Family Planning Communication between Wives and Husbands: Insights from the 2017 Indonesia Demographic and Health Survey

Frequent inter-spousal communication is regarded as an indicator of safe family planning practice. Nevertheless, communication on family planning within couples in Indonesia is still largely unexplored. This study assessed the levels of inter-spousal communication on family planning and its associated determinants, using cross-sectional and nationally representative data from the 2017 Indonesia Demographic and Health Survey, from a randomly selected cohort of 8,925 currently-married couples. Data on sociodemographic characteristics, inter-spousal communication behaviors, and attitudes regarding family planning were collected. The dependent variable in this study was wives’ responses to how frequently couples discuss family planning. The level of inter-spousal communication on family planning was classified into: never, once or twice, or more frequent. The determinants of the study were region, marital duration, couples’ fertility preference, wife’s exposed family planning message on television, wife’s health problem due to contraception, wife’s discussed family planning with doctor, nurse/midwives, or field worker, husband’s exposed family planning with field worker, husband’s approval and couples’ contraceptive use. The analyses were stratified based on the frequency of inter-spousal communication: never, once or twice, or more frequent. There was a greater husband’s approval of family planning and communications with family planning field workers, and that those encouraged inter-spousal communication in Indonesia.

rather with both spouses. [16][17][18] Both women and men should share equally their roles and responsibilities for achieving mutual pleasure and avoiding reproductive illnesses. The need for men to be involved in reproductive health and family planning should be considered, based on men's roles as reproductive and sexual partners. Thus, matched-couple data is crucial in reproductive health studies. 18,19 Indonesia has been chosen as the setting of this analysis of inter-spousal communication for three reasons. First, during the last decade, modern methods of contraceptive use in Indonesia remained relatively stagnant. The contraceptive prevalence rate from 2007 remained at 57% in 2017. 20 Secondly, the unmet need of family planning in Indonesia did not significantly decrease in that time; it was 13.1% in 2007 and 11% ten years later. 20 Lastly, little is known about the extent of husband-wife communication about family planning in Indonesia. Therefore, this study aims to explore that issue by using the couple dataset derived from the 2017 Indonesia Demographic and Health Survey.

Method
This study used couple data from the latest Indonesia Demographic and Health Survey (IDHS) from 2017. There were two types of IDHS's questionnaires utilized in this study: woman's questionnaire to gather information from 8,925 selected wives and man's questionnaire to collect information from 8,925 selected husbands. This study obtained 10 informations available from the wives responses, consisted of: (1) frequency of spousal communication; (2) the region that wives lived; (3) marital duration; (4) the wives' couple fertility preference; (5) the exposure of wives from family planning message on television; (6) the wives' health problem due to contraception; (7) the wives' discussion with doctors regarding family planning; (8) the wives' discussion with nurses/midwives related to family planning; (9) the wives' discussion with family planning health workers; (10) approval of their husbands on family planning issues; and (9) the wives' reports on current contraceptive use. Furthermore, this study utilized four questions from the husbands, consisted of: (1) the region that he lived; (2) marital duration; (3) the husbands' fertility preferences and (4) the husband's report on current contraceptive use.
The population of this study was all Indonesian couples who were formally married. The samples were married couples-the women aged 15-49, the men aged 15-59-who had been successfully interviewed by the Indonesia Demographic and Health Survey team. 21 The study was restricted to 8,925 wives and 8,925 husbands. The advantage of using the couple dataset was to control for husbands and wives' characteristics associated with inter-spousal communication. 7,8,22 The sample weights associated with the husbands were used in all analyses, since male respondents constituted just one-third of the women respondents. 20 The dependent variable in this study was the frequency of couples discussing family planning with each other versus family planning decisions based on the wives' responses. The measure of inter-spousal communication about family planning was collected from the question, "How often did you talk to your husband/partner about family planning in the past year?". It is a trichotomous variable (never, once or twice, and often). Responses of the husbands were acknowledged for the discussion with family planning field workers. The wives' responses were also utilized for variables related to health problem due to contraception, husbands' approval, discussion about family planning with doctors, nurses, or midwives, and family planning field workers. The region, marital duration, fertility preferences, and contraceptive use were grouped to create couple variables.
The region was grouped into the Java-Bali Province and outside Java-Bali Provinces. The marital duration was divided into two categories: more than 15 years, and less than 14 years. Couples' fertility preferences fell into three categories: both wanting another child, either one wanting another child, and neither wanting another child. Couples' exposure to family planning messages via television was categorized into ever exposed and never exposed. Responses about family planning discussions with doctors, nurses, midwives, or family planning field workers were divided into two categories-yes and noas were health problems. Husband's approval of family planning was classified as approved or disapproved. Contraceptive use by couples was divided into both, or either one using a modern method, or both not using modern methods.
Three stages of statistical analysis were applied for the quantitative method. The initial stage was a univariate analysis to reveal the distribution of variables. The second stage was bivariate analysis (cross-tabulation and chi-square statistics) to test for the significance of the association between dependent and independent variables at a 95% level of significance. 23 Multinomial logistic regression was performed due to the trichotomy of dependent variables to estimate the relationship between the predictor variables and outcomes, reporting the Adjusted Odds Ratio (AOR) and 95% Confidence Interval (CI). 24

