Social issues and acceptability

CICELY MARSTON: OK, so why is it important to look at social issues to deal with family planning? Well, first of all, family planning’s in society. And so provision of contraception and abortion is permeated by all the ideas in societies to do with gender, to do with family life, to do with sexuality. All of those kinds of things affect how services are provided and how they’re received in communities. So it’s really important to understand those aspects if you’re planning a family planning programme. And also to understand why women or men may or may not take up particular methods. So I’m going to give you three examples of the kinds of ways that social factors are important to illustrate that point.

Right, the first example is that, for instance, in some parts of some communities, fertility restriction is considered unacceptable or undesirable. So, for instance, in Ghana, we did some work where we spoke to women about their family planning practises. And they had quite low levels of fertility. And it seemed that they were not using modern methods of contraception from survey data. So we went and we asked them, well, how are you controlling your fertility? When we asked them, it turned out that, in a lot of cases, their husbands were against them using family planning methods. And so what they were doing was that they were using injectables.

And the reason that they were using injectables was because they could go to market, they could get an injection, they could leave their client cards with the providers, they could come home, and their husbands would be none the wiser. And so they also didn’t have to have pill packets lying around the house or any evidence that they were actually using a modern method of contraception. So, in that case, the secrecy or the ability to use the method secretly was an incredibly important part of their method choice. And if we hadn’t been looking at social factors, then we wouldn’t necessarily have realised that that was such an important aspect of the method.

So my second example is the way that side effects are dealt with by clients and by providers. So, for instance, a lot of, especially hormonal contraceptive methods, have major side effects. So there might, for instance, be disruptions in bleeding or there might be– women sometimes complain about weight gain and so on. Now often, providers don’t take those issues very seriously. So for instance, women who complain about weight gain are often seen as, or kind of treated as though they’re vain for being worried about something like that, rather than having it taken seriously as part of their experience of using the method that they find undesirable.

And similarly, bleeding, disruptions in bleeding is often taken– is often sort of assumed– seems to be assumed that women should just put up with it. And so if they have reduction in bleeding because they’re using a hormonal method or if the bleeding stops altogether, for some women, that’s completely unacceptable. But, quite often, that’s seen as a sort of making a fuss about nothing. Or, that maybe they should be glad that their bleeding is stopped because it’s inconvenient anyway. And their concerns are not always taken very seriously. So understanding why it is that providers don’t take women’s concerns seriously is really important in providing programmes.

So my final example links back to last week’s work on young people’s access to health services. And they have particular needs when it comes to sexual and reproductive health services, which is different from those of older adults. So, for instance, young people might feel that they can’t actually go to the services because if someone sees them, then they might know that being– that they’re sexually active. And they’ll get kind of told off or they’ll get castigated within their community. So that’s one aspect that’s different from the provision of services to older adults. They might also want different methods because, for instance, they wouldn’t want permanent methods probably because they’re likely to have– want to have– children in the future.

So the provision of methods will also– the method mix will also vary. One aspect of provision of services to young people is that it’s often assumed that young people are ignorant and that’s why they’re not using methods even if they don’t want to have a pregnancy. But in fact, that’s not necessarily the case. I mean, for instance, if methods are very stigmatising, say, girls carrying condoms, they might risk their reputation for carrying the condom. And so if their partner, when it comes to sex, doesn’t have a method, or doesn’t have a condom, for instance, they might end up not using them. Quite apart from the fact that they would know that there was a pregnancy risk.

They might then go ahead and have sex anyway. Older adults often just say, well, well that’s ridiculous. Young people should just not have sex and then they wouldn’t get pregnant and then all these issues wouldn’t be a problem. And that’s one way of dealing with it. But often those very same adults are the ones that are having or have had sex before marriage themselves or they might even be having extramarrital sex themselves. There’s quite a lot of hypocrisy when it comes to policing people’s sexual behaviour. And young people are often at the sort of sharp end of that because the services simply aren’t provide to them. Because people say, well, it’s just inappropriate.

It’ll encourage them to have sex, for instance. And there’s absolutely no evidence that that’s the case. The other thing about saying that young people should abstain is that that assumes that young people are always the sex they want to have, which unfortunately, is not always the case. So all the examples I’ve given explain why it’s really important to take social factors into account when planning family planning programmes. So, for instance, the dynamics between the service providers and the clients might affect use of services. For instance, with young people who may feel judged by the service providers when they go in.

And so even if they ostensibly have access to use friendly services, if the providers themselves seem judgmental, young people may stay away. Similarly, services that don’t allow women to use the method secretly might not be acceptable in a context where women are not able to be open about their desire to limit their fertility. And so all of those kind of– and the side effects as well taken seriously or not taken seriously by providers may also put women off from using services. So all those examples together show how social factors are absolutely crucial in both planning and understanding why family planning programmes and interventions work or don’t work.