2016. Obzornik zdravstvene nege, 50(2), pp. 107-125. Original scientific article/ Izvirni znanstveni članek Qualitative analysis of factors associated with the experience of contraception in rural setting Kvalitativna analiza dejavnikov, povezanih z doživljanjem kontracepcije v ruralnem okolju Špela Črnigoj, Mirko Prosen ABSTRACT Key words: society; family planning; health literacy; quality of life; phenomenology Ključne besede: družba; načrtovanje družine; zdravstvena prosvetljenost; kakovost življenja; fenomenologija Špela Črnigoj, RN; General Hospital dr. Franc Derganc Nova Gorica, Ulica padlih borcev 13a, 5290 Šempeter Correspondence e-mail/ Kontaktni e-naslov: spela185@gmail.com Senior Lecturer Mirko Prosen, MSc, BSc, RN; University of Primorska Faculty of Health Sciences, Polje 42, 6310 Izola The article is based on a diploma thesis of Špela Črnigoj The rise of birth control and its importance for women (2015)./ Članek je nastal na osnovi diplomskega dela Špele Črnigoj Vzpon kontracepcije in njen pomen za ženske (2015). Received/Prejeto: 21. 12. 2015 Accepted/Sprejeto: 18. 5. 2016 Introduction: The phenomenon of contraception, its prevalence and its implication for women's emancipation is influenced by a number of social factors, including the environment. The purpose of this study was to examine the phenomenon of contraception through the eyes, knowledge, experience and perception of women living in rural areas. Methods: The phenomenological approach was used within the framework of qualitative methodology. The purposive sample included eight women aged 20 to 50 years, living in the rural areas of western Slovenia. The research was conducted in April and May 2015. The data obtained through semi-structured interviews were analysed using the method of phenomenological text analysis. Results: The analysis yielded four thematic groups which conceptualize the studied phenomenon: (1) the factors affecting the choice and use of a contraceptive method and its acceptance, (2) the importance of contraception for women, (3) the education and acquisition of adequate contraceptive knowledge, (4) the women's social status. Discussion and conclusion: Results of the research indicate that contraception is an important dimension of women's quality of life and their social status. The acceptance of contraception and the selection of a contraceptive method are influenced by a number of social factors and guided by various support systems. The knowledge of these factors enables nurses to systematically plan and deliver health education. Further research of the phenomenon could be conducted also among urban female population. IZVLEČEK Uvod: Fenomen kontracepcije ter njene razširjenosti in pomena, ki ga ima ta za emancipacijo žensk, krojijo številni družbeni dejavniki, med njimi tudi okolje. Namen raziskave je bil preučiti fenomen kontracepcije skozi videnja, vedenja, izkušnje in doživljanja žensk, ki živijo v ruralnem okolju. Metode: V okviru kvalitativne metodologije je bil uporabljen fenomenološki pristop. Namenski vzorec je vključeval osem žensk, starih od 20 do 50 let, ki živijo v ruralnem okolju zahodne Slovenije. Raziskava je potekala aprila in maja 2015. Podatki so bili pridobljeni s pomočjo delno strukturiranih intervjujev in analizirani s pomočjo metode fenomenološke analize besedila. Rezultati: V analizi so bile identificirane štiri tematske skupine, ki konceptualizirajo preučevani fenomen: (1) dejavniki, ki vplivajo na izbiro in rabo kontracepcijske metode ter njeno sprejemljivost, (2) pomen kontracepcije za ženske, (3) vzgoja in pridobivanje ustreznega znanja o kontracepciji, (4) družbeni položaj žensk. Diskusija in zaključek: Izsledki raziskave kažejo, da je kontracepcija pomembna dimenzija kakovosti življenja žensk in njihovega družbenega položaja. Sprejemljivost kontracepcije in izbiro kontracepcijske metode oblikujejo številne družbene okoliščine in usmerjajo mnogi podporni sistemi. Medicinski sestri poznavanje teh informacij omogoča načrtovanje sistematične zdravstvene vzgoje. Priložnosti nadaljnjega raziskovanja se kažejo v preučevanju fenomena na populaciji žensk v urbanih okoljih. http://dx.doi.org/10.14528/snr.2016.50.2.85 108 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Introduction Throughout history, mankind has tried to limit family size (Glasier, 2002). The idea of contraception has been around for thousands of years and has been documented through various forms of art and written word (Evans, 2009). Birth control methods throughout history have ranged from ritualistic and mythical to practical and effective. Until the last century, this was largely achieved by behavioural modifications, including abstinence, infrequent coitus, the avoidance of intercourse during the fertile period of the cycle and coitus interruptus (the withdrawal method). Breastfeeding, which inhibits normal ovarian activity, has been, for instance, one of the most important means of limiting fertility, whereas for individual couples, coitus interruptus, first mentioned in the book of Genesis, has had a major role to play (Glasier, 2002; Cook, 2004). Many of the contraceptive techniques used in the past are not so different from the methods popular today (Evans, 2009). Contraceptives have been used in one form or another for thousands of years — throughout human history and even prehistory. In fact, family planning has always been widely practiced, even in societies dominated by social, political, or religious codes (Gordon, 2002; Stankuniene & Maslauskaite, 2008; Planned Parenthood Federation of America, 2012), that required people to "be fruitful and multiply" — from the era of Pericles in ancient Athens to that of pope, today (Planned Parenthood Federation of America, 2012). Today, several methods of contraception are available which the medical science divides into traditional or natural, and modern. The modern methods include male and female sterilisation, contraceptive pills, intrauterine devices, contraceptive injections, implants, rings, condoms, sponges, spermicides, and diaphragm. The traditional contraceptive methods encompass breast-feeding, withdrawal and natural family planning (Cook, 2004; Evans, 2009; Oliveira da Silva, et al., 2011). Scott (2013) states that women's contraceptive needs change throughout their lives. Sexually active women can choose the most effective contraceptive method that will best suit them in particular life circumstances and psychosocial needs (Tone, 2012). In 2011, worldwide an estimated 63 per cent of women were using a contraceptive method, though contraceptive prevalence levels varied widely across major areas and sub-regions (United Nations, 2013). According to the most recent data available, contraceptive prevalence among women of reproductive age who are married or in a union varies between 4 percent in South Sudan and 88 percent in Norway. Contraceptive prevalence was lowest in Africa (31 percent), and 70 percent or higher in Europe, Latin America and the Caribbean, and Northern America. In developed countries short-term and reversible methods (e.g. pill, injectable and male condom) were more commonly used, while in the developing countries female sterilization and the Intra Uterine Device (IUD), the longer-term or permanent methods, were the two most common methods used by married or in-union women worldwide (United Nations, 2013). According to the National Institute of Public Health, nearly a million packages of birth control pills were dispensed in Slovenia in 2012, which indicates that more than 77, 000 women of reproductive age (15-47 years), that is 162 out of 1000 women use hormone contraception. The use of the latter has increased in adolescents and young women between 20 and 24 years of age. On the other hand, the use of hormone contraception in women aged over 30 years is in decline. Hormonal contraceptives are used by one out of three women aged 20-24 years and one out of five women aged 15-19 and 25-29 years. The IUD was commonly used in the 1980s and in the early 1990s, but later its use decreased. In the last decade its use has been on the rise again. Condoms remain the most common contraceptive method among the young beginning their sexual life (Nacionalni institut za javno zdravje, 2014). The impact of contraception of women's emancipation Birth control plays an important role in controlling family size and population growth. It is also central to the welfare of population, especially women (Gordon, 2002; Cook, 2004; Benagiano, et al., 2007). Gordon (2002) argues that women's status cannot be linked to a specific system of sexual or reproductive regulation. The changes of the latter go hand in hand with the change in women's status. They influence and reflect each other. There is a strong correlation between women's subordination and birth control prohibition. Birth control has played an important role in society's attitudes toward gender inequality and has always been central to women's status. On the other hand, women's emancipation and equity between sexes may open new paths to family planning and women's reproductive rights. Lupton (2003) claims that contraception and abortion are focal points in societal ambivalence about the feminine role, the right of women to take control over their bodies and their reproductive destinies, and the subsequent impact upon their potential for emancipation. By the end of the 19th century the conventional medicine abandoned the idea of further development of oral contraceptives. Half a century later, Margaret Sanger and Katherine Dexter McCormick, the American birth control activists and ardent supports of women's rights, spurred its development. McCormick financed the then controversial research conducted by Gregory Pincus, Min Chueh Chang and John Rock. They tried to produce an oral contraceptive based on synthetic progesterone, the distribution of which 109 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. was approved in 1960 (Lupton, 2003; Prescott, 2011; Planned Parenthood Federation of America, 2012; Wigginton, et al., 2015). Although the first pill was far from perfect, it was the first time in history that women gained an unheard-of effective and simple control over reproduction. Subsequently, the pill made the sexual liberation movement of the 1960s a lot less risky than the one which occurred after World War I (Planned Parenthood Federation of America, 2012). The second sexual revolution spread the idea of free love and free sexuality. The double standard of evaluations of sexual behaviour existing among the two genders gradually faded away and women were granted the right to their own sexuality and sexual pleasure. The non-reproductive sexual relationships and non-conceptive copulations began to be separated from the sexual reproductive function, which gave way to openness of sexuality and commercialisation of sexual sphere (Anurin, 2002). Giddens (2000) argues that the sexual revolutionary changes are closely related to women's emancipation which contributed to their sexual and emotional equality and freedom. Although the sexual freedom is only partial, there is a huge difference with what it