Men's Knowledge of and Attitudes Toward Birthspacing and Contraceptive Use in Jordan
Context: Jordan has begun to consider a strategy of targeting men for family planning services. However, little is known about Jordanian men's knowledge of and attitudes toward issues related to birthspacing and contraception.
Methods: A cross-sectional survey was conducted among a convenience sample of 241 men whose wives delivered in three hospitals in Amman in 1996-1997. Findings for the overall sample are presented, as are results of chi-square testing to examine differences by men's educational status and income.
Results: Virtually all men (98%) had heard of birthspacing, but only 40% could correctly define the term. About two-thirds of respondents knew of male contraceptives, but a similar proportion did not know where to get information about them. Some 86% believed that men are as responsible as women for preventing pregnancies, and 52% thought that men's contraceptive use would rise if male-oriented services were available. Attitudes toward birthspacing and contraceptive use were more positive among men with at least a secondary education and among those with a higher income than among their less-educated and less well-off counterparts.
Conclusions: Culturally sensitive family planning services designed specifically for men in Jordan would increase their involvement in contraceptive use.
International Family Planning Perspectives, 1999, 24(4):181-185
Until recently, data about men's family planning knowledge, attitudes and practices were scarce. Most large-scale family planning surveys—the knowledge, attitudes and practice surveys; the World Fertility Surveys; the Contraceptive Prevalence Surveys; and the first round of the Demographic and Health Surveys (DHS)1—included only women and focused on determinants of their contraceptive use. The lack of attention to men in surveys probably reflected their limited options for participating in contraceptive use.2
A woman can, of course, control her fertility without her husband's cooperation; yet when men and women are aware of and responsive to each other's health needs, they are more likely to obtain necessary services. Moreover, strengthening communication between partners about reproductive health and involving men in health promotion can lead to better health for the entire family.3 Consequently, in recent years, the importance of including men in reproductive health matters has received increasing recognition. A key recommendation of both the 1994 International Conference on Population and Development and the 1995 Fourth World Conference on Women was that programs encourage husbands and wives to share in responsibilities pertaining to fertility and reproductive health. A first step toward increasing men's participation in reproductive health is to understand their knowledge, attitudes and practices regarding a range of issues.
In Jordan, where husbands are the main decision-makers in the family, their attitudes and practices regarding contraception have become a major concern of the National Population Committee (JNPC), which has begun to consider a strategy of targeting men for family planning services. However, research on Jordanian men's involvement in family planning practices is limited. This article presents data from a survey conducted in Amman on men's views regarding birthspacing and contraceptive use.
THE JORDANIAN CONTEXT
Jordan lies in the central expanse of the Near East. It covers an area of approximately 90,000 square kilometers and shares borders with Israel, Syria, Iraq and Saudi Arabia. A predominantly Islamic country, Jordan has been directly affected by most of the political events, as well as economic events, that have reverberated through the region in recent decades.
According to the 1998 census, Jordan's population is 4.8 million and is growing at a rate of 2.6% annually. Four in five households are urban; nearly two-thirds are in the region that includes the capital, Amman. More than four-fifths of adults have had at least a primary education, and about one-third have at least completed secondary school.4
The total fertility rate, as estimated from the 1996 Jordan Population and Family Health Survey (JPFHS), is high (4.6 births per woman), yet has declined approximately 18% since 1990. Comparison of the 1990 and 1996 rounds of the JPFHS reveals that the average household size has declined by about 13%.5
Largely because of migration from rural to urban areas, the country has experienced rapid urban growth; the proportion of the population living in urban areas increased from 70% in 1980 to 79% in 1994. Additionally, as a result of political and economic events of recent decades, a huge number of migrants and refugees from Palestine and the Arabian Gulf have made their way to Jordan.6
Jordan's ability to absorb its growing population is strained by a scarcity of natural resources, a narrow economic base and the fact that 89% of its total area is semiarid.7 Economic decline and increased poverty levels in the aftermath of the economic crises of the late 1980s, coupled with an unprecedented level of immigration in the aftermath of 1990-1991 Gulf War, placed additional strain on the main water and food resources, as well as on the health care system.
