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CHAPTER2 Literature review
INTRODUCTION
This chapter presents a review of family planning literature that was perused. Several sources of family planning practices were consulted, including libraries, Word Health Organization (WHO) manuals, the WHO Reproductive Health Library CD-ROM, Ministry of Health and Social Welfare records, universities and the Planned Parenthood Association. It was noted that most literature acknowledged that Sub-Saharan Africa has the lowest rate of contraceptive use in the world, ranging for instance between 4,0% in Niger and 48,0% in Zimbabwe (CDC 1999:14). Several factors contributed to this low rate, including difficulties in obtaining contraceptive supplies, limited numbers of family planning clinics, the largely rural nature of populations in the region, the low socio-economic levels of women, high rates of infant and child mortality and the high value many cultures place on large numbers of children (Hatcher & Kowal 1999: 14).
Based on this information, relevant literature was reviewed confirming some of the cited deterrents to family planning. The literature review is organised according to the research questions presented in section 1. 4.
FACTORS THAT ARE RESPONSIBLE FOR THE POOR USE OF MODERN FAMILY PLANNING SERVICES IN SWAZILAND
Limited studies that address factors responsible for poor use of modern family planning methods were identified in Swaziland. However, various studies conducted internationally were also reviewed, and were accordingly categorised as outlined in this chapter.
Societal attitudes toward family planning
In traditional societies like Swaziland, the male is the dominant family member who determines all that takes place within the family, including family planning (Mkhonta 1999:4). However, family planning research, policy and programmes side-stepped this important rule in Botswana ( Chipfakacha 1993 :82). The exclusion of men from family planning efforts has ramifications for the preferred family size and have consequently resulted in negative attitudes toward contraceptive use.
Bankole and Singh ( 1998: 15) conducted a demographic and health survey in 18 developing countries, including 13 Sub-Saharan countries. The main objective of that study was to understand the role of husbands/men in reproductive decision-making by focussing on their preferred family sizes and intentions to have additional children. The phenomenon was examined by comparing the responses of husbands with those of their wives, in order to identify the similarities and differences in their perceptions. Logistic regression analyses compared the attitudes of respondents. The results showed that men and women in the countries involved desired large families (five or more children). However, husbands tended to want more children than their wives (two or more children than their wives). The use of modern family planning methods was low (20,0% for husbands and 13,0% for wives), but knowledge was high, ranging from 57,0% in Burkina Faso to 100,0% in Brazil. Knowledge of modern family planning methods was found to be lower among husbands in West Africa than elsewhere. Demographic characteristics, including age, type of marriage, literacy, type of work and area ofresidence predicted the use ofmodern family planning methods in nine out of 14 countries for which data was available. The findings by Bankole and Singh ( 1998) could be compared to the attitudes of Swazis regarding childbearing practices, where the fertility rate is as high as 6,4 births per woman and contraceptive prevalence is 29,0% (SNAP 2000: 13). It is therefore important to examine cultural practices which discourage the use of family planning in Swaziland.
A limitation of the study by Bankole and Singh (1998) was the exclusion of unmarried men and women, as these clients might have different reproductive goals form those of their married counterparts. With regard to the methodology of the study by Bankole and Singh (1998), in-depth interviews providing men’s and women’s attitudes, preferences and behaviours regarding contraception and childbearing practices would have yielded valuable additional information. A longitudinal study, succeeding this cross sectional survey might have provided a better understanding about reproductive attitudes and preferences concerning contraceptive use and fertility regulation issues in the communities included in the study by Bankole and Singh (1998).µ
Biddlecom, Casterline and Perez (1997: 108) evaluated spouses’ attitudes toward contraception in the Philippines. The sample comprised 780 matched couples from both rural and urban areas. The results revealed that 72,0% of the husbands and 77,0% of the wives approved of contraceptive use. At the couple level, however, men’s perceptions about contraception often differed from those of their wives. Disagreements existed, particularly about the importance of certain contraceptive attributes, and about the extent to which these attributes applied to specific contraceptive methods. This disagreement was associated with lower levels of contraceptive use and with greater conflict over intentions to use contraceptives in the future. For example, when both spouses approved of family planning practices, 81, 0% of couples shared the same intentions to use contraceptives. However, among couples who disagreed over contraceptive use, 4 3, 0% of couples shared intentions about future contraceptive use. As much as the study by Biddlecom et al ( 1997: 108) revealed negative attitudes toward family planning issues, it should be noted that it focussed only on couples, and ignored sexually active single adults and adolescents. In contrast, this research attempted to identify deterrents to the utilisation of contraceptives among Swazi women, men and adolescents.
