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I.N.E.D
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200 pages
p. 929 à 957
doi: en cours
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Vous consultez
Selected from Population 2001
Volume 57 2002/6
Demand for Contraception in Sahelian Countries: Are Men’s and Women’s Expectations Converging?
Burkina Faso and Mali, Compared to Ghana
Armelle Andro [*] Armelle Andro, Institut National d’Études Démographiques, 133 bd Davout, 75980 Paris Cedex 20, fax: 33 (0)1 56 06 21 99, tel: 33 (0)1 56 06 20 02, Véronique Hertrich [*] Véronique HERTRICH, tel: 33 (0)1 56 06 21 32,
The low level of contraceptive practice in the Sahel countries is often attributed to the deficiencies of family planning services. It is assumed, on the basis of surveys among women, that a demand for contraception exists. This article re-examines the issue of demand for contraception, looking not just at the expectations of women, but also of men and of couples.
The analyses are based on the Demographic and Health Surveys carried out in Burkina Faso (1993) and Mali (1995-1996), with Ghana (1993) being used as a comparison.
The findings point to considerable heterogeneity in the demand for contraception. The demand for family limitation is non-negligible among women, much weaker among men, and almost insignificant among couples. This heterogeneity constitutes an important barrier to the spread of contraception, since men play a decisive role in initiating contraceptive practice. In both Mali and Burkina Faso, the probability of using contraception is chiefly dictated by men’s attitudes, and women’s views count for little. This pattern, however, seems to be changing among the younger generations, where men’s and women’s attitudes are more convergent. El bajo nivel de uso de anticonceptivos en los países del Sahel se atribuye frecuentemente a las deficiencias de los servicios de planificación familiar. Basándose en encuestas realizadas a mujeres, se asume que la demanda de anticonceptivos existe. Este artículo reexamina la cuestión de la demanda de anticonceptivos, tomando en cuenta no sólo las expectativas de las mujeres, sinó también las de los hombres y las parejas. Los análisis estan basados en las Encuestas de Demografía y Salud realizadas en Burkina Faso (1993) y Mali (1995-1996) y la realizada en Ghana (1993), que se utiliza como base comparativa.
Los resultados señalan una considerable heterogeneidad en la demanda de anticonceptivos. La demanda de anticonceptivos para limitar el número de nacimientos es significativa entre las mujeres, débil entre los hombres y casi insignificante en el caso de las parejas. Esta heterogeneidad constituye una barrera importante a la expansión de la demanda de anticonceptivos ya que los hombres juegan un papel decisivo en la iniciación de su uso. Tanto en Mali como en Burkina Faso, la probabilidad de usar anticonceptivos está básicamente determinada por la actitud de los hombres; los puntos de vista de las mujeres cuentan muy poco. Esta pauta, sin embargo, parece estar cambiando entre las generaciones más jovenes, en las que las actitudes de hombres y mujeres son más similares.
The analyses are based on the Demographic and Health Surveys carried out in Burkina Faso (1993) and Mali (1995-1996), with Ghana (1993) being used as a comparison.
The findings point to considerable heterogeneity in the demand for contraception. The demand for family limitation is non-negligible among women, much weaker among men, and almost insignificant among couples. This heterogeneity constitutes an important barrier to the spread of contraception, since men play a decisive role in initiating contraceptive practice. In both Mali and Burkina Faso, the probability of using contraception is chiefly dictated by men’s attitudes, and women’s views count for little. This pattern, however, seems to be changing among the younger generations, where men’s and women’s attitudes are more convergent. El bajo nivel de uso de anticonceptivos en los países del Sahel se atribuye frecuentemente a las deficiencias de los servicios de planificación familiar. Basándose en encuestas realizadas a mujeres, se asume que la demanda de anticonceptivos existe. Este artículo reexamina la cuestión de la demanda de anticonceptivos, tomando en cuenta no sólo las expectativas de las mujeres, sinó también las de los hombres y las parejas. Los análisis estan basados en las Encuestas de Demografía y Salud realizadas en Burkina Faso (1993) y Mali (1995-1996) y la realizada en Ghana (1993), que se utiliza como base comparativa.
Los resultados señalan una considerable heterogeneidad en la demanda de anticonceptivos. La demanda de anticonceptivos para limitar el número de nacimientos es significativa entre las mujeres, débil entre los hombres y casi insignificante en el caso de las parejas. Esta heterogeneidad constituye una barrera importante a la expansión de la demanda de anticonceptivos ya que los hombres juegan un papel decisivo en la iniciación de su uso. Tanto en Mali como en Burkina Faso, la probabilidad de usar anticonceptivos está básicamente determinada por la actitud de los hombres; los puntos de vista de las mujeres cuentan muy poco. Esta pauta, sin embargo, parece estar cambiando entre las generaciones más jovenes, en las que las actitudes de hombres y mujeres son más similares.
There is a tendency to forget that contraception-and the decision to use it-involves two persons. This is so the world over, but it can have particular significance in societies where the status of women means they have little freedom of choice compared with their husband or partner. In a rigorous analysis of survey data from three African countries, Armelle Andro and Véronique Hertrich show male demand for contraception to be very low in some countries. Even among women, where demand for contraception is greater, high fertility remains greatly prized. With male and female partners alike still reporting an ideal family size of 6 children or more at age 35, and with fewer than 25% of women and 10% of men at that age wanting to stop childbearing once and for all, it is clear why contraceptive practice remains very limited.
The fertility transition began in sub-Saharan Africa during the 1980s, starting with pioneer countries in southern and eastern Africa, and has since been widely diffused over the continent (Cleland et al., 1994; Cohen, 1993; Kirk and Pillet, 1998; Locoh, 1994, 2002; Tabutin, 1997; Tabutin and Schoumaker, 2001; Vimard et al., 2001). The fertility decline has yet to reach the landlocked countries of the Sahel. In the mid-1990s, the total fertility rate still exceeded 6.5 children per woman in Burkina Faso (6.9) and Mali (6.7), and only 5% of married women were using a modern contraceptive method (and 8% any method, i.e. including traditional methods) (Coulibaly et al., 1996; Konaté et al., 1994).
