“I just had to pay the money and be supportive”: A qualitative exploration of the male-partner role in contraceptive decision-making in Salt Lake City, Utah family planning clinics

Abstract

Objectives:

Peers and intimate partners can influence contraceptive decision-making and use. We aimed to explore the male-partner role in contraceptive decision-making, and describe ideal male-partner roles and how they relate to contraceptive use, specifically uptake of long-acting reversible contraception (LARC).

Study design:

We used a phenomenological approach to explore cis-hetero partner involvement in contraceptive decision-making and conducted semi-structured in-depth interviews with 30 cisgender women and 30 cisgender men in heterosexual relationships who presented to Salt Lake City family planning clinics. Participants, stratified by sex assigned at birth and current contraceptive method (LARC vs non-LARC), described the male-partner’s role in the most recent contraceptive decision and discussed how ideal-partner involvement could look in contraceptive decision-making. We iteratively developed a codebook and identified dominant themes using a constant content and comparative analysis.

Results:

We did not identify thematic differences by LARC vs non-LARC users. Participants universally considered that contraceptive responsibility falls on women. At the time of the interviews, both men and women indicated a strong desire to prevent pregnancy, and felt that men’s actual contributions to decision-making were limited. Themes around gendered-differences of contraceptive knowledge, responsibility and risk, and sexual priorities emerged, as well as inadequate knowledge and contraception options for men. In analyzing discussion around ideal partner support, participants suggested emotional, financial, and logistical support options and placed high importance on interpersonal communication.

Conclusions:

The decision to use a method of LARC did not influence sentiments around male-partner involvement or stated desire for partner involvement. Limited contraceptive knowledge and male options restrict the contraceptive decision-making role and contraceptive engagement for men, although participants suggested other supportive options.

Implications:

This work suggests the desire of both men and women for men to participate in contraceptive decision-making, but their role remains limited. Future interventions focused on comprehensive contraceptive education and modeling of communication strategies for men are tangible steps to support men in this role.

1. Introduction

The declining rate of unintended pregnancy in the United States (US) over the last decade, due in part to increased use of long-acting reversible contraception (LARC), still remains one of the highest among high-income countries [1,2]. Unintended pregnancy due to contraceptive failure most commonly occurs with incorrect or inconsistent use of methods other than LARC [3]. Prevention of unintended pregnancy requires a multi-faceted approach and increasing partner support for contraceptive users is one intervention which could make an important contribution [4].

Contraceptive decision-making can be a complex process, and one which is largely placed on women [5]. A woman’s social network, including her male sexual partner, can influence both her use of contraception and her choice of method [6,7]. Female peers will often pass along their own knowledge and experience through “informal feminized health networks” [8]. Male partners’ opinions can both promote and discourage women’s contraceptive method selection and use, even if she does not formally include him in the contraceptive decision [6,9]. Women in committed relationships reported their male partners were active participants in the decision process, providing both information and contributing to the discussion on family size and timing [6]. The involvement of well-counseled and educated male partners increases contraceptive use [10]. However, male partners may also create barriers for their female partners. Many male partners lack knowledge of contraceptive methods, especially LARC [9,11,12]. This can promote misinformation and perpetuate misconceptions that could deter women’s use of these methods [6,9,12-14]. In casual relationships, men may be focused on the sexual act, rather than on pregnancy prevention [11]. Men may also have negative effects on female contraceptive usage through abuse, pregnancy coercion, or contraceptive method sabotage [11,15]. There is a high prevalence of these negative male effects reported in previous studies among women utilizing family planning clinics [16,17].

These prior studies focused primarily on men’s contraceptive knowledge, women’s perceptions of men’s involvement, or the negative role’s men may play in contraceptive use or non-use. The prevalence of reported LARC use in the 2015 to 2017 US National Survey of Family Growth increased nearly 3-fold over the previous decade (6.2%–16.7%) [18]. Many of the prior studies on men’s involvement occurred prior to this increase in LARC use and male partners may be less likely to sabotage LARC than barrier, shortacting, or behavioral contraceptive methods. Thus, the objective of this study was to explore the male-partner role in the contraceptive decision-making process from both men’s and women’s perspectives. We sought to understand how women involve men, whether men support or hinder women’s ability to obtain their desired contraception, and whether these roles vary between those selecting methods of LARC and non-LARC. We also explore the concept of ideal partner involvement. This study design and recruitment stratified groups by use of methods of LARC or non-LARC to explore how unique method characteristics of LARC (e.g., provider placement, long-acting, highly effective, etc.) might related to actual or ideal male-partner involvement.

