Instrument of freedom or oppression
In this article, the workers at Gonoshasthaya Kendra (People's Health Centre) in Bangladesh report on their efforts and problems in making family planning an instrument of emancipation and self-determination of women rather than of oppression. A fuller account of the work of this health center will be given in the next issue of the ISIS bulletin. This report is dated December 1977.
Family planning is the field which has perhaps most exercised our minds over the last two and a half years. It is not so much that we believe in the overriding importance of the population issue over other problems facing Bangladesh, but because we have seen how a concept that should serve to increase the quality of life of the poor, and in particular, should lead to greater freedom and self-determination of women, has become perverted into another instrument of oppression. Despite numerous analyses which show that poverty is a cause of the population explosion rather than its result, the myth of population control is perpetuated by an interplay between the large donors, who reflect the terror of the industrialized rich at the teeming Third World poor, and local greed, which finds an opportunity to line its pockets when money Is thrown about In crash programs. Our experience in this respect has inevitably influenced our thinking and practice of family planning.
During 1974, when the idea of family planning had become more familiar to many of the local Savar Thana women, we received more and more requests for more long-term, and less cumbersome methods than the Pill, and we started to offer tubectomies (female sterilization). Soon we found that the doctors could not cope with the additional workload, and they gradually trained a small number of female paramedics to do the operation. The paramedics showed great ability and manual dexterity and the results, both in terms of client demand and of operative complications and infection rates, were excellent.
This new venture caught the eye of, among others, some UNICEF officers, who encouraged us to set up a satellite program in the subdividisonal town of Jamalpur, about 100 miles north of Savar. For over a year, from the end of 1974 onward, we had an arrangement where a team from our center should go each week to Jamalpur for two or three days, to operate and provide a - very limited - maternity and child care service to tubectomy clients. Our work was then carried out on the premises of the Jamalpur subdivisional hospital and financed by UNICEF.
From the beginning, sterilization programs on the subcontinent, usually conceived as single-purpose, short-term crash affairs have been dogged by incentives doled out to medical personnel, "agents", and clients. Our approach was different. At the Savar Center, where people were by then used to our policy of asking for payment of services, we charged 6.00 taka per tubectomy, while in Jamalpur this charge was paid to us by the Thana Family Planning Officer out of government funds because the people of the area were suffering from the effects of severe floods and many were destitute.
After some months, we became aware that the Family Planning Officer had been paying incentives to some of our clients under the pretext of "transportation allowance", in accordance with government practice elsewhere, although we had insisted that this was quite unacceptable to us. We then saw with our own eyes how even these miserable 15.00 taka, when offered to starving people, made them willing to compel their wives or daughters-in-law to undergo the operation. Soon afterwards, we were also able to observe the effects of the government organized sterilization camps in various places, where larger incentives to all parties involved were given, the accompanying corruption as well as the element of coercion which is inevitable once incentives arrive on the scene. The funds for these expensive program came from USAID, channeled through the government Family Planning Officers, as well as such organizations as the Family Planning International Assistance (FPIA), and the International Projects of the Association for Voluntary Sterilization (IPAVS) and their Bangladeshi branches.
At the time, we were tempted to follow the counsel of despair and wash our hands of sterilizations and family planning in general, as it seemed impossible to provider service which preserved the interests and dignity of the poor. But in the end, the experience served to clarify our position on the issue: we believe that family planning should be one pgrt of a general, permanent, primary health service, where women can be assured of constantly available advice and supplies, and where family planning is a means toward the emancipation of women. We must resist an attitude where pregnancies and babies are treated as an epidemic that has to be eradicated once and for all.
