Family planning promotion in the Arab world: Practices perceptions and the effectiveness of birth spacing campaigns in Amman, B Buchholz

Tags: family planning, contraception, birth spacing, Amman, reproductive health, Jordan, Ministry of Health, husband, counseling, married women, Family Health Survey, awareness campaign, pharmacists, societal level, maternal and child health, effectiveness, commercials, interviews, attitudes, contraceptive methods, perceptions, Nasser, methods of contraception, social constraints, contraceptive advice, counseling services, practices, forms of contraception, traditional methods, contraceptive pills, modern methods, Jeries Salaytah, Jordan Population, campaign, ORC Macro, interviewed, Jabal Amman, Jordan University, Michael Bernhart, Nadine Khoury, birth intervals, population health, maternal health, contraceptive knowledge, women, modern method
Content: family planning Promotion in the Arab World: Practices Perceptions and the Effectiveness of Birth Spacing Campaigns in Amman By Brittany Buchholz
Family Planning Promotion in the Arab World: Practices, Perceptions & the Effectiveness of Birth Spacing Campaigns in Amman Introduction Today, the nation of Jordan faces two major threats to the overall health and social well being of its population. One threat is due to the Kingdom's unsustainable annual population growth rate of 2.6%, the result mainly of high fertility rates.1 A second threat, posed by inadequate birth intervals and the lack of family planning, endangers women's and children's health. Research has shown that spacing births less than two years apart may compromise the development of the child and the ability of the mother's body to replenish the nutrients needed during pregnancy.2 New evidence shows that birth intervals of three to five years--well above national averages in Jordan--are the healthiest options for both mother and child. Clearly, efforts at both the governmental and societal levels are necessary to deal with these challenges to population health. The Jordanian government and its people, however, face two significant obstacles if they are to deal with these problems. One is that family planning is still a relatively new concept in the Arab world. The second is that, in Jordan, any attempt to implement family planning must consider the context of gender constructions and family-centered Social Networks. The identity, if not the value, of many Arab women is often shaped by their ability to reproduce. An acceptance of the limiting and spacing of children through contraception would therefore signify notable changes in cultural values. It may, in some cases, signify a movement away from the primacy of childbearing toward attitudes of population health, economic sustainability, and social responsibility. Thus, an important question for the Hashemite 1 Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key Findings, Calverton, MD, USA: ORC Macro, 2003. 2 Setty-Venugopal, V. and U.D. Upadhyay, Birth Spacing: Three to Five Saves Lives, Population Reports, Series L, 13: 2. Baltimore: John Hopkins Bloomberg School of Public Health.
Kingdom remains whether or not the potential for such positive change in women's family planning practices exists in Jordan. In an attempt to answer to this question, Jordan's Ministry of Health, with the cooperation of the Primary health care Initiatives (PHCI) Project, has implemented an extensive campaign aimed at increasing birth spacing awareness and societal family planning acceptance. Planning for the current national campaign began in 2001 with funding from the United States Agency for International Development (USAID).3 The campaign, which features a cartoon child named "Sahhii"4 in a real world environment giving advice about various reproductive health issues, is being implemented in three distinct phases. Given the culturally acceptable time after marriage in which contraceptive knowledge may be disseminated to women, each phase primarily targets pregnant women and newly married couples. The first phase began in January of 2003, promoting the benefits of a healthy mother and child during pregnancy as well as informing women of the benefits of breastfeeding. The conclusion of this first phase in August of 2004 coincided with sixteen focus group discussions to evaluate its effectiveness. Used to develop the second phase of the campaign, the focus group suggestions allowed program planners to modify the Sahhii character and address participant concerns. The second phase, set to run through the end of December 2004,5 focuses on the benefits of birth spacing and informs women about the availability of various contraceptive methods. Campaign messaging consists of appeals to values such as child health and nutrition, maternal health, and the general well-being of family, in order to promote spacing between children of at least two to three years. Its success would mean widespread knowledge and acceptance of spacing 3 Hamzeh, M. Interview, 11-24-2004, Ministry of Health Department of Health Education, Amman 4 Arabic word for "healthy"
methods necessary for fewer mistimed or unwanted pregnancies, a decline in Infant mortality and an increase in maternal health. To reach women in all sectors of society, the campaign has utilized a full range of media outlets including television advertising, radio messaging, billboard signage, printed handouts, and documentary film, each bearing the consistent message encouraging two to three years spacing between children. Commercials air on three government television channels and FM and AM government radio stations. Eight television commercials are aired daily while fourteen messages are played on the radio each day. A sample of 200 women tested the commercials before they were aired.6 The Ministry of Health's birth spacing campaign takes place at a time when traditional gender roles and current trends in Jordan's population growth rate seem to suggest that the usage of birth spacing methods is quite low and attitudes toward contraception primarily negative. Through personal interviews with several Amman-based healthcare providers and a random sample of women taken from various areas of Amman, it is expected that the opposite will be proved true. The resulting data will likely find differing attitudes toward various methods of birth spacing and a variation in attitudes and levels of knowledge between age groups as well as marital status. Yet considering Jordan's current socio-economic situation, women's attitudes towards family planning should be quite positive overall, and the influence of the Ministry of Health's awareness campaign promising. As such, the present study focuses on levels of knowledge, contraceptive practices and sources of information as indicators of family planning campaign success. It is ultimately my intention to examine the cultural constraints, which determine the effectiveness of such 5 The third and final phase of the campaign will begin in December of 2004, focusing on knowledge and utilization of the Ministry's health centers in an effort to improve contraceptive and information access. The third phase will build on the messages created during the previous two segments of the campaign. 6 Hamzeh, M. Interview, 11-24-2004, Ministry of health department of Health Education, Amman
campaigns in Jordan. In the process, however, I hope to evaluate the impact of the current reproductive health campaign by attempting to understand the attitudes Jordanian women hold at the present time towards family planning and birth spacing. policy makers and educators face numerous barriers in the distribution of family planning information, many of which are cultural or social in nature. These obstacles make it difficult to predict the success of family planning promotion programs in influencing women's current attitudes toward contraception. A better understanding of the underlying cultural or social barriers may allow program planners to capitalize on positive social forces, using the available social norms to construct more effective campaign messaging. Rationale Family planning issues in Arab societies are often subject to strong underlying social factors that demand careful understanding before an effective awareness campaign is created. Several studies completed within the last five years address reproductive health needs of women across Jordan in an attempt to do so. These studies have stressed the need to utilize birth spacing and contraceptive use as part of a Comprehensive Plan to reduce rapid population growth and improve population health. In addition to regular demographic health surveys completed every five years in the Kingdom, a surprising amount of literature exists on the factors influencing family planning decisions in Jordan. While the most substantial studies were completed in Jordan over three years ago, they provide us with the conditions against which to base the findings of the current study. Conducted under the premise that the private or subconscious attitudes of women toward contraceptives will determine their willingness to adopt a family planning method,7 the 7 Bernhart, M. and N. Khoury, Perceptions of Contraceptives Among Jordanian Women, CMS/Jordan and Market Research Organization: 2001
first study reveals several important socially-shaped perceptions toward three well-known methods of contraception. Researchers Michael Bernhart from Commercial marketing strategies (CMS/Jordan) and Nadine Khoury of the Market Research Organization employed a projective technique in which the underlying feelings and beliefs of Jordanian women toward three contraceptive methods were explored by asking them to interpret fictitious medical records of other women. The three methods assessed in the study were voluntary surgical contraception (VSC), the rhythm method, and the intrauterine device (IUD). Each method yielded a very different reaction from participants, according to Bernhart and Khoury. First, compared to other methods, VSC--also known as surgical sterilization--received the most negative reactions from the women.8 The majority viewed the woman utilizing the VSC method as uneducated and unaware of the consequences of her actions. They also perceived this woman to be indifferent to her husband, living in poverty, and incapable of caring properly for her family. This unfortunately seems to suggest a social perception that a woman adopting a permanent method of contraception cannot handle her primary responsibility of childrearing. The second method tested in this study, the rhythm or calendar method, also produced negative reactions among the women, though to a lesser extent than that of the VSC patient.9 The fictitious woman choosing to use only the rhythm method was perceived as a decent person, though old-fashioned and traditional. While she refused to change her life to adopt a modern method, she was also perceived as willing to take risks with an unreliable method. Her husband, interestingly, was described as less concerned with the care of his family than would a husband whose wife had used a modern, more effective method. Previously, a lack of 8 Bernhart and Khoury, 23 9 Bernhart and Khoury, 2.
