The Sexual, Marital and Fathering Behavior of Men in Sub-Saharan Africa 1

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1 The Sexual, Marital and Fathering Behavior of Men in Sub-Saharan Africa 1 Akinrinola Bankole 2, Susheela Singh, Rubina Hussain and Deirdre Wulf The Alan Guttmacher Institute 120 Wall Street New York, New York, Abstract Understanding men s sexual and reproductive preferences and behaviors as well as their roles as partners in sexual relationships, marriage and family building is essential to address their sexual and reproductive health information and service needs. Identifying and meeting these needs are crucial because the more informed and more effective men are in living safer and more fulfilling reproductive lives, the better it will be for not only them, but for their families as well. The sexual and reproductive behaviors and health needs of men aged in 22 Sub- Saharan countries were examined using nationally representative data collected in these countries by the Demographic and Health Surveys (DHS) between 1994 and 2001.The study found that the years between first sex and marriage represent a period of enhanced risk of STIs and premarital pregnancy for many sexually active unmarried men in Sub-Saharan African (SSA). Men in SSA want and have large families. At age 40 54, men have had seven or more children in 14 of 21 countries with data, and about six children in the remaining six countries. However, desired family size is declining: Men want fewer children than do men in their early 50s around 4 6 children compared with 6 10 and more, respectively. Although substantial proportions of sexually active men have more than one partner, the majority are not using condoms to prevent HIV/AIDS and other STI. Men in SSA need targeted information to help them make informed choices in their sexual and reproductive behaviors. Men also need information to help them meet their responsibilities as husbands and fathers. Men, especially those who live in areas with high prevalence of HIV/AIDS and other STIs, need better access to condoms and health services for the prevention, diagnosis and treatment of STIs. If these information and services are put within the reach of men, the gains for them will inevitably be gains for their partners and children. Introduction Largely as a result of HIV/AIDS a worldwide problem but one that has affected Sub-Saharan Africa the most severely the family planning and reproductive health field is now paying more attention than in the past to men's sexual and reproductive behavior. This is a welcome development because men have health care and information needs in these areas that have long gone unrecognized. It is also a positive trend because attention to men's 1 Acknowledgments: The authors thank Patricia Donovan, Beth Frederick, and Jennifer Nadeau and two anonymous reviewers for reviewing earlier drafts of this report and for their valuable suggestions. The research leading to this report was made possible through a grant from the Bill and Melinda Gates Foundation. 2 Akinrinola Bankole is Associate Director for International Research, Susheela Singh is Vice President for Research and Rubina Hussain is Research Associate at The Alan Guttmacher Institute. Deirdre Wulf is independent consultant.

2 22 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 roles and needs in sexual relationships, marriage and family building will have substantial benefits for their partners, wives and families particularly in the urgent area of HIV prevention. In an attempt to fill the information gap surrounding men's roles as sexual partners, husbands and fathers, this paper provides an overview of the sexual and reproductive health behavior and needs of men aged in 22 Sub-Saharan African countries. Data Sources Unless indicated otherwise, this paper is based predominantly on analyses of 22 Demographic and Health Surveys (DHS) carried out in Sub-Saharan Africa between 1997 and The DHS looked at the sexual behavior, contraceptive practice, knowledge of sexually transmitted infections, including HIV, condom use, union formation, fathering, pregnancy prevention and fertility preferences among men (15 59 in a few countries). The paper presents information on 22 countries that account for about 77% of all men in Sub-Saharan Africa. However, no countries in Southern Africa are represented in this overview because the data for these countries are lacking. The paper also uses findings from a wide range of studies both quantitative and qualitative dealing with issues not necessarily covered by the DHS (abortion or attitudes to condom use, for example). Additional sources of information include UNAIDS, the World Health Organization, the United Nations Development Programme, the United Nations Population Division and data from censuses, international research and health organizations. Readers seeking more extensive analysis or a or more detailed bibliography may go to the web site of The Alan Guttmacher Institute ( and follow the links to the full publication on which this summary is based: In Their Own Right: Addressing the Sexual and Reproductive Health Needs of Men Worldwide. The Context of Men's Lives In Sub-Saharan Africa, as in every other region of the world, men's sexual, marital and reproductive behavior does not exist in a vacuum. Rather, a wide range of social, cultural and economic factors shape expectations of men's behavior and their actual behavior as partners, husbands and fathers. Paramount among these factors are the high proportion of the population living in rural areas, the influence of worsening overall health conditions, particularly because of HIV/AIDS, the impact of recent trends in urbanization and internal migration, generally low levels of education, widespread poverty and the impact of some aspects of rapid social and cultural change.