The low level of contraceptive practice in the Sahel is often attributed to deficiencies in the supply of family planning. Indeed, only recently have Mali and Burkina Faso taken an official position on fertility control
[1].However, there are indicators that point to the existence of a demand for contraception. The country reports of the Demographic and Health Surveys conducted in Mali (Konaté et al., 1994) and Burkina Faso (Coulibaly et al., 1996) estimate that one in four currently married women was suffering from an “unmet need for family planning”. Based on these figures, contraceptive practice could involve a third of all married women if the entire contraceptive demand were met.
But can the demand for contraception be measured reliably on the basis of women’s statements only? In populations where the conjugal bond is weak, and where men and women expect different benefits from their offspring, the possibility cannot be excluded that the potential demand for contraception will reach different levels according to whether it reflects the expectations of women, of men, or of couples. It is from these different points of view that we consider demand in this article. A comparison of men’s and women’s intentions in the matter of fertility and contraception leads on to a discussion of whether there exists a demand for contraception. The analyses then proceed at the level of the couples, by comparing the expectations of either spouse in order to assess the emergence of joint marital fertility intentions and their importance in determining the onset of contraceptive practice.
Data from the Demographic and Health Surveys conducted in Mali in 1993 and in Burkina Faso in 1995-96 are used. The case of Ghana (DHS1993) is used as a comparison. In 1969, this neighbouring country was the first in west Africa to introduce a national family planning policy, in 1969, and in the late 1980s became the first to initiate its fertility transition.
I. The demand for contraception What demand? Whose demand?
Demand for contraception is generally analysed by distinguishing two components: satisfied demand, i.e. actual contraceptive practice; and latent or potential demand (the “unmet need for family planning”). Unmet need corresponds to the gap between individual desires and practices in matter of contraception. Part of the population wishes to reduce its fertility but is prevented from doing so by various constraints (access to family planning services, cost of contraception, lack of knowledge, familial and social disapproval, etc.)
Unmet need is present in all populations, but it is believed to be particularly high at the very early stages of the transition, when fertility ideals are changing but reproductive behaviour is not. Various authors have posited a model of the evolution of contraceptive demand linked to the stages of the fertility transition (Bongaarts, 1991; Bongaarts and Bruce, 1995; Ngom, 1997; Westoff and Ochoa, 1991; Westoff and Bankole, 1995). Bongaarts and Westoff identify different stages in the evolution of the level and structure of the need for family planning. In pretransitional societies, the demand for children is high, and the demand for contraception is very low. In the early transition stage, the desire to reduce fertility increases faster than contraception is diffusing, resulting in a rising demand for contraception, much of it unmet. As the fertility transition progresses, the demand for family planning continues to expand, but as contraceptive prevalence rises, unmet need declines. When the transition is complete, contraceptive practice satisfies almost the entire demand, and the unmet need is negligible once again.
1. Measuring the demand for contraception
Measurement of the demand for contraception began in the 1960s with the KAP surveys into women’s Knowledge, Attitudes and Practices in the area of fertility and contraception. A fresh impetus came in the late 1980s with the wide-ranging Demographic and Health Surveys (DHS) programme which collected large amounts of data on women’s fertility and contraception in the less developed countries.
The first indicator, known as the “KAP-gap”, gave a crude measurement of unmet need as the proportion of women in unions who were not using contraception but reported wanting no more children. It was widely criticized
[2] and has been superseded by more subtle and sophisticated indicators that introduce other factors, including women’s exposure to the risk of conception and the demand for birth spacing, which is high in Africa.
A consensus has gradually formed around the indicator developed by Westoff (Westoff, 1988; Westoff and Bankole, 1995; Westoff and Ochoa, 1991; Westoff and Pebley, 1981). This takes unmet need for contraception to exist among women who are in a union and fecund, are not using contraception and do not want to have a child for the next two years, as well as among pregnant or amenorrhoeic women whose current or last pregnancy was unwanted or mistimed. This unmet need has two components: the limiting component (demand by women wanting no more children, including pregnant and amenorrhoeic women whose pregnancy was unwanted) and the spacing component (demand by women wanting to postpone the next birth for two years or more, and pregnant or amenorrhoeic women who became pregnant too soon). This is the measure used in the DHS reports.
Efforts to improve understanding of the demand for contraception have, therefore, focused mainly on the measurement tool and have resulted in increasingly refined and sophisticated computational procedures. By contrast, the appropriateness of considering the demand for contraception among women only has gone unquestioned for over two decades.
This restriction, which is rooted in the historical and cultural background of the field of demography (Greene and Biddlecom, 2000; Andro, 2001), carries with it the “default” assumption that women are the sole arbiters of their reproductive behaviour. The point of view of men is ignored, as are the negotiations within couples concerning reproductive choices such as the decisions to have, avoid, or postpone a conception.
And yet, at the time of the European fertility transition in the eighteenth and nineteenth centuries, birth control was far from being an exclusively female matter. The contraceptive methods used (chiefly withdrawal and periodic abstinence) are proof that men were active participants in this first contraceptive revolution (McLaren, 1990; Leridon, 1999).
There is no reason a priori for thinking that men in present-day Africa do not influence reproductive choices, or that a conjugal agreement exists which is reported by the woman acting as the “neutral representative of a pair who always think and act in harmony” (Ryder, 1983, p. 18). Quite the opposite. The logic of family organization and gender relations can be expected to encourage disparities between men’s and women’s fertility aspirations. Indeed, the implications of producing children are different for men and women, the marital bond is weak and the spouses generally have separate budgets, while male dominance in family-related matters has institutional legitimacy
[3] his heterogeneity could explain the persistence of high fertility in some countries of sub-Saharan Africa: the high level of demand for family limitation recorded among women would simply be an artefact if men were in fact the main decision makers and had a much lower demand for contraception.
