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Policy and practice of family planning in Mongolia

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Policy and practice of family planning in Mongolia
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Rak, Kimberly
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142 leaves : illustrations ; 28 cm

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Birth control -- Mongolia ( lcsh )
Birth control -- Law and legislation -- Mongolia ( lcsh )
Birth control ( fast )
Birth control -- Law and legislation ( fast )
Mongolia ( fast )
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theses ( marcgt )
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Includes bibliographical references (leaves 136-142).
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Department of Anthropology
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by Kimberly Rak.

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Full Text
POLICY AND PRACTICE OF FAMILY PLANNING IN MONGOLIA
Kimberly Rak
B.S., Syracuse University, 1994
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Anthropology
by
2003


This thesis for the Master of Arts
degree by
Kimberly Rak
has been approved
by
9.
Date


Rak, Kim (M.A., Anthropology)
Policy and Practice of Family Planning in Mongolia
Thesis directed by Professor Craig R. Janes
ABSTRACT
Mongolia has been exposed to western discourses and ideology for little more than a
decade. These global dialogues, in particular involving reproductive health and
family planning, are laden with biases fundamentally different from local meanings.
Family planning programs, as they are currently implemented with a top-down
approach, are being mediated and resisted by local women in order to lessen foreign
control over their bodies and to try and make the programs responsive to their needs.
A shift from goal oriented policies to one more sensitive to local culture would not
only increase the options available to women but also foster a view of womens
health that goes beyond a narrow focus of reproductive activities.
This abstract accurately represents the content of the
its publication.
Signed
m


DEDICATION
I dedicate this thesis to my family who have spent many hours listening to me work
through ideas and for (re) reading the many drafts.


ACKNOWLEDGEMENT
Many thanks to Dr. Janes for the opportunity to work with him in Mongolia and for
all his help in the writing of this thesis. I would also like to thank the other members
of my thesis committee, Dr. Corbett and Dr. Brett, for their insights and suggestions.
A special thank you to the staff of the Graduate School for their support and
understanding.


CONTENTS
Figures......................................................ix
Tables........................................................x
CHAPTER
1. INTRODUCTION...............................................1
2. DESCRIPTION OF METHODS AND SAMPLE POPULATION..............22
Research Design........................................23
Data Collection Methods........................!.......25
Samples and Phases of Research.........................28
3. THE CONCEPT OF FAMILY IN MONGOLIA.........................43
Family Size............................................46
Age Women Start Having Children........................49
Marital Status.........................................50
Age at First Sex.......................................52
Number of Sexual Partners..............................53
Youth Statistics.......................................54
Data from Clinical Records.............................55
Conclusion.............................................57
4. BIRTH CONTROL KNOWLEDGE & USAGE...........................59
Birth Control Methods Known............................61
- vi -


Current Usage of Birth Control
65
Reasons for Not Using Birth Control........................66
Geographical Variation in Birth Control
Preference/Usage...........................................68
PAP Tests..................................................78
The Calendar Method........................................79
Side Effects of Birth Control Methods......................84
Emergency Contraception....................................88
Effects of Religion & Gender Status
On Birth Control Use.......................................90
Conclusion.................................................92
5. ABORTION......................................................94
The Rate of Abortion in Mongolia...........................98
Information, Education, and Communication
Programs on Abortion......................................101
Characteristics of Women having
Abortions.................................................102
Why Women Have Abortions..................................103
Reasons Doctors Recommend
Abortion..................................................107
Conclusion................................................108
6. CONCLUSION...................................................110
- vii -


APPENDIX
A. HUMAN SUBJECTS RESEARCH COMMITTEE AT THE
UNIVERSITY OF COLORADO AT DENVER APPROVAL...122
B. GENERAL PRACTITIONER INTERVIEW.............123
C. DESCRIPTION OF PROFESSIONAL INTERVIEWS.....125
D. APPROVED LEVELS OF CARE....................127
E. GENERAL WOMENS INTERVIEW..................129
F. GENERAL YOUTH INTERVIEW....................132
G. ABORTION RECORDS FROM THE MATERNAL
CHILD HOSPITAL..............................133
H. GLOSSARY OF ACRONYMS.......................134
I. GLOSSARY OF MONGOLIAN WORDS................135
REFERENCES........................................136
- vm -


FIGURES
Figure
2.1 Research Methods and Interrelations.....................................24
2.2 Research Sites..........................................................36
2.3 Residence of Survey and Interview Populations...........................39
- ix -


TABLES
Table
1.1 Total Fertility Rates of Selected Countries, 2002....................12
1.2 Percentage of Household Population 6-24 Years
of Age Attending School..............................................15
2.1 Private Health Care Institutions in Mongolia in 2001 ................33
4.1 Frequency a Method of Birth Control was Mentioned....................64
4.2 Methods of Birth Control Used.......................................66
4.3 Current Methods of Birth Control by Residence.......................70
4.4 Soum Birth Control Distribution Records..............................75
4.5 Side Effects Mentioned for Birth Control Methods.....................86
5.1 Abortion Pricing at a Public Hospital................................97
5.2 Complications of Voluntary Abortions, 1998..........................98
5.3 Number of Abortions a Woman Has Had.................................102
5.4 Reasons Women Had an Abortion.......................................105
5.5 Reasons Practitioners Gave for Why Women Have Abortions.............107
- x -


CHAPTER 1
INTRODUCTION
This thesis describes the current state of womens reproductive health in
Mongolia and addresses some of the unpredicted outcomes generated from the
implementation of international policies and programs. The initial focus of the
investigation was suggested by a close reading of family planning literature from
Mongolia. This literature described a problem, unique to developing countries,
where high levels of contraceptive knowledge and availability were not producing the
desired result of lowering abortion rates. Why were women not using a form of birth
control to prevent these unwanted pregnancies?
As the investigation proceeded the research focus shifted from this initial
inquiry, framed in terms of western ideas of rational behavior, to a focus on how
Mongolian women were interpreting (and sometimes resisting) a global, technical,
results-oriented approach to their fertility. In contraceptive research, the user is
thought of as a rational being who prefers to avoid pregnancy. The preference is
supposed to be clearly conscious, with no ambiguities and no temporal variations
(Barroso and Correa 1995:301). This view does not acknowledge the potential
interplay of the romantic, emotional and identity aspects of fertility as it is intimately
related to sex. The investigation instead focused on how larger international and
national programs and policies interact within a specific cultural and historical
- 1 -


context that defines options and constraints within which women make decisions
(Browner 2001). When globalization is viewed, not as a homogenizing economic
system, but as a cultural process, the potential transformative effects of local
ideologies can be investigated (Sjorup 2003). Similar to Adams (2001:224) [the]
inquiry is focused upon ethnomedical concerns of and about women, their sexuality,
and the inscription of social agendas on their bodies... [SJince female sexuality is a
site upon which modernist state and national projects are often launched, studying
local theories about these bodies and their ailments is one way to learn about larger
state projects and thus the particularity of the modem. Control of womens bodies
and their fertility is not a new phenomenon, but as solutions and policies are imported
the regulating agencies are changing from family and community members who try
and enforce cultural norms to national and international groups informed by global
discourses (Pearce 1995). This, then, is a study of the local particularities of the
modem global discourses on reproductive health.
By investigating the global discourses surrounding family planning their
culturally and historically constructed nature can be exposed (Escobar 1995). We
need to anthropologize the West: show how exotic its constitution of reality has been;
emphasize those domains most taken for granted as universal (this includes
epistemology and economics); make them seem as historically peculiar as possible;
show how'their claims to truth are linked to social practices and have hence become
-2-


effective forces in the social world (Rabinow 1986: 241). The knowledge systems
that inform the dialogues create and reinforce systems of power (Foucault 1980). The
forms of knowledge and the systems of power must be seen as mutually
interdependent; with each creating and recreating the other. Those in power set the
rules of the game: who can speak, from what points of view, with what authority,
and according to what criteria of expertise; it sets the rules that must be followed for
this or that problem, theory, or object to emerge and be named, analyzed, and
eventually transformed into a policy or a plan (Escobar 1995:41). The discourses
are operationalized through processes of labeling, monitoring, institutionalization,
bureaucratization and professionalization. However, these discourses and their
practices are not hegemonic, in that from many Third World spaces, even the most
reasonable among the Wests social and cultural practices might look quite peculiar,
even strange (Escobar 1995:12). These Third World spaces offer a site where
resistance, modification and alternative discourses can be explored.
The modem family planning dialogues have their roots in the post World War
II era. As the world was being transitioned from colonialism to newly formed
independent countries, the west adopted paternalistic policies to help develop these
backward nations in the image of themselves (Escobar 1995). These dialogues and
subsequent policies functioned to allow developed nations to maintain social control
over developing nations without the high costs of direct military intervention. It was
-3 -


argued that over-population was an impediment to development and poverty
reduction1. Reducing fertility became an important goal for the betterment of
individuals and countries alike (Hartmann 1995). The belief that development
strategies, as dictated by the west, and population control could reduce poverty served
to divert attention from the reality that the poverty was created by unequal access to
resources aggravated by years of colonial domination. Massive poverty in the
modem sense appeared only when the spread of the market economy broke down
community ties and deprived millions of people from access to land, water, and other
resources. With the consolidation of capitalism, systematic pauperization became
inevitable (Escobar 1995:22). Thus women in the Third World became a
homogenized, faceless group in international discourses that were only visible for
their reproductive functions that needed to be controlled. This had the effect of
establishing a Third World other associated with poverty, ignorance and an
inability to control ones own life. The opposite of this other, which served as the
benchmark to be measured against, was the modem woman of the developed
nations. A relationship of power is implicit to the debate.
1 William H. Draper, head of the Draper Committee that studied the U.S. Military Assistance Program
and other international aid programs, told the Senate Committee on Foreign Relations in May 1959:
The population problem, Im afraid, is the greatest bar to our whole economic aid program and to the
progress of the world (Quoted in Hartmann 1995).
-4-


In the 1970s several social and political factors brought women to the fore in
development discourses: women began to work in the development organizations,
womens role in economic activities began to become visible, and the links
between womens empowerment and lowered fertility were better understood. This
new visibility resulted in the United Nations Decade for Women (1975-1985) which
generated discourses that sought to empower women and view them as more than
reproductive bodies. This view of women had the effect of creating a homogenous
group in need of aid. The reality, as described by Mueller (1987:4) is:
Women in development texts do not, as they claim, describe the
situation of Third World women, but rather the situation of their
own production. The depiction of Third World Women which
results is one of poor women, living in hovels, having too many
children, illiterate, and either dependent on a man for economic
survival or impoverished because they have none. The important
issue here is not whether this is a more or less accurate description
of women, but who has the power to create it and make claims that
it is, if not accurate, then the best available approximation...The
Women in Development discursive regime is not an account of the
interests, needs, concerns, dreams of poor women, but a set of
strategies for managing the problem which women represent to the
functioning of development strategies in the Third World.
Womens rights, Women in Development and Empowering Women became
familiar slogans of this era and into the present. For the most part programs focusing
on women ignored local culture and voices; they were just extensions of already
existing international policies and programs. There was no fundamental shift in the
discourses just the inclusion of a new target group- women.
-5 -


By identifying (labeling) a problem, the international organizations could then
bring in experts to study it. Using scientific, rational methods a solution to the
problem is developed that offers a technologically oriented solution. Technology
was seen as neutral and inevitably beneficial, not as an instrument for the creation of
cultural and social orders (Escobar 1995:36). Next a plan is formulated to achieve
set objectives and target goals which then get implemented through various
institutions and professionals. This new reality of how things should be is
transformed from a social creation into an objectified truth by these processes
(Escobar 1995). Much of an institutions effectiveness in producing power relations
is the result of practices that are often invisible, precisely because they are seen as
rational (Escobar 1995:105). One can replace the word development in Escobars
(1995:44) discursive analysis with family planning to accurately describe how this
operates:
Development was- and continues to be for the most part- a top-
down, ethnocentric, and technocratic approach, which treated
people and cultures as abstract concepts, statistical figures to be
moved up and down in the charts of progress. Development was
conceived not as a cultural process (culture was a residual variable,
to disappear with the advance of modernization) but instead as a
system of more or less universally applicable technical
interventions intended to deliver some badly needed goods to a
target population.
However, when these western discourses are applied in a different cultural context the
inevitable inability of these imported programs to achieve the externally established
-6-


goals (typically the benchmark of western fertility rates) does not lead to a
reassessment of the discourses but to placing blame either on the backwardness of the
local culture or the inefficiency of local institutions. Similar to Piggs (1992:17-20)
work in Nepal:
The generic village should be inhabited by generic
villagers.. .People in development planning know that villagers
have certain habits, goals, motivations and beliefs...The ignorance
of villagers is not an absence of knowledge. Quite the contrary. It
is the presence of too much locally-instilled belief.. .The problem,
people working in development will tell each other and a foreign
visitor, is that villagers dont understand things. To speak of
people who dont understand is a way of identifying people as
villagers. As long as development aims to transform peoples
thinking, the villager must be someone who doesnt understand.
The adherence to these discourses further serves to obscure any alternatives that may
already exist at the local level. Also, by defining problems (such as high fertility)
as isolated features that can be abstracted from larger cultural, social and political
relations, these discourses eliminate the possibility of programs that address the more
encompassing needs of an individual or community.
I argue that international organizations, both governmental and non-
governmental, have imported western notions of womens rights, in particular, rights
of access to healthcare that in the end serve to reinforce gendered stereotypes that are
detrimental to the overall well-being of Mongolian women. Article 12 of the 1979
Convention on the Elimination of All Forms of Discrimination against Women (the
-7-