This situation underscored the need for a comprehensive government population policy that addresses issues related to population growth, the labor force, the environment and the country's available resources. Therefore, a national birthspacing program was established in 1993, with the aim of increasing women's awareness of family planning and encouraging the use of modern contraceptives.
Results from the JPFHS demonstrate that the prevalence of modern contraceptive use among currently married women increased from 27% in 1990 to 38% in 1996. Nevertheless, the average family size, while declining somewhat, has remained high (6.0 in 1996, compared with 6.9 in 1990). Furthermore, birth intervals in Jordan are among the shortest ever recorded; 25% of women give birth within 18 months of their previous delivery.8
Before the birthspacing program was initiated, the main source of information about men's attitudes toward family planning was a brief quantitative survey carried out in 1985 to follow up on a 1983 survey of married women. The results showed that 53% of husbands believed that God determines how many children a family will have and that husbands were less knowledgeable than their wives about contraceptive methods. Furthermore, the findings revealed that the majority of husbands in Jordan held negative attitudes toward contraception and had no desire to regulate their fertility.9
In 1995, two years after the birthspacing program was established, the JNPC conducted a qualitative study exploring Jordanian men's and women's attitudes and practices concerning family planning.10 Findings from 24 focus-group discussions held throughout the country revealed that respondents typically defined family planning as "a deliberate decision to limit all future births." Most said that economic considerations were the main reason that they used (or intended to use) family planning, although some cited the ability to provide a good quality of life for their children as the most pressing reason for wanting to limit their family size. Echoing other research findings, many men opposed their wives' use of contraceptives—some because they feared negative health consequences,11 others because of religious or cultural reasons,12 but the majority because they believed that women have no right to make reproductive-related decisions on their own.13
However, a 1996 survey of 1,000 men and 1,000 women throughout the nation revealed that 74% of men approved of family planning. Men aged 25-44 had higher approval rates than other age-groups. When asked about the degree to which they concurred with seven attitudinal statements about outcomes of family planning use, men who had ever used a method recorded significantly more positive views than never-users. The survey results also indicated that communication between partners is significantly associated with contraceptive use; male current users were twice as likely as never-users to have discussed contraception with their wives.14
DATA AND SAMPLE
This article presents descriptive statistics and results of chi-square analyses of data gathered as part of a general male survey conducted to examine men's knowledge, attitudes and practices regarding birthspacing and the use of contraceptives. The sample consisted of 241 husbands of women delivering between February 1996 and October 1997 in three hospitals in Amman (Jordan University Hospital, Al-Basheer Hospital and the Royal Medical Services). Potential respondents had to have at least one other child; every third eligible man was asked to participate.
After giving written (or, if they preferred, oral) informed consent, participants were interviewed by a specially trained male doctor or male nurse. At the end of the interview, which lasted approximately one hour, respondents were given five Jordanian dinars (JD)*for their time.
The questionnaire was designed for the study and was tested on a sample of 20 men (who were excluded from the final sample) in early February 1996. The final version consisted of 108 questions covering participants' background characteristics; information about the couple's marriage and fertility; and respondents' views and attitudes toward birthspacing and contraceptive use. The final instrument was tested for its content validity and reviewed by four scholars; its reliability was measured and was found sufficient (Cronbach's alpha=.87).
Respondents were predominantly Muslim (94%) and aged 30-35 (34%); 22% had a secondary level of education, and 30% held a university degree. They most commonly reported working for the government (41%); 41% said that their monthly income was less than 200 JD, and only 22% reported a monthly income of 300 JD or more. Participants' wives were mostly 25-30 years old (43%); the largest proportion (32%) had a secondary education, and 78% did not work.
It is important to note that the sample is not representative. However, 93% of annual deliveries in Jordan take place in hospitals in Amman, and the hospitals in the study represent the main health sectors and services in the country. (Jordan University Hospital is the largest teaching hospital in the country and is a referral center for complicated cases. Al-Basheer is the largest governmental hospital; Royal Medical Services is the second-largest, serving mainly military personnel.) Therefore, it is reasonable to assume that these men share many characteristics with the general population of men residing in Amman, particularly those using the same health services.
