Categories
Carrying Capacity

Glimpse at Religion in Africa

            In Africa, as elsewhere in the world, religious beliefs have an influence on the number of children a woman will bear. There are many factors that go into family size choices, and religion is one that is rarely explored.

            In the USA, Utah is an example of how religion influences family size. It has had the highest fertility rate, probably in part because of its large number of Mormons (Latter Day Saints). This religion has traditionally encouraged large families, and many Utahans have complied. I know an example from my practice. An LDS patient from Utah requested reversal of her tubal ligation, which was done after her 5th child was born. She regretted the sterilization and wanted more children. I succeeded in putting her tubes back together, and she ended up with 12 kids!

            In many African countries—especially south of the Sahara—the predominant religions encourage high fertility. Many groups of both Christians and Muslims believe that children are gifts from God and feel that contraceptive use is prohibited. Part of the motivation for large families seems to be that there is strength in numbers—especially if a group feels threatened. In addition, agrarian people tend to look upon children as a resource for work, while urban societies may consider kids financial burdens. Furthermore, rural people have less access to contraception than those who live in cities. A third major group of religious believers, those who follow traditional faiths, tend to have many children, perhaps because they are more likely to be subsistence farmers. 

            What can be done to help women get effective birth control? IUDs and implants, the most effective temporary contraceptive methods, are expensive and require skilled providers. Fortunately, a promising new variation of an old method has won favor in several African countries. For over 50 years women have trusted DMPA (DepoProvera®) for contraception. It is very effective, but requires a shot every 3 months—which is especially difficult for rural women. Some women have sickle cell anemia, an inherited disease in Black Africans, which causes painful crises. DMPA can actually prevent these crises in addition to preventing pregnancy!

            Sayana Press® is the same medication in a more convenient form. In a trial, Ugandan women who chose Sayana Press® were taught how to give themselves the first shot in a clinic. They went home with 3 more shots to self-administer at 90-day intervals. This meant only one clinic visit a year—much better for someone who might need to walk miles or take an expensive bus to the nearest family planning clinic.

            Education is an important way to empower women and for them to gain control of their fertility. Perhaps this teaching could include mention of the advantages of smaller families. In Sub-Saharan Africa, as in other parts of the world, the more years of school a girl or woman attends, the smaller her family is likely to be. Joyce Asimit Simiyu of northwest Kenya is a good example. She is the oldest of seven kids. Although elementary school was free, her family didn’t have resources for her to go to secondary school. The Quaker Girlchild Education Fund provided scholarship aid for high school and eventually she finished college. She and her husband are the parents of only two.

            There are innovative ways that family planning services are delivered in Africa. Catholic dogma is against modern contraceptive methods, but people have found ways around that doctrine. I asked a Catholic nun who runs a health center in Tanzania if they provided contraception. “No,” she said, “we leave that to the Protestants down the road.” Rwanda is another example, where much of the health care is provided by the Catholic Church. After the 1994 genocide, the government recognized the importance of family planning and placed a family planning clinic close to each of the Catholic facilities.

            Many places in Africa already exceed the land’s ability to feed its people, yet the world’s fastest growing populations are there. What works to slow growth? In many cultures religious leaders are key to promoting successful family planning. Although they may not be interested in slowing the growth of their congregation, most leaders will want to improve the health of their mothers and children. One of the best ways of doing that is with contraception to lengthen the interval between pregnancies.

© Richard Grossman MD, 2022

Categories
Population

Chastise Texas about its unsafe abortion law

Women’s March, 3 October 2021, in Durango, Colorado

There is no such thing as banning abortion, there is only banning safe abortion.

            Texas has just passed the country’s most draconian and restrictive law on abortion, which the Supreme Court initially refused to consider. What bothers me is not just the lack access to safe abortion services but also some aspects of the law.

            S.B.8 (nicknamed the “Texas Heartbeat Act”) prohibits a doctor from performing an abortion if a fetal heartbeat is present. Before performing an abortion, doctors must know if the fetal heartbeat can be seen by ultrasound. An abortion can only be performed with a heartbeat if there is a “medical emergency”, although that term is not defined. I assume that would include true medical emergencies (such as an infected pregnancy), or if the woman has a serious medical condition that might kill her if the pregnancy were to continue, such as a tubal pregnancy.

            The law empowers normal citizens to be abortion “vigilantes”. It says: “Any person… may bring a civil action against any person who….” Reasons for legal action include a doctor who performs an abortion with a heartbeat, a person who helps someone else get an abortion, or even a person who has the intention to help someone have an abortion. The penalties are dire, and include a bounty of not less than $10,000 for each abortion. The law has no exceptions for rape or incest.

            What is really remarkable is that the law prevents the usual enforcement, but rather encourages spying and snitching. It states: “…shall be enforced exclusively through the private civil actions….” This law allows anyone, in or outside of Texas, to attempt to grab the bounty on a doctor who performs an abortion beyond 6 weeks.

            The people who wrote this law knew that it would be challenged and that the challenge would probably go to the Supreme Court of the USA, so put in a remarkable clause: that no regard would be given to “a defendant’s belief that the requirements of this subchapter are unconstitutional….”

            Furthermore, the legislature has stopped using the correct medical term for an early pregnancy, “fetus”, but rather substituted “unborn child”. Although this might be satisfying for people who are against abortion, I hate to see legislators change medical terminology for their nefarious purposes. Isn’t there a law against lawyers practicing medicine? To make things worse, courts are playing legal pingpong with women’s reproductive rights, the law having been stayed by one court, then reinstated by another.

            What can we expect to see as a result of S.B.8? More women will travel outside of Texas for abortion care. One clinic in Oklahoma City already reports that two thirds of their patients come from Texas. More concerning is that there will be more unsafe abortions as women become desperate—as was the case before Roe v. Wade in 1973. We can expect an increase in maternal mortality in Texas, as has happened in states when they have enacted laws that decrease access to safe abortion services. Texas already has a higher-than-average number of women dying from pregnancy-related problems. 

            A brave Texas OB-GYN, Dr. Alan Braid, openly broke the law and wrote about it in the Washington Post. His patient, a 42-year-old mother of 4 young children, couldn’t leave them to go to another state. Braid wrote that during his training, before 1973, he saw 3 teenagers die from illegal abortions; this is part of his motivation for performing safe abortions. 

            What can be done? Studies in other countries have shown that home abortions with medications can be safe. Women can put away their hangers and knitting needles and safely purchase the medications needed on Internet. AidAccess is one source of information about the medications that can cause an abortion safely. For Texas women who live close to the border, misoprostol is available in Mexico and is a safe way to cause an abortion by following instructions at the International Women’s Health Coalition website.

            What is clear, according to a recent Economist survey, is that the majority of Americans favor access to safe, legal abortion services. Texans, don’t be bullied by religious fanatics!

© Richard Grossman MD, 2021