awareness and acceptance of contraceptive methods has been widely believed to be a socially constructed adherence to tradition, often with religious implications.10 Yet from data collected during their study, Bernhart and Khoury conclude that "A traditional method is not used out of attachment to tradition, but at least in part out of doubts about side effects...associated with modern methods of contraception. Tradition is not, in itself, valued when it comes to contraception."11 Finally, in contrast to the prior two methods, participants asked to evaluate the woman using the IUD responded with far more positive than negative perceptions. She was described as a modern woman, who cared for her family and had a good relationship with her husband.12 From this method, one general implication that may be drawn is the strong link between modern forms of contraception and care for the family, especially the family's standard of living.13 Ultimately, the study found that to limit or space births is viewed as a responsible act that protects the welfare of family members. A second study entitled, "The Contraceptive-adoption process in Jordan," conducted in 2001 by Commercial Marketing Strategies Jordan (CMS/Jordan), in collaboration with the Jordan Center for Social Research, analyzed the process used by Jordanian women when adopting a modern method of contraception.14 As part of the study, 155 married women who had adopted a modern method of contraception in the last 18 months were surveyed. The study examined some of the elements of the contraception-adoption process for Jordanian women, ranging from the women's satisfaction levels with different contraceptive methods to their 10 Underwood, C. "Islamic Precepts and Family Planning: The Perceptions of Jordanian Religious Leaders and Their Constituents," International Family Planning Perspectives, 2000, 26(3). 11 Bernhart and Khoury, 3. 12 Bernhart and Khoury, 3. 13 Bernhart and Khoury, 23.
confidantes and counselors in the decision to use them. According to the study, women most frequently sought the advice of physicians when contemplating a family planning method. Alternatively, a woman's husband, while influential in her decision to begin or discontinue contraception, was much less so when it came to selecting a contraceptive method.15 One major finding of the study dealt with contraception discontinuation. Michael Bernhart and Mousa Shteiwi, researchers for CMS/Jordan and the Jordan Center for Social Research, respectively, found that "very few women abandoned fertility regulation altogether."16 Instead, women dissatisfied with modern methods either switched to a different modern form of contraception or decided to use a less reliable form of traditional contraception. While the results of the current study show otherwise, the CMS/Jordan study also attempts to prove that the majority of women using traditional methods of contraception were not dissatisfied former users of modern contraception, dismissing the role of side-effects in a woman's perceptions of hormonal methods. The majority of subjects in the CMS/Jordan study did readopt a method of contraception after discontinuing usage of the first. However, this study does not address the underlying factors that may lead a woman to discontinue contraception in the first place. It is such broader societal barriers that most greatly undermine the possibility of adopting family planning methods, limiting the effectiveness of contraceptive counseling and weakening a woman's social access to reproductive healthcare. The government's current campaign to raise awareness about birth spacing and reproductive health stems from the outcome of similar studies conducted by various marketing firms throughout the Kingdom. Outreach campaigns now include television and radio 14 Bernhart, M. and M. Shteiwi, The Contraception-Adoption Process in Jordan, CMS Jordan and Jordan Center for Social Research: 2001. 15 Bernhart and Shteiwi, 3. 16 Bernhart and Shteiwi, 14.
commercials as well as door-to-door grassroots work, the training of medical providers, and counseling services in hospitals and clinics. It is crucial to assess the effectiveness of awareness campaigns in delivering information to women in Jordanian society if resources are to be used most effectively in creating positive social change in the future. Methodology Reproductive health decisions impact the lives of women across all parts of Jordan. For purposes of narrowing the focus of this study, I will concentrate primarily on women living in the capital city of Amman. As I have chosen to limit my analysis to women and healthcare providers within the city, the results of my research will be applicable to this urban population only. Rural populations may display different levels of social conservatism as well as more limited access to information and birth spacing methods. Modern communication methods used by the birth spacing promotion campaign such as television advertisements are often inaccessible to rural populations living in small villages and Bedouin communities. Recognizing that an urban study would still need to account for the situations and perceptions of a very diverse group of women, my research sample is comprised of twenty-two women of various ages and socio-economic levels residing throughout the city. As the sample is limited, it is not my intention to claim that the findings of this study are entirely representative of the larger population of women in Amman, only that the experiences and beliefs expressed by these women exist and contribute to the broader understanding of women's reproductive health in Jordan. In this context, a randomly selected, diverse sample of women provides the most meaningful insight into the range of attitudes and perceptions Jordanian women hold toward family planning. Conducting research across various social groups and geographic areas also allows for an evaluation of the scope of the current family planning and birth spacing
awareness campaign in the Kingdom. Participants ranged in age from 19 to 53, with an average age of 30.6 years. Marital status was similarly varied. Just under one-third (31.8%) of the women interviewed were either unmarried or engaged. Nearly two-thirds (63.6%) of the subjects, were married, while one woman had obtained a divorce. Reflecting the societal reality present in Amman, the majority of participants were Muslim (of which, roughly three-quarters wore the hijab), with only one participant identifying herself as Greek Orthodox Christian. Fifty percent of all women interviewed were employed outside the home. Of the remaining half, 13.6% described themselves as full-time students, while 36.4% were unemployed or worked as homemakers.17 I chose to draw subjects from several different areas of Amman, once again to collect a broad range of values and perceptions. Participants were randomly selected and approached for interviews in Abdoun, Jabbal Hussein, Jabal Amman, Downtown and areas of East Amman, as well as the area surrounding Jordan University. These areas were selected for their potential to represent the extent to which differences in economic levels may influence current practices and perceptions. I began by creating a list of questions that would be asked of each woman.18 Many of the questions served to elicit descriptions of the women's practices as indicators of their attitudes toward contraception and family planning. Others more directly asked the women to describe their comfort with certain practices and to explain their perceptions of the current birth spacing awareness campaign. Due to the sensitive nature of the subject, I felt it necessary to hire a translator for the areas in which little English was spoken. The translator was shown a copy of the questionnaire and made aware of her obligation to maintain the confidentiality of 17 See Table 1 for all demographic information on subjects. 18 See Appendix A.
participant responses. Translation was utilized in Jabal Hussein, Downtown and East Amman. As each subject was approached, she was given an explanation of the study and the concept of confidentiality was explained. The conversation did not begin without documentation, information and verbal consent. To protect the identity of each woman, all were given a subject code prior to the discussion of any information. The code served as the only identification information recorded with notes from each interview. The sensitive nature of family planning in Muslim countries necessitates the use of culturally-appropriate terminology when discussing the issue. Sexuality in Jordan is rarely discussed openly, especially with strangers. Therefore, in order to effectively communicate with my subjects, applicable reproductive health terminology was translated into Arabic and evaluated for its cultural appropriateness before the interviewing began.19 Understanding the values present in this society helps to take a more delicate approach to an already sensitive subject. Terms such as "family planning," "birth spacing" and "reproductive health" were used in place of the inappropriate term, "contraception" (which literally translates to "prevent births" and may be viewed as disrespectful toward Arab cultural values of family and children) or potentially offensive terms such as "sexual health." These considerations were made to avoid making subjects uncomfortable in any way during the interview. The cultural implications embedded in language alone highlight the challenges facing those in charge of marketing efforts for the Kingdom's family planning campaign. To supplement the series of personal interviews conducted throughout the city, several professionals were interviewed--both doctors and pharmacists--who were responsible for the direct provision of both contraception and reproductive healthcare counseling. These 19 See Appendix B for English translation of terms used during each interview.
