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Psychosocial Consequences to
Women of Contraceptive Use and
Controlled Fertility
Rum Dixon-MueHer
Recent research on the consequences of contraceptive use and controlled
fertility has focused almost entirely on the physical health of women and children
as measured by rates of maternal and child morbidity and mortality. Little
attention has been paid to the broader implications of trends and variations in the
reproductive behavior of women that is, to their psychosocial consequences
as reflected in the way women in differing socioeconomic circumstances feel and
talk about themselves and their family and work situations. Given the evidence
on the connections between psychosocial stress and physical disorders (albeit
mostly from industrialized countries), it is remarkable that the literature on health
consequences of contraceptive use and controlled fertility essentially ignores this
component of health and well-being. Indeed, neither the multicountry World
Fertility Survey nor the Demographic and Health Survey includes questions that
would permit analysis of the relationship between reproductive behavior and
psychosocial stress or disorder.
In examining the health consequences for women of contraceptive use and
controlled fertility, we should adopt the broadest conceptual approach in order to
capture the full range of costs and benefits of different reproductive behaviors.
Women alone bear the physical risks of pregnancy and childbirth. Women also
bear the physical risks of using female methods of contraception-the oral pill,
the intrauterine device, injectables, and tubal ligation, for example and of vol
Ruth Di~con-Mueller is research associate, Graduate Group in Demography, University of Califor-
nia, Berkeley.
140
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PSYCHOSOCIAL CONSEQUENCES i41
untary pregnancy termination as well. But the calculus of health benefits and
costs cannot stop here. For many women the psychosocial aspects are at least as
salient as the purely physical aspects, if not more so, in both their positive and
negative manifestations. Of particular importance are levels of psychosocial
stress associated with women's concerns about the timing or spacing of their
births, about subfecundity or excess fertility, and about the use of specific meth-
ods for avoiding unwanted pregnancies.
Concepts of health and illness are highly culture bound, of course. Developing
a set of indicators of how respondents perceive their physical health, yet alone
their mental health, would be extremely difficult. Nevertheless, such conceptual
and methodological difficulties should not prevent us from incorporating this
crucial aspect of women's reproductive lives into our theoretical frameworks and,
subsequently, into our data collection as well. Doing so would help to narrow the
gap between current research on morbidity and mortality and the World Health
Organization's definition of health as a 'estate of complete physical, mental and
social well being and not merely the absence of disease or infirmity."
The purpose of this paper is to suggest a framework for thinking about the
psychological consequences to women of contraceptive use and controlled fertil-
ity. The literature based on empirical studies is scant. Instead, this paper draws
primarily on common-sense possibilities and on ethnographic reports of how
women talk about their lives.
CONCEPTS OF HEALTH AND WELL-BEING:
INDICATORS OF PSYCHOSOCIAL STRESS
Stress, whether chronic or episodic, may be categorized as systemic (i.e.,
primarily physiological); as psychological (i.e., primarily cognitive); or as social
(i.e., induced by the disruption of some social unit or system. For convenience
the concepts of psychological and social stress are combined in this paper.
Psychosocial stress can manifest itself in at least three types of mental disorder:
depression, anxiety, and hostility, which, in some Western populations, at least,
constitute distinct dimensions, or subscales, of mood. Each type of disorder is
relevant to the analysis of health consequences to women of contraceptive use and
controlled fertility. Each may also be related to or perceived and expressed
as physical disorders, as, for example, when a woman anxious about whether
she can provide adequate food for her children complains of dizziness, headaches,
or nervous exhaustion.
Depression is usually assessed by respondents' self-reported emotional symp-
toms, such as feelings of despair, helplessness, worthlessness, shame, being in a
Elvis discussion draws generally on the literature on the connections between psychosocial stress
and physical disorders, notably Levine and Scotch (1970), Monat and Lazarus (1977), Cohen and
Syme (1985), and Barnett et al. (1987).
r
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142 RUTH DIXON-MUELLER
"low" mood, etc., and by physical symptoms such as lethargy, marked changes in
eating or sleeping habits, and other indicators. Anxiety is measured by feelings of
generalized or specific worry, fear, and intense dread or foreboding as well as by
physiological indicators such as raised blood pressure or increased heart rate.
Hostility is represented by feelings of anger, conflict, or hatred, as expressed
perhaps in violent, erratic, or abusive behavior toward self or others or in social
withdrawal, with associated physical symptoms.
The discussion in this paper will be directed primarily to the phenomenon of
anxiety, which, cross-culturally, is probably the most common disorder that
women experience in relation to their sexual and reproductive capacities. As one
reviewer (Harrison, 1983; see also Ford, 1964) of the cross-cultural literature on
pregnancy and childbirth concludes:
The major, single, unifying theme that runs through bow cultural accord and
divergence on Me subject of childbearing is that the entire experience is not only a time
of discomfort but a Irene of danger, the source of which may be physical or supematu-
ral. In consequence, it is a time of vulnerability and anxiety, and the penalties for
failure are high (p. 69~.
