Iucd Utilization in Family Planning Client in Sudan
- Enquiry article
- Open Access
- Published:
Social norms and family unit planning decisions in South Sudan
BMC Public Health volume 16, Article number:1183 (2016) Cite this article
Abstract
Background
With a maternal bloodshed ratio of 789 per 100,000 alive births, and a contraceptive prevalence charge per unit of 4.vii%, S Sudan has i of the worst reproductive wellness situations in the globe. Understanding the social norms effectually sexuality and reproduction, across different ethnic groups, is key to developing and implementing locally appropriate public health responses.
Methods
A qualitative study was conducted in the state of Western Bahr el Ghazal (WBeG) in South Sudan to explore the social norms shaping decisions about family planning among the Fertit customs. Data were nerveless through five focus group discussions and 44 semi-structured interviews conducted with purposefully selected customs members and health personnel.
Results
Among the Fertit customs, the social norm which expects people to have equally many children as possible remains well established. It is, however, under competitive pressure from the existing norm which makes spacing of pregnancies socially desirable. Young Fertit women are increasingly, either covertly or overtly, making family planning decisions themselves; with resistance from some menfolk, but also support from others. The social norm of having equally many children as possible is besides nether competitive pressure level from the emerging norm that equates taking good care of i's children with providing them with a good education. The return of peace and stability in South Sudan, and people'south aspirations for liberty and a improve life, is creating opportunities for men and women to challenge and subvert existing social norms, including but not limited to those affecting reproductive health, for the better.
Conclusions
The sexual and reproductive health programmes in WBeG should piece of work with and leverage existing and emerging social norms on spacing in their health promotion activities. Campaigns should focus on promoting a family ideal in which children become the object of parental investment, rather than labour to till the land — instead of focusing direct or solely on reducing family size. The conditions are correct in WBeG and in South Sudan for public health programmes to arbitrate to trigger social change on matters related to sexual and reproductive wellness; this window of opportunity should be leveraged to achieve sustainable change.
Peer Review reports
Background
Later a long ceremonious state of war (1955–2005), South Sudan became an contained country in July 2011. The war has destroyed much of the public infrastructure, and economic activities and opportunities are few. The newfound freedom and peace have been regularly disrupted by violent civil conflict in some parts of the state. The wellness care system is besides weak, with severe shortages of health workers and functioning health facilities [1, two]. As a result, Due south Sudan has i of the earth'due south worst population health indicators; this is particularly and so for sexual and reproductive health (SRH). For case, at 789 deaths per 100,000 live births, it has one of the highest maternal mortality ratios (MMR) in the earth [iii]; similarly, the contraceptive prevalence charge per unit (CPR) is merely four.vii%, with only 1.7% of women reporting using modern methods [4, v]. While reliable data disaggregated by state and ethnic group are not available, information technology is reasonable to await that, minor differences notwithstanding, the situation is similar in all 28 states. S Sudan'south SRH challenges relate both to the supply and need sides of SRH services.
In this context, and with the purpose of informing the development of a locally appropriate intervention arroyo, a study was conducted to explore factors influencing SRH-related behaviours and decision-making on a range of SRH bug, including 'family unit planning', in Western Bahr el Ghazal (WBeG) country. Prove [vi] shows that increased contraceptive use lonely has "cutting the number of maternal deaths in developing countries past about twoscore% over the past 20 years" [7]. Since 2011, unlike some other parts of Due south Sudan, WBeG has been relatively peaceful, and at the fourth dimension of the study, some forms of bones health and reproductive health services, including modern contraceptives, were generally available across the state. Thus, demand-side, population-level factors are perhaps every bit important every bit the supply-side factors for the depression CPR in WBeG.
S Sudan is home to more than than 50 ethnic groups; at the national level, the Dinka and the Nuer constitute the biggest ethnic groups. While they constitute a sizeable part of the population in Due south Sudan, in some states other ethnic groups tend to predominate. For instance, in WBeG, the three chief ethnic groups are the Fertit, Luo (or Jur) and Dinka; the Fertit, a moniker used to refer to a loose conglomeration of more than 23 not-Dinka, non-Arab, not-Fur and non-Luo people, are the predominant group [8]. Dissimilar the Dinka and the Nuer, who are pastoralists, the Fertit are predominantly agriculturist people involved in subsistence farming. The Fertit, like all other South Sudanese ethnic groups, are patriarchal; men accept the power to decide on all aspects of the family and in gild at large, and women'due south position is subordinate to men [9–xi]. Edwards [12] argues that a range of societal, historical and political processes have led to a situation where gender inequalities in S Sudanese society have go entrenched and disadvantage women in social, economical and political realms akin.