2. Methods

2.1. Recruitment and sample

We chose a qualitative study design, using a phenomenological approach, to explore male partners’ role in contraceptive decision-making. We used purposive sampling to recruit women and men who presented to 2 Salt Lake City Planned Parenthood Association of Utah clinics either for a visit or as an accompanying support person for their partner between June 2016 and March 2017. Eligibility criteria included English language fluency, age 18 to 35, report of a current heterosexual relationship, and use of a prescription contraceptive method during the current relationship. We chose the age range based on those under 35 years reporting the highest frequency of reversible contraception use [19] and on the clinic population served in the recruitment sites. We excluded potential participants if either they or their partner had a history of sterilization. We gave everyone who came into clinic a study information sheet. As more women typically seek care in these clinics then men, we gave women both a study information sheet for themselves and a separate information sheet for recruitment of their male partner or other eligible men. We recruited, enrolled, and interviewed women and men separately, not as members of a couple, and no linkage occurred if both partners of a couple did participate. Study staff collected basic demographic information on all participants and we used a semi-structured interview guide to conduct the in-depth interviews. The University of Utah Institutional Review Board approved this study.

2.2. Interview procedures

We employed a stratified sampling method to enroll 60 participants into 4 groups based on sex assigned at birth and contraceptive method: (1) women using LARC, (2) women using other hormonal methods (non-LARC), (3) male partners of women using LARC, and (4) male partners of women using other hormonal methods (non-LARC). We planned enrollment of 15 participants per group, anticipating thematic saturation within each group at 12 to 15 participants [20]. We structured these groups to obtain the perspectives of both men and women and to assess the viewpoints from partners using a spectrum of contraceptive methods. Two team members (KES and NW) who had qualitative interview training conducted the semi-structured, in-person interviews in a private Planned Parenthood Association of Utah clinic room. Both interviewers identify as women. We developed the interview guide with the assistance of qualitative methodologic experts, sociologists, and family planning clinicians. The guide focused on exploring the various factors that can affect male partner support for contraception and engagement in the contraceptive discussion. This included open-ended questions with followup probes on their current relationship, previous pregnancy and contraceptive experiences, knowledge regarding different contraceptive methods pictured on a chart, decision-making regarding their chosen method, and experiences with reproductive health providers. We then explored how women involve their male partners in the decision, what information the male partner contributes, whether they are a positive influence or adding further barriers to women obtaining their chosen contraception, and participant suggestions on areas of improvement. At the completion of the interview, we asked each participant to complete a brief demographic questionnaire. All participants received a $50 Amazon gift card as compensation for their time.

2.3. Data analysis

We audio-recorded and professionally transcribed interviews verbatim, then employed Dedoose version 7.0.23 (Los Angeles, CA) qualitative coding software to manage the data for analysis. Two research team members (KES and NW), under the mentorship of a qualitative coding methodologist (JNS), coded and analyzed the transcripts using constant content and comparative analysis concurrently with study enrollment [21]. Together they created the working codebook via open coding of snippets and iteratively refined the categories of themes and concepts through axial coding. The study team then used selective coding to compare identified themes and relationships between men and women and LARC and non-LARC users and identify core themes. We added the demographic questionnaire data to Research Electronic Data Capture (REDCap) for data management and analyzed these data in Stata v14.2 (College Station, TX) using descriptive statistics [22]. The coders identified thematic saturation within and between groups when they reached 8 to 10 interviews in each, but the study team opted to complete the pre-determined number of interviews to ensure balanced recruitment. Interviews lasted on average 38 minutes (range 17–70). We present our key themes in the results section and incorporate supportive quotes. We removed or masked all identifying information, used pseudonyms assigned by a member of the study team and language that conforms with the gender identity of our participants.

3. Results

3.1. Participant characteristics

The final study sample included a total of 60 participants; 30 women and 30 men (all participants identified as cis-gender) with 15 per contraceptive method group. Participants had a median age of 23 years (range 18–33). Forty-two participants identified as non-Hispanic white, 51 were employed, 48 were never married, 39 reported insurance coverage, 35 identified as non-religious and 14 as members of the Church of Jesus Christ of Latter-Day Saints, and 38 had attended at least some college (Table 1).

Table 1.

Sociodemographic characteristics of male and female participants from family planning clinics in Salt Lake City, Utah stratified by contraceptive method use by the female partner in their relationship.