Results
The results of this study revealed that more than 50% of Indonesian couples had never discussed family planning with their spouses, either in Java-Bali Provinces or outside Java-Bali Provinces ( Table 1). The percentage of couples who had longer marital duration declared less frequent in communicating family planning with their husbands than those couples who just married less than 14 years. The percentage of Indonesian couples who declared their opposition to another child and never communicated with each other about family planning matters were relatively similar to those couples where either one wanted another child or both still wanted another child. Those couples whose wives had been exposed to family planning information through television had higher correlations on the percentage of inter-spousal communication related to family planning than couples who had never been exposed to family planning information through television. Table 1 also shows that couples whose wives had experienced health problems admitted more frequent interspousal communication than couples who had never experienced health problems. The percentage of interspousal communication on family planning matters was much higher for couples who had met with family planning field workers rather than couples who only discussed family planning matters with nurse and midwives. The percentage of inter-spousal communication was still low among couples whose husbands decided the family planning matters. There were 71,4% of those non-contraceptive-users-couples who declared that they had never communicated family planning issues with their husbands. Table 2 shows the results of multinomial logistic regression. Husbands who approved of family planning to-ward communicating family planning once or twice might affect their communication 5.44 times more frequently than husbands who disapproved. Compared with no communicating couples, as revealed in Table 2, couples whose husbands approved of family planning were 4.48 times more likely to discuss more frequently, compared to couples whose husbands disapproved of family planning. Table 2 also reveals that couples who use modern contraceptive method were 2.10 times more likely to communicate family planning with their spouses once or twice than couples who did not use a modern method. Finally, Table 2 shows that couples who utilized modern contraceptive method were 2.02 times more likely to communicate about family planning than those couples who do not use a modern method.
This study also found that a husband's and wife's discussion with family planning workers was a significant variable for inter-spousal communication. Compared with the no communicating couples, those whose husbands discussed with family planning workers were 1.5 times more likely to communicate with each other once or twice than couples whose husbands did not talk with family planning workers. Couples whose wives talked with family planning workers were 1.4 times more likely to discuss family planning once or twice in a year than couples whose wives did not talk with family planning workers.
Couples whose wives discussed family planning with nurse/midwives were almost twice as likely to communicate with their spouses once or twice than wives who did not communicate with nurse/midwives. Furthermore, wives who discussed family planning with nurse/midwives were 2.5 times more likely to communicate with their spouses than wives who did not discuss it with nurse/midwives. Compared to noncommunicating couples, wives who discussed family planning with their doctor were 1.6 times more likely to communicate with their spouses than wives who did not do that. Couples who were exposed to family planning messages from television were 1.6 times more likely to communication once or twice with their spouses than couples who were never exposed to those TV messages. Finally, couples whose wives experienced health problems due to contraception were 1.4 times more likely to communicate family planning once or twice than couples whose wives who had not experienced it.