3 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 23 Urbanization continues apace throughout the SSA region, as a result of many factors, including high unemployment and poor educational and work opportunities in rural areas. In some war-torn or drought-ridden countries, many rural residents, particularly the young, move to urban areas in search of a more secure and better life. Yet in all countries except Gabon, less than half the population live in urban areas, although this proportion has increased rapidly over the past 30 years (Appendix Table 1, column 2), Levels of schooling among men living in SSA are low. In 10 of the 22 countries covered, the vast majority of men in their early 20s have no more than a primary education (see Appendix Table 1, col. 3), although educational achievement is improving, especially in urban areas. In addition, life expectancy for men is low (the mid-30s to the mid-50s) and even declining in some countries hard hit by the HIV/AIDS epidemic. Moreover, health, communications and transportation infrastructures are underdeveloped. For example, in Ethiopia, there are 25,000 people for every trained physician (compared with 609 in Great Britain). No more than six in 10 households in most SSA countries own a radio, and access to other media is even more limited. Many countries in Sub-Saharan Africa are among the poorest and least economically developed in the world, with annual average gross domestic product per capita ranging from $523 a year in Tanzania to $2,635 in Zimbabwe 2000 (Appendix Table 1, col. 4). (Gabon, a very small country with an annual per capita GDP of over $6,000, is not representative of average wealth levels in the rest of the region.) In some parts of the developing world, social and economic change or instability and the effects of rapid modernization can erode prevailing cultural and community norms regarding many aspects of men's behavior including their sexual and health-seeking behavior and their treatment of women and can sometimes undermine men's traditional family roles as providers. In industrialized countries, research has drawn links between pervasive conditions of cultural and economic disadvantage and some kinds of reckless behavior among men. Pervasive poverty and diminished life prospects can foster violence, hopelessness and patterns of sexual promiscuity, and may offer little incentive for some people especially young men to take good care of themselves. The World Bank estimates that in Sub-Saharan Africa in 2000, about 13% of years of life lost to premature death or disability among men are attributable to traffic accidents, violence, war and self-inflicted injuries a much higher proportion than in the rest of the world (World Bank Dalys Tables). Yet social conditions in Sub-Saharan Africa are improving in some important aspects. And, as in other parts of the developing world, improvements in educational achievement, urbanization and increased exposure to a wider world and to information programs about the risks of unsafe sexual behavior are associated with growing acceptance of family planning, diminished preferences for large families and improvements in the

4 24 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 protective behaviors (delayed initiation of sexual intercourse, condom use and fewer sexual partners) likely to reduce the spread of sexually transmitted infections (STIs). Men's Sexual Behavior Many young men in the 21 Sub-Saharan African countries with available data covered by this summary, as in many other parts of the world, begin their sexual lives in their teenage years. Half of men in their early 20s first had sexual intercourse between the ages of 15.7 (in Gabon) and (21.6 in Ethiopia) see Appendix Table 2, col. 1. At the same time, many young men delay the initiation of their sexual lives until they are somewhat older. In fact, between 4% (in Gabon) and 47% (in Ethiopia) of men aged are not yet sexually experienced, a finding that somewhat contradicts the widespread assumption that young men everywhere are invariably sexually active. In addition, fewer than half of unmarried men in their early 20s in Burkina Faso, Chad, Ghana, Malawi, Mali, Niger, Nigeria, Ethiopia, Uganda and Zimbabwe are currently sexually active, that is, they had intercourse in the three months preceding the survey (Chart 1). Nevertheless, some men in their teenage years and in their early 20s not only are sexually active but have had two or more partners in the past year. Among sexually active unmarried men 15 24, about one in five in Ghana, Ethiopia, Uganda and Zimbabwe, about one in three in Benin, Guinea, Togo, Gabon and Tanzania, and even higher proportions in the other countries (50% or more in Cameroon, Chad and Mozambique), had two or more sexual partners in the past 12 months (Appendix Table 2, col. 2). Among comparable men 25 39, these proportions are similar, or higher, in every country except Mozambique (Appendix Table 2, col. 3). This common pattern of multiple partners among unmarried men has grave implications for the possible spread of STIs, including HIV, in many Sub-Saharan African countries. In addition, the period between when men first become sexually active and when they first marry 3, or form a union, can be one of aggravated health risk, especially if it is lengthy and involves multiple sexual partners with poor or no protection against STIs and unplanned pregnancy. For example, men in Kenya, Gabon and Guinea, spend an average of 9 10 years between first sex and first marriage. 3 The term marriage is used here to indicate legal marriage, cohabitation, and consensual unions in which couples live together without a religious or civic ceremony but with societal approval.

