Why do high-parity Malawian couples fail to achieve their desired family size? A study identifying the linkages between couple relationship dynamics and the practice of family planning in Malawi

Objectives. To explore the contextual influences around couple relationship dynamics which inhibit the practice of family planning and failure to achieve reproductive intentions

Background. Even as of 2010, Malawian couples have more children than they desire, with 26% having unmet need for contraception (14% for spacing and 12% for limiting), a level largely unchanged from the 28% in 2004. This is especially true for high-parity couples, where 63% want to limit their family size to four children.

Methods. Qualitative methods were utilized for data collection and analysis. A total of 20 focus group discussions and 20 in-depth interviews, covering a sample of 159 individuals, were conducted across the five regions of Malawi. Thematic analysis was utilized to identify recurrent categories and patterns.

Results. Couples often fail to limit family size to desired levels, despite knowledge and intentions to use contraceptives. Among the recurrent themes arising in the narratives were the importance of children in defining marriage and family; a tension between community fertility norms and individual family size desires; dissonant views of spouses regarding the meaning of contraception in marital relationships; and the absence of and inability to adopt a birth planning orientation. These themes framed a common experience among couples reaching a high-parity threshold before their motivation to use contraception is crystallized.

Conclusion: Achieving smaller family size desires requires understanding couple relationship dynamics in the context of community, family and marriage. These constructs may govern the timing of contraceptive adoption and can inform the content of public health messages.