In this episode, guests will discuss social and gender norms, and cultural contexts, which are key to understanding and improving family planning programming in fragile settings.
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From Knowledge SUCCESS and MOMENTUM Integrated Health Resilience, this is Season 4 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season on Inside the FP Story, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I’m pleased to introduce our narrator, Charlene Mangweni-Furusa.
Narrator Welcome to Season 4 of Inside the FP Story, where we are exploring the topic of family planning and reproductive health in fragile settings. Last episode, we offered an introduction to this topic—including the concepts of fragility, health resilience, and the humanitarian-development nexus. We discussed the drivers of fragility, and the impact on family planning and reproductive health. In this second episode, our guests will discuss social and gender norms, and cultural contexts, which are key to understanding and improving family planning programming in fragile settings.
Narrator As we discussed during last season, “social norms” are unwritten rules of behavior for a group or society. While reproductive health decisions can be very personal and sensitive, an individual’s decisions about fertility and family planning are often heavily influenced by gender and social norms in their community. This can be exacerbated further by the pressures and multiple stressors within fragile contexts.
Moses Okwii, a Research and Innovations Associate with Dev Con consulting in South Sudan, provided his perspective on social norms as well as gender norms.
Moses Okwii Social norms, these are simply implicit or maybe unspoken rules that predict behaviors of a particular group or maybe a community. In other words, they refer to the expected level of behavior that they want to see in this particular person. And when we talk about some of these behaviors, it could be what I think others typically ought to do or what they do. Sometimes they could be what I think others expect out of me. So it is simply an expected level of behavior of a person who's in a particular specific group or maybe a community.
Gender norms, these are specific to how women or men are expected to actually behave. For instance, in most of the research I've done here, sometimes you find yourself engaging communities on what are the roles of women and men. For instance, when it comes to issues of family planning and overall reproductive health, most of the assessments that I've done here, you find that a woman is specifically married to actually give birth. So it is an expectation that once you are married, that is bride price paid for you. It is expected that you produce as many children as possible. That is the crosscutting between actually gender norms as well as the social norms, because they do expect you to give birth.
Narrator When comparing fragile and non-fragile settings, are there differences in how gender and social norms affect family planning? We asked Erica Mills this question. She is a Family Planning and Reproductive Health Technical Advisor with Pathfinder International, who works with the MOMENTUM Integrated Health Resilience project.
Erica Mills I don't think there's one way to define how gender and social norms are different in fragile settings than they are in others. But I think from the places in which our project works and, and what we've seen is a lot of more traditional norms where the male head of household might have more control over health decision making, for instance. And I think you see that across both fragile and non-fragile settings. But it's definitely something that we've seen come out very strongly.
We did a social norms assessment in South Sudan, and I think that came out very clear. There's a lot that goes into the decision to use family planning and not all of that lies within the woman or the individual client themselves. There's a lot of other people and norms that might impact the decision. So that comes both from who makes the decisions within the household, but also stigma and misconceptions around family planning that might exist within the community as a whole, and how that might inhibit willingness to access those services for fear of shame or discrimination or potentially in some situations, even violence.
Narrator Here is Dr. Henia Dakkak—Head of the Policy and Liaison Unit with the Humanitarian Office of the United Nations Population Fund (or UNFPA). We asked her how gender and social norms related to family planning and reproductive health play out in fragile settings.
Henia Dakkak In many countries, women are considered second class citizens, unfortunately still, and, and gender norms do not really give women the ability to control their bodies. And this is something across many countries in many different places around the world, it's not just one country. More developed, less developed, wherever—low income, higher income, it doesn't matter. There is a lot of bias.
For example, when a woman can get contraceptives or not in many countries, one of the questions they will ask a woman before she gets a contraceptive. “Does your husband agree for you to get a contraceptive?” In many places, adolescent girls are at even higher risk of unintended pregnancy, because even health providers in many places, they will ask the first question, “Are you married or not?” before they even offer contraceptives. For an adolescent girl, this is where, I think the gender norms, gender equality is still not existent in many places. And, many times, you know, there are many laws written and unwritten, let's say, because it's not about only the law. It's also the society and how society looks at what is the role of a woman in a society.