individuals provided me with further insight into the social constructs shaping their role in the family planning process and will be discussed in further detail shortly. Finally, it was necessary to interview a representative from the Ministry of Health responsible for the planning and implementation of the national reproductive health campaign. Findings Personal conversations with each of the twenty-two women revealed several important themes, which may be taken either in context or in contrast to the findings of more quantitative studies. Regular demographic health surveys can assess the practices of women as indicators of family planning acceptance, and thus use statistical data to evaluate the success of family planning campaigns. Yet, statistics alone cannot fully explain concepts as complex and socially driven as contraception and family planning. Attitudes may evolve before any change is seen in practice if action is impeded by social restrictions, just as practices may change without the development of new attitudes. It is therefore essential to understand the cultural factors guiding this change. The attitudes of each woman, articulated during the interviews, provide valuable insight into the complexity of their perceptions, as well as clues to the most effective modes of reaching Jordanian women with reproductive health information. While this was not designed as a statistical or quantitative study, I have found it interesting to note some of the behavioral trends before attempting to analyze the more qualitative findings of the project. First, when taken collectively, the fertility rate for married women surveyed was 3.120--just under the national rate of 3.5 reported by the 2002 Population and Family Health Survey.21 The wanted fertility rate, or the number of children desired by the women (used to determine the rate of unplanned or unwanted pregnancies), was 2.9 for the 20 See Table 1.
total sample of women interviewed and 2.5 when considering only the wanted fertility rate of married women.22 At the national level, this rate among married women is 2.6, while the rate for women living in urban areas and in the central region of Jordan (both of which include Amman) is 2.5.23 This indicates that the present sample interviewed, though seemingly representative of the city's population as a whole when considering similar fertility rates, may be less demonstrative of the gap between actual and desired pregnancies when compared to the findings of the national survey. One of the most promising results of this study was the 100% familiarity with the concepts of birth spacing and family planning, even among those unfamiliar with specific contraceptive methods. Only slightly less widespread were the levels of awareness for the Ministry of Health's "Sahhii" campaign, with eighty-five percent of all women interviewed familiar with Sahhii, the central character in each of the promotional commercials. Only two women were unfamiliar with the Ministry's new marketing strategy. These women were among the youngest in comparison to the majority of participants. They had just finished school, had not attended the University, and claimed to watch very little television. These women were aware of family planning and birth spacing, but had learned about the concepts from an alternative source. Reasons for supporting family planning and the spacing of births were varied, but included maternal and child health, financial stability and family responsibilities as expressed through Islam. As one woman explained, "I told my husband I needed four years to rest after my first son was born. Then my son needed an extra year on his own, before another child, and 21 Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key Findings, Calverton, Maryland, USA: ORC Macro, 2003. 22 See Table 1.
my husband did not object because it was my decision." Echoing an emerging awareness of the development and regenerative benefits of waiting, a second adds, "We must have two years, baby and me." Virtually all women expressed plans to wait between pregnancies to give each child time to grow. Yet, while each woman quoted two, three, or even five year intervals between births as ideal for child and maternal health, this knowledge was far from practiced. Forty-percent of married women interviewed expressed prior experience with an unplanned pregnancy--either mistimed or unwanted.24 In one-third of these cases, women revealed that their husbands had objected to the timing of the pregnancy, suggesting the important role of male involvement in delaying and spacing births. While this study found that attitudes toward spacing are for the most part very optimistic, it also shows the many ways in which social factors prohibit women from achieving their desired intervals. One 32 year old woman nursed her ninth child as I interviewed her in her home. Her husband had told her that it would be better to have kids one after another, so that she could "rest when she was done." While some women cited their husband's desire to have more children and their own desire to allow for natural processes as reasons for birth intervals of less than two years, the most surprising data revealed that gender preference was one of the most influential factors driving the decision to space children. The average birth interval for women whose first born child was female was 1.7 years, while couples who first gave birth to a male infant waited an average of 2.7 years to have another child.25 These data are consistent with what I have learned from speaking with the individual women: if a female child is born first, a woman will be less likely to wait the recommended two years before trying 23 Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key Findings, Calverton, Maryland, USA: ORC Macro, 2003. 24 Revealed through personal interviews with each woman. See questionnaire used during interviews (Appendix A).
to become pregnant again, in hopes of having a boy. Every woman interviewed, married and single, acknowledged the desire and ever-present societal expectation to have a male child. With one exception,26 male was the gender of the last child in all families with multiple children, suggesting that a woman will have children until she produces a male or, if possible, more males than females. Just as gender preference may play a significant role in determining birth intervals, a woman's decision to breastfeed her child seems to correlate with the spacing of children as well. Several specialists in the field of women's reproductive health have suggested a connection between fertility and the duration of breastfeeding, particularly as an indicator of birth intervals.27 That is, women who breastfeed their children for short periods of time or not at all tend to have shorter intervals between births. The current study reveals the median duration of breastfeeding for my sample is just less than 10 months (9.9 months);28 alarming considering the median duration of breastfeeding is 12.7 months for the population living in the Central Region of Jordan and 13.0 months for the population living in urban communities.29 In Jordan, breastfeeding is widely understood--somewhat falsely--to act as a reliable form of contraception.30 While lactation may indeed make pregnancy less likely, the sole use of this method may result in unplanned pregnancies which paradoxically will lead to shorter periods of breastfeeding. Several participants in this study, in fact, admitted to an unplanned pregnancy that had occurred while breastfeeding without the use of modern contraception. These women admitted to breastfeeding for a maximum of six months, often less than three depending on 25 See Table 1. Birth intervals calculated as average number of years between first and second child. 26 In the only family where this did not hold true, the woman had had four daughters in an attempt to have a son. The mother was nearing menopause and had given up on prospects of becoming pregnant with a boy. 27 Setty-Venugopal and Upadhyay, 17. 28 See Table 1 for individual breastfeeding intervals.
when pregnancy occurred. Conversely, women who choose to breastfeed for only a short period of time will not benefit from lactation's contraceptive effect and are more likely to become pregnant if no other method of contraception is employed. Besides the obvious health benefits to the child, this is one reason many experts encourage women to breastfeed for the full two years and consider a second form of contraception if they do not wish to become pregnant. Dr. Amin Nasser, Senior Consultant at Red Crescent Hospital in East Amman, explains that each mother must be aware of the failure rates of breastfeeding as a form of contraception. He expresses his concern saying, "The longer a woman breastfeeds, the more likely it is she will become pregnant. If she commences her period during lactation she must use another method and take care not to become pregnant."31 In addition to the health-based motivation for breastfeeding a full two years, my interviews have identified a very powerful source of persuasion in Islam. Chapter two, verse two-hundred thirty-three of the Qur'an calls Muslim women to breastfeed their children for two years.32 "The baby must take milk from a woman's body for two years," one woman explained in reference to this holy edict.33 Faith-based recognition of the relationship between breastfeeding and birth spacing on the part of several participants, married and unmarried, provided them with an authoritative reason to space their past--or future--pregnancies. Islam may even inspire women to utilize modern methods of contraception while breastfeeding in order to ensure the full two-year lactation period prescribed by the Prophet Mohammed. 29 Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key Findings, Calverton, Maryland, USA: ORC Macro, 2003. 30 Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman 31 Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman 32 The Noble Qur'an, University of Southern California Muslim Student Association, 33 See Table 1.
