AJTUXX Media Review Vol. 2 No. 1. 1987 e African Council on Communication Education Family Planning Communication and tneftfrican Women's Liberation: A Ghana Case Study by Alexina Arthur* Abstract This paper looks at the role Family Planning communication plays in promoting the general welfare of women, in accordance with the spirit of the Women's Lib movement. It is based on a case study done in Ghana, where the mass media channels have been put to good use in creating awareness and motivation for family planning. The author discusses the achievements and failures of the Ghanaian campaign, and makes some recommendations for improvement. Cet article passe en revue le role que joue la communication en planification familiale dans la promotion du bien-etre ge'ne'ral de la femme dans l'esprit du mouvement de libeYation de la femme. II est base' sur une e'tude de cas faite au Ghana ou les canaux des mass meidia ont ete' u tilise's a bon escient pour susci ter la conscience et la motivation pour la planification familiale. L'auteur analyse les succes ainsi que les echecs de la campagne Ghaneene et fait quelques recommandations en vue de son amelioration. •Mrs. Alexina Arthur Is a Lecturer at the Department of Modern Languages, University of Ghana, Legon. 38 Introduction The 1970s and especially the 1980s have seen a clear and increasingly vigorous convergence of interest in the issue of women and children. Within this period the United Nations has declared the International year for Women as well as the Year of the Child. There is also a UN Declaration on the Elimination of Discrimination against Women which in part states that "equal rights for women and their full participation in all spheres of social life are a necessity for the full and complete development of a country, the welfare of world and the cause of peace".l Yet to date while there has been a surge of written literature on these areas, there has been only a little change in the position of Women in many countries of the developing world. There has been a systematic and inbuilt imbalance against women in the areas of education, politics, economic and social life in many countries and though some women have occupied and occupy responsible positions in state affairs, this is as yet an exception and not a rule. The desire to cement the unity of women in their efforts to achieve peace, secure equality in the family and in society found expression in the Women's Lib movement in the advanced western countries. How did the African view the Women's Liberation Movement? A combination of historical, political, socio-economic and cultural circumstances has rendered Africa a very complex continent, and solutions to its myriad problems are more often rendered impracticable because of the existence of multi- directional political systems, unintegrated economic and trade policies between countries, as well as the anglo-franco affiliations of the countries in Africa This is only to mention a few. In the same vein, the women's Lib concept though human in both content and form was regarded as a Utopian solution to the woes of the African woman who is caught up in such trends as cultural nationalism and religious fundamentalism which tend to reinstate patriarchal systems and restrict social progress by both physically and mentally demobilizing women. Women are expected to be custodians of traditional culture, given a primary role as educators. At the same time, a male dominant society allows a culture of consumerism through the media to generate powerful advertisements on general image, create artificial needs, distort 39 image, and often lead to a fragmentation of women's consciences. The purpose of the gathering today, is not to find solutions to the long standing problems of how women can rub shoulders with men, achieve economic independence and social security. Of course in a free country, a woman is capable of achieving anything a man can. But let us leave the political and economic aspects of women's liberation and come to the home where women seek more importantly, happiness for themselves and their children. The findings of a number of studies done on Family Planning and family life in Ghana show that the Ghanaian woman is yet to enjoy full domestic liberation - she does not have full control over her own body, health and happiness as well as the happiness of her children. There are many aspects to the women's question, but one of the aspects we as communicators should be interested in, for example, is the role Family Planning Communication has played in helping our women to enjoy a full family life while being alive to their marital responsibilities. Family Planning Communication in Ghana The expression "family planning" is a euphemism for "birth control" or "planned parenthood".(2) The scope of family planning communication according to Rogers, is (1) to create knowledge of the idea of Family Planning, of Specific Family Planning methods, and/or the small family norm, (2) to form or change individuals' attitudes towards these ideas so that they are more favourable and (3) to secure the adoption of Family Planning methods, so as to prevent births. Thus all Family Planning activities are, in a broad sense, part of a communication process"(3). He identifies at the same time some characteristics which distinguish Family Planning Communication from other forms of communication.