Graduate School of Development Studies
Men’s Participation in Family Planning Services in
Rwanda:
A case of Gatsibo District-Eastern Province
A Research Paper presented by:
Christine Mukankundiye
(Rwanda)
in partial fulfillment of the requirements for obtaining the degree of
MASTERS OF ARTS IN DEVELOPMENT STUDIES
Specialization:
Women, Gender and Development
(WGD)
Members of the examining committee:
Dr.Loes Keysers [Supervisor]
Dr.Dubravka Zarkov [Reader]
The Hague, The Netherlands
November, 2011
Disclaimer:
This document represents part of the author’s study programme while at the
Institute of Social Studies. The views stated therein are those of the author and
not necessarily those of the Institute.
Research papers are not made available for circulation outside of the Institute.
Inquiries:
Postal address:
Institute of Social Studies
P.O. Box 29776
2502 LT The Hague
The Netherlands
Location:
Kortenaerkade 12
2518 AX The Hague
The Netherlands
Telephone:
+31 70 426 0460
Fax:
+31 70 426 0799
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Contents
List of Tables
List of Figures
List of Maps
List of Acronyms
Abstract
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Chapter 1 General Introduction
1.1 Introduction
1.2 Background
1.3 Statement of the problem
1.4 Research Objective
1.5 Research Question
1.5.1 Main question
1.5.2 Sub Questions
1.6 Methodology
1.6.1 Selection of the research site
1.6.2 Sources of data collection
1.6.3 Interviews
1.6.4 Observation method
1.6.5 Sampling
1.7 Ethical considerations
1.8 Scope and Limitations of the study
1.9 Organization of the paper
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Chapter 2 Conceptual and Theoretical Framework
2.1 Introduction
2.2 Gender
2.3 Gender hierarchies
2.4 Masculinity and Femininity
2.5 Sexuality (Reproductive sexuality: fatherhood &Motherhood).
2.4.1 Motherhood
2.4.2 Fatherhood
2.6 Reproductive health rights and sexuality
2.7 Power
2.8 Agency
2.9 Social construction theory
2.10 Intersectionality
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Chapter 3: Settings of Family Planning in Rwanda
3.1 Introduction
3.2 Back ground of Rwanda
3.3 Overview of family planning services in Gakenke health centre
3.4 Rwanda National Family Planning Policy and its implementation
3.5 Community practices of family planning services visa-versa family
planning policy
Chapter 4: Masculinity in the State Policies, Programs and
Experiences of Family Planning
4.1 Introduction
4.2 Family Planning Programmes and Methods: The inter-connections
of masculinity, femininity and sexuality
4.3 How do men participate and what does the users and services
providers think of their participation?
4.4 Family Planning and the Intersections of class, religion, education and
age
4.5 Strategies which can be adopted to improve men’s participation in
family planning services
Chapter 5: Researcher’s Own Considerations
5.1 Summary and conclusions
5.2 Recommendations
Appendices
References
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List of Tables
Table.3.1: Methods of family planning available in Gakenke health center.
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List of Figures
Figure 2.1: A set of concepts framing men’s participation in family
planning services
Error! Bookmark not defined.
List of Maps
MAP of Rwanda showing Gatsibo District
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Acknowledgements
My immeasurable thanks go to my supervisors Dr. Loes Keysers, my second
reader Dr, Dubravka Zarkov for making this paper complete and valuable. My
Grateful thanks to NUFFIC, for providing me with a scholarship to pursue my
education in the Netherlands and to the entire WGD staff, classmates whom
we shared the journey for the completion of this course.
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Dedications
To the Almighty God,
To you my dearest parents,
Brothers and Sisters, Friends,
I dedicate this book.
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List of Acronyms
ADEPER
Association des Eglises de Pentecote au Rwanda
CHW’s
Community Health Workers
EDPRS
Economic Development and Poverty Reduction Strategy
FGDs
Focus Group Discussions
FP
Family Planning
GAD
Gender and Development
HDS
Health Demographic Survey
HIV/AIDs Human-Immune Deficiency Syndrome
ICPD
International Conference on Population and Development
IEC
Information Education and Communication
IHI
Intra-Health International
MoH
Ministry of Health
NFPP
National Family Planning Policy
NGO
Non-Governmental Organization
PCN
Pre-and Post Natal Care
PMTCT
Prevention of Mother to Child Transmission
RWAMREC Rwanda Men’s Resource Centre
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s and Education Fund
USAID
United State Agency for International Develop
VCT
Voluntary Counselling and Testing
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Abstract
Promoting gender equality is among the countable achievements Rwanda has
achieved in a small period just after the 1994 Genocide. To achieve this, there
have been various strategies like gender mainstreaming in all development sectors. Family planning has been seen as a priority in Rwanda as the health minister once noted that “family planning is a tool of development”. To achieve
this, men have been called upon to participate since little can be achieved
without their contribution. This study therefore aims at investigating men’s
participation in family planning services and how it influences family planning
uptake.
The Research findings demonstrates that, the number of men participating in
family planning services in still low and this has a direct connotations with the
patriarchal settings of the country also related to cultural believes and norms
which still places reproductive issues as a woman’s concern mostly in rural
areas and also the fact that, most programmes available are female oriented.
The fact of having a small number of men in family planning services leads to a
direct influence of family planning uptake.
Finally, I conclude basing on the research findings that, many signs of cultural constructs which draws specific roles for men and women are still given
value in the society and men have to submit to this in order to be proven as
real men.
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Relevance to Development Studies
Family planning has been pointed out as one of the channels to sustainable
development in many developing countries including Rwanda. It has been put
in place by most developing countries that, family planning could be one way
of overcoming the overwhelming problem of poverty, promoting gender
equality as well as realising women rights. The fact that, Family Planning has
been given a place in achieving the development goals, one can therefore point
out that, there is no any other suitable area of study to place it than in
development studies. This study therefore seeks to demonstrate further
considerations in this field to the policy makers, scholars and development
agencies. The knowledge produced in this study therefore could be of
importance to all those who work on interventions in the sexual and
reproductive health Arena.
Keywords
Family Planning, Gender, Men and Masculinity, Sexuality and Participation
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Chapter 1
General Introduction
1.1 Introduction
“Change in both men’s and women’s knowledge, attitudes and behaviour, are
necessary conditions for achieving the harmonious partnership of men and
women. Men play a key role in bringing about gender equality in most
societies, men exercise predominant power in nearly every sphere of life. It’s
essential to improve communication between men and women on issues of
sexuality and reproductive health and understanding of their joint
responsibilities so that men and women are equal partners in public and
private life” (ICPD: 1994: 35)
1.2 Background
Family planning is a “key component of reproductive health”. It is a state
where individuals are having a complete wellbeing of physical, mental and
social life not only having no diseases but also meeting their needs in all
reproductive functions and processes in their reproductive systems.
Reproductive health therefore implies that, people are able to have a satisfying
and safe sex life and the capability to reproduce and make choice on if, when
and how to do so (Rebecca et al.1996: 115). At the 2005 World summit,
Governments Committed themselves to achieving Universal access to
reproductive health including family planning by 2015, as set out at the
International Conference on Population and Development (World
Contraceptive use 2007) where the right to reproductive health was a key
discussion issue.
“Reproductive rights embrace certain human rights that are already
recognised in national laws, international human rights documents and
other consensus documents. These rights rest on the recognition of the
basic rights of all couples and individuals to decide freely and responsively
the number, spacing and timing of their children and to have the
information and means to do so and the right to attain the highest
standard of sexual and reproductive health” (Sen and Batiliwala 2000: 16).
The Millennium Development Goals (MDGs) sets gender equality and
women empowerment as objective 3. The objective therefore calls for the
integration of gender considerations in all programmes. It’s for this reason
that, men’s participation in family planning services is required if gender
equality is to be acquired. Therefore, matters of reproductive health should be
a broader concern for all not just for women and should be both family and
society matter (Wondimu 2009: 1).
Historically, most focused family planning programs have been offering
their services exclusively to women, which indicates that, women have been
seen as the target group and very little attention has been paid to the role that
men might have in respect to women in reproductive health decision making
and behaviour (Ibid). It’s just of recent in the 1990s that, most women
organisations realised the broader intervention of reproductive health for
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stance during the Cairo program for actions conference which discussed on
male responsibility.
Rwanda being a signatory of the Universal access to Reproductive
Health, recognises the importance of family planning in the country’s
development. However, the country is still struggling with many challenges in
establishing and implementing fully fledged family planning systems. As the
Rwandan minister of health noted. “Family planning is a tool of development, the
experience of this country over the past several years shows what an important role family
planning plays in a country’s development but it still has challenges”. (Solo 2008: 4). The
relevance of Family planning for Rwanda is contained in the country’s vision
2020, the umbrella Program for the country’s sector strategies.
According to its vision 2020, (the umbrella program for the country’s
sector strategies) and Economic Development and Poverty Reduction Strategy
(EDPRS) for 2008-2012, Rwanda is one of the highly densely populated
countries in the sub-Saharan Africa estimated to reach over 13 million by 2013,
(MoH 2008: 8). To realise this, Rwanda has committed itself to reducing high
fertility rate, reducing high maternal mortality rate and infant mortality rate
through family planning promotion.This is considered to have a big role in
achieving the EDPRS as it’s the second medium-term strategy towards the
attainment of the vision 2020 (Pand et al.2010: 1) however, this assumption
can be critically reflected on that, family planning cannot be the sole factor
responsible for poverty reduction since there are other factors which can
contribute and therefore viewing its application as the sole solution leads us to
a critical thinking using Thomas W.Merrick’s ideas in his article “population
and poverty” where he stresses that, “economic policies determine poverty
reduction and that contraception is a “private good”.
He further points out that, not all people agreed that family planning
programs would effectively work in ending poverty instead some economists
points out that, poverty may lead to high fertility due to the fact that, poor
people consider many children as a source of wealth, providers of house hold
labour and also the only form of social security to parents during their old age
(Merrick 2002: 42).
The main focus in his paper shows that, family planning has nothing to do
with poverty reduction due to the fact that, in 1950s and 1985, the population
in most developing countries doubled but this didn’t prevent most countries in
this region to rise in their standards of living for stance china is the most
populous country in the world and “over the past 20 years, china’s gross
domestic product which stated at a very low level, has grown at a rate far
higher than that of any region of the world-about 10% a year.(Ibid. ).
Due to Rwanda’s population increase, and reducing high fertility rate being
its objective by 2020, family planning programs targeting women only without
men will achieve less, therefore increasing the number of men as clients,
supportive partners and agents of positive change in family planning services
has been set as a strategy to increase the participation of men. The assumption
2
of looking at men into 3 categories can be critically reflected on in the way
that, firstly, in most patriarchal communities including Rwanda, men are the
bread winners in most families and therefore, participating in family planning
programs would be seen as a wastage of time. Secondly, there are still other
factors deeply embedded in the society for stance cultural norms which are still
binding men in certain behaviours and in certain images which could make
their practice in the above motioned 3 categories difficult. Family planning
programs could look first at the strong mechanisms to challenge the existing
barriers mostly connected to social norms if men’s participation is to succeed.
