Concordance,communication,and shared decision-making about family planning among couples in Nepal: A qualitative and quantitative investigation

Abstract

Couple communication and joint decision-making are widely recommended in the family planning and reproductive health literature as vital aspects of fertility management. Yet, most studies continue to rely on women’s reports to measure couple concordance. Moreover, the association between communication and decision-making is often assumed and very rarely studied. Arguably, associations between dyadic communication and shared decision-making constitute a missing link in our understanding of how communication affects fertility-related practices. Informed by Carey’s notions of transmission and ritual communication, this study sought to address those gaps with two complementary studies in Nepal: a qualitative study of married men and women and a quantitative study of 737 couples. To assess spousal concordance on matters of family planning-related communication and decision-making in the quantitative study, responses from the couple were compared for each question of interest and matched responses were classified as concordant. Quantitative results found that more than one-third of couples reported spousal communication on all measured family planning-related topics. Nearly, 87% of couples reported joint decision-making on both family planning use and method type. Partner communication was significantly and positively associated with concordant family planning decision-making in both bivariate and multivariate models. Couples communicating about three family planning topics had more than twice the odds of concordant family planning decision-making than did those not reporting such communication. The qualitative findings provided insights into discordant as well as concordant interactions, revealing that decision-making, even when concordant, is not necessarily linear and is often complex.

Keywords

Couple concordance couple data family planning shared decision-making spousal communication reproductive health

Background

Studies of family planning and reproductive health interventions designed to influence family planning attitudes, contraceptive use, or audiences’ ideal family size often recommend that future programs encourage couple communication and joint decision-making (Bhattathiry & Ethirajan, 2014; Goel, Bhatnagar, Khan, & Hazra, 2010; Underwood & Kamhawi, 2014; Vaughan & Rogers, 2000). There is an underlying assumption that partner communication will encourage joint decision-making, which in turn will prove consequential for health outcomes. While the associations between couple communication and fertility-related health practices have been fairly widely studied, and correlations between joint decision-making and health practices have also been explored, if to a lesser extent, the associations between these two factors have rarely been studied. Indeed, a search of the literature found only one qualitative study (Hartmann, Gilles, Shattuck, Kerner, & Guest, 2012) and no quantitative studies that examined the relationship between fertility-related communication and joint decision-making based on reports from both members of the dyad. Arguably, associations between dyadic communication and shared decision-making constitute a missing link in our understanding of how communication affects fertility-related practices.

Despite compelling calls for couple-level studies to assess communication, attitudes, decision-making, and practices related to family planning and reproductive health, first made in the 1990s (Bankole, 1995; Becker, 1996), many, even most, studies in this broad area of scholarship continue to base their conclusions solely on women’s self-reports. Yet, there is no reason to believe that men’s influence on fertility decisions can be captured by proxy information from their wives (Bankole, 1995).

The positive association between family planning communication and contraceptive use has been demonstrated in a broad range of countries. Evidence from women-only studies (or studies that analyze data based on individual results and did not measure concordance between spouses’ responses) indicates that spousal communication is associated with contraceptive uptake and, in some of the published studies, contraceptive continuation (Bawah, 2002; Harman, Kaufman, & Shrestha, 2014; Irani, Speizer, & Fotso, 2014; Islam, Padmadas, & Smith, 2006; Kim, Kols, Bonnin, Richardson, & Roter, 2001; Kimuna & Adamchak, 2001; Link, 2011; Rimal, Sripad, Speizer, & Calhoun, 2015; Sharan & Valente, 2002; Wegs, Creanga, Galavotti, & Wamalwa, 2016). Only two of these (Irani et al., 2014; Islam et al., 2006) were based on analysis of data from both spouses.

Fewer studies have explicitly explored associations between dyadic decision-making and specific reproductive health-related practices. Among those studies, one relied on a sample of 592 pregnant women recruited for interviews after receiving antenatal care and found that women who reported that they jointly made decisions with their spouses were also significantly more likely to report that their husbands were involved in pregnancy health (Mullany, Hindin, & Becker, 2005). Among the few studies that utilized data from both dyadic members, one found mixed results on the relative importance of husbands’ compared with wives’ reports of decision-making power on reproductive health practices (Jejeebhoy, 2002).

Finally, the one quantitative study that reported concordant responses rather than separate responses for husbands and wives found that couples in which both reported joint decision-making compared with those who concordantly reported husband-only, or the involvement of others in, decision-making had lower odds of unmet need for contraception (Uddin, Pulok, & Sabah, 2016). That study controlled for husband–wife communication based on a question about the wife’s frequency of family planning-related communication in the last 3 months but did not examine spousal concordance in this respect. A qualitative study conducted in Malawi and based on interviews with 60 individuals, or 30 couples, pointed to the value of encouraging and supporting shared decision-making, which the authors argued could likely increase men’s involvement in reproductive health programs (Mbweza, Norr, & McElmurry, 2008). Thus, there are clear gaps in the literature regarding concordant couple communication, concordant joint decision-making, and the associations between the two. Too often, studies rely on women’s responses regarding their partners’ attitudes and fertility-related practices, including communication and decision-making, rather than asking men directly. Even when men are interviewed, as detailed above, concordance is rarely assessed.

