Local and institutional interpretations of IUDs in southwestern Nigeria

Pergamon

Sot'. Sci. Med. Vol. 44, No. 8, pp. 1141-1148, 1997

¢{')1997 ElsevierScience Ltd

PII: S0277-9536(%)00249-3

All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00

LOCAL AND INSTITUTIONAL INTERPRETATIONS OF IUDS IN SOUTHWESTERN NIGERIA ELISHA P. RENNE Office of Population Research, Princeton University, 21 Prospect Avenue, Princeton, NJ 08544-2091, U,S.A. Abstract--ldeas about fertility and the appropriate manner of its control are reflected in interpretations of Western contraceptives. This paper examines views of one contraceptive--the intrauterine device (IUD), variously regarded by government health workers and family planning personnel and by Ekiti Yoruba women residing in one village in southwestern Nigeria. Their ideas about the IUD reflect particular views of the body, infertility, and human agency, with their attendant moral connotations. These views are evidenced in debates among family planning practitioners about how the IUD works and in the ambivalent regard of some village women for whom its use connotes infertility. This local disinterest in the 1UD also reflects a general distrust of government programs and intentions which recent funding cutbacks in medical services have reinforced. © 1997 Elsevier Science Ltd Key words--lUD, Nigeria, family planning, infertility

INTRODUCTION Different interpretations of fertility and beliefs about appropriate means of its control relate to distinctive cultural ideas about conception, infertility, and human agency. This paper examines fertility and its control from the perspective of family planning and medical personnel and Ekiti Yoruba village women in southwestern Nigeria, by focusing on a single type of fertility control--the IUD (intrauterine device). Their interpretations of the IUD suggest how the "multiple spheres of value" on which these perspectives are based may be brought within a single analytical frame. All things, rather than having a single objective meaning, are contextually interpreted (Thomas, 1991, p. 28). By examining the cultural meanings attributed to the IUD, the basis for its promotion by family planning and health personnel and its rejection by village women may be more clearly understood. This approach also illustrates the process whereby hitherto unknown things such as Western contraceptives acquire meaning in particular contexts. As William James (1890) has suggested in his concept of "the fringe" (Vol. I, p. 258), ideas about unknown things are extrapolated from one's prior knowledge of a particular object and its relations with other things. One extends the borders of knowledge by a sort of transitive property of ideas whereby what one knows about object a and its relations is associated with object b, and then extended to an unknown object c. Objects thus serve as vehicles for ideas from which conceptions of reality are inferred and classified: Every object we think of gets at last referred to one world or another...It settles into our belief as a common-sense

object, a scientific object, an abstract object, a mythological object, an object of some one's mistaken conception. or a madman's object... (James, 1890, Vol. II, p. 293). For some, the IUD is classified as a "mythological object", with emphasis placed on supernatural practices which have immoral implications. For others, it is considered a "scientific object" associated with experimental procedures, stressing more positive social implications. Despite these classifications, the IUD is neither a bit of technology devoid of social context nor simply a social construct without manufactured polyethylene parts (Latour, 1993); rather, it is both. How it is interpreted and classified reflects particular historic a l l y - a n d culturally--grounded values associated with fertility and procreation. Two views of the IUD

In the Nigerian context, views and values regarding the IUD are informed by ideas about the morality of contraception, abortion, and the propriety of human intervention in such matters as conception and birth. Federal and local Ministry of Health personnel associated with family planning programs promulgating IUD use in hospitals and clinics in Nigeria believe that fertility can and should be controlled by human action--for the health of individual family members and for the development of the state--through the use of effective modern contraceptives. Since the idea of birth control has been subject to criticism by some Nigerian religious leaders who see it as human interference in God-given functions, family planning personnel are anxious to disengage contraceptive use from more controversial types of birth control, particularly abortion

