Perceptions of Postpartum Family Planning in Extended Postpartum Period among Men in Morogoro Municipality, Tanzania: A Qualitative Study

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Introduction
The World Health Organisation (WHO) defines postpartum family planning as the prevention of unintended pregnancy and closely spaced pregnancies through the first 12 months following childbirth (World Health Organization, 2013). Globally, there is a highly significant unmet need for family planning in the postpartum period (Morroni & Glasier, 2020), and the situation is worse during the extended postpartum period (Mihretie et al., 2020). The postpartum period is categorized into three distinct stages; the initial or acute period which involves the first 6-12 hours postpartum; the subacute postpartum period, which lasts 2-6 weeks; the delayed postpartum period, which can last up to 6 months; and delayed postpartum period, which can last up to 8 months (Romano et al., 2010).
Studies have shown that approximately 95 % of women who are in the first 12 months post-delivery prefer to avoid pregnancy in the next 24 months, nevertheless, at least 70% of them are not using contraception (Coomson & Manu, 2019;Mahande et al., 2020). Postpartum contraceptive preferences include condoms, injectables, oral contraceptive pills, sub-dermal implants, and intrauterine devices as well as vasectomy and female sterilization (Mahende et al., 2020). Numerous studies have reported that pregnancies during the postpartum period pose the highest risk for mothers and their newborns, and have increased risks of adverse of their health outcomes (Teka et al., 2018;Dangura, 2020).
Tanzania is one among many countries in sub-Saharan Africa with high rates of women attending antenatal and postnatal in health facilities (Gupta et al., 2014), where the opportunity to provide postpartum family planning is very high. Although there is a more significant opportunity for teaching to curve the pregnancy interval, it is estimated that about 20% of pregnancies in Tanzania are either unintended or unplanned due to unmet family planned needs (Wende et al., 2019), nearly more than one-half of births are conceived before the first 12 months of post-delivery (Ministry of Health, Community Development, Gender, Elderly and Children, 2016). The maternal mortality rate in Tanzania is 432 (urban) and 336 (rural) deaths per 100,000 live births (Levira & Todd, 2017). Uptake of contraception during postpartum has the potential to significantly reduce maternal deaths (Coomson & Manu, 2019;Gallagher et al., 2021). However, contraceptive use and family planning in Tanzania remain low (Yussuf et al., 2020). The Tanzania Demographic and Health Survey (TDHS) in 2016 indicated a contraceptive prevalence rate amongst women of reproductive age was reported to be 38.4% (Ministry of Health, Community Development, Gender, Elderly and Children, 2016).
In Tanzania, gender roles and norms are predominantly significant in influencing spousal communication and consequently postpartum family decision-making in substantial ways. Despite that postpartum family planning methods and the respective services are often geared toward women, the primary decision-makers remain (Sundararajan & Kihunrwa et al., 2019). The cultural practices that put men ahead on the decision of family matters including marital-related issues deter women to initiate conversations about family planning matters. The opposition of male partners has been documented as one of the key determinants that affect the use of family planning in Tanzania (Brooke et al., 2020). Mostly, men have been considered as potential barriers to women's decision-making when it comes to contraceptive use as well as healthcare utilization (Massenga et al., 2021).
Several policies, programs, and interventions that have aimed to expand rates of postpartum family planning among women than among men in low -and middle-income countries, including Tanzania, have been developed and implemented (Hackett et al., 2020). Similarly, such interventions have aimed to accelerate the use of contraception in the immediate and extended postpartum periods amongst women (Hackett et al., 2020). According to various literature, the availability of postpartum family planning services to meet the needs of men is often questionable in Tanzania (Kiondo et al., 2020). This could be attributed to the notion that postpartum family planning is for women (Mahende et al., 2020). Research illustrates the association between compliance with postpartum family planning services and partner (male) involvement and improved maternal health (Williams et al., 2021). It is estimated that accessibility and utilization of male contraceptive use for extended postpartum family planning could prevent more than 30% of maternal and 10% of infant deaths by effectively spacing birth-topregnancy intervals by at least 2 years and birth-to-birth intervals by at least 3 years (Ganatra & Faundes, 2016).
Although previous studies have shown that male partners (husbands) are the major decision-makers on matters associated with family planning at the household level (Mosha et al., 2013;Dadi et al., 2020), there is a paucity of studies looking at perceptions of postpartum family planning in extended postpartum period among men in Morogoro Municipality, Tanzania. The study provides insights into the knowledge of postpartum family planning, preference for postpartum family planning methods and decision-making, accessibility of postpartum family planning services, and religious considerations and beliefs.

