Study sites

The study was conducted in Wau county in the state of WBeG in South Sudan. Two locations were selected based on the homogeneity of the residents (all Fertit). Further, the locations were also within the coverage area of health services, particularly SRH services. This was important, as the geographical coverage of health services remains poor in many parts of WBeG. Finally, the two locations represented two different settings in Wau county: one in Wau town and the other a rural area. The a priori assumption behind choosing these two locations was that perhaps within the same social group the way norms related to behaviour and decisions might be moderated differently in different settings.

Sampling, recruitment of study participants and data collection

The main categories of study participants are summarized in Table 1. Community members were purposefully selected with the help of village elders, health workers from a local non-governmental organization (NGO) and the county health department. Among community members, only those aged 18 years and above were included in this study; a separate but linked study has been conducted among adolescents. We purposefully categorized participants into those between 18 and 35 years and those above 35 years — the assumption being that the former would be more subject to the norms related to sexuality and reproduction, and the latter would be the ones involved in enforcing the norms, shaping preferences, setting expectations and influencing the decision-making and health-seeking behaviours of the former.

Data collection began with FGDs among community members to identify different aspects of the subject, and differences in views among participants on the subject. This was followed by SSIs to obtain more in-depth understanding. For FGDs with community members, participants were homogenous in terms of age and marital status, yet diversity was sought in terms of social and economic status (based on: inputs from elders related to social identity, ownership of assets such as bicycles, level of education). FGD participants were not involved in the SSIs.

Health facility personnel working in the local health centre of the study sites were included in the study. First, an FGD was conducted to identify different aspects of the subject, and differences in views among health workers on the subject. Participants included a clinical officer, two nurses, a health assistant and two community health workers. The FGD was followed by SSIs with those personnel specifically responsible for reproductive health at the health centre. FGD participants were not involved in the SSIs.

Key informants were also purposefully selected for inclusion in the study; they were selected based on their active SRH-related role within the health system and the study community, and identified through the initial stakeholder consultations. Key informants included traditional leaders, traditional birth attendants, state- and county-level SRH service managers and NGO representatives. Given the serious shortage of health and social workers in South Sudan, the pool of managers and NGO representatives was small — in fact there was only one SRH-related officer at both county and state health department level, and both were interviewed. Similarly, all three NGO representatives working on SRH in Wau county were interviewed.

Data were collected between October 2014 and April 2015, from three visits to Wau. FGDs and SSIs with community members, traditional leaders and traditional birth attendants were conducted by research team members who hailed from the study area, were fluent in the local language and had experience in conducting qualitative research; interviewers and participants were matched by sex. FGDs and SSIs with health workers, managers and NGO representatives were done in English. Data were collected until data saturation was reached and no new insight emerged; this was possible to assess, as at the end of each day of data collection, the research team debriefed and discussed the emerging findings. In total, 5 FGDs (with 38 participants) and 44 SSIs were conducted. This is congruent with the general experience on saturation; according to Creswell [19], a sample size of around 30–50 is generally sufficient to achieve analytical saturation in a qualitative study.

Data analysis

SSIs and FGDs were digitally recorded, translated from Wau Arabic into English (where applicable) and transcribed verbatim; the translations were independently checked. Analysis of the transcripts was carried out using a comprehensive thematic matrix to facilitate the identification of common patterns and trends arising from the narratives, using NVivo 10 software. This was done in parallel by three researchers (SK, MK, MR), and emergent conceptual categories were arrived at through a process of argumentation and consensus. Validity of findings and of the analysis was further assured through a data validation workshop (n = 10) and interviews with key informants (n = 2), and also through follow-up interviews with some (n = 4) of the study participants in both study sites. The daily debriefing sessions and insights from these validation interviews and workshop were also used to develop and further clarify emerging analytical themes.

Ethical considerations

The study was approved by the Independent Ethics Committees of KIT Royal Tropical Institute, Amsterdam, and the national Ministry of Health of the Government of South Sudan. Administrative approval was given by the WBeG Ministry of Health. Informed consent was taken from all participants. Consent was sought only after the person had been contacted to participate (and had in principle agreed), but before any of the interview questions were asked. For those who could read, the consent form was given to them and also read out to them to seek both their written and oral consent. For those who could not read, the consent form was read out to them, and their consent was recorded. Confidentiality was maintained throughout, and steps were taken to anonymize the data and to minimize risk of accidental disclosure and access by unauthorized third parties.

