The surprisingly low level of attention given to sexuality and sexual pleasure in the field of reproductive health is well documented. Philpott, Knerr and Maher comment on the absence of concern for sexual pleasure in HIV and STI programming and highlight the irrationality of this omission, given that the "pursuit of pleasure" is a key reason people engage in sex.^1(p.2030) Dixon-Mueller, in her pioneering 1993 article, criticized the family planning field for focusing exclusively on unplanned pregnancies, disease prevention and contraceptive use.² According to Dixon-Mueller, "a visitor from another planet would be mystified about sexual behavior if he/she/it were to depend on demographic and family planning journals for information."² She urged the field to understand the diverse ways sexuality is experienced and expressed. In particular, she advocated for a gender-sensitive approach, one that investigates how women negotiate their sexual behavior to increase pleasure and reduce harm, and how these negotiations influence their reproductive and sexual health decision making.²

However, 14 years after Dixon-Mueller’s writing, Higgins and Hirsch lament the continued "pleasure deficit" in the field, especially as it pertains to women.³ While acknowledging that we have increased our understanding of the impact of gender and class inequalities on reproductive health decision making, they argue that the public health community has failed to explore what constitutes optimal sexual functioning, especially for women, and how women’s pursuit of pleasure might be connected with high risk behaviors and outcomes.³ They point out that although studies have explored the links between male sexual desire and risk-taking, the field has largely ignored those between women’s pleasure seeking, libidos and ability to achieve orgasm and women’s sexual behaviors and decision making.³

In addition, Higgins and Hirsch maintain that the field’s exclusive focus on gender power differentials and inequalities, although much needed, has generated the untested notion that women like using condoms, whereas men do not.³ In their own study, conducted in the United States, they found that more women than men reported disliking how condoms felt during sex.⁴ A more recent study from the United States echoed these results and found that women complained about condoms hurting them during sexual intercourse, while men did not.⁵ Furthermore, Higgins and Hirsch contend that current behavioral models of contraceptive decision making consider women’s contraceptive use and choice of methods only in terms of access, effectiveness, ease of use and desire to use a contraceptive method, but ignore considerations of sexual pleasure.³

However, studies also caution against focusing on women’s pleasure-seeking behaviors in isolation. These studies indicate that women’s pleasure seeking is often influenced by their broader relational and social context, their desire for social affirmation and their economic dependence on men.^3–6 Higgins and Hirsch found that although pleasure mattered for women, these experiences were strongly interconnected with gender and social class.³ Hence, the authors contend that for a better understanding of women’s sexual needs, one must pay attention to the broader relational and social context within which these behaviors are nested; power dynamics at the dyadic level and gender inequalities at the structural level may be linked to behavior.³ For instance, their study found that women disliked using condoms primarily because it took away from male sexual pleasure, which in turn hampered their own sexual enjoyment. Another study from the United States examining the associations between class and gender and sexual risk-taking found that many poor and working-class women saw male sexual desire as innate, and believed its nonfulfillment could lead to ill health or aggression.⁵ These women spoke of using sex not just for sexual pleasure but also to avert infidelity, conflict and even violence.

In Sub-Saharan Africa, although there has been an interest in broadening understanding of the relationship context of contraceptive use, this research has primarily focused on partner characteristics and interpersonal variables such as couple communication, gender power differentials and household decision making.^7–10 Studies directly examining the associations between sexual pleasure and decision making on contraceptive use are sparse. A few studies on microbicide acceptability and condom use for HIV prevention raise concerns about sexual pleasure and the broader structural issues that affect it.^11–14 Although sexual pleasure was not their key focus, these studies touch upon the importance of sexual pleasure in relation to contraceptive method choice. Moreover, as in the West, these studies highlight that considerations of sexual pleasure, especially for women, are interconnected with broader structural realities.

