1. Engaged and Engendered: Women, Men, and Child Spacing in Mali Susan Igras, Marie Mukabatsinda, and Sékou Traore Men, Masculinities and Family Planning Conference, UCLA October 2010

2. Method Concept & Efficacy Trial 1999-2002 Pilot Studies 2000-2004 Operations Research 2003- 2005 Integration Studies 2005 - 2007 Scale-Up Case Studies 2007-2012 SDM is an evidence-based practice

3. Method Concept & Efficacy Trial 1999-2002 Pilot Studies 2000-2004 Operations Research 2003- 2005 Integration Studies 2005 - 2007 Scale-Up Case Studies 2007-2012 SDM is really a set of evidence- based practices in scale up phase Male engagement Couple communication Couple services Social diffusion Champions Advocacy Institutional’tion

4. Using Mali SDM Scale-Up Assessment Data + other country studies & take gender lens to FP service provision Women and men’s attitudes in different decision spheres Gender-equity interventions CAREF/IRH 2009 To What Extent is the SDM Integrated into FP Programs in Mali? 194 Facil assessments Interviews with 278 providers 1,246 women/men id’d as couples

5. Mali Total Population: 12.9 m CPR/mod methods: 6.9% Unmet need : 31% TFR : 6.6 IFS (women): 6.2 children FP program since 1970s Low use of health services, particularly RH services Great distances demand institutionalized outreach strategies by MOH

6. Why are women and men not interested in using family planning? (CAREF/ATN Evaluation of FP Campaign 2008) Secondary effects Rumors and misconeptionsWhite dominance over Africans Money making scheme for whites Reduces sexual pleasure Favorises prostitution and adultery Sterility Refusal of male partner in using FP Hidden FP use by woman Against religion

7. Views of service providers – gendered, cultural, structural, or otherwise determined? Of those not offering the SDM, top reasons why: Not trained in SDM Think method is complicated Think method not acceptable to male partner Method not available at health center

8. FP policies and program norms tend to favor women Do policies, norms and service standards explicitly name men? Are there explicit strategies for reaching men as clients, within the couple, as community change agents? What might this mean in resource-constrained environments such as Mali? MS/Div Sante de la Reprod Guide pour l’engagement constructif pour hommes en sante de la reproduction Janvier 2008 MS/Div Sante de la Reprod Guide pour l’engagement constructif pour hommes en sante de la reproduction Janvier 2008

9. Partner Communication Matters: Findings From an Analysis of 14 DHS Having Female and Male Data (Source: Gebreselassie, T, Spousal Agreement on Reproductive Preferences in Sub-Saharan Africa, Macro International, 2008) Overall reduction in fertility intentions of both partners (leading to increased use of FP) Couple agreement on having / not having more children Couple agreement on ideal no of children

10. Couple Counseling Results in Better Continuation Rates

11. Baseline Data: Simulated Client Results (IRH/USA) Couple relations Couple issues and method use Clinic environment n=24 visits

12. How Can We Engage Couples More? Couples-based services Programming is directed towards couple Couples-focused services Do not involve both partners but address issues related to the relationship or male partner Begins with an individual female client and may expand to include partner

13. 13 “She Says/He Says” Quiz to facilitate RH discussion in couples

14. In a couple, who should make the following decisions? (624 ♀, 624 ♂ ) CAREF/IRH 2009 * p<.001

15. Couples do not always agree…Is it normal for a husband to hit or beat his wife when - (n=624 ♀, 624 ♂; CAREF/IRH 2009) * p<.001

16. Couples don’t always agree…It is OK if the wife refuses to have sex with her husband if (n=624 ♀, 624 ♂; CAREF/IRH 2009) * p<.001

17. If a woman refuses to have sex with her partner, when he wants to, he has the right to

18. What do these differentials mean? Decision-making power plays out differently depending on decision. Intimate decision-making around reproduction may be more egalitarian than economic decision-making in the Mali study. Perceptions of sexual rights – of men, of women – are paradoxical. Men seem to be giving women more power than they are exercising. Women seem to think that men have more power than men believe they have!

19. SOME APPROACHES TO ENGAGE MEN AND WOMEN IN NEW WAYS IN FP

20. Example: Engaging Men via Community- based Water-Sanitation Program in El Salvador (Source: Lundgren et al, Cultivating Men’s Interest in FP in Rural El Salvador, Studies in FP 2005) Messages: Reflected cultural context, values, and conservation analogy to appeal to men Work with leaders: Water and sanitation committees reached men with FP info and referrals Results after 18 mon o Significant increases in KAB o Demonstrated power of social networks

21. Messengers: Agricultural agents and community volunteers reached farmers with SRH info Messages challenging behaviors/norms using low literacy materials stressing child health benefits of birth spacing (plus violence, intimacy, etc): Family planning use increased 37 – 55% Reaching men through extension programs in rural El Salvador (Source: Gribble, J et al. Being Strategic About Contraceptive Introduction: The Experience of the Standard Days Method, Contraception, 2008)

22. Supporting (male) religious leaders as FP advocates in Mali and NE Kenya Health Policy Initiative-Mali: Engaging local religious leaders in deliberations, creating consensus on role of FP in Islam and their public actions. (This is not training!) SDM is common ground - bi- directional gateway to modern FP acceptability Results -6 mon/6 districts in Kenya after similar activities: >250 new FP/SDM users (FHI,2009)

23. Social network diffusion by engaged women in Mali Strategy: Talk to >4000 women reached by women’s savings club clubs members, supported by trained educators, so FP acceptability can diffuse Results in 1st phase 2008: 13% of women in savings clubs using modern FP versus 6% non-members. ( CARE, 2009) Results in 2 nd phase 2010: Affected health districts saw after three months of network FP action, increases in FP users above past new user trends (IRH, 2010)

24. FINAL THOUGHTS on closing gender gaps and addressing unmet Need gender/social analysis and formative research to identify actionable gender-equity practices and outreach strategies and messages for women and for men Social/gender norms shifts are incremental over time. Identify where there is already a base of agreement How to encourage women to use the space already given to them by men?

25. Experiment more with male-friendly and couple-focused service delivery models in facilities and community services to facilitate male involvement More programming using community mobilization and social networks approach