COUPLE RELATIONSHIP QUALITY AND

CONTRACEPTIVE DECISION-MAKING IN

, GHANA

Wednesday Noon Seminar Series

Johns Hopkins Bloomberg School of Public Health

Department of Population, Family and Reproductive Health

October 24, 2012

Carie Muntifering Cox, MPH, PhD

Monitoring, Evaluation and Research Advisor

IntraHealth International

Overview 2

Background

Contraceptive Use

Relationship Quality

Study Design and Results

Objective

Methods

Findings

Implications and Next Steps

Contraceptive Use 3

Beneficial for women, families, communities, and countries

Over 200 million women have an unmet need for family planning*

2012 London Summit on Family Planning – Renewed efforts and commitment in family planning

Contraceptive use is stagnant or declining in many West African countries

*Singh, S., & Darroch, J. E. (2012). Adding it up: Costs and benefits of contraceptive

services - Estimates for 2012. New York: Guttmacher Institute and UNFPA

What is Couple Relationship Quality

and Why Does it Matter? 4

Spanier & Lewis’ definition of marital quality:

The subjective evaluation of a married

couple’s relationship on a number of

dimensions and evaluations*

Majority of individuals spend a substantial

portion of their adult lives in one or more

intimate relationships.

*Spanier G.B. & Lewis R.A. 1980. Marital Quality: A Review of the Seventies. Journal of

Marriage and Family, 42:4, 825-839.

Relationship Quality, Health, and

Well-Being 5

Relationship quality is associated with:

Individual well-being

Physical and mental health

Family health and development

Emerging research also suggests that it is

associated with contraceptive use

Relationship Quality and Contraceptive

Use 6

Research in high-income countries:

Measures various aspects of relationship quality

Mixed research results

Majority of findings suggest a positive association

Research in sub-Saharan Africa:

Recent focus on couple characteristics as potential

determinants of contraceptive use

Limited research on relationship quality

Study Objective 7

Better understand how

various components of

relationship quality

among married and

cohabitating couples in

Kumasi, Ghana are

associated with the use

of contraception.

Kumasi

Marriage and Contraceptive Use in

Ghana 8

Median age of marriage

Females: 20 years

Males: 26 years

Contraceptive Prevalence Rate

(Married Women):

24%-all methods

17%-modern methods

7%- traditional methods

Unmet Need for Contraception: 35%

Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. 2009. Ghana

Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro.

Data Source

9

Family Health and Wealth Study-Ghana

Longitudinal, cohort study in peri-urban communities

Used baseline data from Kumasi, Ghana

800 married and cohabitating couples of reproductive

age

Measurement of Relationship Quality 10

Five dimensions of relationship quality measured in FHWS:

1. Commitment Subscale (Sternberg Triangular Love Scale)

2. Dyadic Trust Scale

3. Constructive Communication Subscale (Communication Patterns Questionnaire)

4. Destructive Communication Subscale (Communication Patterns Questionnaire)

5. Single item on relationship satisfaction

Scales adapted based on results of Confirmatory Factor Analysis

Examples of Scale Items 11

SCALE ITEM

Commitment Subscale

I am committed to maintaining my

relationship with my current partner

Dyadic Trust Scale

My partner treats me fairly and justly

Constructive Communication

Subscale

We try to discuss the problem

Destructive Communication

Subscale

We threaten each other with negative

consequences

Relationship Satisfaction

(Single Question)

Please rate how happy you are in your

relationship

Dependent Variable 12

Dependent Variable: Current Contraceptive Use

No Use

Non-Awareness Method Use

Injectable, pill, IUD, implants, and diaphragm

Awareness Method Use

Periodic abstinence, withdrawal, condoms, and spermicide

Respondents who were pregnant, used permanent

methods or “other” methods were excluded

Data Analysis 13

Bivariate and Multivariate Multinomial Logistic Regression Analysis

Controlled for the following variables:

Age, Religion, and Education of the female respondent

Household wealth

Number of children

Difference in partners’ age and education

Relationship type (monogamous or polygynous)

Relationship duration

Relationship status (married or cohabitating)

Characteristics of Study Sample 14

Characteristic % or Mean (n = 698)

Woman’s Age (mean, years) 33.6

Difference in age (mean,years) 7.5

Education (mean, years) 5.9

Difference in education (mean, years) 0.7

Religion (%)

