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Family planning (re)defined: how young Nepalese women understand and negotiate contraceptive choices a

Iccha Basnyat & Mohan J. Dutta

b

a

Communications and New Media Programme , National University of Singapore , Singapore b

Communication , Purdue University , West Lafayette, USA Published online: 26 Jul 2011.

To cite this article: Iccha Basnyat & Mohan J. Dutta (2011) Family planning (re)defined: how young Nepalese women understand and negotiate contraceptive choices, Asian Journal of Communication, 21:4, 338-354, DOI: 10.1080/01292986.2011.574711 To link to this article: http://dx.doi.org/10.1080/01292986.2011.574711

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Asian Journal of Communication Vol. 21, No. 4, August 2011, 338354

ORIGINAL ARTICLE Family planning (re)defined: how young Nepalese women understand and negotiate contraceptive choices Iccha Basnyata* and Mohan J. Duttab

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Communications and New Media Programme, National University of Singapore, Singapore; b Communication, Purdue University, West Lafayette, USA (Received 18 August 2010; final version received 18 March 2011) The dominant framework of health communication constitutes family planning under the framework of Third World pathology, writing over the bodies of women of the Third with a script of modernity. This manuscript engages the culturecentered approach to co-construct the narratives of young Nepalese women living under poverty, seeking to create entry points for cultural voices that have been rendered silent in mainstream health communication discourses. Through narratives situated at the intersections of structure, culture, and agency, we explore the meaning-making processes through which women negotiate family and societal expectations to make decisions about family planning, constituted in the midst of competing tensions. Semi-structured, open-ended interviews were conducted to explore how women understand and construct contraceptive choices within their local contexts, offering insights for understanding how the experiences of marginalized participants create opportunities for exploring the social shaping of meanings of health. Narratives offer spaces for understanding how women conceptualize family planning and, in turn, how they negotiate these meanings to enact their health behaviors. Keywords: family planning/contraception; culture-centered approach; narratives; reproductive health; women’s health

Dominant approaches to health communication have traditionally constructed women of the Third1 as bodies to be worked on through top-down interventions of family planning (Dutta, 2006, 2008; Dutta & Basnyat, 2008). Absent from global discursive spaces are the voices of women from the marginalized sectors of Third World spaces, who have continually been circulated as passive recipients of development messages and as subjects of postcolonial health interventions. Particularly absent are the voices of those women who constitute the majority of the poor, the underemployed, and the economically disadvantaged (Dutta, 2008; Nussbaum, 1995; Sen & Grown, 1987). This missing perspective of women who constitute the margins of contemporary globalization processes offers a powerful vantage point from which we can understand women’s experiences, and transform the inequities that exist in contemporary discursive spaces of global health communication (Basu, 1998; Dutta, 2006, 2008; Esacove & Andringa, 2002; Sen & Grown, 1987).

*Corresponding author. Email: [email protected] ISSN 0129-2986 print/ISSN 1742-0911 online # 2011 AMIC/SCI-NTU DOI: 10.1080/01292986.2011.574711 http://www.informaworld.com

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Creating discursive openings for listening to the experiences of marginalized participants creates opportunities for exploring how interpretations of health, health decisions, and relationships of health-seeking are located in the backdrop of the structural inequalities in health (Dutta, 2008; Popay, Williams, Thomas, & Gartrell, 2003; Shaikh, Haran, & Hatcher, 2008). In this essay, we engage the culture-centered approach to challenge the dominant hegemony of health communication approaches that construct women living in poverty in the Third World as bodies to be worked over, and to create a discursive entry point for listening to the stories of family planning as constructed by women (Dutta, 2008). Stories offer entry points for understanding the processes through which the margins are constituted, the interpretive frameworks through which margins are negotiated, and the openings for transformative politics that co-construct narratives of health with the margins. The narratives co-constructed in the discursive spaces aim to understand the everyday experiences within local contexts, offering opportunities for marginalized groups to participate in knowledge construction (Dutta & Basnyat, 2008). More specifically, we engage in dialogues with women living at the margins of Nepal to understand the ways in which they participate in discourses of planning their families and negotiating their contraceptive choices. Approaches to reproductive health We will first review the literature on reproductive health discourse, followed by discussions of family planning campaigns that constitute the dominant framework of health communication. This discussion of the mainstream approaches to health communication will be set up as a framework for introducing the culture-centered approach. With its emphasis on deconstructing the erasures in the mainstream, the culture-centered approach will offer a theoretical entry point for co-constructing narratives of health with women living in the margins of contemporary healthcare systems that foreground family planning as the solution to the structural inequities in communities at the margins of healthcare. Reproductive health discourse Reproductive health discourse is predominantly constructed as reproductive rights. Reproductive rights as defined internationally include: (1) the freedom to decide how many children to have and when to have them, and (2) the entitlement to family planning information and services. The broader discourse of reproductive rights also refers to a third component, which is not yet included in the basic definition of rights, reflecting the ‘right to control one’s own body’ (Dixon-Mueller, 1993, p. 113). The definition of women’s reproductive health in the dominant framework is far too narrow, constituted within the Eurocentric logic of individual choice and individuallevel decision making (Dutta, 2008). Individual women are seen as backward target audiences of interventions who can be persuaded through interventions (see for instance Storey, 2000, and Storey & Jacobson, 2003, as some examples of such campaigns, and Dutta and Basnyat, 2008, for the critique of the design documents of the Radio Communication Project [RCP] targeting Nepali audience members with messages of family planning). In the specific context of Nepal, family planning campaigns such as the Radio Communication Project have been carried out under

