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Throughout South America, serving the "mother with child" client has been the
foundation of many reproductive health policies and projects. But this focus may exclude
many people who need services, such as childless women, women who have completed
childbearing and men. Moreover, "mother-father" and "mother-doctor"
relationships are also vitally important for reproductive health.
Studies by FHI's Women's Studies Project in Bolivia highlight the need to explore
multiple relationships in the reproductive health arena, rather than focusing on women
alone or on women and their children.
A survey of 630 couples in Cochabamba, Bolivia, sought to understand family dynamics
surrounding reproductive health by examining the relationship between men's knowledge and
attitudes concerning fertility control and their wives' use of contraceptives.1
Study results showed that men knew slightly more than women about different
contraceptive methods. Men generally approved of contraceptive use and reported a
willingness to use a contraceptive method or support their partners' use of methods.
However, only half the men reported having talked with their wives about family size. For
a significant proportion of couples, both partners did not agree on what method was being
used: Among couples in which at least one partner claimed the couple was using the rhythm
method, in only two out of three couples did both partners report using this method.
Attempts to reach beyond women clients to the men in their lives include innovative
reproductive health services provided by La Casa de la Mujer (The Women's House) in Santa
Cruz, Bolivia. La Casa was organized by women to empower women, but participants gradually
discovered that focusing on women exclusively rarely solved women's problems and, in some
cases, created new difficulties for them.
"When the man does not participate, problems arise," explains Ane Mie van
Dyke. a La Casa nurse. "A woman learns something new that the husband doesn't
understand, and he does not like to feel stupid in front of his wife." When one
client refused sexual relations in order to adhere to the rhythm method of contraception,
her partner hit her and forced her to have sex. When she became pregnant, he hit her
again. Another client's husband accused her of being unfaithful when she brought home
condoms in an effort to space births.2
"We've seen that working only with women doesn't solve the problems," says La
Casa gynecologist Dr. Lourdes Uriona. "In terms of family dynamics, reproductive
health needs to involve both partners. In medical terms, as well, men need to participate.
In the case of sexually transmitted infections, if the man isn't treated at the same time
as the woman, our efforts are in vain."
La Casa's efforts to involve men in education and services include conducting family
planning workshops for couples, working with young men and women, and attempting to
incorporate partners of female clients in center activities.
Health professionals
Gender awareness not only helps couples to analyze and
improve their relationships, but enhances relationships between clients and health
professionals as well.
An FHI study of the Center for Research and Development of Women (CIDEM)'s health
center in El Alto, Bolivia, focused on the center's efforts to empower local women. CIDEM
has enabled and encouraged participants to make decisions about their own reproductive
health, and to help design health policies and projects. These efforts were challenged,
however, when women who had learned to demand respect and to take responsibility for their
own health encountered professionals unwilling to share greater knowledge and
decision-making.3 Other researchers in El Alto found that many
women believe providers are not informing them about alternative method choices or side
effects of each method, or not allowing them to take part in decisions about the need for
cesarean sections and other medical procedures. They concluded that the tendency of clinic
doctors and staff to dismiss clients' questions and concerns about contraceptive methods
undermined the providers' ability to counter misinformation and relieve women's fears.4
CIDEM questioned the established practice of medical professionals making important
diagnoses and treatment decisions with little input from patients. The organization
developed an approach in which providers and clients discuss options in a collaborative
manner. Professionals learned to respect clients, listen to them, and speak their
language, both literally and figuratively, in ongoing relationships characterized by a
sharing of knowledge, as well as power, over reproductive health issues. This approach has
led to increased provider-client cooperation, more accurate diagnoses and improved client
health.
CIDEM encouraged the use of this model of client-provider decision-making by referring
its childbirth patients to clinics where medical personnel participated in
CIDEM-facilitated workshops and made a commitment to such practices. Women who have
received care in participating centers indicate that treatment has improved substantially.
Celia Pérez, a young mother of two from El Alto, contrasted the care she experienced
during her first childbirth to the positive attention she received during her second
delivery: "Many women, especially those in traditional dress, accept abuse from
doctors because they think doctors are superior. With CIDEM, I learned that they have no
right to treat me like that. The second time I went to give birth, I told the doctor, 'I
am going to cooperate with you, and I want you to cooperate with me,' and it was much
better."
Body and mind
Sexual biology influences the development of cultural roles and relationships in
complex ways. That women bear and nurse children, for example, is a fundamental factor in
the development of gender identities and symbols, although these identities vary
tremendously across cultures and through time.
Likewise, gender practices affect women's physiological development and functioning.
Tight corsets, foot binding and female genital mutilation are just a few practices that
harm women's health and sexuality. While the use of modern contraceptives has many
important benefits, methods can sometimes produce undesirable side effects. As such, they
can affect women physiologically.
Psychological factors also play a role. Dr. Uriona of La Casa believes that shame, fear
and guilt can harm her clients' health. A repressive social environment, she says,
discourages open conversations to help resolve psychological and physical problems.
"The stress and oppression that women experience in their lives are often manifested
in physical problems, especially gynecological problems," she says. Most of this pain
is rooted in her patients' inability to express their feelings and needs. "For some
women, shame and repressed emotions interfere with the ability to feel pleasure or pain in
the genital area," she says. "This condition not only harms marital relations
but interferes with medical diagnosis."