For each of the aforementioned reasons, breastfeeding holds great potential to be one of the most effective culturally appropriate methods of prolonging birth intervals. This may also be one of the reasons the Ministry of Health chose to emphasize breastfeeding during the first phase of the campaign, prior to the promotion of birth spacing and family planning. By acknowledging the importance of breastfeeding each child for two years, women may seek family planning methods to prevent unplanned pregnancies during this period. It is important, of course, to acknowledge that underlying perceptions about contraceptives may undermine the effectiveness of a campaign entirely contingent on breastfeeding promotion. While all married women interviewed for this study were familiar with some form of contraception,34 perceptions were surprisingly negative for modern methods and varied among the traditional methods employed. Of the married women interviewed as part of this study, just under three-fourths (73%) had used a form of contraception at some point.35 Sixty percent had used a modern form of contraception. Of these women, only onethird were still using that method,36 while another third had discontinued use due to pregnancy or to become pregnant. One woman had reached menopause and the remainder felt more comfortable with traditional methods such as the rhythm method or withdrawal. Very few women interviewed had experience with more than one modern method. The reasons given for either discontinuation or non-usage were extremely varied, though each response merits careful consideration of its possible cultural implications. The most common reasons for stopping a modern method of contraception were related to the side effects and the health consequences of modern contraception. Many women turned to more 34 Several married women described their knowledge of contraceptives as limited, or were only familiar with one or two modern methods. 35 See Table 3.
traditional methods after discontinuation of either the Pill or the IUD for this reason. Several felt uncomfortable with the hormones in oral contraceptives, but were completely satisfied with condoms. Other motives for non-usage of reliable forms of contraception included infertility concerns, age (if the woman felt she had little childbearing time left at the time of marriage), a desire to let the number and spacing of children be determined by the will of God or nature, and a stated lack of information.37 Provider Perceptions: Insight from Doctors and Pharmacists As the primary providers of family planning counseling and services, doctors and pharmacists have much insight to offer a study on the underlying cultural factors contributing to a woman's attitudes towards family planning and birth spacing. For the purposes of this study, the perceptions of doctors and pharmacists interviewed will be used strictly to illustrate their own rationale for types and methods of counseling services provided and the women's observable behavior, rather than as an attempt to make claims about the attitudes, perceptions and driving forces behind decisions made by the women they serve.38 Dr. Jeries Salaytah, a private obstetrician/gynecologist in Amman, sees one to two women daily about their contraceptive and family planning needs.39 The majority of his patients are between the ages of 30 and 35, though he does see a small number of women in their twenties. This older age group may be explained mainly by a social expectation of pregnancy immediately following marriage. The younger women--those either engaged or newly married--will not likely seek contraceptive guidance from a physician until after their first pregnancy. Dr. Nasser, who sees between 700-800 women per year at the Ministry of 36 Twenty-percent of all married women surveyed were currently using a modern method of contraception as compared to the urban rate of 42.6% according to the 2002 Population & Family Health Survey. 37 See Table 3.
Health's Comprehensive Post-Partum Center (CPP), expands on this concept, estimating that "not more than five to ten percent [of engaged women] will go for contraceptive advice before marriage...Once married, it's rare for a woman to consult a physician about contraception because she's trying to become pregnant."40 In fact, he says many women come only if they do not become pregnant within the first few months of marriage. Infertility, Dr. Nasser emphasizes, creates a fear in many young women perpetuated by an understood procreationdriven and defined worth in the eyes of "nagging mother-in-laws." The counseling a woman receives determines, in part, her perception of various methods, while her current situation will determine which method works for her family planning goals at that point in time. A woman may strongly support the concept of family planning, but if a lack of comprehensive information has instilled in her a fear of modern methods, she has been robbed of the capacity to plan pregnancies and control the spacing of her children. Both doctors had much to say on the topic of contraception counseling and usage, particularly in relation to their place in the dialogue. When asked to describe his role in advising women about various contraceptive methods, Dr. Nasser explains: In proper counseling, you don't tell a patient what to take--you let her decide. You have to give attention to what the patient wants; this is most important. Each woman has her own life, knows what will work for her and what she'll follow through on. It's the doctor's role to give the positives and negatives of her choice.41 Listening to a woman and attempting to apply individual circumstances to the provision of care are important steps in a positive direction, though many cultural tenets still affect the provision of counseling. This may be because an understanding of the needs and desires of the women 38 It should be noted that all currently-practicing doctors interviewed during this study were male, while all pharmacists were female. 39 Salaytah, J., MD, Ob-Gyn. Interview, 11-22-2004, private clinic, Amman 40 Nasser, A., MD, Ob-Gyn. Interview, 11-30-2004, Al-Amal Hospital, Amman 41 Nasser, A., MD, Ob-Gyn. Interview, 11-30-2004, Al-Amal Hospital, Amman
served is inevitably influenced by a doctor's underlying cultural preconceptions. Dr. Salaytah explained to me the preference of young, married woman toward oral contraception as opposed to the IUD as he understood their motivations behind this preference. "I try not to prescribe the IUD for women without children, or male children in particular as there is a greater risk of PID with the IUD," Dr. Salaytah explains.42 Pelvic inflammatory disease, or PID, is a leading cause of female infertility, which in this context clearly exemplifies a perpetuation of gender preference norms in Arab society. Dr. Nasser clarified for me the fact that advice on methods of contraception depends on a variety of factors--culture, a woman's situation, the number of children she has, and her age, among others. The previously discussed Contraception-Adoption study completed by CMS/Jordan and researchers from the Jordan Center for Social Research found that of women seeking advice on method selection, 72% sought advice from a physician.43 Yet this same study acknowledged that the most personal information may come instead from pharmacists, who have more time to devote to each woman and have comparable knowledge levels. One pharmacist I interviewed acknowledged the more significant role of doctors in contraceptive counseling. "Here they depend more on doctors than they do on pharmacists. What he advises, she takes," she said, "I can educate people, but I need people to listen."44 She feels the pharmacy is the best place to dispense contraception, commenting that people do need to be more educated about pills, condoms and all kinds of contraception. "People in Jordan like children--3, 4, 5--even if there's no money." The ability of many doctors to provide quality counseling was another issue. Continuing she said, "Some doctors here--they need education. Not all of them are educating women about family planning. Some of them are doing a good job, but some work 42 Salaytah, J., MD, Ob-Gyn. Interview, 11-22-2004, private clinic, Amman 43 Bernhart, and Shteiwi, 3.
