Written by Carolyn Sargent, PhD, professor in the Department of Anthropology in Arts & Sciences
Between 2001 and 2009, I had the opportunity to interview West African women living in Paris, France, and consult for reproductive health care in the French public health system. Structured interviews with 130 women led to further informal questioning of those who were willing, and to a handful of intense personal relationships. These relations, in turn, generated a wealth of data and enduring friendships.
My original research question focused on the factors shaping West African women’s use of contraception, which I knew to be strongly encouraged by hospital clinicians but rarely used in the immigrants’ regions of origin. My first challenge was to obtain permission to collect data in the public hospitals. The Chief of the Maternity Service at one such hospital gave me open permission to attend any consultations. I selected the prenatal consultation ward and the postpartum ward. Five midwives, the core professionals in the French maternity system, allowed me to shadow them. The maternity psychologist also became a close adviser.
It was on the postpartum ward that I met several patients who later invited me to their homes. The postpartum stays at that time ranged from three to five days. Women hospitalized there were easily accessible and I could make return visits daily, to establish rapport. I also accompanied midwives at all discharge meetings with postpartum women, at which time discussions of contraception were scheduled to occur. Repeatedly, I talked privately with women about contraceptive methods. Most indicated that their husbands were opposed to contraception on religious grounds, and they also thought that Islam prohibited contraception. This is a popular, rather than a theological interpretation. Nonetheless, about 70 percent of the women I interviewed were “secretly” contracepting. They told me of their experiences in West Africa, where they had used depo-provera. They would have preferred this invisible injection, but in France were more likely to be prescribed the pill or a contraceptive implant. Not everyone used contraception in secret. One woman told me that she was proud to take the pill: her husband kept the packet and distributed it to her when he was home on weekends. I explained that the pill had to be taken daily, not two days per week, and we discussed how to approach her husband, who worried that if she had control of the pill packet, she would not remain faithful to him.
In the course of observing discharge interviews where contraception was discussed, I was troubled that some midwives handed women a set of prescriptions, including one for the pill, without explaining the purpose of the pill or how to take it properly. This may be one of the explanations for the short intervals between pregnancies among women taking the pill; another reason is probably that the pill of preference should be taken at the same time daily, with a two-hour grace period, to insure maximum efficacy. And in many West African households, where large families are crowded in small lodgings, clocks and chronological routines do not figure prominently in everyday life. It was not uncommon for me to walk into the prenatal consultation waiting room and be greeted cheerily by a pregnant woman, who said “don’t you remember me? You talked with me in this same waiting room last summer.” One such woman explained that she had trouble remembering when to take the pill and it had unpleasant side effects. She returned to the prenatal unit to ask a midwife what to do, and was told to take it anyway. By the next year, she was pregnant.
The maternity psychologist introduced me to a “problematic case” about which she hoped I would have insights because of my research experience in West Africa. Her patient was a young woman, recently arrived in France, who had miscarried at six months, and had left a four-year-old daughter “at home” in Africa because her new husband did not want to care for a stepchild. The patient was deeply depressed and cried constantly. I offered to visit the woman at home. I brought her cherries and she talked about her fears and her dreams in which she conflated the dead baby and her daughter in Africa. Eventually, the psychologist and I decided an unusual intervention was necessary. The psychologist called in the woman’s husband and told him that for his wife to recover (and become pregnant again), she needed to (a) go back to be with her daughter or (b) bring her daughter to Paris. A group of us mobilized our networks of social workers and health professionals and managed to acquire a visa for the child. I have known them now for 10 years. The formerly shy young woman, afraid to take the subway, has become involved in import-export between France and the Emirates. She has two small sons, in addition to her daughter. And she takes the pill regularly and correctly. Her husband told her that she developed a “swelled head” when she came to Europe and is no longer the “serious girl” he had married.
How do these cases inform public health policy?
First, the ethical and practical problem of dispensing birth control pills without explanation. I talked with midwives in several hospitals about this practice. All were familiar with it but said that time and linguistic constraints prevented more discussion. Finally, I found myself seated next to the administrative director of the Great Mosque of Paris. I took the opportunity to tell him (a physician/bioethicist as well as a theologian) of my concerns. He proposed to discuss the problem at the level of the Minister of Health. I do not know if anything has changed, but hospital budgets have been cut, interpreters and personnel reduced. This may not be the moment when adding time to patient encounters is likely to occur.
Second, I learned how important religious interpretations drawn from popular understandings of Islam are to decisions regarding contraception. When I interviewed 20 midwives, recent graduates of the national midwifery school, none had any idea that religion might be a factor relevant to contracepting. Nor were they aware of tensions between spouses on this issue, leading them to perhaps unwisely broach the subject of contraception with postpartum women and their husbands together. In future meetings over the years, at different public health venues, we have debated the pros and cons of differing strategies for proposing contraception. And when speaking to public health and social work audiences, I have often repeated the narrative of one devout Muslim woman, who did not use contraception. She had 10 children and her social worker periodically stopped by to inform her of the benefits of contraception. Apparently, each time, the social worker spoke more loudly. My informant told me, “I understood her the first time and I am still not interested.”
Ultimately, the intimate relationships I developed with West African women offered me a nuanced perspective on how immigrant women use the public health system in Paris and allowed me to grasp the layers of meanings that inform reproductive health decisions.
Structured interview schedules offer a reliable and seemingly objective method to elicit information from a sample population. Semistructured interviews and participant observation add depth and meaning to the more structured methodology. Had I not spend time in the homes of West African women whom I first met as research subjects, I would not have learned about “secret contraception,” or about the complex rationales that women and men use to strategize about the religious legitimacy of contraception. Ultimately, the intimate relationships I developed with West African women offered me a nuanced perspective on how immigrant women use the public health system in Paris and allowed me to grasp the layers of meanings that inform reproductive health decisions. It was this multifaceted perspective that gave me the capacity to convey these meanings to clinicians and to participate in enhancing clinical communication with immigrant patients.