representation of family planning

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Between Tradition and Modernity: Representation of Women in Family Planning Campaigns in Pakistan

Pakistan, the fifth most populous country in the world, has had various family planning campaigns since the 1960s, but the contraceptive prevalence rate (CPR) has remained low compared with other South Asian countries. The promotional messages of the nonprofits Greenstar Social Marketing Campaign (GSM) and DKT International Pakistan are analyzed to see how the discourse surrounding contraception and women’s identity oscillates between the notion of tradition and modernity. The first part of the article focuses on how the promotional messages portray the dialectics between the traditional and biomedical approaches to family planning, while the second part examines how women’s identities are portrayed in these messages. This research is grounded in a culture-centered approach to health communication. Fairclough’s critical discourse analysis (CDA) approach was used as the main methodology. Promotional messages, including Facebook posts, newsletters, brochures, and images from 2009 to 2019, were analyzed. The biomedical approach to family planning is presented by GSM and DKT as a healthier, more successful, and more prosperous approach for Pakistani women, while the traditional approach is backgrounded in these messages or associated with poverty and misery, if mentioned.

Male Social Representations regarding Family Planning

Wesley gomes da silva, 1 rodrigo guimaraes dos santos almeida, 2 sebastião junior henrique duarte 3*.

1 Nurse, Master in Nurse, Federal University of Mato Grosso do Sul (UFMS). Campo Grande, MS, Brazil

2 Nurse, Doctor in Sciences, Professor at the Federal University of Mato Grosso do Sul (UFMS). Campo Grande, MS, Brazil

3 Nurse, Doctor in Health Sciences, Professor at the Federal University of Mato Grosso do Sul (UFMS). Campo Grande, MS, Brazil

Corresponding Author*: Sebastião Junior Henrique Duarte, Nurse in Health Sciences, Professor at the Federal University of Mato Grosso do Sul (UFMS), Campo Grande, MS, Brazil.

Received Date: 26 August, 2021

Accepted Date: 17 September, 2021

Published Date: 21 September, 2021

Citation: Silva WG, Almeida RGS, Duarte SJH (2021) Male Social Representations regarding Family Planning. Int J Nurs Health Care Res 4: 1255. DOI: 10.29011/2688-9501.101255

Objective: To know the social representations of men participating in a family planning program.

Method: Exploratory, descriptive research, with qualitative approach, carried out in Campo Grande-MS. The participants were 54 men: 31 had already undergone vasectomy and 23 were intending to undergo the method. A structured form containing characterization data was used and an open interview was also conducted with the guiding question: “what is your opinion about family planning?” The collective subject discourse method and the Theory of social representations were used to organize the results. The research was approved by the ethics committee.

Results: Of the participants, 47.9% were married and the mean age was 35.8 years (±7.23). The majority, 33.3%, have three children and a family income of two minimum wages (40.7%) (±1.25). The statements comprised six collective subject discourses, organized in positive social representations: satisfaction with vasectomy, controlling the number of children, satisfaction with the family composition and preservation of the partner’s health, and negative ones: fear related to the procedure and difficult access.

Conclusion: The social representations of the participants were positive in relation to vasectomy, which demonstrates that some men postulate the definitive method of family planning, even if access still requires improvements.

Keywords: Family planning; Vasectomy; Sexual; Reproductive health

Introduction

The World Health Organization has advocated health universal access and coverage to all peoples. To do so, social, cultural, economic and geographical barriers need to be eliminated, in addition to institutional ones, and health systems need to be able to meet the needs required by individuals, collectivities and health professionals [1]. Regarding health needs, the Agenda of the United Nations (UN, 2016), from 2016 to 2030, established 17 interdependent sustainable development goals to be assumed by member countries, including Brazil. Among the 169 goals to be achieved is universal access to sexual and reproductive health services, including family planning, information and education, as well as the integration of reproductive health into national strategies and programs. In Brazil, family planning is part of public health policies and ensured by the Federal Constitution through Article 226 and Law no.9,263. According to that law, family planning is a “set of actions to regulate fertility that guarantees equal rights of constitution, limited or increased number of children by women, men or couples” [2]. The National Policy of Integral Attention to Men’s Health (PNAISH) emphasizes the discussion on the male sexual and reproductive health, including sexual and reproductive rights, as well as planned parenthood [3]. Oliveira et al. point out that the improved access to family planning requires expanding the supply of services and contraceptive methods to the male population, given the low participation of men in birth control [4].

Among the personal determinants, education levels, economic class and cultural factors stand out as influencing elements of male participation [5]. This demonstrates the relevance of developing studies capable of knowing this population in order to contribute to their real needs [6]. Costa (2016) states that, although timidly, male participation is increasing over time and the main reasons for this choice are: the desire to share the responsibility of contraception with their partners, the concern with the economic aspect due to the family increase and the knowledge of successful experiences with vasectomy [7].

In this sense, even with the difficult access, the change in male behavior is remarkable, seeking to participate more in family planning actions. Subramanian et al. recommend men’s insertion in sexual and reproductive education activities as a strategy to improve knowledge about the procedure, as well as the development of new contraceptive methods for men, which confer greater freedom and protection to sexual and reproductive health [8]. Considering the relevance of the theme and the intention to contribute to studies focused on the sexual and reproductive health of the male population, this research aimed to know the social representations of men participating in the family planning program.

This is an exploratory, descriptive and qualitative research, carried out during from November 2017 to May 2018, in Campo Grande, Mato Grosso do Sul, in the Municipal Specialized Center (CEM), which is the central reference place for family planning and care for candidates to vasectomy in the state. The participants were 54 men: 31 already submitted to vasectomy and 23 others preparing for the procedure. All those invited to participate in the study accepted the invitation, with no exclusion of participants. They were informed about the objectives of the research and requested to sign the Informed Consent Form (ICF).

Data collection was performed through a structured form with the following variables: age group, color, region of residence, religion, marital status, level of education, profession, family income and known contraceptive methods, performed through individual interviews to obtain their statements and social representations from the guiding question: “what is your opinion about family planning?”. The data were arranged in an Excel spreadsheet, using the double typing technique, which allows organizing the results and their subsequent illustration in tables. The interviews were recorded, transcribed and organized according to the collective subject’s discourse method and analyzed with the aid of the Theory of Social Representations [9]. According to the collective subject discourse is a technique to organize material resulting from fieldwork, usually derived from interviews, questionnaires, papers, graphic materials, etc. Social representations are considered as popular knowledge, myths, beliefs and customs, which converge in common sense and are socially shared [10,11]. The discussion was constructed after analyzing the findings according to the Theory of Social Representations based on official sources, such as the Ministry of Health and others resulting from studies published in indexed journals. The research was approved by the Human Research Ethics Committee at (information blinded for peer review purposes ) .

The characterization showed that the mean age was 35.8 (± 7.16). It is interesting that young men are seeking a definitive contraceptive method, despite reversible. Especially when changing the opinion in relation to increasing the number of children, the success is not guaranteed in 100% of the reversals, in addition to their limited access by the Unified Health System. Regarding the level of education, 14.8% of the participants had college degree; only 5.5% did not complete primary education; 38.8% completed primary education and 40.7%, high school, as in (Table 1).

Concerning the participants’ marital status, most men are married or in a stable union, demonstrating that men who seek family planning have fixed partners. The average family composition regarding the number of children varied between one and five children with a significant concentration between two, three and four children. Another important variable refers to their family income, ranging from one to eight minimum wages, with an average of 2.8 wages among the participants, as revealed in (Table 2).

