No. 12 / June 1999
Involving Men As Partners in Reproductive Health: Lessons Learned from Turkey
John M. Pile, Cigdem Bumin, G. Arzum Ciloglu, Ayse Akin
Men are frequently described as the forgotten reproductive health clients, particularly in family planning services and perinatal care. In effect, men's involvement in the reproductive health care system often stops at the door to the clinic: when they accompany their partner to a facility, men may find no programs that encourage or allow them to participate in family planning or perinatal counseling and services.
Yet to exclude men from information, counseling, and services is to ignore the important role men's behavior and attitudes may play in couples' reproductive health choices. For example, in some countries, societal norms, religious practices, and even legal requirements give men great influence over decisions that affect their family's reproductive health. In addition, as many as 30% of couples worldwide use a contraceptive method--vasectomy, condoms, withdrawal, or periodic abstinence--that requires the active cooperation or participation of men. Perhaps most importantly, around the world many women and their partners have said that they would like both partners to participate more fully in reproductive health counseling and services.
In response to these factors, facilities are increasingly seeking ways to develop programs that allow men's constructive involvement in family planning and other reproductive health services. The challenge is to develop initiatives that reach out to men during their often brief contacts with the reproductive health care system, that address men's unique concerns, and that increase access to counseling and services for couples who want joint participation without at the same time compromising women's autonomy or their independent access to these services.
Over the past eight years, several institutions in Turkey have been working to build such initiatives. In general, these programs provide counseling and services for men that correspond to some of the most critical reproductive health services for their partners--family planning, abortion, and perinatal services. By taking advantage of opportunities within the health care system and by tailoring the programs to the circumstances under which services are sought, these institutions are attempting to build broad, sustainable programs that meet couples' and individuals' needs.
As part of AVSC's Men As Partners initiative [Figure 1], this paper describes the efforts of these programs and the lessons Turkish service providers have learned about designing reproductive health services and activities that encourage the constructive involvement of men. Although there are still many challenges ahead for increasing male involvement in Turkey, these providers are pioneers whose experiences can be of great value to other institutions in Turkey and to emerging programs in other countries around the world.
Since the 1950s, Turkey has pursued progressively liberal policies and legislation designed to improve maternal and child health, to increase access to family planning services, and to eliminate the threat to women's health posed by complications stemming from unsafe abortion. Although these efforts have led to a decline in infant and child mortality, widespread acceptance of family planning, and the near-elimination of unsafe abortion as a public health threat, there are many continuing challenges for reproductive health programs in Turkey.
Family Planning and Abortion Services in Turkey
Family planning education and the provision of temporary contraceptive methods became legally available in Turkey during the mid-1960s, although abortion and sterilization remained prohibited until the early 1980s. Access to temporary contraception was limited at first, and the use of modern contraceptive methods remained low throughout the 1960s and 1970s. In 1968, use of modern methods was estimated at 11%, and this number had increased to only about 15% by 1978 (Institute of Population Studies 1980).
Abortion was fairly common in Turkey even before legalization, but the human costs of unsafe abortion were high. In 1980, the Ministry of Health reported that an estimated 450,000 abortions were performed annually in Turkey and attributed the high maternal death rate--207.5 deaths per 100,000 live births--to the practice of unsafe abortion (Bryan and Senlet 1990). Many women, unable to afford the high rates charged by private physicians, appeared at public hospitals seeking treatment for complications due to incomplete, self-induced abortion.
"At that time, people who needed abortion didn't have the money to afford it," said one hospital director in Ankara. "Clients would come to this hospital for treatment after self-induced abortion with herbs, hooks, whatever they could find, and it was often too late to help them. Perhaps the saddest thing about this was the fact that the average age for these women was only about 25."
In 1983, public law legalized the provision of abortion and sterilization services in Turkey, and provisions in the law required married women to obtain written spousal consent before abortion and sterilization [see footnote]. In addition, the law widened the range of staff who could provide IUDs and included other provisions designed to improve family planning and maternal and child health.
The immediate results of the legalization of abortion were dramatic. From 1983 to 1987, the rate of abortion virtually doubled, from 12.1 to 23.6 abortions per 100 pregnancies (Institute of Population Studies 1989). As safer techniques became more available, unsafe abortion ceased to be a serious women's health problem. By 1992, the maternal mortality rate had dropped to 132 deaths per 100,000 live births (Huntington et al. 1996).
In 1994, the MOH included guidelines for the provision of postabortion family planning services in the national service delivery guidelines. Linkages between abortion and family planning services remained low, however, despite governmental support of abortion-related family planning services. Although the Turkey Ministry of Health does not promote abortion as a family planning method, in practice many couples rely on abortion as a "backup" to traditional methods such as withdrawal. According to a 1994 situational analysis study (SAS), 44% of all abortion clients were using withdrawal at the time they got pregnant (Ministry of Health, Turkey, et al. 1995).
