Motivation and involvement of men in family planning in Pakistan.

Kiani, M. Framurz K.

The study of men in involvement and use of family planning methods is important because of their dominant role in family decision-making in the socio-structural context of Pakistan. The objective of present study is to examine the changes in knowledge and attitude of men about family planning, and also to estimate the extent to which it affects their contraceptive use behaviour. The findings show that men's knowledge and contraceptive use has increased three times during the period from 1968-69 to 1990. The important factors that determine men's contraceptive use behaviour are the approval of family planning, the communication with wife on family planning matters, and the desire for children. The multivariate analysis shows that men living in urban areas, with greater knowledge and a positive attitude towards family planning, are more likely to use contraception. In addition, wife's autonomy is also important in explaining men's involvement in the use of family planning. The study reveals that most Pakistani men approve of family planning and suggests that men should receive an equal focus together with women in the population welfare programme activities.

1. INTRODUCTION

The important role of men in reproductive decision-making and its effect on contraceptive use behaviour of couples has been increasingly recognised as a subject of interest in the global context [Bankole and Sing (1993); Omandi-Odhiambo (1997); Karra, et al. (1997)]. The ICPD-POA (1) and the 1995 Beijing Conference on Women and Reproductive Health reaffirmed the importance of responsible parenthood and the need to include men in family planning and reproductive health programmes and actions [Piet-Pelon (1999); U.N. (1994); Khorrum and Wells (1997)].

In Pakistan, where men play an important role in family decision-making and are perceived as those disapproving the use of contraception, it is of interest to study issues relating to men's motivation and involvement in the use of family planning. It is generally recognised that the issue of male involvement in family planning has not received due attention in the formulation of Pakistan's population programmes. Most demographic surveys in the past have collected data on women alone, and information on men's attitudes and knowledge about family planning is quite limited. With the recent downward shift observed in Pakistan's fertility from 6.3 in 1975 to 4.8 in 2000-01, and a notable increase in contraceptive use from a low level of 14 percent in 1990-91 to about 28 percent in the year 2000-01, it appears that men must have contributed to some extent in catalysing the change in fertility and contraceptive use behaviour. To better understand whether men have played a role in reproductive decision-making and have contributed to the increase in contraceptive use, it is important to study their attitudes and motivations concerning family planning and its use.

Very few studies have focused on Pakistani men's attitudes and family planning behaviour primarily because of limited availability of information and less recognition of their role in family building behaviour. The first National Impact Survey (NIS) of 1968-69, undertaken to evaluate the impact of the programme, collected some information on the knowledge and attitudes of wives and their husbands about family planning. The results of that survey showed that men with more education, better knowledge of programme services, and communication with their wives had reported a proportionately higher contraceptive use and knowledge about the programme [Azhar and Hardee (1977)]. Some two decades later, the Pakistan Demographic and Health Survey of 1990-91 (PDHS) provided information on husbands' knowledge and attitudes about fertility-related questions, which permitted the assessment of men's involvement in the use of family planning. Based on those data, some studies have documented that men's views about contraceptive use are positive and that the percentage of wives and husbands who approve of family planning does not differ much [Mahmood and Ringhiem (1996)], thereby dispelling the impression that men view the use of family planning negatively. Other studies based on the NIS and PDHS data that have used the couple approach suggest that the role of spousal agreement is highly significant in promoting the use of contraception, and that men should be made equal targets of the family planning programme in Pakistan [Shah (1972); Mahmood (1998)].

Following up on these issues, men's involvement and participation in family planning has been recognised as an important component of the population and reproductive health programmes of Pakistan [Pakistan (2000)]. Given the sociocultural context of Pakistan, where men apparently have a predominant role in family decision-making, it would be useful to examine whether men's knowledge and attitudes towards the use of family planning methods are changing, and to see which of men's characteristics are more important in affecting their reproductive and contraceptive use behaviour. The 1990-91 Pakistan Demographic and Health Survey data provide the possibility of studying the level and extent of family planning knowledge and its use for men because of its separate module of husbands' sample. Given that, the specific objectives of the study are: (1) to examine knowledge and attitudes of men regarding fertility and family planning; and (2) to study what social and demographic characteristics of men affect their contraceptive use behaviour as different from those of women.

2. MEN'S PARTICIPATION IN FAMILY PLANNING IN THE SOCIO-CULTURAL CONTEXT

Male involvement in family planning has been defined as "participation of men in family planning decisions which predict their behaviour and their influence on wives to reach consensus for contraceptive use" [Omondi-Odhiambo (1997); Karra, et al. (1997); Bankole and Sing (1998)]. The available evidence shows that women's reproductive preferences and behaviour are strongly influenced by their husbands' reproductive motivation, not vice versa. This influence is considered to be a function of men's dominance and women's financial dependency on their husbands [Ezeh (1993)]. Men's dominance and influence prevails in terms of gender and age because a woman's marriage to an older man and economic dependency is due to traditional beliefs that women are subordinate to their husbands and a woman should obey her husband as head of the family or even other male members of the family [Karra, et al. (1997); Sathar and Kazi (1997)]. It is because of this dominance and influence that a woman's reproductive motivation is influenced by her husband.

