Tài liệu Involving Men in Reproductive Health: Contributions to Development pdf

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1. INTRODUCTION

Men’s intimate involvement in sex and reproduction cannot be disputed. Yet for much of its
history, the population field focused almost exclusively on the fertility behavior of women,
paying little attention to men’s roles in its study of the implications of population growth and
fertility rates.
1
As a consequence, population policy was implemented almost exclusively
through basic family planning programs serving women. If men were involved, they were
involved in a limited way, often to ensure contraceptive continuation and acceptability
2
or to
promote the diagnosis and treatment of sexually transmitted infections.
3


Since the 1994 International Conference on Population and Development in Cairo (ICPD),
international family planning has slowly given way to a different paradigm. International family
planning has expanded from its emphasis on the delivery of clinical services to married women
of reproductive age. This emphasis has made important contributions to the health and well-
being of women and their families. But in recent years, the limitations of this model have
increasingly been recognized, and a new, more comprehensive approach to reproductive health
formulated.

Several changes have occurred at once. First, family planning programs are now expanding
beyond their traditional contraceptive focus to address the prevention and treatment of sexually
transmitted infections, the reduction of maternal morbidity and mortality and counseling and
treatment of sexual problems. The second change is that programs now have a mandate to serve
the needs not only of married women, but adolescent boys and girls, men, and unmarried women
of all ages. The third important shift has been a move toward a broad, development-oriented
concept of health that moves away from a narrow focus on service delivery and acknowledges
the social relationships that constrain health more fully.

There has been a formal recognition that more equitable relations between men and women and
reproductive rights are important ends in themselves as well as the central means of reducing
fertility and achieving population stabilization. The HIV and AIDS epidemic sharpened the
recognition that existing reproductive health programs were having a limited impact in helping
countries achieve overall reproductive health and development goals.
4
The 1994 ICPD
Programme of Action, agreed to by 179 countries, unequivocally links programs to improve
sexual and reproductive health with efforts to address the gendered values and norms that harm
both men’s and women’s health and impede development. In this sense, the newer concept of
reproductive health has helped to situate sexuality and reproduction within a broader
development agenda. Reproductive health goes beyond the health sector, and is more than a
women’s health issue.

Involving men has been a prominent part of the shift from family planning to the broader
reproductive health agenda. Men obviously make up a significant new clientele for programs.
They constitute an important asset in efforts to improve women’s health. And efforts to involve
them in ways that transform gender relations and promote gender equity contribute to a broader
development and rights agenda. While international family planning programs were essentially
about women’s health, reproductive health as it has now been formulated goes beyond health to
broader development issues.

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This paper begins by outlining the key issues involving men in reproductive health entails and
presents a conceptual framework within which to consider male involvement efforts. The second
major section reviews existing data on men – their health needs, their attitudes, and their
practices – and identifies gaps in our knowledge of men’s experiences. Programmatic activities
have their limits when policy context does not support male involvement, so the next section
reviews work at the policy level to support and institutionalize male involvement in reproductive
health. Next, the paper reviews programs that involve men in varied aspects of reproductive
health, highlighting the evolution of programming, and emphasizing best practices and success
stories. Monitoring and evaluation shape and motivate programs, and also exert a conservative
influence on programs, inhibiting change despite the paradigm shift in the field described above.
The next section thus reviews recent efforts to conceptualize program “success” and approaches
to measuring it. A brief conclusion reviews what we have learned from the diverse examples of
work to promote men’s involvement in reproductive health. The basic argument of this entire
document is that men’s roles in sexual and reproductive health must be recognized, understood
and addressed much more extensively than they have to date, and that doing so will have
implications well beyond reproductive health for other aspects of development.


2. CONCEPTUAL FRAMEWORK

The Millennium Development Goals and reproductive health
The Millennium Development Goals lack an explicit objective on reproductive health, but it is
widely understood that its goals cannot be achieved without taking sexual and reproductive
health into account. The tendency to see reproductive health as a women’s health issue has
contributed to a narrow, clinical focus limited to the health sector. Yet we know that social
relationships determine people’s ability to manage their sexual and reproductive lives, with
implications not only for their health, but also for a myriad of other life choices.