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the top-down framework of development, targeting Nepali women on the basis of Eurocentric assumptions that are far removed from the lived experiences of the women (Dutta & Basnyat, 2008). Dutta and Basnyat (2008) further note that the targeting of Nepali women under the family planning framework is justified by the portrayal of Nepali women as backward and primitive, and devoid of agency. The communicative processes of erasure of subaltern voices are carried out by population policies that generally attempt to alter the levels of fertility in order to bring demographic processes in balance with national development goals, by promoting certain ideologies through top-down interventions directed at changing the beliefs, attitudes, and behaviors of women (Airhihenbuwa, 2007; Dixon-Mueller, 1993). A critical reading of reproductive health discourse suggests that the term reproduction and the discussion around it should be subject to analysis beyond the processes of production to include the discussions of power and structure that constrain and/or enhance women’s health as well as the social context within which women’s decisions reside (Jordanova, 1995). In other words, a critical entry point into the reproductive rights discourse suggests that women’s reproductive health care needs to be understood within a broader context of health care culture (i.e., sanitation, housing, clothing, food, and resources) and societal oppression (i.e., sexism, classism, patriarchy, and ethnocentrism) that affect the overall quality of life such that reproductive policies and programs can be tailored to the diverse realties of women and their experiences (Amaro, Raj, & Reed, 2001; Dixon-Mueller, 1993; Nelson, 2005). For example, Zachariah (2003) points out South Asian women are mothers first. In many parts of South Asia, a young woman faces familial and societal pressure to prove her fertility soon after marriage (Pachauri & Santhya, 2002). Another study in rural Bangladesh by Schuler, Bates, Islam, and Islam (2005) found that often families looked for a daughter-in-law who could be molded and shaped by her husband and family. Independence was not highly regarded as there is a power status differential. The articulation of reproductive health in such contexts differs dramatically from the dominant readings of reproductive health that highlight individual choices in decision-making. In addition, the traditional understanding of reproductive health is concerned primarily with healthy childbearing, without extending the focus beyond periods of childbearing, thus restricting women’s health to a narrow focus on fertility and failing to address wider women’s health to their rights of social well-being (Ostlin, George, & Sen, 2003; Zurayk, 2001). The narrow emphasis on childbearing fails to acknowledge the lived experiences of women and the health needs of women above and beyond childbearing. Also, this emphasis on the biomedical model overshadows the socioeconomic, cultural, and environmental factors surrounding health and health care decisions (Ostlin et al., 2003). In contrast to these narrowly top-down frameworks of health intervention as designed by experts who are far removed from local communities in Nepal, listening to women’s voices creates alternative rationalities and frameworks for interpreting women’s health in diverse cultural contexts (Dutta, 2008). Family planning discourse Referring to the dominant discourses of family planning, Dixon-Mueller and Germain (2007) note that ‘contraceptive prevalence, with its assumption that

