literature review on male involvement in family planning

• Open access
• Published: 03 May 2023

Reassessing the level and implications of male involvement in family planning in Indonesia

• Sukma Rahayu 1 ,
• Nohan Arum Romadlona 3 ,
• Budi Utomo 1 ,
• Riznawaty Imma Aryanty 2 ,
• Elvira Liyanto 2 ,
• Melania Hidayat 2 &
• Robert J. Magnani 1  

BMC Women's Health volume  23 , Article number:  220 ( 2023 ) Cite this article

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Although there is global recognition of the importance of involving men in family planning and reproductive health matters, this issue has received insufficient attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify the correlates thereof and assess the implications of male involvement for unmet need for family planning.

A mixed methods research design was used. The main source of quantitative data was 2017 Indonesian Demographic Health Survey (IDHS) data from 8,380 married couples. The underlying “dimensions” of male involvement were identified via factor analysis. The correlates of male involvement were assessed via comparisons across the four dimensions of male involvement identified in the factor analysis. Outcomes were assessed by comparing women’s and couple’s unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants.

Indonesian male involvement as family planning clients remains limited, with only 8% of men using a contraceptive method at the time of the 2017 IDHS. However, factor analyses revealed three other independent “dimensions” of male involvement, two of which (along with male contraceptive use) were associated with significantly lower odds of female unmet need for family planning. Male involvement as clients and passive male approval of family planning, which in Indonesia empowers females take action to avoid unwanted pregnancies, were associated with 23% and 35% reductions in female unmet need, respectively. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher levels of involvement. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males highlight the quantitative findings.

Conclusions

Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Plain English Summary

Despite global recognition of the importance of involving men in family planning and women’s health matters, this matter has received insufficient the attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify correlates of male involvement, and assess the implications of varying levels of male participation for family planning outcomes.

The study used a mixed methods research design. The main source of quantitative data was a 2017 Indonesian Demographic Health Survey (IDHS) data set of 8,380 married couples. Factor analyses were undertaken to identify the underlying dimensions of male involvement. The correlates of male involvement were assessed via comparisons across the four underlying dimensions of male involvement group identified in the factor analysis. Outcomes were assessed by comparing women’s and couple’s unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants.

The study found that male involvement as family planning clients remains limited, with only 8% of men using contraceptive methods themselves. However, Indonesian men are involved in other ways such via approval of family planning and active communications that contribute to lower female unmet need for family planning. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher versus lower levels of involvement. The most important contribution of males to realizing couple-level desires to limit or space births is via the approval of family planning, which empowers females take action to avoid unwanted pregnancies. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males are highlighted in the quantitative findings.

In the way of an overall conclusion, Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Peer Review reports

Interest in men’s roles in family planning data back to at least the 1980s [ 1 ]. A global consensus as to the importance of involving men in family planning and broader reproductive health matters was reached at the 1994 International Conference on Population and Development in Cairo (ICPD) [ 2 , 3 , 4 ]. A sizeable literature has since been amassed making the case that men constitute an important asset both in the realization of reproductive aspirations and in efforts to improve women’s health [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 ], documenting the determinants of male involvement [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ], assessing the impact of male participation (or lack thereof) on reproductive health outcomes [ 22 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ], and assessing the progress being made [ 36 , 37 , 38 ]. Engaging men and boys in family planning is included among the high impact practices (HIPs) for family planning [ 39 ] and the Male Contraceptive Initiative [ 40 ] has elaborated on how increased attention to male contraception could contribute to the realization of each of the 17 Sustainable Development Goals (SDGs).

Although Indonesia’s National Family Planning Program (NFP) is generally viewed as having been successful, the program has experienced some degree of stagnation in the past two decades. The contraceptive prevalence rate (CPR) increased only from 60.3% to 2002 to 63.6% in 2017 and the modern contraceptive prevalence rate (mCPR) from 56.7% to 2002 to only 57.2% in 2017 [ 41 ]. The level of demand for family planning (i.e., fecund women of reproductive age who desire no further children or to delay their next child by two years or more) grew during this period from 69.7% to 2002 to 74.2% in 2017, but the level of unmet need for family planning also increased (from 8.6% to 2002 to 10.6% in 2017).

One issue that has perhaps not received sufficient attention in trying to revive the NFP is that of male involvement in family planning. While national reproductive health/family planning policy clearly establishes optimizing the reproductive health of families, like many national family planning programs the Indonesian NFP has over the years focused programmatic attention primarily on women. Indeed, Hull [ 41 ] observed many years ago Indonesia missed an opportunity early on to promote use of male methods. Collectively, researchers have attributed insufficient attention to male involvement to three primary factors: [ 1 ] Emphasis on clinical service delivery to women of reproductive age and on women’s barriers to contraceptive use, [ 2 ] Assumptions about open communication and evenly shared reproductive decisions between men and women, and [ 3 ] Lack of research on men’s attitudes and behaviors and gaps in evaluation data for interventions on men.

Greene et al. [ 2 ] propose that the male involvement in family planning may be viewed as falling into three domains: men as family planning clients, men as partners, and men as agents of change. The participation of married men as clients in Indonesia remains limited. Among currently married women who reported contracepting at the time of the 2017 Indonesian Demographic and Health Surveys (IDHS) [ 42 ], only 8% were relying on “male controlled” methods – 1.5% vasectomy, 36.7% male condoms, and 61.9% withdrawal. However, outright opposition to family planning among Indonesian men is also limited – per the 2017 IDHS, only 4.3% of husbands in the “couples sample” disapproved of family planning. The key to identifying potential program opportunities to strengthen the NFP via increased male involvement thus lies in acquiring a deeper understanding of the vast majority of married Indonesian men who are neither family planning clients nor opponents of family planning in terms of their reproductive aspirations, perspectives on male involvement in family planning decision making, and actual levels of and barriers to increased involvement. To date no such systematic, in-depth assessment has been undertaken. The existing Indonesian studies on these matters are either dated (i.e., based upon data from 2010 or earlier), focus on particular local settings, or were not peer reviewed [ 32 ].

The present study sought to characterize the male spouses of currently married Indonesian women with regard to their level of involvement in family planning, identify the correlates of different levels of male involvement, and assess the implications of varying levels of male participation for family planning outcomes in order to better understand the key “levers” that might be used by the NFP to increase male involvement in family planning. The study was undertaken from the perspective of married couples since understanding the family planning-related actions of men requires knowledge of the reproductive aspirations of both marital partners, which may or may not be the same. The need for couples-level analyses was recognized many years ago by Stan Becker [ 43 ], who developed an algorithm for measuring unmet need for family planning among couples. Although this conceptual insight has subsequently received relatively little attention, we believe that it is crucial to understanding male involvement in family planning.

Methods and materials

A mixed methods research design was used in the study featuring both quantitative and qualitative data. The main source of data for the quantitative portion of the study was the 2017 Indonesian Demographic Health Survey (IDHS). We created a “couples” dataset consisting of responses to the female and married male IDHS questionnaires for 8,380 married couples.

Three [ 3 ] forms of quantitative analyses were undertaken. All analyses were limited to couples in which the female partners were fecund. First, as background for the remainder of the study we assessed the degree of concordance (or lack thereof) in terms of demand for family planning (i.e., desire to limit or space future pregnancies) and the contraceptive behaviors of both partners associated with partner combinations. Second, we examined variables measured in the 2017 IDHS that depicted male involvement in family planning. These consisted of a combination of attitudes, behaviors, and future expectations. The variables considered were:

Approve of FP.

Discussed FP with wife in last year.

Discussed FP with other persons in the last 6 months.

Involved in decisions whether wife should/should not use contraception.

Disagreed with the statement that “Contraception is women’s business; men should not worry”.

Disagreed with the statement that “A woman is the one who gets pregnant, so she should be the one to get sterilized”.

Using a contraceptive method at the time of the survey.

Expect to use a method in the future.

After documenting the level/prevalence of these variables in the full sample of couples, we then assessed the covariates or correlates of these indicators of male involvement. The factors considered included socioeconomic background factors, geographic residence, and exposure to family planning program interventions. We then assessed whether the eight variables “hung together” such that a meaningful male involvement scale could be produced. However, factor analysis/principal components analysis indicated that there were four [ 4 ] independent underlying dimensions of male involvement in family planning in Indonesia (details provided below in the Results section). Accordingly, the factor scores for sample couples on these four dimensions were used as the measure of male involvement in subsequent analyses. We assessed the covariates or correlates of the four underlying dimensions of male involvement with regard to socioeconomic and geographic residence background factors, and exposure to family planning program interventions via ordinary least squares (OLS) regression.

The final step in the quantitative analysis was to assess the relationship between dimensions of male family planning involvement identified in the factor analysis and unmet for family planning for both females and couples. Demand for family planning was defined in the case of women as women desiring to avoid further births or wanting to delay their next birth by at least two years. Couple-level demand was defined as either spouse desiring to limit or space further births. Unmet need for family planning in the case of women was defined as women with demand for family planning but neither she nor her spouse were using a contraceptive method at the time of the 2017 IDHS. Unmet need for couples was defined as either spouse having demand for family planning and neither were using a contraceptive method. Both unmet need calculations included women and couples in which the women was pregnant or breastfeeding at the time of the 2017 IDHS using data on the wanted status of the current pregnancy or most recent birth to define unmet need from the female perspective. Couples in which women whose current pregnancy was either mistimed or unwanted (from their own perspective) were classified as having unmet need, as were couples in which the most recent birth of women who were breastfeeding at the time survey were reported as having been either mistimed or unwanted (again from female perspective). This procedure will understate the actual level of couple’s unmet need as it does not consider current pregnancies/recent births that were wanted by the wife of married couples but not the husband. This bias is unavoidable since husbands were not asked about the wanted status of current pregnancies/recent births in the 2017 IDHS. However, it is likely to be small in magnitude as cases of discrepant demand for family planning within couples in which the male had demand for family planning and the female did not is relatively rare among married Indonesian couples in which the wife was neither pregnant nor breastfeeding at the time of the 2017 IDHS (see Table  1 in the Results section).

Qualitative data were collected from four [ 4 ] groups of key stakeholders via virtual focus group discussions (FGDs) from August 12–18, 2021. Members of the following key stakeholder groups were recruited as FGDs participants: married men of reproductive age (23 participants), married women of reproductive age (24 participants), program managers (24 participants), community and religious leaders (24 participants). Equal numbers of participants were chosen from National Population and Family Planning Board BKKBN priority districts in each of the three major regions of Indonesia (western, central, and eastern Indonesia) so as to ensure geographic diversity. FGD participants were chosen by staff at local BKKBN offices and advised on when to come to the office to participate in the FGDs. Gender perspectives were obtained on the following matters via the FGDs with married men and women: [ 1 ] knowledge of family planning, [ 2 ] family planning information, [ 3 ] gender roles in and decision-making regarding family planning, [ 4 ] decision making regarding number of children, [ 5 ] family planning experience, and [ 6 ] barriers to men using family planning. The FGDs with program managers focused on: [ 1 ] financing male family planning, [ 2 ] adequacy of service providers, [ 3 ] training, [ 4 ] socio-cultural factors influencing uptake of male family planning, [ 5 ] government programs, [ 6 ] perceptions on male family planning participation, and [ 7 ] geographic access issues. The FGDs with community and religious leaders focused on: [ 1 ] perspectives on family planning and family planning programs, [ 2 ] influence of sociocultural and traditional beliefs, [ 3 ] role of religious institutions, [ 4 ] forms of collaboration with family planning programs, [ 5 ] barriers to supporting family planning programs, and [ 6 ] barriers to men using family planning. All discussions were recorded and transcribed verbatim. After validating the transcripts, the narratives were translated into English and verified for accuracy by a native speaker. Analysis of the data was conducted using thematic content analysis and included several iteratives steps. Direct quotations from men, women, program managers and community and religious leaders are presented in italics to highlight key findings.

We first present the quantitative results, followed by insights and perspectives provided by the qualitative data. Insights from the quantitative and qualitative analyses are then synthesized in the Discussion section of the manuscript.

Couple-level data on demand for family planning and contraceptive use at the time of the.

2017 IDHS the are displayed in Table  1 . Overall, the level of demand for family planning was 74% among females and 66% among males. Concordance in demand for family planning is observed for the large majority (75%) of couples – 58% both wanting to limit or space future births and 17% neither wanting to limit or space. Among the 23% of couples whose demand for family planning was discordant, cases of females wanting to limit of space while their spouse did not aspire to do so were twice as common (16%) as discordant cases in which it was the male that wanted to limit or space, and the female did not (8%).

Table  1 also documents the contraceptive behaviors of both marital partners at the time of the survey in relation to couple-level demand for family planning. Several observations emerge from these data. First, male contraceptive use appears to be largely unresponsive to variations in either male or couple-level demand for family planning with only minor variations observed around low levels of male contraceptive use. Female contraceptive behavior on the other hand appears to be directly responsive to female demand to limit or space births as well as to satisfy male demand – 60% of women who did not want to limit or space future births but whose husbands did were using a contraceptive method at the time of the 2017 IDHS. Second, there appears to be substantial level of contraceptive use even in the absence of a desire to limit or space births by either marital partner. 30% of couples without apparent demand for family planning were using a contraceptive method at the time of the 2017 IDHS – 25% of females and 2% of males, with 2% of couples practicing redundant contraception. 39% of these couples were either uncertain about wanting more children or were not sure when, while 61% wanted a child within two years and may have been contracepting to delay the pregnancy. The redundant use of contraceptive methods by marital partners is also noteworthy. In virtually all cases this entailed males using condoms or withdrawal to supplement contraceptive use by their wives.

* Excludes couples in which the wife was infecund, pregnant, or breastfeeding at the time of the 2017 IDHS.

Eight variables extracted from the 2017 IDHS were used in the study to characterize men’s involvement in family planning in Indonesia (see Methods section for details). The levels or prevalence of male involvement indicated by these variables are documented in Fig.  1 . As may be observed, Indonesian men overwhelmingly approve of family planning and about 65% have been involved in contraceptive use/non-use decisions. 61% of men had discussed family planning with their wife in the 12 months prior to the 2017 IDHS and 21% had discussed family planning with others in the six months prior to the survey. A majority of men did not subscribe to the view that family planning was the sole responsibility of the female. However, involvement as family planning clients was relatively low – only eight [ 8 ] percent were using a male-controlled contraceptive method at the time of the 2017 IDHS and six [ 6 ] percent of men who were not using a male-controlled method at the time of the survey expected to use such methods in the future.

Levels of Male Involvement by Type of Involvement

Table  2 presents data on the sociodemographic and residential correlates of the male involvement indicators considered in the study. As may be observed, the indicators tend to vary systematically by socioeconomic level and residence. The exception is approval of family planning, which is close to universal. For all other indicators, men with higher levels of education, greater household wealth, and with professional or clerical occupations were more likely to be involved in family planning. The same was true of men residing in urban vs. rural areas and for the most part men residing on Java-Bali vs. those residing on outer islands. However, men residing on Java-Bali vs. outer islands did not differ on male contraceptive use or expectations to use contraceptive methods in the future. Younger men showed higher levels of involvement than older men with the exception of approval of family planning and current contraceptive use.

(ns) not significant; * p value < 0.05 ; ** p value < 0.001.

Table  3 presents data on the correlates of varying levels of male involvement related to exposure to family planning interventions. As may be observed, the strength of association of program variables with level of male involvement was generally lower than that for the sociodemographic variables. The most sizeable and statistically significant differences observed were for the Method Knowledge and Media Exposure variables, with men with greater method knowledge and media exposure being consistently more likely to be involved in family planning across the set of male involvement indicators considered. Only small and often not statistically significant differences are observed to the other program exposure variables considered.

To assess whether the eight male involvement variables could be combined into a meaningful male involvement scale or index, a factor analysis/principal components analyses was run. The analysis, the results of which are displayed in Table  4 , yielded four [ 4 ] independent dimensions of male involvement in family planning in Indonesia. Per standard practice in factor analysis, the dimensions of factors are interpreted or “named” based the variables that “load” on the respective factors. Only two [ 2 ] variables have significant loadings on Factor 1, both pertaining to discussions or communications about family planning, leading to the proposed naming of this factor as “Involvement via Consultation”. This factor is characterized by lukewarm approval for family planning and no involvement as a family planning client. Similarly, two variables have sizeable loadings on Factor 2, both pertaining to positive gender-role perceptions toward family planning, leading to the proposed naming of this factor as “Involvement via Positive Gender Role Perspective.” It will be noted that the discussion of family planning with wife and current/expected contraceptive use variables also had modest loadings on this factor. Factor 3 also has two variables with strong loadings, involvement in contraceptive use decision making and male contraceptive use and thus appears to correspond to “Active and Direct Male Involvement.” Only one variable loads on Factor 4, albeit very strongly – Approval of family planning. This dimension appears to represent “Passive Support via Approval.”

To assess the correlates of the four underlying dimensions of family planning involvement, ordinary least squares (OLS) regressions were run using the same set of correlates considered above as independent or predictor variables. The results are shown in Table  5 . With regard to age, the scores for older men on Factors 1 (Communications regarding family planning) and 3 (Active direct involvement) and higher scores on Factor 4 (Passive approval of family planning). Men with higher levels of education had higher scores for Factors 1–3 but not Factor 4, reflecting the fact that approval of family planning is nearly universal among Indonesian men. Occupation and household wealth were not strongly associated with any of the styles of male involvement depicted by the four factors identified in the factor analysis, although men with professional or clerical occupations had somewhat higher scores on Factor 3 (Active direct involvement). Male involvement factor scores were largely unrelated to urban-rural residence, while men residing on Java-Bali had higher factor scores for three of the four factors (all except Factor 3 – Active direct involvement). Higher scores for this factor outside of Java-Bali might reflect the need for men to be more directly involved due to the greater barriers to women sustaining contraceptive use in such locations as compared to Java-Bali.