Involving men in reproductive health is central to the achievement of rights within and beyond
the health sector. It is obvious that woman-centered MDG goals 3 (promoting gender equality
and empowering women) and 4 and 5 (improved child and maternal health) are mutually
reinforcing. Indeed, they cannot be attained independently of one other. A key interim report of
the Millennium Project points out that the third development goal of promoting gender equality
and empowering women “cannot be achieved without the guarantee of sexual and reproductive
health and rights for girls and women.”
5
This is because a commonly used dimension of
women’s empowerment measures their control over sexual relations; their ability to make
childbearing decisions and their use of contraception and access to abortion.
6
In addition,
“greater economic independence for women, increased ability to negotiate safe sex, [and]
awareness about the need to alter traditional norms about sexual relations . . . [are] essential for
halting and reversing the spread of HIV/AIDS. . . .”
7


Research conducted on how to achieve the MDGs provides much to buttress a broader
interpretation of reproductive health. The Interim Report on Task Force 4 on Child Health and
Maternal Health, for example, points to the reality that,


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“the non-biological aspects of health and health care carry particular significance
in the area of maternal health. Sexuality and reproduction – each separately and
both together – lie at the heart of many of the intimate, the economic, and the
institutional arrangements that drive development.”
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Social and institutional relationships shape people’s health because they reflect the power and
resources upon which individuals can draw to protect their health and prevent and treat disease.
By “resources” the authors mean a broad range of elements including money, prestige, social
networks, education, information, legal claims, and so on, all of which are strongly influenced by
sexuality and reproduction. These resources help to determine agency, or people’s potential to
determine the course of their own lives, which is at the core of sexual and reproductive health
and rights.

Evidence of the need to involve men in sexual and reproductive health
Often overlooked in the general appreciation of the interdependence of MDGs 3, 4 and 5 is the
role played by men and their relationships with women. There is little excuse for overlooking
men in this regard. Ten years ago, the 1994 United Nations International Conference on
Population and Development (ICPD) stressed “male responsibilities and participation” in sexual
and reproductive health. The conference’s 20-year Programme of Action advises that

efforts should be made to emphasize men’s shared responsibility and promote
their active involvement in responsible parenthood, sexual and reproductive
behavior, including family planning; prenatal, maternal and child health;
prevention of sexually transmitted diseases, including HIV; [and] prevention of
unwanted and high-risk pregnancies.
9


A growing body of ethnographic and anthropological qualitative research has been reinforcing
these recommendations, examining even more closely the impact of men, as individuals, as
social gatekeepers and as powerful family members who enforce cultural practices, often to the
detriment of women’s reproductive health.
10


Gender inequities are widespread
The grand recommendations that emerge from international meetings do not simply get realized,
but are struggled over every day in men's and women's lives.
11
The ICPD Programme of Action
recognizes that gender roles are strongly reinforced in cultural beliefs and practices, and that the
social construction of masculinity and femininity profoundly shapes sexuality, reproductive
preferences, and health practices. The extensive research on women’s subordinate status in most
societies that informs the Programme of Action points to widespread patterns of male
prerogative and power, visible in social discrimination such as lower levels of investment in the
health, nutrition, and education of girls and women.
12
Institutionalized legal disadvantages for
women underpin laws that keep land, money and other economic resources out of women’s
hands
13
by foreclosing protection and redress, contribute to violence against women.
14

Discrimination has negative implications for women’s health, reducing, for example, their timely
access to health services during labor and delivery,
15
their use of antiretroviral treatment to
reduce mother to child transmission of HIV because of fear of disclosure,
16
or their ability to
control the type and frequency of sexual practices, to initiate and refuse sex, and to negotiate

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condom use to prevent HIV and STIs.
17


Acknowledging these realities, advocates have fought for the recognition of women’s human
rights, including the rights to decide freely whether, when, and with whom to have children, and
the rights to determine whether, with whom, and under what circumstances to engage in sexual
relations. The exercise of these “social rights,” which are integral to reproductive and sexual
rights, is highly dependent on the social and economic circumstances or enabling conditions that
make women’s choices and negotiation with men possible.
18
As conceived of at the ICPD, the
enabling conditions for the promotion of women’s reproductive rights and equity will also lead
to fertility decline and improved reproductive health.

By increasing people’s ability to control their childbearing, reproductive health programs can
reduce unwanted fertility. By increasing women’s alternatives to childbearing, reducing child
mortality, and influencing social norms, including increasing the value of girl children, multi-
sectoral development policies influence the numbers of children people want. Population and
development policies require coordinated efforts across multiple sectors to address the gender
biases in access to resources (jobs, credit, land, and education, for example) that leave women
economically dependent on men and undermine their rights.

