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Family Planning

Pulling it all together and moving past ‘increasing access’

November 21st, 2008 by maggie chen 2 comments »

If my math is right, this is our seventh round of blog posts. In this post, I’m going to try to pull together what I’ve been writing about, and look at how to move forward from here.

My intent in this blog was to address the status of family planning on an international level by examining the different ways in which organizations are working to connect women who desire contraception with the actual methods and supplies needed to successfully contracept. I also wanted to look deeper into longer term birth control methods. After covering Implanon and IUDs, I came to a bit of a wall. To my knowledge, there aren’t any other long-acting reversible methods. I’ve heard it quoted that out of all pharmaceuticals, we spend the most money each year on reproductive research (not sure if this is actually true in the numbers). However, it appears as though further development of long-acting, reversible contraception is not a high priority right now. Some work is being done, though. A year ago, I helped out with a study of a method-in-development that will be similar to the NuvaRing, but lasts for a year. NuvaRing is one per month, but this new vaginal ring can be used for 12 months. The dosing schedule is the same, 3 weeks in and 1 week out, but the new ring is saved during the week out and re-inserted at the start of the new cycle as opposed to being thrown away. The main pros are less hormonal waste in landfills and fewer pharmacy trips.

This is all to say that I’m surprised it only took two blog entries to cover the range of long-acting, reversible methods. In terms of initiatives to connect women with contraception, I tried to provide snapshots into actual initiatives and provide a rationale for the importance of family planning.

In my earlier posts, I wrote repeatedly about “increasing access.” For awhile, I have believed that increasing access to family planning is the first step in assisting women who do not want a baby right now or at all in the future. Lately, I’ve been questioning whether access is the most appropriate way to approach the issue. Today in a meeting for my thesis, one of the researchers I’m working with threw out her opinion on increasing access. She said, “Access doesn’t seem to change the numbers of women who are actually using birth control.” This is only the opinion of one person, but perhaps access should not be viewed as the cure-all for increasing family planning use.

The question that follows is, Then what should we focus on? A guiding theme throughout this class has been the importance of involving women in interventions or movements that target them. This is important to the acceptability, initial success, and sustainability of the intervention. If ‘increased access,’ which is itself a vague term, is not the answer to enabling women to control their fertility, then we should start back at what women want. Research on contraception for women in developing countries and rural areas should focus on those women’s voices (this could be called a needs assessment). Key questions that need to be addressed are: How is family planning traditionally viewed and performed in their community? What are their opinions on different forms of birth control? If a woman does not want a baby right now, what is her preferred way of preventing pregnancy?

Women’s Center of Jamaica Foundation

November 21st, 2008 by jliebner@stanford.edu 1 comment »

This week I want to being to talk about some groups that are taking an active approach towards addressing the problem of teenage pregnancy in Jamaica.   I was both surprised and excited when I read about the work of the Women’s Center of Jamaica Foundation who takes a different approach to preventing teenage pregnancy.  Rather than following a solely prevention approach (distributing contraception, reproductive health education, etc), the WCJF focuses on preventing repeat pregnancies during adolescent years by providing educational programs and helping adolescent mothers return to school.

Since 1977, the WCJF has helped over 22,000 adolescent mothers return to school and become economically self-sufficient.  In 1977, 31% of all births in Jamaica were births to teenage mothers, who were likely to have subsequent pregnancies during their adolescent years, leading to 3-4 children by the age of 20 (…and hence the proposal in Parliament to sterilize these girls…).

The WCJF “Programme for Adolescent Mothers” provides educational and training programs for pregnant or lactating girls under age of 16.  Its goals are for the girls to return to school after the birth of their child, to delay second pregnancy until professional goals are achieved, and to raise employment potential so that the young women could become self-sufficient and rely on opportunities other than men for financial support. The Programme has 7 centers and 6 outreach stations across the island and provides education and nutrition programs, as well as nursery and counseling services.

Pregnant girls are required to leave school, so the education program provides academic training to help prepare participants academically to return to formal schooling or to take the necessary final examinations to receive their diplomas.  Skills training is offered to help the young women obtain employment (clothing manufacturing, embroidery, farming, bee-keeping, etc).  By being able to complete secondary schooling and get a job, girls can become more self-sufficient.  They not only can take better care of their children, but also gain more financial security.

What I think is great about this program is that it really is a source of empowerment.  We talk a lot (or rather, we talk around) the idea of female “empowerment”, but I think this is really an excellent example (with great results!) of how education can really affect an individual’s life and create opportunities for a young woman that can remove her from unhealthy situations.  This program is particularly valuable because it not only addresses a problem (teenage pregnancy) and provides “treatment” programs (education programs), but it also works to decrease barriers of access to such programs, namely through its nutrition, and nursery services.  In class, we talked about incentives to get (or allow) young girls to go to school in some regions.  Providing a meal is a great way to encourage attendance, and it benefits the baby as well, both in utero and breastfeeding.  The programme also offers caretaking while the mothers attend classes, and most importantly, individual and group counseling.  I think counseling is a critical component of any treatment program because it not only increases understanding about certain issues, but it contextualizes them in terms of other people’s experiences, which I think is an incredibly powerful experience. Counseling also provides a sense of community, and through this, fosters self-respect.

