The Choice of Health
The Choice of Health
Christian Family Planning among Cosmopolitan Educated Professionals inTime of HIV/AIDS in Botswana
Abstract and Keywords
Based on the reproductive histories of about seventy educated professional women and fifteen educated professional men in Botswana, a country with an HIV/AIDS infection rate of 25 to 30 per cent, this chapter discusses the exceptional life courses of Pentecostal women who have remained childless in their marriages. The chapter discusses Comaroff and Comaroff’s hypothesis of the creation of the ‘right bearing, responsible “free” individual’ launched by English nonconformist Methodist missionaries. It analyses how these women have come to prioritise their health over having children. Christian, and in particular Pentecostal, ethics are shown to be a pool of globally circulating biomedical ideas that stress the controllability of the body and favour postponement. As a transnational religion charismatic Christianity thus launches a health ethic that is attributed to the positionality of new middle-class subjectivities.
PATRICIA IS 45 YEARS OLD and suffers from a condition that, in biomedical terms, is labelled ‘infertility’. She works in a managing position in a bank and is a member of a leading Pentecostal-charismatic church.1 She was 30 years of age when she entered into her first marriage, still childless. Her marriage turned sour and she did not feel secure having children with her husband: ‘We never sat together and planned to have a baby’, Patricia indicated. After little more than one year of marriage, she divorced. Although she remarried, she has not had any children, yet (interview, 3 October 2010).
Tswana people – one of the main ethnic groups in Botswana – have been described as valuing motherhood and childbirth (Upton 2001; Mogobe 2005). How is it then that educated and financially independent women in Botswana do not pursue having children in their marriages? This is the starting question of this chapter. In what follows, I explore the impact of elite lifestyles, HIV/AIDS, and Christianity on reproductive moralities and decisions. This question is a rather unexplored angle in the study of both HIV/AIDS and Christianity. Anthropologists study the shaping of sexuality through Christianity on the African continent (Ojo 1997, 2007; Sadgrove 2007; Bochow and van Dijk 2012), ranging from religious involvement to matters of HIV/AIDS (Becker and Geissler 2009; Nguyen 2009). From an epidemiological point of view, it is not only sexuality that becomes potentially infectious, but conception (Wilcher et al. 2009), birth (Chapman 2010) and breastfeeding as well (Blystad and Moland 2009).
In a context with an HIV prevalence of 30 per cent, the likelihood that one or the other partner is HIV-positive is one in three. Educated professionals in Botswana are highly aware of this fact. Under these circumstances, reproduction bears the risk of contracting or passing on an HIV infection, unless both partners cooperate and seek medical help; and confronts women and men with a dilemma: if they want to have children they must have unprotected sexual intercourse, and yet having unprotected sexual intercourse would expose them to the risk of being infected. In my contribution, I will problematise women’s decision-making or non-decisionmaking on child bearing, which is tied into general reflections on decision-making in the context of family planning in relation to female life courses. This relates to the literature on Christianity and subject formation in this region: Comaroff and Comaroff (1997: 365–6) pointed to the psychological power of Christianity that introduces a moral imagination with a sense of personhood and a ‘modernist self’, which is the ‘right bearing, responsible “free” individual’ among the Tswana-speaking community in the nineteenth century. Thereby, these new conceptions (p.247) of personhood travelled via English nonconformist Methodist missionaries into local Tswana culture. The choice of health versus having children appears to be influenced by if and how Christianity enables individuals to make decisions in twenty-first-century Botswana. The transnational elements, which will be discussed in this contribution, are the travelling ethics of health, the body and personhood, and how these are implemented in single individuals’ reproductive life courses.
Personal tragedy and social change in individual biographies: notes on concepts and methodology
My analysis of the changing reproductive dynamics among Christian urban professionals in Botswana is based on biographical interviews with about seventy urban women and fifteen men that I conducted during several visits to the country in the years 2009 to 2011. These interviews were conducted alongside fieldwork and participant observation in urban households and at the University of Botswana. I will analyse the biographical interviews of three women in particular, who have remained childless in their marriages, partly because they have been protecting themselves from HIV/AIDS. I call them Patricia, Ruth, and Tsholo (interviews, 3 October 2010; 1 March 2011; 16 November 2010).
People who remain childless are exceptions in Botswana as well as in most other societies, even though people in Gaborone have perceived infertility to be a common problem. Their situation is particular and appears to be a personal problem rather than a social one. Anthropologists working on infertility have pointed out that infertility is likely to appear in women’s life courses, if ‘something goes wrong’, and have coined the term ‘reproductive disruption’ for these cases (see Sundby and Larsen 2006; Inhorn 1996, 2002; Feldman-Savelsberg 1999). Infertility often results from unusual circumstances in a person’s life, and these circumstances may be attributed to social dynamics. Poor health care for women who had an abortion might be an example (Hörbst and Schuster 2006). Other circumstances described in the literature include education that postpones childbirth in women’s life courses and therefore heightens the risk of remaining without children (cf. Caldwell 1982). I argue that these life courses I encountered during my fieldwork in Botswana reflect reproductive dynamics; they speak about new gender roles, new approaches to the body, new spiritualities, and alternative ways into reproduction. Looking into biographical circumstances, I propose, allows understanding of some of the factors that have shaped gender relations, reproductive moralities, and reproductive decisions (compare also Leonard 2002).
