Graduate School of Development Studies

A Research Paper presented by: Christine Mukankundiye (Rwanda) in partial fulfillment of the requirements for obtaining the degree of MASTERS OF ARTS IN DEVELOPMENT STUDIES Specialization: Women, Gender and Development (WGD)

Members of the examining committee: Dr.Loes Keysers [Supervisor] Dr.Dubravka Zarkov [Reader]

The Hague, The Netherlands November, 2011 Disclaimer: This document represents part of the author’s study programme while at the Institute of Social Studies. The views stated therein are those of the author and not necessarily those of the Institute. Research papers are not made available for circulation outside of the Institute.

Inquiries:

Postal address: Institute of Social Studies P.O. Box 29776 2502 LT The Hague The Netherlands Location: Kortenaerkade 12 2518 AX The Hague The Netherlands Telephone: +31 70 426 0460 Fax: +31 70 426 0799

2 Contents

3 List of Tables

4 Acknowledgements My immeasurable thanks go to my supervisors Dr. Loes Keysers, my second reader Dr, Dubravka Zarkov for making this paper complete and valuable. My Grateful thanks to NUFFIC, for providing me with a scholarship to pursue my education in the Netherlands and to the entire WGD staff, classmates whom we shared the journey for the completion of this course.

5 Dedications To the Almighty God, To you my dearest parents, Brothers and Sisters, Friends, I dedicate this book.

6 List of Acronyms

ADEPER Association des Eglises de Pentecote au Rwanda CHW’s Community Health Workers EDPRS Economic Development and Poverty Reduction Strategy FGDs Focus Group Discussions FP Family Planning GAD Gender and Development HDS Health Demographic Survey HIV/AIDs Human-Immune Deficiency Syndrome ICPD International Conference on Population and Development IEC Information Education and Communication IHI Intra-Health International MoH Ministry of Health NFPP National Family Planning Policy NGO Non-Governmental Organization PCN Pre-and Post Natal Care PMTCT Prevention of Mother to Child Transmission RWAMREC Rwanda Men’s Resource Centre UNFPA United Nations Population Fund UNICEF United Nations Children’s and Education Fund USAID United State Agency for International Develop VCT Voluntary Counselling and Testing

7 Abstract

Promoting gender equality is among the countable achievements Rwanda has achieved in a small period just after the 1994 Genocide. To achieve this, there have been various strategies like gender mainstreaming in all development sectors. Family planning has been seen as a priority in Rwanda as the health minister once noted that “family planning is a tool of development”. To achieve this, men have been called upon to participate since little can be achieved without their contribution. This study therefore aims at investigating men’s participation in family planning services and how it influences family planning uptake.

The Research findings demonstrates that, the number of men participating in family planning services in still low and this has a direct connotations with the patriarchal settings of the country also related to cultural believes and norms which still places reproductive issues as a woman’s concern mostly in rural areas and also the fact that, most programmes available are female oriented. The fact of having a small number of men in family planning services leads to a direct influence of family planning uptake.

Finally, I conclude basing on the research findings that, many signs of cultural constructs which draws specific roles for men and women are still given value in the society and men have to submit to this in order to be proven as real men.

8 Relevance to Development Studies Family planning has been pointed out as one of the channels to sustainable development in many developing countries including Rwanda. It has been put in place by most developing countries that, family planning could be one way of overcoming the overwhelming problem of poverty, promoting gender equality as well as realising women rights. The fact that, Family Planning has been given a place in achieving the development goals, one can therefore point out that, there is no any other suitable area of study to place it than in development studies. This study therefore seeks to demonstrate further considerations in this field to the policy makers, scholars and development agencies. The knowledge produced in this study therefore could be of importance to all those who work on interventions in the sexual and reproductive health Arena.

Keywords Family Planning, Gender, Men and Masculinity, Sexuality and Participation

9 Chapter 1 General Introduction

1.1 Introduction “Change in both men’s and women’s knowledge, attitudes and behaviour, are necessary conditions for achieving the harmonious partnership of men and women. Men play a key role in bringing about gender equality in most societies, men exercise predominant power in nearly every sphere of life. It’s essential to improve communication between men and women on issues of sexuality and reproductive health and understanding of their joint responsibilities so that men and women are equal partners in public and private life” (ICPD: 1994: 35)

1.2 Background Family planning is a “key component of reproductive health”. It is a state where individuals are having a complete wellbeing of physical, mental and social life not only having no diseases but also meeting their needs in all reproductive functions and processes in their reproductive systems. Reproductive health therefore implies that, people are able to have a satisfying and safe sex life and the capability to reproduce and make choice on if, when and how to do so (Rebecca et al.1996: 115). At the 2005 World summit, Governments Committed themselves to achieving Universal access to reproductive health including family planning by 2015, as set out at the International Conference on Population and Development (World Contraceptive use 2007) where the right to reproductive health was a key discussion issue. “ Reproductive rights embrace certain human rights that are already recognised in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic rights of all couples and individuals to decide freely and responsively the number, spacing and timing of their children and to have the information and means to do so and the right to attain the highest standard of sexual and reproductive health” (Sen and Batiliwala 2000: 16). The Millennium Development Goals (MDGs) sets gender equality and women empowerment as objective 3. The objective therefore calls for the integration of gender considerations in all programmes. It’s for this reason that, men’s participation in family planning services is required if gender equality is to be acquired. Therefore, matters of reproductive health should be a broader concern for all not just for women and should be both family and society matter (Wondimu 2009: 1). Historically, most focused family planning programs have been offering their services exclusively to women, which indicates that, women have been seen as the target group and very little attention has been paid to the role that men might have in respect to women in reproductive health 10 decision making and behaviour (Ibid). It’s just of recent in the 1990s that, most women organisations realised the broader intervention of reproductive health for stance during the Cairo program for actions conference which discussed on male responsibility. Rwanda being a signatory of the Universal access to Reproductive Health, recognises the importance of family planning in the country’s development. However, the country is still struggling with many challenges in establishing and implementing fully fledged family planning systems. As the Rwandan minister of health noted. “Family planning is a tool of development, the experience of this country over the past several years shows what an important role family planning plays in a country’s development but it still has challenges”. (Solo 2008: 4). The relevance of Family planning for Rwanda is contained in the country’s vision 2020, the umbrella Program for the country’s sector strategies.

According to its vision 2020, (the umbrella program for the country’s sector strategies) and Economic Development and Poverty Reduction Strategy (EDPRS) for 2008-2012, Rwanda is one of the highly densely populated countries in the sub-Saharan Africa estimated to reach over 13 million by 2013, (MoH 2008: 8). To realise this, Rwanda has committed itself to reducing high fertility rate, reducing high maternal mortality rate and infant mortality rate through family planning promotion.This is considered to have a big role in achieving the EDPRS as it’s the second medium-term strategy towards the attainment of the vision 2020 (Pand et al.2010: 1) however, this assumption can be critically reflected on that, family planning cannot be the sole factor responsible for poverty reduction since there are other factors which can contribute and therefore viewing its application as the sole solution leads us to a critical thinking using Thomas W.Merrick’s ideas in his article “population and poverty” where he stresses that, “economic policies determine poverty reduction and that contraception is a “private good”. He further points out that, not all people agreed that family planning programs would effectively work in ending poverty instead some economists points out that, poverty may lead to high fertility due to the fact that, poor people consider many children as a source of wealth, providers of house hold labour and also the only form of social security to parents during their old age (Merrick 2002: 42). The main focus in his paper shows that, family planning has nothing to do with poverty reduction due to the fact that, in 1950s and 1985, the population in most developing countries doubled but this didn’t prevent most countries in this region to rise in their standards of living for stance china is the most populous country in the world and “over the past 20 years, china’s gross domestic product which stated at a very low level, has grown

11 at a rate far higher than that of any region of the world-about 10% a year. (Ibid. ). Due to Rwanda’s population increase, and reducing high fertility rate being its objective by 2020, family planning programs targeting women only without men will achieve less, therefore increasing the number of men as clients, supportive partners and agents of positive change in family planning services has been set as a strategy to increase the participation of men. The assumption of looking at men into 3 categories can be critically reflected on in the way that, firstly, in most patriarchal communities including Rwanda, men are the bread winners in most families and therefore, participating in family planning programs would be seen as a wastage of time. Secondly, there are still other factors deeply embedded in the society for stance cultural norms which are still binding men in certain behaviours and in certain images which could make their practice in the above motioned 3 categories difficult. Family planning programs could look first at the strong mechanisms to challenge the existing barriers mostly connected to social norms if men’s participation is to succeed. This research is therefore attempting to hear from men and women in the rural area in Rwanda, their views concerning men’s participation in family planning services, what could be the challenging facts on the ground and also to get to know how men who have already participated have managed to do so regardless the existing barriers. Evidences of this study is drawn from the empirical data obtained from 7 FGDs comprised of both men and women who are users and non-users of family planning services as well as other professionals in this field.

1.3 Statement of the problem Family planning has attracted the attention from both developed and developing countries where the main discussions drawn from the Cairo 1994 conference stated that, “The aim of family planning programmes must be to enable couples and individuals to decide freely and responsibly make available a full range of safe and effective methods”(ICPD 1993: para, 7.12). Although the Rwandan Ministry of health encourages all partners to fully participate in the utilisation of family planning services, most women in rural areas are not utilizing these services and this could rise from different factors. Firstly, the possibility that, their male partners do not allow them to use contraceptives due to various misconceptions around family planning in the community (Joshua et al.2008: 2). Secondly, the fact that, in most African societies, men are still the decision makers at home, women do not have control over their sexual reproductive rights including utilisation of family planning services. Again the fact that, most men in rural areas of Rwanda still believe in the idea of having many children as a source of security in their old age, It is in this regard that, the ministry of health calls upon all couples to fully participate in family planning services However, the number of men is still very low in

12 almost all health centres in Rwanda. (MoH 2008: 8), The absence of men in family planning services has been evidenced as one of the reasons which affects the general utilisation of family planning contraceptives among rural women (USAID 2010: 1).