What I like most about this program is that it doesn’t give up on the girls who have, in a sense, failed the prevention efforts.  While preventing the issue altogether would be incredible and prevention programs (contraception, reproductive health awareness, addressing social norms) are definitely needed, efforts to help pregnant teenagers are essential, particularly to prevent them from having more children soon after. This is particularly important for an issue like teenage pregnancy in Jamaica, where young women, after their first pregnancy in their teenage years, have subsequent pregnancies before they are 20.

Here are some of the amazing statistics from the program.  Only 1.4% of the participants had a second child in any given year during the program, and the participants themselves have gone on to become teachers, doctors, lawyers, etc.  The scope of the programs is impressive as well.  In 1997, the program reached 51% of the 3,016 girls under the age of 16 who gave birth nationwide.  What is most impressive is, however, that the positive results have continued into the next generation – all the children of the program participants are in school, and no pregnancies have been reported among the adolescent children.

Last week I talked about the importance of providing youth-friendly services.  I think this program is an excellent example of a youth-friendly service and is doing great work in Jamaica!

Pamela McNeil. “Women’s Centre, Jamaica: Preventing Second Adolescent Pregnancies by Supporting Young Mothers.” Family Health International youthnet.

American Black Nationalists on Population Control

November 20th, 2008 by mjromano 2 comments »

“Don’t let a pregnancy get in the way of your crack habit,” read the billboard offering $200 cash to chemically addicted people who consent to take long-term birth control. Although few Americans agree with the goals of that mid 1990’s billboard of Positive Prevention, a population control organization in Seattle formerly known as Children Require A Caring Kommunity (CRACK), population control rhetoric permeates US domestic and foreign policy. Positive Prevention works in cities across the United States and has come under scrutiny for targeting low-income people of color through its ads. If you have read any of my previous postings, the coercive aspect of a “voluntary” program like this one should already be clear. Offering large cash incentives to poor people for their fertility often puts them in a position of choosing food, clothing, shelter, or drugs over their own reproductive autonomy. Positive Prevention combines its insensitivity to the nature of drug addiction, its able-bodied supremecist view of the children of drug addicts, its ignorance of the power dynamics of rape and sex, and its exploitation of vulnerable people to produce an altogether distasteful program. While my previous blog postings focused on international issues and Puerto Rico, this posting will concentrate on domestic population policies and different responses to them, specifically from Black Nationalists movements.

Since World War II American eugenicists have tried to distance their population control policies from Nazi eugenic policies modeled after American laws. By the 1960s, the US had restructured its domestic and international population programs around ecology rather than Eugenics. Although President Johnson expanded government funding for population control (excluding abortion), President Nixon really made family planning official state policy. Following the Watts riots in 1965 and increasing concerns about poverty within the United States, Congress passed the Child Health Act in 1967 that mandated 6 percent of all government maternal child health grants be dedicated to family planning (Nelson 93). On the international front, Nixon eliminated democracy as a condition for foreign aid and introduced family planning in its stead. Nixon said, “population control is a must…population control must go hand in hand with aid” (Connelly 254). Although Nixon distanced himself from the family planning movement by 1970 in the face of opposition from the Catholic Church and increasing calls for the legalization of abortion, his administration had mainstreamed family planning as a core aspect of population control in poor neighborhoods of the US.

Black nationalist responses to government family planning programs are consistently and unsurprisingly negative. The Black Panther Party and the Nation of Islam both condemn governmental intervention in black peoples’ reproduction and see “family planning” as a population control in disguise. In the words of historian Jennifer Nelsen,

both the Black Panthers and Black Muslims believed that attempts to quell urban riots or to end poverty through family planning were palliatives used by the federal government to avoid more sincere efforts to change the circumstances that caused poverty in communities of color. They argued, rather than curb the poor black population through fertility services, government planners should end poverty by helping strengthen the economy in neighborhoods of color and incorporating blacks and Hispanics into the national political process. (94)

Black Muslims opposed birth control on conservative theological grounds, and they specifically opposed US government-sponsored birth control as a black genocidal plot. Lonnie 2X, writing in the Nation of Islam magazine Muhammad Speaks, linked US-government supported sterilization clinics in Virginia with US-funded coercive sterilizations in New Delhi, India. “Black leaders across the country have pointed to this state’s sterilization clinics as proof that there is a deliberate effort to destroy the Negro population of America by surgically stripping young black women of their ability to bear children.” The Nation of Islam continues to oppose birth control in all forms to this day.

The Black Panther Party also opposed birth control of all forms through the early 1970s, but then interestingly changed its rhetoric. The 1970 Black Panther Party Paper entitled Birth Control echoed Lonnie 2X in Mohammad Speaks by criticizing birth control as an insufficient palliative for deeper oppression. The Paper states “the relevant question is not, ‘If you have all those babies, how will you care for them?’ But ‘Why can’t we all get enough to care for our children?” and goes on to describe the birth control pill as the “weapon of the pigs” in reference to male oppressors (Nelson 105). While this Paper exemplifies the Black Panther perspective on modern birth control, it mostly addresses the government control of contraception. In 1973 the leader of the Black Panther Party, Huey Long, fled to Cuba amid accusations of murder, and Elaine Brown stepped in to replace him. Although Brown’s tenure atop the militant black nationalist organization ended three years later with Long’s return from exile, her leadership fundamentally changed the organization. Brown sought to promote a less violent image of the party by supporting more community-controlled institutions and becoming more involved in local politics. Through these local institutions, the Black Panther Party reclaimed birth control and abortion rights and became an outspoken birth control advocate. Although the Party continued to oppose government-enforced birth control, they accepted the importance of a variety of safe, cheap, accessible birth control to poor black women, especially after the passage of the Hyde Amendment in 1976 that prohibited Medicaid payment for abortions. While the Nation of Islam continued to oppose all forms of birth control through its conservative theology, the Black Panther Party became an outspoken supporter of voluntary birth control while maintaining a firm stance against government-enforced family planning that threatened communities of color.

