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Your faith of mine: a pregnancy spacing intervention in an ultra-orthodox Jewish community in Israel.

Abstract: Ultra-orthodox (haredi) Jews in Israel have an exceptionally high fertility rate of 7.7. As most fathers spend their days studying the Bible, the women struggle to support their large families under severe economic pressures. Some women experience maternal exhaustion coping with this life situation. Contraception for pregnancy spacing raises myriad dilemmas in the haredi community, however, many of which apply to promoting family planning in religious settings more generally. In a health promotion course For 23 haredi registered nurses at the University of Haifa in 2006-2007, pregnancy spacing was selected as the subject of the class project, the main aim of which was to convey an influential health message in a culturally acceptable manner As the issue was debated, it was agreed the project should also address a range of women's health problems as well as pregnancy spacing. Thus, maternal nutrition, pelvic floor tone, dental health, maternal exhaustion and competition over number of children were added. A brochure was prepared and widely distributed in the haredi community, where it was well received. This paper describes the classroom dynamics during the planning and application of the project. It illustrates the importance of cultural awareness when addressing sensitive issues and communities with particular cultural dispositions.

Keywords: maternal health, family planning, health promotion, beliefs/norms/values, Judaism, Israel

Resume

Les Juifs ultra-orthodoxes (haredim) en Israel ont un taux exceptionnellement e1eve de fecondite de 7,7. Comme la plupart des peres passent leurs journees a etudier la Bible, les femmes peinent pour e1ever leur famille nombreuse dans des conditions economiques difficiles. Cette vie conduit certaines femmes a developper un epuisement maternel. Neanmoins, la contraception pour l'espacement des naissances souleve une multitude de dilemmes dans la communaute haredi, dont beaucoup s'appliquent plus generalement a la promotion de la planification familiale dans des contextes religieux. Dans un cours de promotion de la sante pour 23 infirmieres haredi a l'Universite d'Haifa en 2006-2007, l'espacement des naissances a ete choisi comme theme du projet de classe, dont le principal objet etait de transmettre un message influent de maniere culturellement acceptable. Au cours des debats, il a ete convenu que le projet devait aussi aborder plusieurs problemes de sante des femmes, en plus de l'espacement des naissances. Par consequent, la nutrition maternelle, la musculation du perinee, la sante dentaire, l'epuisement maternel et la concurrence sur le nombre d'enfants ont ete ajoutes. Une brochure a ete preparee et largement distribute dans la communaute haredi qui l'a bien accueillie. Cet article decrit la dynamique de classe pendant la planification et l'application du projet. I1 montre qu'il est important d'avoir conscience des enjeux culturels lorsqu'on traite des questions sensibles et des communautes dispositions culturelles particulieres.

Resumen

Los judios ultra ortodoxos (haredi) en Israel tienen una tasa excepcionalmente alta de fertilidad de 7.7. Dado que la mayoria de los padres dedican sus dias al estudio de la Biblia, las mujeres luchan por mantener a sus amplias familias bajo enormes presiones economicas. Algunas mujeres sufren agotamiento materno lidiando con esta situacion. La anticoncepcion para el espaciamiento de embarazos plantea diversos dilemas en la comunidad haredi; sin embargo, muchos de estos se aplican a la promocion de la planificacion familiar en ambitos religiosos mas generalmente. En un curso de promocion de la salud para 23 enfermeras diplomadas haredi, en la Universidad de Haifa en 2006-2007, el espaciamiento de embarazos fue seleccionado como el tema del proyecto de la clase, cuya finalidad principal era transmitir un mensaje influyente sobre la salud de una manera culturalmente aceptable. Segun se fue debatiendo el tema, se acordo que el proyecto tambien deberia tratar varios otros problemas de salud de las mujeres. Por tanto, se anadieron nutricion materna, tono del piso pelvico, salud dental, agotamiento materno y competencia por el numero de hijos. Se preparo un folleto y se distribuyo por toda la comunidad haredi, donde fue bien recibido. En este articulo se describen las dinamicas de la clase durante la planificacion y aplicacion del proyecto. Se ilustra la importancia de la conciencia cultural al tratar temas delicados y dirigirse a comunidades con determinadas disposiciones culturales.