was decades ago. Contraception caused drastic changes which freed women from constant fear of repetitive pregnancies and therefore of maternal or infant death, given the substantial proportion of women who perished in childbirth. Not only did contraception allow women to plan and space pregnancies, it also brought about deep changes in women's lives. According to Giddens (2000), sexuality became malleable and "a potential property" of women in a manner that allowed them to escape men's dominance' (te Velde, 2011). The ethnographic research on sexuality in Slovene rural communities from the beginning of the 20th century to 1960 (Miklavcic, 2014), describes the harsh and unenviable position of women who were denied equal rights. Their sole responsibility was to be a good housewife, bear children and meet their husbands' needs. Boh (1975) discussed an important effect of contraceptive pill and other modern contraceptive methods on women's freedom which started in 1970s. Women no longer needed their husbands' cooperation in family planning, they could regulate and control their fertility without men's consent or control. Ule and Kuhar (2003) stated that with the introduction of safe and reliable contraceptive methods it became possible to separate sexuality from its reproductive consequences. Women, especially young ones, suddenly had full control over their bodies and reproduction. The availability of simple and effective methods of contraception fundamentaly changed partner relationships within and outside the family. Women joined the workforce and became equal to men in this respect. Having children became an issue of women's personal choice who tend to delay motherhood due to training for jobs and careers (Ule & Kuhar, 2003; te Velde, 2011). Speaking of the Central and Eastern European countries, the described changes are, however, not equally and universally present. In the post-communist European countries of the 'new' Europe, including Slovenia, the enormous changes started in the family formation and fertility patterns which followed the second demographic transition, namely, individualism, secularism and female emancipation. The family changes have been taking place in the region only since 1990s (Stankuniene & Maslauskaite, 2008). The measures that would help curb the population explosion are also frequently blocked by political regimes and by those professing conservative religious beliefs, but the world's religions are not uniformly conservative on issues of family planning (Maguire, 2003). The Roman Catholic Church does not approve of intrinsically evil 'artificial' contraceptive methods, claiming that it enhances promiscuity and acts against nature (Tone, 2002). Medicalization of contraception Controversies regarding the provision of contraception and safe methods of contraception of women have revolved around notions of the ideal motherhood and the desire of medicine to preserve the control over women's reproduction (Lupton, 2003). Lowe (2005) claims that medicalization of contraception attracted attention of several feminist researchers. They emphasise that one of the significant differences between the historical and current use of contraception lies in the involvement of medical profession and its control over women's body, especially their reproductive role. Riessman (1983) argued that medicalization of women's health became a reality of contemporary society. Women themselves allowed biomedicine enter into their lives in their desire to free themselves of the burden of natural, biological processes. According to te Velde (2011), women will never give up their newly gained independence and freedom in the 1960s. Before the 1960s only a small minority of women discussed a medically controlled family planning. At that time, most of the couples relied on the diaphragm as medicalized birth control method. For several reasons couples prefered condoms and other natural contraceptive methods, and it fell out of favour. The introduction of contraceptive pill caused a large medicalization of contraception, used against unintended pregnancy by millions of women worldwide (Tone, 2012). Lowe (2005) claims that contraception has an extraordinary status in medicine. As it is prescribed to a vast number of healthy women, often for a long period of time, and therefore these women can not be treated as patients in the classical sense. On the other hand, Tone (2012) believes that the introduction of the pill and its popularity normalized the prevailing influence of medicalization 110 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. on contraception and women's reproductive health, and opened the path to other hormonal contraceptives and medicines of the modern lifestyle. Aim and objectives The aim of the research was to examine the phenomenon of contraception through the perception, knowledge and experiences of women in rural areas. Several social factors, including environment, affect the contraceptive use and its impact on women's emancipation. Due to the multifaceted nature of the phenomenon, the research was primarily focused on women's perception of contraception. The following qualitative issues were researched: - The contraceptive knowledge, attitude and practice among rural women. - The influence of micro-level living environment on the use of female contraception. - The impact of women's contraceptive knowledge and motivation on the selection and consistent use of contraception. Methods A qualitative research method and a non-probability purposive sampling were used in a phenomenological study to obtain in-depth information pertaining to participants' understanding, viewpoints and perception of contraception. Description of the research instrument The data were gathered through a semi-structured interview. According to Kvale (2007), the purpose of a qualitative research interview is to gather descriptions of the life-world of the interviewee with the intention of interpreting the meaning of the described phenomena. The interviews were organised around a set of predetermined open-ended questions, with other questions emerging from the dialogue between interviewer and interviewees (DiCicco-Bloom & Crabtree, 2006). The questionnaire consisted of 12 general open-ended questions which later developed into a more individual in-depth interview, delving deeply into personal matters regarding contraception and its consequential effects on quality of life. Following are some examples of research questions: What are your views on the status of women in modern society?; Was sex education and contraception part of your early health education at home?; When did you first consider the use of birth control?; What is your personal opinion about birth control?; How does birth control effect your sexual life and the quality of your life?; Did you let your gynaecologist choose the contraceptive method you are currently using?; Did you decide upon a contraceptive method prior to your visit to a gynaecologist? Description of a sample A purposive sample was used because it enables the collection of opinions and understanding of social phenomena through the eyes of the target population whose experience is invaluable for research (Robinson, 2006). The sample consisted of eight women living in rural western Slovenia. The respondents' age ranged from 20 to 49 years, the average age of the sample was 34.6 years. According to Mason (2010), a number of issues can affect sample size in qualitative research; but the guiding principle should be the concept of saturation. Detailed information about the respondents is given in Table 1. Description of the research procedure and data analysis The potential participants were personally invited to take part in the research, using the snowball sampling technique. They were informed about the Table 1: Demographic data Tabela 1: Demografski podatki Name/ Ime Age/ Starost Education/ Izobrazba Employment status/ Zaposlitveni status Marital status/ Zakonski stan Number of children/ Število otrok Contraception method used/ Uporabljena oblika kontracepcije Dajana 28 Higher Employed In a relationship 0 Condom professional Eva 38 Secondary school Unemployed Married 4 Sterilization Ana 31 College Employed Married 2 Condom Jana 46 Vocational school Employed Married 3 Condom Katja 49 Primary school Unemployed Married 3 IUD Maja 38 Vocational school Unemployed Married 7 None Janja 27 Secondary school Employed In a relationship 0 Condom Meta 20 Vocational school Student In a relationship 0 Contraceptive pill 111 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. aim, purpose and research procedures. The interviews were conducted at the respondents' homes from April 4, 2015 to May 3, 2015. In compliance with ethics of qualitative research (British Sociological Association, 2002; World Health Organization, 2016), the respondents freely signed the so-called informed consent, which included information in appropriate detail, and in terms meaningful to participants, about its goals and aims, how research is to be disseminated and used, the risks and benefits, the confidentiality of personal information, anonymity, the duration of interview, the right to refuse participation whenever and for whatever reason they wish, and the feedback on findings. At the beginning of the interview each participant was asked to provide some basic demographic data. The interviews were sound-recorded. Each interview lasted approximately 25 minutes. The data gathered were analysed by means of thematic content analysis technique used in phenomenological research, as described by Robinson (2006). The interviews were sound-recorded and listened to several times. Recordings were then transcribed into written form, using the so-called unfocused transcription, which does not include the details of conversation and characteristics of interaction (Gibson & Brown, 2009). The respondents' real names were changed. The entire transcripts were re-read several times and studied, searching for the key phrases, statements and commonalities referring to the phenomenon investigated, which led to identification, organisation and integration of phrases into cluster groups. The phenomenon was conceptually defined. In order to ensure credibility and reliability of data, the final conceptual definition was confirmed by the co-author. On the basis of frequency of similar phrases, the cluster groups were organised hierarchically. Results Four main themes emerged from the studies of contraception as perceived by the study participants. The cluster groups are hierarchically presented in Table 2. For better clarity and transparency each individual phrase is presented within a larger context of interview transcription. Table 2: Themes identified and cluster groups Tabela 2: Identificirane teme in tematske skupine Theme/Tema Cluster groups/Tematske skupine Number of phrases/ Stevilo fraz Religious attitudes and beliefs are still reflected in the contraceptive method 103 selection (it should be remembered that according to religious teachings artificial contraception is considered a mortal sin). Nevertheless, even women with a Catholic upbringing increasingly use artificial contraception. The choice of contraceptive methods among younger women is significantly influenced by their peers or other women. Most women discuss the choice of contraceptive method with their partner, although they believe that it is primarily their choice, and expect their partners' support. Opinions concerning the importance of gynaecological expert counselling in their choice of contraceptive methods vary across women. It is believed that side effects of some contraceptive methods (especially oral contraceptives) may have a negative impact on a woman's body, which also determines the choice of contraceptive method. Women change their contraceptive method mainly because of their health problems or because they want to deepen their relationship bonds. As the sensation during sexual contact is an important factor in contraceptive selection, the condom use may sometimes be problematic. The problem may also be the correct and consistent use of contraceptive pills and their side effects. Making the best choice of birth control will take some time and a lot of thought. Women find support in the use of birth control methods in different mass media. They are especially supported by their gynaecologists who recommend the use of contraception. 