Narrator As Henia mentioned, these gender and social norms particularly affect adolescents and young women. A note that Episode 4 of this season will delve into this topic more, as we focus on adolescents and youth. Henia also mentioned the importance of involving men.
Henia Dakkak We need to ensure that males are being involved also in this, we change their attitudes and norms and social norms. It's a must. We cannot continue saying, “Oh, it's the business of the woman. She will have to find the solution.” I think this is a society issue that we need to address and we need to change norms and change the way we think about contraception and make sure that contraception and family planning is part of universal healthcare. Unless we do that, we will not get where we want to be.
Narrator Moses discussed a social norms assessment he worked on in South Sudan, the findings of which are being used to inform social and behavior change activities for MOMENTUM Integrated Health Resilience and the Breakthrough ACTION project, including the development of county-level action plans. He shared some key results with us, which also relate to community norms.
Moses Okwii This is the assessment we were trying to look through the issues of social norms within South Sudan, and it had a number of components within it. We were trying to look at factors such as menstrual health. We were also trying to look through issues of contraceptive use. We're also trying to look [at] issues of early marriage and then gender based violence. Let me begin by sharing with you about the use of contraception. Generally, community perception about use of contraception was negative. They don't expect a woman to use contraceptives because some attributed it to having lots of side effects, like limiting a woman's ability to actually give birth in future. But the most vivid concern was limiting a woman's ability to give birth because they felt like the population is very low and therefore, any attempts to prevent a woman from giving birth was treated to be something not acceptable.
Secondly, there's also the issue of bride price surrounding women during marriage. [Men] felt like lots of cows or bride price is always paid out. Therefore a woman is expected to actually give birth to as many children as possible. And therefore she does not have the right to use contraception.
When contraceptives are to be used, a man's consent, that is the husband, has to give consent to a woman. You would find that even the service providers are usually afraid of giving out a contraception because they would sometimes be attacked by the spouse or even some of the local chiefs would actually penalize you or ask why you give out a contraception without the consent of the husband. So when you use contraception without the consent of the husband, this attracts gender-based violence. So sometimes you are either beaten or even chased away from the family or even divorced by the husband. And this is all acceptable within that part, community. So, meaning that even if you went to the elders or to the local authorities, they will still be in support of the actions taken by your husband. So those are some of the major highlights I can share with you about some of the social norms concerning family planning that we extracted out of that particular research.
Narrator These research findings, described by Moses, speak to the ways that social norms affect the use of contraception in South Sudan. In addition to social and gender norms that often prevent women from using contraception, there are also harmful norms in place that can lead to violence or other negative consequences when a woman chooses to use contraception. In addition, health workers that provide contraception may also experience violence.
These gender and social norms are common in a variety of settings—not solely fragile settings. However, there are other factors within fragile settings in particular that can affect gender and social norms. For example, as Moses has alluded to, there can be different fertility desires among communities that have been affected by war and conflict. In particular, when many children have died because of war, famine, or other disasters, families may want to have more children. However, this is not always the case.
Henia also provided insight about this topic, and discussed the ways that the multiple stresses within fragile settings impact social norms around fertility desires. She discussed the importance of understanding the nuances within each context.
Henia Dakkak One of the things that I learned over the years in my work, in some settings, we really have to look at the impact of what happened during that emergency and how we prioritize what the woman wants over everything else and put the woman at the center of that decision making. In many places when, especially after a famine, people lose children or after, children are dying because of the war, there is always a tendency after that immediate emergency for the community to replace the lost lives. And that's something that’s always going to really be there. It's not an easy decision, but it is a decision that the community and the family and the woman has to make. But there are always two tracks that we see: one track where we see a baby boom after such emergencies, and in some places we actually see a regression in the numbers of deliveries after such a situation. And therefore, it is important to understand first and really put emphasis on making sure that the women make this decision based on information and ability to predict what would be a good course for them.