Womens Convention) states that all appropriate measures to eliminate
discrimination against women in the field of health care in order to ensure, on a basis
of equality of men and women, access to health services, including those related to
family planning. While formulated to work towards rectifying perceived universal
stereotypes that exclude women from social, economic and political opportunities
within their communities that transcend a view of women being different from men in
their gender-role as a reproductive unit, paradoxically the following statement serves
to reinforce the view of womens medical needs (and role within a community) as
being mostly a reproductive one. International and local support of womens rights is
quite frequently distilled down to policies that highlight access to family planning and
reproductive health. Oftentimes the introduction of modem methods of birth control
is expected to empower and free women where such techniques hold out the hope
for a more rounded perception of females, where the procreative role will cease to
overshadow all else... [b]ut I have suggested here that while modem contraceptive
methods may be helpful in assisting women to redefine and develop their own
sexuality, as technical solutions they are insufficient (Pearce 1995:206). Even the
term family planning has been usurped by western knowledge systems to such an
extent that the narrow focus on contraceptives alone, to the exclusion of child rearing,
goes unquestioned. Making the assumption that this highly generalized approach will
positively effect the lives of women without consideration for the underlying gender
-8-


biases and cultural factors that constitute such a position can lead to impacts at the
local level that fall short of any real achievements in womens status and health
(Paolisso and Leslie 1995).
International family planning programs are highly influenced by concepts of
overpopulation or the so-called population explosion. This is seen as the cause of
environmental degradation and an impediment to economic development (Hartmann
1995; Morsy 1995; Pearce:1995). For example the United Nations Population Fund
(UNFPA 2002) states [l]ong-term demographic and economic data from 45
developing countries show that high fertility increases poverty by slowing economic
growth and by skewing the distribution of consumption against the poor. This view
is socially constructed and its origins can be traced historically. Schneider and
Schneider (1995) linked the belief that limiting family size is a sign of individual
fortitude and social responsibility to the practice of coitus interruptus starting in late
eighteenth century France.
Through sexual sacrifice in the cause of respectability- [people]
were taking part in the widespread construction of a reproductive
hierarchy that became characteristic of European (and American)
societies. Other peoples large families, associated with relaxed
standards of sexual behavior, became stigmatized as unworthy- a
judgment that is implicit in antiwelfare, culture-of-poverty
propaganda...[ajround the block or across the globe, high fertility
came to mark some families as reproductive others, (Schneider
and Schneider 1995:192).
-9-


The result is a mostly unquestioned assumption that having too many children is a
detriment that needs to be corrected at all costs. Beginning in the mid 1960s concerns
of overpopulation began to be incorporated into foreign policy and development
(Justice 1986). Acceptance of family planning and population policies has become a
component of Structural Adjustment Programs (SAPS) sometimes backed with the
threat of not receiving much needed financial assistance (Sai and Chester 1990,
Warwick 1982). Despite the allocations of sizable budgets for family planning,
historically these programs have not done much in the way of reducing population
growth. These failures are due to the fact that reduced population size and smaller
families are a product of social, economic, and cultural conditions (Justice 1986).
When the development and environment argument is accepted in an (unnatural)
association with womens empowerment and maternal and child health, it
becomes a western doctrine that few would question. However, the attempt to
merge interest in population control with interest in the health of women is often
suspect given the design and implementation of many of the family planning
programs (Pearce 1995:199).
The normal association of rapid population growth and the need for family
planning is largely irrelevant for Mongolia.
- 10-


The total fertility rate2 3 dropped from 5.5 in 1985 to 4.41 in 1993 to an estimated 2.37
in 2002, a 43% reduction in seventeen years (CIA World Fact Book, 2003). Table
1.1 shows the total fertility rate for selected countries. The average annual population
growth rate from 1989 to 2000 was 1.4 percent compared to an annual growth rate
exceeding 2.5 percent for the period of 1956 till 1989 (National Statistical Office of
Mongolia 2001a). The 2000 census for Mongolia placed the total population at
2.3735 million people. This equates to the very low population density of 1.3 persons
per square kilometer. The population densities of the three largest cities; Ulaanbaatar,
Orkhon and Darkhan-Uul (162, 85 and 25 respectively) are much higher and reflect
the ongoing urbanization of Mongolia resulting from the transition from a centrally
planned to a market based economy. High rates of urban unemployment, 24.3%
versus 10.2% in rural areas (National Statistical Office of Mongolia 2001a), and
poverty are often viewed through a population lens instead of investigating the
impacts of economic restructuring that reduced many forms of social welfare and
2Total fertility rate refers to the average number of children that would be bom per woman if all
women lived to the end of their childbearing years and bore children according to a given fertility rate
at each age. The total fertility rate is a more direct measure of the level of fertility than the crude birth
rate, since it refers to births per woman. The indicator shows the potential for population growth in the
country. High rates will also place some limits on the labor force participation rates for women. Large
numbers of children bom to women indicate large family sizes that might limit the ability of the
families to feed and educate their children (CIA World Factbook,
http://www.cia.goV/cia/publications/factbook/docs/notesanddefs.html#2127. last accessed April 6,
2003).
3 These percentages may be considered to be higher for both categories if the number of people who
are not currently working because they are discouraged and do not think any work is available is added
to those actively seeking employment.
- 11 -


support programs4. The United Nations Development Report (UNDP 2000) has
observed recently that, the incidence of poverty also seems to have been plateaued in
recent years. However, because of population growth, the total number of poor has
increased slightly.
Table 1.1- Total Fertility Rates of Selected Countries, 2002
Country Total Fertility Rate

Tajikistan 4.23
Uzbekistan 3.03
Mongolia 2.37
Kazakhstan 2.12
United States 2.07
China 1.82
South Korea 1.72
Japan 1.42
Russia 1.30
Source: CIA World Factbook 2002, http://www.cia.gov/cia/publications/factbook/fields/2I27.html.
accessed April 6,2003.
The important question here concerns the goals of international organizations
family planning programs as implemented in Mongolia. There seems to be a
singularity of focus on increasing the rates of birth control usage among women in
Mongolia. The reproductive health programs are developed on the assumption that
things were not modem or functioning properly before the introduction of their
policies and ideals, and that when these are adopted things will be improved, with no
4 The United Nations Human Development Report: Mongolia 2000 reported that between 1992 and
1998 government spending (as a proportion to GDP) on health, education and social security fell from
16.2% to 14.8% (United Nations Development Programme 2000).
- 12-


real sense of how or for whom. Extensive information, education and communication
(IEC) programs were implemented, birth control was made available free of charge,
social marketing of contraceptives was initiated, and the distribution of birth control
supplies has been highly studied and improved. All practical barriers preventing
access to contraceptives have been eliminated. Elowever, the geographical,
informational and economic availability of contraceptives in Mongolia has not
resulted in any substantial increase in birth control usage over the last four years5. It
is of great concern to various governmental departments and international
organizations that the introduction of free contraceptives at all levels of care in
Mongolia has not resulted in lower numbers of abortions. Comments such as .. .the
reported rate of 12,870 abortions (262 per 1,000 live births) in 1997 is still
unacceptably high... It indicates that there is still a large unmet demand for family
planning services (United Nations Population Fund 2000c) and [t]he abortion
statistics would suggest there is still considerable unmet need for family planning
among married, parous women, mostly for reliable, long-term protection (United
Nations Population Fund 2000a) illustrate prevalent attitudes. The question for
international organizations becomes one of why women who are having abortions are
5 The 1998 Reproductive Health Survey (National Statistical Office of Mongolia and UNFPA 1998)
found that about 44% of women are currently using a method of birth control. This investigation,
conducted in 2002, found that 45% of the sample population was currently using a form of birth
control.
- 13 -


not using birth control to prevent unwanted pregnancies. The theory that access to
contraceptives will lead to use and therefore a reduction in pregnancies ending in
abortion falters in the specific cultural context of Mongolia.
It has been argued that in developing countries the more education a women
receives the fewer children she will have and those children will be spaced farther
apart. Mongolia has just a little over 10 years experience with western aid and
notions of family planning. Socialist rule dominated Mongolia from 1924 to 1992.
During this time women were thoroughly integrated into all aspects of educational,
professional and family life. Women received the same educational opportunities as
men, they were not constrained in career choices by societal norms of women being
suited for unskilled or soft and nurturing type jobs (in the west the traditionally
lower status and lower paying positions), and having a family was not considered at
odds with education and career (Cook 1995, Paolisso and Leslie 1995). Women
participated in and were an active, vital part of the society. Most importantly, women
did not have to choose between personal fulfillment and family which, in the west, is
lauded as an inescapable biological conflict faced by all women and is an underlying
assumption that governs international family planning policies.
The school enrollment rates are relatively the same for males and females
aged 6 to 10. However, for all older ages, the enrollment rate for females exceeds the
- 14-


rate for males. For Mongolia the educational level for females is higher than that of
males. Table 1.2 shows school enrollment rates by sex for 1998.
Table 1.2- Percentage of Household Population
6-24 Years of Age Attending School
Age Group Male Female
6-10 61.6% 62.6%
11-15 79.6% 89.6%
16-20 29.2% 34.6%
21-24 8.0% 12.5%
Source: National Statistical Office of Mongolia and UNFPA (1998:15)
The unquestioned westem/modem assumption is that for a woman to obtain a
higher education or a career (and by extension be a participant and consumer in the
world market) she must delay having a child, have fewer children, and space them
farther apart. Historically, this has not been the case in Mongolia so again the
question is what is the actual need of family planning in Mongolia? During the
socialist era women in Mongolia began childbearing before or commensurate with
obtaining a higher education. Women were expected to contribute towards
centralized planning goals and were supported in the workplace by state sponsored
childcare facilities. Extended family members, in particular grandparents played a
role in rearing children so that new parents could continue school and/or work
(Aassve and Altankhuyag 2002). Extended networks allow parents to achieve
educational and career goals while also providing the elderly with responsibilities and
-15-


a role to fill (Colen 1995:85; Morsy 1995:205). The practice of extended support in
child care is still common in Mongolia. In our recent survey of elderly in Mongolia it
was found that many of the elderly provide childcare for their grandchildren and other
relatives (Janchiv 2003).
With the transition to a market economy and the introduction of international
aid in 1991 so too came the culturally biased doctrines of the donor (developed)
countries. In keeping with international pressures over the last twenty years to fully
recognize womens rights and needs, one of the most visible aid programs in
Mongolia centers on reproductive health (RH) and family planning (FP). This
resulted in programs that supply contraceptives free of charge to woman and drugs to
treat sexually transmitted infections.
There is no denying that these programs provide an invaluable service to
Mongolian women, but how these programs are implemented at the local level and
the impact of the underlying assumptions about womens status and role that some of
these programs carry with them requires investigation.
In the absence of real social transformation, the emphasis will
probably be on motivational efforts to sell the idea of small
families. Many of these messages will push the consumer model:
with fewer children, you can buy more and degrade the
environment less, which of course is a doubtful proposition. Social
marketing of contraceptives, rather than the establishment of
comprehensive health services, will continue to be the priority
(Hartmann 1995:154).
- 16-


For Mongolia, in the absence of the specific concerns that have traditionally guided
reproductive health and family planning programs, the current international agendas
appear to be the application of generic top-down models that reproduce the need for
their presence by the very failure they create by not taking into consideration the
needs of the people they are designed to address (Justice 1986).
Within Mongolian structural adjustment programs6 there is a trend towards an
integrated approach to health care services (Janes 2003). However, the momentum
and funding for family planning services keeps these services functionally separate
with articulation only at point-of-service. The singular focus on family planning,
acceptably packaged in the name of womens rights, has detrimental affects because
the unilateral (or vertical as described by Justice 1986) approach undermines the
primary health care initiatives that address more broad based concerns of women
(Hatmann 1995; Justice 1986; Morsy 1995). Women are more than reproductive
bodies; they are affected by malnutrition, abuse, and illness as well as environmental
and occupational hazards. Discussions so confined distract from the links
Between womens compromised health and state policies in
historical and global contexts... the state and international
development institutions will continue to be presented as the
6 In order to address the health concerns described in the World Banks 1993 World Development
Report (Investing in Health) the World Bank recommended that low income and middle income
countries should improve family health by educating girls and empowering women; shift the focus of
governmental investment away from tertiary health care toward public health; and, more
controversially, promote diversity and competition by introducing private or social insurance
schemes, and foster competition in the delivery of health services (Abbasi 1999:869).
- 17-


promoters of womens well-being, absolved of responsibility for
the social production of compromised health, while this
responsibility remains assigned to culture and potentially
innumerable discrete variables ranging from those designated
individual to those labeled institutional (Morsy 1995:173).
Family planning programs have to be understood within a context where
women actively play a role in decisions about their fertility, albeit with differing
options and/or constraints defined by social and economic factors. [M]otherhood,
that presumptively natural feminine accomplishment, [is] a complex array of
consciously and unconsciously crafted strategies by which many women managed
economic adversity and organized culturally rewarding identities (Lewin 1995:104).
Family planning is not a magic bullet that will be universally acceptable to all
women and viewed as the solution to their personal empowerment. It is easy to forget
that women may want to have a baby. This is reminiscent of the problem of
teenage pregnancy in the U.S. A staff member at a school-based health clinic in
Louisiana said the worst problem we are having are pregnancies and repeats. I used
to think it was a lack of knowledge about contraceptives; they didnt know what they
were doing. But now I find the attitude has changed; they know all about birth-
control pills, condoms and the other things. Whats disturbing is that theyre
planning pregnancies now (Ward, 1995:154). The teenagers are opting to have
children as a way to establish an identity for themselves and it is the personal biases
of the health care provider, not the girls, who is labeling this as deviant. Women
- 18-


make what they think is the best choice for their lives from the limited options
presented to them. In the global context of population policies, disease, and
disasters of all kinds, local populations seek to envision continuity through children
and act to ensure that continuity (Mullings 1995: 123). Family planning has to be
viewed as just one option among many (one of which is to have children) and even
though donor agendas dictate that it is the most appropriate course of action, women
may decide differently given the specifics of their situations. The relationship
between information and behavioral change is a complex one where information
plays a small, albeit vital, part in the process of behavior change and that the
information must be relevant to the persons life. Attitudes, skills, and social and
economic factors are equally-if not more- important in determining behavior, sexual
and otherwise (Gordon 1996:375).
Women are not passive actors. They will mitigate or reject outright programs
that do not address their needs. People desire improved health but fear disruption
and external control by regulatory powers that undermine both the authority of their
own traditional specialists and the practices through which cultural reproduction,
more broadly, is assured (Ginsburg and Rapp 1995:21). The voices of Mongolian
women are conspicuously absent from the agendas of donor agencies. As outlined by
Pritchett (1994), an economist at the World Bank, it is not the availability of family
planning but a womans desire to have fewer children that reduces family size.
- 19-