5 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 25 Chart 1: In their Early 20s most Unmarried Men are Sexually Active Chart 1. In their early 20s most unmarried men are sexually active Benin Republic Burkina Faso Cote D'Ivoire WEST AFRICA Ghana Guinea Mali Niger Nigeria Togo Cameroon CENTRAL AFRICA Central African Republic Chad Republic Gabon Ethiopia Kenya Malawi EAST AFRICA Mozambique Tanzania Uganda Zambia Zimbabwe Percentage of never-married men who are currently sexually active. Source: Source: Special Analyses analyses of the DHS of in these DHS countries. in these Countries Marriage Marriage is virtually universal in Sub-Saharan African countries, and most men have been married by the end of their 30s. Half of men in the region are married by their early to mid- 20s (Appendix Table 2, col. 4); the median age at first marriage among men ranges from almost 22 in Uganda to about 26 in several countries. Age at first marriage has changed very little in the past 15 years in most countries. However, in Cameroon, Gabon and Kenya, men now marry for the first time one and a half to two years later than their fathers' generations did. Men in Sub-Saharan Africa typically marry women 4 8 years younger than themselves (see Table 1). The age difference is wider in West Africa than in East and Central Africa. In countries with conservative religious, social or cultural values, an older husband is assumed to be able to exercise authority over his younger wife. Older men, who are more likely than younger men to have established themselves and to have higher earnings, are probably seen as better potential providers. However, a wide age difference could exacerbate unequal gender relations between a man and his wife, especially with respect to discussion and decision-making about such issues as contraception, condom use and the number of children to have (Bankole and Olaleye, 1995).

6 26 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 Table 1: Difference in Median Age at Marriage, Men vs. Women West Africa Benin 7.0 Burkina Faso 8.6 Côte d'ivoire 7.2 Ghana 5.7 Guinea 7.3 Mali 7.5 Niger 6.3 Nigeria 6.9 Senegal 8.1 Togo 5.6 Central Africa Chad 6.1 Cameroon 6.5 Central African Republic 5.0 Gabon 3.9 East Africa Ethiopia 5.1 Kenya 4.6 Malawi 5.0 Mozambique 4.6 Tanzania 4.5 Uganda 4.3 Zambia 4.7 Zimbabwe 4.6 Source: United Nations (UN), World Marriage Patterns 2000, New York: Population Division, Department of Economic and Social Affairs, UN, Having multiple sexual partners is not limited to unmarried men. Between 7% and 53% of married men report having had intercourse with a woman other than a wife in the past 12 months (Appendix Table 2, col. 6). However, as men get older, this behavior lessens: Among married men in their 40s and early 50s, the proportion with multiple partners in the past year ranges from 4% to 39% (Appendix Table 2, col. 7). Nevertheless, the persistence of this practice continues to put men and their partners at risk of STIs and unintended pregnancy. Extramarital relationships partly reflect the widespread sexual double standard that exists throughout most of the world. But in addition, in some countries in the region, some married men spend long periods away from home, working or searching for work leading to separations that increase the likelihood of infidelity. Another probable reason for married men to have multiple partners is the practice in some parts of Sub-Saharan Africa of a long period of postpartum abstinence after a recent birth. The duration is particularly lengthy in some West African countries.

