Better for Whom? -The pregnancy experience among Bangladeshi Women
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In September 2001, The Lancet, a prestigious medical journal, published an article entitled, “Do better family planning services reduce abortion in Bangladesh?”(1)
The principal author, Dr. Rahman, contended that the lower abortion rates in one area of the Matlab Thana region of Bangladesh were due to “better” family planning there. Women in the comparison area had been left mostly to their own devices, so to speak, while in the treatment area aggressive promotion of modern contraceptives was pursued. The author hoped to prove something contraception promoters have never been able to show - that more contraception means less abortion. What follows is a commentary by Dr. Dominic Pedulla exposing the failure of this strategy, especially in comparison to modern methods of non-contraceptive birth control, namely, Natural Family Planning.
Better for whom? The pregnancy experience among Bangladeshi Women
Response by Dr. Dominic Pedulla
Dr. Rahman et al asks the question: Do better family planning services reduce abortion in Bangladesh?(1) The investigators are aware of studies in Japan and Chile, well-reviewed by expert demographers, (2) revealing a great deal more than mere failure of modern contraceptives to reduce abortion rates. Indeed, a reasonable conclusion from these data is that chronic use of modern contraceptives constitutes abortion-prone behavior, and this chronic behavior may well be the most salient risk factor for this destructive public health epidemic.
The authors want to show that ''better'' family planning (actually more aggressively promoted high-potency contraceptives) in the MCH-FP area leads to reduced abortion rates relative to the comparison area which lacks these services. 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. Pregnancies in both areas increased throughout the study and abortion ratios (abortions: total pregnancies) underwent dramatic relative increases; this is a far more reliable measure of pregnancy unacceptedness than the DSS survey instrument used to assess pregnancy intendedness. Granted that researchers have increasingly challenged the meaning of ''unintendedness'', (3) it is still remarkable that 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.
Most disturbing from the perspective of empowerment of women (a welcome and growing sensitivity in the global reproductive health movement), women in the MCH-FP area found all categories of pregnancies increasingly unacceptable regardless of intendedness (up to a 430 percent increase in abortion-proneness overall) and results could not exclude a surprising 880 percent increase in abortion-proneness even for intended pregnancies! Considered objectively then, the most important study results, concordant with the work of others, (2) may well be that modern contraceptives increase abortion risk and can cause a relatively abortion-averse population to become relatively abortion-prone. The differential abortion rates (not ratios) in the two areas are more likely due to discrepancies in availability of quality medical care and other services, a phenomenon others have identified in studying maternal mortality declines exclusive to the MCH-FP area.
My own opinion is that the Billings ovulation method would be vastly superior to the MCH-FP approach, not only because it has been shown to be effective and highly desirable by the capable Bangladeshi women who used it, (4) but also because, in contradistinction to modern contraceptives, natural family planning can at least produce some evidence of an abortion-preventing effect. (4, 5) Regardless of personal opinion however, what is truly mandatory is that an authentically open dialogue about feminine empowerment take place, and one not rigidly, ideologically or in any other way attached to contraception, sterilization, and abortion. If this cannot occur, objective observers will increasingly see interventions as efforts to impose foreign values, rather than what they intend to be -- efforts to help.
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
Dr. Rahman's response to this ongoing dialogue, as well as the second letter written to him by Dr. Pedulla in response to his letter, may be read by clicking on the red archives tab at the bottom of this page.
References
(1) Rahman et al. Do better family planning services reduce abortion in Bangladesh? Lancet 2001; 358: 1051-56.
(2) Omran, A. R. Abortion in the Demographic Transition, in Rapid Population Growth: Consequences and Policy Implications, report of a study committee of the National Academy of Sciences (Baltimore, 1971), 481.
(3) Klerman, L. V. The intendedness of pregnancy: a concept in transition. Matern Child Health J 2000 Sep; 4(3): 155-62.
(4) Labbok, M. H. Factors Related to Ovulation Method Efficacy in Three Programs: Bangladesh, Kenya and Korea. Contraception1988; 37:577-589.
(5) Mikolajczyk, M. and Rauchfuss, M. Different Concepts of Dealing with Fertility: a Comparison of Berlin and Krakow. Geburtsh Frauenheilk 2001; 61: 121-146.
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