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October » 2008 » Family Planning

Archive for October, 2008

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

October 30th, 2008

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.

Puerto Rico Revisited

October 30th, 2008

I suspect that my last blog entry on Puerto Rican sterilization policy inadequately dealt with the complexity of the topic, so I am going to delve a bit deeper into the same subject this week. Last week I explained that Law 116 in Puerto Rico, influenced by the Model Eugenical Sterilization Law from the US mainland, made sterilization the most accessible form of birth control and led to the sterilization of one third of Puerto Rican women by 1968. I now need to retract part of my assertion from last week because I provided too simplistic of a conspiracy theory explaining the trend toward high sterilization rates in Puerto Rico. This blog post will explain that no single unilateral program of oppression led to high sterilization rates, but rather several social and political movements converged to sterilize a problematically high proportion of Puerto Rican women.

Puerto Rico legalized contraception in 1937, the same year that the government passed Law 116, which allowed sterilization under the direction of a Eugenic Sterilization Board, but Law 116 was not directly responsible for the subsequent spike in Puerto Rican sterilizations. Prior to 1937, private organizations promoted various contraceptives, some with US funding under the New Deal’s Puerto Rican Reconstruction Administration (PRRA), but mostly independent of the US government.  Puerto Rican opposition to contraception was rooted in the island’s strong nationalist and religious traditions. Historian Laura Briggs explains that skepticism of US government plots to sterilize Puerto Ricans dated at least to the early 1930s when Dr. Cornelius Rhoads (who later performed chemical weapons tests on unprotected U.S. soldiers during World War II) purportedly injected cancer cells into unsuspecting Puerto Ricans in his research supported by the Rockefeller Foundation (76-77). Other Rockefeller Foundation- and US government-supported programs promoted relatively unsuccessful spermicidal jellies as a form of contraception, which gave birth control an early reputation of being ineffective (Briggs 102). Although the US judicial system exonerated Dr. Rhoads, Puerto Rican skepticism remained and led to strong nationalist and Catholic opposition to the PRRA and other US government programs during the 1930s. After the legalization of contraceptives in 1937 and the creation of the Eugenics Board, sterilization became more available than other effective birth control methods. The Eugenics Board used “poverty” as a legitimate reason to review and authorize forced sterilization, and ordered the sterilization of about 48 people in the following decades. By 1968, Puerto Rican sterilization rates for women aged 18 to 45 reached 35.3 percent according to a study by the Puerto Rican demographer Dr. Jose Vasquez Calzada. Overall, the historical emphasis on ineffective birth control methods (e.g. spermicidal jellies) followed by the ready accessibility of sterilization after 1937 led to the spike in sterilization rates. Law 116 played a largely symbolic role and was not directly responsible for the vast numbers of sterilizations. Rather the confluence of several powerful social and political movements resulted in an environment unusually inclined to sterilize women.

The eugenics movement and women’s rights movements were strange bedfellows on the mainland US (as I discussed in the blog “One little history of population theory”), and in Puerto Rico they allied with socialist professionals and international developers to support sterilization. Liberal professionals in the Puerto Rican Socialist Party supported birth control in order to strengthen the working class by freeing them from their “oppressive” parental obligations (Briggs 90-91). The rise of birth control as the subject of women’s liberation on the American mainland supported Puerto Rican liberals’ opposition to the dominant pronatalist Catholic society. Malthusian rationales for population control were not useful in Puerto Rico because by the 1930s the island imported most of its food and devoted a large proportion of its labor to producing cash crops, so any increase in population would not overburden local resources. During the early 20th century whenever Puerto Rico’s economy grew and its birth rate fell, unemployment and poverty rates actually increased because the wealth was largely concentrated in the hands of foreigners. The underlying causes of poverty in Puerto Rico were not overpopulation or scarcity of arable land, but rather the poor organization of social and economic power. After World War II, Puerto Rico served as a test case for American producers establishing manufacturing facilities overseas to make goods for sale on the mainland. In Puerto Rico, eugenicists, socialists, and transnational companies all supported policies to make sterilizations more accessible.

