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Indian Journal of Community Medicine

Dhanwantri Oration: Strategically Orienting Reproductive Health Encouraging Male Responsibility

Author(s): R.K.Sachar, Prof.

Vol. 28, No. 2 (2003-04 - 2003-06)

Deptt, of Community Medicine, Dayanand Medical College & Hospital, Ludhiana (PB)

Respected Chairperson, Esteemed Colleagues, Dear Friends, Ladies and Gentlemen, I am indeed thankful to IAPSM for having bestowed this exceptional accolade on me by awarding the most esteemed "DHANWANTRI ORATION".

I dedicate this oration to my late parents & to my family who have always been a source of inspiration and strength and especially to my friends who have made it possible by their co-operation, encouragement and support.

India's efforts to address the problems of maternal and child health, during the last half century have been a series of exercises in semantics, frequently changing the name of the programme, the latest being the 'Reproductive and Child Health approach'. The problems, by and large, have continued to defy any solution, mainly because of a woefully inadequate focus on the real issues. Strategic planning for an improved health scenario has been noticeably missing. The planners' preoccupation of meeting the demographic goals of reducing fertility is evident from the fact that the family planning component has largely overshadowed the other aspects of the programme. Moreover, there has been a "genderisation of family planning responsibilities". In the sixties, 11% of the sterilizations were tubectomies, in 1993, they accounted for 96% of the same. Government sponsored programmes have conveniently overlooked the fact that procreation is the result of an equal and active role of both the partners. Encouraging male responsibility has largely remained only an "idea". Unfortunately, the women have been at the receiving end of all experimentation of reducing fertility through contraception or other methods.

There has been a scant involvement of men in reproductive health programmes, though the National Population Policy 2000 calls for an increased participation of men. The male role has been gradually declining over the years largely due to the entire focus of these programmes being on women. The male belief that childcare is the exclusive domain of women or regarding STDs as women' s diseases or as shameful diseases have discouraged men participation. This has been further compounded by lack of acceptance of health care providers of the opposite sex and needless to say that the health care work force is female intensive. The attitude of health care providers can also be a barrier. Men made to feel unwelcome, there is lack of discretion/confidentiality and rules of counselling are misapplied. Insufficient quantity of appropriate and high quality IEC materials and low level of knowledge among men concerning reproductive health issues and availability of services are some of the key issues which need to be addressed if men's involvement is to be worthwhile.

The relationship between mens' self-interest and reproductive health has largely been ignored. Men feel that reproductive health does not concern them and have not yet realized its advantages. High cost of services, geographical distance and cultural barriers to accessibility and availability of reproductive health also come into play. The male perspective has also been largely ignored by researchers. Husbands were interviewed in only 7% of world fertility surveys. Again they were interviewed in only 33% of Demographic and Health Surveys in progress or completed till 1993. A 40 year analysis of POPLINE graph has led experts to conclude that men are neglected in research on fertility and family planning.

Gender inequality is the root cause of men being invisible from the reproductive health scenario, which is further compounded by their palpable sense of masculinity. Equality between men and women is a matter for society at large, but it begins in the family. Understanding gender discrimination means understanding opportunities and constraints as they affect men as well as women. Men's attitudes and behaviours are strongly influenced by societa expectations about what it means to be a man.

In particular, the assumption that contraception, pregnancy, childbirth and prevention of sexually transmitted diseases are exclusively womens' concerns reinforces mens' lack of involvement in safeguarding reproductive health - both their own and that of their partners. Their masculine image deters them from getting involved in these feminine activities. The overtly "gynocentric" approach of the policy makers to reproductive health issues further discourages male involvement. Men, by and large remain invisible from the reproductive health scene.

Culture is an important determinant of human behaviour. Gender inequality leads to different kinds of and cultural expectations. It is taken for granted that change in the public sphere - economic growth, political transformation, and new means of communication and transport - will be reflected in changes in individual attitudes and behaviours. But this expectation does not extend to the private sphere, where basic issues of identity and family are involved. Society may change, but gender roles are not expected to change with it.

This anomaly is at the root of continuing gender inequality. Many cultures maintain a traditional patriarchal system in which men are the primary decision makers in family and social relationships. However, these are not being addressed by the reproductive health programmes. Although the result is generally not to their advantage, women may acquiesce to keep their place within the community and eventually to earn the respect due to a mother or an elder.

In many cultures, increased status and rewards accrue to women later in life, after they have ceased to bear children. This can result in compliance from older women, while the expectation of future benefits can mute younger women's dissatisfaction. Alternatively, fear of family or community disapproval may compel women's acquiescence, particularly when it is reinforced by threats of physical punishment or expulsion. The traditional arrangement reinforces mens' sense of power and competence. This may become more important when men face external challenges, as in periods of rapid social and economic change. For men of relatively low status in their societies, control over women offers a position of power denied in other parts of their lives.