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IN some communities, both the discourse and practice of family planning are still rife with ethical dilemmas and potential tensions between health policies and individuals' beliefs and values. These dilemmas apply to health promotion more generally. In order to adopt healthy behaviours people must first possess accurate knowledge and become aware of existing options, which they can then apply. However, knowledge dissemination is far from sufficient. Quite often, healthy choices are more costly and time-consuming, may conflict with a community's culture, or exceed local or personal influence. Thus, in order to be effective, health promotion interventions need to be highly context sensitive. (1-4)

The present paper traces the planning and application of an educational project on family planning, targeting women in a small, exceptionally pronatalist community in Israel, the Jewish Orthodox haredi. The project was conducted in a course for nursing students, themselves religious Jewish women. The author was the course instructor, a secular, Jewish sociologist from the University of Haifa. The differences rendered cultural sensitivity vital.

Contraception for pregnancy spacing is a highly contested territory in the haredi community. Approaching the subject thus raised myriad dilemmas, many of which apply more generally to promoting family planning in religious settings: Was it appropriate for me, an outsider to the community, to use my academic authority to talk the students into probing this tender sphere? In a community where the number of children is a woman's main source of power and self-realisation, was it ethically right to encourage women who had consciously rejected this secular worldview, if only tacitly, to have fewer children? Did it patronise the women, assuming that an outsider could see better what was good for them? Were the women at all able to negotiate contraception? Even if these questions were answered favourably, addressing the subject in a culturally sensitive manner was a challenge.

Background: the haredi community

The haredi comprise 7% of Israel's population. (5) They have an exceptionally high total fertility rate -7.7, (6) rising to nine in some young communities--whereas among Jewish Israeli women as a whole, the total fertility rate is 2.75. (7) Haredi women joke that a woman who is not pregnant at her eldest child's wedding is not fulfilling her familial duty.

Over half of haredi fathers (55-60%) spend their days in institutions of advanced Bible studies and only 30% earn any money beyond a small student's allowance. (8) Breadwinning is thus by and large the wife's responsibility as well as raising the children. However, attending to their extensive households, possessing but basic education, and anyway being subjected to the general gender discrimination in Israel's labour market, haredi women are seriously disadvantaged in the workplace competition. Only 45% are gainfully employed, (9) and even they must rely heavily on state child allowance. Since the mid-1990s, when haredi political power was at its peak, these allowances privileged large families and paid a higher proportional allowance for "higher order" children. However, since 2002, these allowances have gradually been reduced, to level out at some US$45 per month per child in 2009. At present, 58% of orthodox families live below the poverty line. (10) Though haredi communities take pride in their material ascetism, the severe financial constraints add to the challenge laid upon the woman's shoulders.

The haredi attribute their high fertility to the biblical commandment that obliges men to "Be fruitful and multiply", which has acquired a pronounced significance after the holocaust. All orthodox streams forbid the use of contraception and abortion unless warranted by a rabbi.

An important factor that enables religious leaders to sustain this status quo is the reduction of interaction with the surrounding society to the bare minimum, and a hermetic ban on mass media, including radio, television and general newspapers and books. The sector has its own press and publishers, Internet and cell phone use are tightly filtered by purpose-designed software to limit their functions. Consequently, haredi communities are disconnected from most of the information, ideas and practices that circulate in the wider Israeli society.

In sharp contrast, to the media silence, haredi rabbis are omnipresent, serving as mentors and personal and spiritual fathers. They exercise practically unbounded authority in all spheres of the community life, including which political party the community will vote for in elections, which marriage arrangements will materialise, of who is allowed to use contraception and for how long. In fact, with every significant question the rabbi's recommendation is obligatory.