So what is the point I am trying to make by complicating my previously simple argument that said Law 116 led to coercive sterilization? I am trying to show that it was not a single coercive policy or monolithic group that supported sterilization, but rather a confluence of several movements involving class politics and transnational economics. While many Puerto Rican nationalists and religious pronatalists opposed the introduction of cheap sterilizations, other Puerto Ricans with business interests and socialist politics supported sterilizations. Explicitly forced sterilizations made up very few of the total sterilizations in Puerto Rico, but when Jose Calzado surveyed sterilized Puerto Rican women in 1979, 36.1 percent of those surveyed were unhappy about having had the operation, which suggests that the circumstances of their surgery may have been somewhat coercive. Some mainland feminists have co-opted the story of Puerto Rican sterilization as an example of unilateral American patriarchy at work in the developing world, but that ignores both the Puerto Rican support for and resistance to many reproductive health policies. Misconceptions about the root causes of poverty drove many to support increased sterilization in Puerto Rico, in some cases to the detriment of Puerto Rican women. An objective feminist critique of Puerto Rican sterilization acknowledges that many Puerto Rican women supported sterilization out of a belief that it would benefit Puerto Ricans, but the ultimate effects of sterilization actually infringed on many peoples’ right to control their own reproduction.

Briggs, Laura. Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico. University of California Press: Berkeley, 2002.

Depo in Madagascar (no, not the animated movie about zoo animals)

October 29th, 2008

I was one of the kids who took International Public Health with Dr. Paul Wise last winter. For me, one of the most engaging lectures in that class was by Dr. Paul Blumenthal, an Ob/Gyn in the School of Medicine at Stanford. His talk was on reproductive health, and he covered a variety of issues and projects. One was on a simple way to do cervical cancer screening with an acetic acid wash. Another initiative he discussed trained women to administer Depo-Provera injections to other women in the community who desired contraception–in Madagascar.

I think Dr. Blumethal’s project in Madagascar is an awesome example of a community based system to offer family planning that does not depend on a clinic and brings the services literally to women’s doors. This initiative was one of the reasons that I wanted to blog on innovative ways to increase access to contraception. I’ve been having trouble finding an article or official write-up of the initiative, but I was able to get some more detail through Dr. Blumenthal’s ‘Letter from Madagascar.

Facing a fertility rate of 5.2 births per woman, the Ministry of Health and Family Planning set the goal of increasing contraceptive prevalence from 18% to 26% by 2008. Since 80% of the population in Madagascar lives in rural areas, the Ministry is focusing on distribution issues, especially of longer term methods, to achieve its goal. Says the Madagascar director for Marie Stopes International, “Reaching isolated communities is the real issue.”

One part of this larger push for family planning is the project that trains community based distributors (who already distribute oral contraceptives) to give Depo Provera injections on the typical 3-month cycle (1 shot every three months). Depo Provera is a progestin only method, and is administered via injection to the arm, hip, upper thigh, or abdomen. On a side note, the Ministry is also looking into distributing Implanon on a wider level to increase contraception use.

In writing about this project, it occurred to me that Madagascar was presented with a similar issue as that in Jamaica–lowering the fertility rate. The two countries took very different approaches to this issue, and I wonder if there is anything about the Madagascar approach that could be useful to the public health officials and politicians in Jamaica who seem to be focused on sterilization (Julia please correct me if I’m wrong).

A History of Government Family Planning Efforts in Jamaica

October 24th, 2008

The Government of Jamaica adopted the National Population Policy in 1992 that aimed for zero population growth “to ensure that the population does not exceed the number of persons that can be supported by the nation at satisfactory standards of living.”  This vision requires an average growth rate of below 0.8 percent per annum over the next three decades and that by 2000, the population should not exceed 2.7 million.  For this goal to be met, the average number of children per woman was expected to decline to approximately 2 per woman by 2000 and be maintained and the contraceptive prevalence rate should rise to 63% by 2000.  The government envisioned that regarding gender, “equal access to decision-making processes is considered and essential element of this goal” and that Family Life Education programs should be strengthened in school curricula (1).

In the 16 years since the ratification of this piece of legislation, Jamaica has a 0.779% growth rate per annum (2008 est) and a population over 2.8 million (July 2008 est).  The total fertility rate is 2.3 children per woman (2) and the contraceptive prevalence rate is 69% (3).

These efforts have been largely due to the work of three government agencies that share the responsibility for policy making regarding family planning and reproductive health in Jamaica: the Planning Institute of Jamaica, the National Family Planning Board, and the Ministry of Health.  According to the National Population Policy, the Planning Institute of Jamaica is responsible for ensuring the integration of the goal of the National Population Policy into development plans, while the National Family Planning Board is the “delivery of family planning services,” particularly targeting women in reproductive years (1).