What is the impact of male involvement on unmet for family planning for both women and couples? Table  6 displays the odds ratios of unmet need (from logistic regressions) for differing levels of male involvement as measured by factor scores on the four dimensions of male involvement identified in the earlier factor analysis. These results indicate that most forms of male involvement in family planning lead to lower levels of unmet need among women. High factor scores on Factor 1 (Active Consultation regarding Family Planning) results in 10% lower odds of female unmet need. The corresponding figures for Factors 3 (Active and Direct Involvement) and 4 (Approval of Family Planning, Passive) are 22% and 35% lower odds of female unmet need, respectively. The exception is Factor 2 (Positive Gender Roles, Passive). Progressive male gender role perceptions in the absence of other forms of involvement appears to do little to reduce unmet need among women. At first glance the results for couple’s unmet need look quite different – however, closer examination reveals that the differences in odds ratios of couple’s and women’s unmet need for other than Factors 3 are nominal (although the odds ratio for Factor 1 is not statistically significant in the couple’s unmet need regression). The major difference is for Factor 3 (Active and Direct Involvement). Why might direct and active involvement in family planning have an impact on female but not couple’s unmet need for family planning? The answer lies in Table  1 . Two observations emerging from Table  1 are salient. First, the incidence of males alone having demand for family planning within Indonesian couples, which drives the difference between female and couple’s unmet need, is quite small (only about 8% of the ”couple’s sample”). Second, Table  1 indicates that male contraceptive use is relatively invariant across wife-husband combinations of demand for family planning (range 2–4%). It is thus the small size of the relevant sub-population for the calculation of the odds ratio for Factor 3 and the low level of male contraceptive use that account for the results observed in Table  6 .

The qualitative data collected for the study reinforced many of the themes emerging from the quantitative analyses. One theme that emerged clearly from the focus group discussions (FGDs) was the role of male knowledge of family planning:

“Many people don’t know about family planning. It is better if the posyandu share information about family planning so that everyone also understands about family planning. My husband already knows about family planning and agrees if I use family planning. I have been using family planning for 20 years, have used injections and switched to using implants until now.” (PL, 39-year-old housewife, Eastern Indonesia). “My husband knows all the type of methods. But because he’s a man, he’s not aware about it. It’s like he doesn’t want to know because it’s a women’s business. At the beginning after giving birth, I wanted to put an IUD and my husband wondered what an IUD was, its uses and side effects. I explain after browsing. He was offered a vasectomy but didn’t want to.” (AN, 39-year-old female, civil servant, Sumatra/Kalimantan). “There are still many men who think that family planning programs are a woman’s business, men’s knowledge of contraception is also still low, and there are still many who do not understand the types of male contraception.” (MI, 30-year-old, housewife, Eastern Indonesia). “Our area received counseling from the midwife/public health center but only the wife, while the men did not participate because they were embarrassed.” (EW, 48-year-old male, farmer Sumatra/Kalimantan). “In general, there is a massive FP program here, but specifically for male family planning, it is still not well understood for the men themselves…, the socialization program can involve those who have done male family planning as ambassadors.” (B, 35-year-old male employee, Sumatra/Kalimantan. “In my environment for family planning, most of their wife use contraception. a few still think that family planning only focuses on the wife. The understanding of the man’s family planning is still cannot be understood when in fact it is an alternative part.” (AB, male employee, Sumatra/Kalimantan).

Regarding involvement of men as family planning clients, the limited choices available to men and concerns/negative perceptions about vasectomy were noted by a number of FGD participants.

“In my area rarely men use contraception because there are more women who use it. … There are still few [male users] because the choices are few – only condoms and vasectomy” (MR, 57 year-old male, entrepreneur, Sumatra/Kalimantan). “Family planning in here common things are often informed by cadre. There are only 2 choices for men.” (MU, 33-year-old male teacher, Eastern Indonesia). “For male family planning, there is less socialization, indeed there are some obstacles that the information obtained by the community is not very accurate. The second one is still many who rely on the religion which mentions it is haram. …. Many circulate that when men taking family planning their passion is reduced and they are afraid to do a vasectomy. (JL, 54-year-old male, village administrative worker, Sumatra/Kalimantan). “Maybe there is a need for more socialization of this MOP (i.e., vasectomy). Because there are still many of men and friends say that MOP is the same as being castrated.” (D, 49 year old male, civil servant, Java-Bali). “People think that after vasectomy, it will be dysfunctional, so they can’t have relationships, or what kind of thing there are still stigmas like that in society. It seems that the strengthening in IEC must really be done and indeed work with experts to carry out education in the community.” (VS, 52-year-old female, program official, Sumatra/Kalimantan).

A major theme in the FGDs was that of perceived gender-assigned responsibility for family planning.

“In theory, the husband’s role is very much needed for the selection of contraceptives. But many applications are surrendered to his wife alone. My husband asked if it was safe for me, it was okay to use it. My husband’s involvement in information about contraceptives is lacking. In Mojokerto, the husband’s participation in male family planning is still rare and is still considered taboo and not an obligation. It’s a woman’s duty.” (NK, age not stated female, lecturer, Java-Bali). “It seems that because it is the woman who is pregnant, women are more responsible for contraceptive use. But there is also an agreement between husband and wife who is readier and more disciplined to use contraception.” (ANR, 49-year-old female civil servant, Sumatra/Kalimantan). “While the wife has more choices in the methods, it’s very rare methods for men. Maybe it’s still taboo to talk about the issue of male contraceptives. … Men have high egos, they don’t want to take contraception, so just tell their wives.” (M, male, 48 years old, private sector worker, Sumatra/Kalimantan). “Family planning matters are left to women…for gender awareness themselves with this paternalistic cultural system in Indonesia…the assumption is actually conservative and still exists in the community if family planning means a kind of castration, no longer manly, no longer able to fulfill needs as husband.” (BI, age not stated female, program manager, Java-Bali).

Other barriers to greater male involvement, particularly as family planning clients, were noted by FGD participants, most notably by program manager participants. Program managers in many locations pointed to distance to health facilities/service providers, limitations in staffing and in particular trained staff trained medical staff on clinical contraceptive services Religious opposition to family planning in general, and of vasectomy (male contraceptive use only in emergency situation when women cannot use contraceptives), was noted in some locations. The continued programmatic focus of promotional and educational efforts primarily on women was also noted.

“For male family planning, it seems that there is no information for male family planning and there is no counseling. So, most of the general public information from PKK, RT, RW are all directed to mothers.” (B, 35-year-old male, civil servant, Java-Bali).

Direct male involvement in family planning as family planning clients in Indonesia remains limited – per the 2017 IDHS data, male-controlled contraceptive methods accounted for only about 8% of the method mix of married couples who were using a contraceptive method at the time of the survey. However, our analyses indicate that Indonesian men engage in family planning matters in several other ways that have material consequences for unmet need for family planning among both women and couples. Indeed, the factor analyses undertaken for the study revealed four [ 4 ] underlying independent “principal components” or “dimensions” of male family planning involvement in Indonesia, only one of which had to do with involvement as family planning clients.

In terms of impact on unmet need for family planning among both females and couples, male approval of family planning appears to be the most powerful form of male involvement (even if not supplemented by further involvement). Given the low participation of males as contraceptive users, the primary mechanism by which male approval translates into lower unmet need is by enabling females to take the lead in realizing intentions with regard to the number and timing of future pregnancies. Although males do facilitate female use of contraception to some extent via communications and participation in contraceptive decision making and male IDHS respondents professed gender-positive attitudes toward responsibility for family planning generally and sterilization specifically, the qualitative data suggest that family planning continues to be seen by large segments of Indonesian society as being the responsibility of women, a perception reinforced by the perception that national family planning program efforts target women. Given male approval, Indonesian women appear to respond to their own desires to limit or space future pregnancies as well as those of their husbands, at least sometimes even when their husband’s desires do not align with their own.

In its Strategic Plan for 2020–2024 [ 44 ], the National Population and Family Planning Board (BKKBN) is focusing on two of three types of male involvement articulated by Greene et al. (2006) – men as family planning clients and men as agents of change. Although the BKKBN also recognizes the importance of men as agents of change as Male Family Planning Groups are envisioned as a key mechanism for advancing the male involvement agenda, the primary focus appears to be on men as family planning clients given the priority assigned to significantly increasing the uptake of vasectomy to reach 5.7% prevalence among married couples using contraceptives by 2024. However, rapidly increasing vasectomy prevalence is challenging in Indonesia, as it has proven to be in other countries [ 45 ], given Indonesia’s sociocultural and supply environment contexts and the level of misinformation about vasectomy circulating in society at large. Reaching the target will thus require concerted efforts on several fronts. Even if the BKKBN target of increasing the proportion of married couples relying on vasectomy to avoid unwanted or mistimed pregnancies to 5.7% by 2024 is achieved, the impact is likely to be modest. To magnify the impact, increased use of male condoms might also be promoted, and more importantly greater attention might be assigned to a third type of male involvement– men’s roles as partners; that is, on how men can help facilitate contraceptive use by females, the receipt of maternal and child health services, and male involvement as fathers in the provision of childcare.

The global evidence suggests that Indonesia may benefit from a more holistic approach that goes beyond a narrow focus on men and family planning. The expansion and culturally nuanced implementation of “Gender Transformative Programming” (GTP) or similar/derivative approaches would seem a logical way forward. The Partnership for Maternal, Newborn & Child Health (PMNCH) defines GTP as an approach that “recognizes and addresses the individual, institutional and cultural dynamics that influence the behaviors and vulnerabilities of men and women [ 46 ]. The evidence reviewed in the 2013 UNFPA/PMNCH “Knowledge Summary” suggests that male roles in Reproductive, Maternal, Newborn, and Child Health (RMNCH) services that can be reinforced via gender transformative approaches include shared responsibility for family planning, contraception, and prevention of STIs; helping pregnant women stay healthy and deliver their babies safely; and engaging in responsible fatherhood and caregiving of children.

However, the available evidence on suggests that gender transformative efforts must go beyond men to also include service providers. Evidence from studies of determinants of male involvement in MCH services in sub-Saharan Africa showed that health providers played a key role in affecting male involvement in Prevention of Mother-to-Child Transmission (PMTCT) and ostensibly for broader RMNCH issues [ 28 , 46 ]. Among the factors identified as discouraging male involvement were harsh behavior/language from service providers and service provider perspectives that taking care of participating male partners is considered an additional burden in settings where health services providers are overworked, stressed, and working with severely limited resources. Based upon these findings, which resonate with comments made by male FGD participants in the present study, alternative service models targeted at men may be needed, including [ 1 ] use of appointment systems to reduce male (and female) “opportunity costs”, [ 2 ] broadening service hours to evenings and weekends, and [ 3 ] use of alternative, more “male friendly” venues not traditionally associated with health care such as religious establishments, workplaces, and other sites where males tend to gather.

The results of the present study provide some clues as to priority targeting. In the aggregate, the results of the analyses of correlates of male involvement in family planning suggest that it is age, education, residence on Java-Bali vs. outer islands), and knowledge of contraceptive methods that distinguish men with higher and lower levels of involvement. The finding with regard to education is nearly universal in earlier studies. Based upon these findings, the priority targets for efforts to increase involvement in family planning should be younger, less well-educated men residing on islands other than Java-Bali and men who are not supportive of family planning. However, as the impact of efforts to increase male involvement in family planning will depend upon both changes in broader social norms and a focused response by service providers a national initiative that will also target community and religious leaders and health service providers will be needed. All efforts to involve men should be designed using gender transformational principles.

An enabling policy environment is essential to making significant progress in more fully engaging males. A recent assessment of policy barriers to and enablers of male engagement in family planning based upon a male involvement framework developed for the HP + Project found that of the 26 countries assessed, only four were identified as having a strong enabling environment with comprehensive approaches to engage men as family planning clients, supportive partners, and agents of change, and included strong provisions to address the principles of male engagement identified in the framework [ 47 ]. The majority of countries assessed (14 out of 26) were categorized as having average enabling environments, while the remaining eight countries were classified as having weak enabling environments. A systematic self-assessment of the Indonesian policy environment for male involvement in family planning by the BKKBN would be a useful starting point in seeking avenues via which to further expand male involvement.

Recent years have witnessed the development of a number of frameworks and sets of guidelines for advancing the male involvement in family planning agenda [ 30 , 33 , 47 , 48 , 49 , 50 ]. Collectively, these efforts produce a set of basic of principles for male engagement in family planning. These include the need to [ 1 ] use age-appropriate, life-stage approaches tailored to cultural contexts, [ 2 ] implement multisectoral and integrated programs, [ 3 ] respect women’s autonomy while meeting men’s and boys’ needs, [ 4 ] ensure that all initiatives are rights-based and entail voluntary participation, [ 5 ] engage men and boys from a positive perspective, [ 6 ] emphasize that choices as to numbers and timing of children have long-term impacts on their own lives, and [ 7 ] ensure the availability of data to track differential impacts of family planning policies and programs by gender. The available evidence also suggests that multi-theme vs. single-issue interventions tend to be more effective in realizing behavior change, particularly those that combine community outreach, mobilization, and mass-media campaigns with group education [ 46 ].

Beyond the desirability of increasing gender equality in all of life’s domains, it might thus be asked why increasing male involvement is important for the Indonesian national family planning program given its level of success with current levels of involvement of men? There are at least two reasons. First, despite the success of the Indonesian national family planning program, significant weaknesses remain – relatively high levels of unmet need for family planning measured at either the female or couples’ levels, relatively high rates of contraceptive discontinuation, and non-trivial rates of induced abortion [ 41 , 45 , 51 ]. It may simply be the case that the national program has plateaued if women continue to bear the responsibility for family planning without more active involvement from their spouses. Second, the present study focused on male involvement in family planning, a program arena in which Indonesia has been relatively successful. Indonesia has been less successful in the maternal health arena, with maternal mortality ratios that are significantly higher than might be expected given the country’s level of economic and health system development – 305 maternal deaths per 100,000 live births [ 52 ]. Here, the meta-analysis results of Yargawa and Leonardi-Bee [ 25 ] showing significant positive effects of male involvement on improved rates of utilization of maternal health services and lower rates of maternal depression during pregnancy and postpartum are instructive. This is especially significant as a recent study showed that poor and near-poor, urban Indonesian women lagged significantly behind non-poor urban women in terms of the quantity and quality of maternal health services received in connection with recent pregnancies [ 53 ]. Greater male involvement as partners that results in pregnant women receiving adequate maternal health services might well be a “game changer” in Indonesia’s long-standing struggle with high maternal mortality.

Although male disapproval of family planning is limited in Indonesia, the predominant form of male involvement remains passive approval, resulting in women bearing most of the responsibility for realizing couple reproductive aspirations. Further actions that engage men as clients and as partners, and address broader gender issues are needed given the prevailing social norms surrounding family planning. Transformative programming must extend beyond men to also target health service providers, community and religious leaders in order to provide an enabling environment for transformative change.

Data Availability

The quantitative raw data for this study are available online in the DHS website ( https://dhsprogram.com ) and BKKBN national programmatic data by applying through the website. The authors lack the authority to upload the data to other repositories.

Abbreviations

Badan Kependudukan dan Keluarga Berencana Nasional (National Population and Family Planning Board)

Contraceptive Prevalence Rate

Discriminant Function Analysis

Focus Group Discussion

Family Planning

Gender Transformative Programming

High Impact Practices

International Conference on Population and Development in Cairo

Intrauterine Device

Indonesian Demographic and Health Survey

National Family Planning Program

Pemberdayaan Kesejahteraan Keluarga (Family Welfare Program)

Penyuluh Lapangan Keluarga Berencana (Community Family Planning Worker)

Partnership for Maternal, Newborn and Child Health

Prevention of Mother-to-Child Transmission

Reproductive, Maternal, Newborn, and Child Health

Sustainable Development Goals (SDGs)

Sexual Transmitted Infection

United Nations Population Fund

World Health Organization

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Acknowledgements

The authors would like to thank National Population and Family Planning Board (BKKBN) for supporting this project by coordinating the qualitative data collection process and United Nation Population Fund (UNFPA) for supporting and funding this project.

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Contributions

SR prepared the quantitative database(s), ran the analysis in STATA, produced the tables and graphics for manuscript, and contributed to organizing the manuscriptNAR prepared the qualitative database(s), and ran the thematic analysis for FGDs BU co-conceptualized the study and reviewed the manuscriptRIA and EL proposed the research topic, secured funding, and provided inputs into the analyses and interpretation of resultsMH approved funding for the study, provided inputs from the UNFPA perspective and reviewed the manuscriptRJM conceptualized the study, co-led the analysis, co-wrote and finalized the manuscript.

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for the study was obtained from the Ethical Committee the Faculty of Public Health, University of Indonesia – Reference number Ket-306/UN2.F10.D11/PPM.00.02/2022. Permission to use IDHS data was obtained from the Demographic and Health Survey (DHS) Program. Participation in the respective IDHS was voluntary.

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Rahayu, S., Romadlona, N.A., Utomo, B. et al. Reassessing the level and implications of male involvement in family planning in Indonesia. BMC Women's Health 23 , 220 (2023). https://doi.org/10.1186/s12905-023-02354-8

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Assessment of men involvement in family planning services use and associated factors in rural Ghana

• Senanu Abigail Kpekpo Kwawukume 1 ,
• Alexander Suuk Laar   ORCID: orcid.org/0000-0002-0721-4533 2 &
• Tanko Abdulai 3  

Archives of Public Health volume  80 , Article number:  63 ( 2022 ) Cite this article

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In low-and-middle income countries (LMICs) less attention is paid to men’s involvement in Family Planning (FP) programs where public health officials have advocated the involvement of men as a strategy for addressing the dismal performance of FP programs. The study assessed the involvement of men in FP use and the factors which promote or hinder the uptake of FP services among partners in a rural setting of northern Ghana.

A cross-sectional descriptive study was used to collect data from 200 respondents. Study respondents were selected through random cluster sampling.

The findings showed that male partners’ knowledge (95.5%) and approval (72.8%) of FP services were high. About 48% of men were involved in FP service utilization. Having living children (aOR; 1.71(1.27, 2.15)) and being knowledgeable (aOR; 6.14(1.38, 10.90)) about FP were positively associated men’s involvement in FP service utilization. The findings also indicated that men had a higher propensity (X 2  = 4.5534, p  = 0.033) of supporting a FP method use. Women who reported that their spouse supported FP method use were more likely to use a contraceptive method (X 2  = 9.5223, P  = 0.002) if their spouse supported FP method use (X2 = 9.5223, P  = 0.002) and if their partners had some education (X2 = 14.1133, P  = 0.000). Reasons for low contraceptive use were health risks, side effects, and socio-cultural norms.

Family planning programs need to include men at all levels of health promotion and education of FP programs to help reduce misconceptions about contraceptive methods to increase acceptance and use among partners in rural settings of Ghana.

