Critical insights on the demographic concept of "birth spacing": locating Nef in family well-being, bodies, and relationships in Senegal.

Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and "birth spacing" intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to "empowering" women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.

Introduction

Since the early 1980s, birth spacing has emerged as a key concept to improve maternal and child health. This concept has triggered interest in birth spacing practices in low-income countries, and drawn attention to prevailing norms in favour of long birth intervals in West Africa.[1] The literature examining birth spacing from a locally situated point of view in sub-Saharan Africa has explored rationales explaining postpartum abstinence, with a focus on beliefs around the relationship between birth spacing and the health of breastfed children,[2] and documenting the use of contraception between births in the Gambia to improve women’s reproductive health and function.[3]

Cultural taboos against short birth intervals are in line with scientific evidence on associated adverse health outcomes. Evidence reviewed by the World Health Organization (WHO) indicates that birth-to-pregnancy intervals shorter than six months are associated with increased risk of maternal mortality. Adverse perinatal outcomes and neonatal mortality for the younger sibling are higher for intervals of less than 18 months (and potentially up to 27 months), while post-neonatal survival up to one year improves with intervals longer than 15 months. The evidence relating to child mortality is unclear.[4] The mechanisms through which short birth intervals affect maternal and child outcomes are poorly understood, however there is growing evidence supporting maternal folate depletion as a mechanism, and some evidence supporting general maternal nutritional depletion, sub-optimal lactation due to pregnancy-breastfeeding overlap, and transmission of infections among siblings. The evidence is conflicting regarding the sibling competition for resources hypothesis.[5] In settings where contraceptive use and birth limitation are socially stigmatised, birth spacing has also been used as a means to promote family planning (FP).[1]

In Senegal, discussions around FP and birth spacing are deeply intertwined. Social marketing of contraceptives and FP policies have long been anchored in the concept of avoiding short birth intervals,[6] in spite of median birth intervals reaching around 33 months or more since the early 1990s,[7] longer than the WHO-recommended 24 months between births. The Wolof term Nef (short birth intervals) refers to women experiencing births that are too closely spaced, and appears to be stigmatising; social norms thereby discourage short birth intervals. The concept of birth spacing is locally rooted in Senegal, and international discourses on the benefits of birth spacing would seem to easily fit into this pre-existing normative environment. However, little is known about how Nef is understood in Senegal in light of social norms and practices, including the important value of “family well-being”, and alignment between the promotion of long birth intervals by the WHO and pre-existing practices of birth spacing in Senegal does not necessarily mean that their rationales coincide. Caroline Bledsoe’s work on contraceptive use in the Gambia shows that there is room for qualitative data to rethink demographic epistemologies.[3,8] Drawing on the literature challenging demographic theories from below,[9] this paper seeks to understand birth spacing through the lens of practices and discourses on Nef in Senegal.

After introducing the concept of Nef, and how the framing of “family well-being” has evolved over time in Senegal, this paper explores women’s and men’s understandings of Nef in Senegal at the intersections of family harmony, women’s and children’s health and gendered forms of body control. Findings will be used to critically reflect on the demographic concept of birth spacing. Our main objective is to better understand what practices are locally reinforced or challenged when stakeholders promote FP by leveraging perceived “local values” in favour of birth spacing.

Methods

This study was conducted as part of the evaluation of a contraceptive supply chain intervention in Senegal.[10] To understand the context in which the intervention was implemented, we reviewed published papers and policy documents (including national policies and plans, policy statements, as well as donor and NGO and government reports) in English and French by undertaking searches for “Family planning” and “Senegal” in relevant databases. We adopted a “snowball” approach by reviewing references of included articles to identify additional publications on FP in Senegal. In addition, we retrieved grey literature from the University Cheikh Anta Diop archives in Dakar, including academic theses. The “bien-être familial”, or “family well-being” in English, emerged from our review as a key umbrella concept used in policy and communication campaigns to frame topics of fertility, reproductive health and FP.

We conducted interviews with key informants involved in FP activities in order to understand the history and political framing of FP activities over time in Senegal. The content of interviews included the “family well-being” framing identified in our literature review. We discussed this framing with key informants previously or currently involved in FP activities with the Ministry of Health or the Senegalese health system.

