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 expand reproductive health care. A National Strategic Plan, unveiled in 2002, supports the reproductive health of the country. It relies on a five-prong approach to increase contraceptive awareness for spacing and stopping childbearing, continued decreases in abortion, expansion of comprehensive reproductive health services, increasing contraceptive access, and variety, and furthering the inclusion of men in sexual and reproductive health efforts. To help meet the goal of expanded births spacing, locating family planning clinics within birthing
5
hospitals (rod domi) or birthing wards is common. TajТkТstan’s national strategy updates in 2014 include an additional focus on issues of HIV/AIDS and the targeting of labor migrant families.
Issues of family formation retain marked state interest in Tajikistan and are subject to frequent policy prescriptions privileging perceived state interests (Harris 2011). The Tajik Ministry of
Health cooperated with UNICEF for large-scale surveys on the health of women and children across the country in 2000 and 2005 and with USAID in 2012. The 2006 adoption of the national
“HОaltСв LТПОstвlОs” currТculum aННrОssОs tСО ОНucatТonal nООНs oП stuНОnts Тn graНОs 7 tСrougС
11. This educational effort, UNICEF assisted, initially targeted 500 schools across the country for intensive training programs to generate a cadre of peer educators, later sent to other schools.
Efforts to expand and improve reproductive health in Tajikistan face significant challenges. In the initial years following independence were marked by low levels of knowledge and poor access to fertility control options asides from abortion. During the mid-1990s, civil war blocked the generation and execution of national health policies. Since the conclusion of armed hostilities in 1997, Tajikistan has faced chronic poverty and widespread permanent and temporary out-migration. Constrained state capacity and limited resources have hindered the effective and efficient utilization of international aid targeting the improvement of reproductive health, particularly in the more remote and rural regions of the country, among ethnic and linguistic minorities and youth. Educational efforts have faced strong opposition in some areas, from both teachers and parents. No comprehensive national curriculum regarding sexual and reproductive health yet exists.
Despite the many challenges associated with reproductive health in Tajikistan, all indicators point to improvements in contraceptive knowledge, access, and use over the past twenty years. Increases in sexual health knowledge, widespread support for birth spacing
6
between children, and preferences for smaller family size attest to the impact of national and international programs in reproductive health. 2005 survey results indicate that approximately
38% of married women were using contraception. While 2012 survey results indicated a decline in marital contraceptive use (to ~26%), an additional 17.9% of married women reported that they intended to use contraception in the future and nearly half of all married women (48.1%) indicated that they had received information concerning family planning at a health facility.
Less than one-quarter (22.9%) of currently married women in the 2012 Tajik Demographic and
Health Survey fell into the category of unmet contraceptive need. Assessing the impact of expanded reproductive health care in Tajikistan affords a valuable opportunity to investigate both structural and attitudinal influences on trends in health coverage, health knowledge, age at marriage and timing of first births.
CОntral AsТa’s rОlatТvОlв rОcОnt ОmbracО oП rОproНuctТvО СОaltС programmТng, status as a region of relatively high HIV and STI risk (Renton et al. 2006), the tradition of early marriage, and pattern of rapid post-union childbearing (UNFPA 2014, Warcholak 2012, Bakhtibekova,
2014). These characteristics generate three specific areas for investigation. First, exploring trends in familiarity with contraception generally and patterns of contraceptive use among sexually active women over the past twenty years informs how knowledge, attitudes, and practices have changed. Second, examining awareness and understanding of sexual health issues and sexually transmitted diseases lends insight to the improvement of comprehensive approaches to reproductive health. Finally, examining how and why patterns regarding continuity and change in age at marriage and the onset of childbearing enable the assessment of the ways reproductive health efforts may translate into broader social, economic, and cultural benefits for women in the region, through the alteration of family formation patterns
7
Methods
I employ a combination of qualitative and quantitative data to address my central questions regarding contraceptive familiarity, health knowledge, and the timing of family formation. The main data sources are the 2012 Tajik Demographic and Health Survey and a series of 16 focus groups conducted with the support of UNDP and Macro International in the summer of 2014. I supplement these data with informal observations at reproductive health clinics and interviews with regional and international officials in 2014-2016. A mixed method approach is best suited to the exploration of both how reproductive health efforts have influenced aggregate knowledge and practices among the women of Tajikistan and how information concerning the effect of the structure of family planning efforts, public opinion, social norms, family expectations mediate the effect of expanded contraceptive access in individual demographic. National demographic data provides valuable insight into what has happened, while focus group and other qualitative data enables the exploration of why and how patterns of continuity or change emerge.
