Reproductive Decision Making and the HIV/AIDS Epidemic in Zimbabwe

Reproductive Decision Making and the HIV/AIDS Epidemic in ZimbabweAuthor(s): Mira Grieser, Joel Gittelsohn, Anita V. Shankar, Todd Koppenhaver, Thomas K.Legrand, Ravai Marindo, Webster M. Mavhu, Kenneth HillSource: Journal of Southern African Studies, Vol. 27, No. 2, Special Issue on Fertility inSouthern Africa (Jun., 2001), pp. 225-243Published by: Taylor & Francis, Ltd.Stable URL: http://www.jstor.org/stable/823326Accessed: 11/12/2009 04:42

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Journal of Southern African Studies, Volume 27, Number 2, June 2001 ~vsUz

Reproductive Decision Making and the HIV/AIDS Epidemic in Zimbabwe*

MIRA GRIESER,1 JOEL GITTELSOHN,2 ANITA V. SHANKAR,3 TODD KOPPENHAVER,1 THOMAS K. LEGRAND,4 RAVAI MARINDO,5 WEBSTER M. MAVHU6 AND KENNETH HILL1

('Department of Population and Family Health Sciences, The Johns Hopkins University School of Hygiene and Public Health; 2Division of Human Nutrition, Department of International Health, The Johns Hopkins University School of Hygiene and Public Health; 3Division of Community Health and Health Systems, Department of International Health, The Johns Hopkins University School of Hygiene and Public Health; 4Departement de Demographie, Universite de Montreal; 5Centre for Population Studies, University of Zimbabwe; 6Department of African Languages and Literature, University of Zimbabwe)

The fertility-stimulating effect of high rates of child mortality on reproductive decision

making (RDM) is a central tenet of population studies, yet the effects of the HIV/AIDS

epidemic on RDM have not been thoroughly explored in the literature. This paper investigates how RDM is articulated in the context of high HIV/AIDS prevalence in Zimbabwe. Using qualitative methods (35 focus groups and 46 in-depth interviews), we

found that childbearing is extremely important in the lives of adult Zimbabweans and that children are needed to cement the couple's relationship, whether it is the first or subsequent marriage. Most respondents said that rates of both adult and child mortality were greatly increasing due to the AIDS epidemic. However, contrary to expectations based upon the insurance strategy, most respondents said that they would have fewer children as a result

of the perceived increase in child mortality. They were also hesitant to continue childbear-

ing after a child death, indicating only weak replacement motivation. Instead, many respondents expressed the desire to limit family size due to concerns about their own

mortality and its negative effects on their children. Furthermore, new reproductive strategies seem to be emerging, which focus upon the health of parents and child and are based upon perceptions of 100 per cent maternal-infant HIV transmission. Adult HIV status is linked to child survival as respondents explained that having a healthy child who survives to age five indicates that the parents are also free of the virus and, at this point, they can

safely continue childbearing. Additionally, couples who have experienced the death of a child are hesitant to give birth again because they believe future children would die.

Finally, there was some talk of having children early in an attempt to avoid contracting

* The data presented in this article come from a study entitled 'Fertility and Child Death in Zimbabwe' carried out from August 1998 through May 1999 and funded by the Rockefeller Foundation. The authors would like to acknowledge the following data collectors for their hard work, insight, and attention to detail, which made this project possible: Ennie Chipembere, Crispen Chipunza, Simbiso Machine, Mandlenkosi Maphosa, Raymond Farai Mapwashike, Webster Mavhu, Gugulethu Ndimande-Nare, Vezumuzi Ndlovu, Kudzai Nhongo, Edmore Tondhlana, Norma Tshuma, and Shyrene Ziswa.

ISSN 0305-7070 print; 1465-3893 online/01/020225-19 ? 2001 Journal of Southern African Studies DOI: 10.1080/03057070120049949

226 Journal of Southern African Studies

HIV. This study presents evidence that Zimbabweans are altering their reproductive strategies in order to protect both parents and children from the threat of AIDS.

Introduction

Reproductive decision making (RDM) is strongly influenced by cultural norms, such as the value of children in a particular society and the specific roles of men and women. Such norms are not fixed; they may be influenced by changes in society, including factors that lead to alterations in perceived and expected mortality.'

Demographers have posited that people respond to high child mortality through decision-making mechanisms such as the insurance and replacement strategies.2 Couples using the insurance strategy give birth to a number of children greater than their desired

family size because they fear that some children might die. In the replacement strategy,

couples have another child in response to a child's death to maintain their desired number

of children. One of the many consequences of the AIDS epidemic in southern Africa has been an

increase in child3 and adult mortality.4 As the AIDS epidemic claims adult victims,

surviving parents and other relatives may have diminished means to provide for children's

needs, which may decrease the demand for future children. However, previous studies in

sub-Saharan Africa have found that HIV testing and counselling seem neither to reduce the

desire for children, nor to increase contraceptive use, nor to reduce fertility in the long term.5 Therefore, it is necessary to study the behavioural fertility responses to increased

AIDS mortality.6 Because AIDS is unique in that both children and adults succumb to the

disease, its effects on childbearing may not be limited to the insurance or replacement strategies.

This paper examines how Zimbabweans make reproductive decisions in a setting where

over a quarter of the adult population is HIV positive.7 Specifically, we attempt to describe

and understand how Zimbabweans respond to increasing levels of AIDS-related adult and

child mortality and to identify any new reproductive strategies that may be emerging as a

result of the epidemic.

1 M. Montgomery and R. Casterline, 'Social Learning, Social Influence, and New Models of Fertility', Population and Development Review, 22, Suppl (1996), pp. 151-175; M. Montgomery, 'Mortality Decline and the Fertility Transition: Toward a New Agenda', Population Council Working Paper No. 122 (New York, The Population Council, 1999).

2 S. H. Preston, The Effects of Infant and Child Mortality on Fertility (New York, Academic Press, 1978), pp. 1-17. 3 UNAIDS and WHO, AIDS Epidemic Update: December 1998, (United Nations Programme on HIV/AIDS and

The World Health Organisation, 1999). 4 S. Gregson, G. P. Garnett, and R. M. Anderson, 'Is HIV Likely to Become a Leading Cause of Adult Mortality

in Sub-Saharan Africa?', Journal of Acquired Immune Deficiency Syndrome, 7, 8 (1994), pp. 839-852; N. J. Robinson and R. Marindo, 'Current Estimates of and Future Projections for Adult Deaths Attributed to HIV Infection in Zimbabwe', Journal of Acquired Immune Deficiency Syndrome Human Retrovirology, 20, 2 (1999), pp. 187-194.

5 S. Gregson, T. Zhuwau, R. M. Anderson and S. K. Chandiwana, 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?', Social Science and Medicine, 46, 3 (1998), pp. 321-330; R. King, J. Estey, S. Allen, S. Kegeles, W. Wolf, C. Valentine, and A. Serufilira, 'A Family Planning Intervention to Reduce Vertical Transmission of HIV in Rwanda', AIDS, 9, Suppl. 1 (1995), pp. S45-51; S. Allen, A. Serufilira, V. Gruber, S. Kegeles, P. Van de Perre, M. Carael, T. J. Coates, 'Pregnancy and Contraception Use Among Urban Rwandan Women After HIV Testing and Counselling', American Journal of Public Health, 83, 5 (1993), pp. 705-710.

6 M. Ainsworth and M. Over, 'AIDS and African Development', World Bank Research Observer, 9 (1994), pp. 203-240.

7 UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic: June 2000, (Geneva, Joint United Nations Programme on HIV/AIDS, 2000), p. 124.

