Title: Reassessing the Level and Implications of Male Involvement in Family Planning in
Indonesia
Version: 1 Date: 20 Nov 2022
Reviewer:  Karen Hardee
Reviewer's report:
This paper addresses an important topic – male involvement in family planning, with quantitative
analysis showing levels of male engagement, couples’ unmet need, and associated demographic,
socioeconomic, and program factors. Qualitative data are used to further illuminate the
quantitative findings.  The construct of the four levels of male involvement is innovative and
frames well the analysis in the paper.  The findings from this paper are important contributions
to the field’s understanding of male involvement and its effects on men, women and couples.
With that said, I have some comments to strengthen the paper.
This is in the abstract, plain English summary, and body of the manuscript:  I understand that the
authors are using Greene’s definition of male involvement – men as users, men as partners, and
men as change agents.  But it seems that the authors are not giving enough credit to Indonesian
men as partners.
Lines 114-117 say that “per the 2017 IDHS, only 4.3% of husbands in the “couples sample”
disapproved of family planning.”  My reading of the manuscript is that while there is little male
overt disapproval of family planning in Indonesia, male involvement influences contraceptive
use in a range of ways and male engagement is shaped by a number of factors.  These point to
opportunities to increase male involvement.
Language: use of the phrases “it would appear that” or “it would seem that,” “would seem to be
the way forward,” sound tentative – it would be better to say “findings from this study suggest
that…” or more directly “findings from this study show that…”
Specific comments:
Line 63: Add “The” before “study found that…”
Background lines 73 to 85:  The terms “involving men,” “male participation,” and “engaging
men and boys” are all used.  Do the authors consider these terms interchangeable?
Background lines 78-80:  Interest in reaching men predates Cairo – for example, Population
Reports published an issue in 1986 titled: “Men-New Focus for Family Planning Programs.”
Population Reports. Series J Number 33 November-December 1986. I think there may have
been a similar report in the 1970s also.  Cairo was important in that it reinforced the need to
better include men in family planning programming.
Lines 86-88: Reference 39 from the Male Contraceptive Initiative is an advocacy piece – I
suggest adding text to show that it is somewhat speculative. “Male Contraceptive Initiative (39)
has elaborated on how INCREASED ATTENTION TO male contraception COULD contribute
to each of the 17 Sustainable Development Goals (SDGs).
Line 94: How is “demand for family planning” defined?  The term “demand satisfied” is more
familiar.  This is important to define since it is used in the analysis also.
Lines 100-102: See Terry Hull’s chapter on Indonesia in Robinson and Ross – he claims that
Indonesia missed an opportunity early on to promote use of male methods.  Hull T. Formative
years of family planning in Indonesia. In: Robinson WC, Ross JA, editors. The global family
planning revolution: Three decades of population policies and programs. Washington: The
World Bank; 2007.
Line 106: Greene was published in 2006 – there are a lot more studies on the topic since then.
Lines 109-111: Since this manuscript is about male involvement, I suggest moving this definition
earlier in the paper.
Lines 116-121: “The key to identifying potential program opportunities to strengthen the NFP
via increased male involvement thus lies in acquiring a deeper understanding of the vast majority
of married Indonesian men who are neither family planning clients nor opponents of family
planning in terms of their reproductive aspirations, perspectives on male involvement in family
planning decision making, and actual levels of and barriers to increased involvement.  What is
the goal?  More male users?  If men aren’t opposed, what is the problem?  I’m not saying that
is enough, but it would help to know what the goal of male involvement is/should be.
Lines 149-150: there is a word missing in this sentence:  “…and men who were not using a male-
controlled method and did not participate in contraceptive use of WORD MISSING HERE?
non-use decisions per the reports
Lines 141-151:  I like the four-category scale of male involvement but have some questions.
For Category 4, were the responses of the wives about which method the couple were using also
taken into consideration – was their any discordance in the methods mentioned by husbands
and wives?
Likewise for Category 1, was the part about non-use of male methods only based on reports from
wives?  And why was the measure of husbands being involved or not in contraceptive decision-
making only based on the responses of wives?
