FHI - Crosscutting Themes and Their Implications

The Women's Studies Project is like a mosaic: small, individual components comprise a larger whole, creating an unique image. Although the WSP subprojects varied in their scope of work and research goals, when viewed collectively, they create a new picture of women's perspectives. In spite of tremendous differences -- in ages, religious beliefs, economic and work status, wealth, educational backgrounds and family size -- study participants shared common experiences and perceptions.

The WSP experience indicates that women's view of family planning is panoramic. Women see contraceptive use as one of many elements of reproductive health, see reproductive health as one element of overall health, and see health as one element of quality of life. Women say health is linked to other aspects of their lives: to their families, their economic conditions, and their goals and values. Family planning's effects are multifaceted and multidimensional. Women may have long held this broad perspective; however, policy-makers and researchers have only recently begun to adopt similar views as they question women in-depth about their perceptions and experiences.

Qualitative and quantitative data from different countries in the WSP show that women generally believe family planning is beneficial. For example, in Zimbabwe, women and men said family planning was an important element of quality of life. In Indonesia, couples said family planning offered them a means to achieve financial stability and harmony within the home. However, for many women, contraceptive use carries a price: Side effects can limit women's physical activities, and the disapproval of family members may exact an emotional toll. Women who use family planning say it gives them freedom to pursue education and jobs, but this freedom exists within the context of gender norms, family dynamics and economic realities that limit women's opportunities.

Investigators found differences among and within countries participating in the WSP -- differences between users and non-users, men and women, providers and clients, rural and urban residents, socioeconomic classes, and women of different ages. What follows are the broader themes that emerged in the analysis of the multiple subprojects related to family planning and women's lives. In keeping with the Project's objective of using research to suggest changes in health policies and programs that reflect the needs and concerns voiced by women, implications and recommendations follow the discussion of each theme.

General Themes

Family planning affects numerous domains of women's lives, including domestic, economic and community spheres.

Family planning is often discussed in terms of its impact on women's physical health. However, WSP research indicates that women often view family planning in broader terms, as a long-term activity that affects the quality of their psychological health, their domestic lives, their ability to participate in the work force, and their ability to join in community activities.

For some women, family planning experiences increase their self-esteem and autonomy. A study in Cochabamba, Bolivia, found that modern contraceptive users had higher levels of self-determination than non-users and also were more satisfied with their sexual relationships.

Several WSP studies suggest that family planning use leads to improvements in couple relationships and stability at home. In Zimbabwe, a woman explained that "without family planning and the consequent child spacing and limitation, there is not quality of life. As a woman, you cannot get enough time to give love to your children and your husband if you have many children."5 In Mali, women said that with smaller families, they had more time to devote to their husbands and children. And in Indonesia, where the government family planning program has been in place for more than two decades, couples saw contraceptive use as a source of domestic tranquility. A woman from North Sumatra said, "Yes, people are happy with family planning. They see that their family is in harmony, their children are big enough to take care of themselves, while the mother can take care of herself."6

In the WSP, study participants said contraceptive use definitely affects their ability to work and go to school. In Brazil, adolescents who sought treatment for complications from induced abortions were nine times more likely to be in school than adolescents who carried their pregnancies to term. In Zimbabwe, female students were frequently asked to leave school if they became pregnant and often did not return after the birth of a child because they were no longer interested, had no time, or had no money.7 Mothers-in-law often volunteered to be caretakers for grandchildren if daughters-in-law returned to school; they saw younger women's loss of education as potential loss of income for the family. "Life is becoming tough," said one older woman. "It is different now from long ago when a working man would manage his family. In today's life, you need to help each other."8

Women had mixed views about whether family planning helped or hindered their participation in the work force. In Mali, women said family planning was a way to gain more time for work inside and outside the home. However, for women in Bangladesh who experienced side effects, contraceptive use was often seen as a barrier to work. One woman, who used oral contraceptives, said, "The man of the house never likes it if the woman can't work. He says, 'Did I marry you to keep you as a pet? I married you to work in my house! If you sit around, who will look after the children, and who will do all of the chores?' This is why I stopped taking the pills."9

"Without family planning and the consequent child spacing and limitation, there is not quality of life."

Zimbabwean woman

In some studies, such as those in China and Zimbabwe, women and men said that family planning enhanced their ability to earn income, and this was viewed as beneficial. In the Philippines, women said family planning allowed them to work outside the home. However, with little or no relief from domestic chores, women did not necessarily see this opportunity as positive. Women spent an average of 46 hours per week working outside the home -- yet they also spent an average of 23 hours doing housework.

In Egypt, where female family planning workers were interviewed, women were proud of their jobs. However, they said their work, coupled with their domestic responsibilities, created stress. They felt they did not have enough time to take care of their children and too little time to devote to their own needs. In Indonesia, women approved of family planning but were not enthusiastic about working outside the home, since they felt it would detract from their duties as mothers and wives.

The dual burden of domestic and work roles was evident in South Korea. Since the 1960s, when the government implemented a nationwide family planning program that encouraged couples to have only two children, the country's fertility rate has declined. The "fertility revolution" has given women additional opportunities in the work place, and men have become more involved in domestic chores. However, this change has sometimes led to family conflict and lower self-esteem for women. Many drop out of the work force around the time they marry or have their first child because their domestic and work responsibilities are too heavy. "I came out of the house at dawn, went to school and taught many students all day long," said one woman. "Teaching was a hard-working job. ...But even after I returned home, my labor did not finish because the housework, which is always a wife's job, was left undone. ...It was so hard, I couldn't help quitting the job."

Some women felt contraceptive use allowed them to participate in formal community activities, including political campaigns. However, many women, such as those in the Western Visayas in the Philippines, said their involvement was limited to certain types of activities, such as religious organizations. In South Korea, younger women also said they had little time or interest in political campaigns; however, these same women expressed heightened interest just a short time later due to the country's economic crisis. In Zimbabwe, formal community participation increased slightly with parity; 5 to 6 percent of women said they participated in community activities at the time they became sexually active, compared with 10 to 11 percent participation after the birth of the fourth child. It may be that as women's status increases with motherhood, it becomes more acceptable for women to play a role outside the domestic sphere. Nonetheless, women who participated in formal community activities early in life tended to continue community activities throughout their lives. Researchers found no link between contraceptive use and formal community participation between births.

"The man of the house never likes it if the woman can't work. He says, 'Did I marry you to keep you as a pet? I married you to work in my house! If you sit around, who will look after the children, and who will do all of the chores?' This is why I stopped taking the pills."

Woman in rural Bangladesh

Policy and Program Implications: While providers have traditionally stressed the health effects of contraception, they should also understand that women see contraceptive benefits more broadly. Providers should be aware that women see family planning as something that affects them psychologically -- by reducing their fear of pregnancy or by increasing their anxiety about side effects. In addition, women consider the effects of family planning on their domestic lives -- whether smaller families will enhance or diminish their happiness at home. Also, providers should understand that some women link family planning use with work. Some women see smaller family size and reduced childbearing and childrearing responsibilities as opportunities to pursue paid work in the informal and formal sectors. Their work may serve as a vehicle for personal fulfillment or as a source of conflict as women try to balance household responsibilities and employer demands. Other women worry that contraceptive side effects may limit their ability to work inside and outside the home and, therefore, are reluctant to initiate or continue contraceptive use.

Family planning policies and programs should expand information, education and communication efforts beyond messages about health. By offering clients a more comprehensive view of its effects on the multiple dimensions of their lives, family planning might become a more attractive option to some couples.

Gender norms strongly influence women's family planning experiences.

Unequivocally, across all WSP studies, women's experiences with family planning are strongly affected by societal constructs of femininity and masculinity. Gender norms and expectations influence every domain of women's lives -- personal, domestic, economic, and community -- and women and men play very different roles in each of these spheres. Gender shapes family planning experience by determining who has access to reproductive health information, who holds the power to negotiate contraceptive use or to withhold sex, who decides on family size, and who controls the economic resources to obtain health services.

Children learn the distinction between men and women's roles at an early age. In Jamaica, where adolescent pregnancy rates are among the highest in the Caribbean region, gender norms have created two distinct sets of reproductive attitudes and behaviors among young adolescents. Twelve-year-old boys viewed sex as pleasurable and fatherhood as a sign of maturity. "Them would big him up and say him a big man," said one boy when asked to describe the reaction of peers to the news a boy had fathered a child. Conversely, 12-year-old girls spoke of sexual activity and unplanned pregnancy as forbidden, shameful and disruptive. "Them would call her sketel [slut]," one girl said, commenting on how peers would react if they learned a young adolescent female was sexually active.

In each WSP country and across age spans, separate roles ascribed to women and men translate into different responsibilities for contraceptive decision-making. In a Zimbabwe study that examined social constructs of quality of life, some men were willing to give women the lead in decisions of family size, since "women are the pillars of the home" and the ones ultimately responsible for family welfare.10 Although most Zimbabwean men believed family planning should be a joint decision, others were not so willing to share their control. "The husband always has the final say," said one rural man. "What happens is that women are limited in their thinking, and if you do not show your dominance, you will have problems."11

In focus groups in China, on the other hand, men tended to grant women authority in family planning decisions by default, saying that such matters are beneath the dignity of men, who are occupied with more important matters.