Peer Review reports

Worldwide, 12% of married or in-union women are estimated to have had unmet need for contraceptive methods [ 1 ]. In LMICs, 214 million women of reproductive age who want to avoid pregnancy are not using modern contraceptive method [ 1 ]. In Sub-Saharan Africa, the proportion of women who have an unmet need for modern contraception is highest at 21% [ 1 ]. Unmet need for modern contraception and family planning (FP) accounts for 80% of unintended pregnancy in LMICs [ 1 ]. In Ghana, the contraceptive prevalence rate among all women aged 15–49 years is 25%, with 20% using modern methods [ 2 ] with a high unmet need of 45.7% [ 3 ]. Contraceptive use interventions and unmet need for FP are important determinants of fertility decline in LMICs [ 4 ]. Promotion of FP and ensuring access to preferred contraceptive methods for women and couples is essential to securing the well-being and autonomy of women [ 1 ]. Men participation in FP can be either as a user of male contraceptive methods and or encouraging and supporting their partners or wives in contraception [ 5 ]. Family planning services are critical to improving maternal and child health and reducing maternal and infant mortality in LMICs [ 6 ]. Expanding FP services and involving men in LMICs such as Ghana could increase utilization of services in this setting could avert up to 42% of maternal deaths [ 6 , 7 ].

Men are also recognized to be responsible for the large proportion of reproductive ill-health suffered by their partners’ use of FP methods [ 8 ]. Although contraceptive methods and services are frequently geared towards women, men are often the primary decision-makers on family size and their partners’ use of FP methods [ 9 ]. It is well documented that men’s general knowledge and attitude about the ideal family size, gender preference of children, ideal spacing between childbirths, and contraceptive methods use greatly influence women’s preferences and opinions [ 8 , 10 , 11 ].

In Ghana, the focus of this study, knowledge of any contraceptive method is almost universal, with 98% of all women and 99% of all men knowing at least one method of contraception and where 50% of all women reported having used a method of contraception before [ 12 ]. According to the Ghana Demographic and Health Survey (2014), only 27% of married women use FP with 22% using a modern method and 5% using the traditional method [ 13 ]. Family planning programs in Ghana dates as far back as 1956 [ 14 ], however, uptake of FP services has not been encouraging and even worst in rural Ghana including the Sissala East District in Tumu of the Upper West Region where utilization of PF decreased from 71.4% in 2011 to 50.7% in 2012 [ 15 ]. In Ghana, The male partner may have an influence in decision-making regarding contraceptive use and the number of offspring they would like to have. Family planning research in rural Upper West Region has been dominated by findings almost exclusively from women studies.

Men in rural Ghana are seen to be the head of the home and influence the healthcare decisions of the entire household affairs [ 16 ]. Studies have also shown an increase in contraceptive use in cases where men partners have been involved [ 9 , 17 ]. Men’s involvement helps not only in accepting contraceptives uptake but also its effective use and continuation [ 9 , 10 , 17 ]. However, male partners’ role in FP services promotion and uptake has often been overlooked and neglected in rural areas in Africa such as Ghana. To fill this research gap, this study assessed the involvement of men in FP service utilization and the factors that determine their involvement in contraceptive uptake among women in a rural district of the Upper West Region.

Study setting

The study took place in Tumu in the Sissala East District in the north-eastern part of the Upper West Region of Ghana. Tumu, the district capital is predominantly rural by nature, with the majority (85%) living in rural settings [ 18 , 19 ]. A large percentage (84%) of the population lives below the poverty line [ 18 , 19 ]. A greater proportion (76%) of the population are being engaged in agriculture. It is predominantly Islam (88.0%) with Christianity being the largest of the minority (10%) followed by Traditional (1.4%) [ 18 , 19 ]. A greater proportion of the population (52.4%) has Some level of education [ 18 ].

Study design

A cross-sectional descriptive study design was used for this study. An interviewer-administered questionnaire consisting of both open and close-ended questions was administered by experienced research assistants to elicit the necessary information from the study population.

Sampling technique and sample size

The sample size for this study was determined using the Yamane method: \(\mathrm{Sample}\ \mathrm{Size}=\frac{\mathrm{N}}{1+\mathrm{N}{\left(\mathrm{p}\right)}^2}\) where N  = Total Population, p  = margin of error (5%). A sample size of 386 was derived from the total population of 11,252.

Study population

The study population consisted of adult males and females aged 15 years and above who were either married or cohabitating. For this study, we aimed at recruiting 386 respondents but finally recruited 200 respondents due to logistical constraints.

Data collection method

An interviewer-administered questionnaire consisting of both closed and open-ended questions was used to assess the knowledge and use of FP services among partners and the level of involvement of male partners in FP service utilization. The study questionnaire was developed based on the objective of this study by the principal investigator. The questionnaire was administered by the first author and two experienced research assistants who understand the native dialect. The questionnaire was translated into the local dialect and administered by the two research assistants for participants who could not understand or speak the English language. The questionnaire was administered among households in five communities or clusters out of the ten in Tumu municipality. These communities were chosen using a simple random sampling method. Forty respondents were interviewed from each community. This method gave the individual an equal chance of being selected. Before consent was sought from respondents, the aim of the study was explained to each individual. They were also assured of confidentiality and privacy of the information they will give. The questionnaires were pretested in a similar environment in the district.

Outcome variable

Male participants were asked whether they approved and/or encourage use FP of their partners, ever discussed FP with their partners, provided material support to their partners to access FP services and whether they have used FP themselves in the past. Responses to these questions were them summed to give the level of male partners’ involvement in FP utilization (with no weight given to these variables); the highest possible involvement score was five (indicating a high level of involvement), a zero score indicated no involvement in FP utilization, and score of 3 was considered as sufficient involvement. The involvement of men in FP service utilization for themselves and/or their partners was the main outcome of the study. Female respondents were also asked; if they discuss FP with their male partners, gets approval to use FP from their male partners and whether they receive support from their male partners to access FP services.

The demographic characteristics (age, education, occupation, and religion) and knowledge about FP were the covariates considered for our analyses.

Data management and analysis

To ensure accuracy, the data collected was checked and screened for completeness. The completed copies of the questionnaire were serially numbered and doubly entered and analyzed using Statistical Package for Social Scientists version 20.0. Bivariate and regression analyses were used to determine the associations between the outcome variables and a host of explanatory variables.

Background characteristics of respondents

Two hundred (200) respondents were interviewed for this study. The study involved 107 men representing 53.5% and 93 women representing 46.6%. Respondents’ age ranged between 15 and 54 for men and 15–49 for women. In all, over 70 % (76.5%) had some form of education ranging from primary to tertiary while 23.5% had no education (Table  1 ). All the respondents were involved in some kind of work with over 60 % (66%) being artisans.

Knowledge of family planning

Majority of the male respondents (95.5%) had heard of FP. Almost half of the respondents (48.1%) had information about FP via the mass media (Television, Radio, and Newspaper) followed by friends (27.5%) and the health facility (23.5%) as indicated in Table  2 .

Twenty eight percent (28.0%) of the men interviewed understood FP as avoidance of unintended pregnancy, 25.2% as limiting family size while 19.6% understood it as spacing of childbirth. Others (27.1%) explained it as two or more of the above definitions as shown in Table  3 . The most common method known and used was the condom (42.5%) followed by implants (32.0%) and the least known method being the foaming tablet (7.0%) among male respondents.

Men involvement in FP

Over 50 % (52.2%) of the male respondents reported they or their partner were currently using some form of contraceptives to delay or avoid pregnancy. However, only 36.4% of women reported they or their partners were currently using contraceptives to delay or avoid pregnancy. The majority of the men respondents (72.8%) approved of the use of FP methods by their partners, 75% of the women respondents also indicated their partners had approved of their use of FP. The findings also indicate that men had a higher propensity of reporting FP use (X 2  = 4.5534, p  = 0.033). For the couples who did not approve of the FP methods, the reasons included: socio-cultural beliefs (31%), side effects (30.8%) such as delayed or absence of menses, and difficulty of conceiving after terminating use of FP and others (38.5%).

Overall, about 48% of men were sufficiently involved in FP service utilization (see Table 1 ). Involvement of men in FP use was positively associated with knowledge of FP and the number of living children (Table  4 ).

Decision making in FP use

We wanted to know from the women whether their partners support them in their desire to use contraceptives; 67.0% of the women answered in the affirmative and 33.0% answered in a negative. Those who answered in the affirmative said their partners support them by providing money for transport to facility and/or for FP services, encouraging and accompanying them to the health facility. Women who reported that their spouse support FP use were more likely to use a contraceptive method (X 2  = 9.5223, P  = 0.002) compared to those who said no. Women who reported their partners had some education were also more likely to use a contraceptive method (X 2  = 14.1133, P  = 0.000). In all, female respondents tended to report more favorable attributes for their male partners’ involvement than the male respondents (Fig.  1 ).

FP involvement characteristics

Generally, a greater proportion of men (77.6%) intend using FP in the future. For those who answered in a negative, 19.1% said most of the contraceptives were designed to suit women and thought it was a woman’s business. Nearly three quarters of women (73.4%) who ever used a FP method indicated their partner had a say in the decision to use. For the women interviewed,70.7% said they would still practice birth control irrespective of their partners’ opinion while 23.9% would not use birth control if their partners were against it, 5.4% were however not certain.

This study assessed male partners’ involvement and factors associated with the use of FP services in Tumu in the Sissala East District of the Upper West Region of Ghana. The study identified several factors that influence FP services use among male partners in this setting. Our study demonstrated that despite the high knowledge of modern contraceptive methods among couples, use was low due to perceived side effects and socio-cultural beliefs. Men’s attitude and social practice towards FP methods also influence the behavior of their partners using contraceptives [ 20 ]. It is found elsewhere that the decision not to practice FP is men-dominated and men are responsible for providing contraceptive decisions when FP is practiced [ 21 ]. A major limitation facing low-and-middle income countries FP promotion programs and population policy development on contraceptive behavior is that men are often not targeted in FP programs [ 22 ].

Our study identified several factors associated with men’s influence in FP service utilization among their partners. Non-approval of  FP methods by men in this study was attributed to perceived risks, side effects, and socio-cultural norms. Focus group discussions with men and women in rural Uganda have come out with similar findings [ 9 ]. Contraceptive knowledge and use are shaped by the socio-cultural environment such as personal attitudes and feelings about contraception. In rural settings in low and -middle income countries most men may be unwilling to have their wives adopt FP, which they have little knowledge about. Evidence shows that some men oppose contraceptive use for reasons of tradition and religion which require men to maintain the honor and position of their extended family, village, religious group and social organization [ 23 ]. Studies have shown with similar findings in settings in rural northern Ghana [ 24 , 25 ]. The complex web of social and cultural factors impedes spousal communication regarding reproductive health issues and that discourages them to take their wives to health clinics to discuss FP issues [ 22 ].

Two important factors were identified to be positively associated with men’s involvement in FP use in our study; Knowledge on FP and the number of living children male partners had were positively associated with their involvement in FP use. Knowledge about FP will influence acceptance and therefore impact involvement of men in its utilization. Similar studies by [ 26 , 27 ] have found FP knowledge to be positively linked with its utilization. Our study additionally revealed that men who had greater than two living children were more likely to be involved in FP service utilization. The number of living children have also been shown to be associated with contraceptive use among women in previous studies [ 28 , 29 ]; couples with living children tend to use contraceptives space their births or limit the number of children. Several interventions can be used to address barriers in the uptake of FP services in this setting. Family planning programs need to target men at all levels of health promotion and education with their partners to reduce misconceptions about FP methods to increase acceptance [ 20 ]. Men’s participation is crucial to help reduce misconception about side effects of contraceptive methods [ 20 ]. Therefore, FP family programs need to target men at all levels of the service. Their involvement will also lead to women’s empowerment to increase effective contraceptive use and continuation to improve better health outcomes in reproductive health [ 30 ]. User experiences indicate that text messages provide a novel way to raise awareness, promote behavior change and address myths and socio-cultural norms [ 31 ].

Limitations

This study has some limitations which need to be taken into consideration. The finding of this study cannot be generalized to the entire region of the Upper West region due to the small sample size. Despite the small sample size, views of groups of our respondents which comprised of married partners and those cohabitating, will not differ significantly from the rest of the entire population in the region. Also, this study provides vital insights for policymakers in Ghana and beyond who are working to improve sexual and reproductive health services for men and women. The need for future study to capture the perspectives of men and women on cultural factors influencing PF services for policy.

Conclusions

Our study demonstrated high knowledge of FP among partners. However, the use of modern contraceptives methods was low due to side effects and socio-cultural norms. Involving men partners in FP programs could give them accurate and complete information on contraceptive methods to help reduce misconception and increase uptake. Reproductive health program designers, policymakers, and population researchers, health professionals need to incorporate the findings into reproductive health programs to help address barriers to improve health outcomes among couples.

Availability of data and materials

The dataset for this study is available on request from the corresponding author.

Abbreviations

Family Planning

Low- and Middle-Income Countries

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Acknowledgements

The authors wish to acknowledge all study participants for their cooperation in providing the necessary information and the research assistants for data collection.

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SAKK conceived the study and conducted the field work. SAKK and TA designed the study and performed the statistical analysis. ASL drafted the manuscript. SAKK and TA reviewed the manuscript. All authors read and approved the final manuscript”.

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Kwawukume, S.A.K., Laar, A.S. & Abdulai, T. Assessment of men involvement in family planning services use and associated factors in rural Ghana. Arch Public Health 80 , 63 (2022). https://doi.org/10.1186/s13690-022-00822-5

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Level of male involvement and associated factors in family planning services utilization among married men in Debremarkos town, Northwest Ethiopia

• Mihretie Kassa 1 ,
• Amanuel Alemu Abajobir 2 &
• Molla Gedefaw 1  

BMC International Health and Human Rights volume  14 , Article number:  33 ( 2014 ) Cite this article

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Men’s participation is crucial to the success of family planning programs and women’s empowerment and associated with better outcomes in reproductive health such as contraceptive acceptance and continuation, and safer sexual behaviors. Limited choice and access to methods, attitudes of men towards family planning, perceived fear of side-effects, poor quality of available services, cultural or religious oppositions and gender-based barriers are some of the reasons for low utilization of family planning. Hence, this study assessed the level of male involvement in family planning services utilization and its associated factors in Debremarkos town, Northwest Ethiopia.

A community-based cross-sectional study was conducted from October to November, 2013. Multi-stage sampling technique was used to select 524 eligible samples. Data were collected by using semi-structured questionnaires. Epi Info and SPSS were used to enter and analyze the data; univariate, bivariate and logistic regression analyses were performed to display the outputs.

Only 44 (8.4%) respondents were using or directly participating in the use of family planning services mainly male condoms. The reasons mentioned for the low participation were the desire to have more children, wife or partner refusal, fear of side effects, religious prohibition, lack of awareness about contraceptives and the thinking that it is the only issue for women. Opinion about family planning services, men approval and current use of family planning methods were associated with male involvement in the services utilization.

Conclusions

In this study, the level of male involvement was low. Lack of information, inaccessibility to the services and the desire to have more children were found to be the reasons for low male involvement in family planning services utilization. Governmental and nongovernmental organizations, donors and relevant stakeholders should ensure availability, accessibility and sustained advocacy for use of family planning services. The family planning programs should incorporate the responsibility and role of males in the uptake of family planning services.

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The involvement of men in reproductive health (RH) matters is important to achieving key millennium development goals (MDGs) including reduction of maternal mortality and the prevalence and impact of HIV/AIDS [ 1 ]. Family-planning (FP) programs have focused attention primarily on women to space and/or limit excessive child-bearing and to reduce maternal and infant mortality; accordingly, most of the services including research and information campaigns used to emphasis on women. This has reinforced the belief that FP is largely a woman’s business, the man playing a very peripheral role [ 2 ].

In Ethiopia, FP was initiated four decades ago; however, even after such a long period of time, the service has been amongst the lowest in Africa with 15% contraceptive prevalence rate (CPR) and 36% unmet need for FP [ 3 ]. Several factors are incriminated for the low coverage of FP services including the desire to have more children, lack of knowledge about contraceptive use and where to find contraceptives, health concerns, religious prohibition, husband opposition and low involvement of males. Male involvement in RH services utilization encompasses the way men accept and indicate support to their partners’ needs, choices and rights including using contraception and their own reproductive and sexual behavior to promote observance of human rights and the need to enforce equity. Consequently, it is particularly relevant in male-dominant cultures where men already have an all-encompassing involvement in decisions pertaining to family and society [ 4 ].

The Ethiopian population policy emphasizes the expansion of FP services through clinical and community-based interventions to attain CPR to 65% by 2015. It also involves encouraging a range of positive RH and social behavior by men to help ensure women’s and children’s wellbeing [ 5 ]. Despite this fact, interventions to involve men in reproductive issues have been low, and yet studies addressing the level of male involvement are scarce in the study setting. Therefore, this study was designed to assess the level of male involvement in FP services and its associated factors in Debremarkos town, Northwest Ethiopia.

Study design, setting and period

A community based cross-sectional study was conducted to assess the level of male involvement in FP services and its associated factors among married males (to explore their experience more) in Deberemarkos town, Northwest Ethiopia; the estimated population of Deberemarkos town was 86,786, of which 41,657 ((47.9%) males and from which about 64% were married)) and 45,129 (52.1%) were males and females respectively. About six in ten women, 26972 (59.7%), use FP services currently with an estimated total fertility rate (TFR) of 4.3%. Due to patriarchal dominance, males’ attitude and practice towards the importance and use of FP methods affect women’s decision - making in the study area. The study was conducted from October to November 2013.

Source and sample population

All married males living in Debremarkos town were the source population whereas randomly selected married males living with their spouses in the selected kebeles (least administrative units) were the sample population.

Sample size determination

Epi-Info version 3.1.1 statistical software was used to calculate the sample size by using single population proportion formula with the assumption of proportion (p) for male involvement in FP to be 65.5% (i.e., p = 0.655) from previous study [ 3 ], 95% CI with 5% tolerable error and design effect of 1.5 (i.e., a strategy of incorporating sampling weights and the design variables into the analysis to avoid errors in inference in complex sampling schemes like multistage sampling [ 6 ].

z = confidence interval (with 95% level of certainty)

w  = margin of error (5%)

p = proportion (65.5%, p = 0.655)

Using the design effect of 1.5 (i.e., 349*1.5 = 524), the total sample size was 524 married males.

Sampling procedures

Multistage sampling method was used. Four of the seven kebeles of Debremarkos town were selected with replacement. A total of 20,183 households and 26,972 couples using FP methods currently were living in the town. By using random sampling method, a total of 524 married males were selected from 11,551 husbands residing in randomly selected 4 kebeles . A household would be the basic sampling unit in each kebele and samples were allocated proportionally to each based on their total household. Households were selected systematically by standing in the middle of the kebeles (as identified by the spinning pencil). Every household where the direction of the pencil point would be included in the study. If the boundary of the first kebele would be limited without getting the required number of respondents, the interviewers turned in the direction of their right hand and continue with the same sampling procedure until the required number was obtained (Figure  1 ).

