pp. 177-179 in
Bioethics in Asia
Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute
Copyright 2000, Eubios Ethics Institute
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5.1. Reproductive Rights and Women
Dhaka University, Bangladesh
The situation of women in one of the poorest countries of the world, Bangladesh, is very bad indeed, judging from whatever angle we want-economic, social, or educational. Available statistics paint a brighter picture than actually exists.
The state of reproductive health in Bangladesh is very grim. A relatively wide range of contraceptive methods are available through the government, NGOs and the private sector network. Unsafe abortions result in approximately 8,000 maternal deaths every year. Very little is known about the status of infertility, and facilities for its diagnosis and treatment are also scarce. However., the problem is considered to be quite prevalent. Information regarding sexual heath also is quite scanty. Maternal mortality is around 5.7 per thousand live births. Maternal morbidity is widely prevalent and it is believed that vesico-vaginal fistula, chronic pelvic infection and secondary infertility are quite common.
Family planning programmes implemented in Bangladesh treat women as numbers to achieve certain targets or goals. Informed consent is almost universally absent in rural areas. The socio-economic conditions in the country hardly allow poor women much free choice in adopting family planning devices. It is not uncommon to find immunological contraceptives (anti-fertility vaccines) used without informing the acceptors about the possible side effects.
Incentives in cash or kind are provided to poor women for tubal ligation. Educated and literate couples in urban areas voluntarily accept artificial birth control methods. But here also the information provided is partial, and often very little about the possible side effects is known to the social workers who are the main informers in this regard. The medical practitioners themselves mostly keep their mouths shut and do not feel responsible for any side effects of the methods they prescribe. Poor and illiterate women in general adopt any method considered most suitable by their husbands and social workers.
Reaction of Women to This Situation
In this kind of situation and context, women, who are educated and quite informed about the pros and cons of each birth control method, have become concerned regarding the helplessness of most women in the country. Poor women are under pressure to adopt one of the methods offered by the family planning agencies. They feel the urgent need for spacing childbirth to earn their living. In most cases poor women are not taken care of by their husbands. Hence they adopt, in order to avoid pregnancy, whatever methods are offered free of cost and often with material incentives.
A convention on "Reproductive Rights and Women's Health," held in January 1993 in Dhaka, expressed concern over the dismal overall situation of women's health, the cruel gender discrimination within the family in regard to women's nutrition and health, the gaps in national health policy in addressing the removal of gender discrimination and women's health needs and the inadequacies and biases in the existing health care and related services provided for women. The experts and the participants present deplored the prevailing thrust of the family planning policies focusing on women alone as acceptors of contraceptives, the malpractices regarding use of obsolete/highly experimental drugs and methods on women, often without any counseling as to dangerous side effects".
This indeed is the real situation. But what are the remedies? What could be done to control population, upholding reproductive rights and women's health as well, in the given situation?
Reproductive health activists in Bangladesh have different answers to these questions. UBINIG a policy research group, is against the implementation of any kind of family planning method except the natural ones. It questions the intentions of the 'imperialistic' international donors, providers and policy makers, faulting them with at least three mala fide intentions: (1) To depopulate developing countries, (ii) to use the poor people of the developing world as objects of experiments; and (iii) to provide the multinational industrialists with opportunities to make profit by selling their products which are obsolete/highly dangerous and not allowed to be sold in many developed countries.
Dr. Halida Hanum Akhtar, the Director of BERPERHT and Dr. Sabera Rahman, Director of the Mohammedpur Centre are diametrically opposed to the above view. Dr Akhtar holds that UBINIG's attitude towards family planning services in Bangladesh is "adversarial and negative". She agrees that women should be able to make informed choices about safe contraceptives, but our expectations should match "socio-economic realities." She also draws attention to the appalling maternal mortality rate-about one in every 25 women in Bangladesh dies of pregnancy-related complications- to underline this point. She even accepts such controversial methods as Norplant and says that the Norplant trial is a case of 'taking a smaller risk for a bigger benefit. She also adds that it is like the fever and discomfort from vaccination children have to endure to avoid disease.' Staff at her centre thinks it is justified to use poor women as experimental objects as "all biomedical advances in the world are made through trial and error."
There are many others who do not advocate complete withdrawal of artificial methods. They maintain that choice of spacing childbirth is a prerequisite for the emancipation of women, both urban and rural. Birth control methods should be adopted by choice and 'informed choice' is essential, and it is the individual woman who should make the choice from among the available methods, knowing the side effects.
In the context of Bangladesh, this group may seem too idealistic. But it may be noted that the group gives importance to some realistic features; (I) without birth control devices available to women in the present inadequate health care system maternal mortality rate will become much higher; (ii) population size will become unmanageable as the country is small in size and its economy is not strong enough to provide for a larger population; and (iii) women will become more and more handicapped and dependent as with multiple pregnancies and childrearing they will hardly get any spare time to empower themselves.
Though this group is not against family planning, it does not approve of 'cavalier-bureaucrats, misguided strategies and poor services that harm women.' They feel that unavailability of birth control devices will make women more helpless and vulnerable. They advocate the extensive use of condoms and diaphragms which have the least harmful side effects. Experimental hormonal contraceptives like Depo-povera and Norplant are not to be used as the side effects are not yet fully known even to the manufacturers.
UBINIG's allegations are not without justification. Family planning policies are determined by the overseas donors and providers as the government of the country is totally dependent on aid.
That the programmes are target oriented and not concerned with the welfare of the clients is quite obvious when we find that information about various contraceptives are not even known to the social workers who have direct contact with acceptors.
IUDs which were used initially for only two years are now being used for six to eight years. This change of instruction is due to an USAID circular (AID letter no 1579, date December 31 1991), to the Director, Mother and Child Health (MCH).
Norplant was implanted in one woman who later finding herself ill come to the family planning centre to remove it. She was told, "Don't you know the price of Norplant? It is 2000 Taka (US$50.00). You must bring the amount before we can remove the implant from your arm." This shows the insensitive attitude of family planning workers.
Advocates of a relatively moderate view are demanding universal education for both men and women and better health care programmes for women. These programmes would enable women to conceptualize better the consequences of accepting family planning methods and have more control over the situation. Better health care services would save them from unnecessary side effects which women usually suffer after accepting artificial birth control devices. The fight for reproductive rights for women in Bangladesh is extremely difficult as we also have to fight against the evils of poverty and patriarchy.
UBINIG-A Bengali name of a NGO.
BERPERHT, Bangladesh Institute of Research for Promotion of Essential of
Reproductive Health and Technologies.
1. Reproductive Rights and Women's Health, A compilation of articles. Women for Women, Dhaka,1993.
2. F.T. Sai, "Political and Economic Factors Influencing Contraceptive Uptake", British Medical Bulletin, 1993, vol. 49, No. 1, P.203.
3. Focus, Dhaka, July 1994.
4. New York Times Magazine, February 6,1994.
5. S.Minkin, Bangladesh: The Pop Con Game, Dhaka,1979.
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