Population policy and abortion rights advocates have both incompletely addressed the needs of Americans of color, and the case of black nationalist opposition to government population control and support of contraceptive rights sheds light on the true complexity of population policies all over the world. Black Nationalist activism in opposition to oppressive birth control helped shape the modern policy agenda on population. Radical activists have a way of explaining the essence of an oppressive policy, and Lonnie 2X and the Black Panther Paper do this quite eloquently. While US government and economic foreign policies have deleterious consequences abroad, those policies also have some domestic relevance. The Black Panther Party and the Nation of Islam both opposed government exploitation in different ways, and created a world in which “organizations concerned with population policy and abortion rights found it increasingly difficult to advocate fertility control for the indigent without including demands for improved health care and resources for the poor” (Nelson 110–11).

Communities Against Rape and Abuse (CARA) and the Black People’s Project (BPP), Fact Sheet on Positive Prevention/CRACK (Children Requiring A Caring Kommunity). Committee on Women, Population, and the Environment, July 13, 2006. < http://www.cwpe.org/node/61>

Connelly, Matthew. Fatal Misconception: The Struggle to Control World Population. Cambridge: The Belknap Press of Harvard University Press, 2008.

Lonnie 2X, “Murder of the Black Unborn: Massive Birth, Sterilization Program Aimed at Reducing Black Population,” Muhammad Speaks, 6 October 1967, 5-6.

Nelson, Jennifer. Women of Color and the Reproductive Rights Movement. New York: New York University Press, 2003.

Roberts, Dorothy. “Women of Color and the Reproductive Rights Movement.” Journal of the History of Sexuality. Vol. 13.4 (2004), 535-539.

Another barrier?: the effect of sociocultural ideas of sexuality on adolescent sexual practices in Jamaica

November 14th, 2008 by jliebner@stanford.edu 2 comments »

Last week I talked about some of the barriers adolescent girls face when obtaining contraception.  Conservative ideas about the age of sexual activity appeared to discourage sexual health providers from giving contraception to young girls, while they were willing to provide contraception to boys of the same age.  This week, I would like to examine this gender disparity in greater detail.  How do sociocultural ideas of gender and sexuality affect adolescent sexual practices in Jamaica?

Part of the disparity, seen in many cultures, is that sexual prowess is viewed differently for men and women. In a study conducted in a rural parish in Jamaica among 15-18 year olds, participants were interviewed about the attitudes they believed affected their decisions to engage in sexual activities.  For men, early sexual onset is seen as sign of manhood, multiple partners as admirable, a sign of virility.  It appears that sex is an important element of masculinity, associated with feelings of dominancy and achievement.  Sex is an expression of masculinity not just in terms of coming of age, but in proving that a man is not homosexual.  Homosexuality appears to be a hypersensitive topic among adolescents: failure to make advances when expected to is perceived as an indication of queerness.

For women, however, early sexual behavior is viewed diametrically differently – early sexual activity is a sign of promiscuity and seeking contraception is only a manifestation and a way of enabling this behavior, something shunned by parents and elders.  Girls report feeling more constrained sexually that their males peers, yet they face conflicting societal pressures.  They are praised by society for practicing abstinence, yet they are pressured by their male peers to have sex in order to prove their love, because among Jamaican adolescents, sex is perceived as an important way to demonstrate love in a relationship.  Yet, unlike boys, when girls have sex with someone they are not in a relationship, they are not praised for this behavior with, but rather considered licentious.  Females appear to face a double standard in this respect.

Abstinence, although advocated, appears unrealistic due to negative social perception, because for adolescents, sexual activities are tied to sexual identity.  For men, to refuse or refrain from having sex is an indication of homosexuality.  Girls reported that their reasons for staying abstinent were the fear of pregnancy, moral/religious beliefs, risk of contracting STIs and for preserving their reputation.  However, the prevalence of abstinence is low.  While some girls (and most males) reported that they felt most males would respect a girl’s decision to remain abstinent, girls reported that sex is difficult to refuse because it was difficult to say no, because according to some, they feared they would lose their partner.

This result appears troubling.  Women report that it is difficult to say no to sex, while men consider themselves “pushy,” but in the end “cooperative” towards their partners’ sexual decisions.  What strikes me is that women appear to have more power than they realize and that men are not being proactive.  It appears that men are receptive towards their partners’ sexual concerns (abstinence and contraception use) but will not take initiative unless their partners actively advocate for it, which the women don’t appear to be doing.  I guess its hopeful sign in one respect, that men are more respectful of women’s sexual concerns than commonly believed.  However, I feel that both women and men need to be more proactive (ie men offering to use a condom rather than waiting for their partner to request it or women to be more firm about their decisions not to have sex).  However, adolescents report that communication about these issues appears to be difficult.