only for the money--they have no time to talk to the patient, no time to educate the patient." Dana Diab, a second pharmacist in Amman, though her place of employment is located in a considerably more affluent area of the city, expanded on the role she plays as a primary source of contraceptive information for many women. "Every other woman comes in asking for contraceptives," Diab says, "Women cannot live without them."45 Her female clientele are all married, and the majority fall between the ages of 25 and 35, she reports. Birth control pills are the most widely distributed form in the pharmacy. In Jordan, contraceptive pills (and IUDs for that matter, though these must be inserted by a physician) may be purchased over-the-counter (OTC) without a doctor's prescription. Diab estimates that between 30% to 50% of the women she assists regularly come to the pharmacy without seeing a doctor. This means that without counseling on the part of the pharmacist, a large percentage of the women currently using any of the available OTC family planning methods could be doing so while lacking adequate information to determine the best method for them and their families. Women & Their Stories: case studies from the Field (* denotes names have been changed to protect the identity of the women) While statistical findings and professional experience have provided a wealth of insight into the cultural factors influencing women's family planning decisions and the campaigns that attempt to shape them, the truly meaningful information has come in the form of personal stories disclosed by the women themselves. The following stories have been provided in an effort to convey the effect social constraints have had on each woman's personal experiences and beliefs, despite a growing social consciousness surrounding birth spacing and reproductive 44 Shoubash, S., Interview, 11-28-2004, Meral Pharmacy, Amman 45 Diab, D., 11-22-2004, Abdoun Pharmacy, Amman
health. The name of each woman has been changed to protect her identity and the integrity of her story. Leila* Married just 3 months ago, Leila is a 28 year old Muslim woman facing her first pregnancy. I met Leila one morning at the office where she works as a secretary. Leila has only recently begun to see a doctor--she had no need before the wedding. In the two visits she had with her doctor before she became pregnant, family planning was never mentioned. Now, Leila faces the prospect of quitting her job to care for a child that came too early. She had wanted to wait longer, though she lacked the knowledge or means to plan. "Doctors don't usually discuss family planning with a woman until the first child is born," says Dr. Nasser, who offers family planning counseling to every patient after delivery, "Contraception is discussed postpartum...you talk to them during or after the pregnancy."46 While still young, Leila is older than many Jordanian women preparing for their first pregnancy. health professionals like Dr. Nasser often hesitate to initiate the dialogue with women in this age group for fear of offending a potentially barren woman. Unfortunately, remaining sensitive to fertility concerns and the value placed on children in this culture often means mistimed pregnancies for recently married women like Leila. Doctors are not the only ones responsible for a lack of information among newlyweds though they are, in fact, the most frequent source of family planning information;47 society as a whole may be to blame. Family planning is a relatively new concept in Jordan, and is even newer to Leila, who, like so many other young Arab women, could not discuss family planning or contraception before marriage. In Jordan and most Arab countries, concerns about women's 46 Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman 47 Bernhart and Shteiwi, 2.
purity before marriage overshadows the importance of reproductive health information. From my conversation with Leila, I was given the impression that she, herself, had not wanted to know about contraception before her wedding night. From this young woman--and many other respondents both single and recently married--it has become very apparent that people will begin to talk if a girl knows too much about contraception before she is married. Now that Leila is aware of birth spacing, she intends to wait two years before the next child. "There should be two years between," she said to me, "That's why I need to start thinking hard now about contraception." She knows very little--only about traditional forms such as the rhythm method, though she is aware of their high failure rate. After three months of pregnancy, Leila still has not broached the topic of family planning with her husband, "After the first baby, maybe," she says, "I don't know enough yet. I will go to the doctor to see any method she advises." Still unsure of available methods as she looks ahead to her first child, Leila has many options but a critical period in which to learn about them. Salma* I met Salma in her home in East Amman, where she lives with her husband and four daughters--ages 19, 20, 21, and 23. Now age 45, Salma, who works part time with the Productive Women's Institute in Jordan, has quite a bit of experience behind her. Married at age 19, she left her family to live with her husband and start a family. She gave birth to a daughter three years later. Less than a year after her first pregnancy she became pregnant again in hopes of bearing a son. Even now, within years of menopause and as her daughters reach marriageable age, her husband's family still pushes her to continue childbearing. "In this culture, it's important to bring a boy," she said, "They told me I needed a boy and should keep having children, but I didn't listen." Her husband supported her choice. Four children had taken their toll on her body--and the family's finances. It was time to stop.
Through experience, Salma now recognizes the value of family planning. Her last two pregnancies were unplanned and all but the last two occurred less than a year apart. Her rapid pregnancies had prevented her from breastfeeding for two years, though she explained the necessity to do so, based on Qur'anic instruction. Unaware of the benefits of birth spacing before her children were born, Salma expressed her support for family planning now. "We must do more to take care of [our children]," she confided in me, "All the girls came at the same time. If you want [your] kids to have a good education, to feed them well, four is difficult. If I'd known it would be this difficult, I would have only brought two." Salma's contraceptive history reflects the lack of reproductive health information she received early in her marriage. She had relied on the counting method, alone, until her last daughter was born. It was only at this point, after four children, that her doctor began to advise her on modern methods of contraception. She opted for oral contraceptives over the IUD, using the pills for nearly ten years before side-effects led her to discontinue the method. Now, Salma's daughter is engaged, and she looks ahead to the time when her daughter will be making family planning decisions of her own. She has been given the opportunity to provide her daughter with the valuable reproductive health information that she lacked at the same age. Salma's personal experience has created valuable opportunities for the next generation. Unlike many girls her age, her daughter is aware of oral contraception, though her knowledge of other methods is extremely limited. Although the discussion of contraceptive methods with her fiancй is not allowed before marriage, Salma's family has decided to sit down with the engaged couple, before the wedding, to discuss family planning issues such as when and how many children the couple will have.48 48 Note the continued parental role in family planning decisions, even among more progressive families where reproductive health concerns are openly discussed.
Fatma* I sat down with Fatma in the dress shop where she works. A single, though nearly engaged Muslim woman in her mid-thirties, Fatma had a lot to say about the current family planning situation in Amman. Born and educated in Kuwait, Fatma knew about family planning and reproductive health, though very little about contraceptive methods. "In this country," she told me, "it's a shame to talk about family planning before marriage." Though she has discussed future children with her fiancй, discussion of methods, as for all unmarried women, is forbidden. Even with her doctor, she cannot discuss the issue. She plans to sit down and discuss methods with her husband and doctor once she is married. Because of her age, Fatma insists, "there is a different look to this subject [of family planning]." She hopes to have four kids someday, and acknowledges that if she plans to space her children two years apart "as Prophet Mohammed instructed", she will have to hope for twins--twice. Fatma learned much of what she knows from her mother. "We must teach our mothers to talk to her kids," said Fatma, "There is a bad thing happening in the new generation--the girls talk amongst themselves and don't ask questions [of their mothers]." Fatma proceeded to tell me the story of a girl who had asked her if a kiss could cause pregnancy. That kind of ignorance astonished Fatma, though she herself lived within the same information-deprived, social constraints as the majority of single Jordanian women. Fatma's own mother had many problems with oral contraception and the IUD. Because of this, Fatma was skeptical of modern methods, instead favoring traditional calendar methods. "All the artificial ways have sideeffects," she added matter-of-factly, though she assured me that she would consider her options according to the doctor's advice once she marries. Conclusions
In general, the attitudes toward family planning revealed in this study have been very positive, with awareness of birth spacing, family planning, and the Sahhii campaign nearly universal within the total sample of women. The Ministry of Health's Sahhii campaign has been very successful in creating messages appealing to the women I interviewed, as well as their husbands and even their children. By capitalizing on such familial values as maternal and child health, financial stability and well-being, and the strengths of paternal involvement in the decision to space births, Sahhii has the potential to reach hundreds of thousands of women across Jordan. Unfortunately, appealing to the right social values oftentimes only allows for attitudinal shifts. It may not produce real changes in practice in the presence of separate cultural barriers such as those encountered during this study. Results of the present study indicate that although the campaign has succeeded in informing the public, it may continue to be undermined by such cultural barriers if not confronted at a broad societal level. While most women agreed with the concept of birth spacing and family planning, for example, most relied on ineffective, traditional methods of contraception or did not have access to the information at all. Many factors, acting beyond the control of women, make it difficult to achieve their family planning goals. Recognizing the importance of each woman's attitudes and perceptions in shaping her current contraceptive and family planning practices is only the first step in effectively reaching women with reproductive health information. Providing women with the ability to effectively change their reproductive health practices means considering existing cultural norms and working within or around complex social and gender constructions. As explored earlier, the first of these underlying social constraints is the primary role of women as child bearers in Arab society and the way in which their children serve as the source
of their identity. A woman's worth lies in her fertility, and as was the experience of many of the subjects interviewed, a woman is often pressured to continue bearing children beyond her family planning goals.49 An effective campaign, while not removing this barrier, may appeal to a woman's care for her family as motivation for spacing births, if not limiting them in number.50 A second factor is the role of the extended family or tribe in family planning decisions such as the number of children a couple will have and how soon. Oftentimes, the family expects the girl to become pregnant immediately, or to produce a large family.51 Again, while not removing the barrier, family planning campaigns may appeal to the larger family--a woman's mother and mother-in-law primarily--in order to give a woman's personal decision to limit or space her pregnancies legitimacy. A third barrier facing women, demonstrated with empirical evidence from this study, is the value of male children and the effect of such genderpreference on birth spacing. This construction must be confronted at the societal level if its influence on a woman's childbearing practices is to be lessened. As seen on a limited scale within this study, gender preference has the harmful potential to undermine the family planning awareness campaign if not addressed. A fourth obstacle to overcome is the concept of purity before marriage as it affects a lack of access to knowledge among single women in Jordan, many of whom are of marriageable age. This problem can significantly compromise a woman's family planning choices and career options by depriving her of knowledge at a time when she is most vulnerable to unplanned pregnancies. Without information about contraception before a first pregnancy, women are unable to effectively plan when they first begin childbearing. Finally, and at a broader level, religion plays an important role in the development of social constraints beyond the notions of purity mentioned above. Considering 49 Setty-Venugopal and Upadhyay, 17. 50 Bernhart and Khoury, 23.
