HEADS, TAILS OR
EQUALITY? :
Men,
Women and Reproductive Health in Zambia
Ityai
Muvandi, Paul Dover, Aloys Ilinigumugabo
Centre
for African Family Studies (CAFS)
In
collaboration with
Planned
Parenthood Association of Zambia (PPAZ
March
2000
Funded
by the Swedish International Development Agency (Sida)
©
2000
Centre
for African Family Studies (CAFS)
P.O.
Box 60054, Nairobi, Kenya
Tel.:
4448618; Fax. 4448621
E-mail:
info@cafs.org; Internet: http://www.cafs.org
ISBN
9966-9704-0-1
All
rights reserved
Cover
photographs
John
Harris
Aimee
Centivany
[Media/materials
clearing house, www.jhuccp/mmc]
AIDS Acquired
Immuned-Deficiency Syndrome
CAFS Centre
for African Family Studies
CBD Community-Based
Distributors
CPS Contraceptive
Prevalence Surveys
CSO Central
Statistical Office
DHS Demographical
and Health Surveys
FGD Focus
Group Discussions
HIV Human
Immunodeficiency Virus
IDI Individual
In-Depth Interviews
IUD Intra
Uterine Device
MCH Mother
and Child Health
NGOs Non-Governmental
Organisations
PPAZ Planned
Parenthood Association of Zambia
Sida Swedish
International Development Agency
SRH Sexual
and Reproductive Health
STI Sexually
Transmitted Infections
TFR Total
Fertility Rate
UNICEF United
Nations International Children’s Fund
WFS World
Fertility Surveys
ACKNOWLEDGEMENTS
First
and foremost, the Centre for African Family Studies (CAFS) would like to
thank the Swedish International
Development Agency (Sida) without whose financial support the study could not
have been conducted.
Secondly, we wish to express our heartfelt gratitude
to CAFS management for the support they have extended for the duration of this
activity.
Special thanks goes to the Planned Parenthood
Association of Zambia (PPAZ) and the Department of Cultural Anthropology and
Ethnology, Uppsala University for their contribution in the designing and
implementation of the study. Particular thanks goes to the PPAZ Research
Officers and Research Assistants for this study. Without their determination
and professional approach to the whole exercise the study would not have been a
success.
We would like to thank the Zambian authority who
facilitated the study.
While the contribution of all the individuals and
parties mentioned above have been duly acknowledged, all errors of omission
and/or interpretation are our own responsibility.
TOP
Executive Summary
THIS report is on male participation in sexual and
reproductive health (SRH) examined within a wider context of gender relations
and the family. It is the result of two
collaborative surveys, one quantitative and one qualitative, which were
conducted in rural and urban areas of the Copperbelt Province in Zambia in
1999. During the quantitative survey
data was collected from men and their partners pertaining to the following
aspects:
·
respondent’s general
background characteristics;
·
marriage and marital
relations;
·
childbearing;
·
family health and family
planning;
·
sexually transmitted
infections (STIs); and
·
HIV/AIDS.
The qualitative survey collected data through focus
group discussions, in-depth interviews and two small community workshops. The
data collected was based on the following areas:
·
youth SRH;
·
marital relations and the
family;
·
partner relations and SRH;
·
domestic violence;
·
family planning,
contraceptive knowledge; decision-making;
and
·
men and women's SRH needs.
Key Elements
The following is a summary of the
main issues which came out of the research:
1.
Young people have little SRH knowledge and exhibit low levels of
contraceptive use. Multiple partners
are common, as is pregnancy before marriage. The small qualitative sample
indicates that some young people are changing their behaviour shifting away
from risky sex. The workshops brought
out a number of different community entry points which can be used to reach
young people and enlighten them on SRH issues.
2.
Men’s level of education as
well as the income earning ability on a regular basis was correlated to
contraceptive use by the couple.
Women’s level of education was not linked to limiting fertility,
probably because most women lack formal employment and regular income.
3.
