African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 15, Num. 4, 2011, pp. 24-32

African Journal of Reproductive Health, Vol. 15, No. 4, Dec, 2011, pp. 24-32

Original Research Article

Men’s knowledge and spousal communication about modern family planning methods in Ethiopia

Connaissance chez les homes et la communication conjugale par rapport aux  méthodes de la planification familiale moderne en Ethiopie

Adugnaw Berhane¹, Sibhatu Biadgilign²,Alemayehu Amberbir³, Sudhakar Morankar¹, Alemayehu Berhane⁴ and Kebede Deribe⁵  

¹Department of Health Education and Promotion, Public Health Faculty, Jimma University, Jimma, Ethiopia;
²Department of Epidemiology and Biostatistics, Public Health Faculty, Jimma University, Jimma, Ethiopia;
³Addis Ababa University, Ethiopia;
⁴School of School of Pharmacy, Gonder College of Medicine and Health Sciences, University of Gondar , Gondar, Ethiopia;
⁵Fayyaa Integrated Development Association-NCMI, PEPFAR-New Partners Initiative, Ethiopia
*For correspondence:  Email:adugnawmph@yahoo.com

Code Number: rh11047

Abstract                                                

This study attempted to determine knowledge, approval and communication about family planning methods among married men in Ethiopia. A cross-sectional study was conducted among a representative sample of 738 married males in Amhara Region. All 738 (100%) of the respondents had heard of family planning. About 558 (75.6%) mentioned the importance of using contraceptives for birth spacing and 457 (61.9%) to limit birth. Four hundred and forty-five (60.3%) of participants had ever discussed family planning with their wives. Thirty-three (33.0%) of the respondents reported that they were the sole decision makers in their families. About 597 (80.9%) approved the use of contraceptives. However, some participants did not discuss and approve family planning with their partner. This recalled an intensive effort has been taken by the concerned body to reach the country’s targeted family planning coverage by involving men in reproductive health endeavor to enhance the discussion and agreement about family planning usage (Afr J Reprod Health 2011; 15[4]: 24-32).

Résumé

Cette étude a essayé de déterminer la connaissance, l’approbation et la communication concernant les méthodes de la planification familiale chez les hommes en Ethiopie.  Nous avons mené une étude transversale au sein d’un échantillon représentatif de 738 hommes mariés dans la région Amhara.  Tous les 738  (100%) des interviewé sont entendu parler de la planification familiale.  Environ 558 (75,6%) ont parlé de l’importance de l’utilisation des contraceptifs pour l’espacement des naissances et 457 (61,9%) pour limiter la naissance.  Quatre cent quarante-cinq (60,3%) participants ont discuté la planification familiale avec leurs femmes. Trente-trois parmi les interviewés ont signalé qu’ils étaient les seuls décisionnaires dans leurs familles.  Environ 597 (80,9%) ont approuvé l’utilisation des contraceptifs.  Pourtant, quelques participants n’ont pas discuté et approuvé la planification familiale avec leurs partenaires.  Ceci a rappelé l’effort intensif fait par l’organisation concerné pour atteindre la couverture de la planification familiale visée par le pays tout en impliquant les hommesdas les tentatives de  santé de la reproduction de promouvoir la discussion et l’accord par rapport à l’utilisation de la planification familiale (Afr J Reprod Health 2011; 15[4]: 24-32).

Keywords: Knowledge, Spousal communication, Family Planning, Ethiopia

Introduction

Reproductive health programs have traditionally focused on women. However, since the International Conference on Population and Development (ICPD) conference of 1994, programs have paid attention to male involvement in reproductive health services ¹. The 1994 ICPD and the 1995 fourth world conference on women acknowledged the role of men in improving reproductive health ^{2, 3}. Reproductive health programs are likely to be more effective for women when men are involved⁴. The role of men in the family, their relationships with their partners, gender patterns of society, male-oriented educational programs, and counseling activities on family planning all influence men’s knowledge and behavior regarding family planning ^5,6. Willingness of husbands to adopt or allow their spouses to use family planning practices determines the pace of fertility reduction⁷. Men can prevent women’s contraceptive use and they themselves are an untapped group of potential users. Males are also primarily considered as a means of increasing contraceptive prevalence ⁸. The multiple decision-making roles of men in reproductive health, particularly family planning, have profound influences on women’s health ⁹. Family planning is key for curbing the growth rate of a population and for the health of women of reproductive age. Total fertility in Ethiopia declined from 5.9 to 5.4 per women within five years ^{10, 11}.

