What exactly is "family planning"? In the minds of many, says cross-cultural midwife Susan Willson, it is too often equated simply with birth control. Willson, a certified nurse-midwife, has worked in family planning and childbirth in both Swaziland and among the Navajo (see her article "Working with the Dineh" in IC #17), and offers these reflections from her experience on what makes a successful, comprehensive family planning program.
It has never been more critical to ensure that the children brought into this world be wanted children – children provided with sufficient food, shelter, education and emotional sustenance. Yet we are daily presented with evidence that far too many of the world’s children are lacking even these basic resources.
As we become more of a "global family," it is imperative that we look at global family planning needs much as we would those of a nuclear family. Such needs differ from country to country, just as they differ for individual families depending on religious beliefs, resources, and personal preferences.
The issues surrounding family planning are extremely complex. They are deeply rooted in culture, sexuality, and the most intimate family matters. In short, it is simply not possible to separate "family planning" from "family" – and yet, in many instances, this is exactly what we do. The term "family planning" has become virtually synonymous in our culture with modern methods of birth control, but prevention of birth is only one small part of the matter. In thinking about global population issues, we often carry this perspective with us, making lower birth rate and increased contraceptive use our primary goals – reflecting a limited understanding both of what is involved, and what is needed.
Family planning – including the related idea of child spacing – affects every aspect of family life, including maternal health, child health, and the amount and distribution of resources available to a family. In most cultures in our world, family health is in fact dependent on maternal health: the mother has primary responsibility for the bearing and raising of children, the care and maintenance of the homestead and family, and in many cases for income production as well. If the mother is sick or weak from the overbearing and nursing of children not adequately spaced, then not only is she unable to carry out her responsibilities – she is also more likely to bear premature or growth-retarded infants. Moreover, in cultures where the status of women is lower than that of men, it is not uncommon for the mother not to eat until everyone else is fed: the choice food goes first to the father and next to the male children, so she may receive fewer of the family’s resources as well as bearing the greater biological burden.
It is also impossible to separate family planning matters, per se, from the problems of sexually transmitted diseases (STDs) and the spread of HIV, as these affect both men and women, and ultimately children and the larger culture as well. In the coming decade, the effects of AIDS in Africa will probably be devastating in terms of the numbers of children orphaned by the disease, as well as the strain on already limited health care resources. Many methods of family planning, both traditional and modern, directly impact the transmission of STDs and HIV.
Family planning and STD prevention hold several things in common: they affect a common high-risk group; they both impact child survival; each needs to address sexual behavior; and both discriminate biologically against women. To be successful, programs in both areas must address the need for a balance of power between men and women in making family planning choices. This is tricky business, however, in cultures where the status of women is that of property. It is difficult to remain true to a culture’s traditions and still help women to reach their own goals for family planning, but it is possible – one can be culturally sensitive while trying to sensitize such cultures to the importance of child spacing. Still, it is a very slow process, as one has to work within the existing power structure – and shed one’s cultural biases about sexuality, birth practice, family size, and the status of women – if one wants to keep the trust of the people one is trying to assist.
THE NAVAJO AND THE SWAZI
Sexual and childbearing/child-spacing practices are very much determined by the mores, beliefs, and traditions of a community, as well as its economics and the status of its women. A key question, always, concerns who makes the decisions about how many children to have, and when to have them. For two cultures in which I have worked, the Navajo and the Swazi, this role traditionally lies with the man.
For the Navajo, inheritance is matrilineal, and the grandmother has a great deal of influence in the family. But the man is considered its head. If there is a difference of opinion about whether to have another child, he will usually prevail. Moreover, the traditional Navajo way does not condone modern methods of birth control.
In the Swazi culture, such decisions also traditionally lie with the man. To have a wife, a man must pay a bride price (called lobola) consisting of so many cattle. It then becomes the wife’s duty to produce many children for him, to repay this expense. She is seen as not dutiful and as bringing shame to her family if she is not fertile.
