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ABSTRACT
This article examines the sociocultural determinants of Nicaraguan women’s use of Depo-Provera as a means of contraception. The prevalence of Depo-Provera in Nicaragua is high and increasing compared to other Central American countries. Drawing on data from structured interviews with 87 women and from focus groups with 32 women, we show how women’s preference for Depo is shaped by both gendered inequalities and socioeconomic constraints. We employ basic statistical tests to analyse correlations between women’s marital status and socioeconomic status (SES) with contraceptive use. Our statistical findings show significant associations between use of Depo and both marital status and SES, such that women who are married or in conjugal unions and women with lower SES are more likely to use Depo. To help explain women’s use of Depo-Provera in Nicaragua, we situate our findings within the context of gender, culture, and power, reviewing the contested history of Depo-Provera in the developing world and dynamics of gender inequality, which constrain women’s contraceptive choices. We conclude with suggestions for reproductive health programming in Nicaragua and beyond, arguing that gender equity and addressing socioeconomic barriers to family planning remain priorities for the achievement of global reproductive health.
Acknowledgements
The authors would like to extend their appreciation to Acción Médica Cristiana of Nicaragua and especially Yamileth Palma for their assistance during data collection and to all the women who participated in this study. Thank you to two anonymous reviewers for their helpful comments on earlier versions of this manuscript and to the participants in the panel ‘International Perspectives on Reproductive Health Care Access’ at the 2014 meetings of the Society for Applied Anthropology for their encouraging feedback. We also thank Alfredo Burlando for his assistance with data analysis.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. Depo-Provera® is the registered name for the pharmaceutical formula depot medroxyprogesterone acetate, a long-acting, reversible hormonal contraceptive currently licensed in the USA by the company Pfizer.
2. The 2008 ENDESA survey found that use of Depo in 2006–2007 among women who were sexually active varied by age, with approximately 74% of sexually active women under 20–24 and 25–29, 63% of women 30–34 and 45% of women 35–39 using Depo. These trends indicate Depo use is increasingly prevalent among younger Nicaraguan women.
3. Rates of Depo use for sexually active women (15–49) in Central American nations in 2006 are: Costa Rica 5.9%, Guatemala 9.0%, Honduras 13.8%, El Salvador 18.3%, and Nicaragua 23.4%. Rates of sterilization for these countries show that Nicaragua is similar to regional trends (ENDESA, Citation2008, p. 141).
4. Nationally, about 30% of women obtain family planning methods from the private (for profit) sector, 5% from the NGO PROFAMILIA, and the remainder from public health centers or hospitals (ENDESA, Citation2008).
5. Traditional methods of birth control refer to methods that do not require biomedical technology, namely the fertility awareness method (‘rhythm’) and withdrawal.
6. We define modern birth control methods as those requiring professional or biomedical technologies, prescriptions, and services.
7. The major suppliers of Depo were international reproductive health associations such as the International Planned Parenthood Foundation (IPPF) and the United Nations Population Fund (UNFPA) (Hartmann, Citation1987).
8. Concerns about Depo's safety persist despite the 1992 approval. In 2004, the FDA ordered a black-box warning to be printed on Depo packaging to alert users and clinicians about the risk of losing bone density, and currently recommends that women do not use Depo for more than two years, unless the use of other contraceptives is inadequate or implausible. See black box warning at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm154784.htm.
9. A cultural aversion to invasive methods in Nicaragua may also explain the choice of Depo over IUDs or other surgical methods (Ministerio de Salud [MINSA], Citation2008).
10. While we were unable to ascertain the purchasing agreement between Nicaragua's MINSA and its supplier of Depo-Provera, the political economy of these national-level drug scheduling arrangements remains an important arena for further research.
11. For an in-depth examination of the challenges of risk/benefit assessments in health interventions in resource-poor settings, see Petryna, Citation2006.
12. The (DHS is a population-based, national survey of population and health administered by US Agency for International Development. See http://dhsprogram.com.
13. While our focus group discussions seemed quite open, participants were somewhat inhibited in discussing their personal sexual or reproductive histories. We believe this is more a reflection of cultural inhibition than a response to the identity of the facilitators.
14. Union libre or ‘free union’ is a term used locally to indicate long-term conjugal relationships assumed to be monogamous that aren’t predicated on formal, legal marriage.
15. Note, one 75-year-old was included since the questionnaire assessed other reproductive health issues besides contraceptive use (namely, cervical and breast cancer awareness); however, the 75-year-old was an outlier as most women were of the reproductive ages included in the Nicaraguan Demographic and Healthy Surveys (ENDESA, Citation2008).
16. At the time of study, there was only one secondary school in the region, making education beyond primary school inaccessible for many young people.
17. Interestingly, a similar phenomenon has been reported in Zimbabwe, where women said they received their Depo injections in tandem with taking their children to the clinic in order to dispel their partner's suspicions that they were planning (Kaler, Citation1998).
18. For an excellent discussion of discourses of the ‘irrationality’ surrounding the reproductive choices of poor women, women of colour, and Global South women, see Krause and De Zordo, Citation2012; also see, De Zordo, Citation2012 for a discussion of health professionals' portrayal of low income Afro-Brazilian women's reproductive choices as ‘irrational’.