Category: Public Health

Categories
Family Planning Population Public Health

Puerto Rico

This story started 30 years ago when we lived in Puerto Rico. Actually, the real beginning was 15 years before that, in Nicaragua.

We returned to Puerto Rico this spring after a three-decade absence. The island seemed even better than when we lived there. There was less trash, people were friendlier and now toll roads bypass overcrowded arteries.

Of course, Puerto Rico is not a separate country, but a commonwealth of the USA. Fortunately Puerto Rico keeps independent statistics, and one of them was a real surprise.

Flash back to 1968. My best experience in medical school was in the little Nicaraguan town of Puerto Cabezas, on the Caribbean coast. I learned a huge amount from the one physician, Ned Wallace, at the Moravian hospital there.

Gail (then my wife of only two years) and I lived in a tiny cabin with another medical student couple, a short walk to the hospital—and to the Caribbean Ocean. We adopted Noxa (“hello” in Miskito), a sociable green parrot.

We traveled by dugout canoe to provide the first medical care some villagers had ever received. Our wives passed out worm medicine and gave immunization shots, while we medical students saw patients in the four languages of the area—Miskito, Spanish, Creole and English. It was not the best medical care, but our patients were appreciative.

Ned was an excellent role model—he could do just about anything! I realized that living and practicing medicine in the tropics had personal advantages, in addition to helping people. At that time I resolved that, if we ever had kids, they should grow up knowing that the entire world was not like the USA, and that everyone didn’t speak English. Fortunately, Gail agreed.

In 1983 we moved our family from Durango to the little hill town of Castañer in central Puerto Rico. I practiced medicine and our two sons, in 3rd and 6th grades, learned Spanish by immersion. It was an enlightening experience in a different culture.

I was frustrated in Castañer by the number of women who wanted to limit their fertility, but lacked the money. Typically women married young and had 3, 4 or more closely spaced children. When I asked older women what birth control they used, the answer was often “my husband takes care of me” (withdrawal) or “I’ve been operated” (tubal ligation). Birth control pills and IUDs, effective temporary means of contraception, were just too expensive in this impoverished area.

Before returning to Puerto Rico this year I consulted the World Population Data Sheet (www.prb.org) for some demographic information. To my surprise the TFR (Total Fertility Rate—the number of children a woman has during her lifetime) was low. For a society to neither grow nor shrink, the TFR has to be about 2.1–one child to replace teach parent, plus a fraction for children who die before adulthood. Puerto Rico’s TFR is 1.6 now, far below replacement! However, it will take several decades for the population to stabilize.

What brought about this change In Puerto Rico? Did people recognize that the island is limited in size, that it has approached its carrying capacity? Is it that there is less adherence to religious doctrine?

Nobody seems to know exactly what happened. As far as I can make out, however, marriage is later and more couples choose to be childless. More women are employed, a common reason people choose smaller families.  The main change seems to be that contraception and tubal ligation (still very popular) are available with governmental aid, helping people achieve their reproductive and economic goals. Legal abortion is less common now that contraception is easier to obtain.

Puerto Ricans live in a beautiful green place of sun and ocean, but they have low incomes by our standards—only a third of the average income on the mainland. Thanks to government support, now people are able to receive the family planning services they desire. Puerto Rico has joined half of the world’s countries where women have sufficient access to family planning so that their populations will eventually stop growing. Where does the USA fit in? our TFR, at 1.9, is slightly below replacement.

Our return to Puerto Rico was lots of fun. We visited with friends and enjoyed the sun and ocean. Teaching our granddaughters to body surf was special for me. I also learned that even a poor area, if it has the will to help women control their fertility, can achieve zero population growth along with an improved economy.

© Richard Grossman MD, 2013

Categories
Abortion Public Health

Lament over Unplanned Pregnancy

The prevention of unwanted pregnancy is more important than ever for the well-being of the family.

Antero Myhrman, Born Unwanted

One of my strongest memories from medical school was a delivery I assisted with. This was the mother’s fifth child and a quick birth. I proudly held up the newborn boy to show him to his mother. She turned her head away and cried.

I don’t remember the names of the mother or baby, who would be about 44 years old now. How his life has gone is only conjecture, but the likelihood is that his path has not been an easy one.

We generally assume that all adults are cut out to be parents, but that is not true. Forced parenthood can have unhappy consequences for the adults, and especially for the children. This column examines the outcomes of children of unwilling parents. Next month’s column will include the words written by a person who, herself, was born unwanted.

The biggest and best analysis of children born unwanted was done in Czechoslovakia at a time when women had limited access to legal abortion. An American psychologist, Dr. Henry David, collaborated with Czech counterparts. Czech women had two chances to request an abortion in the 1960s. The first chance was at a local clinic. If the woman were turned down, she could apply again at a regional level, the last resort for a legal abortion. Unfortunately, the many advantages of adoption were not considered in this study.

One of the Czech psychologists had a list of women who had been twice denied for the same pregnancy. Because of the excellent record keeping of that country, the children born to these women with unwanted pregnancies could be followed for many years. They were carefully matched to children who were desired—same age, same socioeconomic class, same school etc. All the families lived in Prague, the country’s capital.

These people, both those who were unwanted before birth and the “normal” controls, were examined and tested at age 9, in adolescence and again in their early 20s. The investigators also looked at records, interviewed parents and spoke with teachers.
The two groups of people ended up significantly different despite growing up in very similar circumstances. Compared to the people who resulted from pregnancies that were planned (or at least accepted), those born unwanted did not fare so well in life.
Specifically, the babies who had been unwanted were not breastfed as long, and did not achieve as well in school even though their intelligence tests were as good as the more desired children. They were more likely to be less social and more disruptive and hyperactive, and were more likely to have criminal records. When asked as adolescents, the children who had been unwanted believed their mothers showed less maternal interest than did the control group.

The young adults in their 20s were asked how they felt about their lives. Again there was a significant difference, with the people who were unplanned being less satisfied with their lives, with their love relationships, with their own mental health and with their jobs. It is interesting that their sexual debut was at an earlier age and they had more sexual partners than control people. Thus, these people were more likely to beget another generation of unwanted pregnancies.

There are exceptions to the general rule, fortunately. Dr. David’s research found three groups of women who requested abortions but were denied. Some had temporary motivation for wanting to abort, such as financial reasons. These women usually accepted the pregnancy and both mother and child did well. For other women the pregnancy resulted from a poor relationship, and they did not do so well with childrearing. The third group of women apparently realized from the beginning that they would not be good parents, and the study, unfortunately, bore this out. Both the women and their children did not fare well.

The Czech study was of women who were denied legal abortion. Those who were allowed to have abortion must have had even more compelling reasons to not parent. If they had been forced to bear their unwanted kids, presumably these children would have had even more severe problems.

What does this mean? A person resulting from an unplanned, unwanted pregnancy starts off life with a handicap, like the baby I delivered in medical school. This can have consequences for society, too. There is a controversial theory, popularized in Freakonomics, that the downturn in serious crime in the USA noted in the early 1990s was due to the decrease in unwanted pregnancies after the legalization of abortion in 1973.

An unwanted pregnancy can be devastating. Sometimes things work out well, but delivering and raising an unwanted baby may be traumatic for the parent(s), and scar the child.

© Richard Grossman MD, 2012