Study on the Perceptions and Social Representations of Husbands on Family Planning in the Health District of Pout/Senegal ()
1. Introduction
The fertility control has always been an issue in the life of societies. Infanticide, abortion and contraception have been practiced since Antiquity, demonstrating the will of humans to escape fatality. The methods used to control fertility have evolved over time to progressively replace the so-called natural methods (interrupted coitus or periodic abstinence). Therefore in the 20th century, modern methods consisting of mechanical devices (Intra Uterine Divice) or medical methods (pill, implant, injection for examples) have succeeded to the old methods. Regarding medical methods, they consist of substances with hormonal activities that affect the functioning of the reproductive organs [1].
Contraception is the set of procedures that aim to obtain temporary infertility in a woman without her ability to conceive being affected in the future. It is crucial for the demographic development, especially low-income countries. In other words, uncontrolled population growth can be a challenge to economic and social development [2].
A larger number of children theoretically increase the economic and financial burden on the family as well as the society. In fact, rapid population growth due to a sustained high fertility rate is associated with higher rates of poverty, low primary education quality and high rate of infant and maternal mortality rates. The high population growth rates without responses to social demand in developing countries constitute an obstacle to the achievement of the Sustainable Development Goals (SDGs).
In the light of that, family planning contributes to social stability, improves purchasing power and subsequently sustains the socioeconomic balance of the population. Considered an essential component of primary health care and reproductive health, family planning plays an essential role in the health of women and children, the well-being of husbands, and allows, among others, savings for the family [3].
In recent years, changes have been seen in the use of contraceptive methods. However, the objective of increasing the rate of contraceptive practice for women in couple from 12% in 2010 to 27% in 2015 has still not been achieved, which may be linked to lack of understanding of birth spacing but also to gender-related inequalities [4]. The involvement of men in the social affairs of family planning may occupy a crucial place in the reproductive health of couples.
Much more than a simple biological fact, female sexuality serves as a projection canvas for societal, cultural and religious conceptions of family and community. “In this area, gender issues definitely interfere with health issues stricto sensu” [5].
Sexuality and procreation take place within the framework of asymmetrical relationships. It is women who carry pregnancies and give birth, but men nevertheless have a crucial role at all stages of the procreation process such as sexual partners but also holders of a large shared decision-making power within the conjugal and family sphere, as main holders of political and economic power. As a result, one of the major aspects of male domination is the appropriation by men of fertility ability of women [6].
Indeed since the 1960s, family planning programs have allowed women around the world to avoid 400 million of high-risk pregnancies and unsafe abortions. Avoidance of these disastrous situations could have led to a reduction of a quarter of maternal deaths [7].
According to the WHO, 800 women die every day around the world during pregnancy or childbirth and most of these occur in developing countries. In 2013, 289,000 women died worldwide from complications during pregnancy, childbirth or within days that followed. Since 1990, the number of maternal deaths has fallen by 45%. Today, almost all maternal deaths (99%) occur in developing countries, mainly in Sub-Saharan Africa. The maternal mortality rate (the number of maternal deaths per 100,000 live births) is estimated at 16 per 100,000 in developed countries while it is 230 per 100,000 in developing countries. As women in developing countries have more children, the risk of them dying during childbirth or pregnancy is 23 times greater than in developed countries. Sub-Saharan Africa is the region of the world where maternal mortality is the highest with over 510 deaths per 100,000 births [8].
In Senegal, the maternal mortality ratio was 315 deaths per 100,000 live births in 2015. Every day, 4 to 5 women die from complications related to pregnancy and childbirth despite the efforts made [9]. In 2017, the Continuous Demographic and Health Survey estimated that maternal mortality ratio at 273 deaths per 100,000 live births. Despite such observed drop of the maternal mortality rate, the region of Thiès (including Pout) annually records 392 maternal deaths out of 100,000 live births [10].
In this context, it is important to investigate the perceptions of spouses on family planning as well as the social representations they build around this socio-medical practice.
