Modernization
and Family Planning Programs in Egypt
Kamran Asdar
Ali
Demographic
research deploys a notion of culture that links models of change
to the acceptability of modern birth control. Unfortunately, this
approach adopts a narrowly construed formulation of culture as communication
within the household with minimal reference to the social, political
and economic forces of the larger society.
In the last decade,
the Egyptian state in collaboration with international donor agencies
has embarked on an ambitious population control program. According
to this program, Egypt's rapid population growth is the prime obstacle
to the development goals set by Egyptian authorities. Between 1980
and 1992, the program increased current contraceptive use among
couples, primarily in the form of IUDs and birth control pills,
from 24 percent to 47 percent. At the same time, it reduced the
total fertility rate from above five to 3.9 percent.1
The process of associating reproduction and fertility
with femaleness, perpetuates a private/public dichotomy and splits
social analysis into female/male spheres. Such characterizations
continue despite the expanded participation of women in the labor
force and advances in female education that have changed the organization
of the household and redefined female space and boundaries. Although
feminist anthropology of the area has described the collapse of
public/private dichotomies,2 social and demographic
research continues to characterize the household primarily as female
space.
To promote the acceptance and use of contraceptive
methods by women, internationally sponsored family planning programs
have begun to focus on male partners. The endeavor to enhance male
involvement in family planning decisions in Egypt by the state and
international development agencies continues historical efforts
to "modernize" the Egyptian poor. Thus, the family planning program
as a pedagogical project is linked to constructions of gender, domestic
life and the emergence of a responsible citizenry in Egypt.
Men and Family Planning
Historically, the Egyptian Family Planning Program
has concentrated on women as recipients of its services. Specific
surveys of women assessed the total fertility rate, the contraceptive
prevalence rate, the age at marriage, the social status of women,
and knowledge, attitude and practice of fertility control. This information
helped policy planners assist women to make "independent choices"
on the available contraceptive methods.3 The relative
invisibility of men in the debates on fertility control and contraceptive
methods was perpetuated by this focus on women.
Recent attention in international family planning circles to how
different cultures organize fertility decisions has induced planners
to study male views on fertility control. Surveys conducted in developing
countries have helped to explain male behavior in fertility regulation
and to identify trends affecting future family planning policies.4
International family planning efforts have successfully integrated
male methods, such as condoms and vasectomy, into their various
programs. In Egypt, however, user rates for these methods are extremely
low. This failure is explained partly by evoking traditional culture,
patriarchal norms, native notions of maleness, the "backwardness"
of the peasant population and "Islamic doctrine." Planners have
attempted to overcome the perceived resistance to family planning
through a concerted media campaign to educate men on the importance
of family planning.5
In 1991, Macro International and the Cairo Demographic Center
conducted a survey_funded by USAID_of male attitudes and behaviors
in Upper Egypt and Cairo with respect to family planning.6
The rationale for the survey was that available data from the 1988
Egyptian Demographic and Health Survey7 indicated
that the percentage of currently married women who had ever used
contraception in rural Upper Egypt was almost half (26 percent)
that of rural Lower Egypt (58 percent). Similarly, the current contraceptive
use among women was three times higher in rural Lower Egypt (36
percent) compared to rural Upper Egypt (12 percent).8
The 1988 survey also showed that a higher percentage of women in
rural Upper Egypt believed that their husbands disapproved of family
planning. The survey was based on the premise that the low current
use in Upper Egypt was due to the persistence of traditional norms
and the dominance of Upper Egyptian males in decision making within
the household. The 1991 survey was set up as a comparison of the
knowledge, practice and attitude of men from Cairo, considered more
modern, and those of the more traditional of Upper Egypt_and especially
rural Upper Egypt.
The first report of the USAID survey showed that the percentage
of men in Cairo who have ever used or are currently using modern
contraceptives with their spouses (81 percent) was twice as high
as that for men in rural Upper Egypt (44 percent).9
The survey reported that men in Upper Egypt were more "likely than
men in Cairo to cite fatalistic reasons (e.g., 'there is nothing
one can do,' 'I accept what God gives me') for not intending to
use [contraceptives]."10 These justifications
for non-use of contraception fit, according to the survey, "with
a view of more traditional men in Upper Egypt."11
Other findings, however, did not confirm expectations. For example,
a higher percentage of Upper Egyptian men (47.3 percent) than in
Cairo (40.3 percent) had discussed fertility issues their wives.12
Similarly, contrary to belief in family planning circles that Islam
is a major hindrance to contraception, religion did not seem to
stop the respondents from using family planning methods. In fact,
rural Upper Egyptian men were less likely (8.9 percent) than men
in Cairo (14.3 percent) to cite "religion as the main reason for
not intending to use" contraception.13
Thus, the results challenged the predictions of the analysts.