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Elisha P. Renne

(Ige, 1991, p. 9). For not only is abortion perceived as immoral by those who believe that life begins at the "moment" of conception--i.e when an egg and a sperm cell unite [as described in school textbooks (Usua and Dada, 1978, p. 127) and religious booklets (Renne, 1996, p. 491)], it is also illegal in Nigeria (Okagbue, 1990). The IUD poses a dilemma for such people. On the one hand, it is a relatively inexpensive and extremely effective form of birth control (Hatcher et al., 1994). On the other, the mechanism whereby it affects fertility is uncertain. Until recently, it was assumed to alter the uterus in such a way that prevented the implantation of a fertilized ovum. In other words, for those who believe that life begins at conception which would include younger Ekiti village women and men with postsecondary education, it acted as an abortifacient described in one book on family planning available in Nigeria: The coil or loop as we have seen, is quite simply an agent of death. It normally acts by forcing the foetus out of the womb rather than by preventing conception... (Golden, 1981, pp. 47~8). However, current research supports the view that the egg remains unfertilized (Alvarez et al., 1988; Sivin, 1989), either because the sperm are immobilized or the unfertilized ovum is affected. A new name, the IUCD--intrauterine contraceptive device--is now sometimes used in Nigeria to emphasize the contracepting character of the IUD (Landry et al., 1992). Yet for many older Ekiti village women with primary education or less, the distinction between contraception and abortion is not the morally relevant one. Ideally, if one is married, one ought to demonstrate one's fertility through the regularly spaced birth of children rather than attempting to limit fertility, for such life and death matters are ultimately "up to God". This ambivalence over the contrast between contraception and abortion is related to village women's belief that life begins when the child's movements are felt ("quickening"), sometime around the fourth month of pregnancy rather than at conception (Renne, 1996). The IUD does not pose the same moral problem for these women. Ekiti village women's concern with the IUD is not whether it acts as a contraceptive or abortive device but whether they have transferred control over their fertility, perhaps irrevocably, to a powerful (i.e. state-certified) stranger--a medical doctor or nurse. They express this concern by referring to the IUD as "turning the uterus" (s'ile omo pada), an earlier term which is associated with infertility brought on through the agency of others. Only individuals with extraordinary knowledge such as traditional diviner-healers and witches (and more recently, modern medical doctors) are believed to be capable of effecting such a condition, which results in indefinite infertility for a woman until the

uterus is "turned back" by these powerful individuals. In the past, no one would willingly have their uterus "turned"; rather, it was something that was outside of one's power, done to one by someone with supernatural power, usually at the behest of an iil-intentioned individual. These interpretations of the IUD and of fertility and its control are examined in the following three sections. The first briefly describes current federal family planning programs and survey findings on IUD use in southwestern Nigeria in 1990 and in Ondo State in 1986. More specific information comes from a case study of fertility and contraceptive use conducted in an Ekiti Yoruba village in northeastern Ondo State in 1991-1992 (see also Renne, 1993, 1996) which was supplemented with interviews of 20 women questioned specifically about the IUD in October 1993. In the second section, local and national interpretations of the IUD and the question of the mutual exclusivity of these interpretations are examined. For example, some educated younger village women have begun to accept the idea of limiting fertility, and family planning personnel are now more cautious about recommending the IUD to nulliparous women. Despite this convergence of perspectives, continuing fears about infertility associated with contraceptives generally (Pearce, 1995, p. 200) and specifically about the prospect of putting one's fertility under another's control discourage IUD use. In a final section these fears are discussed in relation to a distrust of government-sponsored programs, particularly of the government's ability to monitor and provide safe health care (Alubo, 1994). While family planning programs now have the persuasive power of the state and medical technology (Foucault, 1973) behind them, they convey an ambiguous moral authority--in a political situation where the interests of the elite are believed to take precedence over those of the "masses" (Alubo, 1990)--that undermines the legitimacy to these programs.

FAMILY PLANNING PROGRAMS AND IUD USE IN NIGERIA

The program to distribute contraceptives in Nigeria began with the establishment of the Planned Parenthood Federation of Nigeria (PPFN), initially organized as a National Council of Women's Societies of Nigeria (NCWSN) committee set up in 1962. Two years later the committee was reorganized as the Family Planning Council of Nigeria (FPCN). After a review of the program by an IPPF team in 1978, the Council's name was changed to the Planned Parenthood Federation of Nigeria and a concerted effort was made to influence federal population policy. In 1988, the federal government drafted a national population policy