The extreme pro-natalist policies enacted in Romania under Ceausescu are an
example of how womens rights can be violated and all personal choice removed
from the individual in determining their own family size (Kligman 1995). It is
important to remember that it is not only a violation of a womans right to choose by
denying her access to contraceptives or abortions but it can also be an equally serious
violation to deny a woman the children she wants to have by imposing western
notions of birth control usage, family size and womens roles.
This research investigated how family planning programs, structured by
western discourses and policies, have been interpreted by women in Mongolia. The
preceding review of the relevant literature indicates the importance of looking
carefully at the local context within which birth control attitudes, preferences, beliefs
and practices develop. The purpose of my research was to reframe the problem
identified by international organizations and national government officials: why more
women were not using a method of birth control to prevent unwanted pregnancies and
subsequently lowering the abortion rate. Historically, the problem has been analyzed
using a top-down approach which focused on removing barriers to access and
increasing knowledge of modem birth control methods. When this has failed to
achieve desired targets the reaction has been to blame the failure on the women
because of some perceived deficiency on their part. Viewing this same question from
-20-


the womens own perspective allows for new interpretations and possible alternatives
to the hegemonic nature of current programs.
In the following chapters I present the results of this research. Chapter 2
describes the methods employed and sample populations of the research project.
Chapter 3 provides a chronology of Mongolian womens sexual and reproductive
lives as well as an overview of the concept of family. Chapter 4 discusses the
research findings on the knowledge and usage of birth control methods. For
Mongolia, the usage rates of abortion indicate that this should be included under the
main heading of birth control. However, abortion is discussed separately in Chapter 5
in keeping with international tendencies to separate it from contraceptives because of
its highly charged political nature. A concluding discussion is presented in Chapter
6 along with areas for future research.
-21 -


CHAPTER 2
DESCRIPTION OF METHODS AND SAMPLE
POPULATION
Investigations took place in Mongolia over a four month period, May through
September of 2002. The research described here was conducted in the context of a
larger investigation of health reform in post-transition Mongolia, funded by a U.S.
Fulbright Program, 2001-2002 New Century Scholars award to Professor Craig Janes.
Other investigators included Casey Hilliard, Oyuntsetseg Chuluundorj, and Khulan
Janchiv. The research team worked together on the larger project, but each also
pursued their own research interests. I developed the research questions, data
collection instruments, and conducted all interviews. The survey and interview
samples described below were chosen in part from households interviewed in the
>1
larger study of health reform. The research was ethnographic in nature and utilized
both qualitative and quantitative methods. The research protocol was reviewed and
approved by the Human Subjects Research Committee at the University of Colorado
at Denver (Appendix A). 7
7 Barfield (2000:189)describes ethnographic fieldwork as follows: researchers...are supposed to
immerse themselves, taking in large amounts of vastly different kinds of data. This range and
abundance of raw experience and observation helps put the more formally acquired information,
gathered through structured interviews, for instance, into context.
-22-


Research Design
Once the phenomena to be investigated had been identified, utilizing
background readings, the initial research plan was conceived with attention to the
importance of the interplay between qualitative and quantitative methods (Strauss
and Corbin 1998:31). Qualitative and quantitative research cannot only investigate
o
different facets of the same phenomena but can also serve to triangulate overlapping
areas of investigation.
The initial research consisted of self administered surveys for women and
semi-structured interviews with practitioners. Based on the preliminary data
collected once we were in the field it was determined that these instruments needed to
be refined and that a valuable source of information, womens own stories, were
missing and would lead to a greater understanding of unwanted pregnancies and the
reasons for abortions. This led to revisions in instruments and the development of
new data collecting methods. In the end, I was able to collect data from many
different sources: womens surveys, interviews with practitioners, interviews with
women, clinical records and interviews with youth. Figure 2.1 illustrates the various
research techniques used and how they are connected to form a web of data which
contributed to a fuller picture of the phenomena under investigation. 8
8 In triangulation, data collected with one specific method are compared with data collected with other
methods (De Munck and Sobo 1998:32).
-23 -


Figure 2.1- Research Methods and Interrelations
Researcher
Perception
Women
Interviews
The training, attributes and personal biases of the researcher cannot be
overlooked in understanding how research is conducted, analyzed and interpreted.
The researcher not only frames what questions to ask but ultimately determines what
information is deemed relevant or important. Therefore, the research does not exist
outside of or remain unaffected by the knowledge base of the researcher. New
information collected throughout the research process enhances, alters or redirects a
researcher.
-24-


Data Collection Methods
I used a survey methodology as a way to determine what womens history and
experiences have been surrounding various aspects of reproductive health. It was
thought that a self-administered survey design would offer a sense of anonymity and
increase the probability that women would answer sensitive, personal questions about
their sexual histories (Bernard 1994). Several problems arose using this
methodology. Some questions were understood and answered differently than
intended due to conflicting cultural constructs and variability in womens literacy.
Many of the women surveyed in rural areas had trouble understanding the questions,
particularly the technical terms used for reproductive health and birth control. The
self-administered design of the questionnaire also did not allow for follow up and
elaboration on unique or vague responses (Sheatsley 1983). So while the survey
generated a good overview of practices for women living in the cities the findings
could not be extended to include the rural populations.
Practitioners involved in the areas of reproductive health,
obstetrician/gynecologists and infectious disease specialists, given their specialized
knowledge and experiences, were considered key informants (Brown 1998; de Munck
and Sobo 1998; Kottak 1999) Key informants were thought to be able to highlight
how the health care system currently operated with respect to providing reproductive
health services, information, and birth control. Practitioners occupy a particularly
-25 -


strategic position with regard to the implementation of family planning at the local
level. Practitioners are but one-step removed objectively from the personal
experiences of the women and they also work in the contested site where international
and national reproductive policies articulate with individual desires and responses.
The tensions created between competing agendas are a product of a doctors relative
ability to negotiate the expectations of their professional role and patients needs.
Perhaps unsurprisingly, the practitioners consistently responded to questions
regarding the paradox between high rates of knowledge and accessibility of
contraceptives and the low usage in terms of the high numbers of abortions by
blaming the women for being irresponsible (Paolisso and Leslie 1995).
Interviewing women allowed not only for elaboration and follow up not
available with surveying, but also gave women a chance to give their own meanings
to the choices they have made. This method of data collection was also useable in
both rural and urban areas, allowing for some rural-urban comparisons. The major
drawback to using this approach was the need for a translator. The questions asked
and responses given were affected by cultural differences in meanings and the
abilities of the interpreters. It is nearly impossible for a researcher to develop rapport
or an atmosphere of trust conducive to asking the most intimate of questions during
short, one-time interviews relying on a translator. Also, the presence of a third person
may add to a womans hesitancy to discuss certain aspects of her personal life.
-26-


Nevertheless interviewing women enabled the investigation to move beyond a view
of family planning needs framed by institutions and international organizations.
People in their late teens and early twenties were interviewed in an attempt to
ascertain the cultural norms regarding dating, marriage, age of childbearing, birth
spacing, and ideal number of children. Questions were not asked about a persons
specific experiences but about what they thought generally or usually happened.
The purpose for selecting a younger age group was to compare how ideas about
family norms have been affected by the economic transition and exposure to western
ideologies.
The collection and analysis of clinical records offered an opportunity to
compare interview and survey findings to patterns evident among larger clinic
populations. Clinical data also reflects the actual practices of individuals versus the
stated goals of national policies or the personal interpretations of practitioners. The
drawback however, is that clinical records reflect only those aspects of a patients
visit that a practitioner deems important, and that this may vary from one practitioner
to the next, and thus from one set of records to the next. For example one OB/GYN
may think it important to keep records of how many abortions a woman has had while
another might record how many pregnancies instead.
-27-


Samples and Phases of Research
There are five phases to the research as outlined above: practitioner
interviews, womens surveys, womens interviews, youth interviews, and clinical
records. Sample populations varied with each phase of research and are described
here.
The first phase of the research involved interviewing practitioners working in
various aspects of reproductive health and family planning in Mongolia. The
interviews followed a general outline (Appendix B) that was tailored to meet the
specialties of those being interviewed but still allow for some comparison of
responses. The practitioners in the capital and regional city centers were asked
essentially the same questions, though the interviews in the rural areas were much
less structured so as to accommodate the greater variability of providers who deal
with reproductive health issues, for example nurses, midwives, community health
workers (feldshers), and doctors. In total 27 people involved with reproductive health
or family planning were interviewed. Selection of interviewees was based on the
particular organization of medical care in Mongolia. Appendix C lists the
professionals interviewed and indicates their particular role within the health system.
For purposes of clarity, I review in the following paragraphs the basic outline of the
Mongolian health care system.
-28 -


The organization of the medical system is in many ways an artifact of that
which developed during the socialist era. There are four principal levels of care
(Janes 2003). A description of these Approved Levels of Health Care and the
responsibilities and functions of each of these four levels is given in Appendix D.
The levels of care are based on geographical subdivisions that also reflect
governmental administrative units: Mongolia is subdivided into 18 provinces, called
aimags, and four independent municipalities. The aimags are further divided into
counties, or soums, and soums are further divided into districts, or bags (pronounced
bawgs). A description of the organization of health care at each level, starting from
the smallest geographic unit to the largest, is presented below with specific
consideration given to how the four levels of care vary between major cities and the
rest of the country. In the cities medical care is also associated with geographic
subdivisions, though the size and names of these subdivisions from those of the
countryside. The city is divided into districts, and districts are made up of
subdistricts, or xoroo (pronounced hoe-row with a hard initial h).
Level 1 is the basic organizational unit of care and is linked to a bag in the
countryside and a xoroo in the cities. At the bag level personnel typically consist of a
nurse, who may have received an additional year of training to be classified as a
feldsher. They are responsible for approximately 550 people. In the cities, the family
doctor group practice is the primary Level 1 health care facility. The members of the
-29-


group practice usually 4-6 doctors and 4-6 nurses work together to serve an
average of 6,000 individuals registered as legal residents in that particular xoroo. An
individual doctor and nurse are typically responsible for 1,200 to 1,600 patients9 but
this number does not reflect all the migrants who are living in their xoroo but do not
have the financial means to officially register. However, family doctors are required
by law to treat these individuals as well.10 Ideally, Level 1 practitioners provide
basic, holistic primary care, and serve as gatekeepers to more complex care at the
secondary and tertiary levels. In practice, family doctors provide little care, and act
largely as a referral service (Janes 2003).
At the next level (Level 2) in the countryside is the soum hospital, which is
responsible for providing primary care to residents of approximately 4-6 bags. In the
cities, level 2 care is comprised of district hospitals and clinics (both inpatient and
outpatient). In most soum hospitals there are supposed to be several doctors and
feldshers (who share duties as statisticians and laboratory technicians, in addition to
seeing patients), nurses, a pharmacist and a midwife. Typically, however, the
facilities we visited were found to be understaffed. The hospital has limited
diagnostic facilities and provides both in- and out-patient care. Depending on the
9 In theory patients are supposed to be able to choose which family doctor they would like to go to, but
in reality it seemed that the doctors arbitrarily divided up the population in the xoroo they are
responsible for.
10 There is some debate over whether individuals who move into a district but fail to register as legal
residents are entitled to health care. The registration fee is quite steep (approximately US$ 50), and
poorer migrants are often unable to pay it.
-30-


hospital, there maybe surgical and emergency obstetric facilities; however, most
soum hospitals provide primary care. Inpatient beds are intended primarily for
patients who need respite care (e.g. convalescing ill, or elderly). In cities, district
facilities provide secondary and tertiary care to residents of the xoroos. One of the
districts of Ulaanbaatar where research was carried out consisted of 18 xoroos.
Because this district was quite large and geographically spread out, the district had
several hospitals. For example the district with 18 xoroos had 3 district hospitals,
where District Hospital #1 served xoroos 1-6, District Hospital #2 served xoroos 7-
12, and Hospital #3 served 13-18. These hospitals usually had specialized doctors
(for example OB/GYNs, traditional medical doctors, departments for the treatment
of sexually transmitted infections (STIs), and dentists) that treated patients referred by
the family doctors. In most of the district hospitals the services are ambulatory and
further referrals are often made.
The next level of care (Level 3) is the aimag or provincial level hospital that
provides secondary and some tertiary care for all residents of the province or city
administrative zone. In Ulaanbaatar, Level 3 encompasses the entire city, and accepts
referrals from all family doctors and district-level clinics and hospitals. The aimag
hospital is a full service hospital with many specialists providing both in-patient and
out-patient care. Diagnostic laboratory tests are also available in these hospitals
-31 -