The research evidence also shows that when men are actively involved in and informed about family planning, the acceptance and continuation of contraception increase [Becker (1996)]. Therefore, the lack of information, accompanied by misconceptions, about family planning on the part 9f men acts as a barrier to the use of contraception among couples. Similarly, accessibility of services and information on male methods could also have a significant effect on potential use, because many women, especially in rural areas, have limited mobility; money and permission from the husband to leave the household are required for travelling alone to a clinic or service outlet.

In the context of Pakistani society, the male is considered as the prime breadwinner and provider of food and shelter for his family. These roles within the family system and the community are determined according to family structure. Pakistani society, being patriarchical in nature, has typical characteristics which emphasise the lineage bond over the conjugal tie. The core of the social relations is based on biraderi (relatives and members of the same cast or group) and family institutions [Shah (1987); Mahmood and Ringheim (1996)]. The traditional beliefs as well as distinct responsibilities and roles of husbands and wives within the family have influenced the range and control of reproductive decision-making. Men are expected to have the information and expertise as well as the financial power to implement their decisions. Although many families have started to operate outside the family norms--and westernisation has now started influencing the society, yet there is a strong influence still of family bonds on the initiation of family life and reproductive behaviour [Sather and Casterline (1998)]. A man may make an individual choice but he will have to ensure that his choice is acceptable to his kinship group and the community [Piet, et al. (1999)]. Due to the low socioeconomic position of women in the family, most husbands are able to assert their preferences and influence women's attitudes towards family planning behaviour.

However, the exact power equation behind the screen of family life is difficult to specify in most instances. The evidence shows that mothers have the leverage for deciding about marriage and education of their children, but other decisions such as when to have children, or how many, may be difficult to specify because this requires detailed information on the changes in the events that occur and how these are decided about and managed. It is also observed that most couples do not talk to each other about having or not having children due to shyness and cultural barriers and most men believe that their own decisions are the best for both [Khan (1997)]. Moreover, restricted by socio-cultural norms, most women rely on their husbands to bring information about family matters into the home, particularly about family planning in terms of the timing and choice of method to be used. Thus, age at marriage, education, age difference between husband and wife, and the type of family in which both are living are some of the indicators that can be used as proxies for assessing men's influence in the family and related decision-making.

It may be noted here that there are marked differences in the socio-economic characteristics of men and women which are indicative of their status and position in society. For example, the average difference of age at marriage of a woman and a man is nearly 4 years. The literacy level among men is 54.81 percent as compared to the 32.02 percent for women [Pakistan (2001)]. The participation rate in the labour force for men is 70.5 percent as compared to just 13.9 percent for women [Pakistan (1997-98)]. These differing socio-economic characteristics of men and women may be contributing to determining the family building behaviour of couples at household level, and may provide the grounds for investigating men's motivation and role in adopting family planning methods.

3. CONCEPTUAL FRAMEWORK

A conceptual framework developed to study the relationship of the social, demographic, attitudinal, and programme method variables to the contraceptive use behaviour is depicted in Figure 1. Among the demographic and social characteristics, current age of both men and women, number of living children, place of residence, and education are considered as exogenous variables affecting contraceptive use.

There are certain variables which determine men's attitudes, which in turn are likely to influence men's contraceptive use behaviour and need to be included in the framework of analysis. These attitudinal variables are the approval of family planning and the desire for children. (Figure 1.)

[FIGURE 1 OMITTED]

Women's status is also critical in affecting the contraceptive use behaviour. In this regard, selected variables such as women's mobility, age difference between husband and wife, and husband-wife communication are likely to play an important role in the decision to use contraceptives. In addition, programme variables such as knowledge of any method, source of supply, and knowledge of sources of condom availability are expected to have a direct relationship with the use of family planning methods. All these variables are expected to have an independent direct relationship to the use of contraception.

4. DATA SOURCES

The present study is primarily based on the 1990-91 Pakistan Demographic and Health Survey (PDHS), which provides information on selected background characteristics of husbands, in addition to family planning knowledge, attitudes, and contraceptive use. (2) The PDHS collected such information largely from a sample of 6611 women, one-third of whose husbands were selected for the male questionnaire. For the present study, therefore, a sample of 1354 men is available for analysis. The response rate for husbands was 77 percent as compared to 97 percent for women. Low response rate for husbands was primarily due to the absence of husbands from the household despite repeated visits by the interviewers. However, the availability of detailed information on husbands for family planning-related questions in the PDHS data provides a good opportunity to assess their involvement in family planning use in relation to background characteristics.

5. METHOD OF ANALYSIS

Using the PDHS-1990-91 data, a bivariate and multivariate analysis is undertaken to study the relationship between the hypothesised independent variables and current contraceptive use. In the bivariate analysis, variations in knowledge and attitudes to and actual use of contraception are examined by socio-economic and demographic characteristics of husbands. In the multivariate analysis, (3) with contraceptive use as a dependent variable, logistic regressions have been used to estimate the net effect of predictor variables on use as reported by husbands. In this regard, three models have been estimated by using different combinations of sociodemographic variables as well as attitudinal, women's status, and programme method variables as portrayed in Figure 1.