In a study conducted in Malawi and Zimbabwe on microbicide acceptability, the female and male participants agreed that male sexual pleasure supersedes female sexual pleasure during sexual interactions.¹⁴ In fact, women were often ambivalent about the meaning of sexual pleasure for themselves and described it as the "absence of pain" rather than sexual arousal or experiencing orgasm. While providing sexual satisfaction was viewed as the female’s duty, for males, it was seen as a sign of vitality. The study participants also indicated that it was not uncommon for a man who failed to ejaculate to blame his wife for having a "wet or loose vagina" and accuse her of sexual infidelity.¹⁴ A related study from South Africa that explored female motivations behind vaginal practices such as dry sex discovered that women’s motivations were complex and primarily driven by their quest for stable relationships and to affect the course of love.¹² The authors argue that by adopting these practices, women hoped to enhance male sexual pleasure as a way to ensure male fidelity, avoid violence, and ultimately gain greater agency and control for themselves in the relationship.

Regarding condom use, several studies from Sub- Saharan Africa have found a dislike for condom use because of its perceived association with reduced sexual pleasure and casual sexual relationships.^15–17 For instance, across Sub-Saharan Africa, a common saying associated with the condom was that "one does not eat a sweet in a wrapper."^17(p.176) In addition, condom use among married couples was fraught with complications because of how sex is viewed within marriage. In fact, suggesting condom use in a steady relationship was often considered taboo and seen as a sign of infidelity.^18–22 A mixed-methods study in Malawi investigating the reasons for low condom acceptance among married couples found that while they viewed condom use as acceptable for sporadic extramarital sex, the study participants considered its use within marriage unacceptable.²² Condoms were seen as an intruder in the domestic sphere, where sex is supposed to be "natural" and "legitimate," sometimes referred to as a "natural candy." On a similar note, in a qualitative study from Ghana, the male participants were concerned that women who used contraceptives were more likely to be unfaithful and abandon their families.²³ The females, on the other hand, expressed their inability to ignore their husbands’ disapproval of contraception because of consequences such as denial of sex, one’s husband preferring another wife or even abandonment. In fact, across African samples, women speak of using contraceptives covertly because they fear their husbands’ disapproval.^24,25

Given these findings, there is a need to systematically investigate the links between sexual pleasure and contraceptive use, and the broader partner dynamics that affect it. In this article, using qualitative data from Malawi, we explore the relationship between male and female sexual pleasure seeking and male and female contraceptive use. We also investigate how partner dynamics are linked to these desires and are involved in contraceptive decision making and use.

Setting

Malawi is a landlocked country in southeast Africa, bordered by Zambia, Tanzania and Mozambique. The country is divided into three regions (northern, central and southern) and 28 districts. It ranks as one of the most densely populated and least developed of the world’s less developed countries.²⁶ Its economy is predominantly agricultural, with the majority of the population living in rural areas. It is one of the 20 poorest countries in the world.²⁶ Malawi was ranked low on the Human Development Index in 2012, positioned at 170 out of 187 countries and territories.²⁷ Among other key development and health indicators, the country’s per capita gross domestic product was as low as US$388 in 2014.²⁶ Female literacy is high; 86% of females aged 15–24 years have attended school. The average Malawian’s life expectancy at birth is estimated to be 55 years.²⁸

Malawi has seen an unprecedented expansion in modern contraceptive use, with uptake increasing from 28% in 2004 to 42% in 2010;^29,30 the majority (93%) of women who use contraceptives report that their husbands are aware that they do so.³⁰ However, 26% of women of reproductive age continue to have an unmet need.³⁰ In addition, the total fertility rate, the average number of children a woman will have over her lifetime at the prevailing fertility rate, is high in Malawi—5.7.³⁰