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‘‘higher is better,’’ does not adequately reflect either women’s reproductive preferences or their difficulties in achieving them’ (p. 46). Instead, Maria Mies and Vandana Shiva argue that women’s health, in particular, South Asian women’s health, has been treated as ‘aggregated uteruses and prospective perpetrators of overpopulation; where Women of the South are increasingly reduced to numbers, targets, wombs, tubes and other reproductive parts’ (Greene, 2000, p. 28). In the discourse of reproductive health, family planning is defined in the realm of the ability to bear and raise children, planning and spacing births, and safe pregnancy and motherhood (Kaddour, Hafez, & Zurayk, 2005), focusing strictly on the biological abilities of women. In doing so, the traditional approach to reproductive health restricts women’s health to fertility-emphasizing family planning programs which focus on providing methods to regulate fertility (Dixon-Mueller, 1993; Ostlin et al., 2003). For this reason, family planning strategies persuading women to avoid potential high-risk pregnancy are likely to be less effective in reducing maternal mortality rate (MMR) than are health systems designed to meet the needs of the women within their local contexts (Dixon-Mueller & Germain, 2007; Dutta & Basnyat, 2008). Noting the politics of power and control in the discourse of family planning, Bradshaw (1975) argues that ‘birth control was renamed family planning and viewed as part of the medical discipline’ (p. 1239), where population policies promote family planning to achieve fertility control through mobilized nation states and international agencies for population control (Shiffman, 2004; Zurayk, 2001). Here, the assumption is that poverty and MMR could be reduced by limiting fertility by effective dissemination of contraceptive technology and knowledge (Sen & Grown, 1987). This discourse of contraceptives for fertility control has medicalized reproductive choices. These are the sites within which many women are (re)constructing and negotiating meanings of their reproductive health, enacting their agency amidst the broader structures of biomedicine. Reiterating the top-down nature of family planning discourse, most public health scholars and campaigns have yet to give much attention to the role of social context in constituting individual health behavior outcomes (Airhihenbuwa, 2007; Dutta, 2008). Furthermore, health campaigns and interventions are directed at a particular audience, for a particular period of time, to achieve particular goals and are time-bound, targetspecific in selected geographical locations (Airhihenbuwa, 2007; Snyder, 2003). For this reason, health campaigns, even participatory action research campaigns, have been criticized for their top-down approach and their erasure of the voices of those communities that are typically turned into the target audiences of campaigns (Dutta, 2008; Dutta & Basnyat, 2008). Additionally, Greene (2000) notes these interventions become an apparatus aligned with global hegemony that seeks to reduce and ‘regulate reproductive rights of women as part of an empowerment strategy to modernize women’ (p. 35). Within this dominant discourse, family planning and reproduction provide individuals and couples with the means to regulate fertility more effectively, leaving out the discussions of power, structure, and dominant ideology within which reproduction is constituted (Dixon-Mueller, 1993). It is in this backdrop that the culture-centered approach foregrounds the importance of participatory dialogue that listens to the voices of local communities as entry points for creating

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locally situated discourses that challenge the dominant rationalities in mainstream structures.

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Culture-centered approach to health Noting the absences of voices at the margins in dominant discursive spaces and epistemic structures of health communication, the culture-centered approach interrogates the mainstream articulations of health for the erasures and the ways in which such erasures define the terrains of health communication (Basu & Dutta, 2008; Dutta, 2007, 2008). Starting from the articulation of absences in dominant epistemic structures, the culture-centered approach foregrounds the narratives of participants living at the margins as entry points for re-constituting the inequities in dominant discursive spaces of health communication (Basu & Dutta, 2008). Dialogic possibilities are explored for reconstituting the discursive spaces of health with subaltern narratives that challenge the mainstream structures of health communication (Dutta, 2008). Unlike the fundamental tenets of approaches such as action research and community-based participatory research (CBPR) that continue to often play out the agendas of the status quo by situating themselves within the frameworks of the status quo, the culture-centered approach draws from postcolonial and subaltern studies theories to listen to the voices of those who have historically been erased. In listening to these hitherto erased voices, the culture-centered approach seeks to render impure the dominant categories of the mainstream, bringing these categories themselves to be questioned, and deconstructing the basic assumptions that are implicit in these categories (Dutta, 2008). Health policies, systems, and practices are continually put into question through their engagement with the margins, thus creating possibilities for the inclusion of the voices in the margins in the processes through which policies and practices are configured (Dutta, 2008). In this project, we seek to engage with the voices of subaltern women in the poorer socioeconomic sectors of Nepal with the goal of disrupting the dominant epistemic structures of family planning with alternative narratives. The presence of these alternative narratives interrogates the hegemony of the dominant discursive spaces of health communication, thus rupturing the takenfor-granted assumptions underlying the dominant narratives. The key elements of the culture-centered approach include structures, culture, and agency (Dutta, 2007, 2008; Dutta-Bergman, 2004a, 2004b). Structures refer to systems of organizing healthcare resources that constrain and enable the capacities of individuals, groups, and communities to seek out health choices. Culture is constitutive of shifting local contexts, and reflects the dynamic spaces of meaning making within which community members come to make sense of the social structures of healthcare. Agency taps into the ability of individuals, groups, and communities to enact their choices in the realm of the social structures that constitute their lived experiences. The emphasis of the culture-centered approach is on creating entry points for seeking out spaces of transformation through the articulation of local narratives that interrogate the taken-for-granted assumptions in dominant narratives of health communication. The local becomes an entry point for re-constituting the global, for interrogating the discourses and meanings that circulate in dominant discursive spaces. Meanings therefore are constituted at

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the intersections of culture, structure, and agency, and offer alternative discursive constructions of health and what it means to be healthy (Dutta, 2008).