The major focus of this anxiety, I propose, is the way in which threatening
reproductive events or conditions, such as failure to bear a child, fear of an
unwanted pregnancy, or expectation of ill health from contraceptive use, affect
women's perceptions of their ability to perform those essential social roles upon
which their survival, security, and well-being depend. The penalties for failure
are indeed high, and they are firmly embedded in the social system.
PSYCHOSOCIAL STRESS AND ROLE PERFORMANCE
The relationship between social structures, social roles, gender, and psycho-
logical distress has been studied in Western populations (Barrett et al., 1987~.
But what approach is feasible for comparative analysis? Studying a sample of
educated Ghanaian women, Oppong and Abu have proposed a framework that is
useful for analyzing the impact of contraceptive use and controlled fertility on
women's lives (Oppong and Abu, 1985; see also Oppong and Abu, 1987~.2 Their
approach identifies seven distinct social roles that affect and are affected by-
reproductive behavior: the maternal, occupational, conjugal, domestic, kin, com-
munity, and individual roles. Elaborated further below, each of these roles
involves particular sets of activities, expectations (rights and obligations), and
social relationships; different patterns of decision making; the investment of time
2For related approaches to role performance and stress based on U.S. studies, see Aneshensel and
Pearlin (1987) and Barnett and Baruch (1987).
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PSYCIIOSOClAL CONSEQUENCES 143
and other resources; and the possibility of psychosocial and perhaps economic
rewards. These various attributes can best be described as role content.
In addition, the seven roles in combination represent a role profile. Like role
contents, role profiles include normative elements that are common to the social
group (however the group may be defined) (see, e.g., Mason, 1983) and elements
that are unique to each woman. Ascertained through individual interviews or
focus group discussions, a role profile represents in configuration a woman's
perception of the varied demands made on her and what aspects of her life she
finds most difficult and most satisfying. The profile allows a researcher to
identify which roles have the highest priority at any given time in a woman's life
cycle, which roles offer the least and the greatest rewards, and which roles
constitute sources of role strain and role conflict.
The concepts of role strain and role conflict are particularly important as
potential sources of psychosocial stress that may result in anxiety, depression, or
hostility. Role strain refers to the extent to which a woman feels unable to cope
with the demands of a particular role with the resources at her disposal (e.g., time,
energy, money, or social networks) (Oppong and Abu, 1987~. Role conflict refers
to We extent to which a woman perceives the demands of two or more roles that
she occupies simultaneously as incompatible (e.g., working outside the home and
caring for young children). In a slightly different formulation, role conflict can
also refer to the extent to which people disagree among themselves about the
normative content of a particular role, for example, when a mother-in-law and
husband (or a husband and wife) hold contradictory views of what it means to be a
"good wife."3 The former definition is more salient to this paper.
The seven-roles framework presents a useful analytic approach for investigat-
ing the psychosocial consequences to women of contraceptive use and controlled
fertility. In every society reproductive events or conditions such as menstruation,
sexual intercourse, the use or nonuse of a contraceptive method, the birth of a
child, breastfeeding, or the inability to carry a pregnancy to term are usually
highly charged with personal and social meaning. Indeed, reproductive events
often form the object of elaborate social ritual (Paige and Paige, 19Bl). Whether
their net impact on women is positive, negative, or neutral depends in large part
on how such events or conditions transform the content of particular roles (as
women perceive them) and the nature of the overall role profile; that is, it depends
on the resulting waves or ripples that flow through the "grid" of a woman's
multidimensional role performance (Figure 1~. It follows that reproductive be-
haviors that intensify rather than reduce role strain or role conflict-particularly
among those roles that a woman defines as most salient to her security and
survival are likely to be perceived as the most stressful.
~- ~ ~
Ibis definition of role conflict is not drawn from Oppong and Abu's work.
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|44 RUTH DIXON-MUE~ER
Cont~acepinrc ~ Role performance
reproduci~vc client or Role content
condition Role strain
~ Role conflict
Adaptive mechanisms
Social support
Infomlaiion
Ecanornic resources
Structural changes
FIGURE 1 Model of the influence of contraceptive and reproductive patterns on stress.
P~chasocial stoner
Anxiety
Depression
Hostility
Stress may be mediated by adaptive, or "coping," behavior, particularly in
settings where women can draw on strong social support networks or on other
material and social resources to counter or dilute the negative effects of threaten-
ing events or conditions (Cohen and Syme, 1985~. Intervening mechanisms
include relying on interpersonal networks (e.g., seeking social support for a
decision to terminate a pregnancy); having access to economic resources (e.g.,
being able to give adequate food and shelter to a newborn child); receiving
accurate information (such as learning about the probability of contraceptive side
effects); and controlling outcomes by making structural changes (such as finding
a good child care provider). Despite such adaptive strategies, however, it is
probably safe to say that most women in most socioeconomic circumstances are
likely to experience extreme stress at some time in their lives that is triggered by
sexual or reproductive events or conditions. The resulting psychosocial distress
may or may not translate directly into physical disorders. I suggest, however, that
its effects are likely to be no less pervasive than those mortality and morbidity
indicators with which we are most familiars When we consider that poverty,
powerlessness, and physical illness are also identified as major sources of psycho-
social stress, we can better understand how certain reproductive events inter-
woven as they are with other insecurities and threats-can engender such high
levels of emotional disturbance, particularly among low-income women.