RDM and the HIV/AIDS Epidemic in Zimbabwe 227

The Desire for Children in Zimbabwe

Lan and Fry both give examples of the flexibility and continual evolution of aspects of culture in responding to great social change.8 As with other aspects of culture, meanings of

childbearing are not static; rather they continually interact with environmental influences, which include the far-reaching effects of the AIDS epidemic.

Childbearing is extremely important among the Shona and the Ndebele, the two dominant ethnic groups in Zimbabwe.9 As in the rest of sub-Saharan Africa, strong ties to

systems of descent and the extended family encourage high fertility.'0 Children are also valued for the security they provide their parents in old age, especially in areas without

governmental social security systems." The anticipation of children also plays a significant role in marriage negotiations. Lobola, the money paid by a man's family to the parents of his future wife, signifies that the children born to this union will belong to the father's clan. Furthermore, the inability to have children may cause a woman to be divorced and sent back to her parents in disgrace.'2 Several sources also refer to childbearing as the rite of

passage into the spiritual world for the parents. Those who die before having children are considered to be spiritually impure and, as a result, may end up as restless, harmful spirits.'3

At the same time, the data show that many people limit their number of children and that fertility is falling as Zimbabwe progresses in the demographic transition. The Zim- babwe Demographic and Health Survey (ZDHS) reports that the 1994 total fertility rate (TFR) - the expected total number of children born to a woman in her lifetime - was 4.3 children per woman, a decrease of 16 per cent since 1992.14 The preliminary report on the 1999 ZDHS indicates that Zimbabwe's TFR has fallen further to 4.0 births per woman.15 In 1994, urban and rural TFRs were 3.1 and 4.9, respectively, and ideal family size was 4.3 children for both men and women.16

8 D. Lan, Guns & Rain: Guerrillas and Spirit Mediums in Zimbabwe (Berkeley, University of California Press 1985), pp. xiii-xix; P. Fry, Spirits of Protest: Spirit-mediums and the Articulation of Consensus among the Zezuru of Southern Rhodesia (Zimbabwe) (Cambridge University Press, 1976), pp. 1-4.

9 The Central Intelligence Agency reports that the Shona and Ndebele make up 71 per cent and 16 per cent of the population of Zimbabwe, respectively. Central Intelligence Agency, The World Factbook: Zimbabwe (Washington DC, Central Intelligence Agency, 1999).

10 J. C. Caldwell and P. Caldwell, 'The Cultural Context of High Fertility in Sub-Saharan Africa', Population and Development Review, 13, 3 (1987), pp. 409-437; J. Bongaarts and S. Watkins, 'Social Interactions and Contemporary Fertility Transitions', Population Council Working Paper No. 88 (New York, The Population Council, 1996); Factors Affecting Contraceptive Use in Sub-Saharan Africa (Washington DC, National Academy Press, 1993), pp. 85-127.

11 M. T. Cain, 'Women's Status and Fertility in Developing Countries: Son Preference and Economic Security' (Washington, The World Bank, World Bank Staff Working Paper No. 682, 1984).

12 M. Gelfand, The Genuine Shona: Survival Values of an African Culture (Gweru, Mambo Press, 1973), pp. 166-179.

13 J. Mutambirwa, 'Aspects of Sexual Behavior in Local Cultures and the Transmission and Prevention of HIV/AIDS', in M.A. Mercer and S. Scott (eds), Tradition & Transition: NGO Respond to AIDS in Africa (The Johns Hopkins University, 1991), pp. 7-14. Gregson et al., 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?'.

14 Central Statistical Office [Zimbabwe] and Macro International Inc, Zimbabwe Demographic and Health Survey, 1994 (Calverton, Maryland, Central Statistical Office and Macro International Inc, 1995), p. 29.

15 Central Statistical Office [Zimbabwe] and Macro International Inc, Zimbabwe Demographic and Health Survey, 1999: Preliminary Report (Calverton, Maryland, Central Statistical Office and Macro International Inc, 2000), pp. 5-6.

16 Central Statistical Office [Zimbabwe] and Macro International Inc, Zimbabwe Demographic and Health Survey, 1994, pp. 29, 94.


AIDS-related Mortality in Zimbabwe

UNAIDS estimates that 25.1 per cent of Zimbabwean adults are HIV positive.'7 Ninety-two per cent of HIV transmission is attributed to sexual contact while maternal-infant transmission is responsible for 7 per cent of HIV cases.18

The substantial increases in adult and child mortality rates in Zimbabwe can be attributed to the AIDS epidemic. In 1995, it was estimated that 52-60 per cent of all adult deaths were associated with HIV/AIDS; this figure was projected to increase to around 70 per cent in the year 2000.19 Local newspapers report that more than 220 Zimbabweans die each week from AIDS.20 Life expectancy in Zimbabwe, having reached 55 and 59 years for men and women in 1986, respectively, may plummet to 30 and 32 years by 2006.21 There is also evidence that the age structures of rural village populations have begun to change as mortality in young adults and very young children is increasing, and the number of orphans is also increasing.22

Despite widespread personal experience with HIV/AIDS, in many Zimbabwean com- munities, persons with AIDS are stigmatized and thus end up hiding or denying their illness,23 which may increase the risk of further transmission.24 Given this stigma and the prohibitive cost of treatment, it is not surprising that the demand for, and access to, HIV testing is very low. At a voluntary counselling and testing trial site, only four per cent of the 2,500 women who received group counselling decided to be tested.25 The great majority of Zimbabweans, like other sub-Saharan Africans, do not know their HIV status.

While vertical transmission rates for Zimbabwe are not available, UNAIDS estimates that 25-35 per cent of children born to HIV-positive women in developing countries will become HIV positive themselves,26 depending upon the presence of risk factors, which include breastfeeding, nutritional status, delivery conditions, and other diseases.27

Current data suggest that Zimbabwe's trends in improving infant and child mortality are reversing. In 1997, the infant mortality rate was 80 per 1,000 live births, an increase of 21.2 per cent since 1992. The child mortality rate - which measures mortality among ages one to five - was 36 deaths per 1,000 live births, an increase of 38.5 per cent from 1992.28 In the capital city of Harare, the infant mortality rate doubled between 1990 and 1996, and much of this increase is attributed to HIV/AIDS.29 The US Census Bureau estimates that

17 UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic: June 2000, p. 124. 18 National AIDS Co-ordination Programme, HIV/AIDS in Zimbabwe: Background, Projections, Impact and

Interventions (Zimbabwe, Ministry of Health and Child Welfare, 1998), pp. 11. 19 Robinson and Marindo, 'Current Estimates of and Future Projections for Adult Deaths'. 20 The Herald, 23 March 1999. 21 Blair Research Institute and Oxford University, The Early Socio-Demographic Impact of the HIV-1 Epidemic in

Rural Zimbabwe (Harare, Blair Research Institute, 1996). 22 S. Gregson, R. M. Anderson, J. Ndlovu, T. Zhuwau, and S. K. Chandiwana, 'Recent Upturn in Mortality in Rural

Zimbabwe: Evidence for an Early Demographic Impact of HIV-1 Infection?', AIDS, 11, 10 (1997), pp. 1269-80. 23 K. Meursing, A World of Silence: Living with HIV in Matebeleland, Zimbabwe (Amsterdam, Royal Tropical

Institute, 1997), pp. 7-341. A. A. Krabbendam, B. Kuijper, I. N. Wolffers, and R. Drew, 'The Impact of Counselling on HIV-Infected Women in Zimbabwe', AIDS Care, 10, Suppl 1 (1998), pp. S25-37.