No matter where i is, planning a family is a complex procedure, with the couple'south decisions regarding family unit size, timing of pregnancy/spacing and contraceptive apply affected past a variety of factors. According to de Francisco et al.'s [13] conceptual framework, a range of interlinking factors in the household, community, larger society and the political environment shape the SRH related decisions and actions of individuals; these factors also shape the consequences experienced by individuals of their decisions and actions. According to the framework, the intimate, family and social relations, including intra/inter-generational relations and gender relations, shape individuals' ability to make SRH related decisions. These close interpersonal relationships are set within an intermediate circle of kinship structures and community institutions, which are, in plow, nested in an outer circumvolve of national political and social institutions, power structures and ideologies. Within these overlapping spheres of influence, individuals and social groups occupy positions of relative advantage or disadvantage with respect to their access to information and other resources — including their chapters to make decisions; this has important implications for their own and others' SRH and rights. A wide range of influences shape both behaviour and opportunities, with consequences for SRH-related behaviours (decisions and deportment); they point out that these influences are transmitted through community-level institutions. For instance, the meaning and value given to what constitutes sexual wellness, reproductive wellness, satisfaction, distress, motherhood and fatherhood is e'er strongly influenced by dominant cultural norms. Similarly, social norms also create powerful ideals of manhood, womanhood, masculinity and femininity, and they define what sexual and reproductive behaviour is appropriate for men and for women, at different stages of life. Social norms condemn or condone SRH-related behaviours, expectations and decision-making processes; they also define admission to resource and information, which together are necessary for decision-making related to health (including SRH).
While factors influencing SRH-related behaviours and decisions include both those related to availability and access to services and social- and individual-level factors, the focus of this newspaper is on the latter. The paper provides insight into how social norms shape behaviours and decisions related to family planning among the Fertit people in WBeG. Such insight can be useful for public wellness policymakers and programmers in WBeG for designing and implementing locally advisable and culturally sensitive SRH interventions; this insight can also be valuable for other states in South Sudan with similar, large agriculturist communities.
Methods
A qualitative exploratory study was conducted. Data were nerveless through focus group discussions (FGDs) and semi-structured interviews (SSIs) conducted with a diversity of purposefully selected informants, as detailed in Table 1. The post-obit sections further explicate the sampling and recruitment principles and processes.
Topic guides for FGDs and SSIs were developed using de Francisco et al.'south [13] conceptual framework. The topic guides included questions exploring social norms and beliefs virtually sex, sexuality, roles and relations between men and women, reproduction, and what shapes the decision-making on matters related to reproduction. The topic guides besides included questions well-nigh preferences and expectations from, and views nigh, current SRH services. The topic guides for wellness and other workers included questions along the same lines, simply with a view to exploring the situation from their perspective. The FGD and SSI topic guides for community members were prepared in English and translated into Wau Standard arabic (by investigators MR and AM). The topic guides were defined further during the initial stakeholder workshops, pre-tested in the study site and as well adapted iteratively as the study progressed. The FGDs and SSIs with community members were conducted in Wau Arabic, a language spoken past all around Wau, including the Fertit people; interviews with health and other workers were conducted in Wau Arabic or English language, depending on the preference of the health worker.
The belittling framework provided by the theory of planned behaviour (TPB) [14, 15] was used to critically analyse factors shaping behaviour and controlling related to family planning among the Fertit people in WBeG. According to TPB, iii major antecedent domains influence a person's intention to perform a beliefs: 1) mental attitude towards and belief that performing the behaviour will lead to the desired outcomes; 2) social norms related to the beliefs; and 3) one's perceived command over or perceived ability to perform the specified behaviour. The TPB contends that a positive attitude and positive outcome expectations alone are not plenty to shape decisions and behaviour; the two domains, the prevalent social norms and i's beliefs about own power and capacity to act, also operate concomitantly to affect individuals' decisions and actions. The TPB is a mid-range theory which has been widely used and is well suited to describe the antecedents of particular behavioural intentions [xvi]. Recognizing that in many situations individuals and groups defy what appear to exist strong social norms [17], and that norms both shape actions of agents and are at the same fourth dimension themselves beingness constantly shaped by these actions, nosotros draw on the critical realist explanatory tradition to go one step further to discuss and explain norm congruence, norm defiance and, thereby, norm maintenance or transformation [18]. To do so, we describe on Archer (1998, Ch 14, p20) [17], who argues for an analysis which approaches structure and agency through "analytical dualism", wherein "the structural, cultural and agential components are analyzed separately, with a focus on their logical relations and the conditions and possibilities that these allow". The analytical emphasis is thus twofold: explaining how the social structures shape the actions and interactions of individuals, and how at the same time the social interactions between agents besides shape the social structures and social relations, both maintaining or reproducing and transforming them.
Study sites
The study was conducted in Wau county in the state of WBeG in Due south Sudan. Two locations were selected based on the homogeneity of the residents (all Fertit). Farther, the locations were also within the coverage expanse of wellness 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 2 different settings in Wau canton: 1 in Wau town and the other a rural area. The a priori assumption backside choosing these two locations was that perhaps within the same social grouping the manner norms related to behaviour and decisions might be chastened differently in dissimilar settings.
Sampling, recruitment of study participants and information drove
The chief categories of written report participants are summarized in Table 1. Community members were purposefully selected with the help of village elders, wellness workers from a local non-governmental organization (NGO) and the county wellness department. Amongst community members, only those aged 18 years and higher up were included in this study; a carve up just 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 onetime would be more subject area to the norms related to sexuality and reproduction, and the latter would exist the ones involved in enforcing the norms, shaping preferences, setting expectations and influencing the determination-making and health-seeking behaviours of the former.