This study seeks to address these gaps in literature by addressing three interlinked research questions quantitatively:

What is the level of intra-dyadic concordance regarding communication about fertility-related topics?

What is the level of intra-dyadic concordance regarding joint decision-making about contraceptive use? The extent to which mutual agreement is found with respect to communication and decision-making will contribute to interspousal reliability.

Is independently reported concordant family planning communication statistically correlated with concordant joint decision-making?

We define concordance as agreement in responses between partners. As a result, responses are classified as concordant when responses from both partners match on any given question of interest. Qualitative findings are included to provide context to, and augment, the quantitative results.

Theoretical considerations

In his seminal text, Communication as Culture (1989), James Carey articulates two broad views of communication, namely transmission and ritual views. As Carey eloquently describes, a transmission view emphasizes the instrumental role of communication or communication as a means-to-an-end in that individuals “transmit” information, ideas, orders, or requests to others and expect them to act upon it. As such, it is more likely to be monologic than dialogic. A ritual view highlights the communal or value-rational (Weber, 1978, pp. 24–25) aspect of communication in that the communicative act becomes an end-in-itself. In Carey’s words, “[a] ritual view of communication is directed not toward the extension of messages in space but toward the maintenance of society in time; not the act of imparting information but the representation of shared beliefs” (Carey, 2008, p. 18). In short, ritual communication is likely to be dialogic. Yet, as Carey readily concedes, any particular communication—and, by extension, any given relationship—may well include elements of both approaches (Cmiel, 1992; Giese, 2004).

Carey’s notion of communication as transmission or as ritual can contribute to our understanding of the relationship between couples’ reports of communication and decision-making. Evidence of transmission communication would include instances when couples reported that they communicated about a topic but then made unilateral decisions, such as when one instructed the other to take a particular action. While we are not privy to the content of communication reported quantitatively, qualitative findings shed some light on the nature of the conversations. Manifestations of ritual communication are evident in the extent to which couples concordantly report that they engaged each other in fertility-related communication and made decisions together, which reflect an orientation toward cooperative action in which their relationship is “produced, maintained, repaired, and transformed” (Carey, 2008, p. 23).

Method

Qualitative and quantitative data analyzed and presented here are drawn from formative and baseline studies conducted by the Health Communication Capacity Collaborative (HC3) Project in Nepal. The Nepal HC3 Project was a United States Agency for International Development-funded initiative that used social and behavior change communication in 13 selected districts and at the national level to address family planning aspirations and practices in Nepal. The Nepal HC3 Project conducted a qualitative formative study in Spring 2015 to identify salient themes for use in program content and to inform quantitative data collection instruments. The formative study was administered prior to the quantitative panel study, which was designed to assess changes in family planning attitudes and practices and their associations with participation in or recall of the Nepal HC3 Project. Quantitative data from the baseline study presented here were collected in Summer 2015. Both studies received approval from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board and the Nepal Health Research Council prior to data collection.

Qualitative methods

To gain a deeper understanding of social norms and other factors that influence couple communication and decision-making related to family planning in Nepal, the research team conducted in-depth interviews with married men and married women from three districts: Syangja (a western hill district), Banke (mid-western Terai), and Siraha (eastern Terai). Participants in the qualitative study included 39 individuals: married youth (women: ages 15–25; men: ages 18–27), married Muslim and Dalit women (ages 15–25), men married to Muslim and Dalit women (ages 15–25), married women with labor migrant spouses (ages 15–25), and migrant men married to women ages 15–25.¹ Local health staff helped identify eligible individuals for recruitment. Prior to the commencement of data collection, details of the study were explained to potential participants. Informed written consent was obtained from adults; written parental permission and written minor assent were obtained for interviews with minors. In the qualitative phase of the research, the aim was to gain a deeper understanding of marital experiences related to communication and decision-making among respondents. To capture a variety of experiences, the study team selected a broad range of individuals, rather than a smaller set of couples, representing diversity in age, social group membership, and spousal labor migration history. With approximately one-third of married women reporting that their husband lived away from the home in 2011 and 2016 (Ministry of Health and Population, ICF, & New Era, 2012; Nepal Ministry of Health, New Era, & ICF, 2017), it was important to include the wives of migrants as well as men who were former migrants.

