Increasing Men’s Involvement in Family Planning; A gender specific and sensitive project.

The authority in global health governance, WHO, asserts that “family planning[1] allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through the use of contraceptive methods and the treatment of infertility” (2017). However, there are 214 million women in developing countries who do not use any modern contraceptive method although they desire to avoid pregnancy (WHO 2017). The benefits of family planning are numerous and range from reducing adolescent pregnancy to decreasing pregnancy-related risks (See https://www.guttmacher.org/report/contraception-and-beyond-health-benefits-services-provided-family-planning-centers). Nevertheless, there are still many countries with low rates of contraceptive use. Guyana, being one of them has a contraceptive prevalence rate of only 34% (UNICEF 2016). This low rate reflects the country’s inability to cater to its nation’s reproductive health; according to WHO, the contraceptive prevalence rate “serves as a proxy measure of access to reproductive health services” (2006). Moreover, the United Nation Population Fund (UNFPA) State of the World Population reveals that Guyana has the second highest rate of adolescent pregnancy in South America and the Caribbean (2013).

[1] Family planning – In this paper family planning refers to the use of contraception and the two terms will be used interchangeably to refer to methods to prevent pregnancy.

It is against this backdrop that this paper aims to focus on the development of a pilot health intervention to increase men’s involvement in family planning (FP) in a rural village in Guyana. It will explore the theoretical perspectives of radical feminism and hegemonic masculinity in relation to contraception. Subsequently, it will examine how hegemonic masculinity will shape the intervention along with how the gender analysis matrix (GAM) will be employed. Lastly, a synopsis of the proposed intervention will be presented.

Theoretical Perspectives/Background

Contraception is paramount to the realization of the aims of feminism (Espey 2015) and its usage has been ‘feminized’ (Hebert 2014). Socialist feminism contends that women deserve unlimited access to contraception (IPPF 2015). While, radical feminism argues that “women’s subordination is rooted in male control over women’s fertility and sexuality, that is, over women’s bodies.” (Connelly et al. 2000, p.124). Satz further supports radical feminism stance by asserting that men have historically had power over women’s bodies by ‘managing’ their sexuality and reproduction (2004). Hence, men may prohibit the use of contraception as a means of maintaining that power. However, radical feminism does not explain why some men allow their partners to use contraception but they themselves are not actively engaged in contraception usage. Therefore, hegemonic masculinity will be utilized to provide reasons for this.

The creation of the birth control pill was a significant landmark in the women’s rights movement (Campo-Engelstein 2012). Gretchen asserts that the history of the pill and the history of feminism are intricately linked, since if women can control their reproduction they also have control over their lives and the first-wave feminists knew this. She further elaborates that it was Margaret Sanger, the founder of the International Planned Parenthood Federation (IPPF) who coined the term “birth control” and the release of the pill in 1960 heralded in the second wave of feminism. Further, it is the belief of many that unlimited access to every kind of contraception is the only way to be a feminist and to oppose contraception is to be anti-women (2016).

Although contraception is widely praised, its use is still contested in the world of feminism. According to Purdy 1996 “Progressive left” feminists, thought that contraception reinforced ‘biologically deterministic stereotypes’ of women. While some feminists insisted that contraception made reproductive matters solely the responsibility of women (Sawicki 1999). This is a valid argument since the campaigns to increase contraceptive uptake often targets females only in Guyana and the world over. Further, in a postfeminist society that claims to have ‘achieved’ sexual liberation, contraception is being used to stop women’s menstruation (Harris et.al 2014). In addition, Freeman declares that in the late 1800s many feminists were against condoms since it was tied to married men’s promiscuity. While, later feminists such as Margaret Sanger, rejected the use of the male condom because they felt with this method of birth control men were wholly in control of contraception. However, in the 1970s, some feminists viewed the pill as a representation of patriarchy in the predominantly male medical and pharmaceutical field and the dangers associated with the usage of the pill were withheld from women which infringed on their rights to informed consent (2018).

While hegemonic masculinity will be used to give understanding to why men are not involved in the FP process in the rural village of Guyana. Hegemonic masculinity is a range of patriarchal practices that enables the sustenance of dominion over women and other types of masculinities (Connell and Messerschmidt 2005). In the Caribbean, for most men, the validity of their manhood depends on a “normative, straightjacket or dominant masculinity” and showing no features of tenderness or ‘femininity’ (Davis and James 2014). However, affirming to such limiting determinations of manhood leads “to disengaged fatherhood, poