Male Perception and Participation in Family Planning Among Tribal Communities of Maharashtra,India: A Mixed-Method Study

Abstract

This study examined male perceptions and awareness about family planning. The study also investigated male involvement in family planning and contraceptive use decision-making. Furthermore, in this study, we assessed men’s awareness, attitude, and practice of modern contraceptive methods and determined the level of spousal communication. In this study, a field survey was conducted among the tribal population of Maharashtra. Both qualitative and quantitative methods were used for data collection. A sample of 385 men whose wives had given birth in the last 2 years were interviewed. Almost two thirds of the surveyed men (64%) had heard about modern family planning. The main source of information for family planning was the multipurpose worker in the village for 48% of men, followed by friends 16% and the auxiliary nurse midwife and accredited social health activist for 11% and 10%, respectively. Results show that the current use of any modern family planning method, including male and female methods, was 18.4%. Among the currently used modern methods, the major modern family planning method was male sterilization (67%), followed by oral pills (11%) and male condom use (10%). This study indicated that the acceptance of male modern family planning methods is very high.

Keywords

male sterilization family planning male participation Gond and Madiya tribes

Introduction

The scheduled tribal population in India is nearly 100 million, and scheduled tribes constitute 8.6% of the total population of India. Approximately 461 tribal groups are distributed over 29 states and union territories. Nearly 74 tribes who have been identified as “Primitive Tribal Groups” (currently known as “Particularly Vulnerable Groups”) are characterized by a preagricultural level of technology, an extremely low level of literacy, and extreme poverty. The health status of the tribal population is worse than that of the other subgroups in India.^1,2 According to the National Family Health Survey (NFHS; 2005–2006), the scheduled tribes in India have a very high total fertility rate (3.12) compared with other social groups.³ Substantial differences in contraceptive use are observed among different socioeconomic groups across the country. The tribal population has a very low use of both spacing and limiting contraceptive methods and a high unmet need for family planning compared with other social groups.^4–7 A study conducted among Rajasthan tribes demonstrated that only 19% of women used modern contraceptive methods, the use of male contraceptive methods was even less, and the practice of extended breastfeeding was universal among the tribes.⁸ Another study conducted among the West Bengal tribes of Santals and Lodhas revealed that these tribes are aware of sterilization but are less aware of spacing contraceptive methods.⁹ The awareness about female sterilization has increased among the rural and tribal populations because of wider information dissemination through the media. However, the information and knowledge about modern contraceptive methods are less among the men.¹⁰

Male participation in reproductive health and family planning has been gaining increasing attention over the past several decades. The 1994 International Conference on Population and Development asserted the importance of active engagement of men in reproductive health and family planning. Following this conference, wider scale efforts through the implementation of programs to increase male engagement and more research on male participation were evident. The 2000 National Population Policy of India recognized men as the underserved population regarding reproductive health. Two decades after the 1994 conference, it is evident from the literature that effective male involvement in reproductive health and family planning produces positive health outcomes for both the mother and child and results in the higher utilization of postpartum family planning services for the spacing and limiting of births.^11–14 However, the desired level of male participation is yet to be achieved. The recent NFHS-4 (2015–2016) showed that the use of male modern contraceptive methods is minimal; only 5.6% of Indian men use condoms and only 0.3% of men have undergone male sterilization (vasectomy), even though the procedure of vasectomy is simpler than that of female sterilization (tubectomy). By contrast, the use of current women-centric family planning methods is 42% overall, comprising 36%, 1.5%, and 4.1% for female sterilization, Intrauterine device (IUD/Postpartum Intrauterine Contraceptive Device (PPIUD), and oral pills, respectively. The survey also showed an unmet family planning need of 12.9% among currently married women aged 15 to 49 years.¹⁵ These findings confirm that traditional family planning programs in India are women-centric and that men are entirely excluded.^16,17 Moreover, studies have shown that in the family, Indian men frequently make important decisions related to reproductive issues, family size, and contraceptive use and continuation.^18–20 Few studies have examined the role, perception, and participation of tribal men in family planning. Some of the studies conducted using large-scale survey data have not provided comprehensive tribe-specific information and health-seeking and family planning behavior but have only provided empirical observations. The cultural and gender norms of male participation in family planning in the tribal population have not been studied adequately. To address this gap in the literature, this study examined male perceptions and awareness of family planning methods. This study also examined male involvement in family planning and contraceptive use decision-making. Furthermore, this study assessed men’s awareness, attitude, and practice of modern contraceptive methods and determined the level of spousal communication.

