(2nd) Reply from Dr. Pedulla to Dr. Rahman and colleagues

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Dear Drs. Rahman et al.,

Thank you for your most courteous and thorough reply. I'm sorry for being so tardy with my response. With your permission, I would like to post each of our reciprocal correspondences on our website.

I have read your response point-by-point. I must immediately bring attention to one troubling issue. Your response seems to regard natural family planning (NFP) as a contraceptive method. However we see the difference between NFP and contraception as much like that between prudent dieting and self-induced purging (bulimia). This distinction would not at all be important if the target weight were an absolute goal no matter the health consequences, or if purging were thought consistent with health and personal dignity. Whereas the contraceptive approach sees fertility-control targets in isolation, legitimizing interventions with diverse personal, psychosocial and moral implications, NFP sees the pursuit of fertility control as important but in need of being harmonized with the other important purposes of sexuality, at the personal, psychosocial, moral, cultural, and gender-specific (not least) levels.

Devout Muslim women, the kind that predominate among your study's subjects, generally have been found to have a religious preference against contraception, (1) as well as against induced abortion, (2) by your own statistics keeping more than 90 percent of their 'unintended' pregnancies. At a minimum therefore, we are surprised that none of you seem worried about a 94-620% increase in abortion of unintended pregnancies, a figure which is quite significant statistically, clinically, morally, psychologically, culturally, etc. Avoiding the uncomfortable implications of these data does not lend credibility to your stated goal of helping the Bangladeshi women to 'be able to find means other than abortion' in meeting their family planning goals, especially since this inducement towards abortion appears to have been a major result of the intervention. Subjects who experience pregnancy now more often choose induced abortion than ever before, while less often choosing the 'means other than abortion', i.e., those means to which you claim to be committed. Yet you have not apparently seen this as a setback for these women.

Moreover, taken together with other data, (3) this approach can ammount to usurping a moral authority that is neither yours nor the government's rightfully, as this influence serves to legitimize an activity your target population considers immoral, by defeating objections and overcoming all resistance. Furthermore, since Rahman himself has reported that help with other crucial needs (oral rehydration and tetanus toxoid) appears to be conditioned on the subjects' acceptance of these contraceptive measures, (4) there is even a kind of thinly veiled coercion that clearly enters the realm of mentionable possibilities, especially given the marked disparity between the ammount of funds requested by the government to provide food versus those requested for 'population control' programs. (5) Why do you claim to have reduced Bangladeshi women's fertility preferences, when other investigators find that they remain substantially unchanged? (6,7) Is your intervention designed to help these women meet their family planning goals, or to induce them to 'convert' to yours? If the latter, wouldn't this be a form of social control?

Abortion rates (abortion per 1000 women) constitute a less discriminating statistic than abortion ratios (abortions per pregnancies) which you include but without emphasis. Notice that while both Tunisia and the Netherlands have low abortion rates, Tunisia's abortion ratios are relatively low, (8) and those in the Netherlands quite high. (9) This means that reduction in pregnancies is only one of the effects contraceptives have had on Dutch women. The other clear (perhaps unforeseen?) effect, seen in both the Netherlands and Matlab Thana, is a pregnancy-maladaptive effect (reduced toleration of pregnancy), the opposite of what should happen with family planning, unless it is not family planning help that is intended but rather the imposition of social control using the instrument of contraceptive programs. The very low fertility rates in the Netherlands should have made Dutch women especially accepting of the few pregnancies they experience, yet in spite of this paradoxically they are less able to accept them or adapt to them. This is a feminine disempowerment syndrome, a true pregnancy adjustment disorder, for is not adaptability to motherhood one of the core challenges of feminine psychosexual development? Is this not also one of the terribly urgent purposes of sexuality, with which fertility control methods must harmonize? Methods that impair the toleration of, or adaptation to, new family members are not 'family planning', any more than purging is prudent nutrition.