Information collection began with FGDs among community members to identify dissimilar aspects of the discipline, and differences in views among participants on the discipline. This was followed past SSIs to obtain more in-depth understanding. For FGDs with community members, participants were homogenous in terms of historic period and marital status, however variety was sought in terms of social and economic status (based on: inputs from elders related to social identity, buying of assets such equally bicycles, level of didactics). FGD participants were not involved in the SSIs.
Health facility personnel working in the local health centre of the written report sites were included in the study. First, an FGD was conducted to identify different aspects of the bailiwick, and differences in views among health workers on the subject. Participants included a clinical officer, 2 nurses, a wellness assistant and 2 customs health workers. The FGD was followed by SSIs with those personnel specifically responsible for reproductive wellness at the health centre. FGD participants were not involved in the SSIs.
Primal informants were likewise purposefully selected for inclusion in the study; they were selected based on their active SRH-related role within the health system and the study customs, 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-scale — in fact there was simply 1 SRH-related officer at both county and state health department level, and both were interviewed. Similarly, all 3 NGO representatives working on SRH in Wau canton were interviewed.
Data were collected between October 2014 and April 2015, from iii visits to Wau. FGDs and SSIs with customs members, traditional leaders and traditional nascency attendants were conducted by research team members who hailed from the study expanse, were fluent in the local language and had feel in conducting qualitative research; interviewers and participants were matched by sex activity. FGDs and SSIs with wellness workers, managers and NGO representatives were done in English language. Data were collected until information saturation was reached and no new insight emerged; this was possible to assess, as at the cease of each mean solar day of information collection, the research team debriefed and discussed the emerging findings. In total, five FGDs (with 38 participants) and 44 SSIs were conducted. This is coinciding with the general experience on saturation; according to Creswell [xix], a sample size of around 30–l is generally sufficient to achieve analytical saturation in a qualitative report.
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 x software. This was done in parallel past 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 assay was further assured through a information validation workshop (n = x) and interviews with key informants (northward = 2), and as well through follow-up interviews with some (n = iv) of the written report participants in both report 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 Imperial Tropical Plant, Amsterdam, and the national Ministry of Wellness of the Regime of South Sudan. Administrative blessing was given by the WBeG Ministry of Wellness. Informed consent was taken from all participants. Consent was sought only subsequently the person had been contacted to participate (and had in principle agreed), but before whatever 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 non read, the consent grade 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 3rd parties.
Sex, sexuality and reproduction are sensitive, intimate and yet social issues. At the offset of the consent process, participants were informed of their right to refuse to respond any questions they might find intrusive. The interviewers were also very conscious of this, and did non press alee with a line of enquiry if they noticed the participant was not comfortable. Furthermore, given the sensitive nature of the topic, there is a risk of opening up hitherto airtight, even so painful chapters and experiences in the person'due south life. To ensure support if such a situation arose, a trained counsellor was available, equally were medical referral services. No such state of affairs requiring counselling or medical referral emerged during data collection. Withal, at that place were many instances of people in the community seeking assist to go treatment for individuals, and this was provided — for example, on 2 occasions, the research team used its car to take a child and his female parent to the state hospital for farther treatment.
Results
Findings are presented along three broad lines: knowledge of and attitudes to pregnancy, family planning and contraceptive utilise; social norms shaping family unit 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'south duty
Both Fertit women and men consider having children very of import. Getting pregnant after matrimony was looked on positively, and a common belief across sexes and beyond age groups is that pregnancy is 'God'southward will':
"Pregnancy is of course from God … pregnancy is from God." (B FGD Thousand under 35)
"In one case y'all go married … if God wills you give nativity right away as that is the main reason." (FGD Males over 35)
"Only 1 of my iii daughters has no kid. But i … God did not give her a child." (FGD Females over 35)
Another related view shared by men and women akin, admitting 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 yous force to give nativity to ten or 12 you will exist lucky." (Traditional Leader)
Spacing pregnancies, the right thing to practise?
All respondents recognized that a sufficient corporeality of time was necessary between ii pregnancies, and had a favourable view of spacing. They believed this for many reasons; a common belief among women was that getting meaning immediately after commitment was bad for the unborn kid:
"… When a woman gives birth and before her baby sits she is pregnant once more this is when you damage your small babe…" (Female over 35)
Another belief was that having frequent pregnancies was bad for the woman'south health:
"And when it is frequent it will affect the uterus and the pelvis will be tired." (Female Married under 35)
"Housework and food besides volition be difficult. If a woman gives birth every twelvemonth it wears her out." (FGD Females Married nether 35)
Men, both young and old, likewise knew virtually the importance of spacing; their arguments, even so, tended to be more than 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, peradventure referring to a local belief, that getting the wife pregnant again earlier 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 infant and when it starts walking, then you can get on superlative of his/her mother over again and so that you lot can bring another child. But if the child born is not yet walking, if you get on elevation of his/her female parent, that child will be paralyzed." (FGD Males over 35)
"Sometimes if there is a baby in the stomach and in that location is [already] a [breastfeeding] child, the [unborn] child can get dehydrated in relation to the child's breastfeeding … the [unborn] child will exist … sometimes you will find a child like this hand of mine … volition 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 noesis almost pregnancy; a traditional leader echoed this thus:
"For our old generation we used to wait even subsequently two years… Our traditions are against that [back-to-back pregnancies]." (Traditional Leader)
Some older women argued that the times were harder at present, that raising children was more difficult at present, and that this made information technology necessary for women to space pregnancies:
"Child delivery in the past is not similar the present. If you bear 10 children, where will they get education…? This is non adept. It is meliorate to bear children and have gaps between them so that they can become good education. But if yous have ten, nine, 5 children, there volition be many, and raising them becomes very hard." (FGD Females over 35)
Others disagreed, pointing out that because childbearing was God's will, 1 could not say how many children one should accept:
"Childbirth is from God. I cannot say they should have this many children.… I don't similar it; I think information technology is very bad. How can they finish a woman from having a child? God has given that to yous. Are they going to stop it?" (FGD Female over 35)
Younger women also had some misgivings; for case, during an FGD amongst younger women, there was much understanding when i of the participants said that if a woman does not have a child for three or four years, it can brand subsequent deliveries more than difficult. A word among younger women during an FGD went equally follows:
"If yous stay long without getting meaning 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 nether 35).
