Men, the missing link in gender-equitable family planning

Background: Across societies, gender norms often allow men to hold key decision-making power within relationships, households and communities. This extends to almost all domains, consisting of family planning (FP) as well. FP programmes have largely engaged men as clients and rarely as equal partners or influencers although across lower and middle income countries (LMICs), and especially in South Asia, men hold key decision-making power on the domain of family planning. The objective of this article is to explore couple dynamics through the lens of spousal communication and decision-making and unpacking male engagement and spousal dynamics in family planning. Methods: This review presents a synthesis of evidence from two peer-reviewed databases, PubMed and Jstor, and and insights from programmatic documents to shed light on gender equitable engagement of young married men in family planning. Inclusion and exclusion criteria for both these databases was set and search strategies were finalized. This was followed by title and abstract screening, data extraction, synthesis and analysis. Results: Study participants included unmarried men (16%, n= 8), married men (19%, n= 9), married women (19%, n=9), married couples (25%, n =12) or more than two respondent categories (21%, n= 10). Almost three-fourth (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacies (n=12, 22%). Conclusion: The evidence presented provides sufficient impetus to expand on gender-equitable male engagement, viewing men as equal and supportive partners for informed, equitable and collaborative contraceptive uptake and FP choices by couples.

It is widely established that men play a key role in decisions around family planning (FP), but programs have continued to keep them on the margins (1,2). While there have been sporadic attempts to engage men in FP programming, they have not been systematic or sustained.
Further, we do not clearly understand the motivations for and barriers to young men (18-30 years) to participate in equitable FP decision-making and contraceptive uptake 2 , and ways in which programs can make male engagement in FP a sustainable reality.
International agreements 3 have long recognized the positive role that men as partners can play in the family planning and reproductive health arena, but multiple factors inhibit their engagement. Family planning continues to be perceived as a woman's concern and hence programs most often concern themselves with women. Multiple family planning programs have hit a roadblock after a certain level of initial success as they have failed to involve and engage men in knowledge enhancement and attitude change efforts. In some programs where men have been engaged, it is mostly in the capacity of clients and not as equal and supportive partners. All this deters a couples' collaborative approach to family planning and reinforces gender roles that men and women are imposed with, wherein, women bear the burden of uptake of family planning methods while men continue to be the primary decision-makers.
This hampers sustained, informed and empowered use of contraception (3).

Objectives and defining the scope of the review
The aim of this evidence review is to provide a synthesis of learnings on best approaches to identify and engage young men in FP in order to achieve couples' collaborative and equitable 2 Contraceptive Uptake: It can be defined as the use of methods or acts intended to prevent reproduction occurring as a result of sexual intercourse (Hubacher and Trussell, 2015) 3 Declarations, such as the Programme of Action adopted at the 1994 International Conference on Population and Development, called for increased engagement of men to share the responsibility for family planning and reproductive health with women. FP 2020 and the Sustainable Development Goals 3 and 5 both direct us to look at the domain of FP more cohesively and strategically engagement in FP. Further, the synthesis also throws light on pathways to decision making for couples, and points at which there are opportunities to tilt the gender equitability quotient in favor of more collaborative family planning decision making processes.
The review aimed to synthesize the existing evidence to answer the following:  What are the motivations and barriers for young men to participate in equitable family planning decision-making and contraceptive uptake?
 How does the interplay of gender norms influence couple dynamic and their FP choices?
What is the evidence that discusses the characteristics and processes of identifying young men who support family planning and contraceptive uptake?

Data sources and search strategy
We examined peer-reviewed research published in two electronic databases, PubMed and JStor, and had customized search strategies based on the research questions and key areas of enquiry. A preliminary search of keywords was first conducted in January 2019 (KS) to test the search terms and validated with the larger research team, these terms included but were not limited to-family planning, engaging men in family planning, spousal communication, decision making, contraceptive uptake, gender norms and family planning, contraception.
PubMed search strategy was built in using medical subject headings (MeSH) while the terms used in JSTOR were chosen from a more sociological lens. Along with this, a manual search of reference lists of the identified studies was also undertaken to comprehensively cover literature. All these searches were conducted between January 2019 to March 2019. The search strategy has been given in Annexure 1. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for scoping reviews (5). The PRISMA checklist is presented in Annexure 2.

