1. Men, Family Planning and Reproductive Health
In this section we will focus primarily on men’s involvement in family planning, reasons why it might be important to change the current situation and barriers that will need to be overcome.
We will then describe some of the strategies that have been used worldwide to reach out to men.
Richard Lord
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2. Men’s Share of Responsibility for Family Planning
What percentage of worldwide contraceptive use involves male methods?
Is this percentage increasing or decreasing?
[Facilitator: Ask participants to name the four methods of contraception that directly require male cooperation.]
The four current methods of contraception that directly require male cooperation are: 1) condoms; 2) vasectomy; 3) withdrawal; and 4) periodic abstinence.
[Facilitator: Ask participants to answer the questions on the slide. Then ask participants to brainstorm the following questions:
What might make male methods attractive to men, women or couples?
Why might men, women or couples not want to use male methods?]
Jane Turner
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3. Male Methods: 26% of Global Contraceptive Use
Female sterilization
Withdrawal and Abstinence: 12%
Male
methods:
33%
Other female
methods 5%
26%
Vasectomy: 7%
22%
14%
This slide is based on the 58 percent of married women in the world who, according to a 1998 United Nations (UN) study, reported that they were using a contraceptive method.
About one of every four of these women (26 percent) said they were relying on a method used by their male partner: seven percent on vasectomy; another seven percent on condoms; and 12 percent on either periodic abstinence or withdrawal.
The great majority (74 percent), however, reported that they were using a female method. Of these, female sterilization was the most common (33 percent).
Condoms: 7%
IUD
Oral contraceptives
Source: United Nations, 1998.
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4. Use of Male Methods Declining as Proportion of Overall Use
1987
1998
According to the UN, reliance on male methods fell from 37 percent in 1987 to 26 percent in Over this same period, reliance on vasectomy and condoms, as a contraceptive method, each fell from nine percent to seven percent.
Most of the 11 percent overall decline in the use of male methods was due to fewer couples relying on withdrawal and periodic abstinence. However, the decline in vasectomy and condoms is less easily explained, particularly as the increased need for protection from sexually transmitted infections (STIs) is provided only by condoms.
In an era of increasing emphasis on prevention of STIs and HIV/AIDS, the number of couples relying on condoms for family planning is falling, in terms of both total number of users and as a percentage of users. In less developed countries, only two percent of all reproductive-age couples reported using condoms for contraception.
Global use of male methods
Global use of vasectomy
Global use of condoms
Source: United Nations, 1987, 1998.
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5. Gender Imbalance: Knowledge/Use of Sterilization
Use of Sterilization in 10 Countries with Highest Levels of Vasectomy
Australia
Belgium
Canada
China
Republic of Korea
Nepal
Netherlands
New Zealand
United Kingdom
United States
Female Sterilization
Vasectomy
Worldwide, vasectomy is much less widely used than female sterilization, despite being safer and less expensive.
This slide shows the 10 countries with the highest rates of vasectomy; only in the Netherlands, New Zealand and the United Kingdom does vasectomy equal or exceed female sterilization. The blue bars represent vasectomy and the red, female sterilization.
In many developing countries, use of vasectomy has actually lost ground to female sterilization over the past decade. The ratio of male to female sterilizations now ranges from one in three in China to one in 35 in India; in many parts of sub-Saharan Africa, vasectomy remains virtually unknown and unavailable.
[Facilitator: Ask participants if they know the ratio of vasectomy versus female sterilization in their respective countries. You can also collect such statistics ahead of time and share these with participants.]
Percent of Married Couples of Reproductive Age
Source: United Nations, 1998.
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6. Why Involve Men in Family Planning?
Male responsibility in reproductive health issues is essential to decreasing HIV/AIDS and other STIs
Men play dominant role in decision-making
Global contraceptive use has reached a plateau
Funds for family planning have declined
Why should we be concerned about the decline in men’s use of contraception?
Male responsibility in reproductive health issues is essential to decreasing the incidence of HIV/AIDS and other STIs. For instance, dual protection against unintended pregnancies and STIs/HIV requires the use of condoms, yet condom use as a percentage of total overall contraceptive use has declined rather than increased in recent years.
Men play a dominant role in household decisions, including the number and timing of births.
Globally, contraceptive use has reached a plateau. In the four years between 1994 and 1998, global contraceptive use increased only one percent – from 57 percent to 58 percent. Efforts are on-going to address continued unmet need.