Christian

Muslim

53.0%

47.0%

Polygynous Unions (%) 7.6%

Relationship Duration (mean, years) 11.8

Number of Children (mean) 3.2

Contraceptive use among women in

study sample 15

Contraceptive Method % of Women (n=698)

No Method Use

No Method

77.5

Non-Awareness Method Use

Pills

Injectables

IUD

Implants

Diaphragm

7.0

3.2

0.4

0.1

0.1

Awareness Method Use

Periodic Abstinence

Condoms

Withdrawal

Spermicide

8.3

2.3

0.7

0.3

Mean Relationship Quality Scores 16

Relationship Quality

(Possible Score Range)

Women’s Mean

Score

Men’s Mean

Score

Commitment

(4-36)

29.92

33.59

Trust

(5-35)

25.40 28.68

Satisfaction

(1-6)

4.51 4.84

Constructive Communication

(3-30)

21.80 25.51

Destructive Communication

(3-30)

4.85 4.54

Unadjusted Multinomial Logistic

Regression: Relationship Quality 17

Non-Awareness Method

Use vs. Non-Use

Awareness Method Use

vs. Non-Use

Women Partner Women Partner

Commitment 1.00 1.07 1.02 1.08***

Trust 0.99 1.05† 1.01 1.04

Satisfaction 0.96 1.35† 1.18** 1.31

Constructive

Communication

1.00 1.05 1.05*** 1.16***

Destructive

Communication

1.06 0.92 1.05 0.97

† p<0.10, *p<0.05, **p<0.01, ***p<0.001

Unadjusted Multinomial Logistic Regression:

Demographic Characteristics 18

Non-Awareness Method

Use vs. Non-Use

Awareness Method Use

vs. Non-Use

Age 0.94*** 0.95*

Education 1.07*** 1.09

Religion Christian

Muslim

Ref

0.46**

Ref

0.68

Wealth Lowest

Lower

Middle

Higher

Highest

Ref

1.16

0.86

0.59

0.75

Ref

1.24

1.22

1.29

1.80

† p<0.10, *p<0.05, **p<0.01

Unadjusted Multinomial Logistic

Regression: Couple Characteristics 19

Non-Awareness

Method Use vs.

Non-Use

Awareness

Method Use vs.

Non-Use

Relationship Type (Mono -Ref)

Polygynous

0.27***

0.12

Relationship Status (Married-Ref)

Cohabitating

1.17

0.90

Relationship Duration 0.98 0.96**

Difference in Age 0.96† 0.98

Difference in Education 0.96*** 1.02

Number of Children 1.01 0.93

† p<0.10, *p<0.05, **p<0.01, ***p<0.001

Adjusted Multinomial Logistic

Regression: Relationship Quality 20

Non-Awareness Method

Use vs. Non-Use

Awareness Method Use

vs. Non-Use

Women Partner Women Partner

Commitment 1.00 1.08 1.02 1.06†

Trust 1.00 1.05* 1.01 1.01

Satisfaction 1.02 1.28 1.21*** 1.07

Constructive

Communication

0.98† 1.08* 1.01 1.14***

Destructive

Communication

1.05† 0.93 1.05 0.98

† p<0.10, *p<0.05, **p<0.01

All models controlled for partner’s relationship quality score, demographic

characteristics and couple characteristics

Conclusion 21

Certain dimensions of relationship quality are important in contraceptive decision-making.

Male partner’s perception of relationship quality matters in contraceptive use.

Association between contraceptive use and relationship quality varies by dimension of relationship quality and type of contraception.

Relationship quality should be considered in reproductive health research and programs.

Limitations 22

Cross-sectional data

Challenges in measuring

relationship quality

Potential bias

Generalizability

Public Health Implications 23

Policy

Establish and enforce policies promoting harmonious relationships and access to quality family planning services

Ensure the individual right to contraception

Programmatic

Incorporate the promotion of positive relationship quality:

Mass media messages

Sexual education

Training curricula for family planning providers

Sexual and reproductive health programs

Next Steps in Research 24

Assess how relationship quality relates to other aspects of contraceptive decision-making:

Fertility desires, Unmet need, and Covert use

Further examine the validity of relationship quality measures in the West African context

Conduct qualitative research to better understand key findings and identify other dimensions of relationship quality important in contraceptive use

Acknowledgements

Co-authors: Michelle Hindin, Easmon Otupiri, and

Roderick Larsen-Reindorf

Gates Institute for Population and Reproductive

Health

Faculty and Staff at JHSPH

Research Team at KNUST

Study Participants

25

Questions?