The second conceptual question that arises out of my research on reproduction among elites in Botswana is how to understand reproductive agency and how it is influenced or directed by culture, gender, and health and family politics, transporting new ideas of the body, health, and technologies. Demographers hypothesise that (p.248) demographic transitions are motivated by larger social processes, as for instance the introduction of schooling on a national level or the enhancement of medical care (Caldwell 1982). Others attribute people’s striving for fertility to specific family and household structures (Caldwell and Caldwell 1987; Lesthaeghe 1989). These studies do not question individuals’ motivation to reproduce. In contrast, personcentred approaches, as they have been put forward by anthropologists like Andrea Cornwall (2007), Jane Guyer (1994) and Liv Haram (2004), discuss single persons’ agency in reproductive decisions, showing how individuals use their reproductive capacities in order to achieve other social goals or how these decisions are embedded in wider processes of producing meaning and moral contestations of family planning practices. In my study, I pursue such a person-centred approach.
Thirdly, I wish to comment on the methodology of the biographic interviews and the context in which these interviews took place. For interviews, I met women (as well as men) mostly in public spaces, cafés, or restaurants. The interviews, lasting between forty-five minutes and two hours, resembled the kind of intimate chats that urban women are used to. My interactions with men outside the context of my research were limited, so I do not know how men usually speak about these issues outside the interview situation. Chatting with me gave women the opportunity to talk about some of their troubling conditions, such as HIV infection or infertility. Narrating their lives, they engaged in meaning making so that the interviews can be read as reflecting reproductive ethics, and how these enter the subjectivities of people. They give evidence of how to evaluate individual agency. In talking about their lives I also refer to ‘life events’, a term that is often used in psychology (compare also Langness and Frank 1981). Like birth, remaining childless is a life event of significant effect in women’s lives.
During the conversation, I took notes, and later I finalised ‘memory minutes’ based on these notes and my memory.2 Twenty-five of the women sought medical assistance in order to conceive; only nine women had not given birth to any child so far. Their ages, and therefore also their chances of conceiving, varied considerably, from 28 to 55. Of this sample, five women showed, like Patricia, that they were strongly influenced by Christian and in particular Pentecostal values (see below). The reproductive histories of these five women were visibly impacted by their Christian/Pentecostal background, and two others suffered a similar fate to Patricia: their reproductive wishes had represented a danger for their health and well-being in their short-lived marriages, and they also did not conceive later on.3 This will become clear in the discussion of their life courses below.
Lastly, I will comment on the religious affiliation of my respondents. As I will show in the following paragraph, the formation of a group of educated professionals (p.249) is deeply rooted in the history of mission churches in African societies. The southern African region is best known for its involvement with the so-called African Independent movements of churches, which put a high emphasis on healing and prophecy (Fernandez 1978; Klaits 2010). Presently, the church with the highest membership is the Zion Christian Church, an African Independent church. However, the Christian landscape is very diverse and fragmented: long-established mission churches, African Independent churches and Pentecostal churches exist alongside one another. Several of my respondents worshipped in one of the biggest Pentecostal churches, and by and large I could recognise that some elements of the Pentecostal paradigm, healing practices and sexual morals, were relevant also for those who were of other denominations. I will write about Pentecostal couples and Pentecostal family planning, and in particular about the life courses of Pentecostal women who had, like Patricia, remained childless or had lower levels of childbirth. The person-centred approach, however, reveals that several Christian influences possibly merge in a single person’s striving for fertility, their bodily practices, and hopes. Women who are members of Pentecostal churches might call upon elements of other forms of Christianity, and non-Pentecostal women might draw upon Pentecostal ideas in their narratives.
In what follows, I will first locate these women in a social-historical context of educated elites in Botswana by illuminating how Christianity permeates the building of elites. I will then discuss the Christian moral sphere of family planning and sexuality that impacts these women’s decisions; and finally I will discuss their childlessness in the light of paradoxical reproductive moralities in twenty-first-century Botswana.
Elites: Christianity and cosmopolitanism
The building of a local educated elite is closely related to the arrival of Christianity. Christianity itself has been described as a transnational religion (Adogame 2005; Nieswand 2005; Krause and Hüwelmeier 2010) that not only brought new ideas of sin, soul, and salvation into the receiving societies but also new knowledge, new modes of consumption, new forms of governance and administration, and new medicines (Comaroff and Comaroff 1991; Vaughan 1991). In Botswana, as in many other African countries, mission churches, such as the nonconformist evangelists of the London Missionary Society described by Comaroff and Comaroff, contributed considerably to the evolution of these elites, as their institutions such as hospitals and schools offered possibilities to gain social prestige outside local hierarchies. Thus, at the beginning of the 1900s, ‘Christian marriage’ with lavish wedding celebrations became popular among elites (Comaroff and Comaroff 1991: 385).
Economic diversification took place in Betchuanaland (today southeastern Botswana and northeastern South Africa) from the first half of the twentieth century (p.250) onwards with men migrating to the mines. These first elites retained their commitment to farming; most men were still raising cattle, the main source and sign of wealth, and most women continued to farm. Even though the local administrators distinguished themselves by the houses they lived in (cemented and roofed) and the vehicles they drove (cars instead of donkey wagons), those who are in their sixties to eighties today displayed modesty concerning their family backgrounds, pointing at the farming activities of their parents. In contrast to South Africa, where educated professionals had a specific function in the colonial administration and later on in the national state of South Africa under Apartheid, in Botswana educated professionals do not focus on their distinctiveness from, but rather emphasise belonging to, these rural communities.