Methods

To address the study objectives, we used a mixed-method approach to collect both qualitative and quantitative data. This approach was used because no study of contraceptive use among tribal peoples in India has been conducted using mixed methods. Moreover, a qualitative study provides a comprehensive understanding of the responses derived from the quantitative study. The qualitative data were used to complement the quantitative results.

Sampling for Quantitative Data

Gadchiroli district in Maharashtra, India, was purposively selected as the study area because the tribal population of the district is the second highest in Maharashtra. The tribal population of the district is 38% of the total tribal population of Maharashtra. Multistage sampling was applied to recruit the estimated sample size of respondents. Gadchiroli district has 12 tahsils (blocks). Of 12 tahsils (blocks) in the district, Etapalli Tahsil (block) was selected because the tribal population of this tahsil is higher (82%) than that of the other tahsils (blocks). Within this tahsil (block), to obtain appropriate representation, 19 villages were selected using probability proportional to size sampling on the basis of the higher percentage of the tribal population in these villages. From each selected village, a list of women who had given birth in the last 2 years was obtained from the auxiliary nurse midwife and accredited social health activist in the villages. On the basis of the list, currently married men aged 15 to 54 years were chosen as respondents. In total, 385 men were selected for this study. A structured questionnaire was used to collect data. The first section of the questionnaire pertained to the socioeconomic profile of respondents. The other section contained direct questions related to respondents’ knowledge of modern contraceptive methods, their current use of contraceptives, the main spouse making the decision for contraceptive use, and the other related information. Data entry was conducted using CSPro 4.0 software, and data analysis was performed using SPSS 20.

Qualitative Data

An anthropological approach was deemed the most appropriate for a comprehensive exploration of existing family planning practices and the participation of tribal men in family planning. The first author lived in the study area between November 2014 and March 2015 while primary qualitative fieldwork was being conducted. Semistructured in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted using pretested guides. The use of IDIs and FGDs enabled in-depth, one-to-one communication and lively dynamic discussions. One FGD was conducted with groups of men whose wives had given birth in the last 2 years, two IDIs with healthcare providers, and two IDIs with a mixed sample of women who had recently delivered. IDIs and FGDs were conducted in the local language combination of Marathi, Hindi, and Gondi. To conduct interviews with women, two female investigators were employed and trained from the same village, so that women would feel more open to express their opinions. All study participants were encouraged to discuss their opinions openly. All discussions and interviews were recorded and transcribed verbatim in Marathi and Hindi. After validation of the transcription, the typed narratives were translated into English and verified for accuracy. Direct quotations from IDIs and FGDs are presented in italics, wherever required, to highlight the key findings of this study. To avoid losing the meaning, the quotations are presented without editing the grammar.

Ethical Concerns

This study was undertaken in a tribal dominated area. Therefore, before survey administration, informed consent was obtained from the respective tribal community head. Consent was also obtained from individual respondents before the interview, and they were assured that they were free to withdraw from the study anytime. Because the study explored the cultural aspects of the tribal community, appropriate consent was obtained from the Gond and Madiya tribal community head to protect their traditional cultural interests. The study purpose was explained to the community and individuals before the survey, and they were assured that information collected from the individuals and the community would be used for only academic research purposes.

Results

Sociodemographic Profile of Study Participants

Table 1 shows the sociodemographic profile of study participants. Nearly 41% of respondents were aged 18 to 25 years and 43.9% were aged 26 to 30 years. The mean and median ages of the study respondents were 27.04 and 27 years, respectively. More than one fourth of the selected men (28.1%) were illiterate; 18.2% had completed primary schooling, 38% completed secondary schooling, and only 15% completed higher secondary education and were graduates. The mean and median years of schooling were 5.89 and 7 years, respectively. Regarding occupation, agriculture (57%) was found to be the main occupation, followed by agricultural laborer (24%) and government or private employee (14%), and only 4% of the sample reported their occupation as others. Regarding family type, 60% of respondents were from nuclear families and 40% from joint families. In the study area, only two types of tribes are living, namely Gond and Madiya tribes, accounting for 36.9% and 62.9%, respectively, of the total population of Gadchiroli district. The mean and median ages at marriage were 21.17 and 20 years, respectively. More than 75% of respondents had arranged marriages and 24% had love marriages.

