Women on top: the relative influence of wives and husbands on contraceptive use in KwaZulu-Natal

As long as (I think) my husband agrees…: role of perceived partner approval in contraceptive use among couples living in military camps in Kinshasa, DRC

BACKGROUND

Male partner's approval is a key determinant of contraceptive use for women living in Sub-Saharan Africa and improving men's support and couple communication is a cornerstone of family planning programs. However, approval is often only measured through the women's perception of their partner's opinion.

METHODS

This study conducted in Kinshasa compares contraceptive approval variables from matched male and female partners (n = 252 couples) to establish the frequency of (in)accurate perceptions by the woman, then test their association with modern contraceptive use. Additional regressions estimate individual and couple variables associated with (in)correct perceptions.

RESULTS

Results confirm women are poorly aware of their partner's opinion but indicate that perceived approval or disapproval by the woman is a much stronger determinant of modern contraceptive use than her partner's actual opinion. Higher educational achievement from the woman is the strongest driver of misunderstanding her partner's approval.

CONCLUSIONS

Women's perceptions of partner's approval are much stronger determinant of contraceptive use than the latter's actual opinion, and stereotyping men's opinion of family planning is a common error of appreciation. However, findings also suggest these misunderstandings might serve women's capacity to negotiate contraceptive use.

Multilevel analysis of the role of women's empowerment on use of contraceptive methods among married Cambodian women: evidence from demographic health surveys between 2005 and 2014

Background

The use of contraceptives is an essential public health concept that improves overall safe motherhood and infant health. Women empowerment has been reported to influence health behaviors in women. With recent efforts to increase access to contraceptive methods, uptake of the same remains a challenge in Cambodia. There are limited studies that have examined the role of women’s empowerment at both individual- and community- level on contraceptive use in Cambodia. This study examined the individual- and community-level factors associated with contraceptive use among Cambodian married women between 2005 and 2014.

Methods

Data from 2005, 2010, and 2014 Cambodia Demographic and Health Surveys were used to analyze 2211; 10,505; and 10,849 women, respectively. Multilevel binary and multinomial logistic regression models were applied to assess the association between individual- and community- level factors, and the use of contraceptive methods.

Results

The prevalence of using modern contraceptive methods increased over time (i.e., 29.0, 38.1, and 42.3% in 2005, 2010, and 2014, respectively). At the individual level, women who attained secondary and higher education were more likely to use any contraceptives [adjusted odds ratio (aOR) = 1.43, 95% confidence interval (CI) = 1.22–1.68, and aOR = 1.23, 95% CI = 1.05–1.44 in 2010 and 2014, respectively] compared with those with no formal education. Similarly, having a high workforce participation level was significantly associated with increased likelihood of using any contraceptive methods [aOR = 1.12, 95% CI = 1.00–1.26, aOR = 1.44, 95% CI = 1.29–1.60 and in 2010 and 2014, respectively]. Other factors such as age at first marriage, residence, and having a health insurance were associated with contraceptive use. The proportional change in variance showed that about 14.3% of total variations in the odds of contraceptive use across the communities were explained by both individual- and community-level factors. Moreover, the intraclass correlation showed that about 5.2% of the total variation remained unexplained even after adjustments.

Conclusion

Both individual- and community- level factors influenced contraceptive use in Cambodia. When designing programs to improve contraceptive use, contextual influences should be taken into account for the effectiveness of the programs.

'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health

RATIONALE

A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment.

OBJECTIVE

We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals.

METHODS

Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework.

RESULTS

Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception.

CONCLUSIONS

The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.

Male partner influence on family planning and contraceptive use: perspectives from community members and healthcare providers in KwaZulu-Natal, South Africa

BACKGROUND

South Africa faces numerous reproductive challenges that include high rates of unplanned and adolescent pregnancies. The uptake and utilization of family planning services and modern contraception methods depend on numerous factors. The male partner plays a key role in reproductive health but data on this topic are outdated or have a predominant HIV prevention focus. The purpose of this paper is to explore the influence of male partners on family planning and contraceptive (FP/C) uptake and use within the contemporary South African setting, and to identify further areas of exploration.

