Fertility Intentions and Perspectives on Contraceptive Involvement Among Low-Income Men Aged 25 to 55

Abstract

CONTEXT:

Unintended pregnancy is disproportionately reported by low-income individuals in the United States, and studies of men’s roles in preventing pregnancy have largely focused on adolescents and young adults. Less is known about the pregnancy-related attitudes and behaviors among men older than 24, who are involved in the majority of pregnancies ending in a birth.

METHODS:

Between December 2015 and August 2016, in-depth interviews were conducted with 26 low-income men in Alabama who were aged 25–55, were sexually active and did not want more children. Interviews explored men’s reasons for not wanting more children, their contraceptive knowledge and attitudes, and their involvement in contraceptive decision making. Transcripts were examined using content analysis to identify themes related to men’s perspectives about preventing pregnancy and using contraceptives.

RESULTS:

Participants’ motivations to prevent a pregnancy centered primarily on their age and financial circumstances. Most men had limited contraceptive knowledge and perceived their risk of causing a pregnancy to be low, regardless of method use. Few men engaged in decisions about contraceptive use, despite their beliefs that men and women had a shared responsibility to prevent pregnancy. Although some men were interested in vasectomy, a few were hesitant about undergoing the procedure because they might want to have children later if their life circumstances changed, and others worried that vasectomy might affect sexual performance.

CONCLUSIONS:

Some low-income adult men were uncertain about their pregnancy desires, and many lacked contraceptive knowledge that would help them avoid unwanted pregnancy. Research is needed to identify the types of programs that could effectively promote men’s constructive engagement in preventing pregnancies over their reproductive life course.

Reproductive health professionals and advocates have long recognized the need to increase men’s engagement in family planning as a way to enhance women’s reproductive health and promote greater gender equity in pregnancy prevention. These views have evolved over the last several decades, from a goal that encouraged men to act as supportive partners in women’s autonomous contraceptive use to more recent perspectives that maintain and expand this goal by recognizing men’s own informational and service needs related to family planning.^1–5

The literature about the ways in which U.S. men are involved in contraception and pregnancy prevention largely focuses on adolescents and young adults aged 24 or younger. This age range includes those most likely to report unintended pregnancy.^6,7 Studies suggest that although many young men want to avoid causing a pregnancy, their other attitudes and behavior regarding pregnancy prevention are not always consistent. Some individuals express ambivalence about getting a partner pregnant,^8,9 and studies of low-income men have found that they do not necessarily view pregnancy during adolescence and young adulthood unfavorably, because for some it is seen as an important transition to manhood and they lack awareness of their financial and legal responsibilities of fathering a child.^10–12 Relatedly, young men’s inconsistent use of condoms and withdrawal¹³ and limited involvement in supporting their partners’ contraceptive use¹⁴ place much of the work of pregnancy prevention on young women.

It is important to extend investigations into how adult men perceive and manage their roles related to contraception and pregnancy prevention, as men aged 25 or older are involved in 75% of pregnancies ending in a birth.^7,9 Men’s reproductive experiences and other life events beyond adolescence likely alter their views about their roles,^10,12,15 and the potential strategies to constructively engage men in contraceptive decision making later in life may differ. Furthermore, involvement in unintended pregnancy remains a common experience—reported by approximately one-third of men who are 25 or older—and is more often reported by those with low incomes and low educational attainment.^7,16 However, outside the limited body of research on vasectomy,^17–19 adult men’s involvement in contraception remains an understudied area.

In this study of low-income men who did not want more children, we explored their motivations to prevent future pregnancies and how their pregnancy intentions related to their role in contraceptive use and attitudes about male involvement in contraception. We focused on low-income men because low-income women and men disproportionately report pregnancies as unintended.^6,9,16 Identifying adult men’s unmet reproductive health needs can inform programmatic approaches that would enhance efforts to promote greater gender equity in family planning throughout the reproductive life course.