We also conducted in-depth interviews and focus group discussions with men and women across 11 regions in Senegal in 2016 and 2017. Written informed consent was sought after researchers conducting the interviews and focus group discussions provided participants with information about the study. Sampling was purposive to represent urban and rural areas and distance from FP services. Interview guides were informed by our literature review, as well as information from previous qualitative work with FP providers and national stakeholders in Senegal, and designed to allow unexpected issues to emerge. During the focus group discussions, participants were shown visual materials from a national Senegalese campaign on birth spacing (“Moytou Nef”) and asked to comment. Interview guides were adjusted iteratively between data collection rounds. Transcripts of interviews, workshops and focus groups were translated into French and independently coded by researchers in London and Dakar along key themes using qualitative software.

Ethical approval was granted by the ethics committees of the Senegalese Ministry of Health and Social Action, and of the London School of Hygiene & Tropical Medicine.

The concept of Nef in Senegal

Our study accounts for diverse contexts and uses of the word Nef across Senegal. Our intention is not to provide a comprehensive definition of the phenomenon, but rather to understand how Nef is articulated in social contexts. A Nef was often defined as getting pregnant while still nursing a child. The required length of breastfeeding varied among participants, but most of our participants suggested an ideal period of two years. It is worth noting that a wider range of terms are used in other local languages to refer to closely-spaced births and related practices. As an illustration, we heard the terms “Cere”, or “Carceere” in Bambara, or “Bato ndiri” in Peul. However, Nef achieves wide recognition throughout Senegal as the term that has been used in national communication campaigns and public health interventions, and in different regions, a nomenclature close to the Wolof existed (such as “Enef” among Diolas or “Nef Gol” among Toucouleurs). Interestingly, the different terms used address issues of birth spacing through different phenomena, including having a child each year, being pregnant while breastfeeding, or being pregnant while having a child who is learning to crawl or walk. Overall, Nef was universally described as socially condemned and stigmatising for women: Nef is very closely related to the concepts of birth spacing and family well-being in Senegal, as we will show, and both concepts are key for the promotion of FP policies.

“Well we talk about Nef when we have a baby that is still breastfed and get pregnant again. If you have unprotected sex or if you don’t do family planning, you can get pregnant. And if you have a child who is still breastfed in this case we talk of Nef.” (Interview with a woman)

“It is more or less banned. When you say a woman is doing Nef, it is not well perceived. It means the woman is at risk and the children as well. It is not well perceived for the woman’s personality because it shows she cannot control herself.” (Key informant, interview)

Locating Nef in the family well-being approach in Senegal

The history of FP in Senegal is embedded in a global discourse on population, health and development. It has been acknowledged that the evolution of national population policies in Senegal mirrors global thinking and its evolutions.[11] However, from the early days, and consistently since, FP policies and activities have also been enacted locally under the recurrent argument of “family well-being”.[12] Although the official government and NGO discourse does not refer to the “cultural” concept of Nef directly, birth spacing has been central to the promotion of FP over the last few decades.

Early FP efforts in Senegal: the emergence of the well-being family approach

FP services were born in Senegal in a postcolonial context and were long constrained by the heritage of a 1920 French law forbidding contraceptive distribution and its promotion.[11] As a result, FP pioneers were operating at the margins of the Senegalese legal apparatus, while FP was increasingly promoted for developing countries at the international level. Also inherited from colonial times was the restrictive regulation on induced abortions.[13] In this context, the beginnings of FP activities in Senegal in the 1970s consisted of isolated interventions preceding any national policies. Initiatives were tested locally at first within both the public and private sectors. The “Clinique de la Croix Bleue” in Dakar was the first facility to offer FP services in Senegal in the late 1960s, under the direction and vision of its owner, Mrs Whest, at a time when contraceptive use was still restricted by the 1920 French law.[14]

The provision of contraception became legal in 1980 when the 1920 law was repealed, while abortion is still heavily criminalised today in Senegal.[15] The 1980s were dominated by two key FP programmes, both implemented by the Senegal Association for Family Well-being (ASBEF) which is affiliated to the International Planned Parenthood Federation. These suggest that “family well-being” may have been used as a translation of “family planning” at that time. The two programmes were the USAID-supported Family Health and Population Project (FHPP) and later in the decade, the UNFPA-supported Family Welfare Project. One of our key informants, who took part in the FHPP pilot and scale-up, highlighted that the project identified key challenges for FP provision, including socio-cultural, socio-economic and sanitation problems, and mentioned that in the early stages of rolling out FP services in health facilities, FP signs were often labelled “family health” or “family well-being”. This participant situates the challenges identified to providing FP services to populations in Senegal in a space that includes clinics but cannot be reduced to the clinical environment. In this space, family well-being is not a fixed concept in Senegal. It has evolved alongside the development of FP activities in Senegal, gaining presence in the built environment, in the public health landscape, in broader public debates and in intimate lives. Part of the evolution of the concept and its (re)articulation over time involved discussions with religious leaders.

