Muslim men's perceptions and attitudes on family planning: a qualitative study in Wajir and Lamu counties in Kenya.

In patriarchal societies like Kenya, understanding men's perceptions and attitudes on family planning is critical given their decision-making roles that affect uptake of contraception. Yet, most programmes mainly target women as primary users of contraceptive methods since they bear the burden of pregnancy. However, women-focused approaches tend to overlook gender power dynamics within relationships, with men wielding excessive power that determines contraception use or non-use. A qualitative study involving focus group discussions and in-depth interviews was conducted in the two predominantly Muslim communities of Lamu and Wajir counties, Kenya. Open-ended questions explored perspectives, attitudes and men's understanding of contraception, family size, decision making on family planning and general views on contraceptive use. Thematic content analysis was used. Findings show that men in Wajir and Lamu held similar viewpoints of family planning as a foreign or western idea and associated family planning with ill health and promiscuity. They believed family planning is a "woman's affair" that requires little or no input from men. Men from Wajir desired a big family size. There is a need for a shift in family planning programmes to enable men's positive engagement. The findings from this study can be used to develop culturally appropriate approaches to engage men, challenge negative social norms and foster positive social change to improve uptake of family planning.

Introduction

Understanding men’s perceptions and attitudes on family planning is critical, given their influence and decision making role in patriarchal societies.[1] Traditionally, most family planning programmes target women as they are the ones that carry the burden of pregnancy and childbirth. The targeting of women is premised on the assumption that women are more motivated than men to use family planning services and usually have more contacts with health care providers. However, the women-focused family planning approach tends to overlook gender power dynamics at household levels, where men wield much power and influence at individual, family and societal level, including for contraceptive use or non-use.[2-4]

Studies done in Indonesia and Bangladesh showed that a husband’s approval was the most important determinant of contraceptive use.[5,6] Furthermore, in situations where male dominance is prevalent, there is a tendency for men to overrule women on contraception.[4,7] A number of reasons have been linked to men’s disapproval of contraceptive use, such as: fear that their wives will be unfaithful and have extramarital affairs; fear of side effects of contraception and perceived ill health associated with it; and losing their role as key decision-makers in the family.[8-10] The covert use of contraceptives by women is a clear indication of power imbalances in sexual and reproductive health matters.[4] Another crucial aspect of the male perspective on family planning use is spousal communication. Global evidence has illustrated a positive correlation between spousal concordance and family planning uptake, yet in most patriarchal societies women’s voices are unreasonably subdued.[9,11,12]

Studies exploring men’s perceptions of family planning have revealed that men in many parts of Africa desire more children than women and marriage has been used by men as a means of reproduction.[13,14] A study in Kenya found that men in the North Eastern region (the study site Wajir is in this region) desire three times as many children as men in Nairobi.[15]

The purpose of this study was to explore the perceptions and attitudes of men in two predominantly Muslim counties – Wajir and Lamu. Findings of the Kenya Demographic Health Survey (KDHS) show that the total fertility rate (TFR) for Wajir is 7, which is almost double the rate in Lamu at 4.3 and the national average of 3.9.[16] These two counties have striking differences in contraceptive uptake. Wajir has the lowest contraceptive prevalence rate (CPR) in Kenya at 2% while the CPR in Lamu is 42%.[16] Our study sought to gain insights into men’s perceptions and attitudes, which could shed light on the huge differences between the counties despite their similar religious contexts. The findings could also help guide conversations aimed at changing men’s perceptions and attitudes towards contraceptives and tailor programmes targeting Muslim communities.

Methods

Study design and setting

This paper describes part of a larger qualitative study conducted in Wajir and Lamu counties in Kenya, with the overall objective of understanding social and cultural factors influencing uptake of family planning in the two counties. While respondents of the larger study included both men and women, the present study used focus group discussions (FGDs) and in-depth interviews (IDIs) among Muslim men. Details of the methodological approach used in this study are published elsewhere.[13]

Apart from the TFRs and CPRs, the two counties have other differences in socio-demographic characteristics. Lamu County is a predominantly coastal community of Swahili ethnicity, while Wajir County is inhabited primarily by pastoralist Somalis. In Lamu, 67% of the population have attained formal education and 13% have secondary education, while in Wajir County only 24% of the population have formal education, and only 4% have reached secondary level.[17]

Study participants and sampling

Participants were selected purposively from three sub-counties: Wajir North and Wajir East in Wajir County, and Lamu West in Lamu County. Community representatives were engaged through local chiefs, health officials and members of the health management teams of the sub-county. These teams further supported the selection of the study participants based on some selection criteria. For FGDs, respondent’s age and place of residence were considered. IDI participants were selected based additionally on their understanding of social-cultural practices, religious teaching and the role they played within the community.

