Categories
Family Planning Women's Issues

Making Family Planning Available to All People

BRAZIL–From: Policies for expanding family planning coverage: Lessons from five successful countries. Hellwig et al., 2024.

            The Cairo Conference “Programme of Action” includes a statement that all people should have the right to decide freely and responsibly the number and spacing of their children. Unhappily, many people have been forced to follow the old adage “the rich get richer and the poor get children”.

            Fortunately, this adage has been disproven in at least 5 countries where voluntary Family Planning (FP) has been made accessible to all, with little regard to income. Brazil, Ecuador, Egypt, Ethiopia and Rwanda were chosen for study because they represent different societies on different continents. 196 policies affecting the availability of FP services were identified in these countries from 1961 to the present, and the effect was described in a 2024 analysis. The progress in the availability of high-quality FP is amazing in all five of these countries!

            The genocide in Rwanda was 30 years ago. Hunger was a factor that led to neighbors killing neighbors. People in many places in this largely agrarian society were not able to produce enough food to keep away hunger. Contributing factors included land degradation and rapid population growth; there was no violence in areas where people had at least 1500 calories of food per day. The average American eats almost twice that amount!

            Back in the year 2000, few low-income people in Rwanda had access to modern FP. The country was largely Roman Catholic, which forbad modern FP and relied heavily on unreliable rhythm for birth spacing. Then, in 2005, the government started supporting a more effective method of natural FP, the Standard Days Method (SDM). The Church approved of SDM and it became popular. It is simple and is up to 95% effective—if used properly. Only 5 years after its introduction, the proportion of the poorest couples using effective contraception had risen to half!

            The year 2005 also marked a presentation that changed attitudes in the Rwandan Parliament. The RAPID Model is a computer-based tool that stakeholders can use to demonstrate the effect of rapid population growth on different sectors, and the benefits of FP programs. The model demonstrated how FP can reduce mortality, improve health and increase the availability of women in the workforce. Rwanda has taken advantage of that benefit: almost 2/3 of members of parliament are women—the highest percentage of any country! RAPID also showed the economic benefits of FP—for every dollar spent on contraception, the government would save four. To quote a minister of health, “family planning is a tool of development.”

            Since the five countries have different conditions and customs, each approached the need to slow population growth with different policies. For instance, the literacy rate is low in rural Egypt, so they used TV to get across FP messages. Ethiopia established primary health care for all—including contraception. Brazil focused on preventing adolescent pregnancies by improving sexuality education and facilitating access to FP for teens. In 2008 a change in Ecuador’s constitution named health care as a right, and ensured that women could make their own decisions about FP. Rwandan policies have already been discussed. It is remarkable that all 5 countries established policies that increased use of effective FP—and in 3 of the countries, there is equity between rich and poor in their use of FP.

            Although each of these countries has its own policies and areas of focus, they all received help from the US government and from other rich countries. Nongovernmental agencies, such as the Gates Foundation, also provided expertise and resources. It is wonderful that all 5 of these countries did what they could to make family planning services available to all.

© Richard Grossman MD, 2024

Categories
Abortion Reproductive Health Women's Issues

Investigate Illegal Abortion

In the early 1990s I read about women who were using a medication to cause abortions without visiting a doctor. Brazilian women had found that misoprostol (CytotecÒ) was available without a prescription, and would cause strong uterine contractions that could expel an early pregnancy.

Since then, this knowledge has spread to all corners of the globe. Misoprostol is now approved by the US Food and Drug Administration for use in conjunction with mifepristone to be prescribed for legal abortions. This combination has been found to be both very effective and very safe. Recognizing the safety of this combination, the FDA has decreased restrictions on mifepristone. The combination can also now be prescribed by telemedicine. However, misoprostol is almost as effective when used alone.

The original indication for misoprostol had nothing to do with abortion. Instead, it was found to protect the stomach lining in people who had irritation from NSAIDs, such as ibuprofen. It has other uses, including induction of labor (in a teeny dose) and is a lifesaver for treating postpartum hemorrhage.

A Honduran friend sent me the transcript of a BBC News Program, “Inside Honduras’s abortion pill black market.” Abortion is illegal under all circumstances in this Central American country—the most restrictive law in the world. Having an abortion is punishable by 6 years in prison. Although “back ally” surgical abortions may still occur, this excellent piece of investigative journalism is about medication abortion. Only misoprostol is available in Honduras, not mifepristone. Unfortunately, this article doesn’t give any follow up on women who use the medicine. There are risks, and some women end up in the hospital.

One of the risks is that the pregnancy will continue; misoprostol alone is only about 90% effective. Follow up is needed to detect the one in 10 women who doesn’t abort. If the first dose doesn’t work, she should use a second dose or she may go to term. Sadly, a fetus exposed to miso early in pregnancy may be affected with serious congenital anomalies—one of the risks of unsafe abortion.

Back to Honduras. The reporter, Laura, first spoke with a young woman who didn’t use protection during a one-night-stand and was 2 months pregnant. She bought 4 tablets of misoprostol on the black market. José, the black-market supplier, charges on a sliding scale. He gets from $70 to $270—depending on what he thinks the woman can pay. In this country they might cost $10, with a prescription. José has to pay off his ex-girlfriend who works in a hospital and supplies the prescription. He may also keep the police happy with bribes.

Honduras’s largest public hospital is in the capital, Tegucigalpa. It treats around 60 women each week for bleeding during pregnancy, either from miscarriage or induced abortion. The UN estimates that there are about 70,000 unsafe abortions in Honduras each year. Making abortion illegal doesn’t prevent desperate women from having unsafe abortions. Without sexual education teens don’t know how to prevent pregnancies; Honduras has the highest rate of adolescent pregnancies in Central America. Could these facts reflect the unrealistic religious teachings in a country where 48% of people are evangelical Christian and 34% are Roman Catholic?

What lessons does Honduras have for the USA? Outlawing abortion doesn’t prevent women from obtaining abortions, but they may be unsafe, expensive and exploitive. Similarly, US states that have acted to restrict or outlaw abortion are among those with the highest teen pregnancy rates, the least sex ed and the poorest support for mothers and children. Many also have high maternal mortality rates, which will probably rise as desperate women take abortion into their own hands.

©Richard Grossman MD, 2023