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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions
married and even currently married men report higher rates than do single men. Many Africans consider it legitimate for a man to have sexual access to cowives, mistresses, or commercial sex workers during any particular wife's postpartum period. Indeed, the ease of availability of alternative sexual partners is cited by many women as an important reason for reducing the period of postpartum abstinence. In this sense, the right of a wife to refuse sexual relations may be a double-edged weapon. When submission to sexual advances, however unwanted, is the only route to other kinds of economic or domestic security, the right to refuse sex may mean very little in practice.2
One reason for refraining from sexual activity in many cultures has been the fear of an unwanted pregnancy in the absence of other fertility control methods. This issue can be separated into two parts. First, can a woman insist on the use of contraception in such cases, and then if her partner is noncompliant, can she refuse sexual intercourse? This question in turn hinges on a woman's ability to practice contraception herself, with or without her partner's consent. If fears of unwanted pregnancy legitimize a woman's refusal of sex, then freer access to contraception can in one sense worsen women's control over their bodies: while contraceptives may free women from the burden of unwanted pregnancies, they may at the same time remove one of the few excuses accepted by men to avoid unwanted intercourse (Folch-Lyon, Macorra, and Shearer, 1981).
The health implications of the lack of a right to refuse sexual intercourse are even more serious when one examines the right to refuse unsafe sex. The current evidence on this matter is scarce, but there is some evidence that in many parts of Africa, the fear of infection is slowly becoming a legitimate ground for refusing sexual relations, most likely due to the increasing prevalence and awareness of HIV infection. For example, Orubuloye, Caldwell, and Caldwell (1993) report that among the Yoruba in Nigeria, women now feel more free to refuse sex with infected partners. Similarly, Awusabo-Asare, Anarfi, and Agyeman (1993) found their female respondents in Ghana relatively free to refuse sexual relations with a partner infected with an STD. However, a refusal based purely on a partner's promiscuity, where an infection was not established, was not believed to be similarly valid.
Healthy sexuality in the more positive sense of access to sexual relations can be thought of under three separate aspects: control over when sexual activity starts, control over the choice of one's sexual partner, and
Sexual relationships are as hierarchical as, and often mirror, other kinds of gender inequality and power structures. Increasing women's sexual autonomy may result from improvements to female status in areas that have no obvious connection with their sexuality.