CHAPTER EIGHT

DECISION MAKING REGARDING TUBAL LIGATION

 

                                                                                                   Introduction

 

One goal of our Tribal Family Planning Project was to make various contraceptive alternatives available to couples still capable of having children.  Many couples with three or more living children decided that the wife should have sterilization.  This is an important decision for them to make, with many interrelated factors.  How do they make this decision?

 

It is not easy to gather data concerning the making of this decision, but through observation and casual conversation with these couples, often at the time they were most actively considering the possibility of the operation, there were certain patterns I discovered:

 

1) No two couples come to the same decision in exactly the same way.

 

2) No couple is able to put into words exactly how they reached the decision they did, with the various factors that led to that decision.

 

3) Even if they could verbalize it, probably no couple would be willing to divulge all the factors that led up to their making the decision.

                                                                                                                                                                                                                        p.152

                                                                                    Who Makes the Decision?

 

There are several groups involved in making the important decision as to whether or not to have tubal ligation.

 

                                                                                        Husband and Wife

 

This is a decision which must be made by both members of the couple involved.  The woman, for example, must actually present herself for the operation, and according to the guidelines our program has developed, the husband must be willing that she undergo sterilization.  This is the primary unit--but not the only one--involved in making the decision.

 

In the average Akha home, the husband and wife do not sit down and discuss in private the pros and cons of such an operation.  One morning while the wife is placing rice on the table the husband may say something like, "Why don't you go get a tubal ligation like the women in Ba Jaw village have done?"  This is not to be taken literally, but is simply his way of opening up the subject to discussion.  The woman may fling back (on the sppur of the moment), "Nobody will cut my body," and the conversation is dropped there for the time being.

 

Several days later the woman may ask her husband how the women from Ba Jaw are feeling following the operation, and then inform him that she has been talking with a friend of hers about the two of them going to have the operation.  The husband realizes that this does not yet indicate her final decision, but it shows that she is considering it.

                                                                                                                                                                                                                        p.153

After discussing it off and on for a period of weeks or months in this indirect fashion, if either of both of them decide against it, there can be no tubal ligation.  Although both of them should decide to have it done, the operation may still not be performed, depending on the counsel of other people (especially the husband's parents), and on other factors (such as their accessibility to the family planning center).

 

There is a general pattern evident in those couples who decide to have the wife undergo sterilization:

 

1) Many have already tried, and been dissatisfied with, other methods of birth control.  For example, about half of the couples have been on some reversible contraceptive before making this decision.

 

2) They usually have high enough status in the village so that making the decision will not make them social outcasts.  People who have lower status are more sensitive to village opinion.

 

3) Their marriage is not about to break up.  If it looks as if they might soon divorce, the wife especially will not be willing to have the operation.

                                                                                                                                                                                                                        p.154

                                                                                                Husband's Parents

 

Some couples may still be living in the home of the husband's parents when they make this decision, although usually by the time they have several children they are in their own home.  Even if the couple have established their own household with their own ancestral altar, they will not likely make such an important decision without at least getting tacit approval from the husband's parents.  I know an instance in which a couple with four living sons and four living daughters desired the operation.  The husband's father, however, continued to blaock it by saying, "I want to be sure to have plenty of grandchildren." (He had only one son.)  As a result of his attitude, the daughter-in-law has not yet been sterilized.

 

The means by which the husband's parents seek to influence the couple is usually indirect.  For example, in the evening when a group of men are sitting around the fireplace drinking tea, the father of a son whose wife is considering tubal ligation may say something to the effect that it is terrible what women are doing these days to get out of giving birth to children.  The son, sitting there listening to this public statement, knows that it is directed at him.  Should he try to justify his actions in that setting, however, his father would probably "win."  The son may talk to his father the next day, and try to win him over.

                                                                                                                                                                                                                        p.155

It may be that the mother-in-law will try to put pressure on her daughter-in-law to drop the idea.  She too will use the indirect approach for the most part, either trying to shame the girl into changing her mind, or frightening her enough that she will decide against it.  On the other hand, I know of at least two cases where the mother-in-lawactively encouraged the couple to have the operation.

 

                                                                                                        Others

 

There are others who will influence the decision, although not as much as the couple and the husband's parents.

 

1) The couple's peer group.  The couple's closest friends among their own peer group will usually be consulted, the husband talking to his friends, the wife to her's.  If the wife is leaning toward accepting sterilization, much of her consultation will be in efforts to talk some other women in the village to go with her.

 

2) Fellow villagers.  The fellow villagers will have some influence on what decision is made, although not as much as the groups already mentioned.  It is important to remember, however, that the decision is made in the context of the village situation, so before and after the operation the couple will be sensitive to the general tenor of village feeling.