CONTRACEPTIVE AND REPRODUCTIVE PATTERNS
AS POTENTIAL STRESSORS
When we shift our attention from the effects of contraceptive use and con-
trolled fertility on women's physical health to women's psychosocial or emo-
tional well-being, we must also include those factors affecting child health and
survival because these become matters of critical concern for women. The
"wontedness" status of a particular pregnancy or birth is particularly relevant
4Harrison (1983) presents a fascinating study of He pervasiveness of psychosocial stress related to
(in decreasing order of frequency) high fertility, contraception, and fetal wastage among a sample of
women living in poverty in rural E1 Salvador.
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PSYCHOSOCIAL CONSEQUENCES 145
here, for obvious reasons. The fear of miscarriage, stillbirth, birth deformity, or
infant death or illness is a major cause of anxiety among women with wanted
pregnancies, while an unwanted pregnancy or birth can drive women to attempt a
dangerous self-induced abortion; to infanticide; or to prolonged hostility, depres-
sion, and despair. Similarly, we must include under women's health not only
reported rates of maternal morbidity and mortality associated with contraceptive
use and childbirth but als~and perhaps more importantly women's fears of
such conditions or events: the fear of getting pregnant accidentally, for example,
or of not getting pregnant at all; the fear of potentially debilitating contraceptive
side effects; and the fear of trauma or death in abortion or childbirth. As noted
above, a woman is most likely to focus such fears and anxieties on her ability to
perform those social roles described below that are most salient to her immediate
concerns with security, survival, and general well-being.
Conjugal Roles
Conjugal roles define a woman's relationship with her sexual partners, whether
in a casual or `'visiting" union, a consensual union (cohabitation), or a formal
marriage (monogamous or polygamous). Oppong and Abu (1987) found that
educated married women in their Ghanaian sample ranked their level of satisfac-
tion with their conjugal roles on average below their parental, occupation, kin,
and individual roles. They also ranked their level of "role deprivation"-that is,
the gap between what they expected of their conjugal roles and what they experi-
ence-as significantly higher than for any other role. Yet women defined the
conjugal role as high priority (second only to the parental role) for their social
standing and personal happiness.
Patterns of contraceptive use and controlled fertility should have an immediate
impact on the conjugal relationship. Some research has attempted to identify
qualities of conjugal roles that influence sexual and contraceptive practices and
fertility outcomes (e.g., the effects of joint vs. segregated role relationships, male-
dominant patterns of decision making, female autonomy) (see, e.g., Rainwater,
1960, 1965; Fawcett, 1973; Luker, 1975; Miller, 19863. Little systematic research
has been done that turns the causality in the other direction. For example, how do
different patterns of contraceptive use (including indigenous methods or no method
at all) affect a woman's conjugal role performance and the levels of stress
associated with her relationship with her sexual partner?
Ethnographic literature from both industrialized and developing countries
suggests that the conjugal relationship itself is frequently a source of psychosocial
stress.5 Houston's (1979) informal interviews with rural and urban women, both
5For a review of the literature on the family in industrialized societies, see, for example Croog
(1970).
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|46 R=N DIXON-M VENEER
literate and illiterate, in six developing countries sometimes elicited ambivalent if
not negative statements from the women about men in general and their own
marriages in particulars It is thus not surposing that contraceptive behavior can
also be difficult, emotional, and conflicted for a number of reasons. Some
conflicts relate to the question of who has the right to use or who should assume
the responsibility for birth control; others relate to manifest or latent disagree-
ments about sexual practices, childbearing intentions, or other aspects of the
conjugal relationship such as women's resentment of male power and privilege or
of their husband's drinking, philandering, or failure to support the family. For a
woman who wants to delay or terminate childbearing, the unwillingness of her
partner to use birth control consistently or at all can cause fights and strong
feelings of anxiety, depression, or hostility. Wives who derived little sexual
satisfaction from their husbands were particularly likely to be resentful about
birth control in a study of lower-class families In the United States (Rainwater,
1960~. The powerlessness of a woman in Sri Lanka was expressed this way:
What is die good of refusing [a husband's sexual demands!, dopey will never let us
alone. [If I refuse] he will go to some other woman and then what will become of me
and my children? (Ryan, 1952:376)
Or, in a resentful mood, a Kenyan woman commented:
The men could not care less about family planning you never see a man going
to a family planning clinic. Some, I think, would like to have more children to keep
the women et home (Huston, 1979:144~.
Women who were focus group participants in a study of attitudes toward
natural family planning in the Philippines complained that it was difficult to get
their husbands to cooperate in periodic sexual abstinence when the man got drunk
and became sexually aggressive or lost control (Ve~zosa et al., 1984~. A woman's
fear of unwanted pregnancy naturally extends to a fear of intercourse, but refusing
sex poses its own threats and anxieties. Among a sample of women attending a
family planning clinic in Lebanon, well over half said they had refused on some
occasions to have intercourse during the previous 5 years because of fear of
pregnancy (Chamie, 19773. The anger of some Latin American women who
complain of their menfolk "he uses me"-often centers on men's refusal to
practice birth control despite persistent sexual demands. One study of attitudes
toward family planning in Mexico City found in focus group sessions that a major
6Huston interviewed rural and urban women, literate and illiterate, in Egypt, Kenya, Sudan,
Tunisia, Sn Lanka, and Mexico. For similar comments on the contradictions and instability of
conjugal roles as women perceive them, see Harrison (1983) and Beneria and Roldan (1987).
