Abstract

Rates of unwanted births and unmet demand for contraception remain high in many countries where men report larger ideal family sizes than their wives. Researchers used an evaluation that varied whether women were given access to contraceptives alone or with their husbands to examine the effect of male involvement in family planning on fertility outcomes. Results suggest that male involvement led to a decrease in contraceptive use, but concealing contraceptives imposed a psychological cost on women.

Policy Issue

The ability to control fertility through modern contraception holds potentially broad social and economic consequences for women and society. However, many countries still report substantial unmet need for contraception and high rates of unwanted births. In addition to insufficient supply and restrictive social norms, low contraceptive use may reflect the outcome of bargaining between partners with different fertility preferences. In many countries, men report larger ideal family sizes than their wives. If men dominate decisions regarding sexual relations and contraceptive use, women who wish to delay pregnancy may have an incentive to adopt concealable forms of contraception when available. However, the opportunity to conceal contraceptive use may increase suspicion and mistrust within the household.

Many family planning programs target women directly and privately, providing them with opportunity for greater reproductive control, while others promote male involvement in family planning. However, there is little evidence on how household bargaining and the opportunity to conceal contraceptives affect either fertility outcomes or intrahousehold dynamics.

Context of the Evaluation

In urban Zambia, fertility and undesired pregnancy are high: an estimated 41 percent of births in Lusaka between 2002 and 2007 were unwanted at the time of conception. However, it is likely that most were unwanted only by the wife: on average, Zambian men want 0.8 more children than their wives. Although contraceptives can be obtained in public and private clinics, the price fluctuates widely and popular forms are often out of stock. Injectables, one of the easiest methods to conceal, are particularly difficult to obtain. Although the legislation changed in 2005 so that the law no longer requires spousal consent for contraception, some providers continue to deny contraceptives without a husband’s explicit approval. However, women use contraception more frequently than men know: 89 percent of the study sample had used a modern form of contraception. Among the 23 percent of men who claim they are “not doing anything to prevent pregnancy,” 59 percent had wives who reported using some form of birth control. Although relatively few women have used injectables, men are generally aware of their existence, and anecdotal evidence indicates that suspicion over hidden contraception may increase marital tension. 

Details of the Intervention

This study evaluated the effect of male involvement on female contraceptive use. Study participants included 749 married women aged 18-40 who had given birth in the last two years and lived in compounds serviced by Chipata Clinic in Lusaka.

Community health workers visited all participating women in their homes twice. During the first visit, husbands were not present. Wives were administered a baseline survey and provided with health information about condom use, prevention of sexually transmitted diseases, and benefits of and options for family planning. 

During the second visit, women received a voucher guaranteeing free and immediate access to modern contraceptives through a private appointment with a family planning nurse. Prior to this visit, women were randomly assigned to either the Couple or Individual treatment group. Women in the Individual treatment were given the voucher alone. In the Couple treatment, the voucher was given to the husband in the wife’s presence. 

Nurses at the family planning clinic kept daily visit logs to track voucher redemption and contraceptive take-up. Two years later, researchers conducted a follow-up survey to study the impact of contraceptive access on fertility and well-being.

Results and Policy Lessons

In total, 48 percent of women visited the clinic to redeem the voucher for a family planning appointment. 

Evidence suggests that sharing information about family planning services with husbands reduced a couple’s propensity to use those services: women whose husbands were given the voucher were 10 percentage points (19 percent) less likely to redeem the voucher, 6 percentage points (25 percent) less likely to adopt an injectable contraceptive, and 27 percent more likely to give birth than women who were given the voucher alone.

The subset of women most likely to benefit from contraceptive access—who wished to delay further childbearing and believed that their husband desired more additional children than they did—were 13.6 percentage points (47.9 percent) more likely to take up a concealable form of contraception when they received the voucher individually.  However, these women also reported lower levels of health and happiness two years later. This suggests that while policies shifting relative control of contraceptive methods from men to women may increase contraceptive use and reduce average fertility in some contexts, there may also be a longer-term psychosocial cost of concealing important decisions within a household.

Sources

1  Partners In Health, “Women’s Health – Reducing maternal mortality, improving reproductive health”, http://www.pih.org/issues/maternal.html. (Accessed September 21, 2009)

2  USAID, “Population, Health and Nutrition Issues in Zambia”,http://www.usaid.gov/zm/population/phn.htm. (Accessed September 21, 2009)

3  UNICEF, “Zambia Statistics”, http://www.unicef.org/infobycountry/zambia_statistics.html. (Accessed September 21, 2009)