The National Family Planning Board (NFPB) offers a wide range of services including mobile clinic units, outreach programs, and distribution programs of non-clinical methods of contraception.  NFPB seeks to promote “fertility regulation while guaranteeing absolute freedom of choice” (4).  Family planning services first became available in Jamaica in the 1930s, due to the work of a few individuals, and in 1967, the government of Jamaica created the NFPB.   The 1970s saw the establishment of Family Life Education teacher training workshops, the distribution of condoms and oral contraceptives, and the launching of the “Two Child Family” campaigns via radio programming, the integration of family planning services with primary health care providers, and the establishment of family planning clinics in underserved areas.  In 1983, the government of Jamaica adopted the National Population Policy to reduce fertility and expand family planning services for men and women of reproductive ages.  In the 1980s, male responsibility programs were established, along with the community based distribution of contraceptives in rural areas, and the formation of adolescence fertility resource centers, mobile units with family planning programs, and services designed for teenagers in urban areas.  In the early 1990s, new sterilization techniques (mini laparotomy under local anesthesia, no scalpel vasectomy for men), and the Personal Choice campaign, a program offering contraception at affordable prices, were introduced (4).

Currently, NFPB offers extensive information on following methods of contraception on their website:

  • Offered in the public sector
    • birth control pills
    • injectable contraception (Depo-Provera)
    • IUDs
    • vasectomy (male sterilization)
    • condoms
    • tubal ligation (female sterilization)
    • Norplant implants: capsules of synthetic progestin – levonorgestrel – inserted under the skin on inner side of the upper arm that thicken the cervical mucus and decrease the sperm’s ability to penetrate
  • Offered in the private sectors and by NGOs – methods of covering the opening of the uterus with a synthetic cap filled with spermidicde
    • diaphragms
    • cervical caps
    • contraceptive sponges
  • “New” methods
    • contraceptive patch
    • essure: permanent non surgical method of contraception – a small, flexible coil is placed into the fallopian tube – tissue grows over it and blocks the fallopian tube
    • mirena: like IUD but contains time release hormones – thickens cervical mucus, thins the uterine lining, and slowing down sperm motility
    • Seasonal birth control pills: taken longer than 21 days
    • Nuva ring: inserted into the vagina and releases progestin and estrogen – thickens cervical mucus and suppresses ovulation (4)

While it appears that government support for family planning services has increased since the 1994 International Conference on Population and Development (ICPD) in Cairo, a major convention regarding population and reproductive health in developing countries, the distribution of such services amongst the population has not been equal in Jamaica.  In particular, adolescents have been neglected despite such improvements.  An analysis published in 1999 on the reproductive health policies and programs in eight developing countries since the conference in Cairo, reports that the provision of reproductive health services for young adults “incites the most vocal opposition,” likely due to the conservative and religious views held throughout the country. But in Jamaica, it seems overtly obvious that sexual and reproductive services and education are urgently needed amongst this particular subset of the population.  The statistics are staggering – 40% of Jamaican women have been pregnant at least once before the age of 20, where 85% of these pregnancies were unplanned (5).

In 1999, the Government of Jamaica was criticized for having no explicit plans to implement a reproductive health program.  While a network of private providers of family planning and maternal and child health services was accessible for most women and mothers, it did not serve adolescents and men well (5).  Often there is a discrepancy between the recognition of the need to improve reproductive health and rights and the translation into effective programs.

However, in recent years, after the national recognition of teenage pregnancy as a serious social and health problems, increased efforts have been made to target such programs at adolescents.  Yet despite the establishment of such programs, barriers still exist that prevent adolescents from receiving such services.

This will be the focus of next week’s entry: adolescent sexual behavior in Jamaica, rates of pregnancy, and interventions and education programs focused towards adolescents.

(1)    National Population Policy of 1992. (The Jamaica National Population Policy. Revised Version, Kingston, Jamaica, Planning Institute, July 1992) http://cyber.law.harvard.edu/population/policies/JAMAICA.html

(2)    Jamaica. CIA Factbook.  Accessed October 23, 2008. https://www.cia.gov/library/publications/the-world-factbook/print/jm.html

(3)    Jamaica. Human Development Report 2007/2008. http://hdrstats.undp.org/indicators/56.html

(4)    The National Family Planning Board of Jamaica. http://www.jnfpb.org/index.htm

(5)    Hardee K, Agarwal K, Luke N, Wilson E, Pendzich M, Farrel M, Cross J. Reproductive Health Policies and Programs in Eight Countries: Progress Since Cairo. International Family Planning Perspectives (25), January 1999. http://www.guttmacher.org/pubs/journals/25s0299.html#22a

Implanon: new birth control rod under the skin of your arm

October 24th, 2008

In my first entry, I discussed how I would be writing about the organizations that are working to increase access to contraception, as well as new methods that are in development. This week, I’m jumping to one such new method.