At the same time, funds to support family planning services and commodities around the world have substantially declined. Program managers and policymakers have asked, “How can we do more with less?” One largely untapped resource is the male half of the population. Men are more likely to have disposable income and vasectomy is a less invasive and less expensive method than female sterilization.
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7. Husband Disapproval Major Factor in Unmet Need
3 of 7 pregnancies in the world are unintended
Contraceptive use and continuation are higher when husband and wife agree
Photo??
The UN Population Fund (UNFPA) estimates that as many as three out of every seven pregnancies worldwide are unintended. Many women who report that they want to delay or end childbearing say they are not using contraception because of the real or perceived lack of approval of their partner. Communication between men and women on subjects of sexuality and reproductive health are often limited or even nonexistent in many parts of the world and this is an issue that needs to be addressed.
According to recent studies using in-depth interviews and survey data in Ghana, Guatemala, India, Pakistan, the Philippines and Zambia, the lack of male approval is a major factor influencing the unmet need for family planning.
In five sub-Saharan African countries, average contraceptive use among married women was three times higher (18 percent compared to six percent) when their husbands approved, compared to women whose husbands did not approve.
Despite the value of men’s participation, women should always have a choice as to whether their partners are involved in contraceptive decision-making. Some women choose to use contraception without their husband’s knowledge, which could put them at risk of violence.
USAgency for International Development
Sources: Bongaarts, Stud Fam Plann 1995;26(2).
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8. Couple Counseling Results in Better Continuation Rates
Percentage of couples
contracepting after 12 months
One-year contraceptive continuation twice as high when husband counseled with wife (Ethiopia)
33%
17%
Studies have shown that men and women who receive couple counseling have better contraceptive continuation rates.
In a study in Ethiopia of some 500 married women who were first-time users of a modern method, married women who received contraceptive counseling at home with their husbands had contraceptive continuation rates almost twice as high after one year as women whose husbands were not included in the counseling sessions.
A study in Turkey showed that couples were more likely to choose a modern contraceptive method postpartum (80 percent) when the husband was involved in counseling as compared to when women were counseled alone (55 percent).
Husband involved in counseling
Husband NOT involved in counseling
Source: Terefe, Am J Public Health 1993;83(11).
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9. Barriers to Men’s Use of Contraception
Lack of accurate information
Provider bias against male methods
Limited access to services
Beryl Goldberg
Although many men have some knowledge as to the range of contraceptive methods available, their understanding of human reproduction and the use of specific methods is often lacking or inaccurate. For example, interviews with men in Uttar Pradesh, India, showed that they consider vasectomy to be a more difficult, less safe and more expensive procedure than female sterilization when, in fact, exactly the opposite is true. In addition, both men and women thought incorrectly that vasectomy will result in impotence and weakness.
Health providers are often ill equipped to offset such biases with accurate information. In Tanzania, some providers actually discouraged men who requested a vasectomy resulting in only 15 percent of men who sought information about vasectomy actually undergoing the procedure.
In Zambia, among providers interviewed, many believed that men should have at least five children before vasectomy should be considered.
Vasectomy is still not universally available. In Bangladesh, for example, vasectomy is only available in about one in 20 local districts.
[Facilitator: Ask participants if they can think of other barriers not addressed in the slide that affect men’s use of contraception, such as masculinity and cultural barriers.]
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10. Barriers to Men’s Use of Contraception (cont.)
Lack of provider training
Men’s misunderstanding of correct use
Limited range of male methods
There have been no major breakthroughs in the development of male methods since the advent of no-scalpel vasectomy 20 years ago. In many parts of the world, service providers have still not been trained in this new technique. Where providers have received training in no-scalpel technique, more vasectomy procedures are being carried out.
Many men do not understand how to use methods requiring male participation correctly, including condoms. In the Philippines, natural family planning (NFP) – another method that depends on male cooperation – is the second most widely used method. Yet a national survey found that more than half of husbands relying on NFP had received no training on how the method works. In one province, neither male nor female users could correctly identify the fertile period.
The lack of reversible, non-coital dependent methods for men is seen as a drawback by many men and women.
[Facilitator: Ask participants if they have other points to make about barriers to services? Take a few responses, and then let them know that you are now going to show a few slides that address some of these barriers.]
