Context and goals

1Despite national and international political commitments to improving contraceptive access in Africa (Lesthaeghe and Jolly, 1995; Ross and Stover, 2001), use of modern methods remains limited in West Africa. Contraceptive prevalence is low among married women not wishing to get pregnant, and even lower among unmarried women (Cleland et al., 2006). Since the number of children born is higher than the number desired, low prevalence is usually analysed in terms of an unmet need for contraception (Cleland et al., 2006), defined as non-use of either modern or traditional methods by sexually active women who do not want to have a child over the following two years (Sedgh et al., 2007). West African societies are in a process of change, and one aspect of this change is a growing need for contraception in a context of increasing, and often socially condemned premarital sexuality linked to the growing dissociation between sexuality and procreation (Onuoha, 1992). A shortening of the period of post-partum abstinence among married women is a second factor of increased demand (Bledsoe and Cohen, 1993). Illegal abortion is frequent in this context; the estimated abortion rate is 23 abortions per 1,000 women aged 15-44 in North Africa, and 28 in West Africa (WHO, 2007). Studies suggest that the incidence of abortion is rising among educated young women and in the most urbanized areas (Desgrées du Loû et al., 2000; Guillaume and Desgrées du Loû, 2002).

2Despite the rapid pace of societal change in West Africa and Morocco, social organization in these countries is still based on the extended family and on highly codified relations between parents and children, and between men and women. In West Africa especially, the status of both men and women is enhanced by having many children: high fertility is socially valued (Kaida et al., 2005; Randrianasolo et al., 2008). Sex, age and, to a lesser extent, ethnic group and social class, are all intertwined in a complex arrangement where female subordination is just one element in the mosaic of social relations. Demand for contraception is a question which – probably even more so than in other social contexts – cannot be understood solely from the woman’s standpoint. Marriage and control of sexuality are central to the reproduction of power relations designed to maintain the social hierarchy between old and young, and between men and women. Thus, condemnation of sexual relations before marriage, especially for young women, and of extramarital sexuality, is the dominant norm, applied with varying degrees of rigour across different countries. At the same time, new representations of sexual models incorporating notions of personal fulfilment through romantic love are spreading, notably via the media. These models compete with older ones, often referred to, rather simplistically, as “traditional” (Cole and Thomas, 2009).

3In such social configurations, where contraceptive use is still rare but where non-procreative sexuality is becoming increasingly common, emergency contraception could reduce the number of unplanned pregnancies and consequently reduce mortality and morbidity linked to illegal abortions, a major public health problem in Africa. By examining the role of emergency contraception in relation to contraception as a whole in three West African countries and Morocco, the ECAF (Emergency Contraception in Africa) project aims to explore contraceptive issues in a broader perspective, analysing contraceptive practices in their relational, sexual and reproductive contexts. This research looks at contraceptive practices (emergency contraception and other methods) in relation to individuals’ sexual, relationship and reproductive histories in order to better understand the meaning of contraceptive failures and of pregnancies that are labelled as “unplanned.”

Methodology

4The ECAF survey was carried out in 2006-2007 by a multidisciplinary team of sociologists, demographers and public health physicians in three countries of West Africa – two French speaking (Senegal and Burkina Faso), and one English speaking (Ghana) – and in one French-speaking country of North Africa (Morocco). The research focuses on the capital cities of the four countries, where new models of contraception are most likely to have become widespread. The countries were chosen because they have different public family planning policies and because their levels of contraceptive prevalence – hormonal contraceptives in particular – are very different. Priority was also given to countries where ECAF team members had already collaborated with local researchers. Morocco, which has many social norms in common with the other countries, but where premarital sex is much more heavily stigmatized, provides an interesting contrast to the three countries of West Africa. Morocco’s societal similarities with the other countries makes comparison interesting, especially since its contraceptive prevalence is high, in contrast to the three countries of West Africa, and the country has experienced a recent and rapid demographic transition. [2]

5These four societies were also chosen because of the way in which male domination is expressed. In Morocco, until recently, the superiority of men was written into law. [3] In contrast, in the three countries of West Africa, men and women have equal status. However, legal equality does not always translate into actual equality, and the distance between the two varies from one country to another, depending on prevailing family and sexual models. Senegalese society is very hierarchical, but, at the same time, women have some autonomy, especially in financial matters (Adjamagbo and Antoine, 2002). Ghana and Burkina Faso are fairly accepting of women’s autonomy, especially in large towns (Attané, 2007; Biddlecom et al., 2007). However, in all four countries, as in any society, gender relations take different forms, depending on how they tie in with relations between generations and between different social categories.

6In-depth semi-structured interviews were conducted in Accra, Dakar, Ouagadougou and Rabat. The sample included women (n = 50 in each city), men (n = 25) and contraceptive providers (n = 15). Respondents were chosen from different social groups on the basis of pre-established quotas based on age (ages 18-35 for women and 18-44 for men to allow for age differences between partners), union status (single, monogamous or polygamous union, widowed or divorced) and level of education (none, primary, secondary, higher than secondary). Respondents were contacted using the “snowball” sampling method via several entry points: family planning centres, pharmacies, colleagues, acquaintances of survey team members.

7Each respondent gave oral informed consent after being read a document that presented the survey and guaranteed their anonymity. Approval was obtained from ethics committees in Senegal (Conseil national de la recherche en santé), Ghana (Ghana Health Service Ethical Committee) and Burkina Faso (Comité d’éthique pour la recherche en santé). In Morocco, authorization was obtained from the High Commission for Planning (Haut commissariat au plan).

8The semi-structured interview guide invited respondents first to give their opinions about the freedom to choose one’s own spouse, without intervention from the family. They were then asked to recount their own relationships and sexual experiences from the time of their sexual debut up to the present. If the topics of contraception, unplanned pregnancy and abortion were not spontaneously mentioned by respondents, specific questions were asked on these topics.