Sampling procedure for level of male involvement in family planning among married men in Debremarkos town, Northwest Ethiopia, 2013.

Data collection procedure

Data were collected using interviewer administered semi-structured questionnaires. The questionnaires were developed in English and translated into local language ( Amharic ). The questionnaire was designed to include socioeconomic variables, knowledge, attitudes and practice towards FP methods. In case where the respondent was not found after repeated visits, the immediate (nearby) household was interviewed. Two health officer research supervisors and ten health extension worker data collectors were trained and undertook the overall data collection activities under the immediate superviovion of the principal investigators for possible guidance.

Data quality control

To assure data quality, the questionnaires were pretested (10% of the total sample) on similar population a week before the commencement of the main research. Two days training was given for data collectors and supervisors. Data were cleaned by using SPSS before analysis.

Data processing and analysis

The data were handled confidentially and entered into SPSS version 16 statistical program for analysis. Frequency tables, graphs and proportions were used to present the data; logistic regression was used to test the associations.

Variables of the study

Dependant variable.

Male involvement in FP services.

Independent variables

Socio-economic and socio-demographic characteristics, approval of FP, spousal communication, knowledge, attitude and practice of contraceptive methods.

Definitions

• Male involvement

Based on the summative score of questions designed to assess male involvement in FP services, men with score 60% and above were considered as having better involvement in FP services.

Positive attitude

Based on the statements assessing attitude, the mean score 3/5 (60%) of the distribution was considered as having positive attitude towards family planning [ 5 ].

Based on the summative score of questions designed to assess knowledge, men with above the mean of the distribution or 60% were considered as having better knowledge of family planning services [ 5 ].

Ethical consideration

Ethical clearance was obtained from the Research and Publication Directorate of Debremarkos University and supporting letter was obtained from Debremarkos town administration. The purposes of the study were explained and informed consent was obtained from all participants. Confidentiality and privacy were maintained throughout the study process by excluding identifications in the questionnaires.

Socio-demographic characteristics

All currently married men in the study responded to the questionnaires making the response rate 100%. Mean age of the respondent was 36.70 (SD ± 5.87) years. More than 50% of the respondents were within the age range of 31–40 years. More than 93% of the study participants were Amhara by ethnicity (Table  1 ).

Reproductive characteristics

The average number of living children per man was 2.7 with SD of 0.63 and the average desired number of children was 3.2 (SD ± 0.66). About four in ten (39.3%) men preferred 3–4 years for birth spacing (Table  2 ).

Knowledge of modern contraceptive methods

Most of the study respondents (99.2%) reported that they had ever heard about FP methods. About 64.9% of respondents listed 2–3 family planning methods while 30% of the respondents reported 1–2 years interval between two consecutive pregnancies. Generally, 91.6% of the respondents had knowledge about modern FP methods (Table  3 ).

Approval and spousal communication

More than half (54%) of married men discussed on such issues as when to achieve pregnancy, and/or prevent pregnancy and the use of contraceptives in the year prior to the study. On the other hand, 44.7% of men supported use of FP methods of their partners/wives. Almost one fifth (19.1%) of the respondents were neutral to approve use of contraceptives and 38.0% did not approve use of contraceptive while only 42.9% approved it. The reasons mentioned for the disapproval were the desire to have more children, wife or partner refusal, fear of side effects, religious prohibition, lack of awareness about contraceptives and the thinking that it is only the issue of women (Table  4 , Figure  2 ).

Reasons not to use FP methods by married men in Debremarkos town, Northwest Ethiopia, 2013.

Almost all (99.4%) participants’ wives (spouses) were using contraceptive methods mainly injections (53.2%); however, 5.3% of the respondents did not know the methods used by their partners. Majority (75.5%) of the participants’ partners use contraceptive methods for child spacing while 21.0% use to limiting birth. On the other hand, only 8.4% respondents were using or directly participated in the use of FP methods mainly male condoms (Figure  3 ).

Family planning methods used by respondent’s partners in Debremarkos town, Northwest Ethiopia, 2013.

Men’s attitude towards FP services

The attitudes of married men were assessed whether they had interest to know more about FP services; accordingly, 51.1% of the respondents had interest to know more about FP services but 48.9% of the respondents had no interest to do so and believed that it is a natural process. Men’s opinions about their roles in FP decision-making were assessed on a three-tier scale of agree, neutral and disagree. Accordingly, most male respondents disagreed that men should make decisions about selected FP issues in the family; 25% agreed that men should decide what to do when unwanted pregnancy occurs; 24.7% agreed that men should decide the types of FP methods; 49.8% agreed that FP practice services would make reduce confidence between husband; 31.6% agreed that men share the responsibility of FP services. Generally, 26.9% married men had positive attitudes towards the involvement of males in FP services utilization (Table  5 ).

Logistic regression analysis

The binary logistic regression analysis of some independent variables in relation to the dependent variable was undertaken. Odds ratio (OR) with 95% confidence interval (CI) were used to assess the association between the variables. Men who had negative opinion about condom use with the believe that it reduces sexual potency were 2.13 times less likely to be involved in the use of FP services than those with positive opinion [AOR = 2.13, 95% CI: 1.28-3.53, p-value = 0.003]. Men who approved FP services utilization were 4.26 times more likely involved in FP services utilization than men who did not approve [AOR = 4.26, 95% CI: 2.51-7.22, p-value = 0.001]. Men who supported their wives to use FP methods were 1.61 times more likely involved in FP services utilization than men who did not support their wives to use FP services [AOR = 1.61, 95% CI: 1.10-2.35, p-value = 0.014]. Men encouraging their spouses to use FP were 1.74 times more likely involved in FP services utilization than men who did not encourage to do so [AOR = 1.74, 95% CI: 1.19-2.55, p-value = 0.005] and men who were using FP methods mainly condoms during the survey were 2.57 times more likely involved in FP services utilization than men who were not using condoms [AOR = 2.57, 95% CI: 1.30-5.01, p-value = 0.007] (Table  6 ).

Involving men and obtaining their support and commitment to FP services is crucial for increasing their uptake. This research assessed the level of men involvement in FP services utilization and highlighted the potential insights of men’s attitude towards FP services utilization in Debremarkos town, Northwest Ethiopia. The desire to have another child, lack of awareness, religious prohibition, fear of side effects, men’s attitudes towards FP use and others were among the reasons reported for low involvement of males in FP services utilization in the study area. Men’s knowledge on FP services was high as compared to previous study; this might be the result of interventions by the health sector and increased exposure to health education and media advocacy. The benefits and types of FP methods particularly for men were not well known by the study participants; however, the study documented positive association of men’s FP knowledge on couples’ contraceptive use and it complements with other studies [ 3 ],[ 7 ]. The average living children per men and the desired number of children by the study participants were lower than study finding from Hosanna [ 8 ]; this could be explained by high knowledge of FP by the study participants. Family panning methods were used for birth spacing than limiting which is in agreement with other studies in Ethiopia and other developing countries [ 7 ],[ 9 ].

In line with other studies, this study revealed negative attitude towards FP methods use among the respondents [ 7 ],[ 10 ]. So, this negative attitude might affect the use of FP methods which is characterized by reduced contraceptive coverage. This indicated the need to introduce accurate information to develop positive attitudes towards the practice of the methods.

In this study the only modern contraceptive method used by males was condom; this finding was in line with the results from Tigray and Wolayita Soddo [ 3 ],[ 7 ] but the attitude of married men towards condom utilization is negative [ 7 ],[ 11 ]. Moreover, this study demonstrated that none of the respondents ever used sterilization. This might be partly due to the fact that none of the facilities in the study area provide male sterilization services to their clients and partly because the cultural norms against male sterilization [ 7 ]. Also some of the respondents had misconception about men permanent methods and did not agree on its effectiveness as well as acceptance as a method of choice showing direction to awareness creation sessions to motivate and reinforce others. Inter-spousal communication is an important intermediate step along the path to adoption and sustained use of FP services eventually [ 9 ],[ 12 ]. Men’s report of the level of spousal communication about family planning and other reproductive health issues was quite poor in this study. A couple can come to a mutual decision on whether or not to use contraception to plan when to have children and how many to have through discussion [ 12 ]. In this study, we found low level of spousal discussion about the issue when compared with other studies [ 3 ],[ 7 ],[ 8 ]; the difference might be explained by cultural differences between the communities.

This study also revealed that married men’s support to use FP methods was less than half which is lower than other study findings [ 7 ],[ 8 ]. Moreover, all men and women currently used short-acting methods for the purpose of child spacing rather than limiting. Similar results observed in other studies done in Ethiopia [ 2 ],[ 3 ]. Thus, counseling of women in negotiating skills is necessary to develop confidence, influence their partner’s attitude towards fertility regulation to develop responsible reproductive and sexual behaviour among men [ 5 ]. Programs should also work and emphasize to reduce providers bias.

Male involvement is not limited to the use of FP methods by itself rather to its supportive attitude that males have towards their spouses to usg FP methods and motivations in sharing responsibility in RH matters. In this study, the level of male involvement was low. Lack of information, inaccessibility to services and the desire to have more children were found to be some of the main reasons against male involvement in FP services utilization. Attitudes, spousal communications and approval were some of the factors associated with male involvement in FP services uptake.

Based on the study findings, the following measures were recommended:

Governmental and nongovernmental organizations, donors and relevant stakeholders should ensure availability, accessibility and sustained advocacy for the use of FP services;

The FP programs should incorporate the responsibility and role of males in the practice of FP service;

Service delivering centers need to be properly equipped with materials to motivate males to use the services.

Authors’ information

MK, AAA and MG are lecturers and public health research fellows in GAMBY College of Medical Sciences and Debremarkos University, Health Sciences College, School of Public Health.

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Acknowledgments

Our gratitude goes to the School of Public Health staffs who supported us in supervision and monitoring of the data collection process. Our special thanks also go to the data collectors for their endeavor. At last but not least our sincere gratitude goes to the East Gojam health sectors staffs and the community who provide us constructive information for the study to be effective.

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The overall duty of this research has incorporated the multiple efforts of all authors from inception to accomplishment as principal investigators of the research. MK, AAA and MG carried out the conception and initiation, design, analysis and writing up of this research article and involved in drafting of the manuscript. All authors read and approved the final manuscript.

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Kassa, M., Abajobir, A.A. & Gedefaw, M. Level of male involvement and associated factors in family planning services utilization among married men in Debremarkos town, Northwest Ethiopia. BMC Int Health Hum Rights 14 , 33 (2014). https://doi.org/10.1186/s12914-014-0033-8

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Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women’s perceptions in two rural districts in Uganda

• Allen Kabagenyi 1 , 2 ,
• Larissa Jennings 3 ,
• Alice Reid 4 ,
• Gorette Nalwadda 5 ,
• James Ntozi 1 , 2 &
• Lynn Atuyambe 6  

Reproductive Health volume  11 , Article number:  21 ( 2014 ) Cite this article

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Spousal communication can improve family planning use and continuation. Yet, in countries with high fertility rates and unmet need, men have often been regarded as unsupportive of their partner’s use of family planning methods. This study examines men and women’s perceptions regarding obstacles to men’s support and uptake of modern contraceptives.

A qualitative study using 18 focus group discussions (FGDs) with purposively selected men aged 15–54 and women aged 15–49 as well as eight key informant interviews (KIIs) with government and community leaders was conducted in 2012 in Bugiri and Mpigi Districts, Uganda. Open-ended question guides were used to explore men and women’s perceptions regarding barriers to men’s involvement in reproductive health. All FGDs and KIIs were recorded, translated, and transcribed verbatim. Transcripts were coded and analyzed thematically using ATLAS.ti.

Five themes were identified as rationale for men’s limited involvement: (i) perceived side effects of female contraceptive methods which disrupt sexual activity, (ii) limited choices of available male contraceptives, including fear and concerns relating to vasectomy, (iii) perceptions that reproductive health was a woman’s domain due to gender norms and traditional family planning communication geared towards women, (iv) preference for large family sizes which are uninhibited by prolonged birth spacing; and (v) concerns that women’s use of contraceptives will lead to extramarital sexual relations. In general, knowledge of effective contraceptive methods was high. However, lack of time and overall limited awareness regarding the specific role of men in reproductive health was also thought to deter men’s meaningful involvement in issues related to fertility regulation.

Decision-making on contraceptive use is the shared responsibility of men and women. Effective development and implementation of male-involvement family planning initiatives should address barriers to men’s supportive participation in reproductive health, including addressing men's negative beliefs regarding contraceptive services.

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Introduction

Research suggests that male involvement can increase uptake and continuation of family planning methods by improving spousal communication through pathways of increased knowledge or decreased male opposition [ 1 – 5 ]. Yet, despite growing evidence on the benefits of engaging men in reproductive health decision-making, fertility rates and unmet need for family planning remain high in many sub-Saharan African countries. While there are many influential factors, low contraceptive prevalence has been attributed in part to men’s opposition to or non-involvement in family planning [ 6 – 8 ]. Male engagement has historically been depicted as obstructive by impeding women’s decision-making on use of family planning, or non-existent among male partners who are absent altogether due to lack of interest in matters related to reproductive health [ 9 ]. However, at the same time, men dominate decision-making regarding family size and their partner’s use of contraceptive methods in many traditionally patriarchal settings [ 10 , 11 ]. Women point to their male partner’s resistance to family planning as a significant barrier to uptake and continuation, resulting in decisions to use contraceptive methods covertly or not at all [ 12 , 13 ]. Fear of spousal retaliation due to disagreements about whether to use contraception has also been shown to be a significant barrier among women [ 14 ]. This seemingly contradictory role among men of being both key decision-makers regarding fertility desires and remaining detached from reproductive health issues has posed considerable challenges in African contexts to involve men to address low contraceptive prevalence rates [ 15 , 16 ].

While family planning services have traditionally targeted women, there is growing recognition that reproductive health is the joint responsibility of men and women. Given that men often have significant influences on a couple’s contraceptive use [ 17 ], pilot programs to engage men have focused on increasing knowledge, enhancing spousal communication, and de-stigmatizing use of family planning methods. Renewed interests in involving men stem not only from women’s reproductive health needs, but also to address men’s own sexual health concerns, as well as efforts to achieve the Millennium Development Goals (MDGs) for reduction of maternal mortality and HIV transmission. Use of modern contraception and family planning services is integral in the prevention of unwanted pregnancy, reduction of unsafe abortions, and promotion of childbirth spacing to lower maternal and child mortality risks in developing countries [ 18 – 21 ]. Family planning also promotes gender equity and greater educational and economic opportunities for women [ 6 ]. Several small-scale initiatives aiming to include men in reproductive health programs have had positive experiences [ 22 ], but in-depth understanding of the rationale for men’s low participation has been underexplored. This is urgently needed in the development and scale-up of evidence-based male-involvement family planning interventions.

Using qualitative research methods, this study examines men and women’s perceptions regarding obstacles to men’s support and uptake of modern contraceptives. Qualitative research methods facilitate in-depth understanding of the socio-cultural underpinnings of health behaviors and health motivations. Yet, there is a dearth of literature on factors which hinder men’s involvement in reproductive health from the perspective of men themselves. The few studies available have largely been conducted in non-African countries with dissimilar cultural settings and varying efforts to integrate men’s views with those of women and local stakeholders [ 23 – 26 ]. Studies conducted in African contexts have found that limited knowledge about family planning is a key determinant of men’s negative perception of and lack of engagement in family planning [ 27 ] as well as gender norms regarding men’s roles [ 28 – 30 ]. Some studies suggest also that spousal communication is low even in cases where men approve of family planning [ 27 , 31 ]. Despite these initial findings, less is known regarding the full range of men’s perspectives towards male and female contraceptive use. To address this gap, this study examines gendered views regarding factors limiting men’s involvement, as evidenced by partner communication, approval, support, or utilization of family planning methods and its implications for future research and intervention design.

Study design

A cross-sectional qualitative study was conducted using focus group discussions (FGDs) with women aged 15 – 49 and men aged 15 – 54 as well as 8 key informant interviews with government and community leaders in Bugiri and Mpigi Districts, Uganda.

Uganda has an estimated population of 34 million people and is one of the youngest populations in the world [ 32 ]. Over 56% of the population is under 18 years of age, and the country has a growth rate of 3.2% per annum [ 32 ]. Recent national data has highlighted current reproductive health challenges. More than half of all pregnancies are unintended and roughly a quarter of maternal deaths are due to complications from unsafe abortions [ 33 ]. Uganda has one of the highest fertility rates in the region at an average of 6.7 children per woman, although the majority of Ugandan women would prefer fewer children [ 34 ]. Within the country, the contraceptive prevalence rates range from 19 to 30% [ 33 , 34 ], and the unmet need for family planning, referring to the estimate of women who desire to delay or prevent pregnancy but are not using contraception, is 36% [ 35 ]. Women and men’s access to modern contraceptive methods is also limited in some settings [ 34 ]. Traditional gender norms within Uganda elevate men as primary decision-makers in women’s use of family planning methods, although spousal communication and utilization of reproductive health services among men remains low [ 34 , 36 ].

Participant selection

All study participants were purposively selected. Comparable to standard reproductive age categories, men aged 15–54 and women aged 15–49 in current married or non-married partnerships who were living in Bugiri and Mpigi Districts at the time of the study and willing to participate were eligible to join. Bugiri and Mpigi Districts were selected to provide a range of contexts for contraceptive uptake. District health officers, members of village health teams, council leaders, and representatives from local women and men’s groups were recruited for key informant interviews. Participants were selected from both rural and urban settings within each of the two districts with the help of local field guides and community leaders.

Data collection

Data were collected in July and August 2012. Open-ended, semi-structured question guides were used to explore perceptions regarding barriers to men’s involvement in reproductive health. Discussions and interviews were conducted in the local languages, Lusoga and Luganda, in Bugiri and Mpigi Districts, respectively, until saturation was reached and no new findings emerged during study team debriefings. Interviews and focus group discussions were held in audibly private areas. Data were gathered by two trained research assistants with experience conducting qualitative research. The lead author of the study supervised all data collection to ensure quality control and assisted in taking notes. All study participants were encouraged to openly discuss their opinions. No personal information in the form of names or other identifying data was obtained.