Interview guides were developed in English and translated into Nepali. Questions explored contraceptive knowledge, aspirations, partner communication, decision-making, and social norms related to family planning. All interviews, which lasted 60–90 min, were conducted in Nepali or Maithili (in Siraha primarily) and audio-recorded. The interviews were conducted in or near participants’ homes in a location that afforded privacy, which was chosen by each participant. The research team transcribed all interviews and translated them into English for the purposes of analysis.

The research team, composed of both American and Nepali researchers, performed a thematic analysis that was guided by qualitative coding and a systematic review of all quotations. All members read transcripts from each category of interview participant to familiarize themselves with the data prior to beginning the coding process. Three members developed preliminary lists of concepts to be included in the final coding framework. These lists, which included both a priori codes and codes based on emergent themes from the data, were shared among the team and merged to develop a preliminary coding framework. The research team then discussed this preliminary coding framework and noted oversights, repetitions, and inaccuracies. The key emergent themes related to family planning decision-making included educational and occupational aspirations for children, desired family size, social norms regarding family size, contraceptive decision-making, spousal communication dynamics, and marital relations.

The preliminary coding framework was then used to code one-third of the qualitative interview transcripts. All coding was conducted in ATLAS.ti (2015). Two members of the research team coded each transcript. Each pair of coders met to discuss and resolve disagreements in coding. Following this initial coding process, final revisions were made to the coding framework and the remaining transcripts were coded by a member of the research team. Following the completion of the coding phase, quotations associated with each code were read and summarized. Constant comparative techniques were used to examine similarities and differences across participants to identify major themes associated with each code (Boeije, 2002; Gale, Heath, Cameron, Rashid, & Redwood, 2013). We draw on these analyses to present data on family planning communication and decision-making among couples in Nepal.

Quantitative methods

The Nepal HC3 Project’s baseline survey was administered in 12 districts: Siraha, Chitwan, Syangja, Kaski, Parbat, Dang, Saptari, Parsa, Tanahun, Baglung, Gulmi, and Kailali. No intervention activities had begun when the baseline survey was administered. A stratified multistage cluster sampling design was used to select eligible households within rural and urban areas using probability proportionate to size sampling, which resulted in a sample of 1,940 households from 97 clusters. Nonresponse was 1%. Households were eligible for inclusion if there was a resident woman of reproductive age (18–49) who had a child under the age of 5.

Individuals were recruited only if they were regular residents of the household, which was operationalized as having spent the previous night there. Dyadic data presented here are drawn from interviews with 737 women with a child under 5 and their resident husbands; each person was interviewed separately in a private location of his or her choosing; interviews lasted 45–75 min.

Questions on recent communication about family planning topics and participation in decision-making about family planning were used to construct measures of partner communication and joint decision-making based on concordance between women’s and men’s responses. Concordance on reported communication with partner was a categorical variable based on couples’ communication on using a contraceptive method, the type of contraceptive method, and where to get the contraceptive method. Concordance on family planning decision-making was a dichotomous variable based on two questions asking who makes decisions on (1) using a contraceptive method and (2) what type of contraceptive method to use. Couples in which both members reported concordant responses to the two questions were compared to all other respondents. All 737 coresident dyads were included in this study regardless of current contraceptive use status as communication and joint decision-making about contraception may be associated with current use, the intention to use, or a mutual decision not to use contraception.

Women’s self-reported age (years), caste/ethnic group, and live births as well as their husband’s age (years) and their household’s rural/urban residence and wealth were included as potential confounders in all models. Women’s and men’s education were not included in final models due to collinearity as suggested by high variance inflation factors (VIFs). Women’s and men’s age variables were left continuous, with a spline term at age 36 used to account for the piecewise relationship between women’s age and all outcomes of interest. Caste/ethnic group was categorized based on Nepal Demographic and Health Survey (NDHS) categories, with terai janajati and/or madhesi groups included in the terai Brahmin/chhetri group due to (1) similarities in associations with outcomes of interest and (2) small sample sizes for this population (Ministry of Health and Population et al., 2012). Rural/urban residence was based on governmental designations (Ministry of Health and Population et al., 2012). Household wealth was measured in quintiles and was based on an index, created using principal component analysis, of 10 measures of household materials, access to drinking water and toilets, finances, and ownership of goods based on recommendations from the NDHS (Rutstein, 2015).