The main objective of this research was to study the perceptions of spouses on family planning in the health district of Pout in 2019. More specifically, we assessed the perceptions of men on family planning to identify their social representations on such practice. This article is split into two parts. The first outlined the rational of the subject and the methodology used. The second attempted to analyse in a socio-anthropological manner the qualitative data collected during the survey.
2. Context
Maternal mortality is a public health problem, particularly in developing countries and family planning is one of the global strategies adopted to tackle such issue. Moreover, several hormonal contraceptive methods help preventing certain types of cancer and condoms help to effectively fight against sexually transmitted diseases, including HIV/AIDS [11].
Although mortality indicators have fallen since 2005, those still remain below the Sustainable Development Goals (SDGs) [11]. Thus, the government of Senegal has undertaken various initiatives in the health sector through the National Health Development Plan for which one of the four fundamental objectives is to reduce the maternal and infant-child morbidity and mortality rate.
With regard to mothers, the WHO goal is not only to reduce the global maternal mortality rate below 70 per 100,000 births, but also to neonatal mortality and deaths of children under five years which is likely possible to prevent. Nowadays, out of 5 children who die before the age of five, one is a newborn. In addition, nearly 150 million people are struggling to afford healthcare and 100 million are falling into poverty because they cannot pay their medical bills. As a result, Senegal aims to achieve universal health coverage, including access for all to safe, effective, quality and affordable medicines and vaccines (PNDS, 2009-2018) A10 [11].
The SDG3 targets the good health and well-being of populations and mainly focuses on mothers and children, the fight against epidemics, road trafic safety and global access to medical care and development.
Target 7 of this SDG entitled “sexual and reproductive health” plans to ensure by 2030, access for all to sexual and reproductive health care services, including family planning, information and education, and inclusion of reproductive health in national strategies and programmes.
Furthermore, for the achievement of SDG3, family planning (FP) plays a key role in accelerating the reduction of maternal, neonatal and infant morbidity and mortality in Senegal. Such goal also aimed to increase the contraceptive prevalence rate from 12% to 27% between 2012 and 2015 in order to achieve notable progress, although the rate set was not fulfilled. However, the efforts made have yielded encouraging results, including [9]:
• A decrease in the maternal mortality rate going from 401 to 315 deaths per 100,000 live births between 2005 and 2016, corresponding to 27% decrease in 11 years;
• A reduction of the infant mortality rate from 61 to 39 per 1000 between 2005 and 2016;
• A drop in the total fertility rate from 6 to 4.7 children per woman;
• A change in contraceptive practice going from 10.3 to 23% between 2005 and 2016.
In the light of the encouraging results, family planning remains one of the most effective interventions available to save lives, improve the health of women and children, but also to unify both women and men regarding some contraceptive methods that require the active participation of men. However, contraception seems to be above all a women’s issue, and the wide range of contraceptive methods available attributes a primary role to women [12].
In a society where everything revolves around males, it is clear that family planning cannot succeed without involving men [13]. Male partners can help women realizing their right by supporting them in their choice, using contraception, avoiding violence and promoting gender equality and equity. This highlights the importance of investigating the issue of social representations and perceptions of spouses in the areas covered by the health district of Pout.
Family planning is therefore a strong tool of preventing maternal, neonatal and infant mortality. Although centered on women, men have a powerful decision-making share which is strongly influenced by social, cultural and religious factors which may ultimately be obstacles. Although being an important factor in the use of contraception, knowledge of contraceptive methods is not yet well understood [14]. The social and cultural determinants and the orientation of the target towards male gender carry all their weight in the choice of the practice of family planning.
3. Methodology
This is a mixed study combining the quantitative and qualitative components in which qualitative data have been used more in this article. Such qualitative approach focuses on the knowledge, perceptions and practices of spouses related to family planning in the area covered by the health district of Pout.
The study population included the entire male population over the age of 18 in the study area and the selection was made independently of the practice of contraception used by wives.
The men included in this study were past or currently formerly married residing in the geographical area of the district. Those meeting the inclusion criteria but absent, refusing to participate or unable to respond were excluded.