It was against this background that our project took place.

A chronicle of the project

The main goal of the project was for the class to convey an influential health message to haredi mothers in a culturally acceptable manner. It was designed during a health promotion class in the 2006-07 academic year consisting of 23 religious Jewish women, of whom 14 were haredi. All of the women were working as registered nurses and midwives and were studying towards a BA in nursing at the (secular) University of Haifa. The class met for two hours once a week for the whole academic year, in the predominantly haredi town of Bnei Brak, near Tel Aviv. I had had no previous acquaintance with the students of the community.

The women's ages ranged from 23 to 46 years (average=30.4). All but three were married and mothers to 1-9 children each (average=4). The haredi women had more children than the others (5.3 vs. 1.4), and were somewhat older. Of the 14 haredi women, nine were married to bible learners. (Four were also part-time teachers.) During the academic year, nine of the students gave birth and in the following four months, four others also gave birth.

The students had all taken a theoretical course in health promotion a year earlier. The present course aimed to deepen their knowledge by means of field application, namely experiencing the full scope of a health promotion project, from selecting a topic, to its theoretical and empirical exploration, planning an intervention, and applying, evaluating and presenting it in a written report. The suggestion to focus on the needs of mothers of numerous children, including contraception, was mine.

Coming from years of infertility research, I was intrigued by the encounter with the opposite extreme and keen to gain a deeper insight into haredi mothers' lives. I assumed that for some haredi women, raising a large family was highly challenging. The students confirmed this but at the same time were reluctant to approach such a sensitive subject. For them, childbearing was a haredi woman's main life goal, her road to self-realisation, her primary obligation towards her partner and her role in nurturing Jewish life.

Witnessing the students' hesitation to my suggestion, I asked whether it was religiously permitted to stop childbearing due to maternal exhaustion. They all agreed that a haredi woman could seek a rabbi's approval for temporary use of contraception. Such approval would normally be granted for some six months, allowing the couple to space the next pregnancy. Indefinite prevention of pregnancy was unacceptable. Some women availed

themselves of this option, they said, and used contraceptives even more liberally than presumed. Others were too embarrassed to present a request and went on conceiving. Drawing on their clinical knowledge as nurses, the students added that the problem was especially critical now, since breastfeeding, traditionally used by haredi women as a natural contraceptive, is carried out fewer times per day than it had been by previous generations, and is therefore less effective, thus leaving women more vulnerable to conception.

The deeper we delved into the subject, the more worthy it seemed. Though I did not present any new information, my "innocent" questions, imbued with astonishment, apparently caused a reconsideration of this taken-for-granted reality. The students decided to devote the year to pregnancy spacing, as they called it, despite its extreme sensitivity. They viewed it as important enough to justify the risk. I felt that although it was my own idea at first, the task appeared worthy to the students and was not discordant with their religious values.

The following weeks were devoted to developing an applicable framework for the project. Within a single meeting it became apparent that addressing pregnancy spacing straightforwardly was out of the question. Any suggestion in this direction was immediately ruled out. Appreciating the students' concern that they might be viewed as advocating birth reduction, I made no attempt to influence their deliberations.

Gradually, a new approach evolved. Merging their medical knowledge with first-hand acquaintance with the community, two students argued that if we genuinely wanted to help haredi mothers, we should address a whole range of their problems rather than just pregnancy spacing. This appealed to everyone, giving the project an indisputable health promotion value. Next they went out to identify the most relevant issues, via a literature review and semi-structured interviews with mothers of seven or more children, using open-ended questions developed collectively in class.

In the ensuing weeks the students reported their findings to the group. The literature search underscored the exceptionality of their community: most studies of frequent pregnancies referred to developing countries where women were often undernourished and lacked access to contraceptives and medical care; teenage pregnancy was described in the context of social marginality and disadvantage; pregnancies at older ages were mostly in working women just starting a family, quite often without a partner. Although not surprised, the students were impressed by the differences. And I wondered how this reflexive encounter was affecting them. Was it ethical to urge a comparison with others on people who intentionally avoided alternative models? I found reassurance in my impression that the students mostly seemed pleased to realise their emergent singularity.

