Contraception Across Cultures: Technologies, Choices, Constraints 9781474214674

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Acknowledgements

The majority of chapters in this volume have been developed from papers originally presented at a two-day international conference 'Changing Contraceptives: Technologies, Choices and Constraints' held at University College Stockton (since renamed 'University of Durham, Stockton Campus') from 12-14 September 1996. Our thanks are due to the Mellon Foundation in New York, and the Overseas Development Administration (now the Department for International Development) and the Simon Population Trust in London, for their generous financial support for the conference, participants at the conference for their camaraderie and insightful comments, and to the staff at University College Stockton for their hospitality. We are particularly grateful to Shirley Ardener, founder and previous director of the Centre for CrossCultural Research on Women at Queen Elizabeth House, Oxford, and editor of the series of which this book is a part, for her enthusiasm and support both for the conference and this book. As reviewer for the series, Anne Coles gave very helpful comments on individual chapters, and contributors worked with diligence and commitment to complete their work within a tight timeframe. We would also like to express our thanks to Kathryn Earle and the staff at Berg Publishers for their advice and alacrity, and to members of the Centre for the Study of Contraceptive Issues and the Department of Anthropology at the University of Durham whose intellectual interest in this project has helped keep it on track. A number of employers are represented amongst the contributors to this book. However, the views expressed within it are those of the individuals concerned and do not necessarily reflect the opinions of their employers. Royalties from the sale of this book will be shared between the Centre for Cross-Cultural Research on Women and the Centre for the Study of Contraceptive Issues. Andrew Russell Elisa 1. Sobo Mary S. Thompson

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List of Figures and Tables

Figures

1.1 Countries represented in Contraception across Cultures 4 3.1 Diagrammatic representation of modernity 54 3.2 For sustainable development to be a reality, the diagram must present a notion of holism, where all the dimensions inter-link and interact 55 Tables

3.1 Contrasts between verbal and visual modes 3.2 Table of exercises and applications 6.1 Number of women who participated in semi-structured interviews, by age and immigration cohort 6.2 Number of women who participated in semi-structured interviews, by residence and marital status 6.3 Percentages of current contraceptive users, by method type (n=33) 6.4 Results ofa multiple regression analysis of the factors that affect the interbirth interval in Ethiopia (n=275 births) 6.5 Results of a multiple regression analysis of the factors that affect the interbirth interval in Israel (n=111 births) 6.6 Number of responses to the question 'Do you want any more children?' by number oflive births (n=72) 6.7 Number of responses to the question 'Do you want any more children?' by ever-use of contraception 6.8 Number of responses to the question, 'Do you want any more children?' by current use of contraception 8.1 Reported side-effects of contraceptive methods (n=50) 8.2 Individuals consulted for contraceptive side-effects (n=47) 8.3 Treatment for contraceptive side-effects (n=48) 8.4 Further treatment for contraceptive side-effects (n=9) 8.5 How husband learned of contraceptive use (n=70)

60 69 137 137 139 141 143 146 147 147 187 188 189 189 191 ix

Notes on Contributors

Jennifer Phillips Davids has a Ph.D. in anthropology and an MPH in international health from Emory University. Since 1993, she has conducted research among the Ethiopian immigrant community in Israel on reproductive decisions, fertility transition, and life course change. In addition, she has conducted research on teen pregnancy and perinatal outcome among African Americans in Atlanta, piloted methods for the field determination of reproductive status (among the Hadza in Tanzania), and examined the social context of interpersonal relationships among patients with Alzheimer's disease. She is currently a visiting lecturer at Hebrew University, Jerusalem. Katarina Greifeld has a Ph.D. in social anthropology (1984) and is an international health consultant and a medical social anthropologist. She works for different cooperation agencies all over the world, mainly in relation to target group issues in health and environment. She lectures at the University of Heidelberg and was recently assigned by the European Commission to expert panels in health, ethics and environment.

Amy Kaler has a Ph.D. in sociology and a minor in Feminist Studies from the University of Minnesota, awarded in 1998. She is presently a postdoctoral fellow at the Population Studies Center at the University of Pennsylvania, where she is working on several research projects concerning culture, gender and reproductive technologies in southern and eastern Africa. Rhoda Kanaaneh received her Ph.D. in anthropology from Columbia University in 1998. She is Assistant Prof. of Women's Studies at New York University. Her forthcoming book on nationalism, globalization, medicalization, gender and reproduction among Palestinians is entitled The Reproductive Measure: Negotiating Babies and Boundaries in the Galilee. to be published by University of California Press.

