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Contraceptive medicalisation, fear of infertility and teenage pregnancy in Brazil.
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PMID:  20972914     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
In Brazil, as in many other countries, teenage pregnancy is widely recognised as a public health problem. Buttressed by a public health science of the economics of teenage pregnancy that emphasises the postponement of parenthood as key to poverty reduction, young people's lack of appreciation for medical knowledge of contraceptives is most often credited for failed attempts to reduce teenage pregnancy. Based on a longitudinal ethnographic study conducted in Pelotas, Brazil, with young people over the course of 10 years, our study found that young women who became teenage parents did not lack medical knowledge but were, rather, highly medicalised. Not only were they intensely concerned with the ill-effects of oral contraceptives on possible future fertility, they also engaged in intricate routines of contraceptive-use as a way of testing and safeguarding their fecundity. Our analysis attends to the way these practices are shaped by the problematisation of the economics of teenage pregnancy, as well as by the gendering of cultural norms relating to the transition to adulthood. We theorise the results by considering how contraceptive medicalisation enabled some women to engage with the authority of normative society, while developing a potent off-stage critique of this authority and of what they considered to be discriminatory messages imbedded in scientific discourses on teenage pregnancy.
Authors:
Helen Gonçalves; Ana D Souza; Patrícia A Tavares; Suélen H Cruz; Dominique P Béhague
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't; Research Support, U.S. Gov't, Non-P.H.S.    
Journal Detail:
Title:  Culture, health & sexuality     Volume:  13     ISSN:  1464-5351     ISO Abbreviation:  Cult Health Sex     Publication Date:  2011 Feb 
Date Detail:
Created Date:  2010-12-24     Completed Date:  2011-04-21     Revised Date:  2013-07-03    
Medline Journal Info:
Nlm Unique ID:  100883416     Medline TA:  Cult Health Sex     Country:  England    
Other Details:
Languages:  eng     Pagination:  201-15     Citation Subset:  IM    
Affiliation:
Programa de Pós-graduação em Epidemiologia, Departamento de Medicina Social, Universidade Federal de Pelotas, Pelotas, Brazil.
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adolescent Behavior / psychology*
Anthropology, Cultural
Brazil / epidemiology
Cohort Studies
Contraception Behavior / psychology*,  statistics & numerical data
Female
Health Knowledge, Attitudes, Practice*
Health Surveys
Humans
Infertility, Female / epidemiology*,  psychology
Longitudinal Studies
Male
Pregnancy
Pregnancy in Adolescence / prevention & control,  psychology*,  statistics & numerical data
Qualitative Research
Sexual Behavior / psychology
Young Adult
Grant Support
ID/Acronym/Agency:
077175//Wellcome Trust; GR077175MA//Wellcome Trust
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Journal ID (nlm-ta): Cult Health Sex
Journal ID (publisher-id): tchs
ISSN: 1369-1058
ISSN: 1464-5351
Publisher: Taylor & Francis
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© 2010 Taylor & Francis
open-access:
Received Day: 27 Month: 4 Year: 2010
Revision Received Day: 2 Month: 9 Year: 2010
Electronic publication date: Day: 22 Month: 10 Year: 2010
Print publication date: Month: 2 Year: 2011
Volume: 13 Issue: 2
First Page: 201 Last Page: 215
ID: 3016605
PubMed Id: 20972914
DOI: 10.1080/13691058.2010.521576

Contraceptive medicalisation, fear of infertility and teenage pregnancy in Brazil
Helen Gonçalves1
Ana D. Souza1
Patrícia A. Tavaresa
Suélen H. Cruza
Dominique P. Béhague∗bc
aPrograma de Pós-graduação em Epidemiologia, Departamento de Medicina Social, Universidade Federal de Pelotas, Pelotas, Brazil;
bDepartment of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK;
cDepartment of Anthropology, Brunel University, Uxbridge, UK
Corresponding author. Email: dominique.behague@lshtm.ac.uk, dominique.behague@brunel.ac.uk

Introduction

In Brazil, as in many other countries, teenage pregnancy has come to be widely recognised as a public health problem of ‘epidemic’ proportions (Heilborn et al. 2006). Although historians and sociologists have shown how the problematisation of teenage pregnancy has developed over the course of the twentieth century in the psycho-medical, legal and pedagogic spheres (e.g. Wilson and Huntington 2006), only recently has a public health science of the economics of teenage pregnancy gained global recognition (Heilborn, Brandão, and Cabral 2007; Sax 2010). New to this science of teenage pregnancy is the reversal of the relationship between fertility and poverty; whereas earlier studies focused on socio-economic disadvantage as a core determinant of teenage pregnancy, research has begun to chart teenage pregnancy as a key cause of poverty itself (Hobcraft and Kiernam 1999; Luker 1996).