In all, 98% of respondents said they had heard about the concept of birthspacing (Table 1). However, only 40% correctly defined it as "planning for pregnancies"; 42% mistakenly thought it means "delivering a smaller number of children," and 10% said that it means "using contraceptives to prevent pregnancy."
|Table 1. Percentage distribution of men, by responses to questions about birthspacing and contraception, Amman, 1996-1997 (N=241)|
|Have you heard of the word "birthspacing"?|
|What does "birthspacing" mean to you?|
|Planning for pregnancies||39.8|
|Delivering a smaller number of children||41.5|
|Do you know of the presence of any male contraceptives on the market?|
|Do not know||10.0|
|Do you think that male contraceptives should be present (marketed)?|
|Do you know of any source of information about contraceptives that is focused only toward men?|
|Which of the following media can be the best source of information to you about male contraceptives?|
|More than one method||45.6|
Although 69% of respondents were aware of the presence of some male contraceptives on the market, 60% opposed the marketing of male methods. Some 70% did not know of any source of information about male contraceptives; 35% stated that media and information programs should be available, including 26% who called for a special television program addressing issues related to male contraceptives.
When asked about their readiness to use male contraceptives, 28% of respondents voiced their willingness to do so (not shown). While 33% said they would use a method if their wives were unable for medical reasons to use any female contraceptives, 60% said they would not use a method in such circumstances, and 15% said that they did not know what they would do.
Men's educational level had a significant effect on many of these measures. Seventy-three percent of men with at least a secondary education defined birthspacing as "planning for pregnancies," while 60% of their less-educated counterparts defined it as "delivering a smaller number of children" (*2=20.49, df=12, p=.06). Better educated men were more likely than those with less than a secondary education to want to limit their family size (73% vs. 53%; *2=38.79, df=24, p=.02) and to say they would use male contraceptives for such purpose (36% vs. 19%; *2=26.17, df=2, p=.01). In addition, they were more likely to think that male contraceptives should be marketed (49% vs. 22%; *2=26.03, df=4, p=.0003), to consider ages 21-25 the best time for a woman to become pregnant (39% vs. 30%; *2=40.45, df=20, p=.004) and to think that a couple should discuss family planning (78% vs. 47%; *2=35.94, df=4, p=.001).
The questionnaire included 15 statements that used a Likert scale to measure respondents' attitudes toward contraceptive use and other fertility-related issues. It is evident from these responses that men see a number of drawbacks to having large families (Table 2). For example, 42% of respondents believed that large families are less happy than smaller ones, and 57% considered communication between parents better when the number of children is smaller. Even greater proportions said that large numbers of children adversely affect the quality of childrearing and parents' physical and mental health; 84% indicated that frequent pregnancies might lead to health problems for the mother. Eighty percent agreed that having few children increases a family's financial status, and only 32% said that it may cause financial insecurity in old age.
|Table 2. Percentage distribution of men, by response to statements about issues related to birthspacing and fertility|
About one-third of men thought that contraceptive use would decrease their wives' satisfaction with sex, and two-fifths thought it would cause infertility. The vast majority (86%) considered family planning as much a man's responsibility as his wife's, and 52% thought that men's use of contraceptives would increase if special male family planning services were available.
Mean scores were calculated for the 15 attitude statements, with higher means indicating higher levels of agreement. Results show that the statement concerning the effect of total number of children on the health care provided to them was associated with the lowest level of agreement, while the statement concerning the effect of frequent deliveries on the mother's health recorded the highest mean (Table 3).