This research is therefore attempting to hear from men and women in the
rural area in Rwanda, their views concerning men’s participation in family
planning services, what could be the challenging facts on the ground and also
to get to know how men who have already participated have managed to do so
regardless the existing barriers. Evidences of this study is drawn from the
empirical data obtained from 7 FGDs comprised of both men and women
who are users and non-users of family planning services as well as other
professionals in this field.
1.3 Statement of the problem
Family planning has attracted the attention from both developed and
developing countries where the main discussions drawn from the Cairo 1994
conference stated that, “The aim of family planning programmes must be to
enable couples and individuals to decide freely and responsibly make available
a full range of safe and effective methods”(ICPD 1993: para, 7.12). Although
the Rwandan Ministry of health encourages all partners to fully participate in
the utilisation of family planning services, most women in rural areas are not
utilizing these services and this could rise from different factors. Firstly, the
possibility that, their male partners do not allow them to use contraceptives
due to various misconceptions around family planning in the community
(Joshua et al.2008: 2).
Secondly, the fact that, in most African societies, men are still the decision
makers at home, women do not have control over their sexual reproductive
rights including utilisation of family planning services. Again the fact that, most
men in rural areas of Rwanda still believe in the idea of having many children
as a source of security in their old age, It is in this regard that, the ministry of
health calls upon all couples to fully participate in family planning services
However, the number of men is still very low in almost all health centres in
Rwanda. (MoH 2008: 8), The absence of men in family planning services has
been evidenced as one of the reasons which affects the general utilisation of
family planning contraceptives among rural women (USAID 2010: 1).
“Men are the gate keepers of current gender orders and the potential
resistors of change. If we do not effectively engage men and boys, many of our
efforts will be either thwarted or simply ignored” (Kaufman in Emily 2006: 1).
It’s in this regard that, if men are not included in family planning programs,
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gender equality, equal reproductive health rights for both men and women and
the increased uptake of family planning contraceptives, will not be attained.
Different studies are of the view that, reproductive health programs are
expected to be effective for women only if men have participated. Drennan
(1998) as in (Mathew et al.2004:34).It’s therefore in this case that, a husband’s
disapproval leads to the reduction in the use of family planning services.
Involving men and obtaining their support and commitment to family
planning, is crucial for family planning success. The fact that, most of the
decisions which affect family lives in homes are made by men, they have a
crucial role in influencing the utilisation of family planning services by their
wives. Various studies have shown that, providing men with information and
involving them in couple counselling sessions can keep them to be more
supportive to contraceptive use and more aware of the concept of sharing
decision making Wells (1997) as in ( Bui et al.2003).
Failing to involve men in family planning programmes therefore, can
cause a serious impact even when women are educated and willing to use
contraceptives, they may fail due to the denial from their partners (Wandimo
2009: 1). This fact is also evidenced in Rwanda where various women wish to
use family planning services but on condition that, they get approval from their
husbands. All these evidences prove men’s absence in the practice (Cornwall
2000: 18). It is due to this situation that, the study aims to investigate the way
men participate in family planning programs in Gatsibo district, Kiramuruzi
sector.1
1.4 Research Objective
The research aims to understand how and why men participate in family planning services and how it influences the utilization of family planning services in
Gatsibo district.
1.5 Research Question
1.5.1 Main question
How dominant notions and practices of masculinity and sexuality influence
men’s participation in family planning programs and services.
1.5.2 Sub Questions
1. Why do men participate or not in family planning services?
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Administrative structure next to the district.
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2. How do men and women perceive family planning services and men’s
participation and how ideals of masculinity and norms of (reproductive) sexuality influence those perceptions?
3. What are the perceptions of service providers towards men’s participation in family planning services and what notions of masculinity and
(reproductive) sexuality are present in those perceptions?
4. What notions of masculinity and (reproductive) sexuality are present in
the state policies and programs of family planning, and in the practice
of the family planning services?
1.6 Methodology
The main focus of this study was to find out how men participate in family
planning services and how their participation or not influence the uptake of
family planning services in Gatsibo district. In order to find out this, various
qualitative methods were employed namely; interviews (in- depth interviews),
FGDs as well as the observation method. The study was qualitative in nature
and both primary and secondary methods of data collection were employed.
1.6.1 Selection of the research site
Gatsibo district and Kiramuruzi sector were chosen purposively for various
reasons. In the first place, before coming for further studies in the
Netherlands, the researcher worked in this district and had got familiar to the
community members and local leaders as well. The researcher then found it
essay to access all the information needed as well as meeting the respondents
easily. Administratively, having worked in this district before, was also an
added value for a reasercher to easy her work due to the fact that,the resercher
knew most of the district personnel very well, so contacting them was very
easy.
Secondly, Gatsibo district being among the districts which has high family
planning prevalence in the country, and as concerns the researchers
information needed, carrying out a research in such district would help to
gather the information in line with how men participate and viewing its
influence on the uptake of family planning services.
1.6.2 Sources of data collection
The researcher used both secondary and primary data. Secondary data was
generated from the internet, MoH reports, health centre reports, Academic
articles, journals among others. Primary data was collected during the month of
July and August 2011.This was collected from respondents in the 6 FGDs, 7
5
interviews with various family planning personnel in Kiramuruzi sector,
Gatsibo district and Kigali city2.
The first FGD was comprised of 12 female clients of family planning, the
second comprised of 9 female non-clients of family planning and thirdly 7 Men
who are family planning clients (These men have not taken any specific family
planning method but they collaborate with their female partners (wives) and
they authorise them to use family planning hence becoming users too).
The fourth FGD comprised of 5 Men who are not family planning clients.
(These are men who haven’t used any family planning method or allowing their
partners to go for one while the fifth comprised of 11 CHWs. (These are
women and men who are community-based distributors who carry out
community mobilizations and community sensitizations sessions working
under the ministry of health. This is aimed at improving health conditions of
community members.The final FGD comprised of un-married girls and boys
but who are not in school. Men and women who were in these FGDs were not
couples; the research used a family planning client’s to list to select the
participants.
1.6.3 Interviews
A number of 7 interviews carried out in this research were in-depth in nature
and were carried out to various key informants working in the field of family
planning. All these interviews were carried out in the respondent’s working
places.The in-depth interviews carried out targeted MoH personnel in-charge
of family planning at the national level, a district personnel in charge of health
affairs, the in-charge of family planning at Kiziguro hospital (district hospital),
the in-charge of family planning services at Gankeke health center, the
personnel in-charge of social affairs at Gakenke sector and finally a staff in the
Rwanda Men’s Resource Centre (RWAMREC).The purposive sampling was
employed in regard to the respondents experience in the field of family
planning.
1.6.4 Observation method
Observation method was also employed as a way of gathering more data on
how men participating in family planning. This aimed at observing the nature
of services men go to receive at the health center, the dynamics of service
providers towards men in the waiting room, observing how many couples went
for family planning services together as well as capturing the interactions
between clients and service providers. This was done 3 times (Once in a week.)
2
Rwanda capital city
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1.6.5 Sampling
Purposive sampling was employed regarding the selection of respondents.
Firstly, due to the information the researcher wanted, the researcher selected
respondents for FGDs basing on the knowledge they had. Respondents
belonging in FGDs of family planning clients were chosen because of their
experiences in the practice. Respondents who belonged in the group of nonfamily planning clients were also purposively selected not because they have
experience in family planning but to give their views and perceptions regarding
family planning. The interview respondents were selected because of their
positions as key persons in the field of family planning that would enrich the
research with their skills and knowledge.
1.7 Ethical considerations
Gathering community members when you are neither a local leader nor a staff
in any government structures is not easy. In the first place, the researcher made
appointments with the local leaders, district and hospital leaders. In these
meetings, the researcher explained the reasons for carrying out the research. In
confirming this, the researcher presented an introduction letter given by ISS
through the second reader. Before proceeding further, the resercher was
requested from the district hospital to first get the authorization letter from the
ministry of health to prove the eligibility for the access of data wanted. The
resercher then went through the process of requesting this letter which
covered all most two weeks due to the absence of some officials. During the
first meeting with the selected respondents, the researcher introduced herself
and explained the purpose of the meeting as well as the research. The
researcher also added that, all what will voluntary and no monetary benefits
arranged.
1.8 Scope and Limitations of the study
The research focused in Gatsibo district where Kiramuruzi sector is located
and also in Kigali city due to the fact that, there was a need to interview some
policy makers in the ministry of health as well as a RWAMREC staff and these
are all located in Kigali.In regard to the study limitation, while conducting
FGDs some of the respondents were feeling shy to talk openly about sexuality
due to the fact that, it’s rarely talked about in public, people consider it to be a
secret. This then forced the researcher to reschedule some appointments to
have different FGDs and in condusive spaces to enable respondents to air out
all their views.
Another limitation encountered was the failure to interview the youth
(school boys and girls) as planned earlier this. This was due to the fact that, by
the researcher corresponded with the time students were in their holidays. The
researcher managed to get boys and girls out of school to cover for youth but
lost the opportunity to have those in school express their views.
There was a plan to hold a FGD with 14 clients of vasectomy but the
researcher wasn’t able to carry out a FGD with them as she had planned
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before due to the fact that, they received this service after the research period.
Finally, some women in a group of non-family planning clients who expected
monetary benefits later withdrew from the process after realizing that there
was no money given. In a way of passing an appreciation to those who
participated, the resercher offered a drink after the FGDs putting into
considerations of the 2 hrs they spent in a discussion.
1.9
Organization of the paper
The paper is organised into five chapters. Chapter one is comprised of the
back ground of the study, statement of the problem, objectives of the study,
main Research question, sub questions and methodology. Chapter two is
comprised of the conceptual and the theoretical frame work. Chapter three
contains the settings of family planning in Rwanda; chapter four includes
research findings and analysis of data looking at the strategies to improve the
participation of men in family planning services and then lastly, chapter five
that highlights the researchers own considerations, conclusions and
recommendations.
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Chapter 2 Conceptual
Framework
and
Theoretical
2.1 Introduction
This research seeks to find out how men participate in family planning services
regardless of the existing dominant notions of masculinity. To carry out this
research, it is useful to come out with the conceptual framework which serves
as a yardstick from which the men’s knowledge and experiences will be viewed
and analysed. The six concepts to be discussed are: (gender: masculinity and
femininity, gender hierarchies, sexuality, reproductive health, agency and power) which are all inter-related to each other in regard to the achievement of
men’s participation in family planning services.
Figure 2.1: A set of concepts framing men’s participation in family planning services
Determinants of men’s
participation in family
planning services.
>Gender: masculinity,
femininity
constructions
>Gender hierarchies
Objective
of
participation
Family
Planning
Policy
Men’s
participatio
n in family
planning
services.
>Sexuality>Fatherhoo
d α Motherhood
>Gender equality
>Equal
reproductive
health rights for (men
and women)
>Increased uptake of
family
planning
contraceptives
Source: Author
>Power
>Agency
>Intersectionality
Source: Author (2011)
The graph above explains that,family planning policy consider men’s
participation as the centre for improving family planning services, equal
9
men’s
reproductive health rights between men and women as well as increasing the
up-take of family planning contraceptives.(big arrow directing from family
planning policy to the objective of men’s participation).