S. Khalaf/Family Health International
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11. Why Some Men Choose Vasectomy
Simpler, safer and less expensive than female sterilization
Love for wife and concern for her health
Desire to take responsibility in family planning
Greater sexual enjoyment by eliminating worries about unwanted pregnancy
Studies show that men have several reasons for choosing vasectomy. When the couple considers their childbearing to be complete, many men decide, after discussion with their partners, that vasectomy is a simpler, safer and less expensive option than female sterilization.
When men understand that repeated pregnancies are associated with health problems, and that some women experience health problems related to use of some female methods, they are often willing to take a more active role in contraceptive use.
Men want to be responsible for family planning or share responsibility with their partners. Some information, education and communication programs have successfully appealed to men’s desire to be caring husbands. “Vasectomy is an Act of Love” was the theme for a media awareness-raising campaign in Brazil that resulted in a substantial increase in the demand for vasectomy.
According to several studies, working with at least one other man who has had a vasectomy is also important to the vasectomy decision.
If desired family size has been reached, men may want to eliminate worries about unwanted pregnancy and thus increase sexual enjoyment.
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12. Condoms: Dual Protection Against Pregnancy and STIs
Can be highly effective in protecting against pregnancy AND preventing HIV/STIs
Should be promoted in family planning, HIV prevention, and other programs
When used correctly and consistently, the condom is the only method that can simultaneously protect against unwanted pregnancy and HIV/STIs. This dual protection can be provided either by the use of a condom alone or by using a condom in combination with another contraceptive method. Abstinence/delay of sexual debut and mutual monogamy with the use of another family planning method are other, very important, means of achieving dual protection.
The actual risk of pregnancy from a single act of unprotected intercourse, occurring during the two middle weeks of the menstrual cycle, is less than eight percent, while the probability of getting an STI, such as gonorrhea, chlamydia, and syphilis, is more than 50 percent (Anderson, 1999; Wilcox, 1995; Trussel, 1998). Because transmission of some STIs is more likely to occur than pregnancy, it follows that, with correct and consistent use, condoms are at least as effective for pregnancy prevention as for preventing HIV and some STIs. Service providers and clients need to be encouraged to move away from focusing on condoms for HIV/STI prevention only because it stigmatizes the condom and disempowers some women’s ability to negotiate condom use.
It is very important that condoms be used by anyone who has more than one sexual partner. For that reason, service providers need to learn enough about their clients’ sexual behavior and risk, to be able to counsel them accordingly.
[Facilitator: If the HIV/STIs module will be presented, let participants know that you will be discussing in more detail reasons for low levels of condom use. If the HIV/STIs module will not be presented, tell participants that a presentation on HIV/STIs, which discusses barriers to condom use and strategies to increase it, is also available.]
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13. Men’s Public Approval versus Private Use
Men report high knowledge and support of contraception even where use is low
Public approval different than private use
Programs need to change attitudes and practices
desire for more children
belief that religion prohibits use
desire for control over wife
DHS data from 21 countries show that men generally know about and say that they approve of family planning; yet actual change in behavior remains limited. In some instances, men report their lack of actual use as being due to a desire for more children; others believe – often incorrectly – that their religion prohibits the use of contraception. Possible infidelity by female partners or a desire for control over a wife are also reported as sources of concern for many men.
In a Kenyan study, EngenderHealth found that more than 90 percent of 300 men interviewed approved of family planning publicly, and many would even say this in a radio interview. Yet, more than half of this group said they would not tell anyone if they were using a method.
Programs need to move beyond increasing knowledge to understanding how to change men’s attitudes and practice.
Sources: Drennan, Popul Rep 1998;J(46); Wilkinson, Man-Myths, AVSC International, 1998.
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14. Creative Outreach Efforts Reach Men in Community
Sports events
Workplaces
Small businesses
Truck stops
Military bases
Media
R. Witlin/World Bank
Special community outreach efforts are often necessary to provide men with accurate information about reproductive health issues and available services.
In Pakistan, barbers have a close relationship with their clients and also perform circumcision. EngenderHealth trained barbers to talk to their clients about reproductive health issues. Religious leaders were also engaged in outreach, letting men know that use of family planning is consistent with the teachings of Islam.
Pro-Pater, an NGO pioneering establishment of men’s clinics in Sao Paulo, Brazil, conducts outreach activities in factories, making educational presentations on reproductive health and contraception.
Other creative programs are reaching men with information and condom promotion messages through sports clubs, factories, small businesses, truck stops and the military, as well as through the media.
[Facilitator: Ask participants if they can think of other places in their own countries where men can be reached.]