Both men and women were discerned to be somewhat resistant to the concept of gender equality. Men said they had no benefits to gain from
equal rights, while women said that whereas their partners should remain ‘head
of the household’, men would gain by being able to share their burden of
responsibility. Many men were seen to
be having difficulties in living up to socio-economic expectations in the
adverse economic circumstances obtaining in the region.
4.
About half the men said they have the final say in their households
regarding decision-making, but quite a number of couples (39%) reported reaching decisions jointly. Women admitted that their partners had
greater say in decision-making, but added that they used
“female tactics” to persuade
Them towards their points of view.
5.
Men were found to be only marginally involved in child health care,
although over a third reported attending clinics with their wives to learn
about family planning counselling.
Women wanted men to accompany them to the clinic. Both men and women said that men should not
be excluded from receiving the SRH and child health information provided
through the Mother and Child Health (MCH) programme.
6.
Sexual networking was said to be high in the communities, but few
people reported extra-marital relations in their own lives. Women were more
worried than men about transmission of STIs/HIV from their partners. They said that the only strategy available
to them was to advise and trust their
partners.
7.
Approximately 11% of couples interviewed reported domestic violence
within the previous three months. Violence was found mainly among youth and
young married couples. A majority of
girls said that they had been subjected to forced sex and had also been beaten
on occasions by their boyfriends.
Interventions for young people would appear especially necessary.
8.
Family planning was found to be understood as achieving desired
spacing between children and limiting children to one’s economic means. Awareness of family planning was found to be
high, but use of contraceptives was low, with less than a third of all women
currently using a modern method. A
number of women reported using lactational amenorrhoea as a family planning
method.
9.
Discussions between husband and wife on family planning were strongly
correlated to use of contraceptives.
Forty-four percent of men indicated that the decision to use the current
method was jointly made, while 39% said it was their lone decision.
10.
Loss of children was significantly correlated to desire for additional
children and low contraceptive use by both women and men.
11.
No great divergence on desired number of children was found between
women and men. Quite a number of couples said that they made joint decisions on
the number of children that they want to have, but ideally, the husband was
seen to be having the ultimate decision–making rights on the planning of the family.
12.
An ideal family norm of four to five children appeared to be
emerging.
13.
The extended family was believed to be influential in fertility
decision-making. But only 11% of
respondents actually reported kin influence on family size. Such influence was for the couple to have
more children.
14.
Both men and women wanted more SRH information and felt that mixed-sex
groups for information dissemination and discussion would be better than
single-sex groups.
15.
People appeared relatively satisfied with the quality of care given by
the local health facilities, but complained of irregular supply, and sometimes lack of contraceptives and
medicines.
16.
Neither men nor women were generally perceived as using the
traditional health sector in preference to the modern health sector for SRH
needs, except for a few specific areas of expertise.
17. Radio would appear to
be the mode of media reaching the largest number of people; about
three-quarters of those interviewed during the quantitative survey.
About 73% of men and 59% of
women listened to the radio daily. Thus
it would appear to be an optimal medium for the dissemination of sexual and
reproductive health knowledge, particularly in rural areas
TOP
INTRODUCTION
THIS report is the result of two collaborative surveys
conducted in urban and rural areas on the Copperbelt Province of Zambia during
1999. The research was co-ordinated and
directed by the Centre for African Family Studies (CAFS). It was conducted together with the Planned
Parenthood Association of Zambia (PPAZ) and funded by the Swedish International
Development Cooperation Agency (SIDA).
The title of this report comes
from a comment made by one of the respondents, a nineteen year old rural young
man, who said that the husband should be "the head" and the wife
"the tail" of the household.
What is revealed by our research is however not that simple. While there is a de jure ideology of male
authority, many people stressed the importance of co-operation and joint
decision-making in the household.
Naturally, in terms of de facto gender relations, the tail can also wag
the dog. Gender relations are changing
in Zambia as they are all over the world.
That said, much still needs to be done to achieve gender equality. In the following sections of this report we
concentrate on gender, sexuality and reproductive rights. Our focus is on men but one can only understand
men and masculinity within the context of gender relations and thus much of our
material also reflects women and women's points of view.
