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Most contraceptive methods are designed for use by women, and as a result, most family
planning programs target their information, counseling and services to women of
reproductive age.
However, this limited focus ignores an important reality in women's lives: Women often
are not the sole decision-makers about contraceptive use. Some make decisions about family
planning and family size in collaboration with their husbands or partners. Others have
little or no autonomy in the home, and husbands, partners, parents or in-laws decide for
them. And others use contraception clandestinely, fearing relatives will disapprove.
Health program providers need to recognize that family planning is often a family
decision. Providers should look for ways to inform, involve and
educate relatives, who may have a tremendous influence on whether contraceptive use
begins, when it begins, whether it continues, who uses contraception and what methods are
used.
The influence of husbands and other family members was one of the topics explored by
researchers in the Women's Studies Project (WSP) at FHI. In analyzing results from 10
countries in the project, researchers concluded that family members, particularly
husbands, play a critical role in women's family planning use and continuation. When
partners or other relatives are opposed to family planning, women can face severe
consequences, including divorce or abandonment, and violence, ridicule or disapproval from
family, friends or their partners.
Couples' decision-making
When surveyed about decision-making in the home, the majority of women in the 10
countries said their husbands or partners were usually involved in contraceptive
discussions, although the nature of that involvement varied. Some men were involved by
supporting women's contraceptive decisions, other men used methods themselves, and others
posed obstacles for women's use of family planning.
In Cebu, the Philippines, more than two-thirds of the 2,200 women surveyed about
household decision-making said they would consult their husbands about contraceptive use.
Some 20 percent said they would consult another adult, and only 12 percent said they would
make a decision without talking to someone.1
One Cebuano woman detailed her husband's assistance as they searched for an acceptable
contraceptive: "Because of the emotional stress that I experienced after the death of
four of my newborn babies, my husband suggested the use of some family planning method to
avoid further stressful experiences." After difficulties with other methods, the
couple decided to practice withdrawal, which requires male cooperation.
Many men in a Zimbabwe study said they supported family planning, believing it was
important to women's health and was a key factor in determining the family's quality of
life. "Having 10 to 11 children may be so detrimental to the psychological well-being
of a wife that she may feel she is being used as a human-making machine," said one
man in Mashonaland East province.2 Men said they expected
their wives to initiate discussions about contraceptive use, but that husbands should be
involved in contraceptive decisions.
"Traditionally, family planning was decided by both members of the couple. With
the advent of modern methods, one partner became responsible, the other was left
out," says Dr. Jane Mutambirwa, a social anthropologist at the University of Zimbabwe
and principal investigator for this study. "Consequently, this very important role
formerly played by men was no longer within their domain. Men made a point that they would
like to have more contraceptive options available to them, to relieve their wives of the
burden of side effects. They emphasized the need to counsel couples."
In Indonesia, where family planning has been widely promoted by the government since
the 1970s, women in West Java and North Sumatra said couples jointly made decisions about
family planning, although husbands were regarded as heads of the household, and few women
used family planning without their husbands' knowledge.3 In a
separate study in Central and East Java, husbands' opinions strongly influenced women's
contraceptive use, although women were responsible for choosing the specific contraceptive
method used.4
In Jakarta and Ujung Pandang, more than two-thirds of 760 married women, ages 30 to 45,
said they had discussed contraception with their husbands, who saw family planning as a
means to reduce the family's economic burden. In Ujung Pandang, nearly 77 percent of the
360 women interviewed said they would make a mutual decision with their husbands to have
another child. Yet, 56 percent of the 400 women in Jakarta said their husbands' wishes
prevailed. "As a wife, I have no freedom to decide something by myself," said a
woman from Jakarta. "I have to ask his permission."5
Authority and responsibility
Because women bear the physical burden and pain of childbearing and are primarily
responsible for childcare, some women say the final decision to use family planning should
be theirs. However, some men say their role as financial provider gives them authority to
decide how many children the family can afford. This was the case in Mali, where a small
WSP study examined the experiences of 55 first-time contraceptive users, married women
ages 18 to 45, who came to the Association Malienne pour la Promotion et Protection de la
Famille (AMPPF) clinic in Bamako.6
Married men, mothers-in-law and women who had never used contraception also were
interviewed in this study, conducted by the Centre d'Etudes et de Recherche sur la
Population pour le Développement (CERPOD). Researchers found that family planning is
considered the woman's responsibility, but both women and men regard decision-making as a
man's domain.
