Navigating the processes
Drawing on the disenabling environment in figure 1, ‘navigating the processes’ demonstrates the journey it takes for a woman to access family planning services at the health centre. Accessing family planning services was not a straightforward process. The process seemed to be influenced by several factors, which were clustered into three sub-categories namely: personal beliefs and motivations, following procedures and inadequate resources.
Most women reported positive insights towards contraceptive use with a few reporting that they had never used any contraception. One participant expressed her confidence on the effectiveness of modern contraceptive methods as illustrated:
‘I can say that family planning methods are good because, as a woman you are not at risk of having an unwanted pregnancy if you are having unprotected sexual intercourse. There is nothing to fear because you are protected’. (Esnat, Female).
Similarly, some men discussed constructive perceptions towards family planning methods. They reported on the health benefits of using contraception which motivated some couples to continue using contraception:
‘Family planning methods are good because a woman is healthy because she does not bear children frequently. As a family, we decide on the number of children to have’. (Yohane, Male).
However, many participants across the three groups explicitly alluded to the notion that the use of family planning methods was detrimental to the health of the woman. One healthcare worker stated her concerns about the effects of modern contraceptives:
‘Personally, as an individual, I don’t like family planning methods. I only tried Depo-Provera once and I bled a lot. So, from that time I never used any family planning method.’ (Grace, healthcare worker)
Participants voiced their dissatisfaction with the care that they received at the family planning clinic. Women who reported to the clinic on an initial visit for contraception had to follow various procedures before accessing the services. This was done to assist healthcare workers to confirm eligibility of a woman to use a family planning method. As stated by one community woman, the procedures were restrictive for a woman to access contraception:
‘I was told to come to the clinic only when I had my period back. When I told her that I am not pregnant, she started shouting at me. They had to send me back after I was already on the couch’. (Esther, female).
Confirming what Esther noted, one healthcare worker acknowledged this practice and how it negatively impacts on women:
‘We tell them to come to the clinic only when they are having menses without considering their concerns of distance and lacking transport money.’ (Fanny, healthcare worker).
Access to family planning methods was only available after having a mandatory blood test. It was noted that the test was being done to all people seeking health services at the health centres:
‘We have the strategy of 90-90-90 strategy, 90% of the Malawian population should know their HIV status, 90% should start antiretroviral therapy (ART), and the 90 % on ART should have a viral suppression, so in order to achieve that target, we need to be testing everyone who comes to the facility for HIV...’ (Max, healthcare worker)
Given the importance of this test, one healthcare worker stated her concerns about the negative influence of the compulsory HIV test; emphasising widespread uncertainties amongst the women in accessing family planning services:
‘I also heard from some women that their friends are not coming for family planning methods because of fear of being tested for HIV.’ (Lusungu, healthcare worker).
Access to permanent and long-term family planning methods seemed to be done under certain limitations. One community woman stated her frustrations when healthcare workers challenged her prospects to undergo tubal ligation:
‘Soon after delivering this child, I wanted a permanent method to be closed, and for my tubes to be cut. I signed the form to go for the closing but the nurse on duty refused me to go for tube cutting since I am still young’. (Linje, female)
Although all family planning methods were reported to be available at each health centre, it was reported that there was lack of a skilled workforce to provide long-term family planning methods. One healthcare worker reflected on how this impacted on her family planning service provision:
‘Like myself and other four nurse midwives have not been trained in provision of long-term family planning methods. In this case she [woman] has no choice so we send the women back home without a service.’ (Linda, healthcare worker)
Given the importance of contraceptive use in averting unplanned pregnancies, its scarcity elevated a woman’s risk of having unintended pregnancies. Another man was concerned that his wife would not have access to her contraception of choice any sooner. He stated:
‘My wife is not using any method because the injection is out of stock at the health centre. She had one injection last year, up to now she is not on any method.’ (Levison, male)
Disempowerment of women
As illustrated in figure 1, this category embraced two subcategories: societal demands and cultural influences. The category provides an explanation of women’s and men’s thoughts regarding the influence of religious beliefs, culture and society on women’s contraceptive decisions. Most of women’s thoughts were grounded in their explanations of lacking empowerment from their spouses and significant others in society to use contraceptive methods.