 In Ethiopia, there have been some efforts in family planning services to increase the prevalence of contraceptive use. The Ethiopian population policy, which was adopted in 1993 has the objective of reducing the total fertility rate, as well as raising the contraceptive prevalence rate to a national coverage of 44% by the year 2015 ¹². In its National Reproductive Health Strategy from 2006 - 2015, The Ministry of Health stated the need  to increase contraceptive prevalence to 60% by the year 2010 and increase couples’ approval of FP to 75% by 2015 ¹³. Study have shown that knowledge and approval of family planning, husband-wife communication, desire for more children, and ideal family size are all significantly associated with current use ¹⁴. Different studies show that discussion of family planning improves knowledge of partner's, husband-wife communication on family planning and wife’s perception of her husband’s approval of family planning positively influence couples’ contraceptive use ^15-18. A study done in the rural western part of Ethiopia indicates that, 90.6% of men approve contraceptive use by their wives, but only 70% of women reported perceived approval by their husbands ¹⁹.

According to DHS2005 report on the overall knowledge of contraception in Ethiopia; 93% of married men have heard of at least one method of contraception ¹⁰. An increase in contraceptive knowledge and utilization has contributed to a decline in total fertility. Although nearly 84% of the population is aware of at least one family planning method, utilization of contraceptive services is very low ¹⁰. Studies show contraceptive utilization ranges from 13.9% ¹⁰ to 25.2% ²⁰. Despite this notable increase, internationally, Ethiopia’s current prevalence still remains low, and the country’s unmet need for contraceptives remains around 36% ²¹. These data show a clear gap between knowledge and utilization of contraception. The mechanisms generating the close linkage between family planning use and spousal communication are poorly understood ²². Additionally, male partner’s approval can be an important predictor of contraceptive use by women ^23,24. Studying men’s knowledge, approval, and communication about family planning is highly relevant to designing appropriate program interventions and strategies in the local context. The current study is designed to determine knowledge and spousal communication about family planning among married men in Angolela Tera District, Amhara Regional State, Ethiopia.

Methods

Study Setting and population

The study was conducted from February 15 to March 14, 2008 in Angolela Tera District, Amhara Region, Ethiopia. The district has 20 kebeles- small administrative units (one urban and nineteen rural). Chacha is the capital town of the district. Family planning services such as injectables, pills, condoms, and Intrauterine device (IUD) are offered free of charge at the district health institutions. The study population was married males residing within the district, age 15-59, with wives in the reproductive age group (15-49 years) and in union for more than six months. Couples were excluded if the husband stayed away from home for more than six months, or if they were infertile or pregnant during the study period. 

Sampling and Data Collection

The Sample size was calculated using Epi Info-6 with the formula for a single proportion. The following parameters were used to calculate the sample size: proportion of men who approved use of contraceptives 62.9% ²⁵ and 95% CI with a design effect of 2. This gave a sample size of 700. Additional 10% allowance for absenteeism and refusal to participate in the study is considered, which resulted in a total sample of 770. The total married male population in the district was 14,975. The kebeles were also stratified based on urban and rural.  From all 20 kebeles, a total of 6 (30%) kebeles were selected in the district by assuming that these kebeles would accommodate the required sample size. From the 19 rural kebeles, five rural and one urban kebele were included in the study. Census was carried out to produce a complete list of all married males who fulfilled the inclusion criteria in the selected kebeles. During the census, couples’ names, ages of husband and wife, perceived pregnancy, perceived infertility and address of the eligible married males were included. Census result showed that a total of 7,732 married men lived in the selected six kebeles. Of those 7,732 married men, 7,483 were eligible for the study (6,463 from rural and 1,020 from urban). Two hundred and forty-nine married men who failed to fulfill the inclusion criteria were excluded from the study. Of those excluded, 63 were aged 60 and above, 140 perceived their wives as pregnant, 35 identified either themselves or their partner to be infertile and 11 reported that they stayed more than six months away from home. The number of study participants to be sampled from the selected kebeles was determined using proportionate-to-population size. From each kebele, lists of eligible married males, simple random sampling technique was used to select the 770 study participants. 