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1 Introduction: Contraception Across Cultures Andrew Russell and Mary S. Thompson

Conceptions and Contraceptions The development of new contraceptive technologies over the last fifty years has profound implications for social relationships between men and women. Conversely, gender and other power relationships at local and global levels have implications for the way the new contraceptive technologies are developed, disseminated and used. The aim of this volume is to investigate the impact of contraception on society, and of society on contraception, from a cross-cultural, anthropological perspective using case studies and overviews from around the world (see Figure 1.1). Compared to recent interest in the new reproductive technologies within anthropology (e.g. Strathern 1992; Edwards et al. 1993), attention paid to contraception has been relatively scant. I While no-one can deny the awesome social and cultural implications of many of the reproductive technologies that anthropologists have addressed, such as in vitro fertilization, the fact remains that few people worldwide are ever likely to have the chance to use these innovations. Contraception, on the other hand, impinges on the lives of the majority of heterosexual couples in their childbearing years, irrespective of income or social status. In light of this, Andrew Russell and Elisa Sobo convened an international conference, 'Changing Contraceptives: Choices, Technologies and Constraints', in September 1996. 2 The conference examined contraception cross-culturally, and the methodological approaches anthropologists and others use to shed light on contraception-related patterns of thought and action. The majority of chapters in this volume were first presented as papers at the conference. This chapter outlines the themes and theories that underlie the study of contraception across cultures, drawing together the work of the other

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2 Psychosocial Data and Cross-Cultural Analyses: Challenges to Anthropology and Contraceptive Research Mary S. Willis and Marion Pratt

Introduction Developing effective, safe and practical contraceptive methods requires an understanding of subjective feelings and sexual behaviours amongst different cultural or ethnic groups around the world. Such information is derived from psychosocial research findings, i.e. information gathered on the ways in which an individual's thoughts, feelings, and behaviours compare to and affect others (Brehm et al. 1999). Although a minimal method mix is now available in most developing countries (e.g. oral contraceptives, condoms, intrauterine devices, injectables, sub-dermal applications or foaming tablets), there are risks associated with each method. Certain methods can compromise the health and wellbeing of the individual and/or incur significant financial or personal costs to the user or the user's family. Thus, improvements in contraceptive technology are still needed. Moreover, the HIV/AIDS epidemic has created a need for the development of new contraceptive methods that provide an effective barrier to the contraction of sexually transmitted diseases (STDs). In order to improve currently available contraceptive options or to design new multipurpose barrier methods, an in-depth understanding of people's past history and current sexual practices is critical. Such information can provide invaluable insights, enabling researchers and users to address mUltiple concerns. Identifying the influence of a particular contraceptive method on the frequencies and types of sexual behaviours practised enables researchers to make changes in the overall

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3 Responding to Reality: The Efficacy of Anthropological and Participatory Methods for the Implementation of Sustainable Contraceptive Programmes Joshua

Levene

Reality and Contraceptive Acceptability Dramatic population increase could be one of the greatest problems currently faced by the human race. Population growth, which is concentrated in, but not limited to, the southern hemisphere (Harrison 1993) has provoked richer nations to intervene on a global scale to introduce effective contraceptive programmes. However, population increase in many developing countries still continues at what many consider to be an unsustainable rate. Many attempts to introduce contraceptives have been largely ineffective in curbing population increase. This is perhaps because population increase stems largely from another of the developing world's ills: poverty. The persistent lack of an assured provision of adequate social security for many of its inhabitants has been linked with high fertility (Seabrook 1995). Unless people in the developing countries believe that they will be socially and financially secure throughout their lives, without the need for large numbers of children to provide for them, population increase is likely to persist. However, even if people do have access to secure social welfare throughout their lives, as do many people living in industrialized countries today, they will still require acceptable forms of contraception. In addition to poverty, then, one of the most salient reasons for some contraception programmes' ineffectiveness, is the discrepancy between planners' perceptions of the acceptability of their contraception programmes and the perceptions of programmes and planners by the 51

4 Fertility Running Wild: Elite Perceptions of the Need for Birth Control in White-Ruled Rhodesia 1 Amy Kaler

Introduction In this chapter, I question some assumptions about women, men, race, families and human nature which bolster theory building in relation to family planning. My subject is discourse about black fertility and overpopulation in Rhodesia, now Zimbabwe, in the 1960s and 1970s, a setting where a small wealthy white electorate coexisted uneasily with an impoverished, disenfranchized and increasingly restive black majority, whom they had ruled and attempted to manage since the advent of white colonists in the 1890s. By the 1970s, the contradictions and tensions inherent in this political and economic structure had produced a plethora of laws and socioeconomic conditions defining the second-class citizenship of black Africans under the government of the Rhodesian Front. 2 Within this context, concern about African reproductive behaviour was part of the intellectual apparatus of colonialism, whether framed as concerns about the labour-supply implications of a too-low birth rate (Vaughan 1989), or as concerns about the political instability of a growing African population in the century's later years. By the 1960s and 1970s, as political tensions climbed, stemming African fertility became a national white obsession because of the threat it was thought to pose to white political security and the challenge it posed to the benevolent white stewardship of a 'backward' African population. By examining the way whites talked about African fertility, I show how the creation of knowledge about population in Rhodesia was conditioned by a specific set of political concerns. Since 1957, the promotion of family planning to Africans had been 81

