Vol. 9, No. 2 March 1998
For What We Have Done And for What
We Have Failed to Do
In the middle of nowhere,
I lie bleeding."
This is the voice of one of the thousands of women who die in pregnancy or childbirth in the developing world each year. The worldwide toll has been estimated to be as high as 600,000 maternal deaths annually. In the U.S., the risk of a mother dying during pregnancy and labor is 1 in 9,000. In Africa? 1 in 13.
Dr. R.L. Walley, medical director of MaterCare International and a professor of ob/gyn who has spent 20 years caring for poor mothers in West Africa, cites five causes for this unimaginably high level of maternal mortality: hemorrhage, infection, induced abortion, high blood pressure and obstructed labor.
"Maternal deaths do not take place in a visible and concentrated way, but occur among very young mothers, in small villages, and a few at a time. Most die in terror from haemorrhage or in agony from obstructed labor as their pelvises are too small" (www.MaterCare.org). "The tragedy," Dr. Walley recently explained at a Vatican conference on women's health issues, "is that the solutions to this suffering have been known for decades and cost very little. Simply put, mothers in our world in the late 20th century are being neglected basically because motherhood is not of political importance" (Walley, "Maternal and Perinatal Care: A Preferential Option for Mothers," delivered in Rome, Feb.20, 1998). Although the medical conditions that might lead to maternal death "cannot always be predicted nor prevented, most of the deaths need not happen if complications receive prompt treatment. ... [The] women who die want to be mothers but are poor, young and have no influential voice to speak on their behalf and thus are denied the emergency care which is readily available and inexpensive. All that is needed is the will to do something significant" (Id.).
Nothing typifies the chasm between obstetrical care in the industrialized world and that in developing countries better than the "forgotten disease" known as obstetric fistula. It is a health, personal and social tragedy almost unknown in the developed world for the past 100 years.
Fistulae occur because of unrelieved obstructed labor. Because the bladder or rectum or both are trapped between the head of the baby and the bones of the pelvis, pressure necrosis results, which in turn leads to the fistulae or abnormal connections to the birth canal, which further results in the mother becoming incontinent. The mother leaks urine and faeces down her legs and thus is wet, filthy and foul smelling and is rejected by her husband, family and society. Tragically, she is also regarded as having been unfaithful to her husband and is condemned and ostracized. There are tens of thousands of these mothers who need loving care, through surgery, excellent nursing care, rehabilitation and counseling (Id.)
Instead, most of these mothers receive only a bowl which they carry between their legs. Some 500,000 to 1 million women, mostly in sub-Saharan Africa, suffer the consequences of obstetric fistulae.
Eradicating such a devastating condition should logically be a top priority of the UN-sponsored "Safe Motherhood Initiative" (SMI). Readers of Life Insight (see, e.g., the October 1997 issue) will remember, however, that SMI has little to do with safety, motherhood or letting women take initiatives. Dr. Walley has found that "almost $5 billion is spent on birth control programmes by aid agencies to reduce world fertility rates, but only a small fraction is spent on helping women survive their pregnancies" (Walley, op. cit).
PRI arranged for a Peruvian doctor and two victims of Peru's massive, coercive sterilization program to brief Congress and the national media. They say that over 100,000 Peruvian women in the past year alone were sterilized, often under duress. Peru, incidentally, has a relatively low population density of 19.5 persons per square kilometer. By comparison, the U.S. population density is 27.8 persons/sq. km. Hector Chavez Chuchon, M.D. described the pressure and incentives on medical personnel to meet monthly quotas of sterilizations. Examples were cited of illness and deaths resulting from sterilizations performed in unhygienic settings by poorly trained staff. After surveying only 30% of Peru's territory, investigators have uncovered the sterilization-related deaths of 18 women and serious injuries to 180 women. Evidence was given that women who were sterilized lacked knowledge of the procedure and could not freely consent to it. Coercive threats and incentives (such as infant nutrition supplements and children's clothing) were used to induce Peruvian women to agree to tubal ligation, which they may have been led to believe is a temporary and reversible form of "contraception." The partial survey found over 1,000 cases of sterilizations performed against the woman's will. (Catholic World Report, March 1998, p. 44)
Bowing to swift public condemnation of the Peruvian campaign and U.S. involvement in it, Mark Schneider, a USAID official, was quick to state that Peru "was abandoning its mass sterilization campaign, abolishing the quota system for tubal ligations, and implementing other reforms," according to a PRI news release. But Peru's Minister of Health Marino Costa Bauer seemed to contradict Schneider the next day. He pledged to "deepen, improve, and extend the family planning program to all Peruvians" and made no mention of abandoning targets, quotas or coercive practices.