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15. Community Education Successfully Involves Men
Honduras:
Agricultural agents and community volunteers reached farmers with reproductive health and family planning information
Interactive materials for low-literacy clients stressed importance of birth spacing for child health
Family planning increased from 37 to 55%
A project in Honduras involving CARE and the Population Council trained agricultural extension workers to use an interactive family management booklet as part of a community education project. These extension workers then trained community volunteers, who in turn provided information to male and female small farmers in rural areas.
The materials were designed for persons with low levels of literacy and stressed the importance of birth spacing. Topics included responsible fatherhood, reproductive health, family planning, STIs, safe motherhood and lactation.
As a result, knowledge increased in all areas, as did couple communication. Use of family planning increased from 37 to 55 percent in the intervention area.
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16. Clinic-based Strategies for Men
Stand-alone male clinics
Separate hours/entrances for men
Integrated services
Male or female counselors
A variety of approaches are being used by family planning programs to reach out to men. Some have tried making services more friendly to men or have provided them with separate hours and entrances. A few, such as PROFAMLIA in Colombia, opened male clinics.
While separate services may be necessary as a first step to reaching men, there is some evidence that integrated services are more sustainable and have the advantage of making couple counseling possible.
A study by PROFAMILIA in Colombia found no difference in use of services when men had access to integrated services, as compared to separate, men-only services.
Men were equally comfortable talking with either a male or female counselor as long as they felt their need for confidentiality was being respected (Vernon, International Family Planning Perspectives, 1991).
Debbie Rogow
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17. Men Respond Positively to Broad Reproductive Health Services
Photo??
Family planning
STI/HIV prevention and treatment
Infertility
Sexual dysfunctions
Reproductive cancers
PROFAMILIA, one of the first family planning programs to offer men a range of reproductive health services, has found that men are more likely to seek services when they have urological problems or fear having an STI. By addressing these needs, PROFAMILIA has not only attracted many more male clients but has also achieved financial sustainability by charging for services such as laboratory work and for drugs.
Many programs now offer men a range of services from STI prevention and treatment to infertility testing and help with sexual dysfunctions. The Planned Parenthood Federation of Ghana has found that offering these services during special clinic hours for men has increased men’s receptivity to family planning.
[Facilitator: Ask participants to give examples of local programs that attempt to provide men with broad reproductive health services.]
W. Graham/World Bank
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18. Involving Men in Family Planning Can Promote Gender Equity
Women want their partners involved:
To support their own contraceptive use
To share responsibility for contraception and protecting health
To increase men’s understanding of reproductive health issues
Many women recognize that their own health cannot be protected without the cooperation of men. They want their partners involved in family planning to support their own use of methods, share the burden of contraceptive use and increase mutual understanding of their reproductive health issues.
Around the world, women are urging health providers to “talk to our husbands.” Increasing men’s share of responsibility for using contraception and protecting reproductive health is important to any strategy to promote gender equity.
Although not all women want their husbands involved in the decision to use contraception, many women do want men to share responsibility.
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19. Assure That Women’s Reproductive Health Needs Remain Primary Focus
Encouraging men to take control of fertility can disempower women
In Zimbabwe, men who wanted sole responsibility for decision-making rose from 27 to 37%
Positioning men as responsible and caring can be productive
Meeting the reproductive health needs of women, including the need in some cases for clandestine use of contraception, should remain the primary focus of reproductive health programs.
Open discussion by men with their female partners should be encouraged rather than suggesting that men take control of contraceptive use. For example, a male motivational campaign in Zimbabwe encouraged men to get more involved in family planning; however, as a result, the proportion of men who believed they alone should be responsible for choosing a method rose from 27 to 37 percent. The campaign used masculine sports images, which may have reinforced male stereotypes such as men having the right to make family planning decisions.
While greater participation of men in family planning is desired by many women and can result in increased use of contraception, it is important that this not be done at the expense of women’s autonomy and access to services. The goal of involving men is to increase gender equity, contribute to the empowerment of women and meet men’s and women’s reproductive health needs.
[Facilitator: Ask participants if they have comments on the direction they think family planning programming efforts should take in the future. End the session with an exercise that focuses on how men can support or hinder their partner’s contraceptive use, titled, “Supporting or Hindering Contraceptive Use” (see Module II Activities List).]
Source: Kim, Involving Men in Family Planning, Johns Hopkins CCP, 1996.
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