Most of them (79.5%) have religion, which denotes that there is no religious interference in the decision to limit the number of children for the study participants. The main reason that led them to seek the family planning service was vasectomy, chosen to preserve the partner’s health, legitimizing the relevance and existence of discussion between couples related to family planning. Thus, this conjuncture corroborates several studies that demonstrate the increased male participation with a leading role in the family composition, demystifying that the theme is only female. Another aspect mentioned was satisfaction with the number of children, a factor not associated with others such as financial, social and health. Regarding financial and social factors, 22.2% cited them as the main reason for seeking a definitive method to control the number of children. (Table 3) shows these findings.

The interviewees were also asked about their previous knowledge of the types of contraceptive methods. Most participants demonstrated knowing between two and four different contraceptive methods, with a predominance of 22% of three contraceptive methods. The participants mentioned 11 methods, with the male condom as the most cited, present in 88.8% of the answers, followed by oral contraceptives, with 83.3% of the answers. Main methods made available by the UHS.

Vasectomy was mentioned by 48.1% of the interviewees when asked about definitive contraceptive methods. (Table 4) shows the previous knowledge of contraceptive methods according to the variable known methods.

The interviews allowed organizing six central ideas, organized in positive social representations: satisfaction with vasectomy, controlling the number of children, satisfaction with the family composition and preservation of the partner’s health, and negative ones: fear related to the procedure and difficult access.

Satisfaction with Vasectomy

“I think the access [vasectomy] was easy...I found it fast through the system, very fast, because it took me less than 3 months and I was already undergoing it…the whole process was good, it does not hurt and the result corresponds to my expectations…I am satisfied because that is exactly what I wanted...I think the service is easy-access, good, helpful…For me it was great...I am enjoying it...I think the male method is better than the female one...in general, the time elapsed was good, I thought it would take longer...since the first day, the treatment has been great, the schedules were very flexible and I am already finishing everything, there was no barrier, so far it has been good ...I found it fast, easyaccess, I found it very good, very fast...it was good, fast, within the period since the first lecture...as a public agency, I comment with several people that the service is very fast, good, the staff is very attentive…we can reason and think more whether it is a good time...it was a good experience, everything has been fine, I am very happy...I think it is reasonable, I do not find it time consuming because when you start to participate, you see many people giving up,so, doing it too fast you may regret later, I think this was a good time”(p 2, p 5, p 6, p 7, p 8, p 9, p 10, p 16, p 17, p 23, p 24, p 26, p 27, p 28, p 29, p 30, p 32, p 33, p 34, p 36, p 37, p 39, p 30, p 41, p 42, p 43, p 44, p 46, p 49, p 50, p 51).

Controlling the Number of Children

“The decision was mine, currently having a child to suffer is not cool...I already have five children...for the educational issue, first of all, and for the issue of the cost of living, we are not so rich...I do not want any more children, that is why I am trying to undergo the vasectomy, I cannot provide for many children, so I prefer a definitive method...our financial condition is not that good, so we cannot have another child, I am seeking a method for me because she cannot do it, as she is only 24 years old...I want a family planning, I want vasectomy because I can only provide for three children, I do not want more children...for me four children are enough because I cannot spend more than I earn...we already have two children and raising a child nowadays is difficult...this decision has already been made by the number of children we have and due to our financial conditions...we are satisfied with all the strands, one of these strands was the financial issue...I already have two children, I am paying alimony for one of them, which is hard for me, as we do not earn that much in nursing, so things are sort of difficult...it is the financial issue, I think four are already enough...the situation is not so good for you to raise children, mainly considering the financial part” (p17, p 20,p 23,p 24, p 28, p 29,p 31,p 33, p 38,p 42,p 47,p 50,p 51).

Satisfaction with the Family Composition

“I am very satisfied because that is exactly what I wanted, I have four children from two marriages, two from the first and two from the second, I said now it is enough...I do not want any more because I already have four children. I decided to undergo vasectomy because I think it is the best for me, because despite preventing, we had a girl, so I decided to do not to occur again. I do not want any more kids; I already have a 25-year-old son. I already have children...there is no way we are having more children, we already have two children...my first two was not from stable relationships, we only had a few dates, she got pregnant twice, so I decided to do it. I was searching for a definitive method because I do not intend to have more children, already have enough” (p 7, p 10, p 22, p 37, p 44, p 48, p 49, p 52).

Preservation of the Partner’s Health

“She suffers too much in the procedure, her process is longer than mine...the recovery is much better for men, and as my wife already has two children from normal delivery, she is afraid of cesarean section...I have chosen vasectomy to protect my wife...I was at the birth, so the husband sees the reality, see it is not easy, if I had been to the first she would not have had the other children because she suffers too much, so I have decided to undergo vasectomy...we see that for men it is better and easier, the male procedure is simpler...I have chosen it because of my wife, she has a problem in the womb...and thinking with my wife, it was better for me then for her because the risks are much greater for her... my wife, in her current health condition, has many infections, if she is going to use the IUD, the situation will get worse, and the pill causes a lot of side effect...I have chosen it because my wife cannot take medicines because of her health problems, I ended up choosing this method because it is a way to protect her health...it was a way to protect my wife and the baby, a way to protect both...I have chosen it because my partner was feeling really bad about the injections she takes...my wife had two episodes of preeclampsia one in the second child and now in the third...the method is much less invasive than with the woman...I have chosen this method because my wife is already 42 years old, she has diabetes so she cannot take the medicine anymore...when we were about to have our daughter, she almost died, she almost did not return...my wife fails to take many drugs” (p2, p3, p4, p6, p9, p18, p21, p23, p26, p29, p32, p33, p34, p36, p38, p39, p40, p41, p43, p44).

Fear Related to the Procedure

“Surgery always gives me the creeps, afraid of something going wrong, fear of being impotent...I thought that the surgery would end [erection] I was afraid of becoming impotent” (p 46, p 52).

Difficult Access

“I was told it would be as fast as possible, but it has not been...I think for those who demonstrate indecision, the deadline is cool, but I think that those who are already sure, the meetings could be separately because it takes 60 days until the surgery, if it was faster it would be better because it hinders my life a little, besides my professional life...it has been about six months because the service stopped at the end of the year but as some tests delayed, it is taking longer...the only thing I found time consuming is that I do not know if it is different from unit to unit, I first went to family planning, I found the waiting time too long to participate in the lecture...in my opinion it is taking a while because it has already been about six months...I find it very complicated, I believe that they ask for too many information for something that is very simple, because I think that whoever is already coming here has already made his decision...my wife can no longer get pregnant, I think it is kind of complicated because during this period there is an impediment to having a relationship with the wife...where I live there is a waiting line for the procedure” (p4, p11, p18, p19, p21, p25, p45, p47).

The data characterization outlined a profile among men who seek the family planning service and gaps in male participation, which are influenced by several factors such as education level, economic class, religious beliefs and the main motivations of those men when seeking the family planning service. In view of the mentioned results, the relationship that the portions with lower incomes, little schooling and living under the margins of development have little representativeness among the participants, even if the group is composed of a contingent of patients from the UHS. Knowing the profile and the opinion of family planning users is of paramount importance to understand the paths that led to building their history. Family planning is still a little explored theme in Brazil, especially when focusing on the man. The study participants were mostly between 30 and 40 years, being in line with the study by in which the largest proportion vasectomized men were older than 30 years, pointing out age as a decisionmaking factor among when talking about definitive methods of contraception [12].

