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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 3  |  Page : 261-268  

Men's involvement in women's reproductive health: A community-based mixed-method study


1 Associate Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Senior Resident, Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
3 Professor and Head, Department of Community Medicine, Indira Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission24-Nov-2020
Date of Decision23-Dec-2020
Date of Acceptance31-May-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Lalithambigai Chellamuthu
Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry - 607 402
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1376_20

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   Abstract 


Background: Female dominion in family planning has underestimated men's participation in female reproductive health. Objective: To assess male's involvement in female reproductive health with regard to safe motherhood and family planning and to explore the factors influencing the participation of males in reproductive and sexual health. Methods: A community-based, mixed-method study was conducted from May 2018 to January 2019 in urban Puducherry. All eligible couples with at least one child were included. Two-stage random sampling with a sample size of 373 was considered. Data were collected separately among spouses using epi-collect 5 and analyzed using the SPSS software version 23. Qualitative data were obtained using free-listing and pile-sorting techniques, analyzed in Anthropac software. Results: 39.9% had planned their pregnancy. Only 33.5% of couples had decided together with the place of delivery. 76.7% of wives wish to involve their husbands in family planning. 88.2% of wives and 89.8% of husbands chose tubectomy as the preferred method of permanent contraception. Both husband and wife were involved in child rearing among 60.3% of participants. The changing dynamics of society, health-care provider initiative, and literacy level favored males' involvement in females' reproductive health. Conclusion: Men were involved in planning the pregnancy, supporting their spouse by accompanying for antenatal checkups, discussing with their partners about the complications faced during pregnancy. Health care facility-related factors and faith were perceived as hindering factors for males' involvement in reproductive health by either gender.

Keywords: Community-based, eligible couples, male involvement, reproductive health


How to cite this article:
Bahurupi YA, Chellamuthu L, Vasudevan K. Men's involvement in women's reproductive health: A community-based mixed-method study. Indian J Public Health 2021;65:261-8

How to cite this URL:
Bahurupi YA, Chellamuthu L, Vasudevan K. Men's involvement in women's reproductive health: A community-based mixed-method study. Indian J Public Health [serial online] 2021 [cited 2021 Dec 2];65:261-8. Available from: https://www.ijph.in/text.asp?2021/65/3/261/326383




   Introduction Top


The process of reproduction warrants shared responsibilities for both genders. Female-biased dominance in family planning has led to underestimating men's participation in reproductive and sexual health.[1] Reproductive health programs with couples as the target population have been more effective than those focused on individuals.[2] Increased male participation had witnessed improvements in the utilization of services and parenting skills by both sexes.[1],[3]

In India, women often fail to avail of health-care services due to an array of reasons. One of the important reasons being the dependency of women on men to access services. Studies reveal that men are the decision-makers for women's choice of health-care services though they have limited knowledge.[4] The inclusion of men in reproductive health has been challenging among couples as there exists culturally defined gender roles, concerns, and fear about the safety of family planning services, reluctance to discuss issues such as sexually transmitted diseases, and human immunodeficiency virus.

There was a dearth of literature on men's involvement in reproductive health. A few facility-based studies have been published about men's involvement focusing only on family planning matters. So far, no research has been done in India among both sexes to understand either gender's perception of reproductive and sexual health as a whole.

The rationale for this community-based study was for bringing out the actual status of men's involvement in reproductive health with the current reproductive health services in India. The adoption of the mixed-method study design was considered novel and appropriate for this study as quantitative results will be projecting the magnitude of men's involvement in reproductive health. However, by knowing the numbers alone will not be enough to address this issue. Therefore, the qualitative results would be helpful in providing the couple's favoring and hindering factors for men's involvement in reproductive health. The findings from both study designs will be useful in framing sustainable strategies for men's involvement in reproductive health.

The objectives of the study were to assess the men's involvement in females' reproductive health regarding safe motherhood and family planning and to explore the factors influencing the participation of males in reproductive and sexual health.