Interpreting IUDs in Nigeria which included the provision of family planning information and services through primary health care centers operated by the various state ministries of health (Olusanya, 1989). This program was bolstered by publicity surrounding former President Babangida's proposal, also announced in 1988, that "Four-is-Enough", advising woman to have no more than four children each (Caldwell et al., 1992, p. 222). Yet despite government family planning and N G O initiatives, levels of contraceptive use reported in the 1990 Nigerian Demographic and Health Survey (NDHS) were quite low--nationally, 3.5% of 6880 women interviewed were using modern forms of contraception. However, modern method use was considerably higher in southwestern Nigeria, reported at 10.5% (Nigeria Federal Office of Statistics, 1992, p. 43). More recent studies suggest that current use of modern methods, including the IUD, has increased further in southwestern Nigeria (Caldwell et al., 1992, pp. 228-229). The I U D

Presently, IUDs available in Nigeria consist of polyethylene t-shaped devices, which are either partially covered with fine copper wire (Copper T 380A) or treated with progesterone (Progestasert T), with a polyethylene string which hangs down into the vagina. The current preference for t-shaped designs is recent; earlier designs include spirals (hence the other colloquial name, "coil"), loops, and circular devices, most of which are no longer marketed. While the effectiveness in preventing pregnancy varies with type of IUD and user characteristics (e.g. age, number of children, etc.), the Copper T 380A is considered to have one of the lowest failure rates of any contraceptive (the first year failure rate in "typical IUD users" is 0.8%) (Hatcher et al., 1994, p. 349). With such effective rates of fertility control and long-term low cost, it is not surprising that, in a monograph sponsored by the Population Council, the IUD is described as "the most popular reversible method worldwide, used by some 90 million women" (Sivin et al,, 1992, p. viii). Despite their positive assessment of 1UD acceptance and effectiveness, N G O agency personnel, medical doctors, scientists as well as lawsuit-shy drug companies place several caveats on their use. For example, they are counterindicated for women with a history or the presence of reproductive tract infections (RTIs), when a woman or her partner has multiple sexual partners, or when modern medical care is not easily available in case of complications (Sivin et al., 1992, pp. 2-3). Some of these health concerns are also held by Ekiti village women. Nigerian survey data

Questions on contraceptive knowledge and practice including IUD use were included in two sur-

1143

veys, the Nigerian Demographic and Health Survey (NDHS; Nigeria Federal Office of Statistics, 1992) and the Ondo State Demographic and Health Survey (ODHS; Ondo State Ministry of Health, 1989), sponsored by state and federal ministries of health and by USAID. The pill was found to be the most popular form of modern contraception, while the IUD was the least popular among four types of modern contraceptives (pill, IUD, injection, and condom) ever used by ODHS women (Ondo State Ministry of Health, 1989, p. 31) and NDHS women (Nigeria Federal Office of Statistics, 1992, p. 41). Use of the IUD was slightly higher among NDHS women (1.6% compared to !.1% for ODHS women), although this difference may reflect the particular emphases of local government hospital or health center programs as well as greater availability of IUDs and insertion opportunities in recent years (Caldwell et al., 1992, p. 229). The low rate of IUD use reported in the ODHS survey may also be related to health concerns, cited by 23% of women interviewed as the main problem with its use (Ondo State Ministry of Health, 1989, p. 29). However, comparable percentages of women worried about the health effects of pills and injections as well. Exactly what these health effects are and why they would differentially affect acceptance of contraceptive use (i.e. why the pill is more widely used despite also being described as having health effects) remain unclear from these large-scale surveys. They are also unexplained in a study by USAID personnel of the family planning program in Ondo State which included interviews with contraceptive providers and with 114 women clients of programs throughout the state: [Contraceptive providers] identified fear of side effects [health concerns] (34%), ignorance (23%), and religion (16%) as the three commonest reasons why women do not use modern family planning methods. Forty percent of the providers interviewed in this survey identified fear of sideeffects as a major constraint for use of contraception in the State (USAID, Policy and Evaluation Division, 1991, p. 9). However, one study of long-term contraceptive users suggests what some of these health concerns may be. From 1989 to 1991, women who used IUCDs and Norplant contraceptive implants attending five hospitals in different parts of Nigeria were interviewed about why they discontinued contraceptive use. It was found that: Menstrual problems were cited by over 20 percent of the IUCD discontinuers in Lagos and Port Harcourt and over 40 percent of the IUCD discontinuers in Maiduguri. In two clinics, Calabar and Ogun, 20 to 24 percent of the IUCD discontinuers reported pelvic infections. Calabar was the only clinic where a sizeable proportion (15 percent) of discontinuers reported expulsion as their reason for discontinuation (Landry et al., 1992, p. 9). Of the women discontinuing use of the IUCD at the Ogun State clinic at Abeokuta, "the majority