Except for day-to-day household concerns, Indonesian women sought their husbands' opinions on most decisions, including household finances and contraception. Women in Indonesia told interviewers that they often felt caught between cultural expectations of wives' subordination to husbands and their need to work to support their family's economic needs. And in Mali, even husbands who supported family planning in principle emphasized that men are the primary decision-makers in the home.

When traditional gender roles are challenged, the consequences for women may be serious. In WSP studies in Bolivia and the Philippines, study participants raised the issue of violence and its effects on their lives. Data from these countries suggest that in cultures where men have ultimate authority, their perceived loss of control -- as exemplified by women's refusal of sex, for example -- may result in verbal and physical abuse of women. In in-depth interviews in El Alto, Bolivia, women explained the difficulties of refusing sex. As one woman put it, "I didn't want to have sex. Then he said I must want to be with another man." Moreover, all 31 male participants in the same study said they had either physically or verbally abused their partners, with half mentioning physical violence.

Similarly among women in the Philippines, 25 percent surveyed in Northern Mindanao said that husbands had physically abused them. Investigators found that husbands were more likely to be abusive if traditional gender roles had been altered; for example, if men were involved in child care or marketing for food, or if women were working for income. The same study showed that women's use of family planning -- possibly indicative of increased autonomy and men's loss of control -- was a factor in domestic violence against women, as was unwanted pregnancy.

Even where there is concordance on family planning decisions and women are encouraged to contribute economically to the household, they may have limited opportunities for rewarding, remunerative work outside the home. They may be poorly prepared for formal sector jobs (as was the case with adolescent mothers in Zimbabwe and Jamaica) or may be restricted to work in low-paying jobs (as in the Philippines). They may be prohibited from inheriting wealth or obtaining credit (as in many African countries). In WSP research, gender norms, internalized by men and women alike, almost always required women to bear primary, and often sole, responsibility for children and home.

Thus, family planning is one strategy that women have available to improve their lives, but gender norms play a major role in determining if, how, and to what extent women can take advantage of the opportunity it offers.

Policy and Program Implications: A woman's experience with family planning is likely to be determined by society's expectations of her multiple roles as wife, mother, and member of her community. To be effective, reproductive health policies and programs must, therefore, take this into account. Program planners might ask how women's domestic responsibilities influence the way they get health information and how they are able to access services. Programs might offer contraceptive services and information to women in the work place. Or, if men are viewed as the primary decision-makers in the home, services that include counseling to promote gender balance in reproductive decisions could improve couple communication and possibly allow women greater household autonomy. Since most women value motherhood as an important -- and often the most important -- role in their lives, family planning messages must acknowledge this by highlighting the benefits of child spacing for the health of the mother and her children.

Nongovernmental organizations (NGOs), including women's advocacy groups, could play a key role in partnerships with health workers and policy-makers, helping to make reproductive health more visible and better understood in the community and advising on how best to respond to women's needs and interests. In particular, women's advocates could help develop guidelines for gender-sensitive programs that promote the concept that women and men can be partners in reproductive health. (The WSP is supporting the development of gender-sensitive guidelines in Bolivia.)

While few family planning programs can afford to provide all the services women need, providers can recognize that women's health needs are multidimensional. Accordingly, programs can collaborate with other agencies to develop referral networks for problems they are unable to address. For example, health workers can inform women of sources of help for domestic abuse, or provide information on women's legal rights, on prevention and treatment of sexually transmitted diseases (STDs), or on income-generating opportunities in the community.

Policy-makers and program managers are unlikely to find short cuts to gender-sensitive programs, but by recognizing the links between gender and women's access to and use of reproductive health services, they may be able to reduce gender discrimination and, over time, modify programs so that they do more to empower women.

Benefits to Women

Most women and men are convinced that practicing family planning and having smaller families provide economic and health benefits.

Across cultures, women and men surveyed in the WSP identified two main benefits of family planning. Smaller family size leads to increased family income, and contraceptives give women respite from pregnancies that are too closely spaced. For many, these perspectives were shaped by the absence of family planning. Study participants cited their own experiences before and after contraceptive use. Others based their views on observations of their neighbors and comparisons between those who used family planning and those who did not.

In China, generational studies indicated stark contrasts in life before and after family planning. In focus group discussions, women and men described the times before family planning as desperate and bleak, and the times after family planning as optimistic. "My parents had eight children," one 56-year-old woman explained. "My father died when I was 20 -- there was no money for the doctor. Some siblings were given to other families. Having too many children -- not only do the parents suffer, but also the children, with bad nutrition and bad housing conditions." Another 60-year-old woman spoke of having six children, five of whom survived. "At home, we had nothing to eat. It is hard to talk about and sad to recall." When questioned about the relationship between family planning and various aspects of their lives, more than 90 percent of survey respondents in North Anhui and South Jiangsu provinces said family planning helped them become more healthy, earn more income, and spend more time on their jobs. "Now our lives are improved," said one 34-year-old woman. "We have fewer gynecological diseases. We have better health education material "

"If my wife makes the decision to use family planning without my consent, I would divorce her."

Malian man

Better health was often cited by women in Indonesia as a reason to begin contraceptive use. "I have had many children," explained a woman in Ujung Pandang. "I thought if I was not using contraception, I would have even more. I was concerned with my own health."12 In Zimbabwe, one woman said she advised her daughter-in-law to space her pregnancies. "You have to plan ahead," she said. "You should not have another when one is still in nappies [diapers]. I tell her not to forget to take her pills be it morning or afternoon."13 In Mali, one woman explained that she began using contraception "to have a rest. It's the first time that I have weaned one baby before having another."

Economics also was a strong motivator for many couples to use family planning. In Bangladesh, one woman described her decision to undergo sterilization, "Having four children nearly made me crazy," she said. "I couldn't give them food and clothes. They wandered from door to door and were driven away like dogs. One day my son asked, 'Why did you give me birth if you can't feed me?'"14 A 43-year-old woman in rural Indonesia said, "With fewer children, expenditures are low, so [the family's] welfare is guaranteed you are economically well-organized."15 A man in Ujung Pandang said, "The phrase 'many children, more economic fortune' is out-of-date. Today, many children means lots of problems, lots of responsibility."16 In Egypt, a study of women with unplanned pregnancies found that both men and women cited the high cost of living as their main reason for not wanting another child.

Policy and Program Implications: Because so many women and men are convinced of the health benefits of family planning, program managers and policy-makers might consider promoting family planning as a form of "health insurance" for women and their families. Because traditional gender norms dictate that the male is the chief financial provider in the family, educational campaigns on contraception could include improved economic status as a benefit for men and their families. Programs could also promote the relationship between contraceptive use and women's ability to participate in income-generating activities as a benefit for families.

Family planning offers freedom from the fear of pregnancy and can improve sexual life, partner relations and family well-being.

For many women, contraceptive use carries important psychological benefits, among them freedom from fear of unplanned pregnancy. This was most evident in Bolivia, where the focus of WSP research was women and gender. A study in El Alto found that among three groups of women interviewed (those who used the intrauterine device or condoms, those who discontinued contraceptive use for reasons other than wanting pregnancy, and those who had not used modern methods), all held similar views about quality of life, couple stability and women's self-esteem and decision-making. However, current users had more positive attitudes about sex and said that contraceptive use had lessened their fears of pregnancy. Another study in Cochabamba, Bolivia, found that women who used modern methods reported higher levels of sexual satisfaction. In the same study, contraceptive users were more likely to have higher levels of self-determination in decisions about their money and their appearance.

In Mali, women said their overall relationships with their husbands improved because they were not worried about pregnancy and because they had time and energy that would not be available to them if they had larger families. "Because you have free time to take care of your husband, you can see the affection is reborn," one contraceptive user said. In Zimbabwe, men recognized the psychological benefits of contraceptive use for couples. "It gives us time to enjoy our wives, especially when it comes to sex."17 Another man noted that women who cannot control their fertility may become depressed if they feel they are "being used as a human-making machine."18

Study participants in other WSP countries also cited benefits of contraceptive use, including more time for themselves and their families. Studies in Cebu and North Mindanao, the Philippines, found women with fewer small children had reduced work burdens in the home. In Indonesia, women said that having a smaller family reduced the years a woman was involved in the care of small children and increased the amount of time she had to participate in community activities and work. In Zimbabwe, both women and men named family planning as an important factor in quality of life. Women said a benefit of family planning was more time for rest and leisure and more time to devote to children and husbands.19

"The phrase 'many children, more economic future' is out-of-date. Today, many children means lots of problems, lots of responsibility."

Man from Ujung
Pandang, Indonesia

In China, more than 80 percent of women and men said family planning gave them more leisure time, as well as more time for work and education. However, the majority of couples said family planning use did not affect their marital relationships or their sex lives.

In the Western Visayas, the Philippines, contraceptive users were somewhat more satisfied, overall, with their lives than non-users. Users were more likely to share decision-making with their husbands about women's work outside the home, travel outside the community, contraceptive use and childbearing. In Cebu, researchers found that each subsequent pregnancy during the eight-year study interval had a negative effect on women's quality of life indicators, which included material goods, labor-saving conveniences, maternal nutritional status and child well-being.