METHODS

This qualitative study was conducted in a community and healthcare provision setting in the eThekwini District in KwaZulu-Natal province, South Africa. Data were collected from twelve community-based focus group discussions (n = 103), two healthcare providers focus group discussions (n = 16), and eight key informant individual in-depth interviews. Following a constructionist paradigm and using the health utilization behaviour model, data were analysed using thematic analysis, allowing a robust and holistic exploration of the data.

RESULTS

The data from this study revealed the complex and evolving role that male partners play in FP/C uptake and use within this setting. Key themes from the data elucidated the dual nature of male involvement in FP/C use. Culturally influenced gender dynamics and adequate understanding of FP/C information were highlighted as key factors that influenced male attitudes and perceptions about contraceptive use, whether positively or negatively. Male opposition was attributed to limited understanding; misunderstandings about side-effects; male dominance in relationships; and physical abuse. These factors contributed to covert or discontinued use by female partners. Pathways identified through which male partners positively influenced FP/C uptake and access include: social support, adequate information, and shared responsibility.

CONCLUSIONS

Understanding the role that male partners play in FP/C uptake and use is important in preventing unintended pregnancies and improving family planning policy and service delivery programmes. By identifying the barriers that male partners present, appropriate strategies can be implemented. Equally important is identifying how male partners facilitate and promote adherence and use, and how these positive strategies can be incorporated into policy to improve the uptake and use of FP/C.

The Relationship between Partners' Family-Size Preferences in Southern Malawi

Studies of the relative influence of partners' fertility preferences on behaviors tend to treat preferences as fixed, largely independent traits despite existing theoretical arguments and empirical evidence suggesting that they are moving targets that may be jointly developed within relationships. In this study, we use couple-level panel data from married and unmarried young adults in southern Malawi to examine the relationship between partners' family-size preferences. We find evidence of assortative mating: young Malawians are more likely to partner with individuals who have similar family-size goals. Additionally, although partners' family-size preferences do not perfectly converge, changes among men's and women's preferences are significantly more likely to be "toward" than "away from" those of their partner. Our findings point to a need for studies regarding the relative influence of partners on reproductive outcomes to consider the interdependence of partners' preferences and the varied ways in which partners can influence shared reproductive behaviors.

Covert contraceptive use among women attending a reproductive health clinic in a municipality in Ghana

Background

Covert contraceptive use (CCU) in sub-Saharan Africa is an indication of women’s inability to exercise autonomy in their reproductive choices. The aim of this study was to assess the prevalence and determinants of CCU among a sample of FP clients in a municipality of Ghana.

Methods

We conducted a mixed method study among women attending a public reproductive health clinic in Sunyani, a city of over 250,000 inhabitants in Ghana. An initial survey inquired into sociodemographic characteristics, use of family planning (FP) methods and partner awareness of contraceptive use. The predictors of CCU were explored using logistic regressions. We used the findings to develop a guide which we applied in-depth interviews and focus group discussions with attendants at the same facility. Qualitative data analysis was conducted using a framework approach.

Results

We interviewed 300 women, 48 % of whom were aged between 26–33 years. The injectable was the most widely used method (56 %). The prevalence of CCU was 34 %. In multivariate analysis, single women were more likely to practice CCU than married or co-habiting women (Adjusted OR = 12.12, 95 % C.I. 4.73–31.1). Muslim and traditionalist women were similarly more likely to practice CCU than non-Muslim, non-traditionalist (Adjusted OR = 4.56, 2.29–9.06). Women who preferred to have their first or next child in 4 or more years from the time of the interview were more likely to be in CCU than women who intended to have children within 4 years of the interview (2.57; 1.37–4.83). Single women saw in covert use a statement of their social autonomy. To succeed in CCU, women wished that clinic attendance cards would not be given to them to keep at home. Though many participants saw in CCU a source of anxiety, they expected health workers to consider it and uphold confidentiality in the provision of services.

Conclusions

Covert contraceptive use was high in this municipality and being single was the strongest predictor of the practice. Providers of FP services should reflect on how to adequately address the challenges faced by women who practice CCU.

