- Email: [email protected]
The impact of HIV on family size preference in Zambia
Carolyn Baylies This paper examines the way in which concerns about HIVinfection are affecting thinkingin Zambia aboutpreferred number of children. It draws on research on the impact ofHIV/AIDS in peri-urban and rural households in 1995, based mainly on in-depth interviews with 65 of300 people who were initially surveyed. In spite ofhigh levels of anxiety about AIDS in these communities, risk from HIV was not always associated with the act of conceiving children, nor did this association necessarily influence actual behaviour or family size preferences. In some cases, however, the threat of ContractingHIVhad led to a decision to have fewer children. Many also worried about leaving orphans for others to look after and the costs which mightbe incurred in taking over the care of orphans left by others. A related reason for limiting fertility was the hope that orphaned children would be better cared for if there were fewer of them. Greater access to contraceptives, and specifically to condoms, is an important element in supporting women’s efforts to protect themselves, and men also need to be involved in strategies for mutual protection. In both communities, however, there was a shared sense oflimited control, notjust over fertility, but also over the wider economic and health environment. An understanding of the complexity of these factors is essential for intervention programmes intended to enhance women’s reproductive rights and support their fertility choices so as to ensure greaterprotection against HIV/AIDS. Keywords:
HIV/AIDS, family size preference,
HIS paper looks at how the threat of HIV infection affects the way people in Zambia think about childbearing and, in particular, family size preference. Conceiving children entails a risk of HIV infection, as do other encounters involving unprotected sex, but the implications may be more wide-ranging. Preference for fewer children will not necessarily reduce episodes of unprotected sex. But it may be one means of limiting risk and its harmful consequences. It is argued, however, that not just risk perception but also cost and welfare considerations mediate the way HIV influences ideas about the number of children one chooses to have. At the same time, personal circumstances, gendered power relations and availability of means of protection against infection and of family planning methods can often impede family size preferences being acted upon and reproductive rights being upheld. This
fertility control, orphans, Zambia
discussion draws on research conducted in 1995 on the impact of HIV/AIDS on households in Zambia.
Study methodology
and location
The study was carried out at Chipapa, just south of the capital Lusaka, and Minga, some 400 km away near the township of Petauke, along the country’s Great East Road. In each site, a cluster of villages around a local health care facility formed the study population. Small surveys of some 150 adults were carried out in each locality to gauge views on HIV/AIDS and assess its impact on households. Quota sampling was used so as to obtain a rough balance of male and female respondents across the age range. The survey was supplemented by focus group discussions (three in Chipapa and four in Mingal, held separately with men and women, to collect
Baylies
general views on local health problems and family planning practices. Participants were recruited with the assistance of local health workers and village elders. HIV/AIDS did not seem to have entered the repertoire of conventional justifications for fertility behaviour, as no one mentioned it as a factor influencing their preferred family size during the initial survey. Further investigation seemed warranted, however, given that AIDS has cost and welfare implications of the sort which seemed to underlie some of those conventional justifications. In-depth interviews of a subset of the original respondents (36 in Chipapa and 29 in Minga) were therefore conducted to ask specifically whether HIV had had an impact on their preferred number of children. The data collected in these interviews forms the basis of the rest of this paper. There was a purposive element to the selection of this subset. In order to investigate how particular circumstances may have affected the way AIDS impacted on fertility decisions, households where long-term illness had been reported were deliberately over-represented, as were those which appeared economically vulnerable. At the same time, given the sensitivity of the subject matter and a concern neither to be intrusive, nor to cause anxiety. in being ‘singled out’ for a second visit, there was a balancing of such households with those where no health or economic difficulties had been reported. While organised around a set of general questions, the course of this second interview was reflexively guided by individuals’ responses. Given the nature of the exercise, these interviews are best treated as a collection of case studies, rather than a representative sample. Table 1 gives some demographic characteristics of the respondents at each site. The local economy of both sites was agriculturally based. Each had suffered from several seasons of drought. They differed in respect of their position along the rural/urban continuum and estimated level of HIV prevalence. Chipapa was chosen for its location within the broad per&urban space around Lusaka and Minga as a contrasting rural settlement. Official estimates of adult HIV prevalence in the districts where the two sites are located were 28.2 per cent for Chipapa and 13.8 per cent for Minga in 1997.’
Table 1. Demographic characteristics, initial survey respondents: Chipapa and Minga,
1995 Characteristics
Chipapa (n=152)
Women Average
49% age of respondents
Married Educated
beyond primarylevel
39
Minga (n=150) 62% 36
12%
79%
41%
10%
4.2
4.4
5.86
6.99
Engaged in farming
95%
95%
Ever having used condoms
51%
9%
Reporting
16%
20%
Average
number of children
Average
preferred
number of children
AIDS-related
death in household
Family size preferences When asked about their ideal family size during the initial survey, about a quarter of respondents in Minga declined to specify a preference, saying that this was up to God. Of the rest, larger families were preferred in Minga, the more rural setting, reflecting broader patterns within Zambia and across much of the region2 In both localities, those who were younger and had higher levels of education preferred a smaller number of children, and there was a clear association between rationales for preferences and level of education and age. Those who were older or who had lower levels of education tended to mention children’s assistance in old age, view children as economic assets or defer to God’s will. Those who were younger or who were more highly educated mentioned the costs of caring for children, typically saying that they did not want more than the3 would be able to feed, clothe and educate properly, often with reference to the ‘bad state’ of the economy.3 The tendency to cite the economic costs of children was particularly pronounced in Chipapa, applying to 72 per cent of the sample, as against 33 per cent in Minga. This represents a shift not just towards a preference for smaller families but also a change in the way children are seen, with greater concern for the quality of children’s lives, balanced against the costs this entails.
Reproductive Health Matters, Vol. 8, No. 15, May 2000
The intrusion of AIDS into considerations about ideal family size Ithas been observed that most choices relating to fertility are made routinely on the basis of cultural conventions, although often involving calculation.4 However, these decisions can vary with changing life circumstances and be overridden in the context of passion, coercion or mishap. The translation of preference or plans into practice may be particularly difficult in the area of fertility. Although preferences are expressed and choices ostensibly made, they are not necessarily acted upon but may be frustrated and complicated by gender relations, lack of access to contraceptives, the dynamics of intimacy and moral prescriptions.5 HIV is an intrusive and dangerous addition to the constellation of factors influencing reproductive behaviour and fertility choices, with variable impact according to level of prevalence and patterns of sexual activity. HIV may not only directly reduce fertility;6-8 it can also alter sexual behaviours and affect the way in which fertility decisions are negotiated. It can even affect the meanings attached to such behaviour, from natural and life-giving to being fraught with potential harm and personal demise. AIDS was generating high levels of anxiety in Chipapa and Minga, and the comments of those interviewed were interspersed with expressions of worry which escaped almost involuntarily: ‘Ibelieve
I will not survive.’
‘AIDS has
caused
me
many
because I can’t stop thinking
sleepless
‘I worry about it more than anything ‘I wonder
nights
about it.' else.’
when it will be my turn.’
‘AIDS is unstoppable
and will kill us all.’
Anguish was also expressed about the enormous costs associated with care of those who were ill, loss of labour for household production, and blighted lives of children. It is therefore not surprising that costs and welfare implications figured particularly strongly in connections drawn between AIDS and family size preferences.