Fear of sexually transmitted infections did not appear to be a deterrent to sexual behavior.  Knowledge and perceived vulnerability to sexual transmitted infections like HIV/AIDS in fact was low and often mistaken, and effected the perception of contraception use. Many thought that STIs are apparent based on outward appearance or behavior so it would be easy to avoid contracting.  However, rather recognizing that condom use is meant to prevent unwanted pregnancy or the possibility of disease transmission, males perceived that the request to wear a condom is an indication that their partner is infected or believed that he is infected, rather than a general safety precaution.  A major problem with this belief system, however, is that adolescents do not see themselves as vulnerable and are thus unlikely to adopt precautionary behavior.  These surprising results indicate that more education is needed to understand the risks of infections like HIV (when the average length of life after diagnosis is only 16 months) and the importance of contraception use to prevent transmission.

Peer pressure appears to be another facilitator of early sex, an influential source dependent upon the perceptions of the opposite sex (which always makes things tricky).  Boys are concerned with not appearing masculine enough and not worthy of associating with certain girls, because girls want someone with experience.  Yet girls feel like they cannot refuse sex, because their boyfriend will leave them for another girl who is more willing.  However, I think peers can be a good source of positive influence and should be a target population for contraception advocacy.  Peer opinion bears an incredible influence upon adolescent lifestyles and one study found that adolescents who felt their peers believed in using condoms were twice as likely to use condoms themselves during intercourse.  This avenue, including peer education, should be explored as a way of promoting health education and awareness of safe sexual practices, regarding both abstinence and contraception.  I think peers will have a greater impact on their peers than anyone else.

This study, and other like it, address influences on the decision to engage in sexual activity, but they do not address decision to use or not use contraception, or practice “safe sex”.  While I believe that understanding the social and cultural influences on sexual initiation is critical, I think these influences not only affect the decision to have sex, but the decisions to use contraception.  The rate of unwanted pregnancies (which seems to be the source of the problem here) is due unprotected sex, which is indeed a function of the decision to have sex, but also the decision to not use contraception.   And I think understanding this decision is what is really key.  One answer is lack of access to contraception (as we saw last week, girls are finding it hard to get contraception in some situations).

After reading a lot on adolescent sexual behavior, something crossed my mind. Can we define sex as being appropriate for an age group?  Is sex among early adolescents still a problem or is it only a problem because of sexually transmitted infections or unwanted pregnancies (because contraception use is low)?

D Smith, M Roofe, J Ehirl, S Campbell-Forrester, C Jolly, P Jolly. Sociocultural contexts of adolescent sexual behavior in rural Hanover, Jamaica. Journal of Adolescent Health (33) july 2003, 41-48.

SF Brown. Small successes, big ideas – Jamaica’s adolescent reproductive health focus. Population References Bureau, May 2003.

the lowdown on IUDs

November 14th, 2008 by maggie chen 5 comments »

Part of my goal for this blog was to profile longer-term birth control methods that have the potential to be effective for women in rural or isolated areas. One of these was Implanon, and I think it’s time to talk about IUDs. (Incidentally, I was at the teen clinic where I used to work today, and they said they were removing Implanons for a lot of the women who had just gotten them in recent months. Women were complaining about having prolonged spotting/bleeding…so we’ll see how this plays into the future acceptability of Implanon).

The IUD, or intrauterine device, has had a long and mixed history in the US, and is currently the world’s most widely used reversible birth control method. The basic concept of the IUD, a device that is inserted into the uterus to prevent the start of a pregnancy, is one of the oldest attempts at birth control. IUDs have taken many iterations and forms; check out this picture of all kinds of IUDs from the History of Contraception Museum.

The IUD got a bad rap among American women in the 1970’s when the Dalkon Shield, a faulty version, was put on the market and used by millions of women, many of whom were injured while using it. There were lots of negative aspects of the Dalkon Shield: it had extensions on each side that made insertion and removal painful, and the string was made of a porous material that sheparded bacteria into the uterus. This resulted in severe pelvic infections, which can cause infertility due to scarring. Turns out that little research was done on the Shield before it was released, and birth control devices were not as strictly regulated at the time.

Needless to say, the Dalkon Shield episode changed the way that the FDA treats birth control methods (restrictions are much tighter now). The positive news is that two forms of safe, effective IUDs are currently available in the US, and they provide a good option for women who desire long term, reversible birth control that usually requires no maintenance. These two IUDs are:

  • Mirena: contains a small dose of progestin, to reduce the heavy bleeding sometimes associated with IUDs, can be used for up to 5 years.
  • Copper-T (Paraguard): non-hormonal, has copper wrapped around the arms of the T, can be used for up to 10 years (some studies show it is effective for 12 years).
  • Both are small, with a basic structure made of plastic, and shaped like a T.

I’m hoping this entry will get the facts straight for us as young American women (and men), since I think some of the impressions from the Dalkon Shield era were transmitted to our generation. It’s important to keep in mind that IUDs play a much bigger role in other countries and are just starting to gain popularity in the US again.