In focus group discussions, men were unanimous in their opinion that women had no right
to use contraception without men's permission. "When the husband says no, it means
no," said one man. Another said, "If my wife makes the decision to use family
planning without my consent, I will divorce her." Fewer than one-third of the men
interviewed thought they would ever want their wives to use family planning.
Women who sought contraceptive services said they discussed the subject with their
husbands, giving examples of how contraceptive use could improve women's health and
benefit the entire family. "Your children will be well taken care of, they will eat
as they should," one woman explained. Another said, "I showed him that the
children are closely spaced and that life is difficult -- it [contraception] would give us
a rest."
In addition, women enlisted the help of other family members to convince husbands of
the benefits of family planning. Older sisters-in-law proved to be powerful allies in
encouraging men's support of family planning. "She [my sister-in-law] asked me to
speak about it first to my husband and, if he refused, to have him talk to her, and she
would make him understand," said one contraceptive user. Although women also relied
on their husband's older aunts, younger sisters-in-law and mothers-in-law were generally
less involved in contraceptive decisions. Mothers-in-law themselves said they were
reluctant to discuss contraception with their daughters-in-law, and daughters-in-law said
the opinions of their mother-in-law were of little consequence.
Seventeen of the 55 women who came to the AMPPF clinic did so without their husband's
permission and used contraceptives clandestinely. By doing so, they risked divorce,
abandonment or indifference to side effects. Most clandestine users chose injectable
contraceptives, while others used pills that were hidden at work or at neighbors' homes.
In Egypt, women's subordinate position often influenced their perceptions of ideal
family size, according to preliminary results from a nationwide WSP study. Fears of
divorce led some women to continue childbearing, even if they did not want more children.7 Another study, which included analysis of 1992 Demographic and
Health Surveys (DHS) data, revealed that men typically want more children than women.
Unless partners communicate their desires about family size, the husbands' wishes usually
prevail.8
In Bangladesh, where women are often totally dependent on their husbands for financial
support, men's views strongly influenced contraceptive use. Interviews with 104 women and
92 men found that women were reluctant to use contraception if they thought their husbands
might view family planning as an economic burden. "My husband does not object to my
taking pills," one woman explained. "But when I get ill and he has to spend
money, he snaps at me, 'You squander my money by taking these [pills]. Have I piled up
money to spend on you?'"9
Elsewhere, men also played a dominant role in contraceptive decision-making. Nigerian
couples said that men's views were more important than women's in family decisions. Among
the more than 3,000 couples interviewed, 88 percent of men and 78 percent of women said
men were the dominant decision-makers in the home. Men and women generally agreed that men
decide whether the couple will have sexual intercourse, the duration of postpartum
abstinence and whether the couple will use family planning.10
A Population Council study in the Philippines found that the husband's desire for more
children ranked as the second most important obstacle for contraceptive use by women who
wish to space or delay pregnancies. (Men and women's concern about contraceptive side
effects was the premier obstacle.)11 In a survey of more than
6,500 households in Turkey, one-fourth of the women said they did not want more children
but did not use contraception because their husbands disapproved.12
But researchers speculate that the lines of authority may be less distinct in some
countries. In a 1991 survey among Egyptian men, most said that husbands had the most
influence in contraceptive decisions. But among men who had ever used contraception, a
substantial number (about a third) said their wives played the more influential role.
Researchers concluded that women play a larger role in these decisions than is openly
acknowledged.13
That couples may not communicate well about family planning is illustrated in a WSP
study in El Alto, Bolivia, which included 101 women and 31 men. Conducted by the Proyecto
Integral de Salud, it found that two-thirds of male participants said that family planning
was a joint decision with their partner, but fewer than half of the women said family
planning was a mutual decision.14
In general, some women say they are too shy or too busy to begin discussions with their
husbands; others fear their husband's response or worry that their knowledge of sexual
issues could be interpreted as promiscuity or infidelity. "I express what I have to
with fear, and it embarrasses me," said one woman in the El Alto study.
Another WSP study, conducted by Cooperazione Internationale, surveyed 630 couples in
Cochabamba, Bolivia.15 More than 90 percent of women and men
said they approved of family planning, that their partner approved of family planning,
that men should take responsibility for family planning by using male contraceptive
methods, and that men should support their partner's decision to use contraception.
However, only half the couples said they talked about family size, and not all couples
discussed contraceptive use.
