Provide Family Planning in the Democratic Republic of the Congo

February 22nd, 2015

DR Congo woman & child small 

The London Summit on Family Planning was the start of something big. If kept, an array of promises made at the groundbreaking July 11 [2012] event could have a major impact on the lives of women and girls for years to come.

                                               Susan A. Cohen, Guttmacher Institute

 

In a prior article I wrote about how it was possible for one doctor to perform hundreds of tubal ligations in one day—but probably not honor the rights of the patients. The next column was about putting human and reproductive rights first and foremost. Today’s column focuses on one country where FP2020 is making amazing improvements in the lives of women and children.

FP2020 is the nickname of the ambitious program started in 2012 at the London Summit on Family Planning. Its goal is to reach 120 million women of the 225 million who are unable to access modern contraception, but wish to regulate their fertility. These are women in developing countries who currently have little or no access to reproductive health care. Typically they have high fertility rates and high rates of child deaths, illegal abortion and maternal mortality. Often these women are the poorest of the poor, have little schooling and are subservient to men. Many of these women live grim lives.

A very high percentage of people in wealthy countries already use family planning (FP); indeed, that is part of how we became wealthy. It is time to share that knowledge and technology with our less fortunate brothers and sisters. Unfortunately where access to FP is limited, infrastructure is also challenging—transportation, sanitation and communication are often poor. Reaching these people will be difficult.

Providing full reproductive health care for every woman in the world who does not currently have access to those services would cost a whopping 40 billion dollars annually—about the same amount as the US military spends in a month. The lives saved by such an investment would make that money very well spent, however. Reaching all people in developing countries with FP and with maternal and newborn care would prevent 79,000 maternal deaths, 26 million abortions and 21 million unplanned births each year.

The cost of providing just FP services for these people would be about nine billion dollars a year. Because moms will be healthier, improved birth spacing alone would prevent over a million infant deaths globally each year!

Funding is a major challenge for FP2020. The programs are jointly supported by developing countries and by donor (wealthy) countries. In addition, generous funding has come from foundations; the Bill and Melinda Gates Foundation is a major source of financial support as well as being a prime mover. Assistance also comes from the UN and the US Agency for International Development, among many other organizations.

One of the FP2020 programs is in the Democratic Republic of the Congo. This beleaguered country has had a miserable history of colonialism, dictators and civil war. Average income there is less than two dollars per day. Only 53 % women are literate, and only one in twenty married women uses a modern method of contraception. Indeed, a 1933 law makes contraception illegal! The average woman bears over 6 children in her lifetime and the country will double in population every 23 years—exacerbating many of its economic and political problems.

Despite these challenges, FP2020 is seeing successes in DRCongo. One project was to map existing FP resources, using a sophisticated system of data collection with cell phones. They now know where there are trained FP personnel and which pharmacies have pills or injectable birth control. Fortunately, all sites offer condoms.

Women in DRCongo have been relying on traditional methods of FP for years, with too many unintended pregnancies—more than a million in 2013. Contraceptive implants (such as Nexplanon®) were introduced in 2014 with great success. So far, the program has recruited almost 200,000 new users of modern contraception.

What FP2020 has meant to women in DRCongo is telling. More than 300,000 unintended pregnancies were averted in 2013. Calculations suggest that 1481 women’s lives were saved, and 76,000 unsafe abortions were prevented by the use of modern contraception.

FP2020 offers hope for the future, especially for people in countries such as DRCongo. I am optimistic that FP2020 can help women and families lead healthier and happier lives and will be a model for the future of family planning. And I expect it and future programs will be built on respect for the people that they serve.

© Richard Grossman MD, 2015

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Thank you! Richard Grossman MD, MPH  richard@population-matters.org

Preclude Abuse in Family Planning Programs

February 4th, 2015

 

Ethiopia-s-Family-Planning-Success_650x400

Image courtesy of Pathfinder International

The London Summit on Family Planning in 2012 was the start of a new focus on family planning (FP). The last time FP had received so much attention was the Cairo conference in 1994.

Several factors had turned attention away from FP. The HIV/AIDS epidemic received a huge amount of attention and funding. Donor fatigue was another factor, since FP programs are expensive and the results can be difficult to measure. Perhaps abuse was the most important reason that people lost interest in FP programs. For instance, it became clear that people in many countries, including our own, had been sterilized without informed consent.

Long ago I assisted with infertility surgery on a woman who had had 3 cesareans in Texas and was unable to conceive a fourth child. We found that her Fallopian tubes had been surgically interrupted without her knowledge or consent. Apparently her doctor in Texas didn’t think she should have any more children and had tied her tubes.

The darkest chapter in the history of FP was eugenics, the practice of trying to improve human genetics. In some cases eugenicists mandated sterilization of “undesirable” people—people of color, people with birth defects or learning disabilities, and people with mental problems. Often the eugenics movement was allied with political goals; the enemies were labeled as “undesirables”. My personal experience is that some of my favorite patients might have fallen into an “undesirable” category.

A number of women in California prisons were sterilized without following proper legal procedure—and probably without respect for the women’s human and reproductive rights. There are also stories of widespread abuse from India and Peru among other countries. It is unforgivable that people have been taken advantage of, but that is no reason to halt all FP programs.

Last month I wrote about the women who died in India after tubal ligation surgery. The press has focused on the terrible conditions where the surgery was performed. Also disturbing is how the women were treated before the surgery—they were not given a choice of temporary contraceptive methods nor told about the risks of the surgery.