Background
The population of sub-Saharan Africa
(SSA) is growing at a rate of 3.2% per annum, but the economic growth within
the same region has been much lower in
the recent past. Not all of Africa's
development problems can be directly attributed to population growth, and
therefore reducing the rate of population growth alone would not be sufficient
to improve the quality of life policies
were introduced to revive economic growth.
But there is widespread concern that rapid population growth is
constraining development on the sub-continent.
Concurrently, the poor quality of life, high child mortality and
economic uncertainty make a contribution to the desire for large families.
Additionally, Africa is the
continent most affected by the HIV/AIDS pandemic. For most families that suffer loss from AIDS related diseases,
the pandemic is not only a human tragedy, it creates additional hardships in
terms of caring for the sick, loss of
labour and income. A further problem is
the plight of AIDS orphans, a situation with which the extended family system
appears to be increasingly unable to cope.
Zambia
Zambia is divided into nine
provinces and 157 districts. The
country has 73 ethnic groups and seven major groupings, namely: Bemba, Tonga,
Kaonde, Lunda, Lozi, Luvale and Nyanja.
The population was estimated at 9.2 million in 1996 (PRB, 1996). The land area is 752,614 square kilometres,
thus giving a national population density of 12 persons per square
kilometre. The crude death rate is 18
per 1,000 population, while the crude birth rate is 43 per 1,000 population,
implying an annual population growth rate of 2.5%. If the annual population growth rate is allowed to continue pari
passu, the population of Zambia will double in about 28 years. This high rate of natural increase imposes
constraints, especially in terms of
provision of social services and creation of employment opportunities.
Population size
(1996 estimate):
9.2 million
Population
under 15 years: 50%
Land area: 752,614
square kilometres
Crude death rate: 18
per 1,000 population
Crude
birth rate: 43
per 1,000 population
Annual
population growth rate: 2.5%
Total Fertility
Rate (TFR): 5.6
The population is youthful, with about 50% under 15 years
of age. Even if the fertility level of
Zambia reaches replacement level now, the number of children to be added to the
population through births would be very substantial due to the built-in
population momentum. This situation is
compounded by the fact that currently an average Zambian woman would gives
birth to between five and six children during her reproductive lifespan.
Zambia is also one of the
countries most affected by the AIDS pandemic.
In a 1997/1998 study in Ndola[1]
the same urban town in which this report's surveys were conducted the
prevalence of HIV infection in men aged 15 - 49 was 23%, and in women of the
same age group, 32%. Among teenagers
aged 15 - 19 years, the rates were 4% for boys and 15% for girls. A recent UNICEF report estimates that 9% of
Zambian children are currently AIDS orphans.[2]
HIV indicators
The number of street children in Lusaka is estimated
to have more than doubled during the 1990s and is now believed to be around
75,000, with about half being AIDS orphans.
Notwithstanding these horrendous figures, demographic projections do not
foresee the AIDS pandemic as having any
major impact on population growth.
The immediate effects of this will be increased poverty, more abandoned
children, overburdened health services and loss of educated and skilled
personnel.
The country has experienced
decline in economic growth since the mid 1970s. It has been highly dependent on copper exports since colonial
times. The British colonial economy was
extractive and little of the wealth from the copper resources was re-invested
in Zambia. Consequently, the first
decade after gaining political independence in 1964 saw a large increase in the general welfare of the
population. The fall in copper prices
in the seventies affected the economy severely and this was compounded by
Zambia's support for the Zimbabwean liberation struggle which was a major drain
on its resources. Added to this, the closure of the border with what was then
Rhodesia had serious repercussions on
the country since Zambia relies on southern Africa trade routes. Despite a stringent structural adjustment
programme, the economy has made no major recovery during the 1990s. Forty-three percent of the population was
estimated to be living in urban areas in 1996 and unemployment is very high. Even for those in formal employment, wages
are often insufficient. High rates of
inflation since the beginning of the 1990s have eaten away at pensions and
eroded purchasing power. Cost recovery
schemes in education and health have placed further burdens on families. According to the UNICEF report cited above,
80% of the rural population lives below the poverty line.