METHODS

Study Design

Between December 2015 and August 2016, we recruited men who did not intend to have children in the future and were potentially at risk of causing an unintended pregnancy to participate in in-depth interviews. Given our focus on the experiences of low-income men, we recruited individuals from agencies and other community venues that served diverse low-income populations in a metropolitan area of Alabama. The first author approached men in health department waiting rooms and common areas of recreation and shopping centers, and also made brief presentations about the study at fatherhood programs; we also posted flyers at these locations. Men were screened for eligibility in a private space. We included men between 25 and 55 years of age to facilitate comparison of attitudes and behaviors with other studies of men in this age range who did not want more children.^17,18 Individuals were eligible if they spoke English, had had sexual intercourse within the last three months with a woman aged 18–49, did not intend to have children and reported that they had not had a vasectomy.

We employed in-depth interviews to explore in detail men’s perspectives and recent experiences related to pregnancy prevention; a semistructured interview guide was developed by examining the literature addressing men’s views about their roles and responsibilities regarding unplanned pregnancy and vasectomy.^10,18–21 The guide included open-ended questions about the following topics: their relationship and pregnancy history with their current partner; the circumstances surrounding the birth of their last child and reasons for not wanting more children; their knowledge and attitudes about contraceptive methods, including female sterilization and vasectomy; their current method use and involvement in contraceptive decision making; and their demographic characteristics. We used probes to obtain additional information or to clarify responses.

The first author conducted and audio-recorded all interviews; each lasted approximately one hour. Participants provided written consent before the interview and received a $40 gift card afterward. We stopped recruiting participants when the first and last authors agreed they had reached thematic saturation. We reviewed the interview transcripts for accuracy against the original recordings and removed identifying information. The institutional review board at the University of Alabama at Birmingham and the research review board at the county health department approved all study procedures.

Of the 52 men screened for the study, 32 met the eligibility criteria and agreed to participate. Twenty-eight attended their scheduled appointment and completed the interview. Because we did not assess whether men had at least one fecund partner until the interview commenced, our initial sample included three participants who mentioned that their primary partner had undergone a sterilization procedure. We excluded two of these men from our analysis because their only partner or both partners had had a tubal ligation; we included the third participant’s interview because his other sexual partner was not using a permanent method. A fourth participant stated that his partner had had a tubal ligation reversal followed by an ectopic pregnancy that resulted in removal of a fallopian tube; we included his interview because he was still at risk of causing a pregnancy. Our final sample comprised 26 participants.

Analysis

We used content analysis²² to create an initial set of broad codes based on our research questions and review of the transcripts. Two of the authors and a qualitative research assistant independently coded the transcripts in successive rounds of coding, meeting regularly to clarify coding definitions and review coding consistency.

In the next stage of analysis, we used Marsiglio’s conceptual framework on procreative consciousness and responsibility^11,23,24 to inform the creation of a set of fine codes and organize these into themes. This framework distinguishes between men’s thoughts and perceptions (i.e., consciousness) and their preferred and actual behavior (i.e., responsibility) related to pregnancy and contraception, as well as connections between them. Specifically, procreative consciousness refers to a man’s general awareness of and attitudes about his ability to cause a pregnancy, including his views of virility and sexual prowess, feelings about having children in the future and ideas about fatherhood. Procreative responsibility refers to a man’s beliefs and attitudes about his obligations and involvement in contraception and pregnancy, such as his sense of responsibility related to contraception, involvement in the use of female-based methods and obligation to provide child support; although not a focus of this study, procreative responsibility also includes a man’s attitudes about his level of involvement regarding pregnancy resolution.

As a final step, we reviewed the coded transcript segments to identify patterns and summarize the main themes. Because prior studies have suggested that there may be racial or ethnic differences in men’s contraceptive knowledge and attitudes,^18,25 we also compared themes by participants’ race or ethnicity. We used NVivo 11 to code and manage the transcripts.