By the time of independence, there were only a handful of graduates, and yet women had belonged to the educated elites since the beginning of the twentieth century (Werbner 2004). These first elite women stood out from their peers and even from their (male and female) siblings. They pursued education, unlike their age mates who usually dropped out at standard five in order to go to South Africa to work or because they became pregnant. These early-educated professionals found themselves well educated and specialised enough to take on responsibilities when the country experienced economic growth and diversification. Reproductive relations and ethics had begun to change from the beginning of the twentieth century onwards, and not only among elites. Schapera (1933) reported that a new childbearing pattern had emerged in rural Tswana communities according to which women bore children before they married.4 In a restudy, Comaroff and Roberts (1977) confirmed this trend. In their analysis, Comaroff and Roberts attribute the detachment of reproduction from the institution of marriage to the decline of polygamy. This, in turn, they attribute to the increasing influence of Christianity. The early elite women of my sample pursued their education, mostly at Lesotho International College, and gave birth later in life when their education was completed. By that time, most of them were in their mid-twenties. They married, however, earlier than most of their peers, as they believed in the Christian ideal of marriage according to which childbirth and sexuality should fall within marriage and not outside marriage. Therefore, the transnational religion of Christianity contributed considerably to the reshaping of the moralities of local communities in the first half of the twentieth century.
After independence and during the time when Botswana’s economy boomed, Christian ethics were enriched by transnational ethics of spiritual healing, new models of monogamous marriage, marital love and sexuality, and from (p.251) the 1990s onwards also by HIV/AIDS prevention campaigns. During the years of economic growth, the government needed highly qualified people to manage the state apparatus and the growing infrastructure. This enabled social mobility for many through education, which was freely provided by the government. By that time, educated professionals increasingly acquired their education not only in South Africa but also in the UK, the US and Australia, where they went to study. Most of them retained their strong Christian orientation. During their travels, they were inspired by global popular culture, which influenced their sense of fashion as well as their views on relationships. Therefore, transnational travels were and are important for the educational histories of these elite groups. Education acquired abroad guaranteed their social mobility. In addition, this outward orientation serves as an identifier so that these educated middle-class and elite groups exhibit a strong cosmopolitan orientation. One example was a divorced woman in whose household I stayed during my first visit to Botswana. She had received part of her education in the UK and the US. As a devoted Christian she had been campaigning to include HIV/AIDS in Christian teaching. In addition, she was an advocate of equal rights for women, on which she was very outspoken in her professional environment as well as in her private life. I met several Christian educated professionals like her during my stay in Botswana. They often play a pivotal role in their Christian communities. Not only do these educated professionals inform themselves on matters of love, life, and health, but they also bring these new ethics on relationships, reproduction, and health into their Christian communities.
Independently of their Christian affiliation, educated professionals are also beneficiaries of private biomedical services that provide fertility care in Botswana. Assisted reproductive technologies are only available in South Africa, which adds to the transnational orientation of some of the educated professionals’ biographies discussed here.
In the following sections I will explore these ethics of Christian family planning as they transpire through the life courses of educated elites.
The travelling moralities of family planning: controlling reproduction
Patricia felt that her marriage did not provide the space for her to take care of her fertility. ‘We never sat down together and discussed things’, she repeatedly stated. Her statement indicates a strong sense that matters of reproduction need communication, consent-seeking and finally cooperation, which she felt was not possible with her ex-husband. From the perspective of this educated professional Christian woman, reproduction (within marriage) does not happen ‘naturally’ but rather needs planning and is subject to a decision.
(p.252) This section will analyse how Christian, and in particular Pentecostal, elite women adhere to ethics of planning reproduction. Herein, Pentecostal reproductive moralities link up with other globally travelling health ethics of family planning and HIV prevention programmes, offering a pool of globally circulating ethics on marriage, sexuality, and health. With their emphasis on the controllability of the body, these ethics differ from historically recorded and culturally important reproductive ethics that emphasise fertility (Schapera 1966). I discuss Pentecostalism in relation to these questions as women’s life courses appear to be impacted by this doctrine in a specific way, although only two of the three mentioned women actually belong to a Pentecostal church (the third exhibits certain elements of Pentecostal-spiritual healing paradigms). This means that all women who appeared to have lower levels of childbirth or who remained without children were members of Pentecostal churches. Again, I would like to point at the messiness of how religious beliefs, practices, and belonging transpire through an individual’s life course. Studying these life courses has a strong heuristical value but statistically relevant claims cannot be made about whether or not elite women have lower levels of childbirth.
Elites striving for fertility exhibit a great need and believe in planning their reproduction. A standardised reproductive life course starts at the age of 20, the average age of first childbirth in Botswana. At that age, women are generally not married yet, as the average age at first marriage was recorded to be 26.4 for women and 30.9 for men (United Nations 2013). The high cost of a wedding and the lobola – these are payments to the wife’s family when a couple marry – postponed the average age of marriage throughout the twentieth century. Women present first pregnancies mostly as ‘accidents’ and as a result of ‘broken condoms’. Sometimes women state in a confessional manner that they had loved their first child’s father, who had also wanted the child and had promised to marry them. Yet, when they had become pregnant the relationship ended. The second child should follow ideally within their marriage in their late twenties or early thirties. This child is then planned and sometimes women face difficulties becoming pregnant again (five of my sample). Women often wish to have a last child in their late thirties or early forties just before menopause.5
Elite women (and men) in their thirties plan their reproductive life. Women at that age often indicated that they wanted to ‘try’ to have a baby and pointed out a specific time when they wanted to have it. This demonstrates that, in their view, having children is a volitional act that they influence with their own decision. ‘Trying’ thereby could imply different things: it could mean to intensify sexual contacts or, when couples were not living and working in the same city, to (p.253) synchronise their visits with the fertile days of the woman’s cycle. Their need to plan their reproduction also derived from educated professionals’ time constraints as working mothers and their concerns over the costs of raising children, especially school fees for private education. They feel the burden of combining their job responsibilities with the emotional task of mothering and they are concerned about the rising costs of education, holidays, and other activities they want their children to enjoy.
