Burkinabe Men s Engagement in Family Planning

Burkinabe Men s Engagement in Family Planning Photo source: fotolia, author: vystekimages Innovation Lab, October 10-13, 2017 Pre-Read

2 Contents 1 2 3 The state of family planning The role of men Potential areas for intervention

STATE OF FAMILY PLANNING Burkina Faso s population is young and rapidly growing 3 BURKINA FASO POPULATION BY AGE BURKINA FASO POPULATION GROWTH SINCE 1960 Age 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Men Women 65% of the population is under 25 0 0.5 1 1.5 2 Population, Millions 30 25 20 15 10 5 0 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 Population, Millions Year Source: World Bank 2016 Population Estimates http://datatopics.worldbank.org/health/population

STATE OF FAMILY PLANNING The past five years have seen rising use of FP and improved RH outcomes for women 4 PROJECTED TRENDS IN mcpr IN BURKINA FASO REPRODUCTIVE HEALTH OUTCOMES FOR WOMEN 35 30 25 Unintended pregnancies averted (thousands) 167 184 203 222 249 2012 2013 2014 2015 2016 Percent 20 15 Unsafe abortions averted (thousands) 53 58 65 71 79 10 2012 2013 2014 2015 2016 5 0 2012 2013 2014 2015 2016 2017 2018 2019 2020 Maternal deaths averted 400 400 500 500 600 All Women Married Women 2020 Goal 2012 2013 2014 2015 2016 However, despite this progress, at the current rate, Burkina Faso will miss its goal of 32% CPR by 2020 Source: FP 2020., http://www.sante.gov.bf/

STATE OF FAMILY PLANNING However, ongoing SRH challenges remain, especially amongst youth 5 Unmet need for family planning (women who do not want a pregnancy but are not using contraception) has grown from 24.1% in 2003 to 28.8% in 2016. 1,2 A high adolescent fertility rate persists: 130 per 1,000 women age 15-19 compared with the regional average of 121. 3 Births to women aged 15 19 years old have the highest risk of infant /child mortality. 4 The under 5 child mortality rate of 129 per 1,000 live births (~1 out of 7) is also higher than the regional average (95, approx. 1 out of 10). 3 The mean number of children living at first contraceptive use is 2.6, indicating late adoption of FP practices. 1 Sources: 1) PMA 2020 2) DHS Stat Compiler, 3) Regional view calculated from weighted averages of most recent DHS STAT compiler data from: Burkina, Benin, Ghana, Gambia, Guinea, Liberia, Niger, Sierra Leone, Senegal, and Togo; 4) WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva.

6 Contents 1 2 3 The state of family planning The role of men Potential areas for intervention

THE ROLE OF MEN 7 TFR is in decline, but the gap between men s and women s ideal number of children is increasing EVOLUTION OF TFR, AND IDEAL NUMBER OF CHILDREN FOR MEN AND WOMEN TFR Ideal Children for Men 15-54 Ideal Children for Women (all) Projected TFR FERTILITY RATE / IDEAL # OF CHILDREN 7.5 7 6.5 6 5.5 5 4.5 4 1993 1998 2003 2008 2013 YEAR Source: DHS Stat Compiiler

THE ROLE OF MEN 8 Men are implicated in many reasons for non-use of family planning REASONS MENTIONED FOR NON-USE AMONG WOMEN WANTING TO DELAY BIRTH BY TWO OR MORE YEARS 1 REASON FOR NON-USE Perceived Not-At- Risk/Lack of Need % (n= 1,423) 46.5% HOW ARE MEN INVOLVED? Women may believe they are not fertile when breastfeeding, or have not menstruated since last birth; Men may reinitiate sex after a woman has given birth, and might not understand her fertility. 3 Women may also believe they are at low risk if having infrequent sex; Couple communication may be challenging when a partner is migrating, or only seen infrequently. Method or Health- Related Concerns 21.9% Women s concerns around side effects often relate to men s perception of/reaction to side effects 2 Women who are concerned about side effects may be relying on calendar methods; men must fully participate in these methods in order for them to be effective Not Married 21.4% Gendered social norms may prevent women from saying they are sexually active before marriage Unmarried women might be more likely to rely on male-initiated condoms 1 ; Gender roles before marriage are in flux and unclear; there are few models for how to communicate 2 Opposition to Use 17.3% May include partner s opposition, or other opposition from men in the community Men may be influenced by religious messaging which discourages FP 2 Lack of Access/Knowledge 12.7% Men may be sources of information to women, yet can feel uncomfortable seeking information in reproductive health settings 2 4 Sources: 1) PMA2020; 2)EngenderHealth AGIR PF Message Testing 3) Rossier and Hellen 2014 5) Daniele 2014