A total of 54 discussants were recruited in seven FGDs (Wajir, n = 4 and Lamu, n = 3). Each FGD was composed of 6–8 respondents. FGDs comprised two groups of religious leaders, two groups of young men (18–24 years), and three groups of adult men (pastoralists, fishermen and teachers respectively). Seven IDIs (Wajir, n = 4 and Lamu, n = 3) were carried out, with four religious scholars and three influential community leaders (chiefs, clan leaders and community elders).

Data collection

Data were collected between July and October 2018. Open-ended, semi-structured question guides were used to explore participants’ knowledge on contraceptive use, perceived barriers, views about Islam and contraception, and fertility preference. Interview guides were developed by the lead author and validated with a team of research assistants in a workshop before fieldwork. Discussions and interviews were conducted in Somali and Swahili languages in Wajir and Lamu respectively, and later translated to English. The lead author (BA) who is fluent in both Somali and Swahili languages, supervised the data collection and analysis process. The FGDs and IDIs had an average length of between 45 minutes and one hour. A team of trained qualitative researchers, supervised by the first author, conducted interviews. Data was gathered until saturation was reached and during regular research team debriefing meetings no fresh details emerged. FGDs were conducted in convenient places agreed upon with respondents, while IDIs were conducted in private places of the respondents’ choice.

Ethical considerations

Ethical approval for the study was obtained from the Research Ethics Committee of the Aga Khan University, Nairobi (2016/REC-56 (v3)). We also obtained a research permit from the National Commission for Science, Technology and Innovation (NACOTI/P/18/14340/20946) to carry out the research at community level. All participants provided consent after being informed about the objective of the study.

Data analysis

All discussions and interviews were recorded and transcribed verbatim and translated into English. The transcripts were validated to ensure accuracy by re-reading the transcripts several times and comparing with audio to ensure no loss of meaning during translation. Analysis of the data, conducted by the first author (BA), included several steps. Using thematic content analyses, the transcripts were reviewed several times, and a set of codes were developed to describe groups of words, or categories, with similar meanings. A code sheet was developed and used for coding the transcripts in ATLAS.ti (Version 7). To evaluate the range and similarities of the perceptions and views of the participants, the themes were compared across the transcripts and particularly the different analytical categories. The first two authors (BA and JO) reviewed the themes independently, discussed discrepancies and reached consensus. Direct quotes are used to illustrate the themes and effectively communicate their meaning.

Results

Findings are reported from seven FGDs and seven IDIs comprising 61 men aged between 18–54 years. About 36% of the participants had no education, 21% had primary education and 43% had secondary education and above. The participants came from diverse occupational backgrounds and almost all had some form of income. Table 1 shows the categories of study participants for both FGDs and IDIs.

Table 1.

Categories of study participants

Categories	Lamu county	Wajir county
Focus group discussion composition
Religious leaders	1	1
Teachers	1	1
Youth	0	1
Pastoralists	0	1
Fishermen	1	0
In-depth interview participants
Religious scholars	2	2
Influential community leaders	1	2

Based on the thematic content analysis, themes shaping the attitudes and the perspectives of men on family planning emerged. Five of the themes arose from topics in the interview guide and a theme on family planning as a western/foreign ideology emerged after further analysis. The themes were: family planning as a western/foreign ideology; using only natural methods; family planning and ill health; family planning and promiscuity; family planning as a “woman’s affair”; and desire for a large family size.

Family planning as a foreign/western ideology

In both Wajir and Lamu, the participants believed that family planning is a foreign/western concept that contradicts their social-cultural and religious beliefs. Family planning was also seen as a weapon used to reduce their population and decimate them. These were widely held beliefs and often used to undermine family planning use, which clearly had little or no support among participants. From time to time, participants repeatedly drew on culture and interpretation of Islam as a basis for rebuffing use of family planning methods.