“Men are the gate keepers of current gender orders and the potential resistors of change. If we do not effectively engage men and boys, many of our efforts will be either thwarted or simply ignored” (Kaufman in Emily 2006: 1). It’s in this regard that, if men are not included in family planning programs, gender equality, equal reproductive health rights for both men and women and the increased uptake of family planning contraceptives, will not be attained. Different studies are of the view that, reproductive health programs are expected to be effective for women only if men have participated. Drennan (1998) as in (Mathew et al.2004:34).It’s therefore in this case that, a husband’s disapproval leads to the reduction in the use of family planning services. Involving men and obtaining their support and commitment to family planning, is crucial for family planning success. The fact that, most of the decisions which affect family lives in homes are made by men, they have a crucial role in influencing the utilisation of family planning services by their wives. Various studies have shown that, providing men with information and involving them in couple counselling sessions can keep them to be more supportive to contraceptive use and more aware of the concept of sharing decision making Wells (1997) as in ( Bui et al.2003). Failing to involve men in family planning programmes therefore, can cause a serious impact even when women are educated and willing to use contraceptives, they may fail due to the denial from their partners (Wandimo 2009: 1). This fact is also evidenced in Rwanda where various women wish to use family planning services but on condition that, they get approval from their husbands. All these evidences prove men’s absence in the practice (Cornwall 2000: 18). It is due to this situation that, the study aims to investigate the way men participate in family planning programs in Gatsibo district, Kiramuruzi sector.1

1.1 Research Objective The research aims to understand how and why men participate in family planning services and how it influences the utilization of family planning services in Gatsibo district.

1 Administrative structure next to the district. 13 1.1 Research Question

1.5.1 Main question How dominant notions and practices of masculinity and sexuality influence men’s participation in family planning programs and services.

1.5.2 Sub Questions 1. Why do men participate or not in family planning services?

2. How do men and women perceive family planning services and men’s participation and how ideals of masculinity and norms of (reproductive) sexuality influence those perceptions?

3. What are the perceptions of service providers towards men’s participation in family planning services and what notions of masculinity and (reproductive) sexuality are present in those perceptions? 4. What notions of masculinity and (reproductive) sexuality are present in the state policies and programs of family planning, and in the practice of the family planning services?

1.2 Methodology The main focus of this study was to find out how men participate in family planning services and how their participation or not influence the uptake of family planning services in Gatsibo district. In order to find out this, various qualitative methods were employed namely; interviews (in- depth interviews), FGDs as well as the observation method. The study was qualitative in nature and both primary and secondary methods of data collection were employed.

1.6.1 Selection of the research site Gatsibo district and Kiramuruzi sector were chosen purposively for various reasons. In the first place, before coming for further studies in the Netherlands, the researcher worked in this district and had got familiar to the community members and local leaders as well. The researcher then found it essay to access all the information needed as well as meeting the respondents easily. Administratively, having worked in this district before, was also an added value for a reasercher to easy her work due to the fact that,the resercher knew most of the district personnel very well, so contacting them was very easy. Secondly, Gatsibo district being among the districts which has high family planning prevalence in the country, and as concerns the researchers information needed, carrying out a research in such district would help to

14 gather the information in line with how men participate and viewing its influence on the uptake of family planning services.

1.6.2 Sources of data collection The researcher used both secondary and primary data. Secondary data was generated from the internet, MoH reports, health centre reports, Academic articles, journals among others. Primary data was collected during the month of July and August 2011.This was collected from respondents in the 6 FGDs, 7 interviews with various family planning personnel in Kiramuruzi sector, Gatsibo district and Kigali city2. The first FGD was comprised of 12 female clients of family planning, the second comprised of 9 female non-clients of family planning and thirdly 7 Men who are family planning clients (These men have not taken any specific family planning method but they collaborate with their female partners (wives) and they authorise them to use family planning hence becoming users too). The fourth FGD comprised of 5 Men who are not family planning clients. (These are men who haven’t used any family planning method or allowing their partners to go for one while the fifth comprised of 11 CHWs. (These are women and men who are community-based distributors who carry out community mobilizations and community sensitizations sessions working under the ministry of health. This is aimed at improving health conditions of community members.The final FGD comprised of un-married girls and boys but who are not in school. Men and women who were in these FGDs were not couples; the research used a family planning client’s to list to select the participants.

1.6.3 Interviews A number of 7 interviews carried out in this research were in-depth in nature and were carried out to various key informants working in the field of family planning. All these interviews were carried out in the respondent’s working places.The in-depth interviews carried out targeted MoH personnel in-charge of family planning at the national level, a district personnel in charge of health affairs, the in-charge of family planning at Kiziguro hospital (district hospital), the in-charge of family planning services at Gankeke health center, the personnel in-charge of social affairs at Gakenke sector and finally a staff in the Rwanda Men’s Resource Centre (RWAMREC).The purposive sampling was employed in regard to the respondents experience in the field of family planning.

2 Rwanda capital city 15 1.6.4 Observation method Observation method was also employed as a way of gathering more data on how men participating in family planning. This aimed at observing the nature of services men go to receive at the health center, the dynamics of service providers towards men in the waiting room, observing how many couples went for family planning services together as well as capturing the interactions between clients and service providers. This was done 3 times (Once in a week.)

1.6.5 Sampling Purposive sampling was employed regarding the selection of respondents. Firstly, due to the information the researcher wanted, the researcher selected respondents for FGDs basing on the knowledge they had. Respondents belonging in FGDs of family planning clients were chosen because of their experiences in the practice. Respondents who belonged in the group of non- family planning clients were also purposively selected not because they have experience in family planning but to give their views and perceptions regarding family planning. The interview respondents were selected because of their positions as key persons in the field of family planning that would enrich the research with their skills and knowledge.

1.3 Ethical considerations Gathering community members when you are neither a local leader nor a staff in any government structures is not easy. In the first place, the researcher made appointments with the local leaders, district and hospital leaders. In these meetings, the researcher explained the reasons for carrying out the research. In confirming this, the researcher presented an introduction letter given by ISS through the second reader. Before proceeding further, the resercher was requested from the district hospital to first get the authorization letter from the ministry of health to prove the eligibility for the access of data wanted. The resercher then went through the process of requesting this letter which covered all most two weeks due to the absence of some officials. During the first meeting with the selected respondents, the researcher introduced herself and explained the purpose of the meeting as well as the research. The researcher also added that, all what will voluntary and no monetary benefits arranged.

1.4 Scope and Limitations of the study The research focused in Gatsibo district where Kiramuruzi sector is located and also in Kigali city due to the fact that, there was a need to interview some policy makers in the ministry of health as well as a RWAMREC staff and these are all located in Kigali.In regard to the study limitation, while conducting FGDs some of the respondents were feeling shy to talk openly about sexuality due to the fact that, it’s rarely talked about in public, people 16 consider it to be a secret. This then forced the researcher to reschedule some appointments to have different FGDs and in condusive spaces to enable respondents to air out all their views. Another limitation encountered was the failure to interview the youth (school boys and girls) as planned earlier this. This was due to the fact that, by the researcher corresponded with the time students were in their holidays. The researcher managed to get boys and girls out of school to cover for youth but lost the opportunity to have those in school express their views. There was a plan to hold a FGD with 14 clients of vasectomy but the researcher wasn’t able to carry out a FGD with them as she had planned before due to the fact that, they received this service after the research period. Finally, some women in a group of non-family planning clients who expected monetary benefits later withdrew from the process after realizing that there was no money given. In a way of passing an appreciation to those who participated, the resercher offered a drink after the FGDs putting into considerations of the 2 hrs they spent in a discussion.

1.5 Organization of the paper The paper is organised into five chapters. Chapter one is comprised of the back ground of the study, statement of the problem, objectives of the study, main Research question, sub questions and methodology. Chapter two is comprised of the conceptual and the theoretical frame work. Chapter three contains the settings of family planning in Rwanda; chapter four includes research findings and analysis of data looking at the strategies to improve the participation of men in family planning services and then lastly, chapter five that highlights the researchers own considerations, conclusions and recommendations.

17 Chapter 2 Conceptual and Theoretical Framework

2.1 Introduction This research seeks to find out how men participate in family planning services regardless of the existing dominant notions of masculinity. To carry out this research, it is useful to come out with the conceptual framework which serves as a yardstick from which the men’s knowledge and experiences will be viewed and analysed. The six concepts to be discussed are: (gender: masculinity and femininity, gender hierarchies, sexuality, reproductive health, agency and power) which are all inter-related to each other in regard to the achievement of men’s participation in family planning services.

Figure 2.1: A set of concepts framing men’s participation in family planning services

Source: Author

Source: Author (2011)

18 The graph above explains that,family planning policy consider men’s participation as the centre for improving family planning services, equal reproductive health rights between men and women as well as increasing the up-take of family planning contraceptives.(big arrow directing from family planning policy to the objective of men’s participation). However, considering most patriarchal societies including Rwanda, men’s participation in family planning is still constrained by various factors like the constructions of gender which defines and sets responsibilities between men and women ( notions of masculinity and femininity) in the society, gender hierarchies which confirms power relations between men and women, sexuality which dictates how a female body is expected to be in relation to a proper mother and how a proper father should look like is relation to fatherhood. The fact that patriarchal societies guarantee much power to men, in most cases men exercise their power over their partner’s agency in order to be recognised as real men. (Small arrows directing from family planning policy to determinants of men’s participation in family planning). Family planning being a priority, Men’s are requested to participation in order to promote gender equality, equal reproductive health rights between men and women as well as increase the up-take of family planning contraceptives however, men’s participation could be confronted by various issues like gender (masculinity, femininity constructions, gender hierarchies, sexuality (fatherhood α Motherhood), power and agency. This research therefore, aims at investigating how men participate in family planning programs in such social constructions.

2.2 Gender “Gender is a social category imposed on a sexed body.”Gender is the social organization of sexual differences except as “a function of our knowledge about the body and that knowledge is not pure, cannot be isolated from its implication in a broad range of discursive practices”. Joan W. (1986) as in (Zarkov 2011: 4). “Gender as a bipolar system produces social expectations, prescriptions, aspirations, and definitions of ‘proper’ ‘manhood’ and ‘womanhood’, by aligning the body, identity and sexual desires” (sexual orientation) (Zarkov 2011: 5). As stated above, gender is a social construction of a man and a woman in a given society. From childhood, females are socialised on how to behave like proper women whereas boys are socialised on how to behave like proper men and these characteristics and identities are respected by the society and anyone who acts contrary to what a proper man or woman is expected from the society, he/she is seen as improper Drawing from this context, society expectations of men and women also influence family planning use in the way that, men fear to engage in what is expected to be a woman issue and as a way of regarding their masculinity, they leave it for women. In relation to this research, gender constructions (theories) will be used to analyze the reality on the field to 19 draw an understanding of how or not men participate in family planning services in Gatsibo district. “Conventional gender norms for men and boys, such as those listed above, are often described as ‘dominant’ (or hegemonic’) masculinities”. “Internalising these ideals is not enough, however, rather they must be repeatedly acted-out by men (Esplen 2006: 2) to demonstrate and prove their masculinity” (Esplen 2000: 3). his identity of being an ideal men is also evidenced when it comes to issues of family planning whereby various men struggle to show their masculinity by denying their partners to go for family planning services. Therefore there is a need to support men so that they challenge these norms in order gender equality to be achieved. (Esplen 2006: 4). This research will therefore help to find out in which ways are men being supported by various institutions to achieve their role of participation in family planning services.