7 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 27 Polygyny is more common in Sub-Saharan Africa than in other regions (Appendix Table 2, col. 5). The practice is more usual in some West African countries than in Central and East Africa. For example, 40% or more of married men in Benin, Burkina Faso and Guinea, and over 30% in Chad, Mali, Niger, Senegal and Togo, are in polygynous unions. The practice of polygyny is also associated with extramarital relationships, given that many polygynous men are probably sexually involved with a subsequent wife before they actually marry her. Having Children Half of men in the 21 Sub-Saharan countries with data have become fathers by their mid-to-late 20s. The median age of fatherhood is lowest in Uganda (22.6 years) and highest in Côte d'ivoire (28.5) Appendix Table 2, col. 8. It is noteworthy that this median age is only 1 2 years higher than the median age at first marriage, which suggests that in most countries, there is little delay for men between marriage and the birth of the first child. Men in Sub-Saharan Africa generally want large families. Kenya and Zimbabwe are the only countries of the 22 included here in which men want fewer than four children, and in nine of the 22 countries, they want seven or more. However, the number of children men say they want is declining in all countries in this region (see Appendix Table 2, Columns 10, 11 and 12 and Table 2). Men in their early 50s report wanting much larger families than men More educated men have smaller families than do their less educated counterparts. In Ethiopia for example, men with less than seven years of schooling have had 7.6 children, on average, compared with 4.2 children among those with seven or more years of education. In some SSA countries, couples disagree quite widely about the number of children to have. For example, in Burkina Faso, Ethiopia and Nigeria, about half of couples are in the situation that the husband wants at least two more children than the wife does. In some countries in this region, actual family size exceeds the number of children men say they want. Only in Ghana and Zimbabwe do men in their late 40s average fewer than six children, and in Benin, Niger, Senegal, Chad and Uganda, they have over nine (Appendix Table 2, col. 9). Moreover, among men in their 40s and early 50s, 40 60% in Ghana, Uganda, Zambia and Zimbabwe and 65 66% in Kenya and Malawi want no more children.

8 28 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 Table 2. Desired Family Size among Men, by Current Age West Africa Benin Republic Burkina Faso Côte d'ivoire Ghana Guinea Mali Niger Nigeria Senegal Togo Central Africa Cameroon CAR Chad Republic Gabon East Africa Ethiopia Kenya Malawi Mozambique Tanzania Uganda Zambia Zimbabwe Source: Special Analysis of the DHS in these Countries Many men in Sub-Saharan Africa continue to father children into their 50s. For example, men in their early 50s have at least three children more than those in their early 40s in seven of the 21 countries with data, and have at least two more in a further 12 countries. However, in some countries in the region, fairly large proportions of men want to stop having children altogether 45% in Ghana, 65% in Kenya and 57% in Zimbabwe.

9 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 29 Chart 2: Younger Men Wan to Have Fewer Children than their Own Chart 2. Younger men want to have fewer children than their own fathers and grandfathers Fathers and Grandfathers do. Do West Africa Central Africa East Africa Desired family size among men 50-54, and Source: Special Analyses of the DHS in these Countries Source: Special analyses of the DHS in these countries. Contraceptive Use Not surprisingly, in a region where men want many children, contraceptive prevalence is low to moderate. In fact, only in Gabon, Kenya and Zimbabwe are 60% or more of men or their partners using family planning to avoid pregnancy, and in 13 of the 21 countries with data, fewer than 40% of couples are doing so (Chart 3). In many Sub-Saharan African countries, men's use of the condom or withdrawal, rather than his partner's use of a modern female method (the pill, injectables, the IUD, spermicides, or female sterilization) or through periodic abstinence, accounts for much of the couple's contraceptive practice. Male sterilization, however, is all but non-existent in Sub-Saharan Africa. The atypically high levels of contraceptive use in Kenya and Zimbabwe are the result of high proportions of couples in these countries relying on methods used by women. In Gabon, it is due to exceptionally high levels of condom use (33% of sexually active men 25 39).

