An exploratory study of women’s role in reproductive decision making in Ekiti shows that women in the state are increasingly taking active decisions on matters affecting their daily lives. More women than ever before believed that they could take decisions on family size, when to have a baby and choice of spacing period. The cultural barrier against short postpartum abstinence appeared to have diminished and sex during lactation was not considered a major cultural and religious taboo. Knowledge of contraception has become universal in recent years, and the majority of women take decisions on the method and timing of family planning. All women who used family planning considered their decision in this regard very important. The ability of women to take decisions on these issues may not only enhance their bargaining power but also reduce their vulnerability to STDs including AIDS from diseased or high-risk partners

Oguntimehin, F

Orubuloye, I. O

Sadiq, T

The Australian National University

Health Transition Review, Supplement to Volume 7, 1997, 329-336Women’s role in reproductive health decisionmaking and vulnerability to STD andHIV/AIDS in Ekiti, Nigeria *I.O. Orubuloye a, F. Oguntimehina and T. Sadiqba Department of Sociology, Ondo State University, Ado-Ekiti, b Centre for Population andHealth Research (CEPHER), PO Box 1904, Ado-Ekiti, NigeriaAbstractAn exploratory study of women’s role in reproductive decision making in Ekiti shows that womenin the state are increasingly taking active decisions on matters affecting their daily lives. Morewomen than ever before believed that they could take decisions on family size, when to have ababy and choice of spacing period. The cultural barrier against short postpartum abstinenceappeared to have diminished and sex during lactation was not considered a major cultural andreligious taboo. Knowledge of contraception has become universal in recent years, and themajority of women take decisions on the method and timing of family planning. All women whoused family planning considered their decision in this regard very important. The ability ofwomen to take decisions on these issues may not only enhance their bargaining power but alsoreduce their vulnerability to STDs including AIDS from diseased or high-risk partners.It is now well recognized that sub-Saharan Africa has been affected by the AIDS epidemicmore than any other part of the world. It has also been confirmed that a large proportion ofAfrican women suffer from a wide range of reproductive health problems including sexuallytransmitted diseases such as HIV/AIDS, and from other harmful traditional practices such asfemale circumcision. In this situation a major social and health concern is the extent to whichwomen take decisions on their reproductive health. In Nigeria and indeed among the Yoruba,there is a very strong link between social and economic factors and the reproductive healthproblems confronting women. The culture of male dominance means that women seldom takedecisions on matters affecting them. Lack of power leaves women unable to negotiate safesexual practices or effectively seek care for their health problems, while men's unwillingnessto control their sexual behaviour and the high incidence of STDs make women vulnerable toinfection by men.The role of women in economic development has become a major issue in recent times.Although most sub-Saharan African women are major producers and are responsible for thegreater part of the labour in farming, certain aspects of the culture have traditionallysuppressed the ability of women to take decisions even on matters that affect them. Thepurpose of this exploratory study, therefore, is to examine the extent to which women areinvolved in decision making on their reproductive health and the extent to which suchinvolvement can reduce their vulnerability to sexually transmitted infection._________________*Paper presented at the SAREC/SIDA Workshop on Individual and Collective Vulnerability toSTD/HIV in Africa held at the University of Ghana, Legon, Accra, 10-12 October 1996.330  I.O. Orubuloye, F. Oguntimehin and T. SadiqSupplement to Health Transition Review Volume 7, 1997The studyThe study reported here was conducted in June-July, 1996 in two locations, one rural and oneurban, in Ekiti , which has since 1 October 1996 become a state. The two different locationswere selected for purposes of comparison. Ekiti is suitable for the study because women in thearea have traditionally enjoyed certain rights and control over their sexuality. In addition,Ekiti has been a major laboratory for the collaborative Ondo State University - AustralianNational University research program on Sexual Networking, STDs and HIV/AIDS since1989.Ekiti state is situated in the northernmost part of the area inhabited by the Yoruba; thecapital is Ado-Ekiti where the urban sample was taken. Ado-Ekiti had a population of about150,000 people in 1991. It is also a major commercial and educational centre in the state.With the creation of the state in 1996, the population of Ado-Ekiti has probably risen tobetween 200,00 and 250,000. It is a university town and has a polytechnic, about a dozenpublic secondary schools and a high density of public primary schools. Ado-Ekiti