This greater awareness of men’s potential role in contraceptive decisions is largely responsible for the considerable increase over the past decade in the number of surveys that take men into account. This increase has happened worldwide, but especially in sub-Saharan Africa, undoubtedly as a result of the manifest failure there of the conventional analyses based on women’s statements alone
[4]
2. The state of knowledge about male demand for contraception and involvement in contraceptive decisions in sub-Saharan Africa
In the late 1980s, following the pioneering work of Fapohunda and Todaro (1988) and the review of the state of the question by Oppenheim-Mason and Taj (1987), a growing body of research began to examine the fertility preferences of both partners, and thus to consider the contraceptive decision as a process and the couple as a locus for negotiation and potential conflict.
The studies carried out in Africa concern chiefly three countries: Ghana and Kenya, both undergoing the fertility transition and for which successive DHS surveys are available that eventually included men (Bankole and Olaleye, 1995; Dodoo, 1993, 1995, 1998; Ezeh, 1993; Lasee and Becker, 1997; Ngom, 1997; Oheneba-Sakyi and Takyi, 1997; Omondi-Odhiambo, 1997), while Ghana also has specific surveys on the topic (Dodoo et al., 1997; Phillips et al., 1997), and Nigeria, where particular surveys have been conducted (Bankole, 1995; Fapohunda and Todaro, 1988; Isiugo-Abanihe, 1994; Mott and Mott, 1985; Oni and McCarthy, 1991; Renne, 1993).
The analyses of male responses do not contradict the existence of a substantial demand for contraception, albeit generally lower among men than among women (Bankole, 1995; Bankole and Olaleye, 1995; Dodoo, 1993, 1995; Ezeh, 1993; Ezeh et al., 1996; Ngom, 1997). But this aggregate-level result is not confirmed at the level of the couple. Fertility preferences diverge among spouses in a large number of cases (20 to 50% of couples depending on the country and the criteria used) (Bankole and Singh, 1998; Becker, 1996). In addition, both quantitative and qualitative studies show the decisive role of the man in the couple’s reproductive behaviour. In Kenya, for example, contraceptive practice is higher when both spouses report a contraceptive demand or discuss family planning together (Dodoo, 1995; Dodoo et al., 1997; Lasee and Becker, 1997; Phillips et al., 1997). In Ghana, the women’s attitudes toward contraception are related to their own characteristics and fertility preferences and to those of their husband, but the reverse is not true (Ezeh, 1993). In Nigeria (Isiugo-Abanihe, 1994; Mott and Mott, 1985; Renne, 1993) as in Ghana (Dodoo et al., 1997), most men and women believe that the husband has a dominant role in fertility decisions.
These studies confirm the role of the man in reproductive choices but also suggest the need to investigate conjugal interactions, and particularly the emergence of a conjugal decision-making sphere. In all the studies cited
[5], inovation in fertility behaviour is linked not only to the spouses’ socio-economic characteristics (especially their educational level) and stated fertility preferences, but also to various indicators of the closeness of conjugal bonds and convergence of views. These include similar fertility preferences, a shared approval of contraception, monogamy, communication, and in some cases a small age difference between spouses. Considered at the aggregate level, the transformation of the conjugal bond can also be considered one of the determinants of the fertility transition. Ngom (1997), for instance, has shown that the indicators of conjugal convergence were changing during the fertility transition in Ghana and Kenya.
These results are based on studies in a handful of countries, and it is legitimate to ask whether they can be generalized to the entire sub-Saharan region. This question applies particularly to the Sahelian countries, where the fertility decline has not yet begun, and where inequalities between the sexes (especially in access to education) and the weakness of the conjugal bond are believed to be the largest in Africa (Lesthaeghe, 1989; Barbieri and Hertrich, 1999)
II. Data and indicators
1. Data
This analysis is based on the Demographic and Health Surveys (DHS) conducted in Burkina Faso and Ghana in 1993, and in Mali in 1995-96. The household sample in each survey is stratified and nationally representative. The female sample comprises all women aged 15-49 identified in the sampled households
[6] The male sample was also selected on the basis of age (15-59 in Mali and Ghana, 18 and over in Burkina Faso) from a subsample of households (one household in three was covered)
[7].A couple file, in which husbands’ and wives’ data were matched (data for polygynists were matched with those of each of their wives) was compiled ex post
[8].
The data collected for men are scanty compared with those for women
[9], and do not allow detailed measurement of their demand for contraception. This means making do with summary indicators of the KAP-gap kind. Also, the questions on reproductive intentions and behaviour are asked without any reference to the respondent’s partners, which makes the results hard to interpret in the case of polygyny and extra-marital relationships.
A number of comments are in order concerning the use of the data on couples. Their relevance for evaluating couples’ demand for contraception depends on two conditions: that the interviewed couples are representative, and that the spouses’ statements are independent. Conjugal relationships take many forms in Africa (Bledsoe and Pison, 1994; Parkin and Nyamwaya, 1987; Hertrich and Locoh, 1999) and there is a danger that some of the unions that least resemble conventional marriages will go unrecorded. The DHS surveys adopt a broad definition of the union. Provided the respondents report them as such, the individual questionnaires record informal unions and unions where the partners are not residing together. The couple file, however, because of the way it is constructed, includes only those partners that live together, and this could bias the analysis if these couples also differed in their attitudes with respect to fertility. Comparison of the contraceptive demand of women living with their spouse with that of non co-resident wives (35% of women in a union in Ghana, 10% in Mali and 8% in Burkina Faso) shows this not to be the case (results not presented here). As regards independent reporting by the two spouses, interviewers were instructed to interview the respondents alone whenever possible. The information on the interview procedures suggests that this was achieved in most cases. Depending on the country, between 10% and 15% of women were interviewed in the presence of other adults, and the husband was present only exceptionally (less than 4% of the interviews). Discussions between spouses are moreover uncommon, so it is unlikely that many couples used the interval between the two individual interviews to harmonize their replies. All in all, it seems reasonable to assume that the statements of spouses are independent.