The view of teenage pregnancy as a key vehicle in the multigenerational cycle of poverty has given renewed impetus to the wide-spread medicalisation of contraceptives and fertility control, now being actively promoted as key to poverty-reduction (Brandão 2006). Although oral contraceptives and condoms are readily available in the Brazilian public healthcare system, efforts have focused, by and large, on tackling issues related to assumed low levels of medicalisation,1 including, for example, lack of knowledge about availability of contraceptives and lack of effective sexual education (e.g. Espejo et al. 2003). Such constraints are said to be particularly problematic for young people, who are presumed to not exhibit the levels of psychological maturation needed to take responsibility for their health.

Initial results from the ethnographic study reported on in this paper suggested that although teenagers do indeed use contraceptives inconsistently, current conceptualisations of the role of medicalisation in their lives are inappropriately one-dimensional. When considering the multiple forms that medicalisation can take in everyday social life, we found that teenage pregnancy, particularly for women, was related not to a lack of appreciation for medical knowledge, but the converse. Specifically, youth who became pregnant as teenagers showed high levels of medicalised concern with the potential ill-effects of oral contraceptives on fertility. They analysed, in quite extraordinary detail, the physiological and medical qualities of oral contraceptives as a way of ascertaining how the pill might affect their bodies and future fecundity and they engaged in intricate routines of regular and irregular contraceptive-use as a way of testing and safeguarding their reproductive health. As we soon discovered, this form of medicalisation was not simply the result of a pragmatic concern with health, but one laden with intense levels of anxiety regarding future wellbeing. Though men also expressed concerns regarding potential sterility, the medicalisation of infertility for woman was tied to the gendering of women's social roles and, specifically, to the cultural primacy of maternity for ensuring a respectable adult identity, as well as social and economic stability.

This paper, based on a longitudinal ethnographic study conducted with young people over the course of 10 years, explores the relationship between fear of infertility, contraceptive medicalisation, and localised reactions to the everyday experience of economic inequities and ideologies of upward mobility. Because of the emergence and widespread dissemination of an economic science of teenage pregnancy, we give particular attention to the way this relationship is shaped by the problematisation of teenage pregnancy within public health science and practice. Following key medical anthropologists’ works on the relationship between medicalisation, power and rituals of dissent (Heilborn and Brandão 1999; Lock and Kaufert 1998), we explore how the medicalisation of the contraceptive pill became a key vehicle through which some women were able to indirectly contest what they considered tobe discriminatory messages imbedded in normative discourses on the role of teenage pregnancy in the multigenerational perpetuation of poverty. Our paper further theorises these results by considering how contraceptive medicalisation can be read as a type of ‘hidden transcript’, to use Scott's (1990) key concept, steeped in what van der Geest and Whyte (1989) have described as the charm of medicines: that is, pill-taking practices enabled some women to engage with the authority of biomedicine and normative society, while developing a potent off-stage critique of this authority.


Methods

The ethnographic study reported upon in this paper is part of a larger birth cohort study that was initiated in 1982, comprised of all births in Pelotas Brazil in that year 6011). From 1982 to 2006, the original epidemiological cohort has been visited at regular intervals using quantitative surveys for a total of 11 follow-ups (Victora et al. 2003). An ethnographic sub-study of 96 mother-child pairs was initiated in 1997, when the cohort youth were 15 years of age, and this same group of youth have been follow-up over time until 2007. We used a variety of methods, including participant-observation, oral histories, semi-structured interviewing and informal interviewing of related family and friends. Mothers and their children were visited several times by the first and last authors of this paper and a team of seven research assistants. Intensive periods of fieldwork, conducted in 1997, 1999, 2000 and again in 2003–2004 and 2006–2007, have been interspersed with periods of analysis and reflection (Béhague and Gonçalves 2008). The sample was selected at random from the pool of participants interviewed in the 1997 epidemiological survey (for details, see Victora et al. 2003), not because we intended to conduct probabilistic analyses, but because we sought to capture the full array of experiences represented by the cohort, including those of particularly introverted and socially isolated youth. The research was approved by the Research Ethics Committee of the Federal University of Pelotas.

Our analysis focused primarily on longitudinal ethnographic case-studies an comparative analysis. The longitudinal aspect enabled us to focus on changes in ideologies of reproduction and class mobility within the context of changing contraceptive practices and life-course decisions. All participants were visited at least once before they became pregnant, enabling us to observe social and personal processes leading up to and resulting from the pregnancy itself.