The use of contraceptives
Equally the following quotes illustrate, younger women, unlike other informants, had a uniformly favourable mental attitude towards using contraceptives, perhaps reflecting a more pragmatic agreement of the state of affairs. They not only know about modern contraceptive options simply also usually apply them, although some women mentioned they had stopped using contraceptives after experiencing negative physical effects:
Facilitator: "Do you know how to programme your family?"
Respondent: "Family unit planning is similar taking pills every morning. These pills are given. If you get to the health center and you say that you lot want to plan pregnancy, they give you lot pills … if the injection does not suit you. There is an injection given for up to vi months. So you need to plan pregnancy." (Female Married under 35)
"Contraceptive pills are very good if you tin can tolerate information technology. I tried contraceptive pills earlier and I used to encounter my menstruation twice a month. This is why I stopped it." (Female Unmarried nether 35)
While all recognized the importance of spacing, and were knowledgeable near modernistic contraceptive options, there were disagreements near their use. Men were mixed in their views about women using contraceptives to space pregnancies. While some took a more than pragmatic view, others, including some younger men, strongly disapproved:
"For younger girls who had children early and exercise not want to become pregnant again, the doctor can offer contraceptive pills … The woman can be given injections or contraceptive pills to preclude pregnancy, and young girls tin go back to schoolhouse." (Male person Married over 35)
"Those condoms, those pills, those injections. Our fathers in the past didn't do it. For what reason should we come up to practice it? Does it mean that nosotros lonely practice not know how to plan a family unit? My wife is not going to eat pills or become injection … for what?" (FGD Males Married over 35)
Many men were concerned about women going behind their backs and using contraceptives, especially the long-acting injectables; while non explicit, in that location 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 utilize modern contraceptives:
"Some women exercise it in agreement with their husbands; others just become to pharmacies on their ain and buy the pills and use it without telling their husbands … the men practise 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 — equally attempts by outsiders to deny them their right to accept many children, every bit outsiders were the ones promoting contraceptive use. The following quote highlights the importance of handling delicately any intervention to promote contraceptive utilise.
"… Allow the youth give nascency because a long time ago we gave nascence likewise, and they would say you are denying their children to have children… They say before nosotros used to give nativity, why at present does the white man want our girls not to requite nascence?" (FGD Health Personnel)
In i of the FGDs, young women recognized that many men had a suspicious attitude towards the health services. They agreed that this was non the right matter to do and that such a state of affairs would brand things difficult for everyone:
"Family planning is good, but … planning should be done later you lot agree with your husband. You tell him that life is hard … other women just go and starting time family planning without involving their hubby, and then it causes bug in the house; the adult female stops the planning, and so she starts giving birth one afterwards the other. So this is a mistake." (FGD Females Married nether 35)
Social norms on childbearing, spacing and contraceptive utilize
The theory of planned behaviour refers to social norms as structural powers which shape people'due south intentions and behaviour. Cialdini et al. [xx] 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 information technology is empirically difficult. Descriptive norms refer to individuals' beliefs about the prevalence of a detail behaviour and about what nigh (relevant) others do in a particular state of affairs. 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 mode, and to perceive that social sanctions will exist 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 utilise.
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 exist able to bear children, to replace dead family unit members. There is social pressure on women to comport children, and not begetting children incurs social disapproval, fifty-fifty ostracism.
"The community is the primary reason for all this, especially neighbours, friends and parents. They complain a lot that their son needs to have babies to supersede a dead uncle or a dead grandad, 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 nascence. This woman must give birth and not have whatever contraceptives." (NGO)
As the post-obit 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 lot ever remember or did you ever ask your wife not to become pregnant?" Respondent: "No, I have never washed that."
Facilitator: "Why?" Respondent: "I accept never idea virtually that before." (Male Married nether 35)
"Our customs does not encourage spacing children." (Male person nether 35)
In fact the social norm is that if a woman does not bear children, and then she, as the quote beneath illustrates, is considered non worth keeping. Further, men are too normatively expected to have multiple children. Those who do not go on to father children run the take chances of existence labelled as infertile and subjected to ridicule; they also hazard their wives leaving them for other men.
"If the wife but stays for six months without getting pregnant, immediately they starting time asking 'Was she brought just to go to the toilet, and who is to pay for that?'." (Health Personnel)
Facilitator: "What does the customs say virtually a family unit where the adult female does non become significant for a while?"