RESULTS

Among the 26 participants who were included, the mean age was 36 years. The majority were black and had at least a high school education (Table 1). Participants reported having between one and seven children, many of whom were from previous relationships; one man had not fathered any children. Most participants were married or cohabiting, and half of these men had been in the current relationship for 4–9 years, while four had been with their partner for 10 or more. Of the 10 men who were single, separated or not living with their partner, six said the relationship started three or fewer years ago; four reported having more than one sexual partner. Nearly half of all participants relied primarily on their partner’s contraceptive method: the pill (six), the injectable (four), the IUD or implant (two), or female sterilization (one). Most of the others, as well as six whose partners used another method, relied on condoms, withdrawal or the rhythm method. Three men reported not using any method with their partner, and two others said their partner was currently pregnant.

TABLE 1.

Selected characteristics of low-income men aged 25–55 who did not intend to have children in the future and were at risk of causing unintended pregnancy, Alabama, 2015–2016

Characteristic	No.   (N=26)
Age
25–29	7
30–39	9
40–49	8
50–55	2
Race/ethnicity
Black	15
White	10
Latino	1
Educational attainment
<high school	6
High school	12
Some college/college	8
No. of children
0	1
1–2	14
3–4	7
5–7	4
Relationship status and duration (years)
Married/cohabiting
≤3	4
4–9	8
≥10	4
Noncohabiting/single/separated
≤3	6
4–9	1
≥10	3
Contraceptive method
Pill	6
Injectable	4
IUD/implant	2
Female sterilization	1
Condom/rhythm/withdrawal*	14
None	3
Partner is pregnant	2

^*Includes men whose main or other partners used the pill (two), the injectable (one), the IUD or implant (two), or female sterilization (one).

We identified two themes related to men’s procreative consciousness: attitudes about future pregnancies and perceptions of pregnancy risk. We also identified two themes related to men’s procreative responsibility: involvement in contraceptive use and responsibility for using permanent contraception. Themes were largely similar across race and ethnicity, age and relationship duration, and we describe the few differences that emerged between groups.

Procreative Consciousness

• Attitudes about future pregnancies.

Many participants expressed certainty about their desire to prevent a future pregnancy, noting that they had met or exceeded their ideal number of children. These men articulated a range of reasons for not wanting more children, including their age, health concerns, the impact additional children would have on their lifestyle and financial considerations. Regardless of age, they frequently commented that that they would not have enough energy to raise a young child. For example, a 42-year-old white man with two children noted, “When you get over 40 years old … you have to think about what it would be like to go through that again. Because when you’re younger, you know, you can miss a lot of sleep and still operate fairly well. You know, when you’re older it’s harder.” Men’s concerns about age also related to their desire to be actively engaged in their children’s lives as they grew into adulthood. Comments often revealed their perceptions of the normative years for having a child and beliefs that they would be “too old” when their children reached important milestones. A 26-year-old white man with four children explained, “The way I look at it is [an] age thing. The older you are, the harder to have a bond with your kids because you ain’t able to go play basketball, or football or something like that.” A 37-year-old black participant with seven children shared these concerns: “Knowing my age and—raising my three youngest—how old I’d be by the time they reach their twenties. I feel like I have passed my window of opportunity to have any more children and be able to healthily raise them to adulthood.”

Nearly all participants mentioned financial reasons for not wanting more children, and half reported this as their primary concern. Men viewed financial support as a key characteristic of being a responsible father and wanted to provide whatever their children needed. Some contrasted their desires to be responsible with their own father’s inability to provide for them when they were children or with other men in their communities who they viewed negatively for having more children than they could afford. Reflecting this sense of responsibility, a 26-year-old married white man with two children commented, “I know the kids I got [to] be able to provide for. I don’t wanna be a deadbeat dad.”

