While post-pregnancy services traditionally focus on women and children, a few
innovative programs and studies are searching for ways to involve men. These approaches
typically emphasize family planning counseling.
Postabortion counseling of men can help prevent repeat abortions by stressing the need
for consistent use of reliable contraception to prevent unwanted pregnancy. Postpartum
contact with male partners offers an opportunity to educate men about the value of spacing
children, an important factor since a man often has substantial influence in a couple's
decision to use family planning.
Worldwide, some 30 percent of couples depend on contraceptive methods that require
men's active cooperation or participation, such as condoms, vasectomy, withdrawal or
periodic abstinence.1 Surveys in Africa and Asia have found
that, except for West Africa, more than 70 percent of men approve of family planning.2 In seven African countries, couples who had discussed family
planning in the past year were four times as likely to be using contraception as those who
did not.3
Communication between partners and with providers is an important component of
contraceptive use. But cultural barriers that prevent men and women from talking about
sexuality, providers' lack of training on how to counsel men, health system procedures
that discourage men from using services, and men's own attitudes toward reproductive
health all can block this communication and the involvement of men in general.
Ideally, everyone should receive lifelong education about reproductive health,
including men. But men are generally less likely to seek healthcare than women. The
perinatal period is one time when men may be brought into contact with the health system
through their wives. "Couple-friendly" interventions can improve reproductive
healthcare, including family planning, experts say.
Men can join in post-pregnancy family planning and care at several levels, says Nick
Danforth, chairman of the American Public Health Association's task force on men and
reproductive health. At the most basic level, they can support their wives' choice and use
of contraceptives. Next, they can use male methods of contraception. And at an even higher
level of involvement, they can discuss future childbearing plans with their wives and take
more responsibility for the health of their children.
In the course of involving men, providers should not neglect individual counseling and
other services for women, or their rights and needs, experts say. "Protecting the
confidentiality of the woman and respecting her rights are fundamental issues that have to
be addressed carefully," says Dr. Dale Huntington, a Population Council associate
based in Cairo. "It is important to understand what husbands need to know and what
women would like them to know."
Crucial messages
For post-pregnancy counseling on family planning, couples need to know when women will
return to fertility. After an abortion, fertility returns quickly -- three-quarters of
women ovulate within three weeks -- so it is most reliable to begin contraception
immediately after the procedure.4 A non-breastfeeding,
postpartum woman can return to fertility within six weeks after delivery. If a woman is
using the lactational amenorrhea method (LAM), which includes full breastfeeding, her
return to fertility is typically delayed by several months.
During the post-pregnancy period, all male methods -- condoms, vasectomy, periodic
abstinence and withdrawal -- are appropriate for breastfeeding women since these methods
do not affect breastmilk.5
Condoms are crucial if a couple is at risk of AIDS or other sexually transmitted
diseases (STDs); however, many providers and clients need education about how to use them
properly. Postpartum abstinence is practiced in many cultures, but natural family planning
is difficult to use after a birth because of unpredictable menstrual cycles. Withdrawal is
commonly used in some countries, often by couples who have had negative experiences with
other methods of family planning, or have health reasons for not using them.6
And some programs are encouraging men to consider vasectomy after their partners' delivery
or abortion as a way to prevent unwanted pregnancies.
Besides receiving information on family planning, men can be given messages about their
own reproductive health, including STD prevention and treatment, and cancer screening.
They also can be encouraged to take part in child care, learn about the value of a girl
child, and be educated about the importance of supporting their wives in breastfeeding,
including the use of LAM. Support from a woman's partner is one of the prime requirements
for successful breastfeeding.
In order to reach men, providers can couch messages in terms of how family planning and
other post-pregnancy health interventions affect everyday life, says Mary Nell Wegner,
director of AVSC International's "Men As Partners" initiative. "Men are
often economically oriented," she says. "That may be an issue counselors want to
touch on." To be effective, she says, interventions also must be culturally specific
and pay attention to the needs of both partners.
Postabortion involvement
In Egypt, a recent Population Council study found that women who entered hospitals for
treatment of incomplete abortions worried about being pressured by their husbands and
families during their recovery.7 They especially feared
castigation for not being able to carry a pregnancy to term. The women did not expect
support from their spouses, but simply hoped they would not become a source of worry.
In order to help improve recovery for such women, Dr. Nahla Abdel Tawab and Dr.
Huntington of the Population Council are studying how to counsel their husbands. In six
hospitals in upper Egypt, with colleagues from the Egyptian Fertility Care Society, they
worked with about 400 couples, randomly divided into two groups. All women who gave
consent to participate in the study received postabortion counseling on a variety of
topics.
Men in one group also received health messages while their wives were being treated.
The messages covered five topics: their wives' need for recuperation; physical warning
signs of postabortion complications; the importance of iron-rich food for preventing
anemia; their wives' return to fertility; and the potential need for contraception to
space children, limit births or, in the case of a miscarriage, to allow the woman's
reproductive system a period of rest.
Women were interviewed 30 days after hospital discharge, to find out if their recovery
and contraceptive use were affected by whether their husbands received counseling. The
study's results will be used to develop a counseling curriculum for men.
While results are not yet available, Dr. Huntington observes some interesting patterns.
Because many of the women receiving abortion treatment entered the hospital with heavy
bleeding or other complications, the experience often frightened both partners. Yet in
most cases, husbands were ignored by the hospital staff.
Men who participated in the counseling appreciated the attention. Counselors --
primarily male doctors -- felt at ease in talking with them and helped allay their fears.
"Involving husbands is relatively easy and immediately acceptable," Dr.
