What do women want?

14 World Heolth • 47th Year, No.3, Moy-June 1994 What do women want? T. K. Sundari Ravindran A !most 30 years after the contraceptive revolution of the 1960s, there are 300 million couples in the world who do not want any more children but are still not using any form of contra- ception, when there are more than 70 different types of contraceptive pills , at least 20 IUDs and four types of injectables, barrier methods , and female and male sterilizations. Take the case of Gowri , aged 29, a poor wage labourer living in a small town in South India who is anxious to avoid any future births, but has not found a suitable method of fertility regulation . She has had six pregnancies and borne five chi ldren, of whom only the fourth and fifth survived. The first was a stillbirth while the second, a girl , was born mentally retarded and died after the second year. The third , a low-birth-weight baby, did not survive beyond the first hour. "I was heart-broken. My husband had turned to another woman because I was unable to bear him a live child. When the fifth child was barely a year and a half, I was pregnant for the sixth time. That was when I decided to have an induced abortion to ensure that the two precious ones grew up healthy and well cared for." Being dependent on daily wages for survival , she cou ld not afford the long delays involved in seeking help from a government hospital. She borrowed money and went to a private clinic, where she had an abortion and had an IUD inserted right away. Following this, her menstrual bleeding lasted nine to ten days instead of five. Already malnourished, she became acutely anaemic. Then she developed an infection of the reproductory tract during the second year, mainly because of the lack of privacy, ~ ~~~~~~~~~~~~~~~~~~~~~============~ The choice of o fertility regulating method depends on many factors , including affordability limited access to water and inability to afford adequate sanitary protec- tion during menstruation. This seriously disrupted her ability to do strenuous work, and in addition the medical treatment proved very costly. Unable to continue with the method, Gowri switched to oral pills bought across the counter. But she could not afford to buy them month after month. She also had spells of dizziness and vomiting, and felt very weak and unwell. "I often had to take breaks during work and lie down for a while." Soon, no one was willing to employ her since she was considered sickly. This left her with no choice but to discontinue the pill. Tubal ligation is the only other option available, but she has reser- vations. Her children are still too young, and she wants to wait till they live to be older. In addition, she has no one to take care of them, or of her, after the surgery. She could not afford to stay away from work for several days , either. Expecting her husband to adopt birth control is a hopeless idea, since he now has another fami ly, and visits Gowri only once or twice a week. Facing realities For women, the safety of any contraceptive method is defined in relation to whether it has adverse health effects that limit their ability to carry on their normal daily tasks, and to earn a living; whether these effects involve costs for medical treatment to alleviate the symptoms; and whether they cause or accentu- ate marital tensions because of the effects on the woman's physical and emotional well-being, and on her libido. World Health • 47th Year, No.3, Moy-June 1994 Acceptability too is based mainly on factors such as the point at which women are in their repro- ductive life-cycle and their repro- ductive history. Women who have suffered child losses and pregnancy wastage would not accept methods that may interfere with their fertility - present or future. Young women who have not begun childbearing and women who plan to have additional children may find a less effective method acceptable, especially if it is free of health risks -as in the case of natural family planning or barrier methods. Women who are wage-earners may be unable to afford taking time off work to go to the clinic regularly, for injectables or to replenish supplies of oral contraceptives. Thus, acceptability of a method is assessed by women according to the circumstances of their lives; they are likely to vary for different women, and for the same woman at different points in her life. Male-dominated society Acceptability of a contraceptive method is also judged within the parameters of a male-dominated society. Men rarely come forward to undergo sterilization, and are usually unwilling to use the condom especially for contraceptive pur- poses. Often, women themselves 15 Fertility control should be o molter for both partners to decide on . reject the idea of male sterilizations, because they do not want the "breadwinner" to take any risks with his health. In discussions with poor women in rural India, I often heard remarks such as the following: • "I do not trust the service provider to remove the implant if I have a problem. I do not want to risk it." • "They (service providers who are part of the government' s family planning programme) do not take responsibility for treating reproductive tract infections that may follow IUD insertion; you have to seek help from private doctors , and that costs money ." • "I am afraid of all methods. All of them have problems, and the service providers don ' t care." Thus, many of the reasons why women do not find a fertility- regulating technology that suits them have to do less with the technology itself, and more with their poor health and overall status; with male control over female sexuality and men's unwillingness to take responsibility for fertility control; and with a poor health infrastructure and quality of care. What is needed is a search for policies and programmes that will remove these constraints. More importantly, women's needs and concerns should be the starting point on which the develop- ment of new fertility-regulating technologies are based. This would involve the search for methods that are not only free from adverse health effects but also provide protection from reproductory tract infections and HIV I AIDS; that are reversible and do not adversely affect future fertility; that do not interfere with lactation; and that are in addition effective, easy to use and affordable. It would also mean according a high priority to the development of a wide range of contraceptive methods and devices for men. • Poor health and low overall status ore often barriers that prevent women from using contraception. Dr TK Sundari Ravindran is Co-Editor of Reproductive health matters, F-17, Hauz Khas Enclave, New Delhi · 1 10 0 16, India.