Marital dynamics in family planning : the role of couple interaction in Jimma zone, Southwest Ehtiopia

Abstract
Introduction : Worldwide, the number of maternal deaths in 2010 amounted to 287,000; almost 90% occurred in developing countries where rural areas typically share the highest proportion of it. In Ethiopia, the maternal mortality ratio (MMR) was 676/100,000 live births in 2011, contraceptive prevalence was 28.6% and the unmet need for family planning 25%. This is echoed in the country’s population growth which does not match the country´s development, as illustrated by the poor living condition among women. Since poor access to and low use of contraceptives exist, it is essential for further family planning interventions to ascertain determinant factors of effectiveness in order to obtain a more efficient use of family planning services. In that perspective, some studies have recommended focusing on couple level analysis in fertility research because it gives a better predictive power of relationships between family planning and couple´s fertility desire. The decision to use contraceptive methods is indeed a complex process influenced by several factors. Few studies, however, have identified how the reasons for use or non-use of contraceptives relate to marital relationship. Objectives and methods : The general objective of this doctoral study was to examine the marital dynamics concerning family planning and to assess the effect that family planning education has on a couple’s interaction and contraceptive use. This family planning education was offered through an intervention program carried out among married couples in Jimma Zone in south-western Ethiopia. For the purpose of this intervention program, we identified three specific objectives. The first objective was to determine the male-female difference in knowledge, attitude and practices of family planning, as well as the factors that lie at the origin of this difference. Second, we aimed at looking at spousal agreement on fertility desire and spousal communication from both husbands’ and wives’ perspective. For that purpose, we measured concordance in fertility desires between spouses. The third objective was to observe the effect of couple family planning education on 1) husband-wife interaction regarding contraceptive use and 2) male involvement in family planning. This objective mainly conveyed the impact of the family planning intervention of this study. We recruited 854 couples for our study and collected data using quantitative technique. A quasi-experimental design was used in which couples were divided in a control and intervention arm. For the intervention arm, family planning education focusing on male involvement in family planning was implemented to analyse its effect on couples’ contraceptive practice. A first intervention focused on males, under the assumption that a better awareness of contraceptives by men would help in promoting contraceptives. We educated men about their shared responsibility not only in decision-making about fertility desire but also by involving them in family planning as such. The second set of interventions targeted couples as a unit. We examined their level of agreement in terms of fertility desire and contraceptive use. We argue that discordance in fertility desire is important to be considered in spouses’ fertility and as a consequence, including both spouses in a survey is likely to result in a better analysis. Thirdly, we used community gatherings to stimulate open discussions without gender segregation. We assumed that interventions in which community and religious leaders are involved might be an important constituent of effective family planning projects. Results : Our study findings indicate that knowledge on family planning is relatively high in the study area, but differences between men and women were observed in knowledge of the types of contraceptives. More specifically, an noticeable gap was discerned on the knowledge of permanent methods and traditional methods. Overall, contraceptive users were women, with the exception of two men. Differences between men and women were also identified with respect to the reasons for not using contraceptives: side effects were more often mentioned by women while men primarily reported a lack of knowledge. Furthermore, educational attainment, a positive attitude towards family planning and an already high number of living children were associated with women’s contraceptive use. This study showed that more than half of the spouses wanted to have more children, even though there was a considerable discordance in fertility desire between husband and wife. In couples where the husband had a positive attitude towards family planning and/or desired no more children, we observed a high contraceptive use by women. In addition, spousal communication about family planning and discussion of family planning, were positively associated with contraceptive practice. The intervention resulted in three main findings: 1) an increase in contraceptive use in the intervention arm among couples who were not using contraceptives at the baseline, 2) a positive effect of spousal communication and 3) the possibility of increasing male participation in family planning. Discussion and conclusion : Our study results highlight the importance of involving men in family planning programs. We therefore believe that a good family planning intervention should include both men and women, as it helps to develop a positive attitude towards family planning and spousal communication. Three additional recommendations can be drawn from this study. First, considering the significant level of discrepancy with respect to fertility preferences that was found between spouses, it is important that data collection from both spouses is collected. Second, family planning interventions aimed at investigating behavioural change should run for more than six months. Finally, empowering women to speak about family planning with their husband helps to enhance their decision-making power regarding contraceptive use within the couple.