Our comparative analysis contrasted the experiences of all teenage parents (131 years) in the sample (n = 17) with a purposely selected subsample of young people who did not become teenage parents, selected to be roughly similar to the sample of teenage parents in terms of socio-economic background and place of residence (n = 33). Of these 33, 5 were excluded from the analysis due to paucity of data and of the 28 that remained in this comparative group, 16 became parents in early adulthood (2024 years). Therefore, this group was comprised largely of youth who did not avoid parenthood altogether, but who simply postponed its occurrence to a more socially acceptable time in the life span. In this way, our comparative analysis was endemically structured rather than artificially imposed; that is, our initial ethnographic work showed that, though young teenagers from a working class background were quite similar with regards to their expectations for their life-course, as they matured they began to explicitly differentiate themselves from other shantytown youth according to reproductive interests and practices and associated ideologies of upward mobility.


Results

Of the 96 young people who were first visited in the ethnographic study in 1997, we were able to follow up on 83 of them until 2007. Loss was due to migration 11), imprisonment (n = 2) and refusal to participate (n = 14). Most of these losses occurred in 2006 and 2007, that is, after the establishment of young adulthood, and so, do not significantly affect our results pertaining to parenthood. Table 1 describes the distribution of our sample according to key socio-economic variables and age at which parenthood began.

Our results, presented in three sections, are meant to reflect the changes that youth experienced as they progressed from early- to late-teenage-hood in various domains, including sexual activity and contraceptive practices, emotional upheavals and moralising ideologies relating to the relationship between maturation and poverty.

Contraceptive use and fear of infertility

Contrary to prevailing assumptions regarding the influence of low levels of medicalisation on the high incidence of teenage pregnancy, findings revealed that most young women who became pregnant as teenagers did not lack medical knowledge about contraceptives but, rather, showed highly medicalised concerns with symptoms produced by the oral contraceptives and with what this might represent for future fertility. At the onset of their sexually active lives, these women were neither less medicalised nor more interested in becoming a teenage mother than those who postponed parenthood. During their early teenage years, almost all of the young women we came to know stated that they did not want to become a parent until much later on in life. As we will show in greater detail below, however, over time, those who became teenage mothers adopted subtle changes in their contraceptive practices changes that became increasingly marked as their worries about potential future infertility intensified. For many young women, then, the medicalisation of the pill indirectly nurtured a desire to become pregnant sooner than had originally been envisaged.

Although most teenage mothers had initiated sexual activity from an earlier age than those who postponed maternity, sexual debut for these women was typified by considerable reproductive control and premeditation. That men are generally disinterested in acquiring medical knowledge about contraceptives and are expected to relinquish contraceptive control to women certainly paved the way for these women's heightened reproductive agency. Many women became sexually active not with a passing fancy, but with a steady boyfriend. Because access to contraceptives through the primary healthcare network is good and because most pharmacists will sell the pill without a prescription, almost all of these young women used a combination of oral contraceptives and condoms from the onset of their sexual lives. Utilisation patterns necessarily involved acquiring high levels of medical knowledge about the pill. Young women read the informational insert with considerable care. Many knew, for example, that the hormonal dosages and combinations vary from one brand to another and all showed clear use of medicalised language to describe the pill, often referred to as um remédio pra não pegar filho or ‘a medicine to avoid ‘catching’ a child.’

Entrenched in these high levels of medical knowledge, women who became teenage mothers progressively nurtured a heightened preoccupation with the pill's long-term effects. The pill interferes with the menstrual cycle, some explained, by either causing breakthrough bleeding or by regulating an otherwise unpredictable menstrual cycle. Others affirmed that the pill tends to leave ‘residues’ in the body (fica no corpo), evidenced in part by the knowledge that physicians generally recommend quitting the pill six months prior to attempting to conceive. Though many knew that the pill can be used as a form of treatment for some diseases, such as endometriosis, they also questioned this benefit by citing medical research that shows that the pill can increase the risk of breast cancer.

Amongst the various biological effects that concerned these women, the most important and immediate related to the fear of future infertility. Women appeared particularly concerned about the effects of using ‘strong’ contraceptives, which are said to have a more intense impact on moods, emotional states, sleeping patterns and weight-gain. Many, therefore, experimented first with so-called ‘weaker pills’ that are known for causing fewer adverse effects. The more these women experimented with different types of oral contraceptives, the more they turned their energies towards identifying which side-effects may be indicative of the pill's immutable impact on fertility levels. Over time, then, even minor symptoms generated fear of the potential negative effects of the pill on reproductive health.

Unlike women who postponed parenthood, those who eventually became teenage mothers not only made more frequent and intense reference to a fear of potential infertility, they also came to enact the fear of the pills’ symptomatic effects through deliberate inconsistent contraceptive use. Several asserted that the avoidance of the pill ‘for a few days’ was an important health-inducing practice. As one woman explained, not taking the pill for a few days allows the body to rest, thereby ensuring the re-establishment of the body's ability to reproduce. Because many knew that hormones continue to circulate through the body for quite some time, intermittent interrupted contraceptive use was, by and large, not seen to alter the pill's protection against pregnancy. Even for those who had been reprimanded by family or health personnel for inconsistent contraceptive use, the fear of infertility, together with continued experiences of the pill's physical symptoms, tended to weigh more heavily in shaping erratic contraceptive practices.