The highest unit is the national level (Level 4). These facilities are the most
specialized of the hospitals and have the best diagnostic facilities. Some examples of
Level 4 facilities are the Oncology Hospital, The Infectious Disease Hospital and the
Mother and Child Hospital. Facilities at this level are all located in the capital city,
Ulaanbaatar, and, of course, are relatively inaccessible to those living in the remote
countryside.
An outcome of the transition to a market economy has been the introduction
of foreign aid and non-governmental organizations. These organizations are playing
an important role in formulating, guiding and implementing reproductive health and
family planning services in Mongolia, and it is therefore crucial that they be included
in the investigation. The two most visible entities were the United Nations Fund for
Population Activities (UNFPA) and the international NGO, Marie Stopes
International11. While the two organizations have a formal association in Mongolia,
for reasons discussed later they will be treated as separate entities. The UNFPA
works directly with the Ministry of Health to affect national policy; it does not
provide direct services to the population. Marie Stopes International does, however,
offer specialized clinical services through a network of clinics.
11 There are other international organizations working in these fields but these are the two that are most
commonly referred to or most visible through their production of pamphlets and posters.
-32-


The economic transition encouraged the development of a private health care
sector, and there has been a rapid growth of specialized clinics. These clinics offer
services, presently without need of prior referral, to all patients, regardless of
residence. As such they stand to some degree outside the formal tiered structure of
the health system. Many of the private hospitals specialize in reproductive health
services, in particular abortion and the treatment of sexually transmitted infections.
Table 2.1 below shows the distribution of private facilities in Ulaanbaatar.
Table 2.1- Private Health Care Institutions in
_______________Mongolia in 2001__________________
Type of Service or Institution Number in All Mongolia Number in Ulaan- baatar

Private hospitals with beds 75 45
Private pharmacies 320 184
Drug wholesale agencies 42 42
Dental clinics 148 83
Gynecological clinics (abortions and STI treatments) 60 43
Traditional medicine clinics 59 45
Source: Government of Mongolia, Ministry of Health and Social Welfare
Given that there are so many layers to the system and that the organization
varies between Ulaanbaatar and the countryside, we decided to interview those
responsible for reproductive health issues at all levels and sectors within two
districuts of Ulaanbaatar and in one rural province. These study sites were chosen
based on knowledge of their general socioeconomic status, and a desire to have both
urban and rural representation. In Ulaanbaatar the districts chosen Chingeltei and
-33 -


Bayanzurkh were comprised primarily of relatively recent migrants to the city. In
the countryside we interviewed residents in five rural counties, and in the provincial
center. The study population was predominately low-income. Issues of access and
knowledge of family planning and the availability of reproductive health services was
considered to be most critical for an economically compromised population who are
most at risk for being left out of the system.
Once the districts were selected, family doctor clinics and district hospital
facilities in two xoroos of Chingeltei and one xoroo in Bayanzurkh were chosen for
study. Level 1 care providers were chosen by focusing on xoroos that were comprised
predominately of ger (yurt) housing as an initial indicator of socio-economic
1 -3
status and then selected based on the availability of a family doctor practice willing
to assist us in the research. Within Chingeltei District two Level 2 hospitals were
chosen for study. The first hospital was selected because it was responsible for the 2
xoroos studied in the Level 1 investigation and the second hospital was chosen
because of its central urban location. I wanted to evaluate the possibility that urban 12 13
12 Ger districts, as they are commonly referred to, are the areas surrounding the main center of
Ulaanbaatar were migrants and families set up their tent like structures and/or build homes within
fenced off plots of land. It is typically associated with lower income status than apartment living in the
city.
13 However, after conducting several household interviews in the ger district it became obvious that
living there was not a clear indicator of economic status. Economic status can vary greatly between
families living next door to each other. One might be considered well off (owns a computer, car, etc)
while the other family might not have enough money to feed themselves.
-34-


health needs and practitioners may have different views than those working in the
predominately ger areas.
Hovsgol aimag was chosen as the rural site of the research because the family
doctor system (an analog of the urban based system) had been introduced in the
aimag center14 several years before. Various practitioners at the aimag hospital and
reproductive health departments were interviewed. Outside of the aimag center, we
selected five soums, and within each soum, two bags for focused study. The soums
and bags were selected randomly. Once the soum and bag was selected, however, the
practitioners interviewed were selected by convenience as there was no telling who
would be available at any given time. It was often the case to have doctors,
midwives, and feldshers absent upon our arrival. Usually we were told that they were
off collecting grasses for animals or that they had left for the day and no-one knew
when they would be back. Figure 2.2 shows the geographic location of the research
sites. Appendix C describes the professionals interviewed.
14 The aimag center is typically the largest city in the aimag where the administrative units are located.
-35-


Figure 2.2: Research Sites
Source: Map was produced by the U.S. Central Intelligence Agency (1996), and is in the
public domain. The map was supplied Courtesy of The General Libraries, The
University of Texas at Austin.
Of the 27 practitioners interviewed, the majority were women (22 or 81.5%).
Of the five (18.5%) male practitioners four were doctors and one was a feldsher. Of
the doctors, one (25%) worked at a soum hospital, one (25%) at the aimag hospital
and two (50%) were working in the private sector.
In the second phase of the research, a survey was developed and translated
into Mongolian. The survey elicited demographic information, various facets of
family planning knowledge and use, and sexually transmitted disease history. The
-36-


survey was completely anonymous with absolutely no indication of identity. The
sample population was drawn from two different sources: eligible women from
households chosen by random number generation, and women who were visiting a
doctors office/hospital within a given span of time and who had agreed to complete
the survey.
The third phase of the research consisted of semi-structured interviews (the
outline for the interviews is given in Appendix E). These interviews were conducted
through interpreters. The information gathered through the interview was intended to
overlap the survey data in many regards so that the two could be combined and
compared. Questions were devised in order to achieve a better understanding of
womens knowledge and beliefs that were not being elicited by the survey
methodology. As with the survey, the interviews were completely confidential with
no indication of identity. As much as was realistically possible, interviews were
conducted in private. If a respondent was uncomfortable answering a question or if
the interview was interrupted by someone, the potentially sensitive questions were
skipped. The sample population was drawn from three different sources: eligible
women from households chosen at random, women in the countryside who were
asked by local health care practitioners to participate, and women who were visiting a
doctors office/hospital within a given span of time and who agreed to be interviewed.
-37-


The fourth phase of the research involved interviewing (interview outline is
given in Appendix F) 16 people in their early twenties to try to ascertain how those
most influenced by the economic transition and introduction of western ideologies
viewed aspects of sexuality and what their ideas of family were. The first four
interviews were conducted with people coming to visit the doctor at a district
hospital. The next six were with people visiting the doctor at the Maternal Child
Hospital. The last six, which were two small focus groups consisting of three
participants each, were randomly selected groups of people hanging out in
Ulaanbaatar. Any potentially embarrassing question was framed as a query regarding
opinion of norms without reference to personal experience.
The fifth phase of research involved an analysis of patient records and internal
statistical data provided by several of the practitioners interviewed. While copying
records great care was taken not to include any patient names or other potential
identifiers. These records are used to supplement and expand information collected
through the various other methods.
There were thus five sample populations used in this investigation that
correspond to the five data collection methods discussed above: 1) a practitioner
interview sample population of 27 individuals responsible for various aspects of
providing reproductive health and family planning related services, 2) a self-
administered survey sample of 91 women, 3) an interview sample of 70 women, 4) a
-38 -


sample of 16 individuals in their late teens and early twenties, and 5) a selection of
clinical records. These sample populations are heretofore referred to as the
practitioner sample, the survey sample, the interview sample, the youth sample and
the clinical records sample, respectively.
The geographical distribution of the survey sample is as follows: 86.8% (79)
were from the capital city and 13.2% (12) were from the countryside (Figure 2.3a).
Of the 12 from the countryside 16.7% (2) were from the aimag center, 41.2% (5)
were from soum centers and 41.2% (5) lived in the remote countryside (bag level).
Figure 2.3 Residence of Survey and Interview Populations
1a- Survey Population 1b- Interview Population
13%
87%
43%
57%
Urban 0 Rural
Urban 0 Rural
The survey population consists of 91 women ranging in ages from 17 to 63
years old. For the women whose ages are known the mean age of the sample is 30.11
years. Self-reported employment status is as follows: 23.9% (21) are employed by a
state organization, 18.2% (16) are employed by a private organization, 10.2% (9) are
self-employed, 6.8% (6) are herders, 20.5% (18) are unemployed, 6.8% (6) are
-39-


housewives, and 13.6% (12) are students. This represents 88 of the 91 women where
the remaining 3 responses were missing. The distribution of educational status of the
population is 42.2% (38) have above a high school level education, 37.8% (34) have
completed 10 years of high school, 16.7% (15) have 8-10 years of high school, and
3.3% (3) have 4- 7 years of education. Not one woman reported never having
attended school. This represents 90 of the 91 women with the educational level for
one of the women missing. For 51 of the 91 women the number of individuals in the
family supported by the reported income is known. The reported governmental
criteria15 to be classified as poor is 13,500 togrogs per person per month and the
classification for very poor is no income. Using the above criteria 27.5% (14 out of
51) of the women fall below the poverty line. Of the 91 women 76 reported having a
spouse or partner and their employment status. One woman (1.3%) has a partner who
is retired, 21.1% (16) are employed by a state organization, 17.1% (13) are employed
by a private organization, 32.9% (25) are self-employed, 5.3% (4) are herders, 17.1%
(13) are unemployed and 5.3% (4) are students. Partners are three times more likely
to be self-employed, 39% less likely to be continuing their education and have a
similar rate of unemployment as the women.
The geographical distribution of the interview sample is as follows: 57.1%
(40) were from the capital city and 42.9% (30) were from the countryside (Figure
15 This is the criteria used by a Family Doctor Practice in Ulaanbaatar for their official reporting.
-40-


2.3b). Of the 30 from the countryside 23.37% (7) were from the aimag center, 43.3%
(13) were from soum centers and 33.3% (10) lived in the remote countryside (bag
level). The percentage of individuals represented from the countryside is over three
times higher in the interview sample than in the survey sample because reading
comprehension severely limited the ability of women in the countryside to complete
the survey. This methodology was abandoned in favor of the interview format during
this section of the research.
The interview population consisted of 70 women ranging in age from 19 to 58
with a mean age of 31.01. Self-reported employment status is as follows: 15.7% (11)
are employed by a state organization, 20% (14) are employed by a private
organization, 17.1% (12) are self-employed, 15.7% (11) are herders16, 18.6% (13) are
unemployed, 2.9% (2) are housewives, 7.1% (5) are students, and 2.9% (2) are
retired. The distribution of educational status of the population is as follows: 34.3%
(24) have above a high school level education, 48.6% (34) have completed 10 years
of high school, 8.6% (6) have 8-10 years of high school, 7.1% (5) have 4- 7 years of
education and 1.4% (1) has never attended school. The lower percentage of women
having obtained a college or university degree probably reflects the higher number of
rural women in the interview sample. These women would have greater financial and
16 Herding is a higher occupational percentage for the interview sample compared to the survey sample
for the same reasons that rural residents are represented in a higher percentage.
-41 -


logistical obstacles to attend an urban based school. Information on income was not
directly collected during the interview. Information on educational level,
employment status and sources of stress or worry were to serve as proxies of socio-
economic status. Also, information on a spouses or partners employment status was
not collected for the interview sample.
The youth population consisted of 16 individuals. The mean age was 20 years
old. Of the 16 individuals 2 (12.5%) were male and 14 (87.5%) were female. All of
the youth population was from Ulaanbaatar.
-42-


CHAPTER 3
THE CONCEPT OF FAMILY IN MONGOLIA
The government of Mongolia has historically held a pro-natalist position
which was encouraged by financial incentives and governmental medals.
Mothers with many children were called heroines of the nation.
Women with five or more children received the Mothers Glory
Grade 2 medal [and 20,000 tg approximately 20 USD], women
with eight or more children received the Mothers Glory Grade 1
medal [and 40,000 tg approximately 40 USD]. Mothers with five
or more children could retire from the workforce five years earlier.
In addition, mothers were entitled to 45 days antenatal leave and
56 days postnatal leave on full pay. They could also take up to two
years maternity leave while maintaining job security. Creches
were provided free of charge for children up to three years of age.
Additional taxes were levied on unmarried adults and childless
couples. (United Nations Population Fund 2000c: 5)
One of the women interviewed described life under socialist rule and gave an
example of how governmental policies influenced women.
[I] was a teacher at the time and rarely saw my children. [I]
worked far away and wouldnt get home till 10 at night. At that
time you had to work hard, times were strict and it was noted if
you worked hard or not. There were free days given for those
giving birth, maybe that is why women had so many children [she
laughs].
Since the transition in the early 1990s the government has halted many of the overtly
pro-natalist policies but there are still a few that remain. For example women or
single fathers receive a one time payment of 60,000 tg (60 USD) if they raise four
children and if they raise five or more children they receive 2,000 tg per child per
-43 -


year (United Nations Population Fund 2000b: 15). Also, through the Social Welfare
Law women who do not have insurance are given maternity payments of
approximately US $20/month for four months from the Social Welfare Fund. In
interviews we were told that the period this covers is the last two months of
pregnancy and the first two months after giving birth. Women who are employed but
earn less than the poverty line and women who are unemployed are eligible for
childcare benefits until the child is two years old. The amounts received are
determined by the established poverty line and varies by location .
These welfare policies, designed to aid poor women and their children, have
had unanticipated consequences. One of the family doctors interviewed thinks some
[women] want government money that they pay until the child is two years old. So
women want to get pregnant again within two years. And although no one admitted
to personally doing this, some practitioners and some of the women interviewed
believe that these financial incentives encourage women to have children as a source
of income. This is a very real possibility, especially for those herding families in the
countryside who have no other way to generate the cash needed to participate in the
new market economy. A practitioner at the Family Planning Department in Moron
was asked if she thought that the practice of having children to get money was in fact
done, she replied that is true especially during 1995 when there was an increase in 17
17 ]n Moron the four months of maternity payments was reported as being about 80-90,000 tg.
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birth rates, but now that is decreasing because we are counseling women that the
money is not a lot compared to the long term costs of raising the baby. This was the
only time we heard of efforts to discourage the practice. Whether the government
revises how these programs are dispersed in light of the ways they are currently being
exploited is yet to be seen.
Due to the difficult socio-economic situation of the first half of the 20th
century, until 1950, population growth was slow. For three years in the 1930s the
crude death rate was higher than the crude birth rate. In the 1940s a modem medical
system (modeled after the Soviet system) was introduced in Mongolia and this,
coupled with improving economic security, initiated a rise in fertility rates along with
a decrease in mortality rates. The average annual growth rate was 2.8% from 1960-
1970, 2.9% from 1970-1980, 2.5% from 1980-1990, and 2.0% from 1990-1998.
(National Statistical Office of Mongolia and UNFPA 1998)
In 1996 the parliament adopted the National Population Policy (NPP) with the
main purpose of increasing population levels, raising high quality children, and
providing the conditions favorable to fostering all aspects of human potential
(National Statistical Office of Mongolia and UNFPA 1998). Targets of the NPP
included maintaining a growth rate of 1.8% until 2010-2015, reducing under-five
mortality by one third, reduce maternal mortality rates 50% from 1990 levels, and to
increase life expectancy at birth. The Reproductive Health Needs Assessment
-45-