24 J. W. McGrath, 'The Biological Impact of Social Response to the AIDS Epidemic', Medical Anthropology, 15, 1 (1992), pp. 63-79.

25 SAfAIDS News, 7, 4 (December 1999), p. 13. 26 UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic (Geneva, Joint United Nations Programme on

HIV/AIDS 1998), p. 48. 27 B. Cohen and J. Trussel, Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities

for the Social and Behavioral Sciences, (Washington DC, National Academy Press, 1996), pp. 94-97. 28 Central Statistical Office [Zimbabwe], 1997 Inter-Censal Demographic Survey Report, (Central Statistical Office

and United Nations Population Fund, 1998), pp. 144. 29 UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic, p. 50.


Zimbabwean infant and child mortality rates are 25 per cent and 43 per cent higher, respectively, than they would have been without AIDS.30

The National AIDS Co-ordination Programme estimated that, at the end of 1996, 110,000 Zimbabwean children were HIV positive,31 and studies have found that the life

expectancy of HIV-infected infants and children in sub-Saharan Africa is very short. In a

sample of HIV-infected infants in Durban, 83 per cent of the HIV-related deaths occurred before ten months of age.32 In another study, the estimated risk of death for HIV-infected Rwandan children at ages 2 and 5 was 45 per cent and 62 per cent, respectively.33 There are also high rates of morbidity in HIV infected children: in Zimbabwe, it is estimated that half of the paediatric hospital admissions are attributable to AIDS-related illnesses.34

Mortality and RDM

There is evidence that HIV-positive individuals are less able to conceive than their

HIV-negative counterparts.35 However, because so few Zimbabweans know their status, the

fertility intentions of HIV-positive and HIV-negative individuals can be assumed to be similar.

Although demographers posit that a fall in the rate of child mortality leads to a decrease in fertility rates,36 there is little information on the effects of rising mortality rates on

fertility. Moreover, increasing adult and child mortality rates attributed to AIDS may affect

fertility in opposing ways. Because high child mortality is associated with high fertility, increases in child mortality may serve to increase fertility through insurance and replacement strategies. On the other hand, increases in adult mortality may cause fertility to fall.37 The AIDS epidemic is unique in increasing rates of both child and adult mortality, making its effects on fertility difficult to project.

There is some indication that, in the past, Zimbabweans have viewed the replacement strategy with ambivalence. In earlier research, Shona women cited the fear that future children would die as a reason not to use the replacement strategy; however, they reported being encouraged to have another child by their husbands, in-laws, and others who believed it was an appropriate way to deal with grief.38 Because the project took place in the early

30 K. A. Stanecki, 'Review of HIV spread in southern Africa with highlights on Zimbabwe' (US Bureau of Census, Paper of International Programs Center, Population Division, 1996), p. 1.

31 National AIDS Co-ordination Programme, HIV/AIDS in Zimbabwe: Background, Projections, Impact and Interventions, pp. 12.

32 R. Bobat, H. Coovadia, D. Moodley, and A. Coutsoudis, 'Mortality in a Cohort of Children Born to HIV- 1 Infected Women from Durban, South Africa', South African Medical Journal, 89, 6 (June 1999), pp. 646-648.

33 R. Spira, P. Lepage, P. Msellati, P. Van De Perre, V. Leroy, A. Simonon, E. Karita, and F. Dabis, 'Natural History of Human Immunodeficiency Virus Type 1 Infection in Children: a Five-Year Prospective Study in Rwanda. Mother-to-Child HIV-1 Transmission Study Group', Pediatrics, 104, 5 (November 1999), p. e56.

34 Cohen and Trussel, Preventing and Mitigating AIDS, p. 96. 35 R. W. Ryder, V. L. Batter, M. Nsuami, N. Badi, L. Mundele, B. Matela, M. Utshudi, and W. L. Heyward, 'Fertility

Rates in 238 HIV-1 Seropositive Women in Zaire Followed for 3 Years Post-Partum', AIDS, 5, 12 (1991), pp. 1521-1527; V. Batter, B. Matela, M. Nsuami, T. Manzila, M. Kamenga, F. Behets, R. W. Ryder, W. L. Heyward, J. M. Karon, and M. E. St Louis, 'High HIV- I1 Incidence in Young Women Masked by Stable Overall Seroprevalence among Childbearing Women in Kinshasa, Zaire: Estimating Incidence from Serial Seroprevalence Data', AIDS, 8, 6 (1994), pp. 811-817; R. H. Gray, M. J. Wawer, D. Serwadda, N. Sewankambo, C. Li, F. Wabwire-Mangen, L. Paxton, N. Kiwanuka, G. Kigozi, J. Konde-Lule, T. C. Quinn, C.A. Gaydos, and D. McNairn, 'Population-based Study of Fertility in Women with HIV-1 Infection in Uganda', Lancet, 351, 9096 (10 January 1998), pp. 98-103.

36 Preston, The Effect of Infant and Child Mortality on Fertility, pp. 1-17. 37 M. Ainsworth, D. Filmer, I. Semali, 'The Impact of AIDS Mortality on Individual Fertility: Evidence from

Tanzania', in M. Montgomery and B. Cohen (eds), From Death to Birth. (Washington DC, National Academy Press, 1998), pp. 138-180.

38 J. R. Folta and E. S. Deck, 'The Impact of Children's Death on Shona Mothers and Families', Journal of Comparative Family Studies, 9, 3 (1988), pp. 433-451.


stages of the AIDS epidemic in Zimbabwe, prior to significant increases in infant and child

mortality,39 factors other than AIDS may have contributed to the ambivalence toward

replacement. As the child mortality rate increases, more parents find themselves in the position of

deciding whether to continue childbearing. In a survey of rural villagers in eastern Zimbabwe, 69 per cent of women reported that they wished to delay the next birth if an infant or child died, whereas 13 per cent said that they would have another child more

quickly than they would have otherwise.40 The researchers suggest that the desire to increase the spacing between children is caused by a lack of confidence that future children will survive; in fact, about half of their informants believed that the chance of infant survival had worsened with the AIDS epidemic.41 In addition, the death of a child may be an indication that the parents are HIV positive because many HIV positive individuals in sub-Saharan Africa become aware of their status only after becoming symptomatic or losing a child. At this point, they have neither the remaining time nor the health required to have more children.42 Furthermore, if people perceive that they will die an early death, it may no longer be important to have children for the help they provide in old age. Therefore, as this evidence suggests, replacement and insurance may not be effective reproductive strategies in the midst of the AIDS epidemic.

Higher rates of adult mortality and morbidity contribute to economic and social

problems, which may themselves influence RDM. Many adults spend resources caring for

family members with AIDS and children orphaned by AIDS.43 In addition, the majority of

people who die from AIDS are young adults, often the breadwinners of the family and the most economically productive group of the country. Resources may be diverted from investments and savings in order to finance the treatment of the opportunistic infections associated with AIDS.44 All of these factors may reduce desired family size by decreasing the resources available for raising children.45 On the other hand, with the uncertainty that

accompanies this increase in mortality rates, it can be argued that parents will focus less

upon the long-term benefits of lower fertility (such as savings and schooling investments), and thus the trend towards lower fertility will inevitably reverse.46

Although an increasing number of Zimbabweans know someone (an adult or a child) who was sick with or had died of AIDS,47 recent evidence from Zimbabwe, Tanzania, and

Uganda suggests that having excess births to insure a specific number of surviving children

may not be an effective response to the high levels of mortality.48 In Tanzania, researchers found that, as the probability of knowing someone with AIDS increased, the probability of

39 Central Statistical Office [Zimbabwe] and Macro International Inc, Zimbabwe Demographic and Health Survey, 1988 (Calverton, Maryland: Central Statistical Office and Macro International Inc, 1989), p. 78.