Although young women who postponed parenthood were also initially concerned about the pill's health effects, as they matured they were more contented with new prescriptions and appeared more reassured when told that the pill's effects on the body could be reversed with time and proper medical attention. As a result, they were also more likely to use the pill in a continuous and non-interrupted fashion during their teenage years. It would be most accurate to state, then, that when compared to women who became teenage mothers, women who avoided pregnancy were both more medicalised in that they assumed physicians have the power to ensure their health under almost all conditions and less medicalised in that they gave little importance to the potential limits of medical knowledge and were comparatively less involved in debating pharmacological effects.

The social imperative to test for fertility

It is important to highlight that the phenomena we have described above are inextricably linked to a broader context in which the social imperative to prove fecundity for women is strong but increasingly implicit and overshadowed by the widespread stigmatisation of teenage pregnancy. Therefore, the apparent causal relationship between early contraceptive use and the fear of its biological effects on infertility is in fact not at all causal. Underlying the fear of infertility was a high premium placed on marriage, healthy fecundity and parenthood, a value system that socialises children well before sexual initiation and experimentation with contraceptives even begin. After feeling reassured that we would not be judgmental, some young women explained that motherhood is an esteemed state for many teenagers, particularly for those who come from a more ‘traditional’ and less urbanised background. Establishing a family fulfils important personal and emotional needs, helps women establish a clear social role and status in society and is sometimes explicitly linked to the search for upward mobility or, at least, financial stability. The high premium placed on a stable marriage translated directly into practices; of the 11 women who became pregnant as teenagers, all did so after having been in a relationship for a year or more and 5 did so with their first boyfriend. By 18 years of age, all were also either legally married or formally co-habiting with their partners.

Though the need to ascertain one's ability to have children clearly took centre stage for some women, it did so not in a way that proudly reaffirms the importance of family-life, but in a way that was highly socially problematised. As we will show in greater detail, the pill, its collateral effects and the concerns about infertility that it generated were not catalysts of the imperative to prove fertility. Rather, the medicalised concern with oral contraceptives became an indirect tool through which young women could comply with two contradictory societal demands that shaped their experience of the world from a very early age. On the one hand, by taking the pill from the upstart of sexual activity, women could show that they were complying with the normative standard that states pregnancy should be delayed until adulthood. At the same time, by having the power to explicitly interrupt pill-taking, they could also simultaneously respond to the social imperative to demonstrate and test their fertility.

We do not mean to imply that these practices were always deliberate and consciously articulated, but rather, that women couched their responses to societal demands in intricate routines of contraceptive practices. Indeed, because of the normative strength of ideologies of delayed childbearing, most women initially engaged with the imperative to test their ability to conceive not by explicitly interrupting their pill-taking, but by focusing on ‘menstrual delays’. This entailed keeping careful track of their menstrual cycle and reporting any delays in menstruation to their boyfriends, as well as to their friends as a ‘possible pregnancy’. Because almost all young girls had had a few episodes of unintended unprotected sex, ‘menstrual delays’ were common topics of conversation. ‘Possible pregnancies’ became the centre of story-telling and were spoken about in an implicitly boastful way; through such studies youth portrayed their fecundity to peers with a mixture of pride, nervous humour, self-critique and dreams of marriage. Young women frequently recounted cases of friends who became pregnant despite the fact they were taking the pill regularly, something that they interpreted as a sign of heightened levels of fertility. Women who experienced frequent menstrual delays while being sexually active - or indeed those who became pregnant shortly after losing their virginity - considered themselves ‘highly fertile,’ to such an extent that they often stated they could not take ‘weak’ versions of the pill.

The converse of these situations was represented by young women who on occasion failed to take the pill consistently, but who never became pregnant and who experienced few, if any, menstrual delays. With time, these women came to suspect infertility and worried, with increasing intensity, that they would never be able to conceive, a process that only heightened the imperative to demonstrate, ‘assess’ and test their fertility. As anxiety levels increased, contraceptive practices shifted from the occasional rupture of daily pill-taking for a day or two, used as a way of temporarily cleansing the body, to inconsistent contraceptive use for more prolonged periods, used as a way of actively testing fertility. In what often became a frustrating cycle of increased unprotected sexual activity and fear of reproductive inability, even slight menstrual delays that ended in menstruation came to represent an anxiety-producing event signalling possible infertility.