Policy and Program Implications: Family planning programs have long emphasized the health benefits of contraceptive use to women, and this should continue. In the future, programs also may want to consider promoting the psychological benefits of contraceptive use for women and men. Concern about diminished sexual pleasure has frequently been a reason for dissatisfaction with contraceptive methods, particularly male methods, such as the condom. However, family planning programs should also inform clients that many couples report enhanced relationships once the fear of unplanned pregnancy is reduced.

Where jobs are available, family planning users are more likely than non-users to take advantage of work opportunities.

The most compelling evidence of the positive effect of contraception and lower fertility on women's employment status comes from WSP studies in the Philippines. Secondary analysis of data from the 1983 Cebu Longitudinal Health and Nutrition Survey indicated that women with fewer children had greater increases in earnings. Mean change in income for women with no surviving children born during the study interval (1983-91) was 2.3 times higher than that of women who had given birth to one or more children during the same period. The change in income in part reflects an increase in average hours worked, especially for women in the informal sector. Piece workers had the lowest gains (19 pesos per week) while wage earners in the formal sector had substantially higher gains -- 63 pesos per week on average. The negative effect of childbearing on income was explained by lower wages and fewer work hours. (See Table 1)

Table 1: Effect of Family Planning on Women's Participation in the Work Force

Country	Study Title	Methods and Sample Size	Findings
Bolivia	Women's Participation in the Work Force: Follow-up of 1994 Demographic and Health Survey	Interviews with 816 women, 62% of women who completed Demographic and Health Survey in La Paz and El Alto in 1994	Women working increased from 58% in 1994 to 64% in 1997 Working for pay in 1997 was associated with being older (OR=1.03),* using a contraceptive method during the past 3 years (OR=1.54), not being pregnant (OR=.49), and working in 1994 (OR=2.69)
Brazil	Comparative Study of the Impact of Female Sterilization on Women's Lives	Survey of 236 sterilized women and 236 non-sterilized women	Although only 12% of sterilized women attributed change in economic situation to their tubal ligation, virtually all (97%) reported an improvement
Egypt	Role of Women as Family Planning Employees in Egypt	64 focus group discussions with female family planning employees; interviews with 19 program managers; analysis of data on 19,610 family planning employees	82 % of 19,610 family planning employees are women Percentage of women in family planning occupations varies from 48% (physicians) to 100% (nurses) In focus group discussions, women expressed pride in family planning work but concern that employment conflicted with time required for domestic duties and personal needs
Egypt	Social and Behavioral Outcomes of Unintended Pregnancy	Survey of 1,300 women who had an unplanned pregnancy between 1991 and 1993	Of 1,300 women who had unplanned and unwanted pregnancy: 49% said the birth increased household expenses 7% were forced for economic reasons to work after the birth 4% quit working after the birth
Indonesia	Family Planning, Women's Work, and Women's Household Autonomy	Secondary analysis of national sample of 4,617 women from Indonesia Family Life Survey; in-depth interviews with 20 women and 20 men	Compared to non-users, women using long-term methods were 60% more likely to be working for pay and 40% more likely to be in the formal wage sector Use of short-term methods was not associated with working for pay, working in the formal sector, or hours worked per week In in-depth interviews, most women said they worked only to help their husbands support the family, even when their own income exceeded husband's income
Philippines	Cebu Longitudinal Follow-up Study	Survey follow-up to 1983 and 1991 Cebu Longitudinal Health and Nutrition Survey, 2,779 women; in-depth inter-views with subsample of 60 women	Significant increase in women working from 46% in 1983 to 77% in 1994 Women with children under 2 in 1997 were less likely to be working for pay Women with 1-3 children earned approximately 112 times the earnings of women with 4-6 children and twice the earnings of women with 7 or more children Women working in the informal sector were more likely to increase earnings through longer hours of work Women in the formal sector were more likely to increase earnings through increased hourly wages In in-depth interviews, most women said they preferred not to work outside the home
S. Korea	Impact of Fertility Transition on Women's Status and Participation in the Work Force	Secondary analysis of data on urban women from a 1991 national survey: 1,093 women ages 25-29 and 644 women ages 45-49; 2 focus group discussions with women	Women's participation in the work force has increased from 39% in 1970 to 48% in 1995, nearly all in urban areas Women in focus group discussions say that family planning has increased opportunity to work outside the home Only 29% of younger women currently work compared with 57% of older women 84% of younger women who worked before their first birth quit jobs around the time of first around the time of first birth Among women working outside the home, 17% of the younger group and only 2% of the older group had professional, technical or administrative jobs Women were likely to continue employment after childbearing if they had professional, technical or administrative jobs of users were employed in contrast to 14% of non-users
Zimbabwe	Impact of Family Planning on Women's Participation in the Development Process	National Survey of 2,465 women ages 15-49	Contraceptive use and work patterns are established early: 17% of women using contraception at first sex were in the work force, compared with 10% of women not using contraception; at marriage 22% users and at first birth 13% of users working for pay contrasted with 6% of non-users. There was no relationship between current work and current use of family planning Although 62% of women in this sample reported contraceptive use, only 32% were currently employed outside the home
Zimbabwe	Mediating Effects of Gender on Women's Participation in Development	In-depth interviews with total of 80 married women of higher and lower fertility, married men, and older women; 8 focus group discussions from same population	Older women and married men expressed support for women supplementing family income but concern that employment outside the home leads to promiscuity

* OR = odds ratio

Focus group discussions and in-depth interviews with women in Cebu, however, revealed that women generally prefer not to work outside the home. This position in part reflects the poor working conditions for women and the increased domestic burden when productive activity competes with time women must still devote to practical household tasks. Most of those who worked said they did so because household income was inadequate to meet the practical needs of household maintenance and childrearing. The investigators concluded that family planning use does, indeed, have a positive effect on women's income, but not without costs to women who now have a longer workday.

Zimbabwe studies suggest that the timing of contraceptive use appears to influence later events in a woman's life. A national survey of Zimbabwean women's participation in development found that women who had started contraception early in their reproductive lives were significantly more likely to be working at the time of survey.20 Yet, the strong tendency for women to delay family planning until they have had their desired number of children appears to put them at a disadvantage in the country's highly competitive job market.

In another study, Zimbabwean women and men associated both family planning and women's participation in the labor force with quality of life, but it was important for women to prove their fertility before using a contraceptive method.21 Similarly, in-depth interviews with Zimbabwean women who had been forced to drop out of school because of pregnancy documented their regret that lack of knowledge of, or access to, contraception had cut them off from the education they needed to pursue careers.22

"I keep quiet. My husband is all I have. He brings us medicine when the children or I are sick, but I don't ever ask him for medicine. I am a woman."

Woman in rural Bangladesh

The WSP in Indonesia found that, compared to non-users, women who used long-term methods such as sterilization, intrauterine devices (IUDs), and implants were 60 percent more likely to be working for income. Among working women, long-term method users were 40 percent more likely than non-users to work in the formal (wage) sector. However, use of long-term methods was not related to the number of hours women worked.

In Bolivia, the 1997 follow-up to the Demographic and Health Survey (DHS) found that among women in La Paz and El Alto, work outside the home was more common among women who were older, who were not pregnant, and who had used contraception in the past three years. The study found that the percentage of women working increased from 58 percent in 1994 to 64 percent in 1997. In Bolivia, this increased participation in the labor force grew out of necessity. Women began to work as unemployment rates increased for men and as rural residents migrated to urban areas.

While contraceptive use has created opportunities for women to take on new roles outside the home, it has not freed them from them from their traditional roles inside the home. In numerous WSP studies, women said they were responsible for housework and child care, even if they helped bring in income. These findings will be discussed later in this report.

Policy and Program Implications: Health providers, women's advocates and policy-makers could promote family planning as a vehicle to help women earn income for themselves and their families. These groups also could work cooperatively to help women better reconcile their roles as homemakers and employees. Additionally, they could establish networks to help women refine and improve job skills; to help working women find child care; and to help homemakers, who may exit and enter the work force, obtain job training.

Family planning helps women meet their practical needs and is necessary, but not sufficient, to help them meet their strategic needs.

In examining the impact of family planning on women's lives, one issue to consider is whether methods and programs help women meet practical needs and strategic needs. Caroline Moser, who has written extensively on gender, defined practical gender needs as those that help women and men carry out the roles and tasks they currently have; for example, earning a living. Strategic needs are those that help women and men achieve greater equity; for example, elimination of job discrimination to help women and men have equal opportunities for work. Moser stressed that both practical and strategic needs occur in a "gendered" context, one in which women are often disadvantaged simply because they are women. Gender norms, Moser said, are those societal and cultural beliefs and practices that define roles, opportunities, and limitations for women and for men. They serve, all too frequently, to limit a woman's access to power and control over her own life.23

In the WSP, women and men saw family planning not as an isolated event in their lives, but an ongoing process that helps them achieve desired practical goals. Decisions to use family planning were connected to other individual and family needs. For example, study participants said contraceptive use is a way to protect women's health from the stress of too many and too closely spaced pregnancies. Family planning is a way to ensure that family size matches the family's economic resources; a vehicle that allows women to obtain an education, participate in the work force or devote additional time to her husband and children; or a way to enhance the quality of the couple's sexual relationship by minimizing the fear of pregnancy.