The survey found that the percentage of men in Upper Egypt who reported
that using family planning methods for the first time was mainly
their wife's idea was higher in Upper Egypt (39 percent, 43 percent
in rural Upper Egypt) than in Cairo (31 percent).14The
survey analysts acknowledged that the results were "...contrary
to expectations,"15 and undermined the conservatism
thesis. They interpreted the findings in a way, however, that obscured
this conclusion, asserting that the "wife's role was negatively
related to the level of modernization."16
Modernization
Although this USAID sponsored survey did uncover some differences
in knowledge, use, attitudes and decision-making practices between
men in Cairo and in Upper Egypt, these differences were not sufficient
to account for the difference in contraceptive use. Indeed, they often
contradicted conventional culturalist expectations. Nonetheless, the
report concluded that prevailing traditional social norms in urban
and rural Upper Egypt influence men's decision making role in family
planning and may be responsible for the difference in contraceptive
use.17 Thus, statistical anomalies were forced to
fit the culturalist paradigm.
The survey's concluding statement clearly reveals the terms and
categories in which the problem was defined and articulated. Questions
about the household, who makes decisions on fertility, compatibility
of responses among husband and wife and freedom of opinion and movement
of women are embedded in the paradigm of modernization theory.18
Previously, modernization meant the establishment of a productive
industrial economy, leading to a general enhancement of wealth and
material welfare. Now it emphasizes the politics of representative
democracy, periodic elections and free speech as practiced by people
who have individual rights.19 Using this new approach,
demographic research deploys a notion of culture that links models
of change to the acceptability of modern birth control. This approach
adopts a narrowly construed formulation of culture as communication
within the household with minimal reference to the social, political
and economic forces of the larger society.20 It
also encompasses the idea that people in traditional cultures are
more fatalistic and leave reproduction "to the will of God."21
This understanding of culture in effect places households/families
and behavior patterns on a continuum of traditional to modern. Modernization
of behavior may, therefore, lead to the constitution of modern families
which are more open to the use of modern contraceptives.
Demographic research in this framework further purports to show
that the level of education, autonomy of women and consensual companionate
marriage is linked to high acceptance of contraception. In this
perspective, notions of autonomous individuals, who as consenting
adults, create the bond of conjugal marriage are crucial. Hence,
the relationship between the individual and the state is seen to
be mediated through new kinds of families where the notion of individual
choice within the nuclear family is paramount. This idea of free
individual choice linked to the language of rights and set in the
context of a companionate marriage and a nuclear household, becomes
the bedrock for most international family programs. The population
planning program sponsored by the Egyptian state and international
agencies attempts to socialize the domestic sphere in precisely
these ways.
Following this argument, it is safe to say that although not explicitly
stated, the Egyptian Male Survey (EMS) assumes the nuclear household
as a progressive, positive and modern space devoid of pressures
from other kin, friends and relatives on reproductive decisions.
It further assumes that household to be a decision-making unit,
free and open to discussion regarding fertility choice and the sole
locus of social respectability. The contrast made with rural Upper
Egyptian men through representative sampling is drawn precisely
to study their departure from this norm.22
Championing Choice?
Furthermore, sensitive to local practices, Egyptian family planning
policy asserts the right of the family as a unit to decide on the
number of children it desires within the framework of religion and
the cultural norms of society.23 In practice, however,
services are primarily provided to women and spousal consent is not
required for the use of most family planning methods.24
International donor agencies favor this approach, championing the
right of the individual, in this case "the Egyptian woman," to decide
the method of contraception.
With the choice of contraception by women linked to their emancipation,
the family planning program and the donor agencies present themselves
as the defenders of the rights of women.25 Nonetheless,
the donor assisted family planning program seeks not only to enhance
the range of individual choice available to women but to create
conditions in which only certain choices can be made. For instance,
the language of individual choice does not allow the option of non-choice
of contraception. Yet, we could interpret some of the EMS survey
results as suggesting that, in Upper Egypt, women and their "traditional
household patriarchs" are equal partners in rejecting modern contraceptives
connected to the authority of the state and development agencies.
Be that as it may, planners have now discovered that they cannot
always bypass the men.