Sex, sexuality and reproduction are sensitive, intimate and yet social issues. At the beginning of the consent process, participants were informed of their right to refuse to answer any questions they might find intrusive. The interviewers were also very conscious of this, and did not press ahead with a line of inquiry if they noticed the participant was not comfortable. Furthermore, given the sensitive nature of the topic, there is a risk of opening up hitherto closed, yet painful chapters and experiences in the person’s life. To ensure support if such a situation arose, a trained counsellor was available, as were medical referral services. No such situation requiring counselling or medical referral emerged during data collection. However, there were many instances of people in the community seeking help to get treatment for individuals, and this was provided — for example, on two occasions, the research team used its car to take a child and his mother to the state hospital for further treatment.

Knowledge of and attitudes to pregnancy, family planning and contraceptives

Social norms on childbearing, spacing and contraceptive use

The theory of planned behaviour refers to social norms as structural powers which shape people’s intentions and behaviour. Cialdini et al. [20] and others [21] argue that when studying the influence of norms on human behaviour, it helps to try to distinguish between descriptive and injunctive norms, even if sometimes it is empirically difficult. Descriptive norms refer to individuals’ beliefs about the prevalence of a particular behaviour and about what most (relevant) others do in a particular situation. Injunctive norms, on the other hand, refer to the extent to which individuals perceive that influential (and relevant) others expect them to behave in a certain way, and to perceive that social sanctions will be incurred if they do not. This section presents findings on how social norms, both injunctive and descriptive, shape the Fertit people’s intentions and behaviours about spacing and contraceptive use.

Ability to act and decide

Kabeer [22], in her influential work on women’s empowerment, frames women’s “ability to define one’s goals and act upon them” as their ‘agency’. Agency is exercised in relation to others; as Kabeer [21] explains, it is “more than about just observable action” and includes the ability to negotiate and bargain, subvert, resist and manipulate, and also more intangible cognitive processes of reflection and analysis (1999: p 438). This section shows how Fertit women’s ability to decide about their pregnancies and spacing of pregnancies is constrained. It also shows how they are using the opportunities available to them to subvert and resist and overcome these constraints — a testimony to the dynamic and relational nature of human agency and how it also shapes social norms.

The multifaceted influence of social norms on procreation decisions

Findings clearly show that while both men and women desire to have many children, they have a good knowledge of the importance and benefits of spacing pregnancies and of using modern contraceptive methods to do so. This knowledge and positive attitude towards spacing is, however, failing to translate into decisions to use contraceptives among the Fertit in WBeG. Two overlapping explanations emerge from our findings. On the one hand, social norms around pregnancy and childbearing and the entrenched patriarchal privileges intersect to concentrate and maintain decision-making powers in the domestic, economic and public realms in men’s hands, and constrain Fertit women’s agency in the reproductive realm. On the other hand, our findings also recognize that men’s agency in the reproductive realm is perhaps similarly constrained by these social norms and by the very hegemonic patriarchy that privileges men. These findings are consistent with the evidence that use of contraceptives and other SRH services is not merely a matter of knowledge and rational choice but is mediated by social norms and power relations based on gender and ethnicity [23, 24]. They are also consistent with the large body of anthropological and sociological literature supporting the view that couples’ reproductive decisions are negotiated within gender-based power relations and within the context of local social norms and health systems [25–28]. In line with our findings, and the hegemonic patriarchal social situation notwithstanding, many caution against a universally tyrannical representation of men’s roles in the reproductive realm, arguing that such a representation is both inaccurate and unhelpful [23, 29]. While the findings above indicate that patriarchy has been reinforced by the violent and fragile environment of South Sudan, they also show how it is being questioned and challenged, both by women and men.

Competing social norms: an opportunity to help define a new normality

For Fertit men and women, young and old, in urban and rural settings alike, having children and expanding one’s family is an important social expectation, and people desire to have children [30]. Similar to other patrilineal and patrilocal societies in sub-Saharan Africa, marriage is a key social institution, and its primary function is ‘childbearing’, with women seen as a means of reproduction [31, 32]. These social norms around reproduction remain strong and entrenched among the Fertit people of WBeG, South Sudan. However, the nature of social norms is such that conformity is conditional: people would stop conforming to a norm if there were doubts or disagreements about what the norm seeks to enforce or if it cannot be enforced. Evidence shows that no matter how permanent and rigid norms might appear, in any society, competing norms are constantly at odds with each other, and norms are constantly evolving, being negotiated and being replaced by other collective beliefs about which behaviours are appropriate in society in the evolving context [33, 34]. Our findings show that Fertit men and women are challenging patriarchal social expectations, questioning, testing and transgressing the boundaries set by existing social norms and in the process opening windows of opportunity for redefining normality in WBeG society. In addition, in both urban and rural areas, the descriptive social norm of having as many children as possible is under competitive pressure from two other social norms: the injunctive norm on spacing pregnancies, and the injunctive norm that one must take good care of children. Unlike before, when providing food and shelter was what primarily entailed providing care, nowadays, good care is understood to involve providing good education to one’s children. People also increasingly recognize that they can bear the responsibility and the cost of providing good education to only a few, and not many, children.