However, considering most patriarchal societies including Rwanda, men’s
participation in family planning is still constrained by various factors like the
constructions of gender which defines and sets responsibilities between men
and women ( notions of masculinity and femininity) in the society, gender
hierarchies which confirms power relations between men and women, sexuality
which dictates how a female body is expected to be in relation to a proper
mother and how a proper father should look like is relation to fatherhood. The
fact that patriarchal societies guarantee much power to men, in most cases men
exercise their power over their partner’s agency in order to be recognised as
real men. (Small arrows directing from family planning policy to determinants
of men’s participation in family planning).
Family planning being a priority, Men’s are requested to participation in
order to promote gender equality, equal reproductive health rights between
men and women as well as increase the up-take of family planning
contraceptives however, men’s participation could be confronted by various
issues like gender (masculinity, femininity constructions, gender hierarchies,
sexuality (fatherhood α Motherhood), power and agency. This research
therefore, aims at investigating how men participate in family planning
programs in such social constructions.
2.2 Gender
“Gender is a social category imposed on a sexed body.”Gender is the social
organization of sexual differences except as “a function of our knowledge
about the body and that knowledge is not pure, cannot be isolated from its
implication in a broad range of discursive practices”. Joan W. (1986) as in
(Zarkov 2011: 4). “Gender as a bipolar system produces social expectations,
prescriptions, aspirations, and definitions of ‘proper’ ‘manhood’ and ‘womanhood’, by aligning the body, identity and sexual desires” (sexual orientation)
(Zarkov 2011: 5). As stated above, gender is a social construction of a man and
a woman in a given society. From childhood, females are socialised on how to
behave like proper women whereas boys are socialised on how to behave like
proper men and these characteristics and identities are respected by the society
and anyone who acts contrary to what a proper man or woman is expected
from the society, he/she is seen as improper
Drawing from this context, society expectations of men and women also
influence family planning use in the way that, men fear to engage in what is
expected to be a woman issue and as a way of regarding their masculinity, they
leave it for women. In relation to this research, gender constructions (theories)
will be used to analyze the reality on the field to draw an understanding of how
or not men participate in family planning services in Gatsibo district. “Conventional gender norms for men and boys, such as those listed above, are often
described as ‘dominant’ (or hegemonic’) masculinities”. “Internalising these
ideals is not enough, however, rather they must be repeatedly acted-out by men
10
(Esplen 2006: 2) to demonstrate and prove their masculinity” (Esplen 2000: 3).
his identity of being an ideal men is also evidenced when it comes to issues of
family planning whereby various men struggle to show their masculinity by
denying their partners to go for family planning services. Therefore there is a
need to support men so that they challenge these norms in order gender
equality to be achieved. (Esplen 2006: 4). This research will therefore help to
find out in which ways are men being supported by various institutions to
achieve their role of participation in family planning services.
2.3 Gender hierarchies
Despite wide spread change in gender roles, women continue to have less
power than men. From the perspective of social role theory, these gender differences in power should be perceived as eroding as women gain access to
male-dominated roles typically associated with power (Diekman et al,2004:
1).This situation is also evidenced in the Rwandan context in the way that, in
most families men has more power than women to the extent that, most of the
decisions which impact family life are taken by men and this is done not because women are not able to take decisions but the fact that, men have the
power to decide even though the decision taken is against a woman’s will, but
he has to show that he is a man and a decision taker in the family. In relation
to family planning, gender hierarchies are much manifested in the utilisation of
family planning services where by a Rwandan woman more especially in the
rural areas utilise family planning services on the approval of her male partner
and in case the male partner say no a woman can’t do so.
In this study, the researcher, will theorise the concepts of Gender (Masculinity & Femininity), Sexuality (Reproductive sexuality specifically looking at
fatherhood and motherhood) and Intersectionality. In such a study, these theories are linked to each other in bringing up a gendered impact on achieving
gender equity in the house hold, equal reproductive rights and increasing the
uptake of family planning service in the community.
2.4 Masculinity and Femininity
Femininity and masculinity or one’s gender identity (Burke et al.1988: 273),
refers to the degree to which people sees themselves as masculine or feminine
given what it means to be a man or a woman in society. Femininity and masculinity are rooted in the social (one’s gender) rather than the biological (one’s
sex). Furthermore, societal members decide what being male and or female
means (for instance by dominant or passive, brave or emotional), and males
will generally respond by defining themselves as masculine while females will
generally define themselves as feminine (Ibid. 1). The same in Rwanda, female
or male identity are constructed by the society where by a male is expected to
behave in a certain way and also a female to behave in a certain way. A women
then is expected to submissive to her husband whereby in most cases she is
not even supposed to question a man’s idea rather respect it. A man is also
expected to show that he is a man by showing domination by taking decisions.
11
Masculinity also refers to a cluster of norms, values and behavioural patterns expressing explicit expectations of how men should act or represent
themselves to others and varies historically across cultures and in specific contexts (Lindsay et al.2003: 4). The identity of masculinity is exercised in interpersonal relations in different spaces. In the family context, masculinity is exercised through domination and control of partner/wife and children. In relation
to this research, masculinity has influenced family planning use in that, some
men feels less concerned and hence leaving the issue to the women. All along
family planning services have been taken as women issues and no efforts
shown to involve men mostly due to cultural settings. Due to expectations of
the society in regard to how an ideal man should behave, some men also fear
to be challenged by the community members and decide to show that they are
real men for stance not participating in issues of family planning services even
though they see the importance of their participation because these matters are
already seen as women issues.
2.5
Sexuality
(Reproductive
&Motherhood).
sexuality:
fatherhood
Changes in both men’s and women’s knowledge, attitudes and behaviour are
necessary conditions for achieving the harmonious partnership of men and
women. Men play an important role in bringing about gender equality since, in
most societies, men exercise preponderant power in nearly every sphere of life,
ranging from personal decisions regarding the size of families to the policy and
programme decisions taken at all levels of Government. It’s essential to improve communication between men and women on issues of sexuality and
reproductive health, and the understanding of their joint responsibilities, so
that men and women are equal partners in public and private life (ICDP: 1994,
para 4.24).
In most African societies, sexuality is seen in what a man is expected to do
as well as a woman. Firstly, discussing about sexuality is a taboo to the extent
that even among married couples, a few of them discuss about sexuality. A
proper man is seen as one who is sexually active who is able to prove his manhood by producing many children, a proper woman is also seen in a picture of
a woman who is able to produce many children and being able to give them
care. In some communities of Rwanda, men are expected to produce many
children not only as a way of proving their manhood but also as a source of
labour and pride in the society. Basing on the above mentioned assumptions of
the society regarding sexuality, men’s low participation in family planning services could be rooted in those assumptions and therefore this research will
probe and find out if there’s a connotation of men’s participation in family
planning and perceptions around sexuality. It is in this regard that, sexuality
derives from gender identities and constructions made by the society which
categorise men and women and therefore due to their gender their sexuality or
sexual expectations are also determined.
It can be noted that, the care and support of an informed husband also
improves pregnancy and child birth outcomes. Supportive fathers can play a
large role in the love, care and nurturance of their children. Often they are the
12
primary providers for their families. (UNFPA, 2005, chap: 6). In relation to
sexuality through determining fatherhood and motherhood, couples may
achieve a lot when they all work responsively in issues of family planning more
especially in deciding together as parents on when, how to have children but in
most societies, due to sexual assumptions, you find that reproductive issues
which include family planning are neglected by men and left as a woman’s concern.
2.4.1 Motherhood
“That is wonderful, congratulations!
‘Oh dear, poor you!’
Really? Do you want to be?’ (Berer 1994: 6)
The above quotations show the meaning of motherhood in the fertility context. These quotations again show the responses given to most women when
they tell their friends that they are pregnant. “The majority of women in the
world remain in the position of having no choice about having children, despite access to the means of birth control. Their societies, families, their religions, their parents and themselves equate the values of women with motherhood” (Berer 1994: 6). “Women are often not in position of deciding if, when
and with whom to become pregnant or to determine the number, spacing and
timing of their children. (UNFPA 2008: 3)
Traditionally, women are valued because of their reproductive role as
mothers. This is evidenced in the Rwandan context whereby a woman to be
respected as an ideal woman needs to be having children. Traditionally,
Rwandan women were expected to bear many children as possible, only that
it’s just changing recently because of the financial-crisis and the fact that men
want to retain their position as a breadwinner.
2.4.2 Fatherhood
The definitions of a father are given in relation to the social constructions of
masculinity. Some analysts have showed that, masculinity is never “undivided,
seamless construction, which becomes in its symbolic manifestation’’. (Segal et
al.1990: 120). It’s therefore stressed that, the meaning of masculinity is linked
to power relations between men and women. According to Brittan 1989 cited
in Segal et al.1990: 120). “Masculinities refer to those aspects of men’s
behaviours which fluctuate over time and which differentiate men”.
Masculinity also presents the natural idea of male domination which is
manifested in the household and other decision making organs according to
Brittan. Brittan’s idea is in line with that of Connell’s (1987) that, ‘hegemonic
masculinity’ manifests the ways in which men’s social ascendancy is embedded
in social practice and ideology’’ (Connell’s 1987: 184). It’s therefore noticed
that, there is still a continuing considerations biographies (life histories) where
the meanings of fathering are constructed (White 1994: 120). Various
experiences in relation to men’s masculinity and the use of family planning has
13
been experienced among most couples where by men have not been showing
any sense of responsibility to most pregnancies caused by them. It is mostly
understood that, in most cases when a women gets pregnant and she discusses
with the husband, the husband asks why didn’t you accept and yet in the first
place he didn’t ask her if she is ready. This was even evidenced during the
research where the respondent noted that,
“It is a women’s responsibility to avoid pregnancy not for a man” (Male
respondent).
This practice therefore has influenced family planning in that, even at a time
where a woman n is using a natural method, it’s probably that, she will not be
able to escape the pregnancy. This reality then brings us back to the need of
involving men in family planning so that at least they are able to comprise with
their partners in all the situations. This experience has been experienced even
among the youth where the boys impregnants the girls but then he use his
power to reject the pregnancy.
It is in this regard that, fatherhood is deeply imbedded in the notion of
masculinity.
2.6 Reproductive health rights and sexuality
“Sexual rights are fundamental elements of human rights. They encompass the
right to experience a pleasurable sexuality, which is essential in itself and, at the
same time, is a fundamental vehicle of communication and love between people. Sexual rights include the right to liberty and autonomy in the responsible
exercise of sexuality” (IDS Bulletin: 2006)
As stated above, sexual rights are expected to be enjoyed by all partners as it
is the fundamental elements of human rights and all couples should have equal
rights about it. It’s in this regard that, family planning is linked to sexual rights
in the fact that, men and women should enjoy their sexual rights equally for
instance in the way they make decisions concerning family planning. For instance having good communication in relation to sexuality at the household
level, will also improve the understanding of family planning among couples.
Family planning is therefore linked to sexuality in the fact that, in case couples
can’t discuss (communicate) freely on sexuality at the household level, even the
achievement/implementation of family planning will take long to be achieved.