According to the Brazilian legislation, vasectomy is legal in men with full civilian capacity aged over 25 years and with at least two children [2]. A minimum period of 60 days is also necessary between the manifestation of the will and the surgical procedure. Moreover, in the study by Bezerra and Rodrigues, there is equalization when observing the marital status of men: those married are higher in relation to those who declared a stable union and even greater in relation to those who declared themselves single, evidencing that the man who seeks family planning seems to show greater commitment in relation to his partner [12]. When verifying the participants ‘social issues, most of them are brown, with complete primary and secondary educations, income between two and three minimum wages and with at least three children. These characteristics are also present in the study by Marchi et al. evidencing that the man who seeks family planning in the public health service is still the one with a higher level of education, whose family income is not so low and who is not so unaware of social public policies [13]. Religious issues were not very influential in this case. Although Christian churches are against various contraceptive methods, as evidenced by the study by Gomes and Carvalho, the religious doctrine does not seem to interfere emphatically in the participants’ behavior [14]. Cultural issues associated with lack of information and low schooling are still the biggest obstacle to new methods, especially those that go against patriarchal society that subjugates man-centered medicine. A study by Marván, Ehrenzweig& Hernández-Aguilera [15], conducted in Mexico, shows the negative positions of the male population with lower levels of education. The discourses found corroborate Azevedo, Gonçalves and Rosa [16], which indicate an improved male participation in family planning, even if discreetly, with this improvement linked to several factors, evidenced in this research when most men indicated their satisfaction in participating in family planning.

This satisfaction of the male population when participating in family planning actions is also mentioned in international studies such as by Simbar [17], who report the satisfaction of the male participants in Iran. Several interviewees reported satisfaction in participating in family planning, mainly because they were motivated by the preservation of their partners’ health. That was the main concern reported.

Among the interviewees, there were several reasons for vasectomy, and the preservation of the partner’s health prevailed in the citations, with a wide advantage, representing 42.5%. This denotes that part of society has understood the harms that hormonal contraception can generate to women’s health and that men need to be co-responsible for their family future. It is noteworthy that the female definitive contraception methods are procedures of greater risk and surgical size, and this risk is a motivator for men to seek an alternative in preserving their partner’s health.

This data is corroborated by the research by Minister, Silva and Melo, who reported that most men demonstrated preferring vasectomy as a method of preserving their partners’ health. Another important point was the awareness that the number of children is already sufficient, presenting itself in second place as motivation for seeking family planning [18]. Another reason highlighted was family income, which has always been in the balance when the subject focuses on family composition. Over time, Brazilian development, the rise of knowledge and the understanding of expenses by the population have generated even more concern about the act of planning and taking care of the number of children. Hamm et al. also note that, although male participation in family planning is still timid, the financial aspect is among the main reasons found among low-income American men living in Pittsburgh, Pennsylvania, and the authors recommend tying the financial aspect to the family planning guidelines for men [19].

Unfortunately, this is not a reality that reaches all social spheres. Chang et al. indicated the correlation of the highest number of vasectomies among men who had higher education level and better economic condition [20].

Despite the remarkable participants’ satisfaction, several discourses reported difficult access, mostly related to the delay in performing the procedure. The inadequacy of schedules, difficult access, either due to the low offer or the difficulty to complete the process, distances them from effective participation when talking about reproductive health. Shattuck et al. state that disorganization of services, low offer and low quality are factors that distance men from family planning [21]. The existing access barriers is explained in Zordo’s (2012) research, which reports men’s difficult access to family planning due to the inefficiency and precariousness of service, making the service itself one of the barriers of access to family planning [22].

In a study conducted with members of the network of family planning physicians in the United States (scholarship, graduates and professors), few family planning physicians do the vasectomy procedure. Even though vasectomy is more effective, safer and less costly than female sterilization, it is still less common in the scenario of this research [23]. The study verified the low number 

of providers of vasectomy as a barrier to access it. Even in developed countries, male contraception is left in the background. According to White et al. respondents living in Texas, in the United States, report that low funding creates a barrier in the offer of vasectomy. The authors also comment on the low interest of the population especially among Latinos, pointing out the presence of access barriers, as well as perceived in other Brazilian and international studies.

A study by Adelekan, Omoregie and Edoni conducted in Nigeria, reveals that most family planning services are understood as not being welcoming to men, with poor health infrastructure for men, including health policies, services and service hours [24]. These reasons, among others, often lead men to give up participating in family planning actions, leading to the non-choice for vasectomy due to access difficulties. Corroborating a review study by Hardeee, Croce-Galis and Gay most programs act in the expectation that women are contraceptive users and that men should support their partners, with insufficient attention to men as users of family planning in their own right [25]. This same review highlights that men show a desire for information and services.

Health education stands out, with the involvement of community members and education workers includes a greater relationship between users and professionals, being all protagonists of health actions. The importance of universities and training centers as responsible for preparing professionals committed to social needs, with educational projects focused on reality and with the strengthening of the UHS, stands out. Even within a group of men postulating vasectomy, 48.1% answered that they had no prior knowledge of this method, which points out the need for disseminating and guiding the population regarding this method of contraception. An American study conducted in seven southern states showed that men without the knowledge about vasectomy showed negative opinions about the procedure, while vasectomized men pointed out and reported perceived benefits. This demonstrate the importance of health education in the field of sexual health in order to disseminate the method and further insert the male population into family planning programs [26]. Health managers and professionals must sensitize the population, especially men, that this procedure does not affect men’s sexual performance or desire [27]. Knowing those who seek health care with an emphasis on family planning is one of the ways of proposing new ways of acting, managing and implementing policies so that planning increasingly changes from a sphere of women’s health to family health. Thus, it is evident the need to improve family planning services in order to meet this population effectively, who has been taking over and understanding, increasingly, their responsibilities, rights and duties regarding their sexual and reproductive health [28].

The discourses found allow understanding men’s thought about family planning and point out some reasons why little male participation persists. The main motivations demonstrate a change in attitude of the male population, now concerned with the health status of their partner, which is the main motivator, in addition to the financial, social and family implications. To conduct a study such as this is to evidence two important points of Brazilian health: man’s distance from the center of family planning policies and the exclusion of some population groups from health programs, due to lack of information or access. Thus, immediate public policies need to be put on the agenda to modify this scenario, as recommended by the Ministry of Health and the United Nations [29]. This goal requires improvements in the work process focused on planning regarding investments, in order to attract a larger population, as well as in the investment in health education, attracting professionals and popularization of contraception in order to reach all populations, generating universality and equity within a system that needs this experience [30]. Promoting the guarantee of existing methods and stimulating the development of new methods are fundamental actions for this change, so that men’s right to sexual and reproductive health is integrally guaranteed.