2. Indicators
Because of the limitations of the data collected from men, we used three simple indicators to assess women’s and men’s demand for contraception:
- An indicator of the demand for stopping childbearing (i.e. for family limitation): the proportion of individuals in the married population reporting that they want no more children.
- An indicator of the total demand for fertility control (demand for stopping childbearing or for spacing births): the proportion of individuals in the married population who report wanting no child in the next two years.
- An indicator of the potential use of contraception: the proportion of individuals in the married population who report using contraception, or intending to use it in the future.
The first two indicators rely on the “fertility preferences” variable that specifies whether the respondent wishes to have another child and, if so, how soon (in the next two years or later). Respondents who were unsure about wanting another child and about the preferred waiting time until the next birth, were assumed to express no contraceptive demand. A “don’t know” reply to these questions is similar to the unwillingness to intervene or decide in fertility matters that characterizes the traditional reproductive regime (van de Walle, 1992; Ryder, 1983).
It must also be noted that only the Burkina Faso survey recorded “prolonged abstinence” as a contraceptive method in addition to “periodic abstinence” (the rhythm method, which was recorded by all the other surveys). The large number of responses for this category inflates contraceptive use in Burkina Faso out of proportion. Since our perspective is comparative, we decided not to treat this method as a contraceptive practice and to classify those reporting it among those “not using and not intending to use contraception”. This is a “lesser evil” type of solution which may well lead to underestimate contraceptive practice and demand in Burkina Faso
[10].
III. Fertility preferences and demand for contraception: the points of view of men and women
The low level of contraceptive practice in the Sahelian countries can only be understood in the context of the great value that continues to attach to large families.
1. Consensus on large families
The ideal family size reported by respondents (Table 1) shows very clearly that the large family is still the undisputed ideal for men and women alike. The proportion of individuals favouring a small family, though on the increase, remains low. The lower category has to be set at five children or less to take in one quarter of the younger (20-29 years) male and female cohorts in Mali and Burkina Faso. In addition, the large proportion of non-numeric answers (“It’s God’s will”, “don’t know”, etc.) indicates that family size remains of minor concern for a significant section of the population (10 to 20% of the younger cohorts, 15 to 35% of the older ones).
Table 1
Reported ideal number of children and cumulative fertility: comparison between men and women aged 20-29 and 40-49, Burkina Faso (DHS, 1993), Mali (DHS, 1995-1996), Ghana (DHS, 1993)
Observed fertility levels in the Sahel are consistent with the reported ideals. Completed fertility among the older cohorts is close to the reported average ideal family size. The lower ideal sizes for the younger cohorts are still around six children (ranging from 5.4 to 7 children) and barely below period total fertility (6.7 children per woman in Mali and 6.9 in Burkina Faso). At the aggregate level at least, a large demand for contraception is not obvious.
This contrasts sharply with Ghana, where an ideal family size of less than five children is reported three times more often than in the two Sahelian countries, and where ideal fertility is below actual fertility. Obviously, the differences in fertility between Ghana on one side, and Mali and Burkina Faso on the other, cannot be explained by differences in the supply of contraception: fertility ideals in Ghana have long been markedly lower than in the countries of the Sahel.
At the aggregate level, then, Sahelian fertility seems to be consistent with expectations, but does this mean that there is no demand for contraception at the level of the individuals?
2. Do men and women have the same demand for contraception?
To judge by the proportion of married individuals who report wanting no children in the next two years, there exists an appreciable demand for fertility control (Table 2). In Mali and Burkina, it concerns approximately six in ten married women, and one in two married men. In Ghana, the indicators are somewhat higher and less differentiated by sex. In all three countries, however, there is little variation in the indicators across cohorts. This can be imputed to a traditional characteristic of African fertility regimes, namely the norm concerning the desirability of an interval of several years between births, which most populations achieve by prolonged breastfeeding (Page and Lesthaeghe, 1981; van de Walle and van de Walle, 1988). This spacing norm remains strong, even at the start of reproductive life, hence the high proportion of individuals from the young ages onward with a “demand for fertility control”.
A very different picture emerges if measurement is limited to the demand for stopping childbearing once and for all. The proportion of respondents who report wanting no more children is very low at the younger ages (2 to 5%), and only approaches the level of total demand (i.e. for both stopping and spacing) for women at the end of their reproductive life, when it concerns just over one in two women in Burkina Faso and Mali, barely fewer than in Ghana (6 in 10 women). The demand for stopping among Sahelian men varies much more slowly with age. For men aged 40-49 it is much lower than for women — 7% in Mali, 16% in Burkina Faso. Such a large divergence between the desires of men and women is specific to Mali and Burkina Faso; in Ghana, men’s demand for stopping is much higher (43%) and closer to that of women.
Does the lower demand of men for putting an end to their fertility account for the weak diffusion of contraception in the Sahel? Are men more reluctant to act than their wives?
Table 2
Reported demand for fertility control by age: comparison between married men and women aged 20-29 and 40-49, Burkina Faso (DHS, 1993), Mali (DHS, 1995-1996), Ghana (DHS, 1993)
3. Intended future use of contraception
The above hypothesis needs to be qualified in the light of men’s statements about their current contraceptive practice, and their intention to use contraception in the future (Table 3). Viewed from this perspective, men’s “demand for contraception” is much higher than their demand for family limitation measured above and as high as, if not higher than, that of women. In Mali and Burkina Faso, nearly half of the men aged 20-29 and a third of those aged 40-49 report using or intending to use a method of contraception, with 15 to 20% reporting that they were using one at the time of the survey. Sex differentials relate mainly to current practice, with men reporting using contraception more frequently than women. The differences run in the same direction in Ghana, with higher levels of demand for contraception.
