An “Imperfect” Contraceptive Society: Fertility and Contraception in Italy

Abstract

Italy represents an unexpected and in some ways paradoxical outcome in terms of fertility control: a drop to one of the lowest birth rates in the world has been accompanied by the preponderant use of “traditional” methods despite the availability of “modern” contraception. Using data from 349 interviews conducted in 2005–2006 in four Italian cities, we argue that Italian women achieve “unplanned” AND desired conceptions through the use of withdrawal and natural methods. While data from other countries reveal similar notions of ambivalence surrounding pregnancy intentions and contraceptive use, Italy stands out for the surprising correlation between highly “managing” the conditions under which children are born and the socially commended approach of “letting births happen”. Such results suggest the need to rethink theoretical understandings of low fertility. Through the use of non-technological methods individuals manipulate culturally produced norms and beliefs about the appropriate moment to have a child; simultaneously, their actions are embedded in larger cultural, economic, and political processes.

Introduction

The title of this contribution recalls an expression by Shorter (1975) who envisioned that a “perfect contraceptive society” would be accomplished through means of a “second sexual revolution” and the diffusion of effective contraceptive methods. Italy, however, represents an unexpected and in some ways paradoxical outcome in terms of fertility control. The drop to one of the lowest fertility rates in the world was accomplished despite the persistent use of “non-technological”¹ methods. Although the use of technological methods has recently started to rise among younger cohorts (especially single women), among Italian women in couples there remains a clear delay with respect to northern Europe and a reluctance to abandon non-technological methods such as coitus interruptus and natural methods². In addition, births out-of-wedlock are uncommon in Italy (in 2006 only 15% of births) compared to many other European countries (e.g. 47% in Denmark, 44% in Britain). We investigate this puzzle through an anthropological demographic lens, using data derived from a large ethnographic research project conducted in Bologna, Cagliari, Padua, and Naples.

In a country where out-of-wedlock births are not common and a significant proportion of women in couples use non-technological methods, what factors drive women’s fertility intentions and the planning of births? In the Italian context, the latter seems to take on particular meanings associated not only with the importance of responsible choice and procrastination, but also with the morality of contraceptive behavior that leaves open the possibility of conception. Of no less importance to contraceptive choices is a way of thinking linked to social class, and to notions that women must protect and preserve their bodies and fertility from a multitude of risks. The use of “natural” contraceptive methods is one way to do this. Surprisingly, such methods are not defined as “traditional” by those who use them, but are instead perceived as markers of a “modern” and informed middle class.

We build on a growing literature that challenges a direct relationship between a decline in birth rates and a change in family values towards more “modern” and secular forms, problematizing a linear and consistent path from “traditional” to “modern” and “western” values. Ethnographic investigations of reproduction in the Western world have shown how notions such as “modernity” take on specific meanings in different contexts, and are often of an ambivalent and complex nature (Strathern 1992, 2005; Edwards et al., 1993; Bledsoe 1996; Gribaldo 2005; Di Silvio 2008). Santow and Bracher (1999), for example, point to the diminution in family-size among southern Europeans living in Australia during the 1970s and 1980s which occurred despite the persistence of “traditional” family values. “The demographer’s flow chart, with an arrow leading from a box called ‘values’ to a box called ‘fertility,’ is a gross over-simplification if not, in some cases, simply wrong” write Santow and Bracher (1999: 70). An anthropological approach allows for a recomposition of the conceptual divide often created between purely “cultural” elements on the one hand, and actual reproductive behavior on the other.

The main theoretical argument advanced in this article is that in the Italian case, the use of non-technological methods among women in couples is shaped by a variety of cultural forces such as individuals’ beliefs about health and sex, social models behind choices to have children, notions of “planning” and “decision-making,” Catholic culture, and links binding reproduction to conceptions of belonging to the “modern” middle class. If the informants interviewed refuse notions of planning and choice, preferring instead those of desire (if ambiguous) and destiny (if procrastinated), then it is not surprising that non-technological methods make sense in a decisional space open to “modernity”. More broadly, the decisional space relative to fertility cannot be separated from larger socio-economic questions, gender inequality, and political policies which today characterize Italy and the Italian family (Barbagli and Saraceno 1997; Bernardi 1999; Saraceno 1994). Following the lead of Greenhalgh (1995:13) this analysis is therefore set within [Italian] “culture and the political economy of reproduction”. This approach allows us to reframe the problem of contraceptive choices in a way that does not define them as “irrational”. It also embraces an examination of contraceptive choices that is embedded in the interaction of political, economic, and cultural processes. The goal is to resist “the tendency of economic accounts to abstract decisions concerning fertility from issues of health, the body, concepts of personhood,” and the “continuously changing process of culture” (Carter 1998:262; Kertzer 1997:152).

Theoretical Background

This article is historically situated within the literature on the demographic transition and dramatic birth decline in Europe over the course of the 19^th and 20^th centuries, enabled by a widespread reliance on coitus interruptus and, to a lesser extent, abortion (Santow 1993, 1995; Schneider and Schneider 1991; 1996, Dalla Zuanna et al. 2005, among others). Yet when fertility began to fall even further beginning in the 1960s, the previously rather homogeneous pattern of contraception across countries began to diverge. Some countries, including Italy, Greece, Spain, Portugal, and Japan, stood out for their extremely low fertility rates combined with a limited diffusion of the pill, IUDs, and sterilization for contraceptive purposes (Schneider and Schneider 1996:149; Dalla Zuanna et al. 2005:21). Santow (1993:784) put it bluntly, suggesting that “Southern Europe’s extraordinary recent fertility decline has been greatly assisted, or even enabled, by withdrawal, despite the availability of modern methods. It would therefore seem premature to predict that the method will lose its importance in these countries […] in the immediate future.”

Our aim is not to predict the future of non-technological contraceptive methods. Rather, it is to shed light on the social and cultural processes that shape Italians’ fertility choices. In order to achieve a better understanding of very low fertility despite the limited use of technological contraception, we build on the theoretical framework pioneered by Bledsoe (1996, 2002), Greenhalgh (1995), Micheli (1995), Kertzer, (1995, 1997), and Schneider and Schneider (1991, 1996), followed by Johnson-Hanks (2002), Krause (2005), Paxson (2004) and others regarding cultural understandings of contraception. Jennifer Johnson-Hanks, for example, in her ethno-demographic work in Cameroon, argues that the desirability of a contraceptive method does not lie in its effectiveness in avoiding pregnancy alone. Cameroonian women’s choice to use periodic abstinence is closely linked with notions of a “modern” identity, as well as “discipline” and “honor”. As she writes, “By claiming that contraceptive practice is about achieving social goals, of which preventing pregnancy is only one, I am arguing that we need to know something about social organization and the kinds of social goals that motivate action in order to understand patterns of contraceptive use” (Johnson-Hanks 2002:231).

The themes of honor, respectability, and the ability of contraceptive choices to represent elements of identity construction have been explored by other authors as well. Jane and Peter Schneider (1996) traced the significance of coitus interruptus as a distinctive element of self-discipline linked to social class in a Sicilian town over the period 1860–1980. Elizabeth Krause, in an ethnographic analysis carried out in contemporary Tuscany, examines the respectability of contraceptive choices in a context in which desire must be “domesticated”: “in contrast to peasant sexuality, a key symbol of modern sexual relation was control” (Krause 2005:121). Elements of respectability, discipline, and control are not, however, sufficient to explain the contradictory discourses with respect to contraceptive choices as expressed by informants in this project. Conversely, they are characterized by notions of “naturalness”, spontaneity, and destiny, combined with marked signs of ambivalence.

Contrary to studies that place the use of non-technological methods in a rational-actor framework,³ we contextualize Italian contraceptive behavior in terms of culture, social organization, and political power structures. David and Blake’s (1956) introduction of “intermediate fertility variables” to describe the biological and behavioral mechanisms through which social, economic and cultural conditions can affect fertility, and later, Bongaarts’ (1978, 1983) identification of “proximate determinants” have contributed to recognizing fertility as being governed by both indirect and direct effects. Research that has built upon this approach has, for the most part, sought to find more accurate ways to calculate fertility, rather than to explore the indirect determinants of fertility or the effect of individual actions on fertility and mortality. Anthropologists, on the other hand, have expressed decidedly more interest in indirect determinants, individual action, and the “culture concept” as these concern demographic processes. Yet just what is meant by culture is often unclear. “If economic models are strong on theory and weak on evidence” writes Kevin McQuillan (1989:333), “approaches which emphasize the role of culture suffer the opposite problem”. The economist Gregory Clark (1988:161) comments that the challenge is to find a way to treat culture as something “other than a residual to be resorted to when all other explanations fail” (cfr. Kertzer 2005).

