
of modern methods of birth control, 67 percent of men and 65 percent of women
said the decision was made by the husbands. For all (modern and non-modern)
methods, the figures are 64 and 57 per cent, respectively for male and female
respondents.
These
men and women were also asked to report on their sources of contraceptive
information, especially the first and last methods that they have ever used.
Table 5 shows that 18 percent of women received information on the first
contraceptive method from their husbands; the figure goes up to 25 percent
for the most recent contraceptive method used. In contrast, for both the
first and last methods ever used, only 5 percent of men said they got contraceptive
information from their wives. These results support the idea that men are
in charge of family decisions, and that they constitute an important source
of contraceptive information for their wives.
What
Happens When Men are Involved in Family Planning?
During
the past decades, the need for family planning - well known as unmet need
- has been rationalized by the proportions of sexually active women who do
not wish to become pregnant but do not practice birth control. Such a measure
may not reflect reality because most reproductive decisions are not made
by women but by men. Several countries in Sub-Saharan Africa have conducted
experimental programs to provide family planning information, services, and
supplies to men. But only programs that also focus on enhancing couple communication
about reproductive behaviour have produced positive results.
Communication
between spouses is positively associated with contraceptive use, duration
and effectiveness of use, and negatively associated with demand for children
and fertility preferences. Furthermore, communication is assumed to lead
to greater empathy and to increase a couple's ability to act together to
achieve goals. However, because of the sensitivity of the topic, feelings
of shyness or modesty, and fear of challenging the husband's authority, women
are less likely to initiate discussions about family planning and sexual
activity. Nonetheless, most women are willing to talk about reproductive
matters if the topics are initiated by their husbands.
The
Ghanaian approach is very interesting. Ghanaian family planning professionals
sponsored tournaments of games that men like, such as soccer and checkers,
to get men and women talking about family planning. They recruited wives
to oppose their husbands, altering the rules where necessary to make a fair
match. In these games, male players are only allowed to use their left feet,
and the female players are allowed extra members. The winners are given a
gallon of condoms, or another prize that will spark conversation about family
planning. Couples are talking, and family planning is losing its wrong connotations.
Half of the reduction in fertility in one rural area in Ghana is associated
with the acceptance of family planning by men.
Another
relevant experiment was conducted in Addis Ababa, Ethiopia (Terefe and Larson,
1993). Married couples were randomly selected and further divided in two
groups. In the control group, wives were given a health talk on their own
during the family planning home visitation education. Husbands were included
in the experimental group. A greater proportion of couples in the experimental
group were practising modern contraception following the home visitation.
The inclusion of husbands nearly doubled the prevalence of modern contraception
(Terefe and Larson, 1993).
Data
in Table 6 clearly show that engaging men's interest and support can considerably
increase contraceptive use. On average, the (perception of) husband disapproval
led to a reduction in use by two-thirds. Furthermore, women who approved
of family planning were more likely to use a modern method if they had discussed
with their husbands in the year before the interview than were women who
approved of family planning but had not discussed it (MacCauley et al. 1994:25).
The
most consistent finding from the preceding analysis is that husbands and
wives frequently do not discuss contraception. As a result, women think their
husbands do not approve of family planning. But in the cases where husbands
are asked, these men claimed to approve of birth control, although they do
not usually talk about the subject with their wives (Chibalonza et al. 1989;
Fakeye and Babaniyi, 1989). As van de Walle and Traore (1986) noted, men
and women live in two different worlds in respect of family planning. This
social boundary must be broken for effective practice of family planning
in marriage.
How
to Include Men?
Generalizations
that emerge from recent research and field observations are that most men
are not against family planning and that they want to learn more about it,
preferably from male workers. Yet, up to now, most family planning providers
are women, or men trained to deliver services to women. Consequently, they
are uncomfortable talking to male clients about sexuality, genitals, erections,
wearing condoms, ejaculation, pre-ejaculate fluid, abstinence, multiple partners,
and all other issues that should be involved in counselling men in modern
or traditional family planning. Though, these sensitive subjects are themes
that husbands and wives need to be able to talk to each other about if they
are going to use contraception effectively.
These
observations call for programs that reach out men and enhance men's cooperation
in the area of reproductive health. Such programs should focus on:
training
of male family planning workers to provide appropriate information to
men;
persuading
men to accept and use male methods, and to be supportive of their partners'
effective use of family planning; and,
promoting
greater spousal communication regarding family planning, as a means to
ensure better sexual life and reproductive health that benefit all the family.