The lower status of Malawian women relative to men has frequently been discussed in the literature. In a Demographic and Health Survey (DHS) comparative study on the status of women in 25 countries, Malawi was ranked very low on the basis of a range of indicators including education, employment and marriage.³¹ According to the Malawi DHS conducted in 2010, 67% of women and 57% of men in the age-group 15–49 years were married or cohabiting, and 14% of women reported being in a polygynous union.³⁰ Although 20% of female adolescents in Malawi are in a formal union, only 2% of their male counterparts are in a union.³⁰ These gender differences in marital patterns suggest that many female adolescents are in relationships with older men, which has been shown to be disempowering for them.^32,33 Furthermore, women are four times as likely as men to be divorced, separated or widowed.³⁰ While only 7% of men and 1% of women reported having concurrent sexual partnerships according to the 2010 Malawi DHS,³⁰ a qualitative study conducted in 2013 across five districts of Malawi showed that participants perceived concurrent sexual partnerships to be extremely common in their communities.³⁴ The lower status of women relative to men in household decision making and access to health care has also been noted in the literature.^35–38

METHODS

This study was carried out as part of a larger qualitative research study conducted in Malawi between March and April 2012 to examine the dynamics of contraceptive use, especially the use of long-acting and permanent contraceptive methods. The study was conducted in two districts in the central region of Malawi, Kasungu and Dowa. Districts in the central region were selected because of the region’s relatively high contraceptive usage (48%).³⁰ Participants were recruited by fieldworkers, with the help of service providers and community representatives, from the catchment area of family planning clinics using a purposive sampling strategy and consisted of married females aged 18–49 and married males aged 20–50 who had some experience using modern contraceptive methods. To ensure socioeconomic diversity, data were collected in two nonpoor urban communities and one poor rural community in each of the districts. In Kasungu district, the two urban sites were Linga and Mankhaka and the rural site was Gogode. In Dowa, the urban sites were Wenela and Misi and the rural site was Msakambewa. The study was conducted in health facilities within the study communities. The health facilities were selected for their high family planning client load so that providers could link the research team with potential participants.

The data were collected using focus group discussions and in-depth interviews. A total of 23 focus group discussions were conducted among men and women (separated by sex) and 10 in-depth interviews were conducted among service providers. The focus group discussions explored social norms and participants’ attitudes about contraceptive methods, with a special focus on long-acting and permanent contraceptive methods. The in-depth interviews explored the dynamics of family planning use from the providers’ and supply side perspective. Although semi-structured focus group discussion and in-depth interview guides were used to conduct the larger study, no direct questions were asked to elicit responses on sexual pleasure and contraceptive use. Local researchers who had qualitative research experience were hired to conduct the sex-matched focus group discussions and in-depth interviews. The interviews and focus group discussions were conducted in Chichewa except in the few cases in which service providers indicated that they preferred to communicate in English. The discussions were recorded after obtaining permission from the participants. A note-taker was also present during each focus group discussion as a safety check. The focus group discussions each consisted of 8–10 participants and lasted an hour, on average; the in-depth interviews took an average of 30 minutes.

We analyzed the data using accepted qualitative techniques of identification of recurrent patterns and themes.³⁹ All audio recordings were transcribed and then translated into English. Focus group transcripts and interviews were read through by two coders to identify common events and categories that reoccurred across discussions. After conflicts were resolved, a coding system based on the identified categories was then developed. Following line-by-line coding, the coded texts were extracted from the focus group discussions and in-depth interviews and organized in a thematic matrix. The process was repeated and the data were reanalyzed to identify additional themes or patterns. This led to a set of overarching themes that captured the essence of female and male pleasure-seeking attitudes and their links with contraceptive use.

Ethical Considerations

The larger study within which this study took place was approved and cleared to proceed for data collection by the Research and Ethics Committee of the College of Medicine, University of Malawi. We followed standard ethical procedures in conducting the study. Once the study team ascertained the eligibility of the participant, a script was used to obtain informed consent prior to participation. Data collection was initiated only after participants understood the objectives and implications of the research and orally consented to participate. During data collection, no individual identifiers were collected from participants.