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(67 percent) said they would not recommend the I U C D " (Landry et al., 1992, p. 10). In both the urban center of Ado-Ekiti and the rural Ekiti village to the northeast where I worked, I U D s are rarely used presently. O f the 601 women living in Ado-Ekiti surveyed in 1991, only 1% of married women and none of the unmarried women were using I U D s (Caldwell et al., 1992, p. 229). None of the 300 women (either married or unmarried) interviewed in the village survey conducted in 1992 were currently using the I U D or had used it in the past (even though 54% had heard o f it). Low levels of I U D use were also reported by the local P P F N representative, Chief Mrs J. M. Oyesanya, who operated a private maternity clinic in a nearby town. When asked about contraceptive use, she indicated that very few of her clients (all of whom were married women) used the I U D : Few women use the IUD, which is called "turning the uterus". If they chose to use the IUD they will be sent to lkole [Hospital] for insertion. They use ampicillin capsules when inserting the IUD to prevent infection. There are up to 60 women coming to the clinic for family planning; of these five or six are using the IUD (interview, August 1991). In order to understand why I U D s are infrequently used by women living in northwestern Ekiti towns and villages and why it is called "turning the uterus", the explanations given by village women interviewed in 1991-1992 and in October 1993 are examined.

Local values and fertility control

can be turned back, she must go to the person who has done this thing to her and make a sacrifice--those are the [herbalist-healers] who can change it back (interview, August 1991). There are two aspects of this process mentioned earlier that relate it to the IUD. First, infertility is brought about by the extraordinary knowledge of others, i.e. traditional medical specialists and witches. The fertility of an ordinary person is no longer in their control since they do not have the knowledge to regain it. Second, while it is a reversible p r o c e s s - - a turned uterus may be turned back--this is not done lightly and there remains the possibility that a turned uterus may permanently remain so. The extension of ideas about "turning the uterus" to perceptions of the I U D is evident in the comments of one 21-year-old married woman, a seamstress with a secondary school education. She explained why she could not risk getting an I U D during her child-bearing years: If one goes on turning the uterus, what if one wants more children again? How would I do it again? It may even have adverse effect. I can only do it if I have finished with having more children (interview, October 1993). This point was made more dramatically by another married village woman, 34 years old, a trader with secondary schooling, who has two children now and wants four altogether: I don't think 1 can go for the coil [IUD] method because it can affect my life. I am thinking that it can kill. I heard of a person at Oye-Ekiti who having gone on the coil, she died. It happened that when the woman experienced a little separation from her husband. She went for the family planning coil but when she came back to terms with her husband, she wanted to have more children. Then she went back to turn the uterus back to normal and in the process, she died. Because of this experience, I can't do it (interview, October 1993).

Understanding the local interpretation of the I U D as "turning the uterus" helps to explain women's wariness of this form of contraception. The idea of the uterus or placenta being " t u r n e d " - - resulting in infertility--is expressed elsewhere in West Africa (Caldwell and Caldwell, 1987, p. 425), with some variation in meaning and techniques. For example, "turning the placenta" may be done only after childbirth is completed as permanent sterility is believed to result. In the Ekiti area, the term "turning the uterus" [s'ile omo pada, literally, to make the house of the child (womb) turn] refers to a technique which alters the position of the uterus in such a way that infertility results. According to one male traditional healer (babalawo), there is a physiological and medicinal basis for this condition, as certain traditional medicines are believed to turn or cause the uterus to curve in such a way that it repels semen which just flows out. However, another healer, a woman (iyalawo), stressed the supernatural aspects of this technique which nonetheless may be countered:

I have heard about various methods of family planning in the hospital. I have heard about turning the uterus. I learned that some people that have experienced it used to menstruate three times in a month and it makes some people to become thin and others to become fat. In the future, I can do it if the doctor recommends that my nature can withstand it (interview, October 1993).