These
programs should be designed to promote male involvement and shared responsibility
for reproductive health, not male dominance (Piotrow et al. 1992). Family
planning managers should know that discussions over contraceptive and sexual
matters may not be considered respectable subjects in some social settings.
Therefore, asking simple questions such as: "Would you be comfortable discussing
this with your partner?" "Would you like your partner involved?" helps avoid
unintended conjugal conflicts. Where feasible, special sessions can be designed
for couples (Bongaarts and Bruce, 1994:42).
Getting
sexual partners to talk to one another about family planning is evidently
an important step towards eventual adoption and sustained use of birth control
(DHS, 1988). However, communication campaigns and counselling are most likely
to be effective when they recognize existing cultural patterns of decision-making.
Informing men, and preparing them to be supportive of women's family planning
needs and practices, is probably the shortest route to low fertility in Africa.
Notes
1This
article is based on a paper presented at the 1994-95 workshop of Options
Fellows Program in Population Policy Communications, the Population Reference
Bureau, Inc.
2The
author is grateful to James Opare, Kelly James, and an anonymous reviewer
for their helpful comments on earlier versions of this paper.
Table
1.Percentage of women who do not use contraception because their husbands
oppose, among all non-users
Country
Year
of survey
%
of non-users due to husbands' opposition
Cameroon
Malawi
Namibia
Niger
Tanzania
Zambia
Burundi
Ghana
Kenya
Mali
Uganda
1991
1992
1992
1992
1991/92
1992
1987
1988
1988/89
1987
1988/89
1.1
2.7
1.4
2.5
3.1
3.7
5.7
6.8
19.8
12.1
8.4
Sources:Demographic
and Health Surveys: for Cameroon, Studies in Family Planning 1993,
24 (2):134; from Malawi to Zambia, Tables 4.11 of DHS country reports; from
Burundi to Uganda, adapted from Bongaarts and Bruce (1994:10).
Table
2.Percentage distribution of respondents regarding family decision-making,
Nigeria, 1991
Who
influences family decisions most?
Husbands'
responses
Wives'
responses
Percent
N
Percent
N
Husband
Wife
Kin/friends
Others
No response
87.7
6.7
1.4
2.0
2.2
1,694
206
42
61
70
77.6
16.0
1.9
1.3
3.2
2,385
492
58
40
98
Total
100.0
3,073
100.0
3,073
Source:
Isiugo-Abanihe (1994:153).
Table
3.Percentage distribution of responses to statements about reproductive
decision-making, by sex of respondent, Nigeria, 1991
Statement
Response
No
option
Agree
Disagree
or
response
Men decide
family size
Male
Female
Men decide
when to have sex
Male
Female
Men decide
duration of abstinence
Male
Female
Men decide
whether to practice family planning
Male
Female
56.7
47.6
59.9
43.8
57.1
42.6
48.0
46.1
25.3
32.3
26.2
36.4
24.6
35.1
33.7
34.9
18.0
20.1
13.9
19.8
18.3
22.3
18.3
19.0
ource:
Isiugo-Abanihe (1994:154).
Table
4.Percentage distribution of user couples by initiator of family planning,
Kinshasa, Zaire, 1991
Who
decided that family planning be used?
Husbands'
responses
Wives'
responses
Modern
Any
Modern
Any
Husband
Wife
Other
67
28
5
64
29
7
65
31
4
57
35
8
Total
100
100
100
100
Source:
Djamba (1994:34).
Table
5.Sources of contraceptive information: first and last methods ever used,
Kinshasa, Zaire, 1991
Source
Husbands'
responses
Wives'
responses
First
method
Last
method
First
method
Last
method
School
Health staff
Parents
Other family
members
Spouse
Friends
Media
Other sources
37
7
3
8
5
28
8
4
23
13
1
6
5
29
16
6
24
16
3
6
18
27
4
2
13
23
3
4
25
25
6
2
Total
100
100
100
100
Source:
Djamba (1994:17).
Table
6.Percentage of contraceptive use among married women by husband's approval/disapproval
of family planning
Country
Year
of survey
Husband
approves
Husband
disapproves
Burundi
Ghana
Kenya
Mali
Uganda
1987
1988
1988/89
1987
1988/89
14
18
36
-
11
3
6
16
-
3
Source:Adapted
from Bongaarts and Bruce (1994:26). Estimates derive from logistic regression
models with controls for age, education, residence, and desire for more children.
(-)
indicates no significant effect.
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Copyright 1995 - Union for African Population Studies