Objective To explore the level of spousal communication in family planning and to gain insight into factors militating against this in Ife Central Local Government area,Osun State,Nigeria with the aim of enhancing men participation in safe motherhood.Methods This is a community survey using both quantitative and qualitative data collection methods.The quantitative data was collected using semi-structured interviewer administered questionnaires while the qualitative data was collected using gender and age-specific Focus Group Discussions.A non- probability sampling method was employed.Data was analyzed using the Statistical Package of Social Sciences（SPSS） software version 13.Relationships between discrete variables were tested by means of chi-square test.Whenever expected cell frequencies were less than five,the likelihood-ratio Chi-square values were quoted rather than Pearson’s.Statistical significance was accepted at P-values of <0.05.Results Four hundred married couples（166 men and 234 women） were interviewed.While majority 383（95.8%） of the respondents have heard of family planning only 200（50%） of the total respondents had discussed family planning with their spouse at least once.Focus group discussions revealed that majority of the men had difficulty discussing family planning with their partners because they felt it was a sign of promiscuity and it was not necessary.The female respondents on the other hand are afraid of rejection and opposition from their partners.There’s a gradual decline in the spectrum from awareness to actual use,compliance and spousal communication in the rural area.Conclusion Spousal communication about family planning should be encouraged in rural areas of Nigeria.Since men as well as women,play key roles in safe motherhood,communication is necessary for making responsible decisions

【关键词】  spousal communication family planning safe motherhood　

　　 Correspondence to  Dr Ernest O.Orji FMCOG,FWACS,Department  of Obstetrics & Gynaecology,Faculty of Clinical Sciences,College of Health Sciences,Obafemi Awolowo University,Ile-Ife,Nigeria
    
　　E-mail: eoorji11@yahoo.com

   　　Nigeria is the most populous country in Africa,with more than 126 million people［1］.It also has a high annual population growth rate of 3.5% and a total fertility rate of 6.0 lifetime births per woman.Additionally,the country has relatively high levels of infant mortality（131 infant deaths per 1,000 live births） and maternal mortality（900～1,500 per 100,000 live births）［2］.Nearly all these deaths could be prevented.The global Safe motherhood Initiative（SMI） was launched in 1987 in Nairobi,Kenya to raise awareness about the scope and consequences of poor maternal health and to mobilize   action to address the high rates of deaths and complications of pregnancy and childbirths.While debates continue about the best strategies to adopt under the safe motherhood initiative,a variety of programmes have been developed to reduce the rising maternal mortality and morbidity［3］.While providing appropriate medical care immediately could save thousands of women’s lives,family planning couldprevent many future unintended pregnancies and abortions.The prevalence of contraceptive use in Nigeria is very low while deaths arising from complications of unsafe induced abortions contribute up to 40% of maternal deaths in Nigeria［4～6］.Women in Sub-Saharan African are in a disadvantaged position in terms of decision making in the home and they are not in control of their sexuality.From research evidences,women have little control at all［7］.They can have as many children as possible even when their health conditions would not support it.The first step that men can take to promote safe motherhood is to plan their families.
   
    It has been suggested that fertility,particularly in developing countries would have been lower if women were in the position to decide when to become pregnant and how many children they want to have because it is women that undergo all the sicknesses associated with pregnancy and delivery and they may lose their lives as a result of pregnancy and childbirth［8］.It has therefore be suggested that the first step that men can take to promote safe motherhood is to plan their families［8,9］.
   
    Spousal communication in family planning is a crucial step towards increasing men’s participation in safe motherhood［9,10］.This is because communication between partners about childbearing and family planning is closely linked to successful contraceptive use.Interspousal communication is a key factor in the adoption and sustained use of family planning in Nigeria because it allows couples to discuss and exchange information that may change strongly held beliefs and to question each other on what may appear unclear［11～14］.This is particularly relevant in Nigeria where men often dominate decision［7,8,15］.There are few studies on spousal communication in family planning in rural Nigerian communities［11,12］.This study was therefore designed to explore the level of spousal communication in family planning and to gain insight into factors militating against this in Ife Central Local Government area,Osun State,Nigeria.
   
    METHODS
   
    The study was conducted in 13 villages of the Ife Central Local Government area.The 13 villages were made up of 169 housing units with an estimated number of 1 married man and 1~2 married women per household.The quantitative study employed a cross-sectional descriptive design.The qualitative study employed the use of focus group discussions（FGD）.The sampling frame was the entire population of married men and women available during the study.
   