Table 1.

Percentage Distribution of Men According to Selected Sociodemographic Characteristics.

Background characteristics	Number of cases (n)	Percentage
Current age (years)
18–25	158	41.0
26–30	169	43.9
31–35	47	12.2
36–40	11	2.9
Mean age = 27.04 years
Median age = 27 years
Education
Illiterate	108	28.1
Primary	70	18.2
Secondary	147	38.2
Higher secondary	50	13.0
Graduate and above	10	2.6
Mean years of schooling =5.89 years
Median years of schooling = 7 years
Type of family
Nuclear family	234	60.8
Joint family	151	39.2
Type of marriage
Arranged marriage	295	76.6
Love marriage	90	23.4
Mean age at marriage = 21.17 years
Median age at marriage = 20 years
Type of tribes
Gond	142	36.9
Madiya	242	62.9
Rajgond	1	0.3
Current occupation
Agriculture	213	57.0
Agricultural laborer	91	24.3
Government/private employee	55	14.7
Others	15	4.0

Male Awareness and Participation in Family Planning

The awareness level and decision-making role regarding family planning are important factors that determine the use of family planning services. Husbands play a crucial role in using the available family planning services. From Table 2, it is evident that almost two thirds of the selected men (64%) had sometime heard about family planning. Furthermore, when asked about the sources of information, 48% of the men reported that they heard about family planning methods from the multipurpose worker (MPW) in the village, followed by friends for 16% and auxiliary nurse midwife and accredited social health activist for 11% and 10%, respectively. From this result, it is clear that grassroot healthcare providers are playing a crucial role in disseminating information on family planning services and on the benefits of using spacing and limiting contraceptive methods among the communities. However, in this study, the current use of any family planning methods among couples was very low at 18.4% (n = 71). Furthermore, participants were asked about the type of spacing and limiting contraceptive method used. Figure 1 shows that the major contraceptive methods used was male sterilization/vasectomy (67%) (n = 47), followed by oral pills (11%) n = 8 and male condom use (10%) n = 7. The unexpected result is that female sterilization is very low, even lower than male condom use. The results are very much contrary to the current trends of contraceptive method use in India. The recently conducted NFHS-4 (2015–2016) for Maharashtra showed that the prevalence of male sterilization is 0.4%, which is lower than the prevalence of 2.1% reported in the last survey (NFHS-3). According to NFHS-4, the current use of female sterilization is 50.9% in Maharashtra; it is even slightly higher at 55% in rural Maharashtra.

Table 2

Percentage of Male Awareness, Source of Awareness, Use of Family Planning Services, and Type of Modern Family Planning Methods.

	Percentage	Cases
Heard about family planning
Yes	63.9	246
No	36.1	139
Source of family planning information
Radio	2.0	5
Television	3.3	8
Newspaper	6.5	16
Friends	15.9	39
Relatives	2.0	5
Multipurpose worker	48.8	120
Accredited social health activist	10.2	25
Auxiliary nurse midwife	11.4	28
Currently using family planning
Yes	18.4	71
No	81.6	314

Figure 1.

Percent of use of modern family planning methods among the surveyed population.

Many explanations can be provided for this higher acceptance of male sterilization among the Gond and Madiya tribes. First, women’s equal participation in farming and manual labor may contribute to the higher acceptance. If women opt for female sterilization, then they are required to take rest; hence, they cannot do heavy work after the sterilization. Second, this finding may be attributed to the government incentive of Rs. 1,400 for male sterilization. Third, the procedure of male sterilization is simple and rapid. The higher acceptance of male sterilization may also be attributed to the efforts of local MPWs toward counselling men for accepting sterilization.

