Category Archives: Post-Partum

Measuring Success in Family Planning: Parity and Unmet Need For Contraception in South Asia

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Population growth over time. Note particularly growth rate since the Industrial revolution.  Image credit to Washington Post

Human population growth over the last 2000 years. Note growth since the Industrial Revolution.1

The human population has skyrocketed since the advent of the industrial revolution, leading to the establishment of family planning programs to help curb the number of births in developing nations, where large families often result in increased child and maternal mortality. The aim of these schemes has historically been simply to reduce the number of births per woman, trusting that the economic, environmental, and healthcare crises would then be mitigated by necessity. The reality of “success” has not been uniform, however. In South Asia programs run by outside Nongovernmental Organizations (NGOs) there is a legacy of forcibly implanted intrauterine devices (IUDs),2 sterilization camps,3 and the sale of IUDs to the Indian Government by the World Health Organization and the Ford Foundation with the full knowledge that the Dalkon Shield IUD was puncturing the endometrial wall and causing rupture and hemorrhage in American women4 in addition to the dangers of its removal thread, which was found to be ‘wicking’ moisture, leading to the spread of Escherichia coli5 and causing pelvic infections, thus creating even more infertility among the women who used it.6 Even more shocking was the fact that the IUDs were intentionally shipped with only one inserter per ten IUDs to make them more “cost effective.”7 As late as the mid-1990s (it may still be continuing), women were given an IUD following the birth of their child, even against their wishes. If the woman later wanted this IUD removed, she would be required to pay to for it out-of-pocket at a private clinic.8 These crises in treatment and accessibility options stem from the mindset that parity reduction is the ultimate measure of success, rather than judging by markers of women’s increased empowerment: a decrease in the number of women reporting an unmet need for modern contraceptive methods, an increase in the number of girls in school, and an increase in the number of births attended and monitored during pregnancy by a skilled birth attendant. Moralizing the choices of women of color in developing nations who have more than two children while saying nothing about the real disparity in resource usage between children in developed and developing nations9 overlooks the greater issues into which family planning needs are wrapped: disparity in resource availability and pervasive misogyny.

In her book on birth in Tamil Nadu, Cecilia Van Hollen translates a number of interviews with doctors, nurses, and multipurpose healthcare workers (MPHW) in which poor women are shamed for being “illiterates” who “do not know what is best” and therefore need to have their decisions made for them.10 When a woman is illiterate she is automatically assumed to be incapable of using more complex forms of contraception (i.e. the pill) and therefore often receives no patient counseling on any methods beyond IUDs and sterilization–if she receives any counseling at all. Women’s fertility becomes a focal point for forcing devices and procedures on women against their will and sometimes even without their knowledge. All women in the Tamil hospitals Van Hollen visited were mandatorily inserted with a “loop” (IUD), even if they protested its insertion.11 These women later had to either remove the device themselves (a dangerous option), accept the contraception, or (if she was able) pay approximately 30-50 rupees to have it removed at a private hospital.12 This total disregard for the wishes and rights of women was treated as ‘business as usual’ by the medical practitioner interviewees, who saw it as simply part of knowing what is best for women who by their illiteracy and poverty are rendered incapable of making their own choices.13

comparison

Dalkon shield IUD as compared to a Copper T IUD. 14

In the 1970s, AH Robins developed the Dalkon Shield IUD for the United States market which was “with the possible exception of Norplant,… arguably the worst contraceptive ever foisted upon American women.” By the time it was recalled, 18 women had died, several hundred were subjected to life-threatening, spontaneous15 septic abortions, and several thousand women were made sterile when it perforated their uteri.16 A class action lawsuit was eventually filed in which 167,000 women made claims and billions of dollars were paid out to victims.17 Because of the nature of mortality reporting, it is impossible to know for certain how many women (or their estates postmortem) did not file claims though they were eligible to do so.18 Just before the Dalkon Shield was finally recalled, Robins with the help of USAID, Planned Parenthood International, Pathfinder, and the Ford Foundation shipped the remaining IUDs- knowing that they were already killing women- to low-resource developing nations, where it was deemed that they would be ‘good enough’ for ‘those women.’19