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Method This paper engages with the culture-centered approach to foreground the narratives of young Nepalese women, to highlight their lived experiences and their understandings of reproductive choices. The goal is to understand the voices of these women in ‘real world situations as they unfold naturally’ (Patton, 2002, p. 40). Therefore, the study is designed to identify and explore inequalities and injustices (e.g., power, social control, class, and agency), for the reason that stories of Third World women are being told not by themselves. Data collection Open-ended semi-structured in-depth interviews were conducted with women between the ages of 1824 years. The interviews lasted about half an hour and no more than 45 minutes, resulting in 32 hours of taped interviews. Highlighting the narratives of the young Nepalese women, we are able to understand how socio-cultural factors influence a young woman’s decision-making about her contraceptive choices. Furthermore, in-depth interviews allow for descriptions to be provided in factual accounts, identified within a culture through a holistic approach that encompasses human experience as it is lived and interpreted through their own eyes (Stern & Pyles, 1986). Bringing to the fore the lived experiences of the women aims to understand the everyday experiences within their local contexts and to uncover the invisibility of women in the dominant discourses that define problems and their corresponding solutions. Through in-depth interviews, therefore, we hope to co-create locally situated meanings with the participants that are negotiated in relationship to the contexts of health. One of the researchers, who grew up in Nepal and is conversant in Nepali, conducted the interviews. The researcher approached participants in the waiting room of a health clinic and asked if the participant would be interested in volunteering their time to be interviewed about their reproductive health. The choice of the health clinic as the site of recruitment created an avenue for initiating a discussion with the women about reproductive health choices; the choice of a health clinic is interwoven with the reproductive health framework. Furthermore, the choice of the health clinic as the site of the research was tied to the reproductive health context of the topic of discussion, a topic that is considered taboo in the cultural context of Nepal. The researcher engaged in self-reflexivity through the processes of journaling. Through this act of journaling her own experiences as she negotiated her fieldwork, the researcher acknowledges and accepts that knowledge is partial and situated; narratives of knowledge can only become possible in co-constructions, while separating the voice of the participants from the researchers. Reflexivity brings to the forefront the personal and professional experiences of the researcher as well as takes into account the researcher’s effect on the study context by addressing the subjective nature of research (Malterud, 2001). For that reason, reflexivity attunes the researcher to

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where self and subject are intertwined by consciously attending to the orientations that shape what the researcher sees and what sense is made out of it (Peshkin, 1988). If the participant was between the ages of 18 and 24 and expressed an interest, the researcher then explained the purpose and intentions of the study. Here, 50 women were selected through the screening process who agreed to participate. The names of the participants have been changed to protect their identities. If a participant agreed, the approved consent form, which had been translated into Nepali, was read to the participants. Participants were informed about privacy and of their rights to withdraw from the interview if they so wished at any point of the interview. The research protocol was approved by the Institutional Review Board (IRB) at the authors’ institution and was evaluated for cultural sensitivity by the clinic where the data were collected. Benoit, Jansson, Millar, and Phillips (2005) note that teaming up with community partner organizations with local knowledge allows access and identification of members of the population who become indispensable to co-constructing alternative health meanings. These interviews were part of a lager study looking at how women negotiate and construct meanings of reproductive health. However, for this article, only the discussion of family planning is highlighted. Data analysis The culture-centered approach formed the basis for interpreting the narratives to make sense of them, to engage in a co-constructive journey for participatory communication, and to understand the ways in which women share their stories at the intersections of culture, structure, and agency (Dutta, 2008). Embodying the notion that cultures vary and therefore the solution must be constitutive of the worldviews of the local participants, the in-depth interviews are directed toward listening to the voices of the women. So, the analysis focused on answering the questions of inequality, structure, power, and agency, through the narratives of women’s experiences. In particular, thematic analysis was utilized ‘as a systematic approach to social justice inquiry that fosters integrating subjective experiences with social conditions in the analysis’ (Charmaz, 2002, p. 510). This approach to analyzing narratives is valuable in understanding and explaining human experiences as it is lived, especially those phenomena that can only be interpreted through the eyes of those submerged in the experience (Stern & Pyles, 1986). Therefore, we started with line by line analysis of the transcripts through open coding to allow for generation of thoughts, ideas, meanings, and concepts emergent from the data. The transcripts were first transcribed in Nepali and then translated into English. We read through the translated transcripts, highlighting chunks of text that suggested a category. Next, axial coding was done for another pass of the concepts and constructs to review, examine, and group them into categories. In addition, Strauss and Corbin (1998) note that axial coding allows the researcher to reassemble the data fractured during the open coding to make connections between categories and sub-categories. Therefore, at this stage we related, integrated, and connected the recurring words, meanings, and concepts by grouping them into broad categories. Finally, selective coding was used to depict the data through the refinement and union of categories. It was during this process that thematic information started to evolve and answers to