Some researchers argue that tribal women enjoy more autonomy than women in the general population; thus, tribal women may send their male partner to undergo vasectomy. During an IDI with a study participant, he expressed that “We don’t know how to use a condom, and we don’t want use it again and again; we just want to finish the childbearing by sterilising ourselves” (male member, age = 28 years).

In villages, healthcare providers, particularly MPWs, are responsible for providing family planning services and counselling to men. Frequently, health workers’ suggestions and counselling efforts help tribal men to adopt family planning methods. However, the use of spacing contraceptive methods was minimal in this study. From the qualitative results, a MPW said that “We have to visit each and every household where more than two children are born. However, we often face rejection for counselling. It is very difficult to teach an illiterate person about modern and spacing methods; therefore, we take them for male sterilisation” (healthcare provider, MPW, age = 36 years).

Decision-Making for Family Planning Service Use

The decision to have children or not is governed by many factors, and decision-making for adopting family planning services is influenced by cultural and traditional factors. However, the major decision-makers are typically the husbands. From Table 3, it is evident that husbands decided the modern family planning method to be used in 40% of the study sample; wives were the decision-makers in only 14% of the sample; and in 45% of the sample, wives and husbands decided the method jointly. The results indicated that more than half of women participated in the decision-making process of the family planning method to be used. Furthermore, we determined the spouse deciding the type and duration of the method. We found that in 36% of the sample, husbands alone made the decision regarding the type and duration of the family planning method, 45% of the sample jointly decided the type and duration, and 18% wives alone made the decision. In this study, to collect information on several aspects of family planning from the men, the selected men were directly asked questions about the importance of male participation in family planning. The results showed that the majority of men (68%) agreed that men should participate in family planning. They felt that men should be responsible for using family planning services. One participant said that “We both are both responsible for the family planning method used, but she is not well, she always has some health problems, and we don’t want more children. In this situation, I had gone for sterilisation, and my wife is happy, and she helps me in farming work” (man, age = 33 years). It has been found that tribal communities have some cultural and traditional beliefs regarding the use of contraceptive methods. They are more concerned about their livelihood than about family planning. However, they agree to undergo vasectomy when healthcare providers counsel them. Specifically, we found that men are willing to participate in the family planning processes because of the counselling and continual follow-up provided by healthcare providers.

Table 3.

Percentage of Men’s Perspectives on Decision and Importance of Male Participation in Family Planning Methods Use.

	Percentage	Cases
Who decided using family planning methods
Husband	40.8	29
Wife	14.1	10
Both together	45.1	32
Total	100	71
Who decided type and duration of method
Husband	36.6	26
Wife	18.3	13
Both together	45.1	32
Total	100	71
Importance of male participation in family planning
Yes	67.8	261
No	32.2	124

Gender Perception on Family Planning and Contraceptive Use

To ascertain men’s views, we asked several questions to examine gender perspectives on family planning and contraceptive use. From Table 4, it is evident that nearly half of respondents agreed that it is the women’s responsibility to avoid getting pregnant and feel outraged if their wife asks them to use a condom. However, nearly 70% of men agreed that either the man or woman can suggest the use of condoms and that the couple should jointly decide about having children. Furthermore, more than half of men (63%) totally agreed that with the decision about the type of contraceptive used should be jointly made by the wife and husband. However, only 31% of men agreed that a woman can suggest the use of condoms, just like a man can do. Differences were observed in men’s opinion about family planning-related issues. However, the differences may be due to other unknown factors. During an FGD, a man expressed that “We men can use a condom or she can eat tablets (contraceptive pills); anything can be possible as per the situation. There is no need for a lot discussion between the wife and husband. However, among our community, most people prefer to finish the child bearing of wife by accepting (operation) vasectomy” (male FGD participant, age = 23 years). Both men and women prefer vasectomy as a limiting contraceptive method, but for the spacing contraceptive method, there is always a burden on women to use contraceptive pills. Moreover, the majority of men accept condom use. This study did not separately collect information on spacing and limiting contraceptive methods.

Table 4.

Percentage of Men’s Responses to Gender Perception on Family Planning and Contraceptive Use.