Educated professionals’ planning also demonstrates their knowledge about reproduction and how to possibly control it, thus showing a sense of their right to monitor their reproductive lives, continuing a process that Comaroff and Roberts had already observed in 1950s Botswana. As many of my interviews have revealed, elites have incorporated the messages of family planning and fertility medicine that regard the procreative body as controllable. If they face reproductive challenges they would first consult a specialist, understand that they need to undergo a lot of tests, and expect that the doctor would be able to help them. Gynaecologists even complain about women’s instrumentalist attitude towards biomedicine and towards the possibilities of manipulating their bodies: women would expect to get a pill that would solve their problem, not understanding that fertility treatments are often time-consuming processes. In this sense, elite women might be labelled as being the prototypical ‘pragmatic woman’ as described by Lock and Kaufert – women who ‘use whatever biomedicine can provide in pursuit of their own goals’ (1998: 7). The preferred method of contraception is condom use in combination with the calendar method. In this societal group, especially male partners (husbands) favour the use of condoms. The contraceptive pill is widely regarded as having negative effects on women’s child-bearing capacities.
Furthermore, in their quest for conception, educated professionals enjoy privileged access to private fertility care. Many women feel that the fertility care offered by the comparatively well-functioning public health-care system does not meet the need for advanced fertility care. This comprises diagnostics and treatment of fertility problems but also cancer screenings and other more pressing needs. The public health-care system provides these services; however women have to wait up to six months for an appointment. Educated professionals, and in fact any woman who can afford to, therefore consult private specialists, who offer a broader spectrum of diagnostics, treatment, and care. Taking care of one’s fertility to such a high standard reflects the material condition of the elites’ fertility practices concerning the controllable and manipulable procreative body.
Elites’ striving for controlled fertility may be informed by various sources that provide information on fertility control as well as knowledge about available technologies and fertility services and biomedical ideas about the controllability of the body. Family planning programmes propagate powerful paradigms in matters of reproduction all over the continent. These programmes travel from the desks of international organisations to the desks of national politicians and from there on (p.254) to health facilities, schoolbooks, and the minds of the people in Africa. By propagating biomedical ideas of procreation, family planning programmes introduce new ethics of well-being into the domain of reproduction (Paxson 2005: 105) and import Western concerns of ‘overpopulation’ to African countries (for a critique, see Hunt 2005). Botswana has always been a sparsely populated country, with only two million inhabitants in a country the size of France. Nevertheless, the government has been integrating family planning into the national maternal care and child health programme since 1973. Thereby, the number of outlets for contraceptives increased from 50 in 1973 to 350 in 1984 (Way et al. 1987: 8), and Botswana is noted for being a country with well-organised distribution of contraceptives, in rural areas more than in urban ones (ibid.). The biomedical idea of controlling and manipulating procreation, if not invented by family planning programmes – Schapera (1966) reported on the method of withdrawal as a common technique to control reproductive outcomes – has been enforced by these programmes. Family planning programmes suggest a specific idea about fertility, namely one that is restricted by biological age but also located in a body comprised of single, functioning, reparable parts and certain medical practices (Woliver 2002: 39).6 With school education teaching the ‘biological facts’ of reproduction and pointing at the possibility and importance of controlling fertility with biomedical measures, educated professionals were and are willing recipients of the biomedical concept of controllable conception.
Controlling conception: Pentecostal reproductive moralities and biomedicine
Churches, and Pentecostal churches in particular, meet educated professionals’ need to plan reproduction and even encourage them to pursue family planning within marriage. They even organise weekends with courses on family planning methods. Family planning and sex education also takes place in pre-marital counselling sessions. It was in one of those sessions that a teacher (his wife had a good position in the civil service) had learned about the practical and technical sides of prevention methods, such as how to hold and roll a condom (interview, 27 August 2011). Pentecostal linkages with the biomedical rationale supporting the manipulation of reproduction are not unique to Botswana: for instance, authors have described Pentecostals’ adoption of global knowledge of biomedicine, (p.255) especially in the domain of (assisted) reproduction, in Nigeria and Ghana (Pearce 1995, 1999; Asamoah-Gyadu 2007). Some of these churches foster an approach to women’s reproduction that supports the biological manipulation of fertility.
Similar to Patricia, many other church members indicated this idea of postponing childbirth, even within marriage, so as to create the ideal emotional and financial conditions for the start of the new family. While her church does not prescribe a specific reproductive timeline as ideal, many members feel that they would like to take some time after marriage before they have their first child (Pastor Seithamo, 27 August 2011). With lavish wedding feasts becoming an indicator of successful participation in Botswana’s economic growth (van Dijk 2010) most couples face huge debts after their wedding (focus group discussion, Molepolole, 2009), or they might want to finish some building project (focus group discussion, Molepolole, 2010). The psychological reason given is that the child shifts the attention of the couple, which might endanger their relationship if it is not well established. Planning in the context of Pentecostal churches makes biological fertility control relevant for pursuing a specific lifestyle, in which having a family with many children is not an indication of wealth and well-being but rather adds costs to the establishment of a lifestyle of prosperity with houses, cars, and private education for the children.
