Talking about sex is uncomfortable. Such conversation about private matters can be tough whether the discussion is with preteens or doctors. It is even more difficult when conducted in two different languages. But Marjorie Sable, Professor and Director of the Department of Social Work, works to break down the communication barrier when it comes to family planning.
As she sits in her corner office in Clark Hall, the sunlight bounces off Sable's glasses. An enormous story cloth is displayed on the wall behind her, a gift and reminder of her connections to South Africa. In the summer of 2007, she embarked on a trip to KwaZulu Natal province, on the east coast of that country, and began her research on the pregnancy intentions of rural South African women. In this particular area of the world, the risk of contracting HIV can reach 40%, Sable says, double that of other parts of Africa. Because HIV is often spread from mother to child, she believes that understanding how women plan for pregnancies might help them reduce the risk of spreading the disease.
Sable began by facilitating a series of focus groups with the goal of understanding pregnancy intentions. The theory behind her investigation, she explains, is that the strongest indicator of any behavior is a person’s intention to perform that behavior. Take smoking, for example. The best way to predict whether you will actually quit is whether you in fact want to quit. But there are also external influences: whether your spouse supports your decision to quit, what you believe others will think of you, and whether you can afford nicotine patches.
This was the theoretical framework Sable used to study why people in South Africa have children and whether they use family planning. What she found was fascinating. For example, she explains that “one of the reasons why people have children is so they will have someone to help with household tasks, such as fetching water from the river.” But that wasn’t the only reason to reproduce. Many women cited the goal of “leaving your face,” in other words, of leaving someone to carry on after they were gone. In this culture the role of the ancestors is very important, and having children is a way to extend the family line and please the ancestors. “Leaving your face,” Sable explains, means creating your tradition and legacy. In cases where people had been infected with HIV, it was considered even more important to bear children so that the legacies of departed parents would not perish.
Sable also found that the community had a huge impact on whether these South African women bore children, with mothers-in-law being the most influential. “When a young woman marries, she goes to live with the husband’s family, and she’s called makoti,” Sable notes. “She’s really subservient to her mother-in-law. If they have a good relationship, the mother-in-law will help her and maybe talk to her about family planning and how to prevent having children if she’s not ready.” If the two women don’t get along, however, all that goes out the window.
Because the conversations that took place in focus groups were in Zulu, a language in which she is not fluent, Sable hired translators who would meet with her afterward and explain what was going on as well as transcribe the exchanges. She hopes to continue this work. The next step, she says, is to conduct a survey within individual households. Ultimately, such research would develop interventions to assist women in gaining control of their pregnancies and access to health services, as well as hinder the spread of HIV.
Sable also works on reproductive issues on a local level. For instance, she recently completed a project that focuses on Columbia’s Hispanic population and the barriers they face in securing reproductive health services. As in South Africa, she has established focus groups, in this case led by native Spanish-speakers. When through a survey of 200 men and women she discovered that more people wanted to be involved in the research, she implemented a project called photovoice.
Her project design was intriguing. There were ten participants and each person received a camera. They were told to take photographs of things that represented or symbolized their barriers. “One guy took a picture of a big sign, one of those big tall signs on the Business Loop advertising several different things,” Sable explains. “He said, ‘Every where you look you see signs, but you don’t see signs about where to go for family planning. We don’t know where it is.’” She then put these photographs on display at the Boone County Department of Public Health. In addition, she developed an intervention program to train thirty people as medical translators and created a Spanish-language brochure to outline where clinics were located and how to use them.
While talking about sex is uncomfortable, Sable is clearly up to the task. She will continue to sit with women — whether in South Africa or in Missouri — in order to talk, learn, and ultimately help them scale whatever barriers to family planning they may encounter.