I challenge all of you, therefore, to show me even one country where abortion ratios (not rates) have declined in the years immediately following the introduction of, or increased access to, contraceptives. I don't think you can find one; certainly the respected demographer Omran could not. Instead he recognized that countries going through the 'fertility transition' (period of contraceptive initiation) often experience a dramatic abortion increase, in his words an abortion 'epidemic'. (10)

A great deal of evidence suggests contraception and sterilization are harming Bangladeshi women physically (11) as well as emotionally. (12) What would be the justification for allowing this harm to continue? If there are very effective methods which pose no harm at all, how can the damaging contraceptives, terribly costly in both human and economic terms, be justified?

Finally, shouldn't any claim of contraceptive efficacy at a minimum require evidence of a selective decrease in unwanted pregnancies, i.e. evidence that unwanted (abortion-prone) pregnancies have decreased more than wanted ones have? Wouldn't this require a gradual decrease in the fraction of pregnancies that are aborted (unwanted)? Since your 'better services' could not demonstrate this, wouldn't this be an indication that contraceptives have little or no preventive impact on pregnancy unwantedness? Or alternatively, have the uninformed subjects exposed themselves to an unexpected conditioning which compromises their ability to adjust to pregnancies, by dramatically increasing unwantedness (abortion-proneness)? Wouldn't this be a undeclared and surreptitous experiment in the manipulation of women's attitudes towards their pregnancies? Could this be the real cause of the population implosion experienced in many Western countries recently? Are your Bangladeshi women increasingly albeit unconsciously engaging in 'pregnancy-aversive sexuality'? (13)

Dominic Pedulla, MD, FACC, CNFPMC Associate Clinical Professor of Medicine at the University of Oklahoma Health Sciences Center, Creighton Model Natural Family Planning Medical Consultant, Board Certified in Cardiology and Internal Medicine

References

(1) Chamratrithirong, A et al. Contraceptive practice and fertillity in Thailand: results of the Third Contraceptive Prevalence Survey. Stud Fam Plann 1986 Nov-Dec;17(6 Pt 1):278-87.

(2) Libbus, K et al. Contraceptive decision making in a sample of Jordanian Muslim women:delineating salient beliefs. Health Care Women Int 1997 Jan-Feb;18(1):85-94.

(3) Cutright. Illegitimacy: Myths, Causes and Cures. Family Planning Perspectives, 1971Jan; 3(1):43-44.

(4) Phillips, JF. The demographic impact of the family planning--health services project in Matlab, Bangladesh. Stud Fam Plann 1982 May;13(5)131-40.

(5) Mosher, S. Map of Shame--Bangladesh. Website of the Population Research Institute. In 1999, the Bangladeshi government requested only $6.9M in foreign aid for food, while requesting $32M for population control.

(6) Freedman, R. Do family planning programs affect fertility preferences? A literature review. Stud Fam Plann 1997 Mar;28(1):1-13.

(7) Koenig MA, et al. Trends in family size preferences and contraceptive use in Matlab, Bangladesh. Stud Fam Plann 1987 May-Jun;18(3):117-27.

(8) Nazer I. The Tunisian experience in legal abortion. Int J Gynaecol Obstet 1980 Mar-Apr;17(5):488-92.

(9) Moore, ML. Adolescent Pregnancy Rates in Three European Countries: Lessons to be Learned? JOGGN July/August 2000.

(10) Mohr, J. Abortion in America. 1978, Oxford University Press, New York; in Boyle, M. Rethinking Abortion. Psychology, Gender, Power and the Law. 1997, Routledge, New York NY, page 83.

(11) Rahim MA. Facts and figures about cancer in Bangladesh. Cancer Detect Prev, 1986;9(3-4):203-5.

(12) Rahman, M et al. Do better family planning services reduce abortion in Bangladesh? The Lancet Vol. 358, Sep. 29, 2001.

(13) Pedulla, D. The psychodynamics of pregnancy-aversive sexuality (PAS). Abstracts of The First World Congress on Women's Mental Health, Berlin, Germany, March 27-31, 2001, in Archives of Women's Mental Health. Vol. 3/4/2001, Supplementum 2, p.74. Springer-Verlag 2001, Austria.