The 2012 Tajik Demographic Health Survey data reflects an extensive bilateral cooperation between Tajikistan and USAID (Statistical Agency 2013). Employing a standard questionnaire, the Tajik DHS gathered data from women in the reproductive ages (15-50) through a nationally representative cluster sample of 6,674 households, split between urban areas
(approximately one-third) and rural regions (two-thirds). The total number of age-eligible women within the selected households is 9,794. An overall response rate of slightly over 98% yielded a final sample of 9,656 women. Data, collected at the household and individual level, focused on issues of reproductive health knowledge, access, and practice, marital and birth histories, health practices, child health and a variety of socio-demographic variables.
8
To better understand the underlying drivers of reported declines in contraceptive prevalence in the summer of 2014 working as a consultant for UNFPA-Tajikistan and USAID
(DHS), c o l l a b o r a t i n g w i t h the Dushanbe offices M-Vector, I collect a series of 16 focus groups on reproductive health among adult women of reproductive age (18-49) across
Tajikistan1. These guided group discussions seek a stronger understanding of аomОn’s attitudes towards and perceptions of reproductive health. Through open-ended discussions of contraception, w e g a i n a clearer understanding of the motivations for c o n t r a c e p t i v e use in addition to insight into how social norms and expectations influence аomОn’s access to information and contraception. These findings can potentially contribute to future policy opportunities, adding to our ability to theorize plausible pathways to declines in overall contraceptive use in the midst of seemingly strong improvements in other indicators of reproductive health. Discussion can contribute insights into topics not covered in extant surveys while providing valuable information on perceptions and processes.
The sampling strategy developed for the groups ensured the inclusion of both women who have ever used contraception and those who have never used contraception. Recruitment strategies guaranteed participation from ethnic and linguistic minorities (Uzbeks, Pamir) and both rural and urban residents. W e strategically sample for age and contraceptive familiarity. We stratify the majority of the groups (10) by age (focusing on those over and under the age of 30).
This approach seeks to provide forums of similar “СТstorТcal” perspectives and to give young women an open forum to discuss issues related to delaying births and spacing and older women more opportunities to share perspectives on stopping childbearing. Six groups of mixed ages
1 I developed the sampling strategy, protocol, materials for ethics review, conducted three days of moderator training, M-Vector provided very skilled moderators, local contacts and logistical assistance, final respondent identification and transcript development. 9
(15-49) provide insights into intergenerational communication and expressions of attitudes. Nine groups were stratified by аomОn’s contraceptive familiarity (ever versus never used) to enable open discussions within groups of uniform contraceptive experience. Seven groups contained women with a mix of c o n t r a c e p t i v e experience to provide insights into how p e r s o n a l experience m i g h t influence how women share information with one another. A full schematic of the focus group design and regional coverage is provided in Appendix One. Each of the 16 groups consisted of approximately eight individual respondents. Summary indicators of individual fertility ideals and individual characteristics for the 128 total respondents appear i n Appendix Two. A listing of the basic protocol is provided in Appendix Three.