The cyclical and longitudinal nature of these social processes is well represented in Elisa's life experiences. She had been dating her boyfriend for three years before she became pregnant at age 18 and though she had always used the contraceptive pill from the beginning of their sexual relationship, like many other girls, she had on occasion failed to remember to take her pill for a few days at a time. Because she never became pregnant, and experienced only a few menstrual delays during this period, she began to suspect they she might have some sort of fertility problem. In the context of a relationship that was becoming increasingly intimate, however, she decided to broach the topic and was pleasantly surprised to find that her boyfriend supported her in the decision to stop using the pill and condoms for a short while as a way of testing their ability to conceive. As Elisa explained:

I thought, well, we thought that I might have some sort of problem, because it took us a long time to get pregnant, three years. … When I told him I was pregnant, he couldn't believe it. He said, ‘That is strange, because one of the two of us has a problem.’ It was only after she was born that I started to actually take the pill.

Although she claimed her eventual pregnancy to have been ‘unplanned’ and even stated she regretted having become pregnant before completing her studies, in the context of what had become both a stable relationship and an intense fear of infertility, the pregnancy brought her a mixture of personal joy and social relief.

For women like Elisa, experiences such as these did not just raise concerns about a possible underlying fertility problem, they also confirmed the suspicion that prolonged contraceptive use and/or use of excessively ‘strong’ pills may indeed have had a deleterious effect on their reproductive capability. Women began to suspect that the few menstrual delays that they had experienced were not related to potential pregnancies as they had first thought and at times, secretly hoped but to menstrual irregularities caused by either underlying hormonal problems or problems stimulated by the pill. Several women held onto this suspicion with considerable anxiety, despite the fact that most sexual educators are aware of this concern and actively try to reassure young people that menstrual irregularity is normal in early- to mid-adolescence.

Flávia, for example, who became pregnant with her first child at age 18, had been taking the pill irregularly and often failed to use condoms with her partner throughout her early teenage years. After a handful of episodes of unprotected sex throughout the first year of their relationship, both Flávia and her boyfriend began to suspect that either Flávia had an underlying hormonal problem or that contraceptive use had somehow compromised her ability to conceive. So worried did she become that she sought medical treatment. The doctor took Flávia's concerns seriously and had already requested several medical examinations when Flavia became pregnant. For Flávia, the medicalisation of the fear of infertility not only lead her to become pregnant sooner than she had originally envisaged, it also brought much-needed legitimacy to her and her partner's concern with reproductive ability.

For many women, the fear of infertility and their ensuing contraceptive practices were (at least initially) highly private and even latent, not only because the stigma associated with teenage pregnancy, but also because of gendered conflicts in men and women's life-course expectations. Paternity became important for men only once in a serious relationship, whereas many women's sense of future livelihood came to depend, with increasingly intensity, on assessing their fertility prior to the establishment of a serious partnership. In fact, for some women, the sharing of latent concerns about infertility with a potential husband constituted an important step towards consolidating the partnership. For men, in contrast, the social imperative to demonstrate both virility and the potential to be a good economic provider were seen to ideally precede paternity. Given the now widely accepted association between early parenthood and poverty, men often said they felt more pressured than ever to demonstrate their ability to complete education and secure a good job, something that also made them weary to commit to a relationship prematurely. While young women feared infertility, then, young men not yet committed to a serious relationship resisted getting embroiled in discussions regarding fertility before their time. The more women encountered such resistance, however, the more insecure they felt about their future and the more they brought their latent fears regarding infertility to the forefront of their relationships in an effort to subtly persuade the couple towards a family life.

Although most of the young women who became teenage mothers did not explicitly plan parenthood, attempting to conceive, even if only through sporadic periods of unprotected sex, became is a risk worth taking for the sake of generating knowledge about their body's fertility. In this way, the cultivation of high levels of medicalised anxiety relating to the potential deleterious effects of the pill on fertility allowed several young women to transform the possibility of becoming young parents into something positive, despite the generalised societal pathologisation of teenage pregnancy.

Such practices demonstrate deeply ambivalent sentiments regarding the significance of maternity such that, often, women found themselves cycling between two divergent positions. In the first, women responded to the growing fear of future infertility by courageously interrupting contraceptive use, trying to conceive and, thus, accepting to some extent the social and economic ‘risks’ associated with teenage pregnancy. On the heels of such practices, women often then resumed regular contraceptive use for fear that the poverty-inducing predicaments of teenage pregnancy may in fact come true. These changing pill-taking practices and interpretations became, conflictingly perhaps, a form of both avoiding pregnancy and testing fertility. They also allowed women to indirectly ‘test’ themselves, to see where their ultimate allegiance lie whether to the normative ideological imperative that they avoid pregnancy at all costs or to the everyday social imperative that they demonstrate fecundity. For women who eventually became pregnant, eventual positive pregnancy tests came to represent a resolution of the ideological ambivalence they had struggled with and a confirmation of their status as future mothers and as healthy individuals.

Life-course expectations, choices and moral landscapes

Underlying many of the experiences and practices described thus far is a deeply engrained and socially-structured incompatibility between parenthood and the realisation of female professionalisation and independence - that is, between parenthood and the aspiration for upward mobility. As we will demonstrate, it is an incompatibility that fostered an increasingly public and moralising polarisation, one that women came to use explicitly as a way of establishing the social legitimacy of their life choices.

