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A life-and-death issue

March 9, 2003 1:08 am

First in a three-part series

Today: The debate over U.S. funding of population programs.

Focus: Group uses photography to explore women's issues. Page D5

Tomorrow: Local representative weighs in on battle over population programs.

Tuesday: Allegations of manipulation, abuses.

Rick Mercier, Viewpoints editor for The Free Lance-Star, traveled to Kenya to examine reproductive-health issues in the developing world. His research was made possible by a World Affairs Journalism Fellowship from the International Center for Journalists and the World Affairs Council.

THE GYNECOLOGICAL ward at Nakuru Provincial General Hospital could use more beds.

The hospital serves more than a million people in this part of Kenya's Rift Valley, and the gynecological ward overflows with women suffering from cancers of the reproductive system, uterine fibroids and fertility problems.

But a section at one end of the ward remains reserved for patients with serious pregnancy-related complications. Nursing officer Jane Gutu says the ward treats 30 to 60 women a month for such problems. Many of these medical emergencies, she says, are the result of illegal abortions.

The women who are treated and released from this section of the ward are some of the lucky ones. In the waiting room of the hospital's outpatient clinic, a poster distributed by Kenya's health ministry makes clear that plenty of women in this country of 30 million aren't so fortunate: "Over 5,000 girls die yearly from abortion Avoid being one of them!"

This East African nation--which prohibits abortion except to save the life of the woman--is no anomaly. According to conservative estimates, more than 75,000 women die each year worldwide from botched abortions, contributing significantly to high maternal mortality rates in the developing world.

Pregnancy-related complications, including those from unsafe abortions, are the leading cause of death among young women ages 15 to 19 worldwide, report UNICEF and the World Health Organization.

As we tour the gynecological ward, I ask my guide, Dr. Frederick O. Ndede, an obstetrician-gynecologist at the hospital, whether changing Kenya's abortion laws would save many women's lives. "That's not the important thing," he says. "The most important thing is to educate people about their sexuality."

But many experts wonder where desperately poor countries such as Kenya will find the resources to do adequate reproductive-health outreach, much less meet the increased demand for reproductive-health care--including family-planning services--that would accompany more effective information and education campaigns.

Reproductive-health advocates say Western governments' unwillingness to meet funding needs for population programs in developing countries is a leading contributor to unwanted pregnancies--and to stubbornly high maternal mortality rates.

The advocates point to efforts by American social conservatives to roll back Washington's commitment to funding population programs through the U.S. Agency for International Development and the United Nations Population Fund (UNFPA).

"I think the Americans are running away from their responsibility," says Cyprian Awiti, Kenya program director for the reproductive-health organization Marie Stopes International. "I mean, how do Americans talk about equality of women, and run away from reproductive health?"

The United States is the world's single largest provider of international population funds. These funds support a variety of family-planning activities: education and information campaigns, counseling and the delivery of a wide range of contraceptive services. Population programs also target maternal mortality and sexually transmitted diseases, although USAID earmarks a separate chunk of funds for HIV/AIDS programs.

To people like Judie Brown, it's the family-planning programs that are the problem. The reason, says the president of the Stafford County-based American Life League, is that USAID "is in cahoots with a lot of people that don't really like families, even though they say they're in favor of families."

Brown, whose anti-abortion group assists lobbyists and claims a membership base of more than 300,000, cites as examples the International Planned Parenthood Federation, which is "really in favor of no parenthood, if you're poor," and the World Health Organization, which "never had a good thing to say about a child."

Brown's group isn't the only Virginia-based organization that has set its sights on international family-planning programs. The Population Research Institute in Front Royal spearheaded a successful campaign last year to get the White House to cut funds to the UNFPA because of its alleged involvement in human-rights abuses.

The group's Web site features a "map of shame" illustrating where USAID supports population programs around the world. Like the American Life League, PRI contends that the United States shortchanges other development programs so it can funnel large sums to foreign governments and nongovernmental organizations for family planning.

The U.S. government spends "way, way too much on contraception," PRI spokesman Scott Weinberg says.

In a 1999 report, the group concluded that "population-control programs in general have outlived whatever usefulness they may once have possessed" and "should be abolished."

About 200 million women worldwide become pregnant each year. According to the United Nations, one-third of pregnancies are unintended and unwanted; tens of thousands of these result in the death of the woman.

Dr. Anne Peterson, assistant administrator for USAID's Bureau of Global Health, says it's easy for Americans to overlook the risks many women and their children face because of unplanned pregnancies.

"We're healthy and don't have as many challenges" as people in the developing world, she says. "But we have to remember that maternal mortality is very high" in poor countries, she adds. "So is child mortality."

Effective population programs can decrease maternal mortality by as much as 25 percent, and enabling families to space out pregnancies significantly reduces mortality rates for infants and young children, Peterson says.

She says population programs, which account for about a quarter of USAID's development-assistance funds and less than 1 percent of overall U.S. development expenditures, are cost-effective. Her bureau cites studies showing that for every dollar spent on family planning, governments save up to $16 in reduced expenditures on health, education and social services.

Barbara Crane, who served in USAID's population division during the Clinton administration, says countries such as India and Bangladesh have shown "you don't need to wait for development to get the benefits of family planning."

Delegates attending the landmark 1994 U.N. population conference in Cairo, Egypt, forged a consensus that stressed women's health and equality, and highlighted maternal mortality as a major public-health issue. Wealthy nations at the conference agreed to boost funding to help meet needs for family-planning services in poorer countries.

But more than eight years after the Cairo conference, the full range of modern family-planning methods remains unavailable to at least 350 million couples worldwide, many of whom say they want to space or prevent another pregnancy, according to UNFPA spokesman Abubakar Dungus.

