OJHAS: Vol. 4, Issue
2: (2005 Apr-Jun)
|Dynamics Governing Women's Decision on Reproductive Health Matters
Reflections from a Qualitative Study in Central India
|Somen Saha, Indian Institute of Management
Gujarat 380 015, India
Address For Correspondence
Indian Institute of Management
Gujarat 380 015, India
|Saha S. Dynamics Governing Women's Decision on Reproductive Health Matters:
Reflections from a Qualitative Study in Central India. Online J Health Allied Scs. 2005;2:5
Submitted: Mar 7,
2005; Accepted: Jun 27, 2005; Published:
Aug 23, 2005
One of the major challenges of Reproductive and Child Health Programme in India
is addressing the barriers in communication and improve dialogue between diverse
stakeholders, particularly women in the community. Through a qualitative study
conducted in one of the rural districts of India, it was attempted to understand
the factors affecting women's decision-making process. It is observed that most
of the factors are affected by strong intrinsic environment and hence it becomes
important for programme managers to understand the environment first in order
to design an acceptable and effective communication strategy. In this study, knowledge, tradition, stigma and accessibility of services
are identified as the key primary factors affecting decision making of women in the community, particularly
on their health related issues. These in turn are governed by various supporting
factors. Finally, it is observed that communication strategies can achieve their
desired objective only when the local intrinsic environment is taken into cognisance.
Reproductive health, Knowledge, Stigma
The centrality of women's decision making towards success of reproductive health
programme was recognised for the first time in the 1997 ICPD Conference in Cairo1,
while the lack of it resulting in their increasing vulnerability towards several
reproductive infections including HIV/AIDS was pointed in the UNAIDS 2004 report
on Global AIDS epidemic.2 Following the recommendation of the ICPD, at Cairo,
the Government of India undertook a major initiative, the Reproductive and Child
Health (RCH) Programme, to reorient the family planning programme towards reproductive
health. The RCH programme, among other things, envisages addressing communication
barriers and improved dialogue between diverse stakeholders of reproductive
and child health programme.
However, proper communication through adequate dialogue process has been a
major challenge for the programme managers. One of the barriers in designing
an effective communication strategy is that often the programme managers tend to develop
communication strategy with a preconcieved notion or set guidelines without
trying to assess the dynamics governing women's decision-making process. Women's
decision making is governed by strong intrinsic environment, which is difficult
to change through external environment alone. Often programme managers tend
to ignore these intrinsic factors while planning for an intervention, resulting
in outcomes which are less than satisfactory.
||Research Objective and Methodology
The major objective was to study the factors that affect the decision-making process of women in
Indian community and identify areas which need to be considered in designing
an effective communication strategy. The primary data was collected
through a qualitative research carried out in one of the rural district of Central
The key research tool used for the study was Focus Group Discussion (FGD),
supplemented by natural group interviews with the target population. FGD technique
was used to elucidate information about group process and practices. A check-list
was developed to elucidate information about general social and education status
of the group, their work pattern, knowledge, attitude and practices on their
own reproductive health problems, behaviour and customs during pregnancy, antenatal
care services available in their community, customs followed in the society
after childbirth, family planning options and practices and sources of information
in the community. Additionally an important component of decision-making in
the family and community was part of the FGD check-list.
The group participants were chosen to cover a wide range of different populations
in the district under study, including those whose decisions play a major role
in the family. They were 'natural groups' in that they pre-existed the research,
such as adolescent girls, newly married women (marital duration less than 2
years) and women above 30 years of age. The three different groups were chosen
for obvious reasons. While adolescents started experiencing various reproductive
changes in their body, newly married women have most probably undergone
pregnancy episodes and the knowledge and beliefs of elder women play an influencing
role for the younger generations. That they were natural groups was important,
as similar age structure and social settings are the ones in which we come to
know about issues which govern their decision making process about reproductive
health matters. The intention was to maximise the interaction between participants
in the groups to see how social knowledge was developed. The second method for
encouraging interaction was the use of facilitator's skills in actively managing
the discussion, pushing participants into accounting for their views, or exploring
disagreements. Maximising interaction allowed access to not only what people
thought, but also to the cultural contexts in which the views were held.