2. Importance of Using contraception increases women's quality of life as it allows them to practice contraception safe and relaxed sex irrespective of the fertile phase of their menstrual cycle. It also 45 for women allows planning of pregnancies so that children are born when they are wanted and when they can be provided the best care possible. The use of contraception has influence on couples' relationships, which are becoming increasingly liberated and less committed. The majority of women claim that the use of contraceptives influences women's social status in modern society. It allows them to choose between a family and a career. As men and women in contemporary society prefer to live in comfort and feel secure, a decision to start a family or even to have several children is conditioned by the economic situation of the couple. Continues/Se nadaljuje 1. Factors that influence selection, use and acceptance of a contraceptive method 112 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Early parental The respondents reported of different experiences regarding sexual education and 43 education and contraception provided by their parents who frequently experienced sexuality as a the acquisition taboo. of adequate Thinking about contraception is triggered by teenage conversations, the first knowledge relations with opposite sex and eventually the first sexual relation as secondary about school students. contraception The health and school systems do not provide adequate education to make informed decisions, so women search for the necessary (albeit erroneous) information about contraception by themselves. Women are generally satisfied with their knowledge about contraceptive methods and are not overly concerned with this issue. 4. Social status of Women hold differing views on gender equality and social status of women, women especially in the field of decision-making. In patriarchal society women are forced to assume 'male' behavioural patterns. Along with employment, motherhood is recognised as the central role of women even in contemporary society. 19 Factors influencing the choice, use and acceptance of contraceptive methods The first thematic group is defined by the influence of social environment (e.g. religion) and support systems (e.g. family, partner, peers, gynaecologist). At the time the study was conducted, all interviewees lived in rural areas where Christian beliefs about contraception still have a strong impact on the choice of contraceptive methods. It is therefore not surprising that some respondents claim that contraception is a mortal sin, which is in accordance with Christian teachings on contraception and birth control - passed on to them by their parents. Nevertheless, religious adherents vary in their views and some find it acceptable to use contraception and birth control. "Those, who have received religious upbringing, disapprove of the use of contraception. In my home, the children were taught that contraception is a mortal sin. As a consequence, I never used contraception in my youth until after a serious consideration hereof." (Katja, 49 years) All interviewees agree that contemporary society is open to different contraceptive methods despite Christian teachings on contraception and birth control. They observed that the use of contraception is largely approved of in mass media and promoted by their gynaecologists. "Today contraception is more widely used and the society is more open towards it. My mother's and my former attitudes towards contraception and our occasional discussions about contraception and sexuality cannot be compared to the conversations I have with my daughters. Today I explain my daughters to do what is good for them. I feel much more spontaneous talking about these topics and I want my daughters to know that I am here to listen to and discuss their problems." (Jana, 46 years) Maja, a mother of seven and expecting another child, told the interviewer that her gynaecologist encouraged her to use contraception and even suggested abortion at the beginning of her last pregnancy. "My gynaecologist persistently offered me contraceptives following every childbirth. In this way she wanted to tell me that I had enough children and it was probably for this reason that she suggested abortion at the beginning of my eighth pregnancy. She gave me a referral for abortion, or, as she said 'curettage'. In such a situation you have to use your own head and follow your wishes". (Maja, 38 years) Younger interviewees reported that their choice of contraceptive methods was largely influenced by their peers. It could be inferred that the latter influenced also the interviewees' choice of and trust in a given gynaecologist. Most of the respondents cited that they discussed the selection of contraceptive methods with their partners, although they believed that it was primarily their choice, and expected their partners' support in this respect. "After our second daughter was born, we (my husband and I) mutually decided that I would use oral contraception. To be honest, even if my husband had disagreed, I would not have bothered. I would have used this type of protection irrespective of my husband' opinion, because I take decision about my body". (Janja, 27 years) The participants' opinions varied as to the importance of gynaecology counselling in contraceptive method selection. One of the participants expressed concern about her gynaecologist's professionalism and claimed that her doctor did not give her adequate information on birth control methods. "I asked my gynaecologist how it was possible that I got pregnant in spite of correct and consistent use of oral contraceptives. She answered: "Yes, these birth control pills are not 100% reliable". But if she was aware of this unreliability, why did she not prescribe me some other, stronger ones, with a higher dose of hormones? I was using this contraceptive to avoid unintended pregnancy. I was really disturbed by her answer. She could have told me before that there are other options available, that some pills are more effective than others and that I was using the brand of contraceptive pill which may not work for me". (Eva, 38 years) 113 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Some interviewees changed their contraceptive method mainly because of their health problems or because they wanted to "deepen their relationship bonds". Others are satisfied with the contraceptive methods currently used and do not consider switching their birth control method. The interviewees' statements indicate that side effects of contraceptive methods (especially contraceptive pills), endangering women's health, largely impact the selection of birth control method. According to the respondents, the use of condoms may be problematic because they reduce or interfere with sexual pleasure and sensation. The problem identified was also regular and correct use of birth control pills and the possible side effects. "I never wanted to use contraceptive pills because I do not support the idea of hormonal contraception. I find condoms most acceptable because they have no side or ill effects on health. This is most important. Therefore I never favoured hormonal birth control methods which affect the system, the body and interfere with hormonal functioning". (Dajana, 28 years) "I could say that there is an awkward moment when a partner rolls the condom on [laugh]. I am sure it could be even better if we did not use a condom". (Dajana, 28 years) Two of the study participants pointed out that today's society offers too much sexual freedom to the younger population and that the use of contraception should for that reason be well thought out. "Freedom leads to contraception, which is not bad by itself. But we should be aware that too much freedom is not good, one should be aware of its limits. The contemporary society lacks the proper judgement that assists in distinguishing right from wrong. I see this also in the youngsters who indiscriminately accept everything that is offered to them. It is the responsibility of adults to properly explain and present the young the dimensions and significance of contraception and abortion". (Dajana, 28 years) The importance of contraception for women The three cluster groups define "the importance of contraception for women" revealing the interviewees' perceptions of contraception and its impact on women's quality of life, partnership relations and their social status. The use of contraception helps women plan their life events and pursue their goals. All the participants using birth control admit that with contraception they may enjoy safer and more relaxed sexuality. Two of them also emphasised sexual freedom during their fertile period when sexual desire is most pronounced. Contrary to these views were the statements of one participant who does not use any birth control and who perceives contraception as acting against herself and against nature (life). All contraceptive users agree that reliable contraception allows planning of pregnancies so that children are born when they are wanted and when they can be provided the best care possible. Three of the respondents highlight the importance of family spacing and size so that a child can receive the necessary care and attention during the tender years of their development and that mothers are not overburdened with obligations and responsibility. The two older participants accentuate the benefits of contraception for perimenopausal women who can still conceive but feel too old for another pregnancy. "Since I was sterilised, my sexual life has gained in quality as I am 100% protected. I no longer fear my visits to the toilet to check if my period has come [...]