In both cultures, children are highly prized. They are equivalent to wealth, so large families are common. Not surprisingly, many of the women who do use contraceptives in these cultures do so surreptitiously – they choose such methods as intrauterine devices and injections, which are not likely to be discovered by their husbands or family. There is some danger in this, however, because of the cultural penalties that may result if they are seen to be infertile. By tradition they may be cast out or divorced by their husbands, or suffer other reprisals such as anger or abuse. Such cases pre-sent a real dilemma: Is it truly helpful to encourage these women to use modern contraception?
Family planning programs, as a consequence, are more likely to succeed if they look at how child spacing is traditionally carried out in a particular culture and do program planning and education around subjects that are more familiar and accepted. For instance, in the Navajo culture, a short period of sexual abstinence following childbirth is traditional (but it is also common and acceptable to have a child every year). In the Swazi culture, where men traditionally have many wives, a man will visit his other wives instead of the new mother, or have sexual relations with her which do not involve penetration, until the child is weaned (approximately two years). Obviously, approaches to promoting child spacing would be very different in these two cultures.
For both the Navajo and the Swazi, as in many cultures around the world, rapid change is creating a great deal of cultural confusion. The traditional ways are fast slipping away, but more "modern" ways have not yet been fully embraced. People rightfully fear losing their culture by embracing "modern" ways. They walk the edge between two ways of being and feel as if they belong in neither. We must remain very sensitive to this as we form our global family, and try to maintain diversity wherever possible while addressing the pressing issues which face us today. For in our diversity lies our richness.
SEX, AIDS, AND SYSTEMS OF BELIEF
What people believe to be true about their health – regardless of whether modern medicine agrees with them – has a large impact on their behavior. For instance, if a culture believes that what we call AIDS is a disease of "wasting flesh" (and watching someone die of AIDS would make this a natural assumption), then they will tend not to believe that condoms – which prevent the transmission of fluid containing the virus – are of any use against the spread of the disease.
Our own North American culture is just as prone to erroneous belief. It is still prominently held in our cultural consciousness that AIDS is a "gay" disease, or one affecting drug addicts, so most people feel it "won’t happen to them." This widespread denial has set us back years in generating solid support toward the effort to prevent and contain the spread of HIV.
In some cultures, the most fundamental question might be: "Do the people believe in AIDS at all?" While in Swaziland I was told by a well-educated man (a teacher at a technical college) that he did not believe in AIDS. He felt it was another creation of the white man, as had been tuberculosis, leukemia, and smallpox before. We had named it as a danger, and we were now going to come over and save them from it. He said "I will go when God takes me. It could be tomorrow from crossing the street; it could be from a disease later on. I don’t worry about it. I will just enjoy life while I am alive." This attitude interested me so much that I posed the same question to several nurses at the field clinics I visited. For the most part, they reported that people do not believe in AIDS, but that those who had watched friends die from it were more apt to believe.
We must remember that in countries where the death rate for many diseases is so high, AIDS is just one more danger in an already tentative life. Death from disease is not the stranger in many third world countries that it is here, so this lack of relative concern about AIDS is understandable. For example, it makes little sense to an HIV-positive African mother that she should not bear more children because of the 33% chance that she might transmit the virus to her child. There is at least a 33% chance that her child will die of something else in its first few years of life anyway, and children are prized, so where’s the gain for her in not bearing a child that might, in fact, survive?
Misconceptions about modern methods of contraception are also fairly widespread. For instance, there is a strong belief among Swazi men who do not use modern contraception that when a condom bursts inside a woman, it is life-threatening to her (a belief so widespread that it made me wonder about the quality of condoms distributed there). Many of these men also believe that condoms cause impotence, or even cause STDs (rather than prevent them). Furthermore, in many African cultures, condoms are associated with prostitutes – it would be an insult to one’s wife to use one with her, because it would mean that you did not trust her. Men in these cultures would be understandably less likely to use condoms, and therefore education would need to take priority over distribution in order to increase condom use.