As with many societies undergoing
rapid socio-economic change there is nostalgia among people for what is seen as
an idealistic past. But for developing
countries on the periphery of technological innovation, global trade and
culture, change is obviously seen as emanating from the outside and the more
developed regions. Given these factors
together with the economic hardships
faced, the AIDS pandemic, rising crime, etc., there is little wonder that the
people featuring in the research data often exhibit a general aura of moral decay. The cultural hegemony of foreign ideas and the loss of tradition
figure constantly as explanatory reasons.
Male participation in Sexual and Reproductive Health (SRH)
Male participation in sexual and
reproductive health (SRH) aims to bring women and men together as partners with equal responsibility and equal
access to information and health services.
Male participation has become an issue in part, due to the perception
that the Mother and Child Health (MCH) focus of primary health services in
developing countries has to a large extent sidelined men on SRH issues,
including the "under-five's" health programmes and child health
generally. As well as ignoring men,
this policy is seen to bolster concepts that contraception, as well as the
health and well being of infants and children are areas of female
responsibility. Thus a practical aspect
of male participation is for men to
increasingly have access to family planning information, as well as
having encouragement towards greater involvement of fathers in child health
matters. This, it is believed will lead
to better partner communication and enhance joint decision-making between women
and men on matters of sexual and reproductive health generally.
Arguments against male participation
·
It can reinforce male hegemony
·
It can divert limited resources from MCH
·
Inputs for women are known to work, there is less evidence for
changing men.
There are arguments against moving towards greater
male participation in SRH. It could,
for example, potentially reinforce male hegemony. In this survey, many men and quite a number of women stated that
the final decisions on family planning should rest with the husband. A clinical officer, in one of our rural
survey areas, said he required a letter of permission from the husband before
issuing contraceptives to women. It is
the praxis of many of the more developed countries that the woman has the ultimate
reproductive decision making rights considering that it is her body which is
most affected. This would also appear
to be the motivating force behind campaigns for women's reproductive rights in
developing countries. Therefore, while
there is an overall gender and development aim for equality between the sexes,
one must concede that women's reproductive rights as child-bearers, supersede
men's reproductive rights as impregnators.
While the advantages of gender
equality for women are clear, just as much as the intellectual and moral
arguments against gender discrimination, what do men gain? If women are to
benefit through gender equality, men must necessarily cede some power. At the same time there are advantages for
men in supporting gender equality, but they are less tangible outcomes than
those seen as accruing to women. The
clearest health advantages lie in changing negative aspects of the social
construction of masculinity. An example
of this would be the male competitive bravado and penchant for
risk-taking. Moreover, the
responsibility men take upon themselves can have negative consequences,
particularly the difficulties men face in living up to ideals of what would be
described as self-sufficient manhood.
During this research, some women felt that men would benefit from gender
equality because it would enable them to share their “burdens of
responsibility” with their wives. Men
are also perceived as often having limited outlets for emotional expression and
hence support. Thus, gender equality
would de-emphasise the ideal of male
“independence and self-sufficiency” and would be a means towards enabling men to enjoy a more fulfilling and
supported (by their female partners) emotional life.
Arguments for male participation
·
Men have been excluded from family planning and SRH information by the
MCH focus
·
Better knowledge will lead to male involvement and greater partner
communication
·
Both men and women have specific SRH needs
·
Men’s participation is necessary to achieve gender equity
There have been a number of media and government
campaigns in developing countries for male participation in family
planning. But there are few definite
ideas of what ‘changing men' in terms of improving gender equality, entails. Some work has been done by men's
discussion groups, mostly in the more developed countries, as well as
small-scale interventions by non-government organisations in developing countries. There are also theoretical differences of
opinion between those who would argue that masculinity and femininity are
grounded in some innate differences between women and men, and those who argue
that they are purely social constructions. This obviously has repercussions in
how “changing men” is envisaged.
