Impact of male partner’s awareness and support for contraceptives on female intent to use contraceptives in southeast Nigeria

Many women of reproductive age in sub-Saharan Africa do not use modern contraceptives due to various factors such as cost, side-effects, availability, influence of the extended family, and lack of spousal support [1‐5]. In Ghana, Bawah et al. [2] observed that resource constraints which placed the purchase of contraceptive supplies in competition with buying basic necessities for family survival became all the more acute and stressful when male partners objected to fertility regulation. Previous studies conducted in Ghana and Nigeria suggest that spousal communication predicts contraceptive use [6, 7], and available evidence shows that women whose partners disapprove of modern contraceptive practice are unlikely to use them [6]. In Ethiopia, barriers to women’s unmet need for contraception include their husbands’ opposition, religion, poor knowledge, and lack of communication between spouses [8].

Although lack of family support, in particular, and several other barriers have been identified against women’s uptake of contraception in low and middle income countries, many family planning programs in these settings are designed with no consideration for the role of men in influencing their female partner’s contraceptive decision-making [8‐11]. Some studies suggest that women who have greater autonomy and are involved in household decision-making are also able to make decisions related to their fertility [2, 12]. Also, changing gender norms, the influence of education, and increased awareness of the benefits of contraception among couples have been shown to influence spousal decisions regarding contraceptive uptake and continuation [2, 13, 14]. Nigeria has a high total fertility rate (TFR) estimated to be between 5.5 and 5.7 children per woman of reproductive age [1, 15, 16], with a low contraceptive use rate (15 %) among married women [15]. Understanding the role of men in their spouses’ contraceptive decision-making could contribute to efforts aimed at increasing uptake of contraception in Africa’s most populous nation. To provide insight into the broader context in which female contraceptive decision-making occurs in relation to the role of their male partners’ awareness and support of modern contraceptives, we analyzed data on a cross-sectional sample of 2468 pregnant women and their male partners who were enrolled in the Healthy Beginning Initiative (HBI), an intervention to increase HIV testing among pregnant women in southeast Nigeria. It is hoped that the resulting data will help to inform the planning of culturally appropriate interventions to address the significant unmet need for use of contraception among married women.

Since Nigeria is the most populous country in sub-Saharan Africa, with an estimated population of over 170 million people [18], use of contraceptives is increasingly important given the substantial level of unmet need for family planning within the country [15]. While previous studies on contraceptive uptake focused on women or men independently [9], our study examined pregnant women and their male partners as a dyad to identify the extent to which women’s desires to use contraception were linked to their male partners’ awareness and support of contraceptives.

The results of our analysis highlight two key conclusions that merit further attention. First, we found that men’s awareness of, and support for, modern contraceptives were largely associated with their spouse’s desire to use contraception. This finding is supported by the cultural norm in Nigeria and indeed much of sub-Saharan Africa where men have important and often dominant role in fertility decisions [2, 9, 19, 20]. It also suggests that men may potentially have more decision-making power with the actual behavior concerning contraceptive use [2, 9]. While this finding does not imply a causal relationship due to the nature of the study’s cross-sectional design, studies conducted in other low and middle income countries have found that decision-making concerning contraceptive use among couples was determined largely by the male partners’ desire for more children [8]. Second, when socio-demographic characteristics of participants were examined further, we found that household size was more important in influencing spousal desire to use contraceptives than area of residence (urban versus rural). This finding supports existing literature which shows a relationship between having more children and an increased desire for contraception [12].

We found no significant associations between most individual level variables considered in this study. For example, the analyses did not demonstrate marked associations between men’s age, or employment and women’s desire to use contraception. This finding suggests that use of modern contraceptives may be influenced by other factors including community level or system level factors such as social/community networks [21‐24] or the influence of mass media [13, 25, 26]. Indeed, previous studies have demonstrated a positive influence of mass media on awareness, support, and decision making concerning uptake and use of contraceptives [26]. Future research on contraceptive perceptions, awareness, and support will benefit from moving beyond individual-level variables to consider how community level factors, such as the role of social networks or the presence of specific diffusion effects such as mass media, influence uptake of contraceptives in low and middle income countries.

The consistent finding regarding the influence of men on contraceptive use desire by their spouses suggests that their inclusion in family planning programs in low and middle income countries is crucial for success [9‐11]. Indeed, focusing on men’s attitudes could potentially increase the opportunity to: 1) explore ways to increase uptake and continuation of family planning methods; 2) increase the proportion of pregnancies that are intended; 3) reduce maternal and infant morbidity and mortality associated with unintended pregnancy; and 4) prevent maternal-to-child transmission of HIV while also improving health outcomes of women of reproductive age. Similarly, programs that seek to increase uptake of contraceptive services by married women in Nigeria and other countries in sub Saharan Africa should include efforts to understand how individual and community level factors influence men and women’s attitudes and behavior towards contraception.