the effect of Qur'anic reference to breastfeeding periods on birth spacing awareness, it may be in the best interest of the Ministry of Health to work with Islamic scholars and clerics in the creation of a more effective reproductive health awareness campaign for Muslim women. While each of the above social constraints has the power to influence Jordanian women's perceptions and practices relating to family planning and birth spacing, they likely do so in different ways and to different extremes, depending on family situation and each woman's status in Amman's highly gendered and socio-economically divided society. In these same familial factors, however, lies the potential to create positive change through reproductive health awareness campaigns at the national level. Of course, it is too early to say with any certainty what the ultimate effect of the current campaign will be on the family planning practices of Jordanian women. A movement toward the widespread use of modern methods of contraception in Jordan has been slow to take hold, and many wait anxiously to see results. The two year minimum spacing goals promoted by the Ministry of Health, once practiced, would mean significant improvements in maternal and child health, and would be a positive step toward achievable family planning goals for all couples. Current practices at the time of this study do not reflect the full impact of the campaign as of yet, though the level of awareness and support is promising. 51 Nasser, A., MD, Ob-Gyn, Interview, 11-30-2004, Al-Amal Hospital, Amman
Table 1 Participant Demographics and Statistical Data
Subject Code Age
U001
22
U002
21
MS01 28
A001
23
A002
28
A003
27
A004
39
A005
31
Marital Status single single married single married divorced married married
Age when married n/a n/a 27 n/a 23 19; div- 25 28 24
Employ. Status student student works works student works former teacher, now homemaker
Religious Affiliation Muslim, no hijab Muslim, hijab Muslim, hijab Muslim, no hijab Muslim, no hijab Muslim, hijab Christian (G.O.) Muslim, no hijab
# of Children 0 0 1M 0 1F + 8 mo. pregnant 4 (2F, 2M) 2 (1F, 1M) 1M + 6 mo. pregnant
Age of Children n/a n/a 10mo n/a 1 F:8,7; M:5,3 F:8, M:5 5
Desired # 3 + until boy 4 3 2 to 3
Breastfeeding plans to, very important for health (& C.*) n/a no
Doctor Pref. either male (better doctors) woman (comf)
plans to, very important
2 4 3 (2 is all able to afford)
yes, 6 mo. yes, 4-5 mo.
2
yes; 18 mo (1), 2 yr now
male female male (doesn't trust fem); prob. w/ 1st delivery
Muslim,
A006
37
married
21
works
no hijab
2M
6, 3
2
yes, 8 mo.
male
H001
22 engaged
n/a
finished
Muslim,
studies
no hijab
n/a
n/a
4 (2M, 2F)
plans to breastfeed 6 mo.
female
homemaker,
studied in
Muslim,
3 (2F,
H002
53
married
28
Baghdad
hijab
1M)
F:22,21, M:17
3
yes, 6 mo.
female
Muslim,
3 or 4
H003
19
single
n/a
works
hijab
n/a
n/a
(2F,2M)
2 or 3
(economic
situation now,
married*
Muslim, 0 + 3 mo
diff to have
yes, 2 yrs (Islamic
H004
28
(3mo.)
28
works
hijab
preg.*
n/a
3+)
teachings, Qur'an)
female female
single
H005
35 (engaged)
n/a
Muslim,
works
hijab
n/a
Plans to, 2 yrs; "Proph. M/
God says we must have 2
years btwn kids--to my
health, to women...The
baby must take milk from
4 (twin M+F)
woman's body for 2
because of
yrs...we must have 2 yrs--
n/a
age
baby and me"
female
D001
26
married
1F (had
Muslim,
2nd but
homemaker
hijab
lost)
1.5
4 "not now"
yes, 1 yr. 3 mo. (got pregnant); Cited Qur'an-- wanted to wait 2 years
male, very close to home
D002
53
married
M001
45
married
M002
32
married
? (done now,
male,
wasn't
Jordan
something
University
Muslim,
7 (4M, M:35,29,26,16; she thought yes, 2 youngest-1 yr. 3 mo.; (has health
16
homemaker
hijab
3F)
F:34,31,23
of)
all others <3 mo.
insurance)
yes, 1 yr. each (became
pregnant, unable to
4 (if known
breastfeed for 2 years);
Muslim,
this difficult,
Cited Qur'an--2 yrs btwn
19
homemaker
hijab
4F
23, 21, 20, 19
only 2)
children
male
? (done now,
wasn't
M:15,9,9, 9
something
female
Muslim,
9 (5F,
mo.; F:
she thought
(same for all
18
homemaker
hijab
4M)
13,12,6,4,3
of)
yes, 1 yr. each
kids)
M003
26
married
U003
27
single
JA01
30
married
Muslim,
2M +
18
homemaker
hijab
preg
Muslim,
n/a
works
hijab
n/a
Muslim,
25
works
hijab
1F
works,
former civil
engineer in Muslim,
R001
39 remarried
27
Baghdad
hijab
4
4, 2 n/a 3 12, 11, 3, 3
3
yes; 1st - 1 yr., 2nd - 4 mo.
3
n/a
2 4 (family wants more)
? 1st - 1 mo., 2nd - 1 wk., twins - 7 mo. ("I was young & didn't understand a lot of things. I wanted my breasts to stay full.")