On the basis of the findings we decided to focus our intervention on maternal nutrition, pelvic floor tone, dental health and the mental health subjects of maternal exhaustion, competition over number of children, and contraception. After considering various formats--evening lectures for women or talks with rabbis who would address these issues in community gatherings the students agreed that an information brochure would be the most appropriate modality. However, when the plan started to materialise, concerns resurfaced.

A few students worried that speaking out on pregnancy spacing was religiously wrong, and might be interpreted as an invitation to birth control. One student argued that we should restrict our intervention to providing information on the physical health concerns of mothers of numerous children. This option started to gather momentum and attracted another six or seven supporters, who argued that if we could help without stirring trouble, we should steer clear of the riskier zone.

I felt differently. To me, pregnancy spacing was the heart of the project. I saw our class as exceptionally well situated to tackle this sensitive subject. We had the advantage of the students' profile: haredi or orthodox women, mostly mothers of numerous children themselves, all nurses and midwives. As such, they were also relatively familiar with the secular world and therefore more likely to interact successfully within it, e.g. when looking for sponsors. The students were also highly motivated to fulfil the course requirements. Then there was my own involvement: a secular, liberal mid-life woman, endowed with the authority of a university professor, who was highly committed to the subject, yet free of community awe. In the classroom, my commitment and effort to accommodate haredi sensitivities translated into closeness and trust with the students, which was crucial for a better understanding of the problem at hand.

Within this context, I read the new reaction as ambivalent, not passionate but rather expressing vague hesitation. The rest of the class kept silent, but the silence was also ambiguous. A student might have opposed tackling pregnancy spacing but wish to avoid disagreement with the course instructor. Or else, she might have supported the subject but prefer not to express this potentially dubious stance. I therefore felt it was ethically justified to assert my academic authority to keep pregnancy spacing on the agenda. This moment was, for me, the most delicate point in the evolution of the project.

I started by asking the students again whether they saw a religious problem with the subject, which they dismissed. I then explained how uniquely we were situated to address this silenced problem and that we should not let the opportunity go just because of some unspecified concern. My talk aimed to augment a sense of calling to assist women in a state of pervasive yet unacknowledged distress. I also reiterated that our ambition was modest: to raise awareness of the legitimacy of contraceptive requests (to a rabbi) and to alleviate some of the women's loneliness by acknowledging the existence of a problem.

This was a somewhat ironic situation: I, the outsider, was standing there preaching about a reality the existence of which I was merely guessing, whereas every student in the classroom seemed to know several such distressed women personally. It was probably this personal acquaintance that eventually convinced the students to adopt the riskier plan. In the final report of the course they later described the process thus:

"What has tipped the scale in favour of the project was the understanding that it was precisely us who could do it, because we belonged to this society and only we, who know the finest nuances that no outsider spots, could promote our own health ... [But] the very idea of addressing this subject flooded us with concerns. That the course instructor was a secular woman, affiliated with a secular university further increased our reluctance, owing to the gap between us and the holiness of the subject for us ... One must be extremely cautious in order to avoid sin or, God forbid, lead other women to sin by interpreting our brochure as allowing them to space pregnancies. At the same time, we, living and working in the haredi community, know better than most people the distress of some women we meet, who literally collapse under the burden of their households, which the husbands do not always share and which the woman also has to support financially."

Out of both respect to the haredi audience and the desire to be heard, the group were attentive to the smallest details of content, form and ethical challenges:

* For a title, we selected a well-known quote from the book of Psalms: "The mother of sons rejoices" that focused on the woman, but as a mother.

* We chose a font that is used in religious circles only, often in religious or related writing.

* We avoided sensitive terminology and visual material (e.g. no use of "sphincter" or "vagina" in the description of pelvic floor exercises, and no illustrations).