. Now we (my husband and I) both feel more relaxed and enjoy making love whenever we feel like it, we no longer need to worry". (Eva, 38 years) "Yes, we are not yet too old to make love and I can still get pregnant until I reach the time of menopause. But I feel that my time to give birth is over. I am anxious to have grandchildren, but I would not go through all that again: give birth to a child, upbringing, school -1 would not be psychologically strong enough, at least not the way I used to when I was younger". (Katja, 49 years) Most respondents believe that the use of contraception may deepen the couple's relationship, which is nowadays becoming more liberated and less committed. Most of the respondents are also convinced that women's ability to use reliable contraception has a significant impact on their social and economic status and allows them to choose between a family and a career. Three participants claim that a decision to start a family or even to have several children is nowadays conditioned by the couple's economic situation. In modern society people want to live in comfort and feel secure. "In the past people used to have one, maybe two partners, and then they got married and had children [...], unlike today when girls and boys have several relationships, they have premarital sexual experiences and only then commit to a marital relationship". (Meta, 20 years) Upbringing and education about contraception The interviewees were also asked if sexuality education and education about contraception was part of their upbringing within a family and where they searched for information about contraceptive protection when needed. The analysis of the data yielded a conclusion that the respondents received different sexual and contraceptive education which was to a large extent conditioned by their parents' attitudes towards sex. As a consequence, some women experienced sexuality education within sex-negative taboos. "My mother and I never had an open, face-to-face discussion about these things. It seems that she was also brought up in a family where discussions about sexual perceptions and behaviours were considered as taboo. 114 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. This issue was not to be spoken about. I think that the Church and religion had an important influence on the fact that we never openly discussed this matter. Even today, the Church opposes the use of contraception". (Jana, 46 years) Some respondents observe that the health and school education do not provide adequate information about contraceptive methods. Women learn about this topic on the internet and in popular magazines when they need contraception. The users of contraception report that the idea of using protection was first discussed among peers, and that they searched for more information when they became engaged in their first love relationships and sexual activity, usually as secondary school students. "The only intimate, confidential discussion I had on contraception was with my peers. Now one can discuss contraception with a medical staff, though neither I nor my friends had such a conversation experience. Maybe, it is different now. At school we were taught something about sexuality and very little about contraception during biology classes, but that was far from comprehensive information. We were provided with little information, at least, that was my experience". (Dajana, 28 years) The participants report that they have no problem using the selected contraceptive method. They are generally satisfied with their knowledge about contraceptive methods and are not overly concerned with this issue. "To be honest, I do not really care if I am adequately informed about contraception. I have no pains, I have no problems, it does not bother me and I stopped thinking about it." (Katja, 49years) Social status of women The respondents showed great interest also in the place of women in the social order. Their discussions about the status of women in a larger social context show that they hold different views on gender equality. Some of them argue that in contemporary society men and women have equal opportunities and are equally involved in decision-making processes, while others claim the opposite. The latter concede that social status of women is better than in the past, but insist that gender equality is still not a reality. Although progress has been made, there is still a gender pay gap and women are not equally represented in decision-making processes. According to one older respondent, the unequal opportunities result also from different models of gender not-neutral parenting and education in the past. "I think that women's social status is much better than it used to be, but gender inequalities still exist in all fields of work. Women do have equal educational opportunities, but the problem arises in the professional career. We are fully aware that women are paid less than men for doing similar work. But the situation is definitely better than it was some 50years ago". (Dajana, 28 years) "It may be that my generation and, of course, earlier generations were brought up with a belief that men were more important and powerful than women and enjoyed a higher status. But when I grew older and started my family, I realised that in fact women hold up three corners of a house". (Katja, 49 years) Three participants are convinced that patriarchal society forces women, who wish to make a career and be successful in their profession, to assume 'male' behavioural patterns. Other participants, however, feel that besides employment, women's mothering is a central and defining feature of the social organization of gender even in contemporary society. "Women are more loving, maternal, emotional, and as such, they should be primarily mothers, responsible for raising children". (Ana, 31 years) "It is interesting that I felt happier with each consecutive child - not that I was not happy when I gave birth to my first baby girl, but each new child intensified my feelings of happiness, fulfilment and differentness, which can be experienced only by having children". (Maja, 38 years) Discussion The use of contraception allows couples and especially women planning their first and all consecutive pregnancies. In choosing the timing of the next pregnancy, individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health-care services, child-rearing support, social and economic circumstances, and personal preferences. Contraception thus exerts an important impact on the couples' life and the quality of women's life (Benagiano, et al., 2007). The complexity of the issue requires further extensive and comprehensive qualitative research of contraception in everyday life of women, within their specific environment, which shapes their beliefs and guides their actions. Such a research aims to explore into a variety of subjective perspectives of women conditioned by their social environment (Pahor, 2007). The results of the qualitative text analysis are clustered around four themes, which define the significance of contraception for women. The hierarchy, which is based on the frequency of similar phrases, content and commonalities, reveals that the dominant theme concerns "the factors influencing the selection, use and acceptance of contraceptive methods". The interviewees are aware that a decision to use contraception should be well thought out. They are also aware that the choice of a contraceptive method is influenced by the users' religious beliefs, the opinion of their peers and partners and their gynaecologist, the side-effects and potential health risks, the desire to deepen their relationship bonds, 115 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. and sexual contact and pleasure. The last but not least important is the press coverage of contraception as described by Garner and Mendez (2014), which excludes women from the debate and confirm the power of political, social, and religious groups to control the contraception narrative and women's lives. The research findings indicate that the religion's restrictive, conservative and pronatalist views still largely impact family planning. Nevertheless, it has been observed that despite the importance of religion in influencing decisions, practitioners of faith do not necessarily adhere to the prescribed doctrines of their faith and increasingly opt to use contraception. The role of religion in determining contraceptive usage should therefore be discussed within a context of a country, local community and family where women have to navigate between various messages about femininity, sexuality, contraception and motherhood. This study produced results which are in agreement with Lowe's (2005) findings which showed that a contraceptive decision is conditioned by the expectation of sexual activity, while the reasons for switching a contraceptive method are often related to health risks and side effects associated with different contraceptive methods or sensation of sexual contact. Another important finding of Lowe's research is that contraception impacts on the quality of women's lives and allows planned parenthood so that every child born is a wanted child. This is related to the second theme that emerged from the study, namely, "the significance of contraception for women". Most of the respondents agree that contraception improves their quality of life and allows them to practice safe and relaxed sex irrespective of the fertile phase of their menstrual cycle, and to plan their pregnancies. Thus the children are born when they are wanted and when they can be provided the best care possible. There is no doubt that contraception has a positive impact also on partnership relations. Sonfield and collegues (2013) report that planning, delaying and spacing births appears to help women to choose between a family and a career, to achieve their education and career goals. Further, there are other social and economic benefits of women's ability to use reliable contraception, including employment, socioeconomic stability, personal satisfaction and social status. The third theme "early parental education and the acquisition of adequate knowledge about contraception" affirmed that the respondents received different sexuality, reproductive and contraception education within their families, often within sex-negative taboos. The respondents reported that they first thought about contraception when talking to their peers, and then during their first relations with the opposite sex and at the onset of sexual activity as secondary school students. They stated that the health and school systems did not provide enough information to make informed decisions about contraception, so they got informed about the necessary information elsewhere, mainly by their peers. The findings of the current study are consistent with those of Lowe (2005) who found that women obtain contraceptive knowledge by themselves and discuss the selected contraceptive method with women in their social surroundings and not their gynaecologist. According to Pinter and Grebenc (2010), adolescent girls develop sexuality at a much earlier age than was true in the past, which has resulted in a growing gap between their sexual and social maturity. In the absence of emotional and cognitive