Background
Many sub-Saharan Africa countries have high rates of unmet need for family planning (FP) [
1,
2] and low rates of contraceptive use [
2]. Individuals and couples who want to limit their fertility, are often unable to obtain the FP methods they need due to numerous barriers [
3]. These barriers include high cost, long distances, poor distribution, medical restrictions and fear of side-effects, or even misinformation. The lack of understanding surrounding what influences FP use and how decision-making takes place in families has lead to the inability of policy and programs to focus on the factors that are most important to helping people control their fertility [
3]. Although much of the available literature assumes that financial cost is the primary factor inhibiting contraceptive use, various studies around the world suggest that fear of side - effects of FP are more influential in decision-making [
3‐
7]. It is estimated that 59% of unintended pregnancies could be eliminated if method-related reasons for non-use were overcome; and fear of side-effects is the most commonly cited reason for such non-use [
4]. For instance, in the Colombia 2005 Demographic and Health Survey (DHS) [
5], 21% of married women with unmet need for FP cited health problems or side-effects as their reason for non-use, while 10% cited cost/access and none cited lack of knowledge. Also the 2001 Uganda DHS [
6] found that 25% of married female non-users cited health/side-effects as the reason for non-use, 20% cited cost/access, and 5% reported lack of knowledge. Similar trends were established in Asia, South America and Africa [
7].
Fear of side-effects is also a commonly cited reason for contraceptive discontinuation [
8]. Many studies have found that while some of these are based on actual health related side-effects, many fears are based on rumors, rather than personal experience [
3,
9‐
14]. A study in Nepal found that side effects were the main reasons cited for discontinuing the use of FP and that most people received information about FP from mass media [
15]. In Nigeria, knowledge of FP is generally high; however, use remains low. The main reasons for this lack of FP use include fear of complications, lack of understanding of methods and fear of opposition from the husband [
16]. Nadia et al. [
17] identified evidence of fear of FP side-effects among females and males from India, Nepal and Nigeria. Furthermore, fear of side-effects from hormonal methods among male partners has also been found to impact females FP decision-making and their fear to use FP [
18]. Generally, researches show that spousal communication can increase contraceptive uptake and continuation [
19‐
22]. Moreover, it is clear that spousal discussion and partner approval are significant in inducing a woman to use modern contraceptives in the Central Terai region of Nepal [
23].
Determinants of spousal communication are varied and complex. In Sub-Saharan Africa, gender roles and norms are particularly salient, shaping spousal communication and subsequent FP decision-making in significant ways. Although contraceptive methods and services are frequently geared toward women, men are often the primary decision-makers on family size and their partner’s use of FP methods [
20,
24,
25]. In addition, spousal disagreement can serve as deterrent because women might fear initiating a difficult conversation about FP [
26]. On top of that, evidence suggests that communication between couples may influence FP method choice and frequency of use among women already using contraception [
27‐
29]. Despite the clear association between spousal communication and contraceptive use, little is known about how communication dynamics influence FP decision-making. For example, what is the content and pattern of decision-making around contraceptive use among couples, and how do women and men perceive this process in the context of their relationship? [
12,
30,
31].
Opposition from male partners has been cited as an important factor that affects FP use [
32]. In Ghana for example, ancestral customs give men rights over women’s procreative power [
33]. In fact women in poorer countries with lower levels of education show the highest rates of unmet needs for FP [
34]. In addition, men have traditionally been portrayed as either explicitly or implicitly unconcerned or unknowledgeable about reproductive health. Generally, men have been regarded as formidable barriers to women’s decision-making about fertility, contraceptive use and health care utilization [
35].
Women’s participation in domestic decision-making is increasingly being recognized as affecting their ability to make reproductive decisions. Demographic literature suggests that active involvement in domestic decision-making indicates the power of women within the household and, consequently, their ability to control their fertility [
36,
37]. Several studies have found that woman with little autonomy in the household are less likely to make innovative decisions [
11,
31]. The influence of gender-based power dynamics in sexual relationship between men and women on reproductive outcomes is becoming increasingly recognized [
38,
39]. The empowerment of women as reflected in their socio-economic and employment status, educational levels, household organization, the dynamics of their marital relations and their involvement in domestic decision-making is an important factor in the decline of fertility levels in developing countries. This connection between paid employment and demographic behavior has been found to be strong, particularly in its impact on contraception and fertility [
31]. The rationale behind this connection is that the financial contribution to the household by women with paid employment is higher, hence enabling them to control resources and household expenditures, as well as their reproduction [
40].