Changes in policy and law which
enhance gender equality are obviously a major means towards altering gender
roles. But in this survey, the majority
of both women and men, young and old, were suspicious of, and often resistant
to, gender equality as a concept. It
would seem that the top-down gender and development political rhetoric is not
working. Perhaps more participatory
approaches which allow people to examine and reflect on gender in their own
lives and communities are needed. Thus,
sensitising men and women to gender issues and allowing them to discover
benefits, as well as ways to move towards gender equality would appear to be an
important means of action. Gender has already entered public debate in the
Zambian media. The school curriculum is
an important area for intervention, as well as incorporating gender
sensitisation into community
interventions by various non-governmental organisations.
A further aspect of male
participation in reproductive health is that the term 'gender' refers to both
men and women. Beyond gender equality
goals are questions of gender specific
needs and sex specific needs. Men and women have specific SRH
psychological and physiological problems.
Some critics maintain that given scant resources money should not be
diverted from MCH to male participation in SRH, but it can be argued that women
and men's SRH needs should not be seen as competing but complementary. Certainly, in many aspects of SRH, male
participation is vital to achieve women's reproductive rights. Meeting gender and sex specific needs would
appear to be part of the equation. For
example, the social construction of masculinity is apparent in cross-cultural
male concerns about potency and beliefs that male sexuality is difficult to
control, concepts which in turn motivate risky male SRH behaviour. Interventions that are directed to enhancing
women's ability for sexual negotiation are only dealing with half of the
equation.
In conclusion, the initial idea of male participation
in SRH has been to help women and men to make informed joint decisions about
their reproductive lives. But in this
report we have given “male participation” a wider interpretation. It is in this sense that the study has been
conducted, examining many aspects of gender relations beyond reproductive
decision-making.
Rationale for the research
Despite increased coverage by family planning
programmes in Zambia, fertility has remained high. This may be due to the way population and family planning
programmes have previously been developed in Africa in general and Zambia in
particular. The tendency has been to
target women, and men have only been marginally involved. Major fertility research programmes such as
the World Fertility Surveys (WFS), Contraceptive Prevalence Surveys (CPS) and
more recently, Demographic and Health Surveys (DHS) have all focused on
studying the fertility behaviour of women.
Few surveys have collected data on men and have often only collected
quantitative information which does not usually shed light on the underlying
motivations for the demonstrated behaviours and attitudes. This study combines both quantitative and
qualitative data collection methods which enabled the researcher to
interpret both statistical and in-depth
material.
Becoming a father has, of course, a large impact on
men's lives. By Zambian customs it
signifies having achieved mature adulthood.
As men are ideally seen as the main providers for the family, they are
also ideally seen as the final arbiters on whether the family can sustain a new
member or not. But conflict should not
be assumed between women and men on decision-making about fertility and,
indeed, may both hold unfounded views of each other’s opinions. As a matter of fact, stereotypes presented
to us during the focus group discussions were not 
corroborated
by the in-depth interviews which examined people’s lives.
Conflict between men and women
Research in Africa shows that men's attitudes towards
family planning are, in general, positive, but that men often feel that they
should be in control of whether and when the couple uses contraception. How are we then to change these beliefs in
male rights to “final decision-making”? This report does not answer that
question but hopefully provides some material towards the realisation of an
answer.
The economic
situation
Our material indicates
problems for men in living up to socio-economic expectations, especially in the
present difficult economic circumstances
Zambia, as other contemporary societies, is undergoing
rapid socio-economic change and this impinges on gender relations, concepts of
kinship obligations and the family. Understanding
male and female roles and identity involves investigating adaptations to new
circumstances. For example, people say
that monetary economy has caused kinship as a form of generalised economic
support to contract. Married men in
Zambia ideally see themselves as the breadwinners for the nuclear family. At the same time, support to kin is still an
important aspect of local values. It is
not only a social obligation but also a means for men to achieve status. Our research reveals that problems for men
in terms of living up to socio-economic expectations, especially in the present
difficult economic circumstances.