Table 3
Proportion (%) of individuals using or intending to use contraception. all methods and modern methods, comparison between the reports of married men and women aged 20-29 and 40-49 Burkina Faso (DHS, 1993), Mali (DHS, 1995-1996), Ghana (DHS, 1993)
The reversal in the relative positions of men and women regarding demand for contraception compared with demand for family limitation is probably due to gender differences in attitudes and practices in the area of sexual behaviour and contraception. Men may report a practice that is current or intended in the future with different partners (co-wives or extramarital relationships). But the multiple unions of a male cannot account for all of the disparity. Over-reporting of contraceptive practice by men compared with women, once the effects of polygyny and extramarital relationships have been controlled for, has been reported in a number of studies (Becker et al., 1999; Ezeh and Mboup, 1997; Koenig et al., 1984), and owes probably as much to the different perceptions and values of men and women in the area of sexuality and contraception as to real differences in actual sexual practices (Andro, 2001). As has been observed in other sub-Saharan African countries, the differences in reporting in Burkina Faso, Mali and Ghana relate essentially to condom use, periodic abstinence/rhythm and, in Ghana, withdrawal. The DHS questionnaire specifies no restriction on duration of use in recording the contraceptive methods being employed at the time of the survey, and it is likely that methods used intermittently (e.g. condoms) or not for a specifically contraceptive purpose (e.g. periods of abstinence) were reported unequally by men and women
[11]. In addition to these observations, the finding in all three countries that, compared with women, men have lower demand for fertility control (Table 2) but are equally in favour of contraception (Table 3), points to a possible difference between the sexes concerning the purpose of contraception, with women clearly associating it more than men with family-building intentions.
*
* *
In summary, the data on expectations over fertility and contraception confirm the potential for diffusing contraceptive practice in the Sahel. Although large families are still highly valued, and contraceptive practice is low, a significant proportion of individuals either wish to control their fertility or state their intention to practise contraception in the future. But while control of final family size is an issue for women, among men it remains much less of a concern.
What impact do these differences in contraceptive demand between the sexes have on the level of contraceptive practice in the Sahel? Whose demand is it that prevails within the couple? Matching the data collected for husbands and wives provides a firmer basis for examining the existence of a shared demand, indicative perhaps of a joint family building project, and its significance in the transition to contraceptive practice.
IV. Is there a shared demand for contraception among spouses?
1. Frequently convergent, but highly conventional responses
The agreement between the reports of spouses on the demand for stopping childbearing, the total demand for fertility control, and the intention to use contraception is shown in Table 4. All the variables considered, treated as dichotomies, reveal a high level of convergence between husbands’ and wives’ responses: 70% to 80% agreement on the demand for family limitation and intentions in the area of contraceptive practice, 60% on total demand for fertility control (all ages together).
Table 4
Agreement between spouses concerning the demand for contraception comparison of responses by married men and women aged 20-29 and 40-49 burkina faso (dhs, 1993), mali (dhs, 1995-1996), ghana (DHS, 1993)
But this agreement relates mainly to the dominant pattern of behaviour
[12]. In Burkina Faso and Mali, for instance, agreement on the demand for stopping childbearing consists in over 90% of cases of a common refusal to limit family size
[13]. On current and intended use of contraception, 80% of the couples giving consistent answers in Burkina Faso and 60% in Mali are non-users reporting that they have no plans to practise contraception in the future. In most cases, therefore, spouses are consistent in their statements because they agree with societal norms about reproduction, not necessarily because they have a joint family-building project. In fact, in only a minority of Sahelian couples do both spouses have a demand for fertility control: roughly 5% in both Sahelian countries for the desire to limit births, and 13% in Burkina Faso and 26% in Mali for the intention to use contraception in the future (Table 4). These low percentages are largely due to the men’s low demand for contraception (only one man in ten wanted to limit births), but also reflect inconsistent demand within couples, including those where the husband has innovative fertility ideals (Table 4). Thus only half the men in Mali and Burkina Faso who express a demand for family limitation have wives reporting the same expectations, and the extent of convergence is similar for the intention to use contraception (46% in Burkina, 63% in Mali). The heterogeneity is even greater in couples where the woman holds modern attitudes toward reproduction: adoption of a innovative expectations more often characterizes women than men.
The situation in Ghana regarding couples’ contraceptive demand and their characteristics contrasts sharply with that in the Sahelian countries. Couples reporting a shared demand for contraception are found more frequently in the former country — around five times more than in Mali and Burkina Faso for agreement on the demand for family limitation, twice more than in Mali and four times more than in Burkina Faso for the intention to use contraception (Table 4). But within-couple heterogeneity is also lower in Ghana: often, when one spouse expresses a demand for contraception, the other does too (70% to 80%). Unlike in the Sahelian countries, the agreement among spouses cannot be interpreted as compliance by wives with their husbands’ expectations, since the discrepancies are no more frequent for husbands of innovative women than for wives of innovative men.
The differences in fertility levels and resort to contraception between Ghana and the Sahelian countries are therefore associated with clear differences in both men’s and couples’ demand for contraception. Contraceptive demand among women in Mali and Burkina Faso is high (and close to that of Ghanaian women), but only a small proportion of men want to limit the number of births, and there are even fewer couples where both spouses agree on such intentions. In Ghana, by contrast, the demand for fertility control is approximately the same for both sexes and the agreement between spouses on a demand for contraception is much higher.
Reports on the intention to practice contraception in the future nevertheless reveal a rising contraceptive demand among men and couples. In younger cohorts (who are at the start of their reproductive lives and therefore do not yet want to limit their fertility), one fifth of couples in Mali and one sixth in Burkina Faso consist of spouses who plan to resort to contraception in the future.
2. Agreement between spouses and contraceptive practice
If the Sahelian countries contrast with Ghana both in the far lower prevalence of contraceptive practice and in the much greater within-couple heterogeneity of demand, questions arise as to the role of conjugal demand in the diffusion of contraception. Does a common point of view among spouses really facilitate the adoption of the practice of contraception? Or, on the contrary, would individual motivation be a sufficient condition, especially in a context where the conjugal bond is traditionally weak?