Data analysis

All discussions and interviews were recorded and transcribed verbatim in Lusoga and Luganda. After validating the transcription, the typed narratives were then translated into English and verified for accuracy. Analysis of the data was conducted by the primary author and included several iterative steps. Using thematic content analyses, the transcripts were reviewed several times, and a set of codes were developed to describe groups of words, or categories, with similar meanings. Transcripts were then coded and managed using ATLAS.ti (Version 7). The grouped categories were refined and used to generate themes emerging from the data. Direct quotations from men, women, and community key informants are presented in italics to highlight key findings.

Ethical consideration

This study received ethics approval by the Makerere University School of Statistics and Planning Ethics Committee and the Uganda National Council of Science & Technology. Local leaders in each of the two districts were also invited to review and approve the study. Prior to data collection, informed consent was obtained for all potential study participants. Only the research team had access to the study data.

A total of 18 FGDs, eight male and ten female groups, as well as 8 KIIs were conducted. This represented a total of 154 individuals, 70 men and 84 women, respectively, who participated in the study. The average duration of FGDs and informant interviews was 90 minutes. The majority of participants were married or cohabiting and had completed secondary education. Five key themes were identified as reasons for men’s limited involvement in reproductive health. These included: side effects of female contraceptive methods, dissatisfaction with male contraceptive choices, perceptions that family planning was a woman’s domain, large family size preferences, and fear of partner sexual promiscuity.

Side effects of female contraceptive methods

A commonly reported disincentive among men to support their partner’s use of contraceptive methods related to perceived side effects which were blamed for reducing sexual pleasure and increasing women’s risks of infertility and illness. Men reported being frustrated by several observed side effects, most notably irregular and prolonged bleeding, as well as vaginal dryness, and decreases in sex drive or libido. Excessive bleeding in particular was seen as having detrimental effects on marriages as long periods of blood loss reportedly led to women’s general fatigue and dampened their interests in sexual intercourse. Bleeding was also attributed to limiting the number of opportunities for men to have sex with their partner. This was seen as a precursor and motivation for developing extramarital sexual relations.

“Some of [the] women lose their sexual appetite, and no longer want to be with a man and others bleed for all the three months. Sometimes this causes problems in the marriages. When you are with your wife, the feeling is as though you do not have a wife. One ends up looking for sex outside their marriage”. Male FGD Participant, Mpigi

“They over bleed throughout. So as men, when you find her over bleeding, you choose to go out for other women. So, we want you to give us some advice because even going for vasectomy has a problem”. Male FGD Participant, Bugiri

While women were perceived as having the physical burden of contraceptive side effects, men considered themselves to be indirectly affected by side effects, resulting in requests by several men that their spouses discontinue contraceptive use altogether. In addition to women’s reportedly decreased interest in sex due to contraceptive side effects, excessive bleeding was also associated with vaginal odors.

“When you have a wife in the house and she is bleeding, the man does not have an opportunity to enjoy sexual intercourses with her. But now, just tell me if you have treated her and she gets fine. Tell me what will happen. Would you accept her to go back for family planning methods? You cannot allow her to go back, so that is the problem”. Male FGD participant Bugiri

“Men are against family planning, saying that women who go for family planning services never reach their sexual orgasm, bleed for so long, and also stink a lot. Such men refuse their spouses from going for family planning services so they end up producing more children”. Female Key Informant, Bugiri

Other perceived side effects which motivated men to oppose women’s use of contraception related to concerns in delayed return or permanent loss of fertility, as well as fears that short-term methods, such as birth control pills or injections, could lead to congenital abnormalities.

“These pills affect the fetus while in the uterus, sometimes women give births to children without some body parts, for instance a child may have no arms and sometimes some other body parts. We are told that pills are the cause of those abnormalities”. Male FGD Participant, Bugiri

Men equated the side effects of family planning methods also with having adverse economic effects on the household. Women’s reports of dizziness, nausea, and tiredness were thought to affect women’s ability to endure the physical demands of agricultural labor, resulting in a reduction in household productivity. Direct or indirect losses in revenue were further exacerbated by additional medical care costs to treat women’s discomfort. While side effects such as pain, mood changes, and breast tenderness were less commonly mentioned, such symptoms may have also contributed to men’s unsupportive involvement.

“If you have a wife that swallows pills, these pills have some side effects on those women like dizziness. The others get nausea. Yet, for us in our area, we are farmers. When they [women] go to the garden, they return late… without any work done [and] complaining of sickness. If your wife has no side effects in using family planning pills then it is okay. But the problem is that women ask for money from us [men] because they are sick and need treatment for the side effects. Some [women] lose energy while others lose their libido and get tired of sleeping with men”. Male FGD Participant, Mpigi

“You find that the money you spend treating your wife because of the problems she got after using family planning methods is more than the money you would have used treating a live child”. Male FGD Participant, Bugiri

Dissatisfaction with male contraceptive choices

A second theme related to perceptions that while men were dissatisfied with the perceived side effects of female contraceptives, the two available male contraceptive methods were equally unappealing, namely male condoms and vasectomy, the surgical removal of sperm ducts. Limited access to a more diverse set of male-led methods was cited as additional motivation for men’s disapproval of family planning. The permanence and irreversibility of vasectomy was noted, in particular, as inacceptable among men and consistent with losing one’s masculinity.

“In every 100 men, you can only find one man or even none practicing family planning. You might not find even one man going to the health center for family planning services because we have only one method of contraception from the health facility which is vasectomy which lasts until death. However, women have many short term methods such as injections, pills, coils, and many others”. Male FGD Participant, Mpigi

“We men have no family planning pills, but we are afraid of what we have for family planning like vasectomy which is equal to castration. I am really afraid of such a method. That is the problem that we men have. Otherwise, we would participate in family planning. ..We only have two methods. Whereby, if you don’t use a condom, then you have to go for vasectomy”. Male FGD Participant, Mpigi

Given the expansion of modern contraceptive methods designed for women, this raises the possibility of unmet need for family planning among men who in some cases expressed desires to limit child birth due to the financial burden of raising large families. Preferences for a male-version of birth control pills were proposed as a potentially convenient male-led method to limit family size. Participants suggested that such short-term technologies for men would increase men’s interest in and uptake of family planning services.

“If we had pills for family planning, as men, that would help us. Maybe we would be involved. For us who want to plan our families, we would be involved [in the] use of contraceptives and family planning. I have paid a lot of school fees and felt the heavy burden. I would have stopped delivering long time ago but because we do not have family planning pills for men, we only have one method of vasectomy”. Male FGD Participant, Mpigi

“If we had something like a string that we would tie somewhere to space children and when it reaches a time when you want more children you would untie, then we would directly get involved in family planning to avoid giving birth to children who roam the streets”. Male FGD Participant, Mpigi

Women echoed similar sentiments relating to the lack of diversity among male contraception methods. There were also views that older men considered male condoms as designed predominantly for unmarried and younger individuals, and thus not well tailored for older sexually active men. Use of male condoms was also associated with distrust among couples.

“Condoms, especially youths, use them to avoid impregnating ladies and also to avoid HIV/AIDS. Other men especially the adults like in their 50s do not want family planning and have a negative attitude towards it. Men regularly say that use of condoms is a waste of time and can even ruin their homes”. Female Key Informant, Mpigi

Perceptions of family planning as a woman’s domain

Social norms as well as health system factors were also identified as stymieing men’s participation in reproductive health services. Men and women highlighted gender norms which assigned the role of childbearing and child-rearing to women. Matters relating to fertility and birth planning were also considered to be within this domain. Engaging men in communication regarding family planning was perceived by some as inappropriate and distractive. Given the social expectations for men to earn income for their families, use of men’s limited time and mental preoccupation to discuss family planning was considered unduly burdensome.

“No, men do not have time and do not want to know anything related to contraceptives. They usually say that such things are for women, since they are responsible for carrying the pregnancy. For them [men], their [men’s] responsibility is to look for money”. Male Key Informant, Mpigi

“Sometimes men have no time. They are busy looking for money. So it’s useless to involve them in such issues of family planning and contraceptive uses since their minds are thinking about money. Usually, it is us women who produce children. Therefore, we carry the burden [of] being pregnant. Therefore, we do not see why we should involve men in such issues”. Female Key Informant, Mpigi

At the same time, men’s lack of involvement was blamed on family planning services, including awareness-raising campaigns, which have traditionally targeted women. This was thought to further define family planning as a woman’s domain, including initiating partner discussions and managing contraception. In cases where male involvement was perceived appropriate, lack of knowledge about how to be involved was often cited by participants as another deterrent for men.

“Men are not involved family planning and promotion of contraceptive use because they do not know. It is common for women to be sensitized because they go for antenatal [care], but the men do not go for antenatal [care]. There are only few who go there. At our village, there are no sensitizations targeting men. It is only a few women who educate their men, and they can’t explain to them very well”. Male FGD Participant, Mpigi

“Sensitize all men about family planning and also train them about their roles when it comes to family planning. By doing so, they will come to know the importance of family planning in a home, as most have no idea at all”. Female Key Informant, Mpigi

Family size preferences

The absence of men’s support of women’s contraceptive use was additionally linked with patrilineal traditions that highly value children and encourage large family sizes. Numerous children were described as a sign of wealth and financial security.

“Men think children are a source of security especially if they are boys, usually if one builds on the right, another left, then people will fear to attack you because you already have security. Again when asking for votes like me if you have many children definitely those are many votes already and you will win”. Male Key Informant, Bugiri

“Most men do not like the issue of family planning because it reduces the size of their families. Men also have negative attitudes towards birth control because they say if you reduce on the number of girls you are to produce then you are reducing on your wealth”. Male Key Informant, Bugiri

In some cases, having as many children as possible was believed to be an inherent and religious directive for couples of reproductive age. Conservative points of view challenged the moral legitimacy of family planning and perceived it as undermining the husband’s fertility desires.

“If it were possible, family planning should be removed or stopped from this country and whoever talks about it should be imprisoned. Because we have been told to give birth to as many children as possible. Now if you tell me that you have brought a plan to hinder me from giving birth to many children that is not good at all”. Male FGD Participant, Mpigi

Promotion of modern contraceptives as a method for birth spacing was also viewed critically by some women who felt such messaging further led to men’s negative views regarding participation in family planning.

“The reasons as to why they are not involved is that our men love having children so much. When you reach 3–4 years without conceiving or delivering for them a baby they feel bad. Yet, as a woman you are mindful of your health”. Female FGD Participant, Bugiri

Fear of partner sexual promiscuity

Participants also voiced concerns that women’s utilization of family planning services may lead them to become unfaithful and reflect women’s intentions to avoid pregnancy within extramarital sexual relationships. Men’s fears regarding women’s perceived sexual promiscuity was additionally linked with stigmatizing beliefs that contraception was most often used in contexts of female commercial sex exchange. It was not considered acceptable for faithful, married women. Both men and women expressed views that men’s anxiety regarding their spouse’s potential infidelity was a formidable barrier in defining supportive male roles in the utilization of reproductive health services.

“The few women who use contraceptives are seen as prostitutes. And usually men refuse their wives to associate with them because they think they will teach them how to use these contraceptives. Yet, men do not want them at all”. Male Key Informant, Bugiri

“Mostly us in the villages, someone who enters in that system of using modern contraceptives we think of her has being among the people who sell themselves or prostitutes. [In] our community, we take that person to be among those who sell themselves [as] prostitutes”. Male FGD Participant, Bugiri

“Men have a negative attitude towards contraceptives. They say they are bad, [and that]…they encourage women to move out with other men”. Female Key Informant, Bugiri

Furthermore, participants noted men’s efforts to defend against other men’s sexual interests in their spouse. Family planning methods were described as enhancing women’s physical attractiveness by delaying or preventing childbearing, which made men reluctant to support women’s contraceptive use. In exceptional cases, women who practiced family planning were also shunned by community members due to perceptions that they were intentionally abandoning the marital relationship.

“They do not want their women to stop producing because when they do, they will look healthy and younger. Men have fears that when their wives look younger, they end up attracting other men”. Female FGD Participant, Bugiri

“The men have other fears of losing their wives especially in case they use contraceptive, it makes them delay and look nice so can easily be taken by other men”. Female FGD Participant Bugiri

Reproductive health decision-making is the shared responsibility of men and women. Growing evidence suggests that involving men in family planning can increase women’s contraceptive uptake. Yet, in many sub-Saharan African settings, few men are involved in issues relating to reproductive health, and there is a dearth of evidence on barriers to men’s constructive engagement. This study found that many participants perceive men to be obstacles to women’s utilization of family planning, and largely uninvolved despite the fact that men are often responsible for decisions which affect the household. This was attributed to men’s reluctance to support use of modern contraceptive methods for their spouses or themselves based on fears of harmful side effects and spousal infidelity, as well as preferences for large-sized families. Institutional and social norms which define reproductive health as a “woman’s issue” and the limited choice of available male contraceptives were also cited as reasons for men’s lack of involvement. There was a common impression that such barriers hindered men’s positive and constructive participation such as discussing the couple’s fertility preferences, accompanying partners to seek reproductive health services, or providing other forms of support. Such sentiments were observed in the majority of focus groups, including male and female groups, in addition to key informant interviews.

Several important lessons emerge from the study which should be considered for future interventions. One key finding relates to comments by participants that men’s lack of involvement from fear and negative health beliefs stemmed from their overall lack of knowledge. This was attributed to the limited number of community-level reproductive health campaigns which targeted men. As a result, the emphasis on barriers related to harmful side effects may reflect heightened perceptions rather than actual experiences based on men’s reliance on informal information sources, such as other male colleagues or relatives. Our findings are consistent with current research which points to a need to better educate men in the public sphere with appropriately tailored health messaging [ 23 – 26 , 37 ].

Secondly, the finding that men were often the principal payers of health care costs relating to treatment of side effects should not be ignored. Men were aware of the direct and indirect costs of family planning services, but may not have associated such costs with long-term savings and investment. Although the role of paying for treatment of side effects was not viewed favorably by men, it highlighted their assumed financial responsibility for the family. Efforts to implement male-involvement family planning interventions should aim to encourage men’s positive role as a financial supporter and consumer of contraceptive services in ways that are mutually acceptable to men and women. This includes addressing men’s views that safe child spacing or limiting overall family size will have negative economic consequences. Both men and women also perceived discussing reproductive health matters with men as a “waste of time” since men were viewed as “too busy” generating income for the family. This highlights the economic context in which men’s participation in family planning is viewed. In contrast, although the preference for large families was a recurrent theme in our study and in previous published research [ 24 , 25 ], some male participants desired to have fewer children given the growing costs associated with raising a family. This suggests that despite the influence of other factors on uptake of contraceptive methods [ 38 ], economic interventions which address men’s perceptions of the direct and indirect financial costs of family planning may also be effective. This includes information on how family planning may contribute to greater financial security or interventions which integrate economic-based incentives or asset development approaches for men. Our study found that men’s interests in household financial matters, by their own report and that of women, demonstrated a need to include information on the economic implications of fertility regulation within male-focused strategies.

A third key finding was men’s interests in the development of convenient and short-term male contraceptives to replace the present-day options of male condoms and vasectomy. The perception that male condoms hinder sexual spontaneity and enjoyment is well known [ 39 ], and long-term methods such as vasectomy are not appropriate for couples who intend to conceive in the future. On the one hand, such requests reveal the unmet need of male fertility regulation methods, at least among men who are not opposed to family planning. On the other hand, these findings also demonstrate the complexity of promoting gender-equitable reproductive planning. Although men reported that family planning was a “woman’s domain,” it did not appear that women were empowered to make the final decision around contraception without significant consequences and stigma. Proposing more options for male-controlled contraceptives may reflect men’s desire to have greater influence in matters of reproductive health than is possible with female-controlled methods. Research in other settings has suggested as well that men’s opposition to family planning is a self-protective concern for themselves, rather than their partners, to mitigate suspicions of extramarital relations [ 39 ].

Lastly, the study contributes to the growing discourse on the need for gender-transformative programs in maternal and reproductive health [ 40 ]. Much of the male-involvement evidence base has examined men’s participation in the context of prevention of mother-to-child transmission and safe motherhood interventions [ 40 ], with fewer initiatives in reproductive health. Our findings showed that encouraging increased male responsibility for family planning will require careful consideration not only to counter men’s negative health beliefs around contraception, but also to shift social and institutional norms which shape how and why men are involved, including raising men’s awareness on the importance of women’s power in reproductive health decision-making. While research has shown that spousal communication and approval are significant determinants to women’s decisions to use modern contraceptives [ 6 ], it will be critical to ensure that male-focused interventions do not bypass efforts to empower women by reinforcing gender inequities, rather than challenging them [ 24 ]. Some programs have inadvertently relied on men’s unequal power to increase acceptance of health services, with little input from women [ 40 ], while women-only approaches to family planning have proven inadequate [ 26 ]. Many also have been criticized for placing undue burden on women to initiate male-involvement strategies on their own [ 7 ]. Future research should examine the comparative effectiveness of male-involvement strategies which promote gender equity by empowering women as well as increasing the positive participation of men [ 17 , 41 ].

Joint reproductive health decision-making among couples which does not neglect the added value of men’s participation is urgently needed. The findings from this study can be used to develop effective male-involvement family planning initiatives which address barriers to men’s supportive participation in reproductive health, including addressing men’s negative health beliefs regarding contraceptive services.

Authors’ information

AK is a doctoral student and an assistant lecturer in the Department of Population studies, College of Business and Management Sciences, Makerere University, Kampala, Uganda. LJ is an assistant professor in the Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. AR is a senior researcher in the Department of Geography, University of Cambridge, United Kingdom. GN is a lecturer in the Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda. JN is a professor in the Department if Population Studies, Makerere University, Kampala, Uganda and at the Center for Population and Statistics, College of Business and Management Sciences, Makerere University, Kampala, Uganda. LA is a lecturer in the Department of Community and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.

Abbreviations

Focus group discussion

Key informant interview

Millennium development goal.

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Acknowledgments

This research was funded by the Wellcome Trust, Grant No.#087540, in conjunction with THRiVE , Training Health Researchers into Vocational Excellence in East Africa, and by the Office of the U.S. Global AIDS Coordinator, National Institutes of Health, and Health Resources and Services Administration (Grant No.#5R24TW008886). The authors are grateful to the focus group participants, key informants, and research field staff for their willingness to participate in and support this study. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the supporting offices.