RESULTS

Study Participants

A total of 192 individuals participated in the study. The 182 focus group discussion participants comprised 132 females (69% of total participants) and 50 males (26% of total participants), while in-depth interviews were conducted with 10 service providers (medical assistants, community nurses and nurse-midwives; 5% of total participants). A majority (60%) of the participants were aged 25–39, 22% were younger than 25, and 18% were 40 or older. Forty percent of participants came from rural sites and 60% came from urban sites.

Overview of Themes

Sexual pleasure and satisfaction formed an important component of the study participants’ perceptions and experiences of using contraceptive methods and was considered in their decisions about contraceptive use. Although both female and male participants were interested in issues of sexual pleasure, we found differences in their concerns. The men were more likely than the women to discuss the sexual pleasure, or lack thereof, associated with a particular method. On the other hand, women’s experiences of sexual pleasure, more so than men’s, were intertwined with gender norms, their perceived role of providing pleasure in sexual relationships and the relationship dynamics these concerns generated. These issues ultimately created formidable barriers to contraceptive use or promoted contraceptive discontinuation.

Specific themes reappear in the data and illustrate the importance of sexual pleasure seeking in decision making on contraceptive use. These themes fall under two major categories: sexual pleasure and satisfaction, and partner dynamics.

Sexual Pleasure and Satisfaction

The effect that contraceptive methods have or could potentially have on sexual pleasure and satisfaction were important considerations in decision making on contraceptive use and method choice. In choosing a contraceptive method, the study participants evaluated the potential effect a particular method would have on their sexual interactions and on the amount of sexual intercourse they desired to have. Along these lines, the participants repeatedly described pleasurable sex as being "sweet," "spontaneous," "unplanned" and "uninterrupted," and they preferred to use methods that were the least obtrusive and preserved the nature and regularity of their sexual practices. This made long-acting contraceptive methods especially popular among some. According to one male focus group participant, "The method [implant] gives you peace of mind and you are at liberty to have sex anytime without the worry." A woman in a focus group discussion noted:

"With [the implant], you can just have sex freely, even at your farm, without the fear of being pregnant, while with condoms you cannot do it anywhere because sometimes you can forget [them] at home. So you are not free."

Given these preferences, methods that in any way limited the amount of sex a couple could have were deemed impractical. For instance, many study participants, especially the males, spoke of how rhythm and other methods that are based on periodic abstinence from sex were unfeasible and bound to fail. As one man in a group discussion said, "These other methods [traditional methods], I see that they are difficult to follow because you cannot say that I will abstain when you only have one bed in the house." Similarly, condoms and other methods whose use require planning were disliked because they made impromptu sex difficult and impeded sexual enjoyment. In a focus group discussion, a man noted that "the difference is that…you need [a condom] when having sex…and you need to prepare to have sex." In addition, withdrawal was perceived as breaking the flow of the sexual act, making prolonged sexual enjoyment difficult. A female focus group participant stated:

"The problem with withdrawal is that when you finish having sex, the husband comes out from you quickly to avoid coming inside you…you cannot be free with each other lovingly."

Furthermore, respondents saw the side effects, real or perceived, associated with modern contraceptive methods, such as bloating, weight gain, prolonged bleeding, and aches and pains, not just as discomforts but as very disruptive of their sexual lives and sexual enjoyment. For instance, several respondents shared how side effects such as the constant or prolonged bleeding associated with certain methods interrupted sex and, given their sexual needs, made it impractical for couples to continue using such methods. One man in a focus group commented:

"There [are] things that prevent couples from using the methods…for example, the other methods that are used cause the woman to be menstruating for a long period, maybe for a month, and there are some men who cannot stay without having sex with their wives for a month so they influence their wives to stop using the method."

Similarly, many study participants did not like using the IUD because they felt the method’s vaginal placement hampered sex, even causing pain to the male partner if his penis rubbed against the device. As a service provider noted, "Sometimes they come and say that when they are having sex with their husband, the husband feels pain because of that method."