 

3) Other Akhas.  There are other Akhas outside of one's own village who may exert some influence on the couple, especially if they are of the same clan, or if they are male relatives of the husband's mother (in the a g'oe relationship).  In the case of the woman, those Akha women of her peer group who grew up with her in her home village have a special place, and so she may consult them.

                                                                                                                                                                                                                        p.156

4) Other friends.  Non-Akha friends are usually not consulted before such a decision, unless the husband felt they would give him backing in whichever way he tended to decide.  If he has decided that his wife should have the operation, he will look for confirmation of this decision.  If the non-Akha friend has a negative attitude, usually it will be dismissed with the feeling that only an Akha knows how an Akha should behave in this situation.

 

There is one Akha village in Northern Thailand with several Catholic families.  At one time four women living in that village (one of whom had been baptised) asked for a tubal ligation.  Before it could be arranged, an Italian Catholic priest who lived nearby talked them out of it.  Later two of the four came for the operation, and after that six other women from that village came for sterilization.  Their strong desire for the operation had overcome the arguments of the priest.

 

                                                                                    Factors Involved in Making the Decision

 

In addition to the various people involved in the making of this decision, there are also certain factors which will help determine the final outcome of the decision.

                                                                                                                                                                                                                        p.157

                                                                                                     Social Factors

 

1) The initial advocate to inform an Akha couple about tubal ligation carries a great deal of weight.  If a respected person presents it positively in an appealing way, this may help them decide for it.

 

2) Reference group opinion is important.  Often when tribal women go with me to Chiang Mai Christian Clinic they are amazed to see some 300 or so Northern Thai women gathered there for contraceptive help.  When they learn that from Monday through Friday of each week there are women that come like this, they are more willing to accept it for themselves, knowing they will not be laughed at by the "sophisticated" Thai population.

 

                                                                                                  Economic Factors

 

1) Probably the most important economic factor is: how can we go on having children to feed and clothe when we can not adequately take care of the ones we now have?  Probably for at least 90% of the Akha women who have tubal ligation this is one of the main factors.

 

2) Although there is no "cost-benefit analysis" in their thought, it is important to most Akhas that tubal ligation is given as a free service.  There is, however, concern about how long it will be after the operation before the woman can get back to work in the fields.  When Akha couples learn that the woman will be able to do light work after a week and heavy work after a month, they weigh this economic factor as well.

                                                                                                                                                                                                                        p.158

3) Opium addiction is an important economic factor.  If the husband is an addict he is faced with a difficult decision.  He needs to have his wife work daily to provide for his opium needs.  Should he let her go for the few days it will take for tubal ligation and recovery, or should he oppose it and run the risk that she will become pregnant thus necessitating even a longer break from her work for childbirth and recovery?  Often it is the woman herself who puts her foot down, saying, "Look, I am not going to have more children.  It ends up that I am the one that has to feed and clothe them, you do nothing to help."

 

4) Many Akha women start out on either contraceptive pills or injections.  They pay 15 cents (3 baht) a month for the pills, or 75 cents (15 baht) for a six-month injection.  If the woman still had many potential childbearing years ahead of her an has all the children she and her husband want, she is likely to be attracted to the possibilty of free steilization, which will put an end to expenditures for contraceptive aid.

                                                                                                                                                                                                                        p.159

5) Some Akha women have children so often that they are hindered from working in the fields.  This means there is less adult farm labor, and not enough food for the growing family to eat.  Some couples see tubal ligation as a possible way out of the dilemma.

 

6) When the 1976 corn and rice crop was eaten by hordes of rats, many of the Akha and Lahu women asking for sterilization said their main concern about the lack of food for the future played a big part in helping them decide to have the operation.

 

                                                                                                Physical Factors

 

1) Most Akha women have never been in a hopsital, so they fear the experience.  In addition, both husband and wife wonder what the operation will do to their sex life.

 

2) The number of children now living and the sex of these children enter into the final decision.  Most Akha couples who ask for the operation have at least one living son.  Only seven Akha women (2.5% of the total) with no living sons have received the operation.  There have been thirty Akha women (10.8% of the total) who had sons only and no living daughters at the time of the operation.

 

3) The current and most recent pregnancies of the wife will be a factor.  Many of the Akha and Lahu women who request sterilization have had a difficult delivery at the last birth, or are suffering complications in a current pregnancy.

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4) The health of the children they have is a factor as well.  If the children are in good health and thus have a good chance of surviving, the couple will look more favorably on having the operation.

 

5) The woman's age is another factor to be taken into account.  Women over forty are concerned about complications of another pregnancy.  Of the 279 Akha women to whom we have given sterilization, 10.4% were forty years of age or over.