Societal demands demonstrate the perceptions that people in society shared collectively as being a gender norm in terms of assigning responsibilities related to contraceptive use and childbearing. Men’s perceptions on their role in family planning and childbearing remained unclear. One man questioned the relevance of men to be involved in family planning issues:
“Aaaa the thing is that a man does not bear children, it is only a woman who bears a child so, why should a man use contraception?”(Lameki, male)
Having many children was perceived to be in alignment with societal expectations of childbearing. As a result, some men considered childbearing to be rewarding. Accordingly, couples feared the ridicule which was a commonplace in society for couples who have challenges to conceive:
“What happens is like we are in a competition to have as many children…. They would also tease a man to allow other men to make the wife pregnant if the woman is failing to conceive”. (Mike, male).
At the other end of the continuum, women spoke of the negative attitudes of their partners towards contraceptive use. For instance, Elas discussed how prohibitive her husband was, towards contraceptive use:
“I am planning that I have the injectable contraceptive so that he does not know that I am on contraception. I will do this because he does not allow me to use any contraceptives…” (Elas, female).
Consistent practices of disapproving contraceptive use were also recognised by significant others in society. These opinion people had substantial decision-making power over contraceptive use and family size as illustrated in this quote:
“The other factor influencing women is the influence of relatives of the husband. They tell the woman that they desire a good number of children. So, as a woman, we do not have power to say no to this.” (Margaret, female)
Cultural influences referred to the cultural beliefs, religious beliefs and other patterns of behaviours that were shared amongst the people in society that either promoted or hindered contraceptive use. Most participants felt that cultural and religious beliefs informed their contraceptive practices.
Both men and women acknowledged the religious teaching that restricts the use of contraception; rendering women to be cautious to use contraception:
“What I know is that the Bible says that we should multiply like sand meaning that it is forbidden for one to use these methods, it is against the Bible teachings….” (Rachel, female)
In contrast, other religious doctrines recognised the need for families to use family planning methods to avert unwanted pregnancies. This permitted some of its followers to be motivated to use contraception as stated:
“I belong to the Muslim faith. There are no restrictions on using family planning contraceptives. Actually, women are encouraged to use family planning methods.” (Patricia, female).
Some participants reported of using unconventional methods to prevent pregnancies. For instance, one man expressed his confidence in using traditional medicine as illustrated in the following excerpt:
‘My wife and I have seven children together and she has been using this traditional method with all these children; and I am yet to have more children.’ (Yankho, male).
Signifying the efficacy of traditional medicine to prevent unwanted pregnancies, one woman testified the usefulness of traditional medicine in offering long-term protection from pregnancy:
“I have been using traditional medicine which I was getting from the traditional healer. He prepares a medicated rope from the bulk of the tree. If the rope contains 3 knots, it means I will be protected from pregnancy for three years.” (Doris, female)
Learning by chance
This category describes the knowledge gap that exists regarding contraceptives that was revealed by participants. Although both men and women could name at least one family planning method, they showed lack of understanding of how the contraceptives work:
“Oky there is the injection, pills, Norplant. I cannot mention in detail how these methods work because I have never used them before.” (Doris, female)
Equally, some men cited lacking awareness of family planning methods including their benefits. However, some mentioned vasectomy as a method of permanent contraception for men. One man had scanty knowledge of how vasectomy is done, increasing his fears to go for the procedure:
“what I know is that they cut a certain part of a man’s private parts. A lot of men including me I do not know much about it.” (Biliati, male)
During family planning consultations, most healthcare workers would not provide one to one counselling regarding the family planning methods.
Chikumbutso told the nurse provider that she had never heard of such contraception [implant]. However, the nurse inserted the implant without informing Chikumbutso what the contraception was all about and what to expect. (Observational field note)
Some participants’ decisions to use or not to use contraception were grounded from distorted messages regarding what contraceptives would do to a person’s body. In general, most participants indicated lack of correct information in relation to what contraceptive methods would and would not do to the body as illustrated:
“The other bad thing that I have heard is that when they want to insert a Norplant, they make a big cut so that they insert it.” (Elina, female)
One participant was scared to hear that a woman who had used contraception for a long time would develop cervical cancer, which could be transmitted to her spouse:
“I have heard that a woman who is using contraception is at risk of suffering from cervical cancer. Eventually, this woman will transmit the cancer to her husband.” (Mike, male)