10 30 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 While Chart 3 illustrates the important role of condom use in helping Sub-Saharan couples in their late 20s and 30s plan their families and space pregnancies, condom use for family planning is actually highest among younger sexually active men, and declines from that point on. In Zimbabwe, for example, 41% of sexually active men are currently using condoms for contraception, but this proportion falls to 13% among men and to 6% among men (columns 18 20). The same pattern is seen in all 21 countries with data, suggesting that as men in this region grow older and marry, couples tend to adopt female methods. Among men in their 40s and early 50s- the age at which many will have had all the children they want protection against unplanned pregnancy through the use of any contraceptive method is low in many countries in the region under 20% in seven countries, and under 40% in a further nine. Many men in SSA are protected from unwanted pregnancy through the practice of periodic abstinence, a technique that is neither a male nor a female method but requires the cooperation of the couple. In fact, 15% or more of sexually active men aged men in Benin, Burkina Faso, Côte d'ivoire, Togo, Cameroon, Gabon and Kenya rely on this contraceptive method (Chart 3). The proportion of men in Sub-Saharan Africa who say they have discussed family planning with their partners provides some indication of attitudes toward contraception. In Ghana and Togo in West Africa, Gabon in Central Africa, and all East African countries except Mozambique, half or more married men report engaging in such a discussion. Yet when both members of the couple are asked whether discussion about family planning has taken place, a somewhat higher proportion of men than of couples report that this has occurred, suggesting perhaps that men and women may not always share similar perceptions about what actually constitutes discussion on this topic. Given that communication about family planning is relatively rare in some countries in the region, it is not surprising that one or both partners often do not know (or are wrong about) whether the other approves of contraceptive use. Low levels of effective contraceptive often result in high levels of unwanted pregnancy. In many parts of the world, couples with an unwanted pregnancy turn to abortion. Abortion is illegal in most countries in SSA. As a result, women seek clandestine and often unsafe procedures. Many women seeking an abortion say their primary reason is that they are not married or are in an unstable relationship. In hospital-based studies, unmarried women account for six in 10 women having clandestine abortions or suffering abortion complications each year in Guinea, Kenya, Mali, Mozambique and Nigeria (Bankole et al., 1999). Being in a troubled or fragile relationship also ranks high among the reasons women give for seeking an

11 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 31 abortion. It was the second most commonly cited reason in Nigeria in 1996 (Fapohunda abd Rutenberg, 1999). In Tanzania, four in 10 adolescent women seeking an abortion reported that the father was a casual sexual contact (Mpangile et al., 1992). Chart 3. The proportion of men using a contraceptive method varies widely in SSA Chart 3: The Proportion of Men Using a Contraceptive Method Varies Widely in SSA Benin Burkina Faso WEST AFRICA Cote d'ivoire Ghana Guinea Mali Niger Nigeria Togo CENTRAL AFRICA Cameroon CAR Chad Republic Gabon Ethiopia Kenya Malawi EAST AFRICA Mozambique Tanzania Uganda Zambia Zimbabwe Percentage of sexually active men 25-39, or their partners, who use contraceptives. Condom Withdrawal Periodic abstinence Methods women use* Other traditional methods *Pill, injectables, IUD, spermicides, diaphragm or female sterilization. Source: Special Analyses of the DHS in these Countries Source: Special analyses of the DHS in these countries. Sexually Transmitted Infections Sub-Saharan Africa has the world's highest prevalence of both HIV/AIDS and of curable STIs of bacterial origin. Of the more than 41 million people around the world estimated to be suffering from HIV/AIDS, more than 29 million live in Sub-Saharan Africa where the virus is transmitted primarily through sexual intercourse and where 42% of those infected are men (UNAIDS, 2002). The proportion of the adult population estimated to be living with HIV/AIDS is relatively low (1 3%) in Ghana, Guinea, Mali,