Men further noted that it was expensive to raise a child and did not feel that it was possible to fulfill their role responsibly given their current circumstances. Those with greater financial stability said the birth of a child would create unwelcome financial strain and stress. Many others struggled financially and reported difficulty covering basic expenses, and some expressed concerns about being unable to see their children or losing custody if they could not meet their financial obligations. A 33-year-old black man with two children who relied on disability benefits described his challenges: “It’s already too hard on me. Then the five-year-old’s mom put me on child support. I’m beginning to go through some of that stuff. It be hard for me to get around. I be havin’ to take the bus…. It’s just hard on me.” Although not all men reported finances as their primary concern, finances often intersected with the other reasons for why they did not want more children. A 43-year-old white participant, who had been struggling with addiction and had fallen behind on child support for his six-year-old daughter after a period of unemployment, spoke of the interrelated nature of many men’s concerns:

“I’ve got outstanding school loans that are hindering my credit. And, so it might be another three, four years and I’ll be fricking … 46, 47, you know. And then have a kid! I’d be 48 when they’re born. It just doesn’t even make any sense to me, to be honest with you.”

Despite their many reasons for not wanting additional children, some men nonetheless indicated that they might welcome having a child in the future. They viewed children as a source of joy and often stated that they would “make do” and find a way to support another child if an unplanned pregnancy occurred; some further volunteered that their response was related to their opposition to abortion. A 29-year-old black man with one child summed up this view by saying he would be “happy with a slight bit of disappointment” if his wife informed him of a pregnancy now, and explained, “It wouldn’t be because of the pregnancy itself. It’d be because I wouldn’t really wanna bring another child here now. Abortion is outta the question. We just gonna hafta make do.” For some men, particularly those younger than 35, their current desire to avoid pregnancy did not necessarily reflect their long-term intentions. These men reported that they might want another child in the future, especially if their current financial circumstances improved or if their relationship with their partner changed. A 32-year-old black man with five children, who was planning to marry his girlfriend of three years, illustrated this perspective:

“I personally [don’t] want no more kids because I’m not financially all the way straight right now. So until we get that house and we are doing real good and all the accounts are pretty good, you know, [then] I wouldn’t mind [having another child], but until then, I do not want to.”

Similarly, a 25-year-old black father of two who had been unemployed for the last eight months reported that he had not wanted a child when his current partner had a recent pregnancy scare but would consider it in the future, because “there’s still that percentage of chance of I know life is gonna be better. It’s not gonna always be like this.… I see it all getting better in the future.”

• Perceptions of pregnancy risks.

The majority of men perceived their risk of causing a pregnancy to be low, regardless of their contraceptive practices. Those who reported no personal or partner contraceptive use and some who relied on less effective methods commented that because they had successfully avoided pregnancy for some time, they were not concerned. A 25-year-old black man said of his contraceptive nonuse with his partner of a year and a half, “I don’t think she will [get pregnant]. I haven’t ever thought about that.” Some men also described fatalistic beliefs, noting that pregnancy can “just happen” and preventing it was somewhat outside of their or their partner’s control. These beliefs framed men’s sense of future risk, like a 32-year-old long-time condom user who commented that if his partner got pregnant, “I would feel that that was just the way it was planned to be then.” A 37-year-old black man, whose wife had an unplanned pregnancy at age 40 and gave birth to their third child (and his fifth), echoed this concern: “She says I have potent sperm. She says it doesn’t matter. Probably whatever she takes she probably will still end up getting pregnant.” His wife was currently using an IUD and he practiced withdrawal, but he went on to say that if his wife got pregnant, “it would probably be ‘cause I think maybe God has favored me for some reason to keep having these children.”