Eligibility Criteria
In order to ensure a relevance to concept and context, we adopted the following criteria for inclusion of articles: -Publication date: between January 2008 to December 2019 -It was set to include evidence which was relevant and applicable in the current times on family planning. A significant focus was given to articles which were published 2012 onwards as India signed the FP2020 commitment in 2012.
Publication year was a crucial inclusion criterion for our review but 6 seminal articles published before 2008 were also included as they supported some key conceptual arguments. Specific insights from 16 other articles from various sources strongly referenced by the included studies were also added to corroborate the analysis.
1) Types of participants: Unmarried men, married men, and married couples within the age of 18-49 years -As the review focused on engaging men, we included articles in which men were the primary respondents/stakeholders, whether married or unmarried and also where respondents were couples. Further, though the focus of the review is indeed young men, it was deemed appropriate to include a wider age range to better understand relationship and reproductive trajectories and varying masculinities.
2) Language: studies which were published in English 3) Types of evidence sources: We included primary research studies of the following design -qualitative, quantitative or mixed methods Articles were not selected if: 1) Were only relating to women (married or unmarried) as the main population of interest.
These were excluded as the review focused on male engagement and how it can lead to a pathway to collaborative and equitable couple engagement. There already exists plethora of evidence around engaging women as family planning is also considered as a woman's domain, hence women only articles were excluded.
2) Full texts were not available 3) They were from high-income countries (HICs) since our focus was only low and middle income countries.

Study Selection and Quality Appraisal
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist and flowsheet to guide the reporting of this review. References for all studies were entered into EndNote (Version 9.3.1) library and this was also used for overall organization of search results.
Authors (KS, AS) removed duplicates and undertook initial screening of titles and abstracts to remove those clearly outside the scope of the review. The full-text papers which met the inclusion criteria were reviewed and included in the final analysis. An article was assessed by considering whether the article reported directly on: • Gender norms influencing family planning decisions and/or contraceptive uptake • Factors influencing spousal/partner communication, decision-making on family planning, and/or contraceptive uptake • Factors influencing male engagement in family planning and/or contraceptive uptake The overall quality assessment of "high", "medium", or "low" was based on the evaluation by two reviewers and active discussion until consensus was reached in the case of rating discrepancies. The final list of included articles was approved by all authors.

Data Extraction, Synthesis and Coding
The data extraction sheet consisted of a breakup of the key areas of enquiry. To detail out the sheet thoroughly, both the reviewers (KS and AS) read the first two articles together and detailed out the sheet, it consisted of domains such as: study settings and demographics, study objectives, data collection and methods, themes around contraception uptake, barriers and motivations of engagement of men, other themes, conclusion. Each extraction column on the sheet was defined elaborately to diminish any potential subjectivity that the reviewers may bring in and to ensure inter-assessor reliability.
After the data from both PubMed and Jstor was extracted, it was synthesized using a thematic synthesis approach (4). This approach uses a step-by-step method to code text, develop descriptive themes based on the codes and generate analytical findings based on the themes.
For this, the domains of the extraction sheet were clustered together thematically to further condense and assimilate data. In this too, each clustered domain was defined in detail.
Following which, the data was coded based on the occurrence of concepts and cell numbers were assigned to each concept and the frequency of the data noted. This process was conducted to understand the data in an comprehensive manner, and also the recurring data points.

Data Analysis and conceptual framework
The synthesized and coded data was further analyzed according to the conceptual framework adapted the ecological systems framework(5) of for unpacking male engagement in family planning. This conceptual framework was chosen as it captures the complexity that exists within the space of health behaviors and the nature of its inextricable relationship with the social environment. It depicts social interactions amongst various stakeholders at different levels of the ecosystem, and the role of social position in health inequities, making a strong case of power which exist in all structural and social spheres. We adapted this framework as below for the purpose of our analyses ( Figure 1), comprising, norms at play, the health system, community and family, the couple and the "man" at the centre of it all. We adopt the same schema to is present our findings in this paper.

Patient and public involvement
This research was done without patient or public involvement. Patients/public were not invited to comment on the study design and were not consulted to develop patient/public relevant outcomes or interpret the results. Patients/public were not invited to contribute to the writing or editing of this document for readability or accuracy.

Search Results
Of 1,069 records initially identified through the database searches, 208 titles and abstracts were reviewed, Of these, 48 were eligible for inclusion ( Figure 2).