40 Gregson, 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?' 41 Ibid. 42 P. Setel, 'The Effect of HIV and AIDS on Fertility in East and Central Africa', Health Transition Review, 5, Suppl.

(1995), pp. 179-189. J. P. M. Ntozi, I. M. Nakanaabi, and Y. A. M. Lubaale, 'Fertility Levels and Trends in the Face of the AIDS Epidemic in Uganda', Health Transition Review, 7, Suppl. (1997), pp. 145-155. M. Ainsworth et al., 'The impact of AIDS Mortality on Individual Fertility: Evidence from Tanzania', in Montgomery and Cohen (eds), From Death to Birth.

43 Ainsworth et al., 'The Impact of AIDS Mortality on Individual Fertility'. 44 R. Loewenson and A. Whiteside, 'Social and Economic Issues of HIV/AIDS in Southern Africa: a Review of

Current Research' (Harare, SAfAIDS Occasional Paper Series No. 2 1997). 45 Ainsworth et al., 'The Impact of AIDS Mortality on Individual Fertility'. 46 Montgomery, 'Mortality Decline and the Fertility Transition'. 47 Gregson et al., 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?'; Central

Statistical Office [Zimbabwe] and Macro International, Zimbabwe Demographic and Health Survey, 1994. 48 Ntozi et al., 'Fertility Levels and Trends in the Face of the AIDS Epidemic in Uganda'; Ainsworth et al., 'The

impact of AIDS Mortality on Individual Fertility; Gregson et al., 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?'


Table 1. Sample size according to method, sex, and location

Urban Rural

Male Female Male Female Total Focus Groups* 7 8 10 10 35

In-depth Interviews** 10 12 13 11 46

* Focus Groups consisted of an average of 7.6 participants per group, ranging from 4 to 15

participants. ** Follow-up interviews were conducted with 14 individuals in order to further explore topics brought up in the first interview.

women wanting another child decreased.49 In another study, when asked directly, 50 per cent of rural Zimbabwean women said they wanted fewer children since hearing about AIDS, while only 3 per cent said they would increase their childbearing in response to AIDS.50 It appears, then, that the insurance strategy is not utilized since people do not

equate high levels of AIDS mortality with the need to have 'extra' children. Yet these studies are based upon people's perceptions of adult mortality. The effect of rising child

mortality on RDM has not yet been determined. In addition, it is not clear how urban-rural and ethnic differences may affect this process.

A review of the literature shows mixed effects of rising mortality levels on RDM, indicating that reproductive strategies commonly used in high mortality situations may not

apply in the HIV/AIDS epidemic in sub-Saharan Africa. Many of the previous studies have been quantitative: they have measured changes in fertility and hypothesized how individuals have responded to the AIDS epidemic. But such an approach does not take into account the

larger socio-cultural determinants of childbearing in a given setting. A more qualitative study with a focus on the exploration of individual perspectives and explanations for behaviour is needed to help understand how Zimbabweans articulate the reproductive decision making process and, specifically, how they respond to rising adult and child

mortality through changes in insurance, replacement, and other reproductive strategies.

Methods

The data presented here were collected in 46 in-depth interviews and 35 focus groups from six sites in Zimbabwe (Table 1). Of the predominantly Shona sites, the two urban sites included Highfield, a high-density suburb of Harare, and Rhodene, a low-density suburb of Masvingo. The two rural Shona sites consisted of a cluster of villages in Chirumanzu and Bikita districts in Masvingo Province. The Ndebele sites consisted of Nkulumane, a high-density suburb of Bulawayo, and a cluster of rural villages in the Lupane district in Matebeleland North Province. Preliminary results indicated few differences in RDM between the Shona and the Ndebele, so they will be combined in the analysis.

The overall study consisted of two phases of data collection. In Phase I, in-depth interviews were used to elicit individual reproductive histories and to explore factors considered in RDM, perceptions of, and experiences with, child mortality, perceptions of HIV/AIDS in the community, and cultural practices surrounding marriage. Fourteen interviewees were then selected for a return visit during Phase II in order to explore further some of the topics brought up in the first interview. In these repeat interviews, specific

49 Ainsworth et al., 'The impact of AIDS Mortality on Individual Fertility'. 50 Gregson et al., 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?'


questions were asked concerning the respondents' decision-making process or circumstances in having each child.

Focus group discussions were conducted in both phases of data collection because local health personnel believed that Zimbabweans speak more honestly in group settings than in one-on-one discussions. The addition of focus groups also allows for methodological triangulation, which enhances the credibility of the results. Focus group topics included reasons to have or not to have children at specific times, desired and ideal family size, individuals involved in RDM, perceptions of child illness and death, and perceptions of HIV/AIDS in the community and their effect on childbearing. In addition, respondents in the Phase I focus groups (n = 13) were presented with a photo and scenario depicting a southern African family, and issues such as HIV/AIDS, child fostering, spousal death and fertility decisions were discussed. This photo story was omitted in Phase II in order to focus more completely upon the reasons for having children and issues of desired and ideal family size.

A field team of Zimbabwean interviewers - six men and five women - collected all data. Prior to the data collection, the field team was intensively trained in qualitative research methods. Interviews and focus groups were conducted in Shona or Ndebele, depending upon the respondents' choice. Consent forms were read to individuals explaining the study and the choice to participate. Small monetary incentives were provided to participants at the completion of the interviews or focus groups.

The interviews and focus groups were audio-taped and later transcribed and translated into English. Random accuracy checks were done by other team members, including three graduate students in African Languages at the University of Zimbabwe. Key words for illnesses and traditional concepts were kept in the local languages.

Participants were either Karanga, a subgroup of the Shona-speaking people, or Ndebele, and had lived within the study sites for at least one year. The informant and the interviewer were of the same sex and the HIV status of the respondent was unknown to the interviewer.

In-depth interview participants were randomly selected from a list of stand numbers (households) in urban areas and from a list of village residents in the rural areas. In the few cases when the stand number did not exist, the next randomly selected household was approached.

Focus group participants were recruited by data collectors or through the local clinic or village headman in some cases. Using local criteria for determining social status, participants were separated into four groups: single women, married women, men under the age of 30, and men aged 30 and above. The moderator and recorder were always of the same sex as the group; however, it was not always possible to match them with the age or the marital status of the group.

Prior to analysis, the data were coded for relevant themes by two of this paper's authors. Inter-rater reliability was verified throughout the coding process by double coding selected documents to ensure that the code-book was utilised in the same manner. The data were then entered into the computer using the Non-Numerical Unstructured Data Indexing, Searching and Theorizing 4.0 (NUD*IST)51 software, and searches were conducted on relevant topics. The quotes presented in this paper were chosen for their representativeness.

51 Qualitative Solutions and Research, NUD*IST 4: Software for Qualitative Data Analysis, (Thousand Oaks, California, Sage Publications, 1997).