The basic analyses for the TDHS data rely upon weighted data relating to contraceptive awareness and sexual health knowledge, with a specific focus on issues of age and marital status among women 15-50. Assessments of average age at marriage exclude women under the age of 25 to avoid issues regarding right censoring. For explorations of first birth intervals, assessments are limited to women who have been married for at least 36 months, functionally excluding women age 15-19. 2
Focus group analyses rely upon transcripts generated by the moderator from tape. All moderators submitted full transcripts and audio tapes of their groups in either Tajik or Russian, which were translated into English by a skilled translator at M-Vector. I edited the preliminary
English version for clarity and consistency of terminology and completed 10% spot checks of the transcription (based on audio files) in 12 of the 16 records. Confirmatory checks on translations
2 I am presently pursuing the analyses of pooled data from 2000, 2006, and 2012 national data, tracing patterns for marriage entrance for Taik women by birth cohort. Preliminary analyses point to consistently hgh levels of mrrital entrance (over 90%) by age 30. Hazard models indicate increases in risksof birhs wthin the first year, and first ighteen month of marriage among younger cohorts, and declining effects of education, sibship size, and uban residence in lowering the relative risk of rpaid first births among women marrying after 2000. I will integrate final version of these analyses into the full final version of the paper. 10
were completed for 10% of the pages for each focus group, with groups displaying translational issues subject to full review and re-translation (2 groups). All transcripts were coded initially with the three question areas of the article, with secondary and tertiary codes developed upon subsequent reading. Preliminary assessments for intercoder reliability indicated a high level of consistency (>90%).3 All included quotations have been subject to back translation.
Results
TDHS data indicate high familiarity with modern contraception, with over 80% of women of reproductive age reporting familiarity with modern contraceptive techniques in 2012.
The importance of increased contraceptive familiar is apparent across nearly all of the focus group discussions, with 14 of the groups discussing the value of broad improvements in health and family planning in the past few years at length. Groups with contraceptors were particularly adamant in their judgment of reproductive health historically in Tajikistan, often referring to the experiences of their mothers and aunts, who had no alternative to numerous and frequent births.
As for women during the USSR period, they did not think about how many children they should give birth. Many of them were not concerned with the family planning issue, especially in rural areas. They did not plan at all. FG 15, R8, 28 and expecting her first child
Before it was hard to get contraceptives, now it is easier. Before women gave birth to more children, now most of them plan their pregnancies. They give birth to fewer kids, thinking before having yet another one. Also, services
In several cases, respondents highlighted the importance of changing knowledge and contraceptive use in their lifetimes, focusing on both the importance of access to contraceptives,
3 Due to what can only be characterized as remarkably bad time management, intercoder reliability was only completed for coding relating to timing of marriage and first birth. This omission motivates the request to avoid citation at present and will be address soon. Anyone interested is asked to please contact the author for a final, quotable, version. 11
ideational change concerning planning fertility, and the increasing socio-economic challenges associated with large families.
Our women gave birth a lot before, and we did not know about the use of such contraceptives. Now, I tell my daughters-in-law not to give birth as much to be able to bring up their children because nowadays it is tough to raТsО cСТlНrОn’ FG8, R 6, age 45 with seven children
Nowadays if you are giving birth, our local doctors warn you to observe the interval between births. They tell you not to give birth for about two years after a child, as it is harmful to the health. When I got married in 1993, there were no such requirements. I bore my children one after another. That time, I did not think about children, I thought about myself. I was badly suffering. FG 11, R 4, age 37 with five children
The discussion of positive changes in the realm of national reproductive health is marked by a high level of interactivity among respondents. While some respondents mention persistent differentials between urban and rural locations and the relatively advantageous position of the highly educated, rarely did respondents in any group mention the exclusion of a particular social category or group outside of the region. No respondents mentioned an age group, marital status, or motherhood status in response to the probe concerning social groups that may have benefitted more (or less) from reproductive health programs. However, subsequent comments appeared to take for granted that reproductive health programs should focus on women who were already mothers.
Many married respondents with children enthusiastically supported the expanded access to information and services currently provided through the national medical service, with discussion linking access to contraception with outreach programs for recent births.
Currently, medical staff visits us at home. They remind us about vaccinations, talk to use about contraceptives, advise us about what and how to use them. Before it was difficult to find contraceptives, there were few of them, and nobody explained them to us. Often a women had to protect herself the best she could, now, she can plan how many children she will have. FG 7, R1 age 39 with three children 12
Discussions among younger women tend to support the interpretation that reproductive health improvements are taking place, but provided far fewer specifics concerning issues of access and levels of knowledge. Young, unmarried women reported that it was highly stigmatizing to reach out to medical professionals for reproductive health information. Variations on the interpretation below were found across all of the group discussions.