* We avoided strong language, e.g. we said that bitterness in the context of childrearing may result in.... We applied this kind of hypothetical grammatical construction throughout the text.

* We always used the expression pregnancy spacing, which implied subsequent pregnancies and emphasised that each case should of course be considered individually (by a rabbi).

* We communicated the authors' commitment to orthodox belief and large families through sentences like: "A great privilege has befallen us, to raise our children, God's children, to the love of God."

* We wrote in the first person plural (our lives, we women) in order to increase identification and suggest authors' sharing in the life situation we were describing.

* Realising orthodox women's difficulty to claim space for themselves, we stressed that a happy and fulfilled mother benefited the whole family.

* Aiming to induce optimism we used positive titles (protecting and restoring your pelvic floor; happiness and self-realisation.)

* We provided respectful yet accessible scientific explanations (folic acid [vitamin B9] to prevent congenital malformations.)

* We made suggestions that could fit into women's busy schedules and modest financial means, e.g. pelvic floor exercises that could be performed anywhere anytime; nutritious foods that were inexpensive, available and easy to prepare.

The students obtained sponsorship from a pharmaceutical company to pay for the printing (US$350). A friend of a student volunteered to do the graphic design. The brochure just needed to be signed by its authors. Initially, we thought it would serve as advertisement for our programme. However, one student suggested that the combination of sensitive content and the secular University of Haifa might actually harm the project. The logic was self-evident. We decided to sign "Nursing students" and omitted all identifying signs.

To distribute the brochure, we approached women-only meeting points, such as gynaecology clinics, maternity wards, brides' preparatory classes, "reborn Jews" classes and the mikveh. * We intentionally aimed at younger women as well, in order to introduce the spacing option at a formative phase of their childbearing years.

At this point, one of the stricter students said we needed a rabbi's approval to be admitted to these places. She named a well respected, relatively open rabbi and volunteered to talk to him. The following week we learnt that the rabbi praised the brochure, but said that it would be much improved without the pregnancy spacing text. At first, the students were ready to follow his recommendation. Sensing my disappointment, they suggested we approach another rabbi. However, I realised that a second disapproval would doom the topic. Largely pushed by my frustration, I dared to suggest a different strategy: that we retain the brochure, as originally planned, as a women's affair, highlighting its "cosy" feminine character. Although a couple of students remained keen to obtain a rabbi's approval, claiming we would be rejected without it, others were less convinced. To my relief (and surprise) the students agreed to proceed without a rabbi's approval.

The brochures were received with unanticipated warmth. Nurses, mikveh managers, bride-guides and haredi mothers went out of their way to express their gratitude. On a feedback round, four weeks after the distribution, the reactions were even warmer. A few women responded to the more sensitive parts of the text. One commented on the competition between women over number of children and another, on her unfulfilled desire to study. We did not receive any reaction to pregnancy spacing, but were actually pleased that there were no hostile responses. More generally, the brochure revealed that standard health education materials had not made their way into haredi communities. This rendered the additional health topics that we addressed more vital than we had appreciated at first. Our brochure thus filled a lacuna and raised our awareness of the community's broader need for health information.

Conclusion

The project described here offers a succinct illustration of the vitality of cultural sensitivity in health education and the effectiveness of using a community's existing structures for the distribution of thousands of leaflets in various community locations. It also illustrates the value of fluent communication between stakeholders (students, interviewed mothers, instructor) for refining a culturally sensitive intervention that would be both influential and acceptable. Technically, the project exemplifies the ability to implement a small but meaningful community intervention with virtually no financial resources, apart from the modest sponsorship which the students managed to obtain.

At a more informal level, the project revealed the significance of the soft margins that even a strict and centralised community like the haredi apparently has, when the students felt, after all, free enough not to get a rabbi's approval. It also illustrates how different authorities, e.g. academic and religious, may compete during the course of a project. Finally, it has shown how even insiders may be partly unaware of the needs of their own community. Despite working and living in the community, the students were surprised by the scope of the informative gap that existed regarding health in their community.