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Department of International Health, Johns Hopkins Bloomberg School of Public Health, Social and Behavioral Interventions, 615 N. Wolfe Street, E5038, Baltimore, MD, 21205, USA

Larissa Jennings

Department of Geography, University of Cambridge, Downing Pl, Cambridge, CB2 3EN, UK

Department of Nursing, College of Health Sciences, Makerere University, P. O. Box 7062, Kampala, Uganda

Gorette Nalwadda

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Authors’ contributions

KA and LA conceptualized and designed the study. As principal investigator, KA was responsible for all aspects of data collection, coding, analysis, and writing of the initial manuscript draft. LJ assisted in the interpretation of findings, provided important scientific content, and wrote and revised several sections of the manuscript. AR, LA, GN, and JN critically edited drafts and added substantive intellectual content. All authors have read and approved the final version of the manuscript.

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Kabagenyi, A., Jennings, L., Reid, A. et al. Barriers to male involvement in contraceptive uptake and reproductive health services: a qualitative study of men and women’s perceptions in two rural districts in Uganda. Reprod Health 11 , 21 (2014). https://doi.org/10.1186/1742-4755-11-21

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Male involvement in family planning use and its determinants in Ethiopia: a systematic review and meta-analysis protocol

• Etsay Woldu Anbesu   ORCID: orcid.org/0000-0002-4532-6720 1 ,
• Setognal Birara Aychiluhm 1 &
• Zinabu Hadush Kahsay 2  

Systematic Reviews volume  11 , Article number:  19 ( 2022 ) Cite this article

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The need to include males who require joint spousal decisions is critical in achieving key reproductive health indicators. Low involvement of males in family planning use is one of the contributing factors for low contraceptive use in Ethiopia. Despite this, there are inconsistent findings on the prevalence and determinants of male involvement in family planning use in Ethiopia. Thus, this systematic review and meta-analysis aimed to determine the pooled prevalence of male involvement in family planning use and its determinants in Ethiopia.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be used to develop the protocol. The online databases PubMed, CINAHL, Google Scholar, and unpublished gray literature will be searched to retrieve available articles from April 10 to August 11, 2021. The two authors will conduct selection of studies, data extraction, and quality assessment. The quality of the studies will be assessed using the Joanna Briggs Institute checklist. The chi-squared test and I -squared statistic will be used to examine heterogeneity among studies. Sources of heterogeneity will be investigated using subgroup analysis and meta-regression based on regions and residence (urban and rural). Publication bias will be examined by observation using funnel plots and statistically by Begg’s and Egger’s tests. A random-effects model will be used to estimate the pooled prevalence and its determinants of male involvement in family planning use.

The role of males in family planning and participation in contraceptive use improves women’s uptake and continuity of family planning use. Although there are studies on male involvement in family planning use, there are no synthesis research findings on the pooled prevalence of male involvement in family planning use and its determinants in Ethiopia. Therefore, the findings from this systematic review and meta-analysis will help the national health sector transformational plane emphasize the pooled prevalence and its determinants that drive low male involvement in family planning use in Ethiopia.

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Introduction

“Male involvement in family planning refers to all organizational activities aimed at men as a discrete group which has the objective of increasing the acceptability and prevalence of the family-planning (FP) practice of either sex” [ 1 ]. Family planning is an effort by a couple to limit or space the number of children they have by using contraceptive methods [ 2 ]. Family planning use reduces unwanted pregnancy, induces abortion, and promotes birth spacing. Moreover, it also helps to reduce neonatal, infant, child, and maternal mortality [ 2 , 3 ].

The need to include men who require joint spousal decisions is critical in achieving key reproductive health indicators [ 4 , 5 , 6 , 7 , 8 , 9 , 10 ]. However, male roles in couples’ fertility decision-making have been given less emphasis. There was a paradigm shift in male involvement and concerns from increasing contraceptive use and attaining demographic goals to gender equality and achieving various reproductive duties since the 1994 International Conference on Population and Development (ICPD) and the 1995 United Nations World Conference on Women [ 1 , 11 ].

Globally, contraceptive method use varies from 69% in southeast Asia to 11% in Africa [ 12 ]. A qualitative review in sub-Saharan African countries showed low involvement of men in family planning use [ 13 ]. To achieve sustainable development goals (SDGs), the participation of men in reproductive health issues is crucial. Moreover, regulating fertility to the level of substitution is essential to increase economic development [ 14 ]. Family planning use can avert 32% and 10% of maternal and child mortality, respectively [ 15 , 16 ].

Studies have shown that factors that contribute to low family planning coverage include the desire to have more children, lack of knowledge, lack of husband education, and negative perception toward family planning use, sex preference, religious prohibition, and low involvement of men [ 9 , 13 , 17 , 18 ].

In Ethiopia, the decision on household-related issues, including fertility, mainly belongs to the husband. The low involvement of men in family planning use is one of the contributing factors for low contraceptive use and high unmet need in Ethiopia. Studies performed in different regions of Ethiopia showed the role of men in family planning use, and male participation in contraceptive use improves women’s uptake of family planning services [ 2 , 4 , 19 , 20 , 21 ]. The contraceptive use was low (41.4%), and there was a high unmet need for family planning (22%), which contributed to a high total fertility rate (TFR) of 4.6, maternal mortality of 412 per 100,000 live births, neonatal mortality of 30, infant mortality of 43, and underfive mortality rate per 1000 live births [ 2 , 22 ].

Although the Ethiopian government set a target for a contraceptive prevalence rate of 55% by 2020 to achieve SDGs [ 23 ] and develop the National Guideline for Family Planning Services [ 24 ], low emphasis has been given to the role of men’s involvement. Dissipating this, there is a lack of nationally representative data on male involvement in family planning use in Ethiopia [ 2 , 22 ]. Several studies have been conducted in different parts of the country on male involvement in reproductive health and utilization of family planning [ 4 , 6 , 25 , 26 , 27 ]. However, there are inconsistent findings on prevalence and its determinants of male involvement in family planning use [ 16 , 17 , 18 , 19 , 20 , 21 , 25 ]. Therefore, this systematic review and meta-analysis protocol aimed to determine the pooled prevalence of male involvement in family planning use and its determinants in Ethiopia.

Research question

❖ What is the pooled prevalence of male involvement in family planning use in Ethiopia?

❖ What are the determinants of male involvement in family planning use in Ethiopia?

❖ To determine the pooled prevalence of male involvement in family planning use in Ethiopia

❖ To identify determinants of male involvement in family planning use in Ethiopia

Study protocol and reporting

A systematic review and meta-analysis protocol will be prepared using the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines [ 28 ]. The PRISMA-P 2015 checklist will be used to report the protocol [ 29 ] (Additional file 1 ).

Eligibility criteria

All observational studies, including cross-sectional, case–control, and cohort studies, will be included. Case reports, case series, conference reports, and expert opinions will be excluded from the review. Studies that reported the prevalence of male involvement in family planning use and its determinants among couples in Ethiopia will be included. Moreover, studies that reported only the prevalence of male involvement in family planning use or at least the measured association between determinant variables on male involvement in family planning use will be included. Studies that only investigate the qualitative approach of male involvement in family planning use will be excluded. If studies address both quantitative and qualitative findings, we will only consider the quantitative findings. Both community- and institution-based studies will be included. Studies published in the English language alone will be included. There will be a restriction on the date of publication since 1994, as this was the period for a paradigm shift in male involvement and concern from increasing contraceptive use and attaining demographic goals to gender equality and achieving various reproductive duties [ 11 ].

PECO search guide

Population: married men.

Exposure: Determinates of male involvement in family planning use. Determinates are exposures that increase or decrease the likelihood of male involvement in family planning use in Ethiopia. The determinates can be marital status, the number of children, discussion with partner, knowledge on contraceptive use, ever used family planning methods, participation in community networks, etc.

Comparison: it is the reported reference group for each determinate in each study: marital status versus single, available children or not, good knowledge versus poor knowledge on contraceptives use, discussion of partners on family planning use or not, etc.

Outcome: The primary outcome of the study will be the pooled prevalence of male involvement in family planning use among married men in Ethiopia. The secondary outcome of the study will be determinates of male involvement in family planning use among married men in Ethiopia. Male involvement in family planning refers to the involvement of males in at least one of the following activities: discussion or spousal communication, support, approval, and contraceptive use of the husband.

Searching strategy and study selection

Online databases including PubMed, Google Scholar, CINAHL, and unpublished gray literature will be used to search articles from April 10 to August 11, 2021. In addition, cross-reference searching of the included studies will be performed to include related studies. Removal of duplicates and irrelevant studies and inclusion of eligible studies will be performed. The two authors (EW and SB) will independently screen the studies. Studies that mentioned the objective of male involvement in family planning use with full text will be further evaluated for quality. The articles will be retrieved and exported to Endnote version 8 reference manager software to collect and organize search outcomes [ 30 ]. The search strategy procedure is shown in the PRISMA diagram (Additional file 2 ).

The search Medical Subject Heading (Mesh) terms will be developed using the authors’ keywords articles and PMID of sample index manuscripts on male involvement in family planning use, titles, and abstracts of studies. Then, search strategies will be developed using different Boolean operators, and modifications will be made based on the types of databases (Additional file 3 ).

Quality assessments

Assessment of articles using their title, abstract, and full review of the manuscripts will be performed before the inclusion of articles in the final meta-analysis. The qualities of each article will be assessed by using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) [ 31 ]. Particular attention will be given to a clear statement of the objective, inclusion criteria, study subjects, setting, standard criteria used for measurement of the condition, exposure measurement in validity and reliability strategies to address confounding factors, outcome measurement, and appropriate statistical analysis (Additional file 4 ). Sensitivity analysis will be conducted to include eligible quality studies in the final systematic review and meta-analysis by investigating the effect size estimates of studies. The quality of the full articles will be assessed by two authors (EW and SB). Any disagreement among reviewers will be resolved by the third author (ZH).

Data extraction and management

A data extraction template will be constructed in Microsoft Excel (2016) to collect data for the elements of data extraction for full-text eligible manuscripts that will be included in the final systematic review and meta-analysis. The data extraction elements included author name, year of publication, study area, study design, sample size, prevalence or proportion, odds ratio, lower confidence interval, and upper confidence interval. Moreover, new variables will be created to use the elements for analysis using log transformation and standard error on an Excel sheet or STATA 14 after importing the data. Piloting of the data extraction will be carried out before the beginning of the authentic data extraction by all authors. All necessary data will be extracted using the prepiloted Excel data extraction tool. The two authors (EW and SB) will independently extract the data. Any discrepancies will be discussed with a third author (ZH) to reach an agreement. Authors will contact the authors of the studies in case of missing data or incomplete reports.

Data synthesis and analysis

The extracted data will be imported to STATA version 14 for analysis. The data will be presented using a narrative synthesis of the included studies, and the results will be presented using tables and figures. Square root transformation of data will be performed using the Freeman–Tukey variant of the arcsine to avoid variance variability [ 32 ].

The pooled prevalence estimate of male involvement in family planning use in Ethiopia will be performed using a random-effects model [ 33 ]. In the random-effects model, we will assume that the true effect size varies from one study to the next and that studies in our analysis will represent a random sample of effect sizes that could have been observed. The summary effect will be our estimate of the mean of these effects. A forest plot will be used to present the pooled prevalence and its determinants of male involvement in family planning use at a statistical significance level of a p value of less than 0.05 [ 34 ]. Heterogeneity across studies will be assessed using Cochran’s Q [ 35 ] and I 2 statistics [ 36 ]. I 2 values of 25%, 50%, and 75% were representative of low, moderate, and considerable heterogeneity, respectively. Subgroup analysis and meta-regression will be performed based on region and residence (urban and rural) to identify the sources of heterogeneity. Moreover, sensitivity analysis will be performed to investigate the effect size estimates of studies. Publication bias will be checked using visual inspection on the funnel plot [ 34 ]. An asymmetry of the funnel plot indicates publication bias. Moreover, Egger’s and Begg’s tests [ 37 ] will be conducted to check the potential publication bias, and a p value of < 0.05 will be used to declare the statistical significance of publication bias.

This systematic review and meta-analysis protocol aims to synthesize the pooled prevalence of male involvement in family planning use and its determinants in Ethiopia. After the 1994 International Conference on Population and Development (ICPD) and the 1995 UN World Conference on Women, attention to male involvement has improved special efforts to emphasize men’s joint responsibility and promote their active participation in reproductive health serves [ 1 , 11 ].

Studies have shown that family planning has many benefits, including  reducing maternal, child, and infant mortality; protecting unplanned pregnancy; and improving sustainable socioeconomic development. Family planning could avert up to 42% of maternal mortality [ 38 ]. Despite these benefits, contraceptive use is still low, and the unmet need for family planning is high in developing countries, including Ethiopia [ 4 , 7 , 9 , 10 ].

Studies in developing countries have examined the role of male involvement in family planning, and male participation improves women’s uptake of family planning methods, increases spousal coordination, supports the success of family planning programs, and provides rights to their partners in reproductive health services [ 9 , 13 , 17 , 18 ].

Currently, there are no synthesis research findings on the pooled prevalence of male involvement in family planning use and its determinants in Ethiopia. Therefore, this systematic review and meta-analysis protocol will help the development of appropriate strategies that will have an impact on male involvement in family planning use.

This study protocol may have the following limitations. Heterogeneity may exist between studies due to differences in study designs, settings, sample size, and publication biases. Only articles published in the English language will be considered. Moreover, only observational study designs will be included. Studies conducted in hospital or health care settings will not be representative of the general population.

Availability of data and materials

Additional files for the review protocol were submitted as supplementary materials.

Abbreviations

Family planning

International Conference on Population and Development

Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument

Preferred Reporting Items for Systematic Review and Meta-analyses

Sustainable development goals

Total fertility rate

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Anbesu, E.W., Aychiluhm, S.B. & Kahsay, Z.H. Male involvement in family planning use and its determinants in Ethiopia: a systematic review and meta-analysis protocol. Syst Rev 11 , 19 (2022). https://doi.org/10.1186/s13643-022-01891-x

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Determinants of male involvement in family planning services in Abia State, Southeast Nigeria

• Chidinma Ihuoma Amuzie   ORCID: orcid.org/0000-0002-6070-1330 1 , 2 ,
• Uche Ngozi Nwamoh 2 ,
• Andrew Ukegbu 2 ,
• Chukwuma David Umeokonkwo 1 , 3 ,
• Benedict Ndubueze Azuogu 3 ,
• Ugonma Okpechi Agbo 4 &
• Muhammad Shakir Balogun 1  

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Male involvement in family planning (FP) remains low in male-dominant communities. Family planning contributes to the regulation of fertility and population growth in Nigeria. Increasing male involvement in family planning services is crucial in reducing maternal morbidity and mortality in patriarchal societies such as Nigeria. This study identified the determinants of male involvement in family planning services in Abia State, Nigeria.

This was a cross-sectional study conducted in twelve communities of Abia State, Nigeria. A total of 588 married men who met the eligibility criteria were recruited using a multistage sampling technique. An interviewer-administered semi-structured questionnaire was used to collect data on the variables. Univariate, bivariate and multivariate analysis was done. The level of significance was set at 5%.

The overall level of active male involvement in family planning services was 55.1% (95% CI:51.0–59.2%). The mean age of the respondents was 42.4 ± 8.0 years. Access to television (aOR = 1.58, 95% CI: 1.05–2.39), spouse employment status (aOR = 2.02, 95% CI: 1.33–2.06), joint decision-making (aOR = 1.66, 95% CI: 1.05–2.62), and accompanying spouse to the FP clinic (aOR = 3.15, 95% CI: 2.16–4.62) were determinants of active male involvement.

At least, one out of every two men was actively involved in family planning services. This was determined by access to television, employment status of spouse, joint decision-making, and accompanying spouse to the FP clinic. There is a need to focus on the identified factors in order to further improve the active involvement of men in FP services.

Family planning (FP) programmes have centered primarily on women. However, with a focus on gender equity for optimal health, there is a shift to engage men in supporting and using FP services [ 1 ]. Men, as the decision-makers in most African families, have an important role to play towards the utilization of FP methods, which is an efficacious intervention recommended and approved by the World Health Organization (WHO) as well as the Ministry of Health (MoH) in most countries [ 2 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they want to have through the use of contraceptive methods. Benefits of family planning include reduced maternal and infant mortality, sustainable development through population control, and enhanced women’s participation in the workforce [ 3 ].

Developing countries make up about 85% of the global population and account for 99% of all maternal mortality cases [ 4 ]. According to the 2018 National Demographic Health Survey (NDHS), the maternal mortality ratio (MMR) was 512 deaths/100,000 live births [ 5 ], and Nigeria accounts for approximately one-fifth of maternal deaths globally [ 6 ]. Additionally, the lifetime risk of maternal death in Nigeria is 0.029 (1 in 34) [ 5 ], compared to 1 in 4900 in most developed countries [ 6 ]. Low level of male involvement in reproductive health practices is one of the drivers of high maternal morbidity and mortality. This has reduced the impact of family planning interventions and intertwines with unregulated fertility that hinders economic development and creates a political imbalance in a country [ 7 , 8 ].

Globally, there is a growing rise in the recognition of the benefits of involving men in family planning services [ 9 ]. It is known from research that gender dominance, particularly men’s disapproval of family planning, has an impact on the subdued prevalence of contraceptive use in sub-Saharan Africa [ 10 ]. A study done in Bangladesh documented a 40% male involvement rate [ 4 ], and a similar study carried out in Western Nigeria documented 39.6% [ 11 ]. This shows that male involvement remains low despite ongoing efforts. The effect of male dominance on the decision-making process heightens the poor indices of reproductive health, as documented in a study in Nigeria where 62% of women had their husbands as their decision-makers and only 6% of currently married women at the time of the survey made decisions for themselves [ 5 ]. Male involvement in SRH (Sexual and Reproductive Health) is an integrated approach engaging men as clients, partners, and agents of positive change in reproductive health issues [ 12 ].

Access to the media, television, and radio, spouse employment status, and average monthly income have all been identified as positive correlates of male involvement in studies [ 11 , 13 , 14 , 15 , 16 ]. However, there is a paucity of data on the factors affecting the male involvement of men in family planning services in our study location. There is a need to generate data to inform decisions taken by policymakers in designing family planning programmes. Therefore, we aimed in this study to identify the determinants of male involvement in family planning services in Abia State.