Rather than treat culture as a “laundry list of traits,” we examine the multiple facets of this concept as they pertain to contraceptive choices. In other words, we examine both the degree of autonomy or “agency” with which “individuals may manipulate culturally produced norms and beliefs for their own ends” (Kertzer 1997:144) and culture, which “does not dictate a particular code of conduct, but instead involves an endless process of negotiation” (Kreager 1985:136). Along with Johnson-Hanks (2002:231), we suggest that non-technological methods remain prevalent because “contraceptive practice often achieves social goals beyond avoiding pregnancy”.

Demographic Setting and Social Context

Contraception has traditionally been a taboo subject in Italy due to the strong influence of the Catholic Church (see below), but political movements encouraging demographic growth have also inhibited its spread. Fascist leaders introduced legislation in 1930 to prohibit publications and propaganda in favor of birth control (Horn 1994). Opposition to this legislation did not begin to grow until after World War II, and the 1930’s prohibition remained in effect even after the fall of Benito Mussolini. In 1956, the Italian Association for Demographic Education (AIED) was founded with “the aim of defending the idea and the practice of a voluntary and conscious limitation of the number of children, and of combating the existing legislation against birth control” (Wanrooij 2001). While supported by the secular lay forces, socialists, and communists, Catholics, who upheld the existing legislation⁴, strongly opposed the AIED. In fact, in 1965 the Constitutional Court declared that information concerning contraceptive methods would remain illegal, in that it offended public morality (Idem). It was not until 1971 that the Constitutional Court decided that legislation forbidding propaganda in favor of birth control was unconstitutional (Dalla Zuanna et al. 2005). It is thus not surprising that until the 1970s coitus interruptus was the most common method of contraception employed (Idem). It was not until the mid-1980s and the emergence of the AIDS epidemic that publicity for contraceptives – especially the condom began – to appear in advertisements and mass media (Idem: 34).

A shift in the use of different contraceptive methods also occurred with the women’s movement in Italy when withdrawal came under critique by feminists. Coitus interruptus came to be seen, in Aries’ (1980:648) words, as “the archaic tool of a macho, phallocratic, and non-permissive society”. “The availability of more reliable and cheaper condoms, prescription sales of the pill, and the IUD dramatically expanded the available options. These technological and market changes brought about an important transition that some authors describe as a ‘second contraceptive revolution’” (Dalla Zuanna et al. 2005:24; Leridon 1987). Yet compared to other European countries, the ‘contraceptive revolution’ was much slower in Italy. For example, in France in 1978, 60% of women in couples were using the pill or IUDs. In 1979 only 16% of women in couples were doing the same in Italy, and by 1996, this had risen to only 34% (de Guibert-Lantoine and Léridon 1998; Dalla Zuanna et al. 2005)⁵. Notwithstanding the relatively slow spread of technological methods of contraception, births fell dramatically in Italy during the 1980s and 90s. While the mean number of children per woman in 1970 was 2.43, this dropped to 1.64 in 1980, 1.33 in 1990, and 1.24 in 2000. (Dalla Zuanna et al. 2005:24).

An important contrast in contraceptive use in Italy has also emerged between women in, and not in, couples, with use of technological methods among the latter increasing much more rapidly over the last 20 years. “Today the usual pattern for Italian young women is to spend their twenties sexually active, but without living with their partners. Most sexually active women born after 1960 use condoms or the pill. In the mid-1990s the contraceptive behavior of sexually active women not living with a partner was close to that of their peers in the Central and Northern European countries” (Dalla Zuanna et Al. 2005:25–27). The 1996 nationally representative survey Family and Social Subjects (FSS) reported that among Italian women born in 1971–75 (age 20–24 at the time of interview), 78% used a form of technological contraception at first intercourse. In addition, FSS data reveal that 54% of Italian women not in couples were using the pill or IUD in 1996 compared to 33% of Italian women in couples.

The contraceptive practice of women in couples has, on the other hand, seen a quite different trend over the last 30 years. Although there has been a decline, the proportion of women in couples using non-technological methods is still remarkable. In 1979, 67% of married women used either withdrawal (58%) or natural methods (9%) as their main form of contraception. In 1996, the proportion remained at least 40%⁶ (34% using withdrawal and 6% using natural methods; Dalla Zuanna et al. 2005). As women in Italy reached some of the lowest fertility rates ever recorded, they used “modern” methods at a dramatically lower rate than in other European countries. According to the United Nations (2004), only 39% of Italian women in a union were using modern methods in 1996, compared to 69% doing the same in France in 1994, 72% in Germany in 1992, and 72% in Denmark in 1988. Women in these countries were using withdrawal and rhythm much less than Italian women (e.g., France 5%, Germany 1%; UN data, 2004).

Simultaneously abortions have declined and births out-of-wedlock remain low in Italy. Sardon (2004) reports that the number of induced abortions in Italy fell from 36 per hundred births in 1985 to 23 per hundred in 2002. With regard to out-of-wedlock births, data from Eurostat report that only 11% of babies were born out-of-wedlock in Italy in 2003 compared to 44% in France and 56% in Sweden. Given the relatively high use of withdrawal and natural methods – despite the availability of “modern” contraception - among Italian women living in couples, combined with relatively few out-of-wedlock births, the achievement of Italian “lowest-low” fertility cries out for further investigation.

Such patterns of non-technological contraceptive behavior continued to be reflected in the interviews conducted in the four urban Italian sites under analysis in 2005–6. Women living with a partner primarily used non-technological methods to achieve fertility control, and there was a tendency to refuse total coverage methods such as the pill or IUD. Sterilization was not even considered. Among those using non-technological methods, most used withdrawal while a significant number also combined the latter with natural methods such as rhythm, ovulation, temperature, etc. Contraceptive behavior among young women not living with a partner, on the other hand, varied more noticeably across the cities, with young women in Naples preferring the condom, while their age-mates in the other three cities showed a preference for the pill⁷. The focus of this paper, however, is on the contraceptive behavior and fertility intentions of women living in couples.

The Role of the Church

Before moving on to the implications of the ethnographic data, it is important to say a few words about the role of the Church in shaping demographic behavior in Italy. Indeed “Churches throughout modern (and pre-modern) European history played a major role in shaping people’s reproductive behavior. They taught what was appropriate sexual activity, they specified which marriages could be contracted and with what timing, and they regulated the breaking off of marriages and the appropriateness of remarriage” (Kertzer 1997:46). Needless to say, the Church has regularly condemned contraception.

The Church has also had a historically strong influence on Italian politics; the Catholic party Democrazia Cristiana (DC) largely controlled the national government from 1946 to 1989 (Idem). On the other hand, since the 1971 law that permitted contraceptive advertising, Italian society has become much more secularized. A divorce law was approved in 1970, and abortion was made legal in 1978. When corruption scandals led to the disintegration of the Democrazia Cristiana in the early 1990s the new Catholic parties that formed were much less powerful than the DC. Despite these changes, the Church continues to have significant sway over Italian political and social life. For example, in 2003, influenced by a vigorous church campaign, the Parliament approved a conservative law on IVF, which allows for use of this technology only by couples, without recourse to sperm or ovule donors (Dalla Zuanna et al. 2005:36).

Scholars such as Dalla Zuanna, De Rose, and Racioppi (2005) have asked why, if the influence of the Catholic Church has been effective in slowing down the diffusion of technological methods of contraception, the same has not held true for non-technological methods such as coitus interruptus. They suggest that historically the Church may have been relatively accepting when it came to withdrawal. Flandrin (1988; cfr. Dalla Zuanna 2005:37) similarly contends that “priests did not ask about this method during confessions; following the position of St Alfonso de Liguori in the 17^th century: “there is not sin without the knowledge of sin’”. The “real” message on coitus interruptus may therefore have been very different from that transmitted by doctrinal language. In addition, the same authors suggest that the spread of technological methods, unlike coitus interruptus, was not a “quiet revolution,” but “needed certain institutional conditions: a public and private health system oriented toward contraceptive devices” (Idem, 2005:37). They suggest that the Catholic Church has been able to influence medical and political institutions more readily than Italians’ personal lives.