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the research questions began to be formulated. Here, the existent categories were combined based on its overarching idea and concepts to further refine the themes.

Results

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The interpretations of family planning decisions among young Nepalese women living at the margins foreground the (1) interpretations of family planning choices and motherhood, and (2) women learning from other women.

Interpretations of family planning choices and motherhood Family planning choices are located within the cultural logic of Nepal. Being able to have a child and become a mother are key markers of power in the familial and social structures of Nepal and, therefore, intertwined with the meanings of family planning. For the participants, the age of first child almost always coincided with the time/age of marriage. Bearing and rearing children are central to a woman’s power and wellbeing in the Nepalese socio-cultural context, and reproduction brings in concrete benefits over the life course. Though reproduction has become fused with women’s bodies, women realize that their reproductive capacity becomes a source for power in the familial and socio-cultural structures. As Bhagwati explains: Yes, used after [referring to contraceptive use after the birth of her first child]. At that time, everyone in the family was suggesting to have a child right away and then to use family planning after I had at least one. Yes, you need to [have one] in order to be part of the family, be fully accepted and have your say.

Bhagwati is making reference to the cultural norms that create expectations from women, an initiation into womanhood and family acceptance through motherhood. Mothering becomes a way women negotiate their identities and find a place in their context. Women may feel pressured to start a family early, but women understand exactly what it means to comply, to have a say in the family, to carve out a place within that structure. Laxmi echoes similar notions of motherhood: I didn’t want to use anything. I mean somewhere I think I wanted to get pregnant (laughing). Besides everyone said I should have one. It’s not like I have a job or anything they [referring to family] said. And you have to be [referring to giving birth] accepted into the family, be part of the family.

Acceptance and being part of the family in a Nepalese context means the ability to become involved in family decision-making. It is in these spaces of legitimacy that women narrate their understandings of family planning. The idea of motherhood is not simply played out in the role of a caretaker, but is embedded in a complexity of family structures and identities. There may appear simply as family expectations where women have no choice, but women understand the leverage, the power they will for negotiation as a mother. Motherhood may appear simply as family expectations where women have no choice, but women understand the leverage, the power they will have for negotiation as a mother. As both Subdhara and Kalpana explain, only after being a mother did they plan for their families:

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Subdhara: We two [referring to husband] discussed, but I only started using the injection after my son was born until now, not before. The injection had a lot of sideeffects for me. I stopped for only 23 months and now after the procedure I want to use Copper-T.

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Kalpana: After my daughter was born, not before because we wanted children. Then I used the three-month injection twice and then I stopped and haven’t used anything after that and then my son was born sometime after I stopped.

Articulations of contraceptives in the conversations with the women disrupt the mainstream assumptions about family planning. That low contraceptive use can be because women want to become pregnant and not because their contraceptive needs have not been satisfied is an assumption that is typically missing from the dominant framework (Dixon-Mueller & Germain, 2007). The mainstream discourse of family planning does not reflect women’s desire for family planning or the understanding of their contraceptives choices within the broader domains of relationships, familial expectations, and negotiations of power. When family planning campaigns target information dissemination for individual behavior choice, they leave out the contexts of social and familial expectations within which family planning is constructed and understood. Nirmala explains her apprehension about using family planning methods: I mean it’s one’s own wish what to use and I think rather than women using, it’s better to use condoms so that there is no difficulty later to have children. Well, I would use something if I had a child already. I don’t want to use anything until I have one, so for now condom is one way. I don’t think it’s safe to use anything else.

The apprehension of using contraceptives and perceptions of risk through experiences of women around them has shaped women’s expectations around family planning, particularly when women are concerned about motherhood as the entry point into spaces of legitimacy. Similarly, for Roshini the desire to become a mother informed her decision about family planning: I heard that it could be risky for your life if you used anything. They said with the injection you don’t get your period on time, and this pills I haven’t taken, I haven’t seen, and I haven’t used that injection either. And I heard that after you have given birth you can use that Copper-T. But, I haven’t done anything.