Welfare and cost considerations: the case of orphans When asked whether they would take in orphans, almost all 36 individuals in Chipapa and 29 in Minga interviewed said they would. At the same time, many remarked on the hardship this could entail. When asked whether care of orphans would have any bearing on the number of their own children, responses varied depending on the age and health of prospective orphans and the extent to which orphans would be considered as ‘their own children’. Economic calculations figured strongly here. Sometimes respondents said that orphans could help out in the house or the fields and thus become an asset. But cost considerations were much more important, persuading some of the need to limit the number of their own children. Most of those who answered this question who were under the age of 50 said they would have fewer or no more of their own children if they took in orphans, with little variation between female and male respondents. Sometimes, responses were framed in anticipation of future responsibilities, but many had already taken in orphans. Jane Soko,g for example, was 32 years old and had returned to Minga after a divorce to live with her elderly mother. Two of her children had died, but the remaining three lived with her. During the initial survey, she reported that a niece and nephew were also members of the household. When interviewed four months later, she was looking after five orphans. At first, she had been unable to cope, but now that she was ‘experienced’, things were easier. Everyone helped out and a little support was received from relatives in town. In view of the costs entailed in their care, however, she had decided not to have any more children of her own. Her own children and the orphans were enough. But she also felt that with AIDS around, she herself was at risk and on this basis as well believed it better to have fewer children.
HIV risk perception and ideas about preferred number of children The possibility that perceived risk from HIV may enter into ideas about reproductive behaviour and may be affecting notions of ideal family size is suggested by a study in two rural areas of
Baylies
Manicaland Province, Zimbabwe.l”,ll About half the women surveyed there said they would have fewer children after hearing about AIDS, with only 3 per cent saying they would have more. Preference for a smaller family was found to be significantly associated with general awareness of the risks of HIV. The way husbands’ extra-marital activities can escalate risk peppered the comments of those in Minga and Chipapa. As participants in a women’s focus group discussion in Minga said, even if wives were faithful, their husbands would go about with other women and bring the disease back home. Men’s tendency in Zambia to have more extra-marital partners than women increases the risk of HIV infection of their wives and children as well as themselves. This is especially so in the early years of marriage, when families are being built, since it is then that men’s ‘wandering’ tends to be greater and the level of sexual activity within marriage higher.1z,13 Zambia’s Demographic and Health Survey 199612 documents the extent to which women’s risk perception accurately reflects these behaviour patterns. Of those currently married, 38.7 per cent regarded themselves as at moderate or great risk of getting AIDS, with over 90 per cent of these saying this was because their husbands had multiple partners. The relevant figures for men were respectively 14.7 per cent and 31.8 per cent. In Minga and Chipapa, people also appreciated that pregnancy could have a detrimental effect on the health of a woman who was already HIV positive. When asked what they would advise a relative with HIV/AIDS as regards having children, the general consensus of those surveyed - who almost invariably assumed that the relative in question was a woman - was that she should have no more children. It was widely believed that pregnancy would accelerate illness and a woman would die soon after giving birth. The act of conceiving children was not always perceived to be associated with risk of HIV infection or progression of illness, however. Nor when acknowledged did these factors necessarily influence respondents’ actual behaviour or their preferences about family size. Thus, when asked directly whether the presence of HIV had had any influence on the number of children they thought of having, five of the 36 interviewed in Chipapa and 10 of the 29 in Minga said it had not. 80
This conclusion, however was reached through a number of different routes.
Circumstances where HIV risk had little bearing on reproductive behaviour A reluctance to link fertility preferences with the presence of HIV was especially characteristic of those who felt that family size was a matter for God. Failing to see a connection between family size preferences and AIDS also applied when AIDS was believed to arise from ‘improper’, ‘deviant’ or ‘dangerous’ sexual activity, dissociated from normal reproductive behaviour. If respondents felt that they did not occupy such dangerous territory, particularly as regards conceiving children, they did not perceive building a family to entail a risk from HIV. This sort of thinking characterised those who considered themselves safe by virtue of assumed marital fidelity. ‘AJDS does not come because of having children; it comes through promiscuity, private injections and using contaminated razor blades. So why should I limit the number of children I wouJd have?’ (Maxwell Zimba) Some, however, believed that they were at risk, but that there was nothing they could do about it. This was typical, for example, of those who felt that sexual desire was ‘natural’ and should not be checked. The case of Adam Mwale, a 29-year-old married man with two young children, illustrates how beliefs about human nature, and specifically men’s nature, can operate to confound the logic of protection in spite of anxiety about the risk of HIV. Adam was worried about the cost of taking in orphans and had decided that if any orphans joined his family, he” would have no more children of his own. The two he had would be enough. His anxiety about AIDS kept him awake at night, and deepened his conviction that he would have no more children. At the same time, he belittled advice that people should refrain from pre-marital and extra-marital sex. Citing the Bible, he declared: ‘Look at David and Solomon. They definitely had more than one wife. And now how can I not have other women? Hgw can I overcome my nature?'
Reproductive
Such comments were more characteristic of the men than the women in this study and often reflected a defiant, perhaps unreasoned, stance in the face of potential harm. But they could also signify priority being placed on norms of masculinity, or on pleasure over risk, in a manner similar to that described in European contextsI In some cases, however, the view that risk was unavoidable arose from a more straightforward fatalism, which resonated with deep feelings of having little control over the circumstances of one’s life. As Nelson Mwanza said:
‘HIV/AIDS is there; it has already been .created and no one can change that. Whether one ends up infected ornotis not truly one’s decision.’ There was little point, he felt, in linking this general susceptibility to decisions about the number of children he might have. Gerald Njobvu made the point more bluntly: ‘I can’t stop having children just because of AIDS. If it comes, it comes.’ But if some were seemingly resigned to fate, others experienced great anxiety about their ‘carnal nature’ placing them at risk. Nicholas Tembo admitted worrying about ‘making a mistake’ - the one wrong move that could lead to death. It was better, he said, to become like a sofa in the house:
‘When it is kept inside, it is safe and may last Long. Leaving the sofa outside on the veranda leaves it vulnerable to attacks by goats and pigs who consequently destroy it. In the same way, a man is better off staying indoors where he is free from temptation, rather than leading a social life where he is open to suggestions and innuendo.’ He had reached the point of sending his children to buy beer and cigarettes for him, lest he ‘wander’, providing a graphic commentary on how ‘nature’ could override reason and undermine rational choices. Even so, he was reluctant to bring this anxiety into his calculations about having children. This was partly because he believed that children were a gift of God and partly because he felt he could not make decisions based on uncertainties, including whether or not he would get AIDS. Distinguishing between
Health Matters,
Vol. 8, No. 15, May 2000