The ways in which men viewed their risk of causing pregnancy also related to their limited knowledge of method effectiveness. Most men viewed condoms to be as effective as, or even more effective than, hormonal female methods. A 32-year-old white man with one child highlighted effectiveness, among other factors, as the reason he and his wife had used condoms for most of the last 15 years: “I think that [birth control methods] are all about the same effectiveness, but it is just a matter of convenience.… Condoms they are right there, you go to the store, you get them.” Nearly all men who relied on their partner’s method had favorable views of its effectiveness at preventing pregnancy and mentioned that it was unlikely that their partner would get pregnant unless she missed pills or was late getting an injection. In many interviews, though, participants’ comments revealed that they did not know how often women needed to take the method for it to be effective. A 26-year-old white man was uncertain about the frequency with which his partner had to take the pill, saying, “I would think every day or once a week, somethin’ like that. I couldn’t tell ya for sure.… Be honest with you, I ain’t too up to date on that stuff.” In another interview, a 37-year-old black father of seven reported that “the Depo shot says 99.9% [effective],” but later commented that the method “should last at least 60 days after your missed appointment for the [three-month] follow-up.”

Although most men were not concerned about pregnancy, three used condoms and one practiced withdrawal with their only partner, in conjunction with her method, for further assurance. These individuals had some reservations about the effectiveness of their partner’s method and lacked knowledge about how often she needed to take it or have the device replaced. One of these men, a 25-year-old black man with two children, remained doubtful about the implant despite his partner’s assurance that it was very effective because she thought she had become pregnant before while using a contraceptive. Therefore, he insisted on using condoms, even though his partner said they “don’t give her the full feeling.” He recounted telling her, “‘We gotta be precautious. I know you on the birth control, and this right here is just … my method of birth control, me helping you protect yourself from getting pregnant.’ The condoms help a lot. They really do.”

Procreative Responsibility

• Involvement in contraceptive use.

Nearly all men stated that both partners should be responsible in some way for preventing pregnancy and using contraceptives, and only three men endorsed a view that women were ultimately responsible for contraception. Despite the majority’s views on shared responsibility, most men’s involvement was typically limited. Men commonly deferred to their partners’ decisions about method use. This was frequently the case for men in new relationships whose partner was already using a method, but men in longer term relationships also reported this. Participants often noted that they left decisions to their partner because she was the one who would experience any side effects. A 29-year-old black man’s description of his wife’s decision to use the injectable after the birth of their only child typified men’s role. Knowing that his partner was concerned about remembering to take the pill and was reluctant to use the hormonal IUD after her cousin had a negative experience, he explained:

“My only input to her was do what you know you’re gonna feel comfortable doin’. I didn’t really wanna press the issue.… No women like to have any other types of complications with their bodies. They go through a complication every month. To add to that would be almost selfish on my part, so my only concern was her bein’ comfortable.”

As indicated by this statement, men were often sensitive to their partners’ concerns about problematic bleeding, hormonal changes and general use of methods. While acknowledging women’s autonomous choice of her preferred method, some men left responsibility for contraceptive use to their partner because of their own negative attitudes about male methods. For example, a 26-year-old white man stated that both partners should be responsible for birth control, but was decidedly uninvolved when the mother of his two children started using the pill again because “it’s her that’s got to take them.” He also noted that she went “back on the pills—’cause like I said, I don’t use condoms,” which he thought decreased sexual sensation.

Other men in longer term relationships were more actively involved and described helping their partner decide on a method following pregnancy or weighing alternatives when she became frustrated or had concerns about side effects. A 37-year-old black man with five children said he and his wife of 11 years decided that she would use an IUD after the birth of their daughter a year earlier:

“We thought together that the IUD would probably be the best way. The birth control pills—you gotta remember to take your birth control pills. Like I said, when I first got with my wife and she had the … Depo shot, it caused her to start having health issues. We definitely wasn’t going back to that.”

Several of these men willingly agreed to use condoms when their partner decided she did not want to use a hormonal method or wanted a break, but noted that they did not use them at every sexual encounter. Their comments also revealed their limited knowledge and shared misperceptions about contraception. A 30-year-old Latino man with no children explained that he started using condoms when his wife began to worry about long-term pill use: “[She] read maybe some article on the internet or something. For example, some [pills] change in the girl’s body, maybe behavior too. I don’t know. Because it’s unnatural.… It’s not your natural metabolism, natural period.” Another participant’s wife stopped using the injectable after seeing a TV commercial stating that it can cause cancer. This 26-year-old man, who had two children, described his decision to use condoms “because if I don’t want no more kids, then it’d be stupid for me not to use a condom.” He also supported his wife’s decision to return to her physician to discuss alternatives that would help regulate her menstrual cycle, because “it’s not right to have a period every other week.”