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PSYCHOSOCIAL CONSEQUENCES 147
cause of women's resentment about their marital situation was a "sense of deep
depersonalization, humiliation, and physical dissatisfaction" caused by their hus-
bands' treatment of them during sexual relations (Lyon et al., 1981~.
In some circumstances women's negative attitudes toward sexuality and to-
ward their partners could be moderated when the fear of unwanted pregnancy is
removed. Indeed, this should be one of the major psychosocial benefits of
cooperative and effective contraceptive use, depending on the method used. We
have little evidence on the effects of different methods on women's sexual
enjoyment and orgasmic capacity, but there is some suggestion that the use of
coitus-dependent methods such as withdrawal or the condom may reduce the
frequency of intercourse and/or the sexual pleasure of one or both parmers as
compared with coitus-independent methods (see, e.g., Verzosa et al., 1984; Cole-
man, 1981~. In any case, women whose husbands can be trusted to practice birth
control consistently often express more positive attitudes about the conjugal
relationship. The expression "he takes care of me" compared with "he uses me"
suggests far more than relief of anxiety about bearing an unwanted child.
A woman who decides on her own to use birth control-either in accordance
with or in defiance of her partner's wishe~incurs a different type of stress from
the woman dependent on her ~er's cooperation. On the positive side, she may
feel in control of her body and confident about her ability to determine her own
sexual and reproductive behavior. But depending on the method used and on
what she has heard or experienced, her anxieties about real or rumored side effects
and about accidental pregnancy can adversely affect her own well-being and the
conjugal relationship. Moreover, she may be resentful at having to carry the
burden of health risks in order to be sexually available to her partner (especially if
she experiences little sexual pleasure herself), or she may be anxious about other
effects of contraceptive use on the relationship, such as her partner's perceptions
of her as being "like a prostitute" or "no longer a woman" (Warwick, 1982, p.
113~. If she uses a method against her partner's will, she may be accused of
sexual promiscuity or be threatened with violence, desertion, or divorce. The
extent to which such threats become personally devastating depends on her access
to adaptive mechanisms such as economic resources and social support
The effects of controlled fertility on conjugal roles are also pervasive. Post-
poning the first birth can eliminate the psychosocial stress associated with a
premarital pregnancy that results in an out-of-wedlock birth or a forced marriage
in which one or both partners feel trapped or the stress incurred within marriage
by an early birth for which a couple is emotionally or financially unprepared.
Similarly, child spacing and limitation may place less stress on the relationship
between sexual partners, other things being equal, leaving more time for couple-
oriented activities. This should result in less role strain or conflict for women and
in higher reported levels of satisfaction with their conjugal relationships.
In settings where family elders place a high value on a first birth soon after
marriage and on more frequent childbearing, however, a couple's (or woman's)
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}48 RUTH DIXON-MUE~ER
decision to postpone or limit births may produce some anxiety in the conjugal role
as it conflicts with the kin role. Being a "good" wife in this sense conflicts with
being a "good" daughter, daughter-in-law, or family member. Moreover, in
circumstances where women are anxious that their husbands might leave them,
frequent childbearing may be seen as a way to prevent desertion or divorce. In
this sense, then, controlled fertility could leave women feeling more vulnerable.
Such fears relate not only to the number of children born but also to child survival.
As an Egyptian woman in a village in the Nile Delta said to an interviewer,
Of course it's important to have more than one child. Do you know what my
husband did after our first two children died, one after He another? He went to his
mower and asked her to find him another wife (Warwick 1982:1()9~.
Less drastically, respondents in the multicountry Value of Children surveys
sometimes stressed the importance of children for strengthening the marital bond
(Fawcett, 1983~. It is not clear how this might be linked to the timing or number
of children, however.
Occupational Roles
Perhaps the most clear-cut area in which contraceptive use and controlled
fertility can reduce psychosocial stress is in women's educational and occupa-
tional roles. Anxiety about having to interrupt or terminate schooling or employ-
ment because of an unwanted pregnancy can certainly be alleviated by the
practice of safe and effective contraception and the availability of safe abortion.
Effective contraception introduces an element of choice, or control, that is gener-
ally associated with lower levels of stress. In particular, contraception or abortion
that results in the postponement of a first birth reduces the likelihood of a woman
having to drop out of school prematurely and either stay home to care for the child
or seek low-wage employment in order to provide minimal economic support. A
study of adolescents in Ibadan, Nigeria, found that almost half of never-marred
female secondary school and university students had become pregnant. Of these,
virtually all of the university students and approximately 80 percent of secondary
school students chose to terminate their first pregnancy by induced abortion so
that they could stay in school (Nichols et al., 1986~.
