Article Text

Original research
Male involvement in family planning and its association with knowledge and spouse discussion in Ethiopia: a systematic review and meta-analysis
  1. Bezawit Adane1,
  2. Bereket Kefale2,
  3. Yitayish Damtie3,
  4. Mastewal Arefaynie2,
  5. Elsabeth Addisu2,
  6. Reta Dewau4,
  7. Kefale Mitiku5,
  8. Tilahun Degu Tsega1,
  9. Amare Agmas Andualem6,
  10. Mahider Awoke7,
  11. Tezera Asfaw8,
  12. Yitbarek Wasihun9,
  13. Melaku Yalew1
  1. 1 Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
  2. 2 Department of Reproductive and Family Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
  3. 3 Department of Reproductive and Family Health, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
  4. 4 Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
  5. 5 Department of Physiology, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
  6. 6 Department of Anesthesia, College of Medicine and Health Sciences, injibara University, Injibara, Ethiopia
  7. 7 Department of Public health Nutrition, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
  8. 8 Department of Anatomy, College of Medicine and Health Sciences, Wollo university, Desssie, Ethiopia
  9. 9 Department of Health Promotion, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
  1. Correspondence to Bezawit Adane; adanebeza1987{at}gmail.com

Abstract

Objective This study aimed to estimate the pooled prevalence of male involvement in family planning (FP) and its association with knowledge and spouse discussion in Ethiopia.

Design Systematic review and meta-analysis using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

Data sources The study was conducted by the articles searched from different databases: (PubMed, Cochrane Library, PsycINFO, HINARI and Google Scholar).

Eligibility criteria for selecting studies This research encompassed investigations carried out within married couples in Ethiopia, specifically focusing on studies where male involvement in FP was the primary outcome. The inclusion criteria comprised studies with an observational study design, encompassing both published and unpublished works, conducted in the English language, with no restrictions on data collection and publication year.

Data extraction and synthesis Following a systematic search of the articles, two independent authors assessed the quality of the studies, and data extraction was conducted using Microsoft Excel. The data analysis was performed by using STATA V.17. The overall level of male involvement in FP in Ethiopia was calculated using DerSimonian and Liard’s random-effect model, with a significance level set at a p<0.05. Heterogeneity was examined using the I2 test, and Egger’s test was employed to assess publication bias.

Results The pooled prevalence of male involvement in FP in Ethiopia was 59.71% (95% CI (47.68% to 71.73%)). Good knowledge regarding FP (AOR 6.63, 95% CI (2.58 to 17.03)) and spouse discussion on FP (AOR 4.36, 95% CI (2.50 to 7.59)) were significantly associated with male involvement in FP.

Conclusions The prevalence of male involvement in FP in Ethiopia was low as compared with other literature conducted outside Ethiopia. Both good knowledge and spouse discussion regarding FP were significantly associated with male involvement in FP. So, the government and healthcare providers should focus on interventions that could increase their knowledge through different media. In addition, encouraging couples to have a discussion regarding FP could be a recalled intervention for healthcare providers.

  • Adolescents
  • EPIDEMIOLOGY
  • Health Education
  • PUBLIC HEALTH

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The study used a comprehensive and systematic search strategy.

  • The study is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

  • The review was restricted to articles published in English.

  • The pooled estimate may be influenced by the language of publication and study design.

  • The heterogeneity of included studies was not resolved despite different efforts made.

Introduction

Male participation in family planning (FP) involves men taking actions independently, such as using FP methods or engaging in discussions with their spouses to endorse and support their utilisation.1 2 Traditionally, the focus on reproductive health was predominantly centred on women. However, after the International Conference on Population and Development, there was a shift in perspective recognising men’s responsibility to actively advocate for responsible parenthood, sexual and reproductive behaviour, including FP.3 4 This shift aimed to address the unmet need for FP often arising from objections by partners.5–7