In our region, if a single woman would like to learn something about the methods of contraception, people would think badly about her. Why would a single woman need to go to the gynecologist or the family doctor about such a matter? This (such action) means something is wrong with her, or she has slept with someone, gotten pregnant or some such thing. ` FG 4, R4, age 25 with 1 child
Such commentary illustrates the challenges young women face in seeking out information concerning reproductive health information before marriage. Only 15 of the 2,060 currently unmarried women (most under the age of thirty) in the 2012 TDHS report using contraception. Respondents often mention the exclusion of women without children, who are typically young, in family planning efforts. As one respondent pointed out,”‘аО Нo not СavО Обplanatorв аork among аomen who have not yet
НОlТvОrОН’”(FG4, R1, age 23). This targeting of women post-birth for contraceptive outreach helps to explain the wide gulf between knowledge levels for women with and without children shown in Figure One. Familiarity is improving, but women who are single or without children remain excluded from these improvements. Women transitioning into marriage and at risk of a first birth are at an informational disadvantage.
13
Figure One. Percent of Reproductive Aged Women with Knowledge of Any Modern Contraceptive, by Age, Tajik DHS 2012
100.00% 92.70% 96.90% 97.10% 97.50% 96.70% 95.20% 90.00% 85.70%
80.00% 84.60% 85% 78.60% 70.00% 76.70% 75.50% 60.00% 70.20% 50.00% 40.00% 43.70% 30.00% 15-19 20-24 25-29 30-34 35-39 40-44 45-49
Has Children (95.9%) No Children (56.2%) Total (82.1%)
The recent expansion of reproductive health education in Tajik schools emerged
Тn sОvОn oП tСО stuНв’s Пocus groups. Several of the youngest respondents note learning about HIV/AIDS and other STIs in addition to basics about family planning. Others in the younger age groups failed to mention the courses, and no respondents shared specific details regarding course content. Even among women under 30 years of age, stark variations in contraceptive intentions and access to information concerning emerge between those who have given birth and those who have not. As seen in Figure Two, nearly 90% of women under thirty with children intend to use contraception, while less than half of those without children express this intention. This marked difference in intention may reflect the much higher access of young mothers to medical specialists
(family planning worker and health clinics). While access to other information channels is not significantly different between young women with and without children, these
14
channels viewed as much less effective generally. As several respondents remarked, even with
Figure Two. Percentage of Women Under 30, Contraceptive Intension and Access to Family Planning Information, by Childbearing, Tajik DHS 2012
No Intention to use contraception*** Visited by a FP Worker, 12 mo.** Visited Health Facility, past 12 mo.*** Heard of Family Planning, Print Media Heard of Family Planning, TV Heard of Family Planning, Radio 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%
No Children (N=2677) Has Children (N=2014) healthcare improvements in recent years, single women and those without children are often limited to second-hand information from friends and relatives concerning family planning and reproductive health.
Do patterns of exclusion also appear regarding broader elements of reproductive health, such as familiarity with HIV/AIDS and other STIs? If women who have yet to give birth are disadvantaged in accessing information concerning contraceptives, do similar patterns emerge regarding sexual health? Across focus groups, both older and young women mentioned the need to protect oneself from sexually transmitted diseases, particularly HIV.
I wish to have another child, but my doctor is persistent in telling me to use condoms or abstain when my husband returns from migration until he is evaluated. I am lucky that my husband is confident in himself and willing to submit to evaluation. FG12, Respondent age 28 with two children 15
Reflecting the national trends in HIV prevalence and incidence, respondents also noted that HIV/AIDS was a particularly important concern for youth, for themselves and their children.