Although the influence of the Church in Italy remains strong,⁸ the relationship between Catholic creed and reproductive behavior is complex. Catholicism permeates reproductive choices and perceptions of the family through a widespread adaptation to a shared cultural climate, more than through religious institutions themselves. While “the proportion of self-declared religious young people is much higher than elsewhere in Western Europe” (Caltabiano et al. 2006: 457), choices relative to sexuality and family-building seem to be above all delineated by an attachment to “tradition” and desires to conform to parental wishes rather than by specific dictates of the Church. Moreover, the “elasticity” of conformation to the writs of the Church often translates into a “religious do-it-yourself” (Garelli et al. 2003) in which even those who don’t respect Catholic dictates “may continue to feel close to this religion, and to recognize themselves as in communion with it” (Caltabiano et al. 2006: 454). Our ethnographic study reveals that religious discourse provides symbols which allow individuals to express certain attitudes towards reproduction. These are never articulated as dogma, but rather as a discursive horizon to which behavior is compared, negotiated, and rethought, and where much ambivalence may emerge. As we discuss below, in constructions of the middle-class family notions of “nature,” “health,” “natural reproduction,” and the mutually constitutive relationship of femininity and maternity are profoundly intertwined with a Catholic cultural model of “the natural family” (Remotti 2008). Although the correlation between Catholicism and “traditional” contraceptive methods is neither direct nor obvious – especially given the use of these methods in countries which are neither Catholic nor subject to policies shaped by religion - in the secular urban settings which are the focus of this paper, the underlying reference point for private dimensions such as the family and maternity remains profoundly embedded in Catholic culture.

Methods

The data used in this article were collected over a period of 15 months in 2005–2006 and consist of fieldnotes from participant observation and 349 in-depth interviews conducted in the cities of Bologna, Cagliari, Padua, and Naples. This research endeavor forms part of a larger project, “Explaining Low Fertility in Italy” (ELFI),⁹ aimed at achieving a more satisfactory understanding of the role played by the culture of reproduction and by kin and non-kin networks in determining fertility behavior. In addition to a far-reaching statistical analysis (see for example, Kertzer et al. 2008), the original study design included an intensive ethnographic research project in the four cities just mentioned. The latter were chosen in order to tease out the complex interactions between cultural processes as experienced by individuals and their families and the socio-economic forces in which they are embedded. The ethnographic portion of the ELFI project thus focuses on women who are in the process—passively or actively—of fertility decision-making. We define this as women aged 23 to 45, based on the actual fertility experience of Italian women (the proportion of all childbirth occurring before age 23 in Italy today is very low). The objective of the study is to capture not only the experiences of these women, but also the social network of which they are a part and the impact of the former on their fertility choices.

In the original design, four anthropologists were to select 50 women aged 23–45 in each city for special study through in-depth interviews. Half of these women were to be from the younger reproductive years (23–32) and half from the older (33–45). In addition, in each cohort, half of the women were to be from a working-class neighborhood and half from a middle-class neighborhood, of varying levels of education and parity. Interviews were also to be conducted (when possible), with the woman’s mother, as well as with the woman’s husband or cohabiting partner. The interviewees were selected through personal contacts gained by a complex indirect snowballing procedure with multiple entries (independently selected initial contacts) in order to avoid a clustered sample. The final sample of interviews (and that used in this analysis) consists of 233 women (age 23–45), 49 mothers, and 67 partners, for a total of 349 interviews (see table 1). The indirect snowball sampling procedure allowed us to stratify the sample by age, parity, and marital status of the woman in order to maximize variation in socio-demographic characteristics (see table 2).

Table 1.

Total number of interviews by city and neighborhood

Cities	Middle-class	Working-class	Total
Bologna	41	45	86
Padua	35	47	82
Cagliari	48	46	94
Naples	41	46	87
Total	165	184	349

Table 2.

Selected characteristics of focal women, age 23–45

Parity	Number of Women
Childless	101
One child	75
Two children	41
Three children	11
Four or more	5
Education
Low education	23
Medium education	102
High education	108
Civil status
Married religious	109
Married civil	13
Cohabiting	34
Single	34
Engaged	34
Divorced	9

While the scope of these interviews is wide-ranging, women, their partners, and women’s mothers extensively discussed their fertility decisions and intentions. Further, because the issue of having very few children is so salient, informants were asked about the kinds of contraception they use, why they made the choice to use certain types over others, and the implications of their choices for bearing children. In order to facilitate analysis, each of the 349 interviews was recorded, transcribed, and examined using the computer program NVivo. As a “code-based theory builder”, the program aids with coding and analysis of qualitative data (Weitzman 1999) and offers the “tools to manage, store, extract, compare, explore, and reassemble meaningful pieces of the data flexibly and systematically” (Manning and Smock 2005:993). In what follows, we select examples from the interviews in order to illustrate common patterns. Given the vast amount of qualitative material, the descriptive quotes are representative of the sample as a whole, unless otherwise specified.

Participant observation, a cornerstone of anthropological methodology, also provided a revealing window through which to understand the contraceptive behavior of Italian men and women. Informal interactions in a variety of public and private settings allowed the anthropologists to immerse themselves in people’s daily lives, achieving an understanding of their worldviews and examining their social relations in holistic context. A corollary of this was a focus on the difference between what people say they do and believe on the one hand, and what they actually do and (more problematically) what they actually believe on the other. More specifically, anthropologists in each of the four cities attended social events where cultural norms about family and fertility were shared and discussed (e.g. prenatal courses, parks, childcare centers, pre-nuptial courses). Subjects were also accompanied throughout various moments of their daily lives, enabling an in-depth understanding of the beliefs and behaviors which in part produce demographic outcomes.

A brief note must also be dedicated to the sensitive nature of the topic of contraception, and the implications this has for scientific research. The large number of women in couples in our sample who declared that they do not use any fertility control likely includes many women who actually use natural methods and/or coitus interruptus. For example, many women may not think of withdrawal as a contraceptive method and will therefore respond negatively when asked “do you use contraception?” (Bonarini 1991; Castiglioni, Dalla Zuanna and Loghi, 2001). Santow (1993:773) has pointed out that “some women may not wish to admit to themselves, let alone to an interviewer, that they have been party to the taking of precautions”. Still others may consider withdrawal to be a method used by their husbands, rather than by themselves. These challenges have plagued statistical investigations of coitus interruptus for decades¹⁰. More generally, family planning programs and contraceptive-promotion programs have a tendency to devalue “traditional” methods, and respondents may therefore be reluctant to identify coitus interruptus as their preferred method. Women may also use more than one method, mixing and alternating them, even within short periods of time (Rogow and Horowitz 1995:141–2; Tsui et al. 1991). Given these challenges, the use of non-technological methods among the women interviewed may be underestimated. On the other hand, the use of qualitative methods such as participant observation and in-depth interviews (described above) are particularly effective for gaining deeper understandings of sensitive issues such as contraceptive choices.

Non-technological Methods: “Natural” and “Healthy”

Increased attention has recently been paid to the body and its conceptualization and metaphoric use in symbolizing the social world (Carter 1995; Johnson 1987; Kertzer 2005:542). Along with other scholars, we argue that such considerations have implications for understanding demographic behavior. Caroline Bledsoe’s (2002) work, for example, reports the surprising finding that women in The Gambia used contraceptive methods to increase rather than to limit the number of births. The author demonstrates the importance of gaining an understanding of how local people themselves conceptualize reproduction and relate it to understandings of the body, health, and social support. Bledsoe stresses the fact that western notions of linear time do not capture how the women under study think of their bodies and their reproductive lives. Understanding their reproductive behavior entails an understanding of Gambian ideas relating to the wearing out of the body occasioned by reproductive episodes. These include not only childbirth but also miscarriage and other events as well (Idem; cfr Kertzer 2005:542).

In this article, we contend that many Italian women perceive “technological” methods as unhealthy and “unnatural”. More broadly, this ties into a larger category of forces that Italians view as potentially harmful to the body (e.g. genetically altered foods, and social illnesses such as “mobbing,” see Molé 2008). Women informants created a discourse of “naturalism” around non-technological methods as opposed to technological methods or “pharmaceutical” methods, viewed as potentially unhealthy for the body (see similar findings in the US by Bledsoe, 1996). Women interviewed across the four cities also tended to use the term “natural methods” to refer interchangeably to withdrawal as well as to the more formally recognized “natural methods” such as rhythm, ovulation, temperature, etc. This was especially true when referring to the “natural qualities” of non-technological methods as they concern the body.

