Table of Contents
Preface
Foreword
Contraception, Empowerment and Entitlement: A Necessary Crossroads in a Woman's Reproductive Life
AIDS and Reproductive Health: Old and New Questions
Motherhood and Female Work: Signaling Trends
Contraceptive Practices and Abortion in Brazil
The Fertility Transition and Violence Against Women
Fertility, Child Education and Gender
Preface
In mid-1994, I was invited by Family Health International to explore and reflect upon the complexities surrounding the various processes of change in the lives of women. These include the spheres of education, employment, social and political participation, moving through gender relations and women's roles in the family, to sexual and reproductive behavior.
The idea was to try to understand this as a two-way process. For example, it is just as valid to suppose that an increase in the participation of women in the work force can lead to a reduction in the number of children as it is to suppose that a smaller family offers new opportunities for women in employment. This point of view breaks with the utilitarian view of one-way causality and was the motivating factor behind my involvement in this initiative.
It was easy to suggest names of Brazilian researchers and invite them to put their thoughts down on paper. Six months after our meeting with Patricia Bailey and Arlene McKay, a seminar was held in São Paulo on December 9, 1994, to present and discuss the six papers prepared using this new perspective.
The papers that make up this publication of abstracts are an indispensable step in the effort to suggest new pathways for reflection on the processes of change with respect to gender and reproduction.
Elza Berquó
Núcleo de Estudos de População
Unicamp, São Paulo
Foreword
In Brazil, considerable research has been conducted on the demographic transition and Brazil's decline in fertility. However, fewer research projects have focused on how this transition has affected women and the changes they have experienced in relation to work, education or other psychosocial aspects of their lives. Access to study findings from Brazil is essential to the development of research and programs that respond to women's needs.
The Women's Studies Project (WSP) of Family Health International is pleased to present here abstracts of six papers. They summarize the current level of knowledge and discourse on topics identified as high priorities during discussions among staff of the WSP and women's health organizations in Brazil.
To facilitate the efforts of Brazilian colleagues, as well as the work of the WSP, FHI asked Elza Berquó to identify what was known and what needed to be answered about how women's lives are affected by contraception and reproductive health services. These review papers explore the impact of family planning on reproductive roles, work force participation, and personal and social aspects of women's empowerment.
FHI is very grateful to Elza Berquó for her leadership and guidance in the development of the six review papers. We appreciate the care and scholarship that was brought to this task by the authors. Finally, we would like to acknowledge the assistance provided by Maria Coleta de Oliveira and the staff of the Núcleo de Estudos de População (NEPO) at the University of Campinas and the Centro Brasileiro de Análise e Planejamento (CEBRAP).
Contraception, Empowerment and Entitlement: A Necessary Crossroads in a Woman's Reproductive Life
by Margareth Arilha
Currently the use of contraceptives in Brazil has reached a level comparable to that of modern developed countries. There has been a drop in the total fertility rate from 4.5 children in 1980 to 3.5 children in 1984 and a further decline to 2.5 children in 1991. Such a reduction has occurred, however, through the extensive use of female sterilization and oral contraceptives, used respectively by 44 percent and 41 percent of contracepting women, ages 15 to 44, living in union. Reduction in fertility has taken place at a high cost to women's health.
Taking into consideration this profile of contraceptive users, it is important to stress two aspects of women's reproductive lives: a large number of Brazilian women still have more children than they desire; at the same time, women have not abandoned maternity as an important part of their life plans. Women continue to want families, to have children and to care for them; however, the weight or costs that women associate with these activities seems to be increasing.
More than three decades have passed since modern contraception was introduced, producing major changes in the world. Yet many questions have not been answered adequately regarding the individual and social needs of women.
In the last few years, several studies have been conducted in Brazil that show:
- women clearly want fewer children;
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- women actively seek contraception;
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- contraceptive use, far from allowing the separation of sexuality and maternity, represents the need to preserve one's health and the opportunity of providing the best care possible for the children one already has; and,
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- for some women, contraception represents the possibility of widening their experiences and becoming more involved in public life.
