‘We should be talking about sex!’ said one exasperated family planning promoter from Vietnam. She was dismayed at how arcane the discussion at the population scientists’ conference had been getting. ‘Population is sex action!’ she insisted. ‘It’s about man and woman having sex!’
Or not having it – as the Bush Administration, the Vatican and other ‘abstinence’ ideologues prefer.
One of the first things President Obama did on coming to office was indicate that he would reverse the ‘global gag rule’ which for seven years had blocked $244 million of US funding for family planning around the world – a promise now tempered by the economic recession.
Heavily influenced by the Christian Right, the Bush Administration had prohibited overseas organizations from receiving US family planning assistance if they used their non-US funds to provide abortion information, services or counselling, or engaged in any abortion rights advocacy.
Furthermore, money was directed away from pro-condom campaigns and into ‘abstinence-only’ drives.
The condom stopped being the ideal item to help protect against both HIV and unwanted pregnancy, and was vilified instead. The latex demon encouraged promiscuity and, its detractors argued with a logic of medieval perversity, thereby caused the spread of HIV.
Typical of anti-condom propaganda is a Tanzanian poster, displayed near a school in March 2008, depicting a skeleton and captioned: ‘Faithful condom user’.
Such campaigns were especially effective in sub-Saharan Africa – a region with the world’s highest fertility rates, the lowest contraceptive use and highest incidence of unsafe abortion. It is also the most devastated by the AIDS epidemic.
Anti-condom propaganda popped up everywhere. I recall a Kenyan health professional telling me that condoms were useless because they had ‘lots of tiny holes in them’.
The damage done is probably immeasurable. But it was made easier by memories of coercive and deceitful ‘population control’ drives in the past that targeted people in developing countries. These give resonance to current religious claims that contraception is all about trying to stop Africans having babies; that family planning is, in short, an assault on African fertility and African culture.
Uganda, which during the 1990s had a bold, proactive and effective HIV prevention policy based on widespread promotion of condoms, had by 2005 turned anti-condom and pro-abstinence. ‘Abstinence’ parties and rallies were held for youth. Without much success. Although nine out of ten young Ugandans surveyed rate religion as an ‘important’ part of their lives, half of 15-19 year olds have had sex. The country has one of the highest fertility rates in the region.
‘We don’t think abstinence is really working in our communities,’ concludes a youth leader from Kabarole. ‘We always come with the message to delay sexual début. But for most [school students] here, this is not enough.’1
Sex goes on being had, without protection, with consequences.
Worldwide, the abortion rate is declining. But not in sub-Saharan Africa, where it is mainly illegal and unsafe. The country with the highest unsafe abortion rate in the world is Nigeria, where one in ten women of childbearing age has had one.2 According to conservative estimates, unsafe abortion claims the lives of more than 3,000 women a year here, which is why Nigeria’s maternal mortality rate –1,100 deaths per 100,000 live births – is one of the world’s highest.3
*Keypoint* - Family planning remains a fundamental women’s rights issue. Worldwide 61% of women who need it have access to contraception. Many of those who don’t, for whatever reason, resort to unsafe abortion.
Women die of complications caused by incomplete abortion, infection and excessive blood loss. Or they may suffer septic shock and trauma to reproductive and other organs. One in four Nigerian women who have abortions experiences serious complications but only a third of these seek the emergency medical treatment they need.
Poor women are most at risk from unsafe abortions because they rely on traditional methods; richer women tend to use the services of health professionals operating clandestinely.