|Table 3. Mean score and standard deviation (SD) for statements reflecting men's attitudes toward birthspacing and fertility|
|Effect of number of children on:|
|Health care provided to them||1.05||0.38|
|Family's financial status||1.27||1.00|
|Parents' tiredness and psychological problems||1.28||0.81|
|Father's physical and mental health||1.39||0.49|
|Mother's physical and mental health||1.54||0.50|
|Feelings of economic insecurity||2.12||1.28|
|Men's responsibility for planning pregnancies||1.20||0.87|
|Probability of male method use if male services are present||1.47||1.29|
|Effect of frequent deliveries on:|
|Marital sexual attraction||2.13||1.35|
|Relationship between women's contraceptive use and infertility||2.22||1.43|
|Effect of contraceptive use on marital sexual satisfaction||2.85||1.56|
|Notes: The higher the score, the higher degree of agreement with the statement. For complete statements, see Table 2.|
Results of chi-square testing reveal considerable differences in men's attitudes according to their level of education (Table 4). For example, men with at least a secondary level of education were more likely than less-educated men to be concerned about the effect of the total number of children on the mother's physical and psychological health (87% vs. 70%). Men with less than a secondary education, by contrast, were more likely than those with more schooling to think that women's contraceptive use may lead to decreased sexual satisfaction (71% vs. 37%).
|Table 4. Percentage of men agreeing with statements reflecting attitudes toward birthspacing and fertility, by level of education|
|Increased no. of children decreases the quality of care given to them.||63||76||13.97 (df=12)|
|Mother's physical and mental health is negatively affected by no. of children.||70||87||46.63 (df=12)***|
|Father's physical and mental health is negatively affected by no. of children.||69||77||29.70 (df=12)**|
|Large families are less happy families.||29||47||35.85 (df=12)**|
|Wife's sexual satisfaction decreases with the use of contraceptives.||71||37||37.77 (df=12)**|
|Frequent deliveries negatively affect wife's health.||66||86||48.28 (df=12)***|
|Frequent deliveries negatively affect sexual attraction between spouses.||31||47||46.26 (df=12)***|
|Increased no. of children is generally reflected in parent's tiredness and psychological problems.||73||86||14.78 (df=8)|
|Contraceptive use may cause infertility complications for the woman.||74||45||29.15 (df=12)**|
|Small no. of children negatively influences economic security of the family.||29||33||11.11 (df=8)|
|Large no. of children weakens the marital relationship.||12||29||34.43 (df=12)***|
|Large no. of children weakens parental communication.||52||59||15.74 (df=12)|
|Large no. of children burdens family's financial situation.||80||83||12.74 (df=8)|
|Husband's responsibility in planning pregnancies is the same as his wife's.||68||93||47.05 (df=8)***|
|Husband would use male contraceptives if they were available.||28||62||41.44 (df=8)***|
Chi-square analyses also showed that annual family income influenced men's attitudes toward birthspacing and contraceptive use (Table 5). For example, 89% of those earning a high annual income (3,600 JD or more) believed that frequent deliveries adversely affect women's health, compared with only 77% of those with a lower family income. On the other hand, while 47% of men in the lower income group believed that the use of contraceptives might cause the woman to become infertile, 36% of men in the high-income group held the same belief. Moreover, 68% of men from high-income families believed that husbands would use male contraceptives (if made available to them), in comparison with 40% of those with a lower family income. Men in the high-income group also were more likely than those in the lower income group to believe that increasing numbers of children in the family have a negative influence on the father's physical and mental health, and on the overall perception of family happiness.
