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Women, both young and old, and also elders, are frustrated about how men and society are letting them down and how they are left to bear the reproductive burden. The poverty and chronic insecurity in South Sudan mean that many men have few sources of pride and achievement; conformity and complicity with the hegemonic practices accord both security and a sense of belonging and privilege to men, often at the expense of women's reproductive health.
Inequalities in the domestic, social, and economic spheres intersect to create social situations wherein Fertit women's agency in the reproductive realm is constrained.
In South Sudan, as long as economic and social opportunities for women remain restricted, and as long as insecurity and uncertainty remain, many women will have little choice but to resort to having many children to safeguard their fragile present and future. Unless structural measures are taken to address these inequalities, there is a risk of both a widening of existing health inequalities and the emergence of new inequalities.
Globally, women bear a disproportionate burden of morbidity and mortality related to sexual and reproductive health SRH. De Francisco et al. They added that how women experience their sexual and reproductive situation and health is embedded within a variety of gendered social relations — relations with their intimate partners, immediate family, community, and, ultimately, broader society. Gender and health researchers have argued for studies to investigate the complex interactions between gender and other structures of social inequalities to understand health situations 2 , 3.
Others have pointed out that the complex nature of these interactions seems to hinder the scholarship on this subject and have urged researchers to take on this challenge 1 , 4 ; this article attempts to do this in the context of the SRH of women in South Sudan. South Sudan became an independent country in July The long war preceding independence has destroyed much of the public systems such as education, health care, and infrastructure. The continued sporadic episodes of violence and chronic insecurity in many parts of the country have also disrupted the social fabric.
According to the Human Development Report of , South Sudan is ranked out of countries and territories for human development 5. The health system is weak, with severe shortages of health workers and poorly functioning health facilities 8 , 9. South Sudan has a maternal mortality ratio of deaths per , live births 10 , a contraceptive prevalence rate of just 4.
These indicators highlight the gravity of the SRH situation in South Sudan; although reliable data disaggregated by state and ethnic group are not available, it is reasonable to assume that the SRH situation is similar throughout the country and across all ethnic groups. South Sudan is home to more than 50 ethnic groups. Although at the national level the Dinka and the Nuer people constitute the biggest ethnic groups, in some states, other ethnic groups tend to predominate. For instance, in the state of Western Bahr el Ghazal WBeG , the main ethnic group is the Fertit, a moniker used to refer to a loose conglomeration of more than 23 non-Dinka, non-Arab, non-Fur, and non-Luo people 13 who freely intermarry.
Unlike the Dinka and the Nuer people, who are pastoralists, the Fertit people are predominantly agriculturists involved in subsistence farming. This article presents an analysis of how gendered social relations among the Fertit people of the WBeG state of South Sudan interact and intersect to affect Fertit women's ability to exercise control over their reproductive choices and decisions and thereby their SRH.
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Such an analysis which exposes how gendered social relations and practices in the domestic, local social, and economic spheres contribute to shape Fertit women's sexual and reproductive agency and health can inform the development of locally appropriate public policy and public health responses.
This insight can also be potentially useful for other parts of South Sudan with a similar social context. Data are drawn from a 2-year study exploring SRH decision-making and actions, conducted within the context of a larger SRH project implemented in South Sudan from to The SRH project aims to improve reproductive health outcomes in three states by supporting the state ministries of health and their development partners to implement the National Sexual and Reproductive Health Strategic Plan — Project activities are geared toward achieving three complementary objectives: As part of the latter, a qualitative study was conducted in Wau county to gain insight into various factors shaping people's SRH choices, decisions, and actions.
Data were collected through focus group discussions FGDs and semi-structured interviews SSIs with a variety of purposefully selected informants, as detailed in Table 1. According to the framework, SRH of men and women is shaped by overlapping spheres of influence within the family, community, and broader society. SRH of individuals is affected by the nature of intimate and family relations, including gender relations set within kinship structures, community institutions, and other social relations, which are, in turn, nested in broader social institutions, power structures, and ideologies.