Respondent: "The customs does not speak well nigh that. They will say that the adult female is non fertile and the homo is wasting his time. He should get and observe another woman who can bear him some children. Sometimes the woman'south family will say that the man is infertile and their daughter needs to find another homo. Some of them will start having an thing." (Male Married under 35)
Thus, injunctive social norms on matrimony and childbearing take a major influence on the intentions and behaviours of men, women and couples near spacing and contraceptive use.
Social norms on spacing
In Fertit society, there is an injunctive social norm that women should get residuum afterwards 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 private level, women and men reported that in gild it is frowned upon if a woman in the family unit becomes pregnant very soon later on childbirth:
"When a woman gives nativity and two months later she gets pregnant again, it is shameful. All your family, even your own mother, volition exist blamed, because they will say why did you let this girl get pregnant and her baby is even so modest. It is a bad reputation in the family." (Female person 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-dorsum pregnancies]; if a woman gives birth to an immature kid [with depression birthweight], she volition be called 'Na-Ngoyo' … ways the mother of an immature child. It is a shame in our community." (Traditional Leader)
Information technology was also clear that at that place were no injunctive social norms which explicitly or implicitly sanctioned the use of modern contraceptives:
Facilitator: "And so there are no traditions that prohibit contraceptives?"
Respondent: "No. If you go for an injection, it is up to you …." (Female person Unmarried under 35)
"You from your own volition and the will of your wife. If you see this woman having [multiple and frequent] childbirths, like for me, perchance I will go to the doctor to requite us family planning." (FGD Males under 35)
Men and women relied on the deportment and experiences of of import others (descriptive norms) to inform their ain intentions and actions; the important others influencing contraceptive decisions and pick included family and close friends, and the traditional leaders. Women'south attitudes to different forms of modern contraceptives were informed past experiences of friends and family unit members:
"This effect of contraception … fifty-fifty me, I wanted it. I have my sis-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 have annihilation and just save myself and pray to God to save me." (Female over 35)
Ability to deed and determine
Kabeer [22], in her influential work on women'south empowerment, frames women'south "power to define ane's goals and act upon them" as their 'agency'. Bureau is exercised in relation to others; equally Kabeer [21] explains, it is "more than near merely observable activeness" and includes the ability to negotiate and bargain, subvert, resist and dispense, and likewise more than intangible cognitive processes of reflection and analysis (1999: p 438). This section shows how Fertit women's ability to decide nearly their pregnancies and spacing of pregnancies is constrained. Information technology 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'due south constrained bureau
Women consistently referred to 'abstinence' after commitment equally the fashion to avoid getting pregnant soon after; in an FGD amidst married young women, the respondents explained how they went most getting their husbands to cooperate — a poignant reflection of the severely constrained nature of women'south agency and of their resigned attitude to the social acceptance of their husbands having sex outside their union, despite existence well aware of the risks of contracting sexually transmitted infections:
"If y'all have a three-month-sometime baby and your married man goes and finds another gamble, let him go. Tell him to find someone who will not bring united states of america disease and who volition bring together me and nosotros talk and laugh. In this way, your infant will not endure." (FGD Females Single under 35)
"You will stay away from the husband a scrap. Y'all can allow your husband to go around similar when y'all accept 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 just do the men and their families uphold and operate within this framework, the entrenched patriarchy operates such that women themselves measure out and express their freedom of choice within this acceptable framework. According to many of the male informants, both young and one-time:
"The woman cannot determine more than the man." (Male Unmarried under 35)
"This decision comes from the man. (…) information technology is the man who will decide." (Male person 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 make up one's mind well-nigh their reproductive lives is constrained in WBeG. Women's credence of this unequal social club, and of the finality with which they have their constrained agency, is illustrated past the post-obit quote:
"The decision comes from the human being. Our relatives encounter that nascence allows inheritance, and if you exercise not want to give nascence, men practice not agree. They should be the ones to accept the determination considering he is the person in charge. He is like the president of the house or the chief of the house. He is the ane to encounter 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 alive at dwelling." (Female person Married over 35)
A young adult female pointed out, "If it is the woman who says that she wants to terminate, they [men and society] have it in a different way." (Female Married under 35)
Subverting the hegemony, covertly and overtly
This constrained bureau, however, is non going unchallenged; both men and women, immature and old, are questioning the ceremoniousness and the continued feasibility, particularly economical feasibility, of the current social gild. The render of peace presents opportunities; unlike before, people now see opportunities across simply subsistence agriculture and survival. Earlier, children were seen equally extra hands to till the state, and the responsibility of the parents was to provide nutrient and shelter. Young men and women recognize these irresolute economic realities; they appreciate the responsibility and importance of investing in children's teaching; and too that one should accept simply as many children every bit ane can afford to provide adept education for.