Study Design and Setting
A qualitative study was conducted to explore the perceptions of men on postpartum family planning in the extended postpartum periods. The study was conducted in Morogoro Municipality, which serves as the capital of the Morogoro region located in Eastern Tanzania. The municipality is estimated to be home to more than 305,000 people, with an annual population growth rate of 2.4 located in the Morogoro region in Tanzania. The municipality is currently serving 29 wards, nevertheless, there is scant accurate population data for each ward. The study was specifically conducted in three health facilities namely: Mafiga Health Center, Malipula Health Center, and Saba Health Center located at Kiwanja cha Ndege ward, Mwembesongo ward, and Mafinga ward respectively. According to the Tanzanian health systems, health centers are at the primary level of health care systems. Health centers provide preventive, curative, and rehabilitative services, and serve as the referral points of dispensaries. The study was conducted from 22 February to 24 March 2021.

Target Population and Sampling
The study recruited men whose spouses were currently in the extended postpartum period. Participants were recruited in the antenatal clinics and were selected among men who had escorted their spouses to the antenatal clinics. The study recruited participants who were using the health facility for a duration of at least six months before this study. All participants recruited in the study had at least one child under 2 years of age. Study participants were selected purposely and conveniently, and those willing to participate were enrolled in the study. The saturation principle guided the recruitment of study participants.

Data Collection Methods and Instruments
An interview guide was used to collect data from men who had escorted their spouses to the antenatal clinics. The interviews were conducted with men in private in order to ensure the independence of respondents. The development of the interview guide was informed by previous studies of a similar nature (Coomson & Manu, 2019;Mahende et al., 2020& Williams et al., 2021. Based on the objective of this study, a series of open-ended questions were developed. The questions aimed to collect information related to the knowledge of postpartum family planning, preference of postpartum family planning methods and decision-making, accessibility of postpartum family planning services, and religious considerations and beliefs. The interview guide was pretested to establish clarity, flow, and relevance of each question. Results of the pretesting were excluded from the study results and were used to modify the interview guide. The interviews were conducted by experienced research assistants who were backstopped by the authors of this paper. The interviews were conducted in the Swahili language (the national language of Tanzania. Each interview was conducted for an average of 35 minutes. A maximum of two interviews were conducted per day. The voice recorder and notebooks were used to record the interviews.

Data Analysis
The interviews were transcribed verbatim in Kiswahili language and then translated into the English language by the first and second authors. Two language experts fluent in both Kiswahili and English languages were used to review the accuracy of the translation. Inductive thematic analysis was used to establish themes from the datawhich were then reviewed to identify appropriate themes and name them. Transcripts were read thoroughly more than twice and coded manually. The codes were systematically organized and sorted considering their similarities, and clustered into major themes. Literature on postpartum family planning in the extended postpartum period was read concurrently during data analysis to guide the development of themes. The themes were also identified by the first and second authors and the final consensus was reached among the two authors. The mapping process was used to indicate the relationships between the themes and the overall focus of the study.

Ethical Considerations
The study protocol was reviewed and approved by Mzumbe University. Also, the District Medical Office reviewed the protocol and granted study permission with reference number R10/MMC.24/. All managements of the selected health facilities for this study accepted the study to be conducted in their respective facilities. Before starting data collection, every contacted study participant was informed about the nature, purpose, and procedures of the study. Participants were informed that their participation in the study was voluntary, and they were informed of their rights to exit from the interview without any consequences. Participants were also informed about their freedom to either answer specific questions or not. In order to ensure anonymity, identity numbers rather than names were used to represent the study participants. Neither compensation nor gifts were given to any participant recruited in this study.