Individuals as well as couples are guaranteed the right to make choice on the
number of children he /she would like to have and also having all the information necessary to do it. (ICPD 1994: 46, para 7.12).
Family Planning is embedded in reproductive health reproductive health
and aiming at increasing the capacity of couples and individuals in to making
choice regarding their family size they wish and also the presence of the services where by people can easily access them. The principle of informed free
choice is essential to the long-term success of family planning programmes. In
every society, there are many social and economic incentives and disincentives
that affect individual decisions about child bearing and family size.(Ibid).The
concept of family planning therefore is linked to this research in the fact that,
14
couples are expected to participate fully in the decision of how many children
they may wish to have, when and how.
Though all couples are expected to have equal sexual rights, in most African societies and Rwanda in particular and mostly in rural areas, it is common
that both partners do not participate equally in issues related to sexuality. The
fact that a woman is expected to have a shy behaviour; she is not expected to
discuss issues of sexuality even with her husband. Issues of sexuality are regarded as a taboo and even a secret the only room for discussion is given to
men. A woman who discusses sexual issues is regarded as a prostitute. It’s
from this view that, a woman who considers discussions around sexual issues
as a taboo, will not be able to talk about family planning issues with her husband and therefore matters related to family planning will continue to be considered women issues.
Family planning helps save women’s and children’s lives and preserves
their health by preventing unwanted pregnancies, reducing women’s exposure
to the health risks of child birth and abortion and giving women who are often
the sole caregivers, more time to care for their children and themselves.
(Ibid).Therefore family planning issues shouldn’t be regarded as women issue
but rather a responsibility for both parents.
2.7
Power
“Power is not an institution, and not a structure; neither is it a certain strength
we are endowed with; it is the name which one attributes to a complex strategical situation in a particular society”. (Foucault 1990: 93). Foucault’s idea gives
us a reflection on what happens in our societies in regard to sexuality. In most
African societies and reflecting in Gatsibo district-Rwanda, the district where
the resecher area located, Men have that power to decide almost all decisions
in the family and this is something which is not granted to them physically but
it’s something socially constructed where by every man is expected to behave
in that line and its absence is the exception. In these situations of power exercitation, men also employ it in sexual relations where it’s seen as a right of a man
to demand his partner sex regardless at what time, or in which situations a
partner is in and in this case a wife can’t say no.
2.8
Agency
Agency is the ability an individual has to make choices and this is again linked
to power where by power is also seen as the ability to make choices and therefore being disempowered implies the denied choices (Kabeer 1999: 436).
It is in this regard that, one can point out that, power is linked to agency. As
said above, agency is the ability to make choices therefore, it requires one to
have power already in order to make an informed choice. This can bring us to
a reflection that, are women in societies more specially Gatsibo district where
the research was conducted have the power to exercise their agency especially
in issues regarding to sexuality especially playing a role in choosing how, when
and with whom to bear children?. This can also be viewed in the angle of men
15
whereby we can view men’s agency in regard to making choices in regard to
sexuality.
One can then say that, depending on the power given to men in most societies like mentioned earlier, men are even able to exercise their agency compared to women and this can further be manifested in family planning issues at
the house hold level where the majority of families men are the ones to make
choice regarding how and when to have children.
2.9
Social construction theory
Connecting to the concepts of gender, gender hierarchies, sexuality, power and
agency, this study will apply Kahn’s theory of social constructionist and Susanne V.Knudsen’s theory of Intersectionality which will help the researcher to
analyse and theorize men’s participation in family planning services. As Raskin
and Bridges (2002) as in (Khan 2009: 90) points out, the social constructionist
theory stresses on particular social factors that gives meaning to experiences.
When explaining gender or masculinity, the social constructionist theory
doesn’t consider so much the specific issues which makes the inside part of a
person for stance the “function of the brain or the gendered beliefs’’ but rather
consider factors that affect the way in which we investigate, categorise, and
discuss gender. It is in this regard that, one can say that, the construction theory helps as to view why things are happening the way they do. Here one can
draw an example of seeing how men are being constructed by the expectations
of the society they live in by trying to confirm what a real man should do, how
he should behave and so on.
The construction theory goes beyond to see how the experiences of things
we go through affects the interpretation we give on different issues (Ibid). Considering the radical feminists idea, masculinity could be linked to power due to
the fact that, there is a need to look at “who gets to determine what” and its
truth for stance who determines masculinity and its effects to others Brickell et
al cited in (Khan 2009: 90). One can then say that, the meaning of masculinity
is constructed by different factors and it’s important to note that, as masculinity is constructed then it differs from time to time and across cultures.
As cited by Addis et al, in (Kahn 2009: 2), Masculinity is defined as “the
complex cognitive, behavioural, emotional, expressive, psychosocial, and sociocultural experience of identifying with being male’’. It can further be assumed
that, there are multiple ways in which people experiences masculinities in the
world. From the above reflection of masculinity, one can say that, the male’s
identity of being a man is more constructed than biological that is to say, it is
learnt and experienced differently that is why men themselves also do not benefit the same from the masculinity world. Further one can stress that, manliness differs and there are a variety and complexity ways of being a man Connell in (Cleaver 2002: 7).
2.10 Intersectionality
As stressed by (Knudsen 2006: 61), “Intersectionality tries to catch the relationships between socio-cultural categories and identities”. Gender, sexuality,
16
race, ethnicity, nationality and class are categories which could strengthen the
complexity of Intersectionality, and point towards identities in transition”. The
theory of Intersectionality will therefore be used to unpack the existing perceptions people give (have) about certain practices according to their identities.
Therefore, the issues of class, education level, age, religions, ethnicity will be
reflected on to see how they influence in one way or the other both men and
women’s participation in family planning services.
Furthermore, Intersectionality is a theory for studying, understanding and
responding to the ways in which gender intersects with other identities and
how these intersections contribute to a unique experience of oppression and
privilege (WREC 2004: 2). “Intersectionality analysis aims to reveal multiple
identities, exposing the different types of discrimination and disadvantage that
occur as a consequence of the combination of identities” (Ibid) This means
that, men are not a homogeneous group but a collection of different categories
and therefore, issues of class, age, religion, ethnicity would contribute to the
high or low participation of men in family planning services. Connell in (Cleaver 2002: 7).
In conclusion, the conceptual and theoretical frame work discussed above
have thrown a light on what could be the factors behind men’s participation in
family planning services and drawing a connection between each other. More
distinction will be drawn between the discussed concepts and the respondent’s
views in the next chapters but firstly the following chapter shows the distinction between the practices of family planning and the national family planning
policy.
17
Chapter 3: Settings of Family Planning in
Rwanda
3.1 Introduction
This chapter analyses the Rwanda National Family Planning Policy, which
guides both clients and family planning service providers in the practices of
family planning services. This analysis bases on the available National Family
Planning Policy elaborated in the National Family Planning Strategic Plan for
2006-2010. The policy states the country’s need of family planning practices as
well as laying strategies for its implementation. In order to come out with an
analysis, an overview of the NFPP will be given and then a look at the course
of its implementation will also be analyzed drawing experiences from the users
and other information got from the service providers who participated in this
study.
3.2 Back ground of Rwanda
Rwanda is situated in East Africa with the current population size being
11,370,425 million people3,the main occupation being agriculture and the
fertility rate of 5.5 per woman whereas the current population growth rate
being 2.6 % per year and estimated birth rate of 41 birth/1000 population
(MoH 2008: 10). This situation in regard to the country size, calls for an
increased attention of family planning services in order to control the births as
well as good provision of reproductive health services.
3.3 Overview of family planning services in Gakenke health
centre
Gakenke health center was the study area for this research, it’s a public health
center which was constructed as a rural dispensary in 1922. Since 2003, the
health center offers PMTCT/VCT and family planning services. The health
center is situated in Gatsibo district, Eastern province of Rwanda with a
population size being 31,761 inhabitants allocated in 56 villages and 45% of
women using family planning while the distance from Gakenke health center
to Gatsibo district administrative area is equivant to 27 kms.It can be noted
that,the 45% of family planning users are only women because even the male
condoms are regarded as a female contraceptives reasons being, men are not
the ones who go and pick them, the service providers gives them to women
who go at the health center to access family planning services and they take the
condoms to their partners.
3
www.Indexmundi.com/rwanda/population.html
18
To achieve this number of people using family planning,Gakenke health
center has been working hand in hand with the ministry of health and also with
the good collaboration of community health workers. Below is the table
showing different methods of family planning delivered at Gakenke health
center. Again, late august 2011, due to the no-scalpe vasectomy campaign
county wide coordinated by the ministry of health, 14 clients of vasectomy
were treated in the area.
Table.3.1: Methods of family planning available in Gakenke health center.
Percentage of clients per method
Family Planning Methods
Pills
Depo-Provera
Implants
Inter-Uterinal Device
Moon beads
Female Condoms
Male Condoms
Vasectomy
Female Sterilisation
Total
Number of clients
Male
Female
1,076
2,211
73
3
5
29
29
3,368
Source: Gakenke health centre
As shown in the table above, the total population Area is 31,761 and
expected Family Planning Clients (Women of reproductive age) per year being
7,496 with a total number of clients in the area being 3,397 the table also
indicates family planning methods utilized in Gakenke health center from
7/2010-6/2011. To note from the table, Depo-Provera (Injectables) is the
most used family planning method with 65% of women using it. During the
field visit, a number of women who use this method gave out their views as to
why they prefer Depo-Provera.
“I like Depo-Provera because once you’re injected, it is done, but for the pills you have to
swallow it every day which I sometimes forget to do. Secondly an injectable is again useful
more specially when my husband doesn’t what me to use family planning, I just leave him and
then I ask the CHW to inject me and here he can’t even know that am using any method
but the pills I can easily be caught”(A female respondent).
Female sterilization and vasectomy are not practiced in Gakenke health
center due to lack of qualified personnel but clients who wish to use either of
the two methods are referred to the district hospital. The table further
demonstrates female condoms among the low utilized method and this is due
to the fact that its accessibility in the areas is very limited. A part from female
19
31.68
65.09
2.15
0.09
0.15
0.86
100
condoms being limited in the area, respondent’s argued that, its practice is
difficult for them due to the fact that, “when you decide to use a female condom, it
means that you have to hold it during sexual intercourse until the whole act of sex is complete
and we do not feel comfortable about this” (Female respondent).
More considerations from the table also shows that, moon beads have been
utilized at a low level and reasons being that, it needs accuracy in counting and
the fact that, the person using it must be with a regular cycle, most rural
women find it difficult in its utilization where as other women noted that, they
don’t use the Inter-Uterinal Device (DIU) due to the fact that, their husbands
hate it.
3.5 Rwanda National Family Planning Policy and its
implementation
Rwanda is one the countries which has put in place a family planning policy
under the vision of “having a modern and prosperous nation, strong and
united, worthy and proud of its fundamental values, politically stable, without
discrimination among its sons and daughters, and all this in social cohesion and
equity” (NFPP 2006: 6).