Sources: 1) PMA 2020 Data 2)Rossier, Sawadogo and Soubeiga 2013 3) EngenderHealth AGIR Message Testing results 4) N Haberland et al. cited in Chau et al 2015 5) Chau et al 2015 6) DHS 2010 7) Casey et al. 2008 8) Dehne 2003 *NOTE: These figures were calculated using PMA2016/Burkina Faso Round 4 data, with a nationally representative sample of 3,202 women age 15-49. THE ROLE OF MEN 9 The role of men should respond to women s family planning needs, which vary by life-stage LIFE STAGE Unmarried Newly Married and/or New Parents NEEDS / USE 1* Unmet Need 17% FP Use 17% Unmet Need 30% FP Use 24% DESCRIPTION Unmarried women may be of any reproductive age, but most are younger; average age of first marriage is 19 1 Navigating complex relationship dynamics 2 May be prioritizing avoiding pregnancy, 2 OR feel pressure to prove fertility and quickly find a partner 3 Adolescent single women may be in a stage of cognitive development where it is challenging to manage risk 7 ; this dynamic may come into play while evaluating and acting on risks around pregnancy and sex Includes young married women between ages 15-24 Particularly in rural areas, may be facing new social pressures around fertility while living in a new household context, without her support network. 4 Norms around post-partum sexuality are changing. 8 Women in this group may be at higher risk for closely spaced births, 5 especially rural women who on average delay ~5 years between first birth and first contraceptive use 1 Experienced Parents Unmet Need 27% FP Use 27% Includes older married women aged 25-49 years May be dealing with new challenges and financial stress as number of children increases Men want about one more child than woman do 6 ; this may cause tensions as a couple decides how and when to limit As women use methods over longer time periods, they may face particular challenges while managing side effects

THE ROLE OF MEN Women s FP needs reflect the major life events happening in those time frames 10 First sex Cohabitation Marriage and/or first birth Additional births Decision to limit Unmarried Newly Married and/or New Parents Experienced Parents SPECIFIC PARTNERSHIP NEEDS Strong communication from partners about fertility desires and future plans 1 Empathy/gender transformation around women s comparative lack of power in pre-martial relationships 1 Support procuring and initiating use of a method (especially male condoms, used by 42.5% of unmarried sexually active contraceptive users) 2 Cooperation during natural method use; strong support choosing an evidence-based natural method 6,7 Couple communication widely recognized as a critical determinant of FP use 9 Support while navigating complex social pressure around fertility in new family structure (pressure from extended family) 3 Support and willingness to delay sex/use FP during the post-partum period, when women may be at risk for a closely spaced births 4, 5 Cooperation during natural method use, particularly with lactational amenorrhea method and Standard Days Method; support choosing an evidence-based natural method 7 Couple communication widely recognized as a critical determinant of FP use 9 Support as women navigate side effects throughout long-term use Women s FP needs may change from spacing to limiting as they grow older; 8 in this stage discordant fertility desires may become a conflict Cooperation during natural method use, particularly with Standard Days Method; support choosing an evidence-based natural method 7 Sources: 1) Rossier, Sawadogo and Soubeiga 2013 2) PMA 2020 3) N Haberland et al. cited in Chau et al 2015 4) Rossier and Hellen 2014 5) Dehne 2003 6) EngenderHealth AGIR Message testing Results 7) Rossier, Senderowicz and Soura 2014 8)Khan et al. 2008 cited in Adebowale and Palamuleni 2014 9) Hartmann et al 2012

THE ROLE OF MEN These three life stages also apply to men, albeit 5-10 years later than women 11 Unmarried Men Newly Married Men Experienced Married Men 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Single Married Living together Divorced, Seperated or Widow Source: DHS 2010

12 Contents 1 2 3 The state of family planning The role of men Potential areas for intervention

POTENTIAL AREAS FOR INTERVENTION Our review of the literature has identified 5 dynamics drive men s attitudes and behaviors towards FP 13 PERCEPTION OF SEXUALITY AND MASCULINITY SOCIAL NORMS COUPLE DYNAMICS KNOWLEDGE AND ACCESS ECONOMIC CONSIDERATIONS The pressure men may feel to engage with women a certain way, in order to show masculinity Social pressures put on men and couples, and norms around spacing and limiting of births Power dynamics and quality of communication within the couple Men receiving conflicting FP information from various sources Access may be hindered by men might not feeling comfortable visiting health centers where they can get reproductive health information Economic drivers change throughout the life course. Finances will impact when a young man can start a family; experienced married men may consider the economic considerations of increasing family size