Adolescents and young women are two groups in particular who, as they are exposed to new life experiences in a process of increased socialization, understand contraception as something that can lead them to the public sphere and to a greater sense of autonomy. In Brazil, young women are growing up in an environment of increasing urbanization, with higher levels of education than previous generations, and with fathers and mothers who want information about sexuality and contraception to be more available in the media, in the schools and in health services, as well as in the home. This group of younger women, without negating the desire for motherhood, will be able to postpone childbearing if they anticipate individual or social means for fulfilling their lives.
Using contraception does not necessarily mean an increase in opportunities for women, especially for older women, but often it does provide women with a relief from having more children than they want and offers the ability to preserve their health to a greater degree. Contraception does not mean sexual freedom, as was thought in the 1960s and 1970s. Nor does contraceptive use guarantee freedom to act in the public sphere. It seems likely, however, that the increase in personal and professional opportunities leads women to use contraception as they create expectations of life plans that take them beyond motherhood.
Some of the data on contraceptive use in Brazil suggest that education influences the decision to use contraception. However, its influence may be relative regarding the choice of method used, especially in context of the limited reproductive health care offered by service providers, where the contraceptive options for Brazilian women are almost completely limited to female sterilization and the pill. In Brazil, the demand for female sterilization is high, including among educated women.
It is important to note that the use of contraceptives does not always accompany economic opportunity for women. Contraceptive use is not necessarily an indicator of a desire to participate in the labor force, for example. Nonetheless, the desire and the need to work can lead to contraceptive use.
As far as the link between contraceptive behavior and women in the marketplace is concerned, studies show that number of children is negatively correlated to women's labor force participation. Nonetheless, the link between women and the process of economic production must be associated with the processes of empowerment and entitlement. Entering the labor force, suffering the consequences of inequality based on gender discrimination, and continuing to bear the load of all domestic work without societal understanding of this situation may do very little to strengthen women's ability to carry out reproductive options. An understanding of one's self as an autonomous subject, as well as a person with "rights," are conditions that, when present, certainly permit a woman to make decisions that give her more control over her life. The processes of empowerment and entitlement that stimulate a development of gender consciousness and a sense of rights in the private domain, together with a perception of women's new abilities, will lead to an increase in the use of contraception among the female population.
Margareth Arilha has a degree in psychology from the University of São Paulo. She is a founder and director of Estudos e Comunicação em Sexualidade e Reprodução Humana (Studies and Communication in Sexuality and Human Reproduction) and participates in numerous political and health research networks/groups. Currently she lives in São Paulo, where she is executive director of the Commission on Citizenship and Reproduction.
AIDS and Reproductive Health: Old and New Questions
by Regina Maria Barbosa
At the end of the 1980s, the increasing incidence of AIDS among women significantly aggravated their already precarious health status in Brazil. Furthermore, the fact that the epidemic is affecting younger women more than older women, and the fact that sexual transmission plays an important role in the spread of HIV among women, have serious consequences for sexuality and reproduction and present a series of issues and challenges in the area of reproductive/sexual health.
The increase in vertical transmission of the virus (from mother to child), for example, has stimulated numerous political and ethical discussions and confrontations, among which are the right of the seropositive woman to bear a child, the illegality of abortion, and the issue of routine/mandatory screening for HIV during prenatal care. These issues must be confronted with a re-articulation of the importance of assuring adequate prenatal care and delivery of services. Changes are difficult given the precariousness of the health care system but are fundamental in order to promote the reduction of vertical transmission. These changes may include the implementation of risk reduction strategies, such as the use of the drug AZT during pregnancy and delivery, the use of Cesarean sections, and the cleansing of the birth canal.
The links between reproduction, sexuality and AIDS give rise to two opposing challenges. On one hand, there is a need to develop technologies that permit conception free from the risk of HIV transmission. Until now, all methods known to reduce this risk, with the exception of mutual monogamy, also prevent pregnancy. Thus, there is a need to separate pregnancy prevention and STD/HIV prevention. On the other hand, but equally urgent, is the need to develop effective contraceptive technologies that also prevent STD/HIV, and from this perspective, it will be increasingly difficult to view pregnancy prevention totally apart from STD/HIV prevention.