One hundred and sixty (160) women of the different age-groups participated in
twenty three (23) focus group discussion sessions. The study was conducted in
a rural district of Central India. Some of the key statistical indicators for
the district are: sex ratio - 932 females per 1000 males, literacy rate - 61.04
per cent with female literacy rate of 34.5 per cent, couple protection rate
- 58.2 and unmet need is 23.9 per cent. 35.7 per cent of the delivery in the
district is institutional and 31.1 per cent female reported symptoms of RTI/STD.3
Although the sample size of the study is not large enough to generalize the
findings, the very nature of the tools used for the study gives a definitive
direction for programme planners in planning for an intervention in the community
involving women of reproductive age group.
Factors affecting women's decision-making in reproductive health matters
Although decision-making in reproductive health of a woman is her individual attribute,
it is governed by interplay of the environments in which she lives. The immediate
environment after her own family is the society she is living in, which is governed
by the culture prevailing in the society. The society in turn is affected by the external
environment comprising of public health machinery of government,
non-government organisations, private for-profit and traditional health practitioners
and other local bodies in the society. This is depicted in Figure 1. Table 1
classifies the primary, supporting and governing factors that affect the decision-making
Figure 1: Social perspective for analysing women's decision-making on their
Women's decision-making typically is affected by three levels of her interaction
with the world outside. The farthest is the external environment which provides
her the services. The next is the society of which she is a part. This society
has its own culture which governs the concepts of right or wrong. The society
and the culture it professes and practices are too close to be made distinct
such that they seem interwoven (hence depicted here by broken lines). This cultural
environment with its societal norms interacts/affects her in ways more than
one. First, these norms go on to shape her elders' perceptions which she is expected
to follow unquestioningly. Second, these norms, on account of lack of awareness, become strong beliefs and stay as
stigmas until the veil of ignorance is removed. Education (or the lack of it) influences the women's perceptions
and affects her knowledge regarding the dos and don'ts of reproductive health and her health in total. Education is partly
governed by the external environment with regard to accessibility and availability
of schools/ colleges. The last but definitely not the least important factor
is the women's access to health services. Here however it must be remembered
that it is not just the accessibility of health services alone but the quality
of the services offered which will go a long way in determining the woman's
choice of reproductive health. If the quality of the services is not up to the
mark it will in all probability be a deterrent for the other women in the community.
The typical decision-making process in the family is exemplified in
a case developed from natural group interview in the district studied (See Box
and Figure 2).
Natural group interview is a qualitative technique to maximise interaction between
participants, as well as between the facilitator and participants with some
access to shared group culture in a naturalistic setting4. This resembles in
some ways the kinds of interaction people might have in their everyday lives.
Decision-making process in the community on seeking a place for child
(The case discussed here describes the typical process of decision-making
in an Indian family. The case is designed using natural group interview
in the district under study.)
Pramila Devi is 22 years old and married for the past two years. She has been
educated till eighth standard and has one child. She had experienced complications
during her first delivery because it was pre-term and baby was underweight.
The delivery was conducted through an untrained traditional birth attendant
in the village. On hearing about her delivery complication, the ANM visiting
her village suggested her to go for institutional delivery on her subsequent
pregnancy. Pramila Devi is now expecting a second child within a span
of 1 year and is thinking of going for institutional delivery this time.
However, she was not empowered to take her own decision in her reproductive
choice. She consulted her husband regarding her wish to go for institutional
delivery. However, due to his education and lack of knowledge about complications
expected during her subsequent delivery, he asked his mother and other
senior members in the family for advice.
A lot of factors govern their
decision-making process as to the traditions followed in case of child
birth, beliefs in the community and experiences of others regarding the
service provider at government health institutions. The stigmas surrounding
the newer practices, willingness to break away from traditions will then
determine their chosen course of action.
Once the family decides to opt for institutional delivery, the next question
in their mind: Are the services accessible/ available in the community?
Remote accessibility of the service provider affects decision-making of
the community towards seeking health services. A positive response will
make the family take a decision on seeking institutional delivery, or
else they would be going for traditional delivery options of their community.
However, the process will not end here - any negative experience of the
family with service provider will create a negative environment not only
within the family, but also among the community about institutional delivery.
Communication without proper service delivery will be disastrous for the
health system. Figure 2 depicts a decision tree discussing the typical
process involved in decision-making on seeking institutional method for
delivery or seeks the help of traditional birth attendant.