6. RESULTS

6.1. Characteristics of Men

Table 1 sets out the background information on the socio-demographic characteristics of men using two different national-level fertility surveys which provide data on husbands, the NIS 1968-69 and the PDHS 1990-91, to examine the extent of change in knowledge and attitudes to family planning according to their background characteristics. The results show that there is an increase in the median age of husbands from 37.3 years in 1968-69 to 37.8 years in 1990-91. This appears to be consistent with an increase in the life expectancy of males over time. The median age difference between husband and wife has reduced from 7.9 years in 1968-69 to 6.7 years in 1990-91, implying an upward shift in the age at marriage of females. The levels of literacy for men have substantially increased from 36 percent to about 49.8 percent during the same period, and the rise in the proportion of men with secondary and higher levels of education has been significant, from only 8.5 percent in 1968-69 to nearly 20.4 percent in 1990-91. It is expected that this increase may have its effect on various aspects of family planning behaviour of men.

Regarding the changes in men's knowledge and attitudes towards family planning, Table 1 shows that there is a significant increase in the awareness of family planning methods over time. The 1990-91 survey data (PDHS) indicate that 79.3 percent of men are aware of family planning methods as compared to only 57 percent in 1968-69. However, an important question remains to be examined: Is a higher knowledge of family planning translated into higher contraceptive use or not? Figures from Table 1 show that current use as reported by men indicates the change from 6.7 percent to 15.1 percent during the period 1968-69 to 1990-91, and a change in ever-use from 15 percent to 24.7 percent. Moreover, 44 percent of men express the desire for more children in 1990-91 as compared with 53.2 percent in 1968-69, indicating some reduction in men's desire for additional children over time.

As for the attitudes of men towards family planning, about 66.6 percent reported approval of use of family planning in 1990-91. Husband-wife communication shows a change from 28.8 percent to 39.7 percent between the two decades, indicating positive attitudes among couples about discussing family planning matters.

6.2. Men's Knowledge about Family Planning

Correct knowledge of contraceptives among men is a basic pre-requisite that may lead to the adoption of contraceptive use. Table 2 shows that the proportion of men reporting having knowledge about family planning methods has increased substantially from 57 percent in 1968-69 to 79.3 percent in 1990-91. As for knowledge about different methods, there are variations in reporting across different surveys. However, the figures for the 1990-91 PDHS and the NIS 1968-69 indicate a rise in knowledge in about all methods. As we can see from Table 2, knowledge about methods such as rhythm, veginal methods, and malesterilisation is low, whereas for methods such as the pill, injectables, female sterilisation, and condom, more than two-thirds of men reported having knowledge.

The knowledge in the case of male methods, i.e., condom, shows the highest increase, from 57.1 percent in 1968-69 to 58.8 percent in 1990-91. Knowledge about male sterilisation is low and has shown a decline over time. This is perhaps due to the fact that the population welfare programme has not campaigned or focused much on vasectomy, and only a small proportion indicate their awareness of this method. As for couple methods, nearly one-third males know of the traditional methods such as rhythm and withdrawal. However, this percentage is lower than for the knowledge about other methods, which reflects the greater emphasis of the family planning programme on modern methods.

With the increase in knowledge of contraceptive methods, it is expected that the acceptability and use of family planning may have risen among men. The evidence shows that ever-use of male methods, especially the condom, (4) shows an increase from 6.6 percent to 12.1 percent during the period 1968-69 and 199091. This is reflective of men's willingness to adopt family planning behaviour and shows that male participation in contraceptive adoption has increased considerably over the years. The concern about the adverse side-effects of hormonal and clinical methods may have contributed to the increased popularity of male methods, especially condoms. Also social marketing campaigns to promote condoms are likely to have increased the availability of condoms and their popularity [Davies (1997); NIPS/IRD (1992); Douthwaite (1998)]. Since condoms can be openly displayed and advertised in the same manner as other consumables, this may lead to success of the campaign. Moreover, men's level of awareness of family planning is high and they are more aware of male methods--especially condom and withdrawal--as compared to women. Men also expressed their opinion in favour of small family preference, for their children to have a good education, and for having a greater gap between pregnancies for better health of their wives [Bhatti, et al. (1996)]. All this suggest that men do intend to limit their family size and, as a result, their participation in contraception use has increased over time.

6.3. Contraceptive Use: A Couple Variable

Although most contraceptive methods are used by individuals, several can be considered couple methods specifically: withdrawal and rhythm, and to a lesser extent condom--because participation of both partners in these methods is necessary. Any contraceptive use can be considered a couple phenomenon when the couple agrees on fertility and contraceptive intentions, and partner's support can be crucial for contraceptive continuation. Male methods such as condom, vasectomy, natural family planning, and withdrawal, each has unique advantages that may attract some family planning clients. The last two methods also promote communication and cooperation between partners. However, research continues on both permanent and reversible methods for men. In the present study, contraceptive use is assumed as a couple variable although there maybe some discrepancy between husbands and wives in the reporting of use.