Consequently, the significance of male involvement in FP gained acknowledgement among reproductive health programme developers, policy-makers and population researchers.8–10 Ethiopia’s Federal Minister of Health also recognised male engagement in FP as a strategy to enhance contraceptive prevalence rates.11 Despite its importance, a notable proportion of men were not actively engaged in FP or other reproductive health services,12 13 contributing to an estimated 31.45% prevalence of unmet contraceptive needs.14

Globally, there are notable disparities in the adoption of male contraceptive methods. For example, the use of methods such as vasectomy, condoms, withdrawal and abstinence is less prevalent in the Americas compared with Asia and Africa.15 In Bangladesh, research indicated that 94.8% of husbands were supportive of their wives using FP methods.16 Southern India reported that 71.2% of males actively practised FP methods.17 A study conducted in Nigeria found that 80% of men had previously used contraception, with 56% currently using it.18 Conversely, in Cameroon, the level of male involvement in FP was determined to be only 57.2%.13 Similarly, across various studies conducted in Ethiopia, the range of male involvement varied from 19.89% to 90.04%.19 20

Despite various studies conducted across diverse regions of Ethiopia, there is a prevailing issue of inconsistent and inconclusive findings, leading to a lack of a nationally representative figure regarding the level of male involvement in FP.19 20 Moreover, conflicting evidence concerning the influence of spousal discussions on FP involvement requires clarification to achieve an unbiased estimation.19 21–23 This study seeks to contribute essential evidence that could inspire prompt action from programme planners and policy-makers. Its primary objective is to evaluate the degree of male involvement in FP and its association with knowledge and discussions with spouses in Ethiopia.

Methods

Study design and search strategy

The study adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines24 in its design(online supplemental file 3). The research encompassed published materials sourced from databases PubMed, Cochrane Library, PsycINFO and HINARI, as well as unpublished articles obtained via the Google Scholar gateway. To identify potential articles, a combination of keywords and indices in line with Medical Subject Headings (MeSH) was employed. These included terms such as “prevalence,” “magnitude,” “male,” “men,” “sexual-partner,” “partner,” “husband,” “spouse,” “involvement,” “role,” “participation,” “determinants,” “factors associated,” “associated factors,” “predictors,” “risk factors,” “family planning,” “family planning methods,” “contraception” and “reproductive health”. The search strategy involved the use of Boolean operators “AND” or “OR” where applicable. Two authors (MY and BA) independently conducted the search for these key terms. The full search strategy is attached as online supplemental additional 1.

Supplemental material

Supplemental material

Patient and public involvement

None.

Study selection and eligibility criteria

Inclusion criteria

  • Population: This systematic review included studies conducted among married/couples in Ethiopia.

  • Outcome: The studies focused on assessing male involvement in FP as their primary objective. To be eligible for inclusion, studies needed to report at least one of the following criteria: men actively using contraceptives, encouraging their spouses to adopt FP methods, endorsing the use of contraceptives, or expressing a willingness to use contraceptives in the future.

  • Study design: All observational studies were included.

  • Time frame: All studies irrespective of data collection and publication year until the end of January 2024.

  • Publication: Either published in peer-reviewed journals or unpublished studies.

  • Language: Studies published only in English language were included in this review.

Exclusion criteria

  • Studies with a poor quality score.

  • Purely qualitative studies were excluded from systematic review and meta-analysis.

Measurement of variables

Outcomes of interest

The main focus of this study is to determine the prevalence of male engagement in FP in Ethiopia. To be classified as having male involvement, participants must exhibit at least one of the following characteristics: actively using contraceptives, encouraging their spouses to use FP methods, endorsing the use of contraceptives or expressing a willingness to use contraceptives in the future.19 Another crucial aspect explored in this systematic review and meta-analysis involved investigating knowledge about FP and discussions between spouses as potential predictors of the primary outcome. According to various sources, knowledge in this context refers to a husband’s understanding of different FP methods. An assessment of knowledge was conducted using a set of questions, and men scoring above the mean of the distribution were considered to have good knowledge, while those scoring below the mean were categorised as having poor knowledge.25 Spousal FP communication was measured based on the question ‘Have you ever discussed about FP with your husband/wife in the last 12 months?’ Hence, the responses were coded as 1 if both spouses agree they discussed or the husband alone reported ever discussed or the wife alone reported ever discussed and 0 if both spouses agree they never discussed.26 These factors were particularly scrutinised due to their frequent mention in individual studies, and conflicting findings in previous articles regarding their impact on male involvement in FP.