   Materials and Methods Top


Study design, setting and population

A community-based, sequential explanatory mixed-method study with the cross-sectional survey as a quantitative component and participatory rural appraisal techniques (free-listing and pile-sorting exercises) as a qualitative component was conducted from May 2018 to January 2019in Lawspet, a densely populated urban area of Puducherry district. The inclusion criteria covered all eligible couples with at least one child residing in Lawspet.

Quantitative component

Sample size and sampling technique

The sample size was estimated by considering the proportion of men approving contraceptives by their spouses as 41.3%[5] with absolute precision as 5% using the following formula N = 4pq/d2,[6] the estimated sample size was 373 participants. We included 373 eligible couples (373 males and females).

A total of 27 wards exist under the Lawspet constituency wherein six wards were chosen by the simple random sampling in the first stage, and the second stage involved selecting study participants by simple random sampling with the “Eligible couples register” as the sampling frame. Sixty-two eligible couples were included from five wards and 63 from one ward to achieve the estimated sample size.

Data collection and analysis

The quantitative data were collected by face-face interview, separately among spouses. The study instrument was a semi-structured questionnaire consisting of questions related to the household's sociodemographic details and a question assessing the involvement of men in reproductive health. Data were captured through a mobile application epi-collect 5.0 and analyzed using the SPSS version 23.0 IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA). Descriptive data were represented as mean (standard deviation [SD]) for numeric variables, percentages, and proportions for categorical variables.

Qualitative component

Sampling technique and sample size

Study participants who were willing to participate were selected using purposive sampling. Based on the ethnography approach (i.e., describing and interpreting the shared pattern of the culture of a group), free listing and pile-sorting exercises were carried out separately among both sexes. The data were collected in the cultural domain till the point of saturation. Five participants among both genders were required to reach data saturation, and thus total ten participants were studied.

Data collection and analysis

First, a free-list exercise was performed on the factors favoring and hindering men's involvement in reproductive health among the participants. The favoring and hindering factors with high Smith's S-value were selected for pile-sorting among the participants. Free-list and pile-sort data analysis were undertaken using Anthropac software.

Ethical considerations

The Institutional Ethics Committee had approved the study. (Institute Ethics Committee number: IEC/PP/2018/09). Written informed consent was sought from all the study participants.


   Results Top


Quantitative part

Sociodemographic details of the study participants are shown in [Table 1].
Table 1: Sociodemographic details of the participants in the quantitative component

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The majority (93.6%) of the couples were Hindu. 82.3% of couples belonged to the nuclear family. The mean (SD) number of children was 1.57 (0.532). Half (53.4%) of the eligible couples had two children, 44.8% had one child, and only 1.9% were with three children.

Results of data collected from female participants in the study

The results of data collected from female participants are depicted in [Table 2].
Table 2: Results of data collected from female participants

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At the time of interview, 256 (68.6%) females were current contraceptive users, whereas 117 (31.4%) were not using any contraceptives. The most common method of contraception among current contraceptive users were intrauterine device (copper T) in 163 (63.7%) and tubectomy in 93 (36.3%) females. On the other hand, the less commonly opted contraception methods were natural method in 5 (2.0%), oral contraceptive pill in 12 (4.7%), and barrier method (condom) in 21 (8.2%). The choice of contraceptive was made by both husband and wife in 123 (48.0%) while the choice was solely by the wife in 111 (43.4%).

At the time of interview, 271 (72.7%) females were past contraceptive users, whereas 102 (27.3%) have not used any contraceptives in the past. More than half of the couples 154 (56.8%) were using barrier method (condom), 97 (35.8%) had opted intrauterine devices (copper T), 10 (3.7%) had taken oral contraceptive pills and 10 (3.7%) followed natural methods as the method of contraception in the past. When asked about decision on contraceptive use in the past, husbands had decided in 122 (45.0%), both husband and wife in 80 (29.5%), and by wife in 69 (25.5%).

Among the female participants, 286 (76.7%) expressed willingness to involve their husbands in family planning. Distribution of eligible couples based on preferences for permanent method of contraception showed that tubectomy was preferred by 358 (96.0%) males and 336 (90.1%) females while vasectomy by only 15 (4.0%) males and 37 (9.9%) females. The most common reasons for opting tubectomy by the females were 148 (44.0%) safe, 82 (24.4%) husbands not willing for vasectomy, and 45 (13.3%) women not willing for vasectomy to their husbands. On the other hand, common reasons for opting for vasectomy were 20 (54.0%) safe and 17 (45.9%) simple method.