In relation to development, the family planning policy also aims at
ensuring healthy citizens who are able to work for themselves and for the
development of their country (Ibid). It goes on pointing out that, family
planning would help Rwandan families who are unable to feed, raise and
educating their children to be able to overcome all these problems. More in
this field is the aim to enable the Rwandan citizens to be able to give “birth to
a number of children which is in the capacity of each house hold to support, in
such a way that every family’’ plus the whole population will become more
productive and hence enabling them to make a contribution to the county’s
sustainable development (Ibid).
Regarding the improvement of reproductive health conditions, the
policy brings it out that, family planning would help to reduce the high number
of ‘maternal mortality rate that places Rwanda “among the countries with the
highest maternal mortality rate in the world,” about 1000 per 100.000 live
births” and therefore family planning will help to achieve the objective of
counting less than 350 women per 100 000 live births as indicated in the vision
2020.This is also in line with the objective of reducing the “ infant mortality
rate (86 per 1000 live births) and the child mortality rate (152 per 1000 live
births), which should also be less than 25 per 1000 live births” according to the
vision 2020 (Ibid). It goes on mentioning that, with the absence of family
planning, there would be a loss of hundreds of women and girls due to illegal
abortion practices done in un-professional ways in attempt to remove the
unwanted pregnancies. (NFPP 2006: 7).
In the way of family planning service’s provision, the policy ensures
“full range of contraceptive methods that are easily accessible throughout the
country”, and that this could be achieved when there is s free choice of
contraceptive methods which everyone is comfortable with including condom
use for either HIV/AIDs prevention or birth control. The question of
20
reflection which comes from mind drawn from the above idea is: Does family
planning methods available favour a client to make a free choice? This will be discussed
more in relation to the findings got from the field.
Regarding the implementation of the Rwanda national family planning
policy, the ministry of health has laid various strategies. First, the creation of an
environment where community members themselves participate in the promotion of family planning services. This has been done through the formation
and the training of Voluntary Community Health workers (CHWs) and distributors at community level. CHWs/distributors come from the community
of their own residence and they are nominated by their fellow community
members basing on their good conduct status, willingness and committement
they have to serve their community. CHWs enfonces the ministry of health’s
initiatives of improving family planning services starting from the ground level.
CHWs do this through initiating/facilitating different discussions during community meetings at village, cell or sector level more especially during umuganda
(Community work).The same CHWs were being trained on how to distribute
family planning contraceptives at community level which saves the client’s time
since they are not travelling long distances.(CHDs distributes the contraceptive
to only old clients (who have been clients already not new ones and the news
are directed to the health centre. This strategy has increased the number of
family planning clients since counsellors are now the neighbours and fellow
community members which have creates a friendly environment between the
CHWs and the clients. While choosing these CHWs gender equality is being
put into considerations whereby 50% should be men and other 50% women.
This shows a good example to community members that, family planning is
not a woman’s issue only even men are concerned and therefore, this could
change the existing cultural norms which largely place gender power relations
between men and women.In order to make family planning contraceptives
accessible to all who would wish to use them, the Rwandan ministry of health
has set the provision of family planning contraceptives at no cost so that even
the poor can be able to get it. Also, in the way of encouraging men to participate and to access family planning services, the ministry of health initiated the
no-scalpel vasectomy pilot project country wide this year aiming at challenging
the existing discourses around vasectomy in the community which has been
contributing to limit men’s participation in family planning services.
The ministry of health could not achieve all this without the help of other stakeholders therefore, there has been a good partnership between the government and the non-Governmental Organizations where by the NGOs have
been prominent in sensitizing the community about the engagement in family
planning services. A case in point is CARE-International and other NGOs
which have helped in addressing existing cultural norms which influences family planning practice. Some of the strategies employed are the use of social analysis and action (SAA) strategy, Stepping Stones and others.
21
3.6 Community practices of family planning services visa-vi
family planning policy
In early 1990s, Rwanda’s national contraceptive prevalence rate was at 13%,
but due to the 1994 Genocide where over 1million men, women and children
died, in the years afterwards there was a trend towards rejecting contraceptives
since people wanted to bring new life and to replace their beloved ones who
died and due to the deconstruction of so many country’s infrastructures
including health facilities and even the death of qualified health personnel,
family planning prevalence dropped from 13 % to 4% in the year 2000.
From 2000-2005, rehabilitation of health facilities had been done and new
health personnel had been trained and already in practice which again boosted
family planning contraceptive up to 10%.
The fact that, family planning is seen as a priority in Rwanda, much effort has
been employed to increase its practice and presently the prevalence has beat
47% however, there are various challenges;
Firstly, the fact that, people had lost so many people in the 1994 Genocide,
people wanted to bring new life by replacing those who died and therefore the
government was feeling shy to talk about the need of family planning and this
favoured people to have many children (Solo 2008: 4). Secondly, the Rwandan
culture has been a contributing factor influencing family planning, like one of
the USAID staff member noted, “The Rwandan culture had always been strongly
pronatalist: a traditional wedding toast encourages newly married couples, “Be fruitful, may
you have many sons and daughters” the catholic church has been a strong critic and
barrier to family planning use (Ibid).
The Rwandan culture has set various assumptions which has influenced the
practice of family planning services for stance the discourses around sexuality
which places sexuality as a taboo. Sexuality being taken as a taboo, many people including partners has tried to make conformity to this assumption which
has even limited discussions about family planning at a household level and as
result family planning as remained a women concern. The society expectations
(constructions) of a real man and woman has influenced family planning practices in the way that, men have not taken a visible participation in family planning services trying to guard their status as real men in order to confirm to the
society’s constructions due the fact that, some men who have managed to do
family planning for stance vasectomy have faced stigmatization in one way or
the other and even others are fearing to have the same as noted by the respondents hence leaving the whole practice for women and therefore men’s
participation is still a challenge
It was indicated in the family planning policy that, men act unconcerned
in family planning services while they are the ones who are supposed to take
the first step (NFFP 2006: 7).It can be drawn from this assumption that, while
aiming at improving family planning practices, the RFFP didn’t put into considerations that there are cultural constructions which has a paramount influence on men’s participation and which were not brought up in the policy.
The fact that, the society has constructed men in a certain image in addition to the absence of much emphasis on men’s participation in the family
planning policy, the demand for family planning services as been largely left for
22
women due to the fact that, women are represented in the society as the ones
responsible for reproductive matters, and therefore men’s demand has remained limited. Men’s low demand of family planning services is mostly due to
the reason that, even the available methods cannot allow them to make a free
choice due to that fact that, they are very limited compared to women’s methods and even some men who use condoms don’t use them as a contraceptive
method but instead they use it as a way of HIV prevention as stated by one of
the respondent. “A condom is rarely used as a family planning contraceptive but rather
used for HIV/AIDs prevention and other STIs, after all, having sexual intercourse using a
condom is like eating a sweet in a poll then paper, it just reduces the sexual pleasure, but I
can just use it for HIV prevention.” (Male respondent).
Furthermore, a critical point can be brought up that, the issue of men’s
participation in family planning services was not given much attention in the
family planning policy yet it had to be brought up clearly. It can therefore be
noted that, the family planning implementation were men are fully participating
should be emphasized on directly from the policy makers. More to what has
been discussed above, the culture has a created an environment where by the
newlywed couple is expected to have children as soon as possible after their
marriage and failure to do this brings about another perception of “failure”
where the couple is seen as failures. It is in this regard that, most couples are
discouraged to use family planning in order to have children as soon as possible hence realising society’s needs.
Another live factor which influences the practice of family planning and
which was not considered in the family policy has been the value given to
children in the Rwandan context where the culture has been always
encouraging new couples to have many sons and daughters (Solo 2008: 5) and
also the fact that, about 50 % of the population were followers of the catholic
church, and yet they are influenced by its teachings of encouraging the
Christians not to use modern family planning services because they are
regarded as a sin of killing. This has encouraged citizens to produce as many
children as they can, claiming that, God will take care. This issue was brought
up by the respondents who pointed out that, this ideology is still existing in
their societies to the extent that, there are local names which parents name
their children which presents the idea that “God will take care” a case in point
are the names like Habyarimana, Harerimana, Hakorimana which insists on
producing many children hoping to be cared for by the creator.
In conclusion, the above analysis between the policy and the practice
brings up various issues which are important to note. In the first place, it can
be stressed that, apart from the attempts to improve family planning services,
the policy has not escaped the gendered imbalance in its design in relation to
which sex is involved much than the other. This means that, men’s
participation has not been given much emphasis compared to women (The
policy focuses much on women). Secondly, in reality, the provision of family
planning services have not yet reached a situation where a client is free to make
a choice on the methods of family planning service he/she wants and the fact
that, there are some assumptions around family planning contraceptives that
they affect women’s bodies, some male partners deny their wives to use the
23
contraceptives which has also affected the practice. Therefore, much remains
to be done by the ministry of health to ensure effective results after the
utilization.
Different discourses around sexuality and masculinity have also
contributed much to create a distinction between the policy and the practice
due to the fact that, the policy has not considered these social constructions
which are holding a big position in most patriarchal societies like Rwanda and
which has created a gendered imbalance between the family planning clients.
Finally, creating a situation where by a policy will easily be implemented calls
upon the government to be able to address the factors which could confront
the smooth implantation of the policy with in the policy itself and immediately
look for ways of addressing these factors in the community instead of just
ignore them. More ideas on what is really happening on the ground will be
discussed in the following chapter.
24
Chapter
4:
Masculinity in the State Policies, Programs and
Experiences of Family Planning
4.1 Introduction
This chapter draws the experiences of men, women, CHWs, service providers
and policy makers in Gakenke sector as well as Gatsibo district in relation to
realities on ground regarding men’s participation in family planning services.
This chapter will further look at the factors underneath men’s participation in
family planning services and latter the discussion will lead us to seeing how
men have presented their agency as well as positioning themselves in regard to
the practice.
4.2 Family Planning Programmes and Methods: The interconnections of masculinity, femininity and sexuality
“Family planning is a woman’s responsibility how can I start to engage in the socalled women’s issues, my fellow men will tease me when they get to know that I went
with my wife to the family planning centre” (Male respondent).
Depicting from the above idea, family planning programmes in Rwanda have
been all along been regarded as women issues and most of the programs
available have been giving big attention to women’s reproductive needs and
ignoring men’s needs. It’s just recently that, the idea of including men is
coming up.
It’s therefore important to note that, the notions of masculinity are still
guiding men’s practices and therefore, men try to behave in ways which
guarantee their masculinity by not engaging in the so-called women issues. This
fact is backed up by Connell’s idea of masculinity that,“Masculinities are
configurations of practices with in gender relations, a structure that includes
large-scale institutions and economic relations as well as face to face
relationships and sexuality” (Connell 2000: 29). In line with this, note one of
the respondent’s idea.
“Family planning doesn’t concern me, my wife is the one responsible....if she like, she can
go, if she doesn’t want that is her business” (A male respondent).
Reflecting on the social construction theory discussed earlier, men’s behaviours are constructed in a way the society wants them to be and this has
affected the participation of men in family planning services. It’s therefore
important to note that, men should think beyond the masculinity lens in order
to participate in family planning programs.The issue of masculinity has also
been manifested in the way family planning programs are designed right from
policy makers and implementers. Much as men are struggling to fix themselves
in the programs, policy makers and implementers have unintentionally done
25
much to limit their participation as notified by one of the service provider below.