More specifically, interviewees consistently described coitus interruptus, observations of cervical mucus, rhythm, and other non-technological methods as “home-made methods” (metodi fatti in casa), sharing characteristics of “domesticity” and “authenticity,” in addition to simplicity of use. As one woman explains,

Let me be perfectly clear, the Billing method¹¹, if done well, is a contraceptive method… Because whatever you use… even the pill might not be a contraceptive, because there are cases in which it hasn’t worked. A condom can break… So contraception is really just in the mind of a person. Are you absolutely against the presence of a baby in your life, or not? This is what makes something a contraceptive. I like the Billing method, it is fun and I get to see my cycle go well and regularly, and I like to see that things are working properly… So it helps me in the management of my body, it’s a relationship that I like to have… so in the fertile period one can have fun doing other things (laughs)… We are practicing Catholics, I’m not saying we’re not… but… they (the Church) sometimes sell us a bunch of baloney (ci vendono anche un po’ di balle), saying that the Billing method or temperature… or leaving the door open to God… Nonsense! (un corno) If you have sex in the infertile period, nothing is born, nothing comes.–Female, age 35, two children

While a number of women talked about the pleasure they derived from “being in touch” with their bodies through the use of non-technological methods, other women gave health-related reasons for not using technological methods. Bonarini (1999), using data from the Inf-2, similarly discovered that among Italian women who had stopped using a “technological” contraceptive method, 43% gave health reasons, compared to 28% who declared that they had done so because they desired a child and 7% who claimed difficulty of use as their reason for stopping. Generally, women in this study found non-technological methods to be more “natural” and thus less risky to their health. They frequently contrasted natural methods with the potentially harmful effects of technological methods, or what they termed “pharmaceutical” methods.

This opposition between healthy non-technological methods and a fear of “unnatural” technological methods is also conditioned by a Catholic culture which closely intertwines love, sexuality, and reproduction. Even women who declared they were secular made no distinction between “reproductive” sex and “non-reproductive” sex, mirroring the Church’s view of intercourse.

Anthropologist: So… at the moment you’re not trying to have a child, you’re going to wait a bit.

Interviewee: Mm, yes, we’re in a waiting phase (smiles)

A: But you’re not using the pill… Have you ever thought about it? Are you at all interested?

I: No, I’ve never used the pill, and I don’t have any intention of trying it.

A: Does it (the pill) worry you?

I: Well… I think it can have consequences, it’s a pharmaceutical… it can have consequences for the female body. So…on the one hand natural methods convince me… as a philosophy, the thought that’s behind it certainly… that is, apart from the fact that it doesn’t damage me (smiles)

A: Ok, so you were saying that you like the philosophy behind natural methods, what do you mean by that?

I: In the sense, that you give importance to the act… I mean, the choice that two people make in order to have, or not have a maternity, a responsible paternity, in the eyes of the Christian family, you know… One consciously decides when the right moment is, the best time to have a child, and what that will mean… using the natural cycle of things (smiles). That’s it.

- Childless female, age 34, practicing Catholic, uses rhythm method, hopes to have a child within a year.

Similar to Bledsoe’s (1996:301) findings on women in the US, Italian women “voice strong preferences for the mildest possible birth control methods: those that are the least intrusive or have the least perceptible chemical effect (especially long term) on the body. Often, these are methods seen as closest to ‘nature’”. In part perhaps because of the perceived “naturalness” of non-technological methods, the Italian women interviewed often considered certain contraceptive methods as “non-methods”; or rather, had difficulty thinking of natural methods and coitus interruptus as a way to control fertility. Coitus interruptus was often described as a vehicle of love, and as exercising a “natural” sexuality. When not using any mechanical or medical devices that prevent births, respondents often responded, “We don’t use anything”. Non-technological methods were often not represented as a contraceptive, which by definition seems to be something “external” to the management of a couple’s sexual relationship.

A: Do you use any kind of contraception?

I: No, never. We use natural methods… we know each other so well, that we’re able to establish… I mean what we need to do…

A: Are you against using contraceptives?

I: Well, I am not… and my husband never has because he doesn’t like the feel. I don’t know, the idea of having the spiral, or taking the pill, I never have done that. I’m kind of against medicines in general, the idea have being bombarded by hormones…But, anyway, I repeat, since we know each other really well, we’ve played our cards well, we haven’t had any difficulties, no abortions… and when we’ve wanted them, we’ve done it. – Female, age 37, two children, uses both withdrawal and natural methods

More broadly, Italian women in couples repeatedly expressed their worries about the potential ill-effects of technological methods while espousing the merits of healthy, non-technological methods such as coitus interruptus, rhythm, ovulation, temperature, etc. In order to better understand this opposition, we now turn directly to ethnographic data on technological methods, in particular the pill.

Technological Methods: the Pill

We argue that technological methods of contraception, such as the pill, require a much higher “decisional level” than is acceptable for many in the Italian context. In addition, refusal of the pill often has cultural connotations, and as such it is important to consider with what criteria different contraceptive methods are being judged. Those who use the pill often do so for motives not directly linked to it efficacy, but rather to concerns about infertility and complaints related to health issues.

In a recent study of reproductive choices in the US, Bledsoe (1996) puts forward a number of important considerations for this analysis, and more generally for how to interpret the discrepancy between social discourse and behavioral outcomes. According to Bledsoe, discourse linked to contraception in middle-class American popular culture is distinct from that concerning pregnancy, births, and even sometimes from sexuality itself. Instead, there emerges significant attention paid towards health risks and the need for natural methods of contraception. Sexual spontaneity, health, and infertility are thus principal themes among the middle class with regard to fertility control.

From Bledsoe’s (1996) research, echoed by Hirsch and Nathanson (2001), we learn that “we may well be entering an era when a woman’s decision to use a certain contraceptive method may stem less from how effectively it prevents an unwanted pregnancy now, than from the risk that it will prevent a wanted pregnancy in the future” (Bledsoe 1996:x). The middle class takes for granted their ability to control the number of births, and given their confidence that they will not have an excess of children, the secondary effects become more important than the primary one. The paradox that emerges from interviews with Italian women living with a partner is that the only methods defined as truly effective – the pill and the IUD – are the ones that are relatively little used.

Italian women’s hesitancy to use technological methods such as the pill and IUD for health reasons is not entirely surprising, given the suspicion physicians in Italy have historically expressed toward the pill (Fabris and Davis 1978). Dalla Zuanna et al. (2005) report that during the 1970s and 1980s, Italian gynecologists were quick to emphasize the pill’s negative side-effects. While the level of hormones in the pill during this period was higher than in many of today’s products, and concerns regarding weight gain or other health complications were in many cases legitimate, women in other countries adopted the same products much more rapidly, and did so with medical approval (Idem). Such patterns may in part be explained by the influence of the Catholic Church. Spinelli et al. (2000), for example, report that 63% of Italian gynecologists are conscientious objectors to abortion (cfr. Dalla Zuanna et al. 2005:40). As this paper is being written, there is an ongoing scandal concerning Italian pharmacies that do not carry condoms, citing religious reasons (La Repubblica 9/10/2008). This has been accompanied by similar articles revealing that in half of Rome’s hospitals the “day-after” pill was refused to an “undercover” investigative couple, notwithstanding that by law and regardless of creed, doctors may not refuse this emergency prescription (Idem).

On the other hand, there is evidence that suspicions on the part of the medical community of the negative health effects of the pill have diminished. Dalla Zuanna et al. (2005) report that when an article was published in 2002 on the potential ill-health effects of the pill, and later echoed by magazines and several TV programs, the President of the Italian Congress of Gynecology spoke publicly against such claims, emphasizing instead “the advantages and psychological merits of the pill for women’s health”. Indeed, the pill has been shown to diminish the risk of osteoporosis, fibroid tumors, ectopic pregnancies, endometrial and ovarian cancers, and premenopausal hot flashes, and to have many other health benefits (Bledsoe 1996:313). Notwithstanding these improvements, married Italian women in our sample consistently gave health-related motives for avoiding technological contraceptive methods.