Often deaths are hushed up. Asked whether death from abortion was common in her community, a 20-year-old Nigerian student responded: ‘Maybe it happens, but who will tell you somebody died from abortion? If someone dies, they will say it is from a brief illness.’ 4
Abortion is most common among women who are young, unmarried and childless. Women like Grace, a student living in a Nigerian city. She first had sex when she was 15, but never used contraception because she didn’t believe she would get pregnant. It was also against her religious beliefs and she feared side-effects. She became pregnant at 18 and decided to have an abortion because she did not want to drop out of school and was afraid of the shame it would cause her parents and the man who had made her pregnant.2
In Nigeria the proportion of women who have unsafe abortions is higher among Catholics (19 per cent) than among Protestants and Muslims (11 per cent and 5 per cent respectively) – even though Catholicism is most condemning of abortion. When women are desperate, legal or religious sanctions have little impact. In Western Europe, where abortion is legal, the rate is 12 per 1,000. In Africa, where it is mainly illegal, it is 29. This figure is probably too low due to under-reporting.5
Abortion – falling globally but rising in Africa
Worldwide the number of abortions fell from an estimated 45.5 million in 1995 to 41.6 million in 2003. But in Africa they rose from 5.0 million to 5.6 million, only 100,000 of which were performed under safe conditions.
An estimated 92% of women of childbearing age in Africa live in countries with restrictive abortion laws. It is absolutely forbidden in 14.
The World Health Organization estimates that in Africa one in seven maternal deaths results from unsafe abortion.
Source: Guttmacher Institute, Abortion Worldwide: A Decade of Uneven Progress, 2009.
When the gate is barred
The abortion rate in sub-Saharan Africa is high for the same reasons that fertility is high: underfunded, family planning is not reaching women who need it and patriarchal and religio-political hostility to contraception prevails.
A high rate of risky abortion is the clearest of all indications that there is a serious unmet need for contraception. In the world generally, poor and rural women are least likely to get the contraception they need. But in sub-Saharan Africa it’s across the board. For single and unmarried women, getting hold of contraceptives is especially tricky. Researcher Agnès Guillaume explains: ‘Family planning is often delivered only through mother-and-child clinics. This is no good for unmarried women without children.’
Poverty and sexism increase the risk of unwanted pregnancy, especially for the young. Young women and girls who are poor may trade sex for money. More than half of adolescents surveyed in Malawi had experienced forced sex and 60 per cent had accepted money or gifts in exchange for sex. And although 90 per cent of 15-19 year olds approved of contraception, most who were sexually active did not use it.6
For married women, gender inequality can play out in different ways. Sometimes women are stopped from using contraception by husbands who fear that it will encourage them to ‘play around’. But one of the most common reasons given by both women and men for not using methods of contraception other than condoms (such as the pill, the IUD, injectables and emergency contraception) is fear of side-effects – especially infertility.
Abortion is perceived as safer than contraception. A 22-year-old Nigerian undergraduate commented: ‘One D and C [early abortion] is safer than 16 packs of daily pills... many girls say this.’4
When asked what forms of contraception they were familiar with, young Nigerians mentioned alum, potash, snuff, white quinine, brandy, Krest (a non-alcoholic mineral drink), detergent, lime water, and various hormonal preparations. Several students believed that antibiotics and aspirin worked as contraceptives. Many did not even mention the condom as a contraceptive method, as they thought of it more as a means of preventing infections than pregnancy.
Such lack of knowledge is not restricted to adolescents. It is common for married women with unwanted pregnancies to say they did not use contraception because they didn’t have sex very often.
Campaigners have their list. Accurate information, widely disseminated, for a start. A full range of contraceptive services with a broad range of methods to suit different people in different circumstances. Guidance, counselling, training on family planning in universities, hospitals, schools. Reform of laws that restrict access to abortion. Better abortion and post-abortion care.
And, lastly, talking. As the Vietnamese delegate said, population is ‘sex action’. That means setting prudish taboos aside and discussing contraception and the wide range of non-procreative sex options that exist. It means being realistic about sex – and the unreality of abstinence.
- Human Rights Watch, ‘The less they know, the better’, Washington, 2005 www.hrw.org
- Guttmacher Institute, ‘Unwanted Pregnancy and Induced Abortion in Nigeria’, New York, 2006.
- World Health Organization, 2007.
- International Family Planning Perspectives, ‘Why Nigerian Adolescents Seek Abortion rather than Contraception: Evidence from Focus Group Discussion’, V Otoide, F Oronsaye, F Okonofua, 2001.
- Guttmacher Institute, ‘Facts on Induced Abortion worldwide’, 2008.
- Guttmacher Institute, ‘Adolescence in Malawi: Sexual and Reproductive Health’, 2005.