For data collection, a structured questionnaire was used. The questionnaire was first prepared in English, then translated into Amharic and retranslated back to English to check for consistency. The demographic variables included were age of men and their place of residence. The social variables included educational level and religion; ethnicity and economic variables were occupation and family income. Married men were asked whether they approve of their wives using contraception, and whether they communicate with their wives about family size and composition so that census can take place regarding contraceptive use. Data collectors were male Community Based Reproductive Health Agents (CBRHA) in the district who speak the local language (Amharic). They were trained in the district capital for four days by the principal investigator on the study instrument and data collection procedure.  The CBRHAs were assigned outside of their residential catchment areas to minimize social desirability bias. Two BSc holders in health were recruited as supervisors. Prior to the actual data collection, the questionnaire was pre-tested on 39 married men at kebeles not included in the study. The principal investigator was responsible for coordination and supervision of the overall data collection. For data quality control, supervisors crosschecked 10% randomly selected households every day.

Statistical analysis

Data were entered, cleaned and analyzed by SPSS version 15.0. Descriptive analysis using simple frequencies were used to see the overall distribution of the study subject with the variables under study. Bivariate and multivariate logistic regressions were done to identify predictors of spousal communication. Ethical clearance was obtained from the Institutional Ethical Review Committee of Jimma University and written consent from Angolela Tera District was obtained.

Results

Socio-demographic characteristics          

In total, 738 married males participated in this study, with a response rate of 95.8%. Six hundred and thirty-five (86.0%) of the respondents were rural dwellers and the remaining 105 (14.0%) were urban residents. Amhara was the major ethnic group, representing 677 (91.7%) of the study population, followed by Oromo, which accounted for 60 (8.1%). Orthodox Christians (718, 97.3%) were the major religious group, followed by Protestants (12, 1.6%). The mean age of the respondents was 37.6 +/- 7.8 years. Little more than one-third (281, 38.1%) of the study population was unable to read and write. Only 25 (3.4%) were educated to the level of high school or above. Farmers comprised the majority (601, 81.4%), followed by merchants (60, 8.1%). A few (58, 7.9%) of the respondents earned less than 1200 birr per annum (Table 1).

Knowledge of contraception

Participants’ knowledge of contraceptives was examined in this survey. All 738 (100%) of the respondents had heard of family planning. Respondents were also asked to inform CBRHAs of any contraceptive method they knew. As shown in Figure 1, the most mentioned methods were oral pills (685, 92.5%), injectables (656, 88.8%) and condoms (335, 45.4%) respectively. The least known reported methods were spermicidal (34, 4.6%) and withdrawal (35, 4.7%). Respondents were also asked about the perceived importance of using contraceptives; 558 (75.6%) mentioned birth spacing, and 457 (61.9%) said to limit birth.

Reproductive characteristics

The mean number of living children of the study population was 3.9 +/- 2.2 and the range was between 0 and 10 live births. The mean number of living female children of the study population was 1.48+/-1.18 and that of male children was 1.31+/-0.94. About 24 (3.3%) had no live children and 280 (33.3%) had 5 or more live children. About 316 (42.8%) of the respondents wanted to have more children. The average desired number of children was found to be 2.25+/-1.097. The mean number of desired female children of the study population was 1.13+/-0.72 and that of male children was 1.19+/-0.65. About 212 (67.1%) of the men desired to have one to two children, and 12 (3.8%) desired to have five or more children. Regarding the preference for sex of the next child, 71 (22.5%) of the study men preferred to have boy, 32 (10.1%) preferred to have girl and 213 (67.4%) preferred to have either sex.