Traditional methods such as withdrawal are very common in Turkey, despite the wide variety of modern contraceptive methods available; the 1994 SAS found that 70% of married couples using a contraceptive method at the time of pregnancy reported using withdrawal or another traditional method.
Overall, there is widespread acceptance of family planning in Turkey, and the 1993 Demographic and Health Survey (DHS) found that nearly 99% of married women were familiar with at least one contraceptive method (General Directorate of Mother and Child Health and Family Planning et al. 1994). This survey also found that 34% of the country's married couples were using a method of contraception that requires the participation or cooperation of men [Figure 2]. Further analysis of the 1993 DHS found that over 85% of women surveyed noted that their husbands were supportive of their contraceptive method--whether it was the pill, IUD, condom, or withdrawal (Akin and Bertan 1996).
The Role of Men in Reproductive Health Decision Making
In Turkey, women are generally responsible for daily decisions regarding family health, but men play an important role in decisions and practices that affect the health services their family receives. The husband is often the primary decision maker, and a wife's economic dependence on her husband gives him great influence in major household decisions (Akin Dervisoglu 1993).
Men's role as decision maker often extends to a couple's reproductive behavior. Many men accompany their wives on visits to health care facilities and are involved in deciding when, where, and how their partners will receive services. Men also have an important say in decisions about family size and contraception, in part due to Turkey's spousal consent requirement for abortion and sterilization services and to the prevalence of traditional contraceptive methods (withdrawal and periodic abstinence) that require male cooperation.
Male involvement at all levels of decision making, such as in Turkey, can be positive if men are supportive of their wives' desires, and if the choices made represent jointly agreed upon, informed decisions. Unfortunately, however, this level of male involvement can also translate into an abuse of power in the relationship and unilateral decision making by the man on issues regarding health and reproductive choice.
Helping men be supportive partners is the goal of AVSC's Men As Partners program, and the goal faces particular hurdles in Turkey. Despite their pronounced role in reproductive health decision making, men are often not included in education, counseling, and services in Turkey. For example, although a husband must be physically present at some facilities in order to grant consent for abortion, he most likely does not receive any information about the procedure his wife is about to undergo or about how the couple can avoid future abortions. Although the husband may have an important say in the couple's use of contraception, family planning counseling is often offered only to women. In addition, while many young fathers are interested in and willing to help out with childbirth and infant care, fathers are usually not permitted to be present during delivery and are often unsure of how they can help participate in infant care.
BUILDING SERVICES FOR MEN
Increasing men's involvement in the reproductive health care system without detracting from services for women requires that institutions develop creative initiatives tailored to the unique circumstances of the individual community and culture. Over the past eight years, a number of institutions in Turkey have tried to do this by making use of existing opportunities within the health care system to provide targeted information, counseling, and services for men.
Programs at the institutions described in this paper fall within three categories:
- Programs at hospitals that use couples counseling or group information for men as a way of increasing couples' access to family planning information and services at the time of abortion
- A prenatal program designed to help couples adopt postpartum practices that promote family health (based on research examining the role of Turkish fathers during the postpartum period)
- Programs to provide increased access to family planning information and vasectomy services to Turkish State Railway workers and their families
All three types of programs utilize existing opportunities within the health care system to provide targeted services for men and couples. The first takes advantage of Turkey's spousal consent requirement for abortion services as a way to provide information and services targeted to couples' immediate family planning concerns. The second takes advantage of the fact that close to three-fourths of urban mothers receive prenatal care; men's presence within the health care facility during this time provides a way to present similarly targeted information and counseling that relate to the family's postpartum health. The third brings services to men by integrating family planning information and services into workers' health care systems.
Abortion-Related Family Planning Services
Abortion has long played an important part in the reproductive lives of Turkish couples, particularly since the legalization of abortion services in 1983. In most parts of the country, there is little stigma attached to obtaining an abortion, and there is little or no cost to obtaining abortion services in public-sector facilities.
In many ways, for clients as well as providers, the period surrounding abortion services is an ideal time to provide family planning counseling, information, and services for men and women in Turkey: couples who choose abortion signal a clear desire to space or avoid future pregnancies; a wide variety of contraceptive methods are available in Turkey; and abortion services are often provided in the same settings as family planning services. Admittedly, the spousal consent requirement for abortion is undoubtedly a barrier to some women whose desire for an abortion may conflict with their partners' wishes. On the other hand, this requirement means that husbands often are present within the health facility at the time of their wives' abortion, thus providing opportunities for educating men about how to more actively support their partners in preventing future unintended pregnancies.
The health facilities described below have made excellent progress in linking abortion services and family planning with an emphasis on increasing the participation of men through counseling. These facilities provide different types of services: some focus on couples counseling, others employ group education for men, and some provide both family planning counseling and vasectomy services at the time of abortion.