Figure 2:
Records Half of the studies used qualitative methods (50%, n=24) such as in-depth interviews, focus group discussions, key informant interviews and semi structured questionnaire. Almost threefourth (71%, n=34) of the studies selected had FP as the primary area of inquiry. Other prominent thematics on which the studies reported were around norms (n=9, 16%), couple dynamics and intimacies (n=12, 22%) Study participants included unmarried men (16%, n= 8), married men (19%, n= 9), married women (19%, n=9), married couples (25%, n =12) or more than two respondent categories (21%, n= 10). The sample size ranged from 15 to about 50,000 men and women depending on the methodology of the study. The unit of analysis in these studies were largely men, whether married or unmarried, and couples. Many studies reported engagement of men and couples on as opposed to engaging only men.
Studies included in the review were conducted majorly in urban areas (50%, n=24) while some were in rural areas (29%, n=14) and there were some studies (20%, n=10) which did not specify.
For detailed characteristics of each study included in the synthesis, see Table 1

Norms of masculinity
Perceptions and conditioning on masculinity play out in a dual manner; while they accord a superior social status to men, they also pressure men to fulfil a range of social expectations.
Peer-pressure encourages unmarried men to engage in risky sexual behaviour, for instance, having multiple sexual partners is often seen as a sign of male virility, (60,61) and for married men by playing their role as a procreator. Those who do not fulfil these expectations are ridiculed. Men also evaluate themselves based on specific markers of masculinity and an inability to perform up to these notions becomes a cause of distress (25). Gender-based violence, sexual abuse of women and homophobia in expressions of masculinity are some of the widely documented negative consequences (11,12 (62).
Both women and men agree it is the main duty of a man to provide sufficiently for the family in their role as providers by maintaining a good standard of living (40). Men also play the role of protectors by perceiving that it is their responsibility to uphold the honour of the women and the family (46). In doing so, they may resort to aggressive behaviour, display strength to guard the sanctity of the family (46) Extending their role in the intimate space, as pleasuregivers, men view women's pleasure as a masculinity achievement and experience performance anxieties if they are unable to (63).

Norms of marriage, fertility, and sex
The norms around marriage also vary contextually and are deeply intertwined with norms around sex and fertility. In South Asia, marriage is non-negotiable which culminates in childbearing (47). Aspirations of young girls and boys are directed towards marriage from very early ages, and once married, both women and men are expected to spend their life within a monogamous marital arrangement.
In certain contexts and communities, marital unions are not socially imposed but are desirable.
In Ghana, Kenya and in many other African countries, it was common for men to have multiple partners and in some cases even for the women (7) (20) (41).
Within contexts where marriage is a norm, sex, too is legitimized and is non-negotiable. Quick consummation of marriage, hence, is a signifier of a healthy and stable relationship. Women are expected to provide sex to their husbands as part of their marital duty (27,44). Men, too, display anxieties around 'performance' and adhere to the notion that 'men always want sex' (12).
Fertility norms are stringent as pregnancies are considered as unwanted if they occurred outside marriage/sanctioned norms of companionship and are subject to serious repercussions like community ostracization and violence (21). There is a perceived sense of "incompleteness" of home without children which encourages couples to have children relatively quickly after marriage, mostly within the first year (48). An evaluation of the PRACHAR programme implemented in rural Bihar, India, reveals the widespread of fear that the capacity of childbearing may decline with age and village doctors alongwith traditional birth attendants also spread this misconception (64).

Systemic Norms
The influence of context on individual behavior is exerted primarily through institutional and social factors (44).

II. Unpacking Intimacies of couples
The intimate space of a couple is also where many norms perpetuate and culminate, and hence, important to understand in the context of FP. There is a dearth of literature which can enable us to fully comprehend how the intimate space of a couple looks like, but we present an analytical understanding derived from available evidence, predominantly within the context of marriage.

Markers of 'Couple-Making'
Studies suggest that 'couple-making' 4 takes place throughout a couple's life but the initial years shape their relationship and define the extent to which they may apply gender based cultural scripts , (26,67). Literature (36,67) points that the playing assigned gender roles influence sexual behavior, expression and contraceptive decisions at various life stages.
Couples look for windows of time to interact and share their emotional states "in the bedroom," or when they were together "out in the evening," in the absence of family members (42,48). In some African contexts, unmarried women may also use pregnancy as a way of solidifying their relationship and to convince their male partners to get married to them (68) and unmarried partners may resort to control and violence to ensure that women get pregnant and prove their fertility. In a study in India with urban men, clear linkages were found between men's attitudes on gender equality and how gender-sensitive is their decision-making around FP and contraceptive use (29).

Knowledge barriers
More than half the studies in the review directed knowledge as the most significant factor (8,12,23) influencing the process of constructive spousal communication. Women and men may possess dissimilar knowledge as a result of their different experiences, exposure and position within the society (9). In patriarchal settings, where mobility of girls is highly surveilled and school dropout rate is high, the social distribution of knowledge 5 is lopsided. In contexts like India, schools contribute very little in informing girls or boys about sexuality and reproduction (54) and couples enter marriages without foundational knowledge about sexual issues and FP, and many newly married couples express a great need for information during their courtship or engagement period (55).