Elephant in the room…part 2

November 13th, 2008 by mjromano 2 comments »

The human rights abuses of the one-child policy in China are varied and well documented, so I am not going to enumerate them in depth here, but I do want to make a distinction between two categorically different critiques of the one-child policy. The first critique is that the state has no right to deliberately control its population, and the intent of the one-child policy’s collectivization of birth control is a violation of a basic individual human right to control one’s reproduction. The second critique is that China has implemented the one-child policy in a way that systematically discriminates against women and girls, thus violating their human rights, regardless of whether collectivization is itself immoral. It is important to distinguish critiques of collectivization of reproduction from critiques of the gender-biased implementation of that collectivization in order to successfully promote human rights.

As I mentioned in my previous posting, the histories of Confucianism and Communism in China indicate that many Chinese people do support the idea of collectivizing birth control. The strong line that Western liberalism draws between a family’s decision to have a child and the community’s decision to have a new member is not a Chinese phenomenon, nor is the liberal feminist line between the oppressive private and empowering public spheres. Many western feminists have decried the one-child policy in a way that ignores Chinese feminist perspectives. Some human rights abuses, such as forced sterilization and induced poverty, stem directly from the collectivization of reproduction as the state tries to restrict couples from having more than one child. But if you can temporarily accept the idea that the state has some collective responsibility to regulate reproduction, then the aforementioned abuses of the one-child policy may seem like the harsh but necessary costs of enforcing a socially acceptable law. Although there is a tendency to accept individual human rights as natural and inalienable, different people may view human rights very differently. If you accept state responsibility for controlling population, then you may still judge other indirect gender-biased results of the collectivization of reproduction as fundamentally unjust because they hurt women and do nothing to achieve the goal of societal birth control.

In addition to the general human rights violations that accompany China’s state effort to exert reproductive control, the one-child policy also led to several gender-based human rights abuses such as female infanticide and sex-selective abortions that do not support the overall goal of collectivizing reproduction. If you assume the perspective that the Communist state has some responsibility to regulate births, these abuses are particularly concerning because they undermine gender-neutral worker solidarity in the Marxist state. The misinterpretation of the “in real difficulaties” clause that I mentioned in the previous posting is one clear way that birth control leads to gender discrimination. Parents say they cannot survive without a male child leads to state exception of the one-child policy. The fault of the situation is not the parents worrying about surviving, but the economic system that makes their survival dependent on patriarchy. The chinese women’s resistance to the one-child policy that I have encountered focuses on the gender-biased implementation of the policy as opposed to the idea of collectivizing reproduction. The All-China Women’s Federation (ACWF) is a Chinese women’s advocacy organization that focuses on the problems that Chinese women face under this policy without challenging the overall goal of the state birth rate control. In contrast to the international human rights community’s condemnation of the intent of the Chinese state to control births, the ACWF selectively fights against women’s discrimination within the system of control. Selectively challenging the gender-biased implementation of the one-child policy may be easier and safer than addressing it’s underlying goal of collectivizing reproduction, and it may be an incomplete tactic for critics working within China, but I think it is a critique well worth our attention.

The overarching question that I am getting at is simply whether China can directly control its population without disenfranchising women. Just as Julia pointed out in her response to my post last week, we wonder if there is a way to use incentives and disincentives within a legal framework to control population from a state level in a gender-neutral way. This line of questioning may appear to run counter to my previous posts that openly criticized all hierarchical reproductive control, but my point here is that many Chinese women do support the goal of the one-child policy, just as many Puerto Ricans supported widely available sterilizations. I am in no position as a white male American to say that these women are wrong in their beliefs, but I am trying to better understand the complexities of human rights relating to population control. I think the most important fault of both the Puerto Rican sterilization debacle and the one-child policy is their exclusion of the women themselves from the policy-making process. By this I do not mean any women should participate in the process, but specifically the women that the policies affect have a role in determining those policies. Maybe this idea itself is a Western democratic imposition on Chinese politics, but it also seems egalitarian (and proletariat-centered) to me.

Although the limited scope of the ACWF may only address part of the human rights complexities of the one-child policy, I think it offers Westerners an opportunity to support Chinese anti-discrimination work. If organizations like the ACWF achieved their goals in removing gender-bias from the one-child policy, then there would be more room to discuss the underlying ethics of state control of population. Can you remove gender-bias from a system that regulates population? All of my blog entries try to address that question, although they don’t provide a monolithic answer. China is so committed to controlling its population, this case study offers me the opportunity to confront my own concerns with population control.

Hartmann, Betsy. Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice. HarperCollins Publishers, 1987.

Sen, Amartya. “Population: Delusion and Reality.” New York Review of Books, Vol 41, No. 15, Sept. 1994.

Wong, Yuk-Lin Renita. “Dispersing the ‘Public’ and the ‘Private’: Gender and the State in Birth Planning Policy of China. Gender & Society, Vol. 11 No. 4, August 1997, 509-525.

Barriers to contraception in Jamaica: “teenage girls denied contraceptives” (!!!)

November 6th, 2008 by jliebner@stanford.edu 2 comments »

One of the more obvious barriers to contraceptive use among adolescents is the physical difficulty in obtaining contraception.  From my previous posts, we’ve learned that a good percentage of adolescents (both girls and boys) are educated in the various methods of contraception. As we’ve discussed before, a significant number of sexually active minors are having sex without using contraception, although contraception for women under 25 has increased to 67.3% at first intercourse in 2002.  Major reasons for not using contraception include not expecting to have sex (52.5% for females, 37.1% for males), not knowing any methods (9.5% for females, 30.5% ofr males), and not being able to get a method (12% for both).  Indeed, sexually active girls report finding it difficult to obtain these methods from health care providers, and as a result, are having unwanted pregnancies and contracting HIV (1).