The options of contraceptive choices for the women are: birth control pills, Depo-Provera, condoms, Norplant, and intrauterine devices (IUD). Many women report that the injections and Norplant do not work well for them, but they have no other options, especially if they live in the hill regions and cannot reach a health post every month. The 2006 National Demographics and Health Survey (DHS; see Demographic and Health Survey, 2006), conducted every five years in Nepal found that majority of men and women (91 per cent and 76 per cent, respectively) have heard about family planning messages through various media outlets; however, 90 per cent of the non-users did not have contact with health professionals that discussed family planning options. Instead women rely on each other to learn about their choices and the drawbacks associated with their choices. Motherhood is a way women negotiate their identities and find a place within the

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familial structures; therefore, decisions of family planning are situated amidst the processes of negotiating roles and expectations around motherhood.

Women learning from other women

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Women learn from the experiences of those around them and in turn making sense of these methods for their own choices through their interactions with the others in their social network. As Sabu indicates, her apprehension about using contraceptive methods came from the experiences of other women: Well (pause), actually I also don’t want to use. My mother used. I have two mothers and between them there are 12 children and I am the oldest. I am eldest sister of 11 and when mom used it she had lots of difficulties. It wasn’t good, poor thing is still sick. She went to have it [referring to Copper-T] removed and from watching others, I am afraid to use.

The understandings of these experiences are co-constructed with other women to inform their own individual decisions. Women rely on each other’s experiences and regard the interconnected network of women’s knowledge as expert/authoritative knowledge to make informed decisions. This ‘authoritative knowledge’2 shapes individuals’ expectations and experiences and ultimately how sense is made of them such that knowledge is not what is correct but what counts (Miller, 2005). For this reason, the ‘authoritative knowledge’ in this environment is not the bio-medical technologies where mothering gets constituted in the realm of biomedicine but is located in the cultural domain of knowledge about reproductive health. In this sense, experiential knowledge in the solidarity network of women is central to informing women about the choices available and the viability of these choices. Manita describes her dread for family planning: Well, I heard it’s like that. You see my sister was using pills and she bled a lot and her period happened ahead of the date. So she used an injection of some sort and from that she bled all the time, like 15 days or even a month. She was getting so thin and sickly so after seeing that I don’t want to do the same to myself.

Though women become great sources of information for each other, the information exchanged may not be entirely correct medically. ‘Authoritative knowledge’ then becomes embodied in the form of accepted practices that are culturally reinforced and given legitimacy through other women, gained through the experiences of other women. Jamunia notes: I was feeling scared. I was scared by others that if I used it, I may have difficulty when I want to have children. Yes, my family and friends were talking. So, I haven’t used anything and I won’t use anything until I have a child.

This horizontal transfer of information is trusted more and becomes a way women construct meanings of family planning, thus challenging the sphere which constitutes the basis of the dominant approaches to family planning. This feeling is shared by the participants, referring to the importance of prioritizing their families’ needs; as a result, questions of contraceptive choices often get put on the backburner. They suggest that contraceptives and family planning are at the bottom of their list, given the everyday

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structures they have to negotiate, in addition to their doubts about utilization. It is in the backdrop of the dominant agendas of population control that women assert their rights to voluntary motherhood as a means of easing into, not necessarily to change, their traditional roles. Mixture of feelings such as ambivalence, uncertainty, expectations, and hesitation all interplay in the decision to utilize family planning for the reason that motherhood is expected and accepted such that women do not want to jeopardize their fertility. This is noted by both Gita and Seema:

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Gita: Everyone in Gaun [village] was saying that you shouldn’t use anything before you have at least one as it may prevent you from having later. That’s what I heard, so didn’t use anything. Seema: Well, you know people have scared me about using other things that I may not be able to have children later or that it may spoil my ovaries that if you take things like the pills it can collect there. So the two of us talked and decided to use just condoms.