Results

The Cultural Context of RDM in Zimbabwe

Throughout the study, respondents stressed the importance of having children. In fact, when asked about reasons to have children, some of the older respondents had difficulties

answering because it seems that they had never before questioned their desire for children. Adult life was taken to be synonymous with childbearing, and many respondents referred to the societal and marital expectations that contribute to the view of childbearing as a duty in Zimbabwean society. One male respondent summed it up with the question, 'What will be the purpose of the wife who refuses to bear children?' Key reasons cited for having children included assisting parents in old age, continuing the name of the clan, and

providing joy or entertainment in the home. Companionship for the parents or for other

siblings was also an important reason to have a child. In particular, having the first child is important in proving one's fertility, in securing the bond between husband and wife, and, for the wife, in strengthening relationships with her in-laws.52

The main thing is that children create the relationship between the husband and wife. I have heard people saying that when there are children, there is ubushlobo [a bond] between the husband and the wife, and the wife and the husband's relatives ... When we have children, we are trying to build a relationship with those relatives.

34 year old urban woman, focus group

On the other hand, there are several factors that cause respondents to have fewer children today than in past years, especially the higher expectations of parents in raising children. Respondents felt strongly that parents should provide both sons and daughters with sufficient schooling, good clothing, and good food, all of which build the foundation of a bright future for the children. The general feeling was articulated by one respondent who said,

They never used to send girls to school. If I was able to send one boy to school, that was all right. Nowadays, every child you give birth to will demand to be sent to school.

30 year old rural woman, focus group

At the same time, when asked about influences on childbearing decisions, almost all

respondents spent significant time discussing the effects of Zimbabwe's economic crisis,53 and there were many references to rising prices and the steep decline of the Zimbabwe dollar, which had lost 50 per cent of its value in the months prior to the data collection.54 Most respondents were pessimistic about Zimbabwe's future economic situation, and were

apprehensive about giving birth to children they could not support financially, explaining that the children would grow up suffering physically and psychologically from a lack of food, clothing and care. Both urban and rural respondents talked of limiting their

childbearing due to the rising costs of bringing up children.

If I were to get enough money, I would just make sure that the four children I have receive a reasonable standard of living. They do not have to suffer ... But now we are failing. They come to us and tell us that their shoes are worn out and we just tell them to continue wearing

52 See also A. V. Shankar et al., 'Understanding Decision Making in the Reproductive Context: a Study in Zimbabwe' (unpublished paper, 2000) for further discussion on these topics.

53 This field work was completed within the first half of 1999, at which time Zimbabweans were experiencing rising prices and other warning signs of an economy in serious distress. Since then, the situation has worsened significantly with a near total collapse of the economy, including shortages of basic commodities and foreign currency, rampant inflation, high levels of unemployment and political turmoil.

54 Standard Chartered Bank, Business Trends in Zimbabwe, No. 62 (Harare, Zimbabwe, Standard Chartered Bank Zimbabwe Limited, November 1998).


them. The child would be affected psychologically in such instances ... I will be having a wish that if it's possible, my children could have an easier life.

42 year old urban man

Mortality Perceptions due to AIDS

Almost all respondents reported that mortality is currently higher than it has been in the

past, and most people attributed this increase to AIDS, sometimes called thathakancane

(literally, 'go slowly,' implying that one dies slowly), or mukondombera (the deadly plague) or simply, 'the disease of today.' There was also recognition that HIV/AIDS is passed from mother to child.

The young children are dying a lot these days because there are now a lot of diseases. Most of our mothers [women] are now carriers of a lot of diseases. A child can be born with a disease and it dies [reference to AIDS].

20 year old rural man, focus group

Some people said that deaths from illnesses such as measles, malaria, diarrhoea, and other diseases have increased dramatically in recent years. Many also said that AIDS was the root cause of the deaths.

In the past you could stay for about a year without attending a funeral. Now, not even a week will elapse ... This thing which is killing children was not there long ago. Now, a child can be born and you hear that they have inkhanda [sunken fontanel]; that was unheard of during our time. A child is born and you hear that the child has been admitted to the hospital, the child has chains [tetanus], the child is dead ... this AIDS is not sparing babies, I tell you.


The increase in adult mortality was emphasized even more than the increase in child

mortality. When questioned about rising mortality rates, many people first focused upon adult mortality and later talked about child mortality.

Q: Is it common here in your community for people to lose children to death? R: Ah, now I think that the major problem we have is that of parents ... That [problem] of

children [dying] appears to be minor, but that of the parents... [indicates that it is a big problem].

54 year old rural woman

The deaths of adults and children are linked. As participants in a focus group discussion

explained, they have seen entire families die of AIDS.

Rl: Right now when we go back home we will find messages that so-and-so has died. We are here [participating in the focus group], but others are actually busy burying someone ....

R2: Today it could be the father, tomorrow the mother, and the next day the child, and it just continues like that. You just can't count.

R3: The sun does not set before you have heard of a person who died. R4: Today you attend this funeral; the next day you are elsewhere; the next day someone else

passes away and again you are called. At times you just need to rest, you cannot go, and so you just send messages. It gets very tiring.

rural married women, ages 25-45 years, focus group

As the above quotations show, the increase in mortality rates in Zimbabwe is largely attributed to AIDS.

RDM Responses to AIDS

Respondents had mixed opinions about the ways that high AIDS-related mortality levels influence RDM in Zimbabwe. Twenty-two out of 46 in-depth interview respondents (48 per


cent) said that the AIDS epidemic causes them to limit their childbearing. However, ten of these 22 respondents talked about others who do not limit their childbearing with regard to the threat of HIV/AIDS. Nine of the 46 respondents (20 per cent) said that the AIDS epidemic has no effect on RDM, while only three (7 per cent) said that it causes people to have more children to ensure that some will survive. The remaining twelve respondents (26 per cent) did not state their opinions on this topic. There was no difference between men and women.

The focus groups confirmed the individuals' responses to high mortality levels in the community: limiting childbearing was independently mentioned in 33 of the 35 focus groups, while increasing childbearing was independently mentioned in only thirteen groups. Participants in nineteen focus groups said that RDM was not affected by higher mortality rates.

Some respondents claimed that educated or urban people are more likely to react to the AIDS epidemic by having fewer children, while rural and uneducated persons do not modify their childbearing in response to the threat of HIV/AIDS. However, this view was not supported by the data; in fact, a higher proportion of rural respondents (15/24 or 62 per cent) said that the AIDS epidemic has caused them to limit the number of children they have, in comparison with urban respondents (7/22 or 32 per cent). In addition, there was no difference between lower and higher educated respondents. Eight out of seventeen respondents (47 per cent) with a primary or lower educational level said that AIDS has caused people to have fewer children, and 13 out of the 27 respondents (48 per cent) with a secondary or higher educational level also believed that AIDS is causing people to limit their childbearing.55

The Effects of AIDS on RDM: Increasing Childbearing

Several respondents spoke about the need to have many children in order to ensure several surviving children, which is a description of the insurance strategy. Some said that this strategy was successful for their ancestors and that Zimbabweans today use it to counter the threat of AIDS mortality. In particular, these respondents were concerned with having at least one or two surviving children, as expressed by the following statements.

There are those who might use family planning to limit the number of children, but if you have few children, they might be all wiped out by AIDS and then you have nothing.

59 year old urban woman

I would want to have three girls and two boys. These days there are a lot of diseases. If I have two or three [only], they could die. [With five], even if some die, at least one boy will remain to keep the home going.


Overall, there were few in-depth interview respondents (3/46) who said they needed to have extra children to ensure that some survived; yet this strategy was discussed much more frequently in the focus groups (13/35).

In a related theme, several respondents said that they will have their children earlier than they otherwise would have, before HIV/AIDS becomes a factor. These respondents spoke as if they would inevitably contract HIV and develop AIDS.

I am thinking of having a child early, before the disease has attacked me. This is because it will spread to everyone.