Based on the themes that emerged in the qualitative analysis and to accomplish the aforementioned objectives, relationships between partner communication and joint decision-making related to family planning were explored. Concordance on partner communication and joint decision-making was measured by percent (%) agreement and the κ statistic (McHugh, 2012). The κ statistic ranges from −1 to 1, with values closer to 1 signifying greater concordance after accounting for chance. Cutoffs originally proposed by Cohen (1960) range from slight (0–0.2) to fair (0.21–0.4), moderate (0.41–0.6), substantial (0.61–0.8), to nearly perfect (0.8–1) (Cohen, 1960; Kulczycki, 2008). Bivariate and multivariate logistic regressions of communication about family planning on joint decision-making on family planning were also conducted. All descriptive, bivariate, and multivariate analyses were conducted in Stata13. Akaike’s information criteria values and VIFs were used to assess parsimony of models and collinearity of independent variables. Hosmer–Lemenshow goodness-of-fit tests were conducted to assess model fit. All models presented here were good fits of the data (p > .05).

Results

Here we present quantitative and qualitative evidence to investigate the prominent links between communication and decision-making related to family planning among our Nepali participants. We first explore spousal communication and decision-making about family planning independently. Subsequently, we examine the quantitative and qualitative relationships between communication and joint involvement in decision-making. The quantitative data are presented first, with qualitative data then used to augment, complement, and challenge associations identified in the quantitative data.

Description of study participants

Table 1 provides select sociodemographic characteristics for the matched husband–wife sample that participated in the baseline quantitative survey (n = 737). Among participants, husbands were older than wives, with a mean age of 31 years compared to 26 years. The couples came from a range of caste/ethnic groups, but a minority were Muslim and Terai Dalit. The majority of couples had one or two children. The majority of couples reported rural residence (62%) as compared to urban residence (39%).

Table 1.

Sociodemographic characteristics of husband–wife dyads.

Sociodemographic characteristics	Total	Total (n)
Women’s age, mean (SD)	26.1 (5.2)	737
Men’s age, mean (SD)	30.7 (6.1)	737
Caste/ethnic group, %	31.5	232
Hill Brahmin/Hill Chhetri	31.5	232
Terai Brahmin/Chhetri/Janajati	24.2	178
Hill Dalit	13.6	100
Terai Dalit	7.7	57
Hill Janajati	17.1	126
Muslim	6.0	44
Parity, %
One	39.6	292
Two	33.2	245
Three	13.2	97
Four or more	14.0	103
Place of residence, %
Urban	38.4	283
Rural	61.6	454
Household wealth, %
Lowest	19.9	147
Lower	21.7	160
Middle	20.6	152
Higher	21.7	160
Highest	16.0	118
Total, %	100.0	737

In-depth interviews were conducted with 39 participants, including married women and men as well as former migrants and spouses of current migrants (Table 2). Women and men from marginalized or disadvantaged groups as well as those from higher socioeconomic positions were interviewed to capture some of the variation in the lived experiences of Nepali people residing in the three districts where interviews were conducted.

Table 2.

Characteristics of women and men with whom in-depth interviews were conducted.

Participant type	Number of participants
Young married women 15–25 years old	9
Men married to women who were 15–25 years old	9
Married women 15–25 years old from a marginalized or disadvantaged group (Muslim or Dalit)	6
Men married to women who were 15–25 years old from a marginalized or disadvantaged group (Muslim or Dalit)	6
Women 15–25 years old married to a man who was migrating or had recent migration experience (at least three continuous months in the past 3 years)	6
Men with previous migration experience married to women who were 15–25 years old	3
Total	39

Husband–wife agreement on spousal communication

The first research question concerns the level of intra-dyadic concordance regarding communication about fertility-related topics. Husband and wife agreement about whether communication had taken place on the three individual family planning topics of interest ranged from 41% to 54% (Table 3). More than one-third of couples reported spousal communication on all three of the family planning-related questions. In contrast, 21% of couples reported communicating about one or two of the family planning topics. For 42% of the couples, the husband and wife either did not agree about whether they had communicated about family planning or agreed that that they had not discussed any of the three family planning-related topics. κ statistics suggested substantial agreement on recent partner communication about family planning (range: .60–.68; Cohen, 1960; Kulczycki, 2008).

Table 3.

Communication about family planning and joint decision-making about family planning according to husband–wife dyads.

Selected communication and decision-making measures related to family planning based on responses from women 18–49, responses from their husbands, the percentage of couples in agreement, and associated κ values	Wives	Husbands	% in agreement	κ values
Communication with spouse on family planning
Using a contraceptive method	62.3	61.7	54.5	.68
Type of contraceptive method	57.1	56.6	48.7	.67
Source of contraceptive method	49.5	50.2	41.4	.66
Index of communication on family planning
No communication*	34.5	32.7	42.1	.60
Communicated on one to two family planning topics	20.6	24.0	21.4
Communication on all three family planning topics	44.9	43.3	36.5
Decision-making with spouse on family planning
Using a contraceptive method	93.4	93.8	90.8	.54
Type of contraceptive method	92.9	93.9	90.2	.48
Index of decision-making on family planning
Joint decision on two family planning topics*	91.2	91.3	87.4	.52

*Discordant responses from couples on communication or decision-making were classified as no communication/joint decision-making in the indices.