female n/a n/a n/a
Table 2
Family Planning & Birth Spacing Familiarity
Subject Code
Knowledge of Family Planning
Knowledge of Birth spacing Concept
U001
yes, very important; loves f.p.--will def. use
yes (2-3 yr)
U002 MS01 A001
yes, not methods (concept only) yes, very important yes, very important
yes yes, plans to wait 3 yrs yes (2-3 yr); rebuild nutrients, child dev't period
A002
yes
yes, 3 years would have been better
A003
yes
yes, 3 yrs: each child has time to grow
Source of Knowledge University n/a (biology in school-names only, plans to ask when married) University (not discussed before marriage in home) University Doctor; Pregnancies unplanned, must prevent in future Husband was a pharmacist
A004 A005 A006 H001 H002 H003 H004 H005 D001 D002 M001 M002 M003
yes, both children planned
yes, never directly discussed with husband
Doctor
yes, both children planned
yes (3-5 yr apart excellent)
Mother, doctor/clinic
yes yes, not methods (concept only)
yes yes (2 yrs between); plans to wait btwn children
Doctor n/a
yes yes, not methods (concept only) yes; didn't consider until pregnant (visited dr. twice before preg., not discussed) yes (concept only); "In this country, it's a shame to talk about f.p. before marriage" (good in one way, bad in another) yes, recent yes, recent yes, only after children (last 2 unplanned); f.p. very good--good for the children (send them to school, feed them) yes yes, talks about freely with husband
yes (2 yrs) yes (2-3 yrs to give time for each child to grow) yes, 2 yrs (now needs to think hard about contraception) yes, plans to space children; b/c of age, will space only 1-1.5 years (knows 2 is best) yes, plans to wait 2 years before next child yes (3 years), spacing btwn last two children yes (2 years); unaware before had children (learned about it 10 years ago) yes, discusses with husband (says better to have kids one after another so she can rest later, tells him it will affect her body but he wants more kids) yes, though diff to have children so doesn't need to plan
University Familiar with b.s. from family/community; 10th grade biology (books) MoH Outreach: Women from MoH came to home when 25-6; Plans to go to dr., will use any method dr. advises (except pills-->side effects) Plans to discuss with husband (has discussed f.p. & future children, not methods) TV; husband, told her before marriage (fiance); doctor has never discussed family planning Reads about it, knows from media (though previous commercials not as strong); after 16 yr old, doctor still didn't advise about f.p. (didn't know much) Doctor advised about pills, IUD; Felt better about the pills Learned about f.p. from dr. after year of marriage (discussed after 1st preg.) Doctor always talks to her about f.p./b.s but husband always wants more children (must do what husband wants) Learned about f.p. after 1st child born (first time learned about f.p.); Dr. did not advise on C. before 2nd child (gave many choices at that point)
U003 JA01 R001
yes, pharmacist yes, pharmacist yes, recent
yes (2 years) yes (2-3 years) yes; would have spaced 2 years; thought b/c fibroid removed after 1st preg, wouldn't get pregnant
First learned about f.p. in University (pharmacy); now, mainly from TV commercials (starting 2-3 years ago) University; MoH Outreach: 2 home visits--"they visit all the houses here to educate people" Had to initiate C. conversation with doctor, no one ever told her--had to ask for contraception; MoH workers come to Safawi, Special Unit in Safawi (population 2000)-->women get free C.; Workshop on R.H. run by charity with help from UNDP
Table 3 Subject Code
Contraception Knowledge of Contraception
U001 U002 MS01
yes (pills) no, not discussed before marriage yes, discussed all options with dr.
A001 A002 A003 A004 A005
yes, pharmacist yes, limited (methods) yes yes (IUD, condoms, pills, rhythm); discuss w/ husb yes (IUD, condoms, pills, rhythm)
A006 H001 H002 H003
yes no, not discussed before marriage yes (pills, IUD), though negative perception no, methods not discussed before marriage
Use of Contraception no (plans to, pills) no yes, condoms no (plans to, unsure method) not prior to this pregnancy; plans to use condoms no (no need now, never has) No modern birth control now, trad./rhythm method only; pills when 1st married (2 yr) none before 1st; after 1st, condoms Never used modern method; Infertility concerns no Never modern methods, rhythm method - yes
Explanation/Rationale F.P. very important "because life is difficult for many"; financial ($ is very important), school expenses not married Condoms don't change body, no hormones; affordable Financially easier (b.s.); Doesn't know body yet (how it will respond to C.), "hormones are the most important things not to play with in the body" Currently studying with 2 small babies; husband upset b/c preg (financial) Doctor recommended IUD, disc. with husband; Unable to use (health reasons) Decided (w/ husband) that didn't need anything--rhythm of life Pills-->headaches, reaction to IUD, rhythm ineffective; 100% satisfied with condoms Initially withdrawal method (3 yrs); found husband low sperm count (7 yrs)-->surgery + artificial insemination; 2nd son naturally; doctor recommended IUD, stayed w/ withdrawal method (IUD-infertility experience, pills-side effects) not married "Contraceptives are like a poison in the body" (side effects); would choose naturally over modern methods
no
not married
H004
very limited (pills, rhythm, withdrawal)
no, current pregnancy unplanned; doesn't know enough yet; will never consider pills, though rhythm/Islamic method is an option
Wanted to wait longer before becoming pregnant; "It will happen by God. Each person has a brain and can think about the decision for own self" (religious reasoning); Discussed usage of "wasta," Islamic "connection" method
H005 D001 D002 M001 M002 M003 U003 JA01 R001
yes, not discussed; plans to talk to dr. & husband when married (agreement important) yes (pills, IUD, condoms) yes (pills, IUD)
no, preferred method for when married-traditional/rhythm method; Decision will be according to body, circumstances, dr advice, new knowledge no C. before 1st child, condoms after daughter born (not always) no C. before 1st two children; IUD used for 4-5 months (didn't wk, caused bleeding); began taking pills (worked better), used rest of time (no longer needs)
Mother had many prob. when took pills & IUD ("all the artificial ways have side effects," but will still consider according to dr. advice); "With my age, there's a different look to the subject (of family planning)"; Doctor doesn't discuss the issue at this time (because not married) Comfortable talking to husband about contraception (he knows more than her about b.s. & f.p.); Husband didn't want second pregnancy so soon (mistimed) Bought pills from pharmacy, doctor did not advise to take; Pregnancy is the will of God; Husband likes many kids--she told him no more, but he didn't care what she wanted (tired of becoming pregnant)
yes yes (pills, IUD,counting method); poor information/ exposed to myth yes (IUD, counting, pills, withdrawal) yes (all methods); pharmacist yes (all methods); pharmacist
No modern methods used before children born (counting only); Used pills after last daughter born (used for long period-stopped 10 years ago; currently only counting Counting method (has never used a modern method) IUD put in at health center after 2nd child; plans to use IUD after this pregnancy no Took pills but stopped 3 months ago to become pregnant
Began to see side effects of pill (nervousness), stopped; "We must do more to take care of [our children]. All the girls came at the same time. If you want kids to have a good education, four is difficult. If I'd known it would be this difficult, I would have only brought two." Wants natural way, told doctor didn't want to use any chemical things (doctor recommended counting); Better for her not to use contraception--has side effects so does not believe in them (pills/IUD cause cancer and have negative effects for body) Hard for her to become pregnant--first child born after 3 years (infertility concerns--doctor most likely hesitant to discuss contraception) not married Wants to have another child, has waited 3 years
Doesn't want more children--she's a professional woman and
Hadn't used previously, now using IUD
already has 4 kids; husband's family pressuring her to have
yes
(afraid to forget pill)
more (had twins and thinks she can again)
Table 4 Subject Code U001
Additional Data Sahhii Campaign
U002 MS01 A001 A002 A003 A004 A005 A006 H001
yes, commercials yes, commercials yes yes unfamiliar yes, commercials yes, commercials & brocures in clinics yes; very popular, 1st campaign w/ impact; using all media: billboards, tv, radio; people identifying with character unfamiliar with campaign