Finally, this new reality challenges the concept of vertical family planning programs, as well as the preference these programs give to the promotion of highly effective methods. By not promoting the use of barrier method contraceptives, which interfere with the sexual act but simultaneously encourage sexual negotiation and sharing of the responsibilities of pregnancy prevention, these programs have introduced a contraceptive culture. This culture today is extremely incompatible with the changes in sexual behavior that the AIDS epidemic demands.
The epidemic of HIV/AIDS requires rethinking vertical programs, whether they are related to family planning, cancer prevention, STD/HIV prevention, or prenatal care. The epidemic demands an effective integration of these activities, which have as a basic foundation the preservation of health and sexual rights.
Regina Maria Barbosa trained as a psychiatrist and holds a doctoral degree in community health from the Institute of Social Medicine at the State University of Rio de Janeiro. Currently she co-coordinates, with Richard Parker, the Program for the Study and Research on Sexuality, Gender and Health at the Institute for Social Medicine in Rio de Janeiro.
Motherhood and Female Work: Signaling Trends
by Cristina Bruschini
The fertility decline and the subsequent increase in women's participation in the marketplace are two phenomena that have occurred with intensity in Brazil since the 1970s. Several considerations can be made regarding the juncture between the economic activity of women and the family, keeping in mind that the unequal positions associated with gender have differential consequences in labor force participation. The availability of women to insert themselves into the marketplace does not depend only on their qualifications or the opportunities that the marketplace offers -- as is the case for men. Women's availability to enter the marketplace depends also on personal and family characteristics, among motherhood, which stands out due to the constant need to reconcile responsibilities.
An analysis of the trends in female employment in the last few decades, in the country as a whole and the Northeast and Southeast regions as well, reveals that, in spite of the difficulties encountered, women have entered and remained in the marketplace. This increase in female activity has occurred especially in urban areas and in the formal sector, in mid-level positions (especially in public administration), in the commercial sector, and in administrative activities. The increase in female labor force participation -- from 18 percent in 1970 to 39 percent in 1990 -- may be explained by economic, cultural and demographic factors, such as the expansion of employment in the tertiary sector, transformations in the relative value of women's roles, the expansion of female education, and the dramatic decline in fertility, which reduced the number of children per woman and freed women to work outside the home.
Reflecting on the personal and family factors that affect female work, motherhood is critical. Because women are still the primary caretakers of small children, children's presence at home and children's ages are the factors that interfere most with women's participation in the marketplace. In 1980, 39 percent of Brazilian women without children worked, but this percentage dropped to less than 30 percent among mothers. However, when children grow up and mothers' caretaking responsibilities can be substituted or supplemented by school, women's availability to work increased again. About 41 percent of mothers with children older than age seven worked in 1980, a higher proportion than women without children.
In the last two decades, important changes in the labor force have taken place for Brazilian women. The entry into the marketplace of married women and mothers in the 1970s and older women and wives in the 1980s, indicates that, in spite of the difficulties, family responsibilities have not been a barrier to women working. In 1990, 55 percent of women ages 30 to 39 years old and 38 percent of wives worked, signaling a change the composition of the female labor force, which had been comprised mostly of younger and single women.
Data also indicate that the increase in economic participation of wives and mothers seems to have been stimulated, in addition to the economic factors, by profound transformations in the role of women in society, given that women who began working were the most educated and from the middle classes.
The growth of female employment can be attributed much more to the great increase in the value of remunerated work of women, the result of an intense process of modernization and cultural changes observed in Brazil beginning in the 1970s, than to an elimination of the incompatibility of family responsibilities and female economic activity. Difficulties still exist, especially for those who have small children. Alternatives for substitute care, such as day-care centers, are still scarce. Few things have changed in the day-to-day life of a family, and there has been no decrease in women's chores in reproduction.