You might remember hearing about Norplant, which was an implantable birth control method used in the 1980’s and 1990’s. Norplant was a set of six small silicone capsules filled with levonorgestrel (a progestin used in many hormonal methods; progestin is the synthetic form of progesterone which occurs naturally in the body). By 1996, more than 50,000 women had filed lawsuits against Wyeth pharmaceuticals, the manufacturer of Norplant. Many of the complaints were from women who claimed they had not been adequately warned about the side effects of Norplant, such as irregular bleeding, headaches, nausea and depression. More on the lawsuits here.

Needless to say, Norplant was taken off the market in the US. Interestingly, it is still used in the developing world: the UN Population Fund found that 6.2 out of 100 rural women in a region of Bangladesh still use Norplant.

When I was working at a teen clinic two summers ago, I started to hear murmurs about how excited the doctors and NPs were about the upcoming Implanon training. Implanon is essentially the follow-up to Norplant. It is a single-rod implantable contraceptive, about the size of a matchstick. After the rod is implanted just under the skin of a woman’s inner upper arm, it provides greater than 99%-effective contraception for up to three years. It contains etonogestrel, which is another form of progestin.

I wanted to shed some light on Implanon this week to hear what you think of the method itself, and its potential for use by women who have limited access to birth control. Consistent use of birth control pills has been difficult to sustain for women in rural areas because of the need for frequent pill refills, and I think that longer term methods, such as IUDs, Implanon, and Depo-Provera should be made available to women who cannot go to a pharmacy 4-12 times a year. The also have the added benefit of being more discreet in some ways, as with these methods, there is no external evidence that the woman is using contraception. However, the possibility of women being able to use contraception without their partners’ approval seems unlikely with the number of countries that require a husband’s permission in matters of family planning.

Forced Sterilization in Puerto Rico

October 23rd, 2008

Population control has been a driving force in US policy for well over a century, as I described in my previous post. One of the more egregious examples of population control is the history of forced sterilization in Puerto Rico. Spain ceded the island of Puerto Rico to the United States in 1898, putting Puerto Rico under tight US control as a territory. Puerto Rico did not gain the right to democratically elect its own governor until 1947, and since then has made strides towards greater autonomy from the US.
The history of coercive population control policy in Puerto Rico begins with a superintendent of the US Eugenics Record Office named Harry Laughlin. Laughlin used a Model Eugenical Sterilization Law to implement the mandatory sterilization of the “socially inadequate” in 30 US states and Puerto Rico. This overtly eugenic policy deliberately targeted groups of people for sterilization (e.g. the feeble-minded, the insane, orphans, ne’er-do wells) and later inspired Hitler’s forced sterilization program in Europe.

Laughlin’s Model Eugenic Sterilization Law spread throughout the US between 1907 an the 1930s. By 1933, US sugar companies owned 13 percent of Puerto Rico and forced large numbers displaced farmers into migrant agricultural labor and urban centers. The glaring poverty rates motivated a government intervention in line with the dominant eugenic discourse of the day. In 1936 Law 116 entered into force making sterilization legal and free for women in Puerto Rico while offering no alternative methods of birth control. The prevailing wisdom was that denial of motherhood was a more effective means of incorporating women into the workforce than affordable childcare. The Puerto Rican government and the International Planned Parenthood Federation ran a sterilization program with US government funding, and by 1968 the program had sterilized roughly one third of Puerto Rican women. Numerous studies have shown that misinformation about the procedure caused high rates or regret among sterilized women. Many women were unaware that the procedure was permanent, due in part to the euphemism of “tying tubes.” Additionally, many women had no alternative affordable contraceptive methods, so they opted for sterilization.

Sterilization in Puerto Rico under Law 113 was “voluntary” only in the narrowest sense of the word. Employer discrimination and a general lack of alternative options gave women a very strong incentive to participate in the procedure. The basic idea that that sterilization would free women from the burden of childbearing to work in an industrialized workforce underwrote the entire program. This was done in the context of a women’s rights movement in the United States strongly supporting birth control as a means for women’s gaining more reproductive rights. Most of the women seeking sterilization already had several children, so the effectiveness of the program in terms of population control was dubious at best.