also enjoysa high concentration of both private and public health institutions and an array of patentmedicine and pharmaceutical stores. Traditional medical homes also abound.The rural location with a population of about 1,200 is 20 kilometres from Ado-Ekiti. Thevillage was founded by an Ado-Ekiti farmer and warrior who fought to defend the townduring the inter-ethnic wars of the nineteenth century; it has become a major rural weeklymarket that serves Ado-Ekiti and the neighbouring towns and villages. The historical andeconomic links between Ado-Ekiti and the village make the choice appropriate.Since the study is exploratory, a random sample of only 100 respondents was drawn fromeach of the selected urban and rural locations. Three different types of interview schedulewere used. The first contained questions on the household; the second was administered to theprimary respondents, and the third to the ‘significant others’ nominated by the primaryrespondents. This paper is based on the schedule administered to the primary respondents. Inaddition to questions on the characteristics of the respondents, decision-making on economicactivities and household expenditure, the schedule contains questions on decision-making oneducation; task allocation; marriage; health; nutrition; circumcision and immunization;fertility and conception; breastfeeding and weaning practices and sexuality.The findingsTable 1 presents the characteristics of the respondents. Except for education, religion and typeof marriage, there are basic similarities in the characteristics of the urban and ruralrespondents, the majority of whom were aged 30-40 years, had at least primary schooleducation and were in stable marital conditions. While most women in the urban locationwere in monogamous marriages, a majority of those in the rural location were in polygynousones. The situation in the village is typical of most rural farming communities in Yorubalandwhere men need more than one wife to provide additional labour in both farming andmarketing of farm products. Although Christianity is the dominant religion in both the ruraland urban locations, the proportion of Muslims in the rural area is four times that of the urbanarea.Table 1Characteristics of respondents (percentage distribution)Urban RuralAge (n=100) (n=100)Under 30 years 10 1530-40 years 80 70Women’s role in reproductive health decision making and vulnerability to STD and HIV/AIDS  331Supplement to Health Transition Review Volume 7, 1997Above 40 years 10 15EducationNo schooling  0 50Primary only 35 20Secondary only 30 20Tertiary 25  0No response 10 10ReligionChristianity 90 60Islam 10 40Type of marriageMonogamy 70 40Polygyny 30 60Decision-making on family sizeThe respondents were asked a battery of questions on decision-making on family size andspacing of births. The responses are presented in Table 2. Asked whether women could decideon the number of children to have, more than half the urban and two-fifths of the rural womenbelieved that women have the ability to take such decisions. However, the pattern ofresponses to whether a woman should decide the number of children to have is slightlydifferent. Three-fifths of both urban and rural women thought that a woman should be able totake such decisions without reference to her husband. Nevertheless, three-quarters of theurban and slightly more than half the rural women had ever discussed with their partnerswhen to have a baby. On spacing of births, nearly all the women in the urban area and slightlymore than half of the rural ones reported that the decision to space births was jointly takenwith their husbands.The pattern observed in this study represents a major change from the traditional positionwhere the husband took decisions on the number and spacing of children. The change islargely a product of Western education, the increasing economic independence of women andthe effects of the structural adjustment program of the last ten years which has led to thegradual erosion of the economic superiority of men over women.Decision on family planningYoruba women have traditionally observed a long period of postpartum abstinence,sometimes as long as 30 months, as a mechanism of child spacing (Orubuloye 1981). Duringthe long postpartum period, sexual relations were prohibited and the woman had the absoluteright to refuse sexual advances from her husband. The society protected and guaranteed suchrights (Orubuloye 1995). The cultural beliefs supporting long postpartum abstinence appear tobe diminishing. Only two-fifths of the urban and one-tenth of the rural women now think thatthere are still cultural-religious beliefs against a woman having sex during lactation, while afew of both urban and rural women believed that the period of postpartum abstinence shouldextend beyond 12 months. By 1991, for the majority of Yoruba women, the period ofpostpartum abstinence had fallen below 12 months (Caldwell, Orubuloye and Caldwell 1992)in contrast to the situation 15 years earlier. The situation has changed. The contraceptiverevolution in Ekiti started with the structural adjustment program and the national policy offour children per woman which were put in place in 1986 and 1988 respectively. By June1996, knowledge of family