^) Some ol these characteristics that should be of interest to us are: 1) Family Planning and fertility behaviour deal with beliefs and values that are very central to individuals. Acceptance of Family Planning therefore may require a restructuring of a man's entire personality, already held beliefs ... A Family Planning decision has to do with his life, his manhood, his sex life, his family and religion... Resistance to Family Planning is therefore, initially very strong. innovation 2) Family Planning communication is "taboo" communication. "These beliefs" writes Rogers, "are extremely private, personal 40 and taboo. Hence family planning ideas are not very interpersonally discussable . .. "(5) 3) Family Planning decisions on the other hand are collective decisions rather than individual decisions. Typically, a couple is involved. This implies discussion and deliberation, thus eliminating impulse and immediate reaction decisions.(6) 4) There are often counter campaigns against Family Planning. Religious groups and traditionalists always raise moral and ethical questions. They believe Family Planning will lead to moral degeneration and promote promiscuity among the youth; and also that anything that interferes with procreation is sinful and must not be encouraged. The application of these characteristics in the Ghanaian context will be discussed in the latter part of this paper. Family Planning in Ghana Family Planning was introduced in Ghana in 1970 as an intergrated part of a population policy, when the 1960 census showed an alarming growth rate of 3%. The government had issued a statement a year earlier entitled "Population for National Progress and Prosperity: Ghana Population Policy". The Ghana National Family Planning Programme (GNFPP) which was established to carry out a Family Planning Programme was charged with two basic functions: 1) 2) to ensure the ready availability and provision of effective contraceptive products and delivery service through which adopters may be easily, safely and conveniently served; and to mount and sustain an education and information programme geared at persuading the population to adopt Family Planning.(7) Information and Education on Family Planning is carried out on two levels - the mass media level and the interpersonal level. The Mass Media Channels The mass media campaign was carried out in three stages. At the initial stage of the campaign, the awareness and even at the subsequent state - motivation stage, family planning publicity and advertising were carried out across all the media - radio, press and television. During the motivation/persuasion stage, outdoor media, and Point-of-Sale display were also employed as supporting 41 strategies - there were double crown posters, car stickers, shelf- strips and point-of-sale dispensers. All these materials carried the Family Planning logo - the red triangle and messages aimed at creating the awareness and benefits of the adoption of family planning - "Family Planning for Better Life" and assuring the public that Family Planning is "Safe, Simple, Sensible". All the points of sale and give-away materials were distributed throughout the country - in Family Planning Clinics, hospitals and other vantage points. In 1971 the GNFPP launched the 1st contraceptive social marketing programme with Sultan Condoms and Emko Foam. The advertising was stopped for a while due to the boomerang effects it created on an apparently unprepared public who reacted negatively to the contraceptive advertisements. In 1973, advertising of contraceptives was reintroduced. 1978, 79 and 80 saw another major contraceptive advertising with the launch of a Social Marketing Programme implemented by Danafco. This was the Westing-House Programme Contraceptive ads for Panther condoms, Florid Oral contraceptives and Coral Contraceptive Foaming Tablets. Family Planning has again become a major component of the Social Marketing Programme, relaunched this year (1986). As part of its programme, the Ministry of Health will use "the public sector clinics, health centres and hospitals as well as community based health programmes to deliver maternal and child health and family planning programmes and provide training for personnel and teaching materials for the widest and most effective dissemination of interpersonal information and education."(8) A second programme will be the "use of the resources and facilities of the private sector through the resuscitation of the contraceptive Social Marketing Programme."(9) The Contraceptive Social Marketing programmes "represent a mixture of private sector, commercial enterprise and public sector social goals. They use the private sector's commercial marketing methods and resources to achieve certain distribution and revenue goals, while at the same time seek to attain such social goals as increasing the individual choice and access to appropriate contraceptives."