However, while contraceptive use has helped many individuals improve the quality of their own lives, it has done little to change existing gender norms. In Bangladesh, a massive nationwide campaign has increased women's contraceptive use to 45 percent of married women, yet women's isolation and subservience persist. In Mindanao, the Philippines, women who used family planning were more likely than non-users to suffer domestic violence.

In Indonesia and China, where contraceptive use is widespread, traditional gender roles prevail, and women acknowledged men as the official head of the household and the primary financial providers. In South Korea, study participants reported that family planning had reduced the time spent in childbearing and childrearing, offering women opportunities to work outside the home. However, while husbands did help with domestic chores, women remained primarily responsible for housework. This was also the case in Mindanao and Cebu, the Philippines, where women worked outside the home but the bulk of housework and child care remained women's responsibility, increasing their work burden.

Family planning led to improvements in the economic status of individual families, and women's contributions to household income afforded them more decision-making power in some instances. But contraceptive use did not lead to gender equity in the work place. In Zimbabwe, women were pleased that family planning allowed them to participate in the labor force; however, with limited job opportunities for both men and women in their country, only 32 percent of women worked outside the home -- similar to the percentage working in the mid-1980s.

As noted previously, some women said that family planning gave them the opportunity to participate in community activities, many of which were religious or related to community betterment. However, women also said they limited their activities to avoid conflict with domestic and work place responsibilities. For example, female family planning employees in Egypt said they supported women's participation in political activities, yet most women said they themselves did not have time to join political activities. In Western Visayas, the Philippines, women and men supported women's participation in community activities -- but few women were community leaders or officers in political or economic organizations. In Indonesia, women said family planning gave them time for community activities, but women also said that decision-making about what they could or could not do ultimately rested with their husbands.

Policy and Program Implications: As WSP research illustrates, increased contraceptive prevalence does not automatically translate into gender or class equity. Women who use family planning may be empowered to control the timing and spacing of their pregnancies; however, they are not necessarily empowered in other spheres of their lives. They may use family planning but still suffer from domestic violence, still bear the dual burden of housework and work outside the home, and still find themselves financially dependent on others. In the long-term, to help achieve gender equity, family planning programs and women's advocates can work collaboratively to link contraceptive services with programs that empower women in other areas of their lives, such as credit programs that help women start their own small businesses, vocational programs that help women gain job skills, or organizations that educate women about voting rights and political participation. Policy-makers should encourage governments to take the larger step of rethinking and restructuring the health, economic and social policies that now limit women's opportunities.

Costs to Women

Contraceptive side effects -- real and perceived -- are a serious concern for many women, more than providers realize.

Contraceptive side effects, often categorized as minor by researchers and providers, are a major concern for many contraceptive users. For women who use family planning, side effects can be a reason for stopping or switching to a less effective method. For women who do not use family planning, fear of side effects can be a reason to never start. Both the perceived and actual impact of side effects can be detrimental to women's use of family planning. (See Table 2)

Table 2: Perceptions and Experiences with Side Effects

Country	Study Title	Methods and Sample Size	Findings
Bangladesh	Social Transformation in Bangladesh: An Ethnographic Study of Family Planning and Women's Roles and Status	Ethnographic study of rural residents of two districts: 139 males and 151 females; key informants	Women often had negative expectations about side effects; a few had regrets regarding abortion and sterilization Some men were concerned that side effects would lead to financial costs and inability of women to work Side effects not always treated by providers
Bolivia	Impact of Men's Knowledge, Attitudes and Behavior Regarding Fertility Regulation on Women's Lives	Structured interviews with 630 randomly selected couples	20% of women interviewed were not using a contraceptive method and were at risk of pregnancy 22% who were not using a method cited fear of side effects or medical contraindication 10% of women interviewed believed that cancer and/or AIDS is caused by IUD, 6% by tubal ligation
Bolivia	Fertility Regulation and its Relationship to the Stability of the Couple, Sexuality, and Quality of Life	In-depth interviews with 3 groups of women: modern method users (36), discontinuers (33), and non-users (32); and 31 men	Qualitative data show persistence of myths and rumors about the ill effects of contraceptives Many users said they were not prepared for side effects and were unable to distinguish contraceptive side effects from unrelated problems
Egypt	Social and Behavioral Outcomes of Unintended Pregnancy	Survey of 1,300 women who experienced unplanned/unwanted pregnancy between 1991 and 1993	6% of women surveyed had not used contraceptives for fear of side effects, even though they wanted no more children
Indonesia	Family Planning, Family Welfare, and Women's Activities	Survey of 931 women and in-depth interviews with a sub-sample of 16 women in Central and East Java	7% of women had experienced a health problem they associated with contraceptive use
Indonesia	Family Planning and Women's Empowerment in the Family	Survey of 800 married women (ages 30-45) and in-depth interviews with 30 couples in Jakarta and Ujung Pandang	Women were generally positive about the results of family planning, but for 30% in Jakarta and 27% in Ujung Pandang, side effects were a negative aspect of family planning use
Indonesia	Reproductive Decision-making and Women's Psychological Well-being	Survey of 800 women, 12 focus group discussions with women and men, and 24 in-depth interviews with women in South Sumatra and Lampung	69% of users were generally satisfied with their contraceptive methods, but 31% reported health problems related to use In-depth interviews revealed a tendency to change methods because of side effects 17% of users said they got insufficient information from providers
Mali	Impact of Family Planning on the Lives of New Contraceptive Users in Bamako	Prospective qualitative study. In-depth interviews: 55 new users, 32 never-users; focus group discussions: married men, older women, experienced users	Most method change and discontinuation by new users was due to side effects Among never-users of contraception, husband disapproval was a greater deterrent than fear of side effects
Philippines	Economic and Psychosocial Influence of Family Planning on the Lives of Women in Western Visayas	Survey of 1,100 married women (ages 15-49); 9 pre-survey focus group discussions and 27 post-survey focus group discussions (some included men); 36 in-depth interviews; 50 key informants	82 of 579 women surveyed reported experiencing health problems attributed to contraceptive use The main reason women in focus group discussions cited for not using contraceptives was concern about side effects In order of frequency, the reasons women surveyed gave for choosing a method were effectiveness(52%), absence of side effects (30%), and convenience (24%)

In Cochabamba, Bolivia, the 25 percent of contraceptive users who said they were dissatisfied with their method blamed side effects. In Zimbabwe, one group of rural women in Chitsungo Ward said they preferred the less effective method of withdrawal to oral contraceptives because pills caused menstrual changes, headaches, weight gain and diminished libido.24 And some Zimbabwean men said they would encourage their wives to discontinue contraception if side effects occurred.

While many contraceptive users said they were counseled about the possibility of side effects, the reality of menstrual disturbances, weight gain, skin blemishes and other problems often proved difficult to accept. As one woman from Mali noted, even though she had been counseled that amenorrhea was a possible side effect of injectables, "to go all this time without seeing my period well, I wasn't really expecting that."25

Study participants' comments illustrated the struggle to find an acceptable family planning method. "The first time [I used family planning] was after the birth of my second child," said a mother of four from North Sumatra, Indonesia. "I used pills, but I started bleeding so I stopped. After the third child, I tried to use the IUD. After four months, I started bleeding, and I expelled the IUD. Then I tried again to use my own [traditional] method. Finally, I decided to use the pill again. After five years of using it, I suffered from heart disease. The doctor said, 'You have side effects [in] your heart from using the pills. Please stop using the pills.'"26

Fear of side effects and even of sterility -- whether based on fact or rumor -- caused some women to avoid contraception altogether. This was true in Cebu, the Philippines, where nearly 40 percent of non-users said they were concerned about side effects. In Mali, one non-user explained, "A woman who lived with us, she used family planning. She fell ill and even had two operations. She has not had any more children. ...When I saw her experience, I was afraid."27 And in El Alto, Bolivia, one man said he and his wife had reservations about using contraception because it was hard to separate rumor from fact about side effects and efficacy. "At times people tell us the truth, and at times a lie, and it makes us doubt the truth. Sure, at times I think of using those methods, but later I decide not to."28

"People said many things about my having the operation [sterilization]. ... 'Don't you stand next to us. Stay away! Even to look at you is a sin!' I would just weep when people said those things to me."

Woman from rural Bangladesh

Policy and Program Implications: Because side effects play such a pivotal role in women's choice of methods, their decisions to start using family planning, and their decisions to stop, providers must address these concerns. Providers must receive additional training in how to manage side effects -- for example, recommending that oral contraceptive users switch to another brand of pill if they cannot tolerate side effects, offering ibuprofen or estrogen to implant or injectables users who report heavy menstrual bleeding, or offering another type of contraceptive altogether. Providers also must counsel women thoroughly -- what they can and cannot expect from contraceptive use. Information will help individuals anticipate how side effects may alter their daily routine, make an informed choice about the method that is best for them, counter persistent myths and rumors about side effects, and help women and men recognize what physical changes may be due to side effects and what changes may indicate a health problem.