2.3 Gender hierarchies Despite wide spread change in gender roles, women continue to have less power than men. From the perspective of social role theory, these gender differences in power should be perceived as eroding as women gain access to male-dominated roles typically associated with power (Diekman et al,2004: 1).This situation is also evidenced in the Rwandan context in the way that, in most families men has more power than women to the extent that, most of the decisions which impact family life are taken by men and this is done not because women are not able to take decisions but the fact that, men have the power to decide even though the decision taken is against a woman’s will, but he has to show that he is a man and a decision taker in the family. In relation to family planning, gender hierarchies are much manifested in the utilisation of family planning services where by a Rwandan woman more especially in the rural areas utilise family planning services on the approval of her male partner and in case the male partner say no a woman can’t do so. In this study, the researcher, will theorise the concepts of Gender (Masculinity & Femininity), Sexuality (Reproductive sexuality specifically looking at fatherhood and motherhood) and Intersectionality. In such a study, these theories are linked to each other in bringing up a gendered impact on achieving gender equity in the house hold, equal reproductive rights and increasing the uptake of family planning service in the community.

1.1 Masculinity and Femininity Femininity and masculinity or one’s gender identity (Burke et al.1988: 273), refers to the degree to which people sees themselves as masculine or feminine given what it means to be a man or a woman in society. Femininity and masculinity are rooted in the social (one’s gender) rather than the biological (one’s sex). Furthermore, societal members decide what being male and or female means (for instance by dominant or passive, brave or 20 emotional), and males will generally respond by defining themselves as masculine while females will generally define themselves as feminine (Ibid. 1). The same in Rwanda, female or male identity are constructed by the society where by a male is expected to behave in a certain way and also a female to behave in a certain way. A women then is expected to submissive to her husband whereby in most cases she is not even supposed to question a man’s idea rather respect it. A man is also expected to show that he is a man by showing domination by taking decisions. Masculinity also refers to a cluster of norms, values and behavioural patterns expressing explicit expectations of how men should act or represent themselves to others and varies historically across cultures and in specific contexts (Lindsay et al.2003: 4). The identity of masculinity is exercised in interpersonal relations in different spaces. In the family context, masculinity is exercised through domination and control of partner/wife and children. In relation to this research, masculinity has influenced family planning use in that, some men feels less concerned and hence leaving the issue to the women. All along family planning services have been taken as women issues and no efforts shown to involve men mostly due to cultural settings. Due to expectations of the society in regard to how an ideal man should behave, some men also fear to be challenged by the community members and decide to show that they are real men for stance not participating in issues of family planning services even though they see the importance of their participation because these matters are already seen as women issues.

2.2 Sexuality (Reproductive sexuality: fatherhood &Motherhood). Changes in both men’s and women’s knowledge, attitudes and behaviour are necessary conditions for achieving the harmonious partnership of men and women. Men play an important role in bringing about gender equality since, in most societies, men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and programme decisions taken at all levels of Government. It’s essential to improve communication between men and women on issues of sexuality and reproductive health, and the understanding of their joint responsibilities, so that men and women are equal partners in public and private life (ICDP: 1994, para 4.24). In most African societies, sexuality is seen in what a man is expected to do as well as a woman. Firstly, discussing about sexuality is a taboo to the extent that even among married couples, a few of them discuss about sexuality. A proper man is seen as one who is sexually active who is able to prove his manhood by producing many children, a proper woman is also seen in a picture of a woman who is able to produce many children and being able to give them care. In some communities of Rwanda, men are expected to produce many children not only as a way of proving their manhood but also as a source of labour and pride in the society. Basing on the above mentioned assumptions of the society regarding sexuality, men’s 21 low participation in family planning services could be rooted in those assumptions and therefore this research will probe and find out if there’s a connotation of men’s participation in family planning and perceptions around sexuality. It is in this regard that, sexuality derives from gender identities and constructions made by the society which categorise men and women and therefore due to their gender their sexuality or sexual expectations are also determined. It can be noted that, the care and support of an informed husband also improves pregnancy and child birth outcomes. Supportive fathers can play a large role in the love, care and nurturance of their children. Often they are the primary providers for their families. (UNFPA, 2005, chap: 6). In relation to sexuality through determining fatherhood and motherhood, couples may achieve a lot when they all work responsively in issues of family planning more especially in deciding together as parents on when, how to have children but in most societies, due to sexual assumptions, you find that reproductive issues which include family planning are neglected by men and left as a woman’s concern.

2.4.1 Motherhood “That is wonderful, congratulations! ‘Oh dear, poor you!’ Really? Do you want to be?’ (Berer 1994: 6)

The above quotations show the meaning of motherhood in the fertility context. These quotations again show the responses given to most women when they tell their friends that they are pregnant. “The majority of women in the world remain in the position of having no choice about having children, despite access to the means of birth control. Their societies, families, their religions, their parents and themselves equate the values of women with motherhood” (Berer 1994: 6). “Women are often not in position of deciding if, when and with whom to become pregnant or to determine the number, spacing and timing of their children. (UNFPA 2008: 3) Traditionally, women are valued because of their reproductive role as mothers. This is evidenced in the Rwandan context whereby a woman to be respected as an ideal woman needs to be having children. Traditionally, Rwandan women were expected to bear many children as possible, only that it’s just changing recently because of the financial-crisis and the fact that men want to retain their position as a breadwinner.

2.4.2 Fatherhood The definitions of a father are given in relation to the social constructions of masculinity. Some analysts have showed that, masculinity is never “undivided, seamless construction, which becomes in its symbolic 22 manifestation’’. (Segal et al.1990: 120). It’s therefore stressed that, the meaning of masculinity is linked to power relations between men and women. According to Brittan 1989 cited in Segal et al.1990: 120). “Masculinities refer to those aspects of men’s behaviours which fluctuate over time and which differentiate men”. Masculinity also presents the natural idea of male domination which is manifested in the household and other decision making organs according to Brittan. Brittan’s idea is in line with that of Connell’s (1987) that, ‘hegemonic masculinity’ manifests the ways in which men’s social ascendancy is embedded in social practice and ideology’’ (Connell’s 1987: 184). It’s therefore noticed that, there is still a continuing considerations biographies (life histories) where the meanings of fathering are constructed (White 1994: 120). Various experiences in relation to men’s masculinity and the use of family planning has been experienced among most couples where by men have not been showing any sense of responsibility to most pregnancies caused by them. It is mostly understood that, in most cases when a women gets pregnant and she discusses with the husband, the husband asks why didn’t you accept and yet in the first place he didn’t ask her if she is ready. This was even evidenced during the research where the respondent noted that, “It is a women’s responsibility to avoid pregnancy not for a man” (Male respondent). This practice therefore has influenced family planning in that, even at a time where a woman n is using a natural method, it’s probably that, she will not be able to escape the pregnancy. This reality then brings us back to the need of involving men in family planning so that at least they are able to comprise with their partners in all the situations. This experience has been experienced even among the youth where the boys impregnants the girls but then he use his power to reject the pregnancy. It is in this regard that, fatherhood is deeply imbedded in the notion of masculinity.

2.3 Reproductive health rights and sexuality “Sexual rights are fundamental elements of human rights. They encompass the right to experience a pleasurable sexuality, which is essential in itself and, at the same time, is a fundamental vehicle of communication and love between people. Sexual rights include the right to liberty and autonomy in the responsible exercise of sexuality” (IDS Bulletin: 2006) As stated above, sexual rights are expected to be enjoyed by all partners as it is the fundamental elements of human rights and all couples should have equal rights about it. It’s in this regard that, family planning is linked to sexual rights in the fact that, men and women should enjoy their sexual rights equally for instance in the way they make decisions concerning family planning. For instance having good communication in relation to sexuality at the household level, will also improve the understanding of family planning among couples. Family planning is therefore linked to

23 sexuality in the fact that, in case couples can’t discuss (communicate) freely on sexuality at the household level, even the achievement/implementation of family planning will take long to be achieved. Individuals as well as couples are guaranteed the right to make choice on the number of children he /she would like to have and also having all the information necessary to do it. (ICPD 1994: 46, para 7.12). Family Planning is embedded in reproductive health reproductive health and aiming at increasing the capacity of couples and individuals in to making choice regarding their family size they wish and also the presence of the services where by people can easily access them. The principle of informed free choice is essential to the long-term success of family planning programmes. In every society, there are many social and economic incentives and disincentives that affect individual decisions about child bearing and family size.(Ibid).The concept of family planning therefore is linked to this research in the fact that, couples are expected to participate fully in the decision of how many children they may wish to have, when and how. Though all couples are expected to have equal sexual rights, in most African societies and Rwanda in particular and mostly in rural areas, it is common that both partners do not participate equally in issues related to sexuality. The fact that a woman is expected to have a shy behaviour; she is not expected to discuss issues of sexuality even with her husband. Issues of sexuality are regarded as a taboo and even a secret the only room for discussion is given to men. A woman who discusses sexual issues is regarded as a prostitute. It’s from this view that, a woman who considers discussions around sexual issues as a taboo, will not be able to talk about family planning issues with her husband and therefore matters related to family planning will continue to be considered women issues. Family planning helps save women’s and children’s lives and preserves their health by preventing unwanted pregnancies, reducing women’s exposure to the health risks of child birth and abortion and giving women who are often the sole caregivers, more time to care for their children and themselves. (Ibid).Therefore family planning issues shouldn’t be regarded as women issue but rather a responsibility for both parents.