Alongside incorporating family planning paradigms of fertility control, Pentecostalism also provides a strong notion of God’s almighty healing power that is stronger than the biomedical healing paradigm of cause and effect. The women inspired by Pentecostalism, like other charismatic and prophetic Christians (cf. van Dijk 1997; Csordas 1997), believe that health is a gift from God, which his children are eligible to receive and which they can acquire through prayer and blessing. Prof. F., one of the founding members of Patricia’s church, said that as a student he had witnessed prayer sessions that had cured blind and crippled people whom he personally knew. He later acquired the gift of healing through the Holy Spirit himself and passed it on to other church members. In Pentecostal circles and beyond, a book called You Shall Not Be Barren, by David Oyedepo, the bishop of the Winner’s Chapel, a Nigerian Pentecostal church, is quite popular. Bishop Oyedepo (1998) assures his readership that ‘God wants you to be fruitful’. It is possible to conceive if one’s faith is strong enough. To support his claim he quotes examples from the Bible of seemingly barren women who conceived at a late age, such as Ruth or Hannah, mother of Samuel. He further works with the technique of affirmation by addressing his audience: ‘I can see the child in your womb. The child is there. You will conceive!’
In my conversation with Ruth, aged 47, married, divorced, and remarried without children, I could sense that she was under the influence of this Pentecostal healing paradigm. She was keen to keep the picture I let her draw to understand her conceptualisation of the process of procreation (it sketched which substances would go from the woman into the new baby and which from the man). Maybe she felt by (p.256) drawing this picture she helped her child to materialise. Also the name Ruth, under which she wanted to appear in this study and which she had chosen for herself, suggested that the above-described Pentecostal imagination was a source of hope for her. Ruth is now seeking to conceive using IVF. In addition, she uses the Pentecostal technique of visualisation in order to conceive (interview, 1 March 2011).
Christianity, and Pentecostalism in particular, enters into strong alliances with the biomedical paradigm and practices, while it also provides the healing paradigm of the ‘all is possible for those who believe’. Building on historical grounds, the alliances of Christianity and biomedical knowledge and practices are well established. Along with its new theologies of sin and salvation, Christianity brought new medicines and medical practices to the African continent that appeared to be efficient cures for many afflictions of the African population. Alongside healing and preaching, Christians created a new language and imaginary of thinking about oneself and the body (Landau 1996: 283). In twenty-first-century Botswana, these new conceptions of the self and the body build on the biomedical paradigm of fertility that reduces the concept of fertility to a bodily biological capability of conceiving children, which can and ought to be controlled and manipulated. If ‘magic’ is, as Frazer has argued, ‘a technique, a way of humans trying to shape the world to their will – if only by mistaken techniques’ (Graeber 2005: 22), both the educated professionals’ use of biomedical technologies (embodied by their gynaecologists) and their use of the omnipotent power of faith to invoke conception exhibit – from an ethical point of view – magic elements of Christian thinking. Contrary to what the debate on ‘rational science’ and ‘irrational religion’ has suggested, throughout the first half of the twentieth century these two practices appear not all that different from one another. Evangelical Christian approaches towards reproduction resemble what Pamela Klassen (2011: xiv) has described as the ‘robust supernaturalism’ of liberal Protestantism in North America that fostered engagement with the public health-care system by the end of the last century and allows for ‘yoga under the cross’ and laying on hands in the twenty-first century. Klassen terms both developments in flirtation with Weber as ‘spirits’ of ‘medicalized, enchanted, cosmopolitan and local rhetoric of love and human universality’ (2011: xiv). Understood through the lens of life courses of educated professionals, Christian approaches to reproduction comply well with family planning messages of replaceable fertility and introduce an understanding of a controllable fertility by means of both faith and biomedicine.
Protestantism, sexuality, and infectious reproduction
This section discusses how Pentecostal moralities on sexuality shape the elites’ reproductive life courses. These moralities are, on the one hand, informed by the Pentecostal doctrine on pre-marital sexual intercourse and, on the other, by the (p.257) biomedical preventive paradigm that enters educated professionals’ discourses on sexuality.
Christian teachings, and the Pentecostal doctrine of sexual abstinence before marriage in particular, have been noted not just for introducing strong sexual moralities into societies that reportedly did not moralise sexuality as such but rather judged people on their sexual behaviour according to their reproductive outcomes: whether children arrived inside or outside wedlock or at all (Schapera 1966; Delius and Glaser 2005). While in the first half of the twentieth century, Christianity’s influence on destroying polygamy had the adverse effect of the detachment of marriage and reproduction, more recent Christian influences on educated professionals’ family planning stem from Pentecostal churches. They propagate sexual abstinence before marriage. This has implications for the age at childbirth, especially in a context in which a woman’s age at first childbirth is 20 while the average age at marriage is 30.
Following the doctrine of her church, Patricia had not yet borne any children when she married at the age of 30. Other women in my sample, though not all women worshipping in Pentecostal churches, had followed a similar pattern, for instance Tsholo, who married at the age of 28 while still childless. She believed in her church’s doctrine of pre-marital abstinence as a means to achieve greater spiritual clarity and greater closeness to God. Consequently, she courted according to the standards of her church, meaning she insisted on not having sexual intercourse with her future husband. When she did not conceive in the first four years of her marriage, her anxieties about remaining childless grew. Considering her age, she was worried about her biological ability to bear children and sought help from gynaecologists.
Taken together the Pentecostal doctrine puts forward new ideas and moralities of family planning and reproduction and introduces a factor into educated professionals’ reproductive lives: time and the experience of having one’s fertility restricted by one’s diminishing biological fertility. Timing and planning reproductive life courses is an approach that not only appears in the context of Pentecostal churches. The Pentecostal doctrine of abstinence before marriage accelerates a process of increasing the emphasis on controlling reproduction and finding the right time for having children, which is indicative for educated professionals’ lives in Gaborone. Restricting childbirth was already a concern of educated professionals in the 1990s, especially among single working mothers (Mannathoko 1999). This raises the question of how to understand ‘time’ and ‘timing’ better in educated professionals’ lives: if and how elite women are timing their reproduction and the moralities that inform their decisions.