Peru is one of over 40 countries in which human rights abuses have been documented in the enforcement of population policies, according to PRI. In Mexico and other countries in the developing world, women may be sterilized or have IUDs inserted immediately after giving birth, without their knowledge or consent, and even against their express wishes.
USAID is not the only channel for funding such coercive programs. The World Bank loans $2.4 billion annually for "health, nutrition, and population" programs. A population sector review issued by the World Bank refers approvingly to an array of family planning incentives and disincentives for example, promising a new well or irrigation system to a village provided all (or nearly all) villagers accept sterilization or another long-lasting form of contraception. World Bank documents (e.g., "Population and the World Bank: Implications from Eight Case Studies," 1982) reveal that the Bank has tied lending and disbursement to the adoption of, and compliance with, population measures.
Some have suggested that the only way to put a stop to the coercion and abuse occurring in the current "family planning" programs is to cut off U.S. funding entirely. Congressional and public support for U.S. funding of international family planning, however, is broad-based. But that support rests on several faulty assumptions:
First, that the family planning programs are voluntary: neither coercion nor serious abuses of human rights are involved.
Second, that funds are exclusively used to provide contraception, not abortion.
Third, that current family planning programs improve the reproductive health of women in developing countries.
Fourth, that voluntary family planning programs are effect-ive in reducing fertility rates.
Fifth, that population growth must be curbed to spur economic development and reduce "overpopulation," with all its perceived threats such as mass starvation and natural resource depletion.
Most Americans would reject a policy that trampled on human rights, violated host country laws against abortion, endangered women's health, was "effective" only when conducted coercively and, finally, was unnecessary. Evidence continues to mount from victims, from human rights groups, and even from agencies that support, conduct or monitor population control activities that the stated assumptions underlying support for population control are not valid.
Although the media have been slow to publicize coercion and abuses in family planning programs, thanks to organizations like PRI the body of evidence is quickly growing.
Life-threatening ectopic pregnancies can also occur. Sterilization elevates the risk of ectopic pregnancy and increases by four to five times the need for a hysterectomy. (Hillis, S.D. et al., "Higher Hysterectomy Risk for Sterilized than Nonsterilized Women: Findings from the U.S. Collaborative Review of Sterilization," Obstetrics & Gynecology, Feb. 1998).
Few American women and doctors are willing to assume the risks of using IUDs, Norplant and Depo-Provera to control fertility. American women aged 15-44 have the following rates of use: half of one percent use an IUD, fewer than 1% use Norplant and fewer than 2% are using Depo-Provera. (Family Planning Perspectives, Jan-Feb 1998) Why, then, do some think the risks are tolerable for other women?
Dr. Walley's heartfelt plea on behalf of his West African patients is disturbing evidence that women's health has been neglected in favor of the goal of curbing population growth in the developing world. His conclusions are echoed by a Kenyan ob/gyn, Stephen K. Karanja, who describes how population control programs undermine his patients' health:
USAID and other Non-Governmental Organizations funded mainly by the U.S. Government have targeted our people with a ruthlessness that makes one shudder....
Our health sector has collapsed. Thousands of the Kenyan people will die of Malaria, whose treatment costs a few cents, in health facilities whose shelves are stocked to the roof with millions of dollars worth of pills, IUDs, Norplant, Depo-Provera, most of which are supplied with American money....
Some of the contraceptives like Depo-Provera cause terrible side-effects to the poor people in Kenya, who do not even have competent medical check-ups before injection. Many are maimed for life. The hypertension, blood clots, heart failure, liver pathology and menstrual disorders cannot be treated due to the poor health services....
Money is not used to educate people on basic hygiene, proper diet or good farming methods that would be useful to development, but it appears that the aim of population controllers is to decimate the Kenyan people....
A mother brought a child to me with pneumonia, but I had no penicillin to give the child. What I have in the stores are cases of contraceptives.
Malaria is epidemic in Kenya. Mothers die from this disease every day because there is no chloroquine, when instead we have huge stockpiles of contraceptives.
