Title: SRH/Family Planning - Learning for Future Programming
Contact Person: Delphine Pinault, Health & OVC Advisor
CO/Region: CARE Rwanda, East & Central Africa Region (ECARMU)

Learning Objective:
To identify the social-cultural factors that hinder women's access to family planning services

December 2006: The Proposal

High population growth coupled with low Family Planning (FP) utilization has contributed to making Family Planning a development issue for Rwanda. The country’s small surface combined with a population growth rate of 3.5% (UNDP, 2007), has contributed to making Rwanda one of the most densely populated countries in the world (321 inhabitants per square mile). According to the latest Demographic Health Survey (DHS), Rwandan women bear an average of 6.1 children (INSR & MACRO, 2005). The research, however, points to a high rate of unmet need among women in Rwanda (INSR & MACRO, 2005). While the relationship between the country’s high fertility rate and its low contraceptive rate is apparent, what are less clear are the reasons behind the low national contraceptive rate estimated at 10%.

We believe that the low contraceptive rate is not only due to geographic accessibility problems but also to socio-cultural factors and unequal power relations between men and women. So to help us gain a greater understanding of the social factors impacting family planning use - and with the ultimate goal of building up our FP program - we submitted a proposal for the Sexual and Reproductive Health (SRH) knowledge sharing fund. If you'd like to read our proposal, please see the attached.

Summer 2006: Addressing the Social Dynamics of Reproductive Health

Working_Paper_Thumbnail_2.JPGBut let's rewind to last summer. Our proposal builds on a publication that we helped the SRH Team to translate into French. It's called Addressing the Social Dynamics of Sexual and Reproductive Health: CARE's Explorations with Social Analysis and Community Action. This publication - a part of the SRH team's Working Paper Series - shares CARE's experience in using social analysis as a way of identifying, analyzing and addressing the barriers to and promoters of good SRH. Through participatory methods like PLA, social analysis helps communities identify their SRH challenges and the social factors behind them.

If you're interested, here is the working paper in English and French.

You can also download them from CARE's website at www.care.org/reprohealth

And if you are really interested, check out this WHO site by the Commission on the Social Determinants of Health - http://www.who.int/social_determinants/en/

March 2007: The Terms of Reference

In order to help us undertake our social analysis we decided to hire a consultant. Someone experienced in using participatory research methods and someone with a comprehensive understanding of gender dynamics and the socio-cultural, demographic and economic context in Rwanda. We drafted the Terms of Reference (below) and advertised for the job. Finding someone with the right qualifications was not easy, but we hired Felix Muramutsa of Smart Consultancy. If you'd like to contact him his email address is felixmuramutsa@yahoo.fr.

May 2007: The Literature Review

The first thing we asked Felix to do was conduct a literature review. In short, we have asked Felix to review existing documentation on family planning in Rwanda, specifically information on social-cultural barriers and barriers related to power relations between men and women. That way once we have a better understanding of what is already known, we won't duplicate research and we will know where the gaps are. To give Felix a head start I shared with him a literature review I did on sexual and gender based violence and proposed a format for this initiative.

June 2007: The Research Plan

CARE, like so many development organizations, does situation analyses before conducting projects. And they usually include qualitative research methods. The initiaal research plan developed by Felix reflected this - a solid participatory research protocol. But we wanted to use this KS initiative to try something different and to dig a little deeper.