Figure 2: Decision tree depicting decision-making process on choosing type
of service delivery
Table 1: Factors affecting Women's decision-making
External Environment, Society and Culture
- Elder's perception
- Societal norms
|Interplay of Society and Culture
- Lack of Awareness
- Societal Norms
|Interplay of External Environment, Society and Culture
- Trust in service
Knowledge, perception and behaviour related to reproductive health and sexual
matter underlie virtually all conditions that Family Welfare programmes address;
hence these are important issues for any service providers. To achieve significant
levels of fertility or decline in mortality, it is essential that the community should
participate in the programme and the programme understands and addresses the
knowledge and prejudices of the community. Knowledge in a society is supported
by interplay of perception and education. While perception is governed by intrinsic
environment, education, particularly in its modern form, is governed by extrinsic
environment. Various myths and customs prevalent in the community like what
will a girl do by getting educated, family preference towards a male child receiving
education, fears that girls will 'get spoiled if sent outside the village', monetary pressure etc.
are the major factors keeping girls away from school. Perception on the other
hand denotes attitude of the community and their level of adaptability to change.
Hence it is of utmost importance to judge the perception of the community about
a particular issue and then move towards designing intervention which can address
the local/community concern.
The result of the field work generated a wealth of information
on how the community relate their knowledge level towards various health problems.
Around 40 per cent of adolescents do not
know about the problems that the adolescent girls face in the community. These may be
attributed to the social taboos prevalent in the community regarding their health
problems. The major problems reported by the adolescents are dizziness, headache
and weakness as symptoms of anaemia.
Reproductive tract infection is perceived to be caused by personal,
social and biological factors and seems to be interlinked. The interplay of
these causes needs to be understood and strategized accordingly. There is a
high degree of ignorance about symptoms of reproductive tract infections in
the community. Majority of women consider changes like itching in vagina, foul
smelling white discharge and irregular menstruation as a routine event and not
a health problem. Interestingly the knowledge level about reproductive tract
infection does not vary significantly across ages. Moreover, certain misconceptions
about reproductive tract infection and menstruation are evident among older
Self-Care: Almost half of the respondents could not recognise proper
ways of personal hygiene and almost two-third of the adolescents do not know
about any precautions to be taken during menstruation. Two-third of the newly
married women are not aware about proper care and precautions during pregnancy.
Knowledge about the need for iron-folic acid (IFA) tablets during pregnancy
is found to be very low. Although mass campaign made them aware about importance of breastfeeding, knowledge about period of
exclusive breastfeeding and immunisation schedule is lacking in the study group.
Knowledge about birth spacing: Oral contraceptive
pills is the preferred spacing method among newly married women, while
older women prefer terminal method. However women in the community are grossly
unaware about the options in case of missed pills. We found evidence of female
infanticide among the community members although validation of the facts was
not possible in the research tool used.
Traditions in a closely knit community of rural India are governed by perception
of senior members of the family and societal norms. The traditions followed
in the community play an important role in the decision-making process of women.
These traditions date back to early age and are inherited through generations
in the community. These practices have become a part of our culture and evolved
through years of experience.
Communities have a traditional system of healing which caters to a wide range
of conditions covering promotive, preventive and curative aspects of health.
The general practitioners or local healers deal with a range of problems like
gynaecological conditions, paediatric disorders, eye disorders and also spiritual
curing. There are some traditions that are related to the lifestyle, occupations etc of particular
communities. The system has a holistic approach towards health care. Traditional birth attendants in villages are older
women in the community who take care of antenatal and post natal care and also
attend to deliveries. Recognising the lack of human resource for attending to
deliveries in rural areas of India, Government of India has trained the dais
for conducting aseptic deliveries. However, this study found that they were not given high credibility in the community. Local
health traditions are time-tested practices in the community and any effort
to influence or affect the tradition can be counter-productive, a phenomenon
depicted in Figure 3.
Stigma is a major barrier to positive attitude and behaviour towards reproductive
health in the community. The negative attitude and behaviour needs to be changed
in order to achieve a positive impact of any programme in the community. Stigma
governs nearly all aspects of practices in India specifically in rural societies.
An insight on the study on stigma prevalent in the community reveals the following
Need to deal with stigma first: Although public health communication strategies
have identified the need for behavioural interaction between the community and
the user, the need to de-stigmatise the family members and community is considered
important. De-stigmatisation as a necessary precondition for effective public
health intervention has been quite a recent development.
Stigma is amenable to communication management: Evidence of various health
programmes has shown that relation between knowledge and attitude on the one
hand and knowledge and behaviour on the other may not be high and positive.
