A Conceptual Framework for the Social Analysis of Reproductive Health
Price, Neil L., Hawkins, Kirstan, Journal of Health Population and Nutrition
Reproductive behaviour is embedded within specific social relations and political and cultural contexts. Creating conditions which support behaviour change--a critical dimension of health and HIV/AIDS policy and programme development--requires analysis of these contexts. However, the dominant conceptual framework for understanding reproductive behaviour is highly individualistic, derived from the fertility cost-benefit models espoused by Becker (1) and Easterlin (2), with the unit of decision-making being the individual or the 'reproductive' couple (3,4--for useful summaries of cost-benefit models in fertility theory). Ethnographies have demonstrated that such a paradigm is flawed both in its understanding of human action and in its assumptions about the central units of reproductive decision-making. Far from being an individual decision-making process, reproductive behaviour is shaped by social relations and institutions at the local level, such as kinship groups, informal social networks, local political institutions, and religious and spiritual advisors and healers, which are influenced by and the product of the wider social, political, economic and historical processes (511).
Inattention to context is evident in many reproductive health interventions and policies. For example, the reproductive rights discourse focuses on the rights of the individual, often to the exclusion of the wider social and economic conditions within which rights are defined and realized. Such a perspective underplays the extent to which the poor and vulnerable are unable to realize their rights to the economic and social resources vital for the protection of their health and well-being.
In this article, we demonstrate the need for social analysis to generate an understanding of the diverse contexts of reproductive health, the ways in which needs and priorities are identified, especially among marginalized groups * and addressed (through inter alia health-service provision) and the social dynamics of exclusion and vulnerability. We start with ethnographic illustrations of how sociocultural, economic and political factors shape reproductive behaviour in relation to four key areas: fertility, culture, gender, and sexuality. We limit our discussion to these four themes because of space limitations, and, in part, because of our professional expertise. However, we acknowledge the impact of wider factors on reproductive behaviour, such as education, access to healthcare, occupation, marital status, and harmful traditional practices.
Following the discussion of context, we set out a framework for conducting a social analysis. Data generated by such a social analysis will enable programmes to assess appropriate means of improving the responsiveness of service-delivery structures, including the quality of care they provide. The article concludes by briefly identifying key interventions and strategies indicated by such an analysis.
THE SOCIAL CONTEXT OF REPRODUCTIVE HEALTH
Most family-planning programmes and fertility-control policies have traditionally failed to take adequate cognisance of the complex forces influencing the demand for children.
In contexts of extreme poverty, for example, lack of resources to meet the rising cost of children are often taken to indicate a decline in demand for children, despite evidence that, in such contexts, children are valued as a source of social, economic and political security. The outcome under such conditions may not be increased demand for modern contraceptive services, but changes in the contexts in which children are conceived and in which they grow up. Increased poverty in many parts of the world combined with globalization of capital provide the context for increased entry of children into the workforce (as an economic resource to their families and as a cheap source of labour (12)), and into economically-based sexual relations (13-17). …