Based on the 1990-91 PDHS results, reporting of contraceptive use is higher among men (15 percent) as compared to women (11.8 percent). The reasons for this discrepancy can be explained in terms of reporting biases and differences in attitudes of both men and women towards family planning. However, more important is knowing about the gap between ever-use and current use. (5) Table 2 shows that this gap remains substantial for all methods used, indicating that some of the methods are discontinued after use or the user may have shifted to another method. The table shows that the gap between ever-use and current use is the highest for condom, withdrawal, and female sterilisation. This implies that some of the users may have other pressing reasons to discontinue, but there is no direct information available to explain the gap between ever-use and current use or the reasons for discontinuation of a method. However, looking into the reasons for non-use for each method in the PDHS data, it is found that the total number of men who reported ever-use of any method is 335, out of which 39 percent (132) are estimated to have discontinued any method. (6) Out of 39 percent who discontinued the use, the majority (27 percent) of them wanted to have another child. About 15 percent said that their wife was currently pregnant and only about 12 percent gave reasons for health concerns and side-effects. The evidence from other surveys also shows that the desire for another child, ineffectiveness of the method by wife's becoming pregnant, and side-effects of the method used are the major reasons for explaining the gap between ever-use and current use or not-intending-to-use in the near future. For relatively older men (aged 35 and above), religious prohibitions are cited as another reason for not using any method [Bhatti (1996)].

Since the data regarding the knowledge and use of family planning were collected for both women and men regarding the same questions in two separate modules, it is possible to examine the extent of agreement and consistency in the information by gender. The results from the 1990-91 PDHS shows that men not only report a slightly higher knowledge of contraceptive methods than women, their reported use is also higher (15 percent) as compared to women's (11.9 percent). The frequently proposed explanations for this gender discrepancy in reporting emerge from the following arguments.

Use of some contraceptive methods differs greatly according to age, parity, and the desire for more children. It may also be affected by differences in response rates by gender. Men are generally more difficult to contact for household interviews because they are away from home for work or other reasons; contraceptive practice may not be the same for those who could not be interviewed. Hence, the differences in the reported levels of contraceptive use between men and women will be exaggerated if comparisons are made between a representative sample of all married women and a sub-sample of husbands of those women. This is because the sub-sample is necessarily restricted to cases where the husband could be interviewed, while the general sample of married women also includes women whose husbands were unavailable.

Even when members of the same couple have been interviewed, husbands and wives do not always report the same contraceptive practice within the conjugal relationship. The reasons for this might include ignorance about a method formerly used that has been stopped, different judgments as to whether the couples practice qualifies as 'current use', a respondent's desire to give a socially desirable response, which, depending on the setting, might lead either to overstatement or concealment of contraceptive practice. Men who use condoms or other male methods may overstate the practice, while women may skip or forget about its use. However, it remains unclear, when partners give different answers, which response is closer to the truth. It is also likely that errors in the data may occur during the interview or during later processing, which may affect the aggregate responses of the wives' and the husbands' samples differently. This is an issue to be investigated further [U. N. (1996)].

6.4. Men's Attitudes towards Family Planning

Research literature on family planning purports to a general perception that Pakistani men are not supportive of family planning, and husband's opposition to the use of contraception is cited as an important reason for non-use by many women [NIPS (1992)]. Therefore, it is important to examine whether men favour or disfavour use of family planning and whether they want to limit or space their children or not.

Table 3 shows the attitudinal variables of family planning by background characteristics of husbands. As we can see, the majority of men (67.2 percent) report that they approve of family planning. This is an encouraging and positive sign for the family planning programme. The variations in attitudes by socio-demographic characteristics show that a larger proportion of men with urban residence, higher parity, higher education, and educated wives approve of the use of contraceptives than those living in rural areas who have had no education. It may be noted that husbands with secondary and above education and with educated wives show the highest percentage of approval for family planning use (83 percent and 86.6 percent, respectively).

It is also apparent from Table 3 that a majority of husbands (80.9 percent) who know the source of obtaining condoms for use approve of family planning. Husbands were asked a number of questions about their perceptions and aspirations of children's education and age at marriage. In this regard, Table 3 indicates that the majority of men who aspire for their sons and daughters to have higher education are also likely to approve of family planning. This shows not only a positive attitude towards improving the quality of children but also reflects that those aspiring for secondary and above education for both sons and daughters are also supportive of the use of family planning.

The figures in Table 3 also show that while 67.2 percent of husbands approve of family planning, about one-third (32.8 percent) desire no more children. The proportion of men desiring no additional children is higher for urban than for rural men, among educated than illiterate men, and among those men who communicate about family size with their wives and have knowledge about the source of obtaining condoms.

6.5. Men's Involvement in Use of Family Planning: A Bivariate Analysis

Table 4 presents the association of various socio-demographic characteristics of men with contraceptive use. It is apparent from the table that the percentage of men ,reporting use is higher in older cohorts and for those with larger number of living children.

Regarding social characteristics, there are marked differentials in current use by urban-rural residence; 27.2 percent of urban men are users as compared to only 9.6 percent of rural men. The educational level of men increases the likelihood of contraceptive use substantially. As Table 4 shows, men with secondary and above education have a much higher use (30.7 percent) than those without education (7.9 percent) or primary-level education (16.5 percent).

The results in Table 4 further show that more than one-third of men (34 percent) who report their wives' ability to go to hospital alone are current users of contraceptives as compared to only 10.7 percent who are not in favour of mobility of their wives to go outside home. There is a negative relationship between the husband-wife age difference and use of contraceptives. This implies that partners with minimum age difference discuss and communicate with each other more about their family size and use of family planning than those with greater age difference. Husband-wife communication has a positive association with contraceptive use.

The desire for no more additional children also appears to be influential in increasing use; about 23 percent of the men who do not want more children are current users as compared with only 7.7 percent of those who want another child. Moreover, men who have heard of any method, know the source of any method, and have 'knowledge of source of condoms' have much higher proportions of contraceptive use than those with no knowledge and no access to use the services.