Turning the uterus upside down is the work of witebes; I know how to undo it...Something like that happened in Oye [a nearby village]. It was people inside the house who did such a thing to [one] woman. She used to say bad words to them so they did this to her. Before the uterus

Two women in the village had used IUDs, both when living elsewhere. One had no problems with the I U D , while the other had hers removed for several reasons:

Aside from these more dramatic concerns, I U D s are associated with certain unhealthy conditions identified with modern contraceptive use more generally. O f 20 Itapa women aged 20-45 questioned about whether they could use I U D s in the future, 12 said they would not use an I U D , with health concerns being the most c o m m o n reason cited (Table 1). Side effects affecting health were mentioned by one 29-year-old married woman, a trader with secondary schooling, with three children now who wants six:

Interpreting IUDs in Nigeria

1145

Table 1. Knowledgeof IUDs and future use among Ekiti villagewomen. 1993 Age group

Have heard of IUD Yes No

20-24(n = 4)

3

25-29(n = 4)

Can use in future Yes No I

3

4

2

2

30-34(n = 4)

4

3

1

35-39(n = 5)

3

2

2

3

40-44(n = 3)

2

1

16 (80)

4 (20)

Total %

l

3 8 (40)

12 (60)

Note: Reasons for not using: ages 20-24: don't know it, irreversible,excess menses/fat/thin ages 25-29: will abstain, prefer other methods ages 30-34: life-threatening ages 35-39: prefer other methods, religion,willabstain ages 40-44: makes fat/thin, painful,will abstain. I happened to have experienced the coil. Later when I had a transfer and I decided to remove the thing since I didn't know whether they could take care of me where I was going. I heard of it from a brother's wife who did it in London...The one I had was painful and that was [also] why I removed it. [After] my experience with [it], I don't intend to use anything of such again. The cord [that was there], each time I had [sexual] connection with my husband, I used to have pain. I can't go on the coil, [but] I use tablets and my menstruation has been regular (interview, October 1993). Most village women, however, do not use family planning pills, the IUD, or any form of modern contraception. Rather, they use abortifacients to control fertility or abstain from sexual relations, although the latter is viewed as protecting the health of the nursing child (Renne, 1993, p. 48n), not as limiting fertility. Their behavior is related to ideas about fertility, "spoiling" the womb, and conception. If one's fertility is considered a divine gift that is ideally "up to God", one should not attempt to, and ultimately cannot, restrict it. Nonetheless, in practice, there are times when a pregnancy may be unwanted particularly by young, unmarried women completing their education. Abortion provides a relatively simple solution as compared to I U D use, as it is discreet, it is available locally, one does not need anyone's permission (unlike family planning clinics where a husband's consent is needed), and importantly, it is inexpensive, assuming no complications arise. Abortion, using various types of patent and traditional medicines or by D and C, is one of the most common forms of fertility control used by village women (Renne, 1996, p. 492, Table 5). Furthermore, abortion actually provides evidence of one's fertility, an advantage for young women seeking to establish long-term relationships leading to marriage but who are still schooling and hence not ready to marry and have children. The I U D provides no such evidence and its association with irregular bleeding and abdominal pain rather suggests infertility instead. While most women

recognize that abortion may endanger their lives and future fertility, that by aborting they risk "spoiling their wombs" (some mentioned perforation of the uterus, infertility, and even death), many seem to regard abortion in the sense of "better the devil you know than the devil you don't know".

DISCUSSION That many Ekiti women associate contraceptive use in general and I U D use in particular with health problems reflects the way that ideas about social morality and physical health may be conflated (Turner, 1984). Regulating one's fertility implies a certain unhealthy, immoral behavior both as an affront to one's God-given blessing of fertility and because it suggests that other activities--such as schooling or w o r k - - t a k e precedence over one's role as mother. Hence, one older Ekiti village woman remarked that young women no longer love children since they get abortions in order to continue their education. But despite older women's consternation about the behavior of younger village women, some fertility-related practices are changing. For example, nursing mothers are expected to abstain from sexual intercourse for a period of at least two years for the health of their children. However, this pattern of sexual abstinence has been modified to some extent (Caldwell et al., 1992, p. 227; Renne, 1993, p. 49). The period of sexual abstinence after childbirth is presently around one year or less, with the two to three year interval preserved by some through withdrawal or the use of contraceptives. Indeed, the continuing social ideal of regularly spaced children has been an important impetus for contraceptive use during child-bearing years, which has been astutely reinforced by the Federal Ministry of Health "Space Your Family" program.