A protest of the Dalkon Shield20

A protest of the Dalkon Shield20

The uterus is a sterile environment21 and thus anything inserted into it must also be sterile or the uterine cavity will become infected (Pelvic Inflammatory Disease–PID), which can lead to sterility, so the microbial cleanliness of an IUD and its inserter is absolutely critical to maintaining a woman’s reproductive health. The IUDs that were sent to South Asia were not sent as was normal for IUDs intended for American and European women. Rather, for every ten IUDs that were shipped one inserter was included.22 Adding to the trouble was that the IUDs were bulk packaged, that is, not sterile, individual packages as they are here, and had one instruction manual was shipped with every one thousand IUDs. 23 These instructions, when a clinic was fortunate enough to receive them, were written only in English, Spanish, and French- none of which are native or official languages in South Asia.24 This alone would have created a massive backlash had it happened in the United States, but goes it relatively unmentioned in reporting on the Dalkon Shield. That an incredibly dangerous device was foisted upon unsuspecting women in a developing nation isn’t mentioned in most reporting on the Dalkon Shield and does not even feature on the IUD’s Wikipedia page.25 This Western-centric myopia has left the literally unknown legions of women and their families locked out of the lawsuits created to gain justice and compensation for victims of the Dalkon Shield. While it is not known exactly how many women were injured or killed by the Dalkon Shield, Pathfinder’s records show that 700,000 Dalkon Shield IUDs were shipped to developing nations.26 By 1986, 192,000 claims had been filed (predominantly in the United States) amounting to $2.3 billion, but there is not a single recorded claim from India.27

Sterilization instruments used in Bihar in 2013.28

Sterilization instruments used in Bihar in 2013.28

Tragically, this pressure for parity reduction continues despite the Indian government’s attempts to ‘change gears’ and reduce abuses.29 The crisis of 4.6 million forced sterilizations in the single year in India30 is shocking. As a woman in a developed country on the payroll for a reproductive rights non-profit who is also beginning to work in family planning in the developing nation context, the figures are particularly alarming. In 2012 the Guardian newspaper revealed that “tens of millions of pounds” of aid money from the United Kingdom had helped to fund such programs, which bribed impoverished women to undergo sterilization, left them “bleeding and in agony,” and resulted in miscarriages and dead babies.31 The tubal ligations32 were performed in rooms with multiple beds to have multiple concurrent surgeries, on bloody sheets, and with rusty scalpels.33 These are all, obviously, incredibly dangerous to the women undergoing the surgeries, which have seen women left on on the ground, outdoors, exposed for “recovery.”34 It’s not particularly difficult to imagine the outrage and lawsuits that would ensue if these atrocities-because that’s what they are-were committed in a Western nation. In the United States much is made of our ‘malpractice litigation-happy’ culture, but it does protect us from abuses like these. The lives of women and our reproductive rights are constantly challenged in the United States,35 but we are at the very least protected from these kinds of horrors.

Women left to recover exposed outdoors post tubal ligation. 36

Women left to recover exposed outdoors post tubal ligation. 36

These completely preventable tragedies are obviously not the intent of the donors and taxpayers who fund the family planning programs behind them, nor are they the result of malicious healthcare workers who want to slaughter their patients, but they are the reality of what occurs when reduction in parity is the primary or only measure of success. When the end goal of a program is simply to reduce the number of children each woman produces, it neglects the reasons why it might be desirable for her to have fewer children: poverty, malnutrition, lack of educational opportunities, healthcare availability, and child marriage, to begin a very long list. It is important to remember that globally only 47% of births are attended by a skilled practitioner,37 1/3 of all girls are married before 18,38 and that 60% of the 61 million children deprived of education are girls.39 These figures are both shocking and unacceptable. It is true that reduction in parity and greater spacing between children does increase the mother and child’s chances of survival, but it is paternalistic (and neo-colonialist for western foundations) to tell women in developing nations how many children they are allowed to have or forcibly create a reduction in fertility.

A keychain featuring the family planning slogan “we two, our two” in Hindi. 40

A keychain featuring the family planning slogan “we two, our two” in Hindi. 40

I am not insinuating that these abuses are the intent of any modern family planning program in the developing world, but the pressure to produce results is particularly dangerous when the result is simply a reduction in the number of children a woman births. The current model has MPHCW receiving bonuses for “acceptors” and seeing demotion when their “goals” are unmet.41 With those kinds of structures in place it is little wonder why coercion in family planning is so common. The measure of the success of a family planning program is the reduction of a woman’s indicated unmet need for contraception and the path to that success is the elimination of child marriage, universal access to high-quality education for all children, and the ensurance that all children are adequately nourished. There are, of course, other important issues to ensure gender equity and that women are given the opportunity to rise out of poverty (see Millennium Development Goals), but those are good first indicators.

