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



Study Design and Results




Contraceptive Use
Relationship Quality
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
6
Relationship Quality and Contraceptive
Use

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.
2.
3.
4.
5.

Commitment Subscale (Sternberg Triangular Love Scale)
Dyadic Trust Scale
Constructive Communication Subscale (Communication
Patterns Questionnaire)
Destructive Communication Subscale (Communication
Patterns Questionnaire)
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 Men’s Mean
Score
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 Awareness Method Use
Use vs. Non-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 Awareness Method Use
Use vs. Non-Use
vs. Non-Use
Age
0.94***
0.95*
Education
1.07***
1.09
Religion Christian Ref
Muslim 0.46**
Ref
0.68
Wealth
Ref
1.24
1.22
1.29
1.80
Lowest
Lower
Middle
Higher
Highest
Ref
1.16
0.86
0.59
0.75
† p<0.10, *p<0.05, **p<0.01
Unadjusted Multinomial Logistic
Regression: Couple Characteristics
19
Non-Awareness
Method Use vs.
Non-Use
Relationship Type
(Mono -Ref)
Polygynous 0.27***
Awareness
Method Use vs.
Non-Use
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 Awareness Method Use
Use vs. Non-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
25





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
Thank You!
26
Questions?
Supplemental Slides
27
Theory and Framework
Couple Self-Regulation Function*
Family Systems
Theory

Acceptance of FP; Fertility
preferences; Motivation to
Prevent Pregnancy
(Individual Attitudes and
Preferences)
Age, Age Difference,
Education, Education
Difference, Religion,
Ethnic Group
(Stable Characteristics)
Prior spousal discussions
on FP; History of violence;
shared fertility goals
(Couple Archival Function)
Interdependence

Feedback

Self-Regulating
Relationship Quality
Decision-making
power; Recent Sex;
Agreement of FP
approval; Marital
Duration; Marriage
Type Parity, HH Wealth
Decision-Making
Process
(Executive Function)
(Couple Context
Monitoring Function)
(Couple Status
Monitoring Function)
Action (ie: Contraceptive Use)
Changed Status
*Adapted from C. Broderick; Understanding Family Process
Attitudes/behaviors of
co-wives and peers;
Lineage expectations/
obligations; Mass media
messaging
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
Community-Level Variables:
(Gender Inequality, Cultural Norms,
Health Facilities)
Couple-Level Variables:
(Difference in Age, Difference in Education,
Marital Duration, Husband’s Absence, Marriage
Type, Household Decision-Making Power)
Knowledge of Family Planning
Acceptance of
Contraception
Contraception
-Related
Health
Concerns
Access to
Contraception
Fertility Preferences (Both Partners)
Family Planning Decision-Making
Power
)
Coital
Frequency
Contraceptive Use
Individual-Level Variables:
(Age, Education, Wealth, Urban/Rural,
Religion, Parity, Ethnic Group)
Motivation to
Prevent
Pregnancy
Spousal
Discussion
on Family
Planning
Relationship
Quality
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.
I can't imagine ending my relationship with my current
partner.
I view my relationship with my current partner as
permanent.
I am committed to maintaining my relationship with
my current partner.
I have confidence in the stability of my relationship
with my current partner.
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
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
My partner treats me fairly and justly
No
No
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
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
My partner calls me names, swears at me, or attacks my
Yes
character
Yes
Destructive Communication Factor
Yes
Confirmatory factor analysis: Women
34
SRMR, standardized root mean square residual; RMSEA, the root-mean-square-error-ofapproximation; 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-ofapproximation; 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