Estimating contraceptive practice at the level of the couple is not an easy task given the frequent discrepancies between the statements of husbands and wives (Ezeh and Mboup, 1997). Such discrepancies should not be interpreted strictly as differences in contraceptive practice by sex, or as evidence of surreptitious contraceptive practice by one spouse. They also reflect differences of perception, whereby methods reported as contraception by one spouse may not be recognized as such by the other (cf. above). In Mali and Burkina Faso, barely half of men confirm the contraceptive practice reported by their wives, while, conversely, that reported by men is corroborated by their wives in only 20% to 30% of cases.
To test the relation between consistency in conjugal statements and contraceptive practice, we selected two measures of contraceptive practice. One is a restrictive measure corresponding to the proportion of couples where both spouses report the practice of contraception. The other is a broader measure corresponding to the proportion of couples where at least one spouse reports that practice (Figure 1). According to the second indicator, contraceptive practice is between twice (Ghana) and six times (Mali) as high as according to the first. The first indicator does not allow for contraceptive use by one spouse unbeknown to the other, with the result that some couples who actually practice contraception are classed as non-users. By including only couples where both spouses are aware of contraceptive practice, this indicator selects couples who have a high degree of communication. Conversely, the second indicator probably overstates the contraceptive practice of the couples since it systematically ascribes to the couple a resort to contraception that may in fact occur with another partner in a polygynous marriage or an extra-marital relationship.
On the basis of the first indicator, it seems clear that spousal agreement on expectations in the area of fertility and contraception has a strong impact on contraceptive practice. Depending on the country and the indicator, the use of a method of contraception at the time of the survey (reported by both partners) is between two and seven times higher among couples where both spouses have a demand for fertility control than where none of the spouses does. Contraceptive practice by couples who disagree on demand for contraception is close to that of couples who agree on the absence of demand. However, the selection effect operated by the indicator of contraceptive practice on couples where the conjugal bond is strongest means that these results must be treated with caution.
The second indicator of contraceptive practice yields much more nuanced results as to a possible relationship between convergent spousal expectations and contraceptive practice (Figure 1B). It is true that couples who agree on innovative behaviour have always a much more developed practice of contraception than those who agree on more traditional behaviour, but the difference is much less marked than for couples who do not agree. It is not consistently observed in the different countries if total demand for fertility control is taken into account. By contrast, the differences in contraceptive practice associated with disagreements between the spouses concerning the demand for stopping childbearing
[14] follow the same pattern in Burkina Faso, Mali and Ghana. In each case the husband’s attitude is determinant, whatever that of his wife: the proportion of users is the same whether or not the wife shares her husband’s expectations. Moreover, the evidence is that women’s demand for contraception is largely disregarded if their husbands do not share it. The level of contraceptive use in this case is close to that of couples who agree on traditional aspirations. Compared with men’s views, those of women have little influence on contraceptive practice. These results support the hypothesis of male dominance in fertility-related decisions.
Figure 1
Proportion (%) of couples using contraception by the demand of both spouses for contraception Mali (DHS, 1995-1996), Burkina Faso (DHS, 1993), Ghana (DHS, 1993)
3. Socio-economic and conjugal determinants of the agreement between spouses
The limited, not to say insignificant, influence on contraceptive practice of the agreement between the spouses over fertility and contraception calls for exploration of what underlies this convergence. Is it the result of a jointly planned family-building project? Or does it rather reflect the selection that occurs on the marriage market and ends up matching spouses with the same socio-economic characteristics and hence the same reproductive goals, without necessarily involving any conjugal negotiation?
The determinants of conjugal agreement on reproductive preferences were explored using logistic regression, taking the two indicators that are most relevant to observe the new reproductive behaviour: agreement on demand for stopping childbearing (Table 5) and agreement on the current or future use of contraception (Table 6). Variables likely to account for this agreement were introduced into the models: the couples’ socio-demographic characteristics (residence, educational levels, age of the wife, number of children born to the wife), marital characteristics (age difference between the spouses, type of union, discussion between spouses about family planning), and the attitude of each spouse toward family planning.
In addition to the demographic variables (age of the wife
[15] and cumulative fertility), the classic indicators associated with modernization have a significant effect in all three countries on conjugal agreement about the demand for stopping childbearing (Table 5). Thus, urban residence multiplies the probability of agreement by 5.1 in Burkina Faso, 3.6 in Mali, and 1.8 in Ghana. Agreement also increases if the husband alone or both spouses are educated. When both spouses have gone to school, couples in Burkina Faso and Ghana are three times more likely to agree on not wanting any more children than couples without any schooling, while the husband’s education alone is enough to double this probability in Mali and triple it in Ghana, compared with non-educated couples. By contrast, the wife’s education has no significant effect on agreement if the man is not educated.
Table 5
Logistic regressions on the variable: agreement between the spouses on the demand for stopping childbearing (odds ratios) Burkina Faso (DHS, 1993), Mali (DHS, 1995-1996), Ghana (DHS, 1993)
The key role of the husband’s characteristics stands out even more when the spouses’ opinion on family planning is considered. Men’s favourable opinion toward contraception is a stronger predictor of joint spousal demand for stopping childbearing than that of women, especially where both spouses have a positive opinion. Other things being equal, in the two Sahelian countries, the probability of agreement rather than disagreement between spouses is between 3 and 10 times higher when at least the husband has a positive attitude toward family planning than when neither spouse does.
Conjugal characteristics have no systematic or decisive effect on the probability of agreement. The effect of monogamy is significant only in Mali, but highly so. The effect of the difference in age between the spouses is ambiguous
[16] and is significant only in Burkina Faso. Furthermore, discussions between partners about contraception have no significant effect in either of the Sahelian countries.
All in all, it seems that family planning programmes in Mali and Burkina Faso seldom correspond to a conjugal demand for family limitation. Not only do very few couples express a joint demand for stopping childbearing (Table 4), but even such agreement as exists owes less to effective conjugal negotiation than to their socioeconomic characteristics. A common social origin in the educated urban minority, far more than discussion, is the source of their similarity of outlook. These findings go right along with the recommendations of Ezeh (1993) and Bankole and Olaleye (1995) concerning the need to distinguish recorded agreement from real, conscious and explicit agreement between spouses. Because they have been socialized in comparable ways and subjected to selection on the marriage market, men and women may have the same innovative fertility intentions, but with different motivations and not necessarily because they exchanged ideas on the subject.