"Schools are expensive, and it is skilful to have sex activity in such a way that she does not go pregnant." (Male Married under 35)
Some immature men are as well calling for the need for a partnership approach to deciding about family unit and family unit planning:
"This family planning depends on two sides. Yous, the homo, and the adult female: this is an agreement betwixt yous, of grade." (FGD Male person under 35)
As discussed to a higher place, women are covertly defying this unequal social club. Every bit the quotes below illustrate, some women are also doing this overtly, taking matters into their ain hands, often to the chagrin of men and other women, and demanding a say on issues affecting their lives. A young woman added:
"You lot tell him [the husband], but if information technology is a husband that will cause problems, you don't tell him. Some men will non have information technology. They don't want their wives taking contraception. … Yes, [then] you go along [secretly] and inject or accept 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, equally the quote beneath indicates, the challenge mounted by some women to this domination by covertly and overtly taking accuse of their reproductive lives is triggering a rethink amid 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 take recently noticed a change in the way women and couples approach the affair — perhaps, as indicated before, a change that is driven past the new economic realities:
"It is only this year that I see women starting to say they exercise non want to requite birth. Simply before this was non in that location; they had the appetite for childbirth. Now because life has become very difficult … this is when I saw women commencement to come up and enquire for the injection and pills." (Health Personnel)
Discussion
Consistent with the theory of planned behaviour [thirteen], nosotros found that a positive attitude and positive outcome expectations most spacing of pregnancies alone are not enough to shape decisions and behaviour; the prevalent social norms and one's beliefs almost ane's capacity to deed also operate concomitantly to affect decisions and actions. The findings above show, and we talk over further in this department, how social norms shape the agency and actions of individuals, and how at the same time, broader changes in social club, the social interactions between agents and their agency also shape the social norms, both maintaining and reproducing or transforming them.
The multifaceted influence of social norms on procreation decisions
Findings clearly prove that while both men and women want to take many children, they have a good knowledge of the importance and benefits of spacing pregnancies and of using modernistic contraceptive methods to exercise and then. This cognition and positive attitude towards spacing is, however, failing to interpret into decisions to employ 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'due south agency in the reproductive realm. On the other hand, our findings too recognize that men's agency in the reproductive realm is possibly similarly constrained by these social norms and past the very hegemonic patriarchy that privileges men. These findings are consequent with the evidence that employ of contraceptives and other SRH services is not just a thing of knowledge and rational choice but is mediated past social norms and ability relations based on gender and ethnicity [23, 24]. They are also consistent with the big trunk of anthropological and sociological literature supporting the view that couples' reproductive decisions are negotiated inside 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 withal, many caution against a universally tyrannical representation of men'south roles in the reproductive realm, arguing that such a representation is both inaccurate and unhelpful [23, 29]. While the findings above signal that patriarchy has been reinforced by the violent and fragile environment of South Sudan, they also show how it is existence 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 akin, having children and expanding one's family is an of import 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 part is 'childbearing', with women seen as a means of reproduction [31, 32]. These social norms around reproduction remain stiff and entrenched among the Fertit people of WBeG, Southward Sudan. However, the nature of social norms is such that conformity is provisional: people would stop befitting to a norm if there were doubts or disagreements most what the norm seeks to enforce or if information technology cannot be enforced. Evidence shows that no affair how permanent and rigid norms might appear, in any social club, competing norms are constantly at odds with each other, and norms are constantly evolving, being negotiated and beingness 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 past existing social norms and in the process opening windows of opportunity for redefining normality in WBeG society. In add-on, in both urban and rural areas, the descriptive social norm of having as many children as possible is under competitive pressure from ii other social norms: the injunctive norm on spacing pregnancies, and the injunctive norm that i must accept good intendance of children. Different before, when providing nutrient and shelter was what primarily entailed providing intendance, nowadays, good care is understood to involve providing practiced pedagogy to ane'due south children. People also increasingly recognize that they can bear the responsibility and the cost of providing practiced pedagogy to but 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 disharmonize and emergence of peace as aetiliogies of macro- and micro-level social change. Lianos [35] argues that individuals, groups and other actors suit their strategies to make the nearly of the new situation, thus participating in enhancing the legitimacy of the emerging new weather. Conflict, post conflict and peace establish social change, and social actors develop strategies to navigate it and benefit from it. This alter, catalyzed by the disruption of the traditional social gild equally 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 written report indicate that the new political and economical realities of the postal service-conflict setting, and the return to peace, might be catalysing the norm alter processes in South Sudan. The return to peace, and Southward Sudanese society's transitions from a militaristic male-dominated gild to a society at present focused on nation building and with aspirations of progress, with improving access to knowledge and services, is also opening upwards 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 do 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 wellness services are encouraging this becomes commonplace, the SRH program in WBeG country may become entangled in the complex gender and power dynamics inside society — to the detriment of women. While recognizing that social institutions such equally the wellness 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 practise 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 wellness. An explicit gender-transformative approach [36–38] that includes interventions which promote dialogue amid couples, family members and society at large, and which builds on social norms around the importance of women to be able to get 'residue between pregnancies', could be a viable and constructive mode forward. Such an arroyo could likewise apply to other settings in Due south Sudan where the situation is similar to WBeG.
Limitations
The written report has some limitations. Based on the conceptual framework, we expected generational hierarchies and some significant others to exist important influences on decisions on sexual activity, sexuality and reproduction. Nosotros did not observe any explicit bear witness of this. While men and women did refer to elders as shaping their decisions, we did not find anyone being specially influential (e.grand., mother-in-law, father, aunt). It is possible that indeed inside the Fertit gild, many people shape and influence decisions on these matters, and not just a few significant others; it is besides possible that our information drove somehow vicious short and that nosotros have failed to place these influences sufficiently.