Lines 155-163: I appreciate the use of the items to develop the middle 2 levels of male
involvement, but it seems that all of the items were given equal weight.  Why was it determined
that 4 was a good cut off for Category 2 vs. 3?  And was any analysis done to see if the items
grouped together?  Some are attitudes, some are behavior, one is future intention, and one, also a
behavior, seems a bit tangential and possibly heavily influencing one of the categories. It would
be helpful to have a table showing responses to these items.  It would be helpful to get more
discussion about these items and the contrast of Categories 2 and 3.  Was any factor analysis
done to see if these items hang together?
• Disagreement with statement that “Contraception is women’s business; men should not worry”
-- this is an attitude
• Disagreement with statement that “A woman is the one who gets pregnant, so she should be
the one to get sterilized” -- this is an attitude
• Expected to use contraceptives to delay or avoid pregnancy in the future. -- This is a future
intention.  How did it relate to the attitudes and behavior in the other items?  Also, is this item
associated with the measure of unmet need among couples?
• Involved in decisions to use contraception -- this is a behavior
• Involved in decisions not to use contraception -- this is a behavior
• Discussed FP with wife in last year -- this is a behavior
• Discussed FP with other persons in the last 6 months -- this is a behavior – but seems much
less consequential to male involvement than having discussed with wife. I suggest considering
dropping this one.  How heavily did it influence the scoring of 3 vs. 4 items since the “Yes”
response is probably very low?
Figure 1 – how is it possible that there could be a score of 0 for the 7 items?
Lines 157-158: Words missing - “A woman is THE one WHO gets pregnant, so she should be
the one to get sterilized”
Line 178: Discriminant function analysis (DEA) may not be familiar to readers. It would be
helpful to describe what it is.
Line 211–216:  The qualitative data are helpful, but only based on 4 focus groups meant to
represent the country.  Who were the participants and how were they selected?  Why was only
one FGD for each of the 4 groups?
Line 246-261: Table 1 is interesting and the discussion of it good. On dual use of condoms and
another method – could that be for HIV prevention?
Lines 257-259:  Words missing in sentence.  “Thirty-nine percent of these couples WERE either
uncertain about wanting more children or were not sure when, while 61% wanted a child within
two years and may have BEEN USING contraception to delay the pregnancy.”
Lines 262-279: This analysis is also interesting – comments above about the items included and
the measurement of Categories 2 and 3 might shift these findings.  The relationship between
knowledge of contraceptives and media exposure is interesting, as is the finding that socio-
economic variables were more strongly associated with higher levels of male involvement than
program variables.
Line 299-313: The section on discriminate function analysis is difficult to follow.  An
explanation of the method in the methods section will help.  Also, explaining what terms
like “canonical correlation” mean will be helpful.  It does not look like the 4 levels of male
engagement were included in the DFA – right?  Just having the column headings in the table
as Function 1, Function 2 and Function 3 is not helpful to readers.  And explain why the same
variables are included in the 3 functions.
Lines 304-307: “Based upon the signs of the coefficients, this function indicates a negative or
inverse relationship between education and contraceptive method knowledge AND level OF
male involvement in family planning.”  Please put a sentence like this in plain language.  I
assume it means that men with less knowledge of contraception have lower levels of male
involvement.
Likewise, the explanation of functions 2 and 3 are opaque.
Lines 317-324: The finding that male involvement isn’t associated (other than level 1 – male
use) with couple-level unmet need for FP is interesting.
Lines 331-332:  The finding that “male use of contraception is more or less the same irrespective
of level of couple-level demand for FP” is interesting – do the data available to the authors show
reasons for using male methods? My understanding is that one of the primary reasons is when
women have side effects/issues with contraceptive methods.
Lines 333-338:  These findings are intriguing – women respond to their own desire to use
contraception and to their partners’ desires.  Is this a sign of male involvement or male influence?
Lines 339-349: These findings are also interesting and show the importance of male support for
family planning.  I had to read the sentence in the text a couple of times to link the 80-85% with
the odds ratios. It would be helpful for readers to explain the findings for female unmet need
and couple unmet need separately.  Male approval has a strong effect on couple unmet need and
an even stronger effect on female unmet need.