Advertising Family Planning
A series of television advertisements in Egypt addresses men's role
in contraceptive decision making. These advertisements, produced by
the State Information Services under technical guidance and financing
from USAID and Johns Hopkins University, focus on men's familial responsibilities
as providers. Some of these advertisements represent men as heads
of families and criticize them as conservative, traditional, and anti-modern
defenders of the status quo--that is anti-birth control. Others encourage
men to be flexible and uncritical towards female decisions to use
contraceptives. Still others use pervasive stereotypes showing an
unconcerned peasant patriarch who rides on a donkey while his wife,
walking next to him, carries a big load on her head. The ads encourage
men to behave better towards their womenfolk and show images of modern
urban men helping their wives in domestic household chores. Another
television spot shows a sheikh admonishing a poor man for failing
in his duty as a father, and for having many children without thinking
of the consequences. The father is blamed for the large family and
the sense of deprivation and inadequacy it creates for all.
In many advertisements, authority figures such as the sheikh and
the social worker stress the responsibility of men to live up to
their roles as providers. By invoking this image, family planning
policy makers seek to shame men into being "real men," that is to
be more responsible individuals, hence have fewer babies. Family
planning is presented in terms of the health and future of the wives
and children, evocations with strong appeal to men.26
The Limits of Modernist Constructions
The Egyptian state in collaboration with international donor agencies
uses its family planning program as a tool to modernize its population.
The state promotes distinctive political and social practices connected
to modern ideas of physical and mental health.27
In this process the normalization of conjugal marriage and the nuclear
family helps construct the modern categories of the "individual,"
the "private" and ultimately "modern citizens."
In Egypt, however, these constructions rest on slippery terrain.
On the one hand, there is an effort to produce socially responsible
fathers who follow the state's advice on family planning. On the
other, high unemployment, socioeconomic deprivation and an undemocratic
political environment push most people to the margins of the system,
creating political conflict and deep resentment. In intellectual
circles as well as among the poor, questions are raised about the
assumed "natural" linkage of economic development and population
control. The increasing disparity in income levels that is quite
independent of family size subjects the emphasis on family planning
to criticism on the grounds of equity of distribution and social
justice. Moreover, popular notions of the body, healing, fertility,
and sexuality undermine the legitimacy of state-sponsored medical
and social impositions.
Rapid socioeconomic changes do not only undermine traditional
male power. As poverty levels increase, women are forced to seek
employment outside their homes to help pay for the increasing costs
of educating and rearing children. For women the economic insecurity
of their male partners undercuts the few benefits of the "patriarchal
bargain"28 they enjoyed. Recent data show that
the ill effects on nutrition and health linked to structural adjustment
are worse for women and children.29 As old support
structures are disappearing new forms have yet to evolve. It is
a time of much apprehension and uncertainty for the underprivileged
in Egyptian society.
Finally, as the Egyptian state and international agencies link
Egypt's future economic growth to the population question, they
combine high-pressure appeals for contraception with the deeper
impact of socioeconomic coercion. Demographic transition may occur
in Egypt. But if it does, it will be less for the classical reasons
usually linked to better standards of living than to the majority
of Egyptians' diminishing opportunities to make a living.
Author's
note The fieldwork in Egypt was supported by a Doctoral Research
Fellowship granted by the Population Council and the support of
the anthropology department at the Johns Hopkins University. Institutional
support while in Egypt was provided by the American University in
Cairo and the Population Council Office in Cairo. The author wants
to thank Talal Asad, Clarissa Bencomo, Caroline Bledsoe, Niloofar
Haeri, Laura Lewis, Emily Martin, Norma Moruzzi, Syema Muzaffar,
Martina Rieker, Michel-Rolph Trouillot and the editors of this journal
for their thoughtful comments. However, I remain responsible for
the final shape of this paper and any shortcomings therein.
Endnotes
1 Egyptian Demographic
and Health Survey (Cairo: National Population Council, 1992), p. xxiii.
2 See Lila Abu-Lughod,
Veiled Sentiments (Berkeley: University of California Press, 1985);
S. Altorki, Women in Saudi Arabia: Ideology and Behavior among the
Elite (New York: Columbia University Press, 1986); and C. Nelson,
"Public and Private: Women in the Middle Eastern World," American
Ethnologist 1 (1974), pp. 551-63.
3 This emphasis
on women echoed the larger trends in family planning policy elsewhere
in the world; see Susan Cotts Watkins, "If All We Knew About Women
Was What We Read in Demography, What Would We Know?" Demography
30/4 (1993), pp. 551-577.