Characteristics of Study Participants
A total of 28 men who visited the selected health facilities for postpartum family planning services participated in the study. The mean age of the participants was 34.9, and their ages ranged from 26 to 48 years. The majority (n=26; 93%) were married, and half (50%) of them hold secondary education. Characteristics of study participants are presented in Table 1. Based on the responses from the in-depth interviews conducted with study participants, major themes emerged from the data. The themes are presented in Figure 1 below: Figure 1. Themes emerged from the data

Knowledge of Postpartum Family Planning
Study participants were asked about their understanding of the term extended postpartum family planning. Their responses indicated that nearly more than half of them were able to explicitly describe what Extended Postpartum Family Planning means. Many men described postpartum family planning as the prevention of unwanted pregnancy: "The way I understand postpartum family planning is that it is a process of starting to use contraceptive methods a few months after delivery in order to prevent unintended pregnancy" (35-year-old man, with 4 children).
Other participants related postpartum family planning with spacing pregnancies for the purpose of allowing the child to receive more attention from both mother and father after being born.  Vol. 14, No. 11;2022 "I think postpartum family planning is related to space pregnancies after childbirth. It helps parents to space their births while providing more opportunity for the newborn to grow as expected while providing maternal health benefits" (31-year-old man, with 2 children).
With regards to where they got this knowledge, they reported that health service providers in the respective health facilities were the main sources of information about postpartum family planning and its overall advantages.
"In fact, we have been receiving reproductive health education here from our service providers. The reproduction health education we have been receiving has helped us to understand many things, including the most appropriate, easiest and safest contraception methods to use; and above all about maternal and child health" (42-year-old man, with 5 children).

Preference for postpartum family planning methods and decision-making
Almost all participants mentioned male condoms as the most postpartum family planning method, and it was cited as one of the most commonly known family planning methods. They stated that male condoms are easily accessible, user-friendly, and harmless as compared to other methods.
"As far as I know, male condoms are the main and easiest way to prevent pregnancy. I was once told that there is a way to protect yourself from pregnancy called female sterilization or vasectomy. But I personally believe even some men must be afraid of these methods" (27-year-old man, with 2 children).
A few men appeared to have less knowledge of the use of the calendar method, which is one of the practices of natural family planning. The most challenge mentioned with regard to the use of calendar methods was that in most cases it is difficult to track the menstrual history so as to foresee when their spouses will ovulate.

"In my opinion, the use of the calendar is very good but there are its challenges. If your partner or a man himself does not have a clear understanding and certainty of the risk dates [unsafe days] then there is a high chance of getting an unexpected pregnancy. And let me tell you -there are a lot of men who have suffered that challenge" (39-year-old man, with 4 children).
All but four participants felt that the withdrawal (pulling out) of the penis from the vagina before ejaculation was the most appropriate method, however, they stated that sometimes this method is not reliable. They had the view that sometimes sperm on spouses' skin can work its way inside their vagina, hence the possibility of getting pregnant becomes high.

"There are times when I think the method of withdrawal is very simple but very dangerous and especially if the partner is in a menstrual period. You know that as soon as a drop of sperm enters the vagina then pregnancy can
be conceived" (26-year-old man, with 1 child).
In the current study, men (husbands) were the major decision-makers with regard to postpartum family planning methods and the methods to be used. They stated that although women are the ones mainly taught about the use of family planning methods, in most cases they tend to listen to the opinions of their spouses (husbands).
"It is not easy for my wife to come and tell me she is using contraception without my involvement or knowledge. One day she told me that she wanted to use contraception and I completely rejected her idea. We are still young enough. We need more children" (28-year-old man, with 3 children).