6.6. Multivariate Analysis

In order to get the net effect of predictor variables on contraceptive use, (7) a multivariate statistical model (Logit Model) has been applied to the husbands' sample. Logistic Regression is used because of the dichotomous nature of the dependent variable, i. e., current use, which takes the value of 1 for use and zero otherwise. The model used is defined as:

Ln (P)/(l - P) = a + [summation]bixi

Where P is the probability of a male having used contraceptive, bi are estimated regression coefficients, and xi are the social, demographic, and attitudinal characteristics of husbands.

Three logistic regression models have been estimated to assess the significance and influence of men's demographic, social, and attitudinal variables in addition to programmatic variables on 'current use'. The operational definitions of the independent variables used in the analysis are presented in Table 5. The categories of the independent variables explain the variation in use from the reference category and its significance after controlling for other related variables.

Using different combinations of independent variables, results of four regression models have been presented in Table 6. The results show that men's current age has significant relationship with current use after controls for other demographic variables. However, the number of living children shows the strong positive effect on current use across all models, confirming the hypothesis that for men, contraceptive use strongly depends on the number of living children. This is reflected by the highest co-efficients for five or more living children. As expected, an exposure to urban living makes a difference in increasing the likelihood of use because urban men show significant effect on current use.

Looking at Model I in Table 6, most of the socio-economic and women's status variables show significant effects on use. However, the predictive power of men's education in promoting contraceptive use disappears even at the secondary and higher level when programme variables are added to the equation (Model II). Almost similar effects for female education are observed on increasing the likelihood of contraceptive use. Regarding women's status and programme variables, wife mobility, husband-wife communication, knowledge of source of a method, and knowledge of condom source emerge as powerful predictors in increasing the likelihood of contraceptive use. This implies that if wives are consulted by their husbands in family planning matters and supplies are accessible, there is more likelihood of adopting the contraceptive use behaviour.

It is important to note that the effect of husbands' education disappears when programme variables are included in the equation (Model-II). It also appears that men who approve of family planning are five times more likely to adopt fertility control behaviour than those who do not approve of it. Desire for no more children does not show significant effect, and this is probably because of the controls for living children in the equation. Additionally, the wife's mobility, i.e., going out of the house independently, and husband-wife communication variables remain powerful predictors of current use, implying that men who have egalitarian views about gender and power relations are more likely to have favourable attitudes towards use of family planning.

In Model III, where all predictor variables are included in the equation, the net effect of the programme variables, knowledge of source and knowledge of condom source, is highly significant. It may be pointed out here that the desire for no more children, which has not emerged as a significant variable in the present study of male sample, has a significant effect when analysis for wives' sample or couple-level analysis is done [Mahmood and Ringheim (1994); Mahmood (1998)]. However, the interaction effect of the desire for no more children and the educational level of each spouse indicates that only husband education has turned out to be statistically significant, reflecting the fact that the desire for children is related to husband's educational level (Model IV). The insignificance of wife's education arises probably because of its correlation with husband's education.

To further check for the interaction effects of certain variables with each spouse's education, two interaction (8) terms--the desire for no more children*/ husband education and wife could go to hospital alone*/husband education--have been included in Model-IV. The results show significant interaction effects of wife mobility and husband education especially for secondary and higher levels. Similarly, the interaction effects of the desire for no more children and husband's education are significant, implying that educated men have favourable attitudes towards their wives' autonomy. (9)

7. DISCUSSION AND CONCLUSIONS

In this study an attempt has been made to provide information and to identify the effects of Pakistani men's participation in family planning practices. The study has addressed two issues about the decision to use family planning, i.e., (a) attitudes and (b) actual use of contraception. The findings suggest that Pakistani men do participate in the decisions regarding contraceptive use, try to plan their families, and support family planning. Men also know more about different contraceptive methods than do their wives and approve of use of contraception to achieve their reproductive goals. The recent transition to lower fertility is probably on account of at least changes in men's attitude [Sathar and Casterline (1998)]. Perceptions of family planning are changing and men play an essential part in this change, especially due to a reversion of social and cultural values, as well as the family planning programme activities, which started showing an improvement in the 1980s [Ross, et al. (1992); Sathar and Casterline (1998)].

Men's participation in family planning means using a condom, coitus interruptus, and periodic abstinence or vasectomy; but more often it means reaching an agreement with their wives to allow them to use other methods. The husband's permission to use contraception is essential for consistent and continued use of the preferred method.

The evidence from the present study shows that Pakistani men are considerably involved in family planning, but the concerns about the social and cultural acceptability of contraceptive practice still exist and efforts to involve men in family planning are lacking [Population Council (1997) and Douthwaite (1998)]. For this purpose, counselling of husbands is most likely to bring positive outcomes through changes in husband's level of involvement; and better counselling can be provided through senior and better trained staff.

In this connection, spousal communication needs special attention. Since women are unlikely to bring up the subject for discussion because they may be hesitant before men, therefore men may be informed about the advantages of family planning as a means of preventing unwanted pregnancies, and about spacing of births or controlling family size. The rural men, who are the majority of the population, need to be aware of the source of family planning services, so as to facilitate their motivation to limit fertility.