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Elisha P. Renne

This social aspect of fertility is emphasized as well in the continuing belief in the power of individuals to affect others' fertility. Many village women are skeptical of medical explanations of infertility and miscarriage that exclude the possibility that antisocial people characterized as witches and wizards can prevent or destroy pregnancies. This association of infertility with witchcraft is not restricted to rural areas. In a study of women and women living to the southwest of Ekiti in urban IleIfe, Oyewumi (1989) found that 68% of those interviewed believed in "witchcraft power as an agent that can cause infertility" (p. 79). Suspicions of witchcraft, however, may be interpreted in a less literal and more metaphorical way. For individuals in social structurally difficult relations, such as those between in-laws or co-wives, such suspicions may been seen as indirect expressions of conflict and enmity, stressing the micro-politics of social relations. In contrast, family planning personnel associate the I U D with medical procedures which have positive implications, related to Western technology and perceptions of progress. Fertility is something that can be scientifically and safely managed through appropriate techniques and technologies. Contentious social relations reflected in witchcraft suspicions are not part of the picture; rather, scientific objectivity and biological processes are stressed. Furthermore, provided that abortion is not involved, the moral question of trivializing a sacred blessing is not an issue. These views of what constitutes appropriate fertility control would seem to reflect two very different perceptions of reality. The I U D appears to be regarded as something progressive by those promoting a Western scientific view of fertility or as something that is an affront to God, only controllable by those with suspect supernatural powers, by those who favor a spiritual explanation of fertility. However, these two views are not mutually exclusive. Almost all health and family planning practitioners in Nigeria ascribe to some form of

Christian or Islamic belief, as do the Ekiti village women interviewed. They share the pro-natalist ideal that one of women's God-given roles in life is to bear children. Presently, while family planning and health workers may promote the IUD, they do so with some reservations, advising women not to use the I U D if they have not had children before, as a nurse at Obafemi Awolowo Hospital in Ile-Ife explained. Similarly, many educated younger village women have accepted the possibility of limiting fertility. These women say that in the future, they will use some types of modern contraceptives when they have had the children they want. It is not simply a matter of two distinct categories of individuals-those who favor either metaphysical or rationalist perspectives on fertility. How the I U D is interpreted is not a simple reflection of culturally or socially constrained thinking on the one hand and objective scientific decision-making on the other (Carter, 1995). Rather, both views reflect a combination of unverified beliefs about the u n k n o w n (the physiological effects of ill will, the workings of the IUD) and of verified experience of the known (IUDs need specialist attention, IUDs require adequate medical facilities). Viewed in this light, it should not be surprising that only a few village women say they will use the I U D (Tables 2 and 3) in the future, preferring injectable contraceptives (Depo-Provera) (see Bledsoe et al., 1994, p. 92) and condoms instead. While assertions of future use should be considered with caution, it is interesting to note that the preference for so-called family planning injections after child-bearing was similar to responses to questions about future contraceptive use in the Nigerian and Ondo State DHS surveys (Table 4). Thus, the Caldwells' (Caldwell and Caldwell, 1987, p. 425) conclusion that a fear of health effects associated with contraceptive use generally would dissipate when women became more knowledgeable about them appears to be only partly correct. Some contraceptives, such as injectables and condoms, are gaining wider acceptance, especially among younger

Table 2. Future birth control to be used at completionof child-bearing,responsesof womenin an Ekiti Yoruba village, 1992(part 1) Age group 15-19 (n = I11) 20-24 (n = 64) 25-29 (n = 33) 30-34 (n = 16) 35-39 (n = 28) 40-44 (n = 21) 45-49 (n = 27) %of total (n = 300)

Condom

FP tablets

22 (24) 47 (30) 39 (13) 25 (4) 14 (4) 10 (2)

3 (3) 8 (5) 3 (1) 6 (I) 10 (3) 5 (1)

(2) 26 (77)

(1) 5 (14)

Types of birth control (% of age group) IUD Injection 1 (1) 2 (1) 3 (1) 6 (I)

7 (2) 2 (6)

18 (20) 14 (9) 27 (9) 31 (5) 21 (2) 14

Safe period 8 (9) 2 (1)

Withdrawal

3 (2)

7

4 17 (52)

4 (13)

1 (2)

Interpreting IUDs in Nigeria

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Table 3. Future birth control to be used at completion of child-bearing, responses of women in an Ekiti Yoruba village, 1992 (part 2) Abstain