Illnesses like HIV place our young men at risk, which is dangerous for our women. Young women must be careful and young men faithful, especially when this illness can be passed on to children. More information for our young women is a type of power that can help them to stand up to such challenges. They cannot protect themselves or their children without knowledge. Nurse, Dushanbe FP Clinic (interview)
Older respondents in the focus groups appear to echo the stigma mentioned above about sexual health education for young women. As a 40-year-old mother of four sons remarked, ‘Proper young women do not require such education
Figure Three indicates that for Tajik women under 30, proper or not, HIV/AIDS awareness is relatively low. In contrast to contraceptive familiarity, young women yet to have a child report higher levels of basic awareness of HIV and other STIs. Women with children who have heard of HIV/AIDS are more likely to support requesting a spouse use a condom in the case of STI risk and are slightly more likely to claim the right to refuse sex in comparison to women without children.
Figure Three. Sexual Health Knowlege Among Women Under Age 30, by Childbearing (percent), Tajik DHS 2012
Never heard of AIDS** Never heard of a STI, other than HIV** Can get a condom АТПО justТПТОН askТng СusbanН to usО a conНom ТП СО… Respondent can refuse sex 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
Has No Children (N=2667) Has Children (N=2014)
16
Basic indicators of HIV/AIDS knowledge do indicate an advantage for women under 30 years of age with children. As seen in Figure Four, among those who are aware of
HIV/AIDS, mothers are more knowledgable of mother to child transmission issues and the protective advantages of condom use, in comparison to young women who have yet to give birth.
Figure Four: HIV/AIDS Knowledge Among HIV Aware Women Under Age 30, by Childbearing (percent), Tajik DHS 2012 MTC Drug treatment available
MTC Breatfeeding*
MTC Delivery*
MTC Pregnancy*
Healthy looking person can have AIDS
Consistent Condom Hinders HIV**
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% Has No Children (N=1280) Has Children (N=1233)
Women preceive improvements in reproductive health in Tajikistan, although differentials in contraceptive knowledge and attitudes remain concentrated among women who have already begun child bearing. In terms of sexual health awareness, an important factor in comprehensive reproductive health, awareness levels are lower than awareness levels for contraception. Differences relating to HIV and STIs are apparent, but the patterning is less clear. Tajik reproductive health is improving, but evidence suggests that state programs emphasizing the importance of family planning of spacing children and associating family planning services with antenatal care may provide structural support for the exclusion of women who have yet to give birth. Similarly, social stigma may deter young women, in particular, those outside of a union, from
17
seeking reproductive health information and care. Both these structural and attitudinal factors contribute to a context in which the benefits from increased delays of first births are unlikely.
In Tajikistan, marriage is both early and universal. In the 2012 DHS approximately, 85% of women between the ages of 25 and 29 are or have been married.
Less than 1% of respondents between 30 and 34 have yet to be married. Among those entering marriage, the average age at first union has remained consistent across age cohorts, with age at first marriage for those 25 to 29 (21.43) indistinguishable from those 45-49 (21.85). As seen in Figure Five, a substantial proportion of women enter into marriage before reaching twenty years of age, and the most recent age group that can be measured (20-24) report an approximately 10% increase in the proportion entering into marriage before twenty in comparison to women aged 25 to 29.
Expansions in reproductive health efforts, to date, are not associated with delays in marital entrance fo Tajik women. Indeed, several reports indicate recent increases in early marriage (Bakhtibikova 2014), despite the adoption of laws barring marriage for those under 18.
18
Figure Five. Percent of Women Entering into Marriage Before Age 20, by Age Group, TDHS 2012
45-49
40-44
35-39
30-34
25-29
20-24
0 10 20 30 40 50 60 70
Focus group participants echo ideas discussed in the literature on early marriage in Tajikistan. Young women who delayed marriage until 22 or 23 remarked on familial pressures to enter into a union, ‘bОПorО Тt Тs too late.' Older respondents noted the cСallОngОs assocТatОН аТtС arrangТng ‘gooН gТrls’ as spousОs Пor tСОТr sons, at tТmОs ОvОn joking that young daughters-in-law are easiest to train4. Discussions of early marriage for young men in two of the 16 groups included observations that marriage before departure might encourage maturity, and make the man a better and more attractive worker. During icebreaker discussion in which women were invited to share a dream they have for the futures, Mothers with children still in primary school spoke of their desire to make a good marriage match for their sons and daughters. As observed historically in Latin America, maintaining early marriage during the expansion of
4 Such interpretations were not met with amusement within younger focus groups.
19
reproductive health knowledge and access can be an effective mechanism to dissuade pre-marital sexual activity, in deference to conservative cultural norms prizing female virginity (Rosero-Bixby et.al 2009).
