Since the 1994 International Conference of Population and Development (ICPD), policymakers have expressed great commitment to moving away from demographic targets toward a broader focus on human welfare, individual choice and gender equality.^1,2 Similarly, reproductive health practitioners have recognized that the failure to target men has weakened the impact of family planning programs, because men can significantly influence their partners' reproductive health decisions and use of health services,^3,4 especially in societies where women do not possess the same decision-making powers as men. However, gender-sensitive strategies have been neglected and, to a large extent, family planning programs have remained female oriented.^5–7 The literature on men's role in reproduction has increased in recent years,^8,9 but much of it has focused on demography and fertility. Research is still limited with regard to males' knowledge and perceptions of and attitudes about family planning, contraceptive use and preferences.¹⁰

Family planning programs implemented in India between the late 1970s and 1990s focused on bringing down fertility levels through vertical programs that emphasized demographic targets and advocated sterilization as the principal family planning method. However, in the spirit of the ICPD, and as a result of dissatisfaction with the overemphasis on demographic targets, insensitivity to client needs, low demographic impact, violation of reproductive rights, neglect of quality and stagnation of the program, India has since made major policy changes.¹¹ In 1996, the government initiated the target-free Community Needs Assessment Approach, which involved formulating plans in consultation with communities.¹² The National Population Policy 2000 clearly set out the demographic goals of the country, but these goals are to be achieved within the framework of gender equity and social development. India thus launched a comprehensive family welfare program, in which all population groups are involved and all modern family planning methods are advocated.¹³ However, according to the latest National Family Health Survey (NFHS-3), two out of three married Indian women aged 15–49 who practice contraception still use female sterilization.¹⁴ In rural areas, the proportion is even higher, with 70% of contraceptive users relying on female sterilization. Overall, 37% of all married Indian women of reproductive age are sterilized.

The present study was conducted in the central Indian state of Madhya Pradesh, one of the country's least developed areas.¹⁵ Family planning programs in Madhya Pradesh have traditionally focused on women, but because of their subordinate status, women are often not able to make their own decisions regarding family planning or health care in general. Therefore, understanding the role of men as "gatekeepers" of family welfare is critical to the success of family planning programs. The aim of this study was to examine how men in rural Madhya Pradesh understand and perceive family planning, paying special attention to male knowledge, perceptions, decision making and reliance on female sterilization.

METHODS

Study Setting

The study was conducted in Sehore and Raisen, two districts of Madhya Pradesh. The state has a total population of 60.4 million people, of which about 73% reside in rural areas. According to the NFHS-3, the total fertility rate is 3.12 for the state overall and 3.34 for rural areas, which are higher than the comparable national rates of 2.68 and 2.98, respectively.¹⁴ About 70% of the residents of Madhya Pradesh depend on agriculture for their income. The sex ratio at birth is 933 females per 1,000 males, the birth rate is 32.3 per 1,000 persons, and about 50% of women and 70% of men are literate.¹⁶

Data Collection and Analysis

The data were drawn from a larger study, "Male Involvement in Reproductive Health in Central India," conducted to identify strategies for positively influencing men's reproductive health–seeking behavior, including participation in fertility regulation, practice of safe sex, support of maternal and child health, and prevention of unwanted pregnancies.

We used a multimethod approach, including focus group discussions and a cross-sectional survey, because we believed that a study of a little-researched phenomenon, in this case male involvement, would benefit from varied methods and contexts. The focus groups and the survey represented public and private contexts, respectively. In addition, the survey enabled generalization of findings emerging from the focus groups. Combining the two methods also helps to bring into focus the varied social aspects of fertility and broadens our understanding of the social mechanisms of demographic phenomena, which are often difficult to capture through surveys.¹⁷

Data collection occurred in three phases between November 2004 and August 2005: pilot testing of data collection tools, focus group discussions and the survey. Currently married men with spouses of reproductive age (15–45 years) were eligible to participate in the study; those who took part in a focus group were excluded from the survey. Informed consent was obtained from each participant.

For the present study, both men whose wives had been sterilized and those whose wives had not were presented with questions regarding their perceptions of female sterilization, decision to adopt the method, use of the method and the chief family planning decision maker in the family. The responses of men whose wives had been sterilized reveal their experience with making actual decisions; the responses of others provide information about the expected norms in sterilization decision-making situations.