To cite other examples, some Swazi women who do not use modern contraception believe that birth control pills go up into your fallopian tubes, eat your eggs, and make you sterile, or cause sterility in other ways. In a culture where a woman’s value is based on her fertility, it would be very important in any family planning program to emphasize the temporary effect of pills, as well as the fact that child spacing offers a greater chance of survival for the children who are born.
The cultural beliefs and taboos surrounding childbirth and contraception worldwide could fill volumes. However, it is not only among "foreign" or "exotic" cultures that these misconceptions exist. The misconceptions surrounding birth control pills in the United States are legion, as any family planning practitioner can tell you.
Finally, there is the widespread cultural and religious concern among many native Africans that using contraceptives is equivalent to killing their children and their culture. Across Africa, the distrust of the white man, and the belief that he is trying to kill their culture and make Africans a weak people, is strong – and based on our history, as well as some of our current approaches to foreign aid. We must be meticulous in our research and understanding of the people we purport to be serving, and sensitive to their desires and priorities, before we begin planning to "help" them.
THE LIVES OF WOMEN
When visioning family planning services, it is important to know as much as possible about the everyday lives of the people to be served – particularly the women, as they do the majority of the contracepting and all of the childbearing. One must find answers to many questions: Who holds power in their world? What brings them pleasure? Status? What does the use of family planning mean in their community? Is the clinic a pleasant place to visit? What is traditionally done to space children? What are their sources of information – or misinformation? Whom do they trust?
Also, do they have privacy within which to practice certain birth control methods, or must they be surreptitious contraceptors, thereby limiting the choices available to them? For example, in both Navajo and Swazi culture, people traditionally live without electricity, running water, or bathroom facilities, and live many people to a dwelling. There is no privacy to use diaphragms and care for them properly, or even to have pills or condoms around, and being discovered as a contraceptor can have serious social repercussions.
It is also important to know what physical and financial resources are available to the people to be served. Are there clinics, health care providers, transportation, supplies, or money to buy them? With limited resources, where does a family place its priorities?
GUIDELINES FOR SUCCESS
Given all these issues, how can we design – or evaluate – good family planning programs, whether in the US (with our diverse cultures) or overseas? Here are a few suggested guidelines:
Keep it simple * When planning programs, introduce as little change as possible from the current state of affairs. Introducing fewer new ideas will increase the possibility for success. For example, child spacing is a strongly held traditional value in Swaziland, so placing the emphasis on child spacing – with traditional or modern methods – and the promotion of breastfeeding (which naturally allays conception) will be more likely to be accepted by these families than will discussing a limit to family size or modern contraception only.
Delay the first pregnancy * Teenage pregnancy is a growing worldwide problem. Some of the reasons teenagers become pregnant are shared across cultures: a need to feel loved and accepted; peer pressure; or the expectation of support (from the father of the baby in some cultures, and/or welfare in others). For some young women, getting pregnant is the only thing they feel they are good at.
Other reasons are more culturally determined. For instance, in the Swazi culture it is felt that a woman should prove her fertility before beginning to contracept (if she does at all). She is more prized as a wife if she has already borne a child. And while sexual activity among teenagers is not traditionally sanctioned, it is increasing there as elsewhere.
There has been some success, both in the US and elsewhere, in preventing teen pregnancy by means of family-life education courses in schools, as well as values clarification exercises and role-playing opportunities. Such things are not usually considered "family planning" – but perhaps we need to stretch the definition and divert some family planning resources toward such programs.
Fill the existing need and demand for family planning services * This is critical for preventing unplanned or unwanted pregnancies. Making sure those who already want services get them, rather than putting the strongest focus on attracting more people into the system, will increase the contraceptive rate – and it is the best form of publicity. If people see other families spacing their children, having healthier children, enjoying more resources and a better life, they are more likely to think about trying it, and the cultural norm will slowly shift.
Educate to increase contraceptive use in a culturally appropriate manner * "Culturally appropriate" means several things. Go through appropriate (and effective) cultural channels. Find out what happens at the family and village level. Form relationships with traditional healers and other trusted health providers. And let go of the marketing mentality, which is so prevalent in American culture. Blanketing the media with messages may not work if the real communication happens elsewhere. For example, if you are working within a storytelling society, you might have better results using stories and dramatizations to relay your information at the village level.