23 year old rural man

55 The educational levels of two respondents were unrecorded. In addition, only two respondents with a lower educational level and seven respondents with a higher educational level said that AIDS has no effect on RDM.


[There is a 2-year spacing between children] because by the age of 30, I did not want to be found having children or breast feeding ... there are now a lot of diseases so it is better if I have all my children now so that I will have had them before the disease ... AIDS is the deadly disease. Any day, any time, you can have the disease and it will kill you.


The Effects of AIDS on RDM: No Link

Respondents who said that the increase in AIDS mortality has no effect on RDM reported that Zimbabweans do not consider mortality when they make decisions about having children. Usually they said that parents do not think that their children will die; therefore, they do not make reproductive decisions based upon the possibility of death.

I know that even if you bear ten [children], if God wishes that all may die, all will die. So I don't consider the mortality of children; I just bear the number that I want. Death has always been there, so mortality should not be considered on children. Even if I have two when people are saying they'll both die, maybe it will be me who will die first, so I won't listen to that!


According to these informants, other factors (e.g. a couple's economic resources) influence

family size to a much greater degree than the fear that children might die. These

respondents also said that people who appear healthy are not influenced by the AIDS

epidemic when they make reproductive decisions.

[AIDS] doesn't influence people on the decision of having children as such. The fact is that people are not aware who has AIDS and who doesn't. So if you want to have [children], you just have them, until you realise that there might be AIDS in the family and then maybe it will be too late to stop having children.


RDM Response to AIDS: Decreasing Childbearing

Many respondents maintained that the AIDS epidemic causes them to limit their childbear-

ing - which is a new reproductive strategy for a high mortality environment. The fear and emotional pain of child death was the most frequently mentioned reason to have fewer children. Interview respondents (18/46) and participants in focus groups (24/35) frequently cited concerns about the health and well-being of children and about the emotional pain of

losing a child as factors in their reproductive decisions.

In the past five to seven years, children have been dying a lot. Even if you look here in the village, you hear, 'A child has died here, and a child has died there.' In the end, someone will say, 'I am now afraid of having children.'


The risk of adult mortality also seemed to influence people to have fewer children.

Although respondents perceived that mortality rates for all ages have increased, they explained that HIV/AIDS has affected young adults (approximately ages 20 to 40 years) more than other age groups, such as young children. Therefore, adult mortality may have more of an influence on people's reproductive decisions than child mortality.

I think there are more funerals of adults than of children. These days, women of childbearing age die more, and I think that makes the death rate rise. But the most affected age group is 30-35 years of age.

49 year old rural woman

Specifically, the fear of contracting HIV/AIDS was a reason to have fewer children, as

explained in several interviews (7/46) and in about half of the focus groups (17/35). Beliefs


that pregnancy and childbearing weaken the body contributed to this view, especially for women.

Nowadays if you have five children, mostly by the time you have the fifth or the sixth, you will already have been infected by a disease. Delivery is what intensifies ... when you deliver, that's when it really gets into your body and you go [die].


Respondents also spoke about limiting their family size so that the children would be less of a burden on relatives should the parents die. This concern was addressed in a few interviews (4/46) and a quarter of the focus groups (9/35).

When you die of AIDS, nobody will look after an extra large family on top of their own family, so the children will suffer ... If there are many, it is not easy to get somebody to look after them.


Female focus group participants, in particular, spoke of their fears of dying from AIDS as a reason to have few children, probably reflecting the view that childbearing causes AIDS to surface. In contrast, male focus group participants focused upon the welfare of the child as a reason to limit family size in the context of the AIDS epidemic.

The Effects of AIDS on RDM: Child Fostering

The AIDS epidemic may also affect the RDM of surviving adults through the additional

responsibilities of raising the children of deceased relatives. A few respondents said that the economic burden of these children influences people to have fewer children.

However, more respondents said that, despite the economic burdens of fostered

children, they would not limit their own family size because one could not depend upon fostered children for old age security.

These [fostered] children will only help around the homestead when they are young. They can go and work elsewhere or get married and build their own homes and so the mother who stays behind - if she did not have her own children - will be left alone.


Furthermore, the financial needs of fostered children are shared among the extended family; therefore, some respondents said that the cost of raising these children is not a deterrent to

achieving one's desired family size.

The Effects of AIDS on RDM: the Five-year HIV Test

Respondents also spoke of concerns for the health of their children and their effects on RDM. All respondents knew about the risks of transmitting HIV/AIDS to an unborn child

through pregnancy and breastfeeding, but they greatly overestimated these risks: almost

every respondent said that all babies born to HIV-positive (but healthy-looking) women would die of AIDS.

Therefore, respondents argued, healthy children indicate the health of the parents, especially the mother. This belief was a factor in the decision-making of some respondents who explained that they carefully watch their youngest children for signs of HIV/AIDS. If a child survives to age five, the parents continue to have children because they are confident


in their own health.56 Interestingly, this was true for both men and women because

respondents said that an unhealthy child indicates that the father is also ill.

If a child is born and reaches four and a half years without dying, it means that the father and mother do not have AIDS. So I wait for five years, or four and a half years, then I say, my wife has survived, I have survived, fire! [he will have sex with her and have another child]


Although this strategy was mentioned in only a few focus groups (6/35) and in-depth interviews (4/46), the universally held belief in 100 per cent transmission suggests that this

strategy may be commonly used. Several individuals took this a step further by saying that people have a child

specifically to determine their own HIV status. Although respondents did not say that they themselves used this strategy, they referred to others who did.

Most people look for proof first because they know that a child cannot live beyond five years [with AIDS] as I was saying. He can have an example of one child in order to prove whether he has AIDS or not. If the child goes beyond [5 years] then he knows he is safe. That's when he continues to have children.


The Effects of Spousal or Child Death on RDM

As more and more Zimbabweans experience the death of a child or a spouse, many of them are in the position of making decisions about future childbearing. In the past, respondents said that couples would quickly have another child after one had died. But in several interviews (10/46) and focus group discussions (13/35), respondents said that they would continue to have children only when they were fairly confident that these future children would survive. When a child dies, the husband and wife may suspect that one or both of them are HIV positive. Since most respondents reported that all children born to HIV-positive women would die before reaching the age of five, they believed that continuing to have children in that situation was senseless.

If the rate of child death is high in my family, maybe I will be HIV positive or my wife, so there is no point in continually having children because they will keep on dying.


However, the situation is not always so clear. Some respondents mentioned that it takes more than one child death for parents to change their reproductive strategies.

In addition, people have different responses to older and younger child deaths, as explained by the following passage.

Q: OK, I know that this question might not be comfortable for you, but since we are learning, we need to ask it. Let's say if one of your children died - either the elder or the younger - would you have another child?

R: Yes, it depends upon who dies. If the younger one dies, I will wait ... I would be interested in knowing what caused her death. If the elder one died, ahh, I will have another one. If a child dies around five years, I can have another one. If the child dies below five years, I will wait to see if the elder one reaches around five years.

Q: Why would you be waiting five years? R: The church that we go to teaches us about diseases. In most cases, people are able to bear

children who are strong, yet they [the children] might be infected. They can survive for two years and then they can die. So if I see a child reaching six years, then at least ... [laughter]

56 In general, many respondents believed that a five-year spacing was ideal. Although they did not always explicitly link this to AIDS, the high frequency of this response may be a reaction to the AIDS epidemic. This could also be reflective of family planning campaigns and the cost of secondary school fees.


