Does family planning affect a man?

Although numerous side effects are associated with FP/C use, increased vaginal wetness and decreased male sexual pleasure were the two most significant side effects described by men.

reproductive-health-journal.biomedcentral.com - Male partner influence on family planning and contraceptive use

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Promotion

The uptake and utilization of FP/C methods and services is key to improving unmet need and decreasing unintended or unplanned pregnancies. In this paper the role of men in FP/C uptake and use was explored within the urban/peri-urban and rural/peri-urban setting in the eThekwini district of KwaZulu-Natal from a community and HCP perspective. Use of chronic or long-term medical interventions such as FP/C methods fluctuate on a continuum of use, resulting in variation of use patterns [43]. The findings from this study showed that the influence of the male partner can result in varied degrees of FP/C use. Three predominant outcomes on use were reported namely: discontinuation, covert, and improved FP/C uptake and use. Contextualisation of findings and awareness of the various macro-structural forces behind male influence on FP/C use is important for increasing the uptake and continued use of FP/C. The use of FP/C methods within marriage continues to be a focal point of policy and research within the sub-Saharan setting. However, unlike other countries in the Sub-Saharan region, South Africa is experiencing a decline in marriage rates with KwaZulu-Natal, where this data was collected, having some of the lowest marriage rates in the Sub-Saharan region [37]. In this study, no male participants reported being married (or had ever been married), and only 3% of female participants reported being married. The decline in marriage rates has implications for FP/C use monitoring, interventions and programs. The CPR for unmarried women in South Africa decreased from 68% in 1998 to 64% in 2016, and unintended pregnancies are strongly associated with single or divorced people [3, 10]. Furthermore, the changes in this fundamental cultural practice has implications for the gender dynamics in relationships. Male participants in this study mentioned how guiding cultural practices involving reproduction are changing. These changes have resulted in men and women renegotiating reproductive behaviour, especially with reported behaviours such as covert FP/C use and male partner abdication of childcare responsibilities. Further research is needed to explore the importance and influence that the change in this fundamental cultural practice may have on the uptake and use of FP/C. Another key finding from this data was the high rates of unplanned pregnancies reported. Most of the community female and male participants reported that their pregnancies were unplanned, despite having knowledge and access to FP/C services and methods. This finding is in keeping with findings from other studies that investigated unplanned pregnancies [9, 13]. The findings from this study sheds some insight into reasons for non-FP/C use that could result in unplanned pregnancies. In particular the role of the male partner as a contributing factor to non-use of FP/C was explored.

Discontinuation of FP/C use

Most of the negative factors that result in barriers to use overlap in their influence and extent in which they result in FP/C discontinuation. Some of the opposing factors resulted in covert, or interrupted use, whereas others led to more permanent discontinuation of FP/C use. Factors linked to discontinuation included limited understanding about FP/C methods, side-effects (real or perceived), gender power dynamics, physical abuse, and FP/C sabotage. Gender power dynamics continue to play a crucial role in the use of FP/C methods and services, as demonstrated by this study and others [8, 16, 30, 48]. Power imbalance was reported more in the marriage setting, where men assumed ownership over female fertility, but the responsibility of raising children belonged to women. In addition to this, discordant fertility desires were also reported with men preferring more children than women. In this context of commodified fertility and reproduction, female partners were subjected to male partner demands and expectations for children. These findings were not unique to this study and was previously reported [8, 28, 49]. Accounts where female participants and HCPs described physical abuse and fear of the male partner were described as reasons to permanently discontinue FP/C use. Female participants described how women may not initiate FP/C use or discontinue use out of fear that their male partners will physically abuse them. This fear is not unfounded since physical abuse is prevalent in this setting where 21% of ever partnered women had experienced abuse by their partners [3]. FP/C sabotage was considered another form of abuse reported by all the participants that resulted in discontinued use. HCPs reported instances where male partners would feel for the hormonal Implant and break it in their female partner’s arm. Community participants described how men and boys intentionally break or damage male condoms to prevent FP/C use. These reports link male opposition to discontinued method use through physical abuse and is a serious concern for FP/C uptake and use, which has been noted elsewhere [50].