Family well-being was never explicitly defined in policy documents, and it has been negotiated by many actors over time. In 1988, when FP programmes had been implemented in a patchwork manner in Senegal for a decade, the Ministry of Planning and Cooperation issued its first National Population Policy. The objective of the policy mentions well-being: The text emphasises the relationship between economic and human resources, mirroring the demographic rationale put forward in international debates of its time,[11] and highlights the multi-dimensional approaches to promoting well-being through population policies.[16]

“To improve the quality of life and promote the establishment of well-being at all levels of the population (…) This action will be the fruit of progress accomplished in the economic and social spheres […] Senegal advocates a global approach to its population problems, and family planning constitutes, in this context, only one component of its national population policy.”[16]

Later in the text, there is a shift from the demographic argument to a health-related argument justifying the necessity of a population policy: We should nuance the content of this document as it may reflect a compromise between different actors involved in drafting it rather than a snapshot of the thinking of the time. However, the first national population policy issued in Senegal overall gives a taste of the negotiations ahead to promote FP and ensure coherence with Senegal’s commitments to the international community and to funders, while simultaneously reinforcing and challenging prevailing social norms of high fertility and family well-being. For example, high fertility is identified as a concern, and the answer offered involves birth spacing, a locally acceptable approach in a setting where birth limitation is not accepted and the strong taboo against short birth intervals (Nef) already prevails.

“The total fertility rate of Senegalese women is among the highest in the world. It presents serious risks to the health of mothers and children. This is why birth spacing constitutes an important component of the policy of improving the health of mothers and children [… .]”[16]

In the 1990s, the family well-being approach was reshaped under the constraints of neoliberal reforms, alongside the birth of the national FP programme in 1991. The 1992 Bamako Initiative reshaped policies in sub-Saharan Africa by promoting cost-recovery practices, and Senegal’s FP policies were also impacted by health system reforms decentralising and privatising health services.[17] In 2005, a new reproductive health law was passed, acknowledging that: This law reaffirmed the family well-being framing of FP by highlighting health implications for children, and interestingly situates birth regulation both within individual and couples’ decision-making processes.

“Everyone is entitled to be informed and to use methods for birth regulation of his choice that are not against the law, methods must be safe, efficient, accessible and acceptable, and provide couples with the best chances to have a healthy child.”[18]

Birth spacing at the core of family planning promotion

After recognising a very slow increase in contraceptive use and high unmet need for FP over several decades,[19] and in parallel with international moves to put FP back on the agenda, FP came under renewed focus in Senegal in the 2010s. In July 2012, Senegal’s Minister of Health, Dr Awa Marie Coll-Seck, announced at the London Summit on Family Planning an ambitious goal to increase the contraceptive prevalence rate from 12% in 2012 to 27% by 2015, and updated Senegal’s commitment in 2017 by setting targets of 45% modern contraceptive use by 2020 and decreasing unmet need to 10%. Bringing together local stakeholders, the government prepared a National Family Planning Action Plan 2012–15 (NFPAP) with four overarching goals: building demand, improving supply chain management, offering quality services, and increasing access.[20] Central to this approach was one key campaign launched in 2013 focusing on the message of promoting long birth intervals called “Moytou Nef” or “avoid closely spaced births” in Wolof.[21] The main objectives of this mass media campaign are to encourage men to support their wives to use contraception in order to delay pregnancy for at least two years after a birth, and to involve religious leaders to promote birth spacing. That the NFPAP promotes FP predominantly through the promotion of birth spacing may seem illogical from an evidence-based perspective in a country where median birth intervals have been longer than the WHO recommendation since the early 1990s.[4,22,23] However, looking at the national NFPAP in the context of the national history shows that promoting the use of FP to avoid short birth intervals, an existing social taboo in Senegal, is also a means by which contraceptive use can be normalised in the country. Promoting contraceptive use for birth spacing is perceived by some organisations as the best way to tackle remaining cultural “resistance”, or low acceptability of FP. Whatever the rationale behind this approach, some decision-makers in Senegal argue that what matters is for FP use to become more widespread. However, it has been shown that this approach can lead to health workers filtering access to contraceptive use, for instance, when health providers refuse to prescribe contraceptives to unmarried women.[24] In addition, using the social stigma associated with a Nef in Senegal may inadvertently risk blaming women for this situation in a context where they do not necessarily have sufficient autonomy to make reproductive choices.