As mentioned above, in the context of a high HIV/AIDS infection rate, reproduction becomes potentially infectious, as it would, if unmonitored by biomedical supervision, ‘naturally’ require unprotected sexual intercourse. Educated professionals are aware of this: ‘Throw a stone and you hit three out of ten’, commented Reneilwe when we discussed ‘making babies’ in Botswana (interview, (p.258) 16 March 2011). For about twenty years, Botswana’s HIV/AIDS infection rate has been one of the highest in the world, the most visible effects being a decadelong experience of death and dying and a radical demographic decomposition of the society. This, in conjunction with various HIV/AIDS-related public campaigns and health interventions, has accelerated the public’s knowledge on HIV/AIDSrelated matters. Education and surveillance campaigns had been launched already in 1988, as well as an ARV programme in 2001, which gave each citizen in need access to free ARVs, and routine testing among pregnant women (Heald 2006). Social marketing campaigns, public testing centres (Steen et al. 2007), and condom distribution were also part of such campaigns. The biomedical preventive paradigm promotes an idea of sexuality as potentially infectious; it thus mediatises sexuality and also dissociates matters of sexuality from matters of reproduction (Beckmann et al., Chapter 1, this volume; Adam and Pigg 2005).
Like many other elite women, Christian educated professionals are aware that unprotected sexual intercourse is potentially infectious, and revolt against the patriarchal rights of husbands to extra-marital sexual intercourse. Feminist-Christian discourses attribute the spread of HIV/AIDS (among other diseases) to these rights and claim that men should be discouraged from engaging in casual sexual intercourse with multiple partners (Dube 2002). In elite women’s discourses on marriage in Gaborone, they commonly accuse men of ‘cheating’, thus indirectly accusing them of bringing them the virus. The female discourses thus inverse a commonplace in patriarchal discourses, which traditionally deems women’s sexuality as polluting. The Pentecostal teaching introduces a morality directed towards the sexual act itself – and not only towards the question of whether children are born within marriage (Schapera 1966; Delius and Glaser 2005) – and provides the moral framework for women’s rejection of (their husband’s) extra-marital sexuality. Even though Pentecostal churches do not explicitly encourage women to use condoms within their marriage for preventive purposes, being a (Pentecostal) Christian strengthens women in their rejection of having unprotected sexual intercourse within their marriage.
The interview with Patricia also reflects this attitude: the experience of emotional abuse was a central topic in the ninety-minute conversation I had with her during our meeting at Wimpy’s, a fashionable fast-food chain restaurant in Gaborone. Her husband was a policeman, and the relationship had turned sour when she was promoted in her job. He started drinking and began cheating on her. She reported that she repeatedly had dreams and visions from God who told her about her husband’s mischievous behaviour. One day, she woke up hearing God’s voice: wake up and call your husband to check where he is! When she did, another woman answered the phone and Patricia discovered that her husband was on a trip with her outside the country.
Talking about visions and God’s voice that led her to discover her husband’s cheating, Patricia refers to a source of female power that women of charismatic (p.259) circles frequently draw upon (see also Klaits 2010). As prophecy is the core element of the widespread African Independent churches, they use an idiom of power and resistance with a long history in this area (Comaroff and Comaroff 1991). Women’s visions were mostly concerned with their close family members’ well-being and contained prospective sickness, accidents, or, as in Patricia’s case, the cheating of a partner. Thus, this rhetoric indicates Patricia’s will to take her life into her own hands as well as her will to protect herself from being infected. In the Pentecostal sphere the widespread practice of having extra-marital sexual partners is transformed into the moral concept of ‘cheating’. In the context of HIV/AIDS, this concept gains urgency as it is related to the medical discourse of HIV/AIDS prevention. Elite women understand that their husbands’ extra-marital relationships are a real danger to their lives, and they feel they have the right to protect themselves against it. Other, non-elite women I talked to exhibited a similar sense of danger originating from their husband. Women from lower economic backgrounds tend to reject marriage or relationships so as not to risk their health but also not to threaten their freedom and financial situation, as they fear that a partner might use their income for his drinking and womanising. One solution that some women propagate is to remain single.
In this Christian context, women expressed that their fear of being infected overshadowed the fear of remaining childless and they insisted on not engaging in unprotected sexual intercourse with their husband.
Ruth, aged 47, had remained childless in her first marriage. She married at the age of 27. When I asked her whether she had already sought medical assistance in order to conceive during her marriage she stated shyly: ‘We had used contraception.’ And added after a pause: ‘Condoms. The marriage wasn’t…’ Leaving the sentence open suggested that she did not feel secure having intercourse with this man without protection against HIV/AIDS.
Tsholo’s anxieties about childlessness gained another dimension when she came to talk about her sexual relationship with her husband. Tsholo courted according to the rules of her church, practising abstinence before marriage. She and her husband met mostly at weekends in restaurants and spent some time chatting. The pastor of her husband’s church presented him as a devout Christian, thus confirming his moral integrity. It was only after the wedding that she discovered her husband’s habit of extra-marital affairs. Her growing anxieties about not conceiving also related to her growing ever more uncomfortable about having unprotected sexual intercourse with her husband. After she had her child she decided to file for a divorce (interview, 16 November 2010).