5 A Clinic in Conflict: A Political Economy Case Study of Family Planning in Haiti M.

Catherine Maternowska

Perhaps the most critical transaction of all in family planning programs is that between the program and the client, for all others ultimately revolve around that nexus. If this transaction fails, the program will fail with it. Warwick (1982: 183)

There had been no electricity in Haiti for month-long stretches during the embargo of 1994; 30 March was no exception. I am visiting clients and staff at a family planning centre built for the residents of Cite Solei!, a desperate slum community in this, the poorest country in the western hemisphere. Inside the clinic it is a typical afternoon: hot, sticky and very still. The staff sit on their metal folding chairs, staring blankly, waiting for the doctors to arrive. The nurse, preparing cotton balls and alcohol, exclaims that it's too hot to move. Nine women from the community, referred to by the staff as kliyan (clients), sit on hard wooden benches in the waiting room. Some are dressed in clothes reserved for Sunday mass and doctor's visits. Others are too poor and they wear rags. All have come to the clinic for more pills, another DepoProvera shot, or relief from irregular bleeding or itching and burning' down there'. Each hopes that the doctor will allay her discomfort. Upstairs is where the doctors see clients. The two Haitian doctors are tall and heavy by national standards. They always look neat and cool when they arrive in their crisp clothing and inevitably they too comment on how hot the clinic is. They speak impeccable French. Their Creole, unlike that of the poor women who attend the clinic, is studded with French phrases, confirming that they are both urban-born and educated. One of the doctors marks his clients' charts with a fancy gold pen. The two examining rooms are small and sparse. The rooms are filled with the din from Route Nationale 1, Haiti's major thoroughfare. 103

6 IWeak Blood and ICrowded Bellies Cultural Influences on Contraceptive Use Among Ethiopian Jewish Immigrants in Israel1 l

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Jennifer Phillips Davids

Introduction In this chapter I examine the ways that culturally informed notions about the body, sexuality, and health influence contraceptive practice. The analysis presented here challenges certain assumptions underlying much international family planning research: 1. that the main barrier to successful fertility control in many traditionally high fertility populations is access to contraception. 2. that the main priority of people adopting family planning methods in these populations is to limit their total fertility rather than space their children. Using data collected from three years of anthropological research among Ethiopian Jewish immigrants in Israel I show that, despite a stated desire to have fewer children and virtually free access to Western contraceptives, the majority of Ethiopian Jewish immigrants do not use family planning methods regularly or consistently. Concerns about the longterm fertility-depressing effects of contraceptives and the cultural preoccupation with proper blood flow during menstruation (believed to be disrupted by the birth control pill, in particular) lead women to reject long-term use of such products. Most women who use birth control, do so without the desire to limit total fertility; instead, contraceptives are used primarily to control the timing of their pregnancies and to mimic the normal and culturally acceptable birth spacing found

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7 New Reproductive Rights and Wrongs in the Galilee' Rhoda Kanaaneh

Introduction When I asked myoId friend and classmate Fadia how some of the girls we had gone to school with were doing, she told me that many of them had married upon graduation and had several children. She called them primiteevim (a Hebrew word derived from the English word primitive). My elderly aunt who had nine children herself said that people today no longer have large families because life has 'advanced': 'Before we didn't know anything. But now only those who are wild (mitwa 'hsheen) keep on having a lot of children, living by their instincts.' Another high-school acquaintance told me about her neighbours: 'They never plan anything. They're like goats, like Barbarians, living by their instincts. They just give birth and throw the children out on the streets without thinking of how they are going to provide for them.' 'Primitive; barbarian; irrational; we must advance': these words have entered the vocabulary of Palestinians in the Galilee in profound ways. The modernisation/development discourse that constructs the 'Third World' as uncontrollably and irrationally over-reproductive and thus poor (Greenhalgh 1996), has been taken up by some people within that socalled Third World. It has infiltrated Palestinian day-to-day constructions of self and other. I argue that a new lens or social standard has emergedthat of reproduction - for assigning social value, negotiating relationships and envisioning progress. Using this measure, many Palestinians today describe other Palestinians of being just like the Third World - wild, animalistic, herd-like, driven by their reproductive instincts, unable to control their reproduction, as opposed to themselves who are rational, cultured, civilized, who carefully plan their sex and reproduction and are advancing in the footsteps of the First World. Palestinians increasingly