Lack of useful information or misconceptions about family planning are probably some of the reasons why men do not take a more active role in family planning activities. Information on the contraceptive methods and how men pass on this information to their wives would be of importance not only for men but also to better understand spousal communication. By introducing the IEC (Information-Education and Communication) material, stating the advantages of family planning can help influence their behavioural change. The ways and means of increasing the communication between husband and wife by using the IEC material can be found particularly for rural men. This is likely to lead to more acceptance of family planning.

There is a need to increase facilities for men in reproductive health and family planning services. In this regard, male workers are essential to provide reproductive health information and services to men. Since men's knowledge about contraception is related to their level of schooling, more structured education about family planning should be directed towards men with the least schooling.

The women's participation in the household decisions and their mobility is another area that enhances use of contraception and thus needs more attention. Women's autonomy in the household decisions is uneven, i.e., somewhere between considerable and highly restricted. If women's autonomy in terms of their mobility and decision-making is enhanced through their education and by encouraging communication with the spouse, its effects on use to contraception and limitation of family size can be far greater than it is now.

Author's Note: The author is thankful to Dr Naushin Mahmood, Joint Director, PIDE, Dr Zeba A. Sathar, Country Director, Population Council, Islamabad, Dr G. M. Arif, Chief of Research, PIDE, and his colleagues in the Demography Section of PIDE for their valuable comments on the first draft of this paper. He would also like to thank Mr Mohammad Sarwar for typing the paper.

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Ross, John A., W. Parker Mauldin, Steven R. Green, and E. Romana Cooke (1992) Family Planning and Child Survival Programmes as Assessed in 1991. New York: Population Council.

Sathar, Zeba A., and John B. Casterline (1998) The On Set of Fertility Transition in Pakistan. Population and Development Review 24:4, 773-796.

Sathar, Zeba A., and Shahnaz Kazi (1997) Women's Autonomy, Livelihood, and Fertility: A Study of Rural Punjab. Pakistan Institute of Development Economics (PIDE), Islamabad.

Shah, Nasra M. (1972) Inter-spousal Communication and Agreement as Variables in the Study of Family Planning. Sc.D. Thesis, Hopkins University, Baltimore, Maryland, U.S.A.

Training, Research and Evaluation Centre (TREC) (n.d.) National Impact Survey Report. Pakistan Population Planning Council, Lahore.

United Nations (1994) Report on the International Conference on Population and Development, Cairo, September. New York, U. N.

United Nations (1996) Levels and Trends of Contraceptive Use As Assessed in 1994. New York: United Nations.

United Nations (1994) Men in Families. Report of Consultation on the Role of Men and Fathers in Achieving Gender Equality. UNICEF. 13-14 January.

(1) International Conference on Population and Development (ICPD), Cairo (1994); Programme of Action (POA), (1994).

(2) The information on men has been taken from two other published survey reports, the National Impact Survey 1968-69 and Males' Attitude and Motivation for Family Planning in Pakistan 1994. The NIS 1968-69 was based on women's sample and the 1994 male survey was based on a male sample. Due to non-availability of data for analysis on computer, the information from these two surveys is based on printed sources. However, wherever needed, a comparison is made with the printed sources.

(3) Discussion on the multivariate analysis is on p. 213.

(4) The information from the recent surveys shows that condom use is on the rise 13.7 percent of the sample. [Hakim, et al. (2000-2001)].

(5) In the NIS 1968-69, the current use by method is not available from the published sources.

(6) Due to limited number of users, there are very small numbers of men in some cells if discontinuation is disaggregated by reasons for not continuing to use any given method. Hence, the table on reasons for discontinuation is not reported.

(7) Contraceptive use as reported by husbands is used for the analysis and is assumed to indicate the use behaviour of couples.

(8) However, initially several interaction terms were included in the model, such as education of spouses and approval of family planning, and husband-wife communication. All these variables did not turn out to be statistically significant. Therefore, these terms were dropped from the analysis.

(9) The interaction term of husband's education and approval of family planning did not emerge as significant and, hence, is not reported in the model.

M. Framurz K. Kiani is Research Demographer at the Pakistan Institute of Development Economics, Islamabad.

Table 1
Selected Social and Demographic Characteristics of the Men
in Pakistan, 1968-69 and 1990-91

Characteristics NIS--1968-69 PDHS--1990-91

Current Age
 15-29 25.8 22.9
 30-39 33.2 33.2
 40+ 41.0 43.8
Median Age 37.3 37.8
Median Age Difference between
 Husband and Wife 7.9 6.7
Place of Residence
 Urban 43.9 50.9
 Rural 56.1 49.0
Education
 Literate 36.0 49.8
 Primary and Middle 27.0 29.3
 Secondary and Higher 8.5 20.4
Number of Living Children
 0-2 40.4 35.1
 3-4 27.4 27.1
 5+ 32.2 37.9
Mean Number of Living Children 3.6 3.4
Knowledge of Family
 Planning Methods 57.0 79.3
Family Planning Use
 Current Use 6.7 15.1
 Ever Use 15.0 24.7
 Intention to Use -- 17.8
Desire for Children
 Want More 53.2 44.0
 Don't Want More 46.7 31.6
 Up to Allah/Don't Know -- 15.4
Approved Family Planning
 Yes 77.9 66.6
 No 22.1 32.4
Husband-wife Communication
 Yes 28.8 39.7
 No 71.2 60.3

Sources: National Impact Survey (NIS)--1968-69 Ist Report.