Motherhood is a vital part of women’s lives, women discuss motherhood as an entry point of acceptance into one’s family, and for this reason many young women fear contraceptives affecting their fertility. Shared experiences and family expectations form the basis of knowledge and understanding about family planning and reproductive choices. However, in the dominant discourses of family planning, the need for contraception is defined by research design and not by the women themselves, such that unmet need may or may not represent an active demand or desire for contraception (Dixon-Mueller & Germain, 2007). The lives of women and their families are affected by the decisions around contraceptives and women do not make the decision lightly. Their choices reflect the lifestyle and needs within the familial context. The narratives of motherhood and the necessity of having a child in order to define a woman’s legitimacy suggest that it is essential to address women’s needs as defined by the women themselves; discourses around birth control and abortion services need to be opened up in allowing women to decide whether or not to use, whether or not to have more children, as well as when and how to have them. The fear of contraceptives affecting one’s fertility and the spaces of legitimacy motherhood creates is also located within the macro structural resources that often limit accessibility and utilization of services. The lack of access to health facilities, inaccessibility to health care providers, and the inability to afford medical treatments have yet to enter the discussion that emphasizes interventions. Nevertheless, women’s lived experiences provide an understanding of how family planning choices are created and negotiated within their own structural and cultural contexts and enacted as necessary for their own lives.

Discussion Focusing our discursive constructions on women’s lived experiences situated within the shifting social, cultural, economic, political, structural, and historical contexts can ensure more realistic and less normative portrayals of women’s lives. It is necessary to connect women’s personal beliefs, desires, and choices with their social expectations and structural situations, creating openings for women from subaltern contexts to enter the dominant discourse and articulate their agency in negotiating local contexts

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and structural configurations. For instance, the Nepalese women’s lived experiences illustrated that their family planning choices are situated contextually. In spite of the biomedical discourse of reproduction that constructs the woman as a body, how she understands her body and creates meaning for her body is based on her own cultural context, shifting from community to community and from family to family, and in turn situating her understanding of health meanings within local contexts. Therefore, the local meanings in this project point toward the heterogeneity of community contexts, with multiple meanings, working simultaneously as well as in opposition to create the broader frameworks of action (Dutta, 2008). The subalternity of the Nepali women from the poorer sectors of Nepal is disrupted through the diverse stories narrated through women’s voices that challenge the monolithic constructs of Nepali women in the mainstream. Worth noting in this project is the dialectical tension between the localized narratives of women that foreground the voices of the women as entry points to meaning and the broader goals of this project to create alternative entry points that are based on the act of aggregating the lived experiences of the women into discernible categories. Attending to local meanings ruptures the hegemony of the biomedical discourse of family planning, calling for alternative interpretations and cultural understandings. The dominant global configuration constituted by biomedicine, global policies, and nation states is juxtaposed in the backdrop of local meanings; in this case, negotiating motherhood and legitimacy are foregrounded instead of an emphasis on controlling the body as a site of production. In doing so, attention is shifted to the relational and community realms of decision-making, particularly in the areas of motherhood and family planning. Beyond the articulations of a linear approach, the narratives presented here draw attention to the multiple ways in which women negotiate their identities and relationships in the area of family planning. Furthermore, these identities and relationships are negotiated within the broader contexts of shifting familial, societal, as well as cultural roles (Dutta, 2008). Therefore, as opposed to the dominant understandings of participation that utilizes participation as a means to achieving specific ends of the power structures, our coconstructed participation with the women in these interviews foreground the active processes of interpreting structures and contexts through which poor women in Nepal negotiate their health choices. In the dominant framework of family planning, interventions are based on the assumption that people of the Third World are poor, and therefore, need to be developed according to Western measures, such that the Western discourse of development is deployed through the practices of planning agencies, local development institutions, and health organizations (Dutta, 2008; Isbister, 2003; Peet & Hartwick, 1999). The assumption is that development follows a simple linear progression from tradition and underdevelopment towards Western definitions of rational modernity (Chowdhry, 1995; Parpart, 1995). Furthermore, Dutta (2007) argues that ‘power over culture is maintained through the panopticon that keeps an eye on the culture and its unhealthy practices, and designs persuasive strategies to alter these unhealthy practices identified at the individual level’ (p. 315). Our culturecentered engagement with this project disrupts the dominant discourses of family planning by locating it in the realm of motherhood; here articulations of identity as a mother become salient within the local context, thus driving the discourses of family planning. In foregrounding the articulations of motherhood, our co-constructions in