By the 1970s US mainland feminists and Puerto Rican anti-colonialists united to end the practice of forced sterilization, but the legacy of distrust of US government intervention in Puerto Rican society remains. I don’t have time to delve into the depths of a discussion of the gendered framework that led to the widespread disabuse of Puerto Rican women’s reproductive rights, but I hope some of this information provides a clear example of how population policy can be used to coercively deny women rights over their own reproduction under the banner of “voluntary sterilization.”

Government proposals violate Jamaican women’s rights to privacy and personal autonomy

October 17th, 2008

Do mandated medical examination of girls’ virginity and mandated female sterilization violate a women’s right to privacy and personal autonomy? How do governments deal with population pressure? Should women be solely accountable for high fertility rates and have to shoulder the complete responsibility of family planning?

In a parliamentary session in 2003, two parliamentary members proposed these drastic measures to reduce the number of teenage and unwanted pregnancies in Jamaica. Citing a breakdown in family values as the cause for the increase in the number of teenage pregnancies and the subsequent burden on the welfare system, parliamentary member Sharon Hay-Web of the People’s National Party proposed compulsory sterilization of young women with more than three children. She advocated that “the state cannot cope with the responsibility of so many unwanted childbirths – we are taking care of people…from the womb to the tomb.” Ernie Smith, a member of parliament from the opposition Jamaica Labour Party recommended mandatory medical examinations of schoolgirls under the age of 16, the age of consent in Jamaica. He believed that such a procedure would serve “to determine if their virginity is still intact.”

Fortunately, these measures are not under serious consideration. Tubal ligation can only be performed if women are told about other forms of contraception, receive counseling, and have a signed form to do the procedure. While voluntary sterilization is the most common form of family planning in the United States and in developing countries, mandating the sterilization of women is a violation of privacy and human rights. Women ought to be able to choose how many children they want to have and preserve their abilities to have children in the future. Tubal ligation is a permanent form of sterilization and to force this measure on an unwilling woman is a form of injustice and a violation of her body.

A 31 year old Jamaica mother of six shared her views about family planning and the role of the government with Trudy Simpson, a journalist from the Jamaican daily newspaper, the Gleaner. As a mother who has a difficult time providing for her children and wished she knew about contraception as a teenager, she reflected that she “would have stopped at three children” and would have had her “first at 20” instead of 17. She admitted that she would have preferred to have had the procedure, but that “the government don’t have a right to say women can’t have any [more] children.”

In a similar vein, to require by law for teenage girls to submit to medical examinations or share information regarding their sexual behavior is a violation of their privacy. Firstly, such medical procedures would be ineffective – the hymen is not a reliable indicator of sexual activity. Tampon use and sports activity can break the hymen. Also, if a girl under the age of 16 were found to be involved in sexual activity, what would come of this information? Would she be punished? Granted, attempting to track and stop incidences of rape or incest is critical, particularly among girls below the age of consent. However, these issues ought to be addressed without requiring all girls to be submitted to required examinations. Emphasis on safety and the persecution of individuals who take advantage of young girls ought to be emphasized without requiring girls to submit to such an examination.

Even though such measures are unlikely to be passed, the implications of such proposals are significant. Teenage pregnancy is still a problem in Jamaica – teenage pregnancy account for 20% of pregnancies in Jamaica, and teenagers are becoming sexually active as young as 14. Jamaica’s National Family Planning Board reports that 66% of all births are not planned, and for women under 20, 40% have been pregnant at least once and 85% of these pregnancies are unplanned.

But the proposed ideas to limit pregnancy – to test for “virginity” and to surgically prevent a woman from ever becoming pregnant again – are not viable solutions. Rather, from a young age, both girls and boys should be exposed to education programs about sexual decision making and be both made aware of methods of contraception and have methods made available. However, Jamaica is predominantly a Christian country. While contraception distribution campaigns do exist in Jamaica, young people are finding it difficult to obtain, given the associated embarrassment and judgmental opinions of pharmacy and clinic workers.

The extreme measures proposed by the parliamentary members represent an often overlooked aspect of family planning and contraception – that it is often made a woman’s responsibility. As Professor Barbara Bailey, the regional coordinator for the Centre for Gender and Development Studies at the University of the West Indies, puts it, “It takes two to tango. Why put the onus on the female?” Tubal ligation may be the most prevalent form of contraception around the world given that it is completely in the woman’s power and that other forms of contraception are more likely to fail if left to the decision of others.

I hope to delve into the issues presented here in more depth in future blogs, particularly the following: the factors contributing to the prevalence of pregnancy among teenagers in Jamaica, the forms of contraception available, proposed solutions to teenage pregnancy, the responses to such solutions, and the burden placed on women, the role of men, and potential ways to address this issue that respect the reproductive rights of women and place equal responsibility on both men and women.