It was, therefore, a logical step to make our presence in the Jamalpur area more permanent, and from April 1976 on-wards, some Savar paramedics together with some local recruits began to live in rented accommodation in the town, while operating from a part of the government center. There are 93 such maternity centers with a standard 15 rooms each in Bangladesh, all of them practically unused. Yet one of the items high on the government's list of priorities is to construct 40 more such centers. At the Jamalpur center, an average of 4 to 5 deliveries a month had taken place and this had been its only function. For the time being, we hoped to put just this center to its proper use and provide a good family planning and maternity service within the guidelines of the government and in cooperation with existing government personnel. However, the District Family Planning Officer, who presumably found his opportunities for money-making curtailed by our presence (sterilization incentives, handling of medicines, etc.), started agitating against our paramedics and instructed his subordinates not to cooperate with us, taking the death of one of our tubectomy clients from tetanus (operated on by a doctor) as a pretext. When our requests for apologies from the officer to the paramedics and proper cooperation were not met, we withdrew from the Jamalpur maternity center in April 1977. Shortly afterwards, the District Family Planning Officer also left the scene: he was transferred because a national newspaper had published serious evidence of corrupt practice on his part.
The health also of the majority of women in the region is a matter for serious concern. Anemia, caused by poor nutrition and worsened by pregnancies, nursing and IUDs, is endemic. Malnutrition and its associated illnesses cause a susceptibility to parasites, infectious diseases and lethargy. These plus constant childbearing drain the strength of the woman whose responsibility it is, on the whole, to provide basic needs of the household.
The Critical Needs of Women
UN Asian and Pacific Center for
Women and Development,
Teheran, Iran
Meanwhile, we had been offered a piece of land by the villagers of Shapmari, about 20 miles from Jamalpur in Sherper Thana, who asked us to come and set up a health service in their area. Our team therefore moved to Shapmari in 1977. As we had promised to Jamalpur sterilization clients a long-term follow-up service, the team continues to hold clinics in Jamalpur once a week.
In the various centers, a total of 2826 tubectomies have been performed, 2351 of these were carried out by 21 different paramedics, 475 by 12 doctors, and 3 medical students. Among the cases operated by doctors and medical students, 42 (8.8% ) experienced wound infections; among the cases operated by paramedics 133 (5.6% ) became infected. Thus, average infection rate was 6.1 %. The infection rate in operations performed by paramedics is lower than that of doctors, but this may be misleading since doctors tended to take on the more difficult-loo cases, and paramedics are instructed to call a doctor if encounter difficulties during operations.
Two tubectomy clients died, both of tetanus, and both in the Jamalpur area before we could organize a general tetanus immunization program. It was our practice to, give tetanus toxoid at the time of the operation. The woman who died had also procured an herbal abortion one week before having the tubectomy, and developed symptoms of tetanus on the 7th post-operative day. We have had three tubectomy failures; two of them operate paramedics, the other by a doctor.
Over the last three years we pioneered the use of and contraceptive method in Bangladesh: the injectible Depo-provera, which was chosen by 3500 women. Although the method Is very convenient (only one three-month or six-monthly intramuscular injection is needed to give protection), many women suffer from menstrual side effects and something that is perhaps more serious In a country like Bangladesh, we found, contrary to the scientific literature on the subject, that the method decreases lactation in some of the women. We have therefore argued against use of Depo-provera In a nationwide program at present time, and suggested that the health authorities organize a wider trial of the method In the eight the adjacent to Bangladesh's medical colleges. We have offered the Pill, and there are, at present. 800 continues (over six months of constant use). Overall, in our insurance area (population 100,000), family planning Is practiced 25% of the fertile population.
Abortion has continued to be In demand, and while in the beginning, women often came with requests for about in the last trimester, they now tend to come earlier. Up to ten weeks, we use "menstrual regulation" (suction) an dilation an curettage; from 11 to 20 weeks, we prostaglandins; and thereafter catheter and/or prostaglan A total of 219 abortions have been carried out. Sir to people working In other areas of rural Bangladesh, we found that the number of abortions carried out by vi midwives and practitioners is very high, and unfortunately we are still quite often faced with resulting sepsis, tetanus or incomplete abortion.