For the quantitative part, we carried out a two-stage cluster sampling. The first consisted of selection of neighborhoods or villages while for the second degree, survey has been used to randomly select the participants by the identification of concessions. A total of 400 questionnaires were administered to men meeting the inclusion criteria.
Regarding the qualitative part, 15 individual interviews were conducted at survey sites and supported by an interview guide.
Data was collected between July and September 2019. These investigations took place in the chosen neighborhoods for the study and in private spaces where husbands felt very comfortable in freely expressing themselves on the subject.
The research protocol, developed as part of the master’s training, had the approval of the university ethics committee and the research authorized by the district doctor. Participation was free and voluntary. There was no conflict of interest.
4. Results and Discussion
4.1. Socio-Anthropology and Family Planning
The anthropology of health evolves within the framework of several research topics related to health. Beyond the numerous biotechnological health determinants, the study of traditional therapeutic must undergo with modern health analysis. The ethno-medical study of beliefs related to illness and care practices, with a culturalist orientation in particular, must come to terms with multifactorial models (economic, social, political, cultural) of the determinants of health and with global health. In short, the traditional rigid boundaries between health and illness or culture and politics are becoming increasingly porous [15].
The socio-anthropology related to the practice of family planning in Senegal highlights not only contraception, which is often based on female methods and social behaviors, but also emphasizes the masculine gender and its knowledge. From a social point of view, this latter is the center of decisions and powers emanating from the family, the ethnic group, the community and Senegalese society in the end. Such social status provides to men a significant place, first in the choice of spacing births or not, then in the choice of contraception methods which in certain situations have a dynamic character such as withdrawal, which is often stigmatized and unmentionable by their users and therefore leads to the decrease of their prevalence in several studies [16].
- Knowledge of family planning
Family planning is enshrined in a human rights framework involving everyone and all potential parents. It is particularly important for women, for their health and well-being but also a great interest and value for men.
The analysis of the data shows that 338 (84.5%) participants supported having knowledge about FP against 62 (15.5%) who didn’t.
Table 1 elicits the distribution of the study participants according to their knowledge in contraceptive methods.
The majority of respondents knew several methods of contraception, including pills (73%), injections (66.5%) and implants (44%) while the collar and spermicides were poorly known, respectively with 5% and 2% of respondents (Table 1).
All the participants interviewed had heard about the concept of family planning through several communication channels, including radio and television, magazines and newspapers, as well as health and educational establishments. Participants who had heard about family planning were able to make a link between birth spacing and the concept of “family planning” to reduce maternal and infant mortality. There has been a good level of knowledge of this socio-sanitary practice in this area. However, this does not mean that other social, economic and cultural factors don’t hinder the success of family planning projects and programs.
- Socio-cultural, economic and religious aspects of FP in Pout HD
Among the populations of the municipality of Pout, it is not new to hear that they are governed by normative values as this is often the case for all African and Senegalese societies. Each society has indeed its own cultural values with its own meaning. One important common point is however the social cohesion of the group, the clan, the ethnic group and the community. Cultural diversification in societies also leads to various fertility considerations. Indeed, households with children generally gain great respect or high consideration in society because offspring appears to be a safety valve and a variable of social recognition.
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Table 1. Distribution of the study participants according to their knowledge in contraceptive methods.
In Senegal, despite the efforts made through programs and campaigns for birth spacing, the contraceptive rate remains low (23%) for a so-called modern methods [17]. Such a reluctance is often due to the existence of social, cultural, economic and religious constraints.
à Social constraints
Family planning is a social aspect that raises questions both in the public and private spheres. It gives rise to biases and misconceptions and may cause in some cases bad treatments from the family-in-law. Neighborhood investigation of the family planning practice is quickly detected after three years of birth spacing. Even though it is a decision of the couple, in-laws begin to question themselves about the fertility of the woman. Such a situation is delicate because it may lead to a social exclusion, divorce and even trigger for polygamy. In other words, with family and social pressure, the couple has less control over their fertility.
During our interviews, we found that there are husbands who are understanding and who accept that their wives use contraceptives and others don’t.