(lO) "The CSM programmes differ from those of the government or private voluntary organisations in their use and application of a marketing approach to management. They focus on the consumer by identifying convenient places and channels for distributing contraceptives, gaining retailer support to sell contraceptives, the developing sales and distribution systems to ensure 42 contraceptive products reach the retailer (and ultimately the consumer) and by using promotional tools to inform the consumer about csm products. The CSM programmes in Ghana and other countries "strive to create consumer demand through advertising that promotes specific CSM brands of contraceptives. In such CSM programmes and their advertising agencies have worked closely with government agencies to prepare messages which are suitable for the mass media as well as sensitive to the culture of the population."(H) Market research has also played an important role in creating effective advertising. Undoubtedly the mass media have been well utilized in the family planning programme - from the introduction of the concept, creation of awareness, motivation and persuasion, education and marketing of contraceptives. The Interpersonal Channels The GNFPP exploits the services available through the extension and educational divisions of governmental and non-governmental agencies. These are the Information Services Department, the Health Education Division of the Ministry of Health, the Department of Social Welfare and Community Development, the Christian Council of Ghana and Planned Parenthood Association of Ghana, which have large numbers of personnel actively engaged in information and education work among the local population. Findings from studies show that poor groups represent a major channel of Family Planning Communication. They feature in all stages but more prominently at the persuasion stage of the adoption of Family Planning. Unfortunately however the messages of communication are misconceptions, misinformation and rumours which go a long way to undermine the believability of mass media messages concerning family planning. Knowledge, Attitudes and Practices of Family Planning and Contraception by Ghanaian Women In the discussions that follow, we will use some of the findings from nationwide family planning survey researches - The Consumer Intercept Survey, February 1986 and Retail Audit Survey June 1986 as well as one Focus group session on contraceptive Advertising, held in Accra May 1986 and six Focus Group Sessions on User and Non-User Perceptions of Family 43 Planning Issues in Ghana held in four cities - Accra, Kumasl, Tamale and Takoradl. These research studies were commissioned by and undertaken for Lintas Ghana Ltd., the major advertising company in Ghana. This writer was actively involved in all the surveys and moderated the female group sessions. It would be expedient at this juncture, before going on to discuss the KAP of family planning and contraception by Ghanaian women, to briefly describe the demographic and socio-economic characteristics of respondents of the surveys and participants of focus group sessions. Male and female adults who entered carefully selected Pharmaceuticals or chemical shops to purchase any kind of drug qualified as a respondent of the survey. Others were intercepted a few yards within the vicinity of the shops. These people were heterogeneous in terms of age and socio-economic status. They were controlled for homogeneity on "parenthood" as a common variable. The respondents of the Retail Audit Survey were pharmacists, managers/manageresses and shop attendants of sampled Pharmaceuticals or chemical shops. Female participants lor user groups were either married or single, young (25 years or below) or old (above 25 years) with at least a single child and a current user of a modern contraceptive. Female participants for non-user groups were of the same demographics except they were currently not using any modern contraceptive but most have used in the past or had never used contraceptives before in their lives. In all cases participants had had only up to secondary school level of education or below. Majority of the 38 participants fell within the C and D socio-economic groupings. Three fell within the E grouping. There were twenty users and eighteen non users who were either Protestants, Catholics or Moslems. that Knowledge of Family Planning and Contraceptives Knowledge of family planning and contraceptives by Ghanaian women is greatly influenced by their sources of information. in Ghana, Even though ownership of radio and television or access to them is universal the majority of respondents and participants first heard of contraceptives not from the mass media but from a friend, a neighbour, a relative or a co-worker. The minority's initial sources were doctors or family planning clinics. 39% of female respondents first heard about the pill from a friend or neighbour. 