		Female participants (N = 30)		Male participants (N = 30)
		Non-LARC (n = 15)n (%)	LARC (n = 15)n (%)	Non-LARC (n = 15)n (%)	LARC (n = 15)n (%)
	Median age (range)	25 (18–29)	22 (18–33)	23 (20–33)	23 (18–32)
	Prior pregnancy	4 (27)	9 (60)	5 (33)	1 (7)
	Have child(ren)	3 (20)	7 (47)	2 (13)	1 (7)
	In serious relationship	12 (80)	13 (87)	13 (87)	14 (93)
	Median # months of current relationship (range)	5 (1–72)	12 (1–72)	12 (2–48)	12 (1–102)
Education
	High school	9 (60)	5 (33)	5 (33)	3 (20)
	College	6 (40)	9 (60)	9 (60)	10 (67)
	Professional	0 (0)	1 (7)	1 (7)	2 (13)
	Employed	13 (87)	11 (73)	13 (87)	14 (93)
	Insured	10 (63)	7 (47)	10 (63)	12 (80)
Marital status
	Never married	11 (73)	10 (67)	14 (93)	13 (87)
	Married	3 (20)	1 (7)	0 (0)	2 (13)
	Separated/Divorced	1 (7)	4 (27)	1 (7)	0 (0)
	Co-habitating	6 (38)	6 (38)	10 (63)	5 (33)
Race
	American Indian/Alaskan Native	0 (0)	1 (7)	0 (0)	0 (0)
	Asian	0 (0)	1 (7)	0 (0)	1 (7)
	Black/African American	1 (7)	2 (13)	0 (0)	0 (0)
	White	12 (80)	8 (53)	11 (73)	11 (73)
	Other	2 (13)	3 (20)	4 (27)	3 (20)
	Hispanic	3 (20)	4 (27)	5 (33)	6 (38)
Religion
	None	9 (60)	7 (47)	10 (63)	9 (60)
	Catholic	0 (0)	2 (13)	0 (0)	1 (7)
	Members of the Church of Jesus Christ of Latter-Day Saints	4 (27)	3 (20)	2 (13)	5 (33)
	Other	2 (13)	3 (20)	3 (20)	0 (0)

LARC, long-acting reversible contraception (e.g., intrauterine devices or subcutaneous contraceptive implants); Non-LARC, prescription contraceptive method (e.g., pills, ring, shot, etc.).

3.2. Shared-goals but gendered-responsibility and risk

Nearly all participants described their current relationship as “serious”, but regardless of the description or length, everyone at least discussed pregnancy prevention and/or their contraceptive choice with their partner. The reasons for preventing pregnancy focused less on the relationship status and more on individual and shared life goals, particularly financial well-being. As John, a 19-year-old non-LARC user explained, “We just both decided that we didn’t want any children, or we didn’t want her to get pregnant because we are so young, and she is at school and I am at school, so we are both busy. We are not financially stable for a child.”

Many participants felt that both partners had some responsibility for the contraceptive decision, but there was near universal consideration that the female partner should have ultimate contraceptive control. Sara, a 24-year-old non-LARC user described, “It could be both mine and my partner’s responsibility, but I think it’s more mine just because it’s my body and I can choose what I want to do.” Participants recognized that most available contraceptive methods are female dependent and that these methods are not without risks or side effects. Since contraceptive methods have a larger impact on women’s lives, they bear a greater responsibility to research and be educated on different methods. Matt, a 24-year-old LARC user commented, “When some women are on birth control it affects your moods and your periods and everything becomes a little bit different […] on the male side we don’t see that […] it is not our bodies, we don’t see how it is affecting the person, we don’t know how it feels.”

Many participants had prior experiences with pregnancy outcomes, either with their current or previous partners. Stories ranged from a missed period with a risk of an unplanned pregnancy, to adopting out a baby as a teen, to traumatic miscarriages, to the challenges of raising children. Regardless of whether experiences were hypothetical or real, participants felt the risks and responsibility of pregnancy primarily impacted women. Don, a 20-year-old LARC user, described his perspective, “There are a lot of health risks with pregnancy that a woman might consider that a guy might not, I would think, just because like you can die giving birth. […] the baby [might] have health issues that you might worry about, or caesarean […] That’s also, kind of, scary, I wouldn’t want to imagine being cut open just to have a baby.” Raising a child was also more likely to fall on women, as Jane, a 24-year-old non-LARC user said, “If she does get pregnant, they’re [male partners] not the pregnant ones. They don’t have to deal with it. So, it’s that much easier to just walk out… it’s definitely more of a woman’s responsibility right now unfortunately.” This risk of a potential pregnancy and the responsibility of child rearing led many female participants, including Jane, to feel more stressed than the men about contraceptive use. Nicole, a 26-year-old LARC user explained, “…the reason why I became pregnant is, um, we were going to put the condom on towards the end, but he fails to… I didn’t want to go through that again.”