Young women who hoped to achieve upward mobility, not through a prospective husband's earning potential but through their own education, actively sought to live within a value-system associated with the upper-middle class, which included the clear postponement of parenthood. The need to test fertility therefore did not figure as prominently, not because these young women were fully confident of their future ability to conceive but, rather, because they came to defend the idea, quite adamantly, that the life-cycle should progress through a distinct linear order of events, from completion of education to professionalisation, to marriage and only then to parenthood. By and large, these women managed to complete more education during their childhood than those who became pregnant as teenagers, despite the fact that all the youth in our sample came from families with similar family incomes and despite the considerable institutional barriers that the poor face in completing education and entering into the formal sector job market (Gonçalves and Gigante 2006).

With time, however, this differentiation also meant that they ascribed to moralising interpretations that posit teenage-pregnancy as a ‘problem of the poor’, a ‘cause of poverty’ and an impediment to upward mobility and female professionalisation. Teenage mothers, these women explained, often act on ‘impulse’ and an ‘immature mind’, failing to think through the long-term social and economic implications of their actions. Ascribing to such interpretations also constituted a practical response to the stigma and stereotypes that surround all poor young women living in the shantytown. That is, it allowed these women to distance themselves from the assumption that all poor young women are promiscuous and ‘at risk’ of teenage pregnancy and its deleterious consequences. As one such woman, Sonia, stated, ‘it could be ignorance on my part, but in my mind, I associate having children [in adolescence] directly with poverty.’ Some such women went so far as to avoid all intimate relationships with young men, despite the social disgrace that is tied to being single, while others continued to date young men and over-compensated for the ‘risk’ of pregnancy by taking on a strong ideological stance in favour of education and against all aspects of shantytown life.

In some instances, women went further and openly criticised those who became pregnant for countering what they considered to be a more socially acceptable way of progressing through the life-course. Theirs was a self-avowed ‘feminist’ stance, an ideological umbrella that legitimised the (initially) implicit and (subsequently) explicit denouncement of their shantytown peers. For them, teenage pregnancy came to represent an acomodação, or ‘the easy way out’, a strategy for settling into what is comfortable and known, of what is widely debated as a working-class mode of living seeped in conformismo (Chaui 1986). Rather than fighting for women's rights, teenage pregnancy was seen to be a blatant disregard for the achievements that have been made for women's emancipation. While pregnant teenagers are known to have high hopes that their quality of life will be improved through their partners’ provisions, girls who avoided pregnancy tended to believe that, in general, the economic status of these girls remained unchanged or, at times, even worsened. The development of strong ideological arguments against teenage motherhood such as these meant that any lingering concerns these women might have had regarding their own fertility ultimately paled in significance.

The values and life-expectations of the young women who became pregnant were in fact considerably more nuanced than the representations described above. Those who became teenage parents came from families where women tend to occupy an important role in the maintenance of the family. However, young women from these families were not simply reproducing a traditional view of the maintenance of family and kinship ties. Though marriage would, it was hoped, provide some economic stability, women also argued that in modern urban life, this no longer provides the same assurance that it has in generations past. They were also quick to point out that formal education holds much less weight in assuring their future than in the past, given growing competition for semi-skilled jobs and exceedingly high levels of school failure. For this reason, they explained, marriage, together with learning how to work and getting a foothold in the job market from an early age, guarantees the future more securely than a formalistic linear view of the life-course. With the increasingly visible failures of the Brazilian state, some emphasised, the importance of nurturing a new family and maintaining links with extended family members that can provide support in times of need has only increased, rather than decreased.

These women defied belonging to either a ‘traditional’ and ‘modern’ ideology; they were identified by others in their community as being ‘traditional’ because they valued, first and foremost, their role as young mothers. At the same time, they were modern because they engaged in highly politicised debates about the limitations of the educational system and the discriminatory power of inappropriate stereotypes regarding teenage mothers, despite the added risk of pathologization that this entailed (Béhague 2009). Indeed, the stereotype of the ‘reproductively prolific’ lower-class woman was sometimes, in hindsight, even adopted in jest as a way of resisting inappropriate but widely-held conceptualisation of the poor. One such woman, Susana, when asked if her second pregnancy had been planned, responded amidst her own laughter, stating, ‘well, planned-planned, no … poor people don't plan pregnancies, now do they …’ and proceeded to use this seemingly off-handed comment as a poignant starting point for reflecting upon her accomplished and fulfilling parenthood.

