CHAPTER 6: DISCUSSION
7.1 CONCLUSION
The introduction chapter of this thesis presented the trend of maternal health in Developing Countries, particularly the background of women’s rights and the exercise of SRHR. Evidence has shown examples of wide implementation of national and international interventions developed worldwide through the years to improve women’s rights, particularly SRHR. On the other hand, evidence has corroborated global efforts to protect girls’ and children’s rights.
Successful interventions, accompanied by the development of national and international legal frameworks to guide and protect women’s rights, have been documented by scholars. Those interventions have helped improve women’s SRHR, particularly in Developing Countries, and are visible through the reduction in global mortality rates and critical maternal health morbidities due to the improvement in the provision and utilisation of maternal health services such as family planning and ANC during pregnancy. Although this study identified a positive trend regarding maternal health (family planning program and ANC) service utilisation, it also found that the use of modern contraceptive methods and ANC attendance during pregnancy among women who married early and reside in Namaacha were low, inconsistent and below the target recommended by the WHO model of ANC. This is considerably worse for adolescent women, particularly the ones living in a community that enforces and embraces early marriage practices such is the case of my study area. Evidence has shown a higher prevalence of early marriage in the SSA region, and the effect of its impact on women’s well-being, particularly their SRH. The extensive negative effects of early marriage practice were also documented in Mozambique with a higher incidence in the north region of the country. However, in the south region of the country, particularly the district of Namaacha, early marriage is still deeply rooted in the community, and no evidence was found of a study that has focused on early marriage and its impact on women’s well-being, particularly maternal health. Thus, this study sought to explore the experiences of women in Namaacha District, Mozambique who married early and how they talked about their experiences of maternal health. In this respect, emphasis was given to examine their decisions regarding the use of modern contraceptive methods or use of ANC services during pregnancy and delivery.
To understand the experience of contraceptive use and ANC utilisation among women who married early, this study needed to understand the exercise of their rights and how they perceive it in a way that affects their decision to seek and use modern contraceptives and ANC during pregnancy. Thus, this study found that early marriage had negatively impacted women’s well- being and further possibilities of growth. Within this context, this study examined women
179 experience regarding the exercise of their SRHR, with emphasis to their experience of modern contraceptive methods use or attendance of ANC services during pregnancy and delivery. Ten participants were interviewed for this study, and none of the women finished secondary education; the majority of participants did not have a stable profession, with the exception of one who worked as a secretary in a local primary school, and they were economically dependent on their husbands. They described living in privation of basic necessities and in an environment where their decision-making power around general issues and private ones were very low, particularly at early stages of their marriage. For instance, some participants reported being forced to accept their marriage due to their circumstances of poverty and to follow the norms of their community that encourage the practice. Their low level of education and early sexual initiation also increased their risk of becoming a child bride. Participants described being forced to accept early in marriage their responsibility to bear children, and this might justify the low use of contraceptives among this group. Participants also described being submissive to their husband’s and other extended family members’ demands. However, they also described having gained more space and decision-making power late in marriage. Overall, participants described being satisfied with the marriage despite the challenges of it. They understand the negative impacts of early marriage on women’s lives, particularly the negative effect on women’s SRH and personal advancement. Therefore, they would never advise girls to marry at an early age.
By understanding the general situation in respect of women’s exercise of individual rights, this study found that participants faced several adversities that prevent them from accessing and using maternal health services effectively, including modern contraceptive methods and ANC during pregnancy. In this regard, despite all women reporting starting to have used some method of contraceptive during their marriage, its use was inconsistent, irregular and ineffective. These women described experiencing several health complications due to the use of contraceptives, and this might have influenced their inconsistent use of these methods. On the other hand, participants described having knowledge of modern contraceptives and could name some. However, they did not mention sterilisation as one of the methods, and only one reported using an IUD. The majority of participants reported using mostly oral pills and injections. They described having access to these methods free of charge mostly at the local health clinic and through other channels available in their community that also provide general information about family planning. However, despite the generally widespread availability of modern contraceptives, multiple determinants prevent women from fully accessing and using modern contraceptive methods. Thus, one of the objectives of the study was to describe the
180 factors that influence women’s decision to use maternal health services such as modern contraceptives and ANC during pregnancy, as it is related to their overall experience of maternal health services and exercise of SRHR.
