How Husbands Influence Women in the Use of Contraceptives – Spousal Factors

1. How Husbands Influence Women in the Use of Contraceptives – Spousal Factors < single image > 4.3cm x 5.5cm Mak Wei Lan Medical Social Worker Medical Social Work Department 9/7/12

2. KK Women’s and Children’s Hospital Medical Social Work Department (MSW)

3. Introduction • Unintended pregnancy – social, psychological and financial costs (Klima, 1998) • Consisting of mistimed and unwanted pregnancies (Moos, 2003) • A burden to a nation’s healthcare and resources, associated with late bookings for prenatal care, lower birth weight and even child abuse (Moos, 2003; Schwartz, 2010) • The use of family planning is thus pivotal in giving individuals and couples the freedom “to anticipate and attain their desired number of children and the spacing and timing of their births.” (WHO, 2011)

4. Introduction • Lack of contraceptive use is one of the causes of unintended pregnancy • Contraception: ‘intentional prevention of pregnancy’ (Moos, 2003) • Barrier methods, steroid hormonal, intrauterine devices, male and female sterilization and emergency contraception

5. IntroductionPatients seen in MSW Department for Abortion Counseling

6. Introduction Determinants of Contraceptive Use Personal Factors Partner Relationship Factors Societal and Cultural Factors Age Social Status of Men & Women Income Quality & Stage of Relationship Accessibility Religion Self-Efficacy & Partner Involvement Education & Working Status Partner Involvement & Communication Unreliable Use of Contraceptives Domestic Violence Lack of Information, Misinformation & Fear of Side Effects Pregnancy Motivations

7. Introduction • Partner Influence is one of the determinants of contraceptives use (Kern et al, 2003; Soler et al, 2000) • The study aimed to explore women’s experiences of how husbands influence their decisions in the use of contraceptives within a Singapore context, using a sample from KK Women’s and Children’s Hospital

8. Methods: Criteria • Female patients from KK Women’s and Children’s Hospital, Singapore • Married • 21-30 years old • English speaking • Have experienced an unintended pregnancy

9. Methods • 5 participants recruited from the Specialist Outpatient Clinic and Medical Social Work (MSW) Department • Open-ended interviews with an interview guide • Interviews conducted over the phone or face-to-face

10. Methods: Interview Guide • 24 questions • Themes: Relationship, decision-making, conflict resolution, communication, influence, contraceptives and pregnancy

11. Methods: Interview Guide Interview Guide

12. Methods: Participants and Procedures • Characteristics of Participants

13. Methods: Data Collection and Analysis • Interviews were taped with permission from participants and then transcribed • Transcripts were read several times to familiarize and gain an overall impression of the data before a deeper analysis was carried out • Primary codes: Contraceptives, family planning, relationship with husband and decision making • Subcategories and categories identified

14. Results (i) Women’s Experiences of Husbands’ Influence in the Use of Contraceptives Opinions on Using Contraceptives Concerns about Family Planning and Pregnancy Relationship with Husband Decision Making Purpose of Using Contraceptives Financial Considerations Display of Concern Satisfaction Concerns towards Use of Contraceptives Children’s Well-Being Communication Compromise with Husband Obtaining Information about Contraceptives Relationship Satisfaction Display of Support Regrets Future Plans Spousal Factors

15. Results (ii) Spousal Factors Consensus with Husband on which Contraceptive to Use Husband’s Limited Role in Decision Making Husband’s Fair Understanding of Contraceptives “because for [my husband], he doesn’t actually do research first. For me I’m someone who will do research for this kind of thing. So I actually went to research on the different side effects of each and every one of them.. So that’s why after that, I was telling him. This will happen, this and this will happen. Cause pregnancy how many percent” “..so I asked [my husband], do you agree. Then he asked, are you comfortable with the injection, the pain?” “for [my husband] I would say he has a fair understanding of it. We do have the mutual respect in the sense that he does understand the consequences if we do not use contraceptives and other things” “I’m the one who gives [my husband] ideas you know. Then he says ok, its up to you. So boring”

16. Results (iii) Relationship with Husband Relationship Satisfaction Display of Concern Communication Frequent communication Husband shows concern Satisfaction with relationship C: “.. he will call me about small things. He understands women’s emotions are hard to control” C: “..so far so good. No problems.” B: “..[my husband] is quite, I would say, easy going. So long as [the contraceptive] doesn’t cause me any harm I would say he is still alright about it” E: “..we are good, we are happy. There is trust between us.” Mutual consultation B: “.. Usually if I decide to do something, I will talk to him.” Perceive husband’s satisfaction D: “[husband says that] I am the best wife” Discussion about contraceptive options Discussion about family size

17. Results (iv) Decision Making Compromise with Husband Display of Support Satisfaction Advice Giving D: “..Sometimes I give in to some of the things that he really wants. We seldom fight about making decisions.” E: “..[husband will say] yeah its true, I need your advice before going into it.” C: “.. When it comes to decisions, we will discuss.. Whatever things, we will talk over.” Mutual communication A: “.. [when it comes to resolving] problems, he will give into me” E: “.. Money problems.. He will ask me for advice..”