planning had become almost universal. Only one-fifth of the urbanand rural women did not know any method of family planning. Two-thirds of the urban332  I.O. Orubuloye, F. Oguntimehin and T. SadiqSupplement to Health Transition Review Volume 7, 1997women and three-fifths of the rural ones knew of one or two modern methods ofcontraception, the chief being the condom.Table 2Family size and birth spacing (percentage distribution)Questions Responses FrequencyUrban RuralCan women decide the number of children to have?Yes 55 40No 35 50Can’t say 10 10Should a woman decide the number of children to have?Yes 60 60No 25 25Can’t say 15 15Who decides on the spacing of your children?Self  0 25Husband  5 10Self & husband 90 55By chance  5  5Others  0  5Ever discussed with husband when to have baby?Yes 75 55No 25 40No response  0  5Do you know any method of family planning?Yes 95 90No  5 10Are you currently using a method?Yes 20 10No 75 55No applicable  5 35One-fifth of the urban women and one-tenth of the rural ones were currently usingcontraception. The condom and the rhythm method were used and the decision to use thesemethods was taken by both partners. Women using family planning considered their opinionin this regard very important. The major sources of information on family planning wereantenatal clinics, hospitals, and the media (radio and television). While the school was equallyimportant in the urban area, friends and relations were important sources of information in therural areas.The supply of contraceptives, especially condoms, had increased since the campaignagainst STDs and AIDS began four years ago. The supply is now seriously threatened by thesanctions recently imposed on Nigeria by many foreign international agencies. The shortagehas resulted in increase in price, which will probably have serious implications forcontraceptive use, especially because of the drop in income and the decline in the value of theNigerian currency.Decision-making on health treatmentWomen’s role in reproductive health decision making and vulnerability to STD and HIV/AIDS  333Supplement to Health Transition Review Volume 7, 1997In recent years, the person taking treatment decisions has become important for healthintervention programs because of the progressive deterioration in health care facilities andmore importantly because of the social and health problem posed by AIDS. It has now beenfirmly established that treatment decisions are delayed because of cost, and when thedecisions are made by the woman in respect of her own health or that of her children, thewoman pays for such treatment (Orubuloye et al. 1991). When decisions on treatment aretaken by both husband and wife, they jointly pay for treatment. The result of furtherinvestigation on this subject indicates that nearly all the women (95% urban and 90% rural)were involved in the decision to seek treatment when they or their children were sick. All thewomen considered taking part in the decision as very important to them.The findings are important, and may have serious implications for health care in the eventof STDs and AIDS. It appears that women will be able to take part in decision making forhealth treatment if they suffer from STDs or AIDS. Because of the economic independence ofmost Yoruba women, they are far more likely to do this and their families will support thisposition, and may even take the initiative.Decision making on sexual activityThe right of African women over their sexual activity has become the subject of debate sincethe advent of AIDS, partly because the heterosexual transmission of the disease is dominant inthe African region, and partly because the majority of HIV-positive women in the world arefound in the region (Orubuloye, Caldwell and Caldwell 1993). It has also been establishedthrough research that although women have on average fewer sexual partners than do men,they have little control over the sexual activities of their husbands and are vulnerable toinfection by these partners. Table 3 presents the results of the series of questions on thepossibility of women refusing sex with their partners under varying conditions.The pattern is as expected. Most rural women are in polygynous marriages and theirhusbands can always turn to other wives if they refuse them sex. Women in the rural areaeither live among or close to their family members, so they can always get support or return tothem if they quarrel with their husbands on such matters.When husbands are infected, nearly all women will refuse to have unprotected sexualrelations with them. Nevertheless, 45 per cent of urban women compared to 50 per cent ofrural women would ask their infected partners to use condoms, while 30 per cent urban and 35per cent rural were undecided.Table 3Ability of women to refuse sex (percentage distribution)Questions Responses FrequencyUrban RuralCan a woman refuse sex with a partner if she does not want another baby?Yes 35 70No 50 25Don’t know 15  5Can a woman refuse sex with an infected partner?Yes 95 95No  5  5Can a woman ask an infected partner to use a condom?Yes 45 50No 25 15Undecided 30 35334  I.O. Orubuloye, F. Oguntimehin and T. SadiqSupplement to Health Transition Review Volume 7, 1997Does a woman have the right to refuse sex with