Despite most men’s limited engagement in contraceptive decision making, several participants acknowledged that they needed to take greater responsibility for preventing pregnancy. These men reflected on their past experiences with casual partners, marital infidelity, or other histories of inconsistent or contraceptive nonuse that resulted in unplanned pregnancies, and wanted to avoid reliving the emotional and financial hardships they had experienced. For example, a 31-year-old white man reported that he “felt down and out” after learning two years ago that he had gotten both his ex-wife and a casual partner pregnant; he said that at that time he was “never the type of person to wear [condoms].” Yet, this father of six explained that he now used condoms faithfully, in addition to his current partner’s use of the injectable, following a conversation he initiated early in their relationship: “I said, ‘Look, I can’t afford no more kids or nothing right now.… I’m goin’ through a lotta things. Have to deal with child support, this and that.’ She agreed.” Recalling his partner’s recent unplanned pregnancy following an extended period of contraceptive nonuse, a 46-year-old black father of four adult children similarly described his plans to start using condoms: “Like I said, we didn’t expect this to happen, but now we know it can.… I can’t do that again.” He also was uncertain whether it was safe for his 37-year-old partner to use the pill and resolved, “I just want to be able to protect both of us until I know.… Until I can hear that, I got to do what I got to do too.” Being interviewed prompted some, like this 54-year-old white man who inconsistently used condoms in his relationships with two younger women, to think more about their role in preventing pregnancy: “I need to be a lot more particular in my sexual partners. And probably after today, I really am going to sit back and reevaluate because the only person I can really depend on is myself.”

• Responsibility for permanent contraception.

When asked which partner should take responsibility for permanent contraception if the couple agreed to not have more children, slightly more than half of participants indicated that female sterilization was the better option or were unsure. However, many said that vasectomy was a better choice, and about one-third said they would consider getting one. Men’s attitudes about their partners’ responsibility reflected, in part, their understanding of the reversibility of female sterilization and vasectomy. For example, men typically explained that female sterilization involved “tying the tubes,” and frequently remarked that a woman could have her tubes “untied” if she changed her mind about having children. Nearly all participants viewed vasectomy as a truly permanent procedure that could not be reversed.

Men who expressed unwavering confidence in their desire not to have more children were not concerned about vasectomy’s permanence, but those who felt uncertain about their current life circumstances often did not view vasectomy as a reasonable option. A 31-year-old white man with a noncustodial six-year-old daughter believed he was getting too old to father another child and was too financially unstable to support a family. Nonetheless, he was not interested in vasectomy because it was permanent; he explained, “I don’t think I would take that step yet.… But if I’m still in the same place I am in right now, a couple of years from now, I’d go ahead and do it.” Another participant, a 52-year-old black man who did not want more children so he could devote his energies to raising his seven-year-old daughter and staying involved with his 26-year-old daughter’s children, said vasectomy was “the very, very least likely method that I would consider or choose.… It’s just interrupting a natural reproductive method.” The recent difficulties he reported in his marriage also seemed related to his view that female sterilization, which he considered reversible, was a better method because vasectomy “is irreversible in case of death or a new marriage,” at which point he might want to have more children.

Other reasons why men said they would or would not consider taking responsibility for permanent contraception related to their perceptions of the risks of the procedure. Many stated that vasectomy entailed cutting or snipping “something in your scrotum,” and those who viewed the procedure more favorably frequently noted that it was less risky and invasive than female sterilization. Additionally, based on what they had heard from other men who had undergone the procedure, they reported fewer concerns about pain during or following vasectomy, and most did not anticipate adverse sexual side effects. For example, a 26-year-old white father of two who was considering vasectomy following his wife’s difficulties with the injectable recounted hearing the following from his relative who had undergone the procedure: “I’ve heard you can still get off, but your sperm’s not active. It won’t swim up into one of the girl’s eggs or something.”

