Engaged and Engendered: Women, Men, and Child Spacing in Mali

1. Engaged and Engendered: Women, Men, and Child Spacing in Mali Susan Igras, Marie Mukabatsinda, and Sékou Traore Men, Masculinities and Family Planning Conference, UCLA October 2010

2. SDM is an evidence-based practice

3. SDM is really a set of evidence-based practices in scale up phase • Social diffusion • Champions • Advocacy •Institutional’tion • Male engagement • Couple communication • Couple services

4. Using Mali SDM Scale-Up Assessment Data + other country studies & take gender lens to • FP service provision • Women and men’s attitudes in different decision spheres • Gender-equity interventions CAREF/IRH 2009 To What Extent is the SDM Integrated into FP Programs in Mali? 194 Facil assessments Interviews with 278 providers 1,246 women/men id’d as couples

5. Mali • Total Population: 12.9 m • CPR/mod methods: 6.9% • Unmet need : 31% • TFR : 6.6 • IFS (women): 6.2 children • FP program since 1970s • Low use of health services, particularly RH services • Great distances demand institutionalized outreach strategies by MOH

6. Why are women and men not interested in using family planning? (CAREF/ATN Evaluation of FP Campaign 2008)

7. Views of service providers – gendered, cultural, structural, or otherwise determined?

8. FP policies and program norms tend to favor women MS/Div Sante de la Reprod Guide pour l’engagement constructif pour hommes en sante de la reproduction Janvier 2008 Do policies, norms and service standards explicitly name men? Are there explicit strategies for reaching men as clients, within the couple, as community change agents? What might this mean in resource-constrained environments such as Mali?

9. Partner Communication Matters: Findings From an Analysis of 14 DHS Having Female and Male Data(Source: Gebreselassie, T, Spousal Agreement on Reproductive Preferences in Sub-Saharan Africa, Macro International, 2008)

10. Couple Counseling Results in Better Continuation Rates

11. Baseline Data: Simulated Client Results (IRH/USA) Couple relations Couple issues and method use Clinic environment n=24 visits

12. How Can We Engage Couples More? • Couples-based services • Programming is directed towards couple • Couples-focused services • Do not involve both partners but address issues related to the relationship or male partner • Begins with an individual female client and may expand to include partner

13. “She Says/He Says” Quiz to facilitate RH discussion in couples

14. In a couple, who should make the following decisions? (624 ♀, 624 ♂)CAREF/IRH 2009 * p<.001

15. Couples do not always agree…Is it normal for a husband to hit or beat his wife when - (n=624 ♀, 624 ♂; CAREF/IRH 2009) * p<.001

16. Couples don’t always agree…It is OK if the wife refuses to have sex with her husband if * p<.001 (n=624 ♀, 624 ♂; CAREF/IRH 2009)

17. If a woman refuses to have sex with her partner, when he wants to, he has the right to

18. What do these differentials mean? • Decision-making power plays out differently depending on decision. • Intimate decision-making around reproduction may be more egalitarian than economic decision-making in the Mali study. • Perceptions of sexual rights – of men, of women – are paradoxical. • Men seem to be giving women more power than they are exercising. • Women seem to think that men have more power than men believe they have!

19. Some Approaches to engage men AND WOMEN in new ways in FP

20. Example: Engaging Men via Community-based Water-Sanitation Program in El Salvador (Source: Lundgren et al, Cultivating Men’s Interest in FP in Rural El Salvador, Studies in FP 2005) • Messages: Reflected cultural context, values, and conservation analogy to appeal to men • Work with leaders: • Water and sanitation • committees reached men • with FP info and referrals • Results after 18 mon • Significant increases in KAB • Demonstrated power of social • networks

21. Reaching men through extension programs in rural El Salvador (Source: Gribble, J et al. Being Strategic About Contraceptive Introduction: The Experience of the Standard Days Method, Contraception, 2008) • Messengers: Agricultural agents and community volunteers reached farmers with • SRH info • Messages challenging behaviors/normsusing lowliteracymaterials • stressingchildhealthbenefits of • birthspacing (plus violence, intimacy, etc): • Family planning use increased 37 – 55%

22. Supporting (male) religious leaders as FP advocates in Mali and NE Kenya • Health Policy Initiative-Mali: Engaging local religious leaders in deliberations, creating consensus on role of FP in Islam and their public actions.(This is not training!) • SDM is common ground - bi-directional gateway to modern FP acceptability • Results -6 mon/6 districts in Kenya after similar activities: >250 new FP/SDM users (FHI,2009)

23. Social network diffusion by engaged women in Mali • Strategy: Talk to >4000 women reached by women’s savings club clubs members, supported by trained educators, so FP acceptability can diffuse • Results in 1st phase 2008: • 13% of women in savings clubs using modern FP versus 6% non-members. (CARE, 2009) • Results in 2nd phase 2010:Affected health districts saw after three months of network FP action, increases in FP users above past new user trends (IRH, 2010)

24. FINAL THOUGHTS on closing gender gaps and addressing unmet • Need gender/social analysis and formative research to identify actionable gender-equity practices and outreach strategies and messages for women and for men • Social/gender norms shifts are incremental over time. Identify where there is already a base of agreement • How to encourage women to use the space already given to them by men?

25. Experiment more with male-friendly and couple-focused service delivery models in facilities and community services to facilitate male involvement • More programming using community mobilization and social networks approach