Covert and interrupted FP/C use

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Promotion

An important finding from this data was that negative male partner influence did not always result in total discontinuation of FP/C use, but also resulted in modified behaviour by female partners, who continued using FP/C without their male partner’s knowledge. Findings from this study revealed that in this setting, covert use may be a common practice amongst female partners and was widely encouraged by female participants and healthcare providers. The extent of covert FP/C use remains largely unknown as this data is not routinely collected [51, 52]. Other studies from the sub-Saharan region found that covert use was not widely practiced [2, 27]. Female participants and HCPs reported that covert use was a means for women to control their own FP/C choices without the permission or knowledge of their male partners. Despite the seemingly positive influence of this, covert use should be treated with caution as it can result in inconsistent or discontinued use [53]. The fact that women use FP/C covertly in this setting suggests that they have limited negotiating power within their relationships, highlighting their vulnerability. Providing adequate, accurate and contextually acceptable information is crucial to improving men’s attitudes and understanding towards FP/C use. Despite the 2016 SADHS reporting that most people of reproductive age in SA has some FP/C information, the data from this study showed that the current provision of FP/C information is inadequate [3]. Most male participants lacked a clear understanding about FP/C methods, their mechanism of action and related side-effects. This resulted in misconceptions and myths about side-effects and the reported concern that FP/C methods could harm male partners. HCPs explained that the lack of male understanding can be attributed to the feminisation of FP/C programmes, where the focus remains on women. According to female participants these misunderstandings resulted in misconceptions and myths related to FP/C use, such as female partner infidelity and excessive vaginal wetness. Side-effects remain a widely reported barrier to FP/C use, in this study and others [26]. Male participants described side-effects as a key reason why they do not like or encourage FP/C use. Common side-effects reported by male partners include decreased male sexual pleasure, reduced libido, abnormal menstrual bleeding, and increased vaginal lubrication or wetness. Side-effects can be linked to inadequate information, cultural constructs about reproductive behaviour, male sexual entitlement, and gender power inequality [6, 20, 54]. Resistance to FP/C use by male partners are also reported in other studies [27, 29, 54, 55]. Male and female participants reported that increased vaginal wetness, whether real or perceived, was a reason for male partners to discourage FP/C use. However, male and female participants had differing views about whether increased vaginal wetness due to FP/C use was an actual problem. Female participants felt that men constructed and exacerbated reports of vaginal wetness to encourage discontinuation of FP/C use. Male participants reported it as a real concern for them as it decreased their sexual pleasure. Increased vaginal wetness has been reported previously within the South African context before and it is linked to discontinued FP/C use [54, 56, 57]. Decreased male sexual pleasure was another reported barrier to FP/C use. Male condom use reportedly decreased male sexual pleasure the most, followed by increased vaginal wetness from hormonal FP/C methods (especially the injection). The 2016 SADHS results show that 58% of women and 65% of men use male condoms inadequately during high risk sexual practices [3]. The importance of decreased male sexual pleasure on FP/C use, especially male condoms, requires further exploration, and is reported in other studies in this setting [55, 58].

Improved access, uptake and adherence to FP/C use

Much has been written about the opposing influence that men can have on FP/C use. Less is known about the supportive role and influence that men can have on FP/use. This study highlighted that male support for FP/C can help female users to overcome barriers to using FP/C by facilitating access, encouraging uptake, and improving adherence to FP/C methods.

Improved access

In this study, male and female participants reported that males accompanied their female partners to their local clinics to obtain their FP/C methods. This differs from other studies where male accompaniments to FP/C facilities are ridiculed and FP/C is considered only a female domain [28]. Men are generally economically more empowered which enables them to overcome access barriers such as transport costs or healthcare related fees [7]. By accompanying their female partners, they provide financial support to improve access to FP/C services [28, 53]. Male partners also provided social support for women to access FP/C services. Community related stigma can negatively impact on FP/C use, especially if unmarried or adolescent women are accessing FP/C services within their immediate community. Female participants reported that little support for FP/C use exists in local communities and this negatively impacts on them seeking FP/C services and methods. In this sense, the male partner accompanying women to clinics can mitigate against community related stigma.

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Promotion

Encouraging uptake of FP/C

Female participants reported that in certain cases their male partners suggested and initiated the use of FP/C methods. This point highlights the need for men to be included in FP/C services and programmes [53, 59]. Men have limited FP/C methods available to them and rely on their female partners to use FP/C methods to prevent unplanned pregnancies. Although this may be viewed as a limiting factor, it may result in men encouraging female partners to use FP/C methods to meet their own needs [59]. The encouragement of FP/C use by men was positively viewed by male and female participants and reflects the recognition by men that cultural and patriarchal practices and attitudes are changing. Cultural change can happen slowly and over many years [23], but if those changes have a positive outcome, then the effects can be tremendous. More culturally focused FP/C programming can greatly assist in constructing new ways in which men and women engage about FP/C use. Male participants pointed out how their perceptions and behaviour regarding FP/C use is changing. This may be linked to changes in marriage practices in this setting. According to these men, traditional cultural practices are still strictly observed in more rural areas, whereas is less constrained in peri-urban and urban settings. Contemporary men and women in this setting are negotiating and constructing new roles that they occupy within this cultural context, whereby women take ownership of their reproductive health, and men adapt their behaviour to encourage FP/C use.

Improved adherence

Improved adherence to FP/C is probably one of the key positive influencing factors that men can have on FP/C use which was reported by female participants. Forgetfulness is a key barrier to continued adherence to any long term chronic treatment. Social support is especially important to ensure that adherence remains adequate and is sustained, especially when negative side-effects can threaten continued use. As demonstrated by this data, men can and do play a key role in improving adherence by reminding their female partners to take FP/C methods, and to attend their scheduled visits at the clinic.

Limitations

While we deem the methodology, sampling size, and strategies used in this study as adequate, some limitations should be noted. Commonly in qualitative studies limited sample size and generalizability of the findings are critiqued [60]. The aim of qualitative research is in depth and description, and not necessarily breadth [61, 62]. Therefore, we should apply caution in generalizing the findings. The data from this study has shown how important contextualisation is when exploring FP/C use. Sometimes not being able to return to the field to follow up on findings, places a limit to the depth of exploration of themes, but returning into the field has cost and time implications. One way to compensate for this limitation is to sample from a variety of participants within a community [63]. Variation sampling was achieved in this study where a variety of participants ranging from community members to healthcare providers were interviewed to obtain a robust exploration to the study question.

reproductive-health-journal.biomedcentral.com - Male partner influence on family planning and contraceptive use

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