As FP programs challenge complex societal norms, they may also challenge traditional gender roles and dynamics and reshape social norms, for example, by endorsing women’s right to refuse sex, and by encouraging couples to discuss and jointly decide on an appropriate contraceptive method [
41].
In Tanzania at 5.4 the Total Fertility Rate (TFR) is still high. Currently, 34% of married women in Tanzania use some method of contraception. Of these, 27% use a modern method and 7% use traditional methods. The most commonly used methods among married women in Tanzania are injectables, pills and female sterilization [
42].
Between 1991 and 2010, five nationally-representative surveys have measured contraceptive use among currently married women in Tanzania. The surveys show that during the last 19 years, there has been a gradual but steady increase of contraceptive use among currently married women, from 10% in the 1991–92 Tanzania Demographic Health Survey (TDHS) to 34% in 2010. In addition, the use of modern contraception methods increased by 20 percentage points, from 7% in 1991–92 to 27% in 2010. The Contraceptive Prevalence Rate (CPR) has increased from 26% of married women in 2004–05 to 34% in 2010. And the current use of modern contraceptive methods among all women has increased from 18% in 2004–05 to 24 percent in 2010 [
42].
Despite the ready availability of FP methods and high contraceptive knowledge, the use of FP methods remains low. In this study, use of modern contraception refers to current use. It is not well-established how people make family decisions on FP use. Neither have their perceptions on FP been well established. These are important issues to be addressed so as to enhance further contraceptive use and lower fertility levels in the East African countries. This study therefore, sought to assess FP decisions, perceptions and gender dynamics among couples in Mwanza, Tanzania. Specifically, the objectives of this paper are threefold: first, to report about people’s perceptions of FP methods in Tanzania; second, to report on the people’s perceptions of FP methods use; and third to report about how gender dynamics impinge on FP decisions. The findings of the present study are expected to contribute insights on the potential interventions that could be designed to further promote the use of FP.
Results
We present the findings from FGDs involving 98 discussants: forty eight (48) males and fifty (50) females. Also, we present the findings from the six IDIs: three from females and three from males. The mean age of the study participants was 36.5. The main themes that emerged are as presented below.
Risks/costs
Use of FP was generally associated with marital infidelity. Some men worried that the methods women used allowed them to have extra-marital affairs without being discovered by their partners, since they would not be able to conceive. One man commented:
When a woman starts proposing FP use, or asks about the number of children we should have, the first thing I ask her is whether she intends to cheat or not? (FGD, males, rural, 30–49 years).
Another man in the semi urban area, who insisted that women using FP tended to have extra-marital affairs, gave similar sentiments.
Some women can have affairs with other men if they use FP methods because they will not conceive… (FGD, males, semi-urban, 18–29 years).
Such sentiments were shared by some of the women, who said that the use of FP was a sign of faithlessness. One woman commented:
… If you try to discuss FP, or you want to use FP, then he will ask you, what do you lack? What do you want to do? Why do you want to use FP? Some men say that if you use FP you will be unfaithful because you will not become pregnant when you cheat on him…(FGD, females, rural, 18–29 years).
However, the in-depth interview informants had different views. Some of the informants said that women could use FP methods, after some discussion and agreeing on the issue with their husbands. If the woman does not discuss and agree on the use of FP with their husbands, then husbands suspect the woman of having an illicit affair. Although some of them agreed that secretive use of FP among women could make someone suspicious, discussants generally affirmed the use of FP. One man opined;
Long time ago people linked the use of FP with infidelity, nowadays people know the importance of using FP, and see it as a normal thing, it is not like in the past when people linked FP with infidelity….(IDI, male, rural, 45 years ).
Risks/costs: perceptions of FP methods side-effects
In the FGD, males and females were both concerned about the side-effects which they feared could occur due to the use of FP methods. The extreme “side effects” mentioned are the result of myths/misconceptions within the community. Males were afraid to allow their wives to use FP methods because they had heard that FP methods have side-effects for women. On the one hand, they mentioned minor side-effects such as headaches, bleeding, weight gain, weight loss, nausea, dizziness and stomach-ache. On the other hand, they pointed out severe side effects such as infertility, cancer and birth deformities including physical and mental handicaps. For example, one male commented:
…Women have irregular periods after using contraception. In addition, once a woman uses contraception later on can give birth to a mentally-retarded child or one with missing organs such as eyes or arms… the woman can give birth to a child who looks like an animal or like a goat (FGD, males, rural, 30–49 years).