26

Thank You!

Supplemental Slides

27

Theory and Framework

Family Systems

Theory

Interdependence

Feedback

Self-Regulating

Couple Self-Regulation Function*

*Adapted from C. Broderick; Understanding Family Process

Prior spousal discussions on FP; History of violence;

shared fertility goals

(Couple Archival Function)

Action (ie: Contraceptive Use)

Relationship Quality

Decision-making power; Recent Sex;

Agreement of FP approval; Marital

Duration; Marriage Type Parity, HH Wealth

(Couple Status Monitoring Function)

Decision-Making Process

(Executive Function)

Changed Status

Attitudes/behaviors of co-wives and peers;

Lineage expectations/ obligations; Mass media

messaging

(Couple Context Monitoring Function)

Age, Age Difference, Education, Education Difference, Religion,

Ethnic Group

(Stable Characteristics)

Acceptance of FP; Fertility preferences; Motivation to

Prevent Pregnancy

(Individual Attitudes and Preferences)

Assumptions of the Family Systems

Theory

An entire system must be considered as a whole rather than its individual parts.

The context in which things occur is essential to consider when interpreting interactions and outcomes of the system.

Systems are hierarchically organized and nested within each other.

All living systems are open, active systems that interact with their environment.

Human systems are self-reflexive implying that individuals are able to reflect on their behaviors and interactions within the system.

Reality is constructed by individuals through their own perspective.

*Jurich and Myers-Brown (1998)

Conceptual Framework

Fertility Preferences (Both Partners)

Individual-Level Variables: (Age, Education, Wealth, Urban/Rural, Religion, Parity, Ethnic Group)

Couple-Level Variables: (Difference in Age, Difference in Education, Marital Duration, Husband’s Absence, Marriage Type, Household Decision-Making Power)

Contraceptive Use

Community-Level Variables: (Gender Inequality, Cultural Norms, Health Facilities)

Family Planning Decision-Making Power

)

Knowledge of Family Planning

Spousal Discussion

on Family Planning

Relationship Quality

Coital Frequency

Acceptance of Contraception

Contraception-Related Health

Concerns

Access to Contraception

Motivation to Prevent

Pregnancy

Commitment Subscale 31

Retained in Final

Scale

Commitment Subscale Female Male

I expect my love for my current partner to last for the

rest of my life. Yes Yes

I can't imagine ending my relationship with my current

partner. Yes No

I view my relationship with my current partner as

permanent. Yes Yes

I am committed to maintaining my relationship with

my current partner. Yes Yes

I have confidence in the stability of my relationship

with my current partner. Yes Yes

Dyadic Trust Scale 32

Retained in Final Scale

Dyadic Trust Scale Female Male

My partner is primarily interested in his own welfare No No

There are times when my partner cannot be trusted No No

My partner is perfectly honest and truthful with me Yes Yes

I feel I can trust my partner completely Yes Yes

My partner is truly sincere in his promises Yes Yes

I feel that my partner does not show me enough

consideration No No

My partner treats me fairly and justly Yes Yes

I feel that my partner can be counted on to help me Yes Yes

Constructive Communication Subscale 33

Retained in Final Scale

Constructive Communication Factor Female Male

We try to discuss the problem Yes Yes

We express their feelings to each other Yes No

We suggest possible solutions and compromises Yes Yes

Destructive Communication Factor

We blame, accuse and criticize each other Yes No

We threaten each other with negative consequences Yes Yes

I call my partner names, swear at him, or attack his character Yes Yes

My partner calls me names, swears at me, or attacks my

character Yes Yes

Confirmatory factor analysis: Women 34

SRMR, standardized root mean square residual; RMSEA, the root-mean-square-error-of-

approximation; TLI, tucker-lewis fit index, CFI, comparative fit index

Confirmatory Factor Analysis: Men 35

SRMR, standardized root mean square residual; RMSEA, the root-mean-square-error-of-

approximation; TLI, tucker-lewis fit index, CFI, comparative fit index

Qualitative Results 36

Dimensions of relationship quality important in

contraceptive decision-making:

Communication

Necessary step

Facilitation of discussion

Communication style important for acceptance

Empathy

Emphatic concern for the well-being of one’s partner and the

family important