2.4 Power “ Power is not an institution, and not a structure; neither is it a certain strength we are endowed with; it is the name which one attributes to a complex strategical situation in a particular society”. (Foucault 1990: 93). Foucault’s idea gives us a reflection on what happens in our societies in regard to sexuality. In most African societies and reflecting in Gatsibo district-Rwanda, the district where the resecher area located, Men have that power to decide almost all decisions in the family and this is something which is not granted to them physically but it’s something socially constructed where by every man is expected to behave in that line and its absence is the exception. In these situations of power exercitation, men also 24 employ it in sexual relations where it’s seen as a right of a man to demand his partner sex regardless at what time, or in which situations a partner is in and in this case a wife can’t say no.

2.5 Agency Agency is the ability an individual has to make choices and this is again linked to power where by power is also seen as the ability to make choices and therefore being disempowered implies the denied choices (Kabeer 1999: 436). It is in this regard that, one can point out that, power is linked to agency. As said above, agency is the ability to make choices therefore, it requires one to have power already in order to make an informed choice. This can bring us to a reflection that, are women in societies more specially Gatsibo district where the research was conducted have the power to exercise their agency especially in issues regarding to sexuality especially playing a role in choosing how, when and with whom to bear children?. This can also be viewed in the angle of men whereby we can view men’s agency in regard to making choices in regard to sexuality. One can then say that, depending on the power given to men in most societies like mentioned earlier, men are even able to exercise their agency compared to women and this can further be manifested in family planning issues at the house hold level where the majority of families men are the ones to make choice regarding how and when to have children.

2.6 Social construction theory

Connecting to the concepts of gender, gender hierarchies, sexuality, power and agency, this study will apply Kahn’s theory of social constructionist and Susanne V.Knudsen’s theory of Intersectionality which will help the researcher to analyse and theorize men’s participation in family planning services. As Raskin and Bridges (2002) as in (Khan 2009: 90) points out, the social constructionist theory stresses on particular social factors that gives meaning to experiences. When explaining gender or masculinity, the social constructionist theory doesn’t consider so much the specific issues which makes the inside part of a person for stance the “function of the brain or the gendered beliefs’’ but rather consider factors that affect the way in which we investigate, categorise, and discuss gender. It is in this regard that, one can say that, the construction theory helps as to view why things are happening the way they do. Here one can draw an example of seeing how men are being constructed by the expectations of the society they live in by trying to confirm what a real man should do, how he should behave and so on. The construction theory goes beyond to see how the experiences of things we go through affects the interpretation we give on different issues (Ibid). Considering the radical feminists idea, masculinity could be linked to power due to the fact that, there is a need to look at “who gets to determine 25 what” and its truth for stance who determines masculinity and its effects to others Brickell et al cited in (Khan 2009: 90). One can then say that, the meaning of masculinity is constructed by different factors and it’s important to note that, as masculinity is constructed then it differs from time to time and across cultures. As cited by Addis et al, in (Kahn 2009: 2), Masculinity is defined as “the complex cognitive, behavioural, emotional, expressive, psychosocial, and sociocultural experience of identifying with being male’’. It can further be assumed that, there are multiple ways in which people experiences masculinities in the world. From the above reflection of masculinity, one can say that, the male’s identity of being a man is more constructed than biological that is to say, it is learnt and experienced differently that is why men themselves also do not benefit the same from the masculinity world. Further one can stress that, manliness differs and there are a variety and complexity ways of being a man Connell in (Cleaver 2002: 7).

2.7 Intersectionality As stressed by (Knudsen 2006: 61), “Intersectionality tries to catch the relationships between socio-cultural categories and identities”. Gender, sexuality, race, ethnicity, nationality and class are categories which could strengthen the complexity of Intersectionality, and point towards identities in transition”. The theory of Intersectionality will therefore be used to unpack the existing perceptions people give (have) about certain practices according to their identities. Therefore, the issues of class, education level, age, religions, ethnicity will be reflected on to see how they influence in one way or the other both men and women’s participation in family planning services. Furthermore, Intersectionality is a theory for studying, understanding and responding to the ways in which gender intersects with other identities and how these intersections contribute to a unique experience of oppression and privilege (WREC 2004: 2). “Intersectionality analysis aims to reveal multiple identities, exposing the different types of discrimination and disadvantage that occur as a consequence of the combination of identities” (Ibid) This means that, men are not a homogeneous group but a collection of different categories and therefore, issues of class, age, religion, ethnicity would contribute to the high or low participation of men in family planning services. Connell in (Cleaver 2002: 7). In conclusion, the conceptual and theoretical frame work discussed above have thrown a light on what could be the factors behind men’s participation in family planning services and drawing a connection between each other. More distinction will be drawn between the discussed concepts and the respondent’s views in the next chapters but firstly the following chapter shows the distinction between the practices of family planning and the national family planning policy.

26 Chapter 3: Settings of Family Planning in Rwanda

3.1 Introduction This chapter analyses the Rwanda National Family Planning Policy, which guides both clients and family planning service providers in the practices of family planning services. This analysis bases on the available National Family Planning Policy elaborated in the National Family Planning Strategic Plan for 2006-2010. The policy states the country’s need of family planning practices as well as laying strategies for its implementation. In order to come out with an analysis, an overview of the NFPP will be given and then a look at the course of its implementation will also be analyzed drawing experiences from the users and other information got from the service providers who participated in this study.

3.2 Back ground of Rwanda Rwanda is situated in East Africa with the current population size being 11,370,425 million people3,the main occupation being agriculture and the fertility rate of 5.5 per woman whereas the current population growth rate being 2.6 % per year and estimated birth rate of 41 birth/1000 population (MoH 2008: 10). This situation in regard to the country size, calls for an increased attention of family planning services in order to control the births as well as good provision of reproductive health services.

3.3 Overview of family planning services in Gakenke health centre Gakenke health center was the study area for this research, it’s a public health center which was constructed as a rural dispensary in 1922. Since 2003, the health center offers PMTCT/VCT and family planning services. The health center is situated in Gatsibo district, Eastern province of Rwanda with a population size being 31,761 inhabitants allocated in 56 villages and 45% of women using family planning while the distance from Gakenke health center to Gatsibo district administrative area is equivant to 27 kms.It can be noted that,the 45% of family planning users are only women because even the male condoms are regarded as a female contraceptives reasons being, men are not the ones who go and pick them, the service providers gives them to women who go at the health center to access family planning services and they take the condoms to their partners. To achieve this number of people using family planning,Gakenke health center has been working hand in hand with the ministry of health and also 3 www.Indexmundi.com/rwanda/population.html

27 with the good collaboration of community health workers. Below is the table showing different methods of family planning delivered at Gakenke health center. Again, late august 2011, due to the no-scalpe vasectomy campaign county wide coordinated by the ministry of health, 14 clients of vasectomy were treated in the area.

Table.3.1: Methods of family planning available in Gakenke health center.

Percentage of clients per method Family Planning Methods Number of clients Male Female Pills - 1,076 31.68 Depo-Provera - 2,211 65.09 Implants - 73 2.15 Inter-Uterinal Device - 3 0.09 Moon beads - 5 0.15 Female Condoms - 0.86 Male Condoms 29 Vasectomy - Female Sterilisation - Total 29 3,368 100 Source: Gakenke health centre

As shown in the table above, the total population Area is 31,761 and expected Family Planning Clients (Women of reproductive age) per year being 7,496 with a total number of clients in the area being 3,397 the table also indicates family planning methods utilized in Gakenke health center from 7/2010-6/2011. To note from the table, Depo-Provera (Injectables) is the most used family planning method with 65% of women using it. During the field visit, a number of women who use this method gave out their views as to why they prefer Depo-Provera. “I like Depo-Provera because once you’re injected, it is done, but for the pills you have to swallow it every day which I sometimes forget to do. Secondly an injectable is again useful more specially when my husband doesn’t what me to use family planning, I just leave him and then I ask the CHW to inject me and here he can’t even know that am using any method but the pills I can easily be caught”(A female respondent). Female sterilization and vasectomy are not practiced in Gakenke health center due to lack of qualified personnel but clients who wish to use either of the two methods are referred to the district hospital. The table further demonstrates female condoms among the low utilized method and this is due to the fact that its accessibility in the areas is very limited. A part from

28 female condoms being limited in the area, respondent’s argued that, its practice is difficult for them due to the fact that, “when you decide to use a female condom, it means that you have to hold it during sexual intercourse until the whole act of sex is complete and we do not feel comfortable about this” (Female respondent). More considerations from the table also shows that, moon beads have been utilized at a low level and reasons being that, it needs accuracy in counting and the fact that, the person using it must be with a regular cycle, most rural women find it difficult in its utilization where as other women noted that, they don’t use the Inter-Uterinal Device (DIU) due to the fact that, their husbands hate it.