|Table 5. Percentage of men agreeing with statements reflecting attitudes toward birthspacing and fertility, by annual family income|
|Statement||<3,600 JD||>=3,600 JD||*2|
|Husbands would use male contraceptives if they were available||40||68||27.65 (df=4)***|
|Husbands are as much responsible about family planning as their wives.||79||96||15.77 (df=4)*|
|Contraceptive use may lead to women's infertility||47||36||24.40 (df=6)*|
|Increased no. of children negatively influences mother's physical and mental health.||77||89||24.83 (df=6)*|
|Increased no. of children negatively influences father's physical and mental health.||69||81||22.87 (df=6)*|
|Decreased no. of children increases family happiness.||35||49||19.95 (df=6)*|
|Contraceptive use decreases >women's sexual satisfaction.||60||41||17.31 (df=6)*|
|Increased no. of children increases family overall problems.||77||89||18.80 (df=6)*|
The survey clearly shows that while virtually all of the men in the sample have heard of birthspacing, most cannot correctly define the term; however, education has a significant effect on men's general knowledge about family planning. These findings are congruent with those from earlier, nationwide surveys.15
Another important finding is that most men acknowledge the man's responsibility in planning pregnancies; moreover, nearly one-third indicate a willingness to use male contraceptives, and one-half believe that men's contraceptive use would increase if services were designed especially for them. This suggests that policymakers should undertake initiatives to expand male services and encourage greater use of male contraceptives.16 Services for men should take into account Jordan's social and cultural context,17 should offer a variety of methods18 and should provide comprehensive information about specific methods and about the broad benefits of contraceptive use.19
Furthermore, educational efforts should be designed to reach men who are not yet receiving family planning services. Given respondents' interest in television as a source of information, special television programs focusing specifically on men should be encouraged. And since men's knowledge about contraception is related to their level of schooling, more structured education about family planning should be directed toward men with the least schooling. Subsequently, contraceptive education programs that address youth at the school level should be initiated. Other studies, in diverse cultures, have yielded similar findings about the association between men's level of education and their contraceptive beliefs and practices.20 Moreover, some have shown that well-informed men are likely to either use a method themselves or support their partners in using a method.21
Seventy-four percent of respondents reported that they discuss issues regarding family planning with their wives. While this finding is similar to results of another Jordanian study,22 it does not necessarily mean that couples reach a decision together, because men in Jordan (as in most Arab countries) are seen as the main decision-makers in the family. A multinational study concluded that family members, particularly husbands, play a critical role in women's family planning use and continuation.23 According to preliminary results from a nationwide study done in Egypt, some women's fears of divorce lead them to continue childbearing even if they want no more children.24 Further research should address Jordanian couples' decision-making on issues related to fertility and reproductive health.
The effect of religion on issues pertaining to family communication should also not be ignored. Islam's consonance with family planning, as well as with specific contraceptive methods, is important to Jordanians, 97% of whom are Muslim. Men, in particular, are interested in religious programs and are concerned about the acceptability of various contraceptive methods within the religious law.25 Since Muslim religious leaders are perceived as an important source of information, their involvement in well-structured educational programs would be valuable. The JNPC has undertaken such a program, but its effectiveness has not yet been evaluated.26
A limitation of this study is that men were interviewed on issues related to birthspacing and contraceptives without their wives' being interviewed as well. Future research should examine attitudes about birthspacing and contraceptives in greater detail, including husbands and wives simultaneously. A further limitation is that, as mentioned earlier, the results are not widely generalizable. Yet, the main findings from this survey are consistent with results from the national JNPC survey.27
*One dinar is equivalent to U.S. $1.44.
1. Drennan M, Reproductive health: new perspectives on men's participation, Population Reports, 1998, Series J, No. 46.
2. Ringheim K, Factors that determine prevalence of use of contraceptive methods for men, Studies in Family Planning, 1993, 24(2):87-99.
3. Drennan M, 1998, op. cit. (see reference 1).
4. Jordanian Department of Statistics, Population and Housing Census, Amman: Jordanian Department of Statistics, 1998.
5. Jordanian Department of Statistics, Jordan Population and Family Health Survey, Report of Principal Findings: 1990, Amman: Jordanian Department of Statistics, 1991; and Jordanian Department of Statistics, Jordan Population and Family Health Survey, Report of Principal Findings: 1996, Amman: Jordanian Department of Statistics, 1997.
6. Jordanian Department of Statistics and Macro International, Jordan Population and Family Health Survey, 1997, Amman: Jordanian Department of Statistics; and Calverton MD, USA: Macro International, 1998.
8. Jordanian Department of Statistics, 1997, op. cit. (see reference 5).
9. Jordanian Department of Statistics, Jordan Husbands' Fertility Survey, Amman: Jordanian Department of Statistics, 1985.