Table 2. Numbers and percentages of focus group participants on future plans of a man whose wife recently died of AIDS

This man will continue This man will remarry having children

% %

Men 14/21 67 15/22 68 Women 7/11 63 14/26 54

Younger* 7/13 54 12/24 50 Older* 14/19 74 17/24 71

* 'Younger' includes men under the age of 30 and unmarried women. 'Older' depicts men aged 30 or older and married women.

Q: What disease is this? R: AIDS


The effect of the death of a spouse on childbearing was treated with more ambiguity. When asked directly, most respondents stated that HIV-positive individuals do not want to

remarry or have more children; however, few Zimbabweans know their true status,

including those who lose a spouse or a child to an AIDS-like illness. As a 27-year old rural man said, 'The problem is that you will never know whether you have it [HIV] or not, so

you will continue having children.' When presented with a scenario about a man whose wife recently died of AIDS, focus

groups participants vigorously discussed the possibilities of his remarriage and future

childbearing. Twenty-nine focus group participants believed that a man in this situation would continue having children, while only 19 said that he would stop having children because of his fears of having the disease himself. As shown in Table 2, a majority of men and women said that this individual would remarry. There was a greater difference between the older and younger focus groups: a higher proportion of men over age 30 and married women (the higher status focus groups) said that remarriage and childbearing would

continue, compared with unmarried women and men under age 30. There are societal pressures for a widower to remarry. Because it is not culturally

acceptable for a man alone to care for young children, he may look for a wife to care for himself and his children. Although some families are wary of widowers who want to marry their daughters, other respondents said that men who are able to pay lobola (the brideprice) are accepted with few questions asked. Having a child in this union is important in securing the bond between husband and wife. Sometimes, respondents said, it is the wife who insists

upon a child to secure her own position in the relationship, whether or not she is aware of her husband's HIV status.

The new wife will want to make her husband happy by bearing a child ... because a person just feels that if I haven't given him a child, our relationship is not yet closely tied.


Finally, the need to have a child was especially strong for individuals who do not yet have children, despite the possibility of being HIV positive. For men, in particular, the fear of never having a child seems to be stronger than concerns about spreading HIV.

In our culture, he [an HIV-positive, childless man] will argue, 'I cannot just die childless'. He will say 'I will certainly have a child. I can't be said to have died without a child' ... so he will certainly marry [again].



Discussion

With the dramatic increases in adult and child mortality and with over a quarter of the

population infected with HIV, the AIDS epidemic is at the forefront of issues facing Zimbabweans today.57 Although this project was not intended to focus upon HIV/AIDS, we found that our respondents did not discuss RDM without talking about the devastating effects and implications of the AIDS epidemic.

Recent surveys have documented dramatic increases in adult and child mortality levels in Zimbabwe,58 and there is evidence that Zimbabweans perceive mortality trends accu-

rately, even if the levels may be overestimated.59 Although many respondents expressed despair at the rate of death for both children and adults, it seems that Zimbabweans have so far experienced the AIDS epidemic more as an adult epidemic than as a child epidemic. Therefore, RDM may be more influenced by the threat of their own death and implications for their families than by the death of their children, thereby diminishing insurance and

replacement effects. In addition, the linkage between child and adult mortality is growing because HIV is

vertically transmitted; if one dies, the other usually follows. In this situation, it seems that

the replacement strategy is no longer viable. The trauma of child death and the fear that it

could happen again were so great that many respondents said they would not want to risk

continued childbearing in this situation. A child death causes the parents to suspect they might be carrying HIV, and many respondents expressed fear that the entire family would

die. Instead of wishing to increase their number of children, they expressed the desire to

focus on the children they already had. As this research indicates, there seem to be important differences between men's and

women's views of replacement. Because of the risks involved in pregnancy and childbirth, women may be less inclined to replace the children they have lost than men. We have found

that pregnancy and childbirth are viewed as weakening the woman's body, thus increasing the chances of their developing AIDS. This is matched by the views expressed in a similar

study in Zambia.6? While women spoke about the negative effects of pregnancy and childbirth on an HIV

positive woman, men may have other reasons for continuing childbearing after the death of

a child or a spouse, such as finding someone to care for his children. There is also evidence that men with no surviving children may try to have other children after the death of a

spouse or a child. Respondents also cited 'others' as continuing to have children after one

died; in reality, therefore, the replacement strategy may be used more frequently than

people disclosed. As the replacement strategy loses its effectiveness because of the direct link between

57 M. Bassett and M. Mhloyi, 'Women and AIDS in Zimbabwe: the Making of an Epidemic', International Journal of Health Services, 21, 1 (1991), pp. 143-156; Loewenson and Whiteside, Social and Economic Issues of HIV/AIDS in Southern Africa: a Review of Current Research; G. Foster, C. Makufa, R. Drew, and E. Kralovec, 'Factors Leading to the Establishment of Child-Headed Households: the Case of Zimbabwe', Health Transition Review, 7, Suppl. 2 (1997), pp. 155-168; Gregson et al., 'Recent Upturn in Mortality in Rural Zimbabwe'. Meursing, A World of Silence.

58 Central Statistical Office [Zimbabwe] and Macro International, Zimbabwe Demographic and Health Survey, 1994. UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic.

59 M. Mahy, 'Perceptions of Child Mortality and their Effects on Fertility in Zimbabwe' (unpublished PhD thesis, The Johns Hopkins University School of Hygiene and Public Health, 1999).

60 C. Baylies, 'The Impact of HIV on Family Size Preference in Zambia', Reproductive Health Matters, 8, 15 (2000), pp. 77-86.


adult and child mortality, the insurance strategy is also limited by several factors. Especially after couples already have one or two children, RDM is influenced heavily by economic concerns, fears of vertical and horizontal HIV transmission, and worries about who will care for AIDS orphans. Even without the threat of HIV/AIDS, few people would have 'extra' children, because of the current economic instability and the increasing costs of bringing up children. In addition, it seems that the risk of dying of AIDS and the problems of finding caretakers for large families may influence couples to limit the number of children they bear. As households suffer from the loss of their breadwinners, the cost burden of children may increase further, and this was also found in the Zambian study.61

While many respondents said that HIV-positive individuals will stop bearing children, the picture becomes less clear when an individual's HIV status is unknown, as in the case of the vast majority of Zimbabweans. According to this study, having a child die of AIDS

may be a better indicator of one's own status - and may influence people to change their reproductive strategies - than experiencing the AIDS-related death of a spouse. However, there are significant cultural pressures to have children; in particular, if the couple has few or no children, the desire to produce living children may outweigh concerns about mortality. In addition, people who attribute the death of a child or a spouse to supernatural causes may not modify their childbearing. People may focus upon these traditional explanations because of the lack of treatment for HIV and potential ostracism of HIV positive individuals from the family and community.

According to this study, Zimbabweans are unlikely to use the insurance or replacement strategies in response to AIDS mortality as some have feared.62 Rather, successful childbearing in this context seems to be measured not only in terms of the number of surviving children, but also in terms of the health of both parents and children, a finding that lends support to a model presented by Bledsoe et al. in The Gambia.63 Their observations were made in respect of a population with low HIV prevalence; the influence of health on RDM may be even greater in countries like Zimbabwe with a higher HIV prevalence.

These new reproductive strategies may take several forms. There is evidence that some Zimbabweans attempt to avoid HIV/AIDS by modifying the timing of their childbearing. Some report that they plan to have their desired number of children quickly, before they are infected or before the disease inevitably emerges. This matches prior research in Uganda.64 Earlier childbearing also allows parents to provide for their children while still healthy, which would counter their fears about leaving young children as orphans.