Cultural barriers to family planning
In most African countries, including Swaziland, customs tend to emphasise the importance of childbearing (Ndubani & Hojer 2001:110). Consequently, family planning services may be poorly accepted in these societies. Another important consideration is the cultural acceptability of contraception to both users and providers. Tadiar and Robinson (I 996:79) state that the prevalence of modern contraception in the Philippines among married women aged 15-49 is as low as 25,0%.
This finding may be due to the fact that the Philippines is a predominantly Catholic country which does not approve of the use of contraceptives. In Swaziland, on the other hand, contraceptive prevalence is 29, 0% (SNAP 2000: 6). This minimal use of modern contraceptives in Swaziland, could be due to fears of rumoured side effects. This possibility poses a challenge to family planning providers who should provide the relevant information to family planning clients and dispel unfounded negative attitudes towards family planning practices (Rees 199 5: 3 4).
Male attitudes toward family planning practices
Mbizvo and Adamchak (1992: 52) observed that there is a relative paucity of male contraceptive data in the scientific literature. Most studies on fertility and family planning focus on women, and ignore men. Bankole and Singh (1998:15) observed that these studies overlooked the primary fertility decision-makers in most African countries . This is particularly relevant to societies like Swaziland where women are considered to be minors to the extent that their husbands’ approval has to be obtained for issues relating to family planning (WLSA 1998 :200). Studies which focussed on both men and women were identified during the literature search, and these studies are briefly discussed in this report.
Mbizvo and Adamchak (1992:52) conducted a survey in Zimbabwe to ascertain male knowledge, attitudes and behaviours relating to fertility regulatory methods directed towards men. Stratified cluster sampling procedures were used, and a representative sample of 711 households completed questionnaires. The results showed that 1,8% of the respondents knew about male sterilisation (vasectomy) as a family planning method, compared to 74,0% who had knowledge about female contraceptive pills. Condom knowledge was as high as 37,8%, but the user rate was estimated to be only 6,0%. Acceptance of family planning methods was only 14,2% compared to 81,6% nonacceptance offamily planning. The main reason for disapproval of family planning was the desire for additional children. The socio-economic characteristics ofmen who disapproved ofmodern family planning methods included their relatively young age (20-26 years), low educational level (primary education) and the fact that about 60,0% of the respondents resided in rural areas. In this study, socio-cultural characteristics will be examined to identify similar influences on the utilisation offamily planning among Swazi men and women.
In another survey by Chipfakacha (1993), 260 Botswana men were randomly selected to form a research sample during face to face interviews. The District Health Team of Botswana investigated their knowledge, attitudes, practices and experiences with regard to family planning. The results demonstrated that knowledge about family planning was as high as 74, 0% , and according to 81,2% of the respondents and health care facilities were identified as the main source of family planning services. Most men, (93, 0%) associated modern family planning practices with condom use, and had minimal knowledge about other family planning methods. With regard to spousal communication about family planning issues, the majority (65,0%) of respondents were nonconversant about family planning issues, and regarded family planning issues as women’s business. Contrary to the above statement, these men would be angry to the point of beating their wives, if they discovered that the women were using family planning methods. These men, according to Chipfakacha (1993 :82), perceived family planning methods as promoting infidelity among women. The negative attitudes of men toward contraceptives were observed by Zwane (2000:9) as the main deterrent to family planning among Swazi women. This finding is consistent with MacPhail and Campbell’s (2001: 1613) report on 44 young men in Khutsong township, Republic of South Africa, in accordance with which it was revealed that deterrents to family planning included a lack of perceived risk of making women pregnant, peer norms in engaging in unprotected sexual intercourse, gender power relations, and the economic context of adolescent sexuality.