We hence observe neither a limited availability of technological contraception (in that the pill is readily available and in some cases free through the national public healthcare system), nor misinformation concerning the side effects on the part of religious or medical institutions. Rather, attitudes of refusal seem to be produced “from the bottom up,” and spread via communication among women of reproductive age. In other words, a closer look at an initial impression of misinformation reveals what is in reality a culturally shared product, produced at the intersects of Catholic ideology, a culture which closely links feminine identity with maternity, a socio-economic context which foresees a delay in family-building, and a setting in which the desire to control one’s reproductive functions and sexual activity must be renegotiated.

As we further discuss in the next section, this reasoning is in part due to the specific nature of the Italian context where “ambivalence of desire” plays an important role. A technological contraceptive’s ability to almost certainly prevent pregnancy requires a much higher decisional level than is often acceptable. When Italian women give health-related reasons for preferring “natural” methods, they reflect a context in which they feel they cannot plan the birth of a child, yet do not want to make it entirely certain that a pregnancy doesn’t happen.

A: Do you use contraception?

I: No, no, we’re just careful in the relationship… but no contraception

A: What is your opinion about contraception?

I: Well, I knew that the pill was bad for you, so I didn’t use it. They told me it makes you gain weight. Anyway, I generally don’t like medicines, so I try to avoid them…The condom is annoying, and other methods… anyways, it wasn’t really a problem if I became pregnant, I mean it wasn’t like it would have been a drama or anything, so why should I use anything? We were just careful and that’s it. If something happened, maybe it was even welcome.

- Female, age 39, two children

A: So did this child just ‘happen’, or was it planned?

I: Well, honestly, it was ‘almost wanted’. Because we were both 32 years old so…You know… it is like when you desire something and… it happened. Even if we didn’t really think that way (smiles), I mean, that it wouldn’t happen.

A: Were you using contraception at the time?

I: No, I did try, but I’m practically allergic, so I prefer not to.

A: Allergic to contraceptives…

I: Yes, both oral medication and condoms

- Female, age 34, pregnant with second child.

The specific health-related concerns cited by women with reference to the pill vary widely and ranged from blood circulatory issues, weakened eye-sight, to incompatibility with smoking. The most frequent motives concerned both psychological health and reproductive health; these spheres were closely intertwined in the interviews. Depression, discomfort, and drop in libido were associated with a medically induced infertility caused by the pill. Women’s health-related rejection of the pill also stems in part from recent bio-medical models of health and well-being, in which women are encouraged to “take care of their bodies” and effuse “natural beauty and well-being”

I’ve never used the pill, except for a brief period, in which it made me feel really badly physically, well, more than physically, psychologically, in the sense that I felt a state of things that… I cried a lot, I was in a mood that wasn’t optimal… After that I didn’t want to try it again and my husband never pushed me to. He said do whatever you feel is best… he said, ‘anyways, I prefer to have a person at my side who is normal rather than someone whose ‘hormones’ make them say or do strange things. – Female, age 31, one child

If women have difficulty delegating to technology the delicate and intimate issue of fertility, it should not be surprising that women do take up the pill in their later reproductive lives, around the age of 40, when they are sure they don’t want any children, and when their fecund lives are ending. The idea that the pill creates problems of infertility was explicitly expressed by a number of women.

I’m kind of against medicines, I always try to take the minimum possible, so I say, why go ahead and take the pill if you know that in the long run… you can’t take it forever, and you have to take breaks, because otherwise you have problems later… It’s something they don’t always tell you. My friend right now has major problems, she wants a child, but it’s been years and she can’t… Anyway, a bit stupid on her part, but also her gynecologist evidently wasn’t clear, because she used the pill for 5 years straight, so now it’s clear that she can’t… let’s say she’s infertile, well not really infertile because the eggs form as they should but she is having trouble….and they’re looking for alternative ways now. – Female, age 31, pregnant with second child.

From the interviews it emerges that the pill is refused through a complicated series of symptoms with evident cultural connotations. Non-technological methods are judged as more advantageous because they are evaluated using parameters that go beyond efficacy. The social legitimacy and the presumed lesser degree of physical and psychological problems that characterize natural methods lead to a preference for them; interviewees are concerned about the reproductive integrity of the female body, see natural methods as more legitimate than technological methods, and perhaps most importantly, praise the flexibility of their use. For married women, technological methods such as the pill become acceptable when used for purposes other than preventing conception; for example, to regulate the menstrual cycle. In the few cases of infertility (linked directly to the procrastination of reproductive choices, which later turns into a desire to have children) the checking of fertile days, using the rhythm method, becomes a “positive” control. While unmarried women may have a greater incentive to avoid pregnancy, which in turn could explain their greater likelihood to use technological methods such as the pill or IUD, the fact that married women seem to suffer more from the collateral effects of technological methods reveals how deeply somatic complaints are linked to cultural constructions, and supports the notion that contraceptive practices can be employed to achieve goals that go beyond avoiding pregnancy.

The Making of Reproductive Decisions: Responsibility and Spontaneity

Italian women often express the view that “it’s never a good moment to have a child,” so that if people desire a child, they should just “let it happen”. Systematically, through informal conversations and in the in-depth interviews, there emerged the narration of a “non-choice,” notwithstanding the evident planning of the reproductive event. This behavior, especially around the age of 30, receives social approval. In a context in which everyone desires children, but few choose to have them, it is as if desire and choice travel on two different tracks. Excluding pregnancy a priori (through artificial means such as the pill) while one is only waiting for “the right moment” is seen as excessive. In the context of a strong sense of responsibility which inhibits spontaneity, or better the pull between the necessity to choose and the desire not to plan too much, the use of coitus interruptus and natural methods finds specific meaning in which pregnancy is not a choice, but a possibility.

Although this attitude towards contraception is comparable to pre-transition (and pre-pill) Western populations (see, among others, Fisher 2000, 2006), what is most striking is the ambivalence of desire with regard to reproductive choices, which does not appear to be something that has “survived” from the past. Among the urban middle class, non-technological contraceptive behavior regains “modernity” at the intersection of socio-economic and cultural contingencies. We are not suggesting that Italian women behave fundamentally differently from their counterparts in other Western contexts. Rather, we are suggesting that an analysis of the Italian case illuminates a way of perceiving contraception that, in a setting where contraceptive methods are widely availably, severs the distinction between dichotomies such as technological/non-technological and modern/pre-modern. Ethnographic data reveal that non-technological methods are reconceived as representing a “modern,” conscious choice, while technological methods, typically considered modern, innovative, and emancipative, are instead associated with social and physical danger.

When examining “choice,” demographers do not often take into account the cultural habitus (Bourdieu 1980) in which complex reproductive behaviors are embedded, and assumptions are generally made on the basis of a “rational actor model”. In a simple rational choice model, the individual, confronted by various forces, selects the behavior that will maximize his/her own well-being. Within this model, “culture” ends up constituting one of many characteristics that influence behavior. Demographers have tended to treat cultural factors as “discrete rules or beliefs: irrational norms, tastes, and taboos on the one hand, and rational perceptions of local cost benefit contingencies on the other” (Carter 1998:251). Rather than see reproductive behaviors as the outcome of rational responses to a given set of factors, we examine the ways that individuals manipulate–and are shaped by - the stock of moral symbols and societal arrangements that surround them. Culture, in this view, is a “continuously changing process, one intimately interwoven with the changing institutional and economic structure and field of political power” (Kertzer 1997: 152–3). In reframing the problem of rationality so as to avoid a rational/irrational dichotomy or a “this too is rational” solution, we problematize the notion of “choice” as it concerns reproductive behavior and the use of contraception.

Micheli (1995:229) has argued that the assumption that declining fertility is based on conscious rational behavior supported by practical instruments used to reach objectives has acquired the power of a “self-fulfilling prophecy”. The author critiques demographers who employ a “rationalistic” model (borrowed from neoclassic economics) to portray individuals as habitually using contraceptive methods who then end up deciding to have their first child 24 months after marriage. Similarly, he disapproves of surveys which simultaneously depict fertility control through use of contraceptives and an unyielding fertility calendar. He points out that both approaches assume the existence of rational choice in desiring a first child, accompanied by the underlying notion that individuals must interrupt contraception in order to have children (De Sandre and Boscarini 1993, Micheli 1995). Micheli (1995: 231) suggests that fertility outcomes might be more attributable to a cultural model that expects one to have children right after marriage than to a programmed use of contraception. Within this category, different if not divergent choices are made: “the same model of family size is thus fulfilled both in situations declared to reflect rational strategizing, and in those declared to be failures in strategically controlling one’s family building outcomes.” This article similarly challenges theories based purely on “rational-strategic” uses of contraception. We advocate looking at cultural models behind choices to have children, and the ways that individuals interpret, use, and mold social expectations.