The influence of wives' and husbands' fertility preferences on progression to a third birth in Nepal, 1997-2009

As couples across the globe increasingly exercise conscious control over their reproduction, both spouses' family-size preferences have the opportunity to influence their fertility. Using couple-level measures of rural Nepalese spouses' family-size preferences and more than a decade of monthly panel data collected subsequently on fertility outcomes, we investigate how both spouses' preferences influence progression to a third birth in a country where the widely professed ideal family size is two children. Contrary to expectations based on women's relative disadvantage, we find that it is wives' preferences that drive couples' progression to a third birth. We find also that the influence of wives' preferences is not explained by contraceptive use but that this influence is moderated by couple communication about family planning. Wives' preferences drive progression to a third birth among couples who had discussed how many children to have.

Relationship characteristics and contraceptive use among couples in urban kenya

CONTEXT

Few studies have used couple data to identify associations between individual- and relationship-level characteristics and contraceptive use in urban areas.

METHODS

Population-based survey data collected in 2010 in three Kenyan cities-Nairobi, Mombasa and Kisumu-were used to identify 883 couples. Bivariate and multivariate analyses were conducted to examine associations between relationship-level characteristics (i.e., desire for another child, and communication about desired number of children and family planning use) and contraceptive use among couples currently using contraceptives; additional analyses investigated intention to use contraceptives among couples currently not practicing contraception.

RESULTS

Sixty percent of couples reported current use of contraceptives. In multivariate analyses, couples who desired another child were less likely to use contraceptives than couples who wanted no more children (odds ratio, 0.5). Couples in which both partners reported spousal communication about family planning in the past six months had greater odds of contraceptive use than couples that reported no spousal communication on the subject (3.8). Results from analyses examining associations between relationship-level characteristics and intention to use contraceptives among current nonusers resembled those from analyses of current contraceptive users.

CONCLUSION

In this study, relationship-level characteristics were associated with current contraceptive use and intention to use contraceptives among couples in urban Kenya. Family planning programs that promote spousal communication about family planning and desired number of children may improve contraceptive use among urban couples.

Putting the C back into the ABCs: a multi-year, multi-region investigation of condom use by Ugandan youths 2003-2010

A major strategy for preventing transmission of HIV and other STIs is the consistent use of condoms during sexual intercourse. Condom use among youths is particularly important to reduce the number of new cases and the national prevalence. Condom use has been often promoted by the Uganda National AIDS Commission. Although a number of studies have established an association between condom use at one’s sexual debut and future condom use, few studies have explored this association over time, and whether the results are generalizable across multiple locations. This multi time point, multi district study assesses the relationship between sexual debut and condom use and consistent use of condoms thereafter. Uganda has used Lot Quality Assurance Sampling surveys since 2003 to monitor district level HIV programs and improve access to HIV health services. This study includes 4518 sexually active youths interviewed at five time points (2003–2010) in up to 23 districts located across Uganda. Using logistic regression, we measured the association of condom use at first sexual intercourse on recent condom usage, controlling for several factors including: age, sex, education, marital status, age at first intercourse, geographical location, and survey year. The odds of condom use at last intercourse, using a condom at last intercourse with a non-regular partner, and consistently using a condom are, respectively, 9.63 (95%WaldCI = 8.03–11.56), 3.48 (95%WaldCI = 2.27–5.33), and 11.12 (95%WaldCI = 8.95–13.81) times more likely for those individuals using condoms during their sexual debut. These values did not decrease by more than 20% when controlling for potential confounders. The results suggest that HIV prevention programs should encourage condom use among youth during sexual debut. Success with this outcome may have a lasting influence on preventing HIV and other STIs later in life.

Partner approval and intention to use contraception among Zanzibari women presenting for post-abortion care

OBJECTIVE

We examined the effect of partner approval of contraception on intention to use contraception among women obtaining post-abortion care in Zanzibar.

STUDY DESIGN

Our data source was a 2010 survey of 193 women obtaining post-abortion care at a large public hospital in Zanzibar. We used multivariable logistic regression analysis to assess associations between partner approval and intention to use contraception.