Feedback on the draft plan is shared below. We hope it helps you understand how social analysis is different from a standard situation analysis. Many thanks to Felix for being so open to sharing!
  1. We already have the answers to many of the questions asked in the FGD guide. For example, traditional KAP surveys should answer most of the knowledge, attitudes and practices questions. We need to build on and deepen our understanding of existing knowledge. In other words, we want to better understand the socio-cultural reasons for not using FP that have already been identified. I think the litterature review needs to be finalized before the research plan to make sure we are not duplicating work.
  2. Start with what we know and then dig deeper. For example, share the DHS statistic that 10% of women want to have as many children as possible and then ask why it is important for a woman to have many children in Rwandan culture? Go deep in the answers by continuing to ask why, why, why till you think you’ve reached the real cause.
  3. Here are some other questions you might want to incorporate into your question guide:
    1. Tradition and customs: How do people space births of their children traditionally? Why do people decide to use modern methods versus traditional one? For those who do not want to use modern FP, what are their reasons? What are the customs around pregnancy and not getting pregnant? Are there times when women should not have children? Are there times when men should not have children? What are ideal numbers of children to have?
    2. Social networks: Who gets involved in discussions around when women should get pregnant or not? Who do women go for advice on getting pregnant and planning births of their children? Who plays a counseling role in the community for women on these issues?
    3. The couple: In what ways are husbands involved in these discussions and decisions around planning births? Around using traditional and modern methods? Do the opinions of women and men have equal weight?
    4. Marginalized/vulnerable women and men (social inequalities): Are there certain community members who feel more pressure than others to have children / not have children? Who? Why? Are there certain community members who are interested in birth spacing but have troubles seeking FP services? Who? Why? Are there certain community members who are interested in birthspacing but have troubles actually using FP methods? Who? Why?

In response to the above, Felix revised the research protocol. The final is attached. Now wish us luck with the data collection!

June 2007: What we learned through the Literature Review

Through the review, Felix was able to identify a number of reasons why Rwandan women are not accessing FP services. They include:
  1. Lack of decision-making power of women in the household
  2. Socio-cultural and religious influences
  3. Informal relationship with multiple partners
  4. Insufficient access to health services in general
  5. Insufficient information and counseling on family planning
  6. Fear of side effects of modern FP methods
  7. Rumors associated with family planning
  8. Perception of family planning as “limitation of births” only
  9. Difficulty in using natural family planning methods
  10. Specific problems associated with widows, separated and divorced women
  11. Lack of access, awareness, and support of adolescent reproductive health services
  12. Early marriages
  13. Impact of the genocide
  14. Factors associated with poverty which impact contraceptive use

Have a look at the full report (below) for more details on each of these reasons.

After reading what existing literature tells us, it seems to me that we’re dealing with two issues. On the one hand, there is a recognition that socio-cultural barriers and that power relations between men and women are part of the access problem. At the same time, we don’t seem to have an in depth and profound knowledge of these two aspects, specifically the impact of religion. The objective of our research will therefore be to explore these two aspects in more depth.

On the other hand, the review also leads to the conclusion that FP programs must engage and involve men and church leaders more actively and strategically. I think our research should explore how to engage men and church leaders in FP programs. We probably need to review our questions a little bit to incorporate more specific questions about that. And we need to include this conclusion in this literature review report as we need to show the link between the literature review and the tools used for the research.

Summer 2007: At Last ... The Research

Our social analysis research included a total 154 participants. Respondents included project beneficiaries and staff from CARE-Rwanda’s VS&L groups, FP service clients, members from a historically marginalized group known as the Batwas, and key informants (community health workers, local authorities, and FP providers). The research was conducted in the eastern and southern districts of Rwanda, and in Kigali (the capital city).

The overall research design was qualitative. Focus Group Discussions (FGDs) and individual in-depth interviews were conducted with respondents and key informants, respectively. FGDs were reinforced with interactive techniques including, ‘Think Like a Genius’ (TLG) and story-telling, in an attempt to initiate the process of social analysis within CARE-Rwanda’s health projects.

What did the Research Participants Say about FP?

Generally, the responses gathered from the FGDs and individual interviews served to reaffirm gender power imbalance as a significant barrier to women’s practice FP. Indeed, the research revealed that family size is largely determined by the male partner. The preference for boys over girls was described as overruling the concern for family size; respondents pointed to the fact that Rwandan women may prefer to give birth to boys in order to please their husbands and in-laws. A woman who hasn’t succeeded in giving birth to a boy may continue to have children in the hopes of bearing a son; this may be in order to please her husband and meet social expectations, and it may also be to keep her husband from either taking another wife or having extra-marital sex to have a son. Several female respondents stated that they do not talk to their male partners about FP issues for fear of being categorized as a ‘dominant woman’. This suggests that by raising the issue of FP with the male partner, a woman is going against social norms.