3.3. Gendered-difference in sexual priorities

Male participants expressed a desire to prevent pregnancy, but both men and women felt that men tended to be more shortsighted, willing to take risks, and to prioritize the sexual act, while leaving the contraceptive decision to the woman. Some women felt the biologic inability of men to get pregnant led to lack of acknowledgement of the potential effects of pregnancy on their female partner. Kate, a 26-year-old non-LARC user expressed her frustration, “I think that men are very sex driven […] I think that they are very excited to go in without a condom on, and they’re kind of like, ‘Just take care of yourself so that I can do my thing.’ And I wish that they could have a vagina for even a month, just to understand.”

3.4. Gendered-difference in contraceptive knowledge

A common reason cited by participants for men having little to contribute to the conversation was a lack of contraceptive method knowledge. Many participants felt the reproductive health education they had received was inadequate or poorly timed. Ben, a 29-year-old non-LARC user, discussed how women know more than men because most methods are female-controlled, “Most men aren’t probably too educated at all about any kind of birth control besides condoms.” Men knew there were a few male-controlled contraceptive options, but most felt these methods were not ideal. Withdrawal was viewed as not effective or not a “real” contraceptive method. Participants did not consider vasectomy a viable option, as most desired children in the future. Luke, a 29-year-old LARC user explained, “The only thing from a male perspective that I could think of is the condom because quite honestly we hate them, they are not fun, they do take a lot of the experience away.”

Almost all participants had some misinformation or misconception regarding contraceptive methods. Kyle, a 28-year-old LARC user, described the mechanism of action of the depo provera shot as: "There is a fluid in there that helps stop the semen from getting to the eggs". James, a 26-year-old LARC user, explained the hormonal IUD “…is inserted into the vagina, it kind of blocks the way for sperms to come inside the urethra”. Many men relied on their female partners to provide knowledge about various methods or ultimately, they had to research methods on their own, most frequently through peer discussions or via the Internet.

Some participants felt that it was overall futile for men to spend much effort on pregnancy prevention and that it ultimately came down to whether the woman wanted to be pregnant or not. Both male and female participants reported concern about potential pregnancy risk-taking behaviors or coercion by female partners to “lock them [men] in.” Jenny, a 28-year-old non-LARC user, further explained, “I honestly believe that if a woman wants to get pregnant, she will get pregnant […] if the woman decides that she wants to have a child she will lie, and she will get pregnant, and the man would not even know about it. I mean I think the guy can also be informed and educated on birth control [contraceptive] methods, but you can only do so much.” However, no participants reported directly experiencing or participating in these behaviors.

3.4. Ideal involvement includes a common desire for male partner participation

The contraceptive conversations described by the participants revealed a limited role for men. Despite the limitations, both men and women expressed desire for the male partner to be involved in the contraceptive discussion. One way that men could be involved is by providing emotional and moral support for contraceptive use. This often involved agreeing with the woman’s decision, being sensitive and understanding of potential side effects, and being sympathetic to their female partner. Men could assist with paying for a contraceptive method or a doctor’s visit. As Ashley, a 20-year-old LARC user, described, “I had to get Plan B [emergency contraceptive pills] 3 times off my own pay check, by myself because he was like ‘oh well you can just go get it at the store.’ I was like ‘dude that’s 50 bucks’ and ‘I will but likewhere’s your end of this? That was like 50% you too’.” Men could pick up contraceptive prescriptions, accompany women to an appointment, or remind women to take their pills. William, a 21-year-old non-LARC user stated: “Just be supportive and don’t be selfish. If there are negative or adverse side-effects from taking birth control [oral contraceptive pills] don’t be so hard… Be supportive and accommodate them because at the end of the day it is their choice and it is their body and all you have got to do is have sex, so don’t be a dick.”

Both men and women felt that if more male methods were available, this would allow the contraceptive responsibility to be more equal. Male participants did not like the limited methods available for them to use (external [male] condoms, withdrawal, or vasectomy). Mary, a 24-year-old LARC user explained the potential for actual sharing of the contraceptive responsibility, “You can still both be on birth control [contraception], if there are more methods for guys. I feel like it’s double protection, it’s…or triple, however many you want to use [….] the more contraceptive methods you use the safer the sex and less likely for pregnancy.” Many participants commented on the improved communication and trust that would result from expanded male involvement in the final contraceptive decision.

