Throughout South America, serving the "mother with child" client has been the foundation of many reproductive health policies and projects. But this focus may exclude many people who need services, such as childless women, women who have completed childbearing and men. Moreover, "mother-father" and "mother-doctor" relationships are also vitally important for reproductive health.
Studies by FHI's Women's Studies Project in Bolivia highlight the need to explore multiple relationships in the reproductive health arena, rather than focusing on women alone or on women and their children.
A survey of 630 couples in Cochabamba, Bolivia, sought to understand family dynamics surrounding reproductive health by examining the relationship between men's knowledge and attitudes concerning fertility control and their wives' use of contraceptives.1
Study results showed that men knew slightly more than women about different contraceptive methods. Men generally approved of contraceptive use and reported a willingness to use a contraceptive method or support their partners' use of methods. However, only half the men reported having talked with their wives about family size. For a significant proportion of couples, both partners did not agree on what method was being used: Among couples in which at least one partner claimed the couple was using the rhythm method, in only two out of three couples did both partners report using this method.
Attempts to reach beyond women clients to the men in their lives include innovative reproductive health services provided by La Casa de la Mujer (The Women's House) in Santa Cruz, Bolivia. La Casa was organized by women to empower women, but participants gradually discovered that focusing on women exclusively rarely solved women's problems and, in some cases, created new difficulties for them.
"When the man does not participate, problems arise," explains Ane Mie van Dyke. a La Casa nurse. "A woman learns something new that the husband doesn't understand, and he does not like to feel stupid in front of his wife." When one client refused sexual relations in order to adhere to the rhythm method of contraception, her partner hit her and forced her to have sex. When she became pregnant, he hit her again. Another client's husband accused her of being unfaithful when she brought home condoms in an effort to space births.2
"We've seen that working only with women doesn't solve the problems," says La Casa gynecologist Dr. Lourdes Uriona. "In terms of family dynamics, reproductive health needs to involve both partners. In medical terms, as well, men need to participate. In the case of sexually transmitted infections, if the man isn't treated at the same time as the woman, our efforts are in vain."
La Casa's efforts to involve men in education and services include conducting family planning workshops for couples, working with young men and women, and attempting to incorporate partners of female clients in center activities.
Health professionals
Gender awareness not only helps couples to analyze and improve their relationships, but enhances relationships between clients and health professionals as well.
An FHI study of the Center for Research and Development of Women (CIDEM)'s health center in El Alto, Bolivia, focused on the center's efforts to empower local women. CIDEM has enabled and encouraged participants to make decisions about their own reproductive health, and to help design health policies and projects. These efforts were challenged, however, when women who had learned to demand respect and to take responsibility for their own health encountered professionals unwilling to share greater knowledge and decision-making.3 Other researchers in El Alto found that many women believe providers are not informing them about alternative method choices or side effects of each method, or not allowing them to take part in decisions about the need for cesarean sections and other medical procedures. They concluded that the tendency of clinic doctors and staff to dismiss clients' questions and concerns about contraceptive methods undermined the providers' ability to counter misinformation and relieve women's fears.4
CIDEM questioned the established practice of medical professionals making important diagnoses and treatment decisions with little input from patients. The organization developed an approach in which providers and clients discuss options in a collaborative manner. Professionals learned to respect clients, listen to them, and speak their language, both literally and figuratively, in ongoing relationships characterized by a sharing of knowledge, as well as power, over reproductive health issues. This approach has led to increased provider-client cooperation, more accurate diagnoses and improved client health.
CIDEM encouraged the use of this model of client-provider decision-making by referring its childbirth patients to clinics where medical personnel participated in CIDEM-facilitated workshops and made a commitment to such practices. Women who have received care in participating centers indicate that treatment has improved substantially. Celia Pérez, a young mother of two from El Alto, contrasted the care she experienced during her first childbirth to the positive attention she received during her second delivery: "Many women, especially those in traditional dress, accept abuse from doctors because they think doctors are superior. With CIDEM, I learned that they have no right to treat me like that. The second time I went to give birth, I told the doctor, 'I am going to cooperate with you, and I want you to cooperate with me,' and it was much better."
Body and mind
Sexual biology influences the development of cultural roles and relationships in complex ways. That women bear and nurse children, for example, is a fundamental factor in the development of gender identities and symbols, although these identities vary tremendously across cultures and through time.
Likewise, gender practices affect women's physiological development and functioning. Tight corsets, foot binding and female genital mutilation are just a few practices that harm women's health and sexuality. While the use of modern contraceptives has many important benefits, methods can sometimes produce undesirable side effects. As such, they can affect women physiologically.
Psychological factors also play a role. Dr. Uriona of La Casa believes that shame, fear and guilt can harm her clients' health. A repressive social environment, she says, discourages open conversations to help resolve psychological and physical problems. "The stress and oppression that women experience in their lives are often manifested in physical problems, especially gynecological problems," she says. Most of this pain is rooted in her patients' inability to express their feelings and needs. "For some women, shame and repressed emotions interfere with the ability to feel pleasure or pain in the genital area," she says. "This condition not only harms marital relations but interferes with medical diagnosis."