To help women better understand the practical implications of method use, family planning programs might establish peer networks, in which long-time contraceptive users are trained to counsel new users. These women could relate their own experiences, explaining how side effects affected their everyday lives and sharing their coping strategies.

Finally, women's concerns over side effects emphasize the need for continued research efforts to develop more effective contraceptive methods that have fewer side effects and are controlled by women.

When partners or others are opposed, practicing family planning can increase women's vulnerability.

Women who use contraception in communities where family planning has not become a social norm can face severe consequences. These women may be treated as pariahs. They may face ridicule and disapproval in their communities, disdain from relatives and friends, even divorce and abandonment by their husbands. In Bangladesh, women who were the first in their village to use contraception faced ostracism by community members. A rural woman who sought sterilization described her concerns. "I talked secretly with eight or 10 women about this. Some of the women said, 'If the elders find out about anyone having this operation, they will not let her live in the village anymore. No one will eat food cooked by a woman who has been operated on.'"29

In Mali, contraceptive use remains a relatively rare phenomenon, and clandestine family planning users faced discovery and reprisal by husbands. Clandestine users hid their pills, or kept contraceptives at a friend's house or at work. One Malian woman said, "On holidays I am nervous. Each time he goes into the room, I tell myself he must have them [pills]. My heart beats faster." Another woman, experiencing amenorrhea, feared her husband would realize she was using family planning. And another woman said, "I know what I am risking by using family planning, and I know the day he [my husband] finds out, it will end in divorce, but I am hiding it so he doesn't find out." Men were clear that clandestine use was a crime deserving of retribution. "If my wife makes the decision to use family planning without my consent, I would divorce her," said one man. Another man said, "What is clear is that a woman who decides alone, without taking into account her husband's opinion, deserves punishment."

In Jamaica, contraceptive use by adolescent girls was seen as an indicator of sexual activity, which was forbidden at their age. One female focus group discussion participant explained that a young adolescent woman who uses contraception would be shunned by her peers. "They would say she taking it [the pill] 'cause she having sex a lot of the time." Another girl said, "Her friends would say them no want her in them company."

In Bolivia, one woman described the physical abuse she encountered during contraceptive use. "He told me we were going to make love, and I didn't want to, and he said, 'Why is it that you never want to? Don't I give you pleasure?' then he started hitting me. I said, 'Don't hit me. ...Why do you want to force me like this?' He kept hitting me. ...He put his hand inside my womb [to remove the IUD]. 'That's how your man wants you to have it,' he said. I was screaming. I don't remember anything else because I had already fainted."

These examples illustrate the great lengths to which some women will go to control their fertility. For many, contraceptive use involves a continual weighing of potential benefits and risks.

Disapproval for those who challenge traditional beliefs comes not only for women who use contraceptive methods, but for women who provide them as well. In China, women who used and distributed family planning during the early years of China's one-child policy compared their work to the unpopular job of tax collection. One woman from North Anhui said, "Family planning work is the most difficult under the heaven. We don't mind working hard, but the worst thing is people don't understand our work." Many other past (and present) family planning workers said if a woman in China can succeed at family planning, she can succeed at anything. A family planning worker in Upper Egypt, where contraceptive use is not as widespread as in other parts of the country, said, "The main difficulty is the feeling of insecurity when visiting households we do not know. Some men say bad words and some husbands and mothers of clients do not meet us nicely and quarrel with us if anything happens as a result of using contraceptives." Another family planning leader likened her work to "swimming against the tide."30

Policy and Program Implications: Health providers should realize that new contraceptive users often do incur significant risks to prevent pregnancy. Contraceptive counseling should include questions that will help women not only evaluate the benefits and disadvantages of particular contraceptive methods, but also assess the emotional and social costs of contraceptive use. Thorough counseling and discussion may help women anticipate and cope effectively with partners' or community reactions.

Again, peer networks may also help women to cope with the emotional costs related to contraception. Referrals to experienced contraceptive users may offer support and advice for new users, helping them adjust to this important change in their lives. Women's advocates could work with health providers to establish these community-based networks. Long-time family planning workers might also share their experiences with novice workers in training sessions.

Where family planning is not the norm, educational campaigns should be carried out at many levels: national or regional media campaigns directed to men and women, information and patient education at service locations, and community-based education for groups of women, adolescents and men at the local level.

When women have smaller families, they may lose the security of traditional roles and face new and sometimes difficult challenges, including the burden of multiple responsibilities at home and work.

Traditionally, women have achieved status and influence through their roles as mothers and wives; often, this was their only avenue. In many cultures, a large family is viewed as a necessity to ensure the survival of the family line (particularly given high infant mortality rates), to provide labor to maintain the family farm or business, and to provide security in old age for the parents.

As child survival rates improve, the economic need for children has declined. The option of having a smaller family has become more attractive to many couples, and modern family planning methods offer a means to this end. In developing countries, women who have come of reproductive age since the introduction of modern contraception some 30 years ago have been pioneers. They are the first generation of women to view childbearing as a choice, rather than to accept it as fate. For many women, this situation is positive, offering new opportunities for family harmony, economic security or personal fulfillment through work or community service. For others, the shift from traditional to new roles is negative, creating stress, confusion and unhappiness.

The most striking evidence of the conflict between old and new can be found in South Korea. In the early 1960s, the government established a national family planning program as part of its effort to encourage economic development. Contraceptive use became widespread, and the government encouraged a two-child norm, precipitating a drop in fertility from six children per family in 1960 to 1.6 in 1990. Yet, while fertility rates fell, cultural values changed little. South Korea continues to have a strong patriarchal culture, where women and men have separate roles and responsibilities. Even now, women are seldom in positions of political or economic leadership.

In focus group discussions, women in their thirties and fifties discussed the relationships between family planning and work. Older women said that they had quit their jobs once they were married, whereas some younger women continued to work after marriage and childbirth. Older women, who adhered to the traditional roles of hyunmo-yang cho (wise mother, obedient wife) appeared happier and had higher levels of self-esteem than younger women. Younger women struggled to perform multiple roles (wife, mother, homemaker, worker), often without help or understanding from spouses or in-laws. One younger woman said, "Many of the professional women I know have merged their dual roles successfully. But no one has escaped without personal sacrifice, inner struggle or conflict." Another said, "My number one priority is my career, then child, then husband. Frankly, sometimes I think I am part of an overlooked but particularly confused generation of women. I have discovered that career alone is not enough. Most of my friends want children, too. But my career is more important to me than my child. Kids are kids for just a couple of years."

In Egypt, where female family planning employees were surveyed, the women said their work had given them opportunities to learn, to travel and to contribute to their communities. Some women said that they had assumed a greater role in household decision-making. However, the women also said they experienced stress in trying to find child care, do housework, and care for sick children. Some experienced harassment from community members who resented or disapproved of their work. And some women said their work outside the home brought them increased respect from husbands and children -- but they also received criticism from family members when they worked late.

In China, women and men spoke of women's changing roles in the work place, and many said women's status has improved because of their economic contributions. However, the divisions of labor within the home fell along traditional lines. Women were expected to be responsible for childrearing and homemaking, even if they worked outside the home. Many women viewed their work as a way to make a better life for themselves, their husbands and children. One 29-year-old mother said, "I have to work more to make more money for my son. I have to build a house for him and his wife and save for myself when I am old."

In Indonesia, nearly 68 percent of the 589 women surveyed in Central and East Java said they worked full-time. However, when asked about responsibility for household chores, 78 percent of women said they were responsible for cooking, 50 percent for cleaning, 53 percent for child care, and 58 percent for laundry. In Northern Mindanao, women spent from three to five hours per day on household chores, in addition to their income-generation activities.

In Zimbabwe, women said work was an avenue to personal fulfillment. Men supported women's income-generating efforts but said women's role as mother and homemaker should remain their top priority.

Policy and Program Implications: WSP studies show that declines in fertility have given women new opportunities, yet women do not always view these opportunities as beneficial for themselves. Women may struggle with how to integrate amorphous non-traditional roles with well-defined traditional ones. For many, it is not an easy task.

Health providers probably can do little to help women reconcile old and new gender roles. However, providers can be cognizant of the multiple demands on women's time and provide health services in settings that are convenient to women (work sites, for example) at times that are convenient to women (after work hours or on weekends).

Barriers to Family Planning Benefits

WSP study participants acknowledge that family planning use carries both advantages and disadvantages. While most women indicate that they want to control their fertility, they note that obstacles prevent them from doing so, thus limiting the benefits they derive from family planning. Women's perceptions of those obstacles are presented below.

Social, political and economic barriers limit benefits of family planning for many women.

Throughout the WSP, study participants noted numerous benefits of family planning, including the opportunities it provided for women to improve their education and job skills, to enhance the family's financial security, or to improve the woman's autonomy and self-esteem. Yet, the impact of family planning on women's lives is restricted by the social, political and economic climates in which they live.

Imagine that a young woman from Bamako, Mali, an immigrant to El Alto, Bolivia, and an adolescent from Fortaleza, Brazil, all realize the value of family planning and initiate use of an effective method. Unfortunately, contraceptive use does not guarantee that social or economic opportunities will magically open for them. For example, many women in Zimbabwe said they adopted family planning after having a baby. For some, pregnancy interrupted their education, and they found it difficult to return to school.

