As with decision-making in general, women's inferior status and lack of power limit couple communication (66, 67, 71, 74, 88, 106, 164, 219, 292). For many women traditional female gender roles mean they have little say in sexual matters and lack the status to influence their partners' behavior ( 67, 85, 164, 248, 264, 292). Even when men and women discuss reproductive health issues, it is usually not on equal terms (64).

Traditional cultures often discourage married women from starting discussions about contraception. For their part, men may feel there is nothing to discuss or no need to take account of their wives' feelings and opinions. In countries such as India, Kenya, and Nigeria, traditional male dominance is a major obstacle to spousal communication about family planning ( 72, 119, 181). Also, a husband might consider his wife promiscuous or unfaithful if she tries to discuss contraception with him (85). In some cultures it is easier for unmarried women and prostitutes to negotiate sexual activity with men, including condom use, than for married women to do so with their husbands (248).

In focus groups Haitian women described a situation that many women face. They said they were afraid of contracting HIV from their husbands but found it hard to discuss the subject with them. Few women thought that their men were faithful, but most felt powerless to change their husbands' sexual behavior. They feared being beaten or raped if they raised the issue of contraception or resisted a husband's sexual advances. They also feared that, if they refused to have sex, their husbands would turn even more to prostitutes or other women (248).

Women's status and communication. As women's equality with men increases, so does their ability to communicate about reproductive matters and to participate in reproductive decisions (28, 164). When a woman shares decision-making power, she is better able to bring up and discuss family planning and sexual relations with her sex partner.

In particular, better-educated women can communicate more easily with their husbands (54, 89, 164, 200). More educated women are better informed, better able to gather information from newspapers and other media, and usually more articulate (203). Education may also increase a woman's earning capacity—and thus her leverage in household decision-making—and raise her self-esteem (164).

The closer a man and woman are in their levels of education, and the more education they have, the more likely they are to discuss and use family planning (54, 65, 164). A study of Nigerian couples found that, when both husband and wife have secondary or higher education, 61% of couples reported discussing family planning. When neither spouse was educated, only 15% reported discussion (164).

A woman who has some economic power also may be more likely to discuss family planning with her husband (89). In Togo women who worked for cash and invested some of it in credit or savings plans reported the highest levels of communication with their husbands about family planning. The level was substantially higher than among women who worked for cash but did not invest or who did not work for cash at all (89).

The type of marriage—whether free choice, arranged, or polygynous—also affects the relative power a woman has and thus the extent that the couple communicates (89, 138, 140, 164). In Togo, for example, women who chose their husbands without any family advice reported the highest levels of discussion with their husbands about family planning. Those in marriages arranged by their families reported the lowest levels of communication (89). Women in polygynous marriage often have low status and report little communication.

Also, the age of a woman at first marriage relates to her ability to communicate. The younger the woman, especially if she is much younger than her husband, the less communication there is about family planning (73, 89).