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Manipulation or helpful information?

March 11, 2003 1:07 am

Before last summer, Beatrice Wambui was like many young Kenyan women.

The 20-year-old had little knowledge about reproductive health, and even the little bit she was taught in secondary school didn't really sink in. "I wasn't paying attention," she confesses.

Then last May, she joined the newly formed Binti Pamoja ("Daughters United") project, which is geared for young women living in Kibera, a massive slum on the outskirts of Kenya's capital, Nairobi. The program offered Wambui and other young women the opportunity to talk and learn about a range of reproductive-health matters, from how to handle pressure to have sex to how to use contraception and avoid sexually transmitted diseases.

The project "has challenged me," Wambui says.

Binti Pamoja member Fatuma Roba says before the program, "I didn't know about my rights. I didn't know where I could go for my health."

Parents of the young women in the project have supported the reproductive-health education, too, Wambui says. "They are willing for youths to be taught" about their sexuality, she says.

But are education and outreach programs such as Binti Pamoja manipulating women in the developing world--taking advantage of their ignorance to push a Western agenda of contraception and smaller families?

Judie Brown, president of the Stafford-based American Life League, thinks so.

"I think if you're propagandizing a poor woman, and you're holding something out in front of her--something that you know she wants--and you tell her the best way to get this is to have abortions or use the pill, she's going to believe you, because you're propagandizing her," she says.

The Front Royal-based Population Research Institute supports Brown's view. The group contends that U.S.-funded family-planning programs sometimes disregard "informed-consent" rules when counseling women on family planning options.

"We're not saying everyone in a USAID program is violated, but everywhere we went, there were violations," PRI spokesman Scott Weinberg says.

PRI has conducted research in numerous countries in Asia, Africa and Latin America, Weinberg says. His group made news last year for alleging that the United Nations Population Fund was supporting coercive family planning practices--including forced abortions--in China.

A U.S. State Department investigation found no direct link between the UNFPA and rights abuses in China and recommended that the Bush administration continue funding the agency.

The use of contraceptives has increased dramatically in many developing countries in recent decades. In Kenya, for example, it has more than quadrupled since 1977.

Still, there remains a significant unmet need for family planning education and services in countries such as Kenya, says Barbara Crane, who worked in USAID's population division during the Clinton administration and now heads Ipas, a reproductive-health organization based in Chapel Hill, N.C.

Crane cites the Kenyan government's most recent comprehensive demographic and health survey, which found 24 percent of married women wanted to space or prevent births but were not using a contraceptive method.

"It strains credibility to say that higher use of contraception is the result of coercion or misinformation or ignorance," she says.

Dr. Stephen Karanja disagrees. Karanja is an obstetrician-gynecologist in Nairobi who promotes "natural" family planning, a method that eschews contraception in favor of teaching couples what times during a woman's menstrual cycle they can have sexual intercourse.

He argues that family planning workers in Kenya who receive USAID assistance don't offer people the information needed to make informed choices about birth control.

"If people--even very poor people--want to choose to use pills, let them make an informed choice," he says. "You cannot make an informed choice without information."

But the assistant administrator for USAID's Bureau of Global Health, Dr. Anne Peterson, says her agency makes every effort to ensure that clients receiving USAID-supported services are in a position to offer their informed consent. "We know what a hot issue this is," she says.

She adds that USAID programs operate under "very strict rules" established by the Tiarht amendment, which Congress passed in 1999 after conservative lawmakers expressed concern about violations of informed-consent principles in Peru.

USAID-assisted programs are required to counsel women on a wide range of birth-control options, including barrier methods, pills, implants and natural family planning. Clinics receiving U.S. funds also must display informational posters on birth-control methods.

But Karanja points to Kenya's community-based outreach programs--often supported by USAID--which he says allow "grade-school failures" to go door to door giving away birth-control pills "as if they were sweets, to illiterate women."

Dr. Sarah Onyango, Ipas' Kenya country representative, dismisses Karanja's characterization of outreach programs. Counseling and screening are done first for all clients, she says, and contraception other than condoms is available only through public-health facilities.

Several types of contraception are distributed on three-month cycles, Onyango says. Subsequent to that, community-based distributors can hand out refills.

"I wouldn't say contraceptives are dished out," Onyango says. "We use community-based distributors to improve service. But they don't give them out the first time."

Contrary to what Karanja contends, a dearth of information may lead to greater resistance to family planning services, insists Dr. Sam Kalibala of the Population Council, an international reproductive-health organization.

"All the new services we introduce in the developing countries, the initial uptake is low, because people don't understand," he says.

People in Africa, Kalibala argues, "tend to be very suspicious of things from the West." Since colonial days, he says, anthropologists have written about how non-Westerners often view health interventions by outsiders "as witchcraft" that will hurt their well-being.

But Karanja wonders how contraceptive use could have increased so much in Kenya over the past quarter-century.

"I have had the chance to talk to people in the slums and have asked them, 'What would you want?'" he says. "And they all say: 'Please, give us the basics of life. Give us clean water, improve our roads. Give us medicines and hospitals, and the size of our families will take care of themselves.'"

He says when he asks people to list their needs, family planning is never included.

"It's very true that when we go to young people and ask what are their needs, reproductive health is not among their needs," Kalibala acknowledges.

Poor people say they want things that will directly relieve their suffering, such as roads and clean water, he says.

But after communities get to understand the benefits of family planning, he continues, demand for contraceptive services increases.

"Family planning alleviates suffering indirectly, and it takes time," he says.

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.