“I think that for the first time we found a concept that is socially relevant and promising with the concept of Nef. Even when we were talking about child spacing, in Wolof it does not really work … But when you talk about Nef, people picture the woman’s health in the background and the child’s health.” (Key informant, interview)

Locating Nef in women’s reproductive lives

We drew on our interview and focus group discussion (FGD) findings to explore the social practices and discourses associated with Nef, in an attempt to understand what practices may be reinforced by referring to the Nef taboo in FP promotion. Several rationales are associated with avoiding short birth intervals. Women and men both shed light on the need to avoid a Nef to allow the women’s body to recover: This argument aligns with the maternal nutritional depletion hypothesis which states that “a close succession of pregnancies and of periods of lactation worsens the mother’s nutritional status because of inadequate time to recover from the physiological stresses of the preceding pregnancy before becoming subject to the stresses of the next pregnancy”.[5] A religious argument was also used – especially by men – referring to the Quran to justify the two-year birth interval. Spacing births also specifically refers to improving health for women, children and children to come: Even though biomedical arguments that emerged from the field are not consistent with current scientific evidence on sub-optimal lactation due to pregnancy-breastfeeding overlap, where short birth intervals could indirectly increase the risk of adverse outcomes for the youngest child,[5] whereas the above quote expresses concerned for the older child, it is interesting to note that implications from both arguments align.

“A woman needs to rest for two or three years, to take time to rest and regain forces.” (Interview with a man)

“I used family planning to rest before going through another pregnancy and to be in good health. I wanted to rest and take care of my body. Too many deliveries distort the woman's body and the woman gets old too early.” (Interview with a woman)

“If a woman does not respect birth spacing it will cause health issues for her and she will have problems to take care of her children, she can develop anaemia because if we give birth each year we can develop blood problems.” (Interview with a woman)

“When the woman is pregnant, there is a new sort of milk that develops for the child in the womb of the mother. The child is drinking someone else’s milk containing vitamins that are not good for him. It is dangerous for his health.” (Focus group with men)

Our interviews also shed light on the temporal dimension of avoiding a Nef in terms of the woman freeing up time to take care of herself and her family.

“A woman who gives birth all the time does not have time for herself.” (Interview with a woman)

“If you don’t have Nef you can take good care of the child and give him everything he needs but if you have a Nef you won’t be able to take care of everything.” (Interview with a woman)

If spacing births allows women to have more time, it does not necessarily provide them with more control over their body:

“The Diolas are against ‘eniong’ [Nef in Diola]. If the woman does one, the family calls the husband to tell him that what he did is wrong.” (Focus group with men)

“My wife does not use family planning because I control her calendar. I know when we can have sex without being at risk of a pregnancy.” (Focus group with men)

In addition to time and health concerns, Nef also refers to an ideal harmonious family. As opposed to the promotion of reproductive rights, or a narrower focus on women’s health, family well-being echoes a sense of harmony between family members: If this interviewee uses birth spacing, family well-being and family planning as synonyms, it would be incorrect to say that the well-being approach is another word used to talk about FP in a more “acceptable” way. When we showed communication materials on FP to an audience of men, the discussion quickly evolved towards ideas of peace and well-being, and how they are enacted in relationships between men and women.

According to you, what is family well-being?

For a family to be in peace, we need birth spacing, in other words family planning. (FGD with a group of men)

What do you mean by family well-being?

Happiness

It is mainly harmony

How about you S, what do you think?

I think first of harmony, love, understanding, religion, finance. I am in favour of spacing births, but I am against western FP. (FGD with a group of men)

Although family well-being can be seen as a consensual concept with a strong health connotation, it is important to acknowledge that it is not a fixed one. Family well-being also translates into “practical norms”[25] through the daily implementation of FP activities in the Senegalese health system, through clinical encounters and private discussions. Its significance has varied across time and it is used differently by policy makers, clinical staff, women and men. While policy and individual discourses refer to family well-being in relation to the health and economic benefits of using FP, family well-being also resonates with an idea of peace and harmony at the core of the ideal imagined Senegalese family. These results show that birth spacing can only be understood in a historical framing of family well-being in Senegal and in the context of avoiding a Nef as the embodiment of a harmonious and peaceful family in which gender relations are articulated.

I see that births trigger health poverty issues, and survival issues in the family. It is difficult for the husband, the wife and children too. In the family that practices birth spacing, everyone lives in peace. She (the woman) lives in good conditions because she can take care of everyone.