The results for Ghana are somewhat different from those for the Sahelian countries. Agreement between spouses on stopping behaviour is more common, and more evenly distributed across social classes (socioeconomic characteristics, especially place of residence, are less significant). Furthermore, unlike in Mali and Burkina Faso, conjugal discussion of contraception increases the probability of agreement on demand for family limitation.
These differences between the Sahelian countries and Ghana relate chiefly to the older cohorts. As noted earlier, the future users of contraception within the younger generations are not identifiable by a demand for family limitation since they are at the start of their reproductive lives and do not yet express such desire. Agreement among spouses about their intention to use contraception in the future is a more appropriate indicator of potential demand for contraception among these young couples. According to this indicator, the level of agreement is higher (Table 4) and has broadly the same determinants in the three countries (Table 6). The variables most indicative this time of conjugal agreement are the discussion of contraception between spouses and approval of family planning by the man as well as by his wife. The intention to use rather than not use contraception is shared by the spouses who discuss family planning between 1.5 and 3 times more often than among those who do not. Approval of family planning by one spouse — be it husband or wife — increases the probability of agreement by a factor of between four (Mali) and seven (Burkina Faso) compared to couples where neither spouse approves. But the effects are most marked when both spouses agree, especially in the two Sahelian countries.
Table 6
Logistic regressions on the variable: agreement between the spouses on current use of contraception or intention to use it in the future (odds ratios) Burkina Faso (DHS, 1993), Mali (DHS, 1995-1996), Ghana (DHS, 1993)
Socio-economic variables, especially place of residence, are of secondary importance as explanatory factors. The predominant role of the husband’s education, noted earlier for agreement on family limitation, especially in Mali and Ghana, is less marked for the intention to use contraception: both spouses being educated becomes the most significant factor in all three countries. The demographic variables (age of the wife and number of children) also lose some of their explanatory power. Finally, except for discussion between the spouses, the conjugal variables (age difference and type of marriage) are not statistically significant.
A comparison of the findings on agreement about the demand for family limitation with those on the intention to use contraception suggest that there are at present two distinct models of contraceptive demand in the Sahel. The first one, apprehended through the demand for family limitation, would appear to concern older cohorts and would be consistent with a society dominated by traditional fertility ideals. Joint demand for contraception comes from a privileged, urban, educated minority, in which, however, the conjugal bond remains weak and decision-making remains a male prerogative. The second model, observed through the intentions to resort to contraception in the future, corresponds to a larger share of the population and is more closely linked to the socio-economic characteristics of both spouses and the relations between them. This model seems more prevalent among the younger cohorts in the Sahel, and is closer to the Ghanaian model.
Conclusion
Our analyses clearly show that the information gathered from women gives only a truncated and incomplete measure of the demand for contraception, particularly in the Sahelian countries. Demand for stopping childbearing is appreciable among women, but much lower among men, and virtually insignificant when measured at the level of the couples. The level of contraceptive practice is consistent with these values, and the idea of a significant “unmet demand for contraception”, caused by shortcomings in the supply of contraception, must be qualified accordingly. Taking only women’s views into account is especially inappropriate in view of the key role played by men in the transition to contraceptive practice. In both Mali and Burkina Faso, the probability of using contraception is determined more by the men’s expectations than by the women’s. Furthermore, various indicators in both countries show that the woman’s opinion has only a weak impact on practice.
The differences between Sahelian and Ghanaian couples in the demand for contraception seems therefore to reflect, at least in part, the respective stages they have reached in the fertility transition. How will the Sahelian model connect with that transition? Will the fertility decline be sustained by changing male attitudes, or, on the contrary, is the disappearance of male dominance a precondition for initiating the transition? Various indications suggest that this explanatory framework, while still dominant in the older cohorts, may no longer be relevant for the younger ones, who have less heterogeneous expectations and seem in the process of developing new forms of conjugal bond. Men and women in the younger generations appear indeed to demonstrate more agreement in their intentions to use contraception, while contraceptive practice itself is rooted in the characteristics and opinions of the two spouses and in the nature of their marital links.
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NOTES
[*]
Institut National d’Études Démographiques, Paris.This article is a version, abridged by half, of an article originally published in the French edition of Population (Andro and Hertrich, 2001). The reader may consult the latter for a more comprehensive discussion of the measurement of the demand for contraception, and for a detailed analysis of the indicators by age.Translated by Glenn D. Robertson.
Institut National d’Études Démographiques, Paris.This article is a version, abridged by half, of an article originally published in the French edition of Population (Andro and Hertrich, 2001). The reader may consult the latter for a more comprehensive discussion of the measurement of the demand for contraception, and for a detailed analysis of the indicators by age.Translated by Glenn D. Robertson.
[1] Although private family planning associations have existed since the 1970s, it was only in 1986 that Burkina Faso first proposed a national policy in favour of family planning, and in 1991 that Mali and Burkina Faso officially adopted their first national population policies (Coulibaly et al., 1996; Konaté et al., 1994).
Although private family planning associations have existed since the 1970s, it was only in 1986 that Burkina Faso first proposed a national policy in favour of family planning, and in 1991 that Mali and Burkina Faso officially adopted their first national population policies (Coulibaly et al., 1996; Konaté et al., 1994).
[2] On this methodological debate, see the discussions between Westoff (1988, 1992) and Bongaarts (1991, 1992) in Population and Development Review, and also Westoff and Pebley (1981), Dixon-Mueller and Germain (1992).
On this methodological debate, see the discussions between Westoff (1988, 1992) and Bongaarts (1991, 1992) in Population and Development Review, and also Westoff and Pebley (1981), Dixon-Mueller and Germain (1992).
[3] These issues are discussed more extensively in the French version of this article.
These issues are discussed more extensively in the French version of this article.