Accessibility of Postpartum Family Planning Services
Some participants indicated their concerns regarding the accessibility of postpartum family planning services in the extended postpartum periods. They mentioned that male condoms were the most available and accessible services. Condoms were mostly preferred as they said that male condoms are easy to use and it has multiple advantages. They had the view that male condoms prevent not only pregnancy but also protect couples against sexually transmitted infections.
"Here we have been told as men that we can get male condoms as a package of the family planning while our spouses are in the extended postpartum period. But most of us prefer male condoms because they are easy to use and can be found even out here. But that vasectomy services no one wants them at all" (38-year-old man, with 3 children).
In contrast, a few participants stated that they would not accept the vasectomy. They were doubtful about if their wives want more children at the time when they have already undergone the vasectomy procedure. There was an exceptional whereby one participant reported having undergone a vasectomy at the secondary level facility (regional referral hospital) because such service was not available in the facilities where this study was conducted. The participants stated that the decision to accept for undergoing a vasectomy procedure was based on the experience of a colleague who informed him about the quality of services provided in the respective facility. However, the participants who reported having undergone vasectomy had more than 50 years of age.
"I have reached a point where I do not think I need children anymore. At the moment I have to raise money just for the sake of educating my children. My wife currently has our last child who is six months old now" (48-yearold man, with 5 children).
Participants seem to be aware that a postpartum visit is between four to six weeks after giving birth. However, participants of the study did not seem to observe recommended planned visits. In addition, they did not appear to be aware that postpartum family planning services in the extended postpartum period are not a one-time service, but rather a continuous process.
"I know I have to come with my partner for postpartum service at least four to six times. But sometimes it fails because we forget ourselves and sometimes it is negligence or there is no fundamental reason why we should not. And that problem I believe is for most men and women" (36-year-old man, with 3 children).

Religious Considerations and Beliefs
Religious considerations and beliefs variation were reported to affect the utilization of postpartum family planning services during the extended postpartum periods. Almost all participants supported birth spacing, but not all of them appeared to support the use of contraceptives use postpartum family planning in the extended postpartum period. Some participants considered childbearing and children as a great and precious gift from God, and using any family planning methods means rejecting those gifts.
"Holy religious literature does not forbid family planning, nor does it forbid husband and wife to plan to space pregnancies or reduce their number. But, religiously speaking we can say contraception is permissible but the biggest challenge here is the methods used for birth control" (44-year-old man, with 5 children).
There were those who believed using postpartum family planning in the extended postpartum period was contrary to what is considered the law of nature, religion, customs, traditions, and culture. Some participants expressed their concerns that if it happens that the couple gets the first child and time passes without being seen pregnant, some people in society would start questioning the couple's fertility.
"In the past, our parents had many children, from one wife. Nowadays, when you talk about having fewer children, then some community members would think you are no longer capable of getting the child due to infertility, which is now becoming a major problem due to several reasons" (37-year-old man, with 3 children).