In spite of physical and emotional costs, women do not want to give up what they consider a victory. To have a remunerated activity can mean greater autonomy and decision-making power, including reproductive decision-making. This has led women to seek alternative ways of reconciling motherhood and work -- such as work in the informal sector, part-time work, work at home, or work for companies that offer some support to employees who have small children (day-care facilities and flexible schedules) -- rather than withdrawal from the market.
Cristina Bruschini has a PhD in sociology from the University of São Paulo and does research at the Carlos Chagas Foundation on the themes of women, gender relations and the role of women's employment in the family and society.
Contraceptive Practices and Abortion in Brazil
by Karen Giffin and Sarah Hawker Costa
In Brazil, the choice of contraceptive methods offered in the public sector is extremely limited, despite the existence of the government program of integrated women's health services (PAISM), designed to guarantee access to information and access to all methods.
In a context of worsening poverty, which has increased the need to reduce family size, couples' subsequent dependency on the private sector for the means to regulate their fertility has had two major consequences: a restriction of choice almost entirely to two contraceptive methods (the pill and female sterilization) and, in the case of poor women, a separation between the practice of fertility regulation and attention to health.
The pill, used without medical supervision by the majority of women, is purchased in pharmacies by women who have the financial means to do so. Women can buy and use the pill, regardless of contraindications or evidence of disease. In many cases, the pill is taken incorrectly, and this incorrect use leads to an increase in side effects which, in turn, reinforce incorrect use. It is likely, especially in these circumstances, that women will try several brands and/or doses in a process that ultimately leads to discontinuation of this method.
Any unsupervised experience certainly increases the likelihood of side effects and also increases the likelihood of unwanted pregnancy, which can raise the chances a woman will seek an abortion. With abortion, conditions and consequences will vary dramatically, depending on whether a woman can pay for the procedure. The less money a woman has, the greater the risk of morbidity and mortality. The same applies to repeated abortions. Women are known to repeatedly attempt abortion until they succeed, sometimes resorting to progressively more dangerous methods with each attempt. There are many failed abortion attempts that have never been studied, yet these attempts carry predictable prejudicial consequences for women's health and that of their offspring. Data that are available indicate a change in the profile of the woman who terminates pregnancy from one who is older and of higher parity to one who is younger and of lower parity.
In the case of female sterilization, there are huge variations in access to services. All sterilizations are basically clandestine, and most are performed in conjunction with an unnecessary Cesarean section, which represents a risk for mother and child. The clandestine nature of female sterilization impairs any standardization or supervision and, perhaps, training in the most recommended techniques. Furthermore, there is no registration or record keeping of these procedures. Under these circumstances, one might expect increased failure rates, albeit undocumented, and more frequent side effects.
Qualitative research shows that women fear possible effects of sterilization on their health and sexuality but do not perceive other alternatives once they reject the option of the pill. In this interval between pill use and tubal ligation, many unwanted pregnancies occur and end in abortion.
Far from playing their desired role of preventing unwanted pregnancies and spacing births, contraceptive practices have led to substantial use of induced abortion. Although there is currently a trend of declining fertility rates, reproductive risks vary widely across different groups and social classes. Paradoxically, it is women's intense motivation to regulate their fertility that has forced them to risk their health and, at times, their lives.
Karen Giffin is a sociologist with a doctoral degree from the University of Toronto, Canada. Currently, she teaches and does research on the themes of gender, sexuality and reproductive health at the National School of Public Health at the Oswaldo Cruz Foundation in Rio de Janeiro.
Sarah Hawker Costa is a demographer with a doctorate from the University of Oxford, England. Prior to coordinating the reproductive health program at the Ford Foundation, she taught and conducted research at the Oswaldo Cruz Foundation in Rio de Janeiro.
The Fertility Transition and Violence Against Women
Maria Filomena Gregori
Discussion of the impact of the fertility transition, which began in Brazil in the mid-1960s, on violence against women imposes several challenges. On the surface, the decline in fertility could point to a positive trend toward women's liberation. Yet domestic violence suggests, in a cruel way, that women are still subjected to oppression.