Decision-making processes in the Italian reproductive arena were illuminated by conversations with informants, allowing us insight into how Italians envision the step towards maternity. A large proportion of the interviewees express the view that “it is never a good time to have a child” and when one desires a child, it is best “to let it happen”. If a conception simply “happens” among very young individuals, however, the event is open to social sanctions. On the other hand, when one reaches an age considered to be socially appropriate to have children (i.e. around 30), a conception that “just happened” is not only acceptable, but often seen in a positive light. A rational actor model is difficult to apply, in that while “responsible choice” plays an essential part in taking on a parenting role, spontaneity appears to be the underlying message running throughout conversations with informants on the topic of conceiving a child.

Planning something like a birth “too much,” whose rightful place belongs in the “natural” sphere of affection and sexuality, goes beyond the boundaries of making “responsible choices”. Too much planning implies an egoistical action, and has negative connotations. A “natural maternity” is a maternity that “happens” and not something one chooses. Similarly, the idea of excluding completely the possibility of conception when a couple is only waiting for the “right moment” is not socially acceptable. It is here that we see emerge the possibility, as foreseen by some demographers, of a re-definition of planning a posteriori, as well as an ambivalent attitude with respect to contraception. From the excerpts of interviews below, we see how reproductive choices are therefore not only postponed, but represented as a “non-choice” or as an attitude maintained thanks to contraceptive methods such as coitus interruptus.

I: We talked about the possibility… before it happened. Like, in June… then I learned I was pregnant in August.

A: So you were trying to have a child at that moment

I: No, not trying, no. It’s clear that… well, we could have, if we hadn’t absolutely wanted it, it could have been avoided. Let’s just say that we didn’t do anything to avoid it, you know? Like taking contraceptives, or not really being careful. – Female, age 31, one child

A: Do you do anything to avoid pregnancy?

I: Well, she wasn’t taking the pill. The condom, sometimes… I don’t think, now, in this day and age, if one doesn’t want a pregnancy… there are a million ways to avoid it. The fact of not using anything, no? In some way, you’re saying… I mean, it’s true that we weren’t really trying, but neither did we do much to make sure it didn’t happen, so sort of like a middle ground.

– Above cited woman’s husband

Informants’ discourse about the inability to plan a birth, while simultaneously being open to the notion of it “just happening,” fits interestingly into the statistics on unplanned births in Italy. Indeed, the conceptions described above are technically “unplanned,” notwithstanding the openness of the informants to having a child, and as such further contribute to the grey area of reproductive decisions and the limits of surveys in capturing such fertility intentions. In fact, in the 1990s, 37% of conceptions were not planned; this rises to 45% among those under 20 and those over 35 (Castiglioni et al. 2001). Surprisingly, those who might be expected to be the most likely to plan – namely, young, educated women living in the north – have the most unplanned births.

The notion that many births are both unplanned and desired is not unique in the literature on unintended pregnancies, fertility patterns, and pregnancy decision making. A 2002 US survey found that although 35% of pregnancies are unintended, only 14% were deemed as unwanted (Chandra et al. 2005). Scholars such as Trussell and Vaughan (1999) have pointed out “that planning or intending a pregnancy may be distinct from wanting to be pregnant; the concept of planning a pregnancy may not be meaningful to some women; and ambivalence about avoiding pregnancy may be expressed in imperfect use of contraception” (Santelli et al. 2009: 6, see also Trussell, Vaughan et al. 1999). A number of scholars have sought to distinguish different dimensions involved in pregnancy intentions, planning, and choices (Miller, Pasta et al. 1999; Bachrach and Newcomer 1999; Stanford, Hobbs et al. 2000; Santelli, Kaiser et al. 2004; Speizer, Santelli et al. 2004). Ethnographic studies have pointed to the importance of understanding social context in analyses of pregnancy intentions, suggesting that the latter are “the product of multiple, complexly interwoven social and economic forces” (Santelli et al. 2009: 7; Moos and Petersen et al. 1997; Petersen and Moos 1997; Santelli, Rochat et al. 2003; Kendall, Afable-Munsuz et al. 2005). Italy does however show some particular patterns here, as seen in a comparison with the United States. The proportion of American women who report having an unintended pregnancy decreases dramatically with age (44% among those under 20–24 declines to 22% among women 30–44) and education (61% among those with less than high school/GED compared to 18% with a B.A. or higher; Chandra et al. 2005). In Italy, by contrast, unplanned pregnancies not only occur frequently among women over 35 (45%, see above), but married Italian women with higher levels of education have proportionately more unplanned first births (12%) than women with low levels of education (6%) (Castiglioni et al. 2001, table 8, using data from the FSS survey).

More generally, the publication of a number of studies on the US and developing countries (see Speizer 2006 for a review), has led to debate on whether “some women who experience contraceptive failure are ambivalent about avoiding pregnancy, and therefore use contraceptives inconsistently” (Idem: 185). Unfortunately, data from the Italian FSS survey do not allow for a clear distinction between unwanted (absolutely undesired) and mistimed pregnancies¹². Furthermore, although the FSS survey asks if the woman was using contraceptives at conception, an affirmative reply automatically classifies the birth as unplanned. Only those not using birth control at conception were asked if this was a planned pregnancy¹³. Hence we do not know, for example, how many, among those using contraception (and especially, for the purposes of this paper, using coitus interruptus or natural methods) had pregnancies that were actually wanted. On the other hand, our ethnographic data do allow us to explore the grey area of “planning” and to challenge the suggestion that there is still “much to be done to improve fertility control and reduce the number of unplanned conceptions and births” (Castiglioni et al. 2001:230).

Interviews across the four cities reveal that the women who experience the most “unplanned” births are surprisingly those who most tend to “plan”, or rather those who most manage their fertility, above all by delaying first births. The more that fertility is “managed” the more, evidently, this brings about “unplanned” births. For this class of women, the first child is always unplanned, almost by definition: for reasons linked to work, to finishing their education, to the desire to build a stabile career, but also, seemingly, to culture and gender motives associated with their geographic area of residence and social background, where the concept of maternity is closely linked to notions of responsibility and “capability” (Gribaldo 2007). What the interviews demonstrate is the existence of a link between “not planning” and the use of non-technological methods. For example:

A: When did you decide for the first time that you want to become a mother?

I: Honestly? I’m not a person who had a great desire to have children, not because I didn’t want them… they just happened. That is after a year with my partner I was pregnant…It’s not that we went to live together and then we decided to have a child… so this great maternal desire that I see on television, these great Stars that want a child…. No, I never greatly desired… it just happened, and I decided to go through with it, but it wasn’t like I was one of those women who say ‘I absolutely don’t want children’. No, both of the pregnancies just happened.

A: Can I ask you a personal question? What kind of contraception do you use?

I: None, never have used any. – Female, age 29, two children

Informants described conceptions as “not something one plans, it just happens”. This pattern of behavior is reminiscent of Carter’s (1995:65) work on “decision-making,” in which he comments that “we do not simply choose among alternative courses of action, which crops to plant or how many children to have, in order to best achieve our desires”. People also evaluate the worth of various possible desires in order to evaluate their consistency with their larger visions of the world. More generally, human agency and the ability to make decisions should not be understood “as a sequence of discrete acts of choice and planning, but rather as the reflexive monitoring and rationalization of a continuous flow of conduct” (Carter 1998:262). Carter (Idem) points out that “cultural principles and social institutions have a virtual rather than a substantial existence, taking shape as they enter into activity.” In choosing to use non-technological methods, and in refusing to “plan” first births, Italians are not simply making “passive-decisions” but rather evaluating the consistency of their desire to have children within larger understandings of what reproductive choices mean at the level of identity construction and social belonging. In the Italian context, reproductive choices are always delayed if not eluded through ambiguous discourse and practices: ambivalence, attribution of the choice post facto, and the use of non-technological methods in a “flexible” way which does not harm the fecundity of the woman, are all parts of this puzzle. Through the use of coitus interruptus and natural methods Italians enact particular notions of planning, which in turn shape and are shaped by larger social processes.

