Archive for the 'Contraception' Category

Provide Family Planning in the Democratic Republic of the Congo

Sunday, 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

Preclude Abuse in Family Planning Programs

Wednesday, February 4th, 2015



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

Reject these Old Memes—2-2014

Wednesday, February 26th, 2014

Recently a friend introduced me to the word “meme”. Now I run across this concept frequently.
The word “meme” is analogous to “gene”, but it is information in our culture rather than in our DNA. A meme is a building block upon which our way of life is built. One definition is: “an idea, belief or belief system, or pattern of behavior that spreads throughout a culture”.
An old example is the Pythagorean theorem—the square of the hypotenuse of a right triangle is equal to the sum of the squares of the other two sides. This meme is ancient.
One accidental meme is changing lives in Brazil. The average family size has dropped rapidly. In 1954, when I visited as a child, women had an average of over 6 children. Now the average is 1.8—less than replacement. This big change is largely because of TV telenovelas, where middle class families are all small.
Some memes are harmful. An example is a tradition in Nigeria that leads to the death of many children. For eons Traditional Birth Attendants used mud or other unclean substances to dress newborn babies’ umbilical cord stumps. If tetanus spores are present, the baby can die a horrible death from tetanus. This improved when TBAs were taught the advantages of cleanliness and sterile instruments. Now pregnant women getting prenatal care are immunized against tetanus and there are many fewer deaths.
Galileo, who was born 450 years ago this month, suffered because of a religious meme. This meme slowed the development of knowledge for centuries.
Ancient Egyptians thought that the sun rotated around them—the geocentric model of the solar system. A Greek may have first proposed that Earth revolved around the sun 2500 years ago—the heliocentric model. For centuries people believed that the earth was the center of the universe, supported by theology that interpreted the Bible thusly. One verse that supports this meme is found in Psalms 104:5: “(God) built the earth on its foundations, so it can never be moved”. There are still people who hold that the sun goes around the earth—including 26% of US citizens, according to a recent National Science Foundation survey!
In the early 17th century Galileo defended the heliocentric theory, for which he was accused of heresy and placed under house arrest for the rest of his life. The Inquisition’s ban on reprinting his works was only lifted a century later. It was not until the 19th century that the Roman Catholic Church removed books advocating heliocentrism from its Index of Prohibited Books. Pius XII was the first Pope to acknowledge the many important contributions of Galileo—in 1939. Yet there are people who believe that heliocentrism is a conspiracy ( It is amazing how long this meme has persisted!
Years ago I sold “green umbrellas” at a public health meeting. From a campaign in Bangladesh (where it rains a lot), these umbrellas carry slogans such as “stay well” and “take health services” in Bengali. A doctor from Bangladesh bought one, then a few minutes later returned and wanted his money back. I asked him what was wrong. He replied that one of the sayings is “small families”, and we should have as many children as Allah gives us. This is another case of a religious meme that has outlived its usefulness, since Bangladesh is very crowded.
I find it amazing that some religions have not yet recognized the benefits of contraception to individuals, to families and to the world. The official doctrine of the Roman Catholic Church is that only periodic abstinence (the “rhythm” method) is acceptable. This policy is ignored by many of the 1.2 billion Roman Catholics worldwide—and many women I have talked with have left the Church because of this policy.
In many Catholic countries, such as Brazil and in Western Europe, couples use modern contraception resulting in average family size less than two. There are places, including some of the poorest countries in the world where this prohibition against effective contraception is followed. They will continue to be stuck in poverty so long as people are prohibited from using modern family planning. Rwanda is an example; its rapid population growth was one factor leading to its genocide 20 years ago.
Memes can outlive their usefulness to society. It is time for women to have the same status and rights as men, and for all people to have the access to the means to manage their fertility.

© Richard Grossman MD, 2014

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