In qualitative interviews, women and men also indicated that communication about family planning—such as family size, contraception, or what method to use—was common. Such communication was frequently framed positively with important implications for the present as well as for future happiness.

It feels good to talk to your husband. [A] husband and wife should discuss about everything with each other. (Wife of migrant, Banke)

If both husband and wife [give] suggestions to each other, they can live with happiness and love throughout life. (Male respondent, Banke)

Often women and men alike indicated that they were very comfortable broaching such topics with their spouses. Family size is a topic most, if not all, participants said that they discussed with their spouses; indeed, no one asserted that he or she made a decision regarding family size without first conversing with his or her spouse about this very central topic. Interviewees also noted that conversations about family size were easy and came naturally. No one expressed discomfort or unease regarding this communication topic with spouses. As one woman explained, “I discuss [with my husband] about limiting the number of children…I feel comfortable as he understands the situation” (woman from disadvantaged group, Syangja).

Women were somewhat more likely than men to suggest that they initiated conversations about family planning. A study participant illustrated this when she said:

I do [start the conversation about family size]. I tell him not to make more babies. We should properly manage it…I feel good [about it]. (Woman with children, Banke)

A woman from Siraha whose husband was migrating said, “I feel it is easy. Why should I feel shy with my husband?” This comfort talking about family planning with a partner was not inherent to all relationships. As one man highlighted, sometimes it took time to be able to talk freely about such topics.

How comfortable do you feel discussing the methods that should be used and should not be used?

I feel very comfortable. There is no difficulty since both [of us] are educated. It was difficult in the past, but now we put forward our problems freely. (Man with children, Syangja)

Sometimes respondents seemed surprised when the interviewers asked them if they discussed these topics with their spouses, noting that “of course” they talk about matters that affect their lives and well-being.

There is good understanding. If he finds anything good, he shares with me, and vice-versa…There is good agreement with my husband. We work in coordination. What else? (Woman from disadvantaged group, Banke)

Several men also noted that marital partners should respect each other as equals, recognize that each can contribute in multiple and unique ways to the family, and each should be free to form his or her own opinions.

The female is similar to that of the male. She can engage in a job and make her career. She has the right; and she is not here just to have babies and cook and take care of the family. (Man, former migrant, Banke)

A few study participants indicated that their husbands did not want them to use modern contraceptives due to concerns about the effects on a woman’s health, in which cases the husband took responsibility to avoid unwanted pregnancies. As a woman from a disadvantaged group in Syangja reported, “medicines have side effects, so he says he would [rather] control himself.”

While many respondents reported being comfortable talking to their spouses about family planning, both quantitative and qualitative evidence showed that some did not talk about such topics. During interviews, a minority of interviewees noted that they felt it was difficult to discuss contraception with their spouses. As one man explained:

I feel shy saying ‘we should do this’ [regarding contraception]. But some important things must be said even if we feel uncomfortable. We should give suggestions and take them as well. (Man, disadvantaged group, Syangja)

It was not only men who expressed such lack of comfort. A woman with children from Syangja made similar comments, saying “I myself feel uncomfortable while talking about such things [contraception].”

Husband and wife joint decision-making

The second research question explores the level of intra-dyadic concordance regarding joint decision-making about contraceptive use. The majority of couples reported joint decision-making on both family planning use and type of method (87%). κ Statistics suggested moderate agreement on joint decision-making about family planning (range: .48–.54; Cohen, 1960; Kulczycki, 2008). Similar findings emerged from the qualitative interviews, with women and men frequently saying, “we decide together” or “both the husband and wife decide together.” Several participants alluded to the association between shared decision-making and intimacy.

Neither I nor he can do it alone. And it is not good to be satisfied alone…It will be comfortable to share with him rather than with other members. I share everything with him, but not with others. (Wife of migrant, Siraha)

Taking the decision together helps to keep the couples happy and see other options as well. (Man, disadvantaged group, Syangja)

A few men discussed the importance of listening to their wives’ opinions and giving them the chance to speak about their hopes and plans, thus creating a more understanding and satisfactory relationship for both.

If I do so on my own [make a decision] it would hurt my wife. It would be a forceful and one-sided decision. That’s why we decide collectively in everything not only in the matter of children. (Man, former migrant, Siraha)

A man who wanted only one child noted that this decision was not his to make alone. He maintained that family planning decisions are only made in concert with one’s spouse and pointed out that an acquiescent, obedient wife was not to be expected or, he implied, desired.