(United Nations Population Fund 2000c) determined that birth spacing would be a
major determinate in achieving growth targets, reducing complications during child
birth and promoting a healthy childhood. Reproductive issues are also addressed in
the National Security Policy because the small population size of Mongolia is
considered a national security issue (National Security Policy of Mongolia 1994).
The Security Policy states that the Mongolian gene pool must be protected against
threats from disease, inbreeding leading to increases in the number of mentally
retarded people, spread of alcoholism and drug addiction, imbalances in sex and age
population, famine and shortage of water, breach of sanitary standards in production
of foodstuffs, and a breach of safety rules in handling chemicals (United Nations
Population Fund 2000b: 13).
Family Size
Of the women interviewed and surveyed (n=161), there were 140 responses
(87%) to how many children were ideal or wanted. The results ranged from one
child (3 responses or 2.1%) to 4 children (23 responses or 16.4%) with the vast
majority wanting 2 or 3 children (combined percentage of 81.4%). The mean was 2.7
children. Not one woman responded that she thought not having any children would
be ideal. With the percentage of women who want only 1 child at 2.1% it is clear that
most women want at least 2 children.
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Women interviewed were asked how many children their partner or spouse
would like to have. Seventeen of the women did not currently have a partner, have
completed their family or did not answer the question. The mean number of children
desired by a partner or spouse is 2.8 with 62.2% wanting 3 or 4 children. The number
of children wanted by women was not statistically different than the number wanted
by men (p=. 1146 one tailed and p=.2293 two tailed).
Information on how many children a woman actually has was available for
153 of the women. Currently 31 (20.3%) of the women do not have any children and
53 (34.6%) have one child. Therefore it can be estimated that at least half of the
sample (or 82.2 women) would like to have at least one more child. When the
women who have not had children are included the mean number of children that a
woman has is 1.58, if these women are excluded the mean number of children is 2.07.
Again the desire to have more children in the future is reflected in the difference
between the means of the ideal versus the actual (2.66 vs. 1.58 and 2.66 vs. 2.07
respectively). At the high end one woman had 8 children. She had reported that 3
would be a good number of children to have. The difference between actual and
preferred cannot be explained by non-use of family planning options as she also 18
18Although not exact due to the differences in sample size the percent is estimated by taking the total
percentage minus the 2.1% who would want only 1 child.
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reported having eight abortions19 which raises her total number of pregnancies to 16.
She explained that she did not use birth control because these were not an option at
the time.
The interview population included 40 women from Ulaanbaatar and 30
women from Hovsgol aimag. Data from this sample group was analyzed to
determine if there were any urban/rural differences in the number of children a
woman has or wants. The number of children a woman has was considered by
residence at the four levels of bag, soum, aimag, and Ulaanbaatar. The mean at the
bag level was 2.10, at the soum level 2.00, at the aimag level 2.14 and in the capital it
was 1.40. When the bag, soum and aimag levels are considered together the mean
number of children a woman in the countryside has is 2.07. From this it can be
concluded that, at least in Hovsgol aimag, women living in a rural environment tend
to have more children than women living in an urban environment. This is supported
by the findings of the Reproductive Health Survey (National Statistical Office of
Mongolia and UNFPA 1998) in which it was found that the fertility rate (TFR) for
19 She reported that she did not use any preventative types of birth control because none were available
at the time. She is 63 years old and had her first pregnancy when she was 19 so it can be assumed that
all or almost all of her pregnancies occurred during the time when Mongolia was a socialist country.
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urban women was 2.46 children per woman while the TFR for rural women was 3.66
children per woman.20 21
Age Women Start Having Children
Women who were surveyed were asked to identity the ideal age for starting a
family. Of the 91 women surveyed, 73 responded (80.2%). Only five (6.8%) women
thought that it was good to start having children before the age of 20 (no one
responded less than 18 years old). The mean age reported was 22 years, and no one
responded that a good age to start having children was above 27 years. In fact, 83.5%
of the women reported that a good age to start having children was 24 years old or
younger.
Women who were interviewed were asked how old they were when they had
their first child. Responses were collected for all 70 women (100%). Thirteen
women (18.6%) had not had any children and 78.5% of the women had their first
child by the time they were 27. Of the thirteen women who have not had a child, the
mean age is 24 years, with 61.5% 24 years or younger. Of the 57 women that have
had a child 82.4% of them had their first child by age 24. The mean age for having a
20 It should be noted that the RHS included aimag centers in their classification of urban while here it is
grouped with the bag and soum at the rural level because fertility patterns supported this division for
Hovsgol aimag.
21 The cumulative percent minus those who have never had a child.
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first child was 22 years, which is identical to the ideal described above. The RHS
found a median age for first birth of 21 years.
Women who were given the survey were asked their age at first pregnancy.
Of the 91 women surveyed, 88 responded (96.7%). The ages at first pregnancy
ranged from 17 to 32 years old. Eleven women (12.5%) had not had a pregnancy and
79.5%22 had had a pregnancy by the age of 27. The mean age for women who have
not yet had a pregnancy is 21.00 with 91.0% of the women 24 or younger. Of the 77
women who have had a pregnancy, the mean age at first pregnancy is 23 years.
Among those women who have not had a pregnancy or a child, the mean age
for not having had a child is 3.23 years higher than the mean age for not having had a
pregnancy which would indicate some form of birth control is being actively used
and/or miscarriages are resulting in delayed age at parenthood. The higher age at first
pregnancy for the surveyed sample (22.66) versus the age at first birth for the
interviewed sample (21.96) may be the result of a larger sample size in the surveyed
group value of 22.66 will be used for comparison basis.
Marital Status
Marital status is known for 155 (96.3%) of the women surveyed or
interviewed. Eighteen or 11.6% of the women are single. Of the remaining women
22 The cumulative percent minus those who have never had a child
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126 (81.3%) are either married or have a partner 8 (5.2%) are either living
separately from their husbands or are divorced and 3 (1.9%) of the women are
widowed23 24. Age was known for 16 of the 18 single women with 56.4% of the single
women 22 or younger. Ages for the single women ranged froml7 to 30 years old. Of
the remaining women the mean age of marriage is 22.2 years. The age at marriage
ranged from 17 to 30 years old. The mean age at marriage is slightly lower than the
mean age for first pregnancy (22.2 versus 22.66 respectively). The Reproductive
Health Survey (National Statistical Office of Mongolia and UNFPA 1998) conducted
in 1998 consisted of interviews with 7461 women of reproductive age (defined as 15-
49 years old). The survey found that the median age at marriage was 20.8 years and
that there has not been much variation in age at marriage over the past twenty years
(p. xix).
23 Many women would talk about their partners as their husbands. For example in one interview (a
household interview for a separate research project) a mother discussed her pregnant daughters
unmarried status but noted that she had a boyfriend. The daughter later joined us and made several
references to her husband. Also, a woman in another interview classified herself as having a partner
but referred to him throughout the rest of the interview as her husband noting that they were going to
make it official.
24 The Reproductive Health Survey (National Statistical Office of Mongolia and UNFPA 1998)
reported 26.6% never married, 59.9% married, 5.7% living together, 2.7% widowed, 4% divorced, and
1.1% separated. The main distinction with the current data presented is the distinction between
married/ not married made in the Reproductive Health Survey and the distinction of single/involved in
a relationship made here.
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Age at First Sex
Of the 161 women, interviewed or surveyed, the age at which they first had
sex is known for 135 (83.9%); 9 women (5.6%) had never had sex. For women who
have not had sex their ages ranged from 18 to 30 years old with a mean age of 22.78
years. For women who have had sex, the youngest age was 14 and the oldest was 26
years old at first sex. The mean age was 20.06 years with 61.5% of the women
having had sex by age 20. The first year where there is a dramatic increase in sexual
initiation is at age 17 (2.2% of the women have had sex by age 16 but by 17 the
percentage increases to 11.1%). Women, on average, are having sex for the first time
more than 2 years earlier than when they get married (20.06 compared to 22.2 years
respectively). This should be taken into consideration in any future reproductive
health surveys in Mongolia. The 1998 Reproductive Health Survey (National
Statistical Office of Mongolia and UNFPA 1998:39) appeared to be biased by views
that currently married women are most in need of family planning services.
The levels of knowledge of both modem and traditional
contraceptive methods are greater for currently married women
than for all women. This can be explained by the greater need for
currently married women to regulate their childbearing and birth
intervals, and to protect their reproductive health.
The youth sample was asked how old boys and girls usually are when they
have sex for the first time. The age ranged from 13 to 19 for boys and 13-20 for girls.
The mean age for first having sex for boys was 16.5 years and for girls it was slightly
-52-


older at 17.29 years. This is three to three and a half years younger than age at first
sex found for the survey population above (at 20.06 years old). Further research
needs to be done to see whether the age at which sexual intercourse is engaged in is
actually decreasing. Thirteen practitioners were asked if they thought the number of
teenagers having sex has increased in the last 5 to 10 years. Twelve (92.3%) of the
practitioners responded that it is increasing while one (7.7%) practitioner thought that
it is decreasing compared to five or ten years ago. Five years ago the situation was
closed (not freely discussed) but now knowledge is [improved] among teenagers.
Number of Sexual Partners
Women who were interviewed and surveyed were asked how many sexual
partners they have had. Of the 124 women who responded, just over half (52.4%)
reported having had sex with only one person. Another 23.4% of the women reported
having sex with two different partners and 15.3% reported having had three sexual
partners. Therefore 91.1% of the women have had between 1 and 3 partners in their
lifetime. A further 6.4% of the women have had between 4 and 10 partners and 2.4%
of the women have had more than one partner but did not specify how many. Where
the number of sexual partners is known the mean number of partners a woman has
had sex with is 1.83.
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Youth Statistics
For the youth population, with 14 interviews representing 16 people, the mean
age at which they wanted to marry was 23.14 years old. Three of the youth
interviewed (a 23 year old female, a 22 year old female, and a 20 year old male) are
already married with the mean age at marriage being 21.33 years old. Another two
individuals (a 23 year old male and a 20 year old female) are planning to get married
very soon. Therefore five of the youth sample are married or plan to get married in
the immediate future. Also, five of the youth sample already had a child or are
expecting their first. The average age for a first child among the five women is 20
years. Among the five who have a child or are expecting their first three are married,
one is planning to get married soon and one is not married and has no immediate
plans to marry (she is currently 22 and stated she would like to marry about age 25).
The second individual (a 20 year old female) who is planning to get married soon
would not like to start a family for another two years. There were nine responses on
how many children a person wanted to have. The mean number of children wanted
was 2.44 with seven (77.8%) reporting two children and two (22.2%) saying they
wanted four children. The lower means for age at first pregnancy (20.00 vs. 22.66),
age at marriage (21.33 vs. 22.2) and number of children desired (2.44 vs. 2.66) when
compared with the other data described above, is most likely an artifact of the small
-54-


sample size. It would be highly informative to conduct future research with this
population to determine if this trend is still visible with a larger sample size.
Data from Clinical Records
Lastly, clinical records for pregnancies in 2002 seen by the OB/GYN
department at a Level 2 District Hospital in Ulaanbaatar were analyzed. There are
three OB/GYNs with a total of 806 pregnancies for the first half of 2002. Ages were
known for 804 (99.8%) of the 806 pregnancies ranging from 13 to 47 years old with a
mean age of 26.52. Of the 804 pregnancies, 321 (39.9%) were the first pregnancy for
a woman. The age distribution for first pregnancy was 13 to 43 years, with a mean
age of 23.28 years and 52% of first pregnancies occurred at age 22 or younger.
Records indicated that 205 (25.4%) of the women were experiencing their second
pregnancy, with the mean age at second pregnancy of 25.8 years. Just over half
(51.7%) of the second pregnancies had occurred by age 25. Almost one quarter of
second pregnancies occurred between the ages of 18 and 22. The records showed
that 115 (14.3%) of the women were experiencing their third pregnancy. The mean
age at third pregnancy is 29.11 years. Almost one quarter of the women having their
third pregnancy were between the ages of 18 and 25. There were 124 women (or
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15.4%25) with a fourth or greater pregnancy. The mean age for having a fourth or
higher pregnancy is 33.40 years with slightly over a quarter of four or more
pregnancies occurring by age 29. A cross sectional analysis of the clinical records
show that there is a 2.52 year spacing between first and second pregnancies and a
3.31 year spacing between second and third pregnancies. The Reproductive Health
Survey (National Statistical Office of Mongolia and UNFPA 1998) collected
information for birth spacing for a combined second or third birth and found the
median number of years since previous birth was 2.81.
There seems to be no standardized requirement for what information needs to
be recorded about each woman beyond age (which is missing for 5% of the 806
women), employment status, gestational age, when antenatal care began, the number
of pregnancies for the woman, and whether or not the pregnancy ended in abortion,
miscarriage or birth. Only one of the doctors kept records on the marital status of the
pregnant women. Her patient records included 253 pregnant women. A full 80.2%
of the women reported being married. Of the remaining women only two (0.8%)
reported that they were not married and the marital status for the remaining 48
(19.0%) women was missing. Although it cannot be determined for certain why so
many of the womens records do not report marital status, it may indicate that a large
25 The number of women included in the discussion of age at number of pregnancies totals 765 out of
the 806 clinical records or 95%. The remaining 5% were missing information on age.
-56-


