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Contraception Use and the Quality of Life in Bolivia -- July 1998

RESEARCH TRIANGLE PARK, NC, USA -- The use of contraception affects not just the number of children born to a couple. It may also affect the physical, social and psychological well-being of women and their families, including a woman's self-esteem, the quality of a couple's marital and sexual relationships, and a woman's ability to participate in the work force.

To learn more about women's views of family planning and its effects on their everyday lives, the Women's Studies Project (WSP) explored Bolivian women's use of contraception and their experiences with reproductive health services. Bolivia was one of 10 countries that participated in the WSP, which was supported by Family Health International (FHI) and funded by the U.S. Agency for International Development.

Four studies were conducted in Bolivia to examine the impact of family planning on women as individuals, women in their roles as wives and mothers, women's work both inside and outside the home, and women's participation in the larger community. These study topics were identified as high-priority topics by local researchers, women's advocates, and health policy-makers and providers working collaboratively.

Women and work. In La Paz and El Alto, two of the largest cities in the country, urban women -- many from poor households -- were interviewed in 1997 about their use of contraception and their economic activities. All of these women had participated in the Demographic and Health Survey (DHS) conducted in 1994 by the Bolivian National Institute for Statistics.

More than 800 women from the 1994 DHS were re-interviewed by the Women's Studies Project research team. Investigators found that nearly two-thirds of the sample (64 percent) were in the labor force, compared with 58 percent in 1994. Better-educated women and single women were least likely to be working, whereas separated and widowed women were most likely to work. As women age, and as their children get older, participation in the labor force increases. Family planning use did not change significantly in La Paz or El Alto during the study interval.

Researchers also learned that one-third of the women who were or had been in a relationship said they had been victims of domestic violence -- either physical or verbal abuse. Some 40 percent of the women reported chronic abuse. Domestic violence was identified by women's advocates and study participants as an important issue; therefore, researchers asked women and men about domestic violence in most of the Bolivian studies.

Family planning services. A study in El Alto examined access to reproductive health services and identified barriers that discouraged migrants from using services. The study found that health workers and clients had very different opinions about the quality and scope of reproductive health services. For instance, the majority of providers interviewed said they spent more than 10 minutes counseling clients. Yet, nearly half the clients said they spent 10 minutes or less talking with providers. Providers and clients also differed on clinic waiting times -- providers thought the times were shorter than did clients.

In interviews and focus group discussions, most contraceptive users said that client treatment was satisfactory, but some, especially those who wore traditional dress, said they had not been treated equally. More than half the clients who used public facilities rated the services as good or excellent, as did 75 percent of those who used private facilities. In contrast, 80 to 90 percent of providers rated their services as good or excellent. Many facilities had only a few family planning methods available, and some modern methods were not offered at all, especially at sites with religious affiliations. In 15 of the 36 institutions surveyed, no reversible contraceptives were available.

Women who were happy with family planning services were often willing to travel long distances and to pay for services if they felt they were receiving high quality care. One woman said, "I prefer to go there, even though it is far away because they treat me kindly. They talk to me, they explain things -- everything. And when I don't understand or don't know, he [the doctor] explains. Even though it is far, other people do not treat me the way he does. Even though I have to pay, that is okay."

Researchers recommend that clinics should provide a greater variety of methods and that providers receive additional training to improve their interactions with clients. Programas para la Mujer (PRO MUJER), a nongovernmental organization in La Paz, conducted the study. The United Nations Population Fund supported field work, and WSP offered technical assistance.

Men's attitudes. In the urban center of Cochabamba, 630 couples of reproductive age (ages 15 to 49) were interviewed to learn about contraceptive use, the attitudes of men toward family planning, and psychosocial aspects of women's lives, including self-esteem, relationship with partner, and self-determination. Interviews were conducted with couples from upper-, middle- and low-income homes. The study was conducted by Cooperazione Internationale, a nongovernmental organization.