Dr. Zekai Tahir Burak Women's Diseases and Maternity Hospital
Dr. Zekai Tahir Burak Women's Diseases and Maternity Hospital (ZTB) is one of the hospitals that use the legal requirement for spousal consent for abortion as an opportunity to provide couples counseling in family planning to abortion clients. A Ministry of Health teaching hospital in a heavily populated district of Ankara, ZTB has a family planning clinic that was established in 1966. In 1983, the hospital began to offer abortion services in the clinic as well, and as of 1998, the clinic was performing over 1,700 abortions per year.
When abortion was first provided at ZTB in the early 1980s, there was no structured provision of family planning counseling, and family planning was provided to abortion clients only at the client's request. In 1991, ZTB became the first full-service family planning clinic in Turkey to offer both temporary and permanent contraception on an outpatient basis in a self-contained unit, and the hospital began to make a concerted effort to improve the linkages between abortion and family planning services. One important part of this program involves providing routine family planning counseling for both partners when clients come to the facility for an abortion.
The family planning clinic at ZTB provides both group education and couples counseling for abortion clients. When a woman first comes to the clinic to verify her pregnancy and to request an abortion, she attends a group-education session in which each available modern contraceptive method is explained through the use of visual aids. This session, which is generally attended only by women, includes discussions in which the psychologist tries to dispel myths about contraceptive methods.
After the group-education session, women are given an appointment for the abortion. They also have an opportunity to schedule time to meet with the counselor alone for additional information or counseling, if they so desire. When they return to the clinic the day of the abortion, married women are accompanied by their husbands in order to fulfill the spousal consent requirement under Turkish law, and the couple meets with a family planning counselor before the abortion. The counselor and the couple discuss the method the couple was using before the pregnancy, talk about the abortion procedure, and have a detailed discussion about the method the couple would like to use after the abortion. If the couple decides not to use a family planning method, they leave the session, and the woman goes on to obtain the abortion. Couples counseling is usually method-specific, since the wife has already acquired basic knowledge about family planning through the group-education session, but the counselor explains all the methods again if the couple has not yet decided on a method.
Providing couples counseling has presented unique challenges that require tact and diplomacy on the part of ZTB staff. Abortion is often a very stressful time for couples, and counselors at ZTB find that many women who had been using withdrawal as their contraceptive method before becoming pregnant are angry at their husbands because the method was not effective. In addition, the husband sometimes does not believe that the method has failed. "With withdrawal, sometimes the man says, 'The child is not mine,' " said a ZTB staff psychologist who provides family planning counseling. "But after we explain the physiology and anatomy, the couple usually understands."
ZTB staff also find that many clients who come in for abortion have never used modern contraception before and have many misconceptions about modern methods. In many cases, abortion services are men and women's first interaction with the health care system. In addition, many do not realize that abortion entails some degree of risk.
"Nobody talks about the disadvantages of abortion, but everyone talks about the disadvantages of methods," said a counselor. "We have a saying, 'When you're running away from the rain, you get caught in the hail.'... I tell them 'This is your third or fourth abortion. Every method has disadvantages, but abortion is not the answer.' "
Although vasectomy is not offered at ZTB, interested couples are referred to a nearby facility that provides vasectomy services. According to ZTB staff, most of the men are not very familiar with vasectomy before the counseling session. "Their first thought is castration," said one counselor, "but after counseling they don't think that." Men are a little more receptive to the idea of vasectomy at the time of abortion, reported this counselor, although those who choose to have a vasectomy are not eager to discuss it with friends and relatives. "Men don't tend to tell anyone when they have a vasectomy."
Contraceptive Use and Counseling
According to client records and reports from clinic staff, the couples counseling service at ZTB has resulted in more effective use of contraception and a reduction in repeat abortions: from 1995-1998, between 98-99% of couples who participated in pre-abortion counseling received a method after abortion and the overall number of abortions declined by almost half [Figure 3]. "Counseling has had great success," says ZTB's director. "When couples leave here, they have a good knowledge of family planning methods."
ZTB staff report that couples counseling appears to be much more effective than the group-education sessions, since both partners can get "on-the-spot" feedback to their questions in a session that is tailored to their specific needs.
Konak Women's Diseases and Maternity Hospital
Konak Women's Diseases and Maternity Hospital, the only Ministry of Health maternity hospital in Izmir, has also been successful in linking abortion services and family planning with an emphasis on increasing the participation of men. Like ZTB, Konak uses Turkey's spousal consent requirement as an opportunity to provide family planning counseling to men, but unlike ZTB, Konak also offers vasectomy services on site.
There are approximately 9,000 deliveries and 3,000 abortions at Konak per year. The hospital's family planning clinic provides a full range of contraception, including both temporary and permanent methods. Vasectomy using the no-scalpel method has been provided at the hospital since 1991. In 1994, nearly 92% of clients who came to the facility for abortion left with a modern family planning method, and approximately 3% of these clients (93) chose vasectomy--a number much higher than the national average of less than one-tenth of 1% throughout Turkey (Ministry of Health, Turkey, et al. 1995). The number of vasectomy users dropped somewhat in 1995 and 1996 (possibly due to the departure of some of the family planning counselors as well as to the introduction of Norplant implants). Yet in 1997 and 1998, the number of vasectomies returned to earlier levels (94 and 97, respectively).