Ruth had never imagined that her insistence on condom use could have such drastic consequences for her life. Towards the end of the conversation, just before we left the table, she commented in a low voice: ‘I never thought I would never have children.’ This indicates that she had perceived her will to protect herself as a measure to save her own life and had not thought about the consequences for her (p.260) reproductive life. Christianity supports a specific imaginary of the procreative body according to which the procreative body becomes controllable through biomedicine and faith. Carried by these beliefs, some educated professionals, like Patricia and Ruth, prioritise their health over their fertility.
At the time of the interview, Ruth had married again, just like Patricia. While Patricia’s husband brought children into the marriage, Ruth’s husband did not. The couple had found it difficult to communicate about the fact that they were unable to have children and Ruth was too shy to ask him whether he had any children from other relationships. Nevertheless, both women were grateful for their second marriage and described their new husbands as supportive and kind. These second husbands also supported them in the fulfilment of their desire for children, accompanying their wives to gynaecologist appointments and agreeing to take the necessary tests (sperm screening) to identify possible causes for the couple’s childlessness. In sum, while the first marriages were marked by experiences of abuse, fights, and cheating, these second marriages are havens of respect and support.
Both women found hope in the prospect of successful conception via in vitro fertilisation (IVF), a treatment that can only be sought in South Africa. The cost of one IVF cycle ranges between 4,000 and 6,000 euros, excluding travelling costs – something that only wealthy people can afford. Patricia had sought IVF twice already, so far without success. During the last course of treatment no more eggs could be extracted. Ruth was planning to undergo IVF at the time of the interview. For both women their second marriage represents a financially and emotionally secure place to seek conception, and both hope for the late realisation of their desire for children.
Perspective on fertility of elite women in contemporary Botswana
Patricia had everything that many Batswana dream of: a good job, a house, a big car, and she had re-married, to a man with two children who was supportive and understanding. Yet, Patricia suffered a lot from her childlessness. While elite women are supported by Pentecostal teachings to plan their reproductive lives and postpone childbirth to their late twenties, childlessness as a solution to reduce the risk of HIV infection is not approved by (Pentecostal) pastors and church members. In fact, it was in one of the Pentecostal churches that I met very harsh comments on my own situation in being single and childless, when I approached people for interviews. However, I did not find any indication that pastors themselves would condemn these women for being childless, and I doubt that they were knowledgeable of the factors that led to their childlessness. Infertility tends to be regarded as a ‘private matter’, as pastors of all denominations explained to me. They would only interfere if church members asked them for assistance.
(p.261) In Patricia and Tsholo’s environment such child-bearing behaviour is met with scorn and disapproval. There are ‘comments’ from people at work, church members, and ‘even my own sibling’, Patricia exclaimed at a certain point in the interview. Tsholo reported that she was asked in a tone full of pretended sympathy: ‘Is it difficult to get pregnant?’ Others were more upfront: ‘Next time when I see you I want to see you pregnant!’ Especially nagging was the hostility from her in-laws: ‘Do you want people to think that our son is infertile?’ Among the comments that both women received was the accusing question ‘what are you waiting for?’ as well as the put-down ‘they have waited too long’. While professional women have practised birth control for decades in Botswana, the practice is still met with suspicion. Especially when children were not arriving at the time when they were expected – namely within the emotionally and financially secure context of marriage and after their education was completed – the common practice of delaying childbirth and controlling reproduction turned against these women, who experienced hostility from many people in their close social environment. Planning reproduction and controlling the body is a good and historically well-established practice of professional women, on top of being encouraged by Christian sexual moralities, but when they fail to have children at all these good signs of elite behaviour turn into being a flaw and let them appear arrogant in the eyes of other women.
The issues of stigma, feeling excluded, and receiving hostility from their social environment that have been reported for childless women in Botswana (Upton 2001, 2003; Mogobe 2005) are a recurrent topic in the literature on infertility across the continent (Inhorn 1996; Feldman-Savelsberg 1999; Larsen 2000, 2003; Hollos 2008). Incorporating the biomedical preventive paradigm into their reproductive practices and relying on Christian-biomedical paradigms of controlling the procreative body have gained legitimacy in the Christian realm, as husbands’ extramarital affairs are reinterpreted as ‘cheating’,7 and educated professionals are supported in their decision to postpone childbirth. However, it does not shield women from the burden of stigma in cases of childlessness. This may reflect the paradoxes of reproductive Christian-biomedical morals that confront educated professionals. While such morals put a lot of emphasis on manipulating and monitoring fertility, the emphasis on childbirth remains intact. ‘Having a child’ is seen as a personal fulfilment as well as a social necessity, as childless women experience stigma and discrimination. Their belief in their right to remain healthy seems, in a few instances, to become stronger than their personal and social fears of remaining without children. With the emphasis on monitoring fertility and their moral stance against ‘cheating’, Christian-biomedical discourses and reproductive moralities introduce elite women to a new dilemma: that of remaining childless.