The framework allowed the topic guides to cover a wide range of issues affecting choices, decisions, and actions related to SRH at household, community, and the broader societal relations level. The topic guides for health and other workers included questions along the same lines, but with a view to exploring their perspectives on the situation. The topic guides were defined further through consultations with stakeholders, and after pre-testing in the study sites, and were also adapted iteratively as the study progressed.
Connell's 14 — 16 relational theory of gender is used to analyze and explain how gendered social relations shape Fertit women's agency in the reproductive realm and thereby their SRH. Connell 15 argued that an analysis of how social relations shape a particular social phenomenon or social situation should do so through an examination of the interplay between these structures , that is, the ways they interact and shape each other and produce social situations.
Connell's relational theory of gender was chosen because it steers clear of assumptions of social categories, hierarchies, and individual-centeredness; instead, by focusing on social relations and their social construction as antecedents of gendering, Connell's framework allows one to approach any social context openly.
Further, Connell's framework does not assume social relations to be ahistorical; as Oyewumi 17 , p.
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Many African gender theorists acknowledge Connell's work as an exception to the often Western-centric and universalist theoretical perspectives on gender 18 , Two locations were selected based on homogeneity of the residents all Fertit. The two locations represented two different settings: The a priori assumption behind choosing these two locations was that perhaps within the same social group the Fertit , depending on the setting, gender relations and the enforceability of social norms might be different and that this might have different consequences for women's SRH.
Community members were purposefully selected with the help of village elders, community health workers from a local non-governmental organization NGO , and the county health department; they were selected based on their potential to provide rich insight into the study subject. The study was explained first to the village elders, who then allowed us to talk to people in their community. This due process ensured unrestricted access to the community.
The actual selection of study participants was done by the research team. Among the community members, only those aged 18 years and above were included in this study; a separate, but linked study has been conducted among adolescents. We purposefully categorized the participants into those aged 18—35 years and those over 35 years of age.
The assumption was that the two age groups might experience gender relations and their SRH-related consequences differently.
Data collection began with FGDs among the community members, which was followed by SSIs to obtain more in-depth understanding. For FGDs with community members, the participants were homogenous in terms of ethnicity, age, and marital status, while diversity was sought in terms of social and economic status based on inputs from elders related to social identity, ownership of assets such as bicycles and level of education.
However, given the widespread poverty in WBeG, most study participants can be considered poor.
Female 18—35 years not in union a 1 8 Community members: Tender is expected to end of colonial rule after joshua thomas and a perfect free! Elyse Jennings Weddings Blog. All over the opportunity with photos of the world. Journal List Glob Health Action v.
Key informants were also purposefully selected based on their active SRH-related role within the study community and the local health system; they were identified through the initial stakeholder consultations. As elaborated in Table 1 , key informants included health facility personnel from the local health centers many of whom were from the Fertit community , traditional leaders, traditional birth attendants, state- and county-level SRH service managers, and NGO representatives.
Data were collected from October to April by research team members who hailed from the study area, were fluent in the local language Wau Arabic , and had experience with conducting qualitative research. Data were collected until theoretical saturation was reached and no new insight emerged. This was possible to assess, as at the end of each day of data collection, the research team debriefed and discussed the emerging findings.
The translations were independently checked by one of the coauthors MR to ensure that the translations were accurate. A thematic content analysis was conducted using Connell's relational theory of gender. Emerging themes were identified through a process of discussion and argumentation within the research team.
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Four key themes emerged. The first theme articulates the high symbolic value attached to childbearing and paternity in Fertit society; the antecedents of the high symbolic value as discussed by study participants are presented. The second theme discusses the status of women in Fertit society, the power relations in the domestic and family spheres generally, and in light of the symbolic value attached to childbearing, and examines the effects of these relational arrangements on Fertit women's reproductive agency.
The third theme builds on these two themes to highlight how broader societal and political circumstances have undermined the social compact among the Fertit and how this amplifies the unequal gender order, further undermining women's ability to exercise their reproductive agency and thereby their reproductive health. The fourth theme presents evidence of how social and gender relations are constantly in flux and are being actively constructed 14 by Fertit women in relation to others at the individual and the societal level.
