1. Fertility Desires and Family Planning Among HIV-affected Couples in Nyanza Province, Kenya Sara Newmann, MD, MPH Men, Masculinities and Family Planning in Africa October 14, 2010 October 14, 2010October 14, 2010

2. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Objective Review background Describe study goals/methods Discuss case study and preliminary themes related to masculinity, fertility, and family planning Discuss early ideas for future interventions 2

3. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine 3

4. HIV care providers, Nyanza “In our community, the Luos, most…use Depo because…they know their husbands will not realize very fast.” “We do manipulate their decisions, that is why when you go to our records Depo is on the highest side.” “We can improve [family planning] by including the males. She tries to hide, but if they come [together] the husband knows that my wife is on family planning..it’s safer than the mother just coming alone.” Newmann, APHA, 2008

5. High unmet need for family planning Future fertility preferences: HIV-infected men and women, Nyanza Newmann, Reproductive Health 2010 Men (n=402)

6. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Study Aim To assess the feasibility of recruiting and separately and simultaneously interviewing partners of heterosexual couples in Nyanza Province To perform qualitative, hypothesis-generating research to explore couple decision-making and relationship power around fertility and family planning among HIV-affected couples in Nyanza Province

7. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Study Population Clinic-based couples: Reproductive-age, heterosexual couples, at least one partner is HIV-infected and a patient at a FACES- supported HIV clinic Community-based couples: Reproductive-age men and women in heterosexual couple relationships in Nyanza Province communities Community leaders Village chiefs, assistant chiefs, community group leaders, village elders, religious leaders, leaders of community committees Study Location Migori, Rongo, Nyatike, districts in Nyanza Province

8. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Specific Objectives To explore: fertility desires gender dynamics in decision-making around fertility and family planning perceptions of contraceptive methods impact of unintended pregnancy …and the influence of HIV infection on the above

9. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Study Design In-depth, semi-structured interviews: –15-20 clinic-based couples –15-20 community-based couples –15-20 Key informants/Community leaders Separate, simultaneous interviews Same-sex interviewers in Dhluo Purposive and chain referral sampling Transcription/Translation Data analysis: Atlas.ti 5.6 Qualitative, grounded theory methods

10. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Study Progress All Interviews completed (includes pilots): 21 clinic-based couples 21 community-based couples 26 community leaders Interviews translated/transcribed: 1 clinic-based couple 2 community-based couples 2 community leaders

11. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Community Couple Case Study Demographics Response to question about male involvement in family planning

12. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine 12 Loss of lineage Religion Traditional Luo culture Political pressure Land ownership/security –Importance of male children Impact of HIV

13. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Community Couple Case Study Response to question about male involvement in family planning

14. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Need for facilitation of FP discussion Family planning stigma Myths/misperceptions Side effects

15. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Community Couple Case Study Demographics Response to question about male involvement in family planning Response to question about clandestine use of family planning

16. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine 16

17. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine Final thoughts Need discourse about family planning in male spaces and with male leaders Emphasize reversibility of methods Encouragement, the only way to encourage people is through talks…Then they hear okay,… so and so only had two children and they are just alive. Then later those children went to school very well, and the kind of assistance they get at home is much easier than one who has a heavy burden. 17

18. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine 18 Thank you Maricianah Onono Rachel Steinfeld Zachary Kwena Elizabeth Harrington Salome Ogola Alphonce Omondi Steve Ajuoga Daniel Grossman Elizabeth Bukusi Craig Cohen Shari Dworkin Lynae Darbes Megan Comfort Nicolas Sheon

19. 19 Thank you Maricianah Onono Rachel Steinfeld Zachary Kwena Elizabeth Harrington Salome Ogola Alphonce Omondi Steve Ajuoga Daniel Grossman Elizabeth Bukusi Craig Cohen Shari Dworkin Lynae Darbes Megan Comfort Nicolas Sheon

20. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine HIV care providers, Nyanza Male influence of contraceptive choice even in their absence Male disapproval of FP seen as barrier Clandestine contraception use Improved safety and use of contraception if men involved “In our community, the Luos, most…use Depo because…they know their husbands will not realize very fast.” “We do manipulate their decisions, that is why when you go to our records Depo is on the highest side.” “We can improve [family planning] by including the males.” Newmann, APHA, 2008

21. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine High unmet need for family planning Future fertility preferences: Married women, KDHS 2008-09 Kenyan Demographic Health Survey, 2008-09 * Within the next 2 years ** After 2 years *** Wants more, undecided when or undecided if wants more

22. Department of Obstetrics, Gynecology & Reproductive Sciences School of Medicine The role of men in family planning decision-making Growing body of literature on men’s role in reproductive decision-making Male disapproval or opposition is frequently cited as a barrier to contraceptive use Interventions to increase male participation in FP decision-making have had variable (positive and negative) effects in sub-Saharan Africa No in-depth studies from Kenya on couple dynamics or reproductive decision-making