A November 2007 article in the Jamaica Gleaner News, reports that health-service providers in most of the public health centers are refusing to give contraceptives to adolescent girls.  One reoccurring theme is morality and personal convictions: often health-service providers believe that girls are too young to be having sex and feel uncomfortable providing contraceptives to minors.  A study presented at the Caribbean Child Research conference in October reveals that health-service providers are refusing to supply contraceptive to girls because they believe they are too young, yet they provide boys with the same service (2).  This is also true of USAID funded programs designed to promote healthy adolescent lifestyles, such as JA-STYLE, Jamaica’s Solution to Youth Lifestyle and Empowerment.  The USAID Evaluation of Adolescent Reproductive Health Activity 2000-2007 reports that the intended focus on adolescent reproductive heath, particularly the availability of contraception, has been significantly reduced given staff ambivalence and reluctance to make condoms available to minors.  In fact, at JA-STYLE program sites, emphasis has shifted more to counseling than ensuring access to clinical services and prevention methods; condoms are not made easily available and are even restricted until youth receive counseling (3).

This has to do with the problems of abstinence-only approaches.  The USAID strategic objective is to increase the age of sexual debut, and thus designs program activities that encourage abstinence among youth that are not sexually active (3).  However, as Margarette Macaulay, chairman of the Jamaica Coalition on the Rights of the Child, eloquently states, “We all have to accept that underage girls and boys are engaging in sexual contact, and if they are, despite what everyone can do to try to convince them to abstain, we still have to protect them because they are vulnerable” (2).

What is particularly disturbing is that legislation designed to protect children appears to be denying them protection and access to contraception.  The Child Care and Protection Act, a piece of legislation designed to protect children from abuse at the hands of adults, may actually be part of the reason why health-service providers are hesitant to provide contraception to minors.  Health service providers report that they fear being prosecuted for failing to report a suspected case of abuse.  If they provide contraception to a minor, they in a sense could be facilitating the abuse of a minor by enabling forced sexual encounters.   However, recent policy also requires public-health service providers to provide minors with contraceptives in cases where they would begin or continue to have sex without it and allows health professionals to give contraceptives to minors without the knowledge or consent of parents (2).

From what I gather, forced and coercive sex definitely appears to be a problem in Jamaica, particularly targeted at young and vulnerable girls.  However, I believe that it is the responsibility of a doctor to report any cases of inferred abuse and provide medical care – which includes providing safe means of having sex if it is occurring.  It is not the role of the doctor to legislate or punish rape, but to report it if it is occurring.  By denying patients access to contraception, a doctor is not preventing it from occurring, but rather making it even more unsafe for the victim.

So while contraceptive education is promoted and contraceptives are available (in the sense, that yes, they do exist in the country), access to methods, and by association, use of such methods appear limited for adolescent girls due to the opinions and actions of health service providers.  However, the Ministry of Health is working on legislation to address the issues and reproductive health and adolescent groups, like Youth.now and JA-STYLE, are working to improve interpersonal relations of health service providers and create more youth-friendly services in order to bridge this gap.  Other efforts include making contraception available in non-health care settings.

(1) CDC, 2003. Highlights from the Jamaica Reproductive Health Survey, 2002–2000

(2) Gareth Manning, “Teenage girls being denied contraceptives.” The Jamaica Gleaner. November 5, 2007.  Accessed November 6, 2007.

(3) USAID. USAID Evaluation of the Jamaica Adolescent Reproductive Health Activity 2000-2007. December 2007.

Perhaps Another Elephant: Linking Contraception to HIV

November 6th, 2008 by maggie chen 2 comments »

In blogging about contraception and efforts to increase its access, I realized that it doesn’t make sense to write about contraception as an isolated topic. Clearly, contraception is one part of the larger picture of sexual and reproductive health (and human rights). I think one of the most important connections to draw is that between contraceptive use and HIV/AIDS.

This Washington Post article has gone so far as to say that birth control is the ‘best-kept secret’ for an HIV-free Africa. Increased birth control access would be targeted at preventing mother-to-child transmission. Discussions of prevention of MTCT often go straight to the drugs that can be administered at birth (e.g. nevirapine), or the decision about whether to breastfeed. We rarely talk about how MTCT can be prevented by allowing women to choose to use contraception.

The article profiles a woman who, at age 27, had given birth to six children and was HIV-positive. She had been widowed, then inherited by another man, based on the community’s tradition. In terms of childbearing, the woman said, “I wanted to be done,” after she learned she had HIV.

HIV-positive mothers face difficult issues and decisions, such as the possibility of dying and leaving their children as orphans, or giving birth to HIV-positive children in rural areas where drugs for MTCT prevention are scarce. Specific attention should be give to the contraceptive needs of this group. After learning in class about the forced sterilization of women with HIV, making sure that birth control programs are structured based on a woman’s choice and not a forced decision seems especially salient.