Gendered social expectations have many implications for women’s and men’s reproductive lives.
Social norms favoring male children and promoting women’s economic dependence on men, for
example, contribute to high rates of fertility in many settings. Inability to negotiate sex, condom
use, or monogamy on equal terms leaves women and girls worldwide at high risk of unwanted
pregnancy, illness and death from pregnancy-related causes, and sexually transmitted
infections.
19
Combating sexually transmitted infections and the heterosexual spread of HIV is
impossible without involving men.
20


Why men’s roles were neglected
This large body of evidence on the legal, educational, economic, and health consequences of
gender norms did not significantly influence population and reproductive health policy until
recently. Research on population and reproductive health tended to describe women’s
disadvantaged position without mentioning men’s roles, usually because the data used were
collected only from women.
21
Incomplete knowledge and powerful assumptions made it possible
for the field to avoid addressing gender inequities and expressions such as violence in its work
on reproductive health. The demographic research that informed family planning programs
justified the conceptual omission of men by pointing to the difficulties and uncertainties of using
men as research subjects or informants. Researchers had to grapple with the ill-defined span of
men’s sexual lives, their assumed inability to report on their progeny, the analytic challenges
posed by polygyny and extramarital partnerships, the unlikely chance that they would be at home
to be interviewed by a survey taker, and the frequency with which children ended up in the
custody of their mothers at the end of a marriage.
22


The assumption that families are all similar to a standard Western model, in which women have
the primary role in childbearing and rearing, and in which men and women are assumed to
communicate openly and agree completely about reproductive matters. This model assumes,
moreover, that partners have a shared childbearing experience, i.e., that either the relationship is

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monogamous and that all childbearing occurs within that union, or that the outside experience of
the other spouse has no influence over childbearing in the current relationship. The cultural
variability of reproductive health conditions, however, makes this model inappropriate in settings
where polygyny, marital instability, infidelity, imperfect communications, and women’s
subordination are widespread, which is virtually everywhere.
23


The social and cultural norms and practices that undermine women’s—and men’s—health have
yet to be fully addressed in reproductive health programs. The persistent challenge is how to
translate the rhetorical support for gender equity into a more holistic approach to sexual and
reproductive health and rights. Despite growing rhetorical support for incorporating gender
equity efforts, woman-focused contraceptive delivery is still very much the norm in most
reproductive health programs. Many male involvement efforts are also still narrowly focused on
increasing contraceptive prevalence among both men and women. These limited approaches
sidestep widespread male control over sexuality and reproduction, and only dimly reflect equity
objectives for involving men. Programs attempting either to influence men’s sexual behavior and
reproductive health or address the limits on women’s choices posed by male control over
sexuality and reproduction have been few and far between. This paper demonstrates that
involving men without acknowledging and addressing gender biases may result in interventions
that inadvertently consolidate male power over reproductive and sexual decision-making.

The evolution of “male involvement”
Male involvement is central to improving reproductive health and to the incremental process of
achieving gender equity. But “male involvement” is an ambiguous concept, and many responses
to the call for involving men are more limited than what was envisioned by the ICPD’s
Programme of Action or by health and rights advocates. Programs diverge in their ultimate
purpose in involving men, and in how they involve them. This section assesses the wide range of
male involvement efforts according to their objectives and outcomes as organized in the
framework above. It provides examples of each of three basic types of reproductive health
programming involving men; the framework is summarized in Box 1. Not every program fits
neatly into one of the three categories listed here, but the typology is a useful way of
distinguishing between differing ultimate objectives.

Before Cairo, international family planning programs concerned themselves more with the
obstacles to contraceptive use that arose from women’s low status rather than women’s status
itself.
24
In the mid-1990s, concern arose about this “unfinished transition,” or the uneven
improvements in women’s lives that had been promised by family planning advocates of fertility
decline.
25
Bangladesh’s family planning program, for example, may have avoided addressing
gender inequities by taking family planning to women in purdah at their homes, placing
responsibility disproportionately on “compliant” female patients and clients and avoiding dealing
directly with men.
26
By “restricting the dissemination of information through selected gender-
specific channels or by reinforcing gender stereotypes that for cultural reasons are not likely to
be challenged or discussed openly,”
27
many programs have worked around gender inequities,
marginalizing men and minimizing male participation.

