Family Planning in Burundi: Hegemonic Discourse, Reproductive Navigation and Embodied Experiences in a Fragile Context

This thesis is about family planning in Burundi. The objective was to explore the reproductive preferences, strategies, practices and experiences of rural women and couples, in a fragile context. By that, I mean in a country characterised by a socio-political fragility, a very poor economic situation that is heavily reliant on the agricultural sector, a high population density and subsequent land pressure and conflicts, and strong gender inequalities.
We aimed at understanding family planning (FP) practices in Burundi from a community perspective, using quantitative and qualitative data that we collected in two rural sites between 2013 and 2016.
Using a political economy lens, we describe how a reproductive governance operated at different periods in Burundi, following political ambitions and needs about fertility and population size. Since the end of the internal conflict that devastated the country between 1993 and 2005, large efforts were concentrated on promoting family planning services and methods to address the growing challenge of population density and land pressure, with support from external actors. These policies and services, adopting strategies such as incentivising provision of modern contraception, are distant from the definitions of reproductive health and rights based on autonomous and free choice. We found that, despite the efforts of the government to diffuse a hegemonic discourse on ‘overpopulation’ causing poverty and land conflicts, utilisation of modern methods of contraception is increasing but low, at 23%. The discourse however has the role, we argue, to shift the debate away from failed governance by setting the responsibility of poverty and land conflicts on the ‘uncontrolled’ fertility of rural populations.
Using qualitative approaches, we describe how preferences and practices of family planning are not linear and that decision-making is not individualist but rather is contingent on complex social, economic and political dynamics. Most women expressed discursively a desire to space or limit their births and to align their family size to their land-dependant livelihoods capacity. We found that for many, contrary to the past or to neighbouring DRC for example, children are no longer perceived as an asset, but rather as a liability in the context of poverty, uncertainty and land pressure. Despite these expressed preferences, echoing the hegemonic discourse, we have shown how reproductive navigation – from preferences to practices of FP – present different family planning subjectivities, and is shaped by multiple dynamic factors situated at different levels across the life-course, grounded in sociality and corporeality. Some women use modern methods of contraception to space or limit their births, but fear abandon from their husband. Some use natural methods taught in Church that are socially valued but constraining and access is limited. Others use nothing or rely on their bodily capacity for natural birth spacing, and would consider using FP methods only if ‘they don’t have the right body’ for that.
Burundi is experiencing deep changes in social norms that are induced by fragility and poverty, and that call for social adaptations, including within the family organisation. We describe how these changes are mostly acting in disfavour of women who have to find strategies to maintain and protect their main resource: their body, in its productive function (working in the fields to sustain the household) and its reproductive function (providing lineage for the family, and subsequent social status). With no access to land, women are dependent on their father or husband for livelihoods and security.
In that overall frame, modern methods of contraception do not appear like a panacea to rural women, because of their frequent and unpredictable side effects. We have described how ‘fear of side effects’ refers to the observed adverse effects of hormonal contraceptives, mostly bleeding, which in these contexts of demanding agricultural work and widespread malnutrition are in fact problematic. As most women maintain their status and access to resources through their bodies, risking physical side effects by using modern methods was assessed perilous by many women. This partly explains the low utilisation of modern contraception.
I argue that typical policy recommendations and programme implementation strategies that focus primarily on educating and sensitising communities to reduce the barriers against utilisation of family planning is problematic in that they focus on modifying fertility behaviour and trends, in disconnection from people’s needs and situations. Greater attention should be drawn on lived embodied experiences of women; local biologies and social and bodily realities should be acknowledged, integrated and reconciled in health care provision.
Expanding reproductive rights and possibilities – by offering a wider choice of methods and improving access – would ameliorate acceptability and adequacy of family planning programmes. Above all, in contexts like Burundi, it is primarily by improving the socioeconomic situation of women and reducing inequalities, especially in their access to land so they do not have to rely solely on their productive and reproductive bodies as the only resources, that positive change in the demographic equation may settle in.