The post-conflict period and opportunities for renegotiating the social compact

Lianos [35] has explored the social processes of conflict, post conflict and emergence of peace as aetiliogies of macro- and micro-level social change. Lianos [35] argues that individuals, groups and other actors adjust their strategies to make the most of the new situation, thus participating in enhancing the legitimacy of the emerging new conditions. Conflict, post conflict and peace constitute social change, and social actors develop strategies to navigate it and benefit from it. This change, catalyzed by the disruption of the traditional social order as a result of the civil war, the chronic insecurity, fragility and the internal displacement, paradoxically offers women and men opportunities and resources to subvert entrenched norms and hegemonies. To some extent, the findings of this study indicate that the new political and economic realities of the post-conflict setting, and the return to peace, might be catalysing the norm change processes in South Sudan. The return to peace, and South Sudanese society’s transitions from a militaristic male-dominated society to a society now focused on nation building and with aspirations of progress, with improving access to knowledge and services, is also opening up opportunities for women and creating spaces for the renegotiation and reconfiguration of socio-political relations; and in the process also emboldening men and women to challenge the hegemonic order.

Navigating change: enabling women to exercise agency

Many Fertit, including men, do not support the status quo. However, some men, in both urban and rural areas, are wary of their women clandestinely using contraceptives. If the impression that health services are encouraging this becomes commonplace, the SRH programme in WBeG state may become entangled in the complex gender and power dynamics within society — to the detriment of women. While recognizing that social institutions such as the health services are gendered spaces, which reflect and reproduce gender inequalities in society, we argue that the WBeG SRH programme must take explicit and immediate action to prevent such an impression from emerging among the menfolk and society at large. SRH services should take care to ensure that women’s agency is not undermined in such a process, and instead work towards creating safe spaces for women to exercise their agency. There seems to be some openness to joint decision-making on reproductive matters; this is a window of opportunity to promote both gender equality and reproductive health. An explicit gender-transformative approach [36–38] that includes interventions which promote dialogue among couples, family members and society at large, and which builds on social norms around the importance of women to be able to get ‘rest between pregnancies’, could be a feasible and effective way forward. Such an approach could also apply to other settings in South Sudan where the situation is similar to WBeG.

Limitations

The study has some limitations. Based on the conceptual framework, we expected generational hierarchies and some significant others to be important influences on decisions on sex, sexuality and reproduction. We did not find any explicit evidence of this. While men and women did refer to elders as shaping their decisions, we did not find anyone being particularly influential (e.g., mother-in-law, father, aunt). It is possible that indeed within the Fertit society, many people shape and influence decisions on these matters, and not just a few significant others; it is also possible that our data collection somehow fell short and that we have failed to identify these influences sufficiently.

The topics of sex, sexuality, reproduction and decision-making on these matters are sensitive subjects. There is a risk that people hesitate to talk openly or that they only give socially desirable answers. These constraints were anticipated, and steps were taken to loosen them. Preparatory trips were made to familiarize the study team with the WBeG context and the study sites. Much effort was put into identifying research collaborators, one male and one female, who not only spoke the local language and had experience of qualitative research but were also Fertit themselves. Preliminary visits were made to the study sites before the actual data collection, to meet the villagers and the elders, explain the nature of the study and effectively seek the village’s consent; these visits were village gatherings and, essentially, elaborate confidence-building exercises. As regards the risk of socially desirable answers, the researchers who conducted the interviews with community members know the Fertit culture well and were aware of such a risk. Furthermore, during daily debriefing sessions we involved a local resource person who is knowledgeable about Fertit society, its traditions and its social norms generally, and on matters related to SRH, to make better sense of research participants’ accounts; her involvement served as both a quality check and also an additional level of insight. Finally, the overwhelming interest and the frank interaction we encountered during data collection, and given that the Fertit are not shy about talking about sex and sexuality, makes us confident of the validity of the study findings.