[Having only one child] is possible only if the husband and wife desire the same number of children. I cannot put my decisions on my wife and expect her to obey. (Man, former migrant, Banke)

It was noted that mutual decision-making was a change from the past in two ways. First, this shift marked a transition away from when men would tell women what to do, and women acquiesced.

[Decisions are] not only taken by husbands now. Now most of the wives are understanding, and it happens through agreement. In the past men used to tell their wives what to do. Men did not [use contraception]. But now if the woman is weak [so cannot use contraception], she tells her husband to use it. Everything is based on agreement. (Man with children, Syangja)

Second, women and men highlighted that joint decision-making between spouses meant that their parents were less involved. One study participant explained clearly this shift in decision-making roles.

What is the reason that only you two take decisions in this matter?

(Children’s voice)

(Laughing) The reason behind it is that, in the past our parents’ used to decide. They used to tell that you have to have this or that number of children. Now it’s our turn to take the decisions for ourselves. (Woman with children, Siraha)

While the dominant opinion was that childbearing decisions were shared, several participants responded unequivocally that it is the man’s decision. This was reflected in a comment by a migrant’s wife from Siraha, who said, “My husband takes the decision. I do not know who tells it to my husband. My husband told me to use this method.” Others justified men’s decision-making role on economic grounds. As a married mother in Banke said, “My husband will decide of course!…Because he is the one who feeds us, looks after us and earns for us.” There was also acknowledgement that, in some families, woman made decisions because they had more economic power. One man from Banke said:

In my home I have a job so I have more rights. But in some houses, there are women working more than men. In some houses the women will have more rights.

Of the family-related decisions couples or individuals made, method choice was a decision that some women reported making on their own. A case in point was a married mother from Syangja who, in response to being asked who decided to use the injection, said, “I did myself; I felt it was good.”

Concordant communication and decision-making

The third research question examines whether concordant family planning communication is a predictor of concordant joint decision-making. Unadjusted and adjusted odds ratios (AOR) and 95% confidence intervals (CIs) for bivariate and multivariate analyses examining the association between spousal communication and concordant decision-making on family planning are displayed in Tables 4 and 5. Partner communication was significantly and positively associated with concordant decision-making on family planning in both bivariate and multivariate models. Couples communicating about three family planning topics had more than two times greater odds of concordant decision-making on family planning as compared to those not communicating or not agreeing about whether they had communicated on these topics (AOR: 2.33; 95% CI: 1.32–4.11; p < .01). There was no significant effect comparing those communicating about only one topic to those who reported not communicating, or who did not agree whether they had communicated, about family planning.

Table 4.

Unadjusted odds ratios for concordant decision-making on family planning.

Explanatory variables of interest	Unadjusted odds ratios with (95% CI)
Partner communication (Ref: No communication on any of the three FP topics)	1
Communication on one to two FP topics	1.22 (0.71–2.13)
Communication on three FP topics	2.01** (1.19–3.39)
Constant	5.33*** (3.93–7.23)

Note. FP = family planning; CI = confidence interval.

***p < .001; **p < .01; *p < .05.

Table 5.

Adjusted odds ratios and 95% confidence intervals of concordant decision-making on family planning.

Explanatory variables of interest	Adjusted odds ratios	95% Confidence intervals
Partner communication (Ref: No communication on any of the three FP topics)	1	—
Communication on one to two FP topics	1.25	(0.70–2.25)
Communication on three FP topics	2.33**	(1.32–4.11)
Women’s age (≤36)	1.05	(0.97–1.14)
Women’s age (>36)	0.86	(0.68–1.09)
Men’s age	1.01	(0.95–1.06)
Caste/ethnic group (Ref: Hill Brahmin/Chhetri)	1	—
Terai Brahmin/Chhetri/Janajati	0.62	(0.31–1.23)
Hill Dalit	0.68	(0.29–1.56)
Terai Dalit	0.38*	(0.15–0.94)
Hill Janajati	0.81	(0.38–1.74)
Muslim	0.20***	(0.08–0.50)
Live births (Ref: One)	1	—
Two	0.66	(0.37–1.17)
Three	0.88	(0.35–2.19)
Four or more	0.33*	(0.13–0.85)
Residence: Rural versus urban	0.48*	(0.27–0.84)
Wealth quintile (Ref: Lowest)	1	—
Lower	0.68	(0.33–1.42)
Middle	0.50	(0.23–1.09)
Higher	0.42*	(0.19–0.90)
Highest	0.33*	(0.12–0.87)
Constant	14.94*	(1.64–135.66)
Observations	737

Note. FP = family planning.