12 32 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 Niger and Senegal), quite high (10 13%) in Côte d'ivoire, Cameroon and the Central Africa Republic and extremely high (22 34%) in Zambia and Zimbabwe (Appendix Table 2, column 16). In addition, the World Health Organization estimates that for every 1,000 men and women in the region, 119 had one or more of four nonviral, therefore curable, sexually transmitted infections (trichomoniasis, chlamydia, gonorrhea or syphilis) in 1999 (WHO, 2002). Poverty, malnutrition leading to weakened immune systems, poor underlying health conditions, the region's inadequate health care structure and patterns of sexual behavior are thought to be among the major factors contributing to high levels of HIV/AIDS and other STIs in SSA. Most men in Sub-Saharan Africa are aware that they run a risk of contracting HIV/AIDS. Nevertheless, there is little correlation between actual prevalence levels in a given country and the proportion of men who believe they are at risk of becoming infected (Appendix Table 2, column 17). In the Benin Republic, for example, where an estimated 4% of the adult population has HIV/AIDS, a higher proportion of men believe themselves at moderate risk of getting the infection (19%) than in Zimbabwe (12%), where 34% live with HIV/AIDS. Protective Behavior to Avoid STIs Correct and regular condom use provides protection against STIs, even if condoms are used primarily for pregnancy prevention, so that the condom use for contraception shown in Chart 3 also contributes to the prevention of STIs, including HIV/AIDS. However, since some men in SSA use condoms specifically to prevent STIs, the levels of condom use shown in Chart 3 underestimate overall levels of STI protection. Analyses of data from a handful of countries in the region reveal that condom use specifically for STI prevention is higher among men who have gone beyond primary school and among men living in urban areas than among their less educated or rural counterparts (see Chart 4). More educated men and those living in urban areas are more likely to have the knowledge and financial wherewithal to find and pay for condoms. More educated men are also more likely to understand the threat to themselves and their families posed by STIs, and to know that condoms provide an effective barrier to transmission.

13 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 33 Chart 4: 4. Men with more education Education and and those those living Living in urban in Urban areas are Areas Are those those most most likely likely to use to condoms Use Condoms for STI protection. for STI Protection Benin Ethiopia Malaw i Uganda Zimbabw e Percentage of unmarried sexually active men who used a condom for STI prevention at last intercourse, by years of schooling. <7 years 7 or more years Benin Ethiopia Malaw i Uganda Zimbabw e Percentage of unmarried sexually active men who used a condom for STI protection at last intercourse, by urban-rural. Rural Urban Source: Special Analyses of the DHS in these Countries Condom use is rising in many SSA countries, particularly among unmarried men: In Benin, Ghana, Kenya, Tanzania and Zimbabwe, the proportion of sexually active men, unmarried using the condom increased at

14 34 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 between 1% and 2% a year between the middle and the late 1990s. In Uganda, a country particularly hard hit by HIV/AIDS, condom use rose by a striking 5.5% a year between 1995 and As in many other parts of the world, condoms are not popular with some men. They are viewed as reducing sexual sensation and pleasure and sometimes even suspected not to be of sufficient quality to prevent pregnancy and STIs. Condoms are also commonly associated with promiscuity a stigma that makes married couples less likely to use them. High cost and poor availability frequently stand between African men's desire to avoid STIs and their ability to obtain or use condoms. However, it is striking that in this region, men with multiple sexual partners show much higher rates of condom use. The Sexual and Reproductive Health Information and Services Men Need Men in Sub-Saharan Africa especially those who live in areas with high prevalence of HIV/AIDS and other STIs need much better access to condoms as well as health services for the prevention, diagnosis and treatment of STIs. However, these services are usually dependent upon a well-functioning primary health care system, including a reliable supply of antibiotics, clinics staffed by well-trained technicians and the availability of what are sometimes costly diagnostic methodologies. This infrastructure is rarely found in Sub-Saharan Africa, particularly in rural areas. Men also play an important role as husbands and fathers, and deserve information that could help them to meet these responsibilities. Yet men's marital and reproductive behavior and thus their most acute needs in these areas change with age. Older men are much more likely than younger men to be sexually active, to be married and to be fathers. On the other hand, young men who are sexually active are slightly more likely than older men to have more than one partner in the past year and to have used a condom the last time they had sex. Chart 5 demonstrates the proportion of men at each age for whom the pertinent sexual and reproductive health information and services would be relevant.

15 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 35 Chart 5. Men's Need for Sexual and Reproductive Health Information Vary, Depending on their Age *Does not include Senegal. Includes consensual unions. Note: Data are averages for all 22 study countries and are weighted by size of male population. Source: Special analyses of the DHS in the these countries Among men at highest risk of contracting STIs those with two or more partners in the past year the proportions who did not use condoms the last time they had intercourse is very high, ranging from 40% to 85% among men and from 49% to 92% among those (Appendix Table 2, col 18 and 19). In many countries in the region, especially in rural areas and among the poor, condoms are not easily available, or men cannot afford them. Chart 5 also indicates that as men reach their 40s, their desire to stop having children increases. Yet some men who want no more children, or want to wait two or more years before having another child, do not use (and their partners do not use) any method of contraception that would enable them to realize this goal. The unmet need for contraception among all men is 50% or more in five countries, 40% or more in four countries and between 20% and 40% in 10 others (column 25). Men also need support and encouragement in talking to their wives and sexual partners about family planning. Spousal communication on this issue is probably not a simple issue in every country in this region. In a country like Kenya, for example, a study in one rural area found that it may be difficult for couples there to talk about family planning. Until women have had the number of boys and girls the couple wants, many women fear that