9The interview guide was tested in 2005 in two pilot surveys involving interviews with 7 women and 7 men in Burkina Faso, 9 women and 5 men in Ghana, 11 women and 7 men in Senegal, 8 women and 8 men in Morocco. These initial interviews were analysed during regular work seminars, a practice which helped to harmonize the materials collected through the survey.

10In each country, the male and female interviewers received at least one week’s training from the research teams. All the interviews with women were conducted by women, and all those with men were conducted by men.

11Interviewers were all natives of the country where the interviews were carried out, so that respondents could freely choose the language they spoke. The interviews were recorded, transcribed and translated if necessary (into English for Ghana, into French for the other countries). First name pseudonyms were assigned to respondents. Finally, a summary was written up for each interview, and information was compiled in the form of individual “portraits” and life histories (Battagliola et al., 1992).

12Secondary analyses were also carried out on results from the Demographic and Health Surveys (DHS) conducted in each country, along with contextual analyses on demographic and health policies.

Special feature

13The five articles presented in this special feature examine the normative tensions surrounding contraceptive use in the four countries studied, focusing on conditions of sexual debut in Rabat, the different realities behind unplanned pregnancies in Dakar and Ouagadougou, and the attitudes of health professionals towards emergency contraception in Burkina Faso and Ghana.

14The first article, by Nathalie Bajos, Maria Teixeira, Agnès Adjamabgo, Michèle Ferrand, Agnès Guillaume and Clémentine Rossier, looks at the normative tensions that structure women’s contraceptive attitudes and practices in the four countries under study.

15The authors show that unprotected or poorly protected sexual intercourse usually stems from attempts to comply simultaneously with competing norms pertaining to procreation and sexuality. These norms are based on a gendered double standard which condemns premarital sex for women while asserting the primacy of male sexual pleasure. The survey shows that the influence of these norms varies across different phases in individual life histories and across different types of emotional and sexual relationship. While the social factors that lead to contraceptive failures appear to be similar in the four countries, the degrees of rigidity of norms, especially concerning premarital sexuality, are quite different, a factor which may explain differences in contraceptive practices between the countries.

16The article by Fatima Bakass and Michèle Ferrand studies the conditions of sexual debut in Morocco, where the prohibition on premarital sexuality for women is stronger than in the other countries covered by the ECAF survey. The effect of the economic crisis, in conjunction with the spread of education, especially among girls, has resulted in a rapid increase in age at marriage and favoured the development of premarital sexuality. Young people are caught in a contradiction between their desire for emotional and sexual fulfilment, and the need to comply with social and religious norms which consider extramarital sexuality as deviant. The authors show how young women engage in a form of “cultural improvization”, with non-penetrative sexual relations emerging as a new arrangement between the two sexes which allows partners to transgress the ban on premarital intercourse while preserving female virginity.

17The analysis of unplanned pregnancies in Dakar by Agnès Adjamabgo and Pierrette Aguessy Koné, reveals the multiple realities underlying this demographic concept, looking at the reasons for their occurrence and the rationales behind decisions to continue or terminate an unplanned pregnancy. The social legitimacy of the relationship within which an unplanned pregnancy occurs is a determining factor in the woman’s or the couple’s response. The two sexual partners are not the only protagonists, and it is important to consider the relations of power – and of gender – which structure the partners’ relations with their families and their social environments. An understanding of young people’s attitudes towards contraception and reproductive decisions must also take increasing economic precariousness into account; many women feel that marriage guarantees some degree of income security. Finally, social norms that stigmatize non-marital sexuality and childbirth appear to be increasingly out of phase with trends in the conditions of transition to parenthood.

18The gender order also assigns specific sexual roles to women and men, starting at sexual debut, and its analysis can improve understanding of unplanned pregnancies in Ouagadougou. Clémentine Rossier, Nathalie Sawadego and André Soubeiga show that young women’s sexual behaviour is still marked by a desire to conform with the dominant moral code; they are more willing to accept unprotected intercourse with a partner whom they consider to be a potential husband. Young men’s premarital sexual activity is more often characterized by the positive status associated with having more than one partner and by male sexual pleasure. Maternity can become a means of attaining the status of spouse, and the same is sometimes true for paternity. Analysis shows that the man often gets his way when there is a disagreement over the decision to pursue or terminate an unplanned pregnancy. The social positions of young men, whose identities are often fragile due to their precarious labour market situation, can influence decisions in this area.

19The last article in this feature, by Susannah Mayhew, Ivy Osei and Nathalie Bajos, discusses contraceptive provider attitudes towards emergency contraception (EC) in Accra and Ouagadougou. Providers appear to favour this method on the whole, but their daily practices are influenced by their perceptions of the legitimacy of women’s requests, with some being considered irresponsible if no contraception was used. These providers also have opinions concerning the social legitimacy of female sexuality. In particular, young women’s premarital sexual activity poses problems for some, who feel that easy access to emergency contraception might encourage “unbridled” sexual behaviour. Other causes of provider reluctance, which is less strong in Ghana, where EC was introduced earlier (in 2000) than in Burkina Faso (in 2003), are the fear that its widespread use would lead some women to stop using regular contraception, and the belief that emergency contraception is a form of abortion. These reservations are encountered in many countries, in both North and South.

20These articles cover just a few of the themes addressed by the ECAF research project. Other analyses of the representations of emergency contraception have been published (see, in particular, Teixeira et al., 2012), and other studies are under way, notably on representations of abortion and the question of its legalization. These analyses highlight the importance of carrying out simultaneous surveys not only of women but also of men and of professionals in the field of sexual and reproductive health. They also illustrate the pertinence of a gender relations perspective in the analysis of social reality.