REPRODUCTIVE TRACTS: ISSUES AND INNOVATIONS IN REPRODUCTIVE HEALTH Four Essays on Birth Control Needs and Risks Ruth Dixon-Mueller, Ph.D., and Adrienne Germain !• L* IWHC International Women’s Health Coalition ■ I f| | »f s . ..... *. •$£..v:s. »......' /Sts f, ,v-..-- • #A; .' ?M*% Mil".J‘; $P'; n *■’- f' ;>. :&m ■-. muyM&mp:$??« :: s k!« ; ’ <v ,• ^.;.; - , V v ' r : r ': ? 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We work in alliance with women’s health advocates, women’s organizations, health professionals, and government officials in Southern countries, and Northern institutions, and together serve as a catalyst for change in national and international policies and programs. Ruth Dixon-Mueller, Ph.D., formerly professor of sociology at the University of California at Davis, is currently working as a consultant on reproductive rights and women’s employment in Southern countries. Adrienne Germain is Vice President and Program Director of the International Women’s Health Coalition. Managing Editor: Jane Ordway Copy Editor: Laura Levin Graphic Design: Curtis & Company Production Assistant: Ken Berg Copyright © 1993 by the International Women’s Health Coalition. All rights reserved. Brief quotations may be reproduced without written permission provided the source is cited. Table of Contents Preface 1 Joan B. Dunlop ESSAY ONE 3 Are We Speaking the Same Language? Women’s Health Advocates and Scientists Talk about Contraceptive Technology Adrienne Germain ESSAY TWO 7 Whose Life is it, Anyway? Assessing the Relative Risks of Contraception and Pregnancy Adrienne Germain and Ruth Dixon-Mueller ESSAY THREE 11 Defining the “Unmet Need” for Family Planning Ruth Dixon-Mueller and Adrienne Germain ESSAY FOUR 15 Abortion is a Method of Family Planning Ruth Dixon-Mueller Preface With this publication, the International Women’s “relative risks” of contraception and pregnancy. Health Coalition launches a new series of essays under Based on an understanding of the realities of women’s the broad title “Reproductive Tracts: Issues and Inno­ lives, the third proposes an expanded definition of vations in Reproductive Health.” Our purpose is to: the “unmet need” for family planning, a definition that poses substantial challenges to policy makers and ■ provide fresh approaches to critical issues within program managers. The fourth argues that abortion the population and related fields; has been and always will be used by some women ■ illuminate what is meant by a reproductive health as a method of family planning. approach; The family planning field has accomplished a great ■ encourage constructive debate and dialogue; and deal in the past two decades by making contracep­ tives available to millions of the world’s women. « stimulate the creation of women-centered repro­ Much remains to be done, however. Women’s health ductive health policies and programs. advocates propose a reproductive and sexual health The four essays included here are bound together by and rights agenda, including access to safe abortion a common theme. Women’s health advocates often services; promotion and provision of condoms for see the world differently than demographers, contra­ birth control and as protection against infection; ceptive researchers, and policy makers. They see the development of woman-controlled technologies to range and calculus of women’s reproductive choices protect against both pregnancy and infection; forth­ from a different perspective. Women’s health advo­ right sex education to emphasize more equitable cates seek to transform some of the key concepts, gender relations; and the connection of science to processes, and institutional structures currently used the human condition. If global population issues are by the population field. We would make them more to be addressed in ways that respond humanely and humane, and thus more responsive to the reality of effectively to people’s needs and concerns, women’s women’s lives. voices must be heard. Each essay challenges some point of “received wis­ The International Women’s Health Coalition seeks dom” that affects women’s reproductive health and to enable women’s health advocates and the popula- rights. Addressing the process of contraceptive devel­ tion/family planning fields to work collaboratively on opment, the first describes how the priorities of wom­ solutions that promote social justice, equity, repro­ en’s health advocates and the perceived needs of ductive health, and basic human rights. individual women may differ from those of scientists and other researchers. The second challenges some Joan B. Dunlop common demographic, medical, and public health President assumptions underlying the calculation of the International Women’s Health Coalition 1 ESSAY ONE Are We Speaking the Same Language? Women’s Health Advocates and Scientists Talk about Contraceptive Technology Adrienne Germain When women’s health advocates and research scien­ developed agendas on the basis of at least three tists meet to talk about the development and intro­ fundamental assumptions: duction of new contraceptive methods, divergent ■ women have the right to control not only their views are bound to appear.1 For example, who decides fertility, but also their sexuality; which methods are appropriate for particular coun­ tries or family planning programs? How are these ■ the exercise of this right requires broader changes decisions made? Are the perspectives of women’s in women’s circumstances, not just more and better health advocates taken into account, or are decisions technology and delivery systems; and driven primarily by technological, demographic, political, or administrative considerations? What are ■ women can and will make rational decisions about the implications of the development and decision­ their fertility and sexuality if appropriate informa­ making process for the quality of service delivery in tion and services are available. different settings, for contraceptive choice, and for Although most contraceptive researchers would prob­ client satisfaction? ably not disagree with these assumptions, the applica­ There is, of course, no single “women’s” or “feminist” tions of such principles to their own work have been perspective on the introduction of new contraceptive rather different from the applications that women’s technology, nor is there a single scientific or even health advocates might make. demographic point of view. Nevertheless, it is possi­ Although both groups want women to be able to ble to identify some underlying assumptions and regulate their fertility, each often has different objec­ objectives that shape the discourse between women’s tives. Women’s health advocates seek to maximize health advocates and research scientists. Some of women’s choices about, and control over, fertility and these lead to shared perspectives, while others sexuality as the basic objective. Many scientists might produce quite divergent points of view. well agree. But those who fund and supervise research have tended to see fertility limitation as a means Assumptions about Women’s Health and Rights to achieve societal objectives: to slow population Women’s health advocates’ ideas about fertility regu­ growth, for example, and perhaps to reduce poverty lation are based on their experiences as women and or protect the environment. Each group may respect on their experiences with other women. They have and to some extent share the other’s objective, but 3 the relative weight assigned to each has profound directly confronted. Scientists have sought to invent effects on the criteria each group uses for research and technologies a woman can use without the knowledge policy choices. or interference of her partner. Many women find such method characteristics very appealing. Unfortunately, Also, scientists and women’s health advocates judge however, such methods also have risks or side effects women’s capacities differently. Women’s health advo­ that many women prefer to avoid. cates’ main concern is to enable women to make their own decisions. Urey seek to empower women How to achieve service delivery standards for particu­ through information, counseling, or support groups, lar methods of fertility regulation has been one of the as well as through technology. Scientists tend to be most important issues of debate between women’s preoccupied with the mistakes women might make. health advocates and population professionals. In They seek to maximize contraceptive efficacy countries where health infrastructures are poor, through method characteristics that minimize the women’s health advocates often recommend methods actions required for women to contracept. that have few or no side effects and require