maturity, early pubertal timing predicts deleterious outcomes for young girls, including risky sexual behaviour and pregnancy. Timely and effective health education, tailored to the expectations and needs of the contemporary society, might significantly modify sexual behaviour among adolescents and reduce unintended consequences of early sexual experimentation. The participants of the current study report that after years of sexual experience and contraceptive use, or having children, they are generally satisfied with their knowledge about contraceptive methods and are not overly concerned with this issue. The interpretative phenomenological analysis has shown that the cluster groups are closely related, which points to the complexity of the phenomenon studied. Although the topic of interest was primarily the respondents' views and use of contraception, the focus extended to the status of women in Slovenia and their emancipation stemming from contraception. The findings of the present research show that the respondents also disagree in their attitudes and views on the "the social status of women in contemporary society", which is the fourth theme identified in the study. Their opinions vary in the perception of gender equality, participation in decision-making and the adoption of male-specific behavioural patterns, helping them progress along their career ladder in a patriarchal society. Some respondents in the age group of 30 to 40 years believe that along with employment, motherhood remains the central role of women even in contemporary society. It is interesting to note that older respondents do not share these views. This phenomenological research has some study design limitations and delimitations: (1) The study is geographically limited, which prevents or restricts generalisations to the larger population studied. If the study were based on a different theoretical framework, with additional questions, etc., the research might yield different results; (2) The phenomenological data analysis is, like in other qualitative studies, based on the researchers' interpretation, and therefore does not lend itself well to replicability; (3) The research did not examine the correlation between detailed demographic data of the respondents (e.g. economic status, religious beliefs, sexual practices, etc.), the provision of which was not even required. 116 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. There is abundant room for future research studies based on a larger sample size and expanded geographical scope to urban areas to ensure appropriate generalizations of the findings of the study. A further study is suggested which would include also the men's views on contraception, women's health, and prevention of sexual risk behaviours. However, such a research can be hindered by the extant cultural values and norms of specific environments. Conclusion With the event of contraception, especially hormonal contraceptives and their availability, women became able to have full control over their reproduction and separate sexuality from its reproductive consequences. Simple and effective contraception has provided opportunity also for female emancipation which led to different levels of gender equity across countries. The results of this study confirm that contraception is an important dimension of the quality of rural women's life, which is associated with their social status. The acceptance and selection of birth control methods are influenced by several social, political and environmental factors, and are determined by various support systems. The nursing professionals should be well informed of these factors to be able to use a holistic and person-centred approach in planning and implementation of sexual health education and health promotion. Slovenian translation/Prevod v slovenščino Uvod Človek je skozi zgodovino poskušal omejiti velikost svoje družine (Glasier, 2002), kar dokazujejo številne umetniške upodobitve in starodavni zapisi (Evans, 2009). Kontracepcijske metode so torej v eni ali drugi obliki, od obrednih in mitičnih pa vse do praktičnih in učinkovitih (Evans, 2009; Planned Parenthood Federation of America, 2012), krojile poskus človeka po uravnavanju števila rojstev. Do prejšnjega stoletja se je to poskušalo predvsem s spremembo vedenja, kar je vključevalo abstinenco, zmanjšano pogostost spolnih odnosov, izogibanje spolnim odnosom med plodnimi dnevi in prekinjen spolni odnos. Tako je bilo na primer dojenje, ki zavira ovarijsko dejavnost, pogosto pomemben način omejevanja plodnosti, medtem ko je bil prekinjen spolni odnos, prvič omenjen v prvi Mojzesovi knjigi (Genezi), pomemben za posamezne pare (Glasier, 2002; Cook, 2004). Nekatere že v preteklosti uporabljene kontracepcijske metode pa se od metod, ki so priljubljene danes, ne razlikujejo veliko, dodaja Evans (2009). Pravzaprav je bilo načrtovanje družine pogosto prisotno tudi v družbah, kjer so prevladovale socialne, politične ali verske ideologije (Gordon, 2002; Stankuniene & Maslauskaite, 2008; Planned Parenthood Federation of America, 2012), ki so od ljudi zahtevale »plodnost in razmnoževanje« - od Perikleja v atenski državi do rimskega papeža v današnjih časih (Planned Parenthood Federation of America, 2012). Danes poznamo številne kontracepcijske metode, ki jih medicina deli na moderne in tradicionalne oziroma naravne. Med moderne metode spadajo ženska in moška sterilizacija, kontracepcijske tablete, maternični vložek, injekcije, vsadki, nožnični prstan, kondom, pene, diafragma in geli, med tradicionalne metode pa uvrščamo dojenje, prekinjen spolni odnos in druge naravne metode (Cook, 2004; Evans, 2009; Oliveira da Silva, et al., 2011). Scott (2013) meni, da se potrebe žensk po zaščiti pred zanositvijo med različnimi življenjskimi obdobji spreminjajo, saj lahko spolno aktivna ženska med različnimi kontracepcijskimi metodami izbere tisto, ki ji v določenem življenjskem obdobju najbolj ustreza (Tone, 2012). V svetovnem merilu je bila po podatkih Združenih narodov (United Nations, 2013) v letu 2011 razširjenost kontracepcije ocenjena na 63 %, čeprav se njena razširjenost po svetu zelo razlikuje. Po zadnjih podatkih je razširjenost uporabe kontracepcijskih metod med ženskami v rodni dobi, ki so poročene ali v zvezi, med 4 % v Južnem Sudanu in 88 % na Norveškem. Kontracepcijska razširjenost je najnižja v Afriki (31 %), najvišja pa v Evropi, Latinski Ameriki, Karibih in Severni Ameriki (70 % in več). V razvitih državah se pogosteje uporabljajo kratko delujoče in reverzibilne metode, v deželah v razvoju pa kontracepcijske metode z dolgotrajnejšim delovanjem in veliko učinkovitostjo, kot so maternični vložek, kontracepcijske tablete in ženska sterilizacija (United Nations, 2013). Po podatkih Nacionalnega inštituta za javno zdravje je bilo v Sloveniji leta 2012 izdanih skoraj milijon omotov hormonske kontracepcije, kar pomeni več kot 77.000 uporabnic oziroma 162 na 1000 žensk v rodni dobi (15-47 let). Pri mladostnicah in ženskah med 20. in 24. letom raba hormonske kontracepcije narašča, medtem ko pri ženskah po 30. letu upada. Hormonsko kontracepcijo uporablja vsaka tretja ženska med 20. in 24. letom ter vsaka peta med 15. in 19. ter 25. in 29. letom. Maternični vložki so bili najpogosteje uporabljeni v 80. letih in na začetku 90. let prejšnjega stoletja, nato je njihova uporaba začela upadati, a zadnje desetletje spet narašča. Kondom ostaja najpomembnejša zaščita mladih, ki začenjajo spolno življenje (Nacionalni inštitut za javno zdravje, 2014). Vpliv kontracepcije na emancipacijo žensk Uravnavanje rojstev je pomembno za velikost populacije in družine ter ključno, ko govorimo o blagostanju, še posebej žensk (Gordon, 2002; Cook, 2004; Benagiano, et al., 2007). Statusa ženske, 117 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. po mnenju Gordon (2002), ni mogoče povezati s specifičnim sistemom seksualne ali reproduktivne regulacije, vendar pa sta oba, status ženske in specifični sistem reproduktivne regulacije v nenehni interakciji. Ko se eden spremeni, se spremeni tudi drugi, kar priča o močni medsebojni odvisnosti. Ob tem je bila še posebej močna povezanost med podrejanjem žensk in prohibicijo uravnavanja rojstev, pri čemer je bilo slednje sredstvo za dosego prvega. Velja tudi obratno, in sicer povezava med emancipacijo žensk in njihovo sposobnostjo, da nadzorujejo reprodukcijo. Lupton (2003) meni, da sta kontracepcija in umetna prekinitev nosečnosti poglavitni točki, ko govorimo o družbeni ambivalenci o vlogi žensk in njihovih pravicah, da prevzamejo nadzor nad svojimi telesi in lastno reproduktivno usodo ter posledično realizacijo njihovega potenciala za emancipacijo. Do začetka 20. stoletja je ideja o oralni kontracepciji v konvencionalni medicini zamrla. Šele v prvi polovici 20. stoletja je to idejo oživela borka za reproduktivne pravice žensk Margaret Sanger, ki se je desetletja borila za zanesljivo kontracepcijo žensk. Skupaj s Katherine Dexter McCormick, ki je financirala tedaj kontroverzne raziskave znanstvenikov Gregory Pincus, Min Chueh Chang in John Rock o oralni kontracepciji na osnovi sintetičnega progesterona, je leta 1960 postala oralna kontracepcija realnost (Lupton, 2003; Prescott, 2011; Planned Parenthood Federation of America, 2012; Wigginton, et al., 2015). Čeprav je bila prva oralna kontracepcija daleč od popolnosti, je ženskam prvič v zgodovini ponudila priložnost nadzora nad reprodukcijo, s čimer je postala seksualna revolucija v 60. letih prejšnjega stoletja manj tvegana kot tista po prvi svetovni vojni (Planned Parenthood Federation of America, 2012). Druga seksualna revolucija je širila idejo svobodne ljubezni in svobodne seksualnosti. Dvojna morala, ki je prej veljala med spoloma, je počasi bledela, ženskam je bila priznana pravica do lastne seksualnosti in spolnega užitka, seksualnost je bila zanesljivo ločena od funkcije reprodukcije, povečali sta se odprtost in komercializacija na področju seksualnosti (Anurin, 2002). V tem pogledu Giddens (2000) meni, da je seksualna revolucija tesno povezana z emancipacijo žensk, saj jim je prinesla spolno svobodo. Čeprav je ta le delna, je, kot sam pravi, neverjetna v primerjavi s stanjem pred nekaj desetletji. Iznajdba kontracepcije je imela radikalne posledice, saj je ženske osvobodila strahu pred nenehnimi nosečnostmi in tudi pred smrtjo, saj je bila v preteklosti velika umrljivost porodnic in novorojenčkov. Vendar pa učinkovita kontracepcija ni pomenila le omejevanja nosečnosti, ampak je vnesla v osebno življenje žensk globoke spremembe. Seksualnost je namreč postala prilagodljiva, ženske so jo lahko različno oblikovale, postala je, kot pravi Giddens (2000), »njihova potencialna last« in način, ki je omogočil pobeg izpod moške dominance (te Velde, 2011). V etnografskem raziskovanju spolnosti na slovenskem podeželju od začetka 20. stoletja do leta 1960 Miklavčič (2014) razkriva težak in nezavidljiv položaj žensk, kjer pravic za ženske ni bilo, razen treh - biti gospodinja, rojevati otroke in skrbeti za možev užitek. V sredini 70. let prejšnjega stoletja je Boh (1975) kontracepcijskim tabletam in drugim sodobnim metodam kontracepcije pripisala izredno pomembno