Discussion
This qualitative study offers in-depth information on the perceptions of postpartum family planning in extended postpartum periods among men in Morogoro Municipality in Tanzania. The study come-up with findings related to knowledge of postpartum family planning, preference for postpartum family planning methods and decisionmaking, accessibility of postpartum family planning services, and religious considerations and beliefs. Participants across the health facilities involved in this study provided useful insights that could inform policymakers, program designers, and planners in addressing the challenges affecting men in the utilization of family planning services during an extended postpartum period.
Most participants demonstrated a good understanding of postpartum family planning and its advantages. They stated that postpartum family planning is associated with spacing pregnancies in order to enable the newborn child to grow to full potential. This finding was consistent with the finding of the qualitative study conducted to explore the barriers and catalysts of postpartum family planning in Burkina Faso and the Democratic Republic of Congo, which showed that study participants linked postpartum family planning with a minimum of two years given to the mother to recover, and the child to have chance to grow well (Tran et al., 2018). Their understanding is probably due to the fact that many of them had had children in the past and so they may have received reproductive health education through various sources.
Literature suggests that men who have been either directly or indirectly involved in either receiving or providing health information related to sexuality, reproductive health, or child spacing are more likely to have a high level of knowledge of the advantages of postpartum family planning; including postpartum family planning in the extended period (Mustafa et al., 2015;Harrington et al., 2019).
Participants of the current study preferred male condoms as their main postpartum family planning method. Their gjhs.ccsenet.org Global Journal of Health Science Vol. 14, No. 11;2022 main argument is that male condom is much cheaper and easy to access and use them. This finding corroborates a similar study conducted to explore potential barriers to male engagement in family planning in Kiambu County in Kenya, which found that male condoms were mostly preferred compared to other family planning methods (Kiogora, 2016). Although male condoms were mostly preferred, some participants expressed their interest and preference for using natural methods such as withdrawal. As documented in the previous study conducted in Wajir and Lamu counties in Kenya, men prefer withdrawal possibly because such a method is free from side effects and costs (Abdi et al., 2021). From the current study, it appears that men have limited choices of postpartum family planning methods, which this challenge could promote pregnancy during the postpartum period. Contrary to previous studies, vasectomy as one of the postpartum family planning methods are often inaccessible and most of the participants had less desire to use such services (Abdi et al., 2021).
Although participants appeared to be aware that they are supposed to visit the facilities at both specific and different times before and after their spouses give birth to get more counseling on postpartum family planning options that fit with their socioeconomic circumstances, their compliance was very low. However, studies have shown that male clients who visit health facilities tend to be very cooperative and attentive at the family planning clinics, and they ask several questions, but their level of compliance has remained a major challenge (Gibore et al., 2019).
Similar to the results of previous studies, results of the current study showed that religious considerations and beliefs about postpartum family planning; including postpartum family planning in extended periods were mixed (Sundararajan et al., 2019). It appears that some of the participants stated that their religion recognized and accepted the practice of family planning while others exhibited that their religion was not in favor of the practice of family planning. Literature indicates that the overwhelming majority of religions in sub-Saharan Africa do not support the use of contraceptives for family planning (Sundararajan et al., 2019;Palamuleni, 2013). This is also reported in the previous study which reported that male participants strongly supported birth spacing but were not in favor of contraceptive use, and they pronounced the use of family planning as an act going against the will of God (Palamuleni, 2013).

Conclusion
Most of the participants had good knowledge of postpartum family planning for an extended period, which may be attributed to their readiness to escort their spouses to antenatal care and postpartum services. Male condoms were mostly preferred as the main postpartum family planning method. Besides condoms, participants had limited choices of postpartum family planning services and their choices of available postpartum family planning affected their perceptions of the costs and their side effects. Strengthened accessibility of postpartum family planning services is key in accelerating progress in improving reproductive, maternal, newborn, and child health outcomes. Active involvement of men could result in the design of a comprehensive postpartum family planning services package that responds to the needs and choices of men. Community sensitization interventions designed to improve male participation in postpartum family planning should be promoted and disseminated. Also, the study was conducted at the primary level of the health systems. It is important to note that postpartum family planning services at the secondary and tertiary differ in terms of their advancements.

Implications of the Study
One of the major implications of the current study is that it provides required empirical results on the knowledge of postpartum family planning, preference for postpartum family planning methods and decision-making among men, accessibility of postpartum family planning services in health facilities, and the role of religious considerations and beliefs. This information will help the policy-makers and potential key stakeholders in reproductive health and family planning service delivery to design appropriate initiatives and actions that will increase the availability, accessibility, and ultimately uptake of postpartum family planning in extended postpartum periods among men in Tanzania. Innovative study to further explore the potential benefits of the uptake of postpartum family planning in a postpartum extended period amongst mothers of children aged less than six months is recommended.

Strengths and Limitations of the Study
The study captures the perceptions of postpartum family planning in the extended postpartum period among men in Morogoro Municipality, Tanzania; which is the first of its kind to be conducted in Morogoro region. The study was conducted by native Swahili language speakers, which enabled the participants to fully express their perceptions, experiences, and opinions. The interview guide was professionally translated and pretested. The inclusion of participants who had had at least one child enabled us to explore postpartum family planning in extended postpartum period practices and experiences. Although this study observed the overall principles of