Myths and misconceptions perpetuate the power structure and weaken women. There may be prejudice against exercise, employment outside the home and even education, because they will make women "too much like men". Womens' sexuality is often feared and is the subject of bizarre and ferocious myth; severe female genital mutilation is only the most extreme means taken to control it, short of murder. Ignorance of alternatives and fear of the unknown reinforce traditional behaviours and attitudes, and make change difficult for men. Better information and open discussion can help the transition, but the best route to change is through example and leadership.

Men can support reproductive and sexual health since they are more likely than women to be literate and to have better access to information, and are often in a better position than women to inform themselves about reproductive health. They lack interest, however, because reproductive health - including everything to do with contraception, pregnancy, childbirth and STDs - is considered to be a woman's concern. "Real men" do not concern themselves with such matters. Even if they acquire an infection, a woman is blamed and sometimes a woman is seen as the "cure". The belief that sex with a virgin can cure AIDS is responsible for an unknown number of infections among young women.

This can be changed. With the correct timing and approach, informing men about reproductive health, maternity and child care leads to more support for safe pregnancy and delivery and breastfeeding. A successful project in Egypt has demonstrated that men are eager to know what they can do to help their wives after a miscarriage and are willing to learn about reproductive health. Dr. Leela Visaria, long active in reproductive health policy in India, concludes that "research needs to go beyond estimations of incidence and prevalence and probe into power relations between partners", including the negotiation and decision - making process.

Various micro level efforts have been made to increase mens'. interest in their own and their partners' reproductive health. Community-based approaches have addressed a range of concerns. Programmes have worked with groups of men, creating opportunities for easier communication. Traditional authorities have been enlisted to motivate men. Better ways for men to find accurate information have been created. Interestingly many of the lessons learnt have been from India.

Several projects in India demonstrate some generally valid points about securing mens' involvement in reproductive health issues.

Men and women often perceive reproductive health issues differently. Among married adolescent couples interviewed in one study, the men described the positive effects of marriage on their daily lives and indicated they believed their wives shared their opinion. Wives had a more mixed assessment of marriage, as they adjusted to the burden of their multiple responsibilities.

Mens' illnesses were immediately apparent because of their impact on wages; wives' illnesses became known only when they told their husbands or when the household routine was disturbed; women were more likely to conceal their health needs because of the expenses. Women felt strong pressure to conceive early in marriage. Men did not know much about family planning and were aware of their lack of information.

Men accompanied their wives to their first check-ups to confirm a pregnancy, but wives did not expect or want further visits with their husbands. Clinic workers seeking to shield other women did not encourage them. Husbands ignored womens' health care during pregnancy except for appreciating the need for a nutritious diet. While they advised women to reduce their workload, they generally did nothing to help, except in some cases where they assisted with household chores.

Discussion of reproductive health concerns offers the prospect of change:

Traditional beliefs can undermine reproductive health. One project found that traditional beliefs about semen and sexuality led to reduced protection from STDs. Traditional beliefs about such matters as erectile dysfunction impeded reproductive health care. Concerns about sexual inadequacy among a minority of young men led to family violence and discouraged them from using contraception.

Efforts to involve men in reproductive health must include education about gender relations and shared opportunities. The NGO Social Action for Rural and Tribal Inhabitants of India (SARTHI) has worked in traditional settings to improve womens' status and reproductive health. The group's initial work on womens' health was found to improve mens' awareness and sensitivity to gender issues. Contrary to expectations, men did not feel threatened by womens' meetings and even volunteered to take on domestic chores so that their wives could participate. SARTHI then began to include men of all ages in the programme and began training men as health workers in a new community health programme serving men and children.

After several years, SARTHI recognized that work to empower women needs to be accompanied by action to sensitize men about gender relations, to free them from patriarchal definitions of masculinity. Personal transformation is necessary before male health workers can become good community role models.

Another NGO, the Centre for Health Education, Training and Nutrition Awareness (CHETNA), started working to involve men in its reproductive health programmes in the early 1990s, when it realized the extent of husbands' domination and neglect of their wives and the effect this had on womens' health; women said they were not even free to decide how much food they ate. CHETNA now concentrates on involving men in early childhood care, including teaching them about nutrition and growth monitoring; teaching adolescent boys about sexual and reproductive health; and using trained male health workers to motivate men to take an interest in womens' health.

These efforts have shown that training is crucial - poorly trained men can perpetuate harmful behaviours and beliefs - and that programmes to encourage mens' participation need to involve members of their extended families. Otherwise, the men may face criticism and ridicule when they help with housework or take on some of their wives' responsibilities.

Creative adaptations of existing institutions can create new opportunities to effect change. Family Welfare Education and Services (FWES) organizes mens' and mothers-in-law clubs to support reproductive health. The men discuss issues such as alcoholism, smoking, malnutrition, family planning and womens' literacy. Mothers-in-law in India exercise great influence in the household; the project encourages them to promote proper nutrition and childcare and to motivate their sons to treat their wives better, because "only a healthy and happy mother produces a healthy child".