vlogo. Prepričana j e bila, da dajejo ženskam svobodo, saj pri nadzorovanju svoje plodnosti ne potrebujejo več sodelovanja partnerja in lahko svojo plodnost urejajo in nadzirajo brez njegove volje ali privolitve. Ule in Kuhar (2003) menita, da je razvoj metod nadzorovanja rojstev, ki je ločil seksualnost od reprodukcije, predvsem mladim ženskam omogočil do tedaj nezaslišano razpolaganje z lastnim telesom, kar je imelo trajne posledice za spremembo partnerstva tako v družini kot zunaj nje. S tem se je tudi uveljavilo prepričanje, da v družini služita denar oba zakonca, o rojstvu otrok pa odločajo predvsem ženske, ki se zaradi drugih življenjskih možnosti, kot sta kariera in zaslužek, odločajo za vse poznejše materinstvo (Ule & Kuhar, 2003; te Velde, 2011). Opisane spremembe pa niso univerzalne, saj nanje vplivajo številni družbeni dejavniki. V postkomunističnih državah »nove« Evrope, tudi v Sloveniji na primer, so se spremembe, vezane na emancipacijo ženske, začele odvijati šele po letu 1990 (Stankuniene & Maslauskaite, 2008). Poleg vpliva političnega režima je pomemben tudi odnos religije do kontracepcije, ki pa se med religijami bistveno razlikuje (Maguire, 2003). Rimskokatoliška cerkev na primer uporabi »umetnih« metod kontracepcije nasprotuje, saj meni, da spodbuja k promiskuiteti in nedovoljeno posega v naravno dogajanje (Tone, 2002). Medikalizacija kontracepcije Kontroverznosti, povezane z zagotavljanjem kontracepcije in varnimi metodami kontracepcije, so se navezovale na idejo ideala materinstva in željo medicine, da ohrani nadzor nad reprodukcijo žensk (Lupton, 2003). Lowe (2005) trdi, da je medikalizacija kontracepcije eno od področij, ki je pritegnilo veliko pozornost številnih feminističnih raziskovalcev. Ti poudarjajo, da je ena od bistvenih razlik med zgodovinsko uporabo kontracepcije in današnjo rabo v široki vključenosti in nadzoru medicine nad ženskim telesom, najbolj pa nad njeno reproduktivno vlogo. Riessman (1983) je bila celo prepričana, da je medikalizacija zdravja žensk postala realnost sodobne družbe, saj meni, da so ženske same pustile biomedicini odprta vrata za vstop v njihova življenja, ko so se želele osvoboditi bremen naravnih, bioloških procesov. Kot poudarja te Velde (2011) o času po letu 1960, se ženske ne bodo nikoli odrekle njihovi na novo pridobljeni neodvisnosti in svobodi. Pred letom 1960 se je namreč le manjšina žensk s svojim zdravnikom 118 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. pogovarjala o medicinskem načrtovanju družine. Takrat je bila najpogosteje uporabljena medikalizirana oblika nadzora rodnosti diafragma, ki pa ni veljala za priljubljeno, zato so pari raje uporabljali metode, kot so kondomi in druge metode naravnega načrtovanja družine. Z odkritjem kontracepcijskih tablet govorimo o obsežni medikalizaciji kontracepcije, saj jih uporablja na milijone žensk po vsem svetu (Tone, 2012). Lowe (2005) trdi, da ima kontracepcija nenavaden položaj v medicini, ker je predpisana velikemu številu zdravih žensk, pogosto za daljše časovno obdobje in tako ženske kot uporabnice niso pacientke v klasičnem pomenu besede. Tone (2012) pa meni, da medikalizacija kontracepcije normalizira idejo uživanja dnevne tabletke ter posledično utira pot razvoju in širitvi drugim oblikam hormonskih kontraceptivov in tudi drugim zdravilom sodobnega življenjskega sloga. Namen in cilji Namenraziskaveje bilpreučitifenomenkontracepcije skozi videnja, védenja, izkušnje in doživljanja žensk, ki živijo v ruralnem okolju. Fenomen kontracepcije, njene razširjenosti in pomena, ki ga ima ta za emancipacijo žensk, krojijo številni družbeni dejavniki, med njimi tudi okolje. Zaradi ugotovljene večdimenzionalnosti fenomena je bil osrednji cilj preučiti doživljajski svet žensk skozi naslednja raziskovalna vprašanja: - Kakšen pomen ima kontracepcija za ženske v ruralnem okolju in kako jo doživljajo? - Kako družbeni dejavniki mikrookolja oblikujejo in/ ali vplivajo na odločitev žensk za rabo kontracepcije? - Kako znanje in motivacija žensk za preprečevanje neželene nosečnosti vplivata na izbor ustrezne oblike kontracepcije in njeno dosledno rabo? Metode Uporabljena je bila kvalitativna metodologija, v okviru katere je bila na namenskem vzorcu žensk Tabela 1: Demografski podatki Table 1: Demographic data opravljena fenomenološka raziskava z namenom pridobitve poglobljenega vpogleda v proučevani fenomen, pri čemer je ta predstavljen tako, kot ga ljudje razumejo in doživljajo. Opis instrumenta Po datke smo pridobili z uporabo delno strukturiranih intervjujev. Uporaba delno strukturiranih intervjujev je namenjena pridobivanju opisov življenjskega sveta intervjuvane osebe za interpretacijo pomenov opisanega fenomena (Kvale, 2007). Pred izvedbo so bila vnaprej pripravljena vprašanja odprtega tipa, med intervjujem pa so bila postavljena še dodatna vprašanja, ki so temeljila na podani vsebini intervjuvanca (DiCicco-Bloom & Crabtree, 2006). Izhodiščna vprašanja, ki jih je bilo 12, so bila zasnovana splošno, a so se z nadaljevanjem intervjuja razvijala v bolj osebna vprašanja, povezana z doživljanjem kontracepcije in njenim pomenom za spoznano kakovost življenja. Primer nekaterih vodilnih vprašanj: kako ocenjujete položaj žensk v današnji družbi; ali menite, da sta bili spolnost in kontracepcijska zaščita del vaše mladostniške vzgoje; kdaj ste se prvič srečali z vprašanjem rabe kontracepcije; kaj vam osebno pomeni kontracepcijska zaščita; kako bi ocenili vpliv uporabe kontracepcije na kakovost življenja in vašo spolnost; ste izbiro kontracepcijske metode prepustili ginekologu ali ste imeli že pred obiskom ginekologa izbrano določeno kontracepcijsko metodo. Opis vzorca V raziskavi je bil uporabljen namenski vzorec, saj nam ta omogoča razumevanje družbenih pojavov skozi oči tistih, ki jih namenoma opazujemo, njihove izkušnje pa so za nas neprecenljive (Robinson, 2006). Vključenih je bilo osem žensk, katerih povprečna starost je bila 34,6 leta - najmlajša udeleženka je bila stara 20 let, najstarejša pa 49 let. Vse udeleženke so med raziskavo živele v ruralnem okolju zahodne Ime/ Starost/ Izobrazba/ Zaposlitveni Zakonski stan/ Število otrok/ Uporabljena Name Age Education status/ Marital status Number of oblika Employment status children kontracepcije/ Contraception method used Dajana 28 Visokošolska Zaposlena V zvezi 0 Kondom Eva 38 Srednješolska Nezaposlena Poročena 4 Sterilizacija Ana 31 Višja strokovna Zaposlena Poročena 2 Kondom Jana 46 Poklicna Zaposlena Poročena 3 Kondom Katja 49 Osnovnošolska Nezaposlena Poročena 3 Maternični vložek Maja 38 Poklicna Nezaposlena Poročena 7 Nobena Janja 27 Srednješolska Zaposlena V zvezi 0 Kondom Meta 20 Poklicna Študentka V zvezi 0 Kontracepcijske tablete 119 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Slovenije. Smernice o potrebni velikosti vzorca se med avtorji razlikujejo, kar ugotavlja Mason (2010), a obenem dodaja, da mora večina kvalitativnih raziskav slediti konceptu nasičenosti izrečenega. Podrobnejši podatki o intervjuvankah so prikazani v Tabeli 1. Opis poteka raziskave in obdelave podatkov Potencialno sodelujoče smo osebno povabili k sodelovanju v raziskavi s pomočjo metode snežne kepe, jim razložili namen, cilj in način raziskovanja ter se glede na njihovo dosegljivost dogovorili za predviden datum intervjuja. Intervjuji so potekali med 10. 4. 2015 in 3. 5. 2015 na domovih sodelujočih. Ob upoštevanju etičnih vidikov kvalitativnega raziskovanja (British Sociological Association, 2002; World Health Organization, 2016) so pred začetkom intervjuja ženske, ki so se odločile sodelovati v raziskavi, podpisale t. i. informirano soglasje ter se tako vnovič seznanile z namenom, cilji, potekom raziskave, tveganji, koristmi, varovanjem zaupnosti podatkov in anonimnostjo, predvidenim trajanjem intervjuja, možnostmi prekinitve intervjuja ter Tabela 2: Identificirane teme in tematske skupine Table 2: Identified themes and cluster groups Tema/Theme Tematske skupine/Cluster groups možnostmi povratnih informacij raziskave. Na začetku intervjuja so intervjuvanke navedle nekaj osnovnih demografskih podatkov. Intervjuji so bili zvočno snemani. Posamezni intervju je v povprečju trajal 25 minut. Podatki so bili analizirani s pomočjo metode analize vsebine, ki jo za fenomenologijo opisuje Robinson (2006). Zvočni zapisi so bili večkrat poslušani, nato pa je bila opravljena transkripcija intervjujev, t. i. nefokusna oblika, ki ne vključuje podrobnosti pogovora in karakteristik interakcije (Gibson & Brown, 2009). Imena intervjuvank so bila nadomeščena z namišljenimi imeni. Transkripte smo večkrat v celoti prebrali in preučili, nato pa v besedilu poiskali ključne fraze oziroma izjave, ki opredeljujejo preučevani fenomen. Sledile so interpretacija pomena, organizacija in integracija posameznih fraz v pomenske oziroma tematske skupine (angl. cluster groups) ter konceptualna opredelitev fenomena. Z namenom povečevanja kredibilnosti in zanesljivosti podatkov je končno konceptualno opredelitev preveril drugi avtor. Glede na pogostnost pojavljanja posameznih podobnih fraz so bile tematske skupine hierarhično razvrščene. Število fraz/ Number of phrases 1. Dejavniki, ki Versko prepričanje še vedno zaznamuje odločitev za uporabo metode kontracepcije 103 vplivajo na (ne smemo pozabiti, da je v skladu z verskim naukom umetna kontracepcija izbiro in rabo spoznana kot smrtni greh), a se kljub temu tudi v katoliški veri vzgojene ženske vse kontracepcijske pogosteje odločajo za uporabo umetne kontracepcije. metode Na izbiro kontracepcijske metode pri mlajših ženskah pomembno vpliva mnenje ter njeno sovrstnic oziroma drugih žensk. sprejemljivost Večina žensk se o izbiri kontracepcijske metode posvetuje s svojim partnerjem, čeprav menijo, da je to predvsem njihova odločitev in pri tem pričakujejo partnerjevo podporo. Med ženskami je prisotna neenotnost mnenj glede pomembnosti ginekološkega svetovanja pri odločitvi za uporabo izbrane kontracepcijske metode. Obstaja prepričanje, da stranski učinki nekaterih kontracepcijskih metod (predvsem kontracepcijskih tablet) negativno delujejo na ženski organizem, kar vpliva na izbor kontracepcijske metode. Ženske se za menjavo kontracepcijske metode odločajo zlasti zaradi zdravstvenih težav in poglobitve partnerske zveze. Občutek spolnega stika je pomemben pri izbiri kontracepcije, zato je raba kondoma včasih problematična, pa tudi doslednost jemanja kontracepcijskih tablet in njihovi stranski učinki. Odločitev za kontracepcijo mora biti premišljena. Ženske opažajo podporo rabi kontracepcije v različnih medijih, zlasti pa takšno podporo doživljajo pri obiskih svojih ginekologov, ki uporabo kontracepcije priporočajo. 