RESULTS

Overall, 23% of participants had used a contraceptive method in the past, and 66% reported intending to use contraception in the future. We found that partner approval of contraception and ever having used contraception in the past were each associated with intending to use contraception in the future. In the multivariable model, adjusting for past contraception use, partner approval of contraception was associated with 20 times the odds of intending to use contraception (odds ratio, 20.25; 95% confidence interval, 8.45-48.56).

CONCLUSIONS

We found a strong association between partner approval and intention to use contraception. Efforts to support contraceptive use must include both male and female partners.

IMPLICATIONS

Public health and educational efforts to increase contraceptive use must include men and be targeted to both male and female partners. Given that male partners are often not present when women obtain health care, creative efforts will be required to meet men in community settings.

Uthando Lwethu ('our love'): a protocol for a couples-based intervention to increase testing for HIV: a randomized controlled trial in rural KwaZulu-Natal, South Africa

Background

Couples-based HIV counseling and testing (CHCT) is a proven strategy to reduce the risk of HIV transmission between partners, but uptake of CHCT is low. We describe the study design of a randomized controlled trial (RCT) aimed to increase participation in CHCT and reduce sexual risk behavior for HIV among heterosexual couples in rural KwaZulu-Natal, South Africa. We hypothesize that the rate of participation in CHCT will be higher and sexual risk behavior will be lower in the intervention group as compared to the control.

Methods/design

Heterosexual couples (N = 350 couples, 700 individuals) are being recruited to participate in a randomized trial of a couples-based intervention comprising two group sessions (one mixed gender, one single gender) and four couples’ counseling sessions. Couples must have been in a relationship together for at least 6 months. Quantitative assessments are conducted via mobile phones by gender-matched interviewers at baseline, 3, 6, and 9 months post-randomization. Intervention content is aimed to improve relationship dynamics, and includes communication skills and setting goals regarding CHCT.

Discussion

The Uthando Lwethu (‘our love’) intervention is the first couples-based intervention to have CHCT as its outcome. We are also targeting reductions in unprotected sex. CHCT necessitates the testing and mutual disclosure of both partners, conditions that are essential for improving subsequent outcomes such as disclosure of HIV status, sexual risk reduction, and improving treatment outcomes. Thus, improving rates of CHCT has the potential to improve health outcomes for heterosexual couples in a rural area of South Africa that is highly impacted by HIV. The results of our ongoing clinical trial will provide much needed information regarding whether a relationship-focused approach is effective in increasing rates of participation in CHCT. Our intervention represents an attempt to move away from individual-level conceptualizations, to a more integrated approach for HIV prevention.

Trial registration

Study Name: Couples in Context: An RCT of a Couples-based HIV Prevention Intervention

ClinicalTrials.gov identifier: NCT01953133.

South African clinical trial registration number: DOH-27-0212-3937

Does integrating family planning into HIV care and treatment impact intention to use contraception? Patient perspectives from HIV-infected individuals in Nyanza Province, Kenya

OBJECTIVE

To evaluate whether HIV-infected women and men in HIV care and not using highly effective methods of contraception thought they would be more likely to use contraception if it were available at the HIV clinic.

METHODS

A face-to-face survey assessing family-planning knowledge, attitudes, and practices was conducted among 976 HIV-infected women and men at 18 public-sector HIV clinics in Nyanza, Kenya. Data were analyzed using logistic regression and generalized estimating equations.

RESULTS

The majority of women (73%) and men (71%) thought that they or their partner would be more likely to use family planning if it were offered at the HIV clinic. In multivariable analysis, women who reported making family-planning decisions with their partner (adjusted odds ratio [aOR] 3.22; 95% confidence interval [CI], 1.53-6.80) and women aged 18-25 years who were not currently using family planning (aOR 4.76; 95% CI, 2.28-9.95) were more likely to think they would use contraception if integrated services were available. Women who perceived themselves to be infertile (aOR 0.07; 95% CI, 0.02-0.31) and had access to a cell phone (aOR 0.40; 95% CI, 0.25-0.63) were less likely to think that integrated services would change their contraceptive use. Men who were not taking antiretroviral medications (aOR 3.30; 95% CI, 1.49-7.29) were more likely, and men who were unsure of their partner's desired number of children (aOR 0.36; 95% CI, 0.17-0.76), were not currently using family planning (aOR 0.40; 95% CI, 0.22-0.73), and were living in a peri-urban setting (aOR 0.46; 95% CI, 0.21-0.99) were less likely to think their partner would use contraception if available at the HIV clinic.