Study quality appraisal and data extraction

The articles identified across all databases were imported into EndNote V.X8, where redundant files were removed. The remaining articles and their abstracts underwent an independent review for potential inclusion in the full-text assessment by two distinct groups (BK and YD). Using the Joanna Brigg’s Institute (JBI) critical appraisal checklist for prevalence studies, the evaluation focused on the methodological aspects of each article. Each question provides three options (yes, no, not clear), with a scoring system of 1 for ‘yes’, 0 for ‘no’ and 0.5 for ‘unclear’. The total value for each article was calculated by adding the scores for all questions. Articles with a cumulative value below 50% were considered for exclusion. However, we found that all articles had a value exceeding 50%, and thus, no paper was excluded based on quality criteria.27 28 The quality assessment of the articles was conducted independently by two authors (EA and MA), and any disparities in their assessments were resolved by averaging their results. The details of this appraisal are provided as online supplemental additional file 2.

Supplemental material

Data extraction was conducted using a Microsoft Excel 2010 spreadsheet, encompassing various variables for the first objective. These variables included authors’ names with initials, study and publication year, study setting, design, sample size, response rate, quality score, participants’ gender, region and study findings. For the second objective, studies reporting any of the aforementioned factors as predictors were initially identified. Two authors (BA and MY) carried out the data extraction for both objectives, resolving any discrepancies through discussion and consensus.

Data synthesis and statistical analysis

The data, initially organised in Microsoft Excel, were imported into STATA V.17 version statistical software for a comprehensive analysis. The overall degree of male engagement in FP in Ethiopia was calculated using DerSimonian and Liard’s random-effect model, with a significance threshold set at a p<0.05.29 The presence of substantial heterogeneity was determined through I2 tests exceeding 75%, prompting additional subgroup and sensitivity analyses. Furthermore, Egger’s weighted regression test method was employed to assess potential publication bias, and a significance level of p<0.05 was considered indicative of statistically significant publication bias.30

Result

Study selection

The review initially identified a sum of 933 articles. Among these, 28 were eliminated because they were duplicates, and an additional 880 records were excluded after screening based on their titles and abstracts. Subsequently, the eligibility of the remaining 25 articles was assessed. Ultimately, nine articles were excluded for reasons such as being purely qualitative, having a small sample size or focusing exclusively on FP users by the authors. The qualities of 16 articles were evaluated using the JBI checklist for prevalence study by two independent authors. This process led to the inclusion of a total of 16 full-text articles in the systematic review and meta-analysis (figure 1).

Figure 1

PRISMA flow diagram of male involvement in family planning and its association with knowledge and spouse discussion in Ethiopia, 2024. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Descriptive characteristics of included studies

All articles included in this study were of the cross-sectional study design, with sample sizes ranging from 272 to 2697 participants across different studies. The study conducted in Gedo town, Oromia and Harar town, Harari, Ethiopia had the smallest and largest sample sizes, respectively.26 31 This systematic review and meta-analysis comprised a total of 9852 participants. Among the 16 studies included, 5 were carried out in the Amhara region,21–23 32 33 5 in the Southern Nation Nationalities and Peoples region,19 20 34–36 3 in Oromia25 31 37 and 1 each in the Tigray, Afar and Harari regions.26 38 39 The majority of the studies (85.7%) focused on married men19–23 25 31–35 38 while the remaining studies focused on married females26 39 (table 1).