I see women coming into my clinic daily with swollen legs they cannot climb the stairs. They have been injured by Depo-Provera, birth control pills, and Norplant. I look at them and I am filled with sadness. They have been coerced into using these drugs. Nobody tells them about the side effects, and there are no drugs to treat their complications.
It is economic development, not contraceptive availability alone, that correlates to reduced levels of fertility. With economic development, girls stay in school longer, marry and begin having children later, and space births more widely to accommodate work outside the home. Development can also lead to a desire for material goods and comforts and a reduced willingness to accept the sacrifices involved in child rearing.
Coercive sterilization programs, like those in China, India, Pakistan, Peru and elsewhere, can reduce population growth, but clearly at a terrible price.
Statistics available from the U.S. Census Bureau, the U.N.'s World Population Prospects: The 1996 Revision, and World Bank documents demonstrate that fertility rates have declined dramatically in recent decades, so much so that we are facing a crisis of too few young people to support the increasing numbers of elderly. In 79 countries (including many in the Third World) fertility rates have fallen to or below replacement level. (U.S. Census Bureau) By 2015, the UN estimates that 67% of the world's countries will be included in this group. The UN's newly adjusted projections (Nov. 1997) expect world population to peak at about 7 billion in 2030 and then decline.
Are we running out of food? The World Bank's World Food Output (1993) reports that "dramatic" gains in food production and consumption since the 1960s far outstrip population growth. The real price of cereals in the world market has declined by more than half between 1960 and 1990. Using only half of the world's arable land, they estimate cereal production could increase 18-fold with current technologies. Per capita calorie consumption in developing countries has increased by 27% since the early 1960s. A World Bank report even recommends that "grain production increases will need to slow if huge stock accumulations are to be avoided" (The World Food Output, Nov. 1993, p.155). Agricultural experts have estimated that the earth could easily feed 11 billion people with current technology and farmland.
Are we running out of natural resources? The prices of oil and minerals continue to drop throughout this century despite explosive demand.
Eberstadt's article demonstrates how the "overpopulation" problem has been misidentified. We cannot even define when population is "over." Density, for example, is not necessarily a problem because population density is greater in Bermuda than in Bangladesh, in Germany than in the Philippines, and in the U.S. than the continent of Africa. The most "overpopulated" spot on earth is the kingdom of Monaco. Growth rates cannot simplistically be defined as a problem either: the rates in Africa are currently the highest in the world, but are still lower than those in North America in the latter half of the 18th century. The problems we associate with over-population hunger, urban crowding, lack of sanitation, disease result from poverty. Eberstadt observes that there are many ways to reduce poverty including "properly functioning markets for labor, capital, and goods." It is both wrong and unnecessary to eliminate people as a means to reduce poverty.
For some people there is another, less altruistic, agenda at work in population control. In the late '60s and early '70s, when population control was first promoted as essential to U.S.for-eign policy, some believed that the rise of strong, populous nations in the Third World might compromise U.S. access to their oil and mineral deposits. There was concern that U.S. investments in the Third World might be confiscated and nationalized, as well as fear that a large, young population might be susceptible to Communist influences and cause political instability.
Still skeptical? See "Baby Bust Ahead" (Barron's, Dec. 8, 1997) in which Jonathan Laing explains how America's richest philanthropists are spending hundreds of millions of dollars annually to solve a problem "overpopulation" that doesn't exist. The otherwise delightful irony of this situation is completely overwhelmed by the magnitude of the human tragedy to which they (and we) are contributing.
Responding to the Holy Father's call in The Gospel of Life, Dr. Walley formed MaterCare International in 1995 with a group of Catholic ob/gyns and midwives. This now worldwide organ-ization of Catholic health care professionals (OBs, neo-natologists, GPs, midwives and others) seeks "to encourage and provide opportunities for integrating professional knowledge, skills and experience with the Catholic faith, in a new and authentic way" (www. matercare.org). Among the major projects MaterCare has undertaken or proposed are the following: a fistula treatment center in Ghana, a training course for doctors and midwives in Africa to improve pregnancy and labor care, publications including a textbook on the scientific foundations of NFP, a video on maternal mortality and morbidity, a website and a newsletter.
The very least we can do is to keep informed, educate the media, and tell Congress to stop funding coercive family planning.