Information and Counseling Services at Konak
Abortion is a two-day process at Konak. The first day clients come in, they receive "pre-abortion" counseling for family planning and undergo a physical examination. If the spouse is present, both partners attend the pre-abortion education session, which is performed for 2-3 clients (with partners) at a time. If the woman desires, she can meet alone with a counselor. After the physical examination, women are asked to come back the next day with the spouse for the abortion. Before the procedure, clients are asked whether they want a postabortion method; if so, they are generally given the method after recovery and before they leave the facility. If not, then they are still allowed to receive their abortion.
Couples counseling itself is comprehensive at Konak. After an explanation of general physiology, clients are shown samples and given information about each method. If the couple seems interested in vasectomy, they receive a detailed explanation of the procedure and additional counseling.
For men who already know about vasectomy and are certain of their choice, additional information on the procedure, postoperative instructions, and follow-up visits are given on the day of the abortion when the vasectomy is performed. Men who are thinking about vasectomy but are not yet sure that they want the method receive information and counseling and are asked to return to the hospital if they decide to have the procedure.
Counselors at Konak report that couples do not have much general knowledge about reproductive physiology, and that myths about contraceptive methods abound. It is not unusual for clients to believe that tubal ligation causes menopause or that vasectomy leads to impotence.
Careful explanation during counseling was described as the most effective way of dispelling men's fears about vasectomy. "When you speak to men, it is important to keep a professional distance," said one counselor. "You need to be serious and open and at the same time overcome your own prejudices. When the man realizes that the person across the table is serious, they may bring up important concerns about their sexuality."
Although the local press has provided substantial coverage of vasectomy services at Konak, staff reported that men generally first hear about vasectomy from hospital staff at times associated with abortion or childbirth.
A retrospective study of vasectomy users conducted at Konak for 1991-1995 (Kirca et al. 1995) showed that 42% of the hospital's vasectomy clients reported that they first heard about the procedure through health staff at the maternity. Over half of these vasectomies (63%) were directly related to the spouse's abortion at the facility. Of all vasectomy clients, 8% had their procedure on the same day as their spouse's abortion.
Social Security Institute (SSK) Ege Maternity and Women's Diseases Training Hospital
Along with the Ministry of Health hospitals, SSK hospitals are one of the health care service-delivery systems in Turkey that include family planning services. SSK hospitals, which are organized under the Turkish Ministry of Labor, provide prepaid insurance coverage for workers and their dependents and serve approximately two-fifths of the Turkish population.
Like Konak, the SSK maternity hospital in Izmir also provides abortion-related family planning information for men, but does so in a separate facility while their wives undergo abortion. The SSK hospital also provides vasectomy services.
Education and Counseling for Men
The current counseling program began in 1995. The hospital provides group education, as well as one-on-one counseling.
On the day of abortion, couples are separated and given education in same-sex groups in order to accommodate the flow of services. Women are given information in their group before abortion, and are informed about what to expect during the procedure. They also receive a general family planning update and information on available contraceptive methods. If she so desires, a woman can meet with a counselor one-on-one for additional counseling before the procedure.
Group education for men, which is usually done in groups of 10-20, takes place while the wives are undergoing the abortion procedure. The education session takes place in a counseling room well stocked with flip charts, samples of contraceptive methods, and anatomical models. The staff counselor begins by giving the group an explanation of reproductive anatomy and of the abortion procedure their wives are undergoing. The men usually have very specific questions about abortion and want to talk about the procedure in some detail.
After this discussion, the counselor first asks men in the group whether they are interested in family planning and then facilitates a discussion about why family planning is important. Each participant is asked about previous abortions and is asked to tell the group what method, if any, the couple was using when the wife became pregnant.
This discussion often uncovers myths and misconceptions about individual methods and leads to a discussion of all the methods available, including the advantages and disadvantages of each. The counselor uses anatomical models and samples of the methods to help dispel myths and rumors about methods. "For example, many people believe that the IUD is heavy and will weigh them down," said one counselor. "To deal with this, we pass around a sample IUD to the group and have them compare the weight of it with their jewelry."
Men who are interested in vasectomy are referred to the vasectomy counseling room in the adjacent building. After receiving further counseling by a doctor who performs the procedure, men who choose to have a vasectomy are registered for the operation.
As in many institutions in Turkey, a relatively low number of men choose vasectomy at SSK, and misinformation about vasectomy is common. However, doctors and counselors at the hospital believe that adequate counseling and convenient services may help change men's attitudes about vasectomy. "If you counsel them, men will be more likely to accept vasectomy," said one general practitioner who performs vasectomy counseling at the hospital. "Turkish men like to be the ones who take responsibility for their families."
Doctors and counselors at the hospital are also focusing more attention on information and counseling related to sexually transmitted diseases. "STDs are becoming more of a serious issue," said one doctor. "The STD rate is rising....Right now, in 1998, there are 115 AIDS patients: 79 in Izmir and 36 from the surrounding area. In the general population, there's good basic information on STDs, but it's not very detailed."