Table 1

Characteristics of studies included for a systematic review and meta-analysis, Ethiopia, 2024

Prevalence of male involvement in FP

The involvement of men in FP in Ethiopia, according to separate estimates, varied widely from 19.89% to 90.04% across different studies.19 26 The analysis depicted substantial heterogeneity among these studies, as evidenced by the considerable variation (I2=99.4%, p=0.000). Employing a random effects model, the combined measure of male engagement in FP was determined to be 60.31% (95% CI (49.47% to 71.15%)) (figure 2).

Figure 2

Forest plot of the pooled prevalence of male involvement in family planning using the random effect model, Ethiopia, 2024.

The sensitivity analysis indicated that there was no single influential estimate that could be attributed to the source of heterogeneity (figure 3).

Figure 3

The result of sensitivity analysis showing the influence of a single study on its pooled prevalence, Ethiopia, 2024.

Even if the funnel plot by itself is not objective, the funnel plot of the pooled prevalence of male involvement in FP looks asymmetrical (figure 4).

Figure 4

Funnel plot showing publication bias on the pooled prevalence of male involvement in family planning, Ethiopia, 2024.

The Egger’s test statistic also revealed that there was statistical evidence of publication bias (p=0.001) (figure 5).

Figure 5

Eggers plot (regression line) showing publication bias on the pooled prevalence of male involvement in family planning, Ethiopia, 2024.

So, trim-and-fill analysis was considered to estimate the unbiased effect size (figure 6).

Figure 6

Funnel plot after conducting trim-and-fill analysis to resolve publication bias on the pooled prevalence of male involvement in family planning, Ethiopia, 2024.

Subgroup analysis

Subgroup analysis was done by different parameters (region, study year, sample size and response rate) to observe the possible sources of heterogeneity (figures 7–10), respectively.

Figure 7

Forest plot of subgroup analysis for the pooled prevalence of male involvement in family planning by region using the random effect model, Ethiopia, 2024. snnp, Southern Nation Nationalities and Peoples.

Figure 8

Forest plot of subgroup analysis for the pooled prevalence of male involvement in family planning by study year using the random effect model, Ethiopia, 2024.

Figure 9

Forest plot of subgroup analysis for the pooled prevalence of male involvement in family planning by sample size using the random effect model, Ethiopia, 2024.

Figure 10

Forest plot of subgroup analysis for the pooled prevalence of male involvement in family planning by response rate using the random effect model, Ethiopia, 2024.

However, heterogeneity was not totally resolved in subgroup analysis and the studies were considered for meta-regression, and none of them were significant (table 2).

Table 2

Meta-regression to identify heterogeneity among included studies, Ethiopia, 2024

Factors associated with male involvement in FP

The effect of knowledge about contraceptives was estimated by using six studies.19 22 36 37 40 41 The pooled odds of male involvement in FP among knowledgeable participants were more than two times high as compared with counterparts (AOR 2.05, 95% CI (1.52 to 2.76)) (figure 11).

Figure 11

Forest plot of the pooled estimate of the effect of knowledge about family planning on male involvement in family planning, Ethiopia, 2024. RR, response rate.

The Egger’s test showed that there was no statistical evidence of publication bias (p=0.392).

Using the random effect model, the aggregated odds of men participating in FP were found to be twice as high among individuals who engaged in discussions with their spouses about FP, in contrast to those who did not have such conversations (AOR 2.00, 95% CI (1.35 to 2.96)) (figure 12).

Figure 12

Forest plot of the pooled estimate of the effect of spouse discussion regarding family planning on male involvement in family planning, Ethiopia, 2024. RR, response rate.

The Egger’s test showed that there was no statistical evidence of publication bias (p=0.832).