The maintenance of early marriage in Tajikistan is inextricably linked to the strong social expectations of a first birth soon after the wedding. This exchange among married women in the 30s in Focus Group 7 reflects the sentiment of the majority of respondents in the study.
R4 There are no talks about contraceptives with women who have not given birth. It is considered very inappropriate. R1 Young families should give birth as soon as possible. They do not need the information on contraceptives. None of the mothers or mothers-in-law, and especially the husbands, will allow a young bride to use contraceptives. R2 It is better to give birth right away. Doctors will not discuss contraceptives with women who have not given birth yet. Medical staff will talk about that
The importance of rapid first births among Tajik couples include references to concerns over infertility linked to environmental concerns, a documented issue of concern in some specific regions (SСaПaǐгТОva 2009). YoungОr аomОn ОagОrlв poТnt out tСat pressure from mother in laws who want to carО Пor tСОТr granНcСТlНrОn аСТlО ‘tСОв arО stТll вoung’ aННs to prОssurОs to bОcomО prОgnant quТcklв.
A related issue concerning rapid first birth is the widespread belief that many types of contraceptives can reduce future fecundity, and are best avoided until a woman has one or two children. Beliefs that hormonal contraceptives dampen the ability to conceive in the future and IUDs (by far the most common contraceptive method employed in Tajikistan) are inappropriate for young women and disliked by young husbands are widespread. 20
Tajik DHS data in 2012 indicates rising percentages of first births within the first 12 months of marriage among young age cohorts. As seen in Figure Six, among women in a marital union for at least 36 months over the age of 25, nearly all have experienced a first birth. Among those under 35 years of age over 40% gave birth in the first year of marriage, indicating the potential efficacy of cultural preferences for rapid first births in combination with the structural exclusion of women without children from contraceptive access in Tajikistan.
Figure Six. Timing of First Birth Among Women Married at Least 36 Months, by age, TDHS 2012 120.0%
100.0% 7.2% 10.4% 11.0% 11.4% 9.8% 11.5% 9.0% 12.0% 80.0% 12.6% 13.1%
33.2% 34.0% 60.0% 36.1% 37.3% 38.3%
40.0%
43% 43.1% 20.0% 37.6% 35.3% 38.9%
5.1% 3.5% 0.0% 1.5% 1.9% 3.2% 25-29 30-34 35-39 40-44 45-49
No first birth First 12 mo Second 12 mo Third 12 mo After 36 months
Conclusions
Discussion
Both qualitative and quantitative data indicate an improvement in reproductive health in Tajikistan, while also indicating many opportunities for improvement in the 21
depth of information provided and the inclusion of young women, particularly those yet to give birth, in programs intended to provide comprehensive reproductive health information. Presently, both social attitudes and the structural practices of health care providers set a context in which health information, contraceptive access, and many other reproductive health issues are far less available to young women before entrance into marriage and the onset of childbearing. In the short term, this exclusion hampers further expansion of reproductive health services in Tajikistan. More troubling, it appears to hinder improvements in the area of sexual health knowledge, identified as a key area by many health professionals.
More broadly, the continued maintenance of early marriage and rapid childbearing is likely to diminish the potential opportunities improvements in reproductive health often generate in raising the status of women. Persistent early childbearing is a barrier to many of the socio-economic gains associated with reproductive health development and contraceptive use. The consideration of more active structural engagement to enhance contraceptive knowledge and access to a wider mix of contraceptive methods will be an effective place to start. Enhanced knowledge and access, through the inclusion of all women regardless of age or pariety, can facilitate more effective communication and consideration of local norms and expectations. The need for additional research and policy development in this area is needed.