Table 1:Socio demographic characteristics of married men in Angolela Tera District, Amhara Region-Ethiopia 2008 (N=738)

Spousal communication and Husband approval

Four hundred and forty-five (60.3%) of the respondents reported that they had ever discussed family planning with their wives. Of those who had discussed family planning, about 45 (10.1%) reported that they had frequent discussions (more than three times within the last 6 months), and 42 (9.4%) reported that they had no discussion with their wives in the last 6 months. Of those who had ever discussed with their wives, about 339 (76.2%) of the respondents reported that they usually started the discussion on family planning methods by themselves. Of those respondents who had not ever discussed or did not remember whether they had discussed, 183 (62.5%) reported that they intended to talk with their wives while 100 (34.1%) did not intend to talk with their wives. Respondents were asked why they choose not to discuss family planning with their wives; thirty-three (33.0%) of the respondents reported that since they are sole decision makers, they do not intend to talk (husband alone should take the decision). Other reasons for not intending to talk were having no children, or wanting more children, which accounted for 29 (29%) of respondents. About 597 (80.9%) of the study men approved the use of contraceptives (Table 2).

Factor associated with spousal communication

Odds ratios (ORs) from binary logistic regressions predicting spousal communication of family planning by socio-demographic characteristics are shown in Table 3. The result showed that men’s education is significantly associated with spousal communication about family planning. Those individuals who are unable to read and write were 50% less as likely to communicate about modern family planning methods with their wife than literates counterpart [OR=0.50, 95% CI = 0.33-0.76)]. The age of spouses also has a significant predictor for spousal communication. Those age group from 20-24 and 30-34 were 3.24 and 3.15 more likely  to communicates about modern family planning methods with their wife than with 50-54 age group counterparts[OR=3.24,95% CI = 1.11-9.41)] and [OR=3.15,95% CI = 1.18-8.39)]. Those spouse whose husband approve of family planning were 3.84 times more likely [OR=3.84, 95 % CI = 2.53-5.84)] to communicate about modern family planning compared to their counterpart (Table 3).

Discussion

Men’s acceptance of contraception requires knowledge about appropriate contraceptive methods, more communication between partners, fostering awareness, and mutual sharing of concerns for partners’ contraceptive practices ²⁶. Studies carried out in Ethiopia under a nationally representative sample showed contraceptive use of any contraceptive method were 8.1% in 2001 Ethiopia Demographic and Health Survey (EDHS) ²¹ and 14.7% in 2005 EDHS ¹⁰. The contraceptive prevalence rate was found to be 22% among all women and 27.3% among married women during the time of the survey in North and South Gondar zones in Northwest Ethiopia ²⁷. Amhara region contraceptive prevalence was 16.1% ¹⁰ and almost half (425, 49%) were current users of modern contraceptives ²⁸. In our study, we found that contraceptive use in the district was 26.7%. This apparent increase in usage might be due to increased awareness and knowledge of the community about contraception, and increased access of family planning services through fully functioning health extension workers in the district.

Individuals who have adequate information about the available methods of contraception are better able to make choices about planning their families ¹⁰. Studies done in similar settings reported that participants’ knowledge of contraceptive methods were high in rural Vietnam (99.4%), West Africa (85%), East Africa (98.8%), and Bangladesh (99.7%) ²⁹. In our study, most of 77.4% male respondents had information about family planning. About 36.6% of the male respondents knew more than one method of family planning ³⁰. In a study carried out on male contraceptive use, about 93% (n=707) of the study participants reported that they had heard of family planning methods, and 644 (91.2%) reported that they were familiar with at least one of the contraceptive methods ²⁵. Ethiopian DHS 2005 indicated that knowledge of family planning is high at 93% among currently married men, which is slightly lower than the finding of this study ¹⁰. Much lower levels of knowledge about family services were found in other studies in Ethiopia where 76.3% of male youth were knowledgeable about family planning methods³¹. All male participants in our study had heard of family planning. This finding is higher than those reported in other studies. The presence of Health extension workers deployed at the community level should maintain the existing knowledge through raising awareness, planning health education activities, and distributing family planning methods in their respective health posts.

