Findings are presented along three broad lines: knowledge of and attitudes to pregnancy, family planning and contraceptive use; social norms shaping family planning decisions; and participants’ perceived control over or perceived ability to make reproductive decisions and choices.
Knowledge of and attitudes to pregnancy, family planning and contraceptives
Childbearing as God’s will and one’s duty
Both Fertit women and men consider having children very important. Getting pregnant after marriage was looked on positively, and a common belief across sexes and across age groups is that pregnancy is ‘God’s will’:
“Pregnancy is of course from God … pregnancy is from God.” (B FGD M under 35)
“Once you get married … if God wills you give birth right away as that is the main reason.” (FGD Males over 35)
“Only one of my three daughters has no child. Only one … God did not give her a child.” (FGD Females over 35)
Another related view shared by men and women alike, albeit perhaps more so by the older generation, was that it was desirable to have as many children as possible — that it was a woman’s duty to bear children:
“Our community believes that bearing a child is from God. If God gives you strength to give birth to 10 or 12 you will be lucky.” (Traditional Leader)
Spacing pregnancies, the right thing to do?
All respondents recognized that a sufficient amount of time was necessary between two pregnancies, and had a favourable view of spacing. They believed this for many reasons; a common belief among women was that getting pregnant immediately after delivery was bad for the unborn child:
“… When a woman gives birth and before her baby sits she is pregnant again this is when you harm your small baby…” (Female over 35)
Another belief was that having frequent pregnancies was bad for the woman’s health:
“And when it is frequent it will affect the uterus and the pelvis will be tired.” (Female Married under 35)
“Housework and food also will be difficult. If a woman gives birth every year it wears her out.” (FGD Females Married under 35)
Men, both young and old, also knew about the importance of spacing; their arguments, however, tended to be more related to the negative effect of frequent pregnancies on the recently born child or on the yet unborn child. In an FGD some older men pointed out, perhaps referring to a local belief, that getting the wife pregnant again before the first child has started walking was detrimental to the health of the unborn child. As the following quotes illustrate, this understanding and a favourable attitude to spacing was shared by the younger men:
“From the time your wife delivers a baby and when it starts walking, then you can go on top of his/her mother again so that you can bring another child. But if the child born is not yet walking, if you get on top of his/her mother, that child will be paralyzed.” (FGD Males over 35)
“Sometimes if there is a baby in the stomach and there is [already] a [breastfeeding] child, the [unborn] child can get dehydrated in relation to the child’s breastfeeding … the [unborn] child will be … sometimes you will find a child like this hand of mine … will be very skinny…” (FGD Males under 35)
Men and women pointed out how this understanding about the importance of spacing was part of their traditional knowledge about pregnancy; a traditional leader echoed this thus:
“For our old generation we used to wait even after two years… Our traditions are against that [back-to-back pregnancies].” (Traditional Leader)
Some older women argued that the times were harder now, that raising children was more difficult now, and that this made it necessary for women to space pregnancies:
“Child delivery in the past is not like the present. If you bear ten children, where will they get education…? This is not good. It is better to bear children and have gaps between them so that they can get good education. But if you have ten, nine, five children, there will be many, and raising them becomes very difficult.” (FGD Females over 35)
Others disagreed, pointing out that because childbearing was God’s will, one could not say how many children one should have:
“Childbirth is from God. I cannot say they should have this many children.… I don’t like it; I think it is very bad. How can they stop a woman from having a child? God has given that to you. Are they going to stop it?” (FGD Female over 35)
Younger women also had some misgivings; for instance, during an FGD among younger women, there was much agreement when one of the participants said that if a woman does not have a child for three or four years, it can make subsequent deliveries more difficult. A discussion among younger women during an FGD went as follows:
“If you stay long without getting pregnant it becomes hard, so three years is reasonable… Four years is too long, and some places will be tight, and it puts women in a dangerous situation … So three years is reasonable.” (FGD Females Married under 35).
The use of contraceptives
As the following quotes illustrate, younger women, unlike other informants, had a uniformly favourable attitude towards using contraceptives, perhaps reflecting a more pragmatic understanding of the situation. They not only know about modern contraceptive options but also commonly use them, although some women mentioned they had stopped using contraceptives after experiencing negative physical effects:
Facilitator: “Do you know how to plan your family?”