That feelings of shame can notably reduce women's sexual pleasure was one conclusion from a study involving focus group discussions and in-depth interviews with 132 women and men in El Alto, Bolivia. When asked the question: "Do you let your partner know what you do or do not like during sexual relations?" men reported with much more frequency than women that they told their partners what they liked. When asked whether they enjoy sexual relations, a majority of men affirmed that they enjoy sex, while a majority of women said they do not.5
For many women in this and other studies conducted in Bolivia, shame was coupled with fear about reproductive events such as menstruation, miscarriage and disease, as well as fear and mistrust of contraceptive technology. Researchers found that fear of contraceptives produces psychosomatic problems related to method use, high rates of discontinuation of pills and injections, and early removal of intrauterine devices (IUDs).6
Client-oriented providers help combat the negative effects of shame and fear commonly associated with sex and reproductive health care by listening closely to what clients say and respecting their feelings. "We begin every consultation with an open conversation in which the patient has the opportunity to express her problems in narrative form," says Dr. Uriona. "We often talk in the native language Quechua, the patient tells me about her life, and I thus begin to get a glimpse of where tensions arise."
In order to improve the population's health in sustainable ways, however, gendersensitive services must be complemented by structural changes in educational, legal, religious and other institutions that generate and reinforce shame, fear and misinformation, hindering sound reproductive health.
Recognizing differences
A gender perspective also helps providers recognize and respond to crucial differences among clients. Two kinds of gender differentiation have been identified in Bolivia. The first involves qualitative differences in the lifestyles and experiences of groups distinguished by their sexual identities, such as wife/mother, single professional mother, or male homosexual. The second involves sexual discrimination in legal, political, religious, educational and economic institutions, where policies and practices tend to transform gender differences into inequalities.
CIDEM's and La Casa's health centers try to take into account the differing practices, expectations and needs of the gender groups they serve, which include market women, male adolescents, prostitutes, rural Indians and middle-class housewives. La Casa staff's awareness of the difficulties inherent in educating and providing services to people with perspectives and experiences different from their own has motivated them to experiment with innovative approaches to learning and communication, such as theater, art and games. A key benefit of these approaches is that they help equalize the balance of power between providers and clients.
Numerous reproductive health programs in Bolivia have attempted to reduce institutionalized gender inequalities through efforts ranging from consciousness-raising courses to advocating national legal reforms, such as recent legislation against domestic violence.
Recognizing that health programs often fail to provide equitable access and care to all clients, CIDEM took steps to make its services more accessible to women who have childcare responsibilities, have limitations on mobility and money, or who fear mistreatment and humiliation. It offered low prices and services located on a bus route in a working-class neighborhood, and treated poor and indigenous women with respect. CIDEM personnel avoid sexist or racist language as part of the effort to develop more equitable relationships, both between providers and clients and among staff members.
Reproductive health and reproductive rights extend beyond family planning. From a gender perspective, women and men are not just reproductive beings, but multifaceted individuals with complex concerns, needs and expectations, all of which are influenced by their gender roles and relationships, developed in specific cultural contexts.
A major concern for most Bolivians is economic survival. Families must seriously consider whether or not they will be able to feed more children. For many women, recent economic crises have meant having to diversify wage-earning activities and increase work hours. As these women wash clothes, sell goods in the market, grow potatoes or perform other paying work, they also bear and raise children and engage in a range of family and social activities. These heavy labor burdens limit access to health care and fertility control services. As a young woman who came to CIDEM for legal advice explained, "I have four children and I have to work. There simply isn't time to go to the clinic, even though there is one near my house." 7
Often, larger issues like economic and food security, legal and political rights, and access to education and information strongly affect sexual and reproductive health. Clearly, providers cannot remedy such problems by themselves. However, a gender perspective can help them to recognize attitudes that govern and shape reproductive health behaviors; identify barriers to reproductive health care; explore new strategies to improve services for women and men; and develop referral programs and collaborative efforts with other organizations to improve the conditions under which different members of the population exercise their rights to sexual and reproductive health.
-- Susan Paulson, PhD
Note: Dr. Paulson, an anthropologist who lives in Brazil, has conducted research about gender issues and has taught at several Latin American schools and universities.
References
- Zambrana E, Reynaldo C, McCarraher D, et al. Impacto del Conocimiento, Actitudes y Comportamiento del Hombre acerca de la Regulación de la Fecundidad en la Vida de las Mujeres en Cochabamba. Research Triangle Park, NC: Cooperazione Internationale and Family Health International, 1998.
- Paulson S, Gisbert E, Quitón M. Innovaciones en la Atención de la Salud Sexual y Reproductiva. Research Triangle Park, NC: Family Health International, 1996.
- Paulson S, Gisbert E, Quitón M. Case Studies of Two Women's Health Projects in Bolivia. Research Triangle Park, NC: Family Health International, 1996.
- Schuler S, Choque M, Rance S. Misinformation, mistrust, and mistreatment: family planning among Bolivian market women. Stud Fam Plann 1994;25(4):211-21.
- Camacho A, Bailey P, Buchanan A. Impacto de la Regulación de la Fecundidad sobre la Estabilidad de la Pareja, la Sexualidad y la Calidad de Vida. Research Triangle Park, NC: Proyecto Integral de Salud and Family Health International, 1998.
- Schuler.
- Paulson, Case Studies.
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