Angela, forty year old Jamaican mother of two who became pregnant at 17, speaks from experience. “My mom said I must be careful not to get pregnant, but I didn’t understand what was happening. Society needs to educate people. We have to begin in schools with adolescents, especially in the inner city, so the cycle can be broken.”

Thanks to Trudy Simpson for the accounts from the women of Jamaica.

Snapshot 1: Planned Parenthood Federation of America

October 16th, 2008

For the next few blog entries, I’d like to provide snapshots of organizations who are on the ground, working on the topic of this blog: increasing access to family planning services for women and men (I realize I didn’t include men in the last entry describing the topic, but the truth is that effective family planning involves both men and women).

One organization that I think we sometimes take for granted is Planned Parenthood. PP is largely responsible for providing reproductive health services to people in the US who are uninsured, underinsured, or are unable to use their insurance due to confidentiality reasons. It also is heavily engaged with legislative and policy work (and after McCain’s commentary last night on appointing Supreme Court judges who share his beliefs on abortion, their legal team may become much busier in the future…but hopefully that won’t happen).

If you’re unfamiliar with Planned Parenthood, take a look at these stats:

  • One in four American women has visited a Planned Parenthood health center at least once in her life.
  • Most of PP’s work is about prevention: 81 percent of their clients receive services to prevent unintended pregnancies.
  • Three percent of all PP’s services are abortion services.

Lastly, PP connects small and medium orgs in developing countries with resources and services to improve their communities’ reproductive health. The PP International Program has three priorities: preventing unsafe abortion, protecting the sexual health of adolescents and youth, and advocacy to protect reproductive rights. Out of these priorities, the projects that aim to protect the sexual health of adolescents is most relevant to our blog. Here’s what’s going on in three different regions:

Philippines: Since the government opposes modern family planning, PP is working to provide low-cost contraception directly to young people through peer educators.

Guatemala: PP’s partner organization, Tan Ux’il, provides sexuality education to teens through peer educators, street theater performances, and a radio show. Tan Ux’il generates income for these projects by running a pharmacy that provides contraceptives to adolescents.

India: PP-supported outreach workers attend pre-wedding and newlywed parties to congratulate the couples, provide entertainment that offers a positive sexual health message, and encourage them to delay childbearing until the women is 18. (The median age of marriage is 16).

Planned Parenthood is a major force in the field of reproductive health in the US. I think it’s an interesting idea for an organization that is heavily US-based in terms of its services and advocacy to reach out to those working on reproductive rights in other countries. Perhaps they can contribute what they’ve learned over time in providing comprehensive services and dealing with the government to those who are just starting up a reproductive services network.

One little history of population theory

October 16th, 2008

It’s hard to identify the origins of the idea of global overpopulation, but in this blog entry I nonetheless want to trace some of the ideological history of the Western concept of “population control.” Although attempts to regulate birth and death rates of populations stretch far back in history, my history of population control is going to begin with in the late 18th century with the aptly nicknamed Thomas “Pop” (short for Population) Malthus.

“Pop” Malthus was born into an industrialized British society that generally agreed that more people in the world led to more production, which would generally benefit society. Malthus saw something different in the population growth of post-Industrial Revolution Britain, and in 1798 he published his Essay on the Principle of Population, which he republished five times over the course of his life. In his Essay, Malthus argues that populations inevitably outgrow their productive capacity to feed themselves. This Law of Population was grounded in a mathematical observation that population increases at a “geometrical” rate (i.e. 1, 2, 4, 8, 16 etc.) whereas food-supply increases at an “arithmetical” rate (i.e. 1, 2, 3, 4, 5, etc.). Therefore, Malthus argued, populations are continually overburdening their food supply and “natural causes, misery, and vice” serve to check that growth. In later editions, Malthus introduced the corrective of “moral restraint” in the form of abstinence and late marriage to prevent the misery and vice necessarily resulting from overpopulation. Malthus opposed contraception, murder, and homosexuality as various forms of vice, which is interesting considering the birth control movements that later benefited from his work. Malthus’ ideas led to the abolition of social welfare programs because “if a man will not work, neither should he eat” (xxiii).