Another barrier expressed by the respondents, and which has also been uncovered by previous studies conducted in Rwanda, is the fear of contraceptive side effects. Female respondents expressed their resistance to contraceptive use as a fear of how the side effects might affect the male partner’s sexual satisfaction. Side effects commonly referred to by participants included: loss of vaginal lubrication, heavy and prolonged bleeding, and loss of female sexual desire. Women’s fear of side effects was attributed to the fear that the male partner would seek out other women to achieve sexual satisfaction. More importantly, the fear of side effects which interfere with the male partner’s sexual pleasure was also attributed to women’s fear of violent repercussions. Key informants explained that as long as the side effects don’t alter the couple’s sexual relationship, the female partner can continue using the contraceptive. Otherwise, she risks experiencing physical and/or emotional violence. It should also be noted that male resistance to women’s use of modern contraceptives was explained as being related to men’s fear that the female partner would be unfaithful. This finding points not only to distrust within couples, but also to efforts by male partners to exercise control over their partner’s sexuality.

Another issue that emerged from the research included the heavy influence of religious leaders on couples’ decision to practice modern contraceptive methods. Participants also pointed to a limited access to FP services that provide modern contraceptive methods; some of the research communities were located nearer to faith-based clinics which do not offer modern contraceptives. A related issue was the one of insufficient and/or poor quality of services offered by health centers. Respondents and key informants revealed that health providers’ lack of adequate skills remain an obstacle to women’s practice of FP. For example, some health workers did not have sufficient information on contraceptive side effects. Interviews with health providers revealed another disturbing factor which acts as a barrier to FP practice; several providers stated that in order to increase men’s involvement in FP, they have made it a requirement for female clients to visit centers with their male partner. Making women’s access to contraception conditional upon men’s approval not only acts as a barrier to FP practice but may serve to perpetuate gender power imbalance in the couple.

So what are the Conclusions and Recommendations?

Generally, respondents acknowledged that the country’s high birth rate is problematic. Respondents among CARE field staff all acknowledged the importance FP for Rwanda, and the impacts of the high fertility rate on the country’s economic growth. This perception was also common among key informants.

The research revealed various socio-cultural barriers to FP practice in Rwanda (e.g. gender power imbalance; preference for boys; ‘pro-birth’ tradition). Family Planning interventions should make an effort to engage men on the issue of FP more specifically and Reproductive Health (RH) more broadly. As was expressed by the respondents, family size is largely determined by the male partner. Hence, engaging men as partners in FP is crucial.

Programs must tackle the issue of gender power imbalance in couples. Hence the need for more approaches that encourage inter-partner dialogue on FP and RH.

FP programs must also address the issue of widespread rumors and misinformation surrounding contraceptive side effects. Health providers need to receive accurate information on documented side effects and must be trained to sensitively and effectively address this issue with their clients.

If you'd like more detail still, here is a copy of the final report from the SAA.

Fall 2007: So what's Next?

The findings from the research were, ultimately, intended to inform the design of CARE-Rwanda’s future FP and RH programs. As stated previously, the research reaffirmed the significance of gender power imbalance in couples’ reproductive decisions. CARE-Rwanda’s programs will have to reinforce the importance of couple dialogue and cross-gender dialogue on sexual and reproductive health issues and will have to focus on men as partners in the promotion of women’s reproductive health. CARE-Rwanda’s programs will also include capacity building for existing FP services by developing health providers’ knowledge of documented contraceptive side-effects so that they are able to effectively address this issue with clients.

Currently, CARE-Rwanda is developing a theatre play that incorporates the social and cultural issues that emerged from the research. The play will address the issue of FP in Rwanda by focusing on the lives of couples dealing with FP. The play will be performed before an audience of CARE staff as a means of initiating staff dialogue and reflection around this issue before being presented to communities.