Discussion
Lack of inter-spousal communication occupies a central role in models of marital relationship deterioration, just as intimate bonds are believed to remain strong to the extent that partners respond with sensitivity to one another. 25 Poor communication had been found as the most commonly cited reason why couples did not seek any contraceptive-related services. 25 This study provides detailed information on the fre-quency of couples who communicate about family planning by categorizing the dependent variables into three categories (never, once or twice, and often). The three categorizations have been made because the frequency of inter-spousal communication about family planning is one of the least researched areas in the field of family planning. Ideally, couples should communicate about family planning before marriage, in order to avoid possible dyad conflicts. More frequent communications between couples may lead to increased understanding and healthier relationships in all aspects of married life, not just family planning. Nevertheless, this study did not delve into further analysis of what kinds of topics those couples might discuss, or whether they would pertain to fertility preferences, contraception, or other family planning issues. The findings of this study, as revealed in Table 1, showed that approximately one-half of Indonesian couples never discuss family planning matters with their spouses. In addition, Table 2 shows that a husband's approval of family planning predicted the greatest odds of inter-spousal communication. It may also be true that no communicating couples feel insecure when talking about sexual intercourse or contraception because it violates their social norms of modesty and privacy concerning sexual matters. 26 Wives are less likely to initiate a dialog about family planning and sexual activity because they tend to feel shyness and distressed at provoking their hus- bands due to the sensitivity of those issues. 27 Inter-spousal communication was found to be high among Indonesia couples living in Java-Bali. They tended to have been exposed to family planning from television, and the husbands approved of it. The wives had experienced health problems due to contraception, discussed family planning with family planning field workers, doctors, nurses, or midwives, and used modern contraceptive methods (p-value < 0.001). Inter-spousal communication appears to have been relatively weak outside the Java-Bali Provinces compared to the Java-Bali Provinces. This could be attributed to the welcoming reception to family planning services in the Java-Bali areas. 28 This study also found that marriages of shorter marital durations were more likely than longer marriages to talk about family planning. This is probably because the child-bearing decisions are more relevant to them. 2,8 Another reason is due to the tendency for couples with longer marital duration may have long ago agreed on their fertility method(s). 29 Behavioral theory also supported these findings to posit that marital distress is also a consequence of poor family planning communication, arguing that "distress results from couples' aversive and ineffectual responses to conflict". 25 Overall, half of the couples who did not want any children and those couples who did want another child stated that they had never communicated about family planning in the last 12 months. The finding correlates with a Pakistani study that found men to be more interested in discussing how to space out the children rather than limiting their number. 23 This study also found that a higher proportion of inter-spousal communication was recorded among couples who had been exposed to family planning messages on television. Television is known as the most popular media among Indonesians. 30 It is also recognized as a tool for developing the gradual initiation of spousal communication about family planning and forming an individual's reproductive attitude and behavior. 31 Communications campaigns through television may provide information for couples that can promote further informed discussion. 32 The results of multinomial logistic regression in this study show that the incidence of health problems resulting from contraception use can encourage inter-spousal communication. A study in Tanzania showed that the effect of ongoing health issues experienced by wives can inspire couples to discuss whether to switch methods or discontinue them altogether. 33 Health issues that may occur consequent to contraceptive use include fatigue, weight gain, missed menses, or excessive menstrual bleeding. 33 Multinomial logistic regression results also emphasize the essential role of family planning field workers for both husbands and wives. The Indonesian Government has assigned family planning field workers for educating, training, and supervising family planning at the village level. Family planning field workers then become the goto people for providing initial information on family planning as well as motivation for every eligible couple to use contraception. 34 This role makes them more familiar and trusted by the village couples. 34 Both husbands and wives who receive information about contraception from family planning field workers tend to use contraceptives. 34 The exposure to health workers can also keep family planning on the couple's agenda for further discussion. That can be a means of exchanging practical information about family planning services, availability, side effects, costs, as well as dislodging misbeliefs about particular contraceptive methods. 35 Health workers may better encourage reproductive couples about health development, especially in the establishment of family planning that involves men's participation for contraceptive use. 36 Health workers can provide convincing and reliable information or counseling to wives about contraception that can be used to motivate their husbands regarding contraceptive use. 37 Husbands' approval is one of the intrinsic factors influencing inter-spousal communication. In Indonesia, the husband's position as the family head places him as the central household decision-maker. 38,39 Men are expected to be involved in deciding whether or not to participate in contraceptive use, which can be completed by deliberat ion. Wives' encouragement is key to motivating their husbands' participation in the adoption of contraceptives. 40,41 This study also shows that the use of modern contraceptive methods by couples increases the probability of inter-spousal communication. Family planning communication between husbands and wives is strongly associat ed with deflating anti-contraceptive rumors. 42 Interspousal communication is recognized as a key factor in the adoption and sustained use of family planning. 4,10 These findings are supported by prior research in rural Nepal that found the use of contraception encouraged couples to more actively discuss between themselves information regarding contraceptive methods. As a result, the use of male contraceptive methods also increased. 43 The strength of this study is that it dealt with a large sample size from a nationally representative IDHS data set. However, it also had several limitations. First, the amount of information available to measure family planning communication between husbands and wives was inadequate. Only one question related to spousal communication on family planning-"How often did the husbands and wives talk about family planning in the past year?"-was asked. Secondly, this study relied entirely on wives' responses to family planning communication with their husbands which might introduce errors of underreporting. Thirdly, this paper doesn't provide longitudinal effect of inter-spousal communication on family planning matters.

Conclusion
In sum, most of the Indonesian couples had never discussed family planning issues with their legal partners. Long-term married couples reported less family planning communication than the other married couples due to distressed married life. There was no huge difference on family planning communication between couples who still want another child and couples who did not want another child. This study also revealed that television had been found as one of popular media among Indonesian couples which could stimulate wives to discuss family planning with their husbands. Furthermore, those couples whose wives had already experienced health problems due to contraception tend tocommunicate family planning matters with their husbands more frequent than the other couples. More broadly, this study highlighted that health providers (doctors, nurses/midwives, family planning field workers had) had played major roles to stimulate family planning communication among Indonesian couples. The present findings also point to the importance of husband's approval on the intensity of inter-spousal communication about family planning matters. Fully understanding the nature of the linkages between inter-spousal communication related to family planning and modern contraceptive use thus requires assessing these variables repeatedly over time in order to adequately develop the inter-link models of these variables. from the Faculty of Public Health, Universitas Indonesia. Informed consent was obtained from all participants. All identifications in the questionnaires were excluded from the study to ensure confidentiality and privacy.

Competing Interest
Author declares that there are no significant competing financial, professional, or personal interests that might have affected the performance or presentation of the work described in this manuscript.

Availability of Data and Materials
Data and materials of this study can be accessed on https://dhsprogram.com/data/available-datasets.cfm.

Authors' Contribution
Dian Kristiany Irawaty conceived of the presented idea and manuscript writing. Suziana Mat Yasin developed the theory and performed the computations. Hadi Pratomo supervised the findings of the work. All authors discussed the results and contributed to the final manuscript.