POTENTIAL AREAS FOR INTERVENTION These dynamics manifest themselves differently during men s life stages 14 Unmarried Men Newly Married Men Mature Married Men Perception of Sexuality and Masculinity Men may perceive condoms to reduce sexual pleasure. 1 In one study, only 54% of sexually active 12-19 year old men had used a male condom. 2 Changes in gender roles may cause tension in relationships. Globally, research shows that may fear that FP use will lead to infidelity, or erode their status as head of household. 6 As established couples make decisions about how to limit, men may have less awareness than women about the care and effort that goes into raising a child 13 Social Norms Relationship norms before marriage are in flux 3 ; marriage is no longer always arranged between families, but between individuals 4 ; there is a lack of models for how to relate and communicate. Norms about the length of post-partum abstinence are in flux, 7, 8 and men are often the ones to reinitiate sex after birth, an important dynamic in early marriage. Extended family may be closely involved in decisions 9, Religious norms may be more important among older men. The number of men giving a non-numeric response about the number of children they wanted increased with age. 14 Couple Dynamics Men generally have more power in relationships than women do, 3 but may perceive that women are being manipulative or using them for money. Couple communication is recognized as a critical determinant of FP use 10. New couples are establishing communication norms; which can be particularly challenging with a large age gap between partners 9. Close communication might not be an established relationship norm within marriages; 13 Older men may not be interested in doing a counseling session with their wife. 9 Women in challenging relationships might use secretly. 17 Knowledge and Access Young men may have limited access to health centers where they can access FP + FP info. 40% of adolescents felt embarrassed or shy while obtaining FP, and 40% did not know where to obtain FP. 2 Diverse media may provide conflicting information 5 Men may lack understanding of when their partners regain fertility after giving birth. 7 Men may be reluctant to visit health centers for FP information11 12 FP Knowledge among men is generally high, with the average man knowing about 6 methods 14 ; but men may not feel comfortable in SRH health centers and lack places to access detailed information. 11 12 Economic Considerations Economic pressures may impact early relationship and family choices 4 Changing economies and family arrangements may be impacting decisions around spacing and postpartum sex 8 As limiting becomes a possibility later in the couple s life, men in rural areas may feel motivated to have larger families to have children who can help with agriculture 15 Urban husbands may feel conflicted about what family size will ultimately lead to wealth 16 Sources 1) Guiella and Madise 2007 2) Biddlecom et al. 2004 3) Rossier, Sawadogo and Soubeiga 2013 4) Calvès, Kobaine and Martel 2007 5) Zare and Yaro 2008 6) Wulifan 2016 7) Rossier and Hellen 2014 8) Dehne 2003 9) Chau 2015 10) Hartmann et al 2012 11) Daniel 2014 12) EngenderHealth Agir PF Message Testing 13) Andro and Hertrich 2002 14) DHS 2010 15) Bankole, 2014 16) Rossier, Senderowicz and Soura 2014 17) Désalliers 2009

POTENTIAL AREAS FOR INTERVENTION 15 During the Innovation Lab, we will brainstorm innovative ideas to increase male FP engagement Key Dynamics Impacting Male FP Engagement Best Practices in Male Engagement Interventions Innovative Concepts to Explore Consider Group Learning Sessions Include Community Outreach Heed Gender considerations Consider Service Outreach Weekly sessions 2-2.5 hours, over 10-16 weeks are advised, with adequate time for discussion between sessions; refresher courses might also be necessary 1 Critical for men to be able to apply knowledge/lessons learned to real-life scenarios 1 Include trained facilitators who can create a safe space 1 Emphasize positive aspects of men s roles, and their ability to create change, and tailor messages to audience; High quality media can also be effective 1 Successful campaigns may identify and engage men who influence others 1 Effective campaigns can last 4-6 months, and often use multiple communication channels 1 Promote couple communication and shared responsibility 2 Challenge and transform problematic gender norms 2 Engage women in creation of programs and be aware of power dynamics in couples 1 Health care workers might need training in how they relate to men ; some men might prefer men providers 1 Physical space of the clinic can be made more attractive to men; Home visits can also be effective 1 Telephone counseling may also be effective 1 1) Barker, Ricardo and Nascimento 2007 2)Croce-Galis 2014

INITIAL RECOMMENDATIONS 16 Recommended approaches ranked by projected MMC use impact APPROACH BAU increases across segments OVERALL IMPACT ON MMC USE 0% 2% 4% 6% 8% 10% 12% 14% 2.0% 6 5 2 Better educate providers on aligning need with method(s) Introduce tools to facilitate recognition of client needs Counsel all women by segment and ID high-risk women 2.0% 2.0% 1.4% 8 1 7 3 9 Develop interventions to support maintaining use Improve the reputation of the HCW as a trusted source Increase the availability of and training on LARC Foster development of innovative delivery approaches Support introduction of new contraceptives in CDI 1.3% 1.3% 1.1% 0.7% 0.6% 11 12 Build parental and adolescent male psychosocial support 0.5% 10 Increase youth consideration with targeted communications 0.4% 13 14 Increase the prevalence of youth friendly service (YFS) 0.2% 4 Improve FLs trust with HCWs 0.1%