It's important to make sure we understand the context very well and address the things that we can do. Most of the families want to have a number that they can sustain and support. But in many places it's also, there are many factors, like I said, loss of children, loss of kids, because of disease or because of the war. And, and then there is this tendency that the society wants to see more children. And then it becomes a social force, from the family, from everybody on the woman to become pregnant. And then the other places, actually, the family itself knows that they don't have the resources and they don't want to have more children. And we see it in many places where absolutely the first thing they ask me for is contraceptives. Okay. I have seen places where they say I need a contraceptive, but we also know that with gender-based violence, ability of women to make decisions for her own body in an abusive relationship—and that constrained women also from having access to contraceptives. We have seen that also during COVID-19, we have seen a rise in intimate partner violence.
We have seen also where women didn't want to get pregnant, but they had to, they got pregnant because access to contraceptives was also limited in many places. So we know from all the literature that this situation is mixed. What is very important is understanding that having contraceptives in an emergency is life saving because you want to save the woman's life from any unintended pregnancy that might actually endanger her life further on. So that's why it's just very important that we take these types of measures in ensuring that contraceptives are available—especially modern long-term, short-term, reversible contraceptives—to allow the woman the time to make the decisions that are appropriate for themselves. It's her right to have access to the contraceptives and the information.
Narrator As Henia underscored, it is crucial to understand gender and social norms with each context in which we work, so programs can then work to improve family planning and reproductive health programming. Here is Moses Owkii with more on this.
Moses Owkii The most important thing we need to be able to do is to identify and build on any supportive social norms. Whereas communities could be against contraception, but they could be positive about child spacing.
So that is a supportive social norm. It could be good to build on that. Secondly, there could be certain aspects to do with childcare and nutrition roles of men and women. So all this will help you to actually build on existing supportive social norms as a basis to actually move forward with family planning programs in those kinds of communities.
The other issue is to be able to identify the key influencers. Who are these people who are highly regarded in this particular environment? Once you identify them, it's now easier for you to begin engaging in inclusive and participatory community engagement using the key influencers.
Narrator Moses made it clear that programs should engage both men and women in community engagement. He also emphasized that addressing social norms can help improve quality of services.
Henia also mentioned tuning into social norms when providing services in fragile settings. She discussed the impact of gender norms on family planning provision in clinic settings.
Henia Dakkak In Za'atari camp in Jordan, for example, for Syrian refugees we have established these services and there is a big uptake among the refugees of contraceptives and most of the time because if you have a service provider who is a female service provider in some settings, it helps to improve the uptake of family planning or contraceptives, because it is taboo to talk about contraceptives with the male service provider. There is a real need also to make sure that we have gender parity of people who are providing the services. So I'm not saying that it has to be only female, or it has only to be male, but I would suggest that in every setting it could be different, and we need to understand.
Narrator As Henia mentioned, it is crucial to be aware of norms and taboos when staffing family planning programs—as the gender of providers can greatly affect quality of care. We will discuss this more in Episode 3, when we highlight a range of other approaches that can improve quality of care.
Pari Chowdhary—a Senior Technical Advisor of Sexual and Reproductive Health Impact at CARE—also talked to us about the importance of understanding gender and social norms. She provided an example of a program in Ethiopia that worked with community members and eventually changed norms that were harmful to young girls.
Pari Chowdhary Social and gender norms have absolutely everything to do with family planning and you would be remiss to go into a community that had strong norms around that topic and not address them. And so a lot of the work that we do, especially in fragile contexts, related to family planning service provision has a very first step that involves, not only identifying what the norms are, but also identifying opportunities or sort of inlets to be able to address them.