44 Most women were aware of family planning and perceived it as important The term "Family Planning" was understood variously to mean 'preventing unwanted pregnancies', "spacing births", and "delaying the onset of the first child", "limiting family size" and "family welfare". A lot of women also knew about, and named soirie modern methods of contraception - the Pill, the Condom, the Foaming Tablet and when promoted, mentioned others like the I.U.D., Injection, sterilization and 'natural' methods such as abstinence and the rhythm methods. The level of knowledge of the workings of the different contraceptive methods researchers were particularly interested in the Pill, Condom, Foaming Tablet and IUD) were however very slow. (the The most widely known was the Pill or more popularly known amongst the C, D, E socio-economic groupings as "21" or "28". Participants of group sessions had only vague notions about how the Pill prevents pregnancy. The general feeling at the point of discussion was that it was not really important or necessary to know this. "It is enough to know it prevents pregnancy" one participant said. Another also said "If you know that you will have sex at 8.00 p.m. then you should take the pill at 6 p.m. and you will be okey". Most pill users however reported taking the pill daily either in the evening or in the mornings. Some of them also said "If you miss one, then take two the next day, if you miss two, take three and so on". The nearest to a correct answer was given by only one participant out of 38. She said "it surpresses the majority of the ovaries". This state of affairs applies to all the other methods of contraception. Attitudes Three major factors affect the attitudes of Ghanaian women towards family planning and contraception. These are the socio- economic well-being of the family, religious and traditionally-held values and beliefs, and lastly lack of the correct information about the side effects of modern contraceptives. Many Ghanaian women, those who do and those who do not practise family planning have realized the need to limit size in order to improve upon the economic well-being of the family. When participants were asked what the ideal number of children in a family should be, those from Accra, Kumasi and Takoradi said three or four. One said, "The way I want to educate my children, I 45 need four of five years between than. I can't have more than three. That way the children will also be very healthy." Another said, "not more than three. If both partners cooperate, they will be able to take care of them and see to it that they are well developed" and a third, "If children are well educated then you are more secure"; "If you want no troubles then two". Not surprising therefore, most of the participants in these same places were of the opinion that the sex of children was not very important - "Any sex is alright I'll stop at the number I want even if all happen to be one sex"; "If you don't take care, you'll have nine children, all boys, no girl". One of the distinctions Rogers makes between Family Planning Communication and other forms of communication is that family planning and fertility behaviour deal with beliefs and values that are very independent to individuals. A decision on family planning affects his manhood, his sex life, his family and religion. Truly, religions and traditionally held beliefs are of utmost concern to the people of the northern regions of Ghana. The indigenes are either Moslems or Catholics whose faith abhors and prohibits anything that interferes with procreation. They do also realise the importance and need for family planning in contemporary times but nevertheless, for them, the ideal number of children a family should have is six or eight and the sex of children is of utmost Importance because both males and females play crucial roles in the traditional family unit. The Dagombas prefer more girls to boys because the cows brought into the family as dowry by prospective husbands are used by the brothers as their dowry for their prospective wives. If there are no daughters, then each son would have to buy his own cows and if he is unable to, he remains a bachelor. If there are only girls or more girls than boys in the tamily, the father becomes rich. The Dagares of the Upper East regions on the other hand prefer boys because of the role adult sons play in the home. Amongst other things, they may decide to keep their divorced mother under the same roof with their father arid ensure her safe upkeep. They also ensure that their married sisters are not maltreated by their husbands nor their in-laws. Furthermore irrrespective of these preferences and as a result of male dominance in these areas, participants in Tamale said it was necessary to have a boy "to represent his father" or "to please your husband". Talking about contraceptives particularly, the lack of accurate information and the spread of rumours have affected many women's attitude towards adopting modern family planning 46 methods. There are mild side effects experienced with the use of contraceptives, but these are not perilous and are usually short- lived. But these have been so grossly exaggerated and spread abroad that it is the major reason why many non-users abstain from using contraceptives altogether. Furthermore, many diseases which afflict people with age, especially beyond 45 years are associated with the pill. If a victim of any of these diseases (hypertension, diabetes, cancer etc.) happen to be a woman and happened to have been a pill user at one time or other, it is blamed on the pill. One participant referred to the case of her 43 year old neighbour who had a swollen stomach because she had been taking the pill. The moderator strongly believed that the neighbour had fibriod. Participants reported having heard about these side effects from friends but none of them knew of any case that had been confirmed medically. An exception was one young non-user in Takoradi who reported she got pregnant whilst wearing the IUD. She believed strongly that the device got lost or swallowed up in her body. The other participants believed her story! These side effects are of great concern to women because they view them as serious health hazards. Even the reduction in menstrual flow, experienced with the use of the pill is perceived as a serious abnormality. In reference to the proper mix for a Family Planning Communication campaign, Opia-Mensah Kumah stated that "an important interpersonal component is essential to counteract the rumours and counter-campaigns which family planning invariably provoke".