Little is known about the dynamics of couples' sexual and reproductive decision-making or about how gender roles affect these decisions. Such decisions can include whether to practice family planning, choosing when and how to have sexual relations, engaging in extramarital sexual relations, using condoms to prevent STDs, breastfeeding, and seeking prenatal care (28, 36, 117, 126, 148).

Gender is just one of many factors that influence couples and affect their reproductive decisions. Education level, family pressures, social expectations, socioeconomic status, exposure to mass media, personal experience, expectations for the future, and religion also shape such decisions (28, 115, 117). Consequently, no two couples' "decision-making environments" are identical (117). Some researchers have suggested that personal reproductive decisions result from many smaller, incremental decisions (35, 174, 281). Other researchers suggest that in fertility decisions social and cultural norms and expectations often prevail over individual preferences (117). In some traditional societies many couples say that the number of children they expect to have is not up to them at all, but rather up to God or to fate.

In some developing countries husbands dominate reproductive decision-making, whether regarding contraceptive use, family size, birth spacing, or extramarital sexual partners (73, 79, 85, 138, 142, 148, 188, 238). In Ghana, for example, some men in focus-group discussions claimed to make all family decisions. As one man asserted:

...We control them from the initial stage. When she comes to the house and maybe she thinks she is now the lady of the house and does something contrary to your regulations, you warn her. We don't allow our women to have influence on us (73).

A study of the fertility decisions made by five generations of one South Indian family also found that the men tended to control contraceptive use and to make fertility decisions. The men in the older generations chose to limit their own fertility by getting vasectomies, usually without telling their wives. The men said that economic pressures were their main motivation to limit the number of children. A survey of all five generations in this family revealed that more than half of the men thought the decision-making was mutual, but only 38% of their wives saw it that way (129).

Men's control over reproductive decision-making may be weakening, particularly among younger generations and in certain cultures. In many societies, as social, economic, and educational opportunities for women increase, traditional gender roles are starting to change. As a result, power is being redistributed between men and women. Evidence from several countries demonstrates that, increasingly, reproductive decisions are being made jointly by couples, not by men alone (96, 180, 200).

In Peru, Argentina, and Brazil, for example, research by Gary Barker has identified a group of young men who, contrary to the widespread machisto image, negotiate sexual and reproductive decisions with their partners and are willing to initiate contraceptive use (23). In Sri Lanka, where women's levels of education and literacy are high, a study among couples currently using contraception reported that more than half of the wives and about two-thirds of the husbands said that decisions about family planning were made jointly (65). Also, Japan's patriarchal culture has been changing away from decision-making primarily by husbands and parents toward decisions made jointly by couples (180).