“Women have been the most targeted groups in most programs responding to
reproductive health issues; it is just recent that, we are finding out the missing gaps of
not including men in these programs. For stance during the IEC sessions, which are
always done at the health center, we don’t include men and what is discouraging is
that, as service providers, we expected women to disseminate the information they get
from the I.E.C sessions to their partners but it has been noted by various women
that, they have not been able to transfer the message to their partners due to the fact
that, most men do not give it time.” (Service provider)
This implies that, before looking at men as deniers of family planning
services, it’s good to look at how family planning programs themselves are
being designed and see if there is a man’s room for participation. Male oriented
programs being limited could also reflect the meaning of family planning
among policy makers and implementers. Family planning programmes
addressing men’s needs have been limited, however there are some men willing
to participate.
“We could have an active role more especially as clients but there are limited methods
of family planning available for us” (Male respondent).
As stressed by (Odhiambo 1997: 29), the only family planning services
available for men are condom use, periodic abstinence, withdraw method and
vasectomy. This is in line with what is happening on the ground whereby one
of the respondents called this “Uneffectiveness”
“I don’t like vasectomy, it’s not effective at all because once you do it, and you can’t
have a chance of producing anymore. And then, if you do vasectomy and latter your
children all die for instance like what happened in the 1994 Rwandan Genocide
where by many parents lost their children and then you need to have others, then
what can you do?” (Male FGD respondent).
Rumors around the act of vasectomy have contributed much to limit men’s
participation in family planning services. According to the in-charge of family
planning services in the ministry of health, he disclosed that, there is a big
number of men who would wish to do vasectomy, but because of the
prevailing misconceptions, that, once you do vasectomy, you are castrated,
many men becomes discouraged. Therefore educations and sensitizations are
still needed in order to bring up the real truth in the community.
The in-charge of social affairs at the district level confirmed this by giving an
example of an education session about vasectomy which took place at the
district, educating district personnel about vasectomy. Participants in this
session (men) who are even educated said that, they can’t be castrated (referring
to vasectomy),this means that, people still have a negative perception about
vasectomy though they have been taught about its practice. A male respondent
also noted that,
“I can’t tolerate being called a woman, I know when I do vasectomy my fellow men
will call me a woman meaning that am no longer a man because am castrated.”
(Male respondent).
26
Noting from the above idea, men’s participation in family planning could
be perfect if the policy makers think of other male methods to complement the
existing ones for stance methods which just last for specific months or years
like those of women and this could create a room for making enough choices
and this would favor men who do not feel comfortable to use vasectomy and
other methods. An intersectional perspective can be drawn here that, though
some of the respondents showed that, family planning programs targeting
men’s needs are limited, the personnel in-charge of health service at the district
level agued differently.
“If men can use effectively the available family planning methods, family planning can be a
success” (In-charge of health affairs at district level).
The above statement can help us to recognize that, people are not
homogenous and therefore, their perception can be drawn differently. It can be
realized that a district staff is looking at men’s participation as a policy maker
without considering the barriers and other men are looking at it as receivers of
family planning services which always brings a distinction. Learning from the
above experiences, men’s reproductive needs especially family planning has
received a little attention compared to women’s needs right from the policy
making to the implementation and this indicates that, the dominant notions of
masculinity also affects policy makers and implementers in the way that, they
regard family planning as a women issue to the extent that, few programs are
responding to men’s needs.
4.3 Assumptions about Male Sexuality: Pleasures, Fears and Taboos
Depicting from the experiences on the ground, family planning has been
largely connected to male’s sexuality in the sense that , a man to prove that, he
is a real man, he has to be successful in regard to sexual pleasure whereby
everything which denies his enjoyment is disturbing his masculinity like one
respondent noted.
“A condom is rarely used as a family planning contraceptive but rather used for
HIV/AIDs prevention and other STIs, after all, having sexual intercourse using a condom
is like eating a sweet in a poll then paper, it just reduces my sexual pleasure, I can just use it
for HIV prevention”(Male respondent).
As stressed by Esplen, “In most cultures, men are expected to be physically strong and sexually successful. These characteristics are referred to as
“gender norms” the culturally accepted ideas about being a man or a woman in
a particular society” (Esplen.E 2006: 2). In this sense, men are failing to use
condoms in order to be sexually successful. This idea brings us to a point of
reflection that, who among the couples is entitled to sexual pressure? If men
do not want to use condoms just because of the fear to lose their sexual pleasure and instead they encourage their partners to use other family planning
methods which could be having other health complications more dangerous
than loosing sexual pleasure, then where is men’s support?.This can just tell us
that, a woman’s sexuality is not catered for, that is whether she gets pleasure or
not, a man has power to negotiate everything including sex which a woman
does not have.
27
According to (UNFPA 2008: 51) “Cultural pressures around masculinity
that fuel men’s need to prove sexual potency can encourage seeking multiple
partners and exercising authority over women”. The fact that, the available
culture guarantee power to men and not women, in most of the cases women
at home do not have negotiating powers for stance in the issue of condom use,
even in the day to day life are not expected to discuss a lot about their
sexuality, therefore, there is no way a man can say that he doesn’t want to use a
condom and a woman challenge him. In most cases, women fear to say no due
to the expectation that, their partners will go and look for other partners.
Women therefore have to agree whatever their husbands tell them in order to
survive and this is very common in rural settings where a man’s word is always
the final. The fact that, men see condom use in another broad way of
HIV/AIDs prevention than a family planning contraceptive, it’s also an
advantage to their lives in that, it protects them from the contamination of
HIV/AIDs which also works hand in hand with family planning.
The fact that, a man’s sexuality is expected to be active, most newly
wedded couples gets pressure from their families demanding them children
more especially a son. Usually, when a man and a woman get married, their
families expect them to have a baby as soon as possible. They sometimes start
to count the months from the wedding day. If the birth does not happen
within at least the first year, family members more especially the parents start
pestering the couple asking grandsons and daughters. In that case, the couple
can’t use any methods of family planning even if they are not ready to have
children. It is very common in Rwanda that, Men and Women who do not
have children would be considered abnormal and selfish and couples who
remained childless would be seen as failures. This is evidenced by the
traditional sayings as seen below.
“Murumbuke, mubyare hungu nakabwa: _Be fruitful, may you have many sons and
daughters….. (Traditional wedding toast to a newly married couple.)
Abana ni umutungo: Children are your wealth(Traditional proverb)
Nimwonkwe kandi usubireyo nta mahwa: _Congratulations, and go back for more,
have more children it doesn’t hurt. :_( Traditional greeting to a new mother)” (Solo
2008: 28).
Various men have manifested their fear in relation to family planning side
effects as one of the reasons why their participation is still low. Though the
ministry of health has been giving different education sessions opposing the
rumors about family planning, many men still have fears about is practices as
one noted.
“ My wife used family planning services and latter developed heavy breeding, having heavy
headache and even getting dry in her private parts which reduced her sexual desires and
pleasure, I decided not to allow my partner to go use contraceptives again’’ (FGD Respondent). However this seems to be another area of research in the future.
Considering Rwanda’s cultural background, issues of sexuality have always
been taken as a secret (a taboo) which are not expected to be discussed about
in public and even among individuals. It has even been a problem to couples
28
since everyone doesn’t want to show that she/he is informed about sexuality
fearing that, the partner will be suspicious about where she/he got those ideas
hence calling he/her a prostitute. This culture has influenced family planning
practices as noted by one of the respondents.
“There is no way I can discuss sexuality with my partners, I can’t dare, am very shy,
we are not even supposed to look at each other when we are naked. We even remove
light when we’re having sex and when he finishes, that is the end. Then how can I
start to discuss family planning, he can just say that am crazy. May be if he begins
the discussion” (A female respondent).
“If cultures are, in part, conversations and contestations including about
questions such as reproductive health and rights…some voices…are more
privileged than others. People largely accept cultural norms and conform to
expected behaviors” (UNFPA 2008: 46).
It can therefore be asserted that, men’s participation in family planning services
should not be looked at as a sole issue instead, it has to be looked at in a
holistic way due to the fact that, men as heads of the families, decision-makers,
and gate keepers of change, their position in society is very delicate and
therefore they also work hard to justify and protect their status in society.
4.4 How do men participate and what does the users and
services providers think of their participation?
It was emerged from the service providers that, men participate as clients in
family planning services and this is evidenced in the way men themselves
go to health centres to look for family planning services like male condoms
and vasectomy. The in–charge of family planning services at Gakenke
health centre pointed out that, “Since the beginning of this year (2011), 14
men are waiting to do vasectomy in this health centre. This has been
possible through a no-scalp vasectomy pilot project orgnisized at a national
level.
Men also act as agents of change. In a way of making every one reached up by
the available services, there are a number of male Community Health Workers
and distributors of contraceptives working under the ministry of health’s
supervision at community level. CHWs are assigned from village level up to the
sector level and they are well trained to sensitize the community through house
to house visits, during communal work meetings, village meetings and so on.
The main objective here is to challenge the existing traditional cultural norms
which are limiting men’s participation in family planning services.
The fact that, half of the CHWs are male, they could work as role models
to other men in changing their mentalities. As pointed out by Green in her
approaches to involve men in sexual and reproductive health, “Addressing
inequality as a means of improving men’s and women’s health and as an end in
itself’’ therefore, it’s important that, men become advocates for change in all
communities” (Green 2006:10).This strategy then demands the policy makers
to strongly empower change agents to be strong in order to bring up change.
This means that, they have to be changed first in order to be able to change
29
others and having strong strategies of coping up with the challenges they could
face resulting from their role.
As stated by (Esplen 2006: 2), “in many cultures, men are expected to
be decision-makers”. It is in this regard that, most men in Rwanda are seeing
their participation in family planning services as limited to giving approval to
their female counterparts. It can therefore be noted that, men exercise their
power over women as most women in most societies including my research
area, wait to get approval from their husbands. Decisions taken by most men
are related to power relations between men and women. The fact that, women
have to get a go ahead about contraceptive use, most men think that they have
participated and that is enough. Like one of the respondent noted.
“I always participate in family planning, once I allow my wife to go to the health
centre to access contraceptives, what else can I do? So long as I give her the
permission, then that is enough” (Male respondent).
“Many men don’t come to the health center but they give their wives permission of
undergoing family planning services by writing an authorization letter and they bring
it to me which confirms a man’s consent. I do receive many letters”. (Service
provider)
Reflecting on what is happening on the ground, most men see their
participation as just limited to allowing their partners to use or not use
family planning contraceptives, and this is mostly due to the reason that,
men want to exercise their power over women and women also submit it
and wait for their husband’s permissions.