à Cultural burden
The use of extended breastfeeding and the geographical separation of spouses after childbirth are well known by the couples interviewed. These methods prevent close pregnancies and are more reliable than modern methods of contraception according to respondents. Wearing a talisman (gris-gris) or potion that protects against unwanted pregnancy was also raised. Our analysis has shown that endogenous knowledge that preceded medical knowledge often preceded the management of birth spacing. Such line has been raised but one of the interviewee Mr. O. N who supported that “our culture does not accept the use of modern methods, because we have our own methods which not have side effects”. There are indeed traditional uses of methods that are natural and do not require taking medication or other products whose dosage can cause adverse effects on the women health.
“Our culture does not accept the use of modern methods by our women, because there are many side effects. In addition, many women do family planning in secret and in a couple everything must be discussed”, adds Mr. BS
The lack of confidence in the health care system and in new contraceptive methods is often mentioned. There are fears of adverse effects such as sterility, reduction and regulation of births by authorities, recurring health problems refer to traditional methods of birth spacing.
There are however other more open-minded spouses who reconcile culture and modern family planning. This was illustrated by Mr. I. C informs us that: “our culture accepts the use of modern methods because the world has evolved. Although tradition persists, modern practices are more and more accessible”. Cultural values are not always an obstacle to the practice of FP. The accessibility of modern methods is an asset to facilitate its use especially through better control and more choices.
“In my opinion, the culture does not exclude modern contraception, but has limits in terms of the methods used and the duration of use because if our child reaches 2 years old, we should able to stop planning to conceive another child”, said another interviewee Mr CTP
Culture is one of the factors that can reduce the contraceptive prevalence rate if uncertainties remain and ambiguities are not resolved. Each couple can freely choose the contraceptive method that suits them according to the woman’s state of health. But it’s not always the case. These comments show that even if for some people the tradition remains an issue to FP, for other people culture does not exclude the use of modern methods of contraception.
According to our cultures, norms and values, women should have many children, and most people did not understand the health risks of repeated pregnancies or how to avoid them. It clearly appears that culture is then one of the determinants that weighs on contraceptive practice. Sociocultural factors influence the use of contraceptive methods. They are identified as a major constraint and are strongly marked by their inadequacy for planning. To legitimize and better popularize the use of contraception, the national programme of FP must imperatively consider traditions, norms and societal values along with technologies.
à Impact of family planning on the couple’s income level
The relationship between family planning and income level is bilateral. Indeed, despite socio-cultural constraints, family planning contributes greatly to the economy of families. It participates not only in spacing of births, fighting against maternal and infant mortality, but also in improving the economic situation of the couple. It also participates in improving the sexual life between the two spouses, reducing the cost of living and increases its quality. The other aspect often highlighted is the preservation of the mother’s health and the well-being of the children.
The interviewee Mr D. C gives his opinion according to which, “most of the time we practice FP because we do not have enough income to manage many children”. This awareness of parents who understand and assume the consequences of taking care of several children is accentuated by social and economic costs (health, education, food, security, etc.). Contraceptive practice reduces poverty and allows families to preserve their economy.
The urban environment is more in tune with fertility control. The management of time and savings, professional and social objectives encourage young parents to better organize their reproductive life.
In rural areas, having several children is in some cases a sign of social wealth because. That shows somehow a sense of responsibility and it is an opportunity in terms of additional arms to ensure abundant agriculture. Addressing this subject, Mantempa J. [18] noted that in African society, men gain socially by the pride they derive from the number of children, especially males, and economically by the importance that constitutes the child as cheap agricultural labour, wealth for the parents, security for their old age. In addition, men hold decision-making power in the couple and in society in general, controlling the resources of the family throughout the advantages they derive from the work of children and women.
Income level may in turn has an impact on FP practice. For example, Mr. L. F supported that: “the level of income can have an impact on the practice of FP because sometimes you can have an appointment without not being able to afford the transport and the purchase of the contraceptive product to use” It is important to specify that family planning is not free. Therefore, although FP allows better management of the children, it requires a minimum of financial resources to ensure the purchase of consultation tickets, the transport and the purchase of the contraceptive product.