(12) Reports from participants of group sessions indicate that the paramedical staff who are actively engaged in the information on education of family planning among the local population are by and large consciously or unconsciously responsible for the misinformation flow. the first Let us review a case, where a young woman goes to the family planning clinic for time and seeks advice on contraceptives. She is briefly told about the Pill, Foaming Tablet, and IUD but is finally convinced to adopt the IUD (because at the particular time the only contraceptive available is the IUD). She agrees to adopt the method and five minutes later walks out of the clinic with an oversized IUD in her womb (the only size of IUD available at the clinic, and therefore the preliminary examinations that must normally take place to decide on the correct size before the IUD is inserted in the womb has not been necessary). Sooner or later, the young woman experiences severe cramps, bleeding, pains in her abdomen and knees and she is not able to stand up straight. 47 She goes back to the clinic to have her device removed, but not before she tells her friends about her experience. Her friends tell her neighbours and co-workers, the latter their neighbours and relatives and so on and on. Where do we apportion blame for the exaggeration that accompanies the story at each stage of transmission? This case is not just a hypothetical one, but one obtained from reports given by participants about the practices at the family planning clinics and the side effects of the contraceptives. Practices Another characteristic which distinguishes Family Planning Communication as noted by Rogers is that, family planning decisions are collective decisions rather than individual decisions. A couple is involved in the discussions and deliberations. Unfortunately, findings from both survey and focus group discussions did not confirm this. Among users of contraceptives, it was only those who were users of the Foaming Tablet who said the decision had been taken jointly with their husbands/partners. (It couldn't have been otherwise!) For the rest of the female respondents and participants, the decision had been solely theirs and almost all of them have been using contraceptives for more than a year without their husband's knowledge. Participants of group sessions in Accra and Kumasi, where the socio-economic pressures of big city living are felt most, unanimously and simultaneously agreed that it was not at all necessary for their husbands to know that they had adopted family planning methods. This attitude had been influenced by: a) b) their husbands/partners lack of concern for their physical well-being in the lace of health hazards of frequent child births. One participant said "The women should be the sole decision makers; the men don't care much. They don't need to know you are practising family planning." Another put in: "My much older husband will not allow me to practise family planning. He wants as many children as possible, but I have to take care of myself." "You have to think about yourself and your health. The men don't care and you know what it's like having children and bringing them up", was another remark. refusal of the husband to increase ribusehold income with increasing number of children or improve in the general 48 c) standard of living. "The problem is, if he gives you three hundred cedis when you have two children, he will give you the same when you have six, so it is up to you, the wqman, to see that you don't have too many children." irresponsibility on the part of the husband/boyfriends towards the welfare of wives/girlfriends and/or children. "Even your serious boyfriend will break up the relationship if you get pregnant, therefore it is better to protect yourself," said a young single woman from Kurnasi. A Pill user from Accra, of the C SES said "My husband will readily dive and bring the money from the bottom of the sea to give me to pay for an abortion than when I ask for money to buy clothes for the children. He doesn't know I am taking the pill. From time to time I announce that I am pregnant and when he gives me the money for an abortion, I use it to buy clothes for my two children." Another participant said, "If the man is not contributing in taking care of the children and you don't have much income to take care of the children, you can sneak behind him and go and see the family planning people." The more subservient women of the North however were of a different opinion. "You must talk to the man and if he is not in favour, you should try and persuade him or call people to come to talk to him." We must admit that communication between even highly educated couples on a subject like family planning or contraceptives does not often take place. Folch-Lyon, delaMaccora and Schearer found out from their studies on Family Planning in Mexico that "although communication between partners is much more common among users (77%) than among non-users (44%) even among users a surprisingly high proportion claim they never discussed the topic with their partner. This confirms group session that marital decision-making about contraceptive use is an emotionally charged topic that sometimes results in covert use by women or in an emotional understanding between couples."