As noted from the (ICDP 1994: 30), “Special efforts should be made
to emphasize men’s shared responsibilities and promote their active
involvement in responsible parenthood, sexual and reproductive behavior,
including family planning.” It’s well documented right from International
statements that, both parents should have equal responsibility in family
issues, but the reality on ground is that, men and women have been
socialized in different ways which has created gender roles and most of the
time, most societies including my research area have confirmed to these
gender roles in response to a definition of a real woman and a real man and
therefore, reproductive issues where family planning is placed, are still
centered in a women’s responsibility. It is for this understanding that, men
have not yet found a friendly environment to participate in family planning
services. We can therefore submit the fact that, the way men participate in
family planning services, has got a connotation with the societal
constructions which guarantee and emphasize gender roles and therefore,
achieving men’s participation will need other powers to challenge what
men have been socialized to. One of the respondents noted that,
“It is a woman’s responsibility no to get avoid pregnant not a man’s responsibility
”(Male respondent).
Though the society has constructed various roles among men and women,
the above idea cannot rule out the fact that, some men have exercised their
agency and challenged the assigned gender roles by admitting that, family
planning is their responsibility like one of the respondent argued below.
30
‘’Family planning is for all of us as parents because children are not for my wife
only that is why I have to take part in all family issues” (Male respondent).
“Family planning is supposed to be a responsibility for both parents but in reality
in most of our families; we are the ones who take responsibilities it’s a few families
where both parents share the responsibility” (A female respondent).
Looking at the social constructionist theory, people learn to behave the
way they do due to the constructions of the society and this can further be
realized from what respondents called “mixed perceptions”.
“Family planning is a woman issue therefore it doesn’t concern men”.
“I know that family planning issues also concerns men but I fear to tell my husband about it
because he will say that, am lazy’’(Female respondent). A number of women as seen in
the above statements have demonstrated different perceptions on men’s
participation in family planning services and that’s what they called “mixed
believes”. Due to the ways society constructs its members, some women still
have the perception that, family planning is a woman issue because they
socializes in that culture and other women who recognizes the responsibility of
men in family planning services, are also constrained by societal constructions
whereby they fear their husband’s reactions.
The fact that, men are guaranteed power from the patriarchal
structures, it has been evidenced that, in cases where a wife refuses to offer
sex, a husband can use force or sometimes beat the wife to accept in his
demand which has contributed to domestic violence in many homes.
The fact that, we leave in patriarchal societies and men are guaranteed with
maximum powers, in most families women have not been able to exercise their
agency in relation to their sexuality and the fact that they are socialized in the
be submissive, in most cases women can’t negotiate with their partners on how
and when to have sex, like we draw from the respondent’s idea.
“It is mostly due to the social constructions that men find it difficult to participate in
the work they think that it is not there’s. It is very annoying that, in most families in
our community, a man can hit his wife if she refuses to have sex the time he asks for
it” (Female respondent).
Basing from the above, most women admit the truth that, men’s
participation in family planning services has always been difficult due to the
fact that, they do not participate in the whole process the few who
participate just take decisions in relation to allowing their partners to use
families contraceptives and the implementation stage has always been left
for women and as a result when a woman becomes pregnant, a husbands
always admit the blame to the wife. It is therefore in this sense that, Men
also should be taught their full role in this practice to confusion of their
decision-making ability and participation they should therefore know that,
their participation is beyond decision making on authorizing their partners
to use family planning contraceptives instead it should go up to the ways of
implementation.
In other instances, women have managed to exercise their agency through
going to health centers for contraceptives without the consent of their
31
male-counterparts and this is mostly when they already know that, even
though they ask for permissions from their partners, the answer they will
get is no. One of the respondents pointed out.
“I do go to the health center to receive family planning contraceptives without the
consent of my partner because I know he can’t allow me”. (Female respondent)
In relation to service provider’s perceptions about men’s participation in family
planning services, most service providers, pointed out that, actually this is what
has been missing. Men’s participation is of high importance in the fact that,
when two partners discusses about their family life, we also find it easy as
service providers and the decision taken by two people is very effective than
the decision taken by one. Respondents further noted that,
“Men have a big role to play in family planning, therefore, without their hand, the
implementations will not succeed. Remember they are the gatekeepers in our homes,
so when we don’t include them it will be difficult to achieve all what we plan”.
“The level of women using family planning services could increase only when men
participate. When men are supporting their wives, women themselves feel safe and
strongly confident to participate in family planning freely but when men don’t
participate, many women feels discouraged”(Family planning in-charge in the
Ministry of health).
The in-charge of family planning services in the ministry of health, further
noted that,
“The step we have reached on now, we can’t say that, family planning is a women
issue only, family planning is no longer even a concern of married people only instead
is a concern of every person who is in the reproductive age starting from the young to
the old people.”
The service provider further noted that, when a woman has a good
communication with her husband about family planning use we also notice it at
the health center. Other authors (Balaiah et al 1999: 218) states that, all the
decision taken to accept a method or not among married people is often taken
by the male partner. This is also evidenced by one of the respondents from the
FGD, who noted that,
“Me and my partner we use natural methods to control child birth. I use a condom
from the time my wife gives birth up to the time she receives the first menstruation
periods and from there we count days, during her ovulation period then I use a
condom and am the one who decided this, I didn’t even consult her about this
decision but she didn’t show any worry”(Male respondent).
Regarding service provider’s views, including men in family planning
services is a necessary practice, which is expected to increase the smooth
implementation of the policies but regarding the reality which is taking
place on the ground, some service providers haven’t yet admitted this
reality and so we cannot rule out the fact that, they are still fixed in that
notion of social construction it’s therefore of importance that, policy
makers should look at the issue of men’s participation not only looking at
32
clients but also looking at those who give the services to check their level
of acceptance in regard to men’s participation.
Finally, Men’s participation in family planning service can create a paramount
change in regard to improve family planning services but we can’t deny to say
that, it is deeply rooted in the societal constructions which exists in most
patriarchal societies and these constructions have created a big difference
between men and women right from designing their roles and responsibilities.
It’s in this regard that, family planning practices have been largely influenced
by the way people are socialized in their respective areas and therefore,
confirming these behaviors mostly to men is seen as a obligatory and away of
succeeding within the demands of their societies. Though men’s participation
in family planning services is constrained mostly by social norms, we cannot
rule out the fact that, some men have exercised their agency and participated in
practice for stance men who have managed to do vasectomy and those who
have committed themselves as Community Health Workers and CommunityBased Distributors of family planning contraceptives.
Similar to Cornwall’s idea, does men’s “involvement” help them to achieve the
capability to resist social norms of male dominance”? Cornwall cited in
(Sternberg and Humbley 2004: 394). It’s from this note that, Some men are
failing to take role in family planning services trying to confirm to existing
social norms. It’s therefore for this reason that, Policies should look for a way
of challenging social norms which are not in favor of the family planning
practice.
4.5 Family Planning and the Intersections of class, religion,
education and age
“There is a need to consider class, race and age when understanding men’s and
women’s lives, and the ways in which they relate to each other” (Cornwell et al.
1997: 71). Issues of reproductive health more especially family planning can’t
be viewed in only one angle due to the fact that, they are influenced by a number of factors. It was evidenced from the respondents that, ignorance in some
places contributes a lot in limiting the use of family planning services. This is
evidenced in most uneducated people who still have a belief that, family planning is for educated people/civilized people, but this idea has a connotation
with the level of education among people. Religion has also been seen as another intersecting factor which has played a role in limiting family planning
services as the minister once noted.
“The minister of health has been outspoken against religious leader’s opposition
to family planning and to condom use for HIV prevention but he acknowledges the
difficulty in having them change their stance”. “For us, we can’t change our
Bishops”(Solo 2008: 28).
“In most case we have to follow our religious beliefs.” (Respondent)
Well understood is the fact that, religion has been preventing its followers
to use family planning contraceptives, a case in point is the Catholic Church
and the born-again churches ADEPER which has been only permitting
33
abstinence and only allows condoms to only PLWHIV. These churches regard
other methods of family planning services as killing and hence arguing to its
followers to limit their birth without killing”. The church has been
discouraging its believers to use family planning service claiming that it’s God
who gave them the right and the ability to produce and therefore they should
produce and God will take care. In my view, this is not an effective strategy
because when you are planning for many people of different status, different
cultures and different believes, suggesting only one method can be
problematic.
Experience further reveals that, class difference matters in relation to who
participate in family planning or not. It was discovered from the research
experiences that, people with a high-level of income, highly participate in
family planning than people with a low level of income. This could be due to
the reasons that, poor people regard many children as a source of security in
their old age which is not the case with the rich people. This also applies to the
educated and un educated people as one of the respondents had to say.
“Am not educated and I don’t have a job, I only survive on the harvests which me
and my wife cultivate, I therefore have to produce many children who will help me in
the future.”(A male respondent)
Finally, the experiences has shown that, men’s participation in family planning services has been mentioned in the family planning policy but most of the
family planning programs and methods in place are still largely focusing on
women. It can therefore be noted that, stereotyping family planning as women
issue has a direct connotations with the cultural norms deeply constructed in
the societies. This has affected the policy makers and implementers in the way
that, they have failed to equally balance both women’s and men’s reproductive
needs. In line with Cornwall’s idea, men could be limited to join family planning fearing to lose their masculinity.
“How are involved men coping with the issues such as losing control over
families if family size is negotiated with wives?
How do involved men respond to the contradictions inherent in their
involvement when social norms dictate that men sure large families, yet they
are involved in interventions whose aim is to restrict family size?
What is the impact of men’s involvement in programs on the lives of men
involved?” Cornwall in (Sternberg and Humbley 2004: 394),
It’s therefore important to sum up that, men’s participation in family planning
services cannot be achieved without first challenging the deeply rooted cultural
beliefs in societies. “Culturally sensitive approaches must be open to the unexpected. Both men and women take part in shaping the gender orders and social
expectations concerning the male and female body, and in varied and unpredictable ways” (State of world population 2008: 43). It’s therefore important
to note that, men would fear their power to be confronted in any way therefore, programs addressing the cultural norms are important to improve men’s
participation in family planning services.
34
4.6 Strategies which can be adopted to improve men’s
participation in family planning services
The following strategies were drawn from the respondent’s experiences on
what they think in relation to improve men’s participation in family planning
services. “Men would like to be part of family planning but the methods are limited. If
there were other family planning methods for men like those of women for stance pills, Injectables among others we would also participate freely” (Male respondent).
The fact that, policy makers have all along neglected men’s reproductive needs,
most men on the ground admit the fact that, their ability to make choice regarding contraceptives in still challenging. Since changing people’s behaviors is
a gradual process, there should be continuous sensitizations in the community
especially in places where people gather in a big number for stance during
communal work. (umuganda) as well as the health center.
Since men are regarded as decision makers and family heads in almost all
patriarchal communities including Rwanda, they are the ones suitable to
challenge the existing norms which influence the practices as one of the
respondents noted.
“Many programs should have been male-centered because men are the ones who have power
in all the decisions taken in homes including reproductive powers. Men are the decision
makers in most homes in the patriarchal societies. But the fact that, even policy makers still
place family planning as women issues, men’s mentality and practices towards family
planning, will take a long journey’’ (Staff from RWAMREC).
Noted from the service provider, further is the necessity to call upon
governments and other non-governmental organizations addressing family
planning issues to initiate a forum operating from the sector to village level
aiming at awarding the best family which participated in family planning
services and in family planning services therefore, these men could act as the
role model to others hence building confidence to other men who are fearing
the social norms.