The topics of sex, sexuality, reproduction and controlling on these matters are sensitive subjects. There is a adventure that people hesitate to talk openly or that they simply requite socially desirable answers. These constraints were anticipated, and steps were taken to loosen them. Preparatory trips were fabricated to familiarize the written report squad with the WBeG context and the study sites. Much effort was put into identifying research collaborators, one male and one female person, who not merely spoke the local language and had experience of qualitative inquiry simply were as well Fertit themselves. Preliminary visits were made to the study sites earlier the actual information drove, to meet the villagers and the elders, explicate the nature of the study and effectively seek the village's consent; these visits were village gatherings and, essentially, elaborate conviction-building exercises. As regards the run a 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 inquiry participants' accounts; her involvement served every bit both a quality check and too an additional level of insight. Finally, the overwhelming interest and the frank interaction we encountered during data collection, and given that the Fertit are non shy well-nigh talking most sex and sexuality, makes us confident of the validity of the study findings.
Conclusions
While the social norm which expects people to have as many children as possible remains well established amid the Fertit customs of the state of WBeG in South Sudan, it is under competitive force per unit area from other existing norms which make spacing of pregnancies socially desirable, and from emerging norms on what entails taking good care of one's children. The latter is changing: the focus is moving from looking at children as labour, to investing in them and providing them with a adept education. People increasingly recognize that they should only have every bit many children as they can afford to brainwash well. The long war has weakened or disrupted the existing social norms in S Sudan. The return of peace and stability and the emergence of a new economic order are creating opportunities for Fertit men and women to challenge and reconfigure social norms on childbearing and family planning. The public health programmes in WBeG should work with and make use of existing and emerging social norms on spacing and caring for children in their wellness promotion activities. Instead of focusing directly or solely on reducing family size, campaigns should focus on promoting a family platonic in which children become the object of parental investment.
Nosotros argue that the atmospheric condition are correct in WBeG and in Due south Sudan to trigger social change on matters related to SRH, and that the mail-disharmonize environment of South Sudan and its people's aspirations for liberty and a amend life offering an opportunity to intervene to change social norms, including but not express to those affecting reproductive wellness, for the meliorate; this opportunity should exist leveraged to achieve sustainable alter.
Abbreviations
- CPR:
-
Contraceptive prevalence rate
- FGD:
-
Focus group give-and-take
- SRH:
-
Sexual and reproductive wellness
- SSI:
-
Semi-structured interview
- TPB:
-
Theory of planned behaviour
- WBeG:
-
Western Bahr el Ghazal
References
-
MoH GoSS. Commonwealth of South Sudan. Ministry building of Health. Health Sector Development Program 2012–2016. 2012.
-
Mugo N, Zwi A, Botfield JR, Steiner C. Maternal and Child Health in South Sudan: Priorities for the Post-2015 Calendar. Sage Open up. 2015;1–14
-
World Health Organization. Trends in maternal bloodshed: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Grouping and the United nations Population Partition. 2015
-
Ministry of Health of South Sudan. Southward Sudan National Reproductive Health Strategic Plan, 2011–2015. 2011.
-
SSCCEC. Summary Findings South Sudan Household Survey. 2010.
-
Ahmed S, Li Q, Tsui AO. Maternal deaths averted past contraceptive use: an analysis of 172 countries. Lancet. 2012;380:111–25.
-
Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet. 2012;380:149–56.
-
Personal accounts: Based on discussions with local scholars and Fertit elders.
-
Scott J, Averbach South, Merport MA, Hacker MR, Cornish S, Spencer D, Potato Thou, Parmar P. An assessment of gender inequitable norms and gender-based violence in S Sudan: a community-based participatory enquiry approach. Confl Heal. 2013;7:iv.
-
Bior Ad. Gender Equality in South Sudan: A Review of Customs and Constitution. Weekly Review. Juba: The Sudd Plant; 2013.
-
Scott J, Hacker M, Averbach S, Modest AM, Cornish S, Spencer D, et al. Influences of sex, age and educational activity on attitudes towards gender inequitable norms and practices in South Sudan. Glob Public Health. 2014;9:773–86.
-
Edwards JK. A strategy for achieving gender equality in South Sudan. Weekly Review. Juba: The Sudd Plant; 2014.
-
de Francisco A, Dixon-Mueller R, d'Arcangues C. Research Issues in Sexual and Reproductive Wellness for Low- and Centre-Income Countries. Geneva: Global Forum for Health Inquiry and World Health Organization; 2007.
-
Azjen I. The Theory of Planned Behavior. Organ Behav Hum Decis Process. 1991;fifty:179–211.
-
Ajzen I. Perceived Behavioral Control, Self-Efficacy, Locus of Control, and the Theory of Planned Behavior. J Appl Soc Psychol. 2002;32(4):665–83.
-
Ajzen I. Attitudes. Annu Rev Psychol. 2001;52:27–58.
-
Rimal RN, Lapinski MK, Cook RJ, Existent G. Moving Toward a Theory of Normative Influences: How Perceived Benefits and Similarity Moderate the Impact of Descriptive Norms on Behaviors. J Health Commun Int Perspect. 2005;10:5. 433–450.