Similarly, postponement of a first birth and the spacing and limitation of
subsequent births (or the avoidance of childbearing altogether) frees women to
pursue employment less encumbered by the stress of conflicting child care de-
mands and with more time and energy to invest in occupational role performance,
other things being equal. It also helps to avoid interruptions in employment that
can harm the future prospects of not only the minority of women in `'career"
positions but also, in some cases, women in wage work if jobs are hard to find
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PSYCHOS'!AL CONSEQUENCES 149
(Standing, l9X3~. A study of low-income mothers of young children who partici-
pated in the Stress and Families project in Boston, Massachusetts, reported that
"the most common reasons given for stopping work were events such as preg-
nancy, birth of a child, or problems with child care arrangements" (Belle and
Tebbets, 1982, p. 184~. In general, the women associated work with "confidence,
self-esteem, accomplishment, dignity, and independence." Women who wanted
to be working but who were unable to do so experienced more symptoms of
depression than did employed women or those who did not want to work (Belle
and Tebbets, l9X2~.
l
Whether fertility limitation is actually translated into more intensive or exten-
sive schooling and employment and into greater self-esteem deriving from these
roles depends, of course, on the priority a woman places on the occupational role
relative to other roles, on the structure of the labor market that determines the
demand for her labor and the returns she is likely to earn, and on her class
position, among other factors. The women interviewed by Huston in six develop-
ing countries perceived themselves as ``having primary responsibility for the
economic wellbeing of their families . . . provided that society gives them the
opportunity to participate in income-generating economic activities" (Huston,
1979, p. 147~. Indeed, they defined the opportunity to work for pay as of top
priority in solving their economic problems, followed by education Hat would
lead to employment, and access to family planning (Huston, 19791. In mm,
whether fertility limitation actually reduces the stress of combining employment
with childbearing depends on such factors as the time and locational flexibility of
the job and the availability and cost of acceptable child care.
Several qualifications to the generalization about controlled fertility reducing
psychosocial stress associated with occupational roles are in order here. First, in
certain circumstances having fewer children or having children of the "wrong"
sex may actually interfere with the performance of a woman's occupation, thus
creating role strain. Examples include secluded Hausa women in northern Nige-
ria who depend on their children to sell foodstuffs that the women prepare in their
homes or West African women traders, beer brewers, oil pressers, or independent
cultivators for whom children often provide essential labor. Occupational stress
induced by a shortage of child labor can often be resolved, however, by structural
changes such as employing other family members, hiring wage workers, or
fostering the children of kinswomen.
In addition, as Standing (1983) emphasizes in his review of the relationship
between women's employment and fertility, in some circumstances "childbearing
and childraising may in fact not constrain the labor force participation of women,
and may have negligible opportunity costs" (p. 519~. The general argument here
is that some occupations, such as home-based manufacturing (crafts) or agncul-
tural work, are compatible with child care. Conclusions such as these are based
on analyses of the relationship between employment and reproductive patterns,
however. Missing is an analysis of the stress that can be engendered by attempt
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~ 50 RUTH DIXON-MUE~ER
ing to breastfeed an infant or keep track of toddlers while engaging in productive
activities that must constancy be interrupted.
Maternal Roles
Perhaps no role presents women with such rewards and anxieties as mother-
hood. A sample of educated Ghanaian women ranked the maternal role as of
highest priority for their well-being (an average score of 2.9 of 3.0) and as most
satisfying (2.5 of 3.0~; at the same time motherhood was associated with high
levels of strain (inadequate resources of time and energy, among others) and with
a considerable gap between expectations and reality (Oppong and Abu, 1987~.
Any parent will quickly identify with the stress as well as the pleasures of rearing
children. As a woman interviewed in Mexico remarked, "My children are my
greatest source of happiness, but also my greatest worry" (Warwick, 1982? p.
113~. The theme of women's ambivalence about the maternal role appears
throughout much of the ethnographic literature.7 Cross-cultural demographic
research on the value of children suggests that wives often place more importance
than husbands do on the social and economic benefits from children but are also
more sensitive to the personal costs of raising them (Fawcett, 1983~.
The question of interest here is whether contraceptive use and controlled
fertility might contribute to lower levels of psychosocial stress (anxiety, depres-
sion, hostility) associated with pregnancy, childbirth, and parenting. This paper
does not address the issue of involuntary subfecundity or sterility which can
produce extremely high stress levels among individuals or couples desiring to
become biological parents.
The psychosocial benefits of contraceptive use and controlled fertility to
women who are at high risk of pregnancy-related disabilities or even death are
obviously great These risks may be associated with a woman's individual
characteristics, her class position, or Me environment of health care services.
Women often express fear of disability during pregnancy and of excruciating pain
or death in delivery.8 Women also express anxieties about miscarriage, stillbirth,
7For a review of some of this literature and an illustration from El Salvador, see Harrison (1983,
pp. 62-75).
Was Harrison (1983) notes,
Childbirth is often prolonged and painful particularly for primiparas, and all societies have
developed special techniques for dealing with difficult births.... Pear of pain is accanpanied by
apprehension about wholeness and viability of the fetus, about whether fetal presentation will be
favorable to an easier birthing, and about survival itself. The ethnographic evidence simply does not
substantiate the clann that the fear and pain associated with childbirth is an artifact of Western
civilization (p. 69).