Another man had this to say:
These FP methods spell trouble for women and our families. For example, if an implant is inserted into a woman’s arm, then she is told not to do hard work such as farming. I wonder how that woman will survive when she earns her food through farming…. It is better that women should not use FP methods because it will make our lives poor (FGD, males, semi-urban, 30–49 years).
Similar sentiments on the side-effects of FP were pointed out in another FGD. One man said:
These FP methods have side-effects on our wives… some of women suffer from uterine tumours, cancer and irregular periods when they use FP methods (FGD, males, semi-urban, 18–30 years).
Women also raised concerns over what they saw as probable side-effects of using FP methods, including cancer, over-bleeding, uterine tumours and infertility. For example, a female discussant said:
FP methods have some side-effects to women. I used FP injection for about three years. I started over-bleeding for three months…I was so scared… I stopped using them. Also, one of my friends who was using injections (Depo-Provera) suffered from uterine tumours. I also heard that FP methods can cause cancer (FGD, females, rural, 18–30 years).
Similarly from the IDIs, informants said that they feared the side-effects caused by some of the FP methods. As one explained:
I used oral pills and started getting my periods irregularly. I went to the hospital and changed into an implant. I suffered from heavy periods and headache… Again, I went to the hospital and opted for an injection. Since then, I have no problem. ..(IDI, female, urban, 34 years).
Another woman commented:
The majority of women fear to use FP methods because of the side-effects they face. It is scary. I think people need more information on FP side-effects and what they should do when they have those side effects (IDI, female, rural, 40 years).
Some of the men mistakenly believed that long-acting contraceptive implants could travel throughout the body and get lost, and causing harm to the users.
Also, some participants showed general lack of knowledge and information on FP methods, as one woman pointed out:
The majority of males and females do not use FP because of lack of knowledge and information about FP side-effects and how to overcome them. Some, people especially men, do not have enough information on FP…(FGD, females, rural, 18–29 years).
Risks/costs: financial consequences in relation to FP side effects
Men who perceived that FP had side-effects, were also concerned about the financial implications for treating their wives once they experienced FP side effects. In fact, many of these men, especially from rural areas, argued that they were poor and did not have enough money to pay for treatment in case their wives suffered from FP side- effects. Some men argued that the government should set aside money for treating women who experienced FP-related side-effects. They pointed out that they disapproved of their wives using FP methods because of financial repercussions from treating their wives if they experienced FP side effects. One man said:
We cannot allow them (wives) to use FP because if they become sick we will not be able to pay for their medical treatment because we are poor… (FGD, males, semi-urban, 18-29 years).
The women were also concerned about who would foot their medical bills if they suffered from side- effects due to use of FP. They argued that, as women, they depended on their husbands for medical treatment. One of them said:
I am afraid of using FP methods. Who will pay for my medical treatment in case I suffered from FP side effects?… (FGD, females, rural, 18–29 years).
Also, the IDIs informants raised concern over some side effects they associated with FP methods. For instance, one woman stated that:
These modern FP methods have several side-effects to women. For instance, I used oral pills for one year. I started over-bleeding and having irregular periods. I went to the hospital and I was told to stop using them. I think if I didn’t go to the hospital I would have suffered a lot (IDI, female, urban, 38 years).
Another informant said:
My wife used Depo-Provera injection for 2 years. She stopped two years ago and we wanted to have another child. She is not able to conceive up to now. We have been consulting different doctors who keep on examining her and telling her that everything is okay. But how? We have spent a lot of money on bus fares and consulting these doctors. We are very worried that she will not be able to conceive another baby (IDI, male, urban, 41 years).
Gender relations: covert use of FP
Many women held the view that FP methods helped them to plan and space children and improve their general health situation. These women pointed out that since they spend most of their time with their children, they are the ones who see their children suffer from hunger and from other basic needs. As a result some women used FP methods without their husbands’ consent. This was done deliberately to protect their health and the plight of their children. One woman said:
I have five children by caesarean section. I have been convincing my husband on using FP methods and he refuses. He wants more and more children. I almost died when I delivered my last child…. Having seen our condition at home that we don’t have enough food and basic necessities, I decided to undergo sterilization without my husband’s consent (FGD, females, semi-urban, 30–49 years).
Some women were concerned about spacing children and their individual health, and, therefore, used FP methods even when they had heard of the family planning side effects. One woman stated:
I did not want to bear children so closely because my health would be jeopardized. I asked my husband that we use FP methods, but he refused, saying that FP methods could cause infertility.
I decided to use FP injectables secretly and I have been doing so for two years now. I don’t want to see my children going hungry or turn into street children (FGD, females, semi-urban, 18–29 years).