Odinegwu (1999) conducted a survey amongst a randomly selected sample of927 married men and women residing in both urban and rural areas of Nigeria. A factor analysis process was used to measure respondents’ attitudes towards, and utilisation of, contraceptive practices. The results revealed that 76,0% of respondents had a sound knowledge of contraceptives, but only 28,0% were using such methods at the time of the investigation. Fewer men than women (42,0% compared to 50, 0%) had ever used modern or traditional contraceptives ( Odinegwu 1999: 87). However, attitudes toward family planning and marital relations were less positive among men than among women. For example, female respondents were more aware ofthe fact that a large family size contributed to social problems within marriage (55,0% females versus 40,0% males). The majority of women (75,0%) registered a high level of support for men playing a role in family planning, yet only 30,0% of men were of the same opinion. These findings demonstrated that even if women were inclined to use family planning methods, culturally they might not succeed as social support was important for the success of maintained contraceptive use. According to Erasmus and Bekker ( 1996: 14) this is also the case with Swazi women who lack social support in practising family planning. It is therefore important to identify partners who can act as change agents to promote and maintain family planning practices in the Swazi culture.
Chapter 1 Overview of the study
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT SWAZILAND AND ITS HEALTH CARE SYSTEM
1.3 PROBLEM STATEMENT
1.4 RESEARCH QUESTIONS
1.5 OBJECTIVES OF THE STUDY
1.6 SIGNIFICANCE OF THE RESEARCH
1.7 DEFINITION OF CONCEPTS
1.8 THEORETICAL BASIS OF THE STUDY
1.9 ORGANISATION OF THE REPORT
1.10 CONCLUSION
Chapter 2 Literature review
2.1 INTRODUCTION
2.2 FACTORS THAT ARE RESPONSIBLE FOR THE POOR USE OF MODERN FAMILY PLANNING SERVICES IN SWAZILAND
2.3 FAMILY PLANNING PRACTICES GENERALLY USED BY SWAZIS
2.4 FACTORS INFLUENCING THE SELECTION OF A PARTICULAR FAMILY PLANNING METHOD
2.5 HEALTH BELIEF MODEL
2.6 CONCLUSION
Chapter 3 Research methodology
3 .1 INTRODUCTION
3 .2 PERIOD OF RESEARCH
3.3 DESIGN OF THE STUDY
3.4 NONEXPERIMENTAL RESEARCH DESIGNS
3.5 TRIANGULATION
3.6 QUALITATIVE DESCRIPTIVE RESEARCH METHODOLOGY
3.7 ORGANISATION OF THE STUDY
3.8 PHASE 1 OF THE DATA COLLECTION PROCESS: FOCUS GROUP INTERVIEWS
3.9 TRUSTWORTHINESS OF QUALITATIVE DATA
3.10 PHASE 2 OF THE DATA COLLECTION PROCESS: QUANTITATIVE RESEARCH METHODOLOGY
3.11 ANALYSIS OF DATA COLLECTED DURING STRUCTURED INTERVIEWS
3 .12 RELIABILITY, VALIDITY AND BIAS
3.13 ETHICAL CONSIDERATIONS
3.14 CONCLUSION
Chapter 4 Presentation of results of focus group interviews
4.1 INTRODUCTION
4.2 FOCUS GROUP INTERVIEWS
4.3 THEME 1: CHILDBEARING PRACTICES
4.4 THEME 3: CULTURAL VALUES
4.5 THEME3: HEALTH PRACTICES
4.6 ANALYSIS OF FOCUS GROUP INTERVIEW’S DATA ACCORDING TO THE BELIEF MODEL
4.7 CONCLUSION
Chapter 5 Analysis and discussion of quantitative data
5.1 INTRODUCTION
5 .2 RESULTS OF THE INTERVIEWS
5.3 SECTION 1: DEMOGRAPHIC DATA
5.4 SECTION 2: CHILDBEARING PRACTICES
5.5 SECTION 3: CULTURAL VALUES
5.6 SECTION 4: GENDER STATUS
5.7 HEALTH ISSUES
5.8 THE HEALTH BELIEF MODEL
5.9 CONCLUSION
Chapter 6 Conclusion and limitations of this study: recommendations for future research
6.1 INTRODUCTION
6.2 CONCLUSIONS REGARDING THE OBJECTIVES OF THE STUDY
6.3 CONCLUSIONS REGARDING THE HEALTH BELIEF MODEL
6.4 LIMITATIONS
6.5 RECOMMENDATIONS BASED ON THE CONCLUSIONS OF THIS STUDY
6.6 CONCLUSIVE REMARKS
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