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PSYCHOSOCIAL CONSEQUENCES 15 t
birth defects, and infant and child death, all of which have the potential of causing
intense emotional distress. Other things being equal, controlled fertility should
contribute to reductions in psychosocial stress associated with entry into the
maternal role.9
The ethnographic literature also suggests that women are often extremely
worried about their ability to provide adequate care for their children, are de-
pressed at their apparent inability to do so, or are hostile about the failure of other
persons or institutions to help them. At the minimum, adequate care means
sufficient breast mills and food, clothing, shelter, and protection from accidents,
illness, and death. Beyond sheer survival it means economic resources for
medical care, schooling, and other investments; time and energy for individual
attention to each child; appropriate socialization to age-related responsibilities;
and the transmission of cultural values and practices.
In general, one would assume that voluntary postponement of the first birth,
longer spacing of subsequent births, and the termination of childbearing at an
earlier age would ease the stress of the maternal role by reducing women's
anxieties about providing adequate care. In Huston's (1979) interviews in six
developing countries, for example, most women considered smaller families
(however defined) to be more desirable and identified the availability of modern
contraceptives as a positive change compared with their mothers' lives:
In expressing their views about planning their families, the women seemed to be
less concerned about themselves dean about their ability to provide for their children
[especially education for good jobs]. When they did speak about themselves, it was
in terms of their heals and the fact that child spacing would give them strength (p.
135~.
On the other hand, controlled fertility may not reduce the stress associated with
raising children if role expectations escalate with regard to the time or intensity of
maternal investment along with aspirations for children's "success." The oft-
cited anxieties of Japanese mothers who are preoccupied with their children's
academic achievements staring even prior to their enrollment in kindergarten is
just one example. In other words, the nature and severity of the stresses relating to
maternal role performance are strongly related to social class and cultural expe~c-
tations. In addition, as Figure 1 suggests, stresses induced by maternal role strain
or role conflict can be mediated by adaptive mechanisms such as social support
networks (e.g., assistance from a husband or other family members with child
care) or structural changes.
Recent research suggests that the effects of later first births and lower parity on maternal and
infant deaths in some developing countries may be small, however. See, for example, Winikoff and
Sullivan (1987) and Trussell and Pebley (1984).
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52 RUTH DIXON-MUE=ER
Domestic, Kinship, and Community Roles
Space does not permit a detailed analysis of the possible effects of contract
live use and controlled fertility on each of these roles. A few points will be
highlighted here.
The domestic role refers to women's housekeeping obligations such as cook-
ing, cleaning, washing, shopping, etc. The sample of educated Ghanaian women
ranked this sixth of the seven roles in priority, the lowest in derived satisfaction,
and the highest in role strain (inadequate time, energy, and money) (Oppong and
Abu, 1987~. Women throughout the world complain particularly of the stresses of
the "double day," when conjugal, maternal, and domestic role expectations are
heaped on top of occupational roles with little modification. Women's anger is
often palpable:
I work in the field, opposite the men, seven hours of hard work, and then I go
home, and I am required to play the role of housewife 100 percent, cleaning, and
washing for the children (Huston, 1979:135~.
I am working outside and inside. I am doing a dual job. Some people Wink diet
work is liberation of women. It is not liberation. Sometimes it is just Mat women
are more exploited (Huston, 1979:135~.
The extent to which controlled fertility eases the stress of this role depends on
many factors, including household size; age and sex composition; standards of
upkeep; and the availability of additional help from household members or from
other relatives, neighbors, or paid workers. In general, one would assume that
having fewer children and spacing them further apart eases domestic role per-
formance. Yet, as in the case of child care, standards for domestic role perform-
ance can escalate with rising incomes, among other factors. Moreover, the
literature on sex preferences and the value of children indicates that most women
hope to have at least one daughter even in countries with very strong preferences
for boys, primarily (but not solely) because girls help around the house more than
boys do. In this sense, then, the failure to bear a daughter could exacerbate
domestic role strain, especially if there are many sons and little help from others.
The kinship role refers to a woman's relationship with her affinal and consan-
guineal kin and in some cases with "fictive kin" (e.g., godparents to herself or her
children) upon which much of her social and economic security and survival may
depend. Good relations with kin can endow women with considerable satisfac-
tion and self-esteem. On the other hand, the kin role can be highly conflicted. A
woman may resent her husband's filial obligations to his parents or other elders if
they conflict with his conjugal obligations to herself and their children, for
example. She may be caught in a dispute between her own and her husband's kin
over a dowry or bride price, with her husband's brothers over property when she
becomes widowed, or with cowives over the allocation of resources to children in
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PSYCHOSOCIAL CONSEQUENCES 153
a polygamous marriage. The expectations of kin regarding a woman's contracep-
tive practices and childbearing may conflict sharply with her own wishes, particu-
larly when elders expect to maintain control over the sexual and reproductive
decisions of the younger generation through mechanisms such as arranged mar-
riages and extended household residence.