Respondent: “Family planning is like taking pills every morning. These pills are given. If you go to the health centre and you say that you want to plan pregnancy, they give you pills … if the injection does not suit you. There is an injection given for up to six months. So you need to plan pregnancy.” (Female Married under 35)
“Contraceptive pills are very good if you can tolerate it. I tried contraceptive pills before and I used to see my menses twice a month. This is why I stopped it.” (Female Unmarried under 35)
While all recognized the importance of spacing, and were knowledgeable about modern contraceptive options, there were disagreements about their use. Men were mixed in their views about women using contraceptives to space pregnancies. While some took a more pragmatic view, others, including some younger men, strongly disapproved:
“For younger girls who had children early and do not want to become pregnant again, the doctor can offer contraceptive pills … The woman can be given injections or contraceptive pills to prevent pregnancy, and young girls can go back to school.” (Male Married over 35)
“Those condoms, those pills, those injections. Our fathers in the past didn’t do it. For what reason should we come to do it? Does it mean that we alone do not know how to plan a family? My wife is not going to swallow pills or get injection … for what?” (FGD Males Married over 35)
Many men were concerned about women going behind their backs and using contraceptives, particularly the long-acting injectables; while not explicit, there was insinuation that the health services were somehow abetting this. They argued that it was because of this trend that some men were forbidding their wives to use modern contraceptives:
“Some women do it in agreement with their husbands; others just go to pharmacies on their own and buy the pills and use it without telling their husbands … the men do not know what the woman is doing; they have no ideas about such things. Such men think it is God who has not blessed them with another baby.” (Male Married under 35)
Health facility personnel shared concerns regarding how some men perceived the promotion of contraception — as attempts by outsiders to deny them their right to have many children, as outsiders were the ones promoting contraceptive use. The following quote highlights the importance of handling delicately any intervention to promote contraceptive use.
“… Let the youth give birth because a long time ago we gave birth too, and they would say you are denying their children to have children… They say before we used to give birth, why now does the white man want our girls not to give birth?” (FGD Health Personnel)
In one of the FGDs, young women recognized that many men had a suspicious attitude towards the health services. They agreed that this was not the right thing to do and that such a situation would make things difficult for everyone:
“Family planning is good, but … planning should be done after you agree with your husband. You tell him that life is difficult … other women just go and start family planning without involving their husband, and then it causes problems in the house; the woman stops the planning, and then she starts giving birth one after the other. So this is a mistake.” (FGD Females Married under 35)
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.
Social norms on marriage and childbearing
Among the Fertit (and most ethic groups in South Sudan), the injunctive social norm around marriage is that a man marries a woman to be able to bear children, to replace dead family members. There is social pressure on women to bear children, and not bearing children incurs social disapproval, even ostracism.
“The community is the main reason for all this, especially neighbours, friends and parents. They complain a lot that their son needs to have babies to replace a dead uncle or a dead grandfather, so they want him to name relatives who passed away.” (Health Personnel)
“Yes, they insist on what they are doing. Regarding family planning, some say I married this woman … why shouldn’t she give birth. This woman must give birth and not take any contraceptives.” (NGO)
As the following interaction during an interview with a young man illustrates, it is normative that women have children, and that asking a wife to stop is just not done:
Facilitator: “Are you married?” Respondent: “Yes.” Facilitator: “Did you ever think or did you ever ask your wife not to become pregnant?” Respondent: “No, I have never done that.”
Facilitator: “Why?” Respondent: “I have never thought about that before.” (Male Married under 35)
“Our community does not encourage spacing children.” (Male under 35)
In fact the social norm is that if a woman does not bear children, then she, as the quote below illustrates, is considered not worth keeping. Further, men are also normatively expected to have multiple children. Those who do not continue to father children run the risk of being labelled as infertile and subjected to ridicule; they also risk their wives leaving them for other men.
“If the wife just stays for six months without getting pregnant, immediately they start asking ‘Was she brought just to go to the toilet, and who is to pay for that?’.” (Health Personnel)
Facilitator: “What does the community say about a family where the woman does not become pregnant for a while?”
Respondent: “The community does not speak well about that. They will say that the woman is not fertile and the man is wasting his time. He should go and find another woman who can bear him some children. Sometimes the woman’s family will say that the man is infertile and their daughter needs to find another man. Some of them will start having an affair.” (Male Married under 35)
Thus, injunctive social norms on marriage and childbearing have a major influence on the intentions and behaviours of men, women and couples about spacing and contraceptive use.
Social norms on spacing
In Fertit society, there is an injunctive social norm that women should get rest after each pregnancy. As the following quote from an older woman illustrates, while having many children is desirable and expected, both at the societal and the individual level, women and men reported that in society it is frowned upon if a woman in the family becomes pregnant very soon after childbirth:
“When a woman gives birth and two months later she gets pregnant again, it is shameful. All your family, even your own mother, will be blamed, because they will say why did you let this girl get pregnant and her baby is still small. It is a bad reputation in the family.” (Female over 35)
One traditional leader highlighted the social sanctions in the form of shaming of the family and the woman if a baby were to be born with a low birthweight because of insufficient spacing:
“Our traditions are against that [back-to-back pregnancies]; if a woman gives birth to an immature child [with low birthweight], she will be called ‘Na-Ngoyo’ … means the mother of an immature child. It is a shame in our community.” (Traditional Leader)
It was also clear that there were no injunctive social norms which explicitly or implicitly sanctioned the use of modern contraceptives:
Facilitator: “So there are no traditions that prohibit contraceptives?”