22
References
Ahbab Mohammad Fazle, and M.H.M. Imrul Kabir (2013) "Factors Influencing Age at First Birth of Bangladeshi Women- A Multi-variate Approach." American Journal of Public Health Research 1(7): 191-195 Agadjanian V and Makarova E (2003). 'From Soviet modernization to post-Soviet transformation: Understanding marriage and fertility dynamics in Uzbekistan,' Development and Change 34(3): 447-473. BakСtТbОkova, Z. 2014. Earlв gТrls’ marrТagО Тn Tajikistan: Causes and continuity. Doctoral Thésis (Sociology). University of Exeter. https://ore.exeter.ac.uk/repository/bitstream/handle/10871/17438/BakhtibekovaZ.pdf?sequence =1 Accessed 15, April 2017. BarrОtt, J. anН C. BucklОв (2007). ‘ConstraТnОН ContracОptТvО Choice: IUD Prevalence in UгbОkТstan,’ International Family Planning Perspectives. 33(2):50-7 Beighenbek – Kyzy, E, and F. Najibullah (2017) ‘End of UN Contraceptive Program in Kвrgвгstan a BТttОr PТll Пor Manв’ RFE/RL https://www.rferl.org/a/kyrgyzstan-contraceptive- pill-un-program/28527777.html Accessed June 10, 2017. BonnОuТl, N. AnН MОНТna, M. (2009) “BОtаООn TraНТtТon anН MoНОrnТtв: TСО TransТtТon oП Contraception Use in Colombia” Dessarollo y Sociedad 66: 119-15. Buckley, C. (2017) ‘EбpanНТng contracОptТvО usО аТtСout broaНОnТng contracОptТvО mix: Implication oП IUD НomТnancО Тn KaгakСstan,’ PapОr unНОr rОvТОа. CСackТОl, J., anН S. ScСkolnТk (1996) “LatТn AmОrТca: OvОrvТОа oП tСО FОrtТlТtв TransТtТon, 1950- 1990.” In Guгmпn, SТngС, Rodríguez, and Pantelides, editors. The Fertility Transition in Latin America. New York, United States: Clarendon Press. Clifford, D., J. Falkingham, A. Hinde. 2010. « Through Civil War, Food Crisis and Drought: Trends in Fertility and Nuptiality in Post-Soviet Tajikistan,» European Journal of Population, 26:3 pp 325-350. Dixon-Mueller, R. 1993. ‘TСО SОбualТtв ConnОctТon Тn RОproНuctТvО HОaltС,’ Studies in Family Planning. 24(5) pp 269-282. FalkТngСam, J. (2000) АomОn anН GОnНОr RОlatТons Тn TajТkТstan’ Country Briefing Paper, Asian Development Bank. Fussel, E. and Palloni, A. (2004) “PОrsТstОnt MarrТagО RОgТmОs Тn CСangТng TТmОs” Journal of Marriage and Family, 66 (December 2004): 1201-1213. Habbibov, N. and H. Zainiddinov. 2017. ‘Do ПamТlв plannТng mОssagОs ТmprovО antОnatal carО utilization? EvТНОncО Пrom TajТkТstan’. Sexual and Reproductive Healthcare, 13 pp 29-24. Hadi,M. (2017) ‘Historical development of the global political agenda around sexual and rОproНuctТvО СОaltС anН rТgСts: A lТtОraturО rОvТОа,’ Sexual & Reproductive Healthcare, Volume 12, 64 - 69 HarrТs, C. (2011). ‘StatО business: gender, sex, and marriage in Tajikistan, ‘ Central Asian Survey. 30:1 pp 97-111. HОaton, T.B., ForstО, R. anН OttОrstrom, S.M. (2002) “FamТlв TransТtТon Тn LatТn AmОrТca: ПТrst ТntОrcoursО, ПТrst unТon anН ПТrst bТrtС” International Journal of Population Geography 8(1): 1- 15.