The traditional woman-focused approach to family planning dominated the field in the years
before the Cairo ICPD and in many respects still does. This approach has focused on providing

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contraceptive methods to women in order to reduce fertility and population growth. Examples of
this model can be found in Bangladesh,
28
Thailand,
29
and Latin America.
30
The measures of
program success that arose from this approach endure today and emphasize contraceptive
prevalence among women, and women’s fertility rates.

An approach that emphasizes men as clients emphasizes the need to provide reproductive health
services to men in much the same fashion that women have received these benefits.
31
There is
no doubt that men have their own set of unmet reproductive health needs and concerns that need
to be addressed. But it reflects a limited interpretation of male involvement if it simply advocates
a remedial focus on men who have been excluded from traditional reproductive health programs.
If programs choose merely to provide services for men, they miss the central point that men’s
and women’s social positions constrain their reproductive roles. This approach to family
planning can potentially accept men’s dominant position in certain cultural settings as a given in
a focus on their needs— rather than on gender relations — to improve reproductive health.

An approach that addresses men as partners reflects the view that men can improve – and
impede – women’s contraceptive use and reproductive health.
32
These programs view men as
allies and resources in efforts to improve contraceptive prevalence rates and other dimensions of
reproductive health.
33
While making important contributions to reproductive health, like the
focus on men as clients, this approach does not address the gender inequities that constrain
health. These two approaches miss the opportunity to address the relationships between women
and men and the sharing of responsibility and action. Each lacks the potential to support broader
social change.

The third approach, emphasizing men as agents of positive change reflects the intent of the
Cairo ICPD. This acknowledges the fundamental role men play in supporting women’s
reproductive health and in transforming the social roles that constrain reproductive health and
rights. Many interventions offer men the opportunity to examine and question the gender norms
that harm their health and that of their sexual partners. It seeks to move toward gender equity by
shaping the way services are delivered. This approach emphasizes how services are provided and
looks to reinforce gender equity rather than specifying which reproductive health services should
be provided and to whom. The interventions that involve men as agents of positive change are
relatively few in number. They serve the interests of men as well as women by increasing men’s
choices, their possibilities for learning and development, and the survival and well-being of
family members.
34


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Box 1. Approaches to Involving Men in Sexual and Reproductive Health



APPROACH


PURPOSE & ASSUMPTIONS


PROGRAMMATIC IMPLICATIONS

TRADITIONAL FAMILY
PLANNING FOR WOMEN

Increase contraceptive prevalence;
reduce fertility
Inclusion of men is not necessary from
an efficiency standpoint

Contraceptive delivery to women, in the context of
maternal and child health
1994 Cairo International Conference on Population and Development


MEN AS CLIENTS

Address men’s reproductive health
needs



Extend same range of reproductive health services to
men as to women

Employ male health workers


MEN AS PARTNERS

Men have central role to play in
supporting women’s health



Recruit men to support women’s health, e.g., teach
husbands about danger signs in labor, how to develop
transportation plans, the benefits of family planning
for women’s health


MEN AS AGENTS OF
POSITIVE CHANGE



Promote gender equity as a means of
improving men’s and women’s health
and as an end in itself

Addressing inequity requires full
participation and cooperation of men

Paradigm shift in how programs are structured and
services are delivered, whatever they are

Broader range of activities, working with men as
sexual partners, fathers, and community members


The next section describes what survey and qualitative data can tell us about men’s sexual and
reproductive lives in the developing world. In the subsequent sections on male involvement
policies and programs and how to assess their impact, we will return to this framework.


3. WHAT WE KNOW ABOUT THE SEXUAL AND REPRODUCTIVE BEHAVIOR
AND HEALTH OF MEN IN DEVELOPING COUNTRIES

What do we know about men’s sexual and reproductive health knowledge, attitudes and
behavior? Until recently, the answer to this question would have been “not much.” Drawing on
information now available from an impressive number of comparative surveys carried out in
developing countries we discuss the larger social and economic context of men’s behavior and
attitudes and point to the reproductive health costs for both men and women when programs do
not reach out to men in sexual and reproductive health.

For years, data existed only on married women of reproductive age, but in the past 10 years or so
nationally representative surveys of men aged 15–54 have been carried out in about 40
developing countries.
35
These surveys were undertaken mainly in response to the global
challenges created by the HIV/AIDS epidemic, based on an understanding that the epidemic
could not be addressed without attention to men. The Demographic and Health Surveys (DHS)
provide a wide range of quantitative information about men’s sexual and reproductive
knowledge and behavior, information that can be compared across regions and countries.