Investigators found that couples did not always communicate about family size. Only half the men and women said they talked about the number of children they wanted.

To learn about women's psychological and social well-being, researchers asked women a series of questions designed to measure self-esteem and self-determination. To learn about self-esteem researchers asked about competence in family and work roles; whether women saw themselves as responsible and intelligent; and whether they were happy. Self-determination was measured by questions about managing personal and household money and making decisions about personal appearance. Questions about relationships with partners included inquiries about the trust and respect between partners and sexual satisfaction and communication. Results showed that contraceptive users had the highest scores for positive relationships with partners, but non-users scored higher than users on self-determination.

Researchers also asked couples about satisfaction with their sexual relationships. Women who were most satisfied were those who had used a modern contraceptive method in the past 30 days, who had some college education and who had been married less than five years. Researchers found that modern method use may minimize couples' fears about unplanned pregnancy, allowing them to engage in sexual relations with less worry.

Researchers also found that nearly all men and women knew about contraceptive methods and approved of them. More than 90 percent of study participants said they approved of family planning, their partner approved of family planning, that men should take increased responsibility for contraceptive use, and that men should support their partner's decision to use contraception. Ninety-nine percent of men and 93 percent of women knew of at least one modern contraceptive method. Two-thirds of those interviewed said they currently used a contraceptive method; 41 percent said they used a modern method, while 26 percent said they used a traditional method. However, even though traditional method use was popular, only 67 percent of women and 53 percent of men using these methods could identify the midpoint in a woman's menstrual cycle as the time she is most likely to become pregnant.

Migrant populations. Another project focused on the quality of life for couples in El Alto, a poor but rapidly growing city near La Paz that attracts migrants from rural areas. Research staff from Proyecto Integral de Salud (PROISA) conducted focus group discussions and in-depth interviews with approximately 100 women and 30 men.

There was little difference between contraceptive users and non-users with regard to stability of the couple, self-esteem, decision-making, and the overall quality of life. However, sexual relationships were better among contraceptive users, in part because they no longer needed to worry about unwanted pregnancy.

A disturbing finding was the extent of physical coercion among couples. More than half the women reported that they had been physically assaulted by their partner, and one-third said they had been forced to have intercourse. One woman said, "I tell him I like it during sex so he won't hit me." Another said, "Yes, many times earlier, I have been hit, and for that reason I have also had an abortion provided by him. Another pregnancy ended in birth a lot sooner than it was supposed to because he hit me." Women identified excessive drinking by men as the biggest problem in the home.

Couples often did not discuss the use of contraceptives or the decision to have another child. Only about half the women who used intrauterine devices (IUDs) told their partners before the IUD was inserted. Even when some couples talked about how many children they wanted, they did not discuss the prevention of unwanted pregnancies, and they conceded that most pregnancies happened "by chance." One woman said, "Our children just appear, that is all. At times, I feel so sad. He, too, says 'What are we going to do? God must want us to have more babies.' So this is how it is." Another woman said, "I am a little shy with him I express what I have to, but with fear, and it embarrasses me."

WSP researchers hope the information from these four studies will be used to improve reproductive health programs and services in Bolivia, to make them better match the needs of women and men. Among researchers recommendations were that couples be counseled about how to improve their communications skills on sexual issues; that men be educated about reproductive health, including contraceptive services available to them; that health providers be trained to identify victims of domestic violence and refer women who want help to appropriate social service organizations; and that couples be educated about the many benefits of family planning, including its effects on marital relationships.

FHI is a US-based, not-for-profit organization that provides the highest quality research, education and services in family planning, STDs/HIV and family health to improve the health and well-being of populations worldwide.

For more information about these studies, contact Barbara Barnett, Senior Science Writer/Editor, Family Health International, at 1-919-544-7040, Ext. 482. Or fax 1-919-544-7261 or e-mail: bbarnett@fhi.org.