• Focus group discussions. To gather a homogeneous group of men who would provide credible information about practices and norms in their community, we used snowball sampling¹⁸ to recruit participants—men currently married to women aged between 15 and 45—in the seven villages included in the study. Overall, 58 men agreed to participate. Discussions were conducted in the local language (Hindi), and lasted approximately two hours. Two experienced male moderators facilitated the discussions. The principal moderator used a pretested guide to direct the discussion, while the co-moderator noted nonverbal cues observed during the discussions. Focus groups were tape-recorded, transcribed verbatim in Hindi and then translated into English. To validate the tapes, we checked them against the translated text for inaccuracies. Data were analyzed by qualitative content analysis, using Atlas TI software.

• Cross-sectional survey. We used findings from the focus group discussions to develop the survey questionnaire, which aimed to quantify and complement the qualitative information.

In each district, villages were randomly selected by first identifying those with a population of at least 1,000 people; the decision to select larger villages was based mainly on logistical reasons. For selected villages, we obtained the best estimates available of female literacy.* Villages in each of the two districts were divided into low, medium and high literacy levels; four villages were randomly selected from each group, resulting in a total of 24 villages. We used a systematic sampling method with a random start for the selection. Because of resource and time limitations, it was not possible to carry out a detailed household listing within each village, so the most up-to-date voters' list was used as a sampling frame.^† About 30 households with eligible men were selected from each village using random sampling with a random start, resulting in a sample of 793 respondents.

Twelve male postgraduate students with social sciences background were recruited from the local state university to be research investigators. Once trained, the research investigators conducted a household survey with the selected men. The survey questionnaire asked men about their socioeconomic and demographic characteristics, sources of family planning information, understanding and usage of family planning, and knowledge and perceptions of reversible contraceptives and female sterilization. The instrument was pretested extensively in areas comparable but not adjacent to the study sites. Because the interviews required privacy, the investigators would take respondents outside of their houses, if necessary, to an area in or around the village where they would not be disturbed. Each participant gave oral informed consent after being provided with details of the purpose of the research. A 10% back-check of questionnaires per village was carried out by research supervisors, who also scrutinized all questionnaires on the same day that they were filled, to check for completeness, consistencies and clarity of marked codes. Data were analyzed using SPSS (13.0).

RESULTS

Background Characteristics

The average age of survey respondents was 30.6 years (Table 1). Half of men reported having less than a secondary level education. Nearly all (94%) were Hindu; among Hindus, 60% belonged to the locally dominant lower caste administratively labeled as "other backward classes." Two-thirds of men depended on agriculture for their source of living. Thirty-eight percent reported a monthly family income of below 1,000 rupees, 39% between 1,000 and 2,500 rupees, and 23% above 2,500 rupees.^‡

Nearly all men (98%) had heard of contraceptives. Twenty-nine percent reported currently using a temporary family planning method. Thirty-four percent relied on female sterilization; of these, two-thirds reported that female sterilization was the first method of family planning they had ever adopted, and one-third had used a spacing method before sterilization (not shown).

On average, men were 20 years old at marriage. About half (52%) reported having a family that consisted of more than just the couple and their children. Men's mean number of children ever born and living were 2.8 and 2.5 respectively (not shown); on average, they had 1.8 living sons and 1.7 living daughters. The average number of living children among men whose wife was sterilized was 3.4; the number among men whose wife was not sterilized was 2.1.

Overall, such background characteristics as education, age, number of children and caste of the focus group participants (not shown) were no different from those of the survey respondents. The age of the discussants ranged from 22 to 39 years (average, 30.8). About half of focus group participants had less than a secondary education; only 7% were illiterate. The majority were Hindus who belonged to other backward castes.