percentage of the pregnant women are not married and felt ashamed or reluctant to
admit it. It would be important for future research to investigate socio-cultural
implications of unwed pregnancy and the impact on health seeking behaviors for both
mother and child. On a national level, in 1990 the number of single mothers was
19,289 which doubled to 38,670 in 1998 (National Statistical Office of Mongolia
1999: 32). One 50 year old woman who we interviewed was asked how attitudes
about sex changed since she was younger and she felt, it is different now-a-days. It
has changed a lot and it is getting worse. A couples relationships are not sincere;
couples are divorcing a lot.
Conclusion
It is telling that more than half (53.7%) of the women surveyed or interviewed
(where information on how many children a woman has is known) indicate that they
desire another child. The important role of family planning for these women involves
not discouragement of more children, but information and methods for delaying
pregnancy until a woman and her family were prepared for another child. These
women would take into consideration how soon fertility would return when
considering what type of birth control to use. The responses of the youth sample for
age at first sex needs to be further investigated, they responded with ages 3 to 3 'A
years younger than survey sample.
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One OB/GYN believes that women have changed and they want to get
married at 30 and have kids later; they want to be more like Europeans. However,
for the women who reached child bearing age during the first 10 years since the
transition to a market economy, this does not appear to be the case. The question is
how imported messages of reduced family size and delayed marriage are internalized,
reinterpreted, or rejected by the next generation and what the consequences might be.
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CHAPTER 4
BIRTH CONTROL KNOWLEDGE AND USAGE
Before 1970, it was illegal to use any form of contraception in Mongolia. The
63 year old woman described previously, who had a total of 16 pregnancies, noted
that at that time there were no methods of birth control. In 1976 this restriction was
relaxed slightly to allow limited use of birth control, primarily IUDs. Then in 1989
oral birth control (OBC) was introduced, followed by the introduction of other
methods of contraception.
Much effort has been directed towards increasing usage, access and
knowledge about various modem methods of birth control (BC) The distinction
of modem versus traditional methods of birth control was outlined in the
Reproductive Health Survey (National Statistical Office of Mongolia and UNFPA
1998) and will also be used here. Modem methods of birth control include oral birth
control pills (pills, OBC), Intrauterine Device (IUD), injections (DEPO), implants
(Norplant), diaphragm, foam, jelly, condom, female sterilization and male
sterilization. Traditional methods are periodic abstinence, withdrawal and the so-
called calendar method. Through various methods; such as instituting family
planning and reproductive health classes in schools, television programs, radio and 26
26 As of 1998, among non-users of contraceptives who do not plan to use birth control in the future,
0.1% said the reason was that it costs too much, 1.6% said it was because of lack of access/too far, and
3.0% knew of no method (National Statistical Office of Mongolia and UNFPA 1998).
-59-