different ‘risks’, his strategy was to reduce his exposure to ‘dangerous sex’, which he defined as sex outside marriage. In contrast, there was the strategy of James Mumba, who was afraid of AIDS and did not believe that he would survive since both he and his wife had other sleeping partners. He used alcohol to side-step reason and blunt his anxieties; when he drank, he would forget his worries, so that ‘everything is all right.’ It was not just men who were having sexual encounters outside of marriage. Several women admitted to this as well. The greater sexual freedom accorded men, however, combined with firmly held cultural expectations that wives should submit to their husbands’ sexual desires, severely compromised women’s ability to protect themselves from HIV infection. For those who are married and whose partners have ‘wandered’, dangerous sex is neither improper sex nor promiscuity. Nor could reproductive activity be distinguished in terms of its ‘safety’ from sexual activity more generally. As Mary Zulu explained, whether one has children or not, one can still become HIV infected if one has an unfaithful husband. ‘One cannot deny one’s husband his conjugal rights because of fear of HIV/AIDS.’ Quite apart from the capacity to act, risk calculations follow from views about the fidelity of one’s partner, and their chastity prior to union. They are bound up in trust, loyalty, intimacy and gendered norms which can work profoundly to women’s disadvantage.15-I8 This can be so even when risk and its implications are close companions. Helen Chirwa, a 30-year-old woman with four daughters, was living with her sister who was HIV positive and had two children. Helen said she would have. fewer children than she might want if she had orphans to look after and even fewer to reduce the risk of contracting HIV. Yet she also acknowledged that she had unprotected sex with her boyfriend, as he ‘did not use condoms’. Economic need can also frustrate protection.1g-21 Theresa Lungu, who was divorced and the sole breadwinner for her five children, said it was difficult for a woman without a husband to avoid sex. Hers was a complicated, pragmatic argument, which acknowledged the dilemmas 81
and vulnerabilities which economic hardship confers on many women. A young lady, she said, cannot afford to ‘show off” or waste time by withholding sexual favours:
‘In any case money is hard to come by these days and it is very easy to be bribed with a bar of one’s favourite soap or a bottle of glycerine.’ Perhaps the most fundamental factor mentioned was the desire for children. Alice Mweene, aged 22 and a single parent, said she would not stop trying to have children because so far she had only one. Desire for children, economic insecurity and gendered power relations can all impede protection against HIV infection. But limited knowledge about or access to means of protection are also inhibiting factors. The Catholic mission hospital in Minga did not supply condoms for family planning, let alone for protection against HIV. In Chipapa, in contrast, a prograrnme sponsored by the Planned Parenthood Association of Zambia had been in operation for several years. While participants in focus group dis82
cussions in Chipapa were able to name several varieties of contraceptive pills, including them alongside the condom as ‘modern methods of family planning’, those in Minga were much less knowledgeable. In one of the women’s focus groups there, queries about family planning elicited reference only to the ‘natural method’, which only a few had ever used. Some in the second group had used what they referred to as traditional methods, often involving the wearing of beads or using traditional medicine, but no other methods. Many in theetwo men’s focus groups in Minga professed no knowledge of family planning. * Just over half of respondents to the initial survey in Chipapa (including 43 per cent of women respondents) reported having used condoms, the great majority to avoid both unwanted pregnancies and STDs. In Minga, however, only 9 per cent had ever used a condom and, of these, a quarter said they simply knew nothing about them. Of the rest, a number of women non-users said their husbands or boyfriends did not like condoms or would not permit their use. Others commented that condoms are ‘used by men’, with
Reproductive Health Matters, Vol.
that control and the ability to act eluded them as women.
the implication
Deciding not to have more children because of AIDS Noerine Kaleeba has argued that everyone should behave responsibly, as if they were HIV positive. z Few in Minga and Chipapa were aware of their HIV status, but rather than subscribe to Kaleeba’s logic, the reverse often applied. Martin Kapaya’s view was that: ‘You can’t make decisions on the basis of what you don’t know’. He was one of a numb& of respondents who preferred to assume that they were HIV negative until shown otherwise by symptoms or, particularly for women, by the illness of a child. Altogether, 14 of the 36 people interviewed in Chipapa (nine women and five men) and one in Minga said AIDS would have no impact on their reproductive behaviour unless and until they found themselves, or their partner, to be infected, at which point they would have no more children. As Betty Manda said there would be ‘little point in having more because they would only end up dying’. For a further 12 of the 29 people interviewed in Minga and five of the 36 in Chipapa, however, the very threat of contracting HIV had led to a decision to have fewer children. Only a few explained this in terms of personal risk. Among them was Patricia Hantuba, a young widow with several children, who quietly disclosed that she had decided not to have any more children because, should she be positive and become pregnant, it would affect her health. More common was a wish to have fewer children in order to reduce the burden on relatives, should one die of AIDS. Victor Phiri was one of 10 people who took this view: ‘With this threat of AIDS, I will have few children so thatlleave fewerproblems formyrelatives.’ Irene Tembo concurred. Personally, she said, she would have only three so that if she contracted the virus she would leave fewer problems for her children and the relatives who would look after them. In several cases, risk calculations converged with cost considerations to strengthen determination to have fewer children. Elizabeth Mkan-
8, No. 15, May 2~00
dawire, a 40-year-old woman who was separated from her husband, had three children, one of whom had suffered prolonged illness. Three others had died in infancy. Her sister’s recent death from what she believed was AIDS added to her worries about her own situation. She wished to have no more children primarily because she believed this would hasten her demise, but also because she did not want to leave problems for her relatives. Worries about causing undue burden to others may be a more socially acceptable reason for limiting fertility than that of reducing personal risk. Alongside its altruistic concern for others, it also incorporates the hope that the quality of care of one’s children will be better, if by being fewer they are less of a problem to future guardians.
Supporting women to secure protection from HIV in the context of family formation HIV/AIDS impinges deeply on people’s lives. Many of those interviewed in Minga and Chipapa had had personal experiences of the illness and death of close relatives and of ensuing hardship, and they expressed deep worries about their own situation. Not all of them, however, made a connection between AIDS and the number of children they wished to have. In some cases, the very notion that AIDS might influence fertility choices remained an abstraction that individuals had not personally grappled with or which they felt was inappropriate to entertain. In others, a sense of fatalism muted agency. But AIDS had influenced some respondents’ intentions to have fewer children that, even when this followed from a sense of personal risk, was more often expressed as anxiety about leaving a burden of care for_ others and worry about children’s future welfare. In a context of uncertainty about longevity due to widespread AIDS prevalence, the tendency of younger people to see children as security in old age has been undermined. Because of high infant and child mortality, people still want ‘enough’ children so that some would survive. Yet the fewer the children they have, the lesser the burden and costs for relatives if they die, and the better care the children might receive. While thus exerting 83
Baylies
downward influence on preferred number of children, concerns about costs of caring for orphans left by others also lead people to think about having fewer of their own children. It is in respect of such costs and welfare concerns that the impact of AIDS may bear most strongly on fertility behaviour, not least because they accord with the more general logic employed by younger and more highly educated people in respect of family size. With reference to HIV risk reduction and ideal family size, preferences are more likely to translate into behaviour when there is a strategy or a plan.23 This can more easily be effected when a degree of consensus has been established between partners, and where there is access to means of protection and methods of family planning. In the communities studied, however, openness between partners in discussing fertility matters, knowledge of and access to family planning and means of protection and wider structures of support were often lacking. In addition, across both communities there was a shared sense of limited control, not just over fertility, but also over the wider economic and health environment. While many were prepared to entertain the possibility of changing their reproductive behaviour, their responses were frequently equivocal, and more often suggestive of the difficulties of doing so than reflecting decisive action. Economic insecurity, lack of access to the means of protection and inability either to trust a partner or affect his/her behaviour can make the issue of choice a moot one. The threat of HIV necessarily transgresses reproductive rights. When a woman wishes to have fewer children in the face of this threat, she needs to be supported on many fronts, not least as regards poverty alleviation and assistance in the care of those who are ill or orphaned. The costs of AIDS weigh particularly heavily on communities already struggling under the effects of national debt and economic crisis. ‘Preferences’ for fewer children may be emerging more because of the depth of hardship than from measured deliberation about how to enhance the quality of life or reduce the risk of infection. Born of desperation or not, however, people’s wish to minimise risk to their own health and that of their children needs support.