In speculating on the potential impact of contraceptive use and controlled
fertility on kin relations, then, we would have to know whether such behavior is
generally supported by significant kin, ignored, or specifically opposed and
criticized. A woman whose behavior is viewed as deviant may experience
considerable guilt, anxiety, or hostility when she seeks contraceptive services or
"fails" to produce a child, or the socially "appropriate" number of children, or a
son. Such examples are common. A wife interviewed in the Nile Delta region in
Egypt commented:
The bride must get pregnant right away. I stayed four months after marriage
without getting pregnant. I was very worried. Everyone was anxious to find out
whether I was pregnant or not. Every time I had my period my husband's family
tallied about me (Warwick, 1982:109~.
On the other hand, fulfilling the reproductive expectations of the kin group
often brings women real satisfaction:
My husband's family treated me differently after I had the first child. I felt
setded and secure among them. I became one of them. They all called me "mother
of Hassan" (Warwick, 1982:109~.
We might include women's concerns about who will support and take care of
them in their old age under the general topic of kin roles, although such concerns
relate more specifically to the maternal and conjugal roles. The absence of sons
or daughters who are able and willing to care for an aged parent creates a strong
potential for anxiety or depression among women without alternative means of
support. In the Egyptian study noted above, "the fear of being a widow without
children, and especially without sons [was] one of the strongest motives for
women to produce more children than they might ideally desire. [Without sons, a
woman] does not feel at ease (Warwick, 1982:113~." The absence of children for
support in old age is likely to strain women's relations with consanguineal or
atonal kin as well, for one of those relatives may have to take on the responsibility
of her care, willingly or not.
Beyond He kin group, women play a role in community relations that may be
broad or limited and of high or low priority, depending on many factors. As noted
in the discussion of kin roles, contraceptive use may or may not be stressful
depending in part on community attitudes and practices: the judgment of reli-
gious leaders, for example (and the salience of these to the individual or couple),
and the prevalence of con~eptive information and use in the community.
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|54 ROTH DIXON MUELLER
Community activities include participation in religious and ceremonial events,
political meetings, sports and recreation, entertainment, community projects, and
general public socializing, among other events. Fertility limitation may or may
not facilitate women's involvement in community activities. In some respects it
could act in a manner similar to women's occupational roles. In other respects,
however, having more rather than fewer children could encourage community
involvement, given that many community activities are child related and children
often involve adults in social interactions that transcend other roles. These
community roles could be stress inducing if they conflict with other roles or they
could be stress reducing if they integrate women into supportive social networks,
increase women's access to other resources, and heighten women's sense of
community identity and self-esteem.
Women as Individuals
The role of "individual" is listed last, not because it is unimportant but because
for many women, especially those with large families living in poverty, it is the
role that women have the least time for. The content of this role includes
activities such as pursuing personal interests; relationships with friends; and
identities relating to women as persons, as individuals, as "themselves." The
educated Ghanaian women rated the role as lower priority on average than their
parental, conjugal, occupational, and kin roles (in that order) but among the most
satisfying (Oppong and Abu, 1987~.
It is difficult conceptually to separate a woman's individual role from others
because her self-perception often derives primarily from her roles as wife or
lover, worker, mother, daughter or daughter-in-law, and so on. Nevertheless,
several aspects of the individual role deserve mention here.
The first relates to how contraceptive use affects women's self-perception. As
mentioned previously, it can contribute to heightened self-esteem where women
believe they are now in greater control over their sexuality and reproductive
capacity and thus, perhaps, over other aspects of their lives as well. Yet contra-
ceptive use also has psychosocial costs to women as individuals.~° One involves
fears about health consequences of contraception, abortion, or sterilization, based
either on rumor or fact. Depending on the method, these fears include but are not
limited to dizziness, physical weakness, pain, nausea, altered menstrual flow,
cancer, bodily darnage, temporary or permanent sterility, and even death. They
also include concerns about whether to continue or discontinue a particular
method. A second cost relates to worries about using a method correctly or
consistently, such as talking a pill every day or inserting a diaphragm or cervical
~ - e following points are discussed In greater detail in, among many others, Scrimshaw (1976),
Hollerbach (1982), and Bruce (1987).
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PSYCHOSOCIAL CONSEQUENCES
155
cap correctly, and the associated self-perception as a person who is "unnaturally"
or perhaps "sinfully" trying to avoid or terminate a pregnancy. A third cost relates
to the psychosocial stress of obtaining services and supplies. Encounters with
service providers often cause great emotional distress, especially in clinic settings
requiring pelvic examinations where clients feel frightened, confused, humiliated,
and shamed. Women attending urban clinics in Morocco, for example, com-
plained bitterly of degrading and dehumanizing treatment by clinic personnel:
If you make a mistake, if you mispronounce a word, the name of a syrup or a pill,
the nurse laughs at you, calls her colleagues to tell them the story and points at you.
You feel the floor crumble away under your feet (Mernissi 1975:424~.
Another woman adds:
.
When we are waiting to gee into a gynecological service, they will shout at us.
'`Take off your pants before going into the doctor's office.'' You take off your pants
in the hall and sit there waiting. There are . . . people walking by. You feel inhuman
(Mernissi, 1975:424~.
Clearly, then, psychosocial stress induced by the act of obtaining birth control
services should clearly be considered in any cost-benefit analysis in addition to
the stress engendered by their use.