In response, doctors at the hospital are spending more time talking about condoms during family planning counseling. Supply of condoms is a problem, however: though the clinic gives out condoms, they have occasional outages, and many men may not want to buy condoms at the drugstore. Men are often not given good condom instructions, and failure occurs frequently as a result of misinformation about the method (for example, counselors report that men often use the same condom twice).
Although counseling for men and women is separated due to the flow of services at the hospital, the possibility of mixing men and women during counseling has not been ruled out. Counselors do find that there are advantages to same-sex family planning counseling. As one counselor remarked, "A lot of men have questions about their wives' contraception that they wouldn't feel comfortable asking in a mixed group."
Interviews with clients before and after abortion services at SSK indicate that the counseling services have been effective in increasing clients' family planning knowledge. The hospital plans to continue to interview clients to assess their needs in order to make the services more client-oriented and to make counseling services more comprehensive.
The program at the hospital is still relatively new, and staff have other ideas about ways to improve the quality of services. For example, they would like to make vasectomy services available at the family planning clinic, strengthen prenatal counseling services, and improve follow-up of all clients at the clinic.
Bringing Fathers into the Picture: Postpartum Family Planning and Health
In 1992, researchers at the Institute of Child Health at the University of Istanbul conducted a diagnostic study of the postpartum family planning and health needs of low-income women in Istanbul (Bulut and Molzan Turan 1995). In the course of client interviews, the researchers were surprised to hear many women say that they wanted to involve their partners more in family planning and child care. The study's findings showed the important role fathers play in decisions and practices affecting maternal and child health during the postpartum period.
In response to these findings, the research team set out to test ways of delivering information and counseling about postpartum health and family planning to new mothers and fathers. With partial funding from AVSC International, they conducted an intervention study from 1992-1994 with over 300 clients at the prenatal clinic of the Istanbul Medical Faculty Hospital at Capa (Institute of Child Health 1996) that was designed to answer the following questions:
- What role do fathers play in postpartum practices such as infant feeding, use of family planning, and use of preventive health care services?
- Can information and counseling in the prenatal period help couples adopt postpartum practices that promote family health?
- Does including fathers enhance the effect of such an information and counseling intervention?
During the intervention study, which focused on first-time parents only, researchers used feedback from focus groups, in-depth interviews, and telephone interviews to design a postpartum program for couples. The program, which included group-education and -information sessions, print materials, and a telephone counseling service, was evaluated through follow-up interviews with clients who participated in the program.
As in many countries, both cultural and logistical barriers affect Turkish men's involvement in health care during the postpartum period. Societal definitions of gender roles, lack of information, and significant barriers within the health care system itself were often cited by clients as impediments. In designing the program, researchers took care to address the barriers identified during interviews and focus groups.
The Role of Fathers
Although most couples reported that men's primary responsibility was to provide for the family economically, many young couples believe that fathers should become more involved with home life. During the interviews and focus groups, many young fathers said that they wanted to become more involved during the postpartum period, but were not sure how to do so. As one expectant father told researchers, "At home we help out with some jobs, but beyond that we don't have any information about feeding or about how we can be helpful to our wives....Nobody taught me, I didn't get any information" (Institute of Child Health 1996).
Difficulties posed by this lack of information are often compounded by pressure from older relatives to maintain traditional divisions of responsibility. "When I am at home putting the baby to sleep, older relatives arrive," one young father reported. "They ask me why my wife isn't doing it." In addition, advice on infant care from family and friends often conflicts with instructions from doctors, leaving many couples confused and looking for "expert" advice.
Although researchers had originally envisioned conducting individual or couple counseling sessions during the intervention phase, participants expressed a clear preference for group informational sessions on pregnancy, birth, and postpartum health. Researchers kept in mind that information given couples during these sessions had to compete with the advice of family, neighbors, and others, particularly during the early postpartum period. Although specific topics were selected for the sessions (childbirth, infant care and feeding, family planning, and pregnancy), each session remained flexible enough to address participants' specific concerns.
Health Care Facilities and Fathers
Men may be actively discouraged from participating by the structure of services or by attitudes of health care workers. "There's an unspoken rule," one staff member at a women's health center told the authors of this paper. "Doctors may not support men who want to join in. A lot of men come to the clinic with their wives, but it stops at the door."
Many men in the study said they were frustrated at being excluded from the birth process and felt helpless. In particular, both men and women said they would have liked the father to be present in the delivery room during the birth. (In many public hospitals in Turkey, fathers are not permitted to enter the delivery room for the fear that they might bring in germs or to protect the privacy of other women who might be delivering in the same room.) In some cases unsatisfactory experiences at the birth hospital resulted in the couple not wanting to return for any type of service after the birth.
To address this problem, group leaders in the informational sessions took care to prepare participants by describing realistically the challenges they would face in dealing with the health care system during the pregnancy.