Branded packaging for the PATH SILCS one size diaphragm. 42

Branded packaging for the PATH SILCS one size diaphragm. 42

Making multiple methods of woman-controlled, side-effect free contraception available to women has been shown to increase the long-term use of contraception.43 When women control their contraceptive choice and understand the method, they are more likely to use it long-term and to use it correctly. Fortunately, a woman-controlled, low-cost, long-term, side-effect free method has been available since the 1930s, though it has fallen out of popularity since the advent of the birth control pill: the diaphragm. The diaphragm’s primary difficulty was that it required fitting by a trained professional, but a new diaphragm developed by Seattle-based NGO PATH is single-sized, eliminating the need for a fitting. Even the old belief that the diaphragm is best suited to women who do not have sex often has been shown as not accurate. Even women who have more frequent sexual encounters (4 or more times a week) rate diaphragms as highly acceptable.44 The more flexible and varied a woman’s choice, the more clear and concise the information given to her, the more empowered the woman will be. Family planning is powerful and necessary because it can make an incredible difference in women’s lives, but it can’t do that through coercion, abuse, and the withholding of information.

1 Image credit: Brad Plumer, Washington Post, 1 November, 2011 http://www.washingtonpost.com/blogs/wonkblog/ post/chart-of-the-day-our-exploding-population/2011/11/01/gIQAVOIScM_blog.html

2 Cecilia Van Hollen, “Moving Markers” from Birth on the Threshold: Childbirth and Modernity in South India, (University of California Press, Beekley), 2003

3 Andrew MacAskill, “India’s poorest women coerced into sterilization,” Bloomberg, 11 June, 2013l http://www.bloomberg.com/news/2013-06-11/india-s-poorest-women-coerced-into-sterilization.html

4 James A Miller, “The case of the Dalkon Shield,” http://pop.org/content/money-for-mischief-usaid-and-pathfinder-1694 (accessed 14 October, 2013)

5 HJ Tatum, FH Schmidt, D Phillips , M McCarty, WM O’Leary, “The Dalkon Shield controversy. Structural and bacteriological studies of IUD tails.” JAMA. 7 (1975); 231, 711-7 http://www.ncbi.nlm.nih.gov/pubmed/1172860

6 James A Miller

7 James A Miller

8 Cecilia Van Hollen, 158

9 For some humbling statistics on resource use and population, Washington State University has created a page based on information from the World Bank. http://public.wsu.edu/~mreed/380American%20Consumption.htm

10 Cecilia Van Hollen, 166

11 Cecilia Van Hollen, 149-51, 156-57

12 Cecilia Van Hollen, 150

13 Cecilia Van Hollen, 155

14 Image credit to University of Virginia School of Law, http://lib.law.virginia.edu/specialcollections/records/mss/ 00-4

15 Jennifer Couzlin-Frankel, “Contraceptive comeback: The maligned IUD gets a second chance,” Wired, 15 July 2011, http://www.wired.com/magazine/2011/07/ff_iud/

16 Jennifer Abbasi, “4,000 years of birth control and counting,” Everyday Health,1 June, 2013 http:// http://www.everydayhealth.com/sexual-health-pictures/4000-years-of-birth-control-and-counting.aspx#/slide-14;
Jennifer Couzlin-Frankel;
Morton Mintz, At any Cost: Corporate Greed, Women, and the Dalkon Shield (New York: Pantheon, 1985), pp. 3–4.

17 James A Miller

18 James A Miller

19 James A Miller

20 Image credit to: Jennifer Abbasi

21 BR Moller, FV Kristiansen, P Thorsen, L Frost, SC Morgensen “Sterility of the uterine cavity,” Acta-Obstet Gynecol Scandanavia (1995), 74(3), 216-9

22 James A Miller

23 James A Miller

24 Technically India has no official language and English is widely understood, but in rural areas it is not the common language of the people and is less well known. Particularly in the case of medical issues, instructions should always be in a language well understood by the practitioner and patient to avoid potentially life-threatening mistakes.