In South Korea and China, national efforts to increase contraceptive use coincided with economic development. Consequently, family planning and economic prosperity were linked for study participants in these countries. In Zimbabwe, although contraceptive use has increased in the past decade, women's labor force participation remains unchanged at 32 percent, because economic opportunities within the country are limited.

"My mother died in the delivery of her third child, of a hemorrhage. The baby was alive but was buried with my mother. Not even the midwife came because my family had no money."

Woman in South Jiangsu, China

For many women in Bolivia and the Philippines, work opportunities have increased but primarily in the informal sector where wages are low and hours are long (although flexible). Women migrating to El Alto because their husbands were displaced from mines or farms find themselves at a disadvantage when looking for work. They often do not speak Spanish and have few skills to compete in the modern economy.

Policy and Program Implications: If a woman cannot read or return to school because she is too old or because policies prohibit mothers from attending school; if she does not speak the economically dominant language or is from an unfavored minority; if she has few marketable skills and no training opportunities; if she needs most of the hours in the day to complete household chores; if she is not well-connected to individuals who can help her get a job; if she does not have transportation to work; and if she does not have child care, family planning by itself will not change these factors.

To deal with this dilemma, health providers and policy-makers should consider offering family planning as part of a holistic approach to improve women's welfare. For example, family planning could be linked to activities that promote women's economic development, women's rights, or women's empowerment. Another route is to offer educational and vocational programs to help women, including those who have dropped out of school or out of the work force, develop job skills. Such comprehensive efforts could enhance the impact of family planning.

The benefits of family planning are reduced when contraceptives are ineffective, used incorrectly or inconsistently, and discontinued early (before pregnancy is desired).

The use of contraceptives should allow women and men to have the number of pregnancies they desire, at the times they desire. In practice, however, many couples do not achieve this ideal. Some couples' plans for a family are threatened by infertility or miscarriages. Others plan for one pregnancy but give birth to twins or triplets. Some couples have little choice of methods, cannot find a method that suits them, have method failures, or do not use methods correctly. Others run out of contraceptive supplies or cannot cope with side effects. Due to a variety of biological, personal and structural factors, true control over fertility is rare in both developed and developing countries.

In several WSP studies, researchers found that many women who use family planning do not always enjoy benefits, due to contraceptive failure or improper use. For example, in the Philippines, a WSP-supported analysis of contraceptive failure in Northern Mindanao was conducted with 1,253 contraceptive users. Pregnancy rates were surprisingly high for all methods except tubal ligation and Depo-Provera: condoms, 77; withdrawal, 47; the lactational amenorrhea method, 43; calendar rhythm, 32; IUDs, 20; pills, 19; Depo-Provera, 9; and tubal ligation, 2.* These failure rates are much higher than have been found elsewhere, including in clinical studies. Researchers concluded that user failure probably accounted for a large proportion of the unplanned pregnancies.

In China, although contraception is widely available, the choice of methods was limited until recently; most women had access to sterilization or the steel ring IUD. Previous studies found a failure rate of 12.6 percent in the first year of steel ring use. In the WSP-sponsored research, 8 to 25 percent of the female study participants reported a contraceptive failure. Many of these failures were in South Jiangsu province, where the one-child family is more strongly enforced and where most women (81 percent of the sample) use IUDs. In the focus group discussions, women and men also raised the issue of the steel ring's high failure rate. One young woman said, "Even when women use family planning, they worry about the efficacy of the method." Failure rates will likely be reduced as the Chinese family planning program switches to more effective IUDs.

Other WSP studies found that contraceptive benefits were minimized when methods were used ineffectively. In Egypt, 62 percent of the more than 1,000 women with an unplanned pregnancy reported that they became pregnant while using a contraceptive method, primarily oral contraceptives.

In Cochabamba, Bolivia, about two-thirds of the 630 couples interviewed reported using a traditional contraceptive method, mainly calendar rhythm, at some point in their lives; only half reported ever-use of a modern method. Twenty-five percent of women reported using the rhythm method at the time of survey. However, only two-thirds could correctly identify the days in which women are most likely to become pregnant. For their male partners, accurate knowledge was even poorer, with only half of the male rhythm users able to correctly identify the fertile period.

Research in Mali prior to the WSP found that discontinuation of modern methods was high. In a 1994 survey of 889 family planning clinic clients in Bamako, 31 percent had abandoned contraception at the end of their first three months of using a new method and 77 percent abandoned their method within 12 months. Some women said they could not tolerate side effects; for others, the cost of methods and time spent going to clinics was too great an obstacle. In-depth WSP research explored women's experiences with contraceptive use and learned that there is typically little support for family planning among Malian men, and most new users said that if their husbands objected to the practice, they would stop. Negative social pressure, therefore, may predispose women to discontinue a method, especially when the women have anxieties about side effects.

Policy and Program Implications: Efficacy of contraceptive methods is important to women. However, many WSP study participants felt they could not rely on the methods they had chosen. Some were willing to sacrifice efficacy for diminished side effects. Others switched methods time and again, searching for a balance.

Health providers can help women meet their contraceptive needs by first offering a variety of methods, including male methods. National family planning programs should ensure that women and men have an array of choices -- a central element of quality of care.

In addition, providers should emphasize correct and consistent use of contraception. Counseling techniques must involve two-way communication, in which clients are encouraged to repeat the instructions given by providers and to ask questions. A follow-up could be scheduled, in which nurses or village workers contact contraceptive users one to three months after they begin a method to learn if they have problems or concerns. Providers could work with local women's organizations to reinforce messages about correct and consistent use. Women's organizations could also disseminate information about side effects and strategies for coping; for example, through printed materials, theater troupes, radio clubs or other popular media.

For some adolescents, pregnancy is wanted.

Most providers discourage adolescent pregnancy because it can bring health risks for young mothers and their infants, and also carries socioeconomic costs for young women whose educations are interrupted by a pregnancy. Yet, when motherhood affords women status and support from their families and communities, some young women may welcome a pregnancy early in life.

In Brazil, among the 367 teens seeking prenatal care at the adolescent clinic at the Maternidade Escola Assis Chateaubriand in Fortaleza, a significant percentage were adamant that their pregnancies were wanted. When interviewed at baseline, 51 percent of pregnant teens were married or living with a partner, and 46 percent said they wanted to be pregnant (although 61 percent said they would have preferred to delay their pregnancies).

At baseline, 54 percent of the prenatal group said they were pleased when they learned they were pregnant, believing pregnancy would improve their relationships with family, friends and partners. When questioned about others' reactions, the majority said their families and friends were happy as well. Seventy-one percent of women said their partners were pleased, 56 said their mothers were pleased, 45 percent said their fathers were pleased, and 62 percent characterized their friends as supportive. At 45 days postpartum, self-esteem among the teen mothers had increased significantly, compared with women who had not carried a pregnancy to term. However, in spite of their generally positive attitudes, some 25 percent of the pregnant teens said they had attempted abortion after they learned they were pregnant. Researchers concluded that, in this setting, many adolescents do not see pregnancy as a negative event in their lives -- nor do their parents, partners and friends. (Interviews conducted one-year postpartum and postabortion, which have not yet been analyzed, may show different perspectives.)

In Zimbabwe, studies found that women's first sexual intercourse typically occurs at age 18 and marriage at age 19. There is little incentive for women to use contraception -- and only 8 percent do so at marriage -- because women are expected to prove their fertility soon after marriage. One man, interviewed in a focus group discussion, noted that delaying pregnancy could mean social scrutiny for a couple. "If a newlywed takes three to four years to conceive, in-laws wonder whether the child belongs to their son or to someone else."

In the study of young adolescents in Jamaica, both boys and girls saw parenthood as a major responsibility, requiring emotional and financial resources. However, young people also revealed mixed feelings about pregnancy and how it might affect their lives. One girl commented that a pregnant teen "would feel happy in a way and sad in a way." Some boys said fatherhood might increase their status among peers.

Policy and Program Implications: Health providers, educators, parents and others who seek to encourage adolescents to delay pregnancy may sometimes face an uphill battle. Curiosity, peer pressure, media images -- all can encourage young people to become sexually active. Many teens who do become sexually active do not use contraception because they lack access to methods and services, they do not plan to have intercourse, or they see parenthood as a logical next step in their journey to adulthood.

Nonetheless, providers should continue to emphasize the fact that adolescent pregnancy can have negative health and socioeconomic consequences -- for the individual woman and the larger society. Health risks can be greater for adolescent mothers and their infants, and a pregnancy can interrupt a young woman's schooling. Faced with the demands of motherhood, many women abandon their education and, thus, lose the opportunity to gain jobs skills.

Policy-makers should increase the resources they allocate for adolescent health programs. Education programs for teens should encourage them to plan childbearing as well as other aspects of their lives, such as work and education. Older women and men who have been teenage parents might be enlisted to counsel adolescents about the advantages and disadvantages of teen pregnancy. In addition, older women and men might also be able to work with teen parents, helping them improve their parenting skills.