Ring

Misc.a

I (1)

3 (3) 8 (5) 3 (I)

2 (2) 3 (2)

6 (2) 4

Sterilize

7

(1) 10 (2) 19

(2) I0 (2) 4 (1) 2 (6)

(4)

4 (ll)

8 (2) 4

1

(ll)

(2)

Nothing

As MD says

Don't know

12 03) 13 (8) 12 (2) 19 (3) 32 (9) 38 (8) 59 (16) 20 (61)

6 (7) 2 (D

25 (28)

10 (2) 4 (1) 4 (11)

6 (21 13 (2) 4 (I) 5 (I) II

(34)

aMisc, refers to responses which mention two or more methods, salt and water, or Bee-codeine. Table 4. Preferred methods of Western contraception for future use in Nigeria (%) ODHS, 1986a

NDHS, 1990"

(n = 567)

(n - 607)

Ekiti Village Survey, 1992b (n = 300)

11 13 41 1

24 4 21 3

5 2 18 26

Method Pill IUD Injection Condom

apercentage of women saying they intend to use these methods after the next 12 months. Sources: Ondo State Ministry of Health, 1989; Nigeria Federal Office of Statistics, 1992. bpercentage of women saying they intend to use these methods after child-bearing is completed. w o m e n (Tables 2 a n d 3). But others, such as the I U D , continue to be seen as endangering health. Educated village women whose values converge with those o f g o v e r n m e n t family p l a n n i n g and health workers say that some m o d e r n contraceptives are acceptable but that I U D s are not, suggesting t h a t other issues are involved. This aversion to I U D use relates to fears a b o u t infertility a n d a b o u t the prospect o f a n o t h e r person h a v i n g control over one's body. Even when childbearing is complete (often in conjunction with b e c o m i n g a g r a n d m o t h e r ) a n d infertility would actually be the preferred state, women are disinclined to use the I U D , suggesting that concern a b o u t having something in one's body which one c a n n o t control a n d a b o u t possible need for future medical a t t e n t i o n m a y be a factor. This is not an u n r e a s o n a b l e concern in a country with high levels o f STDs (Erwin, 1993, p. 136), where easy access to medical care can be problematic even in u r b a n areas a n d where polygynous marriage as well as o t h e r informal liaisons are c o m m o n l y practiced. Since 6 0 % of I U D s used in Nigeria are obtained a n d inserted in g o v e r n m e n t facilities (Nigeria Federal Office o f Statistics, 1992, p. 48), the continuing decline o f Nigerian health services (Popoola, 1993) discourages I U D use that may require future specialized medical a t t e n t i o n at u n k n o w n expense. F o r all but the very wealthy, the uncertainty associated with c o n t e m p o r a r y health care in Nigeria has reinforced rather t h a n dispelled the sense of per-

sonal risk and loss of control locally associated with " t u r n i n g the uterus". Economic a n d political instability attributed to federal leadership and policies in recent years has done little to alleviate these local concerns. For example, one educated Ekiti village w o m a n ' s comment captures the sense that the g o v e r n m e n t is neither practically n o r ultimately in control regarding family planning: [For myself], Government has said its own but Government is not the one that will be helping me to take care of my children. Government says four children [are enough] but some won't have more than two...Government cannot put a child into a woman's womb, she will have the number given by God (interview, 1991). These c o m m e n t s suggest a sense that federal officials have provided neither the moral leadership n o r the infrastructural support for health care in recent years to convince village w o m e n that they should follow their advice. The g o v e r n m e n t ' s inability to provide sense of political a n d economic stability counters future prospects for I U D use in southwestern Nigeria, as no one knows what the future may bring. In trying to choose a course o f action in this season o f uncertainty, Ekiti village women presently interpret the I U D " t h r o u g h a context that the world provides" (James, 1978, p. 74).

Acknowledgements--An earlier version of this paper was presented at the workshop, "Situating fertility: global visions and local values", organized by the Joint

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Committee on African Studies of the Social Science Research Council and the American Council of Learned Societies, held at Johns Hopkins University, Baltimore, 25-27 February 1994. I would like to thank Barbara Bianco and Gillian Feeley-Harnik for organizing the seminar and for their suggestions. Additional thanks go to Kayode Owoeye for research assistance. REFERENCES

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