 

6) Having problems with the contraceptive method currently being used can be a factor with some women.  Perhaps the contraceptive pills are making her ill or causing dark blotches on her face.  Or she may be worried since the DMPA injections are interfering with her menstrual cycle.

 

7) The physical well-being of women from their own or nearby villages who have had this operation will be another factor the couple will consider.  If there have been several women who have had a successful operation and are in good health, the prospect of choosing this alternative is more appealing.

 

                                                                                                Religious Factors

 

1) One Akha woman who is a shaman (nyi pa) had a friend ask me if the operation would cause any damage to her ability to go into a trance.  I sent word that the operation would not affect her head, which is the area of the body they are most concerned about while in a trance.

                                                                                                                                                                                                                        p.161

2) If the Akha couple sees tubal ligation as something which is opposed to the 'Akha way,' they may decide not to have it.  If the couple does not have a son to carry on the religion, of course, the chances are very strong they will decide against it. {footnote 1: Some of the women who have had the operation in spite of not having sons are Christians.  In other instances there were physical problems which necessitated the operation.}

 

3) If they think about it (and many must think about it a great deal) a very attractive aspect of having tubal ligation is that there will be no more threat of having 'human rejects.'  There have been two Akha Christian women from Burma who had had twins (which are considered to be 'human rejects,' it will be recalled) before coming for sterilization.  They both mentioned that their fear of having more twins was one of the major factors involved in causing them to choose this alternative.

 

4) Christians seem to choose sterilization more readily than non-Christians.  Of the Akha women who have come for sterilization from the Burma side, 140 out of 170 (82.4%) of them have been from Christian villages (either Baptist or Catholic).  Of the ones from Thailand, 22 out of 109 (20.2% of them have been from Christian villages (either OMF or Catholic.)  {footnote 2: The high percentage of Christian Akhas coming from Burma is due in part to the fact that some 40-50% of the total Akha population in the southern part of Kengtung State is Christian.}

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                                                                                                  Other Factors

 

1) The desire to educate their children has been an important factor for a few Akha couples, especially those from the Akha villages of Pa Mi, Ho Sa, and Ba Go, where they have special interest in sending their children to boarding schools.  Educating their children in this way becomes too expensive if there are too many children.

 

2) Our program offers much more than just contraceptive aids.  We are brought into intimate contact with families at many levels and in many different situations.  Confidence engendered through those relationships may be a final factor for some couples in opting for the operation.

 

                                                                                             Making the Decision

 

When the Akha couple learn of the possibility of having tubal ligation and think through the issue[s] involved, they eventually come to a decision.

           

                                                                                                      Timing

                                                                                                                                                                                                                        p.163

The length of time it will take to make the decision depends on the couple, their particular situation, and the weight they give the factors that are involved.  For example, if a couple only have three children (one boy and two girls), they will probably take much longer thinking about sterilization than a couple with six or more children, several of whom are boys.

 

The more often the couple is confronted with the advantages they will receive from such an operation, the more quickly they will tend to make a positive decision, especially if there is the added factor that others in the village are deciding to have the operation as well.

 

Sometimes a crisis shortens the time.  In one instance, a cousin of the woman involved died in childbirth.  This made a very deep impression on both the woman and her husband, so they came to ask me if the wife could have a sterilization before she got pregnant again.

 

                                                                                                Acceptance

 

How many factors does it take for the average Akha couple to decide they will have a tubal ligation?  One major factor favoring it may be enough to lead the couple to have the operation;  for others it is a combination of several lesser factors that would combine together to persuade them.

                                                                                                                                                                                                                        p.164

When a couple decides to have the operation, at first the decision tends to be a bit shaky.  Both spouses will look for arguments to use to back up their stand.  They may still have some fears and reservations, but by giving their name to either me or a field worker they have made a public declaration of their decision.

 

                                                                                                Rejection

 

When some couples come to this point, they decide against the operation.  There are three major factors which play a major role in rejecting this innovation:

 

1) The character of the change agent.  If the couple or those they consult do not trust the field worker or the director, the chances are very high that they will reject sterilization.

 

2) The character of the group confronted.  If the couple feels this is out of harmony with their Akhaness, they will reject the innovation.

 

3) The character of the innovation itself.  If the couple feels this is too drastic a step to take, or that somehow it threatens them or their family, they will reject it.  Perhaps the benefits are too far in the future for them.

 

An innovation can be rejected because of any of these variables, or any combination of them.  One change is taking place among Akhas now which is causing some who formerly rejected the innovation to seriously consider adopting it.  Better medical aid has made for a higher survival rate in the children they do have.  This makes a distinct difference in the rate of acceptance and rejection of sterilization.

                                                                                                                                                                                                                        p.165

                                                                                               Conclusion