84
Women’s skill in negotiating safer sex strategies would be enhanced by their greater knowledge of means of protection. Accessibility of contraceptives, and specifically to condoms, is an important element in this. Crucial too is the inclusion of men in family planning initiatives and discussion between couples both about family planning and mutual protection from HIV infection.24,25 Support and interventions can be most appropriately designed with knowledge of the way in which economic situation and access to means of protection influence both fertility choices and the probability of their being enacted. But a persistent challenging of gender inequalities is also required if fertility choices are to be less constrained by concern over the dangers and implications of HIV and AIDS.
Acknowledgements This research was funded under the Overseas Development Administration (now Department for International Development) Links between Population and the Environment Research Programme, administered in the UK by the Development Planning and Project Unit, University of Bradford, and in Zambia under the auspices of the Economic and Social Research Bureau, Lusaka. I owe a debt of gratitude for research and administrative support to Veronica Manda, Mbozi Haimbe, Oliver Saasa, Beatrice Liatto-Katundu, Mary Zulu, Epiphano Phiri, Christopher, Bornwell Maluluka, Edwin Cheelo and Melanie Ndzinga. Correspondence Carolyn Baylies, Department of Sociology and Social Policy, University of Leeds, Leeds LS2 9JT, UK. E-mail: [email protected]
Reproductive
References
Health Matters, Vol. 8, No. 15, May 2000
and Notes
1. Ministry of Health (Zambia], 1997. HIV/AIDS in Zambia, background, projections, impacts and interventions. Lusaka. 2. Data were analysed through the use of SSPSX. A test of the difference between the sample means for preferred number of children (5.86 for Chipapa and 6.99 for Minga) yields a value of z = 3.14, significant at p<.Ol. 3. For the variables level of education and reasons for preferred number of children chi square figures were 8.76 (df=l, p= 0.003) in the case of the Minga sample and 9.22 (df=l, p= 0.001) for the Chipapa sample; for the variables age and reasons for preferred number of children, the chi square figures were respectively 7.69 (df =l, p= 0.006) and 31.10 (df= 1, p= 0.00) for Minga and Chipapa. There was no significant difference between men and women as regards reasons given for a preferred number of children. 4. Carter A, 1995. Agency and fertility: for an ethnography of practice. In: SituatingFertility: Anthropology and Demographic Inquiry. S Greenhalgh (ed). Cambridge University Press, Cambridge. 5. Greenhalgh S, 1995. Anthropology theorizes reproduction: integrating practice, political economic, and feminist perspectives. In: SituatingFertility: Anthropology and Demographic Inquiry as 141. 6. Carpenter L, Nakiyingi J, Ruberantwari A et al, 1997. Estimates of the impact of HIV infection on fertility in a rural Ugandan population cohort. Health Transition Review. 7(Suppl2):113-26. 7. Desgrbes du Loi? A, Msellati P, Yao A et al, 1999. Impaired fertility in HIV-l-infected pregnant women: a clinic-based survey in Abidjan, CBte d’Ivoire, 1997. AIDS. 13: 517-21.
8. Gregson S, Zaba B, Garnett G, 1999. Lower fertility in women with HIV and the impact of the epidemic on orphanhood and early childhood mortality in sub-Saharan Africa. AIDS. 13(SupplA): S249-S257. 9. Pseudonyms have been used throughout for participants in the research. 10. Gregson S, Zhuwau T, Anderson R et al, 1997. HIV and fertility change in rural Zimbabwe. Health Transition Review. 7(Suppl2): 89-112. 11. Gregson S, Zhuwau T, Anderson R et al, 1998. Is there evidence for behaviour change in response to AIDS in rural Zimbabwe? Social Science and Medicine. 46(3):321-30. 12. Central Statistical Office (Zambia], Ministry of Health, Macro International Inc, 1997.
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Health Transition Review. 7(Suppl2):169-88. 17. de Bruyn M, 1992. Women and AIDS in developing
18 Baylies C, Bujra J, 1995. Discourses of power and empowerment in the fight against HIV/AIDS in Africa. In: AIDS, Safety, Sexuality and Risk. P Aggleton, P Davies, G Hart (eds). Taylor and Francis, London. 19. Baylies C, Bujra J et al, 1999. Rebels at risk, young women and the shadow of AIDS. In:
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Zambia Demographic and Health Survey 1996. Calverton MD: Central Statistical Office and Macro International Inc. 13. Baylies C, 1999. HIV/AIDS and older women in Zambia: concern for self, worry over daughters. Presented at DSA Women’s Study Group Annual Conference in conjunction with Ethnic and Racial Studies, York University, 29 May. 14. Maotti J-P, Hausser D, Agrafiotis D, 1997. Understanding HIV risk-related behaviour: a critical overview of current models. In: Sexual
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AHRTAG/Pandora Press, London Doyal L, 1994. HIV and AIDS: putting women on the global agenda. In: AlDS, Setting a FeministAgenda.L Doyal, J Naidoo, T Wilton(eds). Taylor and Francis, London. Kaleeba N with Ray S and Willmore B, 1991. WeMiss You AJJ:AIDS in the Family. Women and AIDS Support Network, Harare. Ingham R, van Zessen G, 1997. From individual properties to interactional processes. In: Sexual Interactions and HIV Risk, New Conceptual Perspectives in European Research. as in [141. Mbizvo MT, Bassett M, 1996. Reproductive health and AIDS prevention in sub-Saharan Africa: the case for increased male participation. Health Policy
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Baylies
R&urn6 Get article
examine comment en Zambie, la crainte de l’infection k VIH influe sur le nombre souhaite d’enfants. 11 utilise la recherche sur l’impact du VIIYSIDA sur les menages periurbains et ruraux en 1995, fondee essentiellement sur des entretiens approfondis avec 65 des 302 personnes qui avaient fait initialement l’objet dune enquete. Bien que redoutant le SIDA, ces communautes n’associaient pas toujours le risque du VIH avec l’acte de concevoir des enfants, pas plus que cette association n’influenFait leur comportement reel ou les preferences en mat&e de taille de la famille. Beaucoup s’inquietaient aussi de laisser des orphelins dont d’autres devraient s’occuper. Une raison de limiter la ficondite etait l’espoir que des orphelins moins nombreux seraient mieux soignes. Un acces elargi aux contraceptifs, et concretement aux preservatifs, est important pour soutenir les efforts de protection des femmes, et les hommes doivent aussi participer aux strategies de protection mutuelle. Les deux communautes partageaient neanmoins un sentiment de maitrise limitee de la fecondite, mais aussi de l’environnement economique et sanitaire plus large. 11 est essentiel de comprendre la complexite de ces facteurs pour les programmes destines a valoriser les droits des femmes en matiere de reproduction et B soutenir leurs choix de ficondite afin d’assurer une plus grande protection contre le VIWSIDA.