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These data have their limitations. The surveys do not include boys younger than age 15, many of
whom are already sexually active. The samples exclude many men living in situations that make
them particularly vulnerable to sexual health risks (men in the military, in prisons, displaced
men, migrants and those living in refugee camps). The few surveys carried out in Asia, the
Middle East and North Africa tend to leave out unmarried men, a disadvantage given the fact
that most men do not marry until their 20s and that most single men are sexually active, often
with more than one partner. And perhaps most importantly, the data collected in the DHS are an
imperfect basis for examining the links between men’s social and economic status and their
sexual and reproductive behavior where we know there are significant gradients among
women.
36
Nevertheless, the surveys provide good data on men in the prime of their sexually
active and fathering years, of a type and quality unavailable until the early 1990s. This section
draws heavily from a review of these data conducted by the Alan Guttmacher Institute.
37
Here
are the bare bones of what these surveys tell us about men’s sexual and reproductive behavior
and knowledge.

The basics of what we know about men’s sexual and reproductive lives and health
While male sexual and reproductive behavior varies widely across the developing world and
among social and ethnic groups within a single country, some broadly similar patterns across
regions do emerge. In almost all of 39 developing countries for which recent information is
available, the majority of men 20–24 report having had sexual intercourse before their 20th
birthday. A substantial proportion first had sex before their 15th birthday. Among unmarried
men aged 15–24 who have ever had sex, 2 to 6 in 10 had two or more partners in the past year.
Despite these high levels of youthful sexual activity, in most Sub-Saharan African countries,
fewer than half of sexually active men 15–24 use a contraceptive method or rely on their
partner’s method, compared with about two-thirds in parts of Latin America and the Caribbean.

Among men in their late 20s and 30s, contraceptive prevalence is lower in Sub-Saharan Africa
than in other regions, reflecting these men’s continued desire for children. In developing
countries where men 40-54 report moderate or high levels of contraceptive use, methods used by
women (especially female sterilization) predominate. Vasectomy is extremely rare in all
developing countries except China. A large fraction of married men aged 25–39, particularly in
Sub-Saharan Africa, report that they have not discussed family planning with their partners.

Marriage is rare among adolescent men and uncommon among men in their early 20s around the
world. Marriage, including cohabitation and consensual union, becomes common among men in
their late 20s and is almost universal among those in their 30s. Almost all men aged 40–54 have
married—some more than once. The more educated men are, the later they defer marriage.
Men’s reported number of sexual partners varies considerably by country. In most countries, a
majority of all men aged 25–39 had only one sexual partner in the past year, in most cases their
spouse. Yet 7–36 percent of married men had had one or more extramarital partners, and some
15–65 percent of unmarried men this age (representing only a small proportion in this age-group)
had had more than one partner within that time period. Similarly, some 4–23 percent of married
men 40–54 have had one or more extramarital partners in a recent 12-month period.


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Strikingly few men in their teens or early 20s have become fathers, but half of them have done so
by their mid-to-late 20s. The vast majority of men in their 40s and early 50s have had the number
of children they want. Many have experienced the breakup of marriage, some are living with or
supporting children from earlier marriages, and some are entering new marital relationships.

The prevalence of curable and incurable STIs (including HIV/AIDS) is higher in Sub-Saharan
Africa and in Latin America and the Caribbean than in other regions. The estimated annual
prevalence of curable STIs among men and women 15–49 ranges from almost 119 infections per
1,000 people in Sub-Saharan Africa to 71 in Latin America and the Caribbean, to 50 in South
and South-East Asia and 21 in North Africa and the Middles East.
38
And of the 18.6 million male
adults and children living with HIV/AIDS in the world, 12.3 million live in Sub-Saharan Africa,
3.8 million in South and Southeast Asia and 1.3 million in Latin America and the Caribbean.
39


Fewer than a third of men in many developing countries know that two ways of avoiding STIs
are condom use and either abstinence or having only one, uninfected partner. The proportion of
men 15–54 who know that condom use is a way of preventing HIV/AIDS varies widely in
developing countries—from 9 percent in Bangladesh to 82 percent in Brazil. The dimension of
the possible risk pool for the transmission of STIs, including HIV/AIDS, can be approximated
from the survey data. Among all men 15–54 in Sub- Saharan Africa and in Latin America and
the Caribbean, 4–18 percent had two or more partners in the past year and did not use a condom
the last time they had intercourse. Some men with STIs do not inform their sexual partners. In
some developing countries, at least three in 10 men 15–54 who had an STI in the past year did
not tell their partners; in Benin and Peru, six in 10 did not. Of sexually active men 15–24 in
Benin, Mali, Niger and Uganda who had had an STI in the past 12 months, only half or less
informed their partners.
40


