Elsevier

Social Science & Medicine

Volume 119, October 2014, Pages 88-97
Social Science & Medicine

Bucking social norms: Examining anomalous fertility aspirations in the face of HIV in Lusaka, Zambia

https://doi.org/10.1016/j.socscimed.2014.08.015Get rights and content

Highlights

  • We use Anomalous Case Analysis (ACA) to examine fertility behavior in Lusaka, Zambia.

  • The Theory of Conjunctural Action helps frame many relevant competing schemas.

  • Respondents with anomalous behaviors prioritized specific norms or “schemas”.

  • These behaviors were influenced by impactful experiences around childbearing.

  • The Theory of Conjunctural Action helps frame many relevant competing schemas.

Abstract

In settings of high fertility and high HIV prevalence, individuals are making fertility decisions while simultaneously trying to avoid or manage HIV. We sought to increase our understanding of how individuals dually manage HIV risk while attempting to achieve their fertility goals as part of the project entitled HIV Status and Achieving Fertility Desires conducted in Zambia in 2011. Using multivariate regression to predict fertility patterns based on socio-demographic characteristics for respondents from facility-based and community-based surveys, we employed Anomalous Case Analysis (ACA) whereby in-depth interview respondents were selected from the groups of outliers amongst the survey respondents who reported lower or higher fertility preferences than predicted as well as those who adhered to predicted patterns, and lived in Lusaka (n = 45). All of the facility-based respondents were HIV-positive. We utilize the Theory of Conjunctural Action (TCA) to categorize domains of influence on individuals' preferences and behavior. Both community-based and facility-based right-tail respondents (outliers whose fertility intentions indicated that they wanted a/nother child when we predicted that they did not) expressed comparatively less control over their fertility and gave more weight to pressures from others to continue childbearing. Partner communication about fertility desires was greater among left-tail respondents (outliers whose fertility intentions indicated that they did not want a/nother child when we predicted that they did). HIV-positive right-tail respondents were more likely to see anti-retroviral therapies (ARTs) which prevent mother to child transmission of HIV as highly effective, mitigating inhibitions to further childbearing. Drug interactions between ARTs and contraceptives were identified as a limitation to HIV-positive individuals' contraceptive options on both sides of the distribution. Factors that should be taken into account in the future to understand fertility behavior in high HIV-prevalent settings include couples' communication around fertility and perception of the efficacy of ARTs.

Section snippets

Background

The effect of HIV on fertility behavior as well as pregnancy preferences complicates reproductive decision-making, negotiation and behavior (Trinitapoli and Yeatman, 2011). Previous individual-based research from sub-Saharan Africa examining HIV status and fertility preferences has generally found HIV to have a depressing effect on fertility desires (Johnson et al., 2009, Kaida et al., 2011). Qualitative work by Baylies in Zambia with respondents in households where long-term AIDS illness had

Anomalous Case Analysis

While survey research provides the power to identify patterns across large groups, qualitative methods are better at revealing new information and the richness of complex dynamics. Anomalous Case Analysis (ACA) is a methodology that tries to employ the strengths of each where anomalous cases identified through logistic regression of survey data can identify individuals that do not adhere to predicted patterns. Qualitative follow-up interviews with these individuals can reveal additional factors

Desired number of children

In the community-based sample, most right-tail respondents ended up having more children than initially desired, ranging from one to five children above their original figure. Right-tail respondents mentioned that economic hardship made it difficult to have many children, but they were not motivated to reduce their fertility desires based on that. Other considerations such as perceptions of what are socially or religiously acceptable, or personal experiences that were highly influential,

Discussion

This application of Anomalous Case Analysis in Lusaka found revealing differences in the relevant structures and schema in place governing fertility decision-making in this high HIV-prevalence context. Among both HIV-positive and community-based respondents in the right-tail of the distribution, higher fertility desires seemed less affected by adverse economic or health conditions. They seemed less in control of their fertility desires than left-tail respondents based on the fact that even

Conclusion

Using survey findings to help draw our sample for the in-depth interviews serves two purposes. It allowed us to: 1) examine in greater depth the perspectives of individuals who hold non-typical fertility preferences in a context of high HIV to understand how these individuals differed in their responses to their social environments; and 2) test the application of the Anomalous Case Analysis methodology in Lusaka, Zambia to learn more about fertility-related behavior in this high HIV-prevalence

Acknowledgments

Thanks to Kumbutso Dzekedzeke who was the in-country principle investigator in Zambia. Tsuyoshi Onda provided assistance with locating literature, formatting citations and administrative responsibilities. We appreciate the guidance provided by the project's Advisory Panel. We would like to thank Sara Yeatman for her comments on this paper as well as John Casterline for his input, particularly around uncertainty and childbearing, and Jennifer Johnson-Hanks, Christine Bachrach, Phil Morgan and

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