Besides the immediate repercussions in Britain, Malthus’ theory informed the birth control and eugenics movements in the United States in the early 20th century. Eugenics is a movement to genetically improve the human race by regulating reproduction. Feminist movements in the US have also focused on birth control in the context of reproductive rights, which led to a strange coalition between feminists and eugenicists in the early 20th century. Margaret Sanger, a famous birth control advocate and founder of the American Birth Control League (which later became Planned Parenthood) was an outspoken eugenicist who argued that “more children from the fit and less from the unfit” was “the chief issue of birth control” (1). American anarchist Emma Goldman was arrested once for distributing a pamphlet entitled “Why and How the Poor Should Not Have many Children” (2). Why did eugenicists and birth control advocates get along so well? Because they were both advocating for deliberate control over reproduction. Eugenicists and birth control advocates both believed that human reproduction could and should be controlled in modern society, and they only differed in the distinction of who should do that controlling. While birth control advocates and eugenicists did not exclusively focus on overall population control, they laid the groundwork for later population policies.

After World War II, President Eisenhower established a committee headed by investment banker and General William H. Draper to study the US Military Assistance Program that ultimately refocused US foreign aid on population control. I will discuss the role of US Agency for International Development (USAID) in future posts, but here I will simply say that at least some of the agency agreed with the USAID official who said that “progress should be measured in the only terms which ultimately matter – births averted.” While official US policy certainly placed an emphasis on population control, private organizations also took an active role in confronting population growth. The majority of US dollars spent on international population control in the mid 20th century bore the names of prominent American philanthropists such as John D. Rockefeller, Andrew Carnegie, John Kellogg, and Henry Ford. These businessmen applied Malthusian arguments to fuel their fear of third world population growth.

In 1969 Stanford population biologist Paul Ehrlich published The Population Bomb , which foreshadowed a shift away from a strictly “third world” population debate. The Population Bomb argued that overpopulation had finally reached its Malthusian limits and predicted mass famines in the 1970s and ‘80s. Although Ehrlich’s predictions were just as inaccurate as Malthus’ nearly two hundred years earlier, he introduced the idea that overpopulation only mattered inasmuch as populations overburdened their natural environments. Ehrlich argued that the impact (I) of humans depended equally on population size (P), affluence (A), and technological capability (T). Mathematically expressed,  I = P A T  introduced the idea that affluent countries with their high consumption were arguably more guilty than poor countries for the overpopulation problem. The Population Bomb’s popularity exemplified a growing American interest in “overpopulation” as the root of the world’s problems, which was mirrored on an international level in the United Nations (UN).

In 1974 the UN held a population conference in Bucharest to mark the officially decreed Year of Population that largely redefined international population policy. The conference brought together world leaders to craft a World Population Plan of Action, which surprisingly refuted uncomplicated overpopulation by emphasizing the “population-development linkage” and calling for more family planning programs. To the surprise of the American delegation headed by then Secretary of Health, Education and Education Caspar Weinberger, the Plan excluded strict population targets and criticized Western consumption. Karen Singh, head of the Indian delegation to the conference, summarized the tone of the conference when she stated that “development is the best contraceptive” (3). At the conference even John D. Rockefeller III, the so-called godfather of the population movement, said that “the place for population planning is within the context of modern economic and social development” (4). I should also note that the renewed emphasis on development was part of a larger economic movement leading to massive international lending and the third world debt crisis of the 1980s. The Bucharest Conference was a turning point in international population policy as it shifted mainstream policy towards family planning and reproductive rights.

Since 1974 international population policy has continued to develop, but I will conclude my brief ideological history of population control then because it marks the shift to the current “family planning” model of population control. The threads of Malthus’ law of population, eugenics, feminism, IPAT, and the population-development linkage all continue to shape population control policies to this day. In general, the current rhetoric of mainstream international population control now focuses on “family planning,” although traces of earlier ideological movements still abound. I have obviously selected only a few facts to tell the history of population theory, but hopefully it will establish some background for current rationales behind population control.

1. Margaret Sanger, A Code to Stop Overproduction of Children. Cited in Elasah Drogin, Margaret Sanger: Father of Modern Society (New Hope, Kentucky: Cul
Publications, 1979), 70.
2. Hartmann, Betsy, Reproductive Rights and Wrongs, South End Press: 1999. pp. 94, 97,
3. Hardin, Garrett, Living Within Limits. New York: Oxford University Press, 1993.
4. Hartmann, p 107.