    The sample size was determined using the formula below:
   
    n=Z2（1-p）p    d2
   
    p=prevalence=50% it was the expected number of people who should have communicated.
   
    Z- Standard normal variance=1.96
   
    d- Absolute standard or precision=0.05
   
    Using the above formula,the calculated sample size was 384.16 which was approximated to 400.
   
    Quantitative data was collected using a pre-tested semi-structured interviewer administered questionnaire.31 questionnaires were distributed per village.The questionnaire was translated to Yoruba for non-English speaking men and women.The instrument was pre-tested in  Edunabon town.
   
    The questionnaire was consisted of 3 sections:section A contained information on socio-demographic data of the respondents,section B contained information on awareness,knowledge and use of family planning method,section C contained information on spousal communication on family planning.The questionnaires were administered face-to-face.Qualitative data was done in form of Focus Group Discussions（FGDs） in 2 of the villages.A total of 4 age and sex specific FGDs were done,2 in each village.The FGD was done by the co-ordinator with the aid of a guide,a note taker and a tape recorder.
   
    Data was analyzed using the PC,SPSS software version 13（Statistical Package of Social Sciences）.Appropriate descriptive and inferential statistics were applied:Indices of location and dispersion were used to summarize continuous data.Others were presented as frequency tables.Relationships between discrete variables were tested by means of chi-square test.Whenever expected cell frequencies were less than five,the likelihood-ratio Chi-square values were quoted rather than Pearson’s.Statistical significance was accepted at P-values of <0.05.Permission for study was obtained from respective village heads.Participants were required to give a verbal consent to participate in the study.The reluctance of the respondents to discuss potentially sensitive sexual matters was eliminated by assuring the participants of the confidentiality of the information provided which is purely for research purposes.
   
    RESULTS
   
    Four hundred married couples of which 166（41.5%） were men and 234（58.5%） were women.173（43.25%） were aged between 30~39 years.Mean age for females was 30.2±7 years while for males it was 38.8±8 years.216 had primary school education（Table 1）.95.8% of the respondents were aware of family planning.Majority 250（62.5%） had difficulty discussing family planning with their spouse with no significant difference between males and females（Table 2）.Majority of the respondents had difficulties discussing family planning with their partners because they felt it was a sign of promiscuity and it was not necessary.The female respondents on the other hand also had a fear of rejection and that their partners may not be supportive（Table 3）.

      　
    
    Though half（50%） of the respondents had discussed family planning with their partner,females were more likely to discuss family planning with their spouse compared to males（P=0.008）（Table 4）.Majority of those who discussed about family planning did so after  first or second childbirth（Table 5）.Of the 200 who had discussed family planning with their spouse  135（67%） had discussed choice of method with their spouse.Of the 135 respondents that had discussed their choice of family planning with their partners,130（96.3%） had their choice accepted by their partners（Table 6）.This increased compliance in 127（93.3%）（Table 7）.Table 1  Socio-demographic Characteristics of the Respondents

   Table 2  Difficulty in Communication on Family Planning between Respondents and Their Partners

   Table 3  Reason for Difficulty with Communication between Respondents and Their Partners

   Table 4  Communication of Family Planning Methods between Respondents and Their Partners 

　
    
     Table 5  Frequency of Communication of Family Planning Method between 200 Respondents and Their Partners Who Had Discussed Family Planning

    Table 6  Relationship between Discussion and Spousal Acceptance of Family Planning Method （Influenced acceptance?）

    Table 7  Relationship between Discussion and Compliance with the Use of Family Planning Methods（Did it improve compliance?）

   Four FGDs were conducted based on age（<35years vs.>35years） and sex（males vs.females）.This is reported verbatim in their own language version to capture their mood and reactions.So their language may appear distorted.
   
    Participants Understanding of Family Planning
   
    FGD participants shared good understanding of family planning.Majority believed it was a means of planning one’s family.It was also described as methods used to space the number of children you want to have.A 40 year old female primary school teacher said:“It involves the use of contraceptives to reduce the number of children thereby providing adequately for the ones you have.”However from the minority that had a poor understanding of family planning,a 45 year old male farmer said:“Family planning is all about abortion,promiscuity and ways that encourage men and women to sleep around.”
   
    The majority of the participants knew about male condoms,injectables,oral contraceptive pills（OCPs）,intrauterine contraceptive devices（ IUCDs）,natural and traditional methods.A 35 year old male primary school teacher also knew of tubal ligation,female condoms and vaginal diaphragms.
   