3.5 Rwanda National Family Planning Policy and its implementation Rwanda is one the countries which has put in place a family planning policy under the vision of “having a modern and prosperous nation, strong and united, worthy and proud of its fundamental values, politically stable, without discrimination among its sons and daughters, and all this in social cohesion and equity” (NFPP 2006: 6). In relation to development, the family planning policy also aims at ensuring healthy citizens who are able to work for themselves and for the development of their country (Ibid). It goes on pointing out that, family planning would help Rwandan families who are unable to feed, raise and educating their children to be able to overcome all these problems. More in this field is the aim to enable the Rwandan citizens to be able to give “birth to a number of children which is in the capacity of each house hold to support, in such a way that every family’’ plus the whole population will become more productive and hence enabling them to make a contribution to the county’s sustainable development (Ibid). Regarding the improvement of reproductive health conditions, the policy brings it out that, family planning would help to reduce the high number of ‘maternal mortality rate that places Rwanda “among the countries with the highest maternal mortality rate in the world,” about 1000 per 100.000 live births” and therefore family planning will help to achieve the objective of counting less than 350 women per 100 000 live births as indicated in the vision 2020.This is also in line with the objective of reducing the “ infant mortality rate (86 per 1000 live births) and the child mortality rate (152 per 1000 live births), which should also be less than 25 per 1000 live births” according to the vision 2020 (Ibid). It goes on mentioning that, with the absence of family planning, there would be a loss of hundreds of women and girls due to illegal abortion practices done in un- professional ways in attempt to remove the unwanted pregnancies. (NFPP 2006: 7). In the way of family planning service’s provision, the policy ensures “full range of contraceptive methods that are easily accessible throughout 29 the country”, and that this could be achieved when there is s free choice of contraceptive methods which everyone is comfortable with including condom use for either HIV/AIDs prevention or birth control. The question of reflection which comes from mind drawn from the above idea is: Does family planning methods available favour a client to make a free choice? This will be discussed more in relation to the findings got from the field. Regarding the implementation of the Rwanda national family planning policy, the ministry of health has laid various strategies. First, the creation of an environment where community members themselves participate in the promotion of family planning services. This has been done through the formation and the training of Voluntary Community Health workers (CHWs) and distributors at community level. CHWs/distributors come from the community of their own residence and they are nominated by their fellow community members basing on their good conduct status, willingness and committement they have to serve their community. CHWs enfonces the ministry of health’s initiatives of improving family planning services starting from the ground level. CHWs do this through initiating/facilitating different discussions during community meetings at village, cell or sector level more especially during umuganda (Community work).The same CHWs were being trained on how to distribute family planning contraceptives at community level which saves the client’s time since they are not travelling long distances.(CHDs distributes the contraceptive to only old clients (who have been clients already not new ones and the news are directed to the health centre. This strategy has increased the number of family planning clients since counsellors are now the neighbours and fellow community members which have creates a friendly environment between the CHWs and the clients. While choosing these CHWs gender equality is being put into considerations whereby 50% should be men and other 50% women. This shows a good example to community members that, family planning is not a woman’s issue only even men are concerned and therefore, this could change the existing cultural norms which largely place gender power relations between men and women.In order to make family planning contraceptives accessible to all who would wish to use them, the Rwandan ministry of health has set the provision of family planning contraceptives at no cost so that even the poor can be able to get it. Also, in the way of encouraging men to participate and to access family planning services, the ministry of health initiated the no-scalpel vasectomy pilot project country wide this year aiming at challenging the existing discourses around vasectomy in the community which has been contributing to limit men’s participation in family planning services. The ministry of health could not achieve all this without the help of other stakeholders therefore, there has been a good partnership between the government and the non-Governmental Organizations where by the NGOs have been prominent in sensitizing the community about the engagement in family planning services. A case in point is CARE-International and other NGOs which have helped in addressing existing cultural norms which 30 influences family planning practice. Some of the strategies employed are the use of social analysis and action (SAA) strategy, Stepping Stones and others.

3.6 Community practices of family planning services visa-vi family planning policy In early 1990s, Rwanda’s national contraceptive prevalence rate was at 13%, but due to the 1994 Genocide where over 1million men, women and children died, in the years afterwards there was a trend towards rejecting contraceptives since people wanted to bring new life and to replace their beloved ones who died and due to the deconstruction of so many country’s infrastructures including health facilities and even the death of qualified health personnel, family planning prevalence dropped from 13 % to 4% in the year 2000. From 2000-2005, rehabilitation of health facilities had been done and new health personnel had been trained and already in practice which again boosted family planning contraceptive up to 10%. The fact that, family planning is seen as a priority in Rwanda, much effort has been employed to increase its practice and presently the prevalence has beat 47% however, there are various challenges; Firstly, the fact that, people had lost so many people in the 1994 Genocide, people wanted to bring new life by replacing those who died and therefore the government was feeling shy to talk about the need of family planning and this favoured people to have many children (Solo 2008: 4). Secondly, the Rwandan culture has been a contributing factor influencing family planning, like one of the USAID staff member noted, “The Rwandan culture had always been strongly pronatalist: a traditional wedding toast encourages newly married couples, “Be fruitful, may you have many sons and daughters” the catholic church has been a strong critic and barrier to family planning use (Ibid). The Rwandan culture has set various assumptions which has influenced the practice of family planning services for stance the discourses around sexuality which places sexuality as a taboo. Sexuality being taken as a taboo, many people including partners has tried to make conformity to this assumption which has even limited discussions about family planning at a household level and as result family planning as remained a women concern. The society expectations (constructions) of a real man and woman has influenced family planning practices in the way that, men have not taken a visible participation in family planning services trying to guard their status as real men in order to confirm to the society’s constructions due the fact that, some men who have managed to do family planning for stance vasectomy have faced stigmatization in one way or the other and even others are fearing to have the same as noted by the respondents hence leaving the whole practice for women and therefore men’s participation is still a challenge

31 It was indicated in the family planning policy that, men act unconcerned in family planning services while they are the ones who are supposed to take the first step (NFFP 2006: 7).It can be drawn from this assumption that, while aiming at improving family planning practices, the RFFP didn’t put into considerations that there are cultural constructions which has a paramount influence on men’s participation and which were not brought up in the policy. The fact that, the society has constructed men in a certain image in addition to the absence of much emphasis on men’s participation in the family planning policy, the demand for family planning services as been largely left for women due to the fact that, women are represented in the society as the ones responsible for reproductive matters, and therefore men’s demand has remained limited. Men’s low demand of family planning services is mostly due to the reason that, even the available methods cannot allow them to make a free choice due to that fact that, they are very limited compared to women’s methods and even some men who use condoms don’t use them as a contraceptive method but instead they use it as a way of HIV prevention as stated by one of the respondent. “A condom is rarely used as a family planning contraceptive but rather used for HIV/AIDs prevention and other STIs, after all, having sexual intercourse using a condom is like eating a sweet in a poll then paper, it just reduces the sexual pleasure, but I can just use it for HIV prevention.” (Male respondent). Furthermore, a critical point can be brought up that, the issue of men’s participation in family planning services was not given much attention in the family planning policy yet it had to be brought up clearly. It can therefore be noted that, the family planning implementation were men are fully participating should be emphasized on directly from the policy makers. More to what has been discussed above, the culture has a created an environment where by the newlywed couple is expected to have children as soon as possible after their marriage and failure to do this brings about another perception of “failure” where the couple is seen as failures. It is in this regard that, most couples are discouraged to use family planning in order to have children as soon as possible hence realising society’s needs. Another live factor which influences the practice of family planning and which was not considered in the family policy has been the value given to children in the Rwandan context where the culture has been always encouraging new couples to have many sons and daughters (Solo 2008: 5) and also the fact that, about 50 % of the population were followers of the catholic church, and yet they are influenced by its teachings of encouraging the Christians not to use modern family planning services because they are regarded as a sin of killing. This has encouraged citizens to produce as many children as they can, claiming that, God will take care. This issue was brought up by the respondents who pointed out that, this ideology is still existing in their societies to the extent that, there are local names which parents name their children which presents the idea that “God will take care” a case in point are the names like Habyarimana, Harerimana,

32 Hakorimana which insists on producing many children hoping to be cared for by the creator. In conclusion, the above analysis between the policy and the practice brings up various issues which are important to note. In the first place, it can be stressed that, apart from the attempts to improve family planning services, the policy has not escaped the gendered imbalance in its design in relation to which sex is involved much than the other. This means that, men’s participation has not been given much emphasis compared to women (The policy focuses much on women). Secondly, in reality, the provision of family planning services have not yet reached a situation where a client is free to make a choice on the methods of family planning service he/she wants and the fact that, there are some assumptions around family planning contraceptives that they affect women’s bodies, some male partners deny their wives to use the contraceptives which has also affected the practice. Therefore, much remains to be done by the ministry of health to ensure effective results after the utilization. Different discourses around sexuality and masculinity have also contributed much to create a distinction between the policy and the practice due to the fact that, the policy has not considered these social constructions which are holding a big position in most patriarchal societies like Rwanda and which has created a gendered imbalance between the family planning clients. Finally, creating a situation where by a policy will easily be implemented calls upon the government to be able to address the factors which could confront the smooth implantation of the policy with in the policy itself and immediately look for ways of addressing these factors in the community instead of just ignore them. More ideas on what is really happening on the ground will be discussed in the following chapter.

33 Chapter 4: Masculinity in the State Policies, Programs and Experiences of Family Planning

4.1 Introduction This chapter draws the experiences of men, women, CHWs, service providers and policy makers in Gakenke sector as well as Gatsibo district in relation to realities on ground regarding men’s participation in family planning services. This chapter will further look at the factors underneath men’s participation in family planning services and latter the discussion will lead us to seeing how men have presented their agency as well as positioning themselves in regard to the practice.

4.2 Family Planning Programmes and Methods: The inter- connections of masculinity, femininity and sexuality “ Family planning is a woman’s responsibility how can I start to engage in the so-called women’s issues, my fellow men will tease me when they get to know that I went with my wife to the family planning centre” (Male respondent). Depicting from the above idea, family planning programmes in Rwanda have been all along been regarded as women issues and most of the programs available have been giving big attention to women’s reproductive needs and ignoring men’s needs. It’s just recently that, the idea of including men is coming up. It’s therefore important to note that, the notions of masculinity are still guiding men’s practices and therefore, men try to behave in ways which guarantee their masculinity by not engaging in the so-called women issues. This fact is backed up by Connell’s idea of masculinity that,“Masculinities are configurations of practices with in gender relations, a structure that includes large-scale institutions and economic relations as well as face to face relationships and sexuality” (Connell 2000: 29). In line with this, note one of the respondent’s idea. “Family planning doesn’t concern me, my wife is the one responsible....if she like, she can go, if she doesn’t want that is her business” (A male respondent). Reflecting on the social construction theory discussed earlier, men’s behaviours are constructed in a way the society wants them to be and this has affected the participation of men in family planning services. It’s therefore important to note that, men should think beyond the masculinity lens in order to participate in family planning programs.The issue of masculinity has also been manifested in the way family planning programs are designed right from policy makers and implementers. Much as men are 34 struggling to fix themselves in the programs, policy makers and implementers have unintentionally done much to limit their participation as notified by one of the service provider below. “ Women have been the most targeted groups in most programs responding to reproductive health issues; it is just recent that, we are finding out the missing gaps of not including men in these programs. For stance during the IEC sessions, which are always done at the health center, we don’t include men and what is discouraging is that, as service providers, we expected women to disseminate the information they get from the I.E.C sessions to their partners but it has been noted by various women that, they have not been able to transfer the message to their partners due to the fact that, most men do not give it time.” (Service provider) This implies that, before looking at men as deniers of family planning services, it’s good to look at how family planning programs themselves are being designed and see if there is a man’s room for participation. Male oriented programs being limited could also reflect the meaning of family planning among policy makers and implementers. Family planning programmes addressing men’s needs have been limited, however there are some men willing to participate. “We could have an active role more especially as clients but there are limited methods of family planning available for us” (Male respondent). As stressed by (Odhiambo 1997: 29), the only family planning services available for men are condom use, periodic abstinence, withdraw method and vasectomy. This is in line with what is happening on the ground whereby one of the respondents called this “Uneffectiveness” “I don’t like vasectomy, it’s not effective at all because once you do it, and you can’t have a chance of producing anymore. And then, if you do vasectomy and latter your children all die for instance like what happened in the 1994 Rwandan Genocide where by many parents lost their children and then you need to have others, then what can you do?” (Male FGD respondent). Rumors around the act of vasectomy have contributed much to limit men’s participation in family planning services. According to the in-charge of family planning services in the ministry of health, he disclosed that, there is a big number of men who would wish to do vasectomy, but because of the prevailing misconceptions, that, once you do vasectomy, you are castrated, many men becomes discouraged. Therefore educations and sensitizations are still needed in order to bring up the real truth in the community. The in-charge of social affairs at the district level confirmed this by giving an example of an education session about vasectomy which took place at the district, educating district personnel about vasectomy. Participants in this session (men) who are even educated said that, they can’t be castrated (referring to vasectomy),this means that, people still have a