16 36 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 such discussion might reflect poorly on their social status, relationship with their husbands and confidence that their husbands will stay with them. The study also found that discussion about family planning is more common when both the husband and the wife are well educated, have achieved the number of children they want and have access to family planning information and services (Fapohunda and Rutenberg, 1999). As well as increased and more effective condom use, the A and B components of the ABC approach to HIV prevention (Abstinence, Being faithful to one partner and Condom use) can also play an important role in combating the epidemic. Efforts should therefore be directed at providing men with comprehensive sex education, both in schools and for adults. Abstinence could be presented as a viable option for men who choose to practice it before they marry, and all men should be advised to limit the number of sexual partners they have. There is some indication, for example, that in Uganda, where HIV infection rates are declining, men are in fact acting upon this recommendation to limit the number of their sexual partners, and that this factor is contributing to the drop in new infections (Singh et al., 2003). Conclusion Improving men's access to sexual and reproductive health information and services represents an acute challenge in SSA. Some pilot projects designed specifically to reach young men provide valuable models of information and service programs responsive to their needs (Panos Institute AIDS Programme, 2000). However, in view of the fact that spending on health care in general in Sub-Saharan Africa is already woefully inadequate, the possibility of expanding programs for men is highly limited. The World Bank estimates that per capita expenditures on health care in SSA currently amount to no more than $89 a year (compared with over $2,000 in countries of the European Union and almost $4,000 in the United States), and that much of this spending is out-of-pocket, rather than from public revenues (World Bank, 2002). It would be short-sighted, however, to dismiss the feasibility of improving men's access to health care information and services services and information that have the potential to benefit not just men but their sexual partners, wives and children as well. In SSA particularly, where HIV/AIDS is devastating families, communities and, in some countries, the viability of the state itself, many men are already taking responsibility to reduce levels of STI transmission through condom use. Those efforts could be enhanced with additional support from international aid agencies, national governments and other funding sources. The stakes are extremely high: the health, well-being and very survival of men, women and children on this continent depend on increased attention to men and on the success of improved efforts to meet their needs.

17 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 37 References Bankole A and Olaleye DO Do marital partners have different reproductive preferences in Sub-Saharan Africa? in Makinwa P and Jensen A-M, eds., Women's Position and Demographic Change in Sub-Saharan Africa, Liège, Belgium: IUSSP, pp Bankole A, Singh S and Haas T Characteristics of women who obtain induced abortion: A worldwide review, International Family Planning Perspectives, 25(2):68 77, Table 4, p. 73. Fapohunda BM and Rutenberg N Expanding Men's Participation in Reproductive Health in Kenya, Nairobi, Kenya: African Population Policy Research Center. Fapohunda BM and Rutenberg N op. cit., see reference 4. Joint United Nations Programme on HIV/AIDS (UNAIDS) AIDS Epidemic Update, accessed January 16, Mpangile GS, Leshabari MT and Kihweele DJ Induced abortion in Dar es Salaam, United Republic of Tanzania, UMATI, unpublished final report submitted to the WHO, Geneva. Panos Institute AIDS Programme Young Men and HIV in Africa: Challenges and Opportunities, prepared for UNAIDS for the African Development Forum Dec., prepared by Thomas Scalway, draft, Nov. 15, Singh S, Darroch JE and Bankole A The role of behavior change in the decline in HIV prevalence in Uganda, Occasional Report, New York: The Alan Guttmacher Institute, No. TK World Bank Human Development Network, Development Data Group, Data Comparative Tables, accessed May 23. World Bank DALYS Tables, accessed March 11.World Health Organization (WHO) Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections, accessed July 7.