newspaper ads, pamphlets and posters and community outreach programs there is a
high level of knowledge about at least some forms of birth control among Mongolian
women. The 1998 Reproductive Health Survey (National Statistical Office of
Mongolia and UNFPA 1998) found that almost 97% of all women and 99% of
currently married women knew of at least one form of birth control. The interview
population was asked to list all the methods of birth control that they knew about.
Currently six methods of birth control are made available at no charge for any woman
who would like to use them. The methods available are condoms, OBC, DEPO,
'yi
Norplant, IUD and just recently emergency contraception was introduced. The
family planning program is organized through the United Nations Population Fund
(UNFPA) and the supplies are donated by the Danish government. In fact the
majority of birth control supplies in Mongolia come from UNFPA programs. The
UNFPA has been involved in the reproductive health care system of Mongolia in a
substantive way. In the second country programme which started in January 1997, it
has allocated $7.3 million (out of $9.3 million total budget) for reproductive health
services (United Nations Population Fund 2000a). The first county programme had
funding of US $4 million dollars. 27
27 Emergency contraception is the use of hormonal pills within 72 hours of sexual intercourse to
prevent pregnancy.
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Birth Control Methods Known
Women were asked what methods of birth control they had heard about. Of
70 women, only two (2.86%) reported that they have never heard of any type of birth
control (this is almost exactly the same percentage of women who do not know of any
method of birth control that the Reproductive Health Survey, conducted in 1998,
found). Of these two, one woman is a 21 year old virgin who has never received any
type of schooling. She lives with her family in the remote countryside and helps with
animal chores involved in their herding lifestyle. The second woman is a 25 year old
herder from the countryside living in a small rural settlement (a hot-ail ) with
relatives. She has only 6 years of education, she has never been married, and has a 3
month old boy. When asked what she would do if she got pregnant within the next
six months, she responded that maybe she would get an abortion because she does not
want to have another baby right now.
In the case of the second woman, a little bit more is known or suspected as to
why she is lacking knowledge about birth control. Right before the interview with
her we had met and talked with the feldsher responsible for the region in which she
lives. He was very shy and often blushed when talking with us. He became
increasingly uncomfortable when asked about reproductive health issues. For 28
28 A hotail is a group of relatives that live near one another and often share in the responsibilities of the
animal chores and participate in a system of generalized reciprocity.
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example, he does all antenatal care for women but last year assisted only 6 deliveries.
When probed if this small number of deliveries was due to women using
contraceptives, he turned bright red and replied that he did not know. He has
injections, condoms, pills, and emergency contraception available. If women ask he
can give these to them free. He was asked where women usually go to get
contraceptives, to which he replied the soum hospital. He is the primary contact for
women in his bag for reproductive health and family planning but he was obviously
not comfortable discussing these topics let alone initiating the discussion. He
subverts his discomfort by not addressing the issue and hoping that the women will
bring these issues up with personnel at the soum hospital. The result would be that
the 90 women, age 16-35, in his bag (who are typically involved in animal chores
from morning till night, and often only have a horse for transportation) would have to
travel about 15km to the soum center. To get there, the women would need to cross a
river that is impassable for part of the year. When the river was not crossable the
women in Nukht bag would go to another soum center located 20 km away.
Of the remaining 68 women, only one (1.47%) had heard of one method of
birth control and that was the IUD. She also happened to live in the same district as
the male feldsher described above. Five women (7.35%) were able to name two
methods of birth control, 12 women (17.65%) could name three, 25 women (36.76%)
could name four methods, 16 women (23.53%) could name five, five women (7.35%)
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could list six, one woman (1.47%) gave seven methods of birth control, and three
women (4.41%) know of at least eight. The frequency of mention for each type of
birth control is given below in Table 4.1. The IUD is the most commonly known
method, probably because it was widely available during the socialist regime. It is
also the method that is most feasible for herding women who would find it difficult or
near impossible to continually have to track down a feldsher or doctor to obtain their
next supplies. Knowledge of the other four methods introduced within the last 12
years through the UNFPA seems to be quite high, with OBCs being the most
commonly mentioned (86.8%) and Norplant being the least frequently mentioned
(22.1%). It is not surprising that Norplant is the least well known of these methods as
it is the most restricted in access for women. As insertion and in particular removal
can be difficult and requires an incision into the arm, Norplant is only available at
hospitals. The newest method29 30 made available through the UNFPA is emergency
contraception which had only been available for a few months when this study was
"J A
conducted The newness of this method is reflected in the low number of times it
was mentioned (2.9%). A preliminary look at emergency contraception usage and
29 The UNFPA also stated that female condoms were being introduced in Mongolia but throughout the
entire study it was never mentioned by a practitioner as being available. Only one women out of 68
even mentioned knowing about it as a form of birth control.
30 A representative of the UNFPA stated that a pilot study on emergency contraception started about
three months ago in two districts in Ulaanbaatar and that any aimag that wished to pilot it as well
could. We were told that emergency contraception was available in the two Districts in Ulaanbaatar
included in this study and it was available, although with very restricted access, in Hovsgol aimag.
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dispensing protocols is described later on. The calendar method, a traditional birth
control was mentioned by almost half of the women. Table 4.1 also lists the results
from the Reproductive Health Survey (National Statistical Office of Mongolia and
UNFPA 1998). The main difference in methods between the Reproductive Health
Survey (RHS) and the present study is that the RHS provided response categories
listing all forms of birth control, whereas my interviews and surveys elicited free,
unprompted lists of contraceptives. Despite methodological differences, the
similarities between the two studies, particularly for the first four methods, is striking.
Table 4.1: Frequency a Method of Birth Control
was Mentioned
Method of Birth Control Number of women who mentioned Percent of women who mentioned (study data) Percent of women who knew a method (RHS data)
IUD 62 91.2% 92.6%
OBC 59 86.8% 86.5%
DEPO 51 75.0% 78.7%
Condom 47 69.1% 88.1%
Calendar 33 48.5% 84.0%
Norplant 15 22.1% 34.1%
Withdrawal 3 4.4% 44.8%
Temperature Method 3 4.4%
Female Sterilization 3 4.4% 45.4%
Spermicide 3 4.4%
Emergency Contraception 2 2.9%
Washing After Sex 2 2.9%
Female Condom 1 1.5%
Male Sterilization 1 1.5% 16.9%
Breastfeeding 1 1.5%
Herbal Birth Control 1 1.5%
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Current Usage of Birth Control
There are differing estimates of the rates of birth control usage. On a poster
located outside the OB/GYN area of a District Hospital in Ulaanbaatar, the birth
control usage rate among Mongolian women was reported as 45% in 1999, 50% in
2000 and 50% in 2002. The Reproductive Health Survey (National Statistical Office
of Mongolia and UNFPA 1998) found that nearly 66% of all women had ever used a
method of birth control and that about 44% were currently using one at the time of the
survey. One OB/GYN in private practice told me that he felt that most all women
were using some form of birth control. When it was mentioned that the government
reports about 50% of women use birth control, he responded that the government
reports only use information from public facilities and is therefore incomplete.
Of the 161 women interviewed or surveyed, information on current birth
control use was available for 129 women: 58 or 45% reported currently using birth
control and 71 or 55% were not currently using birth control. The methods used are
listed in Table 4.2; some of the women are using more than one method (i.e. calendar
and condoms) so the total percentages are greater than 100%. The most commonly
reported method currently being used was condoms, followed by the IUD and then
the calendar method. Information was available for 148 women on whether or not
they have ever used a method of birth control. Of these women 102 (68.9%) had used
a method of birth control in the past and/or currently. Forty six women (31.1%) had
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no prior history of birth control usage. Table 4.2 also displays the methods of birth
control that women have used in the past (or are currently using). Some women have
tried more than one method and for the women interviewed up to four methods used
in the past were recorded therefore the total percentages do not add up to 100. Some
women who reported using the calendar method also reported using condoms during
their unsafe days. Of the methods having been tried in the past or currently the
IUD is the most popular method with the calendar method being second.
Table 4.2- Methoc s of Birth Control Used
Method of Birth Control Currently Using Percent Currently Using Ever Used Percent Ever Used
Condoms 22 37.9% 34 33.3%
OBC 6 10.3% 24 23.5%
IUD 18 31.0% 44 43.1%
DEPO 5 8.6% 12 11.8%
Calendar 13 22.4% 30 29.4%
EC 1 1%
Herbs 1 1.7% 1 1%
Chinese Abortion Pill 1 1%
Withdrawal 1 1.7% 2 2%
Reasons for Not Using Birth Control
Of the 71 women not currently using a form of birth control, 45 described
why they have chosen not to use any. The most common reason why women are not
currently using birth control is that they are currently pregnant or are trying to get
pregnant (22 women or 48.9%). Two women we talked with had been using the
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calendar method and three had been using pills but they all stopped using birth
control because they wanted to get pregnant. Another woman interviewed has never
used any type of contraceptive because she wants to have more children if money is
not an issue. A 40 year old woman we talked with has one boy who is 18 years old.
She is not currently using any method of birth control because she and her husband
*3 1
want to have another child .
The second most frequently cited reason for not using birth control is that the
woman has never had sex (10 women or 22.2%). Tied for the third most commonly
cited reason is that the woman has just given birth and believes that she cannot get
pregnant again until her period returns (5 women or 11.1%) or a woman believes that
she is too old to get pregnant or has undergone menopause (5 women or 11.1%). For
example, a woman we spoke with told us, It is said that after giving birth a woman
cannot get pregnant until her period returns so that is why I am not using birth
control. A 58 year old woman with four grown children said, If a mother
breastfeeds then a woman cannot get pregnant. This is a kind of birth control, a
traditional one. Mothers breastfeed all the time even outside in the open; maybe this
is the reason they are breastfeeding [she laughs]. One woman is not currently using
birth control but is planning to get an IUD in the near future. Another woman who 31
31 This woman has had two prior abortions: one in 1986 because she was in sports and one in 1996
because she was going to Korea.
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was described above has no knowledge of birth control methods and has never used
any type. The remaining woman is separated from her husband, whom she has not
seen in three years, and therefore does not currently need to use birth control. Her
husband left to study in Ulaanbaatar and didnt come back. She heard he is currently
farming in Selenge.
Geographical Variation in Birth Control Preferences/Usage
The interview data was investigated to see if there is a preference for method
of birth control by residence (urban/rural). Table 4.3 shows methods of birth control
currently being used separated by urban/rural residence. Of the women residing in
Ulaanbaatar 16 out of 40 (40%) women are currently using birth control and of the 30
women at the aimag, soum and bag level 20 (66.67%) are using a method .
These data suggest that the dramatically higher birth control usage rate in the
countryside is due to a system of direct accountability for practitioners in the rural
areas versus the more difficult-to-access healthcare system in the capital city. As
outlined in the methodology section, the four levels of care are all found
simultaneously in Ulaanbaatar, with each level performing a specific role in
reproductive health services but offering overlapping care. This four-tiered system
becomes even more complicated when private clinics and NGOs are included in the 32
32 For the interview population 51.4% of the women reported currently using a form of birth control.
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options of where women can go for care. It is often left to the woman to decide who,
if anyone, she will approach for her family planning needs. It was often mentioned
that women prefer to go to private doctors or Marie Stopes International clinics
because they offer more privacy, have shorter waits, and are more confidential than
public services. A representative from Marie Stopes noted, We opened four years
ago and every year the number of customers has grown. We dont have the long lines
and you dont have to wait a long time like at the other hospitals. A private doctor
noted that in most medical hospitals the services are not very good and not very
private. Here things are very private. Sometimes teenagers and pregnant women are
treated rudely at the state hospitals and this makes the patients feel bad but that is not
the case here. However, private doctors are not among those who receive the birth
control provided through the UNFPA and therefore can only prescribe birth control
for their patients to buy. Typically private clinics are clustered in urban areas and
the cost of services restricts their use to women in the middle and upper income
brackets, leaving low income women to maneuver through the public system. It is a
sad commentary that the Marie Stopes clinics in Ulaanbaatar which were supposed to
be working in conjunction with the UNFPA as models of policies in action for
family planning and reproductive health clinics throughout Mongolia have gotten
As of 2000 there were 59 private gynecological clinics with 43 (73%) in Ulaanbaatar and 16 (27%)
in rural areas (National Center for Health and Development and UNFPA 2001:7-8).
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market position and forgotten the initial plan. They are not showing a good example
and teaching others -just running on their own and making money (an official from
UNFPA).
Table 4.3- Currenl Methods of Birth Control by Residence
Method of birth control Rural Residence Rural Percentages Urban Residence Urban Percentages
Condoms 3 15% 9 56.25%
OBC 2 10% 1 6.25%
IUD 11 55% 3 18.75%
DEPO 3 15% 0 0%
Calendar 2 10% 7 43.75%
Herbal 1 5% 0 0%
Withdrawal 0 0% 1 6.25%
If a woman does decide to go to a reproductive health professional in the
public realm they have to deal with potentially long lines, long waits and virtually no
privacy. When a practitioner is lucky enough to have an office to themselves, there
will still be many interruptions during a womans visit with people continually
opening the door to peak in and /or walking in. Theres no privacy. Four family
doctors sit in the same room and we dont like everybody hearing everything
(United Nations Population Fund 2000c: 24). Throughout Mongolia there still is a
tradition of not forming lines and waiting for ones turn but of jostling to establish a
position in the front of any crowd waiting for a service. This practice results in
women frequently opening closed doors to check to see if the person they are waiting
for is available and sometimes of walking right into someones office regardless of
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what is taking place inside. This was seen often at various gynecological clinics
visited throughout Mongolia.
The doctors themselves even seem to be unsure of their responsibilities in this
area. When asked if they routinely talked with patients about their sexual history and
practices, two family doctors said yes and two said no. For the two who said yes,
these types of questions were seen as an important part of providing care to their
patients: [I ask] about history because I have to find out about partners and give
exams, and the other family doctor asks about, womens diseases and about
partners, how does a woman feel about their sex life? how do you feel during sex?
how do you feel after sex, are you forced to have sex?. The other two doctors
responded that, she asks but not often and she doesnt ask, if they ask she will talk
about it but she doesnt ask. This last comment suggests that some doctors perceive
issues of family planning and reproductive health to be the responsibility of the
patient. One OB/GYN at a level 3 hospital said it is the personal liability
(responsibility) of the woman to use contraceptives. An OB/GYN at a level 2
hospital noted that [some women] dont care about themselves and that is why they
didnt use any birth control. This OB/GYN also said that she doesnt ask about
their sexual lives, she thinks they know about sex from journals and TV. When
asked who is most likely not to use birth control, a teen doctor responded in much the
same way, that women who do not care about themselves are most likely not to use
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birth control. When asked why the number of abortions is increasing despite all the
public education on birth control, an OB/GYN at the level 4 hospital said maybe the
woman doesnt care for herself and that is why she got pregnant. A private doctor
told us, if someone catches a disease or gets pregnant it can be said that it is their
fault.
All of these responses appear as an attempt to explain why, with so much
public education and knowledge of family planning, women are not using birth
control. This is similar to what Martha Ward (1995:146) describes for teenage
pregnancy programs in the U.S. She writes that, one of the effects.. .has been a
search for causative or independent variables.. .that could be leveraged against the
problem. This causative agent must have a cheap remedy, and it must place the onus
for change outside the system (dont blame us). Framing the reason in such a way
shifts responsibility away from the doctor and places blame on patients. It also
highlights the general impression that birth control services are widely available, from
many different facilities, so a doctor does not have to accept direct responsibility for
providing this service (ONeil and Leyland-Kaufert 1995).
This can be further demonstrated by the low rates of free contraceptive
distribution as evidenced by records for a district hospital (level 2) in Ulaanbaatar.
While the typical procedure for obtaining contraceptives is to go through ones family
doctor, they can also be obtained through OB/GYNs at the next level of care. At this
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hospital there are three OB/GYNs, each is responsible for approximately 5,000
women of reproductive age. The period covered by the records ranged from 4 14 to 6
months during 2002 During this period, OB/GYN #1 gave 61 DEPO injections (out
of the 26 women who were due for their next shot during that time period, only four
women (15.4%) came back for their next shot); inserted 80 IUDs; dispensed birth
control pills to 56 women; and dispensed condoms to 25 women. OB/GYN #2 gave
73 DEPO injections (out of these 47 where first shots, 6 were second shots, 1 was a
third shot and 1 was a fourth shot); inserted 52 IUDs; dispensed birth control pills to
69 women, and dispensed condoms to 22 women. OB/GYN #3 gave 60 DEPO
injections; inserted 67 IUDs; dispensed birth control pills to 49 women; and
dispensed condoms to 9 women.
Provision of family planning and reproductive health services in rural areas is
markedly different from that described for Ulaanbaatar. In rural areas there are fewer
providers, and the system is closer in structure and function to the highly rationalized
socialist one of the pre-transition era. The roles and responsibilities of health care
practitioners at every level are clearer, and there is less of a chance of a woman being
lost in the system due to doctors passing the buck, so to speak. This is perhaps
reflected in the higher prevalence of birth control usage, as well low levels of
abortion in this particular rural area (the reduction in abortions will be discussed in
the next section). Care is more likely to be vertically integrated, and this enables
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direct links between policy goals, program implementation, and program evaluation .
A representative of the family planning Department in Moron described a policy
where county doctors send in a list of women who should not have any more children
for various reasons such as poverty, already having a large family, or health
problems. When the physicians in Moron receive this list they determine what
method of birth control might work for each of the women, and send these guidelines
to the local doctor. After a few months the Department follows up to make sure the
woman have received prescribed birth control. The representative also noted that
family doctors and soum doctors advise poor families with many children to use birth
control. The criteria used by soum doctors to determine which women should use
birth control are not clear, and may reflect his or her personal biases. It is also
unclear how much choice a woman has in using the recommended birth control.
The pursuit of targets and family planning goals may be fostering an environment
among practitioners in this aimag that places usage rates above the individual rights
of women. A.. .problem with a population control approach is that, even in
countries without coercive official policies, it can lead to ethical violations, because
rights of individuals are viewed as less important than the goal of fertility limitation
(Lane 1994:1308).
The impact of vertical integration of services on birth control use in rural
areas is further illustrated by examining the free contraceptive distribution records
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from two soums in Hovsgol aimag. These data are shown in Table 4.5. In Tarialan
soum, 49.3% of the women were reported to be using a contraceptive, of whom
73.2% are using the IUD. Galt soum has even higher rates of birth control use
(60.8%) of which 53.6% are using the IUD. One feldsher/midwife in Arbulag soum
reported that the rate of unwanted pregnancy there was 2.6% with 570 of 1300
women using birth control.
Table 4.4- Soum Birth Control Distri DUtion Records
Tarialan Soum Tarialan Soum Vulnerable Women34 Galt Soum Galt Soum Vulnerable Women
Women of Reproductive Age 1701 690 1544 478
Using Birth Control 839 481 938 93
IUD 614 386 503 49
Injection 59 29 47 11
OBC 42 18 196 24
Norplant 3 2 0 0
Condoms 60 24 143 9