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• Mahmood H, Khan Z, Masood S (2016) Effects of male literacy on family size : a cross sectional study conducted in Chakwal city. J Pak Med Assoc 66: 399-403.
• Asare O, Otupiri E, Apenkwa J, Odotei- Adjei R (2017) Perspectives of urban Ghanaian women on vasectomy. Reprod Health 14: 21.
• Costa CC (2016) A esterilização masculina: perfil e percepções de homens que optaram pela vasectomia. O Social em Questão, 36: 425 -446.
• Subramanian L, Cisek C, Kanlisi N, Pile JN (2010) The Ghana vasectomy initiative: facilitating client–provider communication on no-scalpel vasectomy. Patient Educ Couns 81: 374-380.
• Moscovici S (2003) Representações sociais: investigações em psicologia social. trad. Pedrinho A. Guareschi. Rio de Janeiro: Vozes. Original publicado em 2000.
• Duarte SJH, Mamede MV, Andrade SMO (2009) Theoretical-methodological options in qualitative research: social representations and collective subject discourse. Health soc 18: 620-626.
• Lefevre F, Lefevre AMC (2006) The collective subject that speaks. Interface (Botucatu) 10: 517-524.
• Bezerra MS, Rodrigues DP (2010) Social Representations of Men on Family Planning. Rev Rene Fortalez 11: 127-134.
• Marchi NM, De Alvarenga AT, Osis MJ, De Aguiar Godoy HM, Simões ESilvaDomeni MF, Bahamondes L (2010) Vasectomy within the public health services in Campinas, São Paulo, Brazil. Int Nurs Rev 57: 254-259.
• Costa IGD, Carvalho AA (2014) Use of contraception by women from different religious groups: differences or similarities? HORIZONTE-Revista de Estudos de Teologia e Ciências da Religião, 12: 1114-1139.
• Marván ML, Ehrenzweig Y, Hernández-Aguilera D (2017) Mexican men’s view of vasectomy. Am J Mens Health 11: 610-617.
• Azevedo MVC, Gonçalves MC, Rosa PP (2013) The man vasectomized by SUS. Scientific Interfaces - Health and Environment 1: 35-46.
• Simbar M (2012) Achievements of the iranian family planning programmes 1956-2006. Eastn Mediterranean Health Journal,18(3),279-286 .
• Ministério JES, Silva LD, Mello PG (2016) VASECTOMY: IMPOSITION OR CONTEMPORARY CONSCIOUSNESS ?. In: Anais da X Mostra de Iniciação Científica do CESUCA, Cachoeirinha, RS, Brasil 232-246.
• Hamm M, Miller E, Jackson Foster L, Browne M, Borrero S (2018) “The Financial Is the Main Issue, It’s Not Even the Child”: Exploring the Role of Finances in Men’s Concepts of Fatherhood and Fertility Intention. Am J Mens Health 12: 1074-1083.
• Chang, YH, Hsiao PJ, Chen GH, Chang CH, Chen WC. et al. (2015) Economic fluctuation affects vasectomy utilization : A single-institution study. Urol Sci 26: 214-217.
• Shattuck D, Perry B, Packer C, Quee DC (2016). A review of 10 years of vasectomy programming and research in low-resource settings. Global Health: Science and Practice 4: 647-660.
• Colomé JS, Oliveira DLLC (2012) Educação em saúde: por quem e para quem? A visão de estudantes de graduação em Enfermagem. Text context - enferm 21: 177-184 .
• Nguyen BT, Jochim AL, Shih GH (2017) Offering the full range of contraceptive options: a survey of interest in vasectomy training in the US family planning community. Contraception 95: 500-504.
• White K, Campbell A, Hopkins K, Grossman D, Potter JE (2017) Barriers to offering vasectomy at publicly funded family planning organizations in Texas. American journal of men’s health 11: 757-766.
• Adelekan A, Omoregie P, Edoni E (2014) Male involvement in family planning: Challenges and way forward. International Journal of Population 1: 9.
• Hardee K, Croce- Galis M, Gay J (2017) Are men well served by family planning programs? Reproductive Health 14: 14.
• White AL, Davis RE, Billings DL, Mann ES (2020) Conhecimento masculino sobre vasectomia, atitudes e comportamentos de busca de informações no sul dos Estados Unidos: resultados de uma pesquisa exploratória. American Journal of Men’s Health14: 4.
• Brasil Ministério da Saúde (2018) Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Saúde Sexual e Saúde Reprodutiva: os homens como sujeitos de cuidado.
• Organização das Nações Unidas (2016) Programa das nações unidas para o desenvolvimento . Transformando nosso mundo: a agenda 2030 para o desenvolvimento sustentável. Disponível em.
• Vieira EM, Souza LA (2011) A satisfação com o serviço de esterilização cirúrgica entre os usuários do Sistema Único de Saúde em um município paulista. RevistaBrasileira de Epidemiologia 14: 556-564.

© by the Authors & Gavin Publishers. This is an Open Access Journal Article Published Under Attribution-Share Alike CC BY-SA : Creative Commons Attribution-Share Alike 4.0 International License. With this license, readers can share, distribute, download, even commercially, as long as the original source is properly cited. Read More .

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Tips for Joint Representation of Spouses (Part 2 of 2)

May 23, 2023 | Business Planning , Family Law , General Estate Planning , Podcasts , T&E Administration

“Tips for Joint Representation of Spouses after the Engagement Letter,” that’s the subject of today’s ACTEC Trust and Estate Talk.

Transcript/Show Notes

This is Margaret Van Houten , ACTEC Fellow from Des Moines, Iowa. Once a joint representation of spouses is underway, what are the best practices for ensuring both spouses are appropriately represented and engaged in the decision-making process? What red flags should estate planners watch out for? Representing an unhappily married couple who may be headed for divorce tests estate planners in practical and ethical ways. ACTEC Fellow, Professor Elizabeth R. Carter , of New Orleans, Louisiana, joins us today to discuss this topic. Welcome, Elizabeth.

Thanks, Margaret. Before I dive in, I want to remind all of our listeners of two wonderful free resources available on the website: The ACTEC Commentaries on the Model Rules of Professional Conduct and the ACTEC Engagement Letters . They both get revised periodically, and they are wonderful resources, particularly for these joint representation issues.

So, with that in mind, I have four tips to consider when you are representing spouses jointly in their estate planning. I will generally refer to spouses in this podcast, but most of this also applies to unmarried romantic partners.

Watch Out for Red Flags

Tip Number One: Keep an eye out for red flags. You want to keep an eye out for any red flags that might preclude joint representation, or that might be a reason that you need to terminate a joint representation. Remember, joint representation is not always possible or advisable. If red flags are obvious at the outset, then you should avoid joint representation in the first place. Sometimes, however, the red flags were not obvious at the outset, and sometimes they do not pop up until after the representation has started. So, what are those red flags?

Well, to have a successful joint representation, spouses should have similar goals and expectations. Their interests should be reasonably aligned, and they should be able to communicate openly and freely with the attorney and with each other. So, anything that runs afoul of those basic principles can present a red flag that might preclude joint representation. Some red flags are obvious. If your clients decide to divorce, then their interests are usually no longer sufficiently aligned for a joint representation. Similarly, spouses with serious marital problems who appear to be on the verge of divorce are not ideal candidates for joint representation.

Other red flags may be less obvious. If the clients have very different ideas about their estate planning goals and expectations, then joint representation may not be possible. Blended family structures and divided loyalties to various family members can cause problems for joint representation. You always want to keep an eye out for power imbalances between the spouses. These might be financial, social, or personality driven. Sometimes, conflicts can arise over thorny classification issues such as when there’s a disagreement about whether or not a significant asset is community property or separate property.

Declining or diminished capacity on the part of one of the spouses may make it difficult to continue a joint representation. If you suspect that one spouse is being harmed financially, emotionally, or physically by the other spouse or even by some other third party, then joint representation may be inappropriate. If you discover that one spouse is hiding assets or keeping major secrets from the other spouse, then the joint representation will have to terminate. Remember, just because you did not see any red flags at the outset of the representation does not mean that you can let your guard down. You have to keep an eye out for these things throughout the representation.

