Dr. Rahman's first response to Dr. Pedulla letter

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Dear Doctor Pedulla,

Thank you for your comments about our article on family planning services and abortion in Bangladesh. You raise several points that we wish to clarify.

You write, “Chronic use of modern contraceptives constitutes abortion-prone behavior.” Our perspective is that both contraceptive use and abortion reflect a desire to regulate fertility. If the former is not adequate for doing so, women will resort to the latter.

You write, “The utter failure of contraception in both areas is demonstrated very well by the ongoing dependence on abortion, despite nearly 20 years of experience, to reduce birth rates.” In fact, abortion rates in Matlab are among the lowest in the world, comparable to those in the Netherlands and Tunisia, where extensive family planning programs have also led to very low abortion rates.

You write, “Pregnancies in both areas increased throughout the study.” In fact, our research shows that pregnancy rates in both areas decreased throughout the study period, particularly for women who said they desired no more children. We attribute this to the increasing availability of contraception during this time.

You write, “Researchers have increasingly challenged the meaning of ‘unintendedness’.” We grant it is not a perfect measure. Circumstances can and do change. Yet studies have shown that measures like that we use to gauge intent, especially when used beforehand, are quite accurate in predicting subsequent fertility and abortion (see, for example, Tan and Tey, 1994, “Do Fertility Intentions Predict Subsequent Behaviour? Evidence from Peninsular Malaysia,” Studies in Family Planning; De Silva, 1991, “Consistency Between Reproductive Preferences and Behavior: The Sri Lankan Experience,” Studies in Family Planning; and Westoff, 1990, “Reproductive Intentions and Fertility Rates,” International Family Planning Perspectives).

You write, “Only in the MCH-FP group did women become more unlikely to accept ‘intended’ pregnancy. This is hardly consistent with an intervention-related decrease in abortion, and instead points to a uniquely powerful abortion-motivating effect of modern contraception independent of, and even despite, pre-existing intendedness.” Again, circumstances can and do change; a woman who says at the beginning of one of the time periods that she would like (or not like) to have a child may later decide that she does not want (or wants) to do so. Furthermore, women care about the timing of their births and will therefore seek to use contraception—or abortion—to give birth at the most opportune time. Finally, we note that the “increase” in abortion of “intended” pregnancy in the MCH-FP area was not statistically significant and that this rate was still far below rate of abortion of “intended” pregnancy in the comparison area and of “unintended” pregnancy in the MCH-FP area.

You write, “Modern contraceptives increase abortion risk and can cause a relatively abortion-averse population to become relatively abortion-prone.” As noted, abortion rates in Bangladesh are among the lowest in the world, coincidentally comparable to those in nations with extensive family planning programs and high rates of contraceptive prevalence.

You write, “Natural family planning can at least produce some evidence of an abortion-preventing effect.” We agree if natural family planning methods are acceptable to women and would be practiced widely and correctly that they, too, could help prevent abortions. The evidence of our continuing work on this topic, however, shows that other contraceptive methods are more effective in preventing abortions, which was the focus of our work and is a goal we assume you share. Among Matlab women who do not want additional children, for example, we find that abortion rates are 1.5 per 100 women using injectables, 2.6 per 100 for women using IUDs or hormonal contraceptives, and 5.7 per 100 for women using traditional methods of contraception. While our data do not allow analysis of abortion rates for women using the Billings method specifically, they show that greater use of temporary contraceptive methods such as IUDs, pills, or traditional methods result in higher abortion rates than those resulting from use of longer-lasting methods such as injectables. Finally, one of the studies you cite in support of your point uses statistics compiled nearly 20 years ago on a sample of 270 women—one third of whom were Catholic and another third of whom were Muslim were in a nation where less than one in 300 are Catholic and more than five in six are Muslim—in contrast to our analysis of nearly 150,000 pregnancy outcomes through 1998.

You write, “Objective observers will increasingly see interventions as efforts to impose foreign values, rather than what they intend to be—efforts to help.” Women in Bangladesh do want to have fewer children. The mean desired number of children in the area we study has declined from about 4.5 in 1975 to 3.0 in 1990 to 2.5 in 2000. The fact that contraceptive use in the areas we study is so high and that women are willing to abort unintended pregnancies is further evidence of this. It is our sincere hope that Bangladeshi women are able to find means other than abortion to achieve the smaller family sizes that they themselves desire.

Very truly yours,
Mizanur Rahman
Julie DaVanzo
Abdur Razzaque