***p < .001; **p < .01; *p < .05.

In multivariate models, caste/ethnic group, parity, place of residence, and wealth were associated with concordant decision-making on family planning. In comparison with couples who identified as Hill Brahmin/Chhetri, couples from other caste/ethnic groups had reduced odds of reporting concordant decision-making on family planning. Differences were only significant, however, when comparing marginalized groups, most of whom lived in the terai (i.e., terai Dalit and Muslims), to individuals identifying themselves as Hill Brahmin/Chhetri in multivariate analyses. As compared to couples with a single live birth, couples with two, three, or four or more live births had reduced odds of concordant decision-making on family planning. Differences were not significant, however, except when comparing women with four or more live births to those with a single live birth (AOR: 0.33; 95% CI: 0.13–0.85; p < .05). Couples living in rural areas had significantly reduced odds of agreeing that they made joint decisions about using family planning and the type of method to use (AOR: 0.48, 95% CI: 0.27–0.84; p < .05). Finally, couples from higher wealth quintiles show reduced odds of concordant decision-making on family planning as compared to those from the lowest wealth quintile.

The qualitative findings provide some insights regarding the linkages between communication and decision-making. Several respondents espoused the idea that communication and decision-making were mutual decisions based on mutual understanding and agreement. One respondent illustrated this link between discussion and mutual decisions:

Who takes the decision between you and your wife about the use of birth control?

We both do.

You discuss it together?

Yes.

Why do you think mutual decisions should be made in the family instead of only one making the decisions?

Decisions should be made mutually. There’s no way only one can make a decision. (Man, disadvantaged group, Syangja)

A Muslim man with migrant experience from Banke pointed to the religious basis of mutual decision-making, noting that “we must work according to our religion,” which requires concurrence regarding not only whether to have a child, but what methods to use. Another man talked about the role of communication in coming to a mutual understanding regarding family size.

I explained to her: suppose we planned for a daughter and we have a son. If we again plan for another baby then the number will go on increasing. Then she said I was right. (Laughs) Then we came to the decision that whether a son or a daughter, we will have one more child. (Man from disadvantaged group, Banke)

While some respondents maintained that all decisions were mutual, others pointed out that it was natural to have some disagreements. One tactic was to wait a day or two before revisiting the subject, another was to take the other’s perspective into consideration and not immediately assume one has all the answers.

You can look after her too…In that time, instead of debating with her I listened to her silently. I think she is also correct. She has to wake up at 4:00 am, but I wake up at 8:00. Women in our village have to face many difficulties. (Man, Syangja)

Several study participants recognized the need to reconsider their own opinions, a sentiment voiced by a former migrant who had recently returned to his home in Syangja, “I appear to be wrong sometimes,” in which case, he continued, he may find that he agrees with his wife’s opinion.

Decision-making, however, was often not a simple, linear matter, but a process that took place over time. Describing how decisions were made often took a variety of twists and turns; it was not uncommon for an interviewee to initially state that it was her husband who made the decision, only to continue by explaining that she was very much part of the decision. This is reflected in the following exchange representative of others that took place during interviews:

Why does your husband decide?

It is because we thought it would be good if we don’t have more children.

Why didn’t your husband use a method?

I told him not to use it since I thought to use it myself. (Woman, Siraha)

In this instance, the woman said that her husband decided, yet continued by noting that it was she who told him which method she would use.

Despite the close linkages between communication and mutual decision-making, findings from these in-depth interviews showed that communication did not always lead to joint decision-making on family planning. Several respondents talked about cases of communication leading to disagreement between husbands and wives regarding contraceptive use; in such cases, it was reported the wife might surreptitiously approach a clinician or female community health volunteer for the method of her own choosing.

Although a minority view, some respondents indicated that decision-making may occur without communicating with their spouse, as reflected in the following comment when the interviewee mentioned that he had decided to use condoms without input from his spouse.

[Method use]…is my own wish. I have to think about it.

Do you have discussion about it or not?

I do not have discussions [with my wife]. (Man, former migrant, resident of Banke)

A woman from Siraha whose husband was migrating similarly reported using a contraceptive method despite not having talked with her husband about it.

Together, these findings provide an in-depth exploration of the complex interconnections between communication and decision-making about family planning in Nepal.

Discussion

Shared decision-making is widely considered an important antecedent to positive health practices (Bhattathiry & Ethirajan, 2014; Goel et al., 2010; Underwood & Kamhawi, 2014; Vaughan & Rogers, 2000). And joint decision-making, by definition, requires communication. Yet, this is the first study to explore couple concordance on fertility-related communication and shared decision-making. The findings support the value of interviewing both members of the couple given that some degree of discordance was evident on both measures. Survey results point to a moderate level of intra-dyadic concordance regarding communication about fertility-related topics with 57% of both dyadic members reporting that they had discussed one or more of the three family planning topics with their spouse. Concordance regarding decision-making was high; 87% of couples reported joint decision-making on both family planning use and type of method. Qualitative results supported this finding as only a minority reported that it was the husband’s—or wife’s—decision alone.

