Program for Malawian Males Results in Increased Contraceptive Use
Contraceptive use in Malawi increased among couples who participated in an educational intervention that trained men to talk with their partner about the financial and health-related benefits of family planning.1 At the end of the randomized trial, 78% percent of men in the intervention group reported using birth control with their partner, compared with 59% of those in the control group. Ease and frequency of communication with one's partner about contraception were the strongest predictors of birth control use.
Rates of early marriage and fertility are high in Malawi, but contraceptive use is low, especially among young women; one-third of females aged 15–19 have been pregnant, and only 8% use a modern birth control method. However, efforts to promote family planning may be hindered by gender inequality, as men make the health care decisions in most marriages. To examine the potential benefits of involving men in family planning, researchers conducted a randomized trial of the Malawi Male Motivator intervention, a program in which trained male peer educators (motivators) discuss family planning and gender issues with other men in the community.
Researchers recruited 400 men from 257 villages in the Mangochi district of Malawi to participate in the trial. Men were eligible if they were at least 18 years old and were married to or living with a female partner younger than 25 who was neither pregnant nor breast-feeding an infant younger than six months. In addition, they and their partner could not have been sterilized, or have used a modern contraceptive method during the past three months.
After completing a baseline survey, men were randomized into the intervention or control group; no more than one man from each village was assigned to the intervention. Motivators met with each intervention group member five times during the six-month trial to discuss gender norms and family planning; encourage him to discuss contraception with his partner; and practice having such discussions. One key goal was to challenge the idea that having a large family is an indicator of virility. Data collectors met with control group members only once, to complete the postintervention survey that was administered to both groups. The survey included scales assessing family planning attitudes, behavior and knowledge; gender norms; and ease of communication. The researchers used paired t tests to examine within-group changes in these measures and generalized estimating equations to examine changes between groups. Items that significantly correlated with contraceptive use, along with demographic variables, became covariates in a multiple logistic regression model.
In all, 397 men completed the baseline survey; 197 were assigned to the intervention group and 200 to the control group. Demographic characteristics were similar in both groups; on average, participants were 25 years old and had two children. The mean age difference between men and their partners was five years. A total of 289 men completed the postintervention survey.
At the end of the study, 78% of men in the intervention group and 59% of those in the control group reported that they and their partner were using birth control. Since neither group had been practicing contraception at baseline, these proportions represented substantial and statistically significant increases in use. Both groups also showed changes on measures of family planning knowledge, including attitudes, self-efficacy, gender norms, and communication ease and frequency.
In multiple logistic regression analyses, men in the intervention group were more likely than those in the control group to have initiated contraceptive use (odds ratio, 2.4); no demographic variables were associated with initiation. However, frequency of discussing family planning with one's partner was associated with contraceptive initiation (1.6), and a marginally significant association emerged between ease of discussing family planning and contraceptive uptake (1.6).
These findings were mirrored by qualitative data from interviews with randomly selected intervention group members. More than half credited the intervention with helping them to discuss family planning with their partner; many attributed their increased comfort with the topic and improved partner communication to their interactions with the motivator. The financial benefit of family planning was the most often-cited reason for practicing contraception; concerns about partners' or children's health also motivated men to use birth control.
The researchers acknowledged some study limitations. For example, the mean ages of participants and their partners, and their mean number of children, suggest that increases in contraceptive use could partially ?reflect couples' maturation. Although men reported nonuse of contraceptives at baseline, they may have been unaware of their partner's use; such use may have come to light when the couple began discussing contraception. Moreover, the researchers could not determine whether reported contraceptive use had been forced.
Nevertheless, they note that "male involvement in family planning matters." The study results, they conclude, indicate that "targeting men with messages focused on the financial and health-related benefits of family planning, information about contraceptive methods and activities to challenge gender norms" can be a "relevant and successful" approach to promoting contraceptive use.—A. Kott
1. Shattuck D, Encouraging contraceptive uptake by motivating men to communicate about family planning: the Malawi Male Motivator Project, American Journal of Public Health, 2011, 101(6):1089–1095.