Power relations and communication barriers
conversations were found to be easier if both partners were knowledgeable on the topic of FP (28). A study in Madhya Pradesh, India, reveals that men's knowledge of temporary methods is mostly limited to their names and they had less platforms to engage on the issue, in comparison to women (69). Men may consider FP if they are informed about it in formal settings, preferably at a facility, by trained providers. Given unequal power relations, comparatively more knowledge with women (even when incomplete), is not taken well by men.
They perceive it as their own inadequacy and do not like being educated by their female partners (42). While sensing tension, women are also unable to argue in support of a method if they do not possess complete information around it. Men, in turn, find it easier to dismiss a method in these cases where women initiate hesitatingly, often with fragmented knowledge (61). Along with multiple myths and misperceptions (24) around side-effects, this limits the couple's ability to communicate equitably and effectively. This impedes their ability to translate their idea of FP from intention, to active and informed contraceptive choice 6 . Some studies show that, in the absence of direct discussion, women may often assume that their male partners are against use of FP (30). One spouse's perception of the other spouse's approval is more likely to be correct if they have discussed FP, than if they have not (3).

Opportunities for negotiation between men and women
Communication about sex and sexuality maybe initiated by men but women do try and make space for their own expression (56). For urban men, it seems acceptable for their wives to talk about sex, and express sexual desire (22) and they seem to want more engagement from their wives, which increases their sexual access. When couples communicate more frequently and effectively about sex, both verbally and non-verbally, husbands' preferences may become a resource for women to draw upon as they exercise sexual agency (ibid) for other domains as well. This may not necessarily translate into an effective contraceptive use but is worth exploring further. In many cases, sexual negotiations precede contraceptive negotiations, and both seem to critically influence the couple's perspective around FP.

IV. Influences and Pathways to Collaborative Decision making around FP
Data suggests that there are a range of factors that couples consider before taking FP decisions which may lie and play beyond the couples' intimate space.

Economics of Method Use
Evidence suggests that financial motivations have a crucial role to play and drive couple's interest in FP. In fact, economic hardships are a standard response for self-use by men, especially in case of vasectomy acceptance (42). On the surface, men might be willing to accept women's contraceptive use but unwilling to bear the costs and perceived risks of FP on women.
In such cases, they may push or convince women to have unprotected sex (70). Side-effects experienced by women due to use of FP methods, is a significant deterrent to use for men (52).
Expenditure on treatment of side effects of their partners as well as loss of agricultural participation (3,19) was seen to put a financial burden on men and make them apprehensive about contraceptive use (37).
Increased expenses related to care-taking and the need to provide adequate food, shelter, education, and opportunities to succeed to their children (3,41,48,67). Educating one's children emerges as a significant reason, especially for men, to rethink their fertility aspirations. Studies in Vietnam, India, Tanzania inform that educating children was felt as a necessity by both women and men, and with smaller family size, they can send their children to school, which in turn will allow them to advance in life (3,17,48).

Concordance in Sexual and Fertility Desires
Where fertility desires of women and men are more aligned and communicated, (37,43,71), couples are also able to resist external pressure (33,42) and take up FP. While women are more open to aligning their choices with men, men are reluctant to change their position (72). A study conducted in Nigeria concluded that men's preferences carry more influence, particularly when the couple has few children (57). The fertility intentions of a couple may also be triggered by son preference and until the desired sex composition is achieved, couple may not opt a modern method (29), and may also switch to traditional methods. Evidence suggests that men who are comfortable and in agreement with their partner about method use are likely to actively support their partner's method use, for instance, reminding partner to take her pill, paying for contraceptives. This may increase the likelihood that she will use the method correctly and consistently (48).

Men look at maintaining sexual frequency
Couples' sexual desires also determine their contraceptive use and in turn their ability to fulfill their fertility desires. While infrequent sexual intercourse is often cited as a reason to not use a method (43), methods which pose a barrier to the frequency and pleasure in sex are also cited as a reason for non-use. In case of condoms, reduced sexual pleasure, oily substance decreasing sexual strength, 'interrupts foreplay', 'ruins the mood' are often cited reasons (52).
For long term methods, especially male sterilization, decreased sexual libido and sex drive were seen a hurdle to use. Male sterilization is not considered to be a tenable option due to a range of reasons from poor knowledge and understanding of the method, rumours, and availability of skilled provider (42). A couple who has achieved their family size and wants to maintain sexual frequency may opt for female sterilization and not depend on any reversible method.
For other women-centric methods such as pills, injectables -vaginal dryness, irregular or prolonged bleeding were standard responses (3,11).
Matters get further complicated in contexts where multiple partnerships are common. In Sub-Saharan Africa, men may rely on one partner to use a female method, while using condoms with a second, and no method with a third (7). This is also representative of the difference in contraceptive-use reporting between men and women and there is evidence which shows that men tend to over-report contraceptive use and provide socially desirable answers (45,73).