86
Resumen En Zambia la preocupacion por el VIH afecta las attitudes acerca de1 ndmero de hijos preferido. El presente trabajo se refiere a investigaciones sobre el impact0 de1 VIWSIDA en 10s hogares rurales y de la periferia urbana en 1995, principalmente entrevistas de fondo con 65 de las 302 personas inicialmente encuestadas. A pesar de 10s altos niveles de ansiedad acerca de1 SIDA en estas comunidades, no siempre se asociaba el riesgo de VIH con el acto de concebir hijos, el comportamiento o las preferencias por familias de cierto tamano. En algunos cases, el miedo de contraer el VIH habia llevado a una decision de tener menos hijos. Muchas personas estaban preocupadas por dejar huerfanos al cuidado de otros. Otra razdn para limitar la fecundidad era la esperanza de que 10s nifios huerfanos fueran mejor cuidados si eran menos. Mayor acceso a 10s anticonceptivos, especificamente 10s condones, es importante para la proteccidn de las mujeres. Los hombres tambien deben involucrarse en las estrategias para la protection mutua. En ambas comunidades, el sentido compartido de control era limitado, no solamente con respect0 a la fecundidad, sino tambien en relation al ambiente economico y de salud en general. Comprender la complejidad de estos factores es precise para 10s programas de intervention que pretenden ampliar 10s derechos reproductivos de las mujeres y apoyar sus opciones en relacidn a la fecundidad con elfin de asegurarles mayor proteccidn en contra de1 VIH-SIDA.
HIV/AIDS, family size preference,
HIS paper looks at how the threat of HIV infection affects the way people in Zambia think about childbearing and, in particular, family size preference. Conceiving children entails a risk of HIV infection, as do other encounters involving unprotected sex, but the implications may be more wide-ranging. Preference for fewer children will not necessarily reduce episodes of unprotected sex. But it may be one means of limiting risk and its harmful consequences. It is argued, however, that not just risk perception but also cost and welfare considerations mediate the way HIV influences ideas about the number of children one chooses to have. At the same time, personal circumstances, gendered power relations and availability of means of protection against infection and of family planning methods can often impede family size preferences being acted upon and reproductive rights being upheld. This
fertility control, orphans, Zambia
discussion draws on research conducted in 1995 on the impact of HIV/AIDS on households in Zambia.
Study methodology
and location
The study was carried out at Chipapa, just south of the capital Lusaka, and Minga, some 400 km away near the township of Petauke, along the country’s Great East Road. In each site, a cluster of villages around a local health care facility formed the study population. Small surveys of some 150 adults were carried out in each locality to gauge views on HIV/AIDS and assess its impact on households. Quota sampling was used so as to obtain a rough balance of male and female respondents across the age range. The survey was supplemented by focus group discussions (three in Chipapa and four in Mingal, held separately with men and women, to collect
Baylies
general views on local health problems and family planning practices. Participants were recruited with the assistance of local health workers and village elders. HIV/AIDS did not seem to have entered the repertoire of conventional justifications for fertility behaviour, as no one mentioned it as a factor influencing their preferred family size during the initial survey. Further investigation seemed warranted, however, given that AIDS has cost and welfare implications of the sort which seemed to underlie some of those conventional justifications. In-depth interviews of a subset of the original respondents (36 in Chipapa and 29 in Minga) were therefore conducted to ask specifically whether HIV had had an impact on their preferred number of children. The data collected in these interviews forms the basis of the rest of this paper. There was a purposive element to the selection of this subset. In order to investigate how particular circumstances may have affected the way AIDS impacted on fertility decisions, households where long-term illness had been reported were deliberately over-represented, as were those which appeared economically vulnerable. At the same time, given the sensitivity of the subject matter and a concern neither to be intrusive, nor to cause anxiety. in being ‘singled out’ for a second visit, there was a balancing of such households with those where no health or economic difficulties had been reported. While organised around a set of general questions, the course of this second interview was reflexively guided by individuals’ responses. Given the nature of the exercise, these interviews are best treated as a collection of case studies, rather than a representative sample. Table 1 gives some demographic characteristics of the respondents at each site. The local economy of both sites was agriculturally based. Each had suffered from several seasons of drought. They differed in respect of their position along the rural/urban continuum and estimated level of HIV prevalence. Chipapa was chosen for its location within the broad per&urban space around Lusaka and Minga as a contrasting rural settlement. Official estimates of adult HIV prevalence in the districts where the two sites are located were 28.2 per cent for Chipapa and 13.8 per cent for Minga in 1997.’
Table 1. Demographic characteristics, initial survey respondents: Chipapa and Minga,
1995 Characteristics
Chipapa (n=152)
Women Average
49% age of respondents
Married Educated
beyond primarylevel
39
Minga (n=150) 62% 36
12%
79%
41%
10%
4.2
4.4
5.86
6.99
Engaged in farming
95%
95%
Ever having used condoms
51%
9%
Reporting
16%
20%
Average
number of children
Average
preferred
number of children
AIDS-related
death in household
Family size preferences When asked about their ideal family size during the initial survey, about a quarter of respondents in Minga declined to specify a preference, saying that this was up to God. Of the rest, larger families were preferred in Minga, the more rural setting, reflecting broader patterns within Zambia and across much of the region2 In both localities, those who were younger and had higher levels of education preferred a smaller number of children, and there was a clear association between rationales for preferences and level of education and age. Those who were older or who had lower levels of education tended to mention children’s assistance in old age, view children as economic assets or defer to God’s will. Those who were younger or who were more highly educated mentioned the costs of caring for children, typically saying that they did not want more than the3 would be able to feed, clothe and educate properly, often with reference to the ‘bad state’ of the economy.3 The tendency to cite the economic costs of children was particularly pronounced in Chipapa, applying to 72 per cent of the sample, as against 33 per cent in Minga. This represents a shift not just towards a preference for smaller families but also a change in the way children are seen, with greater concern for the quality of children’s lives, balanced against the costs this entails.
Reproductive Health Matters, Vol. 8, No. 15, May 2000
The intrusion of AIDS into considerations about ideal family size Ithas been observed that most choices relating to fertility are made routinely on the basis of cultural conventions, although often involving calculation.4 However, these decisions can vary with changing life circumstances and be overridden in the context of passion, coercion or mishap. The translation of preference or plans into practice may be particularly difficult in the area of fertility. Although preferences are expressed and choices ostensibly made, they are not necessarily acted upon but may be frustrated and complicated by gender relations, lack of access to contraceptives, the dynamics of intimacy and moral prescriptions.5 HIV is an intrusive and dangerous addition to the constellation of factors influencing reproductive behaviour and fertility choices, with variable impact according to level of prevalence and patterns of sexual activity. HIV may not only directly reduce fertility;6-8 it can also alter sexual behaviours and affect the way in which fertility decisions are negotiated. It can even affect the meanings attached to such behaviour, from natural and life-giving to being fraught with potential harm and personal demise. AIDS was generating high levels of anxiety in Chipapa and Minga, and the comments of those interviewed were interspersed with expressions of worry which escaped almost involuntarily: ‘Ibelieve
I will not survive.’
‘AIDS has
caused
me
many
because I can’t stop thinking
sleepless
‘I worry about it more than anything ‘I wonder
nights
about it.' else.’
when it will be my turn.’