A feminist on population control…

October 14th, 2008

Today there are around 6.58 billion people on this planet, and nearly half of them are women. As the global population continues to grow, people feel threatened by the concept of diminishing resources. Individual communities confront shortages of physical capital and draw the rational conclusion that fewer people would use fewer precious resources. For North Americans visiting many parts of the world, overpopulation appears to be the clear cause of much human suffering. From single mothers supporting multiple children to environmental degradation due to overgrazing or excessive firewood harvesting, the evidence seems to point clearly at “overpopulation” as the root cause of continual cycles of poverty and pain. In seeking to address “population,” our policies disproportionately focus on women’s roles as mothers, specifically women of color who live in the third world. Although male condoms and male sterilization exist around the world, they constitute only 15 percent of global contraceptive use compared with women-directed methods such as female sterilization, IUDs, birth control pills, and injectable contraceptives constituting 75 percent of contraceptive.(1) But in order to address the issue of population growth, we must understand multiple influential factors and not solely address the last step in a complex chain reaction. Population control is not a “magic bullet” that summarily addresses the evils of our world, but rather a small solution to a very big problem. The problem is that poverty leads to high birth rates and high birth rates contribute to poverty, and efforts to address poverty must be multifaceted beyond a simple belief that fewer people will make the world better. The association between population growth and poverty is more complex than a simple cause and effect argument, and this blog aims to present a feminist perspective on the coercive nature of population control policies around the world.

I am drawn to this issue by my disgust at how enfranchised Americans use “overpopulation” as a rationale for blaming poor women of color for all the ills of the world. There are many problems with that rationale. Firstly, population growth per se is not of serious concern, but rather our concern is with humankind’s rapid depletion of natural resources and consequent suffering. The strict population control argument is problematic because resource depletion depends not only on how many people are extracting resources, but also on how much each person is extracting. According to population biologist Paul Ehrlich, Impact = Population x Affluence x Technology. This equation suggests that how much people consume affects overall environmental impact just as much as how many people consume. For example, if our concern is that the world will run out of drinkable water, then the average American who consumes water at nearly ten times the rate of the average Sub-Saharan African is really of greater concern.(2) But highly resource-consuming individuals seldom lay blame for global problems on themselves, and instead seek ways to solve their problems elsewhere.

Another reason why poor women of color’s procreation is not responsible for the ills of the world is that society has systematically and deliberately disenfranchised them, therefore suggesting that blame belongs to their oppressors. The insinuation that women deliberately refuse reproductive control ignores the complexity of human decision-making and the context of their reproductive lives. Nobel Laureate Economist Amartya Sen argues that famines and other forms of human deprivation are not fundamentally caused by overall resource shortages, but rather by our systems of ownership and entitlement. Population alone does not cause suffering, but rather the systems through which resources are distributed cause suffering.

Additionally, a woman’s individual reproductive rights are not automatically subsumed by the public health concern of “overpopulation.” The recent shift in rhetoric from “population” and “birth control” to “reproductive health” and “family planning” suggests that this shift in priorities is underway. Any effort to address population growth must be tempered by a strong belief in human rights and the right of a woman to control her own procreation.

I see two general feminist perspectives from which I can confront these issues of coercive population control and reproductive rights.(3) The first is a reformist lens that calls for enforcement of women’s reproductive rights in place of strict “population stabilization” through a variety of contraceptive methods, education, and other reproductive health services. The reformist lens critiques strict demographic rationales for population control policies, but it also pragmatically acknowledges those rationales as means to securing resources for reproductive health work. The second feminist perspective is more radical and critical of “population stabilization” efforts. The radical perspective rejects any attempt to control women’s reproduction as an instrument for achieving demographic goals. This second perspective demands strict adherence to an individual human rights rationale for improving women’s control over their own reproduction. The radical and reformist feminist perspectives will guide my analysis of population control issues throughout my writing here.

This blog will discuss population control practices as they pertain to the oppression of women. I will start with a history of population politics from Malthus to Ehrlich, and suggest some of the ethical repercussions of these population theories. Then I will discuss numerous examples of exploitative or coercive population control policies that have violated women’s rights, viewed from either a reformist or radical feminist perspective or both. I hope to conclude the blog within a few months with a few entries on useful strategies that address both women’s reproductive rights and population stabilization. As a disclaimer, I will state that I am a liberal, American, male, humanist, feminist writer completing this blog for a class assignment. I hope to learn more about feminism, ethics, and myself through the writing of this blog. I hope you learn from my research and ramblings, and please comment if something strikes a nerve in you.

1. World Population Monitoring, 2002: Reproductive Rights and Reproductive Health
By United Nations Dept. of Economic and Social Affairs. Population Division, United Nations
Published by United Nations Publications, 2004
2. http://earthtrends.wri.org/index.php World Resources Institute
3. http://www.cwpe.org/resources/popcontrol/uspoppolicy