35 negative perception about vasectomy though they have been taught about its practice. A male respondent also noted that, “I can’t tolerate being called a woman, I know when I do vasectomy my fellow men will call me a woman meaning that am no longer a man because am castrated.” (Male respondent). Noting from the above idea, men’s participation in family planning could be perfect if the policy makers think of other male methods to complement the existing ones for stance methods which just last for specific months or years like those of women and this could create a room for making enough choices and this would favor men who do not feel comfortable to use vasectomy and other methods. An intersectional perspective can be drawn here that, though some of the respondents showed that, family planning programs targeting men’s needs are limited, the personnel in-charge of health service at the district level agued differently. “If men can use effectively the available family planning methods, family planning can be a success” (In-charge of health affairs at district level). The above statement can help us to recognize that, people are not homogenous and therefore, their perception can be drawn differently. It can be realized that a district staff is looking at men’s participation as a policy maker without considering the barriers and other men are looking at it as receivers of family planning services which always brings a distinction. Learning from the above experiences, men’s reproductive needs especially family planning has received a little attention compared to women’s needs right from the policy making to the implementation and this indicates that, the dominant notions of masculinity also affects policy makers and implementers in the way that, they regard family planning as a women issue to the extent that, few programs are responding to men’s needs. 4.3 Assumptions about Male Sexuality: Pleasures, Fears and Taboos Depicting from the experiences on the ground, family planning has been largely connected to male’s sexuality in the sense that , a man to prove that, he is a real man, he has to be successful in regard to sexual pleasure whereby everything which denies his enjoyment is disturbing his masculinity like one respondent noted. “ A condom is rarely used as a family planning contraceptive but rather used for HIV/AIDs prevention and other STIs, after all, having sexual intercourse using a condom is like eating a sweet in a poll then paper, it just reduces my sexual pleasure, I can just use it for HIV prevention”(Male respondent). As stressed by Esplen, “In most cultures, men are expected to be physically strong and sexually successful. These characteristics are referred to as “gender norms” the culturally accepted ideas about being a man or a woman in a particular society” (Esplen.E 2006: 2). In this sense, men are failing to use condoms in order to be sexually successful. This idea brings us to a point of reflection that, who among the couples is entitled to sexual pressure? If men do not want to use condoms just because of the fear to lose 36 their sexual pleasure and instead they encourage their partners to use other family planning methods which could be having other health complications more dangerous than loosing sexual pleasure, then where is men’s support?.This can just tell us that, a woman’s sexuality is not catered for, that is whether she gets pleasure or not, a man has power to negotiate everything including sex which a woman does not have. According to (UNFPA 2008: 51) “Cultural pressures around masculinity that fuel men’s need to prove sexual potency can encourage seeking multiple partners and exercising authority over women”. The fact that, the available culture guarantee power to men and not women, in most of the cases women at home do not have negotiating powers for stance in the issue of condom use, even in the day to day life are not expected to discuss a lot about their sexuality, therefore, there is no way a man can say that he doesn’t want to use a condom and a woman challenge him. In most cases, women fear to say no due to the expectation that, their partners will go and look for other partners. Women therefore have to agree whatever their husbands tell them in order to survive and this is very common in rural settings where a man’s word is always the final. The fact that, men see condom use in another broad way of HIV/AIDs prevention than a family planning contraceptive, it’s also an advantage to their lives in that, it protects them from the contamination of HIV/AIDs which also works hand in hand with family planning. The fact that, a man’s sexuality is expected to be active, most newly wedded couples gets pressure from their families demanding them children more especially a son. Usually, when a man and a woman get married, their families expect them to have a baby as soon as possible. They sometimes start to count the months from the wedding day. If the birth does not happen within at least the first year, family members more especially the parents start pestering the couple asking grandsons and daughters. In that case, the couple can’t use any methods of family planning even if they are not ready to have children. It is very common in Rwanda that, Men and Women who do not have children would be considered abnormal and selfish and couples who remained childless would be seen as failures. This is evidenced by the traditional sayings as seen below. “Murumbuke, mubyare hungu nakabwa: _Be fruitful, may you have many sons and daughters….. (Traditional wedding toast to a newly married couple.) Abana ni umutungo: Children are your wealth(Traditional proverb) Nimwonkwe kandi usubireyo nta mahwa: _Congratulations, and go back for more, have more children it doesn’t hurt. :_( Traditional greeting to a new mother)” (Solo 2008: 28). Various men have manifested their fear in relation to family planning side effects as one of the reasons why their participation is still low. Though the ministry of health has been giving different education sessions opposing 37 the rumors about family planning, many men still have fears about is practices as one noted. “ My wife used family planning services and latter developed heavy breeding, having heavy headache and even getting dry in her private parts which reduced her sexual desires and pleasure, I decided not to allow my partner to go use contraceptives again’’ (FGD Respondent). However this seems to be another area of research in the future. Considering Rwanda’s cultural background, issues of sexuality have always been taken as a secret (a taboo) which are not expected to be discussed about in public and even among individuals. It has even been a problem to couples since everyone doesn’t want to show that she/he is informed about sexuality fearing that, the partner will be suspicious about where she/he got those ideas hence calling he/her a prostitute. This culture has influenced family planning practices as noted by one of the respondents. “There is no way I can discuss sexuality with my partners, I can’t dare, am very shy, we are not even supposed to look at each other when we are naked. We even remove light when we’re having sex and when he finishes, that is the end. Then how can I start to discuss family planning, he can just say that am crazy. May be if he begins the discussion” (A female respondent). “ If cultures are, in part, conversations and contestations including about questions such as reproductive health and rights…some voices…are more privileged than others. People largely accept cultural norms and conform to expected behaviors” (UNFPA 2008: 46). It can therefore be asserted that, men’s participation in family planning services should not be looked at as a sole issue instead, it has to be looked at in a holistic way due to the fact that, men as heads of the families, decision- makers, and gate keepers of change, their position in society is very delicate and therefore they also work hard to justify and protect their status in society.

4.4 How do men participate and what does the users and services providers think of their participation? It was emerged from the service providers that, men participate as clients in family planning services and this is evidenced in the way men themselves go to health centres to look for family planning services like male condoms and vasectomy. The in–charge of family planning services at Gakenke health centre pointed out that, “Since the beginning of this year (2011), 14 men are waiting to do vasectomy in this health centre. This has been possible through a no-scalp vasectomy pilot project orgnisized at a national level. Men also act as agents of change. In a way of making every one reached up by the available services, there are a number of male Community Health Workers and distributors of contraceptives working under the ministry of health’s supervision at community level. CHWs are assigned 38 from village level up to the sector level and they are well trained to sensitize the community through house to house visits, during communal work meetings, village meetings and so on. The main objective here is to challenge the existing traditional cultural norms which are limiting men’s participation in family planning services. The fact that, half of the CHWs are male, they could work as role models to other men in changing their mentalities. As pointed out by Green in her approaches to involve men in sexual and reproductive health, “Addressing inequality as a means of improving men’s and women’s health and as an end in itself’’ therefore, it’s important that, men become advocates for change in all communities” (Green 2006:10).This strategy then demands the policy makers to strongly empower change agents to be strong in order to bring up change. This means that, they have to be changed first in order to be able to change others and having strong strategies of coping up with the challenges they could face resulting from their role. As stated by (Esplen 2006: 2), “in many cultures, men are expected to be decision-makers”. It is in this regard that, most men in Rwanda are seeing their participation in family planning services as limited to giving approval to their female counterparts. It can therefore be noted that, men exercise their power over women as most women in most societies including my research area, wait to get approval from their husbands. Decisions taken by most men are related to power relations between men and women. The fact that, women have to get a go ahead about contraceptive use, most men think that they have participated and that is enough. Like one of the respondent noted. “I always participate in family planning, once I allow my wife to go to the health centre to access contraceptives, what else can I do? So long as I give her the permission, then that is enough” (Male respondent).