Men’s responses on family planning issues	Totally agree	Partially agree	Disagree
It is a woman’s responsibility to avoid getting pregnant	48.4	30.6	21.0
I will be outraged if my wife asks me to use a condom	52.8	25.2	22.0
Either the man or woman can suggest condom use	69.0	21.2	9.8
Couple should decide jointly if they want to have children	69.5	18.9	11.6
Man and woman should decide jointly what type of contraceptive to use	63.3	24.1	12.6
A woman can suggest condoms use, just like a man can do	31.9	38.7	29.4

Discussion

Studies conducted worldwide have explored male perceptions and participation in family planning by using different methodologies; they have shown inconsistent results, with findings of higher and lower male participation in family planning in different studies. They have also demonstrated that male involvement can lead to the higher acceptance and use of male contraceptive methods.^12,21,22 Moreover, a previous study found that the use of male contraceptive methods is less and that the decision of number of children and type of methods is usually made by the husband.¹⁸ Most studies on male participation have been exclusively conducted with women. Few studies have been conducted with couples.^23,24 In the absence of studies that have exclusively focused on male opinions about male participation in family planning, the results of this study are crucial. Our study, conducted specifically with Gond and Madiya tribal communities, examined male perceptions and participation in family planning. Therefore, the results of this study may not be comparable to those of studies conducted with women participants in other places.

The study results are contrary to those of previous studies and NFHS-4 results. In this study, male acceptance of vasectomy was very high. Thus, male-specific contraceptive methods were highly used in these tribes. The higher acceptance of male contraceptive methods among the Gond and Madiya tribes in the Gadchiroli district of Maharashtra, India, is a valuable example how grassroot workers such as the MPW, auxiliary nurse midwife, and accredited social health activist play crucial roles in educating and empowering men to accept the responsibility of family planning. The higher acceptance of male modern family planning methods may lead to the reduction in the unmet need for family planning and in the number of unwanted births. In addition, these factors may largely contribute to reducing the total fertility rate and maternal mortality and morbidities among the tribal communities. From our study results, the role of community-based healthcare providers in engaging men in reproductive health and family planning is evident. Therefore, when formulating strategies to increase male engagement in reproductive health and family planning, training of these healthcare providers in the gender aspect should be emphasized. This may largely benefit the communities without spending more financial resources.

Conclusion

This study is a positive step forward for the government, nongovernmental organizations, and people working to increase male participation in reproductive health and family planning. This study clearly demonstrated the gender egalitarian attitude and the higher acceptance of male modern family planning methods. Previous studies have investigated the knowledge, patterns, trends, and reasons for the discontinuation of family planning, but the cultural aspects, which are more important to any tribal community, and male perceptions about family planning have not been not investigated. Therefore, this study examined the perceptions of men in a specific population within cultural and traditional contexts. None of the study participants used spacing contraceptive methods. Moreover, 73% of men said that they participated in the family planning process because of counseling and continual follow-up provided by healthcare providers. Thus, the findings indicated that the crucial role of healthcare providers.

Study Limitations

This study has several limitations that are worth mentioning.

This study was conducted with specific tribal communities governed by some unique sociocultural ideas; therefore, these results may not be generalized to other tribal communities.

Data collection in this study was based on quantitative methods, and the qualitative results presented here only complement the quantitative results. The qualitative results were not analyzed using any qualitative software. The quotations were taken directly from the qualitative study.

The higher acceptance of male modern contraceptive may be due to other unknown factors, which were not investigated in this study.

Footnotes

Acknowledgments

The authors gratefully acknowledge the healthcare centers and their staff who supported during this study and the women and men who participated in the study.

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Suresh Jungari is an assistant professor, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University Pune, India. His research interest focuses on maternal and child health, gender issues in the maternal health, and male participation in maternal health. His research areas include, gender, formal demography, violence against women and public health. He is extensively worked in tribal areas of Maharashtra. He has published his research in various national and international journals. He also presented research papers in scientific national and international conferences.

Balram Paswan is professor and head of department of population policies and programmes, International Institute for Population Sciences, Mumbai, India. He has 30 years experience of teaching and research on key population and health issues in India. His research focuses on exploring the health and family planning issues in India particularly among the tribal communities. He has lead several large scale surveys research projects on health issues in India.