An optimist might argue that if there were a negative impact of fertility transition on violence, society would be historically poised to overcome the problem of asymmetry between the sexes and violence against women would be eliminated. However, it is necessary to be cautious. To establish connections or suggest a relationship of cause and effect between fertility transition and domestic violence runs the risk of oversimplification of the problem and ignores the complexity of family relations between men and women.
Violence against women gained visibility in the 1980s as a result of the feminist struggle, followed by legal and judicial interventions as well as research on the topic. One of the most striking characteristics of this new visibility is that the majority of charges women made were related to physical aggression and, in most cases, the perpetrators were married to the victims. The denunciations of violence against women in Brazil correspond to conflicts associated with gender roles and positions within the family. One of the obstacles to overcome in the study of domestic violence is the lack of data related to fertility; most of the studies of the last 10 years do not even include information on women's parity. The empirical evidence that does exist has come from qualitative research on domestic violence.
An important first step in the study of domestic violence is a discussion of how the decline in fertility, taken in isolation, might change patterns of how couples relate to one another. Some interesting studies that have examined demographic changes and changes in family and individual paths point to the fact that the family in Brazil should not be thought of as homogenous. The family should be viewed as an multifaceted entity with multiple arrangements. When examining the family, one should expect social, gender and age differentials.
It is important to note that demographic change does not lead to easy conclusions or to a vision that contrasts the traditional lifestyle with the modern. This is because the relationship between values and social practices always occurs in an unequal way, depending on the context in which social agents are situated and the myriad of meanings and motivations that any single phenomenon can suggest. It is important to highlight that one does not witness a devaluation of the family as an institution, even though minority sectors of society are questioning the most traditional arrangements. There are no guarantees that these demographic changes reveal real signs of transformation in the relations of inequality between the sexes.
It is impossible to ignore the advances gained by women in the last two decades. The marketplace has incorporated female employees, although their salaries are less than those of their male counterparts. Women are better qualified academically. The Brazilian constitution of 1988 increased women's rights, and institutions are more sensitive to the problems of gender. Nevertheless, most studies suggest that women live with and relate differently to oppression. The process of domination is a difficult web to untangle, and the problem of domestic violence illustrates this complexity.
The domestic violence that is reported corresponds to a pattern of relationships in which conflicts are lived. These abusive relationships include repeated physical aggression, which leads to the search on the part of women for external help to re-balance their day-to-day living arrangements, making them at least minimally tolerable. Campaigns to prevent violence against women and the existence of the Women's Police Delegacies increase the potential for women to defend themselves. However, it is too early to affirm that women themselves are convinced that aggression constitutes a crime and that it is the result of inequality between the sexes. In this sense, questions about these violent relationships deserve to be analyzed. It is crucial to confront the fact that even marital violence -- only one of the facets of the more general problem of violence against women -- does not correspond to a homogenous profile of women, of men, or even of motivation or conflicts that lead to aggression.
This author's research on women who were beaten and sought help at SOS-Woman in São Paulo during the early 1980s shows that most women had two to four children. Also, most women were in the midst of the fertility transition, and most were married or in union for an average of nine years, with small children. This is the situation worth stressing: It is not so much the size of the family that makes a difference but the daily activities, sexuality, and chances of independence that are compromised when a woman has children in this phase of greatest dependence.
Being a mother imposes responsibilities -- sometimes dramatic ones, when one considers the lack of material resources -- and alters the configuration of sexual roles and the positions of masculinity and of femininity in the couple's relationship. It is a propitious moment for conflicts to emerge -- although our society stresses only the pleasure and the happiness that motherhood brings. Often people do not know how to cope with difficulties, and there are few resources for assistance and support to help them find solutions. This is the case with women who seek help at SOS-Woman.
Violence takes place in the context of a relationship between partners that is, in many circumstances, neurotic. There is no advantage in reducing violence to merely a conflict between traditional and modern values or to simply claim that it is the result of the traditional roles associated with women, among which are staying at home, taking care of children, and not feeling sexual pleasure.