Respondent: “No. If you go for an injection, it is up to you ….” (Female Unmarried under 35)
“You from your own will and the will of your wife. If you see this woman having [multiple and frequent] childbirths, like for me, maybe I will go to the doctor to give us family planning.” (FGD Males under 35)
Men and women relied on the actions and experiences of important others (descriptive norms) to inform their own intentions and actions; the important others influencing contraceptive decisions and choice included family and close friends, and the traditional leaders. Women’s attitudes to different forms of modern contraceptives were informed by experiences of friends and family members:
“This issue of contraception … even me, I wanted it. I have my sister-in-law who has an IUD inserted, and it is giving her a hard time: every month she bleeds a lot. So I decided not to take anything and just save myself and pray to God to save me.” (Female over 35)
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.
Entrenched patriarchy and women’s constrained agency
Women consistently referred to ‘abstinence’ after delivery as the way to avoid getting pregnant soon after; in an FGD among married young women, the respondents explained how they went about getting their husbands to cooperate — a poignant reflection of the severely constrained nature of women’s agency and of their resigned attitude to the social acceptance of their husbands having sex outside their marriage, despite being well aware of the risks of contracting sexually transmitted infections:
“If you have a three-month-old baby and your husband goes and finds another chance, let him go. Tell him to find someone who will not bring us disease and who will join me and we talk and laugh. In this way, your baby will not suffer.” (FGD Females Unmarried under 35)
“You will stay away from the husband a bit. You can allow your husband to go around like when you have a child in your hand.” (FGD Females Married under 35)
Entrenched patriarchy among the Fertit bestows on men the status of the head and the sole decision-maker of the household; not only do the men and their families uphold and operate within this framework, the entrenched patriarchy operates such that women themselves measure and express their freedom of choice within this acceptable framework. According to many of the male informants, both young and old:
“The woman cannot decide more than the man.” (Male Unmarried under 35)
“This decision comes from the man. (…) it is the man who will decide.” (Male Married over 35)
“It is the man. How he does it … he must tell her the reality that life is difficult.” (Male Married under 35)
Women’s acceptance of these socially bounded and constructed cultural expectations reflects the extent to which their ability to decide about their reproductive lives is constrained in WBeG. Women’s acceptance of this unequal social order, and of the finality with which they accept their constrained agency, is illustrated by the following quote:
“The decision comes from the man. Our relatives see that birth allows inheritance, and if you do not want to give birth, men do not agree. They should be the ones to take the decision because he is the person in charge. He is like the president of the house or the chief of the house. He is the one to see if his wife should give birth every year or after how many months, whether it will affect her health or affects upbringing of children or the way they live at home.” (Female Married over 35)
A young woman pointed out, “If it is the woman who says that she wants to stop, they [men and society] take it in a different way.” (Female Married under 35)
Subverting the hegemony, covertly and overtly
This constrained agency, however, is not going unchallenged; both men and women, young and old, are questioning the appropriateness and the continued feasibility, particularly economic feasibility, of the current social order. The return of peace presents opportunities; unlike before, people now see opportunities beyond just subsistence agriculture and survival. Earlier, children were seen as extra hands to till the land, and the responsibility of the parents was to provide food and shelter. Young men and women recognize these changing economic realities; they appreciate the responsibility and importance of investing in children’s education; and also that one should have only as many children as one can afford to provide good education for.
“Schools are expensive, and it is good to have sex in such a way that she does not get pregnant.” (Male Married under 35)
Some young men are also calling for the need for a partnership approach to deciding about family and family planning:
“This family planning depends on two sides. You, the man, and the woman: this is an agreement between you, of course.” (FGD Male under 35)
As discussed above, women are covertly defying this unequal social order. As the quotes below illustrate, some women are also doing this overtly, taking matters into their own hands, often to the chagrin of men and other women, and demanding a say on issues affecting their lives. A young woman added:
“You tell him [the husband], but if it is a husband that will cause problems, you don’t tell him. Some men will not accept it. They don’t want their wives taking contraception. … Yes, [then] you go along [secretly] and inject or take the pills.” (Female Unmarried under 35)
All three traditional leaders interviewed were strongly of the view that the man should and does decide on all matters related to reproduction in the household. However, as the quote below indicates, the challenge mounted by some women to this domination by covertly and overtly taking charge of their reproductive lives is triggering a rethink among the Fertit elders and shaping a new normality:
“Couples are supposed to agree together on when to produce children, but in many cases women will say they have been told in health facilities that it is not yet time for a child. This is what is frustrating many men in families.” (Traditional Leader)
This is also along the lines of what some health facility personnel and reproductive health service managers indicated: that they have recently noticed a change in the way women and couples approach the matter — perhaps, as indicated earlier, a change that is driven by the new economic realities:
“It is only this year that I see women starting to say they do not want to give birth. But before this was not there; they had the appetite for childbirth. Now because life has become very difficult … this is when I saw women start to come and ask for the injection and pills.” (Health Personnel)