225 million women worldwide want to avoid pregnancy but don’t have access to modern contraception. How can services to these people be delivered without abuse?

The goal of the London Summit is monumental, but attainable: to reach 120 million new users of FP by the year 2020. This effort is nicknamed FP2020. The memory of past abuses triggered concerns that such an ambitious goal could lead to new abuses. One of the first steps FP2020 took was to consult social scientists about ways to decrease the chances of coercion. In their report they asked: “How can we ensure public health programs oriented toward increasing voluntary family planning… respect, protect and fulfill rights in the way they are designed, implemented, and evaluated?”

In response they developed an innovative plan. Instead of focusing on getting people to adopt FP, they recommend working from a basis of human rights. That is correct: family planning should be based on human rights.

Although this seemed revolutionary to me at first, I realized that a major reason I became interested in FP is to further human rights. On the individual scale the lives of parents are improved if they have the right to choose how large their family will be. Of course their children benefit, too! On a global scale people’s rights may be trammeled as population density increases.

The authors of the report define reproductive rights as reproductive self-determination; access to reproductive health services, supplies and information; and nondiscrimination. Self-determination is the key—people must be able to choose what method of family planning (if any) they use. Both information and supplies need to be readily available for this to succeed. In most of the world, including the USA, lower-income folks are less able to access FP, but this discrimination must stop.

How can policies be made so rights are more important than quotas? Standards will be made and enforced to deliver quality care. Supplies are often a problem in developing countries, but that problem can be solved with technology. Production should be judged not by the numbers of patients served but by how well they are served. For instance, clients can be given questionnaires before they leave a clinic to be sure that they were given information about all available FP methods.

So far, this is theoretical; it remains to be seen if reproductive and human rights can be honored consistently. Next month I’ll report on FP2020 in action.

© Richard Grossman MD, 2015

Condemn “Assembly Line” Sterilizations

January 3rd, 2015

News media focused in November on deaths in India after women had surgery at a sterilization “camp”. Authorities suspect that the surgeon caused more than a dozen deaths, so he is in prison.

More people are added to the population of India each year than to any other country. India has family planning programs, but abuses occur. This epidemic of deaths may have occurred because of disregard for established standards.

Indian gynecologist Pravin Mehta holds the world’s record for the number of tubal ligations that one doctor has done—over a quarter million. He told me how he could do 300 surgeries in one day; Henry Ford would have been amazed!

I didn’t realize how crude Mehta’s process was until I saw a movie of him working in a surgery camp. Operations were performed in a tent, and conditions were very primitive.

Nevertheless, Dr. Mehta’s safety record was remarkable. He offered a reward for anyone who reported a problem, including pregnancy, after his surgery, but gave out very few rewards. Indeed, I believe that his complication rate was lower than surgeons doing tubal ligations under modern conditions.

Were all these surgeries truly voluntary? During the era when Dr. Mehta worked—1970s and 1980s—India had aggressive sterilization programs for both men and women. Acceptors were given a small stipend if they agreed to the surgery. Recently the stipend for a person getting sterilized was equivalent to less than $10—a small sum by our standards but more than a villager might see in a month.

Reports of the recent sterilization tragedy frequently mention that women wanted to limit their family size, but that they were not given information about temporary methods of family planning. Even if women knew about temporary methods, they were not available.

Many problems were found after these Indian surgeries that killed many young mothers. The operating room was not clean, the staff were untrained, the medicine was contaminated. The same syringe and needle were used to inject local anesthesia for many women. Even worse were systemic problems: almost all of the funding was used for administration and too little paid for actual health care, there was little counseling or informed consent, no access to temporary contraceptive methods, and providers were pressured by numerical targets.

Two Americans are making a documentary about sterilization. Quartz published quotes from some of the Indian women they interviewed; here is the link: http://qz.com/299712/these-are-the-voices-you-did-not-hear-after-the-chhattisgarh-sterilization-tragedy/. One of the women, Archana, said:

“I was 19 when I got married and I have 3 kids. I don’t have much income, that’s why I got sterilized. When our income is limited what’s the use of having so many kids? ASHAs [Accredited Social Health Activists] came to visit me and told me about sterilization. When I got sterilized I went with my sister-in-law to the hospital and was given Rs600 in compensation. My husband and my mother-in-law were supportive. It took me about a month to recover fully. After a week I had to cook for my kids and take care of the house. I would have liked an entire month to recover, but we didn’t have anyone else to do the work. I chose this method because I had so many kids, and I didn’t know of other methods of contraception at that time. Now I’ve learned about more temporary methods. Copper T is not available here, you have to go to the cities, but you can get pills and condoms here.”

Please remember that conditions and standards in developing countries are different from what we know. Nevertheless, people must be respected and well informed about their health care.

Can family planning programs provide services to millions of people and yet assure that care is truly voluntary? Delegates at the International Conference on Population and Development 20 years ago felt that it is best if family planning were a part of comprehensive reproductive health programs. Since then our population has grown by 1,600 million people, with consequent increasing problems. Much of this growth is in developing countries, but remember that it is we in the rich countries who cause the worst impact because of our consumption!

Some of the family planning workers have real concern for the people they serve. After this tragedy one ASHA (health activist), Mitanin, is quoted as saying: “with what face we will tell people to go for sterilization?  Now, even if they come to us for it, we will hesitate.”

A new program, FP2020, is working to provide quality family planning services while respecting reproductive justice. More about FP2020 soon.

© Richard Grossman MD, 2014

Woman after sterilsation surgery in Bilaspur

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.