That feelings of shame can notably reduce women's sexual pleasure was one conclusion
from a study involving focus group discussions and in-depth interviews with 132 women and
men in El Alto, Bolivia. When asked the question: "Do you let your partner know what
you do or do not like during sexual relations?" men reported with much more frequency
than women that they told their partners what they liked. When asked whether they enjoy
sexual relations, a majority of men affirmed that they enjoy sex, while a majority of
women said they do not.5
For many women in this and other studies conducted in Bolivia, shame was coupled with
fear about reproductive events such as menstruation, miscarriage and disease, as well as
fear and mistrust of contraceptive technology. Researchers found that fear of
contraceptives produces psychosomatic problems related to method use, high rates of
discontinuation of pills and injections, and early removal of intrauterine devices (IUDs).6
Client-oriented providers help combat the negative effects of shame and fear commonly
associated with sex and reproductive health care by listening closely to what clients say
and respecting their feelings. "We begin every consultation with an open conversation
in which the patient has the opportunity to express her problems in narrative form,"
says Dr. Uriona. "We often talk in the native language Quechua, the patient tells me
about her life, and I thus begin to get a glimpse of where tensions arise."
In order to improve the population's health in sustainable ways, however,
gendersensitive services must be complemented by structural changes in educational, legal,
religious and other institutions that generate and reinforce shame, fear and
misinformation, hindering sound reproductive health.
Recognizing differences
A gender perspective also helps providers recognize and respond to crucial differences
among clients. Two kinds of gender differentiation have been identified in Bolivia. The
first involves qualitative differences in the lifestyles and experiences of groups
distinguished by their sexual identities, such as wife/mother, single professional mother,
or male homosexual. The second involves sexual discrimination in legal, political,
religious, educational and economic institutions, where policies and practices tend to
transform gender differences into inequalities.
CIDEM's and La Casa's health centers try to take into account the differing practices,
expectations and needs of the gender groups they serve, which include market women, male
adolescents, prostitutes, rural Indians and middle-class housewives. La Casa staff's
awareness of the difficulties inherent in educating and providing services to people with
perspectives and experiences different from their own has motivated them to experiment
with innovative approaches to learning and communication, such as theater, art and games.
A key benefit of these approaches is that they help equalize the balance of power between
providers and clients.
Numerous reproductive health programs in Bolivia have attempted to reduce
institutionalized gender inequalities through efforts ranging from consciousness-raising
courses to advocating national legal reforms, such as recent legislation against domestic
violence.
Recognizing that health programs often fail to provide equitable access and care to all
clients, CIDEM took steps to make its services more accessible to women who have childcare
responsibilities, have limitations on mobility and money, or who fear mistreatment and
humiliation. It offered low prices and services located on a bus route in a working-class
neighborhood, and treated poor and indigenous women with respect. CIDEM personnel avoid
sexist or racist language as part of the effort to develop more equitable relationships,
both between providers and clients and among staff members.
Reproductive health and reproductive rights extend beyond family planning. From a
gender perspective, women and men are not just reproductive beings, but multifaceted
individuals with complex concerns, needs and expectations, all of which are influenced by
their gender roles and relationships, developed in specific cultural contexts.
A major concern for most Bolivians is economic survival. Families must seriously
consider whether or not they will be able to feed more children. For many women, recent
economic crises have meant having to diversify wage-earning activities and increase work
hours. As these women wash clothes, sell goods in the market, grow potatoes or perform
other paying work, they also bear and raise children and engage in a range of family and
social activities. These heavy labor burdens limit access to health care and fertility
control services. As a young woman who came to CIDEM for legal advice explained, "I
have four children and I have to work. There simply isn't time to go to the clinic, even
though there is one near my house." 7
Often, larger issues like economic and food security, legal and political rights, and
access to education and information strongly affect sexual and reproductive health.
Clearly, providers cannot remedy such problems by themselves. However, a gender
perspective can help them to recognize attitudes that govern and shape reproductive health
behaviors; identify barriers to reproductive health care; explore new strategies to
improve services for women and men; and develop referral programs and collaborative
efforts with other organizations to improve the conditions under which different members
of the population exercise their rights to sexual and reproductive health.
-- Susan Paulson, PhD
Note: Dr. Paulson, an anthropologist who lives in Brazil, has conducted research
about gender issues and has taught at several Latin American schools and universities.
References
- Zambrana E, Reynaldo C, McCarraher D, et al. Impacto del
Conocimiento, Actitudes y Comportamiento del Hombre acerca de la Regulación de la
Fecundidad en la Vida de las Mujeres en Cochabamba. Research Triangle Park, NC:
Cooperazione Internationale and Family Health International, 1998.
- Paulson S, Gisbert E, Quitón M. Innovaciones en la Atención de la
Salud Sexual y Reproductiva. Research Triangle Park, NC: Family Health International,
1996.
- Paulson S, Gisbert E, Quitón M. Case Studies of Two Women's Health
Projects in Bolivia. Research Triangle Park, NC: Family Health International, 1996.
- Schuler S, Choque M, Rance S. Misinformation, mistrust, and
mistreatment: family planning among Bolivian market women. Stud Fam Plann
1994;25(4):211-21.
- Camacho A, Bailey P, Buchanan A. Impacto de la Regulación de la
Fecundidad sobre la Estabilidad de la Pareja, la Sexualidad y la Calidad de Vida.
Research Triangle Park, NC: Proyecto Integral de Salud and Family Health International,
1998.
- Schuler.
- Paulson, Case Studies.
For more information, visit Family Health International's Website at www.fhi.org
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