Discussion

The combined extent of male engagement in FP in Ethiopia was recorded at 60.31 (95% CI (49.47 to 71.15)), with a notable correlation found between this involvement and both knowledge about FP and discussions between spouses on the subject. This overall involvement aligns closely with findings from a study in Cameroon (57.2%)13 and it is comparable to another study in Southern India (71.2%).17 However, it falls below the figures reported in studies conducted in Nigeria (80%)18 and Bangladesh (94.8%).16 The potential reasoning for these discrepancies might be rooted in sociocultural variations, particularly in the roles men assume in reproductive health services such as FP. Additionally, traditional norms and religious beliefs prevalent in different countries could also contribute to these differences.42–45

Individuals who possessed a comprehensive understanding of the subject, as opposed to their counterparts with lesser awareness, demonstrated a higher likelihood of active involvement in FP. This correlation can be explained by the inherent principle that knowledge frequently acts as a precursor to action. Specifically, understanding the importance and implications of FP becomes a motivating factor for males, influencing their decision-making process. This influence extends to the choice of either personally using FP services or actively supporting and encouraging their utilisation by their female partners. Moreover, a profound knowledge of FP goes beyond mere awareness; it instils a sense of responsibility among men regarding the process of childbearing. This association between knowledge and increased male responsibility aligns with findings from a qualitative study conducted in Uganda, where a robust understanding of FP was identified as a catalyst for men taking a more active role in decisions related to family size and the timing of pregnancies. This insight underscores the transformative power of informed awareness, suggesting that a deeper understanding of FP not only shapes individual attitudes but also propels men towards greater involvement and responsibility in matters of reproductive health.46

Similarly, the probability of men actively participating in FP exhibited a notable increase among individuals who engaged in open conversations about FP with their spouses in comparison to those who did not partake in such discussions. This observed correlation might be attributed to the idea that engaging in these discussions stimulates a more thoughtful and rational consideration of the subject matter. The act of discussing FP may cultivate a heightened sense of shared responsibility and ownership, particularly in the collaborative determination of the desired number of children and the optimal timing for their arrival. This association between male involvement and spousal communication in FP implies that dialogues within the marital unit play a pivotal role in shaping perspectives and decisions related to FP. The exchange of thoughts and preferences within these conversations contributes to a more informed and mutual decision-making process, fostering a collaborative approach between partners. This collaborative approach, in turn, is likely to enhance the level of male engagement in the overall FP dynamics.47

While the study exhibited strengths, certain limitations must be acknowledged. The scope of the investigation was restricted to articles published exclusively in English, which could introduce a potential bias by excluding studies published in other languages. Additionally, all the studies incorporated into the meta-analysis were observational, specifically cross-sectional studies. This design limitation implies that establishing clear relationships between temporality and causality is challenging. Furthermore, despite concerted efforts to address it, heterogeneity persisted among the included studies, indicating variations in methodologies or populations that were not fully reconciled. To address these limitations and advance the depth of future research, it is advisable to consider a more inclusive approach. Specifically, incorporating interventional studies into the research design is recommended. Interventional studies can provide a valuable complementary perspective, offering insights beyond the constraints of observational data. This broader inclusion of study types has the potential to enhance the overall robustness of findings and contribute to a more comprehensive and nuanced understanding of the subject matter.

Conclusions

The level of male engagement in FP in Ethiopia was notably lower compared with findings from studies conducted in other regions. Having comprehensive knowledge about FP and engaging in discussions with spouses regarding this matter were both significantly linked to increased male participation in FP. Therefore, it is imperative for the government and healthcare providers to prioritise interventions aimed at enhancing men’s knowledge through diverse media platforms. Additionally, promoting discussions between couples about FP could be an effective intervention strategy for healthcare providers to implement. The government and non-governmental organisations should organise community awareness programmes specifically targeting male involvement in FP, aiming to augment its extent within the country.

Supplemental material

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication

Acknowledgments

Our special thanks go to all public health staff for their help when needed.

References

Supplementary materials

Footnotes

  • Author’s contribution BA, BK, YD, MY and EA: involved in the conception of a research protocol, literature review, study design, data extraction, data analysis, interpretation and wrote the result, MY, BA, BK, YD, MA, TDT and YW: involved in literature review, screening and drafted the manuscript, TA, TDT, KM, EA, BA, MY, RD and MA: undertake quality assessment, edited and revised the manuscript. BA act as guarantor. All the authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.