This has two clear implications for communication planning. One, campaign managers
can not rely on mass media alone to bring about a significant gain in knowledge
among the different segments of population. Two, campaign managers also need
to examine the characteristics of source (expertise versus attractiveness),
message (one-sided versus two-sided presentation of arguments) and media (media
mix strategies) in order to strengthen knowledge-attitude and knowledge-behaviour
linkages. High knowledge with no significant change in attitude and behaviour
is the least effective situation from a practical standpoint. Hence it is the
degree of attitude-behaviour relationship which plays a major role in the process.
Stigma in the community regarding reproductive health: In this study,
a host of stigma relating to reproductive health and health-seeking behaviour
prevalent in the community were found. These decide to a very large extent the attitudes
and behaviour of average rural Indian. There are not many ways through which
these stigmas could be challenged and mitigated. For example there are stigmas
related to girl education, menstruation, reproductive tract infection, hygiene
and delivery practices. Often older members of the family - mothers, mother-in-laws -
create barrier in education of their children, especially girls. Added to this
are rumours against sending girls outside the village for education. Knowledge about
importance of education does not remove the stigma. There seems to be a weak
link between attitude and cognition. Similarly, stigmas related to menstruation
are a result of lack of awareness among the community. The lack of awareness
is again related to lack of education which is governed by external environment.
This shows that existing communication strategy did not percolate well in the
society. There is a high degree of myths and misconceptions about causes of
menstruation and related customs prevalent in the community. It was found that
even among adolescent groups, traditions related to menstruation are considered
as an old tradition which can not be changed and have to accepted.
Accessibility of Services and Practices
Private health facilities in villages are characterised by local practitioners
practicing in the village or touring the community from a nearby village. They
are accessible to the larger community and poor patients visiting the facility
often have options to avail services on credit or through barter system. However,
more than these, it was observed that patients often visit them due to perceived
quality, confidentiality and lack of taboos attached with visiting these facilities,
especially in case of sexually transmitted diseases.
The growing preponderance of private health facilities attract maximum number
of patients in the community; however, majority of them are not satisfied with
the services available over there. Although there are an extensive network of
public health delivery system in place, overcrowding, unavailability of doctors,
lack of confidentiality, lack of empathy showed towards poor patients, indifferent
staff behaviour, distance from community and longer waiting time in the facility
are some of the major reasons that lead to people losing trust in the public
health delivery system.
Getting the communication process work
In order to inculcate positive and empowered decision-making among women in
the community, particularly on their reproductive health matters, there is a felt-need to create an enabling environment in the system. As mentioned in Figure
1 and Table 1 above, there are three different environments: External Environment,
Society and Culture, with the latter two forming part of the internal environment
in the system. However, it appears that the present system lacks co-ordination
between the different environments due to the lack of enabling communication
channel. There are serious inherent rigidities in the system. The experiences
suggest that the communication process between the environments has some serious
flaws. These are characterised by:
- Fragmentation of health care delivery system by creating operating islands without
any mechanism of coordination and information sharing between the existing culture
and norms of the community; and
- Structural rigidities in the system leading to the lack of enabling environment
for communication process
Figure 3: Observed and proposed structure to address communication barriers
In Figure 3, the observed structure depicting the factors contributing
to communication barrier in the community are summarised. As mentioned earlier,
society has its own culture which governs the concept of right or wrong. The cultural
environment with its societal norms and traditions are governed by elders' perception
and beliefs prevalent in the community. Local practices are inherited through
generations in the community and these practices become a part of the culture
in the community. Over a period of time, the community developed trust and confidence
in the system and hence any effort to bring about a radical change in the system
will result in strong resistance to change. Bringing about a sustained and durable
change in the system requires continuous engagement with the community, identifying
areas of willingness to change and then designing strategies to make the change
process work. And this requires creating a supportive
environment from among the community.
Communication strategy must make efforts to identify the change agent and design
culturally adaptable campaign strategies. The alternative structure proposed
here aims to convert these intrinsic environments into a supporting change agent
leading to attaining the desired objective of the communication strategy and intended
behaviour change in the community. This ultimately will lead to positive and informed
decision-making among women in the community. The task is not simple and is a
continuous process of understanding the community and acting upon the same to
make the communication process work effectively. What may work well in one community
or set-up, may not work in another and hence the strategy needs to be fine tuned
The author is grateful to Population Foundation of India, New Delhi and Ranbaxy
Community Healthcare Society, Dewas for facilitating the field work.
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- UNAIDS. Report on the global AIDS epidemic. 4th global report. July 2004.
- IIPS. Reproductive and Child Health Project- Rapid Household Survey (RCH-RHS).
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- The Mission Report 2003. Priorities for Mental Health Sector Development in
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