Gendered power dynamics and women’s negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya

Abstract

In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples’ negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women’s and couples’ negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or at the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male-dominated reproductive decision-making and women’s agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.

What motivates serodiscordant couples to prevent HIV transmission within their relationships: findings from a PrEP implementation study in Kenya

“…Heterosexual relationships in western Kenya are often marked by unequal power dynamics (Harrington et al 2016; Kenya Ministry of Health and National Bureau of Statistics 2015). For example, in western Kenya, less than half of the married women who earn their own income make independent decisions on how to spend those earnings (Kenya Ministry of Health and National Bureau of Statistics 2015).…”

Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana

“…It is possible that restrictive sociocultural norms and attitudes toward adolescent SRH act in tandem with structural factors, as well as interpersonal ones, to influence adolescents’ willingness and ability to engage SRH care; however, this has not been comprehensively studied (Levandowski et al 2012; McGuire and Stephenson 2015). Gender norms that emphasize motherhood, religious norms regarding the immorality of sex outside of marriage, or cultural norms that devalue adolescence as a life stage, for instance, may shape systems-level approaches to adolescent SRH care and education (Harrington et al 2016; Jesmin and Cready 2016; MacPherson et al 2014). …”

How Do We Get Partners to Test for HIV?: Predictors of Uptake of Partner HIV Testing Following Individual Outpatient Provider Initiated HIV Testing in Rural Uganda

“…HCT is commonly segregated by gender for clinical reasons, and because women nearly universally receive testing in ANC, the burden often falls on women to engage their partners to test (32, 53). Couples-based testing and programs that engage men are especially important in settings where men have more decision-making power in a couple’s prevention behaviors (5, 68), but more research is needed on effective ways to increase male partner testing.…”