As an example of that, CARE has this program called TESFA, which has been running in Ethiopia for several years. And the intention of the program was to improve family planning awareness among young girls in that community. But because we did not previously have access to young girls in that community, we explored the norms in the community and realized that there's a very common cultural practice in Ethiopia of equb, which is a savings group. And it's common for adults, especially male adults, to participate in these savings groups with other members in their community where they're doing income generation, and it's like a loans-based program. And we realized that if we could do that, but with girls instead, that could give us an opportunity to use an existing norm of the community, but then extend it to a population that has not yet been afforded that norm.
And so what we did was, we worked with community members to normalize them to this idea that girls would participate in girls-only saving groups and in these saving groups where it was only the girls, they not only were taking part in loans and savings activities, but they also started to receive family planning education. And so while they were learning about how to manage their money, while they were learning about vocational skills to earn income—which was well received by the community because they saw it as, “okay, you're taking our young girls into a space that they haven't been before, but that means that they will be able to bring more income into the households.” And so that's how the community was okay with it. And then while they were in the groups, they also started to receive family planning education, and that grew into a larger family planning initiative for multiple populations within the community.
So we had even community members engaged in it. We had the husbands of the girls engage in it and things like that. So, in that case, we were able to leverage the existing social practices to start to shift their social norms around the use of family planning by younger girls.
Narrator Since the program included both married and unmarried girls, it was able to address the acceptability of family planning use regardless of marital status. Part of CARE’s work involved engaging all levels of the community in conversations while leveraging the savings program that the community valued. Pari explained some of the results of this program—and shared key insights that can help others work within communities to shift social norms around family planning.
Pari Chowdhary TESFA did not have this explicit goal around reducing child marriage per se. The whole point was to increase just family planning education and hopefully that would eventually translate to increasing family planning use, but we weren't even tracking update at facilities. We were just trying to inform the knowledge and attitudes around family planning. So the program was initially a four year program. And at the end of four years, we did an evaluation that showed us that there had been an improvement in perception of attitudes towards family planning use, which is great.
Two years later, after we had left the community, we went back to do another evaluation just to see if things had changed. And we realized that actually the community had been carrying on and maintained all of the program activities that we had first set out for them. And also some of the girls had even replicated the program activities by creating new groups of girls with whom they were now running the family planning curriculum. And so we also found that there was this unintended consequence that there had been a reduction of child marriage in that community as a result of participating in this program—because girls were now saying that not only did they want to use family planning, but they recognized the dangers of pregnancy for girls of a younger age. And so they were advocating more for their younger sisters and younger cousins to not be married until a later age. And so that was another example of how we were working towards shifting a social norm and ended up shifting a few others in the process. And so I think that is something that probably a lot of programs experience in that these norms are not exclusive with one another because social, gender, and power norms are all correlated and have overlaps in terms of the reasons why they exist in the first place. So if you're attempting to shift one, you have to be well-versed in the factors that are contributing to that environment as a whole, and then address all of those sorts of pieces in your programming.
Narrator The TESFA program in Ethiopia showed the importance of truly comprehending the cultural context before attempting to transform gender and social norms. It also highlights how sometimes norms can be shifted unintentionally—and how different norms can be interwoven within a context.
Narration Another factor that is greatly important in this context is migration. As communities move, due to a crisis situation, they bring with them their own social norms—which can both affect and be affected by their new setting. Here is Henia with more on the impact of migration on communities—particularly women and girls.
Henia Dakkak The more movement becomes the norm, I think the difficulties that women face become harder. Every time you have to move, you have to really understand your context again, and where do you find the information? How do you access the contraceptives? It's not always that the international community is there to support and provide that support. There are many limitations in many places, for example, we still see very limited ability to access because of language barriers. And we have seen that, during also, Mediterranean, influx from Syria, from other countries. They had to go into different countries with different laws and different situations where these elements that they were used to before, you know, having access before in their communities, it's not the same. They cannot speak the language. There are many, many barriers. Even the services that are provided don’t even think about family planning.
Narrator As Henia explained, women and their families have to become accustomed to the culture of their new settings. And even when contraception is available, it may not be accessible, due to language or other barriers.