“We think that family planning is not a good thing. Why should one compete with God? God said that we should fill the world, then some western countries come to us and make us disobey that.” (FGD fishermen, Lamu)

“We believe the provider is God and not a human being this idea of planning to have a certain number of children is not part of our religion and culture, I can say this is amzungu (Whiteman) way of thinking. As a Somali community we believe having many children is good for the family and the community in any case why would certain people or a country want to reduce our population when Islam tells us to produce and fill the earth.” (FGD religious leaders, Wajir)

Another widely held belief by men in Wajir was that family planning use was common among young and educated women who were mostly thought to be influenced by western culture and social values that are premised on looks and beauty. In the participants’ worldview, giving birth to many children was socially acceptable and perceived to be in tandem with the basic tenets of Islamic beliefs and cultural norms. The association of family planning as a western concept by the participants reinforced the scepticism and negativity around contraception, particularly in Wajir, where support for family planning was exceptionally low.

“Educated women want few children because of western ideas and to keep their body looking beautiful and young, but illiterate ones want more children because children are blessings from Allah.” (FGD Pastoralists, Wajir)

“ … There are a few educated couples who want few children to have a manageable family size with a view of providing good education and good life, in my view this is a western ideology, because in Islam we are not to worry about rizk (provision) – it is Allah who provides.” (IDI Influential leader, Wajir)

Using only natural methods

Family planning was misconstrued as limiting family size contrary to men’s desires, social-cultural beliefs and religious teachings. It is however noteworthy that men in both study sites were more accommodating of the concept of family planning within the prism of child spacing with a focus on natural methods. Their preference for natural methods (lactational amenorrhoea, withdrawal, calendar and abstinence) seems to be largely informed by the belief that child spacing is recommended in Somali and Swahili culture, as well as Islam.

“Actually I’m a family man I have not used family planning so far. But many people in our community use withdrawal method, which is natural method of family planning.” (FGD, Youth, Wajir)

“I prefer withdrawal method or other natural method like calendar method, because these methods are not haram (forbidden) like the modern methods.” (FGD Religious leaders, Lamu)

“The modern contraceptives such as pills and injections are haram (forbidden) and they foreign to Islam. To the best of my knowledge what is allowed is natural methods such as breast feeding, withdrawal or calendar method.” (IDI influential leader, Wajir)

Family planning and ill health

Participants in both counties expressed their concerns about ill health associated with use of modern contraceptive methods. They expressed fears of side effects (real or perceived) associated with family planning. For example, one recurrent view was that contraceptives have the potential of causing ill health to their partners or secondary infertility. There was the fear that some family planning methods such as pills and injections can cause more harm than good. Because of the perception that modern family planning methods cause ill-health, most men preferred to use natural or traditional methods such as withdrawal or calendar methods which were deemed safe – a repeated theme being a justification that these methods do not have adverse outcomes or side effects. Some of the common illnesses associated with contraceptive use which participants mentioned include excessive bleeding, obesity, diabetes and infertility.

“Use of family planning can also lead to obesity, for example many women gain weight especially those who use injection and this can lead to disease like diabetes. We also hear some methods cause infertility, so these pills and injection can cause more harm.” (FGD teachers, Wajir)

“If it won’t have a negative effect, then it is ok. For example, when my wife uses the family planning pills, she may stop having menstruation periods for three to four months, and when the periods come, she bleeds a lot. So, I rejected the idea of her using the pills. So, with methods like withdrawal or calendar I think we are safe. In short, there are some methods we reject because of the health effects and others we agree with them.” (FGD teachers, Lamu)

Family planning and promiscuity

Many men opined that family planning use (whenever it occurs) is accepted only within the context of marriage among Muslim communities. However, the use of family planning was not given any value in society as most participants affirmed that modern family planning methods are not for the faithful, married and respectable women among Somali society.