I see a poor husband who struggles to manage his family, and this causes problems. The other one is rich. (FGD with women)

Birth spacing is a very important component of the national FP strategy in Senegal and has an important role in contributing to what can be considered healthy and harmonious families. In context, we see that the repertoire developed around the concept of family well-being is embedded in the politics of gender in the broader cultural, social and religious environment. The body of the woman is sometimes reduced to its reproductive function and its capacity to fulfil the needs of her husband and children. Healthy feminine bodies strongly associated with birth spacing and contrasting with practices of Nef create, in the family well-being lexicon, the preconditions for peaceful, harmonious and happy families. Although it is tempting to read local discourses around women having more time for themselves as an assertion of women’s control of their lives, of their body, and ultimately to see birth spacing as part of a women’s empowerment process, we should acknowledge that Nef also refers to a normative repertory that reflect social norms of control over women’s bodies. Caroline Bledsoe and colleagues have highlighted the overlap between international consensus on the benefits of birth spacing on health and local use of contraceptives to space birth in the Gambian context, while radically challenging western fertility in contexts when contraceptive devices are used to maximise the number of healthy children rather than limit family size.[3] Similarly, our study unveils critical tensions between a relational understanding of birth spacing and a western understanding of women’s rational choices over family size.

Our results therefore confirm previous studies identifying “fault lines”[26] between the discourses of demographers on population control, or of advocates of reproductive rights as a means to empower women, and the actual conditions of reproduction women face in the context of their daily lives and aspirations.[27] Notably, while it is argued internationally that contraceptive use is a means to women’s empowerment and ability to pursue educational or occupational activities, our findings suggest that in Senegal the use of FP for birth spacing can also reinforce women’s primary role as family caregiver. Furthermore, looking at how different actors frame the concept of well-being and birth spacing practices sheds light on duties assigned to men and women in a marriage. Women are not solely responsible for ensuring family well-being; however, their responsibilities as mothers are located in their body. However, that does not mean that men do not want to be involved in FP activities: during our study, we also encountered men who were eager to be more involved in the awareness and communication FP activities targeting women. Not being invited fuelled a sentiment of being excluded from secretive practices. Unpacking the concept of well-being in Senegal therefore allows documenting both norms and practices as well as dynamic pathways of inclusion and exclusion, in contrast with binary approaches of acceptable versus non-acceptable FP.

Our results also intersect with research looking at how notions of race, gender and class have been encapsulated in different framings, policies and technologies of reproductive health: “Reproductive health was not a biological thing with clear bounds, but a multifaced and distributed effect in time and space, a problem both material and political to which questions of state, race, freedom and individuality and economic prosperity were bound in ways that connected the micrological and the transnational via embodiment”.[28] The intersections or disconnects between the concept of well-being at a programmatic level and the local idea of family harmony need to be explored further in relation to the paradigm of women’s autonomy.[29] This discussion needs to take place away from a framework interested in translating foreign concepts or models into acceptable programmes, as our study shows that looking at the taboo against Nef as a local translation of international policies against short birth intervals overlooks broader implications in relation to family wellbeing, harmony, and women’s reproductive lives. In this sense, the concept of historicity is useful to try and connect “the micrological and the transnational”. Jean Francois Bayart defines the concept of historicity as a means to understand “the singularity of historical configurations of all societies, polities, political struggles and cultural representations of politics, that we have to however apprehend with universalized tools and concepts”.[30] Understanding the multiple meanings of the birth spacing rhetoric in Senegal, and their articulation in complex and dynamic contexts, creates space to reflect on demographic concepts implemented under different global reproductive regimes.[15] Birth spacing and family well-being have proved to be dynamic concepts that have adapted to different health reforms and social change in Senegal and it is by closely looking at local narratives that a grounded theory of change[31] relevant to women’s reproductive lives can be developed.

Conclusion

Our findings are consistent with the literature looking at cultural understandings and reasons for birth spacing in sub-Saharan Africa, and reinforce the relevance of engaging with women and men around FP activities and policies in Senegal through the notion of birth spacing. Contextualised accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can sometimes legitimise constraints faced by women on control of their body. Our results therefore confirm previous studies identifying “fault lines”[26] between the discourses of demographers on population control, or of advocates of reproductive rights as a means to empower women, and the actual conditions of reproduction women face in the context of their daily lives and aspirations.[27] Looking at how different actors frame the concept of well-being sheds light on duties assigned to men and women in a marriage, and the implications these assigned duties may have for women’s reproductive choices. Challenging international assumptions that promoting FP is a means to promote women’s empowerment, our study shows that locally relevant theories need to be developed to accompany policies promoting birth spacing that can address women’s reproductive concerns in the social and economic context in which their reproductive choices are made.