Another example of how migration affects gender and social norms is among Rohingya refugees living in Bangladesh. Since 2017, over 742,000 refugees have fled to Bangladesh to escape violence in Myanmar. To learn more about this setting, we spoke with Monira Hossain, Project Manager—and Dr. Farhana Huq, Regional Program Manager. Both work with Pathfinder International on a program in Cox’s Bazar, Bangladesh. Here is Monira describing what the situation was like when Rohingya refugees first started arriving.
Monira Hossain So at that time it was in the mood of accelerating all services—that’s shelter, health, nutrition, WASH… And at that time, it was a very traumatized situation for the Rohingya people and their situation was pretty uncertain. And their focus was to settle down in camps and to have that introduction with the Bangladeshi community, Bangladeshi culture, and the new camp environment.
Narrator Leaving their communities, culture, faith, and traditions behind can have a great impact on refugee communities. In addition to becoming familiar with a new country and a new culture, many Rohingya families were also unfamiliar with modern family planning methods.
Monira Hossain When they arrived in 2017, they were not much familiar with family planning. The only methods they were familiar [with] was the oral contraceptive pill and Depo [Provera]. I have asked several patients about the availability of family planning commodities in Myanmar. So it was not that much. In general, health that’s also not available for the Rohingya people in Myanmar for a long time. That’s the history of Rohingya people. So, they were not aware of other modern methods and where they will access them, and what is the importance of the family planning methods for the Rohingya people themselves and also for the upcoming situation residing in camp settings in Bangladesh.
Narrator Here is Farhana with more on the context.
Farhana Huq When the Rohingya influx actually began in Bangladesh and they arrived, many of them had the history of sexual violence and they were pregnant which was unintended. But the thing is that they arrive in such conditions, and we were struggling to give them shelter. Then the health support was quite difficult, especially the family planning. And the thing is that they were not aware of family planning as they came from very conservative backgrounds.
Narrator The crisis is ongoing in Cox’s Bazar, as the Rohingya communities remain displaced from their home country. Over the last five years, Pathfinder International has worked to counteract some of the gender and social norms that affected these communities—with the goal of increasing knowledge and use of family planning, preventing and responding to gender-based violence, and preventing unintended pregnancies.
In order to do this, it was crucial for them to understand the norms and customs that the Rogingya communities brought with them—including social taboos and stigma—prior to implementing the program. And one strategy that has led to a successful family planning program among the camps was community participation, which helped them overcome some harmful social and gender norms to be able to provide sexual and reproductive health services. Here is Farhana with more on involving communities, particularly community leaders.
Farhana Huq From my view I think that to engage some influential leaders from the Rohingya community, we can accustom and continue conversations in their local language, it will be very helpful for us to mix with them easily and to talk with them and understand the services we are going to provide are useful and beneficial for them.
Narrator Engaging influential leaders—including religious leaders—has been crucial for family planning programs among Rohingya communities. Pathfinder has also implemented a number of other approaches, including male engagement, to improve quality of reproductive health care in the camps.
Narrator As we have heard from our guests this episode, analyzing the context of each fragile setting is crucial before implementing family planning programs. They shared how engaging with a range of partners and community members is imperative to address and impact social norms. They also brought up the ways that supportive norms improve the quality of services. Join us for Episode 3 of this season, where we’ll explore more strategies for improving quality of family planning and reproductive health services within fragile settings.
Season 4 of Inside the FP Story is produced by Knowledge SUCCESS and MOMENTUM Integrated Health Resilience. This episode was written by Sarah Harlan and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Brittany Goetsch, Natalie Apcar, Christopher Lindahl, Terry Redding, Lorelei Goodyear, Christine Lasway, and Kamden Hoffman.
Special thanks to our guests Moses Okwii, Erica Mills, Henia Dakkak, Pari Chowdhary, Monira Hossain, and Farhana Huq.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher; and visit knowledgesuccess.org for additional links and materials.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
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