Other new strategies are based upon misperceptions of HIV/AIDS and may have negative health implications. There is anecdotal evidence that some health workers may be suggesting that there is 100 per cent vertical transmission of HIV/AIDS, presumably in an effort to discourage childbearing among HIV-positive individuals and out of concern for the rapidly growing numbers of orphans in Zimbabwe.65 But, as this study has found, these efforts may have some unintended consequences, as Zimbabweans may be using the health and survival of their children to age five as an indicator of their own HIV status. People using the 'five-year HIV test' strategy may mistakenly believe that they are free of the virus and continue to have children until they have an unhealthy child. Or, parents may acquire

61 Ibid. 62 Setel, 'The Effects of HIV and AIDS on Fertility in East and Central Africa'. 63 C. Bledsoe, F. Banja, A. G. Hill, 'Reproductive Mishaps and Western Contraception: an African Challenge to

Fertility Theory', Population and Development Review, 24, 1 (1998), pp. 15-57. 64 Ntozi et al., 'HIV/AIDS and Fertility Levels in Northern Uganda'. Ntozi et al., 'Fertility Levels and Trends in

the Face of the AIDS epidemic in Uganda'. 65 A health worker in Bulawayo mentioned this in an informal conversation with one of the project co-ordinators.


HIV after a healthy child is born and mistakenly believe that they are free of the virus. Since respondents expressed great concern about the well-being of their children, it is

possible that they would have decided against further childbearing had they used a more reliable method of testing. Even if these children escape the infection - as up to 75 per cent will66 - they are at high risk of becoming orphans because their parents are likely to die within five to ten years.67 Although there is little evidence in Zimbabwe that orphans are

stigmatized for having a parent die of AIDS, these children may experience discrimination due to the poverty that often accompanies their status as orphans.68

On a related theme, there is also evidence that some individuals may be having children

specifically to determine their HIV status. This is not unique to Zimbabwe; in urban

Uganda, the local explanation for an increase in pregnancies in 1989-90 was the desire to determine one's HIV status.69 It is important to understand how individuals and couples make this decision. Respondents of both sexes referred to men who use this strategy because the photo story activity involved a man whose wife had died of AIDS; however, it is important to know to what extent women use it. Despite closer ties to the health of a child because of pregnancy and childbirth, a woman who wants to know her HIV status

may believe that her only option is to have a child, because to request that her husband gets tested implies a lack of trust that could have negative consequences.

This study found that respondents spoke frankly about their expectations for shortened lives, which may mean that some Zimbabweans are looking for short-term, rather than long-term, reproductive strategies. In this study, respondents repeatedly emphasized the need for children for old age security; yet they were greatly concerned about their children's chances of survival, especially until the age of five, and also until they could support themselves. As AIDS continues to claim its victims, people may focus less on long-term benefits such as security in old age and more on the short-term benefits and costs of children.

Finally, the attempt to continue a normal life - which in most cases means having children - may be a coping response to the high rates of death and dying in the community. As other researchers suggest, childbearing may be an attempt to return to the normalcy of pre-HIV life for those recently diagnosed.70 For those who do not know their status, childbearing may also be an attempt to carry on a normal life as long as possible.

Limitations

Death and fertility intentions are a sensitive topic in many cultures. In some cases, people may fear that talking about the death of a child may make it come to pass; their concerns about the mortality risks of their children may, therefore, be greater than they express

66 UNAIDS and WHO, 'Report on the Global HIV/AIDS Epidemic'. 67 J. Z. J. Killewo, J. Comoro, J. Lugalla, G. Kwesigabo (eds), Systemic Interventions and their Evaluation Against

HIV/AIDS in Kagera Region, Tanzania, Proceedings of a workshop held in Bukoba, Tanzania, 10-11 May (Dar-Es Salaam, Muhimbili University College of Health Sciences, 1993); Ainsworth and Over, 'AIDS and African Development'.

68 G. Foster, R. Shakespeare, F. Chinemana, H. Jackson, S. Gregson, C. Marange, and S. Mashumba, 'Orphan Prevalence and Extended Family Care in a Peri-Urban Community in Zimbabwe', AIDS Care, 7, 1 (1995), pp. 3-17; G. Foster, C. Makufa, R. Drew, S. Mashumba, and S. Kambeu, 'Perceptions of Children and Community Members Concerning the Circumstances of Orphans in Rural Zimbabwe', AIDS Care, 9, 4 (1997), pp. 391-405; G. Foster, C. Makufa, R. Drew, and E. Kralovec, 'Factors Leading to the Establishment of Child-headed Households: the case of Zimbabwe, Health Transition Review, 7, Suppl. 2 (1997), pp. 155-168.

69 E. M. Ankrah, 'AIDS and the Social Side of Health', Social Science and Medicine, 32, 9 (1991), pp. 967-980. 70 S. Allen, A. Serufilira, V. Gruber, S. Kegeles, P. Van de Perre, M. Carael, and T. J. Coates, 'Pregnancy and

Contraception Use Among Urban Rwandan Women After HIV Testing and Counselling', American Journal of Public Health, 83, 5 (1993), pp. 705-710.


openly.71 To the extent that this is the case in Zimbabwe, respondents may have understated their fears of, and responses to, the AIDS epidemic, especially when asked about the possibility of their own children dying. We tried to minimize this bias by using qualitative research methods, which are good at delving into sensitive topics.

Another limitation concerns informants' perceptions of the interviewers. Because there have been widespread HIV/AIDS awareness campaigns in Zimbabwe, respondents may have associated the data collection with these campaigns and may have tailored their responses accordingly. Especially in the rural areas, outsiders can easily be viewed as authority figures. For example, informants may have merely repeated what they were taught about not having children if they were HIV positive, rather than what they would actually do in such a situation. To minimize these interviewer effects, data collectors were trained to encourage the respondent to be the expert in these topics.

Future Directions

This study has implications for the field of demography and, in particular, the nature of the link between mortality and fertility. While the insurance and replacement strategies seem to be minimally utilized in an AIDS epidemic, the decline of health and life expectancy has caused new strategies to emerge that need to be identified and described in order to determine ways to stop the spread of the epidemic.

Fears of childlessness and personal risk of HIV/AIDS have implications for RDM in the context of the AIDS epidemic in Zimbabwe. Further research is needed to understand these issues in other cultural settings. While perceptions of risk appear to have some effect on RDM,72 it is unclear how these perceptions are formed and what additional mechanisms may prevent individuals from developing a sense of risk of HIV.

Finally, this study supports evidence that the gradual discovery of one's status may be preferable to the suddenness of a conventional HIV test.73 Because there is evidence that parents are using the survival of their children to determine their own HIV status, efforts need to be made in dispelling the 100 per cent transmission myth as well as in making other forms of testing more acceptable and available.

MIRA GRIESER 1348 Parkwood Place, NW, Washington DC, 20010, USA. E-mail: [email protected]

71 S. C. Randall and T. K. LeGrand, 'Is Child Mortality Important? Reproductive Decisions, Strategies and Outcomes in Senegal' (unpublished paper, 2000); S. Castle, '"The Tongue is Venomous": Perception, Verbalisation and Manipulation of Mortality and Fertility Regimes in Rural Mali' (unpublished paper, 1999).

72 Gregson et al., 'Is There Evidence for Behaviour Change in Response to AIDS in Rural Zimbabwe?'. 73 Krabbendam et al., 'The impact of counselling on HIV-infected women in Zimbabwe'.

Documents

Reproductive Decision Making and the HIV/AIDS Epidemic in Zimbabwe