“From the Somali cultural viewpoint there is negative perception about women who use modern family planning, they are associated with lack of good morals and the society generally does not view them as good people.” (FGD Youth, Wajir)

The notion that family planning may encourage extramarital affairs was expressed by several participants. For example, men in Wajir perceived women who used modern family planning methods to be morally loose and in contravention of the teachings of Islam, as well as Somali social-cultural expectations. Similarly, men in Lamu indicated a common view that family planning gives women sexual freedom, which leads to promiscuity within marriage.

“Only those who are married can use family planning because in our religion, sex should happen within the context of marriage … . Even among the married many of the men are of the opinion that women who use family planning can cheat on their husbands.” (FGD Teachers, Wajir)

“Sometimes family planning promotes adultery, since your wife knows she can’t get pregnant, she finds a side kick (extra marital affair) to assist you in bed affairs while you are busy.” (FGD fishermen, Lamu)

Family planning is a “woman’s affair”

In both Lamu and Wajir, there was consensus that family planning was the responsibility of women, and therefore required little or no input from men. As such, many men did not actively seek information about family planning or engage with their spouses on matters regarding family planning. Men who spoke in favour of family planning or practised family planning were seen to be weak or under the control of their wives.

“Men have ego issues and negative attitude in regard to family planning. Some have the perception that family planning is for women and therefore they don’t want to discuss the matter.” (FGD fishermen, Lamu)

“We as men don’t discuss about family planning issues, many Somali men think that this is a woman’s business, most of the time it is the women who take children to the clinic and talk to the nurses.” (IDI influential leader, Wajir)

Although men stated that decision-making on family planning was left to women to deal with and regarded the matter as a “woman’s affair,” at the same time, they seemed to overtly or covertly “police” women on contraceptive use. Most said that their spouses needed to consult them to use family planning and seek their concurrence. However, some men reported that women use family planning in secrecy.

“Woman cannot use family planning without her husband’s consent. The decision has to be mutual but I have heard women using pills in secret.” (FGD teachers, Wajir)

“If a woman has to use family planning she has to consult the father of the house (husband) at the end of the day he is the one who the family relies on in terms of family upkeep and education, basically all the needs at family level.” (FGD fishermen, Lamu)

Perceptions on family size

The participants had varying opinions on family matters, including ideal family size. The influence of perceived social-cultural beliefs and Islamic teachings of family and marriage were apparent in all the discussions across the study sites. Men from Lamu indicated that they desired a reasonable family size of four to six children that they can support based on their economic earning.

Most of the men from Wajir were unable to give an exact count of ideal family size. They insisted that it was culturally inappropriate to count one’s children. In addition, it was believed that it is up to Allah to provide the ideal number of children, and opposition to a big family size was viewed as contrary to Islamic teachings. However, a few participants went against the norm and shared their perspective on ideal family size. For such men, the ideal number of children was 15 and more.

“I want many children … in our culture we don’t ask how many children we want to have because it is God who provides and plans for children.” (FGD Youth, Wajir)

“Currently I have two children, I lost one. But I want at least 17 children from the three wives.” (FGD Pastoralist, Wajir)

However, a minority of participants from Wajir and Lamu supported the idea of a “smaller” family size premising their position on quality over quantity. The desire was to be able to provide for basic needs such as food, education, shelter and good health for the family. There were, however, minor differences in the two locations on how “small” a family could be. Those in Wajir regarded a family of six to eight as small while in Lamu a small family of four to five children was perceived as the ideal family size. It is important to note that religious scholars in Lamu justified the need for smaller families from the Islamic perspective, unlike their counterparts in Wajir.

“I think we cannot disregard the fact that we are Somali … . We should have a family of six members so that we are capable of sustaining them in term of education and sustain their survival.” (FGD Youth, Wajir)

“Nowadays people want to have few children because of the economy. They want children that they can be able to raise well. And Islam permits you to bear few children that you can raise well, but remember, Allah says He is the one who provides for every creature in this world.” (IDI influential leader, Lamu)

“The Quran says we bear as many children as possible, many people want children but they can’t because of the economic constraints faced in the country. Islam is a religion of mercy and we are not allowed to burden ourselves. It’s better you have a child that you can take care of.” (IDI Religious Scholar, Lamu)

Generally, discussants from Wajir linked having many children to broader social, economic and political issues at the community level. Children were viewed as a source of pride and a pathway for the continuation of one’s lineage, thereby making it valuable to have many children. The discussants alluded that the strength and security of a clan or sub-clan depend on the number of its people. They gave examples of how having a large population gave one, or the community, an edge in politics and, by extension, in the allocation of resources both at national and local level. They indicated that procreation and population growth originate at the family level and it is something that should be encouraged.