Huntington says. "It fills a need, both for the husbands and, we hope, for the
patients."
Turkish men are also being encouraged to become involved in their wives' post-abortion
care. Induced abortion is legal until the tenth week of pregnancy in that country, and
many women have repeat induced abortions, which are available in both the public and
private sectors. However, abortion and family planning services are not well-linked.
Male involvement is particularly important in Turkey because many repeat induced
abortions are the result of contraceptive failure, primarily withdrawal. One study found
that three-quarters of Turkish women who sought abortions were using withdrawal at the
time of conception.8 In addition, many couples do not realize
the potential health risks of repeat abortions, which can impair fertility.
For married women, a husband's consent is required to perform an abortion -- a barrier
to obtaining it. But John M. Pile of AVSC International (AVSC) and Turkish doctors found a
way to take advantage of this requirement. They encouraged hospitals offering abortions to
counsel men while their wives were being treated.
Some staff members simply offered husbands a brochure about family planning. Other
hospitals provided group and couple counseling on family planning and sexually transmitted
diseases, health risks of repeat abortions, and the abortion procedure itself. Men had
many misconceptions about women's contraceptive methods, and these sessions helped dispel
them, Pile says. The efforts were both inexpensive and relatively easy to provide, he
says.
The Konak Maternity Hospital in Izmir, Turkey offered a more extensive program, with
both counseling and vasectomy services on site. According to a 1994 study, 3 percent of
men chose the surgery, compared with less than 1 percent prevalence nationwide.9 Overall contraceptive use is high at the hospitals that counsel
men after their wives' abortions. For example, at the Zekai Tahir Burak Women's Hospital
in Ankara in 1995, almost 98 percent of couples who had received counseling chose a
contraceptive method after the abortion.
Postpartum involvement
At Çapa Hospital in Istanbul, researchers from Istanbul University and Johns Hopkins
University found that men also wanted to be involved in perinatal health. Many husbands
expressed curiosity about fetal development and a desire to care for their wives and
infants, but did not know what to do, the researchers found. Women also reported that they
wanted their husbands' support.10
To find out how best to involve men, the researchers tried three health interventions.
They offered group counseling sessions for both members of the couple, opened a telephone
hotline to answer questions about postpartum issues, and developed a booklet on perinatal
health.
While men said they wanted to be involved in postpartum care, relatively few
participated in the group sessions or used the hotline, blaming the difficulty on long
work hours and lack of free time. The men were more inclined to read the booklet. For
future interventions, the researchers recommended encouraging men's participation, but not
insisting on it.
Another approach to perinatal involvement of men is beginning in Mexico. Its national
postpartum family planning program has primarily focused on offering women two
contraceptive methods -- IUDs and sterilization -- during the immediate postpartum period.
While its success at reaching women has made it a model in the developing world, it has
faced criticism because of the limited methods offered, reports of pressure on women to
accept them, and the concern that offering methods during the intrapartum or immediate
postpartum period is not ideal.
To encourage the use of male methods, Mexico's Ministry of Health is planning to work
with AVSC to counsel men during the prenatal period about vasectomy, in conjunction with
counseling for their partners. Beginning next year, men can choose to have vasectomies in
the same hospital where their wives give birth -- even at the same time -- or men can
choose to have surgery at a family health center at any time. The Mexican Social Security
Institute already offers postpartum vasectomy.
While it may be easier to offer vasectomies in the health centers, linking them to
postpartum care is an important symbolic step, says Dr. Alcides Estrada, director of
AVSC's Latin American and Caribbean regional offices. Emphasizing "postpartum
vasectomies" reminds providers to talk with couples in the perinatal period about
male methods, he says. "It is important to involve men in reproductive health at any
moment we have contact with them."
-- Carol Lynn Blaney
Carol Lynn Blaney, a former Network staff writer, is a science writer based in San
Jose, CA, USA.
References
- Pile JM, Bumin C, Ciloglu A, et al. Involving men as
partners in reproductive health: lessons learned from Turkey. AVSC Working Paper No. 11,
Draft. New York: AVSC International, 1997.
- Ezeh A. Reproductive preferences and behaviour: how men
and women compare. Planned Parenthood Challenges 1996;2:5-19.
- McCauley AP, Robey B, Blanc AK, et al. Opportunities for
women through reproductive choice. Population Reports, 1994;Series M(12).
- Balogh SA, Cole LP. Contraceptive services for the
postpartum and postabortion woman. In Gynecology and Obstetrics. Eds, Droegemueller
W, Sciarra JJ. (Philadelphia: J.B. Lippincott, 1994) 1-11.
- Rivera R, Kennedy K, Balogh S. Postpartum
Contraception: Contraceptive Technology Update Series. Research Triangle Park, NC:
Family Health International, 1994.
- Oodit G. Withdrawal: a time-honoured but risky method? Planned
Parenthood Challenges 1996;2:25.
- Huntington D, Nawar L, Abdel Hady, D. An Exploratory
Study of the Psycho-social Stress Associated with Abortions in Egypt: Final Report. Cairo:
The Population Council, 1995.
- Huntington D, Dervisoglu AA, Pile J, et al. The quality
of abortion services in Turkey. Int J Gynecol Obstet 1996;53(1):41-49.
- Pile.
- Istanbul University Institute of Child Health. Postpartum
Family Planning and Health in Istanbul: Bringing Fathers into the Picture. Final Report. Unpublished
paper. Istanbul: Istanbul University Institute of Child Health, 1996.
For more information, visit Family Health International's Website at www.fhi.org
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