(13) findings their peer groups. This shows Findings from the Ghana group sessions also show that after adoption, women discuss family planning methods with members of family planning communication is not so much "taboo communication", as Rogers distinguishes, as it was sometime in the past. Participants spoke very freely and expressed candid opinions about sensitive areas relating to family planning, such as stating the ages at which they started having a relationship with the opposite sex, why they personally practice family planning and so on. that 49 It is among peer groups that most of the misinformation is carried on. For fear of "ill health" resulting from the "side effects" of contraceptives some women use other unconventional methods as a means of preventing unwanted pregnancy. Some non-users reported swallowing a bottle of (hundred tablets) saccharin, (a crystalline solid used as a sugar substitute) a few days before their menstrual date. "I take the whole bottle of tablets two days before my period." Another reported increasing her intake of hard alcohol (whisky or brandy) mixed with Guiness Stout as she gets closer to her expected menstrual date and she has had no problems with the method. Conclusion and Recommendations The mass media channels have been well utilized in Ghana for creating awareness and motivation of family planning. However in the process, message content has been inadequate and this is why the interpersonal channels have had the opportunity to fill the gap with misinformation. There is an urgent need for contraceptive advertising to contain more information on family planning methods and facilities. Most women are unhappy at home due their husbands/partners attitude towards their welfare and that of their children, amongst other problems, and have therefore adopted family planning methods in their own interests and that of their children. Communication efforts should be male - directed and they must be motivated in discussing and taking decisions on contraception and family planning with their partners. The GNFPP should involve marital counselling. to An intergrated and concerted educational campaign must be initiated as a supplement to, or an intergral part of the ongoing or any family planning educational campaign that would be carried out in the country, to educate the target audience and potential users of contraceptives about the safety and efficiency of the products. The rumour must be discussed in editorial feature articles, letters to the editor. TV and radio discussion programmes to allay the lears that tbese rumours might have instilled in women. The media have a great role, a responsibility, to inform correctly on the usage, and effectiveness of these contraceptive products. On the interpersonal levels, all paramedical staff working on the programme, both in the field and clinics should themselves be well informed about family planning methods and their actual side effects so that they pass the correct information on to consumers. 50 The Family Planning Clinics should also be well equipped to motivate new adopters and ensure the continous use by older adopters. The CSM programmes in Ghana will eventually eliminate most of the problems associated with family planning if well carried out. It is our ardent hope that in the process they will help Ghanaian women gain self confidence in their capabilities as wives and mothers and enjoy what minimum happiness family planning can offer them at home. ACKNOWLEDGEMENT A large debt of thanks is owed to Lintas Advertising Company, Ghanajbr permitting the use of their research data - and to Mr. K. Mensa-Bonsu of the same company for reading through the original paper. REFERENCES 1. Many Voices, One World, Communication and Society Today and Tomorrow, (Kogan Page/Unipub/UNESCO). 2. 3. 4. 5. 6. 7. 8. Rogers, Everett M; Communication Strategies JOT Family Planning. Cited from Opia-Mensah Kuma. Ibid. Page 32. Ibid, page 34. Ibid. Kuma, Opia-Mensa; "Perception and comprehension by Rural Dwellers of Family Planning messages conveyed through the Poster Medium: A study in communication of Innovations." (MA Thesis, School of Journalism and Communication, University of Ghana, August 1979) p. 35. Kuma: Ibid, p. 37. From speech by PNDC Secretary for Health at the launching of the Ghana Social Marketing Programme on April 16, 1986, p. 1. Ibid. 9. 10. From Brochure, Ghana Social Marketing Programme, Accra. 11. 12. Kuma: Op. Cit. p. 33. Ibid. 13. E. Folch-Lyon, L. de la Maccora, S-B. Schearen "Focus Group and Survey Research on Family Planning in Mexico" Studies in Family Planning. Volume 12. No. 12, Dec. 1981. 51