Study design and setting

This was a community-based household cross-sectional study that was conducted from September to December 2019 in 12 communities of Abia State in southeastern Nigeria. The State had an estimated population of 3,901,620 in 2018 projected from the 2006 national population census with an annual growth rate of 2.7% [ 17 ]. Geopolitically, Abia State is divided into three Senatorial Zones—Abia North, Abia South, and Abia Central—with 17 Local Government Areas (LGAs) and has 291 political wards. Igbo language with varying dialects, and English are the major languages for communication. Abia State is inhabited mostly by the Igbo ethnic group, who are predominantly Christians with a few people who practice traditional religion. The Catholic doctrine forbids the use of modern family planning methods.

There are 517 public primary healthcare centres, 17 public secondary healthcare facilities, and two public tertiary healthcare centres. Family planning services are available across all health facilities and can be assessed at all levels of health facilities in the state, including chemist stores and private health facilities. There are no known existing taboos against family planning use in the state.

Sample size determination

Estimation of sample size was done using the sample size formula for cross-sectional studies [ 18 ]. A minimum sample size of 616 was determined at a confidence level of 95%, a design effect of 1.5 with a margin error of 5%. This was based on the proportion of male involvement in reproductive services (30.9%) in a previous study [ 11 ]. A non-response rate of 20% was assumed.

Study population and sampling strategy

The study population included men in a marital/cohabiting relationship with a spouse or partner in the selected communities. This category of men is believed to have had some experiences relating to reproductive health issues in marriage and/or fatherhood. Participants were included in the study if they met the eligibility criteria of being in the age group (15–59 years) as defined by NDHS 5, in a marital or cohabiting relationship, and living in the study area 6 months prior to the study. However, those with debilitating illnesses such as cerebrovascular diseases that could interfere with communication were excluded. A total of 616 men were recruited using the multistage sampling technique. Stage one: Six LGAs were selected using the balloting technique. They included Aba North, Umuahia North, Ohafia, Ugwunagbo, Bende, and Ikwuano LGAs. Stage two: In each LGA selected, the list of communities was obtained and they served as clusters. In each of the LGAs, two clusters were selected using a simple random sampling technique. Stage three: All the households in each cluster were enumerated. The respondents were proportionally allocated based on the number of households in each cluster. We used computer-generated random numbers to select the households. In each of the household visited, only one eligible respondent was selected. In households with more than one eligible respondent, simple random sampling was used to select only one of them. The process was continued until the required sample size was attained in each cluster.

Study tool and data collection process

A pre-tested interviewer-administered semi-structured questionnaire (Additional file  1 ) with open- and closed-ended questions was used to collect information from the participants by trained research assistants. The questionnaire was adapted from previous studies [ 11 , 19 ]. The questionnaire was assessed for content and face validity and the Cronbach’s alpha index was 0.71. The Igbo translated version which was translated back to English to ensure that the original meaning was maintained, was also available for use. The questionnaire used for this study has three sections. "Background" SSection 1  addressed sociodemographic and socio-economic variables such as age, marriage type, educational status, occupational status, religion, and denomination, income, access to mass media, number of living children, educational status of spouse, and employment status of spouse. Section  2  included socio-cultural variables such as decision-maker on FP issues, accompanying spouse to FP clinic, and community and family support for accompanying spouse to FP clinic. Section  3  contained composite questions to measure the level of male involvement in family planning services. These included; Are you currently using any family planning method (s)? Have you ever discussed FP with your spouse/partner? Are you aware of any male FP method (s)? Have you ever attended any FP clinic? Have you ever discussed FP with a friend? And would you recommend FP to a friend?

There was no compensation for the respondents participating in this survey. Revisits was done up to three times to potential participants.

Quality control and data management

The research assistants were properly trained to ensure accuracy in data collection . The questionnaire was pre-tested to detect and correct possible errors and identify any ambiguities before the initiation of the study using sixty (60) respondents (10% of the study sample size) in Old Umuahia (Umuahia South LGA) which was not selected for the study,

Measurement of variables

The dependent variable was the level of male involvement in family planning services. It was created as a composite variable comprising six (6) questions covering respondents’ FP practices and FP perceptions. The responses were dichotomized (Yes/No), with a score of ‘No’ = 0 and ‘Yes’ = 1. This gave a maximal score of six (6) and a minimum score of zero (0). A total score of 0 was classified as ‘None involvement’, while a score of 1–3 was classified as ‘passive involvement’ and a score of 4–6 was classified as ‘active involvement’. For the logistic regression, a score of 0–3 was recoded as ‘passive involvement’. Additionally, active involvement was coded as ‘1’ and passive involvement coded as ‘0’ for the binary logistic regression analysis. The independent variables included age, educational status, occupational status, average monthly income, number of living children, educational status/employment status of spouse, decision-maker on FP issues, accompanying spouse to FP clinic, community and family support on accompanying spouse to FP clinic.

Statistical analysis

Data coding, entry, cleaning, and analysis was done using IBM SPSS statistics for Windows, version 20.0. We performed univariate analysis and determined the association between the independent variables and level of male involvement in family planning services using the binary logistic regression. The variables were dichotomized for ease of data analysis and interpretation. P values < 0.05 and 95% confidence interval excluding the null values were considered significant. Multivariable logistic regression analysis was done to identify the significant predictors of men’s involvement in family planning services. Factors that fitted into the regression model, were those with P values < 0.2 at the level of bivariate analysis. Adjusted odds ratios with 95% confidence intervals were estimated and the analysis was done based on a significance level of 5%. Appropriate charts and tables were used to display the results.

Social-demographic characteristics of the study participants

A total of 588 respondents participated in the study with a response rate was 95.5%. The mean age of the study respondents was 42.2 ± 8.0 years. Respondents were almost distributed similarly between the 35–44 years age group (41.0%) and those aged over 45 years (41.2%). Two hundred and forty-one (41.0%) had secondary education with the majority (93.2%) of them in a monogamous relationship. The majority of the respondents (55.1%) had 3–4 living children. Five hundred and seventy-three (97.4%) were Christians with more than 40% belonging to the Pentecostal denomination. Close to one-third of the respondents (31.3%) were traders and 88.9% of them had resided in their abode for more than 2 years (Table  1 ).

Proportion of agreed responses on male involvement in family planning services by indicators

A large majority of men (84.2%) had discussed FP with their spouses in the past 6 months prior to the study. The majority (70.4%) were aware of male-focused FP methods. Only 57.3% were currently using a FP method and 64.8% had discussed FP with their friends. In contrast, less than half of the men (49.3%) had ever attended a FP clinic and recommended FP to their friends (48.5%) in the past 6 months prior to the study. ( Table  2 ).

Socio-economic/cultural characteristics of the respondents

Two hundred and forty-one (43.3%) were in the ≥₦60,000 monthly income category. The median income was ₦50,000 (IQR: ₦30,000–₦50,000). The majority of the respondents had access to - newspapers (66.3%), radio (88.3%) and television (68.2%). Two hundred and fifty-six of the respondents’ spouses (43.6%) had a minimum of tertiary education and the majority (62.9%) of them were employed. The majority of the respondents (78.6%) made joint-decisions with their spouses on FP issues. However, close to half (49.8%) of them agreed to accompany their spouse to the FP clinic. The majority of the respondents (92.0%) agreed that FP was not solely a woman’s responsibility and more than 75% of the respondents believed that FP was supported by family members and the community ( Table  3 ).

Factors associated with active male involvement in family planning services among the respondents

Among the respondents, 55.1% (95% CI: 51.0–59.2%) were active in FP services compared to 39.6% (95% CI: 35.6–43.7%) who were passive. However, 5.3% (95% CI: 3.6–7.4%) were not involved in any form of FP services.

The participants who had access to television were more likely to be active in family planning services compared to their counterparts. (OR = 1.70, 95%CI:1.20–2.40) Respondents whose spouses were employed were 90% more likely to be actively involved in FP compared to those whose spouses were not employed. (OR = 1.90, 95%CI:1.35–2.67) Respondents who had joint decision-making with their spouses on FP issues were also more likely to be involved actively in FP services compared to those whose spouses solely took decisions. (OR = 2.15, 95%CI:1.43–3.23) Active involvement was three-fold higher in men who agreed to accompany spouses to the FP clinic. (OR = 3.39, 95%CI:2.41–4.77).

There was a positive association with the active involvement and support of family members in accompanying spouse to the FP clinic. (OR = 1.78, 95%CI:1.20–2.64) Furthermore, those who believed that their community supported accompanying spouse to the FP clinic were 80% more likely than their counterparts to be active in male involvement (OR = 1.80, 95%CI: 1.18–2.75). (Table  4 ).

Predictors of active male involvement in family planning services

Male involvement in family planning services was predicted by access to television (aOR = 1.58, 95% CI: 1.05–2.39), spouse employment status (aOR = 2.02, 95% CI: 1.33–2.06), joint decision-making (aOR = 1.66, 95% CI: 1.05–2.62), and accompanying spouse to the FP clinic (aOR = 3.15, 95% CI: 2.16–4.62). ( Table  5 ) .

We conducted this study to determine the level of male involvement and its predictors in family planning services among men of Abia state, southeastern Nigeria. We found out that at least, one out of two men was active in FP services. Access to television, the spouse’s employment status, joint decision-making, and accompanying the spouse to the FP clinic were the predictors of male involvement in FP services.

The findings in this study showed that slightly more than half of the respondents were actively involved in FP services. This is in contrast to a study done in Ogun State, Nigeria, that noted an active involvement rate of 30.9% [ 11 ]. Additionally, researchers have reported lower rates of active involvement in Ghana (34.5%), Ethiopia (44%) and Bangladesh (40%) [ 4 , 19 , 20 ]. However, a recent study in Ethiopia reported a higher active involvement rate of 68%, while an earlier study in an urban municipality in Bangladesh noted a male involvement rate of 63.2% in FP [ 14 , 21 ]. Poor involvement could be attributed to the patriarchal societies that exist in the African context, few male family planning methods and the prevailing myths and misconceptions associated with family planning use [ 8 , 20 , 22 , 23 ]. Improving the services available for men and disseminating accurate information on the associated myths and misconceptions associated with FP services should be encouraged.

Access to television was a significant factor in determining active involvement in FP services by men. Access to the media is likely to enhance attitudes and behaviour change leading to improved male involvement in FP. Some researchers have also observed these findings in their various studies [ 11 , 14 , 24 , 25 , 26 , 27 ]. In Nigeria, the mass media play a crucial role in disseminating health information and increasing awareness about health education. 13 This, over time, changes the attitude and behaviour of the masses to achieving optimal health [ 13 ]. Seeing FP messages on television and hearing them on the radio are associated with reported modern FP use [ 28 ]. The media plays an important role in attenuating the public perception of risks and provides a key link in the risk communication process. Efforts should be made to increase media coverage, especially in areas where they are not easily accessible.

The employment status of the spouse was a predictor in this study. This finding is consistent with the results of studies done in Ogun State and Bangladesh [ 11 , 14 ]. Women who are employed are likely to be involved in decision-making [ 29 ]. Decision making is paramount in the uptake of reproductive health services. Additionally, women who are employed tend to plan their family size in such a way as to avoid hindrances to their services at their workplaces. Men should be encouraged to allow their spouses seek for jobs and women should be made to understand the benefits of getting employed.

Men who accompanied their wives to the FP clinic were more likely to use family planning services. This is consistent with a South African study which admitted that social support and joint responsibility for family planning and contraceptive use (FP/C) positively influence male participation [ 30 ]. However, the finding of a study in Osun State is at variance with this result [ 31 ]. Accompanying wife to FP clinic is likely to influence involvement in FP services because it is an outcome of spousal communication and joint decision making, which play a vital role in reproductive health issues.

Respondents who made joint decisions with their spouses or partners had an increased odds of being involved in family planning services. This is similar to findings from an earlier study conducted in Cross River State, Nigeria where the likelihood of using FP services increased when the decision was made jointly by both husband and wife [ 32 ]. This is also comparable to a study in Ethiopia which noted discussion with the spouse about FP issues to be a significant factor of male involvement [ 33 ]. A qualitative study in Malawi documented that joint decision-making in FP responsibilities is assisted by male involvement [ 34 ]. Furthermore, higher odds of male involvement were reported among men who jointly participated in decision-making with their partners [ 35 ]. Men are known to be culturally dominant and are expected to meet the sociocultural expectations and values attached to women and marriage [ 36 , 37 ]. Men are beginning to accept the key messages of reproductive health services, and as such, take decisions that positively influence their involvement in FP practices.

The major strength of this study was that men were directly interviewed, instead of using their spouses as proxies. This gave the men better opportunities to express their opinions, ideas, and views more confidently. It was also a community-based study which would increase the generalizability of the study’s findings. Concurrently, the limitations of this study included: being a cross-sectional study, causal inferences cannot be conclusively made; the certainty of recall bias and social desirability bias. Additionally, there was no single index for measuring male involvement at the time of this study, this might have contributed to the variances observed with similar studies. These were, however, mitigated by assuring the respondents of their confidentiality and privacy, and an extensive literature review was done to select the suitable questions used for measuring the dependent variable.

The prevalence of active involvement in FP services was 55.1%. This was influenced by access to television, employment status of spouse, joint decision-making and accompanying spouse to the FP clinic. We recommend FP sensitization campaigns targeting men to encourage their participation in FP services. There is a need to improve the existing family planning programmes with a focus on the identified factors in order to enhance the active involvement of men in FP services.

Availability of data and materials

The dataset analyzed in this study are available from the corresponding author on reasonable request.

Abbreviations

Adjusted Odds Ratio

Contraceptive Prevalence Rate

Family planning/contraceptive use

Family Planning

International Conference on Population and Development

Interquartile range

Local government area

Maternal Mortality Ratio

Nigeria Demographic Health Survey

Nigeria Field Epidemiology and Laboratory Training Program

Sexual and Reproductive Health

Total Fertility Rate

World Health Organization

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Acknowledgments

We thank the research assistants for their hard work in the data collection. We also thank the study participants for their collaboration. A special thanks also goes to the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) and the Department of Community Medicine, Federal Medical Centre Umuahia, for their training and mentorship throughout the study period.

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The study was conceived and designed by CIA, who was also in charge of the analysis, interpretation, and drafting of the manuscript. UNN and AU supervised the study, interpreted the data, and edited the manuscript. CDU and BNA contributed to the data interpretation and editing of the manuscript. UOA was responsible for data collection, data analysis and contributed to the design of the study. MSB contributed to data interpretation and editing of the manuscript. All authors revised the manuscript and approved the final manuscript.

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Approval for this study was obtained from the Ethics and Research Committee of the Federal Medical Centre, Umuahia with reference number FMC/QEH/G.596/Vol.10/301, and verbal permission was obtained from the paramount rulers (Eze) of the 12 communities to be studied. Written informed consent was taken from all the study participants before enrolment in the study.

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Amuzie, C.I., Nwamoh, U.N., Ukegbu, A. et al. Determinants of male involvement in family planning services in Abia State, Southeast Nigeria. Contracept Reprod Med 7 , 15 (2022). https://doi.org/10.1186/s40834-022-00182-z

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Prevalence and determinants of the involvement of married men in family planning services in Ethiopia: A systematic review and meta-analysis

Bekalu getnet kassa.

1 Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Lebeza Alemu Tenaw

2 School of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia

Alemu Degu Ayele

Gebrehiwot ayalew tiruneh, associated data.

Supplemental material, sj-docx-1-whe-10.1177_17455057221099083 for Prevalence and determinants of the involvement of married men in family planning services in Ethiopia: A systematic review and meta-analysis by Bekalu Getnet Kassa, Lebeza Alemu Tenaw, Alemu Degu Ayele and Gebrehiwot Ayalew Tiruneh in Women’s Health

Supplemental material, sj-docx-2-whe-10.1177_17455057221099083 for Prevalence and determinants of the involvement of married men in family planning services in Ethiopia: A systematic review and meta-analysis by Bekalu Getnet Kassa, Lebeza Alemu Tenaw, Alemu Degu Ayele and Gebrehiwot Ayalew Tiruneh in Women’s Health

Background:

Male involvement in family planning includes not only using contraceptives but also encouraging and supporting their partners’ contraception needs and choices, encouraging peers to use family planning, and influencing policy to make male-related programs more conducive. In Ethiopia, the prevalence and associated factors of male involvement in family planning were highly inconsistent across studies. As a result, the goal of this study was to use a systematic review and meta-analysis to estimate the pooled prevalence of male involvement in family planning and its associated factors in Ethiopia.

Electronic literature search using PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences were performed without time restriction to identify the primary studies. Data were extracted using a pretested standardized data extraction format and analyzed using STATA 14 statistical software. A random-effect model was used to estimate the pooled prevalence of male involvement.

A total of 17 studies were included to give the pooled prevalence of male involvement in family planning in Ethiopia, which was 39.66% (95% confidence interval = 29.86, 49.45). Educational status (adjusted odds ratio = 1.99, 95% confidence interval = 1.26, 3.14), discussion of family planning with wife (adjusted odds ratio = 4.15, 95% confidence interval = 2.21, 7.80), knowledge (adjusted odds ratio = 1.83, 95% confidence interval = 1.26, 2.64), positive attitude about family planning (adjusted odds ratio = 2.57, 95% confidence interval = 1.70, 3.90), and approval of contraceptive use (adjusted odds ratio = 2.57, 95% confidence interval = 1.70, 3.90) were found to be significantly associated with involvement of men in family planning service.

Conclusion:

The overall prevalence of male involvement in family planning in Ethiopia was significantly low. Male involvement in family planning should be made available, accessible, and advocated for by government and non-governmental organizations, service providers, program planners, and stakeholders. In addition, to increase the role of men in the use of family planning services, a conducive environment for education, behavioral change, and open discussion about reproductive health issues is required.

