Sunday, April 15, 2012

Population Control: Propaganda is Not Information

Ida Odinga, writing for Kenya's The Star newspaper gets it right: an estimated 7,700 women dying each year from pregnancy related complications means the "need to address safe motherhood [is] a human rights imperative". But Kenya's Public Health Permanent Secretary, Mark Bor (also cited in Kenya's Star) attributes "the numerous statistics in maternal mortality and unsafe abortion to unwanted and unplanned pregnancies". Many mothers suffer serious illness, injury and death because of a lack of accessible and safe healthcare. All women attending healthcare facilities in Kenya are at risk, not just pregnant women, let alone those who don't plan their pregnancy. As for unsafe abortion, this is quite separate from conditions in health services because abortion is illegal in Kenya.

Odinga identifies high maternal mortality as "the single greatest indicator of health systems that fail to meet the basic needs of the society's poorest and most vulnerable: women." She also notes that maternal deaths have increased from 414 deaths per 100,000 live births in 2003 to 488 in 2008/9. In addition to the negative consequences for families, communities, the economy, the environment, peace and stability, failure to reduce maternal morbidity and mortality will also keep child and infant morbidity and mortality high. Newborn deaths are currently estimated at 140 per day.

For Bor, population control is the solution to the problem. For Odinga, birth control is only part of the solution Also required are skilled health practitioners, emergency obstetric care and the like; in fact, development of health requires development of education, infrastructure, security and good governance. Bor seems to think that all those things, and more, will follow population control and he sets a goal to increase use of family planning. Even the estimated 70% figure for urban dwellers living in slums Bor puts down to lack of population control, certainly not to a failure of the government to develop cities and reduce the number of people living in unacceptable conditions.

Both Odinga and Bor are probably referring to the same figures, but they seem to start with entirely different paradigms. Odinga appears to feel that adequate levels of development will include better conditions for mothers as one of its consequences. Bor clearly hopes that population control will include adequate levels of development as one of its consequences, that improvements in health, education, infrastructure and the rest will somehow magically follow from greater use of modern contraceptive methods. The experience of countries that are now developing, and of those that are developed, suggests that Odinga is right and that Bor is wrong (although he is not at odds with much of the development community, which shares his paradigm).

Bor is reacting to figures from the "Measurement, Learning and Evaluation (MLE) Project and the Kenya Urban Reproductive Health Initiative (Tupange)". Yet this shows that there is little difference between use of modern contraceptive methods among the poorest and richest quintiles in three of the five areas surveyed; rates are higher among poorer quintiles in the other two areas. Differences in fertility, on the other hand, are quite marked between rich and poor, being a lot higher in poorer quintiles. This could suggest that fertility is related to many factors, rather than just to attitudes towards and use of family planning.

Although the survey finds that about 10-15% of women would like access to contraceptives to space births and about 10% would like to have fewer births, the authors conclude that this represents an 'unmet need' of over 20%. However, giving a response to a survey about contraception does not necessarily translate into greater use of whatever methods the funders of this survey are trying to push. Everyone who has worked in marketing knows that.

Frighteningly, almost half of those using modern birth control methods are using injectable hormonal contraceptives, which are suspected of increasing HIV transmission from women to men and from men to women. Those collecting the data, Bor and others stress the need for education and information, but those without education are not in a good position to evaluate some of the information they may be receiving, especially where that information is, effectively, sales pitch; by pharmaceutical companies selling their wares; by NGOs selling their services; and by politicians and philanthropic institutions selling their ideologies.

Despite decades of pushing birth control on people in developing countries, with promises of development, wealth, success, etc, people are not convinced about much of the 'information' they have been receiving. The vast majority of males and females adhere to beliefs that are considered to be myths by the promoters of birth control. Hardly any say they don't use birth control because of lack of knowledge or because or lack of access or high costs. The main reason for not using contraceptives is a desire to have children.

The research also supports Odinga's contention that the problem relates to health systems, perhaps even health as a whole, through some of its other findings. Providers of all kinds of contraceptive in all areas surveyed had stock-outs in the last year, 40-50% of facilities or higher. Quality assurance has a low priority; many facilities are lacking in basics such as piped water, dedicated phones, storage areas and even appropriate private facilities. 41% or fewer recipients of family planning services felt they were treated 'very well' by their provider. It sounds like those who think family planning is going to solve most problems are not even getting that aspect of health provision right.

While maternal health is an extremely important indication of the health of a nation, low levels of maternal health and high rates of morbidity and mortality will not be addressed by the mere provision of contraception. Family planning is an important right, but it is just a part of overall health, it is not health itself. Many Western institutions and even governments feel that lack of development is due to large family sizes. However, history has shown us that large family sizes are partly due to low standards of health, education, infrastructure, etc. Provision of family planning in developing countries needs to be separated from a population control agenda, which all too often degenerates into various forms of extremism.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]


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