Health providers, policy-makers, community leaders, religious leaders, women's advocates and educators should work collaboratively to develop programs that will help adolescent mothers continue their education and refine their jobs skills after pregnancy. The Program for Adolescent Mothers, offered by the Women's Center of Jamaica Foundation, could serve as one model.31 Established in the mid-1970s as a pilot project, the Women's Center now operates islandwide, providing education for pregnant teens, counseling about family planning and on-site child care.

In addition, programs should address the needs of adolescent fathers -- who, while they may not be forced to drop out of school -- may feel increased pressure to forego their education to provide financial support for their new families.

Family members, particularly husbands, play a critical role in the quality of women's experiences with contraceptive methods.

Most women do not make contraceptive decisions alone; other family members are involved. This involvement may include joint decision-making by a woman and her partner about contraceptive methods and family size. It may include a dictate from the male partner about what the woman can and cannot do. It may include conversations with female relatives, who offer advice and information based on their own experiences. Or it may include considerations about how another birth would affect the lives of current family members, especially children. (See Table 3)

Table 3: Contraceptive Use and Family Relationship

Country	Study Title	Methods and Sample Size	Findings
Bangladesh	Social Transformation in Bangladesh: An Ethnographic Study of Family Planning and Woman's Roles and Status	Ethnographic study of rural residents of two districts: 139 males and 151 females; key informants	Husbands' views of family planning determine women's initial use and continuation or discontinuation
Bolivia	Impact of Men's Knowledge, Attitudes and Behavior Regarding Fertility Regulation on Woman's Lives	Structured interviews with 630 randomly selected couples	Women contraceptive users were more likely to have higher sexuality scores than non-users (OR=1.66)Women with higher sexuality scores had higher self-esteem scores (OR=1.98)
Bolivia	Fertility Regulation and its Relationship to the Stability of the Couple, Sexuality, and Quality of Life	In-depth interviews with 3 groups of women: modern method users (36), discontinuers (33), and non-users (32); and 31 men	Women and men, regardless of method and consistency of use, believe contraception reduces the fear of pregnancy, thus making sex less undesirable for women
Brazil	Adolescent Longitudinal Study: Social and Behavioral Consequences of Pregnancy among Young Adults in Fortaleza, Cear?t;/TD>	Interviews: 367 pregnant women ages 12-18; 196 abortion patients ages 13-18;	Pregnant adolescents expected pregnancy to have positive effect on relationships with partners, family members, and peers; by 45 days postpartum, the adolescent mothers reported significant improvements in their relationships with their mothers, but a worsening in their partner relationships Adolescents who had terminated their pregnancies expected less positive relations with partners (31%), family (15%), and peers (18%); by 45 days post-abortion, relationships with family members did not change, but they had worsened with partners
China	Impact of Family Planning on Woman's Lives	Focus group discussions with women and men of 3 generations; survey of 6,000 men and women; case studies of 30 families	80% of women and men said family planning increases time for leisure, employment, and education but does not improve marital relationships
Egypt	Social and Behavioral Outcomes of Unintended Pregnancy	Survey of 1,300 women who experienced an unplanned/unwanted pregnancy between 1991 and 1993	For 16%, unplanned birth had negative effect on marital relationship For 17%, the birth negatively affected ability to care for other children 42% of husbands wanted the pregnancy
Indonesia	Family Planning and Woman's Empowerment in the Family	Survey of 800 married women (30-45) and in- depth interviews with 30 couples in Jakarta and Ujung Pandang	64% of women in Jakarta and 69% in Ujung Pandang have discussed family planning with husbands 76% of couples in Jakarta and 79% in Ujung Pandang agreed on desired number of children
Malaysia	The Effects of Family Planning on Marital Disruption in Malaysia	Secondary analysis of 2 Malaysia Family Life Surveys: 1976 (n=1,262) and 1988 (n=1,867)	Contraceptive users were 56% and 60% less likely than non-users to experience marital disruption
Mali	Impact of Family Planning on the Lives of New Contraceptive Users in Bamako	Prospective qualitative study. In-depth interviews: 55 new users, 32 never-users; focus group discussions: married men, older women, experienced users	Husbands are considered ultimate authority in reproductive decisions Elder sisters and husbands' aunts can intervene when husbands are opposed to family planning Mothers-in-law have little influence on family planning decisions Women whose husbands approve of contraception say family planning has led to more satisfying marital relationships Clandestine users fear that discovery by husbands will result in divorce
Philippines	Social and Economic Consequences of Family Planning Use in Southern Philippines	Surveys of 650 ever-married rural women and 1,000 ever-married urban women; 6 mixed focus group discussions	25% of all women, rural and urban, reported ever having been physically abused by a spouse Significant socio-demographic correlates of abuse were: earlier age at marriage, Catholic religion, ever-use of family planning, longer duration of family planning use, and unwanted pregnancy Significant household correlates of abuse were: lower household income, wife working for pay, and husband sharing household chores
Zimbabwe	Consequences of Family Planning for Woman's Quality of Life	Focus group discussions with 16 groups of women, 3 groups of men	Both men and women said that family planning enhances quality of life when couples share more time together and have a more satisfying sexual relationship
Zimbabwe	Mediating Effects of Gender on Woman's Participation in Development	In-depth interviews with total of 80 married women of higher and lower fertility, married men, and older women; 8 focus group discussions from same population	Older women tend to favor large families and advise young women to delay family planning Most husbands believe their role as providers gives them authority in reproductive decisions Influence of mothers-in-law is secondary to that of husbands

In Cebu, the Philippines, only 11 percent of the more than 2,200 women surveyed said they would not consult anyone when making a decision about family planning. More than two-thirds said they would consult their husband, while 17 percent said they would consult a female adult relative. When asked who should make family planning decisions, 16 percent of study participants said the woman, 11 percent said the man, and 70 percent said it should be a mutual decision.32

In West Java and North Sumatra, Indonesia, women said couples jointly made the decision to use family planning, although husbands were regarded as the head of the household, and few women used contraception without their husband's knowledge. For some women, contraceptive use was not an option if husbands did not approve. "I dare not do so [use contraception]," said a woman from North Sumatra. "My husband doesn't permit me to use contraception. It is okay like this, suffering besides, I am not brave enough, so I follow his advice. We have many children already. It is okay if we have another. My children are grown up, so there will be one among them helping."33

In Bangladesh, most women were totally dependent on husbands for financial support. Consequently, husbands' views of family planning were pivotal in their contraceptive use or discontinuation. Women feared that physical side effects would curtail their ability to work, something that would be unacceptable to the family's chief financial provider.

"I don't want to begin until I have four children. Then I'll use family planning."

Malian woman

In Brazil, adolescent girls reported that their relationships with their mothers actually improved after their babies were born, but their relationships with partners deteriorated. Most teens believed that a pregnancy would improve their relationships with family or partner, but relationships with partners improved only among girls who planned their pregnancies. Conversely, aborting teens received little support from parents and partners for their pregnancies; friends, relatives, mothers and partners were the ones who typically recommended Cytotec and herbal teas to induce abortion.

In the Mali study, one of the surprising findings was that sisters-in-law were powerful allies for new contraceptive users, especially when husbands were opposed. Elder sisters-in-law were seen as authorities. "She accompanied me there [to the clinic]," one new contraceptive user explained. "My sister-in-law is aware," said another woman. "She intervened because of my son and then the twins I had. She asked me to use family planning. She told me not to stop [using contraception], to continue with it." Mothers-in-law played a less critical role than researchers expected. "As for my mother-in-law getting involved, this only concerns my husband and me," one woman said. Although sisters-in-law were influential, husbands made the final decision about family planning, citing their role as the head of the house, religious beliefs, or fear that wives might become promiscuous.

In Zimbabwe, husbands' relatives often played an important role in decisions about family life, including how many children a couple should have. Older women advised daughters-in-law about contraceptive use and family size. Most mothers-in-law favored large families and said contraceptives should be used to space children or by women who already had large families. "I expect five children from my daughter-in-law to help increase the size of the family."34 Daughters-in-law said they listened, but did not always heed the advice.

However, the influence of mothers-in-law was secondary to the authority of husbands in Zimbabwe. Husbands felt they should make final decisions on family size because in their role as providers, they bore the burden of economic support for the family, and because of gender norms that placed men in authoritarian positions. "If I want four children and my wife wants six, she has to listen to me because I am the one who supports the family financially. If I decide to have five children, this is because I know I can look after them. The husband is the head of the family, and the wife can never tell me the number of children she wants to have."35

Policy and Program Implications: WSP results showed that family planning is often a family decision. Women, who often define themselves in terms of their relationships with others, make decisions about contraceptive use based on relatives' perceptions, as well as their own views.

An important step to improving women's reproductive health is the involvement of men. Policy-makers should allocate additional resources for reproductive health education, for male contraceptive methods and male health programs, and for provider training. Health program managers could conduct campaigns to educate men about reproductive health and the role they can assume in family planning, whether using contraception themselves, supporting their spouses' decision to begin contraception, or supporting their spouse while she is using contraception. Health programs should offer counseling to help men and women improve their communications skills. Men also should be educated about the health risks to women when pregnancies are spaced too closely, or when pregnancies occur before age 20 and after age 40. In urban areas, employer-based education programs for men might be an option. In rural areas, community or village meetings could be a forum to promote family planning.