K. K gives his opinion according to which, “the level of income may not have an impact on the practice of FP, because the methods are not too expensive”. Contraceptive methods are accessible and available at affordable prices. Therefore, the impact of income level on contraceptive practice is unlikely.
Respondent EL. M. D asserts that “the level of income may have an impact on the practice of FP for some and may not have any impact for others, because it is God who decides so”.
Inequalities in income levels exist in every society and affect contraceptive practice. Thus, ensuring quality of health care is primarily the responsibility of the government, local authorities and communities. Health is an inalienable and claimable right at the same time.
Contraceptive products are offered at the same prices so that everyone can afford them. However, existing social inequalities are sharp indicators for distributing contraceptive products according to social categories and income levels.
In any case, income appears to have an impact on the practice of family planning. In terms of virtues, the practice of FP allows parents to better manage their children and educate them well with the limited means at their disposal. It can also reduce poverty, promote economic growth by improving family well-being, and allow the foundations for the demographic dividend.
à Religious aspect
In addition to the socio-cultural and economic aspect, religious beliefs influence contraceptive prevalence according to our respondents.
It should be noted that religion is not disconnected from family planning. Indeed, the 1994 United Nations International Conference on Population and Development (ICPD) and the 2000 Millennium Development Summit called for the establishment of universal access to services and information on family planning. The Islamic countries present at the ICPD essentially gave their support to the conference’s Program of Action, although they reserved the right to interpret and adopt its recommendations in accordance with Islam [19].
- Compatibility between religion and contraception
All muslims should know that Islam encourages FP if it is used for birth control and to space pregnancies. Such assumption is included in the objectives of family planning. In other words, Islam is not against birth spacing. Mr. M. N affirms that “…Islam requires us to breastfeed our children up to 2 years before another pregnancy to prevent the child from being malnourished”. Islam would therefore be in favor of family planning if the spacing of pregnancies and the limitation of their number improved the physical condition of the mother and child, the financial situation of the father, and in particular insofar as these actions do not violate any of the prohibitions of the Koran or the tradition of the prophet.
Islamic jurists who study family planning have provided several justifications for contraception. “Allah, God narrated by the Prophet Muhammad Psl, ordered Muslims that it takes from fertilization at least 30 months for the spacing of births. 30 months, including 8 to 9 months for pregnancy and the rest, around 2 years, to feed the child with breast milk, his main food” [19].
These comments, which derive from the interpretation of religious texts, are in line with the Senegalese urban health initiative project which aims to raise contraceptive prevalence as implemented by a consortium of NGOs and international organizations under the government support. An area of intervention of the project was devoted to the training of muslims religious leaders and the production of two documents, namely the Islamic argument on birth spacing and for a better understanding of family planning according to authentic Islamic teachings. Without referring to human rights, the documents argue for the conditional legality of family planning.
The use would be in accordance with the Islam teachings if it is done in the aim to spacing births within the framework of marriage, by reversible methods which do not cause abortion and because of health reasons [10]. The religious values put forward clash with the foundations of reproductive rights and in particular with the principles of decision-making, autonomy and non-discrimination.
For the Christian religion, marriage is not limited exclusively to reproductive purposes. Family planning helps families to avoid health risks to the mother, the transmission of diseases from parents to their children, and to preserve the physical health of women. “According to our religion which is Christianity, we can do family planning without any problem, because it will allow us to be in good health, to breastfeed our child normally, but also to earn our living as it should be, because health comes first. God never said to have children just anyhow” adds the interviewee Mr. J. B. G. From this same point of view, Christianity also considers FP useful.
- Discrepancy between religion and contraception
In Senegal where muslims represent up to 94%, the interpretation of the Islam often constitutes an obstacle to the adoption and use of modern contraceptive methods. These are sometime described as practices incompatible with the Muslim religion. The remarks of Mr. T. D are a convincing illustration of this. According to him: “in the Muslim religion, parents have the duty to increase the grandsons of the Prophet Muhammad (PSL) and to this end, you must have a certain number of children”. Muslims who apply Sharia as written, follow this logic of procreation, but if the number of Muslims is to be increased, it must be accepted that contraception helps families achieve serenity by having children when they wish and when they are ready to have them.