Moreover, the study participants, especially the males, were greatly concerned about the impact modern contraceptive methods have on the females’ sexual appeal and sexual drive. There was a common belief that women who use modern contraceptives lose their sexual appeal. They were often described as lacking "sweetness," making them less sexually desirable to their partners. One male focus group participant said:

"Some of us…will tell the women that when you go for these medicines [hormonal contraceptives], you are no longer sweet during sex and sometimes we hear that women who are using the methods lose interest in sex. So they are no longer attracted to their husbands anymore."

As just noted, part of this reduction in female sexual appeal was attributed to a reduction of sexual desire among those using hormonal methods, making sex with them less exciting for their partner. A female group participant remarked:

"There is a belief that once you start practicing modern family planning methods, you lose sexual taste and our men might run away from us since they will not be feeling the same in bed as they used to feel before."

Similarly, the male participants were greatly concerned about the perceived influence of contraceptive methods on their own sexual appeal and sexual drive, making methods such as male sterilization unpopular. Many male participants were concerned that male sterilization hampers their ability to perform sexually, making them appear sexually "weak" to their partners. As one male focus group participant stated:

"We hear that there is male sterilization as one of the major family planning methods for men but most men in this area have not gone for it. We prefer that a woman should go for sterilization than us because if we go for it, we lose our manhood. We may not feel manly so all women will know that you are not man enough since you went for sterilization."

Some of the men also believed that male sterilization causes a general loss of sexual interest in women, taking the "fun" out of life. They described it as the "death of maleness." Service providers also pointed out that these beliefs were deep-rooted, making counseling on and acceptance of the method a challenge.

Partner Dynamics

Participants’ discussions of sexual pleasure and satisfaction were couched in terms of cultural and gender norms, as well as socioeconomic conditions. These norms and conditions can exacerbate relationship anxieties and make the adoption and continuous use of contraceptives challenging, especially for women. The normative acceptance of extramarital relationships and polygamy, coupled with the economic dependence of women on their male partners, makes it difficult for women to neglect issues of male sexual pleasure in their marital life. Repeatedly, the women spoke about how any reduction in male sexual pleasure and enjoyment, whether real or perceived, provides the men with an additional excuse to justify extramarital sexual activity and abandonment of their families. A female focus group participant noted:

"You stop [using a method] because you hear that when you are on family planning, you have unpleasant sex, so the husband starts having extramarital affairs. You decide that maybe you should be like the girlfriend, who is not on family planning, then maybe the husband will not go outside your marriage."

Hence, ultimately women must weigh these perceptions and attitudes, and balance concerns about sexual pleasure with the risk of unintended pregnancy or STIs, when making their decisions about contraceptive use. As a woman in a focus group commented:

"Sometimes, we do have the polygamous husband, who just impregnates several women…the men have lots of secret lovers and prefer to have children from each lady. With fear that the man might run away from the house, women are forced not to practice family planning methods."

Similarly, although less so than for the women, such fears were also prevalent among the men, and their decision making on contraceptive use also involved similar anxieties. The men said that they fear adopting a method like male sterilization because of its perceived impact on their sexual drive, which would ultimately encourage female sexual infidelity. As one man in a focus group discussion said:

"They say that the man has reduced sex drive [after male sterilization]. So when we hear such speculations, we are afraid…assuming the drive has really reduced and your wife knows it…then [she] starts going out because maybe she compares you now and before and she feels you are not there yet. So these issues bring it a lot of conflicts in the family."

As opposed to their own concerns about a reduced sexual drive because of method use, the men fear that women who use discreet methods become more sexually active and are more likely to become promiscuous. According to one male focus group participant, "Here in the village, when a woman inserts [the] loop, she sleeps around because no one will know and she will not get pregnant even without using condom."

