While contraceptive use and uptake of family planning in Sub-Saharan Africa (SSA) have been on the rise in recent years and decades, especially after the 2006 adoption of the African Union’s Maputo Program of Action, the 2012 London summit on Family Planning and the biannual international FP conferences after that (with many taking place in SSA), there remains quite some geographic variation. Especially in West- and Middle Africa, modern contraceptive prevalence rates have remained low, and fertility rates high. Millions of women have an unmet need for modern contraception. Contraceptive discontinuation rates are also high. And that was before the current global pandemic hit, heavily impacting health systems and SRH for many women in the region. All these trends could explain why SSA’s population is expected to grow a lot by 2050 in global population estimates. Recent IHME modelling in the Lancet even foresees 3 billion people in SSA by 2100.
The (still too) low rate of family planning and contraceptive use also negatively impacts maternal mortality rate in an area with some of the poorest maternal outcomes. SSA accounts for 520 deaths per 100,000 from unsafe abortions, about 62% of all unsafe abortion-related deaths. The first step in improving maternal and child outcomes, therefore, is to provide barrier-free access to contraceptive and family planning so people can make informed decisions.
Primary prevention through contraceptive use is important as women can space out their pregnancies, control their family size and avoid unwanted pregnancies which in turn can promote economic development, by increasing the labour force and decreasing resource competition. This is widely recognised, and significant efforts have been made to increase contraceptive use in SSA; such initiatives often target improving health systems, educating women on contraception and improving access to services. However, they are often women-centric and ignore the role of the male.
Impact of male perceptions, cultural norms and power dynamics
There are a variety of reasons for the low use and uptake of contraception and family planning, which range from mode of access to cultural beliefs. However, current research shows that spousal consent or perception is a key issue, for instance, one study found that where female empowerment was restricted, contraceptive use was limited and the gap between male and female fertility preferences was significantly large. In SSA, men are often the primary decision-makers in issues of family planning and size – a study in Malawi found that joint decision-making resulted in a 6-fold increase in contraceptive use. Several reported interventions targeting men through general educational methods, such as counselling, promotion via local leaders and mass media campaigns have shown some success, nevertheless, the negative male perception of contraception continues to account for 15% of the overall unmet need for contraception in SSA.
Gender roles, informed by ancestral customs, also play a prominent role in the use and uptake of contraceptives and family planning. For example, a survey of men and women in Kenya found that men were only likely to take up contraceptive use if it was economically viable and upon request by their wives. However, women, especially if younger, less educated and of lower socioeconomic groups, were unlikely to engage in communication as the topic is culturally associated with promiscuity, can be offensive to men and potentially incite abuse.
Ezeanoule et al found that men’s knowledge was directly dependent on their wives’ desire to use contraception, making spousal communication an important modifying factor. Yet, a study found that among couples that communicated about contraceptive use, 25% of men could still not correctly identify what their wife wanted, indicating a gap in communication styles or effectiveness. One potential reason is cultural – men reported being resistant to contraceptive use due to its link to promiscuity, and cultural and religious opposition. Men surveyed by Aransiola et al agreed that while they are not opposed to contraceptive use, women need to approach the topic carefully to win their support, although women’s perceptions were a strong influence on them.
General educational interventions have shown poor results with men resisting attending family planning clinics. This resistance was related to power dynamics as these centres are female-centric and most believed that such engagement would make others think the man was being controlled by his wife. SSA regions vary in their specific beliefs and barriers, it is therefore important to ensure that interventions are context-specific. However, there is a lack of information on the factors that affect men’s perception of contraception, which could inform future interventions around improving contraceptive use in SSA.
Although there is a clear information gap with respect to the impact of men on contraceptive use in SSA, women’s autonomy to discuss contraceptive uptake is also an important factor. Unequal gender relations are pervasive, and gender inequality in reproductive decision-making remains a key social element. Cultural and contextual factors may also impede the discussion of family planning and contraception, especially among younger couples.
While the acknowledgement of, and interest in male perception as an important factor in contraceptive use have increased, more needs to be done. The challenge of increasing men’s involvement in family planning is to identify the messaging that will most effectively encourage involvement. Apart from the resources cited above, there are few examples of thoroughly evaluated male-centric interventions, which are required for sustainable change. In the short term, the government can look to policies that ensure women stay in school and receive an education. This may prevent early marriages and decrease women’s time at risk of pregnancy. A comprehensive approach, backed by sufficient evidence, can increase contraceptive uptake in this region of high fertility and population growth.