“I think the idea of having many children is both religious and cultural, from the religious perspective we want the ummah (Muslim community) to be more, then in the cultural perspective pastoralist families want many children to take care of their animals as well as be defenders of the communities. Also pastoralists take pride in having big families as a sign of wealth, influence and prestige.” (IDI Religious scholar, Wajir)

“Yes, we as Somali men we prefer more children especially from my sub-clan – many children is a big strength in many ways, look at our politics the sub-clan that has more people get votes, and it is pride too. I think after worshipping God, next is to produce more children.” (FGD Youth, Wajir)

“Traditionally as a Somali community we know that a large family is a blessing, the more children a family has the better, it is a strength and a sign of prestige and wealth.” (IDI influential leader, Wajir)

Discussion

There is growing evidence that family planning uptake requires participation and involvement of both men and women. Thus, understanding men’s perspectives on family planning is crucial in order to design family planning programmes that consider men’s concerns and address knowledge gaps. This study provides insights into Muslim men’s perspectives on family planning in two counties that have striking differences in poverty and education levels, as well as in utilisation of modern contraceptives. Remarkably, the findings illustrate that men in the two counties, despite dissimilar desired family size, have almost similar perceptions of family planning as a foreign idea; family planning and ill health; family planning and promiscuity; and family planning as a woman’s affair.

Our findings show that men’s viewpoints are mainly shaped by culture, politics and religious belief. For example, men in both counties opined that family planning use is a western/foreign ideology that contravenes Islamic teachings. Suspicion and fears expressed by participants that family planning is a strategy employed by western countries to reduce the Muslim population, and the resulting scepticism around family planning, has been documented in other Muslim countries such as Pakistan.[18] However, many Muslim scholars opine that family planning is as old as Islam. The companions of the Prophet (Peace Be Upon Him) practised al-azl (withdrawal) and the Prophet did not prohibit the practice. By analogical deduction, this has been inferred to imply that all non-permanent methods are permissible in Islam.[19] This probably explains why a number of Muslim countries such as Egypt, Iran, Malaysia and Indonesia have impressive family planning uptake and enabling policy frameworks on family planning as well as support from men.[20-23] Most of the respondents in Wajir linked family planning use to being educated and influenced by western culture. It is worth noting that the county has low education attainment levels compared to Lamu and thus it is plausible that the low uptake of family planning in Wajir could be linked to low education levels in the county.

The study found out that men in both counties preferred natural family planning methods as opposed to modern contraceptive methods. Their preference for natural family planning is informed by beliefs that only natural methods are in tandem with their culture and Islam. Similar studies among Turkish men reveal men’s preference for natural methods.[24] These perceptions held by men have implications for contraceptive use given the role of men as decision-makers at family level, including decisions on use of modern family planning methods. These findings are in line with other studies in similar settings.[13] The perception that only natural methods are permitted in Islam shows the lack of knowledge and misconceptions around family planning and Islam, which also agrees with other studies.[25,26]

Our analysis shows that men are concerned about ill health (perceived or real) associated with the use of contraception. Since men are breadwinners, they take the associated ill health as a potential financial obligation that will affect the family, a finding that is in line with other studies conducted in Uganda and Tanzania.[9,10] The perception that family planning methods cause diseases such as diabetes and infertility can be attributed to lack of knowledge among men and the fact that most family planning interventions have targeted women.[4,9,10,27]

Additionally, in both sites, participants alluded to contraceptive use being associated with promiscuity and this could be one of the reasons for low uptake of family planning in Wajir. This perception is in agreement with studies done elsewhere in sub-Saharan Africa.[4,9,10,28] Studies conducted among men in Nigeria revealed that two in five men reported that women who use family planning may become promiscuous. The same study in Nigeria pointed out that Muslim men who are uneducated and rural dwellers link contraceptive use with promiscuity. This corroborates our findings.[29]