This study found that modern contraceptive use is affected by women’s low level of education, low socio-economic conditions, fear of side effects, husbands’ and extended family’s lack of support, fear of violence and abuse perpetuated by their husbands and women’s negative perceptions. Positively, this study found that community acceptance of family planning and a favourable environment open to disseminating information regarding family planning and its benefits could motivate women to use these services. This study also found that majority of women were religious, belonging to the Zion church, and they described having support from their church peers to use modern contraceptives. Thus, religious spaces my encourage women to use modern contraceptives.
Although participants described having positive support from their community regarding family planning, women still needed their husband’s approval to make decisions about their own SRH. This is evident due to the higher fertility levels they reported, which for some was a result of part of their responsibilities as married women and to fulfil their husband’s desires to have many children. Some of the elder’s participants stated that if they had the current knowledge about family planning and its benefits as well as the easy access to modern contraceptives early in their marriages, they would not have so many children. This trend seems to be changing where the young participants reported starting to use contraceptives early in marriage, and their reproductive intention is to have few children in the future. The young participants in this study were very articulate, and despite their low level of education, expressed an understanding of women’s rights, particularly the right for education, health and to decide the number of children they want. However, this intention may be affected by the impact of individuals and external barriers that prevent women from accessing family planning methods. These barriers that prevent women from consistently using modern contraceptives impacted more the elder participants, who reported higher parity and being married at times that information and the availability of modern contraceptives were not as accessible as today.
All the participants in this study were mothers with higher parity reported mostly among the elder participants. These participants reported that they became first time mothers during their adolescence and so they experienced some difficulties during their pregnancies. Participants reported experiencing some health complications derived from pregnancy that ultimately led them to attend ANC consultations to treat some of these complications. Participants reported understanding the benefits of ANC in protecting the mother’s and child’s health and so they
181 made it a priority to use these services. However, this finding seems to be contradictory and not fully accurate since the majority of participants reported attending ANC late in pregnancy and having less than four visits. Exceptionally, the ones who started early did so to treat some of the complications. Participants could describe some of the interventions they were offered during ANC appointments. Some of these interventions were physical through examinations and others more informative about pregnancy care and recommendations for delivery.
However, their descriptions were not very articulate and coherent and so they were not fully aware about details of the services they were offered. However, their level of understanding about the benefits of ANC were sufficient to lead them to attend these services at one point of pregnancy and ultimately for some to deliver at the local health facility with the assistance of a skilled health professional. Thus, this study found that despite not attending ANC four or more times during pregnancy as recommended by the WHO ANC model, participants in this study understood the real risks of pregnancy and the importance of attending ANC to prevent pregnancy complications. Thus, they made an effort to visit these services so they can benefit from a variety of services offered free of charge and ultimately obtain a patient card that could guarantee the delivery of the baby in the health centre. The challenge in this regard is to motivate women to start attending ANC earlier in pregnancy. Therefore, this study also examined the determinants that may prevent women from attending ANC early in pregnancy as part of their overall experience of use of maternal services, in this case ANC during pregnancy.
This study found that the low levels of early ANC attendance (four or more times) among women who married early in Namaacha District was associated with their low socio-economic level; the occurrence of health complications derived by pregnancy; their low level of education; women’s personal beliefs and individual behaviour; distance of health facility;
quality and attitude of health provider and husband’s and extended family’s support. Thus, these determinants interrelate and have been found to influence women’s decision to seek and use these services early in pregnancy, despite being offered free of charge. On the other hand, this study found that the community was supportive of women attending ANC and so this channel could be considered to encourage women to seek ANC early in pregnancy, while developing effective strategies to increase the level of ANC attendance among women who married early.