Researchers conducted four focus group discussions and in-depth interviews with 31 men and 101 women of rural origin now living in El Alto, in order to understand how their quality of life is affected when contraceptive methods are used, as well as the effects of discontinuation or nonuse of contraceptive methods.

Bolivia

In El Alto, one of Bolivia's poorest cities and the destination for many rural immigrants, the annual population growth rate exceeds 9 percent. El Alto's immigrants hold strong social and cultural links to their rural origins. Understanding how their quality of life is affected when contraceptive methods are used, as well as the effects of discontinuation or nonuse of contraceptive methods, may provide the groundwork for improving service delivery programs for Bolivia's expanding urban populations.

Research Findings

Researchers conducted four focus group discussions and in-depth interviews with 31 men and 101 women. Three groups of women were interviewed: those who used the intrauterine device (IUD) or condom; those who discontinued modern contraceptive methods for reasons other than wanting to become pregnant; and those who knew about modern methods but never used them.

• Many women said they had been physically or verbally abused by their partner. Refusal or reluctance to have sex were sometimes catalysts for violence. One woman said, "I tell him I like it during sex so he won't hit me." Another said, "He told me we were going to make love, and I didn't want to. He kept hitting me." In spite of the prevalence of domestic violence, the majority of women and men said their partners respected and trusted them.

• Approximately one-third of the women surveyed had been forced by their partner to have intercourse, usually after men had been drinking. Women claimed that one of the biggest problems at home is that men drink too much.

• Results from the in-depth interviews indicated there were no marked differences between contraceptive users and nonusers regarding the stability of the couple, self-esteem and decision-making, and the overall quality of life. However, users and nonusers had different perspectives on sexuality: Some condom and IUD users felt their sexual life had improved since they no longer feared an unplanned pregnancy.

• Women did not place much importance on how they looked; however, they did place great importance on how they felt (healthy or not) and on whether their bodies served them well for all of their daily household tasks. The majority of respondents reported feeling satisfied with their bodies, and the parts of the body that they liked the most were those that they used to accomplish their tasks. One woman said her best physical feature was her hands "because they help me work." Appearance was among several items that were proxies for self-esteem.

• Men said they made the decisions at home because they were the heads of the household; however, half of the women interviewed said that men and women made household decisions jointly. Half of those interviewed responded that the decision to have another child was made jointly, even though they admitted that pregnancies are usually unplanned and not something that had been discussed. Users and nonusers did not vary on these issues.

• Regarding decisions about responsibilities for family planning, only half of the IUD users had talked with their partners before insertion. However, almost all of them had consulted with their partners before having the IUD removed. Even though couples talked about how many children they would like to have, they did not talk about how they could prevent unwanted pregnancies. "Children just appear, that's all," said one woman. "At times, I feel so sad. He too says 'What are we going to do? God must want us to have more babies.' " Half of the women interviewed said they could talk to their partners about what they did and did not like sexually. However, many women said this type of dialogue embarrassed them. "I'm a little shy with him. I express what I have to, but with fear, and it embarrasses me."

Recommendations

Domestic violence is a problem for many couples in El Alto. Although the causes are complex, health providers should be aware of how common violence is in the home and understand that for many women, contraceptive use occurs in this context. Providers can help women choose the most appropriate method for their situation. Providers also should consider linking with other nongovernmental organizations to develop referral systems for abused women seeking help. The use of alcohol is firmly rooted in many cultural traditions, especially in rural Bolivia. However, alcohol abuse was identified by women as a major problem at home, linked to domestic violence and coercive sex. Mass media campaigns that focus on the detrimental effects of drinking on the overall quality of life are a first step in raising the public's awareness of how widespread the problem is and its consequences. Furthermore, women may feel less isolated with their own situations and seek help.

Study Details

This study was conducted by the Proyecto Integral de Salud (PROISA). Dr. Amparo Camacho is PROISA's executive director and the study's principal investigator. Support came from the Women's Studies Project at Family Health International, through a cooperative agreement funded by the U.S. Agency for International Development and field support from the Mission in Bolivia. Dr. Patricia Bailey was the FHI staff person responsible for this project.