Pakistan Demographic and Health Survey (PDHS)--1990-91 Ist Report
Table 12.1 (p.170).

As reported in Shah, Nasra (Table A. 1) p.183.

As reported in Azhar and Hardee (Tables 11 and 18), p. 27 and 37.
Research Report No. 100.

Table 2
Percentage of Males by Knowledge, Ever Use, and Current Use of
Family Planning Methods, 1968-69 and 1990-91

 Current
 Knowledge Ever Use Use

Contraceptive NIS PDHS NIS PDHS PDHS
Method/Survey 1968-69 1990-91 1968-69 1990-91 1990-91

Any Method 57.0 79.3 15.0 24.7 15.1
Women's Methods
 Pill 44.1 54.9 1.7 4.6 0.8
 IUD 37.2 28.6 3.8 2.9 1.4
 Injectable -- 50.0 -- 2.9 0.5
 Veginal Method -- 12.6 -- 0.4 0.4
 Female
 Sterilisation 51.2 65.7 0.6 4.0 3.8

Couple Methods
 Rhythm 23.9 38.9 2.2 11.7 3.2
 Withdrawal 29.2 39.9 1.3 8.3 1.7

Male Methods
 Condom 57.1 58.8 6.6 12.1 3.6
 Male Sterilisation 45.1 31.7 0.3 0.1 --
 Others 20.2 1.6 0.4 0.3 0.2

Sources: NIS 1968-69, National Impact Survey Report, Tables 3-16, p.
79. PDHS 1990-91, Pakistan Demographic and Health Survey, 1st Report,
Table 12.4, p. 173.

Table 3
Attitudinal Variables by Selected Characteristics, PDHS 1990-91

 Attitudinal Variables

 Approve

Characteristics Categories % (N)

All 67.2 (1336)
Living Children 0-2 66.4 (455)
 3-4 65.2 (397)
 5+ 69.6 (484)
Age Difference 0-4 70.8 (541)
 5-9 70.4 (450)
 10+ 57.4 (345)
Place of Residence Urban 75.7 (407)
 Rural 63.6 (928)
Husband Education None 60.9 (677)
 Primary/Mid. 67.4 (389)
 Sec./Higher 83.0 (270)
Wife Education None 63.0 (1096)
 Educated 86.6 (239)
Husband-wife Communication Yes 84.0 (531)
 No 56.2 (804)
Know Source of Condom Yes 80.9 (659)
 No 54.0 (676)
Ideal Education for Sons None/D.K * 36.4 (77)
 Primary/Mid. 61.8 (102)
 Sec./Higher 70.0 (1148)
Ideal Education for Daughters None/D.K. * 45.0 (262)
 Primary/Mid. 63.4 (372)
 Sec./Higher 78.0 (695)

 Attitudinal Variables

 Desire for
 More Children

 Categories % (N)
Characteristics
 32.8 (1294)
All 0-2 7.4 (459)
Living Children 3-4 36.2 (390)
 5+ 57.1 (445)
 0-4 30.4 (527)
Age Difference 5-9 32.0 (431)
 10+ 39.2 (337)
 Urban 43.5 (386)
Place of Residence Rural 28.9 (908)
 None 30.4 (661)
Husband Education Primary/Mid. 33.4 (371)
 Sec./Higher 40.1 (262)
 None 31.1 (1067)
Wife Education Educated 43.4 (226)
 Yes 45.6 (531)
Husband-wife Communication No 24.7 (762)
 Yes 40.8 (623)
Know Source of Condom No 26.3 (670)
 None/D.K * 47.4 (76)
Ideal Education for Sons Primary/Mid. 28.7 (101)
 Sec./Higher 32.8 (1107)
 None/D.K. * 33.1 (263)
Ideal Education for Daughters Primary/Mid. 24.9 (365)
 Sec./Higher 38.1 (658)

Note: The total number of cases by each category may vary from overall
totals because of missing values.

* Do not know.

Table 4
Percentage of Men by Current Use of Any Method, by Selected
Socio-demographic Characteristics PDHS--1990-91

 Men
Characteristics Categories % (Number)

All -- 15.1 (1354)
Current Age 15-29 10.0 (319)
 30-44 16.7 (641)
 45+ 16.4 (390)
Number of Living Children 0-2 8.4 (463)
 3-4 16.8 (400)
 5+ 19.9 (487)
Place of Residence Urban 27.2 (415)
 Rural 9.6 (935)
Education None 7.9 (683)
 Primary/Mid. 16.5 (393)
 Secondary/Higher 30.7 (274)
Approval of Family Planning Approved 20.9 (899)
Method Disapprove 3.4 (438)
Desire Future Children Want another Child 7.7 (601)
 No More/None 23.0 (390)
 Up to God/Undecided/
 D.K. 3.9 (254)
Can Go to Hospital Alone Go alone 34.0 (253)
 Accompanied 10.7 (1089)
Husband-wife Age Difference 0-4 17.7 (548)
 5-9 13.9 (453)
 10+ 12.6 (349)
Husband-wife Communication Yes 24.6 (533)
 No 8.8 (817)
Heard of Any Method Yes 24.2 (687)
 No 5.6 (663)
Source of Any Method Yes 23.1 (873)
 No 0.2 (477)
Knowledge of Sources of Condom Yes 26.1 (666)
 No 4.2 (684)