During the IDIs, some informants pointed out that some women used FP clandestinely as their husbands oppose the use of FP methods.
…Some women can use FP without the consent of their husbands, because their husbands disapprove of FP use. But couples who approve of FP, discuss with their partners and reach a consensus on using FP (IDI, male, urban, 39 years).
Other women feared that if they used FP methods and suffered side-effects, it would be easy for their husbands to discover that they were using FP behind their backs. In that case, they feared being divorced by their husbands.
One woman alleged:
Some of us are afraid of using FP methods without our husbands’ consent. If we use FP methods and suffer from side-effects, our husbands will not pay for our medical treatment. We could be left untreated… to die … we could be divorced, because we have gone against our husbands’ wishes (FGD, females, semi-urban, 18–29 years).
Gender relations: couple communication
Communication among the couples is important in FP use and decision- making on the number of children a couple wants to have. In rural areas, there was little or no communication among the couples on the use of FP and on desired number of children. As one participant put it:
In rural areas many couples do not discuss FP… the majority of them lack FP knowledge … (FGD, males, urban, 30–49 years).
In addition, the findings show that some people believe that discussing FP issues with their partners was not that important. For example, one woman had this to share:
Most people in rural areas do not discuss FP issues with their partners. Some men believe that it is not an important thing to them. Other men believe that it is the responsibility of women that is why they don’t discuss it (FGD, female, rural, 30–49 years).
Another man put it in this way:
I think it is not important to discuss FP issues or the number of children to have with your partner. Children are a blessing from God, and knows what they will eat. That is why even in the Bible, family planning is not mentioned (FGD, male, 18–29, urban).
Moreover, the findings show that it was difficult for women to engineer discussions, as they perceived that men largely made key family decisions. One woman commented:
Men are the decision-makers in the households, including on the number of children to have and FP use or not use…. (FGD, females, rural, 18–29 years).
In urban areas, participants expressed different perceptions, sharing that most couples talk about FP and number of children to have. One woman said:
In urban areas, most couples discuss about FP and number of children to have… life in urban is hard people want to have children who they can feed and take care of (FGD, females, urban,18-29 years).
Likewise, the findings from the IDIs show that most of the couples nowadays discuss FP use because of economic hardship. People want to have manageable families they can afford to take care of. As one key informant said:
It’s normal nowadays for couples to discuss FP. Life nowadays is hard and people want to have the right number of children they can take care of. People do not want to have children who will turn into street-children … (IDI, male, urban, 39 years).
Another woman opined:
I discuss the number of children to have as well as the spacing between our children with my husband. We must prepare ourselves before we add another child. We must plan our lives beforehand (IDI, female, urban, 29 years).
Male involvement
Findings show that participants were of the view that, traditionally, men were the heads of households and decision-makers in all issues in their respective households. Men decide on FP and the number of children as well as how to use what is produced by the family. Also, the findings show that since men were the decision-makers, they were expected to initiate discussions on FP and the number of the children the couple want to have. Men were perceived as the sole providers for their family needs. Women were not considered decision-makers, but implementers of what had been decided by men, without questioning men’s decisions. As one male commented:
In this place, men don’t discuss FP, because we think there is no need to…, men are the decision-makers. They can tell their wives that they should have ten children and that is it. It is, a man who has to decide. A woman cannot oppose anything that has been decided by a man (FGD, males, rural, 30–49 years).
A rural woman made similar comment during the FGD:
A man decides on FP and the number of children to have. If a woman decides the man will ask her whether she is the one who feeds the children? Or whether she is the one paying for school fees? …. (FGD, females, rural, 18–29 years).
Similar sentiments were given in a semi-urban area. One woman states:
Traditionally men have to decide on issues related to FP, although you can discuss them with your husband; however, he is the one with the final say (FGD, females, semi-urban, 30–49 years).
Some women went against the norm, noting that women were the decision-makers. They pointed out that FP issues were in the women’s sphere and, thus, they should be left to decide on the number of children as well as the FP methods to use. After all, they argued women were the ones who suffer during pregnancy and delivery. That was why some women used FP methods without their husbands’ knowledge. One woman stated:
I think women should decide on the number of children to have. For instance, I had eight children and was tired of giving birth to more children while we were poor. I asked my husband for permission to use FP methods but he refused. However, I started using FP methods secretly (FGD, females, rural, 30–49 years).
On the other hand, men viewed themselves as the decision-makers in their households, arguing that they provided for the households’ needs and so they should be the decision-makers. Also, they contended that Sukuma traditions and customs recognize men as decision-makers. (Sukuma is an ethnic tribe in Tanzania).