Introduction

Men are often the primary decision-makers on family size and their partner’s use of family planning (FP) methods, even though contraceptive methods and services are frequently geared toward women. 1 Furthermore, spousal disagreement can act as a deterrent because women may be hesitant to bring up the subject of FP. 2

Men have historically been devalued in receiving and disseminating information about sexuality, reproductive health (RH), and birth spacing. Many FP programmers have neglected or precluded them in some way because FP is seen as a woman’s affair. Women were not seen as decision-makers, but rather as implementers of what men had agreed, without questioning the men’s choices. 3

Men’s involvement in RH has grown in popularity since the 1994 International Conference on Population and Development (ICPD). Evidence suggests that increased spousal interaction can lead to contraceptive uptake when men are involved. 4 , 5 Male participation in FP has become a big topic among RH program designers, policymakers, and population researchers recently. 6

In developing countries, increasing the availability of FP services and improving their use could prevent up to 42% of maternal deaths. 7 Maternal and child health (MCH) centers provided the majority of FP services. The majority of studies and public awareness campaigns focused on women, assuming that women are the ones who bear children. This emphasis on women has reinforced the perception that FP is primarily a woman’s responsibility, with the man playing only a minor role. 8

Male involvement in RH service utilization encompasses how men accept and express support for their partners’ needs, choices, and rights, including the use of contraception and their own reproductive and sexual behavior to promote human rights observance and the need to enforce equity. 9

In Ethiopia, a number of primary studies were conducted in order to estimate male participation in FP. 10 – 26 According to the reports, at the national level, there is a significant variation in the level of FP involvement among males, ranging from 8.4% 13 to 68.1%. 12 The cause of these disparities in male involvement in FP among Ethiopian men has yet to be determined. As a result, estimating the pooled prevalence of male involvement and associated factors is critical in order to identify existing gaps and make suggestions for strategies that increase male participation while reducing the burden on women from contraceptives, unmet needs, and unintended pregnancies. Ethiopia’s population policy prioritizes expanding FP services through clinical and community-based interventions in order to achieve a contraceptive prevalence rate (CPR) of 65% by 2015. It also entails encouraging men to engage in a variety of beneficial RH and social behaviors in order to ensure the well-being of women and children. 27 Despite this, there have been a few attempts to engage men in reproductive issues. As a result, the findings of this study will be used as a benchmark for policymakers and program planners when it comes to incorporating males into FP programs and strategies.

Protocol registration

The purpose of this study was to estimate the pooled prevalence rate of male involvement in FP utilization in Ethiopia using a systematic review and meta-analysis. It was submitted to the prospective international registry of systematic reviews (PROSPERO no. CRD42021260084). It was done in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) checklist guidelines. 28

Eligibility criteria

Inclusion criteria.

The review included married men whose wives were of reproductive age and lived in Ethiopia. Married men from a variety of socioeconomic backgrounds, ethnic groups, and dialects were also included. All published and unpublished observational (cross-sectional) studies that evaluated male involvement in FP and factors affecting their involvement up to 15 June 2021 were included.

Exclusion criteria

The review excluded articles written in languages other than English, qualitative papers, case studies, and secondary works (e.g. review articles, commentaries, editorials, and unpublished conference abstracts).

Searching strategy and data source

The primary studies were identified by searching PubMed, Google Scholar, EMBASE, HINAR, Scopus, and Web of Sciences without regard for time constraints. Gray literature was also searched in online repositories at universities and research institutes. Initially, the full titles (male involvement in FP and associated factors among married men in Ethiopia) were examined, and then the following terms and phrases (“Male” OR “male partner” AND “involvement” OR “participation” AND “family planning” OR “family planning utilization” AND “associated factors” OR “predictors” OR “determinants” AND “married men” AND “Ethiopia”) were searched (Additional file 1).

Identification and study selection

All identified studies were imported into the Endnote X7 reference manager software, and duplicated articles were removed. After reviewing the titles and abstracts, studies were screened. Articles were screened and evaluated independently by two authors (L.A.T. and B.G.K.). The full text of the study was evaluated based on its objectives, methodology, participants/population, and key findings (male involvement in FP and associated factors). Disagreements were resolved through discussion and consensus-based on predetermined criteria, or by the last two investigators (A.D.A. and G.A.T.).

Quality assessment

The Newcastle–Ottawa Scale quality assessment tool adapted for cross-sectional study quality assessments was used to assess the quality of each included original cross-sectional study. 29

The tool has the three major components; the main component is rated from one to five stars and focuses on the methodological quality of each primary study. The tool’s second component concentrated on the comparability of the primary studies included in this systematic review and meta-analysis. The final component, which was based on three stars, assessed the quality of primary articles in statistical analysis and outcome point of view. Using these pointers, three authors independently weighted the qualities of each original study. The analysis included primary studies with a medium score (satisfying 50% of quality evaluation criteria) and high quality (7 out of 10). The three investigators’ differences were managed using the results of their quality evaluations (Additional file 2).

Data extraction

The data were extracted independently by two authors (L.A.T. and B.G.K.) using a pretested standardized data extraction format. The primary author, year of publication, study setting, sample size, study design, response rate, the prevalence of male involvement in FP, and specific factors associated with FP involvement are all included in the format. The variables in this study were chosen because they were found to be a significant factor in two or more studies. When the investigators could not agree on how to abstract data, they reached a consensus, and the final two investigators took over (A.D.A. and G.A.T.).

The outcome of interest

The primary outcome of this meta-analysis was male involvement in FP service utilization. The second objective of the review was to determine the factors affecting involvement in FP among married men in Ethiopia.

Publication bias and heterogeneity

A qualitative visual inspection of the funnel plot graph reveals the presence of publication bias. We also used Egger’s correlation tests with a 5% significance level to quantitatively assess the presence of publication bias. 30 , 31 In addition, study regions were divided into subgroups to reduce random variations in the point estimates from the primary study. To identify the potential source of heterogeneity, a sensitivity analysis was carried out. The random-effect model with inverse-variance ( I 2 ) statistics and corresponding p -values was used to assess heterogeneity across studies.

Statistical analysis

The extracted data were first entered into Microsoft Excel before being exported to STATA version 14 for analysis. Based on eligibility criteria, the associated factors of male involvement in FP were investigated. We looked at least two studies that shared a measure of effect and a 95% confidence interval (CI) for at least one associated factor of male involvement. To compare the studies, a random-effects model based on the DerSimonian–Laird method was used. Texts, tables, and forest plots were used to present the findings, which included effect measures and a 95% CI.

Description of studies

A total of 687 records were identified using electronic search. From these identified studies, 319 were excluded after reviewing their titles due to duplication, and the remaining 368 studies were further screened for inclusion. Out of 368 studies; 297 studies, were excluded due to irrelevance, and 54 were removed due to inappropriate use of statistical analysis, irrelevant target population, and inconsistent study reports. Finally, 17 articles fulfilled the inclusion criteria and were included in this systematic review and meta-analysis ( Figure 1 ).

Flow chart describing the selection of studies for the systematic review and meta-analysis of the prevalence of male involvement in family planning and associated factors among married men in Ethiopia, 2021.

Characteristics of the included studies

All of the 17 studies included in this review were cross-sectional in nature and reported in English. A total of 9117 married men took part in the systematic review and meta-analysis. The sample size for the primary articles ranged from 286 10 to 804 11 in Oromia regional state. The highest prevalence of male involvement in FP was observed in Debre Tabor Town Northwest Ethiopia (68.1%), 12 and the lowest was from Debre Marko’s Town (8.4%). 13 Regarding geographical distribution of the studies, five studies were conducted in Amhara regional state, 12 – 16 six from the Southern Nation, Nationalities, and Peoples’ Region (SNNPR), 17 – 21 three conducted in Oromia, 10 , 11 , 22 one from Benishangul-Gumuz, 23 one from Tigray, 24 and one in Afar 25 ( Table 1 ). Concerning the quality score of the primary studies, eight studies had a quality score of eight, six studies had a quality score of seven, and the remaining three had a quality score of nine. Hence, all of them had a good and above quality score (Additional file 2).

Summary of the 17 observational studies included in the meta-analysis assessing involvement of males in family planning in Ethiopia, 2021.

AF: associated factors; CI: confidence interval; C/S: cross-sectional; MIFP: male involvement in family planning; SNNPR: Southern Nation, Nationalities, and Peoples’ Region.

Prevalence of male involvement in FP in Ethiopia

The pooled prevalence of male involvement in FP among married men in Ethiopia was 39.66% (95% CI = 29.86, 49.45) ( Figure 2 ). A random-effect model was used to estimate the pooled prevalence of male involvement in FP as a result of extreme heterogeneity across the included primary studies ( I 2  = 99.8%, p  < 0.001).

Forest plot of the pooled prevalence male involvement on family planning in Ethiopia, 2021.

Publication bias

Publication bias was observed among the included studies as evidenced by the asymmetric shape of the funnel plot ( Figure 3 ) and Egger’s regression test ( p  < 0.001). To correct the observed publication bias, trim and fill analyses were conducted, but the trim and fill analyses were not filled (data unchanged) ( Figure 4 ).

Funnel plot to test the publication bias of included studies on male involvement in family planning in Ethiopia, 2021.

Trim and fill analysis for adjusting publication bias of the included studies on male involvement in family planning in Ethiopia.

Sensitivity analysis

To identify the potential source of heterogeneity observed in the pooled prevalence of male involvement, the authors conducted a leave-one-out sensitivity analysis. The result of the sensitivity analysis found that the finding did not rely on a particular study. The pooled prevalence of male involvement was varied and ranged from 37.87% (28.34, 47.41) to 41.61% (32.32, 50.90) after the deletion of four studies ( Table 2 ).

Sensitivity analysis of the prevalence of male involvement in family planning among married men in Ethiopia, 2021.

CI: confidence interval.

Subgroup analysis

Subgroup analysis by region was calculated to compare the involvement of males in FP service utilization across regions of the country. Accordingly, the highest pooled prevalence of male involvement in FP was observed in the Oromia region 44.66% (95% CI = 36.04, 53.28), followed by the Amhara region 37.79% (95% CI = 14.65, 60.93), whereas the lowest prevalence of male involvement was observed in SNNPR 32.56% (95% CI = 16.81, 48.30) ( Table 3 ).

Subgroup analysis of male involvement in family planning among married men in Ethiopia, 2021.

Factors affecting the involvement of males in FP

In the current systematic review and meta-analysis, men’s educational status, discussion of FP options with their wives, knowledge of FP, a positive attitude toward FP, and approved FP service utilization were all found to be significantly associated with male involvement in FP service utilization.

In this review, three primary articles 14 , 19 , 23 found that men who had received formal education were nearly two times (adjusted odds ratio (AOR) = 1.99, 95% CI = 1.26, 3.14) more likely than men who had not received formal education to use FP services. There was very little heterogeneity between the studies ( I 2  = 23.1%, p  = 0.273). As a result, the pooled odds ratio was estimated using a random-effect model ( Figure 5 ).

Association between education and male involvements of family planning.

Seven primary articles 12 , 17 , 19 – 21 , 23 , 26 noticed married men who have discussed with wife regarding FP issues were four times (AOR = 4.15, 95% CI = 2.21, 7.80) higher the odds of their involvement in FP than their counterparts. The heterogeneity test showed higher heterogeneity across the studies; as a result, we used the random-effects model to estimate the pooled odds ratio ( Figure 6 ).

Association between discussion on FP with wives and male involvements of family planning.

Knowledge of men about FP is also another important determinant of male involvement in FP as highlighted by four primary studies. 12 , 17 , 23 , 25 Married men knowledgeable about FP were nearly two times (AOR = 1.83, 95% CI = 1.26, 2.64) increased the odds of involving in FP service utilization than their counterparts. The heterogeneity test showed ( I 2  = 66.7%, p  = 0.029). Hence, the pooled odds ratio was estimated using random-effect model analysis ( Figure 7 ).

Association between knowledge and male involvements of family planning.

Similarly, having a positive attitude toward FP was also a key factor for male participation in FP service, which was mentioned by three studies. 17 , 18 , 23 Men with a positive attitude toward FP were 2.6 times (AOR = 2.57, 95% CI = 1.70, 3.90) more likely to be involved in the service than those who had a negative attitude toward FP service. Since heterogeneity between articles was I 2  = 31.7% and p  = 0.231, random-effect model was the preferred model for analysis ( Figure 8 ).

Association between attitude and male involvements of family planning.

Finally, three studies 13 , 19 , 21 reported that approval of men in contraceptive use was highly associated with involvement in the FP service. Men who approved FP services utilization were 9.56 times (AOR = 9.56, 95% CI = 3.74, 24.48) more likely involved in FP services utilization than men who did not approve. Random-effect model analysis was conducted to estimate the pooled odds ratio because of the higher heterogeneity effect ( Figure 9 ).

Association between approval and male involvements of family planning.

Males’ role in FP is getting more attention these days, as population planners recognize the importance of men’s influence over reproductive decisions around the world. 32 This systematic review and meta-analysis present findings from documented primary studies and experience in a different part of Ethiopia to assess the current state of knowledge regarding this issue. The review’s current goal is to improve men’s knowledge and attitudes about FP, with the ultimate aim of encouraging behavior change and active participation in the issue.

According to this review, the national pooled prevalence of male involvement in FP was 39.7%. This finding was consistent with a study conducted in Turkey, 33 Ghana (34.4%), and (38.9%), 34 , 35 and Uganda (40%). 36 However, the level of male involvement in FP was lower than a study conducted in Bangladesh (63.2%), 37 Vietnam (63.7%), 38 Kenya (52%), 39 Nigeria (89%), 40 and India (71.2%). 41

This disparity could be due to low socioeconomic status, differences in health infrastructure, and media reports of a lack of male involvement promotion. This could also be due to a lack of shared responsibility, low educational attainment, a negative attitude toward male participation in FP services, and a misunderstanding that FP is solely a woman’s business. Male participation in FP is once again given insufficient attention by program planners and policymakers. Men’s low participation was also due to the lack of various contraceptive options available to them. To increase male participation in FP services, more involvement of healthcare providers to motivate governmental concerns, media coverage to raise awareness, and individual motivation may be required.

The subgroup analysis of this systematic review and meta-analysis revealed regional differences in male involvement in FP. The Oromia region had the highest pooled prevalence of male involvement in FP (44.7%), while the SNNPR had the lowest prevalence, which was 32.56%. This disparity could be due to a time difference, a difference in study settings, or a socio-cultural difference in the community.

Based on the current review, educational status of men was a significant positive predictor of male involvement in FP. When the educational status of males increases, the active involvement of males in FP improves, which is inclined with previous studies done in Bangladesh, 37 sub-Saharan Africa, 42 Nigeria, 40 Kenya, 39 Ghana, 43 and Cameroon. 44

This could be because educated men have a better understanding of FP and its importance, which encourages them to engage in active FP use. Furthermore, men’s educational attainment has a positive impact on a couple’s RH decisions and overall fertility preferences. Moreover, uneducated men frequently hold misconceptions about FP methods, particularly regarding side effects. These misunderstandings are frequently the cause of low male participation. As a result, obtaining at least a primary education is a critical intervention for improving male involvement in FP.

Parental discussion on the issue of RH, including FP, had a positive association with men’s involvement which is supported by studies done in Bangladesh, 37 India, 45 and Nigeria. 40 The possible explanation might be that spousal discussion regarding reproduction and FP is viewed as successful to the extent that it directly increases the use of contraception and favorable attitudes toward contraception among couples. Furthermore, through open discussion, couples communicate with one another about RH-related issues such as the types of FP methods they will choose, problems encountered with RH and sexual life, and the best decision from which they will seek appropriate RH services. On the contrary, lack of discussion may reflect a lack of personal interest, hostility to the subject, or a customary reticence in talking about sex-related matters. Thus, implementing strategies to improve spousal communication between couples on the issue of reproduction is an important weapon to tackle; one of the major barriers to the unmet need for FP was women’s perceptions of husbands’ opposition by scaling up men’s participation.

In this systematic review and meta-analysis, men’s level of knowledge about FP positively correlates with their involvement. Men who had sound knowledge about contraceptives were nearly two times more likely to scale up their involvement in FP than their counterparts. Findings from Bangladesh, 37 Myanmar, 46 New Guinea, 47 Nigeria, 48 Ghana, 34 , 49 Kenya, 39 and Cameroon 44 also concluded that improved knowledge of different contraceptive methods was a positive predictor of male involvement. This could be because men who have adequate knowledge of contraceptive methods are willing to participate in the selection of a suitable method for use with their wives. Furthermore, men with sufficient knowledge of various FP methods, particularly male contraceptive options, may be directly involved in FP use and encourage their partners to do so, reducing maternal mortality because knowledge of FP is a prerequisite for male involvement in FP use. As a result, there is a need to improve men’s knowledge through education and media training.

Similarly, men who had a positive attitude toward FP service were nearly three times more likely to participate in FP service utilization. Findings from sub-Saharan Africa 50 and Nigeria 40 , 48 provided consistent outcomes to those reported in this study. This implies that men’s positive attitude toward contraceptives approves either to use contraceptives on their own or support their wives to use contraceptives. Furthermore, men who have a positive attitude toward FP may like the service and might be interested in participating in their partners’ FP service. Whereas those who have a negative attitude toward FP may even refuse and violet their partner not only to involve but also to stop the FP method used by their partner. Hence, this review highlights the need to convert men’s negative attitudes into positive attitudes and then into positive behaviors through intensive RH education.

As mentioned elsewhere, men’s approval for FP was strongly associated with men’s involvement in FP. 42 , 48 , 51 , 52 This may be due to the accessibility of information and shared responsibility; female partners were taking responsibility for FP. Besides, men approving FP service utilization increases women’s confidence in the decision-making process regarding various reproductive issues, including FP.

Despite its significant importance, this systematic review and meta-analysis have their own limitations. All of the primary articles enrolled in this meta-analysis were cross-sectional; as a result, increased risk of biases, affected by heterogeneity and the outcome variable, might be affected by other confounding variables. Besides this, some of the studies enrolled in this study had a small sample size, which may affect the actual prevalence of male involvement at the country level. Furthermore, all regions in Ethiopia were not represented in this systematic review and meta-analysis due to a limited number of studies in the country (only six regional states were represented in this study). As a result, the finding of this systematic review and meta-analysis may not exactly estimate the national pooled prevalence of male involvement in FP service.

In a conclusion, the overall national pooled prevalence of male involvement in FP in Ethiopia was significantly low. Educational status, open discussion on the issue of FP with their spouses, knowledge, attitude, and approval of FP were among the significant predictors of male partner involvement in FP service utilization. Both governmental and non-governmental organizations, service providers, program planners, and different stakeholders should ensure availability, accessibility, and sustained advocacy for male involvement in FP services utilization. Besides, creating a conducive environment for education, behavioral change, and open discussion concerning RH issues, including FP. FP programs should also incorporate males in the uptake of FP services.

Supplemental Material

Acknowledgments.

The authors acknowledge the sources of all primary studies.

Author contribution(s): Bekalu Getnet Kassa: Formal analysis; Funding acquisition; Investigation; Methodology; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing – review & editing.

Alemu Degu Ayele: Data curation; Investigation; Supervision; Visualization; Writing – original draft; Writing – review & editing.

Gebrehiwot Ayalew Tiruneh: Methodology; Resources; Supervision; Validation; Writing – review & editing.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Availability of data and materials: The data set used in this review is available upon a reasonable request to the corresponding author.

Supplemental material: Supplemental material for this article is available online.