Still, many men with STIs take action to avoid spreading the infection. In Brazil and Peru, for
example, about two-fifths of such men aged 15–54 said they avoided having intercourse while
they were infected, and in the Dominican Republic, more than one-half said they did so. Roughly
one in 10 infected men in a few countries reported that they continued to have intercourse but
used a condom, and almost four in 10 in a few Sub-Saharan African countries reported that they
had taken some kind of medicine, although it is not possible to determine whether the drug was
appropriate for their particular infection. However, one-third of infected men in Nigeria and
Peru, and almost one-half in Burkina Faso—but only one in 10 in the Dominican Republic—said
they did nothing to avoid infecting their partner.

In some parts of the developing world, men may be prepared to use condoms but unable to
obtain them, especially young men, and those with limited resources or living in rural areas.
When sexually experienced Sub-Saharan African men 15–24 were asked if they knew where to
obtain condoms, only half or fewer of those in rural areas of Guinea, Mali, Mozambique, Niger,
and Chad knew of a source.
41
Today, an estimated 6–9 billion condoms are distributed each year
for family planning and for STI prevention,
42
but many more (perhaps 19–24 billion a year) are
needed to protect populations from unplanned pregnancies, HIV and other STIs.
43
Differing
regional levels of risk of unintended pregnancy can be clearly seen in the fact that some 20–46
percent of men 25–54 in Sub-Saharan Africa and 15–30 percent of those in Latin America and

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the Caribbean do not want a child soon or do not want any more children but are not protected
against unplanned pregnancy.

Men exert important influence on their partners’ reproductive health
The policy and programmatic implications of the DHS findings are urgent not just for men
themselves but also for their families, especially their wives and female sexual partners. Men can
influence their partners’ reproductive health in various ways.

Men’s influence on family formation and contraception
There can sometimes be discordance between women’s and men’s desire for children, including
the desired number and the timing of women’s pregnancies and births. Partner communication
about sex, desired family size and contraception can be poor or nonexistent. Some women do not
know or incorrectly assume what their husband’s wishes on family size and family composition
are; and some men do not know their wife’s wishes because the couple does not discuss this
issue. In the absence of discussion, both men and women may fail to achieve their childbearing
goals, and sometimes coercion can result. Condoms, periodic abstinence and withdrawal require
communication and negotiation between partners to be used effectively. Male partners may also
significantly influence the use of other female methods. Men may control the economic
resources required to access these methods, may indirectly impede or directly prohibit women
from attending health facilities to obtain these methods, or may not approve of women’s actual
use of these methods. Some women use contraceptives secretly to avoid confrontation with their
unsupportive partners.

Men’s influence on abortion
Few studies directly address men’s roles in women’s abortion decisions and experiences,
however some indirect evidence is available. In developing countries, where abortion is largely
banned and many terminations are performed in unsafe circumstances, many women end
unwanted pregnancies because of unstable relationships with the men in their lives. In many
countries, being in a troubled or fragile relationship ranks high among the reasons women give
for seeking abortions. A 1992-1993 hospital based survey of abortion patients aged 15-35 in
Honduras found that it was the leading reason, and a study among abortion providers in Northern
Nigeria indicated it as the second most commonly cited reason in Nigeria in 1996. Other studies
in Chile (in 1988), Honduras (in 1992–1993), Mexico (in 1967–1991) and Nigeria (in 1996)
show that the proportion of women seeking abortions because of troubled relationships is fairly
high (20–42%).
44


Many women seeking abortions say their primary reason is that they do not want to be single
mothers. This response suggests that many of these pregnancies result from extramarital
relationships or relationships between unmarried people; that the man may have threatened to
abandon the woman if she had the baby; and that the breakup of a relationship may have been
imminent. Hospital-based studies in Brazil, Guinea, Kenya, Mali, Mozambique and Nigeria
indicate that unmarried women account for six in ten having clandestine abortions or suffering
abortion complications each year.
45
In Tanzania, roughly three-quarters of women seeking
abortion are unmarried, and one-half of unmarried adolescent women seeking abortion have been
in the relationship for less than one year.
46

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