Cambodia still says no to birth control
Male attitudes blamed for low use of contraception
A woman carries an infant through a rural village in Cambodia (photo by Will Baxter)
At twenty-one years old, Duorn Chea is just days away from giving birth to her second child. If she had her way, she would be on birth control rather than expecting another baby. But her husband ordered her to stop using contraception and, in this deeply rural community where women are often marginalized, his word is the last.
“I always used to get birth control injections at the health center, but my husband wanted another baby and made me stop,” says Chea, with a sigh of resignation.
With an abusive husband, a two-year-old, and in-laws who make little effort to control their son, Chea struggles daily. “I feel like I live in a prison.”
In Cambodia, the vast majority of women are aware of contraception. Among married women, a full 95 percent are aware of modern methods of birth control while 75 percent of all women “know at least one traditional method of family planning,” according to the government’s latest demographic and health survey taken in 2010.
“Major obstacles to contraceptive use were adequate knowledge on perceived or real side effects, not lack of awareness and geographical access,” pointed out Dr. Marc Derveeuw, United Nations Population Fund Representative.
But while awareness is widespread, usage rates remain among the poorest in the region. Despite large gains over the past decade, just 51 percent of the population uses any type of family planning – a figure that drops to 35 percent if only modern methods of contraception are counted.
In the region, only Myanmar, where 46 percent of the population uses birth control, and Laos, at 38 percent, boast lower numbers. Though abortion is legal in predominantly Buddhist Cambodia and birth control is cheap and readily available, that low figure ties it with the Philippines – which has seen fierce and successful opposition to contraception by the powerful Catholic church.
Part of the challenge, say health workers, is addressing the problem Chea faces: an unwilling husband.
“[The women] are dominated by the husband because he is the head of the household and he is the breadwinner. If she faces any sort of health problem, she will be blamed by her husband and he will threaten that he might not take care of her if she uses family planning. Some husbands want many children because they consider it as a labor force… for men, it’s very hard to make their behavior change,” said Sek Sisokhom, a monitoring evaluation specialist with the Reproductive Health Association of Cambodia (RHAC).
RHAC noted the problem during routine surveys over the past few years, and other research has backed that up. In a 2010 study by the Guttmacher Institute – a US-based reproductive health organization – researchers tapped husbands’ opinions as a key factor in usage rates.
"The odds of contraceptive use among women who agreed with the statement "Your husband thinks it is a good idea for you to use a contraceptive method" were nearly three times those among women who disagreed,” notes the paper, titled The Role of Social Support and Parity in Contraceptive Use in Cambodia.
“Women who believed that their husband had a positive attitude toward contraception were more likely than others to be using a method…women who reported that their husband makes the contraceptive decisions were significantly less likely than others to be current users.”
Chief among the conclusions were to “focus on increasing men's approval of contraception.”
Apart from husbands, women heavily weigh the opinions of peers and relatives, notes the Guttmacher study.
“In particular, when women are uncertain of the merits of modern contraception, they decide about method use on the basis of discussions with network members.”
What women are not doing, according to research, is consulting health centers.
Just 14 percent of women made decisions based on the advice of health workers, according to a 2013 Ministry of Health survey.
For Cambodia, which has an average fertility rate of 2.9 children per women – among the highest in the region – shifting those points of influence will be key to improving the lot of the nation’s poorest women.
“Young people are interested in using family planning. I think [usage] will increase a lot in the next two to five years,” said the RHAC’s Sisokhom. “But there are still problems in rural areas, where access to information is very limited and the families are very uneducated.”
In the meantime, said Sisokhom, situations like Chea’s will continue to be the norm in rural areas.
“Our surveys show that women don’t want more children but they don’t use family planning.”
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