Interestingly, before Republicans took control of the US Congress in 1996, Kenya experienced a significant decline in fertility that was fueled by widespread groups of community health workers who offered BC pills and contraceptive counseling. More recent funding for this initiative brings us back to PEPFAR. While public health officials argued for the inclusion of family planning efforts in PEPFAR, citing contraception’s crucial role in preventing MTCT, the Bush administration refused to allow PEPFAR money to be used to purchase contraceptives.

At a time when condom use has proven to be a difficult behavior to increase in the broader issue of HIV prevention, addressing MTCT prevention through increased availability of contraception could be an area of significant impact.

The Elephant in the room, part 1

November 6th, 2008 by mjromano 2 comments »

Now that we have published over 8,000 words in this blog on the topic of human rights and population policy, I think it’s ample time to mention the elephant in the room: China. The absence of China from my previous postings reflects a surprising general dearth of international outrage about reproductive human rights abuses in China. Many people are aware of China’s “one-child policy” and many Americans have a strong opinion on it, but somehow feminist critics and international human rights advocates have failed to create a unified voice in opposition to coercive birth control. What I want to do in the next two blog entries is to introduce some history of population policy in China, and then describe two distinct human rights questions that it raises. Firstly, should reproduction be collectivized in a Marxist state? Secondly, is that collectivization inherently gender-biased? I argue that critiques of gender-bias within the one-child policy are different than critiques of collectivization of reproduction itself.

But before we can talk about the human rights abuses in question, I need to give a little Chinese history to balance my extremely ethnocentric “little history of population theory”. Traditional Chinese society and Western society differ greatly in their conceptions of public and private spheres. The Confucian order of imperial China made no clear distinction between the spheres of family and state, which is to say that an individual’s familial obligations are fundamentally similar to her or his societal obligations. The Mandarin Chinese expression for the word “nation” is “guojia,” which is actually a compound word consisting of “guo,” meaning “state,” and “jia,” meaning “family” or “patriline.” This overlapping of state and family identity contrasts sharply with Western liberalism that persists from 18th century European urbanization and emphasizes the privacy of the family as a female sanctuary (or prison, according to liberal feminists) contrasted with the public polis as a venue for male citizenship. I emphasize this overlapping of society and family so strongly because Western critiques of the Chinese population policy often assume a liberal feminist ideal of the public as an arena for exercising individual rights, which ignores the spatial and temporal provenance of liberalism.

With the foundation of a People’s Republic of China (PRC) in 1949, Marxist ideals about collectivization of production and reproduction collided with those traditional Confucian values. Chinese communism includes a strong aversion to arcane “feudal” practices, including gender bias and the exclusion of women from the workforce. The collectivization of women’s reproduction accompanied the collectivization of women’s labor. Introducing Chinese women into the workforce subverted traditional gender hierarchies in many ways, but that came at a cost. A central guiding goal of the Chinese Communist Party is “Lianzhong shengchan yiqi zhua,” that is, “grabbing production and reproduction together.” This goal stems from Frederick Engel’s emphasis on the interdependence of material production and human reproduction, and the idea that the communist state should regulated both production and reproduction. State planning of reproduction has been a central tenet of Communist rule in China since the 1950s. By the 1970s, the national campaign for “later, longer, and fewer” pregnancies reflected a new government priority of limiting population growth.

In 1978, the PRC incorporated state birth planning policy into its new Constitution, laying the groundwork for the one child policy. The first “one child policies” first appeared in Sichuan Province in 1979 and offered a package of financial and social incentives and penalties to limit childbirth to one child per family. Similar policies proliferated throughout the PRC to limit reproduction using a variety of measures. Parents of single children received large cash subsidies, priority in education, employment, and medical care, and plots of land for family production. Violators of the policy were subject to severely limited social benefits (which is particularly devastating in a socialist state), employment insecurity, and fines. Agricultural decollectivization policies in the 1980s pressured parents to bear more children as they transitioned back to more independent farming, so after 1984 couples “in real difficulties” were allowed second children. This provision originally targeted impoverished families, but it later included parents of girls that still desired sons, which revealed the underlying gender-bias of the policy. Other notable exceptions to the one-child policy were ethnic minorities with populations of less than 0.1 million and parents with one disabled child. As I examine the one-child policy from my Western perspective, the affirmative action of birth control in China contrasts with American discourses on affirmative action, which clearly highlights the immense difference between Western and Chinese cultures.

I can critique the one child policy from essentially two different perspectives. Either I can argue that the idea of collectivization of reproduction is fundamentally wrong, despite its historical depth in Chinese culture, or I could accept the Marxist Chinese desire for the collectivization of reproduction and instead argue against the disproportionate affects of the one-child policy on Chinese women and girls. I will discuss this distinction more next week, but hopefully you have an idea of where I am going with this distinction of perspectives.

Hartmann, Betsy. Reproductive Rights and Wrongs: The Global Politics of Population Control and Contraceptive Choice. HarperCollins Publishers, 1987.

Sen, Amartya. “Population: Delusion and Reality.” New York Review of Books, Vol 41, No. 15, Sept. 1994.

Wong, Yuk-Lin Renita. “Dispersing the ‘Public’ and the ‘Private’: Gender and the State in Birth Planning Policy of China. Gender & Society, Vol. 11 No. 4, August 1997, 509-525.

With contraceptive methods available in Jamaica, why is there a problem with teenage pregnancy?

October 30th, 2008 by jliebner@stanford.edu 3 comments »

Note: whenever I refer to “young adult” males or females, I am referring to men and women ages 15-24.