For example, lines 343-346 - “In the aggregate, the quantitative data considered in the study
suggest male partner approval of family planning is the more important determinant of couple-
level unmet need for family planning than the level of male involvement other than via
involvement as a family planning client.” Could this please be rendered into plain language.
Line 350: Qualitative findings.  It looks like the quotes are mostly from Sumatra/Kalimantan
(9), with other quotes from Eastern Indonesia (3), and Java/Bali (4).  See comment above about
adding more clarity of recruitment of participants for the FGD. Also, there labeling of the
respondents associated with the quotes is not consistent.
Line 445: Discussion.  The discussion section seems to be a vehicle for promoting Gender
Transformative Programming (GTP) from PMNCH.  It isn’t that gender transformational
programming isn’t important, it is that this discussion goes beyond the findings in the paper –
which focused on male involvement in FP.  Gender transformative programming is bigger than
involving men.  To do it justice in this paper would require more discussion of the social and
gender context in Indonesia, and decisions made in the early days of the family planning program
to focus on women, and inclusion of findings in addition to family planning in the results section.
As I said above, the findings in this paper on male involvement are a contribution to the field of
FP – this gets buried in the discussion section that seems to be promoting an initiative’s model
(GTP from PMNCH).  Maybe not using the acronym GTP would help, since that further “brands”
it.  PMNCH is not the first to identify the importance of gender transformative programming.
448-450: The authors note that the BKKBN has a male involvement unit.  What is its goal?
Given that there are vastly many more methods for women than men, is it unrealistic that women
are the predominant users?  Should a recommendation be that more male methods need to be
developed/made available?  That a concerted effort should be made to dispel misinformation
about vasectomy and promote that method (see earlier comment about Hull chapter).
492-496: Here we read that expanding use of vasectomy and promoting its use are the primary
goals of the BKKBN male involvement unit.  It would be helpful to have this information earlier
(see my last comment – asking at line 448 what the goal of that unit is).
Lines 475-487:  The paper pivots to maternal health – that male involvement in maternal health
could help bring down Indonesia’s still high maternal mortality rate.  It would be helpful to link
male involvement in FP to this – are the authors saying that the focus on women in FP has also
spilled over into other health areas, including maternal health, and that a broader focus on male
involvement beyond family planning, for which there is little male opposition, but some level of
“benign neglect” with the assumption among most men that FP is a women’s issue, is important?
Programs have perpetuated the view that FP is women’s business too.
Lines 542-554:  This paragraph introduces the need to work with providers – but uses data on
HIV from Africa to make the point – with an unsubstantiated statement that the findings “are
broadly applicable to Indonesia.”  While working with providers is important, this paragraph
feels tangential to the results presented in the paper.  This important topic needs its own
treatment, with data from Indonesia to show that men are being maligned by service providers in
relation to family planning, if that is the case.  Given the low rates of use of male methods (and
really, only vasectomy requires provider attention, how many men actually encounter providers?
555-564:  The summary of findings in this paragraph is good: “In the aggregate, the results of
the two sub-analyses of correlates of male involvement in family planning suggest that it is age,
education, residence in urban areas, knowledge of contraceptive methods, media exposure, and
access to family planning information from different sources that distinguish men with higher
and lower levels of involvement.”  Again, rather than saying “the priority targets for GTP efforts”
should be, why not say “the priority for strengthening efforts to engage men in family planning”
should be…  Then you could add that efforts to involve men should be designed using gender
transformational principles, or something like that.
I got to the end of the manuscript still thinking that the authors are giving short shrift to men as
partners in Indonesia.  Maybe when the index levels 2 and 3 are better defined and reanalyzed, the
findings on levels of male involvement will be less negative.  At the same time, the paper makes
a strong case that it is important to work with those segments of men who are not supportive
of family planning – and this paper clearly shows that their attitudes make a difference to
family planning use.  That programming should be carried out in a gender transformative way
is clear, that programming for male involvement should pivot to being called “GTP” which the
conclusion implies, to me is distracting.