Nikki van der Gaag labours her way
through the labyrinth of
contraception, pregnancy, birth - and politics.
SEVEN even months pregnant with my first child, I was standing in line at a pharmacy when an old woman sitting on a nearby chair called out to me.
'First baby, is it?' I barely had time to reply when she went off into a reverie:
'I remember my first... ooh I had a terrible time. Took three days, it did. Blood everywhere. And I was in such pain - they didn't have your fancy painkillers then.'
'When was this?'
'1938. It was 5.15 am on Tuesday 22nd March.' She remembered with unhesitating precision.
At this point she was called to collect her prescription. I breathed a sigh of relief.
'Well, good luck,' she called cheerily.
'Thanks.' By this time I felt I needed it.
In the months that followed it was extraordinary how many women told me their birth stories. Often, like the woman in the pharmacy, they were alarming. Sometimes they were wonderful, the woman's face glowing with joy as she spoke. Mostly they were a mixture of both. I felt I had entered a special world, a world of women's deepest experiences and most precious secrets. I also felt bloody nervous.
About the same time that I was having these conversations I was beginning to notice how much people were staring - or trying hard not to stare - at my belly. It was as if I no longer existed. It was the child inside me that was now the focus of attention, not the woman who contained it. Complete strangers at parties (particularly but not exclusively men) felt at liberty not only to patronize me, but to pat my stomach as though it was in the common domain rather than a part of me. My body had suddenly become public property.
And I suppose it was. Being pregnant means not only preparing to become a mother, but entering a fraught and complex world, where people feel they can tell you what to do and everyone wants a piece of the pie - which in this case happens to be your body, or rather, your womb.
Adrienne Rich's memorable book, Of Woman Born, points out the many and contradictory ways in which society views a pregnant woman: 'as proof of her husband's sexual adequacy; as dangerous to crops or men; as especially vulnerable to the evil eye or other maleficent influences; as an embarrassment; as possessed of curative powers.'
Pregnancy is a symbol of the mystery of sex and creation, the harbinger of birth and perhaps even a way of cheating death. No wonder it is seen as powerful. And there is an important dichotomy here. Being pregnant heralds a new person, but one who is brought into the world by another who already exists. They are one, and yet not one. Mother-and-baby, but also baby - and mother. It is often forgotten in these debates is that it is generally the woman's responsibility not only to bear the baby but to raise the child it becomes.
But who is more important? Who gets precedence if there is a conflict of interests? And who decides? The mother? Those who say they speak on behalf of the baby? The medical establishment? The father? The mother-in-law or father-in-law?
Society exerts its own pressure on a woman, depending on her age, race, sexuality, class, where she lives and how much money and education she has. For many women reproduction happens in a context where they have no power to make even the most day-to-day decisions. 'No contraceptives,' says her husband, 'I want another son.' 'No abortion,' says the government or the Church or the Imam. 'This is what you must do,' says the doctor or the traditional healer in the village. Common practice, local beliefs and lack of power dictate how she is born, how she lives, and all too often how she must die.
Because for too many women, birth is the end rather than the beginning of life. One woman dies every minute from causes related to pregnancy and childbirth. For each death at least 13 others suffer a less serious threat to their health - one which can leave them permanently disabled.
Most maternal deaths are in the Majority World. A woman in Africa is 500 times more likely to die of pregnancy-related causes than a woman in Scandinavia - although poor or minority women everywhere are the most at risk.1 In the US, for example, black women face a risk nearly four times as high as white women. 2
It is a tragedy that women die giving birth. And what is worse is that in large part it is an unnecessary tragedy. Women die because they lack proper medical care; or because they can't pay for it; sometimes they die because they don't have transport. They also die because they try to abort an unwanted baby themselves - illegal abortion accounts for an estimated 20 to 25 per cent of maternal mortality worldwide.
And they die because they are still children themselves, their bodies too young to give birth safely. One in four women in Asian and Africa is married before the age of 16.
But things are changing, albeit slowly. In some countries - especially parts of sub-Saharan Africa and Latin America - early sexual activity (which generally means early marriage and early childbirth) is declining.1 Increasing numbers of people have access to contraception (though 350 million couples who want it still can't get it) and there is growing awareness of the harmful nature of female genital mutilation.
An active women's health movement has made sure that reproductive rights remain on the international agenda as well. 'After all these years,' said Sandra Kabir of the Bangladesh Women's Health Coalition at the UN Conference on Population and Development in 1994, 'the world is finally talking about reproductive health policies.' 3
In India, for example, the Supreme Court banned the use of the drug quinacrine for sterilization earlier this year after women worldwide campaigned against it. In Australia, feminists are demanding the decriminalization of abortion laws. 4 In Afghanistan, women are refusing - often at considerable personal cost - to cede control over their bodies, their minds and their lives to the prevailing fundamentalist version of Islam.
but will this young woman in Nepal be under pressure
to have more children than she wants?
HARTMUT SCHWARZBACH / STILL PICTURES
In the West, we are bombarded daily with stories of new scientific developments: we're promised cloned babies; artificial placentas; the ability to conceive after menopause and many other 'advances'. The challenge here is to decide which technology will improve women's choice and control over reproduction, and which will take it away. Very often new scientific developments have wide-ranging moral and ethical implications. These need to be considered before new reproductive technologies are introduced, not after.