Last week I talked about the efforts the Jamaican government has made to make contraceptive methods available in Jamaica.  In response to Maggie’s post about injection contraceptives in Madagascar and its potential in Jamaica, I wanted to clarify that injections are actually the most commonly form of contraception used in Jamaica (used by ~50,000 women in 2000), followed by the pill (~37,000), and then condom usage (~15,000).  The pill is the preferred method among adolescents, while injection was more popular among older women.  The accumulated total number of women who had undergone sterilization by 2000 was 53,0000.   75,500 women have been sterilized (voluntarily) (see Product and Services, Family planning board).

However, it seems that contraceptive methods are not being targeted at a particularly vulnerable portion of the population, adolescents, despite the high rates of unplanned and teenage pregnancies.  In a 1999 Statement of Jamaica to the Hague Forum, it was acknowledged that “adolescents have historically been marginalized both by structure and operations of the reproductive health programme”.  In the next few weeks, I will try to address the barriers to contraception that adolescents face and more recent efforts that particularly this part of the population.

Teenage girls account for nearly a quarter of all births in the country.  This is a result of two main factors: early age of first sex and low contraception use.  It appears that youth in Jamaica are having sex and their first pregnancy at young ages, with what appears to be difficultues accessing contraception or information about pregnancy.

Early sex
A contributing factor is that adolescents are beginning to have sexual experiences at relatively young ages.  Despite the strong Christian roots and teaching in the country, adolescents are becoming sexually active as early at 14. The 1997 Reproductive Health Survey reports that 70% of young adult females and 84.9% of young adult males have ever had sexual relations, with a greater percentage of sexually active males than female in each age bracket.  The median age at first sex among young women is 17.

Early sex and pregnancy can be associated with many factors – cultural, social, and economic – including poverty, the absence of male role models, cultural approval of early-childbearing, coercive relationships, and rape.  In Jamaica, women risk being labeled as “mules” (sterile) if they don’t have a child by their twenties.  While this cultural ideal may contribute to 19 and 21 as the respective median ages of first pregnancy and birth among Jamaicans, young women also face economic pressures that can involve them in transactional relationships with men, where they receive money or gifts in exchange for sex.  Also, many teens become pregnant involuntary due to rape or incest.  20% of women 15-49 report having been forced to have sex at some point during their lives, particularly among young girls ages 15-19, low SES, and with little education.

What I mean to report here is not that Jamaican adolescents are becoming pregnant because they are having sex at young ages.  There are definitely ways to have safe sexual experiences without getting pregnant, if the right methods are used.  The problem is that it appears that these methods are not being used.  In particular, the younger adolescents begin sexual activity, the less likely they are to use contraception (given awareness and access), which increases their risk of pregnancy.

Low use of contraception
The UN Population Fund reports that contraceptive use among Jamaican teens is low. While the reported contraceptive use rate in Jamaica is 69%, the National Family Planning Board reports that 66% of all births are not planned and 43% are mistimed.  For women under the age of 20, the impact is even greater – 40% have been pregnant at least once, where 85% of these pregnancies were unplanned (International Conference on Population & Development (ICPD) Paragraph 7.2).  From the 1997 Reproductive Health Survey, only 56% of females and 31% of males report using a contraceptive method at the time of their first intercourse.  Young adult females explain that they did not expect to have sex when they did (rape may be a factor) and males reveal that they did not know of any methods.  Surveys show that the mean age of first use of contraception is 19.5.  However, the median age at first sex among women ages 15-49 is 17.

Failure of education programs?
From these statistics, we see that contraceptive use is particularly low among adolescent men, and that young people in general are facing obstacles in using contraception when they decide to have sex.  Either they are not planning on having sex when they do (rape, again) or that they are not aware of contraceptive methods.  I initially thought that this was due to the failure of educational systems to promote basic reproductive health information among adolescents, influenced by the efforts of conservative groups.  According to the International Conference on Population and Development (ICPD) paragraph 7.2, in 1994, only 64.5% of young adult women ages 15-24 reported having received information on pregnancy before their first period and even less (62.8%) reported having received information on pregnancy before having sex for the first time.  Exposure to this type of information increased with the number of years of education and socioeconomic status.

I was initially going to harp about the failures of abstinence only education, thinking that religion was influencing national politics.  However, statistics from the National Family Planning Board (from 2000) suggest that knowledge about contraception is relatively high among Jamaican adolescents, higher among young women than young men.  85% of young women and ~72% of young men ages 15-19 report having received a course on family life or sex education either in school or outside of school and 87.7% of young women and 82.8% of young men knew where to go to receive information on contraceptives or on sexual relations.  Young women report receiving health information mostly from parents or health personnel, where as men report receiving health information mostly from parents and peers/friends/siblings.  Condoms, pills, and injections appear to be the most common taught methods of contraception.

Despite such prevalent knowledge of contraceptive methods though, contraception use is low among Jamaican adolescents.  This suggests that barriers to access and not lack of knowledge (although efforts focused towards male adolescents could be improved) is what is preventing adolescents from obtaining and using contraception, among other factors.  I just discovered the USAID 2000-2007 Evaluation of Jamaica Adolescent Reproductive Health Activity Report (yay for some more recent data) and I promise (as I have for the past several weeks), that my next blog will address these barriers to access.