Finding the Time
Long work hours and difficulty in taking time off work to attend services were also cited as reasons many men would be unable to participate. In general, women said they wanted to attend group-information sessions with their husbands, but men, although they thought this would be a good idea in theory, did not feel it would be possible to find enough time to attend.
This concern was also addressed in the program's design. To reach the men who could not or would not attend sessions at the health facility, a question-and-answer booklet and a telephone counseling line were developed.
Results of the Study and Intervention
The study has already had an effect on the way perinatal services are provided at Capa Hospital. Group-education sessions on pregnancy, birth, infant care, postpartum health, and family planning are now a regular part of prenatal care, and these sessions are open to all pregnant women, their husbands, and other family members.
Results of the intervention suggest that programs like this have the potential to have a positive impact on some postpartum health behaviors, particularly regarding the couple's use of a family planning method postpartum. Mothers who attended sessions were more likely to use a modern family planning method than women who had not (70% vs. 53%). Participants often described the decision to adopt a contraceptive method postpartum as a "couple decision," and couples in which both partners participated in the program were found to be more likely to have adopted a modern family planning method by four months postpartum (80%) than were those couples where the partner had not (55%).
The study results also suggest some positive effect of the program on maternal and infant checkups, though the program's effects on other types of postpartum behaviors, such as infant feeding, were inconclusive.
Perhaps the most important finding from the study was the difficulty involved in getting men to participate in such a program. Despite special efforts to arrange sessions on evenings and weekends, few men attended group sessions. The telephone sessions were also more highly used by women than by men. In fact, the channel utilized by the most fathers in the study was the question-and-answer booklet. Many participants who did not attend educational sessions said that transportation was a major impediment to attendance, and many said that a location closer to their homes would have made the difference in their attendance.
Though it is important to give fathers the opportunity to become more involved in family health care, forcing couples to participate in joint counseling could easily become a barrier to services, since requiring husbands and wives to come together might prevent some women from coming alone. In light of this finding, researchers suggest that sessions be left open to men to encourage their attendance, but providers should not insist that couples come together.
"Strong efforts should be made to include men in the process, mainly because women want them to be involved," said one of the study's designers. "They want the psychological support, and they want men to be the supporters."
On the whole, clients reported being very happy with the program. As one researcher said, "They couldn't believe something like this was offered free of charge in the public hospital."
Counseling and Services for Turkish State Railways Workers
Republic of Turkey State Railways Hospital, Ankara
The Turkish Republic State Railways (TCDD) provides medical care to its current and retired employees and their dependents (between 250,000-300,000 clients served by nearly 900 service providers) through 5 hospitals and over 40 clinics. TCDD provides condoms, IUDs, and oral contraceptives. Tubal sterilization and no-scalpel vasectomy are provided by referral at TCDD hospitals in Eskisehir and Ankara.
Over the past eight years, the Ankara hospital has developed a number of workshops and programs aimed at increasing workers' general knowledge of contraception and of the family planning services available at the facility. One of these programs, a 1991-1992 intervention study, was designed to find out how educational sessions for male railway workers affected their knowledge, attitudes, and behavior regarding family planning (Bicer 1993).
This study was conducted in three phases. In the first phase, family planning knowledge, attitudes, and behavior of male workers were assessed. In the second phase, a team comprised of a general practitioner, a psychologist, and a midwife from the hospital trained 15 "peer leaders" selected from the workers in maternal health and family planning. Each peer leader then conducted three monthly educational sessions for a group of approximately 25 workers. In the third phase of the study, changes in workers' knowledge, attitudes, and behavior were evaluated five months after the last educational session.
The majority of men in the study were married (approximately 95%) and had between one and three children. Approximately 68.3% of married couples stated that they did not use a family planning method before their last pregnancy, and approximately 18% said that their last pregnancy had ended in abortion.
As illustrated in Table 1, the study's findings showed a notable difference in participants' use of modern contraceptive methods after the training. Participants also reported considerable changes in their attitudes and understanding. For example:
- After the training, there was an increase in the number of workers who reported that they had started making family planning decisions with their partners.
- The number of workers who said that both the man and the woman should share the responsibility for family planning increased.
- A number of workers gained a positive attitude toward vasectomy and tubal ligation after the training.
- Although most men in the study already knew something about vasectomy before the trainings, their understanding of the effects of the procedure increased.
The male-involvement programs discussed in this paper are quite different from one another, yet they all share a few common goals. All of these programs are striving to increase the constructive participation of men in reproductive health decision making, and all of them make use of existing opportunities within the health care system to provide counseling and services for men.
Because almost all of them take advantage of occasions when men are already within the health facility for related purposes, these programs have been able to effectively involve men in counseling and services, without subtracting from the resources needed to provide services for women.
In many cases, there does not appear to be a need to set up separate programs for counseling and services geared solely toward men, since, as the experiences of postabortion vasectomy providers show, many men appear to be willing to obtain these services from a female-dominated maternity hospital.