Couple communication can play a pivotal role in contraceptive use. In a study in
eastern Ghana, funded by the Population Council, the Navrongo Health Research Center
(NHRC) examined factors that influenced adoption of family planning methods. The NHRC
conducted a pilot project and established a community-based health center and family
planning services. At the time the project began, only two of the 2,000 women in the
community used contraception. Within 18 months, 225 women were using family planning. The
two most important factors in determining contraceptive use were communication between
spouses (including wives' perception that husbands supported their contraceptive use) and
communication with people outside the family who offered encouragement and support for
family planning.16
Other family members
While husbands and male partners have a tremendous impact on women's contraceptive use
or non-use, other family members can play significant roles as well.
In some countries, parents and in-laws view grandchildren as necessary to extend the
family line, to provide labor on family farms, or to provide financial support for parents
during old age. They may discourage couples from using family planning to delay pregnancy,
but encourage couples to use family planning to limit or space births after they have a
large family.
WSP research in Zimbabwe showed that although contraceptive use is high nationwide --
about 48 percent among married women of reproductive age -- contraceptive use before first
pregnancy is low. Only 8 percent of women use family planning at the time they marry, but
after first birth, the percentage increases to 59 percent.17
"You get pressure from both your family and your husband's family to get
pregnant" soon after marriage, explains Dr. Marvellous Mhloyi of the Center for
Population Studies at the University of Zimbabwe, a principal investigator for one of four
WSP studies in Zimbabwe. "If you do not get pregnant in three months, people will
come and say, 'There is a darkness in this house.'" In addition, having children
affords women more status. In another Zimbabwe study, mothers-in-law said they encouraged
contraceptive use, but only as a means of limiting pregnancies once a couple had the
number of children they wanted.18
Dr. Laila Kafafi, FHI senior resident research advisor in Egypt, says that many young
married women may not see the benefit of using family planning to delay pregnancy.
"Once you get married, you have to have a child right away," she says.
"Mothers-in-law want daughters-in-law to prove fertility."
Preliminary findings from one nationwide WSP study in Egypt found that mothers-in-law
influenced women's decisions about family size.19A woman in a
village near Assiut said that her mother-in-law threatened her if she did not have more
children and told her she would find another bride for her son. When asked if they would
advise their daughters-in-law to plan their families, one woman said, "after the
first child, to know if she is fertile or not." Another said, "After the first
male child." Men also suggested that couples should have a child as soon as possible
after marriage. "Why else does a girl get married?" asked one man in Alexandria.20
Other studies have also found that mothers-in-law and other elder family members
influence women's decisions about family size. In India, 56 of the 100 women interviewed
in Uttar Pradesh said they deferred to their mothers-in-law for decisions about health and
child welfare.21 In some homes, where couples live with
parents or in-laws, lack of privacy can discourage use of some contraceptives, such as the
pill, condoms or a diaphragm.
In a study in Kenya, conducted in four rural communities in Nyanza province,
three-fourths of the women surveyed said they discuss family planning with someone else.
Most of these conversations (94 percent) involved other women, especially family members.
Women said they weigh information they receive from health providers against information
from female relatives and friends.22
In Brazil, a WSP study found that some adolescent girls wanted to be pregnant,
believing it would enhance family relationships.23
Researchers interviewed 367 teens who sought prenatal care at the Maternidade Escola Assis
Chateaubriand (MEAC) clinic in Fortaleza, Ceará, plus 196 teens who came to the emergency
ward for treatment of complications from incomplete abortion. Among the prenatal group,
only 12 percent used contraception at the time of their pregnancy, and 46 percent said
they wanted to be pregnant.
During an interview, conducted during their initial visit to the MEAC clinic, pregnant
teens said they thought their pregnancy would improve their relationships with parents,
friends and partners. However, when interviewed at 45 days postpartum, adolescents
reported that their relationships with their mothers had improved, while their
relationships with their partners had deteriorated. When interviewed one year later,
adolescents reported no improvements in relationships with their mothers. Relationships
with partners deteriorated in both groups at one year.
In Jamaica, seventh and eighth grade girls said that their peers might be reluctant to
use family planning. If parents and friends learned of contraceptive use, they would
assume a girl was sexually active, which would be forbidden at a young age. One girl
suggested that if a mother found her daughter's contraceptive supplies, she "would
curse her. She would think she was having sex."24
-- Barbara Barnett
References
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- Mutambirwa J, Utete V, Mutambirwa C, et al. Zimbabwe: The
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Report. Research Triangle Park, NC: Family Health International and University of
Zimbabwe, 1998.
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For more information, visit Family Health International's Website at www.fhi.org
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