4. Discussion

Both men and women in this study strongly desired men’s participation in the contraceptive decision process, but they also acknowledged limitations to their potential contributions. These limitations are primarily due to the salient theme that women are using most contraceptive methods and bear the risks of side effects and method failure. Until more contraceptive methods allow for shared responsibility, increasing general contraceptive education and teaching communication strategies regarding family planning topics are tangible first steps. Prior studies reported limited contraceptive knowledge in male participants [10,13,23]. Low knowledge levels may result in perceptions of lack of reproductive control or agency, which can feedback into men not prioritizing pregnancy prevention because it is out of their control. Acknowledging that society, not biology, is the main driver of the phenomena around gendered-sexual priorities and gendered-risk and responsibility is also an important step in balancing the unjust division of contraceptive labor [5].

This study design stratified groups by use of methods of LARC or non-LARC to explore whether method characteristics and efficacy may affect the sense of reproductive control or desires for male-partner involvement. In this sample, we did not identify any variation in themes reported by method selection. This similarity of themes across participants and method use may be due to lack of knowledge on differences in characteristics or efficacy between methods; or more likely due to greater attention being given to gendered-context for contraception labor across methods, despite certain methods being more costly to women-physically, emotionally, and financially. Additionally, the study sites are in a US state with a high uptake of methods of LARC, potentially normalizing the selection with other, more user-dependent methods [24].

Recent family planning research highlights many of the potential negative influences that male involvement in pregnancy prevention and the contraceptive discussion can have [16,17,25], as well as the potential to intervene with education. Men in this study felt that they received inadequate contraceptive education, which is not surprising as Utah state law encourages abstinence-only public sexuality education [26]. Participants often did not feel prepared to talk with partners about contraception, with many men relying on their female partners to initiate discussions and provide them with information and knowledge regarding contraception. They did not understand tangible ways to help with contraceptive acquisition or use. Informed sexual consent requires both adequate understanding of available contraceptive methods, as well as respectful communication skills with one’s partner. Prior research identified that men and women indicate consent in different ways, with men relying more on nonverbal strategies [27]. Greater education for both men and women in how to better verbalize and communicate family planning goals with their partners will allow them to take an equal role in the contraceptive discussion [28].

Both men and women in this study reported enthusiasm for more male-controlled contraceptive options. Expanding the types of contraceptive options would allow men greater reproductive control and allow couples to work together to prevent pregnancy, especially if both partners were using effective methods. Prior surveys of men and women support acceptability and desire for a male hormonal method [29]. This is a long-term strategy, as there has been difficulty maintaining industry support of research and development of new methods [29].

Prior studies documented male contraceptive sabotage and reproductive coercion, particularly among lower socioeconomic couples and those using family planning clinics [17,18]. No participants in our study reported these behaviors, however our participants overall had relatively higher socioeconomic status and education level and, by eligibility requirements, used female-controlled prescription contraceptive methods in their relationship. Participants in our study were particularly concerned about potential pregnancy risk-taking behaviors by female partners. Exploring coercive behaviors by women to become pregnant is an opportunity for future research. A recent qualitative study of low-income men reported coercive behaviors by women as contributing to perceived low reproductive control [30]. This area warrants further exploration to gain a better understanding of these behaviors and their prevalence.

Study limitations include the recruitment strategy, which enrolled men whose female partner sought family planning services, resulting in a sample of more stable relationships. Our findings may not reflect the views of those in less stable or transient relationships. We did not recruit or analyze participants as couples/dyads to gain more diverse voices/relationship types. Both interviewers identify as white women, which may bias recruitment and interview responses, thus clinic assistants who are more diverse served as the primary recruiters. The primary coders engaged other research assistants, who identify as men and/or persons of color, to develop the interview guide, give feedback on recorded interviews, discuss emergent themes and ensure correct quotation interpretation. The inclusion criterion of use of prescription contraception or devices did not capture the voices of those who use barrier or behavioral methods or those unable to access female-controlled methods due to male partner interference. The racial, ethnic, and religious composition is consistent with the family planning clinic patient population and catchment area, which includes primarily Salt Lake City, but also surrounding states for which the clinics serve as referral centers. This composition may not be generalizable to other areas of Utah, in which the proportion of those who identify as members of the Church of Jesus Christ of Latter-Day Saints is higher, or to areas of the country with different types of diversity. The participants were mostly well educated, making findings less generalizable to low-literacy groups. This leaves opportunity for future research evaluating the decision process in more diverse couples.

In this study, men feel limited in the contributions they can make to pregnancy prevention, but a majority of this study’s participants reported desire to be involved. Due to few male-controlled contraceptive methods and often-limited reproductive knowledge, emotional, financial, or logistical support are a few ways male partners can be involved in the contraceptive decision. Better sexual and reproductive health education for all people regardless of sex is an essential first step to allow men to be more involved, share in the contraceptive responsibility, and potentially influence consistent and correct use of contraceptive methods by their partners.