25 http://en.wikipedia.org/wiki/Dalkon_Shield

26 James A Miller

Morton Mintz

27 Gabriella Wass, Corporate Activity and Human Rights in India, (Human Rights Law Network, New Delhi, 2011)p. 56

28 Image credit to Andrew MacAskill/Bloomberg. “Surgical instruments used in the sterilization procedure are seen in a tray in a clinic in Sonhoula, Bihar state, India.”

29 Cecilia Van Hollen, 163-165

30 “India’s forced sterilisation nightmare,” Aleteia, 11 July 2013, http://www.aleteia.org/en/world/documents/indian-voluntary-population-control-2304002

31 Gethin Chamberlain, “UK aid helps to fund forced sterilisation of India’s poor,” The Observer via The Guardian, Saturday 14 April 2012, http://www.theguardian.com/world/2012/apr/15/uk-aid-forced-sterilisation-india

32 The surgical procedure to permanently sterilize a female-bodied person. The woman’s abdominal cavity is opened and her fallopian tubes are cut, tied, and cauterized (burned).

33 Andrew MacAskill

34 Celeste McGovern, “Who’s behind India’s barbaric mass sterilization camps?,” Life Site News, 11 March, 2013, http://www.lifesitenews.com/news/whos-behind-indias-barbaric-mega-sterilization-camps/

35 Adalia Woodbury, “Republicans have launched 694 attacks on women’s reproductive rights in 3 months,” Politico, 14 April, 2013 http://www.politicususa.com/2013/04/13/republicans-propose-694-attacks-womens- reproductive-rights-3-months-2013.html
Bodine, Larry, The nationwide attacks on reproductive rights (12 June, 2013), http://www.huffingtonpost.com/larry- bodine/it-started-in-arkansas-wh_b_3418944.html

36 Image credit to Carol Kuruvilla,,” Horror in a mass sterilization camp: unconscious indian women were dumped in a field after undergoing painful sterilization operation,” Ny Daily News, 7 February, 2013, http:// http://www.nydailynews.com/news/national/indian-women-dumped-field-sterilization-operation-article-1.1258314

37 WHO, http://www.who.int/gho/maternal_health/skilled_care/skilled_birth_attendance_text/en/ (accessed 14 October 2013)

38 International Center for Research on Women, http://www.icrw.org/child-marriage-facts-and-figures (accessed 14 October, 2013)

39 Campaign for Education USA, http://www.campaignforeducationusa.org/educating-girls-women-in-developing- countries (accessed 14 October, 2013)

40 “We two, our two” family planning awareness program, India. Image credit to e-junkie.info http://www.e- junkie.info/2011/11/giveaway-chumbaks-fun-vibrant-keychains.html

41 Cecilia Van Hollen, 158

42 Image credit to PATH A Catalyst for Global Health http://www.path.org/projects/silcs.php

43 Nuriye Ortayli, Aysen Bulut, Hacer Nalbant, and Jane Cottingham, “Is the Diaphragm a Viable Option for Women in Turkey?” International Family Planning Perspectives, Vol. 26, No. 1 (2000), p. 36 http://www.jstor.org/stable/ 2648288 .

44 Julie E. Maher, S. Marie Harvey, Sheryl Thorburn Bird, Victor J. Stevens and Linda J. Beckman, “Acceptability of the Vaginal Diaphragm among Current Users,” Perspectives on Sexual and Reproductive Health, Vol. 36, No. 2 (2004), p. 64 Nuriye Ortayl, et. al., p. 38

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New Placenta Options!

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Know Your Rights!

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It can be difficult to work and continue to provide the best possible nutrition for your baby, but, fortunately, most states and the federal government protect the rights of nursing mothers to some degree. Here in Washington women are protected from indecent exposure laws whether pumping or feeding and are allowed to use their breaks during the work day to either nurse their child or express milk. Even better, the 2010’s Health Care Reform requires that employers provide a reasonable period of breaks and a private, non-bathroom place to nurse or express milk; it also allows for breast pumps and childbirth education classes to be reimbursed from your Flex Spending Account.

If you or another nursing mother is told that you are unable to pump or breastfeed for any reason, arm yourself with facts. Breastfed babies are healthier and their parents miss less work, which creates lower work and health costs as those children aren’t seeing the doctor (or getting prescriptions) as often and co-workers don’t need to cover for mums and dads staying home to care for a sick child. Nursing mothers heal more quickly after delivery and are less likely to become pregnant while continuing to nurse, spacing out maternity leaves. Everyone wins with breastfeeding. Everyone.