Finally, there is the question of how women's roles as individuals are affected
by fertility limitation. Delaying the first birth, spacing subsequent births, and
limiting the total number should leave women more time to pursue their own
interests as individuals (other things being equal) and perhaps to develop a
stronger individual identity. This is particularly true of women who avoid
childbearing altogether. Yet whether fertility limitation translates into a more
individualized role or a more positive or negative self-image for women depends
on many factors.
Much depends on the structural and cultural opportunities provided to women
for individual role behaviors in each society and on the relative priorities that a
woman herself places on the individual role compared to others (particularly,
mamage and motherhood) in her role profile. Where opportunities are plentiful
and priorities high, fertility limitation should reduce individual role strain and
thus the stress engendered by having "no time for myself' or wondering "who am
I?"
Yet marriage and motherhood are highly valued in all societies. Women who
remain childless by choice or who have one or two children may be viewed as
selfish, irresponsible, or unnatural!, while those with larger families are often seen
Thor a review of literature on provider-client transactions, see Lapham and Simmons (1987).
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i56 RUTH DIXON-MUR~ER
as warm, loving persons who are willing to make sacrifices and take on adult
responsibilities. (Having "too many" children may also be viewed as selfish or
irresponsible in some settings, however.) Women may consequently experience
considerable anxiety about their worth as persons if their reproductive behavior
deviates significantly from the social norms of their group. Once again, however,
psychosocial stress can be diluted by the adaptive mechanisms identified In
Figure 1. In particular, if the environment offers some choice and a woman has
the resources, she can seek out those activities and social networks that offer the
strongest conflation of her role as an individual.
CONCLUSIONS
With few exceptions the demographic analysis of the health consequences to
women and children of contraceptive use and controlled fertility has essentially
ignored the question of mental health.~3 Yet the psychosocial consequences to
women of contraceptive use and controlled fertility both positive and nega-
tive-are no less compelling than the consequences to their physical health and
life chances.
Because most reproductive events and conditions are highly charged emotion-
ally and socially, it is essential that the psychosocial as well as physical conse-
quences of reproductive behaviors be routinely included in any calculus of health
benefits and risks. In a parallel fashion it is not just maternal mortality or
morbidity that are relevant but also the broader notion of reproductive mortality or
morbidity (or, conversely, reproductive health), which encompasses the health
risks and benefits involved in attempts to prevent pregnancy as well as of preg-
nancy, childbirth, and sexual behaviors.~4 Third, the question of how women and
men throughout the population perceive and interpret health consequences may
be as important to our understanding as are the formal measures of morbidity and
mortality routinely collected.
~ ~ . . . .
three distinct (although interrelated) dimensions of psychosocial stress have
been identified in this paper anxiety, depression, and hostility. Clearly, such
attitudes and behaviors are not easy to measure. Some women may express such
feelings verbally; others suffer in silence; still others act out in compulsive or
damaging behaviors. Anxiety, depression, and hostility may also be expressed in
real or imagined physical symptoms. A study of rural women in E1 Salvador, for
example, identified a remarkable range of psychophysiological "folk" symptoms
that compare with standard definitions of anxiety states and depressive neurosis
(Harrison, 1983~. Many of these symptoms were attributed to stresses relating to
i2See, for example, Rainwater's (1960) study of lower-class couples in the United States.
i3A major exception to the charge of neglect is represented by Bogue's (1983) review article. See
also Schearer (1983).
~4See the discussion of risks of pregnancy prevention in Winikoff and Sullivan (1987).
OCR for page 157
PSYCHOSOCIAL CONSEQUENCES -157
reproductive patterns, child survival, and contraceptive use, over and above those
engendered by other factors such as poverty and fears of the supernatural.
In analyzing the psychosocial consequences to women of contraceptive use
and controlled fertility, it is helpful to identify the ways in which such behaviors
affect women's perceptions of their performance of seven social roles: conjugal,
occupational, maternal, domestic, kin, community, and individual (Oppong and
Abu, 1987~. Reproductive behaviors that intensify rather than reduce role strain
or role conflict, particularly among those roles that a woman defines as most
salient to her security and survival, are likely to be the most stressful. Negative
outcomes may be reduced or avoided by adaptive mechanisms such as social
support networks, economic resources, information, and structural changes that
alleviate role strain or conflict and the resulting psychosocial stress.
Each of the four main elements in this model of reproductive behavior and
psychosocial stress differs significantly among women according to numerous
individual, group, and environmental characteristics: the nature of reproductive
events and conditions (the potential '~stressors" of primary interest in this model);
the content and configurations of social roles; the nature and availability of
intervening adaptive mechanisms; and the frequency, nature, and intensity of
symptoms of psychosocial stress. Each element is also highly relevant to popula-
tion and health policy in ways that cannot be pursued here. The four elements and
their interconnections are intertwined in personal life histories and are deeply
imbedded in social structures and ideologies of kinship, class, and caste. Further
research on this topic requires not only culturally sensitive measures of psychos
cial stress but also an analysis that is sensitive to the content in which sexual and
reproductive behavior acquires meaning.
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Representative terms from entire chapter:
psychosocial stress