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this project render impure the dominant categories of passive Third World women as articulated in development discourses. Motherhood offers the space of legitimacy for women within familial and cultural structures, and articulations of family planning are located in the realm of motherhood. Also, women construct their meanings of health in the midst of the local epistemologies and ontologies, seeking information about family planning, the efficacy of methods and technologies, and the side-effects of methods and technologies from other women in their social networks, questioning the global hegemony of the biomedical model. Experiences and stories within the community network become information resources that are privileged over the expertise-driven information resources constituted under the biomedical model. Finally, meanings of family planning and contraception get negotiated within relational and familial networks, constrained and enabled within structural configurations. The culture-centered approach in this project therefore offers an entry point into the discursive spaces of family planning and reproductive health by listening to the voices of the local women located at the margins of the mainstream. In co-constructing the meanings of family planning, we engaged in interviews with the women at the waiting room of a health clinic. Whereas on the one hand, the waiting of the health clinic created the context for the discussion of family planning and reproductive health, topics that are considered taboo in Nepal, it is also worth noting the possible limits on the discursive possibilities created by the structures of the clinic. In the dominant framework of family planning, health becomes a commodity that can be controlled within the tradition of illness prevention and identification of cause and effect, and consumers can be persuaded to acquire it at individual cost, where power is enacted through the one-way flow of knowledge with the ability to control the discursive space and praxis (Dutta, 2007; Escobar, 1995; Lupton, 1994; Raphael & Bryant, 2003). This top-down, public health knowledge is exercised somewhat paternalistically, exercising the power of patriarchy, and simultaneously marginalizing the voices of women (Lupton, 1994). Here, Lupton (1994) argues that medicine is not viewed as a product or part of a culture, but as an objective body of scientific knowledge outside of culture. The reliance of women on their kinship networks for information also suggests a gap between the dominant public health infrastructures and information resources and the lived experiences of the women, suggesting the relevance of developing information and communication resources that are responsive to the narratives, lifestyles, and information needs of the women. The information networks of women situated in the backdrop of (in)access to dominant public health platforms also highlights the necessity of understanding the intersections between structure and culture; structural inequities are played out in the realm of the absence of culturally situated understandings of the local context within which information infrastructures might be developed (Dutta-Bergman, 2004b). As the narratives of the young Nepalese women noted, individuals make sense of their culture through stories and shared experiences where authoritative knowledge comes from those around them, and is constituted in the realm of the community and the direct experiences of community members. Therefore, we must develop new models of health promotion that include cultural implications of health behaviors, rather than perpetuate models based on assumptions, theories, and frameworks of the dominant system (Airhihenbuwa, 1992). These findings are locally situated in the context of Nepal, but they also offer insights into the ways in which health communication can be

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theorized and practiced in other contexts. Through women’s articulations, we are able to connect women’s personal beliefs, desires, and choices with their social expectations and structural situations. In addition, alternative understandings grounded in women’s experiences rupture the dominant discourse of reproductive health through the presence of the voices of the poor women that centralize lived experiences in traditionally marginalized spaces (Dutta, 2008; Dutta-Bergman, 2004a, 2004b). Additionally, Dutta (2008) notes, stories provide individuals with a framework for understanding and interpreting their own health, such that narratives of health are understood within those contexts, and offer ways for negotiating structures. Wilkins (2000) notes: ‘by situating strategic social change within the context of power, we can recognize both the ability of dominant groups to control hegemonic process through perpetuating their ideological interest and the potential for marginal communities to resist’ (p. 2). Therefore, it is not possible to understand the values of decisions and behaviors, unless understood from within the contexts that cultured these values (Airhihenbuwa, 2007). This was also articulated by the young Nepalese women, where meanings are created and enacted collectively, situated within collective networks of solidarity of women living in poverty in Nepal. The collective network of solidarity creates expectations and encourages social relations that value kinship and community, such that behaviors are negotiated within those spaces and understandings. Here, women’s choices are imbued with meanings and interpretations that are culturally situated. The narratives of the young Nepalese women are informed, understood, and made sense of within their cultural contexts and are played out within those structural spaces that constitute the logics, rules, and functions of these narratives. Furthermore, these locally situated narratives provide entry points for making sense of structures and enacting agency where meanings, behaviors, and choices are located. The presence of voices enables the (re)construction of the dominant discourse as well as extends the notion of culture as a dynamic context of meaning-making. Notes 1. The Third is used here consistently to refer to the politics of First and Third World spaces that constitute the materiality of contemporary discourse guiding the construction of health communication policies and campaigns. The Third World refers to those sectors of the globe that are typically categorized in dominant approaches as underdeveloped and primitive, and therefore, in need of modernist interventions. 2. The idea of ‘authoritative knowledge’ derives from Brigitte Jordan’s work from the 1970s in which she took a biosocial approach to exploring birth practices in four different cultures. In this work Jordan explored how ‘authoritative knowledge’ contextualized and shaped women’s expectations and experiences of birth (Miller, 2005).

Notes on contributors Iccha Basnyat, PhD, MPH, is a visiting fellow in the Communications and New Media Programme at the National University of Singapore. Mohan J. Dutta, PhD, MA, BTech, is Professor of Communication at Purdue University. He is also the Associate Dean for Research and Graduate Education in the College of Liberal Arts at Purdue University.

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