Results of data collected from male participants in the study

Two hundred and eighty-six (76.7%) couples together decided on expenditure, whereas 77 (20.6%) of wives and 10 (2.7%) husbands decided on expenditure in the households. Three hundred and forty-seven (93.0%) husbands accompanied their wives for pregnancy registration in last pregnancy as per the husbands' responses.

Decision-making on opting for the method of contraception was together (both husband and wife) in 179 (48.0%) and by wife in 172 (46.1%) and by husband in 22 (5.9%). Three hundred and eight (82.6%) husbands discussed with their wives while opting for contraception and 65 (17.4%) husbands did not discuss with their wives. When male participants were asked for their preferences on the permanent contraception methods, 358 (96.0%) and 15 (4.0%) opted for tubectomy and vasectomy, respectively. Husbands responded to discussing menstrual problems with their wives, which revealed 298 (79.9%) husbands discussed with their wives. On the discussion about sexual health matters with others, it was found that 104 (27.9%) husbands discussed. Among those who discussed sexual health matters with others, 80 (76.9%) were for the husband's sexual health, and 24 (23.1%) were for the wife's sexual health. Men commonly approached 33 (31.7%) friends, 26 (25.0%) relatives, 24 (23.1%) doctors, and 21 (20.2%) nurses/auxiliary mid-wives for discussion on sexual health matters.

The study revealed that, in 226 (60.6%) couples, both partners were involved in child-rearing while only the women were involved in 147 (39.4%) couples. When husbands were asked how they help in child-rearing, common responses were babysitting/taking care of children, assisting wives in household chores, economic/financial support, moral support, and outdoor activities such as buying groceries.

The common suggestions given by husbands for the involvement of males in reproductive and sexual health were awareness generation, social, cultural, and behavioral change at the community level through health care providers; improve the literacy rate in the society; premarital counseling for the couples on child-rearing and reproductive health; imparting adolescent reproductive and sexual health education at school level.

Qualitative part

Six participants belonged to the 26–35 years age group and four participants belonged to the 36–45 years age group. Six of them completed schooling. Two homemakers, four skilled and four unskilled participants, were included.

[Table 3] depicts the results of free-listing and [Table 4] describes the pile-sorting exercises. Motivating factors (government initiatives and male peer initiatives) and community-level factors (changing dynamics of society, health care provider initiative, and literacy) were the most favoring factors for male involvement in reproductive health among men and women. Health-care facility factors (nonsupportive environment at the health facility, female health care providers, and female-centered services) and faith (cultural norms and misconceptions) were the most hindering factors for male involvement in reproductive health among men and women, respectively.
Table 3: Results of free-listing exercises among study participants

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Table 4: Results of pile-sort exercises among study participants

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   Discussion Top


Supporting in accessing healthcare services

Most of the husbands in this study accompanied their spouses for pregnancy registration in their previous pregnancy, and almost all husbands accompanied their wives for antenatal checkups. These findings were better than an African study where most men had not supported their spouses completely for utilizing antenatal services.[7]

Decision-making in reproductive health

In more than half of the couples, the decision on the number of children was from the women's parents while the wife was the decision-maker in one-third of the couples. These findings were quite contrasting from an abroad study where around 40% responded that husbands should decide on the family size. The cultural differences between countries might have influenced the results.[8] Decision-making on the place of delivery was by both husband and wife in one-third of the couples in the present study. Similar findings were reported earlier.[7] Studies reported that husbands dominated the decision in adopting family planning methods.[9],[10],[11],[12],[13],[14],[15] Meanwhile, in the current study where females were the decision-makers in choosing the family planning methods. This could be attributed to the fact that geographical or cultural variations exist, different literacy levels, and family planning programs focusing on different family norms.