Botswana’s Christianity, and Pentecostal Christianity in particular, has been absorbing globally circulating biomedical ideas on reproduction, the body, and health. This chapter provides an analysis of how urban educated professionals’ striving for fertility has been influenced by these Christian ethics. Taken together, this group of educated professionals are consumers of travelling Christian moralities and ethics of well-being and the controllable body; they are beneficiaries of travelling contraceptive technologies and are themselves transnational patients during their ‘medical travels’ (Inhorn and Shrivastav 2010; Kangas 2010). Thus, educated professionals are beneficiaries in a landscape of ‘stratified reproduction’ in which fertility care is privately provided in an otherwise well-functioning healthcare system. Supported by the Christian medicalised, enchanted paradigm of the ‘make-ability’ of reproduction, the controllability of the body through biomedical technologies and faith, as well as the feminist-Christian reinterpretation of male patriarchal rights to extra-marital affairs as ‘cheating’, some elite women insist on safe conception. As the life courses of these women turned out, their second marriages offered them the financially and emotionally secure space for safe conception. Do rural women or those who work as shop assistants, bar staff, servants, or maids in Gaborone pursue paradigms of safe conception? And if so, how do they go about it? I do not know whether they would relate their childlessness to their husband’s cheating or safe sex practices. Neither would I know whether they seek divorce soon after marriage and find a second husband, this time one who is supportive. However, they are certainly not able to pay the cost of intensive IVF technologies. I suggest that women of lower socio-economic status would have little agency to insist on condom use and may face difficulties in seeking divorce due to the husband’s cheating.8 Safe conception presents itself therefore as an emotional and financial privilege of these educated Christian groups of professionals supported by Christian teaching on reproduction and sexuality. Safe conception turns into a luxury good that not everybody appears to be able to afford in Botswana.
The ‘choice of health’ versus the ‘choice of fertility’ that some educated professionals appear to pursue seems to confirm Christianity’s production of a liberal subject as the right-bearing, responsible, free individual as proclaimed by Comaroff and Comaroff (1997: 365–6; see also Beckmann et al., Chapter 1, this volume). The previous discussion paints a much more complex picture of how choosing health versus choosing fertility is produced in educated professionals’ lives. The medicalised, enchanted paradigm of the body’s controllability that evolved from Christian-biomedical discourses put forward a notion of self-governance (p.263) in educated professionals’ accounts. Educated professionals who have remained childless never present their choice as a positive choice against having children. Rather, educated professionals seem to apply moralities and doctrines of Christian sexual pureness and biomedical sexual safety. Therefore, their condition of not having children does not present itself as having been a conscious decision. The biographies of the women mentioned above rather seem to be a response to changing reproductive ethics, and women therefore paradoxically do not appear as the ‘right-bearing, responsible, “free” individuals’ that Christian doctrine proclaims them to be. Their ‘choice of health’ appears to be determined by several reproductive ethical principles – that of sexual pureness, that of postponing reproduction, that of prevention in the context of HIV/AIDS, and that of the controllability of the body – that are blending in the Christian sphere. The ‘choice of health’ is therefore multi-faceted and inclusive of several ethical principles that favour postponement. By introducing a new morality that prioritises reproductive control and sexual pureness over fertility, Christian ethics support individuals to make choices against immediate reproduction. This re-evaluation of the reproductive and sexual body ties into globally circulating biomedical ideas of reproduction as put forward by family planning programmes and HIV prevention programmes. By proposing strong ethics of body control Christianity bears the potential to translate these health ethics into moral practices. Furthermore, elites are especially prone to take on these ethics of body control and health, so that some of these choices can be regarded to be specific to individuals of a certain social position. As a transnational religion, charismatic Christianity thus launches a health ethic that is characteristic of the positionality of new middle-class subjectivities. Following these new doctrines and making these choices, however, does not free those who remain without children from social exclusion.
This research was only possible with the support of the Fritz-Thyssen-Foundation and the Max Planck Institute for Social Anthropology, Halle, and was conducted with the permission of the Ministry of Labour and Home Affairs as well as the Ministry of Health, the Gaborone Private Hospital (Dr Music and Dr Eaton), and Bokamoso Private Hospital (Dr Abebe). I thank all the institutions and people involved who have supported my research, and especially Günther Schlee for his intellectual support. My special thanks go to Abigail Morgan (Women’s Health Nurse at Bokamoso) and Pastor Seithamo, who actively helped me make contact with patients and church members. Pearl Sechele and Abigile and John Hamathi assisted me during my research. I thank especially John Hamathi for inspiring conversations and his help in connecting me with the right people, as well as Sethunya Mosime, Godisan Mokoodi, and Treasa Galvin from the Department of (p.264) Social Science and Musa Dube and Francis Nkomasana from the Department of Theology and Religious Studies at the University of Botswana. Last but not least, I want to thank Rijk van Dijk from the ASC, Leiden, who introduced me to these colleagues.
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(1) To ensure the anonymity of my informants, I not only use pseudonyms but also disguise other markers of their origin and identity. Therefore, I will not name the churches, places, or professions of those I interviewed.
(2) Most respondents did not feel comfortable when I recorded.
(3) Two other childless women, who are now beyond child-bearing age, suffered abusive relationships and finally divorced. However, their inability to conceive was (at least partially) attributed to medical problems.
(4) Not all women in this study are Tswana, but in the process of nation-building Tswana became a lead culture among educated professionals (Werbner 2004). Especially among urban educated professionals elements of Tswana became popularised. I therefore use the historical reports on these groups as a background against which I understand and analyse contemporary developments in this group.
(5) While in rural settings these last born children are also those who will stay on the farm and take care of their parents in old age and inherit the farm from them, elite women’s reasons for having a last child are expressed on the basis of emotions: they want this child ‘before the house becomes empty’.
(6) Feminist-inspired literature has claimed women’s rights to their bodies. It has criticised biomedical advancement as a way of subjecting women to biomedical regimens and authorities (that are mostly male) and therefore fostering women’s dependency on these technologies, which leads to women’s alienation from their bodies.
(7) Urban educated professional women often do have extra-marital affairs and indicate that having pleasure is important in these relationships. This is only to indicate that ‘cheating’ is not limited to males’ sexual behaviour.
(8) During a visit to Ramotswa, a rural town, I witnessed a discussion of a group of women aged around 50 during which one of the women complained about her husband’s cheating but that her pastor would not allow her to seek a divorce.