Two local health centres offer services for adolescents and a letterbox has been set up for their questions about sex and reproduction. There has been a definite change in young peoples' awareness and perspectives in the five years since the project began. Boys now ask fewer questions about girls' virginity, and more about the involvement of men in raising children. Questions about STDs, AIDS, contraception and safe sex are also frequently asked. Boys expressed increasing concern about girls' problems and are now more likely to ask about menstruation. More young people now view sex as not merely about pleasure or procreation, but as a part of "expressing and sharing love". More girls want to share household chores and child-rearing with their future partners.

In FWES project villages, girls' enrollment in schools has increased and sex ratios for newborns have not changed, unlike neighbouring villages, where girls' enrolment has decreased and female births have declined sharply. However, the clubs have not caught on in other villages and involvement has reached a plateau. In urban Delhi a project, Men in Maternity is similarly encouraging men's participation.

Other NGO efforts to involve men: In Mali, the Association de Soutien au Development des Activites de Population worked with a Centre for Development and Population Activities/ACCESS project to expand community-based family planning services and encourage mens' participation. With the backing of traditional leaders, male volunteers were trained to distribute contraceptives and provide information about reproductive health, including STD/AIDS prevention, high-risk behaviours and condom use. The project increased mens' interest in the health of mothers and children and led to greater interest in modern methods of child-spacing. In Nicaragua, the NGO CANTERA offers workshops on masculinity and sexuality; gender, power and violence; unlearning machismo and communication skills. During a 1997 evaluation, many men reported that CaNTERA courses had changed their lives: two third reported that they had a different self-image and more than two third said they were less violent. Nearly half the women said their partners were significantly less violent after their training and an additional 21 per cent said that they were a little less violent. Both men and women reported that the men were significantly more responsible sexually.

Various programmes focus on adolescent boys' roles and responsibilities. In Brazil, the NGO Citizen Studies, Information and Action targets teenage fathers in a campaign involving radio, television and comics. Save the Children UK has supported the making of four films in Bangladesh, India, Nepal and Pakistan; the project "Let's Talk Men" uses the films to build awareness on gender relations, so boys will adopt more responsible attitudes about women and sexual relations.

There is a common agenda for men and women in matters of reproductive health. The efforts to involve men in reproductive health programmes is picking up momentum and useful programme models have been developed. In developing these activities, programme design must take care to ensure that they do not divert scarce resources from activities directed towards women, as some womens' NGOs fear. Greater involvement of men in reproductive health decisions should give more power to women, not less. Mens' and womens' different needs should not be in competition for resources. The common aim is the well-being of all family members.

Men can advance gender equality and improve their family's welfare by:

  • Protecting their partners' health and supporting their choices
  • adopting sexually responsible behaviour; communicating about sexual and reproductive health concerns and working together to solve problems;
  • considering adopting male methods of contraception (including vasectomy and condoms);
  • and paying for transport to services and for service costs;
  • Confronting their own reproductive health risks
  • learning how to prevent or treat sexually transmitted infections, impotence, prostate cancer, infertility, sexual dysfunction and violent or abusive tendencies;
  • Refraining from gender violence themselves and opposing it in others and promoting non-aggressive conceptions of male sexuality and masculinity;
  • Practising responsible fatherhood
  • supporting their partners in child rearing and household tasks;
  • protecting their childrens' health and investing in their future;
  • teaching their sons respect for womens' needs and perspectives;
  • developing open and supportive relationships with their daughters;
  • and providing their children with accurate and sensitive information;
  • Promoting gender equality, health and education
  • supporting the education and training of girls and women;
  • promoting womens' participation in health, education and economic activity;
  • lobbying for increased funding for basic social services and working to improve the quality of programmes;
  • demanding that family life education be taught in schools.

To strategically orient reproductive health by taking men into account we need to make reproductive health services more available and more accessible to men by adding a masculine dimension to reproductive health programmes. The aim should be to remove the socio-cultural barriers to mens' involvement. The skills of social and health workers need to be strengthened. The following set of activities is suggested to give a masculine dimension to the reproductive health programmes at a national level to encourage male responsibility.

  • Reorganization of reproductive health services make services available in work place and other male dominated areas.
  • Integrate mens' reproductive health into existing services
  • Organize advocacy activities to motivate men to utilize reproductive health services, primarily by targeting men and secondarily by focussing on male opinion leaders and mens' organizations and also by generating political will and support.
  • Encourage coalition with wives on matters of reproductive health.
  • Revise training curricula to include the offering of mens' reproductive health services
  • Develop messages that are relevant and acceptable to men; choose appropriate messengers (IEC)
  • Research in reproductive health problems of men.
  • Promote positive role model images.
  • Use of simple inbuilt evaluation indicators like number of men or couples visiting facilities providing reproductive health care.

The involvement of men is thus essential both in the design and implementation of reproductive health programmes, thereby ensuring that all reproductive health issues including pregnancy are a matter of male concern and responsibility.

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