Actively Involve Both Spouses in The Joint Representation

Tip Number Two: Keep both spouses actively involved in the joint representation. In a joint representation, you want to make sure that you really are representing the interests of both spouses. To do this, you have to keep both spouses actively involved in the conversation. Doing this can also alert you to some of those red flags that I just mentioned. Sometimes, one spouse will try to dominate the decision-making or steer the course of the representation. Try not to let this happen. You want to ensure that both spouses are as involved as possible in the decision-making process.

One fairly easy way to help keep both spouses involved is to include both spouses in all of your communications. Copy both of them on emails. Get both of them on the phone with you. Get both spouses to come to the meetings. Make it clear to the more domineering spouse that you’re not going to take that spouse’s direction without consulting with the other spouse. Make sure both spouses are responding to the questions that you ask. If one spouse is quieter, be sure to ask that spouse directly if they have any specific questions or concerns. Sometimes, people will need you to prompt them like that in order to voice their thoughts.

Advise Clients of the Risks Associated with Various Planning Options

Tip Number Three: Advise your clients about the risk associated with various planning options, including the unpleasant risk. Often, the burden is going to be on you, as the attorney, to bring up the unpleasant “what-if” conversation. Don’t just assume that your clients will remain married. Don’t assume that one will not have an affair resulting in extramarital children. Don’t assume that one spouse will not remarry if the other one dies first. Rather, the better practice is to tell the clients about the risk associated with various planning options, including the types of risks that I just mentioned.

You should not ignore the possibility of unpleasant scenarios just because the marriage seems happy or because the clients don’t bring those questions up themselves. For example, suppose the spouses plan to leave everything to each other with the expectation that the survivor will leave property to their children in equal shares. This is a pretty common estate plan, of course. But you want to at least point out to your clients that there is some risk that the surviving spouse will change their mind.

The surviving spouse might favor one child over the others. The surviving spouse might remarry and favor that new spouse. The surviving spouse might have a new romantic partner. The surviving spouse might have children with someone else. Sometimes, clients will ask questions about those risks directly. But often, spouses do not raise these issues on their own, in part because they can be a bit awkward. In my opinion, it’s good practice for attorneys to raise these unpleasant possibilities in a tactical, but straightforward manner.

You don’t want to make the clients more worried about these possibilities than they need to be. But also, clients are often in a better position to know just how worried they should be about these possibilities than the attorney is. So, you at least want to point out these possibilities so that the spouses can make informed decisions. Personally, if I sense any hesitancy at all on the part of either spouse, then I like to give them some time to think things over before I ask them to make a specific decision. Give them some space to process their thoughts and feelings before asking them to lock down a position.

Remind Clients of Independent Representation Options

Tip Number Four: When appropriate, remind the spouses that they can seek independent representation. Whenever the spouses seem as though they might be at an impasse, or if a particular plan presents some real risk to one of the spouses, then you should remind the spouses that they can seek outside independent representation. In doing this, you may want to remind them that your role and advice are somewhat limited by the fact that you have a joint representation. Obviously, you want to go about this in a friendly way, in a way that really normalizes the idea of seeking outside representation.

If you sense a major conflict on the horizon, or a major risk to one spouse, or some major hesitation on the part of one of the spouses, then you might even insist that the spouse seeks separate representation. You can always point out to the spouses that you’re happy to work collaboratively with another lawyer if a spouse does seek that outside representation. This can help normalize their feelings. To normalize the idea of seeking outside representation.

To summarize, my four tips for joint representations are:

• One, keep an eye out for red flags that might preclude a joint representation or cause it to terminate.
• Two, keep both spouses actively involved in the joint representation.
• Three, advise your clients about the risk associated with various planning options, including the unpleasant risk.
• And finally, number four, when appropriate, remind the spouses that they can seek independent representation.

Thank you, Elizabeth, for that very helpful and informative presentation.

You may also be interested in:

• Tips for Joint Representation of Spouses: Engagement Letters (Pt. 1 of 2) (May 2023)
• 3rd Edition of ACTEC Engagement Letters  (sample engagement letters available for download)
• What should attorneys have in their Engagement Letters? (Feb 2018)
• Ethical Considerations in Representing Clients in Connection With Family Businesses (Sep 2018)
• Family Law podcasts

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Joint Representation of Spouses in Estate Planning: Understanding Your Ethical Obligations

Estate planning, a niche area of law, requires special skill and knowledge—not only legal knowledge, but also financial, tax, and accounting knowledge. The creation and administration of estate plans can be complex.

So, too, can family dynamics.

And with complicated family dynamics comes the potential for, and actual existence of, conflicts of interest. Conflicts of interest tend to arise more in blended families with children from previous marriages. But conflicts of interest surface in nuclear families, too. A prenuptial agreement, gift, or inheritance may be a catalyst. The reality, though, is that conflicts may emerge even in the most innocent and unsuspecting situations.

Undertaking joint representation of spouses requires you to be mindful of your ethical obligations under the Michigan Rules of Professional Conduct, a number of which are at play in the estate-planning context.

Rule 1.4(b) requires you to explain matters to the extent reasonably necessary to permit your clients to make informed decisions about the representation. Rule 1.6(b) prohibits you from knowingly revealing confidences of your clients. When you undertake joint representation of spouses, honoring your duty to keep them adequately informed and protect their confidences requires a delicate balance.

Rule 1.7(a) requires you to decline or withdraw from representation of a client if the representation will be directly adverse to another client, unless (1) you reasonably believe that the representation won’t adversely affect your other client, and (2) each client consents to the representation after consultation. Rule 1.7(b) requires you to decline or withdraw from representation of a client if your responsibilities to another client may materially limit the representation, unless (1) you reasonably believe that the representation won’t adversely affect your other client, and (2) each client consents to the representation after consultation regarding the risks, benefits, and implications of the common representation. The comment to Rule 1.7 expressly identifies estate planning as an engagement in which conflicts of interest may arise. The comment to Rule 1.7 also recognizes that conflicts of interest “may be difficult to assess” in estate planning and other non-litigation contexts.

There’s some debate over whether Rule 2.2, which outlines the circumstances in which you may act as an “intermediary between clients,” is applicable. On the one hand, the focus of joint representation in the realm of estate planning is not necessarily on the relationship between spouses, but rather on the relationship between spouses and third parties (such as tax authorities and beneficiaries). On the other hand, you may find yourself in an intermediary role when spouses express differences of opinions on important decisions. Indeed, the comment to Rule 2.2 indicates that you act as an intermediary when you represent “two or more parties with potentially conflicting interests.”

Assuming applicability, Rule 2.2 allows you to act as an intermediary between spouses if you (i) consult with them concerning the implications of the common representation—such as the advantages, risks, and effects on the attorney-client privilege—and obtain consent from them, (ii) reasonably believe that you can resolve the matter on terms compatible with both of their interests, (iii) reasonably believe that there’s little risk of material prejudice to either of their interests if your efforts to resolve the matter are unsuccessful, (iv) reasonably believe that they’ll be able to make informed decisions, and (v) reasonably believe that you can undertake the common representation “impartially and without improper effect” on other obligations to them.

The view of many commentators, including the American College of Trust and Estate Counsel, is that estate planning is generally non-adversarial in nature and joint representation of spouses is generally acceptable, if not beneficial. After all, spouses usually come to you with comparable, harmonious interests—providing for the support and education of their children, as but one example—and want you to create synchronized estate plans. Joint representation is an advantageous and cost-efficient method of accomplishing their shared objectives.

But circumstances change. Joint representation may start out cordial but ultimately leave you in an unenviable, if not impossible, position. Consider a scenario in which one of the spouses approaches you, alone, and expresses a desire to change the estate plan. You have a duty to keep the confidence of the spouse. But you also have a duty to keep the other spouse informed. And in the end, you may have a duty to withdraw from the representation.