It shows how Fertit women are leveraging opportunities presented to them by the particular setting they are in at this time, to influence the gender order — although probably in a very limited way. Among the Fertit, as the following quotes show, fertility and childbearing are seen as markers of respectability and responsibility. Having many children — expanding one's family and spreading the family name — is a key aspect of manhood.
A good man in the community is responsible. When he is a responsible person in the community, he is well respected and has his children. When a man does not have children, in the community he is seen as not responsible. If the boy becomes a man he needs to extend his family by getting married and having children. In this way the family expands and they become well known to the people. Further, among the Fertit, children are seen as a means of carrying on one's family name. Those men who do not father many children are seen as wasting their lives.
Symbolically, children are also seen as a means of replacing lost dead family members; in fact, children are often designated as replacing specific lost relatives. In the last three decades, given the war and widespread human losses, this social practice has become a powerful force to entrench the symbolic value attached to childbearing; the result being the furtherance of the masculine hegemony, often at the expense of women's agency in the reproductive realm. If a man stays without having children we think that he may die and leave no name behind. Whatever he owns will be a waste.
Fertit women are expected to give birth to as many children as the man and his family members wish, because it allows inheritance and the continuation of the man's family name; this is an entrenched social norm. Consistent with the quote below, study participants across age, sex, marital status, and geography noted that a woman is meant to bear children for her husband's family and that women do not really have a say in this matter. Our relatives see that birth allows inheritance and if you do not want to give birth, men do not agree.
They husband and his relatives don't agree when women decide they do not want to have children. The Fertit, like the other South Sudanese ethnic groups, are patriarchal; men have the power to decide on all aspects of the family and in society at large, and women's position is subordinate to men 20 — The Fertit consider the notion of being respectable, and worthy, of great importance; boys and men count, whereas women do not.
This was a cross-cutting theme mentioned by all the participants; for instance, in an FGD with young women, there was consensus when one of the participants pointed this out; probing by the facilitator led to a discussion wherein it emerged, as the following quote illustrates, that this was indeed a given among the Fertit.
A boy is respected because he is a boy. But if you are a girl, you are just a girl. You are not respected. The following sections will illustrate how this structurally lower status accorded with women and girls in Fertit society intersects with and also shapes other structural forces, and prevents women from exercising their agency in many social realms, particularly in the reproductive realm.
In Fertit society, the decision-making power on matters related to sex and reproduction rests with the man and his family. The man is the man, and this is his responsibility … so the decision on matters related to sex and reproduction should come from the man. A key feature of Fertit society is that the family is a consanguinally based unit built around a core of brothers and sisters blood relations. The wife is not seen as part of the family, but as an outsider whose role is to bear children for the man's family.
Women who wish to differ and make their own reproductive choices are subject to serious social pressures, particularly from the husband's family.
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Women are often at risk of being abandoned by their husbands, and given that economic opportunities are so few in South Sudan, particularly for women, they are left with no choice but to submit to the demands of the husband and his family. As the following quotes from two young women highlight, these unequal power relations are reflected within intimate partnerships too.
Many women see themselves as beholden to the man who brought them into his house.
Not only do women need to consider it their duty to listen to their husband, but not refusing to have sex is also seen as essential to being able to keep one's husband and as key to preventing him from going to other women. This surrender of agency is thus driven by a confluence of the social position of women in society, the fear of the man bringing home sexually transmitted infections, and also, given the harsh economic situation of South Sudan, the fear of abandonment.
A woman's responsibility is to listen to her husband, do the house work and look after your children, and you don't roam randomly outside. You listen to the person who brought you at home. The man insists on sex, and if the woman refuses he will go look for another woman. So if you want to keep your husband, you need to have sex with him whenever he wants … So women try to please their husbands; that is why they become pregnant without planning. In WBeG, and across South Sudan, women outnumber men, are poorer than men, and are less educated than men.
Economic opportunities are few for women, and many women are dependent on men 6 , Our findings show that many women are left with no choice but to resort to competing with each other to keep their men by using their capacity to bear children for him and his family.