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8 My Body, My Problem': Contraceptive Decision-Making among Rural Bangladeshi Women Nancy Stark

Introduction Reproductive anthropology has highlighted the need to recognize the restrictive influence of society and culture on women's ability to independently control their fertility (Lock and Kaufert 1998; Harcourt 1997; Newman 1995; Sen, Germain and Chen 1994; Browner 1986; Sargent 1982). Sargent (1989) cited the interaction of both extrinsic and intrinsic factors that shape reproductive decisions and result in 'juggling' multiple agendas based on both ideological and material considerations. Ideological and cultural concerns that make up fertility decisions are entwined within the family. As Newman (1995: 16) observes 'contraceptive decisionmaking is a product of multiple and continuing negotiations in the family arena ... a concern not only of the couple, but of the extended family' (see also Mumtaz and Rauf 1997). Further, pressures from extended family toward certain reproductive goals often stand in contrast to the goals of international family planning programmes targeting young married women of childbearing age with strong messages promoting contraceptive use (Sen et al. 1994). This is especially relevant to family planning efforts in Bangladesh, a poor, oveFpopulated country (Hartmann and Boyce 1989, Maloney 1986). Family planning efforts have been a successful cornerstone of a broader development strategy intended to alleviate poverty (see Cleland et al.1994). While early family planning research in Bangladesh focused on appropriate population control policy (Paul 1986), programming (Bhatia 1980), cost effectiveness (Caldwell and Caldwell 1992; Simmons et al. 1991) and factors affecting fertility, more recently attention has turned to cultural factors - specifically considerations of gender (Aziz 179

9 Uzbekistan in Transition - Changing Concepts in Family Planning and Reproductive Health Monika Krengel and Katarina Greifeld

Introduction Uzbekistan became an independent Republic of the Soviet Union in 1991. It is a society in transition, where old and new values, communist and Islamic traditions, and Western influences overlap. This chapter examines the present government policy and the related position of reproductive health. We discuss continuities and discontinuities in the institutional setting, and attitudes to contraceptives and reproduction among clients and health professionals. We will show how reproductive health is conceptualized in Uzbekistan and how changes in theories regarding contraceptive choice and practice are introduced into the lives of Uzbek women. Conflicting notions regarding tradition and change, practice and policies are a central concern of this chapter. Setting and Methods The material presented was collected within the framework of a bilateral Uzbek-German health project, 'Promotion of Reproductive Health in Uzbekistan'. 1 K. Greifeld was a project co-ordinator in Uzbekistan between 1995 and 1997 and M. Krengel worked as intermittent coordinator and carried out two studies in 1996 and 1997 (of four and three weeks respectively) as part of the project. The results of these studies are previously unpublished. The first study focussed on 'Conceptions of Reproductive Health at the Village Health Centres and Midwife Level'. It was primarily based on Focus Group Interviews (FGls) with ninetysix midwives in fifteen focus groups. The second study was concerned with 'Life Plans of Young People, their Knowledge and Conception of 199

10 Family Planning or Reproductive Health? Interpreting Policy and Providing Family Planning Services in Highland Chiapas, Mexico 1 Mary

s. Thompson

Introduction Since giving up its long-standing pronatalist stance on the family in the 1970s, the Mexican government has increasingly viewed population control as a facet of the economic and social development of the country (Singh 1994: 217-8; Merrick 1985: 1-3). The introduction of family planning services was intended to bring about large decreases in the national fertility rate which came to be seen as an impediment to the modernization of the country. Since the widespread introduction offamily planning services a major disparity has developed in the uptake of these services between urban areas, where contraceptive prevalence rates are high, and rural, and particularly indigenous areas, where the uptake of services remains very low. After the development of an international consensus on reproductive health at the International Conference on Population and Development in Cairo in 1994, which brokered a truce between reproductive health advocates and defenders of population control under the umbrella of sustainable development (cf. Hartmann 1995: 131), Mexico introduced a new programme of reproductive health in which it legitimized both concerns (Poder Ejecutivo Federal 1996: iii). In this way, population control is retained as a legitimate policy goal with respect to the modernization of the country (cf. Direcci6n General de Planificaci6n Familiar 1995: 7), whilst at the same time the concerns of reproductive health advocates are also addressed through the adoption of an informed choice agenda. 2 This agenda, based upon respect for individual and cultural beliefs for the improvement of health and social

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