Male Concepts of Family Planning

According to the focus group discussions, men were familiar with the local terms for contraception, but their understanding of the terms was different from the definitions used in government family planning communication campaigns. For example, the government uses the term "garbha nirodhan" to mean any form of contraception, including sterilization; however, men understood this term to be a means of spacing or delaying pregnancies, not including sterlization. Similarly, the term "garbha nirodhak sadhane" is used by campaigns to refer to all forms of family planning methods, including permanent procedures; however, men understood it to refer only to temporary modern contraceptive methods, such as the pill and condoms. Finally, most men commonly understood the general term for family planning, "parivar niyojan," to be synonymous with sterilization—a method adopted once one's desired family size is reached, involving an operation that permanently stops further births. As one discussant said:

"Parivar niyojan is done after we have our desired number of children."—32-year-old, fifth-grade education

Another focus group participant commented:

"About parivar niyojan, I only know this much, that by getting the operation (sterilization) done, conception stops and children are not born afterwards."—33-year-old, 12th-grade education

Furthermore, the general term for sterilization "nasbandi," which literally means "tying the tubes," was mainly used by men in the focus groups to mean the more popular "mahila nasbandi" or female sterilization.

Family Planning Knowledge

Among men who participated in the survey, 81% mentioned, unprompted, at least three methods by which conception can be either delayed or avoided (Table 2). Ninety-seven percent mentioned condoms, 85% the pill and 83% female sterilization. Among those who spontaneously mentioned female sterilization, 35% mentioned it as the first option (not shown). Another 15% confirmed awareness of female sterilization when asked specifically whether they had heard of it.

Although men could name various family planning methods, the qualitative data revealed that their knowledge of the methods was superficial. Men commonly mentioned their limited information about contraceptive methods and asked the moderator to provide a more accurate explanation. One discussant said:

"We do not know what family planning is, so what will we tell you? You tell us, then."—30-year-old, no education

Another participant commented:

"Parivar niyojan is this only, that there should be a small family, there should not be children in great numbers, what else? It means nasbandi."—33-year-old, seventh-grade education

When they were asked by the moderator if they had heard about about any methods other than nasbandi (sterilization), one man responded:

"We know of other means, but no one has adopted them.—26-year-old, seventh-grade education

Another commented:

"We only use nasbandi.—38-year-old, fourth-grade education

And another said:

"There are many things. We don't even know what they do properly. Now you tell, only then will we come to know."—28-year-old, 10th-grade education

Primary Source of Family Planning Information

According to the survey, men most commonly learned about family planning from the mass media, with 58% reporting television or radio as their primary source of information. Only 24% reported receiving information primarily from village health workers, 9% nongovernmental organization workers, 7% friends and 2% family or other sources.

During the focus groups, men indicated that women had better and more direct access to information through the village health workers. As a result, men sometimes saw their wives as important sources of information on family planning. One man said:

"The ANM (auxiliary nurse midwife) gives [information] to the women only. Our wives sometimes discuss with us about what they learn from [her]."—30-year-old, 10th-grade education

Peer groups were another important source of information. One discussant said:

"We get some information from our friends in the village. The one who knows, tells….Other people hear of it and then come and tell us, and we then tell some others, and so on."—28-year-old, 10th-grade education

Furthermore, as in the survey, men in the focus groups cited television as an important information source, but also addressed their urgent need for more direct and personal contact with someone knowledgeable:

R1

Sometimes [they] give information on television also.—27-year-old, eighth-grade education

R2

Yes, TV is important but we have so many questions on parivar niyojan. Whom do we ask?—35-year-old, seventh- grade education

M: Besides TV and friends, do you get information from anywhere else?

R1

We get to know a lot from this type of discussion, like the one we are now having.

R2

Like you people have come, if [people] keep coming like this, give us information, we will get information and become aware….And if we have any problems or questions, we could ask them.

Discussions from another focus group also brought out the need for more interpersonal communication on family planning—28–38-year-olds, average 8.0 years education:

R1

As such, sir, there should be a health center in the village.

R2

Or at least, sir, someone who knows should come and talk to us about these issues.

R3

Now when there is no one, if there is a problem, who do we ask?

R4

[We] should keep getting information from people who are knowledgeable.

Reasons for Female Sterilization Preference Among Men

The vast majority (93%) of men who were not relying on a permanent method at the time of the survey indicated their willingness to adopt sterilization in the future, including 79% who said their wives would adopt female sterilization (Table 3). Only 2% of men were unwilling to adopt either type of sterilization, and 4% were not sure (not shown). The main reasons cited by men who said their wives would adopt female sterilization were that "only women undergo sterilization and not men" (31%) and that "it is the wish of the husband [that the wife gets it done]" (19%).