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19 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men Appendix Table 1: Selected demographic and economic characteristics of men in Sub-Saharan Africa. West Africa No. of men % of total population living in urban areas GDP per % of men 20- capita (PPP 24 with 7 US$) years of schooling 2000 % of households that own a radio Benin Republic, , Burkina Faso, , Cote D'Ivoire, 1998/1999 4, , Ghana, , , Guinea, , , Mali, 1995/1996 2, Niger, , Nigeria, , Senegal, , , Togo, , , Central Africa Cameroon, , ,703 5 CAR, 1994/ , Chad Republic, Gabon, ,237 73

20 40 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 East Africa N0. of men % of total population living in urban areas % of men with 7 years of schooling GDP per capita (PPP US$) % of households that own a radio Ethiopia, , Kenya, , , Malawi, , Mozambique, , Tanzania, , Uganda, 2000/ , , Zambia, , Zimbabwe, , , Sources: Column 1: United Nations (UN), World Population Prospects: The 2000 Revision, Annex Tables, New York: UN, Colunms 2: UN, World Urbanization Prospects 1999, New york: UN Column 3 and 5: The Alan Guttmacher Institute (AGI), unpublished tabulations of the Demographic and Health Surveys (DHS). Column 4: Ethiopia, Gabon, Guinea, Malawi, Nigeria and Uganda: UN Development Programme (UNDP), Human Development Report 2000, New York:, UN, 2000, pp ; all other countries: UNDP Human Development Report 2001, New York: UN, 20001, pp

21 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men West Africa Among men 20-24, median age at 1st sex % of sexually experienced men not in union with 2 or more partners in last 12 months Among men 25-29, median age at 1st marriage Appendix Table 2: Sexual and reproductive behaviors and needs of men in Sub-Saharan Africa. % of married men who had sex with another % of sexually woman in active men past 12 Desired family size currently using months among men condoms Among married men 25-54, % in polygynous marriage Among men 25-39, median age at which they first became a father Among men 45-49, mean number of children fathered Estimated % of adult population living with HIV/AIDS % of men who believe they have at least a moderate risk of getting HIV/AIDS Among sexually active men with 2 or more partners in the past year, % who did not use a condom at last intercourse % of men with an unmet need for contraception* Benin Republic, Burkina Faso, Cote D'Ivoire, 1998/ u Ghana, Guinea, Mali, 1995/ Niger, Nigeria, Senegal, u u u u u u u u u 0.5 u u u u Togo, 1998 u

22 42 African Population Studies Vol. 19 N 2/Etude de la population africaine vol. 19 n 2 Central Africa Among men 20-24, median age at 1 st sex % of Sexually experienced men not in union with 2 or more partners in last 12 months Among men 25-29, median age at 1 st marriage Among married men 25-54, % in polygynous marriage % of married men who had sex with another woman in past 12 months Among men 25-39, median age at which they first became a father Among men 45-49, mean number of children fathered Desired family size among men % of sexually active men currently using condoms Estimated % of adult population living with HIV/AIDS % of men who believe they have at least a moderate risk of getting HIV/AIDS Among sexually active men with 2 or more partners in the past year, % who did not use a condom at last intercourse % of men with an unmet need for contraception* Cameroon, CAR, 1994/ u u u u u u 47 Chad Republic, Gabon, u East Africa Ethiopia, u u Kenya, Malawi, u Mozambique, Tanzania, u Uganda, 2000/ Zambia, Zimbabwe, *Men who are sexually active and fecund, and who want to delay or avoid having children but are not relying on a contraceptive method. Notes: Married men include those cohabiting or in a consensual union. Sexually active men are those who had intercourse in the past three months. u=unavailable. Notes: Married men include those cohabiting or in a consensual union. Sexually active men are those who had intercourse in the past three months. u=unavailable. Sources: For all columns except column 16 : AGI, unpublished tabulations of (DHS). Column 16: Gabon, Guinea, Niger: Joint United Nations Programme on HIV/AIDS (UNAIDS), Report of the Global HIV/AIDS Epidemic, July 2002, Geneva: UNAIDS, 2002; All other countries: UNAIDS, Report of the Global HIV/AIDS Epidemic, July 1999, Geneva: UNAIDS, 1999.

23 Akinrinola Bankole & al: The Sexual, Marital and Fathering Behavior of Men 43 40