Table 5
Operational Definitions of the Independent and Dependent Variables

Independent Variables Definitions

Demographic Characteristics
Husbands' Current Age [AGE.sub.1] 15-19 = 1, otherwise = 0
 [AGE.sub.2] 30-44 = 1, otherwise = 0
 45+ = Reference category
Number of Living Children 0-2 = Reference category
 3-4 = L child 2=1, otherwise = 0
 5+ = L child 3=1, otherwise = 0
Men's Social Characteristics
Place of Residence Urban = 1
 Rural = Reference category
Education of Husband
 None = Reference category
 [Edu.sub.1], Primary/Middle = 1,
 otherwise = 0
 [Edu.sub.2], Secondary/Higher =
 1, otherwise = 0
Women's Status
Wife Education No Education = Reference category
 Educated = 1, otherwise = 0
Go to Hospital alone Go alone = 1, otherwise = 0

Husband-wife Communication Communicated = 1, otherwise = 0

Attitudinal Variables
Approved Family Planning Approved = 1, otherwise = 0

Desire Future Children Desire no more = 1
 Have another/Up to God = 0

Programme Variables
Heard of Any Method Yes = 1, otherwise = 0
 No = Reference category

Source of Any Method Know the source = 1, otherwise = 0
 No = Reference category

Knowledge of Source Know the source for condom= 1,
of Condom otherwise = 0
 No = Reference category

Table 6
Logit Regression of Current Contraceptive Use on Selected
Independent Variables for the Sample of Men; PDHS 1990-91

Independent Variables Model-I Model-II

Current Age of Men
 15-29 0.72 0.83
 30-44 0.85 0.86
 45+ [perpendicular to] [perpendicular to]
Living Children
 0-2 [perpendicular to] [perpendicular to]
 3-4 1.98 *** 1.81 **
 5+ 2.96 *** 2.61 ***
Place of Residence
 Urban 1.78 *** 1.42 *
 Rural [perpendicular to] [perpendicular to]
Men's Education
 No Education [perpendicular to] [perpendicular to]
 Primary/Middle 1.69 ** 1.16
 Secondary/Higher 2.34 *** 1.18
Wife's Education
 No Education [perpendicular to] [perpendicular to]
 Educated 1.54 ** 1.51 *
Wife Could Go to
Hospital Alone
 Go alone 2.11*** 2.11 ***
 Accompanied/Depends [perpendicular to] [perpendicular to]
Husband-wife Communication
 Yes 1.74 *** 1.82 ***
 No [perpendicular to] [perpendicular to]
Approval of Family Planning
 Approve 5.06 *** --
 Disapprove [perpendicular to] --
Desire Future Children
 No more/none 0.91 --
 Have another/Up to God [perpendicular to] [perpendicular to]
Programme Variables
 Heard of Any Method -- 1.05
 Knowledge of Source
 of Any Method -- 1.26 ***
 Knowledge of
 Source of Condoms -- 1.97 **
Interaction
 Husband Edu.1 by Desire
 Husband Edu.2 by Desire
 Husband Edu.1 by Go Alone
 Husband Edu.2 by Go Alone
 Wife Edu. by Desire
 Wife Edu. by Go Alone
-2 log Likelihood 904.611 861.088
Model Chi Square(df) 237.933(12) 281.456(13)
No. of Cases 1280 1265

Independent Variables Model-III Model-IV

Current Age of Men
 15-29 0.72 0.74
 30-44 0.84 0.84
 45+ [perpendicular to] [perpendicular to]
Living Children
 0-2 [perpendicular to] [perpendicular to]
 3-4 1.79 ** 1.72 *
 5+ 2.48 *** 2.47 ***
Place of Residence
 Urban 1.54 ** 1.43 *
 Rural [perpendicular to] [perpendicular to]
Men's Education
 No Education [perpendicular to] [perpendicular to]
 Primary/Middle 1.17 0.79
 Secondary/Higher 1.16 0.66
Wife's Education
 No Education [perpendicular to] [perpendicular to]
 Educated 1.37 1.84 *
Wife Could Go to
 Hospital Alone
 Go alone 2.09 *** 1.29
 Accompanied/Depends [perpendicular to] [perpendicular to]
Husband-wife Communication
 Yes 1.52 ** 1.50 *
 No [perpendicular to] [perpendicular to]
Approval of Family Planning
 Approve 4.13 *** 4.21 ***
 Disapprove [perpendicular to] [perpendicular to]
Desire Future Children
 No more/none 0.91 0.66
 Have another/Up to God [perpendicular to] [perpendicular to]
Programme Variables
 Heard of Any Method 1.07 1.05
 Knowledge of Source
 of Any Method 1.23 *** 1.24 ***
 Knowledge of
 Source of Condoms 1.83 ** 1.91
Interaction
 Husband Edu.1 by Desire 2.24 *
 Husband Edu.2 by Desire 1.38
 Husband Edu.1 by Go Alone 1.43
 Husband Edu.2 by Go Alone 3.98 *
 Wife Edu. by Desire 0.92
 Wife Edu. by Go Alone 0.59
-2 log Likelihood 833.081 822.680
Model Chi Square(df) 309.463(15) 319.86(21)
No. of Cases 1257 1254

* P<0.10 ** p<0.05 *** p<0.01. [perpendicular to] Reference category.