In the focus group discussions, men also cited social and cultural reasons for adopting female sterilization. For example, one man stated:

"Men work hard for the family, while women stay at home."—25-year-old, no education

And another man said:

"If I get it done, people will laugh at me and say, 'Why are you doing the women's thing?'"—32-year-old, eighth- grade education

And regarding the economic implications, a discussant stated:

"If we do not get [female sterilization] done, there will be more children, the family size will increase and then there will be many more problems."—37-year-old, eighth- grade education

Male Sterilization

Most men did not consider male sterilization, or "purush nasbandi," to be a feasible option. In the focus group discussions, when the moderator would try to begin a dialogue on male sterilization, men would often steer the discussion toward female sterilization. One respondent stated:

"Male sterilization is...very unpopular. Due to inadequate information, people talk of various side effects of the method like men become weak, men cannot do any heavy work, limbs become weak and painful, and men get cold and fever."—33-year-old, seventh-grade education

Another man said:

"We are willing to get operated. But someone will have to give us complete information about the method, convince us that there will be no problems with it; that a man does not start lacking in anything [become impotent] after the operation."—28-year-old, 10th-grade education

Men went on to state that male sterilization is almost never discussed, either with women or men. "Why talk about male sterilization when women are ready to get sterilized?" was a common response among discussants. This partly reflects the fact that male sterilization is not often brought up as an option by the local health workers.

Perceptions of Dissatisfaction: Female Sterilization

Despite female sterilization being the most common currently or potentially used method among men's wives, men voiced dissatisfaction with the method, including certain undesirable side effects or method failure. For example, one discussant commented:

"We know that female sterilization has failed in many cases. Women have conceived even two years after getting [an operation]." —29-year-old, seventh-grade education

In the survey, both men whose wives had been sterilized and those whose wives had not done so spontaneously reported perceiving specific negative side effects associated with sterilization, like general weakness and excess weight gain (Table 4). Thirty-seven percent of men with a nonsterilized wife believed their wife would not experience any changes if she were sterilized or said they were not sure if any such changes would occur; none of the men whose wife had been sterilized reported no changes after sterilization or not being sure.

In some focus groups, men stated that weakness was a side effect of the method:—28–36-year-olds, average seventh- grade education:

M: Do you know about female sterilization?

R1

Yes, [we] know. Here, a Silawat [caste] has had it done. Earlier, his wife looked very nice and healthy, but after the operation [sterilization], the poor wife has absolutely become very thin, almost all skin and bones. The poor husband is very troubled.

R2

Yes, sir. Weakness sets in with female sterilization.

R3

There are complaints of back and stomach pain, too.

Men's Roles as Family Planning Decision Makers

Although men felt that they did not have enough or accurate information on temporary methods or tubal sterilization, about one-third (31%) of survey respondents reported that they themselves were the main decision makers with regard to reproductive health (not shown). Fifty-eight percent of men said that they made such decisions jointly with their wife. Small proportions (2–3% each) of men said that their wife alone or one or both of their parents made reproductive health decisions.

The results of the focus groups were somewhat different than those of the survey. During discussions, men represented themselves as the main decision makers, both with regard to general household decisions and family planning acceptance. For example, a 28-year-old with 10 years of education who had been married for six years stated "In my family, only one brain works, and that is mine. So, if there are any decisions, it is I who make [them]."

DISCUSSION

In rural Madhya Pradesh, female sterilization has remained the predominant method of contraception, despite long-term efforts by the government to promote other methods. Our experience in implementing a comprehensive reproductive health program in the area in 2001–2005 revealed a need for greater clarity on how couples viewed family planning and the role men played. Although men's knowledge, attitudes and perceptions in regard to family planning have received some attention in India,¹⁹ the current literature does not address men's conceptualization of family planning. According to our results, men conceptualize family planning in ways different from the government family planning promotion campaigns. An understanding of local terminologies and concepts used by men would help policymakers and program planners devise and implement more effective strategies to promote reversible contraceptive methods.