2. Pomen Uporaba kontracepcije povečuje kakovost življenja, saj zagotavlja varno in 45 kontracepcije sproščeno spolno življenje ne glede na plodne dni ciklusa ter omogoča rojstvo za ženske načrtovanega, zaželenega otroka v časovnem obdobju, ko sta zanj zagotovljeni optimalna skrb in nega. Uporaba kontracepcije vpliva na partnersko zvezo, ki v sodobnem času postaja vse svobodnejša in neobvezujoča. Večina žensk meni, da uporaba kontracepcije vpliva na trenutni družbeni položaj žensk, pri čemer izpostavljajo možnost izbire med družino in kariero, medtem ko je odločitev za družino, še posebej številčnejšo, v današnji družbi pogojena z ekonomskim stanjem, saj sodobni človek hrepeni po varnosti in ugodju. Se nadaljuje/Continues 120 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Vzgoja in Prisotna je neenotnost mnenj intervjuvank o vključevanju spolnosti in 43 pridobivanje kontracepcije v njihovo mladostniško vzgojo v družinskem krogu, pri čemer ustreznega izpostavljajo problem staršev, ki so spolnost doživljali kot tabu temo. znanja o Razmišljanje o kontracepciji sprožijo najstniški pogovori med sovrstnicami kontracepciji in vzpostavitev prvih partnerskih zvez ter posledično prvi spolni odnosi v srednješolskem obdobju. Zdravstveni in šolski sistem ne dajeta dovolj informacij o kontracepciji, zato si ženske potrebne informacije (čeprav morda neustrezne) poiščejo same. Ženske so z doseženo stopnjo znanja o njihovi kontracepcijski metodi zadovoljne oziroma se s tem ne obremenjujejo. Družbeni Prisotna je neenotnost mnenj o enakopravnem položaju žensk v družbi, pri čemer položaj žensk izpostavljajo zlasti problem vključevanja v procese odločanja. Patriarhalna ureditev povzroča pri ženskah prevzemanje »moških« vzorcev vedenja. Materinstvo je poleg zaposlitve še danes videno in spoznano kot osrednja naloga žensk. 19 Rezultati Identificirane so bile štiri tematske skupine, ki opredeljujejo fenomen kontracepcije v očeh vključenih žensk v raziskavo. Tabela 2 hierarhično prikazuje tematske skupine. Zaradi večje preglednosti in jasnosti so posamezne fraze predstavljene v širše zajetem besedilu intervjuja. Dejavniki, ki vplivajo na izbiro in rabo kontracepcijske metode ter njeno sprejemljivost Prvo tematsko skupino opredeljuje vpliv družbenega okolja (npr. vpliv religije) in podpornih sistemov (npr. družina, partner, sovrstnice, ginekolog). Vse intervjuvanke so med raziskavo živele v ruralnem okolju, kjer je versko prepričanje pomemben dejavnik, ki še vedno zaznamuje odločitev za uporabo kontracepcije. Tako nekatere intervjuvanke trdijo, da je v skladu z verskim naukom, ki so ga bile ali so ga deležne, kontracepcija spoznana kot smrtni greh, navajajo pa tudi, da kljub krščanski vzgoji in povezanim vrednotam uporabljajo kontracepcijo. »Kar nas je versko vzgojenih, smo proti kontracepciji, tako kot sem bila tudi sama, saj so me doma učili, da je kontracepcija smrtni greh, zato se tudi sama v mladosti nisem nikoli odločila za uporabo kontracepcije, vse dokler nisem začela o tem resno razmišljati.« (Katja, 49) Vse intervjuvanke se strinjajo, da je današnja družba, kljub vplivu Rimskokatoliške cerkve, odprta za različne oblike kontracepcije. Podporo rabi kontracepcije opažajo tudi v različnih medijih, zlasti pa pri ginekologih, ki uporabo kontracepcije priporočajo. »Danes se družba kar razširjeno poslužuje kontracepcije in je bolj odprta za te stvari. Tudi če pogledam odnos moje mame in mene, koliko smo se z mamo pogovarjale o zaščiti in spolnosti ali pa kako se jaz o tem pogovarjam s svojimi hčerkami, je razlika res očitna. Jaz danes svojim hčerkam povem, kaj je dobro zanje. Sem precej bolj odprta glede teh stvari, saj se mi zdi pomembno, da punce vedo, da se z mano lahko o tem pogovarjajo.« (Jana, 46 let) Maja, mati sedmih otrok, ki je med intervjujem pričakovala osmega, pripoveduje, da jo ginekologinja spodbuja k uporabi kontracepcije, v začetku trenutne nosečnosti pa ji je predlagala splav. »Ginekologinja mi po vsakem porodu vztrajno ponuja kontracepcijo. Reči želi, da imam že dovolj otrok, verjetno mi je zato tudi zdaj v začetku osme nosečnosti napisala napotnico za splav oziroma kot je sama rekla »čiščenje«. Pri teh rečeh mora človek uporabljati svojo glavo in slediti sebi.« (Maja, 38 let) Mlajše intervjuvanke poročajo, da na izbiro kontracepcijske metode pomembno vpliva mnenje sovrstnic, iz njihovih izjav pa je mogoče razbrati, da ima mnenje sovrstnic širši vpliv, saj vpliva tudi na izbiro ginekologa in zaupanje njegovemu mnenju. Večina intervjuvank navaja, da so se o izbiri kontracepcijske metode sicer posvetovale s svojim partnerjem, čeprav menijo, da je to predvsem njihova osebna odločitev, vendar pa pričakujejo njegovo podporo. »Z možem sva se takrat po dveh puncah pogovorila in se skupaj odločila, da se jaz zaščitim s tabletkami. Vendar prav po pravici povedano, tudi če se mož ne bi strinjal z zaščito, se sploh ne bi obremenjevala s tem. Ravno tako bi se odločila in jemala tabletke, saj sem jaz tista, ki odločam o svojem telesu.« (Janja, 27 let) Udeleženke so bile neenotne v mnenju glede pomena ginekološkega svetovanja pri odločitvi za uporabo izbrane kontracepcijske metode. Ena od udeleženk je med intervjujem izrazila dvom o profesionalnosti osebne ginekologinje, saj je dejala, da ji ni podala dovolj informacij o njeni kontracepcijski metodi. »Najbolj me je zmotilo, ko sem ginekologinjo pri tretji nosečnosti vprašala, kako je sploh možno, da sem zanosila kljub temu, da sem tabletke redno jemala, nisem zamudila niti ene, dam roko v ogenj. Njen odgovor pa je bil: »Ja, saj pri teh tabletkah bi lahko kadarkoli zanosila.« Samo če je ona to vedela, da te tabletke niso tako močne, zakaj mi jih ni vmes zamenjala? Jaz sem tabletke jemala z namenom, da ne bi več zanosila. To me je res vrglo s tira, da mi tako odgovori. Gotovo bi mi lahko že prej povedala, da obstaja več vrst tabletk, da so ene bolj močne kot druge in da imam jaz šibkejše ter obstaja možnost zanositve.« (Eva, 38 let) 121 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. Nekatere intervjuvanke so se za menjavo kontracepcijske metode odločile zaradi zdravstvenih težav in po njihovem mnenju »poglobitve partnerske zveze«, druge pa so s trenutno kontracepcijsko metodo zadovoljne in ne razmišljajo o zamenjavi metode. Iz izjav udeleženk je razbrati, da so stranski učinki nekaterih kontracepcijskih metod (predvsem kontracepcijskih tablet) pomemben dejavnik, ki vpliva na izbiro ustrezne kontracepcijske metode, saj je večina udeleženk prepričanih, da ti negativno delujejo na ženski organizem. Za mnoge intervjuvanke je pri izbiri kontracepcijske metode pomemben občutek spolnega stika, zato je raba kondoma včasih problematična. Prav tako so problematični doslednost jemanja kontracepcijskih tablet in njihovi stranski učinki. »Nikoli se nisem hotela posluževati hormonske kontracepcije, ker tega ne podpiram. Kondom se mi zdi še najbolj sprejemljiv, ker ne pusti nobenih posledic in stranskih učinkov na zdravje. To mi je pa pomembno. Zato nisem nikoli uporabljala tabletk, prav zaradi posega v sistem, v telo, v spreminjanje hormonskih funkcij.« (Dajana, 28 let) »Mogoče bi lahko samo rekla, da malo pokvari tisti trenutek, ko si mora fant nadeti kondom [smeh]. Sigurno bi bilo še boljše, če bi bila brez kondoma.« (Dajana, 28 let) Dve intervjuvanki pa še posebej poudarjata, da današnja družba mladim ponuja preveč svobode na spolnem področju, in ravno zato menita, da mora biti odločitev za uporabo kontracepcije premišljena. »S svobodo je prišlo tudi do kontracepcije. Kar v bistvu ni nič slabega, a zavedati se moramo, da preveč svobode tudi ni dobro v življenju, poznati moramo svoje omejitve. Vsak bi moral razsodno pristopiti k tej stvari, to se mi zdi, da manjka današnjemu svetu. Ta razsodnost, da ni vse dobro, kar nam družba ponuja. To vidim tudi pri mladih, ki zagrabijo vse, kar jim ponudiš. Tu bi morali mi odrasli drugače pristopiti in mladim te stvari glede kontracepcije in splava malo drugače predstaviti.« (Dajana, 28 let) Pomen kontracepcije za ženske Tri tematske skupine opredeljujejo temo »pomen kontracepcije za ženske«, znotraj katere intervjuvanke razkrivajo, da je uporaba kontracepcije pomemben dejavnik, ki vpliva na njihovo kakovost življenja, partnersko zvezo in družbeni položaj žensk. Uporaba kontracepcije po njihovem videnju omogoča lažje načrtovanje življenjskih dogodkov in doseganje zadanih ciljev. Vse intervjuvanke, ki uporabljajo kontracepcijo, menijo, da jim ta zagotavlja varno in sproščeno spolnost, dve od njih pa še posebej poudarjata pomen spolne svobode med plodnimi dnevi ciklusa, ko je spolno poželenje največje. Nasprotno pa ena od intervjuvank, ki kontracepcijske zaščite ne uporablja, kontracepcijo dojema kot nasprotovanje sami sebi in nasprotovanje življenju. Vse intervjuvanke, ki kontracepcijo uporabljajo, se strinjajo, da njena raba omogoča rojstvo načrtovanega, zaželenega otroka v časovnem obdobju, ko sta zanj zagotovljeni optimalna skrb in nega. Ob tem tri intervjuvanke še posebej poudarjajo pomen načrtovanih časovnih razmikov med rojstvom enega in drugega otroka, saj menijo, da se s tem otroku v najnežnejših letih življenja omogoči potrebno nego in pozornost, mater pa se razbremeni prevelikih obveznosti in odgovornosti. Starejši intervjuvanki poudarjata pomen zaščite v predmenopavzalnem obdobju, ko je nosečnost še vedno mogoča, njuna doba materinstva, kot sami pravita, pa že končana. »Odkar sem sterilizirana, vem, da sem sto procentov zaščitena in imam kvalitetnejše življenje. Ne grem več s strahom na wc in čakam, ali bo prišla menstruacija ali ne [...] Zdaj sva oba bolj sproščena in si lahko brez strahu izkazujeva ljubezen, ko si tega zaželiva, praktično sva oba brez skrbi.« (Eva, 38 let) »Ja, nismo še toliko stari, da tega ne bi več počeli, in še vedno lahko zanosim, do menopavze je nosečnost mogoča. Vendar čutim, da je šla moja doba materinstva oziroma rojevanja mimo. Saj komaj čakam vnuke, ampak da bi pa še enkrat morala dati vse to skozi: porod, vzgojo, šolo, se mi zdi, da psihično tega ne bi zmogla, vsaj ne več tako kot takrat, ko sem bila mlada.« (Katja, 49 let) Večina intervjuvank meni, da ima uporaba kontracepcije velik vpliv na partnersko zvezo, ki v sodobnem času postaja vse svobodnejša in neobvezujoča. Večina jih tudi verjame, da uporaba kontracepcije vpliva na družbeni položaj žensk, pri čemer izpostavljajo možnost izbire med družino in kariero. Tri intervjuvanke trdijo, da je odločitev za družino, še posebej številčnejšo, v družbi danes pogojena z ekonomskim stanjem, saj sodobni človek hrepeni po varnosti in ugodju. »Včasih so ljudje imeli enega, največ dva partnerja, potem so se mladi poročili in imeli otroke [...], danes pa večina punc in fantov poskusi več zvez, ima izkušnjo spolnosti že pred poroko, po navadi tudi z različnimi osebami in se šele potem odloči, kdo je tisti pravi.« (Meta, 20 let) Vzgoja in pridobivanje ustreznega znanja o kontracepciji Intervjuvanke smo spraševali tudi o tem, ali sta bili spolnost in kontracepcijska zaščita del njihove mladostniške vzgoje v krogu družine oziroma kje so poiskale potrebne informacije o kontracepcijski zaščiti, ko so se srečale s tem vprašanjem. Na podlagi izločenih fraz oziroma izjav lahko sklenemo, da so si intervjuvanke neenotne v mnenju, povezanem z vključevanjem spolnosti in kontracepcije v njihovo mladostniško vzgojo, pri čemer izpostavljajo problem njihovih staršev, ki so spolnost doživljali kot tabu temo. 122 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. »S svojo mamo se nisva nikoli na štiri oči usedle in pogovorili na to temo. Zdi se mi, da je bila že moja mama tako vzgojena, da je bilo vse v zvezi s spolnostjo tabu, o katerem se ni smelo govoriti. Menim, da sta na to, da ni bilo med nami tiste odprtosti glede te teme, imeli velik vpliv tudi Cerkev in vera, ki kontracepcijo še danes prepovedujeta.