Address the potential for conflicts of interest between the spouses at the outset. A candid discussion and a retainer agreement are the best practices.

At your initial meeting with the spouses, fully explain the scope and nature of the representation. Advise the spouses that if they want you to create separate estate plans, there may be occasions in which you want to consult with them separately. Discuss your ethical obligations and inquire of their willingness to waive the duty of confidentiality. If obtained, memorialize the waiver in the retainer agreement.

Be sure the spouses understand that if either wants to change the estate plan in a way that adversely affects the other spouse, you’ll need to consult with and obtain consent from the other spouse before you can ethically change the estate plan. You may consider including a provision in the retainer agreement in which the spouses acknowledge that (1) they’re unaware of any existing conflict of interest, and (2) if any conflict of interest arises in the future, they’re duty-bound to promptly bring the conflict of interest to your attention.

Set out the parameters of the representation. If the spouses engaged you to create estate plans, make sure they know and the retainer agreement reflects that the attorney-client relationship ends upon execution of the estate plans. Advise that any changes to the estate plans in the future will require new engagements and new retainer agreements.

That segues to another ethical obligation of which you should be mindful. If the retainer agreement provides that the attorney-client relationship terminates upon execution of the estate plans, the spouses become “former clients” after execution of the estate plans. Rule 1.9(a) outlines your ethical obligations if one of the spouses returns to you and seeks to engage you “in the same or a substantially related matter.” There may be circumstances in which Rule 1.9(a) doesn’t apply. For example, you may have created separate trusts that contain different provisions or beneficiaries and operate independently of one another. Thus, an engagement to change one of the trusts may not cause a conflict of interest or require a waiver.

When the engagement does concern the same or a substantially related matter, Rule 1.9(a) requires you to decline the engagement if the spouse’s interests are “materially adverse” to the other spouse’s interests, unless the other spouse consents after consultation. Unlike Rule 1.7, which provides that some conflicts of interest cannot be waived, conflicts of interest that implicate Rule 1.9 can always be waived. Even when you obtain a waiver from the other spouse, you need to remain cognizant of Rule 1.9(c), which imposes obligations on you with respect to information related to the prior representation. You cannot reveal such information unless otherwise authorized by the Michigan Rules of Professional Conduct, or use such information to the disadvantage of the other spouse.

On a related note, if one of the spouses seeks to engage you to make changes to the estate plans during the pendency of a divorce, make sure you ascertain whether there’s an order prohibiting changes to the estate plans. You don’t want to be the subject of a contempt proceeding.

In sum, joint representation of spouses in estate planning is generally acceptable, beneficial, and cost-effective. But proceed with caution because conflicts of interest can and do arise.

Joshua I. Arnkoff

[email protected] 248-351-5440

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Measuring women’s agency in family planning: the conceptual and structural factors in the way

Nandita bhan.

a Research Scientist, Center on Gender Equity and Health, University of California San Diego, School of Medicine, La Jolla, CA, USA.

b Tata Chancellor Professor of Society and Health, Department of Medicine; Professor of Education Studies, Division of Social Sciences; Director, Center on Gender Equity and Health, University of California San Diego, School of Medicine, La Jolla, CA, USA

Edwin E. Thomas

c Research Coordinator, Center on Gender Equity and Health, University of California San Diego, School of Medicine, La Jolla, CA, USA

Priya Nanda

d Senior Program Officer, India Country Office, Bill & Melinda Gates Foundation, Seattle, USA

The FP-Gender Measurement Group

In 1994, the International Conference on Population and Development (ICPD) called for centralising women’s agency within reproductive health research and programmes. This shift was made possible by years of feminist scholarship and activism within population and development programmes. Even as global development goals have acknowledged the importance of women’s education and rights in moving the needle for reproductive health access, ICPD recommendations have not been fully integrated into health programmes. As a result, almost 30 years later, despite evidence on the importance of women’s empowerment for health seeking 1–5 , family planning programmes continue to see contraception use and targets as the predominant goals for nations and communities, and contraceptive use as a marker of women’s choice in family planning. Barriers to centralising women’s agency in sexual and reproductive health programmes have included conceptual and methodological challenges in measuring women’s empowerment and choice, particularly women’s agency in influencing family planning behaviours and service use, within the theory of change and evaluations.

The lag in prioritising women’s agency over contraceptive targets may be due in part to the lack of consensus in the meaning and measurement of agency and choice specific to sexual and reproductive health. Shared consensus and vision are needed both at the conceptual level (definitions and components, theorising connections to outcomes and developing survey measures) and in relation to structural dimensions in the field (the flow of learnings and resources between researchers and implementers, and the space given to women’s voices within research and programmes).

What do we know about women’s agency? What gaps in knowledge persist?

An evidence review 6 of women’s agency measures used in family planning research and programmes shows that the field uses a diversity of constructs to define women’s power, voice and choice within the contraceptive user journey, including women’s autonomy , family planning self-efficacy , reproductive coercion , quality of care , male engagement and attitudes related to contraceptive use. However, the review also reveals several theoretical as well as empirical challenges that continue to plague conceptualisation and empirical validation of measures. Measures of women’s agency can be summarised into four typologies in family planning programmes :

• Constructs and measures that are well-understood or accepted among scholars as best evidence measures: these have demonstrated validity along with ease of use, brevity or clarity, but need wider recognition and use in the field (e.g. decision-making agency 7 and reproductive coercion 8 ). New measures, for instance, like decision-making agency, go beyond who made the final decision and capture the decision-making process, how perspectives are shared and valued, and agreed upon 7 . Similarly, the reproductive coercion measure provides an understanding of resistance faced by women from their partners in exercising their contraceptive choices 8 .
• Constructs and measures that are being tested across diverse contexts or populations: (e.g. a family planning norms 9 measure that demonstrates validity in one context, but needs further adaptation and testing to assess relationships with family planning outcomes). This measure allows us to understand the enabling environment driving contraceptive choices, but can be context-specific in their content and use.
• Constructs for which measures exist and need adaptation, particularly simplification in construct or measure length for ease of use in programmes: For example, lengthy proven measures such as family planning self-efficacy 10 and contraception stigma 11 could be created as short-form measures for integration into family planning programme surveys and into monitoring and evaluation systems.
• Constructs for which promising measures need further conceptualisation and theorisation, more formative research and psychometric testing: These include fertility preferences ( i.e. intention, choices, timing, preferences around completion of family size, women’s or couple’s ability to conceive); negotiation and decision-making including reproductive bargaining (e.g. what a woman may give up to get her husband’s acquiescence to her reproductive choice); norms related to fertility planning and contraceptive use ; couple communication on sex; method switching and discontinuation ; and stigma including backlash (e.g. abuse or alienation from husband or family as a consequence of her contraceptive choices).

In addition to these typologies of constructs and measures of women’s agency in family planning, there is also variation in and under-representation of key populations and constituencies including adolescents, young unmarried women and men, zero- and low-parity women, non-heterosexual/non-cisnormative couples/individuals, and couples who do not desire children, in family planning research and programmes. Family planning surveys and programmes at present focus disproportionately on married populations, more specifically women, reinforcing family size goals and contraceptive targets instead of recognising the circumstances or contexts wherein women make fertility and family planning choices. Youth, in particular, and their sexual activity prior to marriage often continue to be stigmatised and the needs for and barriers to health services among youth remain unrecognised and unaddressed. Men have also not received adequate focus in family planning programmes, unless they are husbands, reinforcing norms that women, and not men, are responsible for contraceptive use. Also under-represented has been an understanding of women’s agency as expressed by non-use, non-desire for contraception or ambivalence towards contraception use. The under-representation of these groups and themes in family planning research and programmes furthers marginalisation and creates wider gender asymmetries in contraceptive access.