10. Johns Hopkins Center for Communication Programs, In their own words: a qualitative study of family planning in Jordan, Information, Education and Communication Field Report, Baltimore, MD, USA: Johns Hopkins Center for Communication Program, 1996, No. 6.
11. Drennan M, 1998, op. cit. (see reference 1).
12. Jordanian Department of Statistics, 1985, op. cit. (see reference 9).
13. Ezeh AC, The influence of spouses over each other's contraceptive attitudes in Ghana, Studies in Family Planning, 1993, 22(3):163-174.
14. Jordanian National Population Commission, Final Report on Family Planning Knowledge, Attitudes and Practices in Jordan, Amman: Information, Education and Communication Project, 1999.
15. Johns Hopkins Center for Communication Programs, 1996, op. cit. (see reference 10); and Jordanian National Population Commission, 1997, op. cit. (see reference 14).
16. Family Health International (FHI), Family planning and women's lives, Network, 1998, 18(4).
17. Marshal J, Acceptability of fertility regulating methods: designing technology to fit people, Preventive Medicine, 1977, 6(1):65-73.
18. World Health Organization Task Force on Methods for the Regulation on Male Fertility, Contraceptive efficacy of testosterone-induced azoospermia in normal men, Lancet, 1990, 336(8721):955-959.
19. Williamson N, How family planning use affects women's lives, Network, 1998, 18(4):4-5.
20. Drennan M, 1998, op. cit. (see reference 1); and Program for Appropriate Technology in Health, Involving men in reproductive health, Outlook, 1997, 14(3):1-8.
21. Drennan M, 1998, op. cit. (see reference 1).
22. Petro-Nustas W, Wives' view of their husbands' role in family planning: some indication from the Jordan Fertility and Health Survey, Dirasat, Medical and Biological Sciences, 1997, 24(2):187-200.
23. FHI, 1998, op. cit. (see reference 16).
24. El-Deeb B et al., The Role of Women as Family Planning Employees in Egypt: Final Report by Women's Studies Project, Research Triangle Park, NC, USA: Cairo Demographic Center and FHI, 1998.
25. Petro-Nustas W and Al-Qutob R, Jordanian men's attitudes and views of birth-spacing and contraceptive use: a qualitative approach, Health Care for Women International, 1999 (forthcoming).
26. Jordanian National Population Commission, The Family Planning Knowledge, Attitudes, and Advocacy of Jordanian Religious Leaders: The Final Report, Amman: Jordanian Population Commission, 1999.
27. Jordanian National Population Commission, 1999, op. cit. (see reference 14).
Contexte: La Jordanie a entrepris l'évaluation d'une stratégie de ciblage masculin des prestations de planning familial. L'on en sait cependant peu sur la connaissance et les attitudes des hommes du pays à l'égard des questions relatives à l'espacement des naissances et à la contraception.
Méthodes: Une enquête transversale a été menée parmi un échantillon de commodité de 241 hommes dont les femmes avaient accouché dans trois hôpitaux d'Amman en 1996-1997. Les observations relatives à l'échantillon global sont présentées, de même que les résultats d'un test chi carré d'analyse des différences en fonction du niveau d'instruction et du revenu des hommes.
Résultats: Presque tous les hommes (98%) avaient entendu parler de l'espacement des naissances, mais 40% seulement pouvaient définir correctement l'expression. Environ deux tiers des répondants étaient conscients de l'existence de contraceptifs masculins, mais une proportion comparable ne savait pas où se procurer d'informations les concernant. Quelque 86% estimaient que la responsabilité des hommes était égale à celle des femmes dans la prévention des grossesses, et 52% pensaient que la pratique des méthodes masculines augmenterait si des services destinés aux hommes leur étaient offerts. Les attitudes à l'égard de l'espacement des naissances et de la contraception étaient plus positives parmi les hommes instruits au niveau secondaire au moins et parmi ceux dont les revenus étaient plus élevés.
Conclusions: L'offre de prestations de planning familial sensibles à la culture et destinées spécifiquement aux hommes permettrait d'accroître, en Jordanie, la participation de ces derniers à la contraception.