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Closing the Womb Door: Contraception Use and Fertility Transition Among Culturally Tibetan Women in Highland Nepal

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Abstract

Objectives Whether in metropoles or remote mountain communities, the availability and adoption of contraceptive technologies prompt serious and wide-ranging biological, social, and political-economic questions. The potential shifts in women’s capacities to create spaces between pregnancies or to prevent future pregnancies have profound and often positive biological, demographic, and socioeconomic implications. Less acknowledged, however, are the ambivalences that women experience around contraception use—vacillations between moral frameworks, generational difference, and gendered forms of labor that have implications well beyond the boundaries of an individual’s reproductive biology. This paper hones in on contraceptive use of culturally Tibetan women in two regions of highland Nepal whose reproductive lives occurred from 1943 to 2012. Methods We describe the experiences of the 296 women (out of a study of more than 1000 women’s reproductive histories) who used contraception, and under what circumstances, examining socioeconomic, geographic, and age differences as well as points of access and patterns of use. We also provide a longitudinal perspective on fertility. Results Our results relate contraception usage to fertility decline, as well as to differences in access between the two communities of women. Conclusions We argue that despite seemingly similar social ecologies of these two study sites—including stated reasons for the adoption of contraception and expressed ambivalence around its use, some of which are linked to moral and cosmological understandings that emerge from Buddhism—the dynamics of contraception uptake in these two regions are distinct, as are, therefore, patterns of fertility transition.

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Notes

  1. In the proximate determinants of fertility model commonly used by demographers, use and effectiveness of contraception is one of the seven major socioeconomic and environmental variables that affect fertility. In contemporary societies contraceptive usage has the most significant influence on achieving low fertility [42].

  2. As illustrated by this information about contraceptive availability in Nubri and Mustang, the authors with long-term and ongoing fieldwork in these regions include for context data about general healthcare infrastructure and contraceptive ability that extends beyond the period in 2012 when data used for the statistical analyses in this paper were collected.

  3. In revising this paper, one reviewer mentioned that this seemed like a question that could be interpreted as a reference to abortion. This is not the case. Abortion is described in Tibetan in terms that do not reference “medicine” (men) but rather in various ways that describe the agentive act of “taking a baby out before its time,” “making the baby no more” or, more rarely, a direct reference to killing the unborn fetus. During our fieldwork, we asked the following question in vernacular Tibetan: trugu ma khorwa men se song e? This translates literally as “[did you] eat medicine to make a baby not be conceived?” This was often preceded or followed by: “men se song e? khab gyab song e?” which, literally translates, means “Did you eat medicines? Did you use an injection?” for women to understand that we were speaking of contraception. Interestingly, the idea of “eating medicine” here covers several contraceptive choices, from the less common birth control pill to the more common use of norplant. The reference to injections speaks directly to Depo-provera. Once we asked these questions, if the answer was “yes” we then discussed the specific method(s) used.

  4. Relative wealth ranking is a method to rank households according to wealth status using emic criteria [43].

  5. The Total Fertility Rate (TFR) is a standardized measure of the average number of children that would be born to each woman if Age-Specific Fertility Rates (ASFRs, births in a year to women aged x divided by the number of women aged x at midyear) remain constant. The TFR is an estimate of the number of children that would be born to a hypothetical cohort of women, not to an actual cohort of women. To estimate fertility we used the Own-Children method (henceforth, OCM), a reverse-survival technique designed to calculate Total Fertility Rates in the absence of detailed data on reproduction [29]. Reverse-survival uses a population’s current age structure and assumptions about mortality to reconstruct that population’s age structure at a previous time. OCM has been applied to large datasets such as national censuses from various countries [44–47] as well as household surveys to estimate fertility in small-scale populations studied by anthropologists [39]. A recent reappraisal of the method finds that in some cases it is more accurate than fertility estimates derived from full birth histories [35]. Our data comes from two surveys: 2012 Nubri, Tsum, and Mustang household and reproductive history survey and 2013 Nubri household and reproductive history survey.

  6. We note controversies in the United States, Canada, and India over the use of Depo-Provera as examples. Vitzthum et al. [50] discusses these issues in relation to hormonal contraception and physiology in non-western contexts.

  7. Personal communication with Margaret Swift. In 2002 she interviewed several women in Nubri about birthing difficulties and family planning issues.

  8. Such comparisons between women and domestic animals also appears in Jan Brunson’s [16] introduction to her new book on Nepal’s family planning history. In the Introduction, she recounts a contentious moment during International Women’s Day in 2002 when the Family Planning Association of Nepal published a poster, the title of which was “Am I am man’s wife or a rooster’s hen?” While there was controversy over this message, this idea of women being compared to reproductive beings with no agency over their reproductive lives resonates.

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Acknowledgments

Most of the data presented in this paper was gathered in the summer of 2012 during a project titled Genes and the Fertility of Tibetan Women at High Altitude in Nepal, which was sponsored by the National Science Foundation (Grant No. BCS-1153911). Additional Funding was provided by grants from the Claire Garber Goodman Fund, the Rockefeller Center, and the Dean of Faculty Innovation and Advancement Fund, at Dartmouth College. The Institutional Review Boards of Case Western Reserve University, Washington University, Dartmouth College, Oxtrec, and the Nepal Health Research Council approved the research protocol. We would like to thank our fieldwork assistants for their hard work and dedication to the project: for Nubri and Tsum, Ang Tsering, Jangchuk Sangmo, Tinley Tsering, Tsechu Dolma, and Tsering Buti; for Mustang, Kunzom Thakuri, Karma Chödron, ‘‘Apu’’ Karma Cho¨dron, Diki Dolkar Gurung, Yangjin Bista, Karchung Gurung, Nawang Tsering Gurung, and Tashi Bista. We also thank the study communities and volunteers for their hospitality and participation.

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Authors and Affiliations

  1. Department of Anthropology, Dartmouth College, 6047 Silsby Hall, Hanover, NH, 03755, USA

    Sienna R. Craig

  2. Washington University, St. Louis, MO, USA

    Geoff Childs

  3. Case Western Reserve University, Cleveland, OH, USA

    Cynthia M. Beall

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Correspondence to Sienna R. Craig.

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Craig, S.R., Childs, G. & Beall, C.M. Closing the Womb Door: Contraception Use and Fertility Transition Among Culturally Tibetan Women in Highland Nepal. Matern Child Health J 20, 2437–2450 (2016). https://doi.org/10.1007/s10995-016-2017-x

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