Adopting family planning methods by the couples

More than half of the couples used the barrier method (condom) in the past. These findings were relevant to earlier studies.[16] The most commonly practiced contraceptive method was oral pills, followed by tubectomy, condoms, and vasectomy.[16],[17],[18] 82.6% of husbands discussed with their wives to decide on contraception. These findings were consistent with a study where 80% of the women had discussions with their partners on contraceptive usage.[5] Around three-fourth of women in the current study were willing to involve their husbands in family planning. Evidence from other studies had identified health effects and impacts to be positive when husbands were involved in family planning.[19] Researches from other countries had pointed out that females whose spouses were engaged in family planning counseling had a higher acceptance rate of contraceptive methods.[20],[21],[22] Both genders mostly preferred tubectomy over vasectomy among permanent methods of contraception in this study. Other studies stated similar results.[23],[24],[25],[26],[27]

Spousal communication on reproductive and sexual health

In the present study, women had engaged in discussion with their husbands about the complications faced in their previous pregnancy, whereas in published studies, husbands were only intimated when their wives experienced pregnancy-related complications.[7] Lack of awareness about partner treatment for sexually transmitted infection was the major reason for not availing partner treatment. Similar findings were documented from Bangladesh.[16]

Reproductive and sexual healthcare-seeking behavior among men

For discussion and advice on sexual health, men commonly approached their friends and peers, relatives, doctors, and nurses/auxiliary midwives. Meanwhile, other studies quoted that the main source of information on sexual and reproductive health was electronic mass media. Men in this regard preferred inter-personal communication through health professionals.[23],[28] Another study had mentioned that health workers and print media were the least mentioned sources of information.[8]

Hindering factors for men's involvement in reproductive health

Patriarchal society, cultural norms, misconceptions, traditional health care approaches to reproductive health (nonsupportive environment at the health facility, female health care providers, female-centered services, lack of awareness, and volunteerism of females) were witnessed as the hindering factors for the men's involvement in reproductive and sexual health when explored among either gender. These findings were consistent with a Kenya study conducted among both genders on factors influencing male reproductive health involvement. Gender-based norms, cultural background, and conventional approaches existing in implementing reproductive health and family planning programs were perceived hindering factors.[29] According to the present study, many other studies also exhibited factors that limit husbands' involvement in reproductive and sexual health.[30],[31],[32],[33],[34] The hindering factors perceived by male participants differed from those reported in a study among men from Uganda, rationalizing five themes for males' limited involvement. Those five themes were perceived side effects of contraceptives; minimal available contraceptive options for males; gender-based norms; conventional women-centric activities in family planning; inclination towards large families; fear of extramarital sexual affairs due to contraceptives usage by women.[35]

Suggestions by male participants for men's involvement in reproductive and sexual health

The common suggestions given by husbands for the involvement of males in reproductive and sexual health were awareness generation at the community level through health-care providers; improve the literacy rate in the society; premarital counseling for the couples on child-rearing and reproductive health; imparting adolescent reproductive and sexual health education at school level. Similar strategies were suggested in earlier studies involving men. Those strategies were establishing male-friendly health-care facilities; engaging men in this regard early in their life-cycle (adolescence); men acting as service providers, employers of nongovernmental organizations working in this regard, peer educators; male village health volunteers; community-based distributors, consumers and leaders.[29],[36],[37],[38],[39],[40]

Being a sequential explanatory mixed-method study, the quantitative findings provided the magnitude of men's involvement in reproductive health while the qualitative results explained the factors influencing men's involvement in reproductive health. The study's possible limitation might be information bias (recall bias and social desirability) with specific questions and a smaller sample size in the qualitative component, which would affect the transferability.


   Conclusion Top


In this study, men's involvement in reproductive health has been noticed in planning the pregnancy, supporting their spouse by accompanying for antenatal check-ups, discussing with their partners about the complications faced during pregnancy. Government initiatives, male-peer initiatives, and raised literacy level of the society were the perceived favoring factors for men's participation that has to be strengthened by the program managers and policymakers. Nonsupportive environment at the health facility, cultural norms, and misconceptions were the identified barriers for men's participation that has to be unerringly addressed with sustainable strategies. The study strongly recommends mobilization of men to act as peer educators, service providers, and volunteers for improving the involvement of males in reproductive health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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