Comments/Other Law student (JU), well-educated; strong preference for male children Not comfortable discussing methods- even to think about it before marriage is bad, not something to talk about before marriage; "of course" would definitely feel comfortable talking to husband about it; asked if I was married, why I chose to study this Wks w/ HPC; Has discussed F.P. with husband, very supportive; Good idea to talk about in schools Already considered self old--"[Older women] always prefer not to wait for 1st child"--no need for contraception when first married; Insistant on purity of unmarried women Has never used C. before now; Husband supportive of F.P.; Ideal for IUD Hormones would effect health if used contraception Lived in Europe for 10 yrs; University distributed condoms in dorms ("useful"); Careful to emphasize that unable to afford a 3rd child emotionally, financially, and physically Needed 4 yrs to rest after 1st child, son needed extra year (5); not husbands decision (personal); R.H. must be taught in schools, teachers need to be more informed, mom/aunt must talk to girl before marriage Would like schools to introduce family planning & reproductive health into school curricula Would not feel comfortable talking to husband about family planning methods and birth spacing; Iraqi family, mother from Baghdad
H002 H003 H004 H005 D001 D002 M001 M002 M003 U003 JA01 R001
yes, commercials; didn't matter b/c already familiar with b.s. no (doesn't watch TV) yes, excellent commercials; good for educated women and non-edu. women alike; Compared to prev. MoH outreach work yes, TV commercials; thinks weird (not used to it in jordan) but useful; women here not well-edu. (esp older); shy--hard for ppl to talk about, sahhiichild-good way to make ppl comf. talking about it indirectly yes, TV commercials, very good; daughter knows them also yes, TV commercials--good, encourages ppl to think about it yes, TV commercials; doesn't say 'stop'--emphasizes planning (not against Islam) yes, TV commercials: excellent, encourages people to know about these things ("in some villages it doesn't work, they won't listen") yes, TV commercials yes, good campaign; easy to teach low-educated people yes, very little (MoH came to house last wk, 2nd visit) yes, feels they need extended family involvement in commercials (not couple's decision, but mothers and mother-in-laws)
Discussed family planning with husband (important), same opinion; Very important for schools to discuss family planning issues Sister is doctor yet never spoken about family planning (not married yet); Felt good to have family planning, though appeared not to have thought about it Awareness in Jordan began ~2yrs ago, family planning is new; Skeptical about effectiveness--sister used pills and traditional method, still got pregnant rt after 1st child (whatever you use, ult. will of God); Best place to discuss f.p./r.h. is in women's clinic, not successful in schools; Age 15** suitable for r.h. education (girls start to ask) Born, educated in Kuwait--edu. system better; 13 = best age for women to learn about R.H. (from personal experience, shame led her to hide her period from her mother for 1 year); "Edu. in this country is weak" (when sit with girls here, surprised--"they don't know anything"); How to solve: schools, tv (sahhii), drs (must talk on this subject), improved reading; "We must teach our mothers to talk to her kids", girls talk amongst selves - don't ask? s; Boys must be edu. too (men still virgins too...prob. on wedding night) Became pregnant a second time, lost the child; learned more about family planning because of pregnancy complications Two eldest children each have 3 kids of their own now (2 girls, 1 boy each); Ask for her advice--> told them 3 was enough, encouraged them not to have more ("Life is changing, day by day") "In this culture, it's important to bring a boy. They told me I needed a boy and should keep having children, but I didn't listen" (husband supportive of decision to stop after 4, didn't need a boy); Used to believe that through God's will, everything will be sent to the child; People confused between stopping(deciding to have no more children) and planning(right with Islam); Jordanians love many kids, to your benefit--more kids = "like an army" (protect you when you're older); Daughter(20) engaged, should learn about f.p. when married; Couple sits down (before marriage) to discuss f.p.-when to have 1st child (3 yrs); Daughter knows about pills but cannot discuss with fiance yet; Best place to learn about f.p./C. is from a doctor/health center; Daughter will find own doctor when married Best time to learn about family planning at age 17/18 (an age where girls can understand; after coming of period, before marriage); Best place to learn about reproductive health--school and home (mother will tell you the truth) Husband supportive of decision to stop after this child, doesn't need more children Pharmacist, Jordan University Pharmacist, Jabal Amman; Was taught very well in the university, but even if university educated, if doesn't learn sciences will not learn about R.H. Uteran Fibroid formed during 1st preg--caused complications during others (fibroids and PID common among Arab women); In rural communities, everything related to Israel (conspiracy theories about C./vitamins); Families love kids, push parents to keep having children--not couple's decision when/how many to have; Woman gets worth from kids (feel have to keep prod--> (percieved as all she does; if stops having kids, looks lazy); Poor families have many kids (uneducated), most have 8-9 kids; 1 man has 4 wives, 30 children--doesn't even know their names ("Everyone looks at him like he's a 'real man'"); After many preg, women breastfeed for shorter periods, then become preg again; Comment on Bedouin comm-->preg not planned/intended, not using C.
Appendix A: Questionnaire Women's Attitudes toward Birth Spacing & Contraception * Denotes a question for married women only 1. In what area do you live in Amman? 2. Do you work or study outside your home? 3. Do you consider yourself a religious person? [Which religion do you practice?] 4. How old are you? 5. Are you married? 6. How old were you when you were married?* 7. Do you have any children? How old are they?* 8. Did you breastfeed your children? For how long?* 9. Do you want to have [more*] children? If so, do you want to wait a while? 10. How many children would you like to have? 11. Were each of your pregnancies planned?* (Did you want to become pregnant?) 12. Are you familiar with `birth spacing' and family planning? a. If no, skip to question 15. 13. What methods of birth spacing are you familiar with? 14. Where did you learn about these methods? When did you first learn about reproductive health and family planning? 15. Are you familiar with the `sahhii' (healthy) birth spacing commercials on television? 16. What is your overall opinion about `birth spacing'/ family planning? 17. [When married,] would you ever consider using a form of contraception/ birth spacing? i. Why or why not? ii. Which ones? 18. Have you ever used a method of `birth spacing'/contraception?* Are you currently using one?* 19. Would you feel comfortable talking to your husband about birth spacing?* Other women? 20. Would you feel comfortable talking to a doctor about birth spacing methods? [Have you?*] 21. Is your doctor a man or a woman? Would this make a difference? 22. Do you know if your doctor/ health clinic offer birth spacing methods? 23. Do you know where you could get them if they didn't? 24. Do you feel they are affordable?* 25. Where do you feel women should learn about reproductive health? At what age?
Appendix B Arabic to English Transliteration as Used During Interviewing Positive Connotations (used in all interviews) Birth Spacing Moba'adat al-Hamel Reproductive Health Al-saHah al-Injahbeeah Family Planning (lit. Organization of Pregnancy) TenDheem il-Usrah Negative Connotations (avoided during interview) Sexual Health Al-saHah al-Jinseeah Limiting Birth TaHdeed il-Nessil *Contraception (lit. Prevention of Pregnancy) Mena' al-Hamel *Denotes that word was used during interviews with translator, as a more complete explanation could be given.
Works Cited Abu Ahmed, A., Tabenkin, H. and Steinmetz, D. Knowledge and Attitudes Among Women in the Arab Village Regarding Contraception and Family Planning and The Reasons for Having Numerous Children. Department of family medicine, Ha'Emek Medical Center, Afula, Israel. Harefuah: December 2003. 142(12): 822-5, 878-9. Bernhart, M. and Khoury, N., Perceptions of Contraceptives Among Jordanian Women, CMS Jordan and Market Research Organization: 2001. Bernhart, M. and Shteiwi, M. The Contraception-Adoption Process in Jordan, CMS Jordan and Jordan Center for Social Research: July 2001. Diab, D., Interview, 11-22-2004, Abdoun Pharmacy, Amman Hamzeh, M. Interview, 11-24-2004, Ministry of Health Department of Health Education, Amman. Improved Access To and Quality of Reproductive and Primary Health Care. USAID-Jordan, No. 278-S003. . Jordan Population and Family Health Survey 2002: Key Findings. Department of Statistics [Jordan] and ORC Macro. Calverton, Maryland, USA: ORC Macro, 2003. Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman National Population Strategy: Reproductive Health Action Plan (RHAP). Higher Population Council General Secretariat. Stage 1, 2003-2007. Amman: April 2003. The Noble Qur'an, University of Southern California Muslim Student Association, . Salaytah, J., MD, Ob-Gyn. Interview, 11-22-2004, private clinic, Amman Setty-Venugopal, V. and Upadhyay, U.D. Birth Spacing: Three to Five Saves Lives. Population Reports, Series L, No. 13. Baltimore, John Hopkins Bloomberg School of Public Health, Population Information Program, Summer 2002. Shoubash, S., Interview, 11-28-2004, Meral Pharmacy, Amman. Underwood, C. "Islamic Precepts and Family Planning: The Perceptions of Jordanian Religious Leaders and Their Constituents," International Family Planning Perspectives, 2000, 26(3):110-117,136.

B Buchholz

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