The more Susana and women like her encountered peers who actively discriminated against teenage pregnancy, the more they attempted to actively resolve the ambivalence they felt for ideologies of feminist emancipation by adopting what could be termed ‘anti-feminist’ moralising interpretations relating to the moral integrity of becoming a young parent. Most young girls who became pregnant as teenagers considered themselves to be more morally ‘pure’ than their counterparts for whom financial independence was often linked to a series of suspect practices, including an active nightlife, drinking and many boyfriends. These women also differentiated themselves from teenagers who had become pregnant because of promiscuity and sexual impulsiveness and, instead, considered themselves to be highly ‘discreet’ in their relationships with young men. Already at age 16, Margarete, for example, described herself and her circle of friends by saying:

We are nice girls, educated… the problem is that the other girls here do things and then they go around saying that we do these things too. They are ‘umas baitas de umas furadas [very promiscuous], we are not … that is why the boys respect us.

This social-moral differentiation begins to take shape right around 15 years of age, a time during which, traditionally, young girls used to progress through a ‘debutante’ ritual that is a testing ground for a young girl to ensure her sexual morality. Though few girls still have debutante events for their 15th birthday, those who did become debutantes explained that this makes them more attractive to boyfriends who are hard-working and respectable.

Through moralising discourses such as these, the incompatibility between young motherhood and professionalisation became increasingly ingrained and teenage mothers became increasingly distanced from those who postponed parenthood until early adulthood. This polarisation led these two groups of women to actively denigrate each others’ life-course decisions, to becoming increasingly entrenched in their positions, defending the choices they had (often implicitly) made and, through this, to take opposing positions regarding the social imperative to demonstrate reproductive capability. For those who became teenage mothers, the fear of infertility and the imperative to test fertility sooner rather than later was, in effect, reinforced by this very polarisation: the more women who feared infertility came up against stereotypes that denigrate young motherhood, the more committed to their moral positions they became and the more intensely they valued a good family life and the need to safeguard and ascertain their ability to bear children.

The polarisation just described was mirrored, and to some extent exacerbated, by a similar bifurcation found amongst men that also became more pronounced as youth neared adulthood. On the one hand, men who were willing to enter into serious relationships at a young age tended to be seen (and to see themselves) as more ‘serious and sensitive’, if also less sexually powerful and, thus, less generally desired by women. On the other hand, these men have also come to be identified as less ambitious, less likely to be economically upwardly mobile over the long-term. No matter how well placed in the job market, these men's acceptance of early parenthood was seen to necessarily mean reduced economic productivity, such that men willing to become young fathers came, in part, to understand their choice as a form of acomodação. Not surprisingly, women who feared infertility gravitated towards men who were willing to provide them with a family life from a young age. Though these women sometimes wondered if they were compromising their true life aspirations, as their encounters with stereotypes that denigrated their soon-to-be-husbands grew, so did their commitment to adopting an ‘anti-feminist’ discourse of young motherhood as a morally superior life choice.


Conclusion

Most studies investigating the reasons for low contraceptive uptake have focused on factors relating to presume lack of medical knowledge and the adolescent's inability to make sound reproductive decisions (Luker 1996; Shoveller and Johnson 2006). The main assumption shaping this body of literature has been one that views teenagers as having no legitimate reason to be concerned with their fertility - as wanting, but being unable, to postpone parenthood, for a host of reasons relating to psychological immaturity. Only a handful of recent studies, particularly in Africa, have shed light on the worries that young people have concerning their fertility, something that may be more common amongst young people than current research suggests (Geelhoed et al. 2002; Rainey, Stevens-Simon, and Kaplan 1993; White et al. 2006; Williamson et al. 2009; Wimberly et al. 2003). This gap in the literature it likely to be more ideological than empirical: global and national public health research agendas have been driven by an overarching concern with population control and the need to lower fertility rates. As such, most of the studies cited above have stumbled upon the question of infertility accidentally, only because they aimed to understand why contraceptive use is low.

Results from this study question some the key assumptions underpinning this body of literature. We have shown that, on the whole, young women had high levels of awareness and agency when it came to making reproductive decisions. Ironically, for those who eventually became teenage parents, the medicalisation of contraceptives was more intricately linked with the fear of reproductive inability than it was for those who delayed child-bearing. Furthermore, these are not just private matters. They are social facts that have been fomented through the medicalisation of fertility-control, together with the institutionalisation of discriminatory attitudes that stigmatise teenage pregnancy and link it, quite fundamentally, to the problems of poverty. Inconsistent contraceptive practices that young women engaged in to address their fear of possible infertility became an indirect vehicle through which the societal imperative to demonstrate both fecundity and commitment to postponing childbirth could be realised, a process that, in turn, may be contributing to increased teenage pregnancy rates.