Although demand for vasectomy services is generally low in Turkey, some of these programs have successfully linked vasectomy and abortion services. The belief that contraception is women's responsibility, lack of knowledge about vasectomy, and the attitudes of health care workers are often cited as reasons for the small number of vasectomy clients in Turkey. Yet experiences at some of the programs profiled in this paper show that many men will consider vasectomy when appropriate education, counseling, and services are in place. This is in keeping with findings from a six-country vasectomy decision-making study which found that the reasons for choosing vasectomy were similar in all of the countries despite cultural, economic, and racial differences, with concern for the women's health as a principal reason (Landry and Ward 1997). In the future, research to explore the vasectomy decision-making process in Turkey would help providers better target informational and educational programs.
Though linkages between abortion and vasectomy services appear to be a good fit in Turkey, this seems in large part to be due to the constraints of the country's spousal consent requirements. It is uncertain whether these results would be as effective in another setting.
Questions and Challenges
Despite the significant, if sometimes limited, successes of the programs described in this paper, the experiences of these health care providers have also established that many questions and challenges remain.
It remains far from certain, for instance, whether single-sex, group-oriented counseling, couples counseling, or some combination of the two is the most appropriate medium for helping clients make family planning decisions. When the man clearly plays a dominant role in decision making and the woman does not feel comfortable asserting her wishes in his presence, a third type of counseling should be provided as well: separate counseling for the woman alone. Also, cultural mores continue to play a large if diminishing role in men's receptivity to modern methods of family planning and child rearing.
While important studies have been conducted, no fully integrated investigation into many aspects of family planning services and perinatal counseling in Turkey has been done. The dissemination of family planning information for women (and, more significantly for this paper, for men) in Turkey has improved immensely over the last three decades, but future advances will depend on more organized and concerted efforts.
* This requirement remains in effect today. While minors are required to obtain consent from a parent or guardian, unmarried women of legal age are exempt from consent requirements. Couples are not generally required to produce a marriage license, and the spousal consent process varies from one facility to the next. While some facilities require that the husband accompany his wife to the facility to ensure that consent has been obtained, others merely require the woman to produce a signed form.
Working Paper #12 Authors:
John M. Pile is senior director, Dr. Cigdem Bumin is program manager, and G. Arzum Ciloglu was formerly senior program officer, AVSC International. Dr. Ayse Akin is a professor in the Department of Public Health, Hacettepe Medical Faculty. From May 1992 to June 1997, she was general director for mother and child health and family planning, Turkey Ministry of Health.
- Akin, A., and Bertan, M., eds. 1996. Contraception, abortion, and maternal health services in Turkey: Results of further analysis of the 1993 Turkish Demographic and Health Survey. Ankara: Ministry of Health.
- Akin Dervisoglu, A. 1993. Psychosocial factors that influence women's decision to obtain abortion and family planning services (unpublished report). World Health Organization Collaborative Study, Project Number 89057, Ankara.
- Bicer, S. 1993. The effect of training on family planning knowledge, attitude, and behavior (unpublished research report). Ankara.
- Bryan, P. J., and Senlet, P. 1990. Turkey: Population assessment, strategy and action plan recommendations for USAID assistance--USAID assessment visit report. Washington, D.C.: Asia-Near East Bureau, U.S. Agency for International Development.
- Bulut, A., and Molzan Turan, J. 1995. Postpartum family planning and health needs of women of low income in Istanbul. Studies in Family Planning 26: 88-100.
- General Directorate of Mother and Child Health and Family Planning, Turkey Ministry of Health; Institute of Population Studies, Hacettepe University; and Demographic and Health Surveys, Macro International. 1994. Turkish Demographic and Health Survey 1993. Ankara and Calverton, Md.
- Huntington, D.; Dervisoglu, A. A.; Pile, J. M.; Bumin, C.; and Menach, B. 1996. The quality of abortion services in Turkey. International Journal of Gynecology & Obstetrics 53: 41-49.
- Institute of Child Health, Istanbul University. 1996. Postpartum family planning and health in Istanbul: Bringing fathers into the picture (final report, AVSC International small grant TUR-26-SV-1).
- Institute of Population Studies, Hacettepe University. 1980. 1978 Turkish Fertility Survey. Ankara.
- __________. 1989. 1988 Turkish Population and Health Survey. Ankara.
- Kirca, U.; Pile, J. M.; and Akin, A. 1995. Postabortion vasectomy in Turkey. Paper presented at the annual meeting of the American Public Health Association, October, San Diego.
- Landry, E., and Ward, V. 1997. Perspectives from couples on the vasectomy decision: A six-country study. Reproductive Health Matters (special issue): 58-67.
- Ministry of Health, Turkey; Gazi University Medical Faculty; Population Council; and AVSC International. 1995. Turkey situation analysis of selected reproductive health care services: Condensed English report. Ankara.