    Utilization of Family Planning Methods among Participants
   
    Of the 6 females >35 years,3 had used natural methods,one traditional method and the rest had never used any form of family planning method.Of the 6 males >35 years,4 had used the male condoms at least once and 2 had never used any form of family planning method.
   
    Of the 7 females <35 years,4 had used natural methods,2 injectables and one had never used any form of family planning method.All the males <35 years had used the male condoms at least once in their lifetime.
   
    Discussion of Family Planning with Partner
   
    One third of the participants from both age group and sexes had discussed family planning with their partner.It was however noticed that their discussion was not necessarily based on desire to choose a particular family planning method but on advice of health personnel,wives of opinion leaders,friends and the media.A 30 year old trader said:“I only talk to my husband about family planning because the health personnel advised me but I was scared of discussing a particular choice.I know he wants more children and I am scared of what his reaction would be.”
   
    And of the participants that had discussed choice and their partner consented to it,a 40 year old primary school teacher said:“My husband agreed to our choice because it is for the benefit of the family most especially our children.”
   
    Reasons given by Participants for Difficulty in Communication of Family Planning Methods
   
    The females expressed fear of rejection and lack of support by their husband.A 31 year old farmer who was using natural methods said:“I tell him stylishly when I am not safe.10 days before and 10 after the start of my period.If  I am blunt with my husband,he might not be interested or even get angry.”Another woman a 26 year old seamstress said:“He doesn’t encourage discussion on sex;he might report me to his family and I don’t want problems with my marriage.” On the other end,a 45 year old farmer said:“Family planning is for the educated and that is why they are promiscuous.”
   
    The males had fears of their wives becoming promiscuous.Others said it was not necessary,that it was the doctor’s duty to discuss family planning methods.A 39 year old farmer said:“My wife is not a dog,allowing her to talk about or use family planning methods would make her a prostitute.” Another said:“I didn’t know we had to discuss such things.Isn’t it the job of the doctors? Is it even necessary at all?”
   
    Relationship between Communication on Family Planning Methods with its Use and Compliance
   
    Of the few women that had discussed Family Planning with their partners,they agreed that it encouraged compliance.The 40 year old primary school teacher said:“My husband’s support has helped me.I rarely miss any of my injections.” However another participant who had not discussed family planning with her husband said:“My husband doesn’t know I use natural methods so I can’t say I am compliant.It’s a sin to refuse your husband sex.”
   
    The men of whom majority had used the male condom were not compliant because of cost and reduced sexual pleasure by partner.A 30 yr old bus driver said:“My wife doesn’t like condoms.She says it isn’t natural so I only use it when she’s not safe.” A 42 year old farmer said:“I have a lot of things to do with money than to use it to buy condoms.If I can’t sleep with one wife,I’ll go to my other wives.”
   
    Encouragingly at the end of the Focus Group Discussions,majority of the participants were willing to discuss as well as imbibe the use of family planning methods in their family.
   
    DISCUSSION
   
    There is high level（95.8%） of awareness of family planning in the population studied but a lower knowledge of family planning methods（76.5 % males and 83.8% females）.This is consistent with findings from previous studies in this country［4,11,12,15］.Interestingly,66.8% of respondents（45.7% males and 54.3% females） said that their partners knew about family planning methods.However,the study revealed that despite impressive knowledge and awareness of family planning and its methods,only 58% of males and 65.8% of female respondents used at least one form of contraception.Male condom was the most common method used by men and natural methods the most common among women15.These two methods were also found to be the most popular among the men and women respectively in terms of knowledge.
   
    The study showed that 48.0% and 52.0% of male and female respondents respectively had discussed family planning with their partners（P value=0.008）.Out of these,only 4.1% of men and 15.3% of females had discussed more than 4 times（Table 4）.The largest proportion（33% males and 35.4 % females） discussed after their first or second child.This is fairly consistent with Nigerian Demographic and Health Surveys（NDHS） 2003 finding,which indicated that the use of any contraceptive method increases with the number of living children［2］.
   
    It is also interesting to note that only 39.2% of males and 30.3% females had discussed their present choice with their partners.Out of these,a large proportion of their partners（95.3% of male and 98.8% of female partners respectively） accepted their choices.This may actually mean that the often reported negative attitude of men towards contraception may after all be exaggerated or that they were reports of research findings many decades ago when there was generally poor knowledge and use of family planning by both men and women［10,11,13~15］.
   