Throughout this paper, we have purposefully left implicit the political ironies raised by our findings, in large part because this reflects the latent way they emerged throughout women's life-course. On the surface, all young women ascribed to normative ideologies of upward mobility that state that youth should postpone childbearing in order to complete school, increase employability and get out of poverty. Because this normative ideology is linked to the wide-spread medicalisation of contraceptives and fertility control, promoted as key to poverty-reduction, open discussions about the positive aspects of fertility and family life were rare. Even so, as women matured, their concerns about their future socio-economic and personal viability grew, as did their politicised critiques of the failures of education and feminism (Béhague 2009). Some began to turn, more explicitly, to reconsider the merits of establishing a family, something that also, logically, ignited anxieties about possible future infertility. Because of the strength of normative ideologies of how to achieve upward mobility, however, these concerns remained latent. Women sought ways to demonstrate an explicit commitment to education and professionalisation via regular contraceptive use alongside a more implicit commitment to setting the groundwork for a strong family life via the testing of fertility through interrupted contraceptive use.

When understood this way, young women's interpretations of the biological effects of the pill and their contraceptive practices can be read a form of covert resistance to normative ideologies (Comaroff 1985; Da Matta 1991; Lock and Kaufert 1998) or, more specifically, a hidden transcript (Scott 1990). As theorised, the concept of a hidden transcript elucidates the way oppressed groups adopt potent public symbols of authority, not only to gain greater understandings of how power functions, but also as a way of indirectly imbedding subversive practices within the core of these authoritative symbols (Scott 1990). In the ethnographic case presented here, teenagers are using the pill in a way that is heavily laden with a diverse symbolic repertoire; through creative contraceptive practices, they are able to ascribe to (and critique) the moral imperative that teenagers demonstrate a desire to delay childbearing, while at the same time, they are able to use the authority that contraceptive use gives them to actively, if covertly, participate in the social imperative to prove they are indeed fertile.

In this sense, the pill takes on some of the core qualities that van der Geest and White (1989) have demonstrated are associated with the charm of medicines. As they describe, in their concrete-ness, medicines objectify complex social relationships; medicines are ‘good to think with’, in part because they facilitate private and public communication about sensitive and difficult-to-articulate social dynamics (van der Geest and White 1989). The young women we came to know used pill-taking practices as a way of thinking through the limits and constraints of the economic science of teenage pregnancy. By taking the medicalisation of contraceptives into their own hands that is, by using the pill in a purposefully interrupted fashion and by debating the limits of medical knowledge regarding the pill's effects young women who became teenage mothers were able to engage with the authority of medicine and normative society, while developing a potent off-stage critique of this authority. Pill-taking practices also enabled the socially justifiable medicalisation of the fear of infertility itself and through this medicalisation, women's concern with ensuring a legitimate place in society, and with the social and economic injustices they encountered in trying to do so, were rendered poignantly visible.


Acknowledgements

This analysis was supported by the Wellcome Trust and the National Council for Scientific and Technological Development (CNPq) of Brazil. Earlier phases of the 1982 cohort study were funded by the International Development Research Center (Canada), the World Health Organization (Department of Child and Adolescent Health and Development, and Human Reproduction Programme), the Overseas Development Administration (currently Department for International Development, United Kingdom), the United Nations Development Fund for Women, the National Program for Centers of Excellence (PRONEX/CNPq, Brazil), and the Ministry of Health (Brazil). The ethnographic has also been funded by the Pan American Health Organisation and the US National Science Foundation. Since 2005, D. Béhague has been supported by a postdoctoral fellowship from The Wellcome Trust (GR077175MA).


Note

1. Our use of the term medicalisation refers to the way in which non-medical processes and problems come to be reconceptualised as medical problems requiring the application of expertise and knowledge from biomedicine (Lock and Gordon 1988).


References
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Tables
[TableWrap ID: T1] Table 1. 

Description of the sample and analytic sub-samples.


Whole ethnographic Sample n = 96 Sample of youth who had not become parents ≥ 24 years (2004 follow-up) n = 55 Teen parenthood (13-19 years) n = 17∗ Became parents in early adulthood (2024 years) n 16∗∗
Family income at birth (minimum salaries)∗∗∗
?1 21 11 5 4
1.1-3 42 22 8 8
3.1-6 24 18 2 2
6.1-10 5 1 1 2
> 10 3 3 - -
Family income at 1819 years of age (minimum salaries)∗∗∗
? 1 7 4 2 1
1.1-3 20 9 7 2
3.1-6 34 21 4 7
6.1-10 14 11 1 2
> 10 17 9 3 3
Maternal schooling (at birth) in years
0-4 25 11 7 5
5-8 49 27 8 9
9-11 9 7 1 1
? 12 13 10 1 1
Young person's schooling (years)
0-4 3 1 1 1
5-8 29 14 10 7
9-11 44 33 6 7
? 12 4 3 - 1

Note: ∗ 12 women, 5 men; ∗∗ 5 women, 11 men; ∗∗∗ one minimum salary is roughly equivalent to US $100.00.



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Keywords: Keywords: infertility, adolescent pregnancy, medicalisation, Brazil.

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