In contrast, men who preferred female sterilization (or who were unsure) knew of few examples in their social networks of men taking responsibility for permanent contraception, noting that “I heard of more females talking about having their tubes tied.” However, many of these men often were unaware of what a tubal ligation involved, beyond the fact that women usually had it done after childbirth. Most were very concerned about the pain during and following vasectomy, and emphatically stated, “Nobody’s cutting on me.” They also worried about how vasectomy might affect their sex drive, sexual sensation and orgasms—problems not associated with female sterilization. Among those who shared this perspective was a 43-year-old white man in a new relationship with a 24-year-old woman: “It takes a lot to keep up with her.… I don’t want to ruin that part of it because—a healthy part of life is sexual activity.… There is a lot of fears when you start messing around with a man’s genitalia.”

Despite expressing a desire to avoid having additional children, a minority of men were uninterested in taking responsibility for permanent contraception because they believed that having the biological ability to father a child was central to a man’s identity. They commented that men have a natural “drive to procreate” and wanted to know that they could still get a woman pregnant, no matter their age or family size. A 25-year-old black man with two children illustrated this desire to maintain procreative ability while voluntarily deciding not to have more children: “I don’t want to be told I can’t [have children]. I don’t want to say, ‘I can’t have kids.’ I just don’t want to have kids. I don’t want you to take anything away from me.” Indeed, these men believed vasectomy would irreparably alter their essential procreative nature and compromise their sense of manhood. A 37-year-old black man with seven children who preferred that his partner have a tubal ligation represented this view: “I feel like being a man, if God wants me to have another child, I at least wanna have … the equipment functioning to do so.” He further commented that vasectomy “cuts [men] off from their manhood…. That’s your root chakra. I wouldn’t mess with those life forces.”

DISCUSSION

In this sample of men who do not want more children, participants often expressed cohesive views about their motivations to prevent a future pregnancy, a central manifestation of procreative consciousness. Men explained that they felt too old to raise another child and be involved in their children’s lives the way they envisioned they should be. Unlike studies of men in their teens and early 20s,^10,11,26 participants we interviewed also had a clear sense of their financial obligations as fathers. They recognized their own financial constraints and wanted to avoid being the kind of man who could not support his children, like other men they knew or that they themselves had been.

However, some men described seemingly incongruous views about the prospect of fathering a child. For many of these men, their affections for children or their partner overshadowed the clear financial and age concerns they had about having another child, or they rationalized that a pregnancy was fated or part of God’s plan. These findings are similar to results from a study of women who did not want more children but would feel happy about another pregnancy,²⁷ and who, like the men we interviewed, reported that they would be able to “make do” should another pregnancy occur. As Edin and Nelson detail in their study,¹² this pattern may suggest that low-income men view having another child as an opportunity to reenvision their role as a father. Additionally, younger men’s desires to avoid pregnancy did not necessarily reflect their long-term intentions but rather their view that current economic circumstances (or the relationship) were not ideal for raising children. Together these findings point to the importance of recognizing the complexity of adult men’s perceptions of pregnancy and the variety of factors influencing their perceptions, as has been described for women.²⁸

Our findings further indicate that men do not necessarily acquire greater contraceptive knowledge with additional reproductive experiences. Most men we interviewed, including those more involved in contraceptive decision making, lacked more than a basic knowledge of reproductive anatomy and vocabulary, contraceptive effectiveness and details of method use. Therefore, when their partners shared frustrations or misperceptions about their current method, men often were unprepared with accurate information that could support their partner’s decision making. Additionally, some men who wanted to take greater responsibility for contraception demonstrated limited knowledge about vasectomy, as revealed in the perceived differences in reversibility between vasectomy and tubal ligation. These findings are consistent with those of other U.S. studies of low-income men and low-resource settings.^18,29,30 Men’s limited knowledge may reflect the fact that family planning programs largely exclude or feel unwelcoming to men.^5,31 However, lack of knowledge also constrains men’s perceptions of acceptable options to achieve their stated goals to not have more children and share the responsibility of contraceptive use later in life.