‘AIDS is unstoppable
and will kill us all.’
Anguish was also expressed about the enormous costs associated with care of those who were ill, loss of labour for household production, and blighted lives of children. It is therefore not surprising that costs and welfare implications figured particularly strongly in connections drawn between AIDS and family size preferences.
Welfare and cost considerations: the case of orphans When asked whether they would take in orphans, almost all 36 individuals in Chipapa and 29 in Minga interviewed said they would. At the same time, many remarked on the hardship this could entail. When asked whether care of orphans would have any bearing on the number of their own children, responses varied depending on the age and health of prospective orphans and the extent to which orphans would be considered as ‘their own children’. Economic calculations figured strongly here. Sometimes respondents said that orphans could help out in the house or the fields and thus become an asset. But cost considerations were much more important, persuading some of the need to limit the number of their own children. Most of those who answered this question who were under the age of 50 said they would have fewer or no more of their own children if they took in orphans, with little variation between female and male respondents. Sometimes, responses were framed in anticipation of future responsibilities, but many had already taken in orphans. Jane Soko,g for example, was 32 years old and had returned to Minga after a divorce to live with her elderly mother. Two of her children had died, but the remaining three lived with her. During the initial survey, she reported that a niece and nephew were also members of the household. When interviewed four months later, she was looking after five orphans. At first, she had been unable to cope, but now that she was ‘experienced’, things were easier. Everyone helped out and a little support was received from relatives in town. In view of the costs entailed in their care, however, she had decided not to have any more children of her own. Her own children and the orphans were enough. But she also felt that with AIDS around, she herself was at risk and on this basis as well believed it better to have fewer children.
HIV risk perception and ideas about preferred number of children The possibility that perceived risk from HIV may enter into ideas about reproductive behaviour and may be affecting notions of ideal family size is suggested by a study in two rural areas of
Baylies
Manicaland Province, Zimbabwe.l”,ll About half the women surveyed there said they would have fewer children after hearing about AIDS, with only 3 per cent saying they would have more. Preference for a smaller family was found to be significantly associated with general awareness of the risks of HIV. The way husbands’ extra-marital activities can escalate risk peppered the comments of those in Minga and Chipapa. As participants in a women’s focus group discussion in Minga said, even if wives were faithful, their husbands would go about with other women and bring the disease back home. Men’s tendency in Zambia to have more extra-marital partners than women increases the risk of HIV infection of their wives and children as well as themselves. This is especially so in the early years of marriage, when families are being built, since it is then that men’s ‘wandering’ tends to be greater and the level of sexual activity within marriage higher.1z,13 Zambia’s Demographic and Health Survey 199612 documents the extent to which women’s risk perception accurately reflects these behaviour patterns. Of those currently married, 38.7 per cent regarded themselves as at moderate or great risk of getting AIDS, with over 90 per cent of these saying this was because their husbands had multiple partners. The relevant figures for men were respectively 14.7 per cent and 31.8 per cent. In Minga and Chipapa, people also appreciated that pregnancy could have a detrimental effect on the health of a woman who was already HIV positive. When asked what they would advise a relative with HIV/AIDS as regards having children, the general consensus of those surveyed - who almost invariably assumed that the relative in question was a woman - was that she should have no more children. It was widely believed that pregnancy would accelerate illness and a woman would die soon after giving birth. The act of conceiving children was not always perceived to be associated with risk of HIV infection or progression of illness, however. Nor when acknowledged did these factors necessarily influence respondents’ actual behaviour or their preferences about family size. Thus, when asked directly whether the presence of HIV had had any influence on the number of children they thought of having, five of the 36 interviewed in Chipapa and 10 of the 29 in Minga said it had not. 80
This conclusion, however was reached through a number of different routes.
Circumstances where HIV risk had little bearing on reproductive behaviour A reluctance to link fertility preferences with the presence of HIV was especially characteristic of those who felt that family size was a matter for God. Failing to see a connection between family size preferences and AIDS also applied when AIDS was believed to arise from ‘improper’, ‘deviant’ or ‘dangerous’ sexual activity, dissociated from normal reproductive behaviour. If respondents felt that they did not occupy such dangerous territory, particularly as regards conceiving children, they did not perceive building a family to entail a risk from HIV. This sort of thinking characterised those who considered themselves safe by virtue of assumed marital fidelity. ‘AJDS does not come because of having children; it comes through promiscuity, private injections and using contaminated razor blades. So why should I limit the number of children I wouJd have?’ (Maxwell Zimba) Some, however, believed that they were at risk, but that there was nothing they could do about it. This was typical, for example, of those who felt that sexual desire was ‘natural’ and should not be checked. The case of Adam Mwale, a 29-year-old married man with two young children, illustrates how beliefs about human nature, and specifically men’s nature, can operate to confound the logic of protection in spite of anxiety about the risk of HIV. Adam was worried about the cost of taking in orphans and had decided that if any orphans joined his family, he” would have no more children of his own. The two he had would be enough. His anxiety about AIDS kept him awake at night, and deepened his conviction that he would have no more children. At the same time, he belittled advice that people should refrain from pre-marital and extra-marital sex. Citing the Bible, he declared: ‘Look at David and Solomon. They definitely had more than one wife. And now how can I not have other women? Hgw can I overcome my nature?'