CONCLUSIONS

Integrating family planning into HIV care would probably have a broad impact on the majority of women and men accessing HIV care and treatment. Integrated services would offer the opportunity to involve men more actively in the contraceptive decision-making process, potentially addressing 2 barriers to family planning: access to contraception and partner uncertainty or opposition.

Attitudes about Children and Fertility Limitation Behavior

The relationship between attitudes and individual behavior is at the core of virtually all demographic theories of fertility. This paper extends our understanding of fertility behavior by exploring how psychic costs of childbearing and contraceptive use, conceptualized as attitudes about children and contraception, are related to the transition from high fertility and little contraceptive use to lower fertility and wide spread contraceptive use. Using data from rural Nepal I examine models of the relationship between multiple, setting-specific attitudes about children and contraception and the hazard of contraceptive use to limit childbearing. Specific attitude measures attempt to capture the relative value of children versus consumer goods, the religiously based value of children, and the acceptability of contraceptive use. Findings demonstrate that multiple measures of women's attitudes about children and contraception were all independently related to their fertility limitation behavior.

Contextual influences on contraceptive use in the Eastern Cape, South Africa

This paper uses linked individual and health facility data from the 1998 South Africa Demographic and Health Survey and the 1998 Eastern Cape Facility Survey to explore community and health facility influences on modern contraceptive use. Several pathways of influence between the community and individual contraceptive adoption are identified, centering primarily on the community climate of female autonomy. Few significant effects of the health facility environment on contraceptive adoption are identified. The residual variation in contraceptive use highlights the deficits that exist in current datasets for capturing community influences on contraceptive behavior.

Gender, sexuality, and antiretroviral therapy: using social science to enhance outcomes and inform secondary prevention strategies

OBJECTIVES

To explore how, within the context of antiretroviral therapy (ART) uptake and adherence, social science research on gender and sexuality could complement existing epidemiological and behavioral research on uptake, adherence, disinhibition and reproduction.

METHODS

Bibliographical database searches on ART uptake and adherence, the sexual practices of HIV-positive individuals, and fertility management among HIV-positive men and women were conducted over a 6-month period using ISI Web of Science and Medline. Articles were sorted by main topic and then analysed to reveal the unarticulated assumptions that have framed research to date.

RESULTS

The adoption of more social scientific theoretical frameworks would move research on uptake, adherence, disinhibition, and reproduction among HIV-infected and affected individuals beyond the current overemphasis on how cognitive and ideological factors shape behavior and towards an understanding of how culture and inequality shapes the way people engage with ART and craft their sexual and reproductive lives. Research that pays greater attention to the social processes that create differentials in uptake and adherence, rather than just the quantification of those differentials, will open up new possibilities for community-based interventions. Similarly, social science research on gender and sexuality can provide insight into the social factors shaping reproductive and sexual behavior, and thus enhance our ability to manage the potentially competing priorities of limiting marital sexual risk and increasing access to reproductive choice among HIV-affected couples.

CONCLUSION

The ability to produce good clinical outcomes and to develop effective policies for secondary prevention will be enhanced by a deeper understanding of how gender inequality and the social organization of sexuality shape the sexual and reproductive behavior of individuals using ART.

Integration of sexual and reproductive health services in KwaZulu-Natal, South Africa

An integrated sexual and reproductive health package is widely regarded as essential for meeting the needs of both men and women. The practical realities of integration in KwaZulu-Natal, South Africa, were examined from the perspective of both providers and clients. Only minorities of clients received any assessment of reproductive and sexual health needs over and above their main presenting need or problem. The majority would have welcomed such assessments and many were classified as being in need, particularly for advice and services with regard to sexually transmitted infections, including HIV. Most providers were positive about integration, but their ability to practice an active form of integration was limited by inadequate training and time constraints. While training defects can be remedied, the time constraints posed by heavy patient loads are less tractable. More skillful use of booking clerks or the introduction of lay counsellors are also possible solutions.