-
Archer M, Bhaskar R, Collier A, Lawson T, Norrie A. Critical Realism: Essential Readings. Routeldge: Centre for Disquisitional Realism; 1998.
-
Creswell JW. Qualitative inquiry and enquiry design: Choosing among five traditions. Thousand Oaks: Sage; 1998.
-
Cialdini RB, Reno RR, Kallgren CA. A focus theory of normative conduct: Recycling the concept of norms to reduce littering public places. J Pers Soc Psychol. 1990;58:1015–26.
-
Kallgren CA, Reno RR, Cialdini RB. A Focus Theory of Normative Bear: When Norms Practice and Do Non Affect Behavior. Personal Soc Psychol Bull. 2000;26(8):1002–12.
-
Kabeer North. Resources, Agency, Achievements: Reflections on the Measurement of Women'south Empowerment. Dev Chang. 1999;30(3):435–64.
-
Lockwood Thou. Structure and behavior in the social demography of Africa. Popul Dev Rev. 1995;21(1):1–32.
-
Price N, Hawkins Thousand. Researching sexual and reproductive behavior: a peer ethnographic approach. Soc Sci Med. 2002;55:1325–36.
-
Dixon-Mueller R. The sexuality connexion in reproductive health. Stud Fam Plan. 1993;24(5):269–82.
-
Oppong C. A high toll to pay: For educational activity, subsistence or a place in the job market. Health Transit Rev. 1995;5:35–56.
-
Renne E. Gender ideology and fertility strategies in an Ekiti Yoruba village. Stud Fam Plan. 1993;24(6):343–53.
-
Rylko-Bauer B. Abortion from a cantankerous-cultural perspective: An introduction. Soc Sci Med. 1996;42(iv):479–82.
-
Connell RW. Masculinities. Sydney: Allen & Unwin; 1995.
-
Page H, Lesthaeghe P. Child-Spacing in Tropical Africa: Traditions and Modify. New York: Academic; 1981.
-
Caldwell P. Issues of Union and Marital Modify: Tropical Africa and the Middle East. In: Suliman AH, Gyorgy A, editors. Family unit and Union in Some African and Asiatic Countries. Cairo: Cairo Demographic Centre; 1976. Research Monograph Series, No. half-dozen.
-
Caldwell J, Caldwell P. The Cultural Context of High Fertility in Sub-Saharan Africa. Popul Dev Rev. 1987;xiii:409–37.
-
Munshi One thousand, Mayux J. Social Norms and the Fertility Transition. J Dev Econ. 2006;80:1–38.
-
Hammel EA. A theory of civilisation for demography. Pop Dev Rev. 1990;16:455–85.
-
Lianos M. Conflict as Change. MICROCON Inquiry Working Paper 66. Brighton: MICROCON; 2012.
-
Mukhopadhyay Thousand, Steehouwer One thousand, Wong F. The Politics of the Possible. Gender Mainstreaming and Organisational Modify lessons from the field. KIT Publishers; 2004
-
Mukhopadhyay 1000. Mainstreaming Gender or "Streaming" Gender Away: Feminists Marooned in the Evolution Business. IDS Message. 2004;35(4):95–103.
-
Tolhurst R, Amekudzi YP, Nyonator FK, Bertel Squire S, Theobald S. He volition ask why the child gets sick and then often: the gendered dynamics of intra-household bargaining over healthcare for children with fever in the Volta Region of Ghana. Soc Sci Med. 2008;66(5):1106e1117.
Acknowledgements
This study was fabricated possible through the funding support of the Ministry of Strange Diplomacy of the Regime of The Netherlands to the South Sudan Health Activeness and Research Project (SHARP). The back up is acknowledged.
Funding
This report was funded by the Ministry of Foreign Affairs of the Government of Kingdom of the netherlands every bit part of the South Sudan Health Activeness and Research Project (Abrupt).
Availability of data and materials
The data in the form of verbatim transcripts will non exist shared publicly because study participants have non given consent for this; they have consented to the use of the data to describe inferences.
Authors' contributions
SK and MK conceptualized the study, developed the inquiry proposal and obtained the grant and ethical approval. SK, MK, AM and MR nerveless the data. SK, MK and MR coded the information. SK drafted the manuscript. MK, AM, MR, Medico and JB reviewed the draft manuscript and gave disquisitional inputs to finalize the manuscript. All authors read and approved the terminal manuscript.
Competing interests
All authors declare that they have no competing interests.
Consent for publication
The written report participants have consented to the publication of their anonymized quotations.
Ideals approval and consent to participate
The study was approved by the Independent Ethics Committees of KIT Royal Tropical Institute, Amsterdam, The netherlands, in a alphabetic character dated 12 June 2014. The report was also approved by the Ethics Committee of the national Ministry building of Health of the Government of South Sudan, in a letter dated 2 Oct 2014.
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Kane, Southward., Kok, Thou., Rial, M. et al. Social norms and family unit planning decisions in South Sudan. BMC Public Health sixteen, 1183 (2016). https://doi.org/ten.1186/s12889-016-3839-half-dozen
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DOI : https://doi.org/10.1186/s12889-016-3839-vi
Keywords
- Family Planning
- Social Norm
- Injunctive Norm
- Traditional Leader
- Male person Married
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