Individuals recognize the efficacy of the pill and spiral – in fact, the choice is not so much about the contraceptive per se, as it is about adopting different attitudes towards the possible birth of a child – requiring different contraceptive stances more or less linked to the method of choice. This model means that there are interviewees who use the pill in “unorthodox” ways, forgetting frequently to take it, and those who use coitus interruptus and natural methods very carefully. In general, non-technological methods are more flexible, negotiable, and for this reason, more “usable” than the pill or IUD. In discussions relative to reproduction, notions of “destiny” and “chance” are not surprisingly quite present, even when the precise moment and number of children has been chosen. Couples who feel they cannot make a decision to have a child often perceive of “society” as hostile to the creation of a new family, which means making a choice that they perceive of as almost “illogical”

Indeed, for the middle class, discourse on having children centers around the impossibility of choosing an optimal moment to do so, in that the preconditions for having a child - a large enough house, stable employment, personal satisfaction at work, economic security, couple stability, adequate maturity – are always too many and too difficult to obtain in the desired timeframe. More generally, the “right time” has negative connotations. As one woman with two children said during the course of our fieldwork, “You can’t decide when to do it. If you wait for all of the conditions, you will never do it.” Or, as expressed in an interview:

A: Is there an ideal age or moment to have a child?

I: I think that, it seems like a very ideal, theoretical kind of reasoning, in the sense that you don’t have a child because the moment is ideal, but simply because it ‘happened’ or because before it couldn’t ‘happen’… the ideal would be to escape this mechanism, this economic system, in order to be able to freely decide when the right moment is… but anyway for me it’s not really a question of a priori reasoning.

- Couple interviewed together, she is 34, he 39, no children, just moved in together.

In a context where individuals feel constrained by economic and political factors including the high cost of housing, a precarious labor market, and a lack of available childcare, accompanied by the socially approved (but difficult to achieve) “right” moment to have children (i.e. education finished, stable employment, home owner), individuals use non-technological methods to “let” births happen. In other words, they use a contraceptive method in order to have children in a socially acceptable way, maneuvering through cultural models and economic constraints that make it “never a good time to have a child”.

This pattern of behavior exemplifies Giddens’s (1992) theory of actors resorting to “nearly constant monitoring and self-reflexivity as they continually uncover new information against which to evaluate themselves” (cfr. Morgan and King 2001:13). This process is, however, inherently anxiety producing, in that actors must constantly calculate the risks involved in each alternative before choosing. Indeed, the anxiety inherent in deciding to have a child before having attained the nearly impossible socially accepted preconditions means that births are not only procrastinated, but Italians often choose a strategy that allows them to have first births in socially acceptable ways. By employing coitus interruptus and natural methods, actors can decide not to decide, and to have “unplanned” first births, which are in many ways “planned”.

I: Let’s say that I’d prefer that it didn’t happen, but if it happens, well, I can be sure that I won’t find a job, I might as well just go directly into retirement…

A: What do you mean, ‘if it happens’? You’re not using contraception?

I: No

A: So it could happen?

I: Well, we try not to let it happen…. but if it happened… but I don’t think it will (laughs), well, then there is a minimal possibility… otherwise, if it was complete excluded, then I would be using contraceptives, but I’m not… - Female, age 27, no children, plans to marry next year.

Non-technological Methods, the “Modern” Middle Class, and Conjugal Intimacy

In this vision of reproduction we can also trace questions linked to a sense of class identity, characterized by a “modern” logic which sees reproductive choices as mediating between a responsible decision and a “natural” dimension. Both of these spheres are influenced by a Catholic culture and representations of belonging to the middle class. Attitudes towards the family and reproduction in Italy form out of the complex relationship between modernity, tradition, and a Catholic discourse on nature, emerging as an authentic and intimate dimension.¹⁴ “To allow oneself” to have children is a condition attributed primarily to the wealthier classes, with whom the luxury of a more “relaxed,” less planned, lifestyle is associated. The rich are seen as having enough wealth to choose the path of “responsible” maternity, while lower-class families with more children are placed within a model of irresponsible maternity and hardship, in direct opposition to the desired reproductive paths of the middle and upper classes. Within this model, the categories “modern” and “traditional” as they describe non-technological methods are negotiable (Paxson 2004).

The use and significance of non-technological methods can take on very different forms according to context, and similar practices do not necessarily have analogous meanings. Santow and Bracher (1999), for example, demonstrate that low fertility among Australians of southern European origin was achieved through use of coitus interruptus in a context dominated by male control. They link declining fertility to a man’s desire to improve his life conditions and that of his children. Schneider and Schneider (1996) argue that the use of withdrawal in Sicily at the beginning of the 20^th century caught on first among the artisanal classes where the management of reproductive sexuality was possible thanks to conjugal intimacy.

We might do well to heed Johnson-Hanks’s (2002:229) warning against unquestioningly using “traditional” as a category for describing non-technological contraceptive methods. Withdrawal, for example, has commonly been placed within a fertility transition model that traces a path from non-technological methods to high-technology methods, accompanied by the “emergence of the calculus of conscious choice” (see also Schneider and Schneider 1996: 141). “Traditional” contraception should thus give way to “modern” family planning through processes of development, as the economic and social costs of effective birth control decline (Idem). Yet as Johnson-Hanks (2007:5) cautions, “When we describe certain forms of contraception as “modern” and others as “traditional,” we invoke a whole range of resonances beyond the technical typology that we are citing. These resonances lead a double life: on the one hand, they give structure to our native common sense about the things we study. On the other hand, they offer the illusion of transparency to what are—sometimes at least—very nuanced and difficult concepts”. A more nuanced look at the use of non-technological methods in the Italian case in fact reveals that many Italians use them to in order to achieve “modern” middle class families.

Demographers working in Italy have also had the tendency to juxtapose “tradition” and “modernity” when investigating contraceptive behavior. In commenting on the results of a recent survey of contraceptive behavior, for example, Dalla Zuanna et al. (2005) write “for all intervals the pill was more widely used among more ‘modern’ women, those living in the Northern and Central regions and with less ‘traditional’ attitudes (emphasis added).” We use our findings to challenge the use of such oppositions and to evaluate the ways in which individuals, through their contraceptive choices and desires to conceive, manipulate the categories of “modern” and “traditional” in reaction to larger social and economic constraints. Interviews reveal that non-technological methods like coitus interruptus and rhythm are seen as vehicles of “trust” that partners place in one another. While technological methods see a shift in responsibility and accountability to women, non-technological methods involve both partners to some extent. This involvement is seen by informants as presupposing the harmony and intimacy of the couple, their trust in one another, and generally, couple stability. In turn, these characteristics were described by the middle class as prerequisites for having children and as the optimal conditions for building a “modern” family. As a result, non-technological methods were similarly described as very “modern”.

A full understanding of the ways coitus interruptus and natural methods are manipulated by informants within the Italian context must include a gender perspective. Indeed, much of the “traditional” versus “modern” binary is based on notions of withdrawal as a “male method” linked to “traditional” marriage and gender inequality, as opposed to “modern” methods which see women in control of their own fertility, set in gender-equal companionate marriages. On the other hand, several scholars have suggested that women’s control of contraception is not necessarily always positive. In an unequal gender system, where men do not share the daily burdens of domestic work, such responsibility simply adds to the unequal division of labor. As mentioned above, technological methods may also pose risks to women’s health; indeed, the “medicalization of women’s bodies has been criticized as the ultimate manifestation of patriarchal power” (Dalla Zuanna et al. 2005:45; Martin 1987; Krause 2005).

Italian contraceptive practices are complicated, however, by a gender system that remains imbalanced. In a comparative study across 36 wealthy countries, Italy has been characterized as having a very “traditional gender system” (Di Giulio and Pinnelli 2003). Di Giulio and Pinnelli point out that the gap with other Western countries in terms of gender equality has narrowed only slowly over last 40 years. “Both the political visibility - at national and local level – and the labor force participation of women were limited …. Data on time-use confirm this traditional position; women usually spend less time in paid jobs and more time as housewives” (Di Giulio and Pinnelli 2003:35). The authors concluded that “It is not by chance that the countries characterized by a ‘traditional’ gender system also exhibited lowest-low fertility and ‘backward’ contraceptive patterns” (cfr. Dalla Zuanna et al. 2005:38). Demographers such as Dalla Zuanna, Castiglioni and Racciopi have suggested that the “traditional” gender system in Italy may help explain the high use of coitus interruptus and limited diffusion of the pill, IUD, and sterilization. Hindering a better understanding of the effect of gender relations on contraceptive behavior, however, is the lack of thorough studies of men’s attitudes towards contraceptives.