[4] Of the 28 third-generation Demographic and Health Surveys (DHS III) conducted in sub-Saharan Africa between 1994 and 1998, 25 included men, compared with 4 out of 9 for Latin America and the Caribbean, and just 3 out of 18 for Asia, the Middle East and North Africa.
Of the 28 third-generation Demographic and Health Surveys (DHS III) conducted in sub-Saharan Africa between 1994 and 1998, 25 included men, compared with 4 out of 9 for Latin America and the Caribbean, and just 3 out of 18 for Asia, the Middle East and North Africa.
[5] For a couple-level analysis, see also Noumbissi and Sanderson (1999) and Keita (1999) on the cases of Cameroon and Guinea.
For a couple-level analysis, see also Noumbissi and Sanderson (1999) and Keita (1999) on the cases of Cameroon and Guinea.
[6] The sample size was 6,354 women in Burkina Faso, 9,704 in Mali and 4,562 in Ghana.
The sample size was 6,354 women in Burkina Faso, 9,704 in Mali and 4,562 in Ghana.
[7] The sample size was 1,845 men in Burkina Faso, 2,474 in Mali and 1,302 in Ghana.
The sample size was 1,845 men in Burkina Faso, 2,474 in Mali and 1,302 in Ghana.
[8] The sample size was 1,146 couples in Burkina Faso, 1,599 in Mali and 547 in Ghana.
The sample size was 1,146 couples in Burkina Faso, 1,599 in Mali and 547 in Ghana.
[9] In particular, information is lacking about the last birth (wanted or unwanted, mistimed or not) and the specific status of each wife with respect to exposure to the risk of pregnancy. For a review of the limitations of the concepts and measures applicable to men, see Ngom (1997).
In particular, information is lacking about the last birth (wanted or unwanted, mistimed or not) and the specific status of each wife with respect to exposure to the risk of pregnancy. For a review of the limitations of the concepts and measures applicable to men, see Ngom (1997).
[10] A less extreme solution would have been to classify some (e.g. a proportion comparable to that in the general population) of the Burkina respondents who reported practising “prolonged abstinence” as using or intending to use contraception. We chose not to do so for several reasons. First, although this solution is applicable at the aggregate level, it cannot be applied at the individual level (final section of this article) and consistency of approach in all analyses seemed preferable. Second, since prolonged abstinence was not accepted as a contraceptive method in the other countries, it is questionable to treat it as such, even partially, in Burkina Faso. Finally, the survey report says that “prolonged abstinence” was misconstrued by respondents and often confused with “postpartum abstinence” to the extent that the authors of the report excluded it from the analysis and equated those practising it to non-contraceptors (Konaté et al., 1994).
A less extreme solution would have been to classify some (e.g. a proportion comparable to that in the general population) of the Burkina respondents who reported practising “prolonged abstinence” as using or intending to use contraception. We chose not to do so for several reasons. First, although this solution is applicable at the aggregate level, it cannot be applied at the individual level (final section of this article) and consistency of approach in all analyses seemed preferable. Second, since prolonged abstinence was not accepted as a contraceptive method in the other countries, it is questionable to treat it as such, even partially, in Burkina Faso. Finally, the survey report says that “prolonged abstinence” was misconstrued by respondents and often confused with “postpartum abstinence” to the extent that the authors of the report excluded it from the analysis and equated those practising it to non-contraceptors (Konaté et al., 1994).
[11] A study in Kenya found that few men reporting use of periodic abstinence had an accurate understanding of the ovulatory cycle (13%, against 34% of women), which suggests poor reporting of this practice by men (Ezeh and Mboup, 1997).
A study in Kenya found that few men reporting use of periodic abstinence had an accurate understanding of the ovulatory cycle (13%, against 34% of women), which suggests poor reporting of this practice by men (Ezeh and Mboup, 1997).
[12] Kappa tests on the three indicators of demand for contraception (see the French version of this article) show that the observed agreement between spouses is significantly different from what would be observed if the individuals’ views were randomly matched. But the difference is generally low in the countries of the Sahel.
Kappa tests on the three indicators of demand for contraception (see the French version of this article) show that the observed agreement between spouses is significantly different from what would be observed if the individuals’ views were randomly matched. But the difference is generally low in the countries of the Sahel.
[13] Reports are more evenly distributed with respect to total demand for fertility control, since it includes the traditional demand for spacing.
Reports are more evenly distributed with respect to total demand for fertility control, since it includes the traditional demand for spacing.
[14] The same pattern emerges if desired family size is taken as indicator of contraceptive demand (cf. the French version of this article).
The same pattern emerges if desired family size is taken as indicator of contraceptive demand (cf. the French version of this article).
[15] The effect of the woman’s age on the probability of convergence varies depending on the indicator used to measure the demand for contraception. The probability of convergence on intended future use of contraception decreases as the woman’s age increases. By contrast, an opposite effect is observed for the joint demand for family limitation: other things being equal, the older the woman, the greater the agreement on the demand for family limitation. This seemingly paradoxical result is linked to an age effect in the case of the desire for family limitation, but to a cohort effect in the case of the intention to use contraception.
The effect of the woman’s age on the probability of convergence varies depending on the indicator used to measure the demand for contraception. The probability of convergence on intended future use of contraception decreases as the woman’s age increases. By contrast, an opposite effect is observed for the joint demand for family limitation: other things being equal, the older the woman, the greater the agreement on the demand for family limitation. This seemingly paradoxical result is linked to an age effect in the case of the desire for family limitation, but to a cohort effect in the case of the intention to use contraception.
[16] Agreement is observed to increase with the age difference. This unexpected finding is probably due to an age effect: young men in the early stages of reproductive life and family formation are found in the lowest categories of age gap, when they have as yet no demand for family limitation.
Agreement is observed to increase with the age difference. This unexpected finding is probably due to an age effect: young men in the early stages of reproductive life and family formation are found in the lowest categories of age gap, when they have as yet no demand for family limitation.
© Cairn 2007
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