Reproductive
Such comments were more characteristic of the men than the women in this study and often reflected a defiant, perhaps unreasoned, stance in the face of potential harm. But they could also signify priority being placed on norms of masculinity, or on pleasure over risk, in a manner similar to that described in European contextsI In some cases, however, the view that risk was unavoidable arose from a more straightforward fatalism, which resonated with deep feelings of having little control over the circumstances of one’s life. As Nelson Mwanza said:
‘HIV/AIDS is there; it has already been .created and no one can change that. Whether one ends up infected ornotis not truly one’s decision.’ There was little point, he felt, in linking this general susceptibility to decisions about the number of children he might have. Gerald Njobvu made the point more bluntly: ‘I can’t stop having children just because of AIDS. If it comes, it comes.’ But if some were seemingly resigned to fate, others experienced great anxiety about their ‘carnal nature’ placing them at risk. Nicholas Tembo admitted worrying about ‘making a mistake’ - the one wrong move that could lead to death. It was better, he said, to become like a sofa in the house:
‘When it is kept inside, it is safe and may last Long. Leaving the sofa outside on the veranda leaves it vulnerable to attacks by goats and pigs who consequently destroy it. In the same way, a man is better off staying indoors where he is free from temptation, rather than leading a social life where he is open to suggestions and innuendo.’ He had reached the point of sending his children to buy beer and cigarettes for him, lest he ‘wander’, providing a graphic commentary on how ‘nature’ could override reason and undermine rational choices. Even so, he was reluctant to bring this anxiety into his calculations about having children. This was partly because he believed that children were a gift of God and partly because he felt he could not make decisions based on uncertainties, including whether or not he would get AIDS. Distinguishing between
Health Matters,
Vol. 8, No. 15, May 2000
different ‘risks’, his strategy was to reduce his exposure to ‘dangerous sex’, which he defined as sex outside marriage. In contrast, there was the strategy of James Mumba, who was afraid of AIDS and did not believe that he would survive since both he and his wife had other sleeping partners. He used alcohol to side-step reason and blunt his anxieties; when he drank, he would forget his worries, so that ‘everything is all right.’ It was not just men who were having sexual encounters outside of marriage. Several women admitted to this as well. The greater sexual freedom accorded men, however, combined with firmly held cultural expectations that wives should submit to their husbands’ sexual desires, severely compromised women’s ability to protect themselves from HIV infection. For those who are married and whose partners have ‘wandered’, dangerous sex is neither improper sex nor promiscuity. Nor could reproductive activity be distinguished in terms of its ‘safety’ from sexual activity more generally. As Mary Zulu explained, whether one has children or not, one can still become HIV infected if one has an unfaithful husband. ‘One cannot deny one’s husband his conjugal rights because of fear of HIV/AIDS.’ Quite apart from the capacity to act, risk calculations follow from views about the fidelity of one’s partner, and their chastity prior to union. They are bound up in trust, loyalty, intimacy and gendered norms which can work profoundly to women’s disadvantage.15-I8 This can be so even when risk and its implications are close companions. Helen Chirwa, a 30-year-old woman with four daughters, was living with her sister who was HIV positive and had two children. Helen said she would have. fewer children than she might want if she had orphans to look after and even fewer to reduce the risk of contracting HIV. Yet she also acknowledged that she had unprotected sex with her boyfriend, as he ‘did not use condoms’. Economic need can also frustrate protection.1g-21 Theresa Lungu, who was divorced and the sole breadwinner for her five children, said it was difficult for a woman without a husband to avoid sex. Hers was a complicated, pragmatic argument, which acknowledged the dilemmas 81
and vulnerabilities which economic hardship confers on many women. A young lady, she said, cannot afford to ‘show off” or waste time by withholding sexual favours:
‘In any case money is hard to come by these days and it is very easy to be bribed with a bar of one’s favourite soap or a bottle of glycerine.’ Perhaps the most fundamental factor mentioned was the desire for children. Alice Mweene, aged 22 and a single parent, said she would not stop trying to have children because so far she had only one. Desire for children, economic insecurity and gendered power relations can all impede protection against HIV infection. But limited knowledge about or access to means of protection are also inhibiting factors. The Catholic mission hospital in Minga did not supply condoms for family planning, let alone for protection against HIV. In Chipapa, in contrast, a prograrnme sponsored by the Planned Parenthood Association of Zambia had been in operation for several years. While participants in focus group dis82
cussions in Chipapa were able to name several varieties of contraceptive pills, including them alongside the condom as ‘modern methods of family planning’, those in Minga were much less knowledgeable. In one of the women’s focus groups there, queries about family planning elicited reference only to the ‘natural method’, which only a few had ever used. Some in the second group had used what they referred to as traditional methods, often involving the wearing of beads or using traditional medicine, but no other methods. Many in theetwo men’s focus groups in Minga professed no knowledge of family planning. * Just over half of respondents to the initial survey in Chipapa (including 43 per cent of women respondents) reported having used condoms, the great majority to avoid both unwanted pregnancies and STDs. In Minga, however, only 9 per cent had ever used a condom and, of these, a quarter said they simply knew nothing about them. Of the rest, a number of women non-users said their husbands or boyfriends did not like condoms or would not permit their use. Others commented that condoms are ‘used by men’, with
Reproductive Health Matters, Vol.
that control and the ability to act eluded them as women.
the implication
Deciding not to have more children because of AIDS Noerine Kaleeba has argued that everyone should behave responsibly, as if they were HIV positive. z Few in Minga and Chipapa were aware of their HIV status, but rather than subscribe to Kaleeba’s logic, the reverse often applied. Martin Kapaya’s view was that: ‘You can’t make decisions on the basis of what you don’t know’. He was one of a numb& of respondents who preferred to assume that they were HIV negative until shown otherwise by symptoms or, particularly for women, by the illness of a child. Altogether, 14 of the 36 people interviewed in Chipapa (nine women and five men) and one in Minga said AIDS would have no impact on their reproductive behaviour unless and until they found themselves, or their partner, to be infected, at which point they would have no more children. As Betty Manda said there would be ‘little point in having more because they would only end up dying’. For a further 12 of the 29 people interviewed in Minga and five of the 36 in Chipapa, however, the very threat of contracting HIV had led to a decision to have fewer children. Only a few explained this in terms of personal risk. Among them was Patricia Hantuba, a young widow with several children, who quietly disclosed that she had decided not to have any more children because, should she be positive and become pregnant, it would affect her health. More common was a wish to have fewer children in order to reduce the burden on relatives, should one die of AIDS. Victor Phiri was one of 10 people who took this view: ‘With this threat of AIDS, I will have few children so thatlleave fewerproblems formyrelatives.’ Irene Tembo concurred. Personally, she said, she would have only three so that if she contracted the virus she would leave fewer problems for her children and the relatives who would look after them. In several cases, risk calculations converged with cost considerations to strengthen determination to have fewer children. Elizabeth Mkan-
8, No. 15, May 2~00
dawire, a 40-year-old woman who was separated from her husband, had three children, one of whom had suffered prolonged illness. Three others had died in infancy. Her sister’s recent death from what she believed was AIDS added to her worries about her own situation. She wished to have no more children primarily because she believed this would hasten her demise, but also because she did not want to leave problems for her relatives. Worries about causing undue burden to others may be a more socially acceptable reason for limiting fertility than that of reducing personal risk. Alongside its altruistic concern for others, it also incorporates the hope that the quality of care of one’s children will be better, if by being fewer they are less of a problem to future guardians.
Supporting women to secure protection from HIV in the context of family formation HIV/AIDS impinges deeply on people’s lives. Many of those interviewed in Minga and Chipapa had had personal experiences of the illness and death of close relatives and of ensuing hardship, and they expressed deep worries about their own situation. Not all of them, however, made a connection between AIDS and the number of children they wished to have. In some cases, the very notion that AIDS might influence fertility choices remained an abstraction that individuals had not personally grappled with or which they felt was inappropriate to entertain. In others, a sense of fatalism muted agency. But AIDS had influenced some respondents’ intentions to have fewer children that, even when this followed from a sense of personal risk, was more often expressed as anxiety about leaving a burden of care for_ others and worry about children’s future welfare. In a context of uncertainty about longevity due to widespread AIDS prevalence, the tendency of younger people to see children as security in old age has been undermined. Because of high infant and child mortality, people still want ‘enough’ children so that some would survive. Yet the fewer the children they have, the lesser the burden and costs for relatives if they die, and the better care the children might receive. While thus exerting 83
Baylies
downward influence on preferred number of children, concerns about costs of caring for orphans left by others also lead people to think about having fewer of their own children. It is in respect of such costs and welfare concerns that the impact of AIDS may bear most strongly on fertility behaviour, not least because they accord with the more general logic employed by younger and more highly educated people in respect of family size. With reference to HIV risk reduction and ideal family size, preferences are more likely to translate into behaviour when there is a strategy or a plan.23 This can more easily be effected when a degree of consensus has been established between partners, and where there is access to means of protection and methods of family planning. In the communities studied, however, openness between partners in discussing fertility matters, knowledge of and access to family planning and means of protection and wider structures of support were often lacking. In addition, across both communities there was a shared sense of limited control, not just over fertility, but also over the wider economic and health environment. While many were prepared to entertain the possibility of changing their reproductive behaviour, their responses were frequently equivocal, and more often suggestive of the difficulties of doing so than reflecting decisive action. Economic insecurity, lack of access to the means of protection and inability either to trust a partner or affect his/her behaviour can make the issue of choice a moot one. The threat of HIV necessarily transgresses reproductive rights. When a woman wishes to have fewer children in the face of this threat, she needs to be supported on many fronts, not least as regards poverty alleviation and assistance in the care of those who are ill or orphaned. The costs of AIDS weigh particularly heavily on communities already struggling under the effects of national debt and economic crisis. ‘Preferences’ for fewer children may be emerging more because of the depth of hardship than from measured deliberation about how to enhance the quality of life or reduce the risk of infection. Born of desperation or not, however, people’s wish to minimise risk to their own health and that of their children needs support.