What are the conceptual barriers to measuring women’s agency in family planning?

While feminist and women’s rights scholars have advanced our understanding of women’s empowerment for health 1–5 , these learnings have not been adequately extended to measuring women’s agency in family planning programmes. This limitation may be due to two reasons.

First, in family planning, researchers have often referred to a diverse range of concepts to measure women’s (reproductive) agency without explicitly locating them within the theory of change in family planning programmes. This lack of conceptualisation and of drawing linkages to outcomes is also noted in the over and interchangeable use of generalised measures of self-efficacy or household decision-making as proxy measures of women’s agency in family planning. While these measures may be valuable in themselves and readily available through large-scale surveys, they lack items that capture family planning context or relevance. For instance, generalised measures of empowerment may not draw on women’s ability to voice their choices pertaining to childbearing, contraception, ideal number of children as well as themes such as bodily autonomy, women’s social position within their family or community and aspirations regarding building a family.

The field needs to critically examine the existing science on women’s agency measures, focused on the individual or the interactional, to understand in which ways current conceptualisations draw from theoretical and empirical understandings of family planning and gender, and how they are informing programmes around contraception choice, uptake and use. Measurement innovations such as decision-making agency 7 have questioned the present focus in survey measures on who decides and have extended them to include what matters to women, whether women share their preferences and feel valued, and are satisfied with their participation and the decision.

The scholarship on measuring women’s agency is also increasingly recognising constructs that operate at the couple, household and community levels, reflecting agency as bargaining and negotiations with one’s partner, experiencing or resisting social pressures to bear children, and encountering support or coercion in contraception use or non-use. The interactions of these constructs with racial, ethnic and other social inequities also bring to light the intersectionalities and variations in voice, choice and participation.

A second barrier to measurement of women’s agency has been the gap between researchers and implementers, despite the need for research and implementation to be interlinked and iterative. This barrier has led to a dichotomy wherein, on the one hand, greater embedding of measures within family planning programmes is needed to provide empirical evidence on women’s agency measures; on the other hand, programme implementers very often do not have access to new or emerging evidence with respect to tested or validated measures. This silo-ed nature of the field has also led to disciplinary tensions between the fields of gender and public health, with the former emphasising contraception choice (to use or not use) as the goal, while the latter is prioritising health-related outcomes of contraception use. In our view, even as these silos get reconciled, it continues to be important to emphasise gender and rights frameworks within public health programmes so as to value women’s satisfaction, dissatisfaction and even ambivalence with the choices available to them in family planning programmes. At the same time, newly developed and viable measures of women’s agency in family planning 7–9 must be palatable, accessible, appropriate for the context and easy to use for family planning implementers.

In family planning, unlike some other domains of women’s empowerment research, there is recognition that measures of reproductive agency 12 , 13 can be attentive to issues at both the individual as well as couple levels, depending on the context. This seeming dichotomy can also be resolved through dialogue between family planning researchers and implementers on effective integration of gendered constructs within family planning programmes. Similarly, striking a balance between context specificity and cross-national comparability is an important challenge for measurement. This balance requires communication and partnerships between implementers and a wider stakeholder group for greater harmonisation of measures across contexts and for use within family planning programmes.

How can we improve measurement of women’s agency in family planning to meet community needs and strengthen family planning programmes?

Despite a vibrant group of scholars, researchers and practitioners advocating for the goal of centralising women’s agency in family planning, programmes and evaluations continue to lack a diverse representation of disciplines and geographies. While feminist scholarship over the decades has often been led by contributions from the global South, the architecture of knowledge, evidence and the flow of resources related to key sexual and reproductive health and rights issues continues to be driven from the global North to the global South. Scholarship and implementation research in the most affected nations and populations has often been led by those not in these nations and of these populations. More inclusive approaches to research generation are needed in family planning that can build a diverse and representative pipeline of scholars for future research in these areas and to bring forward the learnings on women’s agency from a greater diversity of contexts.

To overcome some of these disciplinary and data bottlenecks, the field may need three sets of synergies. First , there is a need to better leverage existing and routine data collection opportunities, particularly in low- and middle-income countries, including national health management information systems and routine surveys that will allow practitioners to embed and examine women’s agency and choice within family planning programmes. Examining these issues through routine data systems can inform policy and strategic partnerships in real time.

Second , the field often derives learnings on women’s agency from large cross-national surveys. There is an increasing recognition of the need to support these surveys with other methodologies including qualitative and mixed-method observational studies, and evaluations. Emerging methodologies including vignettes, digital platforms, big data and phone surveys may also be useful in filling key data gaps and give voice to community needs and the lived realities of women in innovative ways. Creative use of digital platforms can allow practitioners to engage more deeply with questions related to access, women’s choice and agency as well as the user experience.

Finally , despite the contribution of gender rights-based scholarship and landmark ideas from the ICPD in driving the field of sexual and reproductive health, the present field of family planning programmes needs more cross-disciplinary collaborations. Investments to increase conversations across disciplines and between scholars and practitioners across fields (e.g. community development, human rights, child marriage, trafficking and violence prevention) can improve our insight into what works to improve women’s access to and agency in family planning.

Without engaging in cross-disciplinary research partnerships, family planning scholars and implementers will find it challenging to present to donors and governments the evidence needed for mainstreaming women’s agency in family planning programmes.

What is the way ahead?

In summary, while the field of family planning has advanced considerably, there is an urgent need to shift from approaches that focus on contraceptive outcomes as a proxy for women’s agency to prioritising women’s reproductive choice and agency as outcomes in themselves. This must draw from cross-disciplinary scholarship across the fields of family planning or public health, as well as from sociology, women’s studies and gender studies 14 , 15 . While several existing and emerging measures of women’s agency are promising, family planning researchers need to make a better case with rigorous evidence that demonstrates the importance of this work for women’s reproductive goals as well as to expand choice within family planning programmes. Investments that centralise women’s agency within family planning programmes may hold the key to strengthening family planning programmes, address unmet sexual and reproductive health needs and deliver effective family planning services to communities.

Acknowledgments

Authors were participants at a meeting on Measuring Women’s Agency in Family Planning organised by the Center on Gender Equity and Health, UC San Diego, on 9 September 2020. The meeting originated out of efforts to build measurement of gender determinants in an India-focused platform on Family Planning-Measurement, Learning and Evaluation supported by the Bill and Melinda Gates Foundation.

Funding Statement

This work is supported by the EMERGE-FP measures project (Bill and Melinda Gates Foundation Grant : INV-002967).

Disclosure statement

No potential conflict of interest was reported by the author(s).