4 See M. A.
Mustafa, Male Attitudes Towards Family Planning in Sudan (Sudan
Fertility Control Association, 1982); Michael T. Mbizvo and Donald
J. Adamchak, "Family Planning Knowledge, Attitudes, and Practices
of men in Zimbabwe," Studies in Family Planning 22/1 (1991), pp.
31-38; Shireen J. Jejeebhoy and Sumati Kulkarni, "Reproductive Motivation:
A Comparison of Wives and Husbands in Maharashtra, India," Studies
in Family Planning 20/5 (1989), pp. 274-90; Mona A. Khalifa, "Attitudes
of Urban Sudanese Men Towards Family Planning," Studies in Family
Planning 19/4 (1988), pp. 236-43; and Hussein Abdel-Aziz Sayed,
Fatma Hasan El-Zanaty and Anne R. Cross, Egypt Male Survey 1991
(Cairo Demographic Center, 1992).
5 The preceding
analysis is based on interviews with family planning officials in
the government, international donor agencies, nongovernmental organizations
and family planning reports and surveys.
6 See Hussein
Abdel-Aziz Sayed, et al., Egypt Male Survey 1991, op. cit.
7 Egyptian Demographic
and Health Survey, op. cit.
8 See Hussein
Abdel-Aziz Sayed, et al., Egypt Male Survey 1991, op. cit., p. 2.
9 Ibid., p.
22.
10 Ibid., p.
32.
11 Ibid.
12 Ibid., p.
45.
13 Ibid., p.
32.
14 Ibid., p.
63.
15 Ibid.
16 Ibid.
17 Ibid., p.
70.
18 Susan Greenhalgh,
"Anthropology Theorizes Reproduction: Integrating Practice, Political
Economic and Feminist Perspectives," in Susan Greenhalgh, ed., Situating
Fertility (Cambridge: Cambridge University Press, 1995), pp. 3-28;
Susan Greenhalgh, "The Social Construction of Population Science:
An Intellectual, Institutional and Political History of 20th Century
Demography," in Comparative Studies in Society and History (forthcoming).
19 See Talal
Asad, "Conscripts of Western Civilization," in Christine Ward Gailey,
ed., Civilization in Crisis (Gainsville: University Press of Florida,
1992), pp. 333-352.
20 See Greenhalgh,
Situating Fertility, op. cit., p. 7.
21 See Jane
Schneider and Peter Schneider, "Sex and Respectability in an Age
of Fertility Decline: A Sicilian Case Study," Social Science and
Medicine 33/8 (1991), pp. 885-95.
22 By the early
20th century, reflecting changing social and economic structures,
marriage patterns by choice and "love," were becoming common among
the elite of Egypt. See Beth Baron, "The Making and Breaking of
Marital Bonds in Modern Egypt," in Nikki Keddie and Beth Baron,
eds., Women in Middle Eastern History (New Haven: Yale University
Press, 1991), pp. 275-91.
23 See H. Sayed
as quoted in Nora Guhl Naguib and Cynthia Llyod, "Gender Inequalities
and Demographic Behavior: The Case of Egypt," Occasional Paper Series
(New York: The Population Council, 1994) and H. Sayed, "Population
Policy in Egypt," in Population Policies in the Third World: Issues
and Practice (Cairo: Cairo Demographic Center, 1988).
24 See Nora
Guhl Naguib and Cynthia Llyod, "Gender Inequalities and Demographic
Behavior: The Case of Egypt," op. cit.
25 International
donors view the policy emphasis on the rights of couples as a direct
infringement of the individual rights of women to decide in reproductive
matters.
26 Using the
rhetoric of overpopulation, Egyptian state and media proclamations
continuously hold the people responsible for their own economic
misery. The family planning program also allows the state to enter
the domestic space of the Egyptian household. On the one hand it
poses as the defender of women's rights. On the other, it undermines
the authority of the patriarch by deeming him irresponsible. Thus
the state carves out the authoritative voice in relation to fertility
decisions.
27 See Talal
Asad, op. cit.
28 Deniz Kandiyoti,
"Bargaining with Patriarchy," Gender and Society 2/3 (1988), pp.
264-72. Kandiyoti argues that by letting men enjoy some privileges
women traditionally guaranteed for themselves a secure social and
economic environment.
29 Heba Nasser,
"The Impact of Adjustment Policies on Nutrition in Egypt," unpublished
paper prepared for the 29th European Association of Agricultural
Economists Seminar on Food and Agricultural Policies under Structural
Adjustment (Stuttgart, 1990).
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