    It may also be safe to say that discussion and acceptance of choice,almost always guarantees compliance.This inference is supported by the fact that 95.4% of men and 92.9% of women who had their choice of family planning accepted but their partners said it had improved their compliance.A large number of the respondents adjudged health personnel,friends and religion（church） as important factors that helped initiate such discussions.This is a pointer to the importance of using multifaceted approaches in disseminating family planning information in these communities［4,15］.
   
    Although a good number of respondents had discussed family planning with their partners,a large number（58.4% and 65.4% men and women respectively） still experienced difficulties in communicating family planning with their partners as shown in focus group discussions.The largest number of respondents believed it was a sign of promiscuity followed by the belief that it was not necessary.The fear of rejection and lack of support was however expressed by most women［13,14］（Table 3）.This shows the perception and views of Nigerian women about their spouses as the sole initiator and decision maker［7~10］.The situation of women in Nigeria is worsened by the fact that there are some traditional norms that tend to sanction men’s behaviour and make women more sexually submissive and less assertive［16～19］.These include the stigma of divorce,the culture of total submission to husband who is the head of the family.Consequently,women cannot determine when to have sex and how to avoid pregnancy［17～19］.The fear of the societal consequences（being beaten,divorced,neglected and rejected ） tend to take priority over fears of the health consequences of such ill-timed or unprotected sexual acts［18］.When one considers the health implications of men’s unrestricted sexual activities vis-à-vis the impact on maternal morbidity and mortality,child survival and the transmission of HIV/AIDS,one appreciates the urgent need for health education to both married men and women on spousal communication in family planning.
   
    The comment by some of the men at the focus group discussions（ FGDs） that family planning will make women to become prostitutes clearly exposes men’s ignorance of the consequences of unplanned and unprotected sexual intercourse.Thus,it has been opined that husbands who cannot appreciate or do not know of the health implications of frequent pregnancies may not give the required permission for their wives to visit family planning clinics［16］.
   
    The issue of male dominance in family decision making in sexuality related matters is not restricted to Nigeria or other African countries.In a Latin American survey［20］,it was reported that young males claimed that they knew little about contraception because they thought this was the girls’ responsibility.Despite men’s ignorance about contraception,studies in many parts of the world have reported men having more sexual partners than women over their lifetime.In the United States for instance,it was found that 50% of adult men surveyed said that they had five or more partners since the age of 18 as opposed to 30% of the women［21］.Studies in the Central Asian Republic revealed that married couples rarely discuss matters related to sex or reproductive health.Most of them said that they leave family planning discussions to their wives,but they expect their wives to ask for approval for contraceptive use［22］.
   
    Qualitative studies among married women with unmet need for family planning demonstrate the powerful role that their husbands play in determining whether they use contraception.In Utter Pradesh,India,87% of women with unmet need said that the decision to use contraception ultimately rests with the husband.More than one -quarter agreed with the statement:“My husband would get very angry if I talked to him about family planning methods”［23］.In urban Guatemala women with unmet need told interviewers that they often deferred to their husbands’ wishes despite their own preferences［24］.In Manila and several rural areas of the Philippines,husbands’ fears explained most of the unmet need［25］.In Nepal many women with unmet need said their husbands opposed family planning［24］.
   
    In order for a husband and wife to agree on the use of family planning,couples must discuss the topic but also accurately perceive each other’s attitude.Sometimes,women do not use contraception because they think that their husband object when in fact their husband approve.Surveys shows that,overall,men are more likely to approve family planning than women believe［24,26］.
   
    Men who discuss family planning with their wives are likely to take good care of the women when pregnant.They are more likely to make sure she gets proper antenatal care,which may entail providing transportation or funds to pay for her visits.He can also accompany her on the antenatal visit,where   he can learn about the symptoms of pregnancy complication.In deed the first step that men can take to promote safe motherhood is to plan their families.
   
    CONCLUSION
   
    Most married men and women in rural areas are aware of family planning.Despite this,there is a gradual decline in the spectrum from awareness to the actual use,spousal discussion and compliance with family planning and or its methods.The discussion of family planning use among couples is fairly constant with their compliance.
   
    RECOMMONDATION
   
    Based on findings from this study,it is recommended that:
   
    （1）  Emphasis should be laid on use and compliance of family planning based on spousal communication and mutual understanding.
   
    （2）  Education of rural dwellers with emphasis on female education and empowerment should be encouraged.
   
    （3）  Health workers and opinion leaders should also be educated and encouraged to counsel rural dwellers on family planning as well as to discuss this with their partners.
   
    ACKNOWLEGDEMENTS
   
    We hereby acknowledge the assistance of various community heads and the respondents who voluntarily participated in this study.

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（Editor LEE）