The Madagascar Case: Decisions on Contraceptive Use in Collectivistic Communities
The Malagasy students had an awkward task: go to a village in the Vatovavy Fitovinany region of Madagascar and ask married couples if they used contraceptive protection. As if that wasn’t enough, they wanted to know why and how the couple decided to use it. Fortunately for the students, people were not shy about discussing their contraceptive use and a total of 756 couples completed the entire survey.
The survey was part of a project funded by MEASURE Evaluation Population and Reproductive Health (PRH) and USAID. Joel Raveloharimisy, director of the Community & International Development Program (CIDP) at Andrews University, and Kayla Piña, a CIDP graduate student at Andrews, received the grant to do research on contraceptive use in Raveloharimisy’s native Madagascar. Because the grant only supported Madagascar-based researchers, Raveloharimisy received additional funding from the Andrews University Office of Research & Creative Scholarship for his travel to Madagascar to lead the research team. Studying the use of contraceptives may seem like a significant departure from Raveloharimisy’s previous research. He has conducted research in Madagascar before, but his focus was the impact of formal and informal institutions on entrepreneurship. His previous research was conducted in Ambatondrazaka, a city in the Alaotra-Mangoro region north of the Vatovavy Fitovinany region. However, both projects fall under the category of public service delivery in health and education, which is his primary area of interest.
Raveloharimisy became interested in the MEASURE Evaluation PRH program for a number of reasons. First, Madagascar was on the list of countries that MEASURE and USAID were developing programs for. This was already familiar territory for Raveloharimisy, and his knowledge of the country made research much easier. Second, Madagascar ranks very low on contraceptive use. While Raveloharimisy was not originally interested in family planning, he was interested in global health and how collectivistic communities live. “If we apply the same processes that people use in collectivistic communities to make decisions for family planning, then we should be able to understand why some people are reluctant to use contraceptive methods,” he explains. Third, he wanted to show his students how to secure a grant. “And the best way is to apply for a grant in a place that you know very well,” he says. Most of the grant application was actually written by Piña.
In collectivistic communities, the entire community is part of any decision process. If an individual wishes to make a decision, they first share their decision with their family members. The decision then becomes a group decision. “There are some things that we consider to be personal and will not share with others. But these concepts are constructs that our society creates. In a collectivist society, people have a different construct of what they consider to be personal,” says Raveloharimisy.
The purpose of the study was to understand how Malagasy couples make decisions regarding the use of contraceptives. “USAID put out the call for grant proposals because they have spent millions in that region [Vatovavy Fitovinany], but the rate of the use of contraception has never increased,” Raveloharimisy says. The Vatovavy Fitovinany region has the lowest use of contraception in the country with only six percent of the population using protection, despite the many different kinds of modern contraceptives (pills, injections, patches and condoms) that have been made available to the region by USAID. Many children die at a young age and the women are not able to spend time in the fields working because they are perpetually pregnant or breastfeeding.
For this reason, USAID hopes to increase the use of contraceptives in this area in an effort to reduce child mortality and the various diseases women may contract as a result of early or excessive pregnancies. “My approach was to understand how they make the decisions and develop a way to educate them based on that. If they want to have children, we need to teach them how to space the pregnancies, when to start, and how many to have instead of just saying ‘Use the contraceptives and that will help you,’” says Raveloharimisy.
In order to see how Malagasy couples make decisions about contraceptive use, Raveloharimisy adapted a survey from the MEASURE sample survey pamphlet and trained Malagasy students via Skype prior to the data collection. The Vatovavy Fitovinany region was divided into 12 different sites and the students went out in pairs over the course of a month collecting data. Raveloharimisy spent several summers doing research in Madagascar and, on at least one occasion, took two Community & International Development students from Andrews, Rachel Buthorne and Andile Ncube, to participate in the research.
“We were interested only in couples, people who were living together, whether married legally or traditionally,” he says, “because we were really interested in the dynamic between the couple and how they talk and make decisions together.”
This proved to be difficult, because the houses were randomly selected. The students worked in pairs and targeted 5–15 households in each community, expecting that at least six of the households would contain a couple that lived together. By the end of their data collection, they had visited 1,500 couples with 756 of those couples completing the survey from beginning to end.
Some of the couples shared information that was separate from the survey questions. Women described to the researchers how they used contraception without the knowledge or approval of their husband. In other instances, the woman did not want to use contraceptives and described how and why she didn’t. While these results were interesting, “that was not part of our study because we were focusing on the discussion and decision, how they are working together,” says Raveloharimisy.
The fact that the data collectors traveled in pairs, a man and a woman, proved vital for their research. The female data collector was often able to speak privately with the female subject and the male data collector with the
male subject. However, some of the male subjects did not like being interviewed apart from their wives and preferred that they answer the questions together.
According to Raveloharimisy’s research model, the couple has to talk, discuss and agree. Talking might include sharing information, but discussion includes agreement, disagreement and even fighting. Raveloharimisy found that 56 percent of the subjects went through all three processes before making the decision, 65 percent had two of the three components and 78 percent of the participants had at least one component of the three. “For me, that was very important, because in most of these developing countries the literature says that the husband is the decision-maker,” he says. “This is a big advance in terms of the role women play in the family in an area where men were thought to be the ones in control. It also shows that women take their health very seriously and they don’t want to just do whatever their mother, mother-in-law or husband says they should do.” For Raveloharimisy, this demonstrated that once a woman is married, she is much more vocal and capable of discussing important decisions with her husband.
The data also showed that once the couples discuss and make a decision together, they then discuss it with their immediate families to see how their parents respond. This led Raveloharimisy to conclude that the promotion of contraceptive use should not just target the woman, as USAID has done in the past, but should be promoted to the husband and family members. Men have been excluded from the training in the past. This should be remedied because, as Raveloharimisy states, “it is not a decision that the women make alone.”
In addition, the dynamic between married children and their parents has never been considered in the contraceptive campaign as the parents are considered to be beyond childbearing age. Raveloharimisy believes that the parents should be included in the campaign because of their influence on their children.
Another implication for the research involves the traditional practice of a trial period before marriage. According to tradition, if the woman does not become pregnant during the trial period, the man is permitted to leave her and find another woman. Legally, they are not considered a couple nor are they considered to be married traditionally. However, the promotion of contraceptive use by USAID may bring into conflict the modern understanding of family planning and the traditional concept of having children as soon as possible.
Now that the data collection is complete, Raveloharimisy is focusing on publishing his results. The first publication, “The Influence of Family Dynamics on Contraceptive Use in Madagascar and the Ensuing Impact on Family Well-Being” was published in the MEASURE Evaluation PRH Working Paper Series in December 2013. Raveloharimisy coauthored the paper with Kayla Piña and Joel Hajason, the monitoring and evaluation specialist and administrator of Works Improve Society and Economy (WISE) in Toamasina, Madagascar.
Photos from Top to Bottom: Data collectors in Lokomby; Joel Raveloharmisy; The village of Marokarima; Dr. Raveloharimisy conducting a survey; CIDP students Rachel Buthorne and Andile Ncube conducting a survey; Data entry team inputting survey answers.