“Many men don’t come to the health center but they give their wives permission of undergoing family planning services by writing an authorization letter and they bring it to me which confirms a man’s consent. I do receive many letters”. (Service provider) Reflecting on what is happening on the ground, most men see their participation as just limited to allowing their partners to use or not use family planning contraceptives, and this is mostly due to the reason that, men want to exercise their power over women and women also submit it and wait for their husband’s permissions. As noted from the (ICDP 1994: 30), “Special efforts should be made to emphasize men’s shared responsibilities and promote their active involvement in responsible parenthood, sexual and reproductive behavior, including family planning.” It’s well documented right from International statements that, both parents should have equal responsibility in family issues, but the reality on ground is that, men and women have been socialized in different ways which has created gender 39 roles and most of the time, most societies including my research area have confirmed to these gender roles in response to a definition of a real woman and a real man and therefore, reproductive issues where family planning is placed, are still centered in a women’s responsibility. It is for this understanding that, men have not yet found a friendly environment to participate in family planning services. We can therefore submit the fact that, the way men participate in family planning services, has got a connotation with the societal constructions which guarantee and emphasize gender roles and therefore, achieving men’s participation will need other powers to challenge what men have been socialized to. One of the respondents noted that, “It is a woman’s responsibility no to get avoid pregnant not a man’s responsibility ”(Male respondent). Though the society has constructed various roles among men and women, the above idea cannot rule out the fact that, some men have exercised their agency and challenged the assigned gender roles by admitting that, family planning is their responsibility like one of the respondent argued below. ‘’Family planning is for all of us as parents because children are not for my wife only that is why I have to take part in all family issues” (Male respondent). “Family planning is supposed to be a responsibility for both parents but in reality in most of our families; we are the ones who take responsibilities it’s a few families where both parents share the responsibility” (A female respondent). Looking at the social constructionist theory, people learn to behave the way they do due to the constructions of the society and this can further be realized from what respondents called “mixed perceptions”. “ Family planning is a woman issue therefore it doesn’t concern men”. “I know that family planning issues also concerns men but I fear to tell my husband about it because he will say that, am lazy’’(Female respondent). A number of women as seen in the above statements have demonstrated different perceptions on men’s participation in family planning services and that’s what they called “mixed believes”. Due to the ways society constructs its members, some women still have the perception that, family planning is a woman issue because they socializes in that culture and other women who recognizes the responsibility of men in family planning services, are also constrained by societal constructions whereby they fear their husband’s reactions. The fact that, men are guaranteed power from the patriarchal structures, it has been evidenced that, in cases where a wife refuses to offer sex, a husband can use force or sometimes beat the wife to accept in his demand which has contributed to domestic violence in many homes. 40 The fact that, we leave in patriarchal societies and men are guaranteed with maximum powers, in most families women have not been able to exercise their agency in relation to their sexuality and the fact that they are socialized in the be submissive, in most cases women can’t negotiate with their partners on how and when to have sex, like we draw from the respondent’s idea. “It is mostly due to the social constructions that men find it difficult to participate in the work they think that it is not there’s. It is very annoying that, in most families in our community, a man can hit his wife if she refuses to have sex the time he asks for it” (Female respondent). Basing from the above, most women admit the truth that, men’s participation in family planning services has always been difficult due to the fact that, they do not participate in the whole process the few who participate just take decisions in relation to allowing their partners to use families contraceptives and the implementation stage has always been left for women and as a result when a woman becomes pregnant, a husbands always admit the blame to the wife. It is therefore in this sense that, Men also should be taught their full role in this practice to confusion of their decision-making ability and participation they should therefore know that, their participation is beyond decision making on authorizing their partners to use family planning contraceptives instead it should go up to the ways of implementation. In other instances, women have managed to exercise their agency through going to health centers for contraceptives without the consent of their male-counterparts and this is mostly when they already know that, even though they ask for permissions from their partners, the answer they will get is no. One of the respondents pointed out. “ I do go to the health center to receive family planning contraceptives without the consent of my partner because I know he can’t allow me”. (Female respondent) In relation to service provider’s perceptions about men’s participation in family planning services, most service providers, pointed out that, actually this is what has been missing. Men’s participation is of high importance in the fact that, when two partners discusses about their family life, we also find it easy as service providers and the decision taken by two people is very effective than the decision taken by one. Respondents further noted that, “Men have a big role to play in family planning, therefore, without their hand, the implementations will not succeed. Remember they are the gatekeepers in our homes, so when we don’t include them it will be difficult to achieve all what we plan”. “The level of women using family planning services could increase only when men participate. When men are supporting their wives, women themselves feel safe and strongly confident to participate in family planning freely but when men don’t participate, many women 41 feels discouraged”(Family planning in-charge in the Ministry of health). The in-charge of family planning services in the ministry of health, further noted that, “ The step we have reached on now, we can’t say that, family planning is a women issue only, family planning is no longer even a concern of married people only instead is a concern of every person who is in the reproductive age starting from the young to the old people.” The service provider further noted that, when a woman has a good communication with her husband about family planning use we also notice it at the health center. Other authors (Balaiah et al 1999: 218) states that, all the decision taken to accept a method or not among married people is often taken by the male partner. This is also evidenced by one of the respondents from the FGD, who noted that, “Me and my partner we use natural methods to control child birth. I use a condom from the time my wife gives birth up to the time she receives the first menstruation periods and from there we count days, during her ovulation period then I use a condom and am the one who decided this, I didn’t even consult her about this decision but she didn’t show any worry”(Male respondent). Regarding service provider’s views, including men in family planning services is a necessary practice, which is expected to increase the smooth implementation of the policies but regarding the reality which is taking place on the ground, some service providers haven’t yet admitted this reality and so we cannot rule out the fact that, they are still fixed in that notion of social construction it’s therefore of importance that, policy makers should look at the issue of men’s participation not only looking at clients but also looking at those who give the services to check their level of acceptance in regard to men’s participation. Finally, Men’s participation in family planning service can create a paramount change in regard to improve family planning services but we can’t deny to say that, it is deeply rooted in the societal constructions which exists in most patriarchal societies and these constructions have created a big difference between men and women right from designing their roles and responsibilities. It’s in this regard that, family planning practices have been largely influenced by the way people are socialized in their respective areas and therefore, confirming these behaviors mostly to men is seen as a obligatory and away of succeeding within the demands of their societies. Though men’s participation in family planning services is constrained mostly by social norms, we cannot rule out the fact that, some men have exercised their agency and participated in practice for stance men who have managed to do vasectomy and those who have committed themselves as Community Health Workers and Community-Based Distributors of family planning contraceptives.

42 Similar to Cornwall’s idea, does men’s “involvement” help them to achieve the capability to resist social norms of male dominance”? Cornwall cited in (Sternberg and Humbley 2004: 394). It’s from this note that, Some men are failing to take role in family planning services trying to confirm to existing social norms. It’s therefore for this reason that, Policies should look for a way of challenging social norms which are not in favor of the family planning practice.

4.5 Family Planning and the Intersections of class, religion, education and age “There is a need to consider class, race and age when understanding men’s and women’s lives, and the ways in which they relate to each other” (Cornwell et al. 1997: 71). Issues of reproductive health more especially family planning can’t be viewed in only one angle due to the fact that, they are influenced by a number of factors. It was evidenced from the respondents that, ignorance in some places contributes a lot in limiting the use of family planning services. This is evidenced in most uneducated people who still have a belief that, family planning is for educated people/civilized people, but this idea has a connotation with the level of education among people. Religion has also been seen as another intersecting factor which has played a role in limiting family planning services as the minister once noted. “ The minister of health has been outspoken against religious leader’s opposition to family planning and to condom use for HIV prevention but he acknowledges the difficulty in having them change their stance”. “For us, we can’t change our Bishops”(Solo 2008: 28). “In most case we have to follow our religious beliefs.” (Respondent) Well understood is the fact that, religion has been preventing its followers to use family planning contraceptives, a case in point is the Catholic Church and the born-again churches ADEPER which has been only permitting abstinence and only allows condoms to only PLWHIV. These churches regard other methods of family planning services as killing and hence arguing to its followers to limit their birth without killing”. The church has been discouraging its believers to use family planning service claiming that it’s God who gave them the right and the ability to produce and therefore they should produce and God will take care. In my view, this is not an effective strategy because when you are planning for many people of different status, different cultures and different believes, suggesting only one method can be problematic. Experience further reveals that, class difference matters in relation to who participate in family planning or not. It was discovered from the research experiences that, people with a high-level of income, highly participate in family planning than people with a low level of income. This 43 could be due to the reasons that, poor people regard many children as a source of security in their old age which is not the case with the rich people. This also applies to the educated and un educated people as one of the respondents had to say. “ Am not educated and I don’t have a job, I only survive on the harvests which me and my wife cultivate, I therefore have to produce many children who will help me in the future.”(A male respondent) Finally, the experiences has shown that, men’s participation in family planning services has been mentioned in the family planning policy but most of the family planning programs and methods in place are still largely focusing on women. It can therefore be noted that, stereotyping family planning as women issue has a direct connotations with the cultural norms deeply constructed in the societies. This has affected the policy makers and implementers in the way that, they have failed to equally balance both women’s and men’s reproductive needs. In line with Cornwall’s idea, men could be limited to join family planning fearing to lose their masculinity. “How are involved men coping with the issues such as losing control over families if family size is negotiated with wives? How do involved men respond to the contradictions inherent in their involvement when social norms dictate that men sure large families, yet they are involved in interventions whose aim is to restrict family size? What is the impact of men’s involvement in programs on the lives of men involved?” Cornwall in (Sternberg and Humbley 2004: 394), It’s therefore important to sum up that, men’s participation in family planning services cannot be achieved without first challenging the deeply rooted cultural beliefs in societies. “Culturally sensitive approaches must be open to the unexpected. Both men and women take part in shaping the gender orders and social expectations concerning the male and female body, and in varied and unpredictable ways” (State of world population 2008: 43). It’s therefore important to note that, men would fear their power to be confronted in any way therefore, programs addressing the cultural norms are important to improve men’s participation in family planning services.

4.6 Strategies which can be adopted to improve men’s participation in family planning services The following strategies were drawn from the respondent’s experiences on what they think in relation to improve men’s participation in family planning services. “Men would like to be part of family planning but the methods are limited. If there were other family planning methods for men like those of women for stance pills, Injectables among others we would also participate freely” (Male respondent). The fact that, policy makers have all along neglected men’s reproductive needs, most men on the ground admit the fact that, their ability to make choice regarding contraceptives in still challenging. Since changing people’s 44 behaviors is a gradual process, there should be continuous sensitizations in the community especially in places where people gather in a big number for stance during communal work. (umuganda) as well as the health center. Since men are regarded as decision makers and family heads in almost all patriarchal communities including Rwanda, they are the ones suitable to challenge the existing norms which influence the practices as one of the respondents noted. “ Many programs should have been male-centered because men are the ones who have power in all the decisions taken in homes including reproductive powers. Men are the decision makers in most homes in the patriarchal societies. But the fact that, even policy makers still place family planning as women issues, men’s mentality and practices towards family planning, will take a long journey’’ (Staff from RWAMREC). Noted from the service provider, further is the necessity to call upon governments and other non-governmental organizations addressing family planning issues to initiate a forum operating from the sector to village level aiming at awarding the best family which participated in family planning services and in family planning services therefore, these men could act as the role model to others hence building confidence to other men who are fearing the social norms. Further, Improved household communication could improve the utilization of family planning services. In most of the Rwandan families, partners do not communicate their sexuality due to the fact that, people have been socialized in an environment which regard sexuality as a taboo. Due to this early socialization, even among married couples it is very common that, they keep silent about sexuality and yet it is the center of the family and a prerequisite to a good family planning process. Many people fear to discuss sexuality issues, even when they are in their homes due to the fact that, community members has a mentality of regarding a person who discusses about sexuality as a prostitute or a spoilt person and as a result, people choose to show that, they are innocent in order to regard their status in the community and at home and this further keeps affecting the whole family setting.