Some evidence does exist that the necessity for male restraint required by withdrawal is sometimes experienced positively by men. Schneider and Schneider in their historical study in Sicily found that men perceive coitus interruptus as “a learned skill … and a source of pride to those who did it successfully.” Users boasted that “the train can go forward, the train can go backward” and all of the social classes associated withdrawal with some sacrifice, but also with a “respectable way of life” (Schneider and Schneider 1991:889). Ramaswamy and Smith (1976:76) note that “for some couples this method is very successful. In these cases, the man has great control over his functions, a protective attitude, and is happy to be in command of the situation” (cfr. Rogow and Horowitz 1991:145). Evidence from our interviews and related fieldwork in Padua reveal that for many men, withdrawal is preferable to condoms. In some cases, condoms raise anxiety related to sexual performance, such as fear of losing an erection. Other men expressed pride in their ability to withdraw “in time”. Women (not living with a partner), on the other hand, often spoke with frustration of trying to convince their sexual partners to wear a condom. They reported male partners frequently said such things as “stay calm, stay calm,” “I didn’t ‘come’,” “I know how to control myself”, and “Don’t worry, I know myself”.

In the Sicilian study mentioned above, “wives viewed the practice of withdrawal in a positive light, expressing gratitude to husbands who “had this much respect,” and praising husbands for being cosciente (conscious, aware), for withdrawing “beautifully, precisely, exactly”, for having tanta voluntà (so much will-power) (Schneider and Schneider 1991:894). Our findings reveal that in Italy today couples do not especially think of coitus interruptus not in terms of its dependence on the male partner, his self-control, and priorities. Rather they see it as a product of a deep partnership between the man and the woman (couples living together), accompanied by profound trust by the female in her male partner. Furthermore, the interviewees tend not to represent coitus interruptus as a type of contraception, but rather as (mentioned above) an expression of the intimacy of the couple.

A: So, between the first and the second child, you didn’t use contraceptives..,

I: No, I always thought that the pill, etc. were in the long run bad for your health… and male methods (the condom) kind of take the poetry out of the relationship. The relationship between a couple is solid when there is involvement, complicity…So we’ve always continued with the old-fashioned way of doing things, beyond maybe what they used to mean… anyways, there are tons of children born using the rhythm method, you know. – Female, age 40, two children

Rarely did women praise male capability as seen in the historical Sicilian study. While literature on coitus interruptus cites a plethora of expressions used to define this method¹⁵ (e.g. the “retreat,” the “backwards march,” being “vigilant,” “discreet,” “making sacrifices,” etc.) among the Italian couples interviewed by far the most common phrase employed was “being careful”; a “watchfulness” which applied to both members of the couple.

A: When you were engaged to your husband did you use contraceptives?

I: A couple of times we used them, but they (condoms) irritated him, he didn’t like them… Anyways we used them occasionally, when we were young, to try it, and maybe to make me feel more safe. But it didn’t go very well, because it broke (laughs) … My husband had said at the time, ‘I already don’t like these things, forget about it now!’

A: Have you ever used contraception?

I: No, never, I don’t know, always an excuse or another, and anyways I’ve always trusted him. Nothing ever happened, in the sense that we have this really strong relationship, very profound, very deep feelings. In fact, even now, he says, ‘it’s incredible, we just have to look at each other and we understand’… - Female, age 33, two children

These narratives also raise questions regarding informants’ views of sexuality. The extent to which women regard sexual activity as functional to their relationship with their partner, and physical pleasure as of secondary importance, may play a role in the ways that Italians link coitus interruptus to “couple intimacy”. A 1986 study conducted in the Italian region of Emilia-Romagna by Giacobazzi et al. (1989) and described by Dalla Zuanna et al. (2005:29), reports that “only 25% of women declared that physical pleasure was among the most important aims of sexual intercourse; 78% answered ‘to enhance communication within the couple’, 61% ‘to exchange love and affection’, 15% ‘to have children’, 9% ‘to follow a natural instinct’”. Further investigation into the importance of the sexual relationship is needed. While couples in this study spoke of coitus interruptus as a method symbolic of their companionate and intimate relationships, withdrawal itself may affect the pleasure of both partners. More broadly, the use of withdrawal could reflect broader gender inequality in Italy. If reproductive decisions continue to be a matter for men, even if expressed in terms of a more equitable relationship, if the movement for women’s control of contraceptives remains limited, if sexual fulfillment is of secondary importance, and withdrawal is employed effectively, it is perhaps not surprising that coitus interruptus continues to be so widespread among certain groups (see also Santow 1993: 782).

Conclusions

The puzzle of a drop to lowest low fertility in Southern European countries coupled with the widespread use of non-technological methods has received much attention in the demographic literature, especially with regard to why such “backward” and “irrational” contraceptive behavior remains so widespread (Dalla Zuanna et al. 2005; Castiglioni et al. 2001). The issue of contraceptive choices has remained relatively little addressed, however, outside of a rational-strategic framework. This has led to a static approach which equates “modern” technological methods with rational choice while non-technological contraceptive methods, notwithstanding their widespread use among Italian women living in couples, continues to be described as “traditional” and “irrational”. Our findings tell a different story. Ethnographic evidence from four Italian cities suggests that individuals use non-technological methods as tools to maneuver their way through the challenges of family building. Rather than understand their choices as “rational” or “irrational,” or “modern” or “traditional” tout court, we endeavor to understand the ways their decisions both shape and are shaped by larger socio-economic and cultural processes.

We argue that Italians’ contraceptive practices achieve social goals beyond avoiding pregnancy (Johnson-Hanks 2002:231). The widespread use of non-technological methods (especially coitus interruptus) in Italy is not a mystery if we think of them as instruments individuals use to create their identities and plan births in socially acceptable ways. Women’s health-related refusals of the pill and their choice to use non-technological methods can thus be seen as a way for women to “plan” in a context where there is “never a good time” to have a child, as well as simultaneously adhere to larger cultural models of health and well-being. Similarly, in deciding to use withdrawal and natural methods, Italians are not simply passive actors making “irrational” decisions; rather they are evaluating the consistency of their desire for children in the context of larger understandings of what reproductive choices mean at the level of identity construction and social belonging. Individuals use coitus interruptus and natural methods to “plan” births in a setting where planning “too much” is unacceptable, and the optimal conditions for childbearing (education, stable employment, couple stability, home-owner) are impossibly hard to obtain within the desired timeframe. In a similar manner, through their contraceptive choices, individuals manipulate categories such as “modern” and “traditional,” and in doing so transform withdrawal and natural methods into an expression of the “modern” middle class. Their choices, however, are also molded by the larger constraints of a gender system characterized by gender inequality.

Although our aim has not been to offer predictions about the pace of the spread of technological methods such as the pill and IUD, nor the future of non-technological methods such as coitus interruptus and natural methods, ethnographic data suggest that the latter will continue to be commonly used in the future, if not to prevent pregnancies, then to allow them to happen in socially acceptable ways. As scholars such as Fisher (2000, 2006) and Szreter and Garrett (2000) have pointed out, a breadth of explanations concerning fertility change open up once more limiting oppositions--such as traditional/modern, irrational/rational, and passive attitude/active choice--have been overcome. For example, through the use of oral histories, Fisher (2006) clearly demonstrates an evident social and cultural rearticulation of the notion of reproductive “choice” in early 20^th century Britain. We similarly problematize this theme in present day Mediterranean Europe through use of ethnographic methodologies and anthropological theory -- too often ignored or underutilized in the demographic sciences. Yet these approaches have the potential to contribute significantly to debate over issues which have important implications for international population programs. A renewed look at Western contraceptive practices provides a critical contribution to problems concerning the social and cultural acceptability of reproductive technologies in wider contexts and the efficacy of non-technological contraceptive methods in reducing fertility rates (without, however, underestimating the importance of effectively protecting against sexual transmitted diseases using the most suitable devices). Our ethnographic evidence thus suggests that working outside of a framework that sees rationality as the basis for social action may reveal the deeper meanings individuals associate with certain contraceptive methods. Culture, in this case, “may be seen as offering a stock of symbols that are invested with moral weight, but which people are able to manipulate for their own ends. Through this continuous process of manipulation culture itself changes” (Hammel 1990, cfr. Kertzer 2005:529).