her partner?Yes 70 75No 30 25Importance of opinion in reproductive health decision-makingThe involvement of women in decisions relating to health treatment, use of contraceptives andbreastfeeding was nearly universal. To understand the degree of involvement, an attempt wasmade to identify individuals whose opinions are important when reproductive decisions are tobe taken. The responses are presented in Table 4, which shows that the opinion of women,both respondents and significant others, about reproductive health is considered veryimportant most of the time. Probably such matters are of more concern to them than to men.For instance, during the field investigation, one of the respondents reported that the decisionto stop breastfeeding a child rests with the mother. A man can tell his wife to stopbreastfeeding so as to resume sexual relations early, but it is usually the responsibility of thewife to decide when to wean a child.DiscussionThe findings of this exploratory study show that women in Ekiti are increasingly taking activedecisions on matters affecting their daily lives. More women than ever before believe thatthey can take decisions on family size, when to have a baby and choice of spacing period. Thecultural barrier against short postpartum abstinence seems to have diminished while sexduring lactation is not considered a major cultural and religious taboo. Knowledge ofcontraception has also become universal in recent years and the majority of women takedecisions on method and timing of family planning. All users of family planning consideredtheir opinion in this regard very important.Most women take part in decisions on when to seek health treatment for themselves ortheir children. Nearly all the women considered taking part in the decision as important tothem. The majority of women believed in their right of control over their sexual activity andwould insist on this right when their husbands were diseased. A good proportion would refusesex with infected husbands or if they did not want another baby.Table 4Persons whose opinions are important in decision-making on reproductive matters (per centdistribution)Subject Relationship torespondentSex Importance ofopinionPercentageRural UrbanChild’s treatment Husband M 1 85 70Husband M 2 - 15Respondent F 1 95 90Sister F 1  5 -Daughter F 1  5 -Neighbour F 1 10 -Co-wife F 1  5 -Mother F 1  5 -Own treatment Husband M 1 80 80Respondent F 1 85 80Respondent F 2 - 10Women’s role in reproductive health decision making and vulnerability to STD and HIV/AIDS  335Supplement to Health Transition Review Volume 7, 1997Neighbour F 1  5  5Co-tenant F 2  5 -Sister F -  5 -Co-wife F 1  5 -Son M 1  5 -Daughter F 1 10 15Sister-in-law F 2  5 -Having a child Respondent F 1 50 75Respondent F 2 25 -Respondent F 3 10 -Mother F 2  5 -Breastfeeding Husband M 1 40 15Husband M 2  5 -Respondent F 1 50 55Mother F 2  5 -Co-tenant F 1 -  5Contraceptive use Respondent F 1  5 20Doctor M 1  5 -Note: 1 = Very important; 2 = Quite important; % is calculated in terms of the ratio of positive responses toquestions relating to the subject matter.These findings are important for possible intervention programs that can halt the spreadof STDs including AIDS. With the current economic situation arising from the structuraladjustment program, women were less reluctant to make decisions in respect of family size,family planning and health treatment for themselves or their children. Yoruba women havetraditionally received support from relatives when they refuse sex with a husband who isdrunk or making a deliberate effort to shorten the period of postpartum abstinence. In recenttimes, such rights are now being transferred to when a spouse is infected with an STD. Thisagain may be applicable to AIDS. The ability of women to take part in decisions on mattersthat affect their daily lives will not only enhance their bargaining power but also reduce theirvulnerability to STDs including HIV if their partners have a high-risk sex life or are diseased.Certainly, women need the support of the community and possibly that of the government toreduce the dangers posed to them by irresponsible partners.ReferencesCaldwell, J.C., I.O. Orubuloye and P. Caldwell. 1992. Fertility decline in Africa: a new type oftransition? Population and Development Review 18,2:211-242.Orubuloye, I.O. 1981. Abstinence as a Method of Birth Control. Canberra: Australian NationalUniversity.Orubuloye, I.O. 1995. Women's control over their sexuality: implications for STDs and HIV/AIDStransmission in Nigeria. In Women's Position and Demographic Change in Sub-Saharan Africa, ed.P. Makinwa-Adebusoye and A.-M. Jonsen. Liège: IUSSP.Orubuloye, I.O., J.C. Caldwell, P. Caldwell and C.H. Bledsoe. 1991. The impact of family and budgetstructure on health treatment in Nigeria. Health Transition Review 1,2:189-210.336  I.O. Orubuloye, F. Oguntimehin and T. SadiqSupplement to Health Transition Review Volume 7, 1997Orubuloye, I.O., P. Caldwell and J.C. Caldwell. 1993. African women's control over their sexuality in anera of AIDS. Social Science and Medicine 37,7:859-872.

Women's role in reproductive health decision making and vulnerability to STD and HIV/AIDS in Ekiti, Nigeria

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