Although men’s narratives varied, our results indicate somewhat greater alignment between their procreative consciousness and responsibility than has been described in studies with young adult men.¹¹ Nearly all participants had discussed contraception with their partner, and a few assumed responsibility for contraceptive use when their partner did not want to use a method or as an additional means of reducing the risk of pregnancy. However, some men’s fertility desires and reports of their pregnancy-avoiding behavior were not aligned, similar to findings among low-income men in Pennsylvania.³¹ Our exploration of men’s attitudes and behaviors indicates a reduced sense of responsibility among these participants, shaped in part by fatalistic views about pregnancy and limited interest in the work of contraception, such as when men did not use a method or shifted all responsibility to their female partner because they did not want to use condoms. The heterogeneity we observe is consistent with Marsiglio’s framework that some men’s procreative awareness and behaviors will remain fragmented over time, and they may not develop a strong sense of responsibility because it counters how they envision their masculine sexual identity.^11,23

Given some men’s incongruous intentions and feelings, and the inconsistency between other men’s desires and behavior, it is important to identify opportunities that allow adult men to reflect on their pregnancy desires and experiences. As demonstrated by comments in these interviews and suggested elsewhere,^26,32 focused conversations or guided self-narratives with counselors, social workers or other health professionals may help men achieve more clarity on these issues. Although male sexual and reproductive health clinics have served as a venue to engage low-income young men,³² other points of contact may need to be considered for older men, given their limited use of reproductive health services.⁴ These could include fatherhood or skills training programs. The diversity of content offered in these programs would allow men an opportunity to consider their current life context with their desires for and perceived risk of pregnancy and anticipated outcomes if a pregnancy were to occur. These programs could include interventions that alter men’s views equating masculinity with sexual power and procreation, and offer alternative positive masculine narratives of respect and responsibility.^33,34

Because men in this and other studies^25,35,36 have limited information about contraceptive methods, providers and health educators could improve men’s knowledge using diverse strategies. When men attend health-related visits, either for themselves or with their partner for contraceptive or prenatal appointments, providers should take these opportunities to counsel and educate them. Counseling about vasectomy, in particular, is uncommon,^37,38 and this likely prevents men from considering it as an option when they are certain that they do not want more children. Community health worker and peer educator models used in low-resource settings may provide an acceptable approach and could address gender norms about male involvement in contraception.^5,29,33 Regardless of the approach used, these strategies must ensure a respectful approach to women’s reproductive autonomy.

Limitations

The experiences reported by the low-income men in this sample, nearly all of whom were black or white, are not generalizable and may not reflect the views and experiences of men of other races or ethnicities or who have higher socioeconomic status. Future research should explore men’s perceptions of their fertility intentions and pregnancy-avoiding behaviors in more diverse populations. Additionally, some of the similarities we observed in men’s uncertainty about their intentions and limited contraceptive knowledge compared with studies of younger men could be attributed to the fact that the younger males in our sample may have experienced only incremental shifts in their thinking about their reproductive goals and behavior as they transitioned into their late twenties. However, men in the upper age range of our sample also shared these ideas, indicating that some men’s knowledge, behavior and perceptions regarding pregnancy may not necessarily change in significant ways as they age.

Conclusions

Despite these limitations, this study brings new attention to men’s fertility intentions and contraceptive behavior and attitudes following young adulthood. These findings demonstrate that men need information and services that will help them clarify and achieve their desires for avoiding pregnancy beyond adolescence. Initiatives that allow men to explore and address these issues, while ensuring respect for women’s reproductive autonomy, have the potential to increase gender equity in contraceptive use.