Males' knowledge of temporary contraceptive methods was mostly limited to their names. Similar to findings from the 2005–2006 National Family Health Survey, the results of our survey show that mass media were men's primary source of family planning information. In addition, our findings are in line with a national report indicating that half of men are exposed to such messages through television and radio, and fewer than one-fourth receive information through interpersonal communication with health workers.¹⁴

Thus, our results confirm that in Madhya Pradesh, family planning messages have seldom been aimed at men and suggest that it would be beneficial to use multiple channels for information dissemination. Television and radio may be major sources of information, as they are very popular among the rural population; however, mass media messages tend to be rather generic, and viewers are unable to ask questions and have their doubts clarified. Even though few men received information from health workers, they said they wanted more interpersonal discussions with knowledgeable persons. Some men mentioned getting information from their wives, who are the primary recipients of family planning information in the villages. This underlines the importance of couple communication in family planning, as well as the need to ensure that both men and women in the community have full and accurate information.

Although the Indian Family Planning Program has adopted new policies over the last 15 years (for example, the target-free approach in 1996 and the National Population Policy in 2000), it continues to be skewed toward female sterilization. Female sterilization is still the most frequently used contraceptive method in Madhya Pradesh— used by 47% of all currently married women aged 15–49.¹⁴ Overall, in our study, female sterilization was the most common method among those practicing contraception and the method mentioned most often by those intending to use a method. Also, for most couples who had adopted it, female sterilization was the first method ever used. This confirms that couples rarely either delay their first birth or space subsequent births.

Men's reasons for opting for female sterilization were based mainly on social norms that assign the burden of family planning to women. Men claimed to be influenced by social, cultural and economic factors, as well as by peer pressure, to get their wives sterilized. One of these factors, according to men, is that women do not do labor-intensive work and mostly stay at home. In addition, men were apprehensive about male sterilization, believing that it would lead to weakness and worrying that something might go wrong during the procedure. These findings are similar to observations in Uttar Pradesh.²⁰ Men feel that the sterilization operation is easier to perform on women than on men,²⁰ although vasectomy is in fact a safer and less invasive procedure than tubal sterilization.²¹ Furthermore, men say that the predominance of female sterilization results from lack of sufficient information about other contraceptive choices, and is not always based on the method's desirability per se.

Both men whose wives had been sterilized and those whose wives had not done so talked about understanding the physical hardships women face on account of sterilization. Men expressed concern for their wives and often perceived that their wives experienced side effects from sterilization; such responses are similar to those previously reported in rural India.²²

Although these ideas may, at least in part, be based on myths, rumors and misconceptions about the method, the men in our study displayed their concern about, or at least their consciousness of, potential negative effects of sterilization on the physical well-being of their wives, as opposed to the normal perception of rural Indian men as callous and unconcerned about women's health. However, to make an informed choice, men need to be better educated, so that they can dispel myths and rumors about side effects associated with female sterilization.

According to our survey results, only one-third of men reported being their family's sole decision maker in regard to family planning issues. In front of other men in the focus group discussions, however, men more often presented themselves as the main decision makers. In many rural settings, males often dominate decision making on important family matters, including those concerned with reproduction, family size and contraceptive use.^20,23,24 Recent reports suggest men have a strong interest in family planning and other reproductive health issues,^24–26and if educated about women's and men's reproductive systems, contraceptive methods and access to specific services, men may be encouraged to involve their wives in discussions and together make reproductive health decisions.⁷ Our study corroborates these findings.

CONCLUSIONS

Although men are aware of various family planning methods, they do not have adequate information about all available methods. This results in most men encouraging their wives to adopt female sterilization, as it is the method most often discussed in the community. It is therefore important to equip men with complete contraceptive information and correct their misperceptions about methods so that they and their wives can choose the method that is best for them.

To achieve this goal, policymakers and program planners need to understand local concepts, experiment with multiple information channels and design strategies for reaching men. In addition, programs must continue to encourage couple communication, so that couples' family planning decisions are made jointly. Some potential strategies suggested by our findings for involving men in family planning programs involve face-to-face dissemination of information by knowledgeable persons, encouraging couple communication within communities, training male health workers to discuss family planning with male groups, and strengthening access to and availability of reversible methods, so that dependence on female sterilization is reduced.