84
Women’s skill in negotiating safer sex strategies would be enhanced by their greater knowledge of means of protection. Accessibility of contraceptives, and specifically to condoms, is an important element in this. Crucial too is the inclusion of men in family planning initiatives and discussion between couples both about family planning and mutual protection from HIV infection.24,25 Support and interventions can be most appropriately designed with knowledge of the way in which economic situation and access to means of protection influence both fertility choices and the probability of their being enacted. But a persistent challenging of gender inequalities is also required if fertility choices are to be less constrained by concern over the dangers and implications of HIV and AIDS.
Acknowledgements This research was funded under the Overseas Development Administration (now Department for International Development) Links between Population and the Environment Research Programme, administered in the UK by the Development Planning and Project Unit, University of Bradford, and in Zambia under the auspices of the Economic and Social Research Bureau, Lusaka. I owe a debt of gratitude for research and administrative support to Veronica Manda, Mbozi Haimbe, Oliver Saasa, Beatrice Liatto-Katundu, Mary Zulu, Epiphano Phiri, Christopher, Bornwell Maluluka, Edwin Cheelo and Melanie Ndzinga. Correspondence Carolyn Baylies, Department of Sociology and Social Policy, University of Leeds, Leeds LS2 9JT, UK. E-mail: [email protected]
Reproductive
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Health Matters, Vol. 8, No. 15, May 2000
and Notes
1. Ministry of Health (Zambia], 1997. HIV/AIDS in Zambia, background, projections, impacts and interventions. Lusaka. 2. Data were analysed through the use of SSPSX. A test of the difference between the sample means for preferred number of children (5.86 for Chipapa and 6.99 for Minga) yields a value of z = 3.14, significant at p<.Ol. 3. For the variables level of education and reasons for preferred number of children chi square figures were 8.76 (df=l, p= 0.003) in the case of the Minga sample and 9.22 (df=l, p= 0.001) for the Chipapa sample; for the variables age and reasons for preferred number of children, the chi square figures were respectively 7.69 (df =l, p= 0.006) and 31.10 (df= 1, p= 0.00) for Minga and Chipapa. There was no significant difference between men and women as regards reasons given for a preferred number of children. 4. Carter A, 1995. Agency and fertility: for an ethnography of practice. In: SituatingFertility: Anthropology and Demographic Inquiry. S Greenhalgh (ed). Cambridge University Press, Cambridge. 5. Greenhalgh S, 1995. Anthropology theorizes reproduction: integrating practice, political economic, and feminist perspectives. In: SituatingFertility: Anthropology and Demographic Inquiry as 141. 6. Carpenter L, Nakiyingi J, Ruberantwari A et al, 1997. Estimates of the impact of HIV infection on fertility in a rural Ugandan population cohort. Health Transition Review. 7(Suppl2):113-26. 7. Desgrbes du Loi? A, Msellati P, Yao A et al, 1999. Impaired fertility in HIV-l-infected pregnant women: a clinic-based survey in Abidjan, CBte d’Ivoire, 1997. AIDS. 13: 517-21.
8. Gregson S, Zaba B, Garnett G, 1999. Lower fertility in women with HIV and the impact of the epidemic on orphanhood and early childhood mortality in sub-Saharan Africa. AIDS. 13(SupplA): S249-S257. 9. Pseudonyms have been used throughout for participants in the research. 10. Gregson S, Zhuwau T, Anderson R et al, 1997. HIV and fertility change in rural Zimbabwe. Health Transition Review. 7(Suppl2): 89-112. 11. Gregson S, Zhuwau T, Anderson R et al, 1998. Is there evidence for behaviour change in response to AIDS in rural Zimbabwe? Social Science and Medicine. 46(3):321-30. 12. Central Statistical Office (Zambia], Ministry of Health, Macro International Inc, 1997.
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examine comment en Zambie, la crainte de l’infection k VIH influe sur le nombre souhaite d’enfants. 11 utilise la recherche sur l’impact du VIIYSIDA sur les menages periurbains et ruraux en 1995, fondee essentiellement sur des entretiens approfondis avec 65 des 302 personnes qui avaient fait initialement l’objet dune enquete. Bien que redoutant le SIDA, ces communautes n’associaient pas toujours le risque du VIH avec l’acte de concevoir des enfants, pas plus que cette association n’influenFait leur comportement reel ou les preferences en mat&e de taille de la famille. Beaucoup s’inquietaient aussi de laisser des orphelins dont d’autres devraient s’occuper. Une raison de limiter la ficondite etait l’espoir que des orphelins moins nombreux seraient mieux soignes. Un acces elargi aux contraceptifs, et concretement aux preservatifs, est important pour soutenir les efforts de protection des femmes, et les hommes doivent aussi participer aux strategies de protection mutuelle. Les deux communautes partageaient neanmoins un sentiment de maitrise limitee de la fecondite, mais aussi de l’environnement economique et sanitaire plus large. 11 est essentiel de comprendre la complexite de ces facteurs pour les programmes destines a valoriser les droits des femmes en matiere de reproduction et B soutenir leurs choix de ficondite afin d’assurer une plus grande protection contre le VIWSIDA.
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Resumen En Zambia la preocupacion por el VIH afecta las attitudes acerca de1 ndmero de hijos preferido. El presente trabajo se refiere a investigaciones sobre el impact0 de1 VIWSIDA en 10s hogares rurales y de la periferia urbana en 1995, principalmente entrevistas de fondo con 65 de las 302 personas inicialmente encuestadas. A pesar de 10s altos niveles de ansiedad acerca de1 SIDA en estas comunidades, no siempre se asociaba el riesgo de VIH con el acto de concebir hijos, el comportamiento o las preferencias por familias de cierto tamano. En algunos cases, el miedo de contraer el VIH habia llevado a una decision de tener menos hijos. Muchas personas estaban preocupadas por dejar huerfanos al cuidado de otros. Otra razdn para limitar la fecundidad era la esperanza de que 10s nifios huerfanos fueran mejor cuidados si eran menos. Mayor acceso a 10s anticonceptivos, especificamente 10s condones, es importante para la proteccidn de las mujeres. Los hombres tambien deben involucrarse en las estrategias para la protection mutua. En ambas comunidades, el sentido compartido de control era limitado, no solamente con respect0 a la fecundidad, sino tambien en relation al ambiente economico y de salud en general. Comprender la complejidad de estos factores es precise para 10s programas de intervention que pretenden ampliar 10s derechos reproductivos de las mujeres y apoyar sus opciones en relacidn a la fecundidad con elfin de asegurarles mayor proteccidn en contra de1 VIH-SIDA.