issue 176 - October 1987
Better safe than sorry
That's the philosophy of modern contraception. But it's
not a philosophy that all women share. Many would prefer to
risk a pregnancy than put up with the side-effects of
'efficient' contraception. Mary Warren reports.
'We would gladly accept family planning,' said women at a village meeting in Java, 'provided that it doesn't interfere with our work, or do us any permanent harm, or be against our religion. It also has to be explained to us by a woman, who will examine us if necessary and keep it a secret. It should also cost very little money.' They seem such simple, such obvious, requirements. Yet, on these grounds alone, not one of the widely touted types of modern contraception would be acceptable.
Take the first two, about health, for instance. Side effects of the IUD and hormone contraceptives like the pill and Depo Provera are major reasons why between 40 and 70 per cent of users in the Third World abandon them within two years. Fear of side effects prevent a further 25 to 33 per cent using them at all. In the rich world, too, women are abandoning the pill and IUD in droves. Pill use in the US dropped from 61 per cent of couples in 1973 to 45 per cent in 1982.
The growing distrust of such methods arises from a mixture of sources. 'A woman in the next neighbourhood has one of those coils inside her,' said someone at a village meeting called by family-planning workers in Bangladesh. 'It hurts and she bleeds all the time. She wants it taken out' 'Go and get her,' the workers ordered. Eventually a frail young woman appeared, shaking with fear, and was taken into a nearby house. Five minutes later she emerged, clearly in pain, covering her face with a sari. One of the family planning workers laughed: 'It may have hurt but she didn't get pregnant. Now she will - and she'll be sorry.' She was sorry. She died later. No-one knew the exact cause, but many had their suspicions.
Such suspicions are justified - not only by individual horror stories, but also by a growing number of scientific studies of the side effects of modern contraception. Half of all maternal deaths in the US in 1975 were caused by contraceptive complications. One in 500 pill-users in the UK are hospitalized each year as a result of its adverse effects. Two-thirds of women using the injectable Depo-Provera experience what has been dubbed 'menstrual chaos' in the first year, some bleeding so frequently that they have to receive transfusions.
This does not mean that all these methods should be banned: on the contrary - banning contraception might simply lead to a sudden rise in both abortion and childbirth, both of which are likely to be at least as dangerous for women's health in a poor country. Even in the rich world, childbirth is between one and a half to three times as dangerous as the pill and nearly 11 times as dangerous as being sterilized or using the IUD.
In fact women are clearly already making this kind of calculation for themselves and many do decide they would rather run the gauntlet of contraceptive side effects than risk a pregnancy and cope with the consequences. But the numbers deciding in favour of contraception are far fewer than might be predicted from a simple comparison of relative death risks. And this has the experts confused. Why, they ask themselves, do women continue to subject themselves to the terrors of a back street abortion or the tortures of perilous labours, when reliable means of preventing pregnancy are at hand?
One reason is that women, particularly in the Third World, are often not aware of the real dangers of contraception because health staff and pharmaceutical companies keep them in ignorance for fear of making them stay away from the clinic. Unfortunately this produces the exact effect they are trying to prevent Without proper information, women simply become suspicious - quite rightly - that they are being manipulated and interpret even perfectly unrelated symptoms as being due to their contraception.
Another reason why so many women reject the battery of contraceptive weapons on offer at the family-planning clinic is that the arsenal has not been designed with their needs in mind. Women who want a number of children, for instance, may not be too concerned that their contraceptive should be 100 per cent reliable. They would gladly put up with a certain level of pregnancy risk if it meant fewer side effects. For them the dangers of infertility - real or imagined - may far outweigh the dangers of fertility. The fact that IUD users are up to nine times more likely than non-users to contract a sterilizing infection is enough to rule it out for large numbers of women, despite it's reliability as a contraceptive device - if they are aware of the dangers, that is. Both the pill and injectables may also interfere with fertility after people have stopped taking them.
Sadly, population planners and contraceptive manufacturers do not seem to share women's concerns. Since 1965, for instance, less than 10 per cent of research money for contraceptives was spent on studies of safety. Over thirty times as much public money was spent globally on hormonal and surgical contraception in 1978 than was earmarked for the less 'reliable' (but infinitely safer) barrier methods, such as condoms and diaphragms. In 1980 to 1983 only 12 per cent of research money went into developing a male contraceptive. And research into traditional methods such as rhythm, Billings, coitus interruptus, breast-feeding and others is negligible.
But, ironically, there is evidence that 'efficient' methods may in fact turn out to be less reliable than their less efficient traditional counterparts. In Bangladesh, for instance, the birth rate in one village went up after the pill was introduced because it both interfered with lactation (90 per cent of users were lactating mothers - and lactation is known to help prevent ovulation), and was abandoned by 80 per cent of the women because of side effects. In the UK a study in 1970 found that people were twice as likely to continue with coitus interruptus than with the diaphragm and in 1974 the International Planned Parenthood Federation declared that this time-honoured method 'probably remains the most widely used of all on a global scale'.
However, the one problem with traditional methods of family planning is that they almost invariably require that the man be involved as well As Gandhi put it 'The problem of unwanted pregnancy would be solved if men would but love their wives'.
Mary Warren is a novelist and Journalist specializing in health and family planning.