While men described family planning as a “woman’s affair,” they still wanted to be consulted or gave directions on use or non-use of family planning. In both study sites, men indicated not only the necessity for women to consult them on family planning matters but also that the ultimate decision on use or non-use of contraceptives rested with them. These findings are consistent with existing evidence in Kenya and Uganda. A study in Kenya showed that a contraceptive method was two to three times more likely to be used when husbands rather than wives wished to stop producing children.[1] In Uganda, studies showed that partners’ disagreement about future childbearing is associated with lower levels of contraceptive use among women, and unmet need was significantly higher among women whose partners wished them to continue childbearing.[30] Our study, in agreement with other studies,[4,31] illustrates the unequal power relations and the ability of men to make decisions and impose their preferences on women in matters regarding sexual and reproductive health. This could explain why men in both sites reported covert use of contraceptives among women, implying lack of spousal communication and the lack of concurrence by men on family planning use.

Our study established differing viewpoints on men’s perceptions of desired family size, with men in Wajir desiring more children. Religion and culture informed the justification for a bigger family size. The discussants in Wajir opined that according to Islamic teaching, the purpose of marriage is to reproduce, produce and “fill the earth.” The inability to define an appropriate family size indicates a deep fatalistic belief among the men that the number of children was “up to God.” These findings concur with studies in Sudan, Nigeria and Uganda.[28,29,32] Unquestionably, the belief that couples are not in a position to plan and it is “up to God” has a huge implication for use or non-use of family planning. It is probable that the low contraceptive uptake in Wajir could be the result of men’s desire for larger families. This could in turn be attributed to their social-cultural background as a pastoralist community where children are seen as a source of family labour to look after livestock and defend the herds and community from external attacks.

Our analysis demonstrates how deep social norms shape men’s perceptions regarding family size. In patrilineal societies, where men are primarily responsible for overseeing household production, politics and other social responsibilities at the household and community level, additional children may bring more advantage to men than to women. Men not only desire more children but, in most cases, they are in a position to actualise the desired family size, given the power inequality with women. The narratives from Wajir confirm the ability of men to decide the family size independent of their wives’ choice. These findings are in concurrence with other studies done in sub-Saharan Africa.[8,33,34] In contrast, men in Lamu desired a smaller family size, corroborating findings of the last Demographic and Health Survey.[35]

This study is one of the few exploring how Muslim men perceive family planning, and contributes to the body of knowledge by revealing interesting insights on perceptions and attitudes of men towards family planning. The study has some limitations. The findings documented may not be generalisable among Muslim men across Kenya and beyond, given the diverse social-cultural settings in Kenya. Due to the limited scope of the study, our analysis could not explore how the observed perceptions were influenced by individual social demographic characteristics such as age, level of education and economic status which are known to influence people’s perceptions on matters of health including contraceptive use.

Conclusion

Understanding men’s perceptions and attitudes is critical to design appropriate family planning programmes. The study suggests that the striking differences in contraceptive prevalence rates between Wajir and Lamu counties could be attributed to educational attainment levels, social-cultural values attached to large family size, economic considerations and “moral labels” attached to women using family planning, as in the case of Wajir.

Religious leaders are influential personalities who shape opinion in society. They are consulted on all matters of day-to-day life, including on matters of contraception. We observe from the results of the study the knowledge gap perpetuated by religious leaders upholding the notion that family planning is a western idea and only natural family planning methods are acceptable in Islam. This is in stark opposition to the teachings of Islam. It is critical that this influential group has correct Islamic interpretations on family planning. It is our view that the misconception of the religious leaders regarding Islam and family planning needs to be demystified through structured dialogue, involving them as change agents. Exchange or learning visits to other Muslim countries that have made significant progress in engaging religious leaders and men as champions for family planning could be pursued. Our study has also revealed other misconceptions held by men on family planning. Desired larger family size could be the main driver of low uptake of family planning services in Wajir. The perception that family planning is a “woman’s affair” despite men taking the lead in decision making was a key finding that requires programmatic shifts towards men’s positive engagement in family planning programmes. The role of education cannot be underestimated and there is a need for government both at national and county levels to invest in girl child education so that women are empowered to make informed choices. The findings from this study can be used to develop culturally appropriate approaches to engage men, challenge negative social norms and foster positive social change to improve uptake of family planning in both counties.