These partner dynamics associated with contraceptive use were reiterated when participants discussed the benefits of female and male sterilization. These discussions highlight the links between perceptions about trust and commitment in a marital relationship and decision making on contraceptive use, especially for those who felt more vulnerable or insecure. For instance, given current gender norms, structural inequalities and the prevalence of extramarital sex, the adoption of sterilization was fraught with anxieties about partner abandonment, especially for females. However, at the same time, both the female and male participants viewed adoption of sterilization by a partner as signifying deep love, trust and commitment in a relationship. For example, a male discussant shared that by adopting male sterilization, a man is indicating his love for his wife and his desire to be faithful to her, increasing her trust in him. Participants felt that a man would adopt male sterilization only if he was absolutely sure that he only wanted the relationship with his current wife and was not looking for relationships with other women. As one male group participant stated, "A man can go for sterilization because of the love he has for his wife…. It gives trust to the woman that you are faithful to her if you go for sterilization." Similarly, a female participant said that for females too, adoption of sterilization is possible only if they trust their husbands because otherwise they would worry about divorce and the attendant need for remarriage and additional children. A female focus group participant stated:

"It also depends on the trust that the woman has for her husband because if the husband is not faithful, she will think that anytime my marriage will break. So, I might have to remarry and in the new marriage, I will need children. So, she cannot go for sterilization unless she trusts her husband."

DISCUSSION

Our study calls attention to the importance of sexual pleasure in decision making on female and male contraceptive use. Invariably, the study participants’ discussions on choice of method emphasized certain themes. The study participants were concerned about the logistics involved in adopting a method and how specific methods could affect the quantity of sex desired. In addition, the participants were concerned about the potential impact a method would have on the quality of their sexual encounters, its influence on their own or their partner’s sexual desire and libido, and the experience of "sweetness," or pleasure, in sex.

Prior studies indicate that "sweetness" is a common metaphor used to describe sexual pleasure in parts of southern and southeastern Africa.^17,40–42 According to these studies, although "sweetness" broadly refers to sexual pleasure derived during sexual intercourse, it sometimes also signifies the timely mixing of female and male ejaculate during sexual intercourse, which is perceived to bring optimum sexual pleasure and is viewed as the goal of sexual intercourse.^17,43 Specifically, in Malawi, a qualitative study exploring sexuality among the aging underlined the importance Malawians place on sexual desire and articulated the importance of "sweetness" or sexual pleasure in romantic relationships.⁴³ Sexual desire was understood to be a necessary element of marital and nonmarital romantic relationships, and was viewed in terms of pleasure and well-being. In fact, the study participants viewed those who did not desire sex as "ill" or "dead."

Moreover, prior studies suggest that perceptions of what constitutes sexual pleasure and the ways to achieve it are often context specific.^17,43 For instance, a study investigating condom use observed that although condom use is disliked both in the West and in Sub-Saharan Africa because of its effect on sexual pleasure, the way it affects sexual pleasure is perceived differently in the two contexts because of differences in local notions of pleasure and ways to achieve it;¹⁷ this needs to be given special attention for the designing of suitable interventions. In the West, where the focus of sexual intercourse is the movement and friction leading to orgasm, condom use is disliked because it reduces physical sensation by preventing direct contact. In contrast, in Malawi, according to the study, condom use is problematic because it does not allow the mixing of bodily fluids, which is considered the essence of sexual pleasure.¹⁷

Interventions need to recognize the ideas associated with specific contraceptive methods to successfully promote those methods. Our study emphasizes that these attitudes on and practices for the attainment of sexual pleasure are associated not only with condoms but with all contraceptive methods, and form a critical component of Malawian couples’ contraceptive choices and decision making. Additional research is required to broaden understanding of how these notions of sexual pleasure correlate with specific contraceptive methods and make the consistent use of methods challenging.

