Zambia has a high prevalence of STDs including HIV/AIDS.  Sentinel surveillance statistics in Lusaka in 1994 indicated 27% of urban antenatal clinic attendees were HIV+.  In order to assess the acceptability and demand for female condoms in Zambia, CARE International in Zambia carried out a study from November 1995 to June 1996.  A female-controlled barrier method would offer Zambian women another option, besides the male condom, to control their own fertility and their health status.

 After three months, a random sample of initial acceptors who never returned for resupply ("discontinuers") and initial acceptors who returned for resupply at least once ("continuers") were asked to participate in separate focus group discussions. In addition, 10 partners of female condom users were invited for individual indepth interviews.

Continuers expressed several reasons for trying the female condom. Around half were on oral contraceptives, but negative side-effects like heavy bleeding and dizziness put them off and caused them to consider the female condom. Most of the women who came back at least once found the female condom to be clean, safe and good protection against STDs. Continuing or not with the female condom correlated highly with their partners appreciation of the method. Most of the discontinuers were apparently not self-motivated: 70% of them said the nurses told them to try it for various reasons. Some had an STD, while others were encouraged to try it as an interim method whilst breastfeeding or awaiting the provision of long-term contraceptives like the Norplant implant.

A few also said that its "lightness" increased sexual sensitivity and they thought it might be possible to re-use it. Some women preferred the female condom because it made their vaginas feel warm, making sex very pleasurable. Some users experienced an unexpected prolonged male orgasm.

The partners of the continuers were positive about the method: they said it was better than the male condom because "it now was the responsibility of the woman to ensure that the condom was in place before sex." They also liked it because it was strong and they thought it could be reused and was a good method for family planning and prevention of STDs.

Unlike the injectable and oral contraceptives that can be taken secretly, the female condom requires the male partner's consent, and some women felt this could be a problem. As men in this culture frequently prefer "dry sex" over wet sex, some women felt their partners might not like the  female condom because it had too much lubrication.  (In dry sex, women use herbs and other substances to dry up the vagina.)  The major reason women discontinued use was their  partners' disapproval: 60% of them said their partners complained, because it would encourage women to be promiscuous and they would not be able to trust them, or that it was a method only for prostitutes.

Some male partners thought the condom was ugly, too big and uncomfortable. Many women said their partners enjoyed "skin to skin sex" but with the labia covered and no skin contact, sex was less enjoyable. Some also found the female condom to be quite noisy, causing uneasiness.

Recommendations for followup research include the further exploration of continuation rates and women's use patterns. For instance, are women using the female condom as dual protection against STDs? If so, are they doing this with their regular partners or only outside of their conjugal relationships?

These findings show that attitudes towards the female condom are sometimes based on  gender beliefs about who holds the responsibility for contraception, social stigma surrounding women's use of contraception encouraging promiscuity or who should be allowed sexual pleasure.  

Still, the strongest reason for discontinuation was the unwillingness of the male partner. If this method is to be widely introduced, its introduction should be accompanied by an education campaign to combat social stigma already associated with male and female condoms, especially in men.

Gladys Nkhama and Tamara Fetters, CARE International Zambia; PO Box 36238, Lusaka, Zambia; Tel:  260-1-265901/08  ; Fax: 260-1-265060; e-mail: care@zamnet.zm.