23
IPPF/UNFPA. (2012) ‘IncrОasТng ContracОptТvО SОcurТtв Тn EastОrn EuropО anН CОntral Asia,' http://eeca.unfpa.org/sites/default/files/pub-pdf/Increasing-Contraceptive-Security-Factsheet.pdf Accessed 15, April 2017. Lyons-Amos M, PaНmaНas SS, Durrant GB.(2014) ‘ContracОptТvО conПТНОncО anН tТmТng oП ПТrst bТrtС Тn Moldova: an event history analysis of retrospective data. British Medical Journal Open 2014;4 doi: 10.1136/bmjopen-2014-004834 Mills, M., Rindfuss, R.R., McDonald, P., Velde, E.T. and Force, E.R.S.T. (2011) Why do people postpone parenthood? Human Reproduction Update, 17, 8484-860. MuОllОr, T., L. GavТn, A. KulkarnТ. (2008) ’TСО AssocТatТon BОtаООn SОб EНucatТon anН YoutС’s EngagОmОnt Тn SОбual IntОrcoursО, AgО at FТrst IntОrcoursО, anН BТrtС Control UsО at FТrst SОб,’ Journal of Adolescent Health 42: 89-96 Ni Bhrolchain, M. anН BОaujouan, E. (2012) “FОrtТlТtв postponОmОnt is largely due to rising ОНucatТonal ОnrollmОnt” Population Studies 66(3):311-327 и , M. Ш и . (2017). М ь Ц а ь А . Та а : - и и ./ . . К Х и (Г ия, и ). – Renton, A., D. Gzirishvilli, G. Gotsadze and J. GoНТnСo. 2006. ‘EpТНОmТcs oП HIV anН sОбuallв transmitted infections in Central Asia : Trends, drivers anН prТorТtТОs Пor control,’ IntОrnatТonal Journal of Drug Policy. 17(6) ; pp 494-503. Rosero-Bixby, L.,.Castro-Martin, T. and Martin-GarcТa, T. (2009) “Is Latin.America starting to rОtrОat Пrom Оarlв anН unТvОrsal cСТlНbОarТng?” Demographic Research 20(9):169-194 SСaПaǐгТОva, G.D. 2009, "TСО cСaractОrТstТcs oП morbТНТtв Тn аomОn oП ПОrtТlО agО rОsТНТng tСО area of Tadjikistan aluminum factory", Problemy sotsialnoǐ gigieny, zdravookhraneniia i istorii meditsiny / NII sotsialnoǐ gigieny, ėkonomiki i upravleniia zdravookhraneniem im.N.A.Semashko RAMN; AO "Assotsiatsiia 'Meditsinskaia literatura'.", no. 2, pp. 50-51. Sonfield A, K. Hasstedt, M. Kavanaugh, and R. Anderson,(2013) ‘The Social and Economic Benefits of Women’s Ability to Determine Whether and When to Have Children, New York: Guttmacher Institute. www.guttmacher.org/pubs/ social-economic-benefits.pdf Accessed 15. May 2017. SpoorОnbОrg, T. (2013) ‘FОrtТlТtв CСangОs Тn CОntral AsТa SТncО 1980,’ Asian Population Studies 90(1) pp 50-77. Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International. (2013) Tajikistan Demographic and Health Survey 2012. Dushanbe, Tajikistan, and Calverton, Maryland, USA: SA, MOH, and ICF International. UNFPA (Tajikistan). 2014.Child Marriage in Tajikistan (An Overview). http://www.girlsnotbrides.org/wp-content/uploads/2013/11/UNFPA-Child-Marriage-in- Tajikistan-2014.pdf Accessed 15, April 2017 АarcСolak, M. 2012. “Earlв MarrТagОs Тn TajТkТstan, ” The Guardian. Wednesday 29 June. https://www.theguardian.com/journalismcompetition/early-marriage-in-tajikistan Accessed 12, May 2017. Westoff, C., A. Sharmanov, J.Sullivan, and T.Croft. 1998. Replacement of Abortion by Contraception in Three CentralAsian Republics. Calverton, Maryland: The Policy Project and Macro International Inc. Yount, K., S. Zureick-Broаn, N. HalТm anН K. LaVТlla. (2014) ‘FОrtТlТtв DОclТnО, GТrls’ АОll- bОТng, anН GОnНОr Gaps Тn CСТlНrОn’s АОll-BОТng Тn Poor CountrТОs,’ Demography, 51:535-561
24