Janet Asiimwe was 22 when, in May 2019, she got married to Isaac Kalemba, 24, in Kampala, Uganda. Coming from a conservative evangelical Christian family, Asiimwe had little knowledge about family planning and reproductive health. The Evangelical Church in Uganda and indeed across Africa teaches abstinence from sex before marriage and does little, if any, sexuality education for young people.
“Now it occurred to me that I was going to begin having sex and possibly have children too but I was quite unprepared, I would say,” Asiimwe recalls. “My fiancée and I were not sure whether we should decide to have children right away or not. If we were going to delay having children, for how long would that be and what were the best contraception methods available? Anyway, I conceived I think in the second week of our marriage, and before our first anniversary, we had a baby girl.”
Before they became parents, Asiimwe and Kalemba had no knowledge of family planning services. “The question then was, were we going to have a second baby immediately? What were we going to do?”
Asiimwe and Kalemba’s story is not unique. It is a story shared by many couples—especially young couples—across Africa: a story of little or no information about family planning services and the use of contraceptives, partly because of the lack of specific family planning programs for this large, unique subset of young people. Programs that specifically address the needs of couples, also referred to as couple-focused interventions (CFIs), conceptualize the couple as the basic unit that the intervention targets as a means to improving reproductive health practices and outcomes.
However, the lack of information about the nature, needs, and concerns of young couples, and how their relationships influence their reproductive health decisions and behaviors, is a field not yet well-explored by family planning programs.
The Evidence to Action (E2A) Project is working to change this. A USAID-funded global project for strengthening family planning and reproductive health service delivery for girls, women, and underserved communities, E2A has been working in recent years in Burkina Faso, Tanzania, and Nigeria on reaching young first-time parents.
Based on these experiences, E2A set out to learn more about the potential of couple-based approaches. E2A conducted literature and policy reviews, which showed young couples were nearly as absent as men in reproductive health programs, research, and policy. The reviews revealed that programs and policy continue to focus on adults or unmarried adolescents, while the needs of adolescent and young couples remain unaddressed—despite the fact that many of these young people are in unions and that the majority of adolescent childbearing occurs in the context of marriage.
E2A’s literature review also revealed that couple-focused interventions were just as effective or more effective than interventions focused on members of the couple alone or separately—and that this held true across the spectrum of reproductive health programming, including family planning, maternal health, and HIV. Because of these findings, E2A believes that CFIs represent an additional valuable strategy to address the needs of first-time parents, such as Asiimwe and Kalemba, and consequently accelerate progress toward achieving reproductive health goals.
Eric Ramirez-Ferrero, E2A’s Technical Director, says that, traditionally, family planning program managers focused on women alone or involved men as an afterthought to “help” women use family planning. “However,” he argues, “if you focus on the couple and aim to change something in their relationship—like their quality of communication around family planning—you will likely get a better outcome.”
Ramirez-Ferrero explains that CFIs represent an opportunity for gender-transformative programming aimed at changing power dynamics within relationships, promoting couple communication and shared decision-making, and altering the perception of male partners—from being seen as obstacles to reproductive health, to the conceptualization of men as a constituent component of reproductive health service delivery and policy.
In CFI programming, the critical shift is from seeing family planning utilization as solely an individual concern to seeing it as a shared concern for the couple. In the case of Asiimwe and Kalemba, the decision over child spacing, including where and what method of contraception to use, may be appropriate for the couple to make together. “In couple-focused intervention, we seek to promote joint learning of the couple, discussion, shared decision-making, and mutual support,” says Ramirez-Ferrero.
There are key considerations for effective CFIs in family planning programs. From a logistics point of view, Ramirez-Ferrero expounds, a small thing—like having an extra chair in the counseling room for the partner—and ensuring privacy for the couple are important. From a human resources point of view, ensuring that your health workforce is trained to provide gender-transformative couple counseling is critical.
Program managers should also ensure that family planning social and behavior change communication materials, such as posters and pamphlets, reflect the couple, and not just the individual; give good information to both partners; and help both feel welcome at the healthcare facility.
It is important, however, to note that the quality of the relationship affects the degree of mutual influence of the partners. Asiimwe and Kalemba freely talked about their hopes and fears in family planning as first-time parents. They seem to have good, honest, and open communication about family planning, which makes joint decision-making about contraception easier. It clearly would not be appropriate to involve an abusive partner in women’s reproductive health care. “We want to make it really clear that even though we think that couple-focused interventions are an important public health strategy, we believe that women’s bodily and reproductive autonomy still needs to be maintained despite the involvement of their partners,” Ramirez-Ferrero stresses.
At the macro level, CFI may also require changes to the entire national health information system in order to collect information about couples and outcomes. E2A’s experience in West Africa shows that, from a program planning perspective, it is critical to recognize that marriage unions and relationships take place within the context of particular cultural settings and that unions themselves are profoundly shaped by cultural and gender norms, meaning that CFIs may work in some settings better than others. For instance, in Burkina Faso—where marriages are the norm, even for young couples—CFIs are likely to be effective because these relationships are relatively stable and of some duration. In other settings, where relationships may be more transient, CFIs may not be as effective.
As noted earlier, CFIs are yet to be well-explored by current family planning programs. To address this, E2A has produced resources that lay out the evidence for CFIs for family planning programs; provide a policy analysis based on global policy documents, such as the Global Strategy for Women’s Children’s and Adolescents’ Health 2016-2030; and feature expert interviews.
The resources, which were launched in March, present a theory of change that maps out pathways in which CFIs can help lead or contribute to the achievement of family planning outcomes. The theory of change focuses on the couple as the principal unit of intervention and the processes of change that inform the decision to adopt behavior that advances the reproductive health of one or more members of the couple and the entire family.
According to Ramirez-Ferrero, the theory of change will help program implementers to be systematic in their approaches to CFIs by laying out how the various program components may work together, define and prioritize strategies to support the mechanisms of action, and help monitor and evaluate specific interventions. E2A recommends the inclusion of indicators for couple engagement in research and multilateral, national, and donor reporting frameworks to create demand for couple-focused programming. This is envisaged to improve reproductive health practices and outcomes while meeting the specific, unique needs of couples such as Asiimwe and Kalemba, the young couple and first-time parents in Kampala.
To learn more about E2A’s work with couples, register for Couple-Focused Interventions: A Global Opportunity to Advance RH, a webinar co-hosted by E2A and FP2030. The webinar is scheduled for March 30th, 2021.