Sterilization 27 5 0 0
Calendar 34 9 49 0
Not only is there a difference between usage rates of birth control but there is
also a very different preference of birth control methods between rural and urban
women (referring back to Table 4.4). Due to logistical constraints imposed by
weather, transportation, and access, it is understandable that rural women use the IUD
most frequently since, once it is inserted, it remains effective for 5 to 10 years.
However, it is not an ideal method for women who have never given birth, women
34 Vulnerable women are those that fell below the state defined poverty level.
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who may want to give birth within 5 years, women who experience cramping during
menstruation and a heavy menstruation, and women who are risk for reproductive
tract infections.
Women who are not candidates for an IUD but want to use a method of birth
control have to address the continuous problem of obtaining their next supplies. This
or
would suggest that a western model of dispensing a limited supply of OBC at a time
should be abandoned [is this the practice in Mongolia? If so, note this] and women
should be given up to a years supply of OBC as long as she has received information
on side effects and risks, and is monitored by the local feldsher periodically for side
effects. It also seems feasible, given Mongolians comfort in self injecting
medications* 36, to supply women with a years supply of DEPO (again stipulating that
a medical practitioner provide requisite information and education and monitor for
any complications). Similar to what Marshall (in Polgar and Marshal 1976: 211)
found, there are many reasons why self injecting birth control might be culturally
acceptable:
First, because of years of exposure to antibiotics and vaccinations,
an injection is an entirely acceptable medical procedure in the
village. Indeed, a villager who was not given a shot during a visit
j5 This is not the case everywhere. Some Planned Parenthoods allow women to take as many refills as
they would like at one time up to the 12 allocated on their yearly prescription.
36 Mongolian people are susceptible to the injection mystique where a greater legitimacy is afforded
to injected medications as they are associated with advanced technology and medicine (Hartmann
1995). According to the local WHO office in Mongolia, Mongolians are one of the most frequently
injected populations in the world.
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to a doctor felt himself somehow cheated. Second, an injection in
the arm avoids both the mortifying experience of exposing ones
genitals to medical scrutiny, and the necessity of handling ones
genitals demanded by the condom, diaphragm, foam, or jelly. Not
only is an injection coitus-independent, but like the oral pill, it is
genitalia-independent, a highly desirable attribute in a culture in
which modesty is imperative and privacy rare. Third, an injection
can be given in the village, even in ones home, thus obviating the
need to visit a threatening and inconvenient hospital or clinic.
As in providing ample supplies of OBC, providing ample supplies of injectable
contraceptives to women may be a feasible way to allow women more control over
the methods of birth control they choose. It is possible that the high rate of IUD
usage in the rural areas is fostered by providers views that woman are incapable of
controlling their own fertility. The IUD is a method of birth control that largely
removes all control from women37. A critical question here is whether it is the real
obstacles, such as long distance travel in winter, which drives birth control decisions,
or the whether it is the biomedical image of mothers as incompetent serving] to
rationalize the medicalization of their reproductive capacities (Morsy 1995:170).
Allowing women to have control over their own birth control supplies would make
the use of OBC and DEPO much more accessible to Mongolian women in the
countryside.
37 To contend with the discrepancy between method efficacy and user efficacy the trend in
development of contraceptives has been to develop methods that would not depend on the users
motivation, skill, memory, ability to understand instructions, attitudes toward the partner, sexual
inhibition, fears, anxiety, unconscious desires, mood, humor (Barroso and Correa 1995:302).
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PAP Tests
In 1984 the Food and Drug Administration concluded that due to the possible
links between OBC and cervical cancer, women on the pill should be given a Pap test
once a year. In Mongolia women do not typically receive a Pap test unless they are
pregnant, or if there is a suspicion of a sexually transmitted infection (STI). Women
who are taking the pills as prescribed have a very small chance of becoming pregnant
(99% efficacy rate) and therefore would only have a Pap smear if an STI was
suspected, and a doctors care was sought (there are concerns about self-treatment for
STIs because antibiotics are easily available in most markets). This low rate of
screening is not only a concern for OBC users, but also for Mongolian women in
general. Especially considering the papilloma virus (an STI that is not routinely
tested for in Mongolia) is a leading cause of cervical cancer worldwide (WHO 1989:
36).
Though exact figures are not available, it is known that annual
incidence of the cancer of the uterine cervix is about the same as
the number of maternal deaths. The pain, horror and suffering in
each of these 5,000,000 annual cases should make us feel the
challenge to prevent this mortal disease. This is much more
important in the light of the fact that the cancer of the cervix is
now recognized as a viral disease, presumably transmitted sexually
in a way similar to HIV, syphilis, chlamydia and gonorrea"
Bergstrom 1994: 3).
In developing countries, cervical cancer accounts for the highest number of
new cancer diagnosis in women at 23% (Paolisso and Leslie 1995). An education
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program is urgently needed that promotes the benefits of having a Pap test done on a
regular basis in order to detect abnormal cell growth and cervical cancer at earlier
stages. Given the costs, logistics and equipment required to make PAP testing
available it might be more feasible to train reproductive healthcare providers on a
low-cost, low-technology procedure for detecting abnormal cell growth. There is a
technique ideally suited for developing countries that utilizes vinegar and an
ingredient used in bottled soda (almost all countries have a soda manufacturing
plant).
The Calendar Method
It is of serious concern that the reported .usage rates of the calendar method,
especially among urban women, are so high: 22.4% of the current birth control users
for the combined interview and survey population, 29.7% of the women who have
ever used a birth control method for the combined populations, and 43.7% of current
urban birth control users have chosen this method. The Planned Parenthood
organization reports that with typical use of this method, 20 out of 100 women will
become pregnant, and with perfect use 9 out of 100 women will become pregnant.
The method is not recommended if a woman has irregular periods, their partner is
unwilling to abstain or practice safe sex during the fertile periods (which is about 10
days a month), or if a woman is unable to keep careful records. Even women who
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experience regular menstrual cycles can be affected by stress, illness and climatic
changes. Because the calendar method can be unreliable, Planned Parenthood
recommends that it is best not to rely on this method alone. It is best to combine the
temperature method, the cervical mucus method, and the calendar method. The
combination of these methods is called the symptothermal method (Planned
Parenthood Federation of America 2003). However, the temperature method and the
cervical mucus method require daily monitoring and can be quite difficult to sustain
over long time periods. Not one woman in the study mentioned using the temperature
or cervical mucus method in conjunction with the calendar method. In fact only one
woman even mentioned the temperature method, and she asked us how it was done.
This method also requires cooperation from ones spouse or partner. As one doctor
put it, a husbands knowledge about sexual life is poor, for example if a wife doesnt
want sex because it is during an unsafe time, the husband doesnt care about it and
wants to have sex.
One of the women interviewed reported having stable periods and has been
using the calendar method combined with condom use during the unsafe times. She
was concerned that she might have gotten pregnant while using this method this past
March and went to her family doctor, where she was given emergency contraception.
She did get pregnant last month when she counted wrong and this pregnancy ended
in abortion. She told us, Since I got pregnant I want to find out about other reliable
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methods with minimal side effects. The family doctor and I have talked about the
shot but I am waiting to find out about the side effects. When asked why she chose
to use the calendar method, she responded, There are no side effects, pills give you a
stomachache, with the IUD you have longer periods, and the shot makes you gain
weight. Another woman had used an IUD for six years and had it removed. Since
she had the IUD removed, she has been using the calendar method. Her period is
every 21 days and she menstruates for 5 days. She divided the 21 days into three
weeks with week two considered the unsafe time during which her and her husband
used condoms. She admitted that she calculated wrong and figured her cycle from
the last day of her period to the first day instead of from the first day to the first day.
She said that this method did not work very well and she became pregnant four times
since the IUD was removed. The first two pregnancies were aborted (for the second
abortion she went to China to buy a medication that she had heard about, but the
medication caused spotting and a foul odor so she had to get a medical abortion). The
third pregnancy was miscarried, which the woman attributed to having had the two
abortions. She was carrying the fourth pregnancy to term. After the first three
pregnancies, this woman continued to use the calendar method, although she either
never asked professional advice on how to use this method, or was given poor
instruction. With a 21 day cycle her fertile time would coincide with the first 10 days
following her period a week that she had been considering safe.
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The important question here is why these women use a method that can be
very unreliable if they so obviously do not want to have more children? The one
thing these women have in common is that they either have personal experiences with
or have heard rumors about the side effects of other methods of birth control. As
noted, the first woman told us that OBC causes stomachaches, the IUD makes your
periods longer, and the shot makes you gain weight. The second woman had used an
IUD in the past, but when she had a second one inserted she experienced abdominal
pains and heavy bleeding, and so she had it removed. Her sister had used
NORPLANT and gained weight. She also stated that she does not like the injections
because they cause you to get fat.- Like the findings of DeClerque et al (1986)
about OBC rumors in Egypt, rumors about modern methods of birth control in
Mongolia affect their acceptability among women. Similarly, in Mongolia these
rumors or personal experiences coincide with the perception that modem birth control
methods are deleterious to womens health. However, unlike the findings of the
Egyptian study, the rumors do not undermine the perceived effectiveness of the
methods; women generally acknowledge that modem methods are highly effective.
However, the rumors of side effects may have a greater influence on womens
decision making about birth control than their perceived efficacy. One World
Development Report (World Bank 1984) found that the main reason given for women
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discontinuing birth control usage worldwide is side effects: from 40 to 70 percent of
pill, IUD, or injectable birth control users (Hartmann 1995:273).
One 42 year old woman who I interviewed is currently using the calendar
method despite the fact that she knows that it is unreliable, and her husband objects to
it (there are so many unsafe days and he does not like using condoms). She believes
that the IUD is reliable but has never used this method. She does not want to use
DEPO because she heard that it causes hormonal changes, and she worries about the
impact of these changes on her health. She has chosen to rely on the calendar method
even though she is worried about getting pregnant because I have had so many [4]
abortions and I am afraid of abortions.
Another woman I spoke with has gone to a Marie Stopes clinic twice with her
husband and learned all about different methods birth control. They chose to use the
calendar method and condoms because he doesnt like any forms of birth control
(pills, injection), and he prefers condoms. He doesnt like the other forms because he
thinks they will affect my body badly he loves me. She has an 11-month old son.
The pregnancy was accidental while using the calendar method. My husband
wanted a baby but I didnt just yet. I decided to keep the baby.
Another factor, related to concerns about side effects, is a womans desire to
have more children in the future. As noted in the previous chapter, a large number of
women have not completed their desired family size. Womens choice of appropriate
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contraceptives involves weighing many costs and benefits, including how to achieve
optimal birth spacing while and at the same time insuring an immediate return of
fertility once a method is stopped. When these considerations are combined with
concerns over side effects, the use of the calendar method seems logical, even when
considering its low efficacy compared to more modem methods of birth control. As
one woman described her experience, In the past we used the calendar method,
during the semester [I was going to school] I did not want to get pregnant, so we used
it. After this we were trying to get pregnant so we did not use any birth control.
When asked why she chose the calendar method, she replied, I think it is the
simplest and least harmful method. Another woman has been using an IUD but plans
to have it removed. She will then use the calendar method. She currently has one
child and told us that she would like to have one more and that her husband would
like to have two more.
Side Effects of Birth Control Methods
How prevalent are these beliefs that various methods of birth control have side
effects? The RHS (National Statistical Office of Mongolia and UNFPA 1998) found
that for women who are not using birth control and who do not intend to use birth
control in the future 13.6% cited health concerns or side effects as the reason why.
Another report cites service statistics that 26% of women in Mongolia stop using a
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method of BC due to health concerns, and 21% discontinue usage because of
dissatisfaction with the method (United Nations Population Fund 2000a). Forty three
of the 70 women (61.4%) interviewed mentioned a side effect for at least one form of
birth control. The results are shown in Table 4.6. Five of the 43 women (11.6%)
who mentioned side effects thought the calendar method was unreliable. One doctor
interviewed noted that women are really worried about side effects such as gaining
weight, their period coming a lot, painful menstruation, and inflammation of chronic
diseases such as kidney problems (associated with OBC use). Some stop using birth
control because of side effects. Given that most practitioners interviewed did not
believe side effects were a concern for women users of birth control indicates that
these concerns are either not normally expressed to the health care provider, or that
the provider dismisses these concerns. Either scenario suggests a breakdown in
communication between patient and doctor.
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Table 4.5- Side Effects Mentioned for
Birth Control Methods
Method of BC Reported for Calendar Reported for DEPO Reported for IUD Reported for NORPLANT Reported for OBC
Side Effect Mentioned 5 (11.6%) 23 (53.5%) 25 (58.1%) 7(16.3%) 24 (55.8%)
Weight Gain 0 (0%) 12 (27.9%) 7(16.3%) 3 (7%) 3 (7%)
Harmful to Body 0 (0%) 5 (11.6%) 4 (9.3%) 2 (4.7%) 0 (0%)
Heavier Period/Cramping 0 (0%) 1 (2.3%) 12 (27.9%) 0 (0%) 0 (0%)
Nausea 0(0%) 0 (0%) 0 (0%) 0 (0%) 7 (16.3%)
Not Reliable 5(11.6%) 0 (0%) 0 (0%) 0 (0%) 1 (2.3%)
General Side Effect 0 (0%) 0 (0%) 2 (4.7%) 2 (4.7%) 8 (18.6%)
From Table 4.5 it becomes clear that while there might be near universal
knowledge about contraceptives, there are side effects -- whether actual or reported
misconceptions, misinformation and exaggerated rumors that may be hindering
usage. When a woman perceives that modem methods of birth control have side
effects that are detrimental to their health, and are faced with a system of care that is
at best confusing, and is not conducive to open, confidential discussions, it is not
surprising that they are opting for the calendar method. Suffering from unexplained
and untreated contraceptive side effects and disillusioned with the quality of service,
a high percentage of women drop out of family planning programs (Hartmann
1995:38). The concern then becomes how to educate women about the calendar
method and other natural family planning methods so that they become more
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JO
reliable While women have been educated about the various methods of birth
control, they are often lacking the basic knowledge about how their bodies work and
how the methods are able to prevent pregnancy. The use of either modem or
traditional methods of birth control without corresponding biological knowledge
keeps women in the dark and serves to increase their misconceptions of, and
contributes to outright rejection of, the various methods.
The effects of misunderstanding the side effects of a contraceptive can be
illustrated by the story of one of the women interviewed for this study. She is a 30
year old married woman who has two children: 7 and 12 year old boys. We met her
at the Maternal and Child Hospital, a level 4 care provider, where she was looking to
have an abortion. She had been using the injection for four years and for a full year
did not have a menstrual period. This caused her to become concerned about her
health, so she began a cycle of getting the shot, not having her period for three
months, then waiting for her period to come and then getting the shot again.
Unbeknownst to her, such a practice caused a lapse in protection from pregnancy.
Not understanding the possible consequences of her actions, and believing that her
next shot protected her for another three months, she did not become aware that she
j8 Most studies done acknowledge the high rates of usage for the calendar method but the UNFPA,
perhaps due to their bias towards modem, technocratic methods, has not committed finances to IEC
programs to educate women on this method or to approve introduction of thermometers and charts that
would improve efficacy.
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was pregnant until she had completed the first trimester (14-15 weeks). Now the
doctors tell her that she is too far along for an abortion and she does not know what to
do. She is concerned that the birth control and strong medications that she had
taken when she did not know she was pregnant might have affected the unborn child.
This is a woman who took precautions to avoid pregnancy and through
misunderstanding ended up pregnant, and without the ability to terminate the
pregnancy. Added to this is the burden of working 12 hour days sewing, only to
return home to take care of housework and the needs of two young children. There
were many opportunities to educate this woman about the side effects of DEPO and
the risks of not having the injection according to prescribed time schedule. When she
first decided to start taking DEPO, a practitioner should have explained side effects to
her, and when she was late visiting the practitioner for a follow-up injection she
should have been counseled in appropriate usage
Emergency Contraception
Emergency contraception (EC) had only been introduced for a few months
when this research was conducted. Even though family doctors provide most
methods of birth control, one practice in Ulaanbaatar noted that they do not provide
emergency contraception, suggesting that at this point it was not available in all
primary health care settings. At a one district hospital an OB/GYN said they offer
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emergency contraception but people do not know about it and so dont ask for it. She
noted that it is intended for women who have had casual sex just yesterday. This
statement reflects her own personal biases regarding who is eligible for its use, and is
also incorrect in the temporal viability of its use. A family doctor at a different clinic
noted that she discusses emergency contraception with patients and some women
have come looking for it. Marie Stopes International supplies emergency
contraceptives and indicates that women often hear about it from friends. One private
doctor said that she doesnt prescribe emergency contraceptives, but if women bring
it to her she can read the directions for them. Another private doctor said that he
recommends emergency contraception to some of his patients, and that it is a real
benefit to them. He also noted that some doctors do not give emergency
contraceptives because they do not have enough knowledge of it. Two OB/GYNs
noted that most of the women who have come to them to obtain emergency
contraceptives work in the hospital. The Family Planning Department in Moron has
supplied soum doctors with emergency contraceptives, but has not given it to the
family doctors in the aimag center. A representative of the Department said that
because it was a new method of contraception, they want to keep good records of who
has used it,and thus do not at this time wish to release it to the family doctors. Family
doctors must thus refer all patients to the Department for these services. This is a
control policy that has direct implications for women. The pills need to be taken
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within 72 hours of unprotected intercourse and delays caused by the need to first visit
a family doctor and then be referred to the Family Planning Department, especially if
it is after business hours or over a weekend, jeopardizes a womans ability to use this
method. A bag feldsher in Hovsgol aimag showed us a pamphlet on Prostinor (the
brand of emergency contraceptive available in Mongolia) but said that she has never
had any supplies. She, carried the pamphlet for information purposes.
Of the 20 women who have used emergency contraception in Moron, none of
the women have had to use it because they were raped. It was noted by a
representative working in the Hovsgol Aimag Family Planning Department that
women are using it that have had sex during unsafe days. The average age of users
was 29.5 years old ranging from 20 to 42 years. There were 15 (75%) women who
were married and 5 (25%) who were not married.
Effects of Religion and Gender Status on
Birth Control Use
Mongolia is unique among many developing nations in that women seem to
hold an equal, or almost equal, status to men. As I described in an earlier chapter,
women in Mongolia have higher levels of education than men, hold professional and
middle-management level jobs, and their access to birth control is not affected by
spousal consent. Only one woman out of the 70 interviewed reported using birth
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