Our study suggests that decision making on contraceptive use is a complex calculus in Malawi and goes beyond such commonly investigated issues as method access, method effectiveness, desire to prevent pregnancy and female negotiation skills. Weighing current relationship dynamics, perceived levels of trust and commitment in a relationship, and how a method could affect these dynamics through its impact on sexual pleasure is important in decision making on contraceptive use. A potential explanation for these concerns and the associated behaviors could be the deep-rooted fear of one’s partner having extramarital sex or of losing one’s partner, which appeared to be widespread among study participants. The negative impact—real or perceived—of contraception on sexual pleasure exacerbated relationship anxieties and made the adoption and continuous use of contraceptives very challenging. Although both female and male participants expressed these anxieties, the females appeared more likely to face actual repercussions. For instance, the male participants seemed to simply avoid adopting male sterilization because of its perceived impact on sexual pleasure and manhood. The females, on the other hand, felt the need to evaluate the reduction in male sexual pleasure associated with a method against pregnancy risk and other concerns because the threat of abandonment by their spouse was a reality in their lives. However, a positive finding from our study hints that, despite these social constraints, couples in relationships high in trust and commitment are better able to negotiate and follow their contraceptive choices.

A limited number of studies from Sub-Saharan Africa, mostly exploring the acceptability of microbicides and use of condoms for HIV prevention, have also emphasized how method choice is driven by consideration of sexual pleasure, especially male sexual pleasure, and how these concerns have to be understood in the context of couple dynamics and broader gender norms.^12,14–16 Moreover, male opposition is commonly viewed as an important component undercutting the adoption and consistent use of contraception in Sub-Saharan Africa.^23,44–48 Our study expands on this knowledge by showing that these considerations are strongly linked with broader structural and gender inequalities that generate a culture of mistrust and vulnerability, making it hard for couples to take advantage of available contraceptive choices. By highlighting the importance of relationship dynamics, our study emphasizes the need to better understand family planning needs and the challenges facing couples by viewing them through the lens of inequitable gender roles.

From a policy and programmatic perspective, these findings, like those of prior studies,⁴⁹ indicate that couple-level approaches could be critical for targeting and helping spouses fulfill their contraceptive needs. These findings also point to the urgent need for family planning programs to gain a better understanding of their clients’ behaviors by recognizing their social and personal contexts. Such an approach will allow family planning programs to help women and couples better satisfy their contraceptive needs and protect themselves from harm. Along these lines, studies from rural Malawi that examined the links between social interaction and HIV prevention and contraceptive acceptance have emphasized the importance of understanding the realities of women’s lives and the strategies they utilize to balance competing social, familial and health goals.^36,50 These studies also show that understanding women’s strategies from their perspective can be helpful in designing interventions that support positive health behaviors.

Our study has several limitations that merit discussion. Because participants were recruited from the catchment area of family planning clinics, our sample potentially has a large representation from individuals who were former or current users of modern contraceptives and were generally favorable toward modern contraception. Another issue potentially affecting the validity of our findings was the possibility for participant reactivity or interviewer bias in the interactions between discussants and researchers. To minimize these effects, we recruited local data collectors and provided them with extensive training. Also, we collected detailed, rich data to get a comprehensive account of the participants’ experience.⁵¹ Because this study was part of a larger study focused on contraceptive use, we were unable to conduct an in-depth exploration of the meaning of sexual pleasure in this context that would have allowed additional understanding of the dynamics surrounding contraceptive practices.

Despite these limitations, our study has several strengths. It explores a pioneering research area, especially in the Sub-Saharan African context. Our study highlights the relevance of understanding the interaction of sexual pleasure and multiple methods of contraception to better serve the family planning needs of Malawian couples. Moreover, by collecting data from both women and men, we were able to capture gender differences and have a more comprehensive understanding of contraceptive use within the context of male-female relationships.

Conclusion

To better tackle unmet need, family planning programs need to help researchers, program managers and policy makers increase their understanding of the nuanced ways notions of sexual pleasure, partner dynamics and the broader social context are linked to decision making on contraceptive use.