Education programs should be developed to reach older women and men, who are the parents of reproductive-age children and who may encourage their adult children to have large families to perpetuate the family line. Because older women say they have more time for community activities, educational programs at sewing clubs, political meetings, or religious gatherings may be a vehicle for education about family planning's benefits. If better informed about contraception, older women might become advocates for child spacing within their families.

Family planning programs must also understand and address the needs of men and women who are not in long-term stable relationships. Education and information campaigns may need to be different for married and unmarried men. For example, reproductive health programs for men in stable relationships might emphasize the economic benefits of contraceptive use for the family or the potential for improved family relationships. Programs for unmarried men might emphasize personal responsibility or the benefits of STD prevention that some contraceptives offer.

Women reap fewer benefits if family planning is initiated late in reproductive life.

Although many women and men recognize the benefits of contraceptive use for spacing or limiting pregnancies, far fewer use contraception to delay early pregnancies. In fact, many women do not begin family planning until they have had all the children they want. Exceptions are in China, South Korea, and Indonesia, where government policy has made early family planning the norm. WSP research in these countries shows that women and men expect contraception to begin early in a woman's reproductive life. However, even in Indonesia, where a national family planning program has been in place for more than three decades, a study in Jakarta and Ujung Pandang found that, while approximately 30 percent of women used contraception before their first birth, the number of users after first birth increased to nearly 50 percent.

Most WSP studies suggest that contraception typically does not begin before the first birth, often because of societal pressure on women to prove their fertility. In Mali, where contraception is available but not yet the norm, women saw family planning as a way to limit births once they have guaranteed continuation of the family line. "I don't want to begin until I have four children. Then I'll use family planning," one woman said. Similarly, a national survey in Zimbabwe, where nearly half the women of reproductive age use contraception, found that 59 percent of women adopted a method after having one child. Although almost all women in the four WSP Zimbabwe studies supported family planning, the older generation of women in focus group discussions and in-depth interviews were emphatic that family planning should be used to space children but not to limit family size. "Young women should have more children before they start to use family planning," said one rural woman. "It is good to have a big family." Not surprisingly, women in the Zimbabwe survey found that higher parity afforded them more autonomy in family planning decision-making; 12 percent of women said they participated in decisions to use contraception after first birth, compared to 39 percent who decided to use contraception after fifth birth.

Egyptian researchers studying unplanned pregnancy also noted that as births increase, women have more interest in delaying or preventing additional pregnancies. The same dynamic can be seen in the Philippines, where women in Western Visayas who used family planning had slightly more pregnancies than contraceptive non-users, and in Cebu, women reported using more effective methods once they reached their desired number of children. Brazilian women who chose tubal ligation began having children earlier -- and had more children on average -- than women who were not sterilized. For these women, the decision to end childbearing was clearly a reaction to current family size.

"Our children just arrive 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."

Woman in El Alto, Bolivia

Despite the tendency of many women to delay contraception, there is evidence from WSP research that some do begin early and, in so doing, experience benefits that distinguish them from delayed users. Women may use different methods, switch methods to try to escape side effects, and temporarily discontinue methods when they want to become pregnant. Nevertheless, for these women, family planning remains constant -- a strategy for achieving health and well-being instead of a reaction to unplanned, or too many, pregnancies. A WSP study in Zimbabwe found that women who reported contraceptive use at first sex, at marriage and after first birth had lower fertility levels than non-users.36 Researchers tentatively concluded that women who use contraception early tend to continue family planning throughout their reproductive lives. The same study also showed that women who used contraception at first sex were more likely to be currently employed, suggesting that early and consistent family planning may contribute to women's strategic economic goals.

Studies in Brazil, Jamaica, and Zimbabwe revealed that younger women are aware of possible missed economic opportunities due to a too-early pregnancy. In Zimbabwe, dropout rates among pregnant adolescents are high, and many do not return to school after the births of their babies. In Brazil, a group of young women who sought hospital treatment for incomplete abortion perceived their unplanned pregnancy as a threat to their education and their ability to earn money. In comparing young women who carried pregnancy to term with those who sought treatment for incomplete abortion, at 45 days postpartum or postabortion, school enrollment had declined from 50 to 30 percent -- but two-thirds of the adolescents who terminated pregnancy remained in school. In Jamaica, young girls and boys, some of whom were already reporting sexual activity without contraception, said parenthood was a major economic responsibility, but 70 percent thought a girl should be allowed to continue her education after pregnancy.*

Policy and Program Implications: Reproductive health providers need to be cognizant of the fact that in many cultures, women do not regard early contraceptive use as beneficial, since it delays a critically important event: motherhood. Throughout the countries in which WSP data were collected, women repeatedly told researchers that their roles as mothers bring personal fulfillment and joy, as well as the respect and approval of families and peers. For these women, the decision to space births or limit family size will come only after this first significant event has occurred.

However, family planning program managers and health workers should continue to emphasize that while contraception can be used to space pregnancies and to end childbearing, it also can be used to delay first pregnancy without adverse effects on fertility. Drawing on what women say they value, reproductive health messages should emphasize that women who postpone childbearing until their twenties are likely to be healthier and to have healthier babies. In addition, providers and policy-makers should emphasize that use of family planning early in a woman's reproductive life may allow her to continue her education and gain job skills. While women in many cultures gain status through motherhood, and young women, therefore, are often eager to begin childbearing, reproductive health providers and educators may be able to temper this enthusiasm with information about the health and socioeconomic risks of too-early pregnancies, as well as the benefits of delayed childbearing.

In addition, formal education about family planning -- which may include use of a modern contraceptive method or a decision to abstain from sex -- should begin early in women and men's lives, before first sexual intercourse. Family planning should be emphasized as life planning for boys and girls and included as a component of reproductive health. Programs should not merely provide information on reproductive biology but provide training to help young people develop skills in decision-making and communications.

Because many youth become sexually active while in school (or while they are school-age), schools are logical settings for reproductive health education programs. To be effective, school health programs that include responsible sexual decision-making should be developed and implemented in collaboration with community leaders, parents, religious leaders, health workers, educators and young people themselves. Special efforts must be made to reach young men and women who do not attend school or who drop out. For this vulnerable population, programs could be offered in churches, youth clubs, or community centers.

Educators and parents who encourage young mothers to continue their schooling will be contributing to women's chances for a stable economic future. Postpartum and postabortion counseling is an effective way to reach women in need of contraception, especially young women who have experienced an unplanned pregnancy.

Service Delivery Issues

Men often have the dominant role in family decisions but tend to be marginalized by family planning programs and services.

As advances in science and technology have fostered an increase in the number and types of contraceptive methods available for women, family planning programs have targeted their services primarily to women. Programs have seldom placed an equal emphasis on educating and involving men. While men continue to play a primary role in decision-making in the family, they frequently do not have access to information and services that would empower them to make informed decisions about contraceptive use. Men's lack of involvement in family planning programs discourages them from becoming effective contraceptive users or supporting their partners' contraceptive use.

In numerous WSP studies, participants cited family planning as women's responsibility. However, decision-making on family issues, including family size, was viewed as the man's responsibility or, in some cases, as the couple's shared responsibility. In many countries, men were insistent that the final decision about contraception was theirs; in other cases, women said they did not want husbands involved. In Mali, men said that the decision to use family planning should never be made without the husband's consent.

In Indonesia, where the country's contraceptive prevalence rate is 55 percent, family planning use is routine for women but not for men. More than 60 percent of the 700 women surveyed in Jakarta and Ujung Pandang said they had discussed family planning with their husbands, and more than 80 percent said their husbands approved of family planning. However, fewer than 20 percent of women said they had asked their husbands to use a contraceptive method. More than 38 percent of women in Jakarta and 11 percent in Ujung Pandang said they would rather not have men involved in family planning.37

"I prefer to go there, [to the family planning clinic] even though it is far away. ...They talk to me, they explain things. ...Even though I have to pay, that's okay."

Woman in El Alto, Bolivia

When asked if local family planning clinics provided services for men, more than 40 percent of the 600 women surveyed said they did not know. When asked how family planning clinics could involve men, women suggested that clinics provide more information, that clinics provide more services for men, that programs promote male methods, and that clinics offer special hours for men.38

Another Indonesia study found that husbands strongly influence their wives' use of contraception, but wives have the responsibility to decide which specific method to use.39 In Central and East Java, 43 percent of the 720 women surveyed said they made the most recent decision about their contraceptive method, and nearly 28 percent said they made the decision jointly with their husbands.

In China, both male and female study participants said services for men were available at local family planning clinics, and both said they would be comfortable if men and women received clinic services at the same time, in the same location. Fewer than 8 percent of couples in South Jiangsu province and fewer than 20 percent in North Anhui said the husband should have nothing to do with family planning. However, the nationwide family planning program has focused on women, emphasizing use of IUDs or female sterilization. In focus group discussions, men said family planning was the woman's responsibility, but one 32-year-old man from South Jiangsu said, "I wish we had better methods for men."

In Zimbabwe, men saw themselves as "executive head of the homestead" and they wanted to be involved in family planning discussions -- a view shared by their wives. When questioned abo

Women's Voices, Women's Lives: The Impact Of Family Planning

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