Don’t forget the men * It is also important to meet men’s needs in family planning. Most men are not comfortable asking questions of a gynecologist, and most family planning programs are aimed at women, since that is where the reproductive burden lies. Groups for men to voice their concerns, ask their questions, and discuss issues of changing culture have received good attendance where tried. Men are highly motivated with respect to satisfying sexual function and treatment of STDs, but it amazes me that we are coming to the end of the twentieth century with so little available in the form of male contraceptives.
All these concerns are talked about quite often among professional program planners. However, program priorities are often set by donor agencies (both private and government) based on their specific agendas, the amount of available funds, and what they want to see done with their money to get quick results in terms of numbers. Laying the groundwork for the more sensitive approach which instills a sense of ownership is often a much slower process, and program sponsors may need to be carefully educated to understand that the reward will be longer-lasting results.
We will be most likely to meet planetary population goals – and preserve precious cultural diversity – when we help people achieve their own stated goals around family planning. This means establishing a relationship of trust, insuring continuity of care, respecting individual wishes and concerns, offering a wide choice of options, ensuring privacy, and preserving dignity and respect. It is high time we made all our children – existing and future, in our own country and elsewhere – a real priority, so that they have the love, care, and life-options they deserve. We must do this, and do it now, if we are to have a positive future.
by Marcy Jackson
"Death With Dignity!" is increasingly the rallying cry for those who seek to bring death and dying out of hiding, away from extreme medical intervention designed to prolong life at any price, and back into the the natural continuum of living where it belongs. But what of those among us dying of AIDS? How can death with dignity be achieved when so much fear, controversy, stigma, misunderstanding and misinformation surround this raging epidemic?
For PWAs (People With AIDS) there are few alternatives to dying in the hospital, often alone, and at an exorbitant cost. Nursing homes are usually full, with waiting lists, and are sometimes not well-equipped to deal with the intensity of care required by AIDS patients. Frequently estranged from their family members, PWAs may have few people available who can provide the ongoing care that could allow them to remain at home. Many find themselves on the streets or in hostile living situations at a time when they most need consistent and compassionate care.
To address such problems and to meet the need for humane, cost-effective care, the community of Seattle decided to do something to respond to the realities of living and dying with AIDS. Over a three year period, an amazing array of individuals from nearly every segment of the community, both public and private, came together in a planning process to address the long-term care needs of PWAs. An organization, AIDS Housing of Washington, emerged from this process and began to focus its energies on the arduous task of creating community-based homelike residential housing, including long-term care services.
After garnering broad community support through its educational efforts, conducting a remarkable fund-raising campaign that yielded $6 million in corporate, governmental and individual donations, and confronting many setbacks and obstacles along the way (such as prejudice from nearby neighbors and businesses), their dream has been realized. Bailey-Boushay House has now been born.
Bailey-Boushay House is a caring, innovative, state-of-the-art residential care facility that has been designed for two basic programs – provision of 24-hour skilled nursing care for 35 residents, and a health-enhancing adult day program for up to 35 others who are living at home. It is the first project of its kind and size that has been built from the ground up, and that is specifically designed for people with AIDS. Concern for medical realities as well the use of art and architecture to create a healing environment have resulted in, according to Washington Governor Booth Gardner, "an atmosphere of beauty and compassion where healing can take place and suffering will be eased."
Bailey-Boushay House will open its doors this spring to fulfill its mission and vision. The commitment to treat residents "with dignity in their living as well as their dying" has been a central guiding principle for AIDS Housing of Washington, and has now become a reality. As Board Member Steve Silha states: "Bailey-Boushay House shines as a reminder that it is possible to overcome the odds, to pull a diverse community together, to tackle seemingly insurmountable problems. To create a community of caring."
Marcy Jackson is Context Institute’s volunteer coordinator. For information about Bailey-Boushay House, contact Christine Hurley at 206/322-5300.