The question arises: What do these violent relationships have in common? They reveal with intensity that aggression is an act that stems from various roots, in which different nuances take place. It is performed, in the beginning, as the creation of new games in the partner relationship. Agreement, understanding or negotiating decisions do not exist. In these relationships, the partners surrender themselves to produce victimization and blame, or to rearrange feminine and masculine images and behaviors. The relationships also highlight the degree of symbiosis to which the couples' marital and family relationships are subjected. They are partners -- involved in a wide array of contradictory feelings, such as love/hate -- bound by private rituals that are repeated daily.
These are relationships that demonstrate, moreover, that the primary problem of gender issues is the asymmetry between the parties (the woman throughout history has been the weak party) and not in a generic condition of oppression. Women are able to occupy different social positions, in the public world and in the private sphere. However, asymmetry -- the difference that a position of unequal power implies -- persists not only in our social structure, but in the depths of symbolic arrangements on which our culture is composed. Therefore, it is very likely that violence will remain. In this sense, the effects of the decline in fertility should be viewed in light of changes in the economic, political, social and cultural arenas.
Maria Filomena Gregori teaches anthropology at the State University of Campinas and conducts research at the Centro Brasileiro de Análise e Planejamento (Brazilian Center for Analysis and Planning) in São Paulo.
Fertility, Child Education and Gender
by Fúlvia Rosemberg
The impact of fertility on child education is a complex issue. To gain a better understanding, research emphasizing child education from the perspectives of both the children in day-care and preschool, as well as the women who work at these sites as professionals, is needed.
Researchers must question analyses that evoke a linear relationship between the decline in the number of children and the needs or limitations of social policies. It is important to take into consideration the new significance attributed to childhood in the very contexts that demonstrate declining birth and infant mortality rates.
A characteristic phenomenon of contemporary urban societies is the expansion of child education in collective settings, indicating a search on the part of families to share the care and education of their children with other social institutions. The literature dedicated to this field has sought to understand this expansion in light of contemporary changes in gender relations (in the public and private spheres) and in light of a greater knowledge of the small child, now perceived as a competent being capable of complex social interactions at a very early age. Thus, rather than perceive this sharing in the education/care of small children as an attitude of "abandonment" on the part of the family, there is evidence that this is a strategy that strengthens the affective family bonds in this new social context.
The studies by Le Vine on how small children are socialized differently in agrarian societies (with high levels of infant mortality and fertility) and in urban societies (with low levels of infant mortality and fertility) provide support in the realm of the psychic life. For contemporary parents, day-care centers and preschools are necessary institutions that intensify the affective investments in children. At the same time, day-care centers and preschools constitute environments necessary to support the individuality of children and make possible the social relationships with contemporaries, controlling centripetal trends.
Despite the observed trend toward the universalization of child education, this departure of the small child from the domestic space occurs under control. It is complementary and does not substitute for the family. Often it reflects, reproduces and creates subordination of class, race and gender in the public context.
Quality of attention is intimately associated with wealth; it is worse in poor countries and worse for poor populations in all countries. In multi-racial countries, such as Brazil, children's education can become an agent in the discrimination against poor and black children. An impressive number of black Northeastern children attend preschool at an age when, legally, they should be in the first grade. In Third World countries, this discrepancy takes place because a model of inexpensive child education has been disseminated and implemented. The model is nonformal and is supported by the work of underpaid women who themselves have low levels of education.
In spite of the perspective that child education is an instrument of change for gender relationships, it also constitutes one of the institutions that most intensely segregates the sexes, often setting up public spaces of confinement for women and children.
Returning to the implications for social policy of the decline in fertility and its impact on education, planners must be alert to: 1) this new social and affective investment in childhood and to the perverse impact of an expansion of child education without the necessary resources; 2) the need for children's education not to constitute a precocious socialization for subordination; and 3) the need for investment in education and professional training of those who work in the education field, especially in Third World countries, in order to minimize the negative effects on the lives of women and children.
Fúlvia Rosemberg has a PhD in psychology from the University of Paris. She teaches social psychology at the Pontifícia Universidade Católica of São Paulo and also does research at the Carlos Chagas Foundation.
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