45 Chapter 5: Researcher’s Own Considerations

Drawing from the experiences from the field, men’s participation in family planning is taking a slow movement and most of the reasons for this are the fact that, the practice has all along been regarded as a women issue and this has originated from the constructed social norms deeply rooted in the patriarchal societies which sets and obligates gender roles in the society. The researcher therefore argue that, some men have changed their mentality and would wish to participate in family planning services but due to the fact that,they are living in societies which construct them in certain expectations, they find it a challenge not to confirm to society’s expectations which can make them loose power.

5.1 Summary and conclusions Various initiatives have been put in place to improve men’s participation in family planning service but many efforts are still needed to achieve this objective. Presently, the Rwandan government through its initiatives of reducing the population size of the country as well as achieving gender equality and equal reproductive health rights (shift from WID to GAD) men have been left out in the field of reproductive health for a long time, the ministry of health is encouraging men to actively participate in family planning since it was discoveredvery little can be achieved without their role.

Men’s participation in family planning services is of a great importance and as said above, very little can be achieved without their contribution since they are the gate keepers in most areas of decision making including households. Though men are being looked at as good partners if gender equality is to be achieved as well as equal reproductive health rights among men and women, men’s full participation in family planning services is still constrained by various social constructions and expectations of manhood deeply rooted in people’s daily practices. It’s in this regard that, various notions which represents men’s dominant masculinity, images, practices and discourses around men’s sexuality are still existing in the Rwandan society and these has a direct influence to men’s participation in family planning services. The following factors therefore can’t stay un-addressed if men’s participation in family planning services is to be achieved.

Firstly, reflecting on the practices and available family planning programs in Rwanda, it’s evidenced that, programs targeting men are still very limited compared to those targeting women and this directly shows dominant masculinity presentations directly from the policy makers. Family planning 46 is a health issue where by both men and women are entitled to and should share equal rights but it has been all along considered as a woman’s responsibility which doesn’t concern men. It is in this regard that, policy makers should see family planning as a right for both men and women and create conducive environment for men also to enjoy their reproductive health right without categorizing ‘women’ and ‘men’. Looking at vasectomy, most men during the field work revealed that, they are not comfortable with vasectomy due to the fact that, when a man do it; he is no longer treated as a real man among his fellow men hence losing his masculinity. Due to social constructions which persists in different societies and which shapes a man in certain way, men are struggling to meet these social expectations which latter affect the achievement of the family planning policy. Secondary, men’s participation in family planning services also has a direct connotation with the definition of sexuality in the society. Sexuality is seen as a secrete phenomenon (taboo) and therefore discussions around its practice are very limited. This has influenced men’s participation in family planning services in the sense that, sexuality is not given time in most homes and yet a man’s role in family planning is expected starting from the household level, and the fact that, a woman has no power to negotiate the number of children they would wish to have, hence an invisible role of men. In most patriarchal societies, men are expected to be sexually active and strong to prove their masculinity. Basing on the findings got from the field, most men refuse their partners to use family planning contraceptives basing on the fears that, family planning contraceptives leads to negative effects and the fact that, men want to prove their masculinity through having successful sexual intercourse, anything which leads to unsuccessful sexual intercourse is seen as an obstacle. Furthermore, struggling to achieve societal expectations as a man has been also found out as a factor which influences men’s participation in family planning services. A case in this is the fact that, a man is seen as a real man when he has children and in any case when a man gets married, he is expected to have children as soon as possible in order not to be seen as a failure. Due to that expectation, family planning will not be considered. In line to what has been discussed above, son preference is also another reason which limits men’s participation in family planning services. It has been found out that, a man cannot allow her partner to use family planning contraceptives due to the fact that, a family without a son is still regarded as an incomplete family in most areas in Rwanda and therefore a woman will continue to produce until she gets to a son child. Thirdly, due to the fact that, family planning issues have all along been regarded as a women issue, many men are still facing the challenges of this shift from women alone issue to both men and women practice. Challenging the deeply rooted practices and ideologies of masculinity in a patriarchal society is a gradual process and many efforts to challenge these practices should be strongly invested in. Dominant notions of masculinity which are

47 still valued in regard to a real man, are still manifested in family planning service provision in the sense that, seeing a man at the health center going for family planning or even when he is escorting his partner, he is not regarded as a real man by those who see him. Also, the fact that, family planning services are largely regarded as a woman issue, men are not feeling comfortable to sit in the family planning waiting rooms mostly due to the fact that, the infrastructures are designed for women and even the fact that men want to show their masculinity, so when they don’t receive that attention from the service providers at the health centre they feel as if their masculinity is lost which leads them to quite the practice. It’s therefore important to note that, men’s participation in family planning is much connected to the dominant masculinity notions which are still covering a big part in the society. Policy makers should therefore put into considerations that, reproductive health also concerns men and therefore men’s reproductive health should be given specific attention in coming up with programs were they feel free to benefit from their rights without being categorized as “men” and therefore, policies should embark much on efforts to challenge the social constructions and gender power relations in societies which limits men’s freedom and therefore, if these issues remain un addressed, men’s participation in family planning will remain challenging.

5.2 Recommendations Basing on the findings got from the field, it’s well-drawn that, men’s participation in family planning services is a necessary practice if gender equality is to be achieved. Gender being a social constructed behavior, it is important that, the ministry of health work closely with the ministry of education to initiate the cultural and reproductive health curriculum starting from primary level showing how the culture has been differentiating man and a woman by setting roles and responsibilities and the need to promote gender equality even within reproductive health like family planning so that young people who are the foundation of the country they can grow –up knowing that men and women are equal. As the experiences drawn from the ground shows, it could really be important to stress that, service providers would look for a way where by clients of family planning get a blood test before the utilization of contraceptives. This strategy would help to foresee which type of a contraceptive matches with a certain type of blood in order to eliminate the complications some of family planning users reported to be the contributing factors leading to the low men’s participation . Depending on what most men addressed during the field study, it is crucial for policy makers to introduce more male family planning contraceptives to enable men’s ability to make free choices. The fact that, methods of family planning available for men are only condoms, withdraw method, periodic abstinence and vasectomy, most men have been finding it a challenge to make choice . Service providers are requested therefore to 48 provide other contraceptives like those of women which can make men free to choose and also which are not permanent like vasectomy.

49 Appendices

Appendix i Interview Guides Interview questions addressed to the key informants. a) In-charge of family planning services at the national level (ministry of health) b) In-charge of health affairs at the district level. c) Personnel in the Rwanda Men’s Resource Center (RWAMLEC) d) Director of Gakenke health Center e) The in-charge of family planning services at Gakenke health center f) The in-charge of family planning services at the district hos- pital g) The in-charge of social affairs at Kiramuruzi sector Questions 1. In your understanding, what is the meaning of family planning? 2. Do you think family planning has an importance to the community? If yes which importance, if no why? 3. Are there family planning services available in this area? 4. Where are they found? 5. Who provides them? 6. How much do family planning services cost? 7. Which methods of family planning services are available in this area? 8. Which strategies do you use to increase the utilization of family planning services in this community? 9. In your understanding, whom do you think is responsible for family planning among couples? 10. What do you think about men’s participation in family planning ser- vices? 11. Do you think men’s participation in family planning services neces- sary? 50 12. Do men in this area participate in family planning services? If yes how? If no why? 13. What are men’s perceptions on their participation in family plan- ning services? 14. Which strategies are there aiming at increasing men’s participation in family planning services? 15. What do you think could be the effects if men participate or not par- ticipate in family planning services? 16. What else do you think could be done to improve family planning services? Guiding questions for focus group discussions Family planning users (men and women)

1. What do you know about family planning? 2. Do you use family planning services with your partner? If yes who 3. Who uses family planning services among you and your partner? Why? 4. Do you think family planning is important/useful to your family and to the country at large? 5. How many children would you do you want to have? 6. Do you discuss with your partner about family planning issues? How often? 7. Who decides the number of children to have in your family? 8. Does the preference of a certain sex influence you and your partner in using family planning services? 9. Who should be responsible for family planning? 10. Do you access family planning services easily in your community? 11. What is the distance from your home of residence to the family planning unit? 12. Is distance from your place constraining you from accessing family planning? 13. Do men in your community participate in family planning services? If yes how?. If know why? 14. How do you regard participation of men in family planning? 15. What methods of family planning services are available for men in your community? 16. Are you satisfied with the available methods of family planning for men? Family planning non-users (men and women) 1. What do you know about family planning? 2. Are there family planning services delivered in any nearby health centre? 51 3. Do you think family planning is important/useful to your family or country? if yes how 4. Have you ever used family planning services with your partner? If yes who? 5. Are you still using any family planning services? If yes which method? If no why? 6. What constrains from participating in family planning services? 7. How many children would you wish to have? 8. Do you discuss with your partner about family planning issues? How often? 9. Who decides the number of children to have in your family? 10. Whose responsibility is family planning according to your thinking? 11. What is the distance from your home of residence to the health? 12. Is distance from your place constraining you from accessing family planning? 13. Do men in your community participate in family planning services?. How? 14. How do you regard participation of men in family planning services? 15. Are you satisfied with the available methods of family planning for men? 16. What do you think can be improved?

Criteria for observation method in the family planning waiting room 1. Number of service providers available in the family planning waiting room. 2. Sitting arrangement in the family planning waiting room. 3. Information Education Communication materials available in the waiting room? 4. Information sharing in the room 5. How Information, Education and Communication sessions are given and to who? 6. Interaction of service providers and service seekers? 7. Service provider’s perception to men who come in the family planning waiting room? 8. Perceptions of women (service seekers) towards men who come to the family planning waiting rooms? 9. Record keeping for family planning services in the health centre? 10. The interactions between men and women who come to seek family planning services? 11. Power dynamics in the waiting room?

52 Appendix ii Community health workers during the community mobilization session

53 Source: Field worker July-August 2011

54 Appendix iii: Family planning clients waiting for family planning services at Gakenke health center

Source: Field work July-August 2011

55 Appendix iv: Family planning methods delivered at Gakenke health Centre

Source: Gakenke health centre 2011

56 Annex v: Map 1 MAP of Rwanda showing Gatsibo District

Gatsibo District

Source (Bayisenge 2008: 60)

57 References

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