Decision making approaches
Depending on the communication and couple dynamics, decision-making patterns tend to take three main approaches: joint decisions, male-dominated decisions, and femaledominated decisions (41). Evidence across Uganda, Nigeria, Vietnam, India and Nepal (13,16,22,24,58) points strongly that traditional gender norms elevate men as primary and mostly sole decision-makers. At times, at best, men inform their partners about the decision being taken and women are expected to accept it.
A truly joint and collaborative decision making remains aspirational, especially when it comes to issues around contraceptive use and family planning. There is not sufficient evidence to suggest that couples who take household decisions together will also display the same equitability when it comes to FP communication and decisions (43). Young women who reported autonomy in terms of household decision-making and access to money were more likely to have received appropriate pregnancy-related care, even after household economic status and women's education were controlled (44).
Studies conducted in Kenya, South Africa and Tanzania suggest that economic hardship and widespread unemployment reduce the chances that young men can exert their traditional masculine identity as providers and protectors of the family as they used to (38). With higher rural to urban migration, higher costs of living, with women playing a larger role in the labour market and more nuclear family structures-the ways in which couples traditionally functioned is slowly changing. It could also potentially apply to decisions around FP as women gather more say in the households but existing literature does not explore this strand.

Discussion
The review highlights that norms and systemic influences that operate within established power structures deeply influence how communities impose demands on young couples to prove and regulate their fertility. This has strong influences on shaping FP choices and contraceptive uptake at individual levels as well. Equitable FP choices can hence be enabled when we address critical imbalances of power and knowledge in the lives of women and men.
Starting from unequal access to knowledge, no emphasis on sex education in schools and lack of safe spaces to gather correct information on body, sex, contraceptives; women and men enter relationships with half-baked knowledge at best and without understanding the importance of consent and their sexual and reproductive health rights within all this. Layered with gendered role expectations, this creates precarious situations for young couples to communicate and decide on their family planning journey. In addition to restraining women's control over reproductive decisions, this also affect couples' ability to translate their idea of family planning from intention to active choice. Moreover, it sheds light on the nuances of where interventions and programs could potentially harness opportunities to engage men.
With the age of sexual debut going down and the age of marriage going higher, family planning policy and messaging in the current times also requires building linkages with the evolving desires and aspirations of women and men, and move their rhetoric beyond just married couples.
To summarize, we recommend the following conceptual pathway for engaging men for better and more gender equitable family planning (Figure 3), while recognizing that couples are situated within an ecosystem (as considered in the conceptual framework at the start of the review).  creation of community spaces where underlying assumptions, myths and gender normative perceptions are addressed on sex, reproduction and FP will encourage more acceptability of couples' needs and aspirations.
Furthermore, in dominant social narratives where children are viewed as legacy-bearers and as investments to secure one's future, FP needs to move beyond its current myopic vision. FP messaging warrants a change to communicate with couples not just in terms of birth spacing and limiting, but in the context of social, economic, and cultural aspects of childbearing in their lives.

Conclusion
The evidence presented provides sufficient impetus to expand on gender-equitable male engagement, viewing men as equal and supportive partners for informed, equitable and collaborative contraceptive uptake and FP choices by couples. It crafts specific insights to on how norms influence the intimate space of the couples, their communication and decisionmaking processes. It presents motivations for and barriers to male engagement in the family planning domain, which has historically been perceived as a woman's task and burden only.
List of abbreviations  Availability of data and material All data is made available in the manuscript and accompanying supplementary material but in case more clarity and data is needed, it may be sought by emailing kseth@icrw.org  Funding The review was undertaken as part of the project Couple Engage: Testing Upto 4 Approaches on Male Engagement for Spacing Methods Using Evidence and Literature Analysis and Human Centered Design.
The project was funded by Bill and Melinda Gates Foundation. The funders had no role in the study design, data extraction and synthesis, analysis, decision to publish, or preparation of the manuscript. Drafting, substantial revision, editing: SN, PA, RV, AS. All authors have agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented. All authors read and approved the final manuscript.