Survey data suggest that about 120 million women worldwide would be using a modern family-planning method if more accurate information and affordable services were easily available, and if husbands, extended families and the community were more supportive, Dungus says.

At family-planning clinics such as the Ribeiro House in downtown Nairobi, Kenya, care providers say they're having a difficult time meeting the needs of poor families.

Margaret Mwaiko, assistant program officer at the clinic, says her already cash-strapped facility was hit hard by funding cuts resulting from the Bush administration's reinstatement of a policy--sometimes referred to as the "gag rule"--that bars U.S. assistance to overseas organizations that perform or counsel on abortion.

The lost funds have forced the clinic to scale back outreach programs and charge higher fees for services, she says. That means more people go without family-planning services they would choose to receive if they had access to adequate information and affordable options, she believes.

Mwaiko says that since the reinstatement of the policy, she's been seeing about 30 clients a day. "Before the gag rule, it was maybe 100," she says.

Nations participating in the Cairo conference--including the United States--committed to providing about $17 billion per year to meet reproductive-health needs. The Clinton administration strongly supported the Cairo objectives, and U.S. funding of population programs reached $576.6 million in 1995.

But a Republican-controlled Congress fought back, and by 1999, social conservatives had managed to slash U.S. population assistance by nearly $200 million. The Bush administration has restored funding levels to about three-quarters of the Clinton administration high-water mark.

Valerie DeFillipo, services director of Planned Parenthood's Global Partners program, says the Bush administration's funding increases may be deceptive, since the White House may be more committed to supporting abstinence-only education and faith-based programs that eschew contraception. In some cases, she says, what the administration backs "won't be what you recognize as family planning."

Still, some social conservatives would like to chip away again at funding for USAID's population programs. "I would say we've got to cut that USAID. I mean, we'd like to eliminate it totally," says the American Life League's Ed Szymkowiak, referring to the agency's population funds.

He says the president "talks a good game" on family-planning issues, but notes that the administration allocated $446.5 million last year for USAID population programs, an increase of $22.5 million from the previous year and a significant rise from the amounts appropriated for those programs in the late 1990s.

"This is where the rubber hits the road, when you get to the money that's going out there," he says.

Reproductive-health experts say inadequate support of population programs has had disastrous effects.

The Global Health Council, the world's largest public-health alliance, released a report last fall suggesting a strong correlation between maternal mortality and inadequate access to quality reproductive-health care, including family-planning services.

According to the report, women around the world had more than 300 million unintended pregnancies between 1995 and the end of 2000. During that six-year period, nearly 700,000 women died because of unintended and unwanted pregnancies.

Sixty-four percent of those women--about 440,000--died as a result of abortions carried out in unsafe, unsanitary and often illegal conditions, the report says.

"One of the most shocking issues is that the number of pregnancies has leveled out, but maternal deaths have not," says Colleen Murphy, a coauthor of the report.

While the council's figures showed that the number of live births worldwide had leveled off at around 131 million a year, they also revealed that an increasing number of women were dying as a result of unintended pregnancies. In 2000, 115,619 maternal deaths were attributed to unintended pregnancies; that was a rise from 112,883 in 1995.

But some social conservatives question the assumptions and motives of research such as the council's. "The word 'unwanted' is a subjective, judgmental term that negates the value of the child. There's no such thing as an unwanted child," Brown says.

PRI President Stephen Mosher, writing in one of his group's publications, portrays "population controllers" in sinister terms: "For all their pretense of providing 'reproductive health care' to give women a 'choice' and reduce 'maternal mortality,' they are totalitarians at heart. They want to radically reduce the number of babies born, and will stop at nothing to achieve this end."

Brown says international family-planning issues became important to her four years ago after a visit to the Philippines. That trip, she says, convinced her that USAID is "just rotten to the core."

"You know, they export all kinds of so-called reproductive-health chemicals that actually cause abortion. And if people are starving, they could care less," she says.

Dr. Stephen Karanja, who runs St. Michael's Medical Care clinic in Nairobi, also is outraged by what he sees as the West's misplaced priorities.

"You can't treat malaria in this country" even though it costs less than $1 per person to do so, he says.

"A woman who has never worn a pair of shoes because she can't afford them can wear a Norplant [birth-control implant] for free," he adds. "It's evil."

Dr. Sam Kalibala, a research associate for the Population Council, an international reproductive-health organization, says family-planning and public-health problems are part of a circle.

"You could say that because malaria kills many young children, it makes people not accept smaller family sizes, because there's no guarantee the kids they have are going to survive," he said in an interview at the council's Nairobi office.

Conversely, while families with two children may be able to afford mosquito nets for both, a family with 10 children may not, he argues.

"So you can say that large families with limited resources affect the malaria agenda."

The solution, Kalibala believes, is for Western governments "to give enough and to give with a whole heart, so that we can deal with health problems in a comprehensive manner."

But Brown says the family-planning establishment needs to address the root causes of poverty, such as corruption and underdevelopment. "Why do we always have to look at children and say, 'Well, the problem is they're having too many children?'"

Glossary of acronyms

USAID--United States Agency for International Development. Charged with disbursing the bulk of U.S. funds for overseas population programs.

UNFPA--United Nations Population Fund (formerly the United Nations Fund for Population Activities). Operates population programs in more than 140 countries. Lost U.S. funding last year after allegations of human-rights abuses in China.

ALL--American Life League. Stafford County-based anti-abortion group with more than 300,000 members nationwide.

PRI--Population Research Institute. Front Royal-based group that tracks human-rights abuses linked to population programs.