18. Discussion (i) • The study aimed to explore women’s subjective experience in contraceptive use, including how husbands influence women in their decision to use contraceptives. • There were significant issues that were raised from this qualitative study, through a variety of experiences that these women shared during the interview. • Findings are consistent with the general trend that birth control is often regarded as the women’s responsibility, with men taking a limited degree of ownership (Bongaarts & Bruce, 1995; Smith et al, 2011)

19. Discussion (ii) • Multi-level interventions & a combination of male and female individual and couple interventions • There may be a need for programs to include support and training for women when it comes to autonomous decision making in contraceptive use.

20. Discussion (iii) • Highlights the need for contraceptive education to have an increased focus on the personal responsibility of men when it comes to the use of contraceptives, which would likely lead to increased involvement in decision-making. • Gender-specific programmes such as through including male-female negotiation concepts within schools, hospitals and family service centres may be useful in achieving a more balanced role in contraceptive decision-making. However, one needs to be cautious that efforts are made to increase male involvement without male dominance (Bongaarts & Bruce, 1995).

21. Discussion (iv) • Most research may tend to focus on women and couples, few actually focuses on healthcare providers. • Healthcare providers: advocates, gatekeepers and partners • Important for them to understand contraceptive users’ culture and social context which they are from as it may affect how they relate to clients. • Explore healthcare providers’ views on contraceptives, the systems within which they are from and work in as a means to meet the needs of contraceptive users and improve service delivery.

22. Discussion (v) • However, with the creation of coitus-independent contraceptive methods such as the pill, women gain more control of contraception • Hence, while more people are calling for increased involvement of men in this area, methods such as the pill in fact allow women to take more control over their reproductive decisions (Darroch, 2000). • To what extent then should men be involved in contraceptive decision making?

23. Limitations • Small sample size • Female perspective • Timing of the interviews

24. Contributions • Exploratory study • However, findings contribute to the literature on gender imbalances when it comes to contraceptive responsibility. • Increasing husbands’ involvement in the arena of family planning seems to be essential in having more effective contraceptive use and fewer unintended pregnancies, as studies have found (Kern et al, 2003; Soler et al, 2000).

25. Conclusions • Limited male involvement in contraceptive decision making. • Male and female as well as couple interventions are recommended • On a macro level, information can be disseminated through various means to educate and increase awareness in the area of contraceptive responsibility and options. • However, given the availability of coitus-independent contraceptive methods, is there really a need for men to play a greater role in this area? And if so, what should the role be?

26. References • Berg, B.L. (1989) Qualitative Research Methods for the Social Sciences Allyn and Bacon Massachusetts, USA • Bongaart, J. & Bruce, J. (1995) The causes of unmet need for contraception and the social content of services Studies in Family Planning (26)(2)(57-75) • Darroch, J. (2000) The pill and men’s involvement in contraception Family Planning Perspectives (32)(2)(90-91) • Denzin, N.K. & Lincoln, Y.S. (2008) Strategies of Qualitative Inquiry Sage Publications Thousand Oaks, California • Fertility Regulation. In RHL The WHO Reproductive Health Library. Retrieved Feb 5 2011, from http://apps.who.int/rhl/fertility/en/ • Kerns, J., Westhoff, C., Morroni, C., Murphy, P.A. (2003) Partner influence on early discontinuation of the pill in a predominantly Hispanic population Perspectives on Sexual and Reproductive Health (35)(6)(256-260) • Klima, C.S. (1998). Unintended Pregnancy: Consequences and solutions for a worldwide problem Journal of Nurse-Midwifery (43)(6)(483-491) • Moos, Merry K. (2003) Unintended pregnancies: a call for nursing action The American Journal of Maternal/Child Nursing (28)(1)(24-30) • Rice, P.L. & Ezzy, D. (1999) Qualitative Research Methods: Health Focus Oxford University Press, Victoria, Australia • Rubin, A. & Babbie, E. (2005) Research Methods for Social Work (5th Ed) Thomson: Brooks/Cole, Belmont, Ca • Schwartz, A., Peacock, N., McRae, K., Seymour, R. & Gilliam, M. (2010) Defining new categories of pregnancy intention in African-American women Women’s Health Issues (20)(6)371-379 • Smith, J., Fenwick, J., Skinner, R., Merriman, G., & Hallett, J. (2011) Young males’ perspectives on pregnancy, fatherhood and condom use: Where does responsibility for birth control lie? Sexual and Reproductive Healthcare (2)(1)(37-42) • Soler, H., Quadagno, D., Sly, D., Riehman, K. Eberstein, I. & Harrison, D. (2000) Relationship dynamics, ethnicity and condom use among low-income women Family Planning Perspectives (32)(2)(82-88)