Finally, the survey examined violence against
women. Whether this is an increasing
problem or whether there is instead an increasing media focus on domestic
violence and a willingness by women to resist and report it, is unclear. There was also no unanimity in the responses
to this question. Violence against
women manifests itself in the form of sexual abuse (rape, incest, etc), as well
as emotional and physical abuse. It is
hoped that the findings from this research will contribute towards
interventions for men, as well as support to women in standing up for their
rights.
The field sites
Many factors in this report can be generalised to the
East and Southern African region. It is, however, important to bear in mind specific aspects pertaining to Zambia
and the field sites in particular, in analysing and understanding the material.
The surveys were conducted in two districts in the
Copperbelt Province, namely: Ndola Urban and Ndola Rural. This part of Zambia has historically been
influenced by the mining industry.
Despite the colonial authorities' efforts to maintain a migratory and
rural-based surplus labour force, large African townships grew up in proximity
to the copperbelt mines. These
districts also lie on the “line of rail” (the railway line connecting Zambia to
the south and to Dar es Salaam in the north), and the Great North Road, both of
which are major infrastructural arteries for the country.
The population of the city of
Ndola itself and the surrounding townships is ethnically mixed, though people
interviewed in the urban field sites were overwhelmingly from the Bemba,
Lamba, and Lala communities. These peoples have traditionally practised
matriliny. This means that the
bloodline is traced through the mother, the children belong to her lineage and
ideally inherit from the mother's brother.
However, factors such as modern economy, the contraction of kinship
solidarity, and also men's preferences, have influenced a move to a greater
paternal emphasis in kinship values.
This has been followed by corresponding shifts in male kinship
responsibility and inheritance norms from the maternal to the paternal line. In
other words, this shift has been from sister’s children to own children. These socio-economic and cultural changes
are not without friction, for conflicting values and claims are rampant. Questions were not asked on land, but where it has not been
privatised, use rights to land will most likely be through matrilineal ties[3].
Ndola and the surrounding areas have suffered from the
decline of the mines. People report a
high level of out-migration. Chifubu, the
urban site, can be categorised as a dormitory township to Ndola. Composed largely of council housing, it has
a small shopping centre and market, three schools, two clinics and a police
station. Many people have purchased
their homes from the council, retrenchment payments having supplied the capital
for quite a few families. With the
present high unemployment, these properties are now difficult to sell and
people have their savings tied up in them.
Two of the rural sites, Chiwala and Fiwale are relatively
close to the city of Ndola and are, to an extent, affected by their proximity
to the urban economy. The third rural
site, Gondwe, is a more isolated rural area, with few facilities and people
reporting farming as the major economic activity.
The surveys
Data were collected through two collaborative
surveys: a quantitative survey and a
qualitative survey. Fieldwork for the
quantitative survey started on 17 May and ended on 28 May, 1999. The qualitative research started on 15 June and
was completed on 24 June, 1999. The
report merges the findings of the two surveys.
Methodology and Sampling
For the quantitative survey, we had planned to interview a probability
sample of 600 married men aged 15-54 years and 300 wives of interviewed
husbands. We actually interviewed 577
men and 297 wives giving response rates of 96% and 99% respectively. The Zambia Central Statistical Office (CSO)
provided us with clusters used for the 1996 Zambia Demographic and Health
Survey (ZDHS) for both Ndola Urban and Ndola Rural. We randomly selected five clusters from Ndola Urban. The sampled clusters had household numbers
varying from 99 to 154. We thus used
proportionate random sampling to select households from each of the five
clusters.
Due to the mobility of urban residents, the household
listings provided by the Central Statistical Office were outdated. Thus, interviews with eligible persons, that
is, married men aged 15-54 years were conducted even if the actual household
head on the listing was no longer resident at any physical address initially
sampled.
For Ndola Rural, the CSO provided us with household
listings for only three clusters in which they had conducted the 1996 DHS. Thus the listing of clusters for Ndola Rural
was not exhaustive. Furthermore, these
three clusters had a total of 301 households,