RECORDED INTERVIEWS AND PERSONAL COMMUNICATIONS
- Dr. Zekai Tahir Burak Women's Diseases and Maternity Hospital, Ankara
- Dr. Oya Gokmen
- Dr. Betigul Guliter
- Dr. Kazim Aral
- Dr. Ayse Evren
- Women and Child Health Training and Research Unit, Institute of Child Health, Istanbul University, Istanbul
- Janet Molzan Turan
- Dr. Aysen Bulut
- Konak Women's Diseases and Maternity Hospital, Izmir
- Dr. Dilek Aksit Unver
- Dr. Uzeyir Kirca
- Izmir Social Security Institute Ege Maternity and Women's Diseases Training Hospital, Izmir
- Dr. Hafize Soyupak
- Dr. Cengiz Cankaya
- Dr. Serdar Yagceken
- Dr. Zuhtu Benli
- Republic of Turkey State Railways Hospital, Ankara
- Dr. Ozcan Atahan
- Dr. Ahmet Metin
- Demiryol-Is, Ankara
- Ali Topcu
MEN AS PARTNERS: RELATED READING
Available from AVSC's Men As Partners Initiative
To request the following publications, write the Men As Partners Initiative, AVSC
International, 440 Ninth Avenue, New York, NY 10001, fax: 212-561-8067, or send
an e-mail to firstname.lastname@example.org.
- Programming for Male Involvement in Reproductive Health: A Practical Guide for Managers
- Offers advice on how program managers can address critical issues when initiating or improving reproductive health services for men. This guide covers topics such as program design, community outreach and workplace programs, counseling, integration of sexually transmitted diseases services, and the special needs of adolescents.
(1997) English, Spanish, French. Copies free.
- Men As Partners in Reproductive Health: Workshop Report
- Reports on the first inter-regional Men As Partners workshop, held in Mombasa, Kenya, in May 1997. Over 140 participants from Africa and Asia discussed practical ways to provide services to men and to support their constructive involvement in the health of their female partners.
(1997) English. Copies free.
- New Paradigms of Male Participation in Sexual and Reproductive Health: Symposium Report
- Reports on the symposium held in Oaxaca, Mexico, in October 1998. Over 100 participants from the Americas discussed issues such as sexuality, fatherhood, violence, different forms of masculinity, and HIV/STD prevention and the impact of these issues on male involvement in sexual and reproductive health.
(1998) English, Spanish. Copies free.
- New Paradigms of Male Participation in Sexual and Reproductive Health: Five Case Studies
- Five case studies of innovative programs in the Americas that are working to constructively involve men in sexual and reproductive health.
(1998) English, Spanish. Copies free.
- Landry, E., and Ward, V. 1997. Perspectives from couples on the vasectomy decision: A six-country study. Reproductive Health Matters (special issue): 58-67.
- Ndong, I.; Becker, R. M.; Haws, J. M.; and Wegner, M. N. 1999. Men's reproductive health: Defining, designing, and delivering services. International Family Planning Perspectives 25: S53-S55.
- Verme, C. S.; Wegner, M. N.; and Jezowski, T. 1996. The language of male involvement: What do you mean by that? Populi 23 (2): 10-12.
- Wegner, M. N.; Landry, E.; Wilkinson, D.; and Tzanis, J. 1998. Men as partners in reproductive health: From issues to action. International Family Planning Perspectives 24 (1): 38-42.
The purpose of AVSC Working Papers is to capture on paper AVSC's experience and to disseminate the results of AVSC-supported operations research. We welcome your comments and suggestions.
The authors would like to especially thank Dr. Oya Gokmen and Dr. Kazim Aral from Dr. Zekai Tahir Burak Women's Diseases and Maternity Hospital, Dr. Uzeyir Kirca at Konak Women's Diseases and Maternity Hospital, Dr. Kenan Ertopcu from SSK Ege Maternity and Women's Diseases Training Hospital, Dr. Aysen Bulut and Janet Molzan Turan from Istanbul University Women and Child Health Research and Training Unit, and Dr. Ozcan Atahan and Dr. Sevgin Bicer from the Turkish State Railways Hospital in Ankara for their work and cooperation in the writing of this paper. The authors also thank Joanne Tzanis and Jeanne Haws for their invaluable suggestions and help in the design,
development, and review of the manuscript. Additional reviewers were Evelyn Landry, Pamela Beyer Harper, and Jill Tabbutt-Henry. Pamela Beyer Harper edited the paper. Finally, the authors would like to thank Dr. Pinar Senlet, population program advisor for the U.S. Agency for International Development, for her support of this research.
This publication may be reproduced without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged. This publication was made possible, in part, through support provided by the Office of Population, U.S. Agency for International Development (AID), under the terms of cooperative agreement HRN-A-00-98-00042-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of AID.
- Amy E. Pollack, M.D.
- Libby Antarsh
- Lynn Bakamjian
- Joseph C. Dwyer
- Pamela Beyer Harper
- Terrence W. Jezowski
- Evelyn Landry
- Cynthia Steele
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