For example, much of the testing of new contraceptives is done on women in the Majority World, often in the name of population control. The alarmist calls sound from loud voices in the US and other Northern nations. But they are directed at the people of Africa, Asia and Latin America:
'It is not physically possible for population growth to continue for long at today's levels. The current size of human population and the additions made to it each year, are unprecedented in history,' says the US-based Population Reference Bureau.
There is no doubt that the world's population is increasing - at the rate of 80 million people a year. What is in question is a) how much of a problem this actually is and b) what to do about it. And here there are three main camps.
First, the conservative position, which is against abortion and contraception (apart from 'natural' methods). This is backed by the Catholic Church and some Muslim states, in alliance with right-wing groups.
Second, the population control people, who threaten Malthusian disaster if growth is not slowed.
And third, those who place the woman's needs at the centre of the debate. This includes the women's health movement, which believes in safe and affordable contraception, but also think that the alarmism over population is misplaced and overrated. It is the fact that the world is unequal that is a problem, they say, just as much as the numbers of people in it. For example, my own two children will consume twenty times as much as two children in Asia, Africa or Latin America - and cause ten times as much pollution.
They believe that women's health choices rather than population control should be the objective of birth control programmes. This means that quality must be the focus of family planning. How is the contraceptive being delivered? Does the woman have enough information about how to use it? About possible side-effects? What about medical personnel? Sterile conditions? Is the woman herself happy with her choice? In control of what she wants to do? If so, then a woman is likely to want fewer children in any case.
Adverse experiences with contraception - lack of information, unpleasant side-effects - are a sure-fire way of putting women off birth control (as I remember well when a particular Pill gave me migraines). Giving a woman the security of a job, a roof over her head, affordable and accessible healthcare and a school to send her children to is a better way of controlling population than any number of forced sterilizations.
In China, there is some debate about how successful its infamous coercive population-control policies and its one-child policy have been. It is true that fertility rates have dropped from 3.3 children per woman in the 1970s to 1.7 in 1994. But China achieved substantial reductions in its birth rate through economic and social changes before the one-child family policy. 5
Improvements in people's standards of living have gone further than coercion in persuading people to limit their family size. Poor people often want more children at least partly as an insurance against old age. They know that some of their children are likely to die. If this risk is reduced through improvements in their livelihoods such insurance becomes redundant.
For many couples in China economic security is not longer just about having babies. As a government minister pointed out: 'In order to become rich more quickly and build up a society that is comfortably off, many couples would like to have fewer children and delayed child-bearing. They prefer 'gold babies' to chubby babies [ie they prefer to get rich before having children].' 5
Unfortunately, for many millions of the world's poor the trend is in precisely the opposite direction. Their babies are neither golden nor chubby. Structural adjustment policies imposed by the International Monetary Fund (IMF) have led to cutbacks in health care, education and infrastructure in many countries, leaving people without even basic medical services. Ironically, spending on family planning is often more than the relatively small amounts spent on health care. This is partly because money for family planning often comes from outside donors while health care is an internal matter, and partly because birth control has been given high international priority. For example, in Bangladesh and India spending on population control absorbs from one-quarter to one-third of the annual health-care budget. 5&6
'Bangladesh has been so preoccupied with the pressing problem of its population explosion that the general health situation has not received enough attention,' says the World Bank. In Indonesia almost twice as many family planning clinics as primary health-care centres have been built. 7 In the meantime, big business makes big bucks out of birth control - multinational drug companies rack up contraceptive sales between $2.6 billion and $2.9 billion a year. 8
Many of these concerns were debated at the UN Conference on Population and Development, held in Cairo in 1994. In addition there was a vocal right-wing backlash led by fundamentalists from a range of cultures and religions, which called for the abolition of legal abortion and the suppression of contraception.
It was a measure of the effectiveness of the women's health movement that the conference moved as far as it did towards recognizing the link between reproductive health and the wider context of women's empowerment. There was also a clear understanding that unsafe abortion is a public health problem; that men too must be responsible for family planning and that gender discrimination, violence against women and female genital mutilation must stop.
For these statements to become reality will take not only serious cash but a serious commitment on the part of everyone, from governments to the grassroots. If it happened it would herald the birth of a revolution in women's lives. But as yet, there isn't much evidence that things have changed substantially since the conference.
If all women are to have the choices that I did then we are talking about a sea-change. The goal is a world where women have control over their own lives and their own bodies; where they have education, employment and access to good health services; a world where a woman has the ability to choose to have the number of children she wants; not to have unsafe sex; not to be genitally mutilated or married at a very young age; not to be beaten or raped.
That would be real revolution. Let's make it happen.
1 The State of World Population 1997 (UNFPA)
2 World Health Organization magazine (Jan/Feb 1998)
3 Quoted in People and the Planet, Vol 3, No 4. Article by Bishakha Datta.
4 Jo Wainer and Nancy Peck, 'By Women for Women: Australia's National Women's Health Policy', in Reproductive Health Matters, No 6, Nov 1995.
5 Betsy Hartmann, Reproductive Rights and Wrongs (South End Press 1995)
6 Imrana Qadeer, 'Primary Health Care: A Paradise Lost', (Indian Association of Social Science Institution Quarterly, No 14)
7 A Adrina, 'Family Planning Program in Indonesia and its impact on women', paper delivered at Hearing on Multilateral Population Assistance, Oslo, 1994.
8 Sonia Corrêa, Population and Reproductive Rights: feminist perspectives from the South (Zed Press 1994).