For example, one man stated:
Men are the decision-makers in all matters in the households. They are the head of the households and provide for the family needs. Even our traditions and culture recognize men as the decision-makers (FGD, males, semi-urban, 30–49 years).
Another man explained:
Women are not decision-makers… and have to move from their parents to their husbands’ homes. A man in African families is the one with the last decision…. (FGD, males, semi-urban, 18–29 years).
Indeed some of the discussants acknowledged men as the providers for the families. The men were perceived as heads of the households. Even in cases where women produced or owned some resources that contributed to the family livelihoods they remained invisible due to the dominant patriarchal norms that treat men as sole breadwinners. For example, one man said:
Men are the bread-winners, they provide everything for their families, and women just stay home taking care of the children… (FGD, males, rural, 18–29 years).
Another woman elaborated:
We take care of the children and family. Sometimes, we work in farms but all that we produce belongs to our husbands. We cannot do anything without the consent of our husbands even with what we produce (FGD, females, rural, 18–29 years).
Some of the participants underscored the importance of maintaining marriage in their society so as to take care of their children. Also, female participants alluded to the importance of respecting their husbands by informing them about FP use to maintain marriages. One woman said:
I think it is important for all of us to protect our marriages. We should discuss and get the consent of our husbands before starting using FP methods. If we use FP without our husbands’ consent our marriages can break down and cause problems to our children (FGD, females, semi-urban, 18–29 years).
Another woman in the rural area commented:
I think women should not use FP methods without informing their husbands … using FP methods without informing partners can cause marriage break ups … (FGD, females, rural, 18–29 years).
Interestingly, some of the participants mentioned households where women both produced and fed their children, while their husbands did nothing apart from drinking. These participants clarified that not all men are the bread- winners for their families; some are just ceremonial heads of households, while their wives handle all the households’ responsibilities. One female key informant said:
Some women work hard to feed their families while their husbands drink everyday and they don’t care about their families (FGD, females, semi-urban, 30–49 years).
During the in depth-interviews, some of the informants offered more nuanced views on male dominance. One key informant put it in this way:
If you love your wife, you will discuss everything with her, because it takes two people to have a baby. I think couples are supposed to discuss with their partners on use or non- use of FP (IDI, male, urban, 39 years).
Urban/rural differences: value of children and use of FP
Particularly in the rural areas, men expressed preference for large families and perceived FP methods as tools for controlling the number of children, contrary to their preferences. Some women said that men wanted to have many children, and hence perceived men as reluctant to allow their wives to use FP methods. As one discussant explained:
I think some men want more children than their wives For instance, I wanted four children but my husband wanted more… (FGD, females, urban, 30–49 years).
Unlike in urban areas, people in the rural areas prefer many children because they help them with farming activities. In fact children in rural areas were generally treated as sources of labor for families. Social norms in rural areas favored having as many children as possible because of the extended family support system that allowed the children to stay with relatives. One woman commented;
…Ten children can participate in farming activities and produce more than a person with two children (FGD, females, rural, 18–29 years).
In addition, findings show that relatives had influence on the number of children a couple might have. Relatives, especially mother-in-laws, could put pressure on their sons or daughter-in-laws to have more children than they had initially planned to have. For example, one woman said:
Sometimes we are afraid to discuss FP with our husbands because some mother-in-laws had made it clear that they want their sons to have as many children as possible. We are afraid to go against our mother-in-laws … for that matter, we do not discuss FP with our husbands (FGD, females, urban, 18–29 years).
In urban areas, on the other hand, the value of children was seen in terms of costs involved in raising children, especially in terms of school, medical services, and other social amenities. Moreover, in the urban areas everything was paid in monetary terms ranging from renting houses, buying food and other amenities. Thus, having more children would mean incurring more costs.
One woman in the urban area commented thus:
In this area, people plan their families and most people use FP methods because life is hard and expensive in urban areas. We buy everything that we eat because we don’t have farms. We use FP methods to have families that I can take care of. In the urban areas, most couples discuss FP and the number of children to have… (FGD, females, urban, 18–29 years).
Similar views came out during the FGD with men as one of them said:
Having many children in urban areas can create difficulties in getting their needs. For everything, you have to pay money; schools fees, medical services… With many children you will not be able to meet their needs (FGD, males, urban, 30–49 years).
Furthermore, one key informant commented:
Nowadays, people know the importance of using FP because life is hard. People want to have children whom they can take care of (Male, 39 years, IDI Urban).