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1 Contraceptive Use and Knowledge: the Importance of Parity for Women Contraceptive Use and Knowledge: The Importance of Parity for Women in Tajikistan ABSTRACT How has the rapid rise in marital contraceptive use in Central Asia influenced the timing of births? I employ observational data, focus groups, and Demographic and Health data to investigate the structural and attitudinal factors underlying the persistent pattern of rapid first births in Tajikistan. Preliminary findings highlight the importance of cultural norms, perceptions of tradition, and the structure of family planning assistance programs in shifting the impact of contraception expansion towards patterns of spacing and stopping. The absence of a delaying effect (postponing first births), is common across the Central Asia region. It generates a pattern of contraceptive impact different from other countries during contraception expansion, excluding unmarried women from family planning and sexual health information. I discuss the pattОrn’s implications for general theories of the effect of contraception on patterns of reproductive health improvements, the social status of women, and patterns of union formation and stability. A rapid expansion of contraceptive knowledge declines in the ideal number of children desired, and substantial growth in marital contraceptive use rates is occurring across Central Asia. National and international programs to improve reproductive health, particularly in the Central Asian nations of the former Soviet Union, are generating rapid shifts towards smaller families, deep reductions in abortion utilization, and broader abilities of families to make fertility decisions regarding the starting, spacing, and cessation of fertility. Detailed demographic assessments of initial reproductive health developments in the region characterize the changes in contracОptТvО knoаlОНgО, accОss anН usО as notСТng sСort oП “rОvolutТonarв” (АОstoПП et al. 1998). Even in Tajikistan, where internal unrest and deeply embedded economic challenges provide intractable challenges to development, the decline in fertility has been dramatic (Falkingham 2000, Clifford et al. 2010). Still, concerns remain regarding the completion of the demographic transition to controlled, and therein lower, fertility and population growth. 1 Analysts examining the end of the 1990s and early 2000s point to rising overall fertility rates in some areas of the region, as economic conditions improve and titular ethnic groups become more dominant (Spoonrenberg 2013, Agadjanian V and Makarova E 2003). Long- standing issues associated with heavy reliance on one method, the IUD, persist across the region (Barrett and Buckley 2007, Buckley 2017). Recent surveys indicate slight declines in martial contraceptive use in some nations of the region (USAID, 2012), and within specific socio- cultural groups. Unmet contraceptive need persist among married women, access to reproductive health services remains unequal, and issues of long-term financing of reproductive health programs and contraceptive provisions continue (Beishenbek and Najibullah 2017). Despite these continuing needs, the improvements in reproductive health and expansions of contraceptive knowledge and access in Central Asia is a development success story. More families have knowledge of, and access to, modern contraception. The expansion of contraception in the region (even if further need remains) offers couples expanded opportunities. More can now choose when they wish to begin childbearing, the most opportune interval of time between births and the best time to conclude childbearing, increasing demographic decision-making autonomy, and resulting in a marked decrease is abortion reliance across the region (Westoff et al. 1998). Reproductive health, while still in need of attention, has improved over the past twenty-five years (IPPF/UNDP 2012). Background CОntral AsТa’s ОбpansТon oП rОproНuctТvО СОaltС takОs placО as tСО global communТtв embraces a broader conceptualization of what reproductive health means and takes a stronger focus on the need to protОct аomОn’s socТal rТgСts anН СОaltС during development. The 1994 Cairo International Conference on Population and Development agreement to place the rights of 2 women and girls in the center of development debates. It marks a watershed moment in recognition of reproductive health as a core human right, an issue of central importance in the 1995 BОТjТng agrООmОnt strОssТng tСО ПunНamОntal rolО oП аomОn’s rТgСts Тn НОvОlopmОnt. Across this period the conceptualization of reproductive health expands to include physical, mental and social well-being, rather than the absence of illness, encompassing issues of sexual health and hygiene related to the reproductive processes, functions, and system across all stages of the male and female life course. By the close of the 1990s, internationally accepted definitions of reproductive health incorporate the ideals of freedom of sexual expression, awareness of sexual health risks, and individual choice in terms of union formation and sexual debut in addition to contraceptive knowledge and practice. Often criticized in more traditional cultural settings for the strongly individualized focus on issues concerning both sexual and reproductive decision-making, international approaches to reproductive health over the past twenty years often raise challenges for fragile states (Hadi 2017). Academic research and policy assessments in a variety of contexts extoll the individual and community benefits of comprehensive reproductive health programs. Decreases in risky sexual behavior, early age at first birth (<20), declines in sexual violence, better adherence to antenatal health checks, decrease in unwanted pregnancies, improved infant and maternal mortality all stem from better reproductive health care (Sonfeld et al. 2013, Habibihov and Zainidinov 2017). Increased educational attainment for women, stronger unions for couples, decreased intimate partner violence, higher socio-economic aspirations, and improved economic and social status of women stem from delaying first births (Ahbab and Kabir 2013, Mueller et al. 2003, Yount et al. 2014, Sonfeld et al. 2013). Expanded opportunities for economic stability, 3 career advancement, and education prompt many individuals to delay childbearing (Mills et al. 2011). The benefits linked to improved reproductive health far exceed decreased population growth. However, such benefits depend on more than increases in contraceptive prevalence. Greater autonomy and decision-making abilities for women, economic opportunity, increases in average age at marriage, and the postponement of first births are key intervening mechanisms. In Latin America, initial increases in contraceptive use fail to spur a concurrent increase in аomОn’s autonomy or to alter patterns of universal and early marriage and rapid first births (Chackiel and Schkolnik 1996, Bonneuil and Medina 2009). As a result, broader benefits linked to autonomy, educational attainment, and union stability did not emerge. Assessments of reproductive health improvements in Central Asia point to a similar pattern of persistent early marriage and rapid first birth. As Hadi contends, the persistence of more traditional family and fertility patterns might reflect a repudiation of the individualist frameworks embedded within many reproductive health programs. In Central Asia, she argues, “the social expectations and economic constraints associated with living in a joint family would make it challenging for women to make individualistic choices about education, marriage, and access to reproductive СОaltС sОrvТcОs’ (2017). Has the growth of reproductive health programs and increase in modern contraceptive use in Central Asia led to improvements beyond increased contraceptive use? Is there evidence of reproductive health improvements other than rising marital contraceptive rates? How might the structure of reproductive health programming influence who benefits, and how, from reproductive health efforts? How do familial concerns, traditions, and social norms reinforce 4 attitudes concerning the formation of unions and the initiation of childbearing, dampening wider effects of reproductive health investments? Within the Central Asian region, Tajikistan provides a uniquely valuable case study for the exploration of reproductive health. Long noted for high fertility rates during the Soviet era, Tajikistan has attracted substantial international assistance and programming in the area of reproductive health from a wide variety of intergovernmental agencies. Since 1995, UNFPA has spearheaded significant efforts to increase reproductive health training among health professionals and expand reproductive health education and access across the country, noting a particular focus on issues of sexual health. Additionally, unilateral assistance from external donors for reproductive health is substantial. Beginning in 2008, the German Federal Ministry for Economic Cooperation and Development has provided resources to Tajikistan (in addition to Uzbekistan and Kyrgyzstan) to enhance health care capacity, particularly in the realm of sexual and reproductive health. US assistance to Tajikistan has targeted contraceptive access and a variety of training and outreach programs in the area of reproductive health, and in 2016 Tajikistan benefited substantially from 16 million dollars of funding through the PEPFAR program, which targets more than 80% towards prevention. A variety of domestic programs and directives in Tajikistan complement international efforts to
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