References

Jungari

Bomble

Caste-based social exclusion and health deprivation in India. J Exclusion Stud 2013; 3: 84–91.

Jungari

Chauhan

BG.

Caste, wealth and regional inequalities in health status of women and children in India. Contemp Voice Dalit 2017; 9: 87–100.

International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005–2006: India. Mumbai: International Institute for Population Sciences.

Kumar

Joshi

KM.

Family-planning methods among the tribal population in South Gujarat: a case study of access and usage. Dev Pract 2008; 18: 258–266.

Prusty

RK.

Use of contraceptives and unmet need for family planning among tribal women in India and selected hilly states. J Health Popul Nutr 2014; 342–355.

Das

Dasgupta

Das

, et al. Unmet need for contraception: a study among tribal women in a district of West Bengal. Int J Health Sci Res 2015; 5: 29–36.

Battala

Raj

Ghule

, et al. Association between tribal status and spacing contraceptive use in rural Maharashtra, India. Sex Reprod Healthc 2016; 7: 78–80.

Sharma

Family planning practices among tribals of South Rajasthan India. J Res Educ Indian Med 1991; 10: 5–9.

Basu

Kapoor

Basu

SK.

Knowledge, attitude and practice of family planning among tribals. J Fam Welf 2003; 50: 24–30.

10.

Char

Saavala

Kulmala

Male perceptions on female sterilization: a community-based study in rural central India. Int Perspect Sex Reprod Health 2009; 35: 131–138.

11.

Adelekan

Omoregie

Edoni

Male involvement in family planning: challenges and way forward. Int J Popul Res 2014; 2014. http://downloads.hindawi.com/archive/2014/416457.pdf

12.

Raj

Ghule

Ritter

, et al. Cluster randomized controlled trial evaluation of a gender equity and family planning intervention for married men and couples in rural India. PLoS One 2016; 11: e0153190.

13.

Tilahun

Coene

Temmerman

, et al. Couple based family planning education: changes in male involvement and contraceptive use among married couples in Jimma Zone, Ethiopia. BMC Public Health 2015; 15: 682.

14.

Jungari

Paswan

Where is the husband? Male participation in maternal health. Econ Polit Wkly 2017; 52: 19–21.

15.

International Institute for Population Sciences. National Family Health Survey Fact sheets 2015–2016. Mumbai, India: International Institute for Population Sciences.

16.

Speizer

Nanda

Achyut

, et al. Family planning use among urban poor women from six cities of Uttar Pradesh, India. J Urban Health 2012; 89: 639–658.

17.

Chankapa

Pal

Tsering

Male behavior toward reproductive responsibilities in Sikkim. Indian J Community Med 2010; 35: 40–45.

18.

Yadav

Singh

Goswami

Agreement and concordance regarding reproductive intentions and contraception between husbands and wives in rural Ballabgarh, India. Indian J Community Med 2010; 35: 19–23.

19.

Mishra

Nanda

Speizer

, et al. Men’s attitudes on gender equality and their contraceptive use in Uttar Pradesh India. Reprod Health 2014; 11: 41.

20.

Kiran

Katke

Mane

, et al. How empowered are women to choose contraception? Int J Med Sci Public Health 2016; 5: 2019–2025.

21.

MacDonald

Jones

Thomas

, et al. Promoting male involvement in family planning in Vietnam and India: HealthBridge experience. Gender Dev 2013; 21: 31–45.

22.

Yore

Dasgupta

Ghule

, et al. CHARM, a gender equity and family planning intervention for men and couples in rural India: Protocol for the cluster randomized controlled trial evaluation. Reprod Health 2016; 13: 14.

23.

Thakor

Prajapati

Naya

, et al. A cross sectional study on gender bias in fertility and family planning choices in a rural area of Patan district of Gujarat, India. International Journal of Interdisciplinary and Multidisciplinary Studies 2014; 1(7): 77–84.

24.

Rao

Uma

Sekhar

, et al. A study on temporary contraceptive practices among eligible couples of rural field practice area of ASRAM Medical College, Eluru. Indian J Public Health Res Dev 2015; 6: 271–275.