Table 2:Reproductivehealth characteristics of married men Angolela Tera District, Amhara Region-Ethiopia 2008

Many women may still need their husbands’ approval to use family planning, and husbands’ intentions may have additional effects on couples’ contraceptive practice and fertility ³². In this study, about 80.9% of the respondents approved use of contraception. This finding is lower than a study done in the rural western part of Ethiopia, in which 90.6% of men approve contraceptive use by their wives ¹⁹. In the Philippines, 72% of husband strongly approved of contraception ³³. About nine out of 10 wives and husbands approved of family planning, and almost identical proportions (83% and 82%, respectively) thought their spouses approved of family planning. In 79% of married couples, both spouses approved of family planning ³². Similar findings were reported in the Ethiopian context, as wife’s’ perceptions of their husbands’ approval of family planning positively influence couples’ contraception us ^{16, 17, 18}.

Table 3: Independent predictors of spousal communication about modern family planning methods among married men in Angolela Tera District, Amhara Region-Ethiopia 2008

Spousal communication helps couples to be aware of each other's perspective about family size and composition so that consensus can take place about contraceptive use. Those who communicate with their wives will be more predisposed towards use of contraception.  Studies support the spousal communication enhancement on usage of family planning, as there is a mutual understanding and decision-making process on fertility and preference. Couple communication is a significant predictor of contraceptive use. It allows shared decision making and more equitable gender roles; discussion between partners is a positive predictor of current contraceptive use ^{34, 35}. In this study, 60.3 % of the respondents ever discussed family planning with their partner. This finding is inconsistent with the result of the study done in Hosanna, in which 66.0% of the respondents discussed family planning matters ²⁵, but similar to a study done in Vietnam which reported couple communication was negatively associated with men’s acceptance of the IUD for contraception. Those men who had accepted IUD use for contraception for 6 months or longer were 1.8 times more likely to have a low level of communication (frequency of more than three times of discussion on family planning in 1 year preceding the survey) with wives than those who had not accepted the IUD ³⁶.   

Men’s acceptance of contraceptive methods requires knowledge about appropriate contraceptive methods, increased communication between partners, fostering awareness, and sharing concerns for their partners’ contraceptive practices ²⁶. Discussion between spouses is expected to increase contraceptive use, because a sizable minority of women cites their husbands’ disapproval of contraception as the reason for nonuse, despite having never discussed family planning with their husbands ³⁷. Various studies have shown that providing men with information and involving them in counseling sessions can help them to be more supportive of contraceptive use and more aware of the concept of shared decision making ^38. A study in Ethiopia reported an increase of contraceptive use among couples receiving husband-wife counseling compared to when women were counseled alone ¹⁸. This increase in contraceptive use might be better explained by the low educational status of this study population (only 3.4% of the study population attended grade 9 and above), An additional difference between this study and ours is that this study used IUD, showing that once IUD use is established, the need for discussing family planning is minimal.

Regarding desire for more children, if men desire more children they do not encourage their partner to use contraception. Other studies have identified knowledge, approval and use of family planning as important factors influencing fertility intentions ^{39, 40}. In this study married men desire about 2.25 ± 1.097 children on average, which is comparable to a study done in Western part of Ethiopia where the mean number of desired children was 2.7 ± 1.3 ¹⁹. Our findings are similar to other study findings, showing that couples need to space their children, and control (limit) births, but do not want to use a modern contraceptive method because of several misconceptions ⁴¹.Additionally, previous studies in Ethiopia and Pakistan have shown that couples’ knowledge, approval and use of family planning are correlated with the desire not to have additional children ^{39, 40.} 

In conclusion, we found that contraceptive use in the district was 26.7%, despite high levels of knowledge regarding contraception. All study participants had heard of family planning, and about 80.9% of the respondents approve use of contraception. However, there is still less approval of female contraceptive use by husbands, as indicated by the 60.3% of the respondents to have ever discussed family planning with their partner, in conjunction with the average married male’s desire for only 2.25 ± 1.097 children. As per our recommendation, intensive effort has been taken by the concerned body to reach the country’s targeted family planning coverage by involving men in reproductive health endeavor to enhance the discussion and agreement about family planning usage. The study also highlights the need for increased community knowledge which can be addressed by health education and community mobilization, secure contraceptive, in order to create a paradigm shift and ensure that reproductive and family planning activities are not left solely for women.

Acknowledgement

This study was carried out with the financial support of Jimma University. Our appreciation also extends to Angolela Tera Woreda administration and to the study participants, supervisors, and the data collectors for their full participation. Beth Links acknowledged for editing the manuscript and overseeing the initial draft.

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