« (Jana, 46 let) Mnoge intervjuvanke tudi opažajo, da zdravstveni in šolski sistem ne ponujata dovolj informacij o kontracepciji. Te si ženske večinoma poiščejo same, najpogosteje na internetu in v različnih poljudnih revijah, in sicer takrat, ko zaščito potrebujejo. Tiste, ki kontracepcijo uporabljajo, se strinjajo, da razmišljanje o njej sprožijo predvsem najstniški pogovori med sovrstnicami, konkretne informacije pa poiščejo ob vzpostavitvi prvih partnerskih zvez ter posledično prvih spolnih odnosih, najpogosteje v srednješolskem obdobju. »Edini pogovor, tak bližnji pogovor, je s svojimi sovrstnicami. Zdaj tudi pogovor z zdravniškim osebjem, jaz ga nisem nikoli zaznala. Niti moje prijateljice niso rekle, da bi se prav zares pogovorile z ginekologinjo, mogoče je zdaj kaj drugače. V šoli smo imeli pri biologiji nekaj o spolnosti, o kontracepciji pa zelo malo. Od šole smo dobili, vsaj moja generacija, malo.« (Dajana, 28 let) Udeleženke se strinjajo, da uporaba izbrane kontracepcijske metode ni zahtevna in so z doseženo stopnjo znanja o svoji kontracepcijski metodi zadovoljne oziroma se s tem ne obremenjujejo. »Če sem prav poštena, se niti ne obremenjujem s tem, ali sem dovolj poučena ali ne. Nič me ne boli, nič me ne moti, nimam težav in o tem sploh ne razmišljam, sem dala iz glave.« (Katja, 49 let) Družbeni položaj žensk Intervjuvanke so veliko razpravljale tudi o položaju žensk v širšem družbenem kontekstu, iz česar je razvidno, da temu namenjajo ustrezno pozornost. V tem pogledu so si mnenja med njimi nasprotujoča. Nekatere intervjuvanke menijo, da so ženske danes enakopravne moškim in dovolj vključene v procese odločanja, nasprotno pa druge trdijo, da je položaj žensk v današnji družbi sicer boljši, kot je bil nekoč, še vedno pa opažajo prisotnost neenakih možnosti med spoloma, zlasti glede osebnega dohodka in vključevanja v procese odločanja. Ena od starejših intervjuvank poudarja še vpliv vzgoje v preteklosti kot pomemben dejavnik, ki je še povečeval prepad med enakimi možnostmi. »Mislim, da je položaj ženske bistveno boljši, kot je bil, smo pa še vedno malo zapostavljene, in to na vseh delovnih področjih. Glede doseganja znanja smo sicer enakovredne moškim, problem nastane na poklicni poti. Točno vemo, da smo manj plačane za ista delovna mesta. Je pa sigurno bistveno boljše, kot je bilo petdeset let nazaj.« (Dajana, 28 let) »Mogoče smo bili mi, moja generacija, pa seveda še generacije nazaj vzgojeni v veri, da so moški pomembnejši in vplivnejši, a potem, ko sem začela malo sama razmišljati in imela svojo družino, sem ugotovila, da resnično na ženski stojijo trije vogali.« (Katja, 49 let) Tri intervjuvanke so prepričane, da patriarhalna ureditev povzroča oziroma prisili ženske, ki si želijo kariere in uspeha v poslovnem svetu, da prevzemajo »moške« vzorce vedenja, medtem ko druge intervjuvanke čutijo, da materinstvo, poleg zaposlitve, še vedno ostaja osrednja naloga današnje ženske. »Ženska je tista, ki je bolj ljubeča, materinska, bolj čustvena in mislim, da smo v splošnem poklicane za materinstvo, skrb za otroke.« (Ana, 31 let) »Zanimivo, da sem vsakega otroka bolj vesela, vsak me bolj osreči, pa ne da me prva ni, ravno tako, ampak čutim neko polnost, drugačnost, ki jo ta svet ne more dati, otroci pa ti jo prinesejo.« (Maja, 38 let) Diskusija Uporaba kontracepcije parom, še bolj pa samim ženskam, omogoča načrtovanje prve oziroma naslednje nosečnosti ob upoštevanju zdravstvenih tveganj in koristi skupaj z drugimi okoliščinami, kot so starost, rodnost, dostop do zdravstvenih storitev, socialne in ekonomske razmere ter osebni interesi, zato nosi velik vpliv na življenje posameznih parov in pomembno vpliva na kakovost življenja žensk (Benagiano, et al., 2007). Zaradi te kompleksnosti je kvalitativno proučevanje fenomena kontracepcije v vsakdanjem življenju žensk in njihovem okolju, ki oblikuje njihova prepričanja in usmerja njihova dejanja, ključno. Proučevanje se tako usmerja v različne subjektivne perspektive žensk, povezane z družbenimi okoliščinami, v katerih te nastajajo (Pahor, 2007). Rezultati kvalitativne analize besedila so osredotočeni okrog štirih tem, ki opredeljujejo pomen kontracepcije za ženske. Hierarhično, po številu podobnih fraz v tematskih skupinah in vsebinskem obsegu, je najmočnejša tema »dejavniki, ki vplivajo na izbiro in rabo kontracepcijske metode ter njeno sprejemljivost«. Intervjuvanke se zavedajo, da mora biti odločitev za uporabo kontracepcije premišljena, a izbiro kontracepcijske metode pomembno zaznamujejo vpliv verskega prepričanja, mnenje sovrstnic, partnerja in ginekologa, stranski učinki nekaterih kontracepcijskih metod, zdravstvene težave, želja po poglobitvi partnerske zveze in občutek spolnega stika ter medijsko ustvarjene podobe, ki jih, kot ugotavljata Garner in Mendez (2014), uveljavljajo dominantne politične, družbene in verske skupine, ki želijo nadzorovati kontracepcijo in s tem življenje žensk. Kot kažejo izsledki raziskave, vpliv verskega prepričanja še vedno zaznamuje odločitev za uporabo kontracepcije, čeprav se tudi v katoliški veri vzgojene ženske vse pogosteje odločajo za uporabo 123 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. kontracepcije. Vlogo religije je zato treba postaviti v kontekst države, lokalne skupnosti in družine (Jain, 2003), kjer ženske krmilijo med številnimi kulturnimi sporočili o ženstvenosti, seksualnosti, kontracepciji in materinstvu. Podobno kot v raziskavi, ki jo je opravila Lowe (2005), tudi izsledki te raziskave kažejo, da je odločitev za kontracepcijo med drugim pogojena tudi z vnaprejšnjim pričakovanjem spolne aktivnosti, menjava kontracepcijske metode pa je pogosto pogojena z zdravstvenimi težavami in občutkom spolnega stika. Ista avtorica poroča, da uporaba kontracepcije povečuje kakovost življenja in omogoča rojstvo načrtovanega, zaželenega otroka, kar se sklada z drugo identificirano temo »pomen kontracepcije za ženske«. Večina intervjuvank namreč pritrjuje, da uporaba kontracepcije zvišuje kakovost življenja, saj jim zagotavlja varno in sproščeno spolno življenje ne glede na plodne dni ciklusa ter omogoča načrtovanje rojstva otroka v časovnem obdobju, ko sta zanj zagotovljeni optimalna skrb in nega, ter pomembno vpliva na partnersko zvezo. Tako se zanje ustvarja možnost izbire med družino in načrtovanjem kariere, ki bi bila sicer brez kontracepcije omejena, kar bi neposredno vplivalo na njihov družbeni položaj. Sonfield in sodelavci (2013) ugotavljajo, da razširjena raba kontracepcije vpliva na stopnjo dosežene izobrazbe žensk, njihovo zaposlitev, socioekonomsko stabilnost, osebno zadovoljstvo in v povezavi s tem na njihov družbeni položaj. Tretja tema »vzgoja in pridobivanje ustreznega znanja o kontracepciji« kaže, da so bile intervjuvanke v družini deležne različne mladostniške vzgoje glede spolnosti in kontracepcije, pri čemer izpostavljajo težavo staršev, ki so spolnost doživljali kot tabu temo. Intervjuvanke zato izpostavljajo, da so bila prva razmišljanja o kontracepciji povezana s pogovori med sovrstnicami, začetki prvih partnerskih zvez in posledično prvi spolni odnos v srednješolskem obdobju. Prepričane so, da jim zdravstveni in šolski sistem nista ponujala dovolj informacij o kontracepciji, vsaj ne praktičnih, zato so iskale informacije drugje, zlasti pri sovrstnicah. Tudi Lowe (2005) navaja, da si ženske informacije o kontracepciji pridobijo same, potrditev izbrane kontracepcijske metode pa namesto pri zdravstvenih delavcih iščejo pri drugih ženskah v svojih socialnih omrežjih. Pinter in Grebenc (2010) ugotavljata, da je v primerjavi s prejšnjimi generacijami opaziti hitrejše biološko (spolno) dozorevanje deklet glede na njihovo socialno in duševno zrelost, zato je zgodnja spolna dejavnost dejavnik tveganja pred neželeno nosečnostjo, saj ji stopnja kognitivnega razvoja v povprečju ne zagotavlja takšne zrelosti, da bi se zavedala posledic. Pravočasna, predvsem pa učinkovita zdravstvena vzgoja (Pinter & Grebenc, 2010), v metodah in obliki prilagojena današnjim generacijam, lahko pomembno prispeva k zmanjšanju posledic tveganega spolnega vedenja. Z odraščanjem, daljšo rabo kontracepcije ali po preteku pomembnih življenjskih dogodkov (npr. rojstvo) je pri intervjuvankah opaziti prepričanje, da so zadovoljne z znanjem, ki ga imajo o trenutni kontracepcijski metodi, ali pa se s tem danes sploh ne obremenjujejo. Fenomenološka analiza je pokazala, da so posamezne tematske skupine med seboj tesno povezane, kar kaže na večdimenzionalnost proučevanega fenomena. Čeprav je pogovor z intervjuvankami potekal o kontracepciji, so tematiko povezale s položajem žensk v slovenski družbi, kar kaže na to, da vidijo kontracepcijo kot pomemben element emancipacije. Četrta tema »družbeni položaj žensk« je tako podobno kot tretja zaznamovana v neenotnem mnenju med intervjuvankami glede trenutnega družbenega položaja žensk. V ospredju teh različnih pogledov sta neenakopraven položaj, ko govorimo o procesih odločanja, in prevzemanje, kot same opisujejo, »moških vzorcev vedenja«, s čimer lažje napredujejo v patriarhalni ureditvi in doživljanju materinstva, ki ga nekatere še vedno vidijo kot osrednjo funkcijo ženske. Presenetljivo je, da je slednje pogosteje pri intervjuvankah, starih od 30 do 40 let, medtem ko so starejše od 40 let drugačnega mnenja. Fenomenološka raziskava ima nekaj omejitev: (1) raziskava je geografsko omejena, kar omejuje posploševanje rezultatov oziroma ne predstavlja stališč in prepričanj širše ciljne populacije; (2) fenomenološka analiza podatkov kot druge podobne metode kvalitativnega raziskovanja temelji na interpretaciji raziskovalca, kar bi lahko ob upoštevanju drugih teoretičnih izhodišč, razlikah v dodatno postavljenih podvprašanjih in podobno prikazalo rezultate drugače; (3) raziskava ni posebej proučevala povezave s podrobnimi demografskimi podatki (ekonomski status, veroizpoved, spolne prakse ipd.) niti ni tega od sodelujočih zahtevala. Priložnosti za nadaljnje raziskovanje se kažejo v razširitvi raziskave na širše geografsko območje, zlasti pa vključitvi žensk, ki živijo v urbanih okoljih. Na drugi strani pa je pogled moških na kontracepcijo in ženske z vidika varovanja zdravja in preprečevanja tveganega spolnega vedenja pri raziskovanju tega fenomena pomemben, a ob upoštevanju kulturnega ozadja v nekaterih okolij morda težje dosegljiv. Zaključek Razvoj kontracepcije, zlasti hormonskih metod, in njena širša dostopnost ženskam ni prinesla le nadzorovanja lastne reprodukcije, temveč tudi priložnost za poskus emancipacije, ki pa je bil v nekaterih družbenih okoljih bolj, v drugih manj uspešen. Izsledki raziskave kažejo, da je kontracepcija pomembna dimenzija kakovosti življenja žensk v ruralnem okolju in dimenzija, ki jo ženske povezujejo z njihovim družbenim položajem. Sprejemljivost kontracepcije in izbiro kontracepcijske metode oblikujejo številne družbene okoliščine in usmerjajo 124 Črnigoj, Š. & Prosen, M., 2016. / Obzornik zdravstvene nege, 50(2), pp. 107-125. mnogi podporni sistemi. Zakaj medicinska sestra potrebuje te informacije? 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