Epilogue

Owing to the private nature of the subject, it would have been very difficult to assess the impact of the project among haredi women. I know of the effect on only one woman, an attractive 32-year-old mother of seven, who I'll call Orit, an emergency ward nurse in a Jerusalem hospital, who was one of the students. She and her husband, a full time bible scholar, lived in a tiny four bedroom apartment near Jerusalem. At the beginning of the year Orit used to arrive in class with her three-month-old son. Photos portrayed a cheerful family. At the last meeting of the class, as the students were chatting about Orit hosting three classmates with their husbands and 22 children from Friday afternoon to Saturday night, she approached me. She said that following our project, she started to consider pregnancy spacing, as she was so exhausted. "But then," she said radiating, "I felt: no, this is wrong. Children are so important; everything else is secondary. So I wanted to tell you that I'm pregnant!" She seemed so happy and confident; and full of energy, as her weekend hosting clearly testified, that I had to ponder about the project. But then, I reminded myself that not every haredi woman was Orit and that her very feeling that it was up to her and her partner to decide, was probably an accomplishment. More pessimistically, Orit's decision can be read as showing how deep and unyielding the community's dictates are. While poignantly raising the question of free will within authoritarian contexts, Orit's hesitation as well as her decision illustrate the importance of conveying health messages across cultural boundaries, as well as the challenges that health promotion entails.

References

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(2.) Kline KN. Cultural sensitivity and health promotion: assessing breast cancer education pamphlets designed for African American women. Health Communication 2007;21(1): 85-96.

(3.) Friedman DB, Hoffman-Goetz L. Assessing cultural sensitivity of breast cancer information for older Aboriginal women. Journal of Cancer Education 2007;(2):112-18.

(4.) Sobero RA, Giraldo GP, Strode ML, et al. Using a culturally competent framework to increase annual breast cancer screening rates among low-income Latinas: a case study of the Orange County Cancer Detection Partnership, Californian Journal of Health Promotion 2003;1(2):101-17.

(5.) Central Bureau of Statistics. Social Survey 2006. Press release, 2007. At: <www.cbs.gov.il[reader[newhodaot/hodaa_template.html?hodaa=200719104>. Accessed 8 January 2008.

(6.) Gurovich N, Cohen-Kastro E. Ultra-Orthodox Jews: geographic distribution and demographic, social and economic characteristics of the Ultra-Orthodox Jewish population in Israel 1996-2001. Central Bureau of Statistics, 2004. At: <www.cbs.gov.il/www/publications/int_ulor.pdf>. Accessed 8 January 2008.

(7.) Adapted from Central Bureau of Statistics. Statistical Abstract of Israel 2007, No. 58, Chapter 3, Table 12.

(8.) Fogel N, Friedman I. Orthodox in the labor market: social survey findings for the years 2002-2005, Central Bureau of Statistics, 2008, At: <www1.ebs.gov.il/www/publications/pub52_h.pdf>. Accessed 8 January 2008.

(9.) Berman E. Sect, subsidy, and sacrifice: an economist's view of Ultra-Orthodox Jews. Quarterly Journal of Economics 2000; 115(3):905-53.

(10.) Prime Minister's Office. Social Economic Agenda for Israel 2008-2010. 2007. At: <www.pmo.gov.il/NR/rdonlyres/ 4835300C-FB14-457E-9376-59ECODC64DF0/0/Agenda.ppt#2>. Accessed 11 January 2008.

* Public baths frequented by Haredi women for ritual purification after their monthly period.

Daphna Birenbaum-Carmeli

Reader, Faculty of Welfare and Health Sciences, University of Halla, Haifa, Israel. E-mail: daphna@research.haifa.ac.il
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Author:Birenbaum-Carmeli, Daphna
Publication:Reproductive Health Matters
Article Type:Report
Geographic Code:7ISRA
Date:Nov 1, 2008
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