The FP-Gender Measurement Group (in alphabetical order)

• Fred Arnold, PhD, ICF
• Sarah Averbach, MD, Center on Gender Equity and Health, UC San Diego
• Sarah Baird, PhD, George Washington University
• Cari Jo Clark, ScD, Emory University
• Kathryn Conn, PhD, The Women’s Storytelling Salon
• Elizabeth Costenbader, PhD, FHI360
• Michele R Decker, ScD, Johns Hopkins University
• Christine Dehlendorf, MD, University of California, San Francisco
• Leanne Dougherty, PhD, Population Council
• Anvita Dixit, PhD, Center on Gender Equity and Health, UC San Diego
• Jeff Edmeades, PhD, Avenir Health and the DHS Program
• Anna Mia Ekström, MD, Karolinska Institute
• Laura Hinson, PhD, International Center for Research on Women
• Kelsey Holt, ScD, University of California, San Francisco
• Sandra Jordan, MA, What Works Association & Independent Consultant
• Celia Karp, PhD, Johns Hopkins University
• Rebecka Lundgren, PhD, Center on Gender Equity and Health, UC San Diego
• Ann M Moore, PhD, Guttmacher Institute
• Caroline Moreau, MD, Johns Hopkins University
• Nandini Oomman, PhD, The Women’s Storytelling Salon
• Elisabeth Rottach, MA, Palladium
• Dominick Shattuck, PhD, Johns Hopkins Center for Communication Programs
• Jay Silverman, PhD, Center on Gender Equity and Health, UC San Diego
• Ilene S Speizer, PhD, University of North Carolina at Chapel Hill
• Carol Underwood, PhD, Johns Hopkins University
• Shannon N Wood, PhD, Johns Hopkins University
• Jennifer Yore, MPH, Center on Gender Equity and Health, UC San Diego
• Kathryn M Yount, PhD, Emory University

United States: Joint Representation Of Spouses In Estate Planning: Understanding Your Ethical Obligations

Estate planning, a niche area of law, requires special skill and knowledge—not only legal knowledge, but also financial, tax, and accounting knowledge. The creation and administration of estate plans can be complex.

So, too, can family dynamics.

And with complicated family dynamics comes the potential for, and actual existence of, conflicts of interest. Conflicts of interest tend to arise more in blended families with children from previous marriages. But conflicts of interest surface in nuclear families, too. A prenuptial agreement, gift, or inheritance may be a catalyst. The reality, though, is that conflicts may emerge even in the most innocent and unsuspecting situations.

Undertaking joint representation of spouses requires you to be mindful of your ethical obligations under the Michigan Rules of Professional Conduct, a number of which are at play in the estate-planning context.

Rule 1.4(b) requires you to explain matters to the extent reasonably necessary to permit your clients to make informed decisions about the representation. Rule 1.6(b) prohibits you from knowingly revealing confidences of your clients. When you undertake joint representation of spouses, honoring your duty to keep them adequately informed  and  protect their confidences requires a delicate balance.

Rule 1.7(a) requires you to decline or withdraw from representation of a client if the representation will be directly adverse to another client, unless (1) you reasonably believe that the representation won't adversely affect your other client, and (2) each client consents to the representation after consultation. Rule 1.7(b) requires you to decline or withdraw from representation of a client if your responsibilities to another client may materially limit the representation, unless (1) you reasonably believe that the representation won't adversely affect your other client, and (2) each client consents to the representation after consultation regarding the risks, benefits, and implications of the common representation. The comment to Rule 1.7 expressly identifies estate planning as an engagement in which conflicts of interest may arise. The comment to Rule 1.7 also recognizes that conflicts of interest "may be difficult to assess" in estate planning and other non-litigation contexts.

There's some debate over whether Rule 2.2, which outlines the circumstances in which you may act as an "intermediary between clients," is applicable. On the one hand, the focus of joint representation in the realm of estate planning is not necessarily on the relationship between spouses, but rather on the relationship between spouses and third parties (such as tax authorities and beneficiaries). On the other hand, you may find yourself in an intermediary role when spouses express differences of opinions on important decisions. Indeed, the comment to Rule 2.2 indicates that you act as an intermediary when you represent "two or more parties with  potentially  conflicting interests."

Assuming applicability, Rule 2.2 allows you to act as an intermediary between spouses if you (i) consult with them concerning the implications of the common representation—such as the advantages, risks, and effects on the attorney-client privilege—and obtain consent from them, (ii) reasonably believe that you can resolve the matter on terms compatible with both of their interests, (iii) reasonably believe that there's little risk of material prejudice to either of their interests if your efforts to resolve the matter are unsuccessful, (iv) reasonably believe that they'll be able to make informed decisions, and (v) reasonably believe that you can undertake the common representation "impartially and without improper effect" on other obligations to them.

The view of many commentators, including the American College of Trust and Estate Counsel, is that estate planning is generally non-adversarial in nature and joint representation of spouses is generally acceptable, if not beneficial. After all, spouses usually come to you with comparable, harmonious interests—providing for the support and education of their children, as but one example—and want you to create synchronized estate plans. Joint representation is an advantageous and cost-efficient method of accomplishing their shared objectives.

But circumstances change. Joint representation may start out cordial but ultimately leave you in an unenviable, if not impossible, position. Consider a scenario in which one of the spouses approaches you, alone, and expresses a desire to change the estate plan. You have a duty to keep the confidence of the spouse. But you also have a duty to keep the other spouse informed. And in the end, you may have a duty to withdraw from the representation.

Address the potential for conflicts of interest between the spouses at the outset. A candid discussion and a retainer agreement are the best practices.

At your initial meeting with the spouses, fully explain the scope and nature of the representation. Advise the spouses that if they want you to create separate estate plans, there may be occasions in which you want to consult with them separately. Discuss your ethical obligations and inquire of their willingness to waive the duty of confidentiality. If obtained, memorialize the waiver in the retainer agreement.

Be sure the spouses understand that if either wants to change the estate plan in a way that adversely affects the other spouse, you'll need to consult with and obtain consent from the other spouse before you can ethically change the estate plan. You may consider including a provision in the retainer agreement in which the spouses acknowledge that (1) they're unaware of any existing conflict of interest, and (2) if any conflict of interest arises in the future, they're duty-bound to promptly bring the conflict of interest to your attention.

Set out the parameters of the representation. If the spouses engaged you to create estate plans, make sure they know and the retainer agreement reflects that the attorney-client relationship ends upon execution of the estate plans. Advise that any changes to the estate plans in the future will require new engagements and new retainer agreements.

That segues to another ethical obligation of which you should be mindful. If the retainer agreement provides that the attorney-client relationship terminates upon execution of the estate plans, the spouses become "former clients" after execution of the estate plans. Rule 1.9(a) outlines your ethical obligations if one of the spouses returns to you and seeks to engage you "in the same or a substantially related matter." There may be circumstances in which Rule 1.9(a) doesn't apply. For example, you may have created separate trusts that contain different provisions or beneficiaries and operate independently of one another. Thus, an engagement to change one of the trusts may not cause a conflict of interest or require a waiver.

When the engagement does concern the same or a substantially related matter, Rule 1.9(a) requires you to decline the engagement if the spouse's interests are "materially adverse" to the other spouse's interests, unless the other spouse consents after consultation. Unlike Rule 1.7, which provides that some conflicts of interest cannot be waived, conflicts of interest that implicate Rule 1.9 can always be waived. Even when you obtain a waiver from the other spouse, you need to remain cognizant of Rule 1.9(c), which imposes obligations on you with respect to information related to the prior representation. You cannot reveal such information unless otherwise authorized by the Michigan Rules of Professional Conduct, or use such information to the disadvantage of the other spouse.

On a related note, if one of the spouses seeks to engage you to make changes to the estate plans during the pendency of a divorce, make sure you ascertain whether there's an order prohibiting changes to the estate plans. You don't want to be the subject of a contempt proceeding.

In sum, joint representation of spouses in estate planning is generally acceptable, beneficial, and cost-effective. But proceed with caution because conflicts of interest can and do arise.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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