The quantitative findings demonstrate that concordantly reported communication was highly and significantly associated with concordant decision-making. The qualitative findings also point to the intersections of communication and decision-making, which suggests that partner communication may not necessarily occur prior to decision-making but instead may be integral to the process itself, a process that is often muddled and nonlinear.

Carey’s account of ritual and transmission modes of communication expands our understanding of couple communication by bringing to the forefront both the instrumental and the value-laden or cooperative aspects of dyadic relationships. To the extent that couples communicate about family planning goals and aspirations and mutually decide how to achieve them, they could be said to be engaged in ritual communication in that their communication is oriented toward “the maintenance of [their relationship] in time” and in “the representation of shared beliefs” rather than toward the transmission of information or direction (Carey, 2008, p. 18). This is not to downplay discordance and those instances in which women (in particular) stated that they abided by their partners’ wishes, but to highlight the fact that concordance was evident in a clear majority of couples’ responses. Moreover, while a few respondents in the qualitative study reported some level of discomfort in broaching these topics, the majority not only felt comfortable discussing such topics with each other, but also felt it integral to their relationship, which again, in Carey’s terms, reflects communication focused on the reinforcement and strengthening of their relationship.

This study has important implications for future health communication programs working in Nepal and, likely, well beyond. Quantitative and qualitative evidence suggested that joint decision-making appeared to be a norm—at least with respect to fertility aspirations and goals—but was also often something that couples aspired to or intended to do with their partners in the future. Efforts should be made to continue to encourage such interactions between partners and to identify the barriers faced by those couples who aspire (but have not yet fully realized their aspiration) to communicate or participate in joint decision-making about family planning topics.

Efforts to understand why couples experience concordant and discordant communication and decision-making will also be necessary. There are aspects of women’s, men’s, and couples’ identities and sociocultural contexts and environments that affect concordance and discordance as well as mutual decision-making. They include caste/ethnicity, age, education, power dynamics, or simply fear of disagreements with partners. These factors could be the target of communication strategies focused on working with couples of reproductive age in Nepal. Additionally, as the findings indicate, it is vitally important to interview and utilize data from both spouses/partners rather than relying on the report of one member of the dyad.

Limitations

It is important to consider the limitations of the analyses presented here. Due to the cross-sectional quantitative data analyzed, the associations presented cannot be interpreted as causal since we were unable to assess temporal order. The quantitative associations are representative of women of reproductive age with a child under 5 who live in the 12 districts where the baseline survey was conducted. These 12 districts cut across ecological zones in Nepal as well as development regions, and thus participants were from a range of different settings. Given the sociocultural diversity that exists within Nepal, however, these findings should not be interpreted as representative of all couples of reproductive age in Nepal. The qualitative data were collected from women and men in three districts in Nepal and were not intended to be generalizable, but instead were gathered to explore how partner communication and decision-making are discussed by women and men to identify themes that could inform future studies and perhaps be transferrable to other settings.

Conclusions

The intersections of fertility-related communication and mutual decision-making demand further quantitative as well as qualitative analysis both in Nepal and beyond. It will be important to examine this relationship in both similar and dissimilar settings to explore not only the extent to which concordant communication is associated with shared decision-making, but also to better understand how contexts, perceived gender norms, and migration affect those intersections. The results reported here add instructive nuances to our understanding of the decision-making process, demonstrating that even when communication is associated with decision-making, the two are not necessarily linked in a linear manner. This points to the importance of questioning assumptions about how to interpret pre-coded responses as well as to the value of relying on more than one data source. The downstream impact of the communication/decision-making nexus on family planning practices or health outcomes should be examined rather than focusing solely on these factors as distinct entities. Future studies should be conducted with longitudinal samples to examine these nuances with more rigorous questions exploring the linkages between communication and decision-making. The qualitative themes presented supported as well as challenged associations identified in the quantitative data, and future quantitative analyses designed in the light of the complexities described herein could contribute to our understanding of the ways in which partner communication and decision-making vary and are interlinked in other global settings and in other health areas using a combination of both quantitative and qualitative methods. Such findings could contribute to the design and implementation of communication programs that could support couples as they seek to achieve better outcomes for themselves and their families.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the United States Agency for International Development (USAID), Cooperative Agreement #AID-OAA-A-12-00058.

ORCID iD

Carol R. Underwood

Open research statement

As part of IARR’s encouragement of open research practices, the authors have provided the following information: This research was not pre-registered. The data used in the research are not available. The materials used in the research are not available as neither the research protocol nor the consent forms indicated that the data would be shared with individuals who were not part of the original research team.

Note

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