Mr. A. P stated that “Family planning allows women not to have many children, and God has given women the power to reproduce. So why not using this power before going into menopause? It’s better than limiting births. It is God who is above everything so let’s not look for other remedies. Religion has no influence on the rate of use of the PF, it only guides its believers”.
Mr. F. T thinks that as believers, we must refer to the Koran, because it teaches us everything. Family planning will only reduce the number of children, so it influences Islam, because we have a duty to increase the grandsons of the Prophet PSL. Birth spacing supported by modern family planning methods contradicts religious prescriptions according to religious leaders. However, if excessive fertility causes proven risks to the health of mother and children, or prevents parents from raising their children as agreed in Islam, Muslims would be allowed to regulate their fertility to limit these difficulties. On both sides, everything is centered on the male interpretations, on socio-anthropological beliefs and attributes. The choice of the number of children and the time of their birth should be consensual in the couple.
Sociocultural, economic and religious aspects are influencing factors to be included in the practice of FP in Pout. They tend to be minimized and in turn constitute pitfalls, latent sources of discouragement in some couples. These different male perceptions stemming from culture, religious beliefs or social attributes imposed on both women and men remain direct or indirect determinants of family planning. These barriers can prevent women from gaining the benefits of family planning even when rally needed.
Family planning has demonstrated benefits in terms of gender equality, maternal health, child survival and HIV prevention. It is a profitable investment on which all emerging countries must invest to give their populations a better quality of life. Indeed, high fertility has the effect of deepening poverty by slowing economic growth, increasing the costs of health care, education and other basic needs, lowering productivity and reducing income and family savings, so many obstacles to achieving the social sustainable development goals (SDG 1: No poverty, SDG 2: Zero hunger, SDG 3: Health and well-being, SDG 4: Quality education, SDG 5: Gender equality, SDG 8: Decent work and economic growth…).
4.2. Fertility and Demographic Dividend
The demographic dividend (DD) refers to the economic benefit that arises from a significant increase in the proportion of working-age adults to young dependents, resulting from the rapid decline in fertility if this is accompanied by sustainable investments in education and skills development, health, job creation and good governance. When fertility and mortality decline significantly, the age structure changes so that there are more working-age adults compared to young dependents in the population. This change can accelerate economic growth through increased productivity of the relatively large working-age population if the economy generates enough decent jobs, well-educated, skilled and healthy workers [20].
Better access to safe and affordable methods of contraception is essential to achieving SDG 3 (Health and well-being) and its targets. When a society manages to control its fertility, it can aspire to progress. Social needs are onerous burdens for both the public and private spheres. To acquire a quality of life, population growth must be in line with the health care capacities of each country.
5. Conclusions
The analysis of the social perceptions and representations constructed by the spouse on family planning allows assessment of the level of their involvement in the socio-cultural, economic and religious determinants.
From the analysis of the perception of the spouses regarding the participation of men in contraceptive practices, it appears that all the interviewees appreciated the participation of husbands in the social projects of couples.
Despite the positive attitudes of spouses participating in this study and their good level of knowledge about contraceptive methods, their involvement in family planning practices remains low. There are gaps to be filled on long-term contraceptive methods, on the quality of information, norms, values, ideas constructed from a social, cultural and religious point of view. These essential determinants of fertility control should be better integrated into family planning projects and programs. The social, cultural and religious attributes acquired with socialization are in some cases obstacles to rational birth spacing. In addition, the weights of religion, culture and social values are pressures that couple experience in their reproductive life.
The interest of focusing on the male target in interdisciplinary research would be useful to remove many ambiguities, and would help to better understand this practice which requires targeted, effective and efficient actions to achieve SDG 3 entitled “Good health and well-being for all” in particular its target 7 focusing on sexual and reproductive health; and lay the foundations for the demographic dividend.