Further, Improved household communication could improve the
utilization of family planning services. In most of the Rwandan families,
partners do not communicate their sexuality due to the fact that, people have
been socialized in an environment which regard sexuality as a taboo. Due to
this early socialization, even among married couples it is very common that,
they keep silent about sexuality and yet it is the center of the family and a
prerequisite to a good family planning process. Many people fear to discuss
sexuality issues, even when they are in their homes due to the fact that,
community members has a mentality of regarding a person who discusses
about sexuality as a prostitute or a spoilt person and as a result, people choose
to show that, they are innocent in order to regard their status in the community
and at home and this further keeps affecting the whole family setting.
35
Chapter 5: Researcher’s Own Considerations
Drawing from the experiences from the field, men’s participation in family
planning is taking a slow movement and most of the reasons for this are the
fact that, the practice has all along been regarded as a women issue and this has
originated from the constructed social norms deeply rooted in the patriarchal
societies which sets and obligates gender roles in the society. The researcher
therefore argue that, some men have changed their mentality and would wish
to participate in family planning services but due to the fact that,they are living
in societies which construct them in certain expectations, they find it a challenge not to confirm to society’s expectations which can make them loose
power.
5.1 Summary and conclusions
Various initiatives have been put in place to improve men’s participation in
family planning service but many efforts are still needed to achieve this objective. Presently, the Rwandan government through its initiatives of reducing the
population size of the country as well as achieving gender equality and equal
reproductive health rights (shift from WID to GAD) men have been left out in
the field of reproductive health for a long time, the ministry of health is encouraging men to actively participate in family planning since it was discoveredvery little can be achieved without their role.
Men’s participation in family planning services is of a great importance
and as said above, very little can be achieved without their contribution since
they are the gate keepers in most areas of decision making including households. Though men are being looked at as good partners if gender equality is to
be achieved as well as equal reproductive health rights among men and women, men’s full participation in family planning services is still constrained by
various social constructions and expectations of manhood deeply rooted in
people’s daily practices. It’s in this regard that, various notions which represents men’s dominant masculinity, images, practices and discourses around
men’s sexuality are still existing in the Rwandan society and these has a direct
influence to men’s participation in family planning services. The following factors therefore can’t stay un-addressed if men’s participation in family planning
services is to be achieved.
Firstly, reflecting on the practices and available family planning programs in
Rwanda, it’s evidenced that, programs targeting men are still very limited compared to those targeting women and this directly shows dominant masculinity
presentations directly from the policy makers. Family planning is a health issue
where by both men and women are entitled to and should share equal rights
but it has been all along considered as a woman’s responsibility which doesn’t
concern men. It is in this regard that, policy makers should see family planning
as a right for both men and women and create conducive environment for men
36
also to enjoy their reproductive health right without categorizing ‘women’ and
‘men’.
Looking at vasectomy, most men during the field work revealed that,
they are not comfortable with vasectomy due to the fact that, when a man do
it; he is no longer treated as a real man among his fellow men hence losing his
masculinity. Due to social constructions which persists in different societies
and which shapes a man in certain way, men are struggling to meet these social
expectations which latter affect the achievement of the family planning policy.
Secondary, men’s participation in family planning services also has a
direct connotation with the definition of sexuality in the society. Sexuality is
seen as a secrete phenomenon (taboo) and therefore discussions around its
practice are very limited. This has influenced men’s participation in family
planning services in the sense that, sexuality is not given time in most homes
and yet a man’s role in family planning is expected starting from the household
level, and the fact that, a woman has no power to negotiate the number of
children they would wish to have, hence an invisible role of men. In most
patriarchal societies, men are expected to be sexually active and strong to prove
their masculinity. Basing on the findings got from the field, most men refuse
their partners to use family planning contraceptives basing on the fears that,
family planning contraceptives leads to negative effects and the fact that, men
want to prove their masculinity through having successful sexual intercourse,
anything which leads to unsuccessful sexual intercourse is seen as an obstacle.
Furthermore, struggling to achieve societal expectations as a man has
been also found out as a factor which influences men’s participation in family
planning services. A case in this is the fact that, a man is seen as a real man
when he has children and in any case when a man gets married, he is expected
to have children as soon as possible in order not to be seen as a failure. Due to
that expectation, family planning will not be considered. In line to what has
been discussed above, son preference is also another reason which limits men’s
participation in family planning services. It has been found out that, a man
cannot allow her partner to use family planning contraceptives due to the fact
that, a family without a son is still regarded as an incomplete family in most
areas in Rwanda and therefore a woman will continue to produce until she gets
to a son child.
Thirdly, due to the fact that, family planning issues have all along been
regarded as a women issue, many men are still facing the challenges of this
shift from women alone issue to both men and women practice. Challenging
the deeply rooted practices and ideologies of masculinity in a patriarchal
society is a gradual process and many efforts to challenge these practices
should be strongly invested in. Dominant notions of masculinity which are still
valued in regard to a real man, are still manifested in family planning service
provision in the sense that, seeing a man at the health center going for family
planning or even when he is escorting his partner, he is not regarded as a real
man by those who see him. Also, the fact that, family planning services are
largely regarded as a woman issue, men are not feeling comfortable to sit in the
family planning waiting rooms mostly due to the fact that, the infrastructures
are designed for women and even the fact that men want to show their
37
masculinity, so when they don’t receive that attention from the service
providers at the health centre they feel as if their masculinity is lost which leads
them to quite the practice.
It’s therefore important to note that, men’s participation in family
planning is much connected to the dominant masculinity notions which are
still covering a big part in the society. Policy makers should therefore put into
considerations that, reproductive health also concerns men and therefore
men’s reproductive health should be given specific attention in coming up with
programs were they feel free to benefit from their rights without being
categorized as “men” and therefore, policies should embark much on efforts
to challenge the social constructions and gender power relations in societies
which limits men’s freedom and therefore, if these issues remain un addressed,
men’s participation in family planning will remain challenging.
5.2 Recommendations
Basing on the findings got from the field, it’s well-drawn that, men’s participation in family planning services is a necessary practice if gender equality is to be
achieved. Gender being a social constructed behavior, it is important that, the
ministry of health work closely with the ministry of education to initiate the
cultural and reproductive health curriculum starting from primary level showing how the culture has been differentiating man and a woman by setting roles
and responsibilities and the need to promote gender equality even within reproductive health like family planning so that young people who are the foundation of the country they can grow –up knowing that men and women are
equal.
As the experiences drawn from the ground shows, it could really be
important to stress that, service providers would look for a way where by
clients of family planning get a blood test before the utilization of
contraceptives. This strategy would help to foresee which type of a
contraceptive matches with a certain type of blood in order to eliminate the
complications some of family planning users reported to be the contributing
factors leading to the low men’s participation .
Depending on what most men addressed during the field study, it is
crucial for policy makers to introduce more male family planning
contraceptives to enable men’s ability to make free choices. The fact that,
methods of family planning available for men are only condoms, withdraw
method, periodic abstinence and vasectomy, most men have been finding it a
challenge to make choice . Service providers are requested therefore to provide
other contraceptives like those of women which can make men free to choose
and also which are not permanent like vasectomy.
38
Appendices
Appendix i Interview Guides
Interview questions addressed to the key informants.
a) In-charge of family planning services at the national level (ministry of health)
b) In-charge of health affairs at the district level.
c) Personnel in the Rwanda Men’s Resource Center (RWAMLEC)
d) Director of Gakenke health Center
e) The in-charge of family planning services at Gakenke health
center
f) The in-charge of family planning services at the district hospital
g) The in-charge of social affairs at Kiramuruzi sector
Questions
1. In your understanding, what is the meaning of family planning?
2. Do you think family planning has an importance to the community? If
yes which importance, if no why?
3. Are there family planning services available in this area?
4. Where are they found?
5. Who provides them?
6. How much do family planning services cost?
7. Which methods of family planning services are available in this area?
8. Which strategies do you use to increase the utilization of family planning services in this community?
9. In your understanding, whom do you think is responsible for family
planning among couples?
10. What do you think about men’s participation in family planning services?
11. Do you think men’s participation in family planning services necessary?
12. Do men in this area participate in family planning services? If yes
how? If no why?
13. What are men’s perceptions on their participation in family planning
services?
14. Which strategies are there aiming at increasing men’s participation in
family planning services?
15. What do you think could be the effects if men participate or not participate in family planning services?
16. What else do you think could be done to improve family planning services?
Guiding questions for focus group discussions
Family planning users (men and women)
39
1.
2.
3.
4.
What do you know about family planning?
Do you use family planning services with your partner? If yes who
Who uses family planning services among you and your partner? Why?
Do you think family planning is important/useful to your family and to
the country at large?
5. How many children would you do you want to have?
6. Do you discuss with your partner about family planning issues? How
often?
7. Who decides the number of children to have in your family?
8. Does the preference of a certain sex influence you and your partner in
using family planning services?
9. Who should be responsible for family planning?
10. Do you access family planning services easily in your community?
11. What is the distance from your home of residence to the family planning unit?
12. Is distance from your place constraining you from accessing family
planning?
13. Do men in your community participate in family planning services? If
yes how?. If know why?
14. How do you regard participation of men in family planning?
15. What methods of family planning services are available for men in your
community?
16. Are you satisfied with the available methods of family planning for
men?
Family planning non-users (men and women)
1. What do you know about family planning?
2. Are there family planning services delivered in any nearby health centre?
3. Do you think family planning is important/useful to your family or
country? if yes how
4. Have you ever used family planning services with your partner? If yes
who?
5. Are you still using any family planning services? If yes which method?
If no why?
6. What constrains from participating in family planning services?
7. How many children would you wish to have?
8. Do you discuss with your partner about family planning issues? How
often?
9. Who decides the number of children to have in your family?
10. Whose responsibility is family planning according to your thinking?
11. What is the distance from your home of residence to the health?
12. Is distance from your place constraining you from accessing family
planning?
13. Do men in your community participate in family planning services?.
How?
14. How do you regard participation of men in family planning services?
15. Are you satisfied with the available methods of family planning for
men?
40
16. What do you think can be improved?
Criteria for observation method in the family planning waiting room
1. Number of service providers available in the family planning waiting
room.
2. Sitting arrangement in the family planning waiting room.
3. Information Education Communication materials available in the waiting room?
4. Information sharing in the room
5. How Information, Education and Communication sessions are given
and to who?
6. Interaction of service providers and service seekers?
7. Service provider’s perception to men who come in the family planning
waiting room?
8. Perceptions of women (service seekers) towards men who come to the
family planning waiting rooms?
9. Record keeping for family planning services in the health centre?
10. The interactions between men and women who come to seek family
planning services?
11. Power dynamics in the waiting room?
41
Appendix ii
Community health workers during the community
mobilization session
Source: Field worker July-August 2011
42
Appendix iii: Family planning clients waiting for family
planning services at Gakenke health center
Source: Field work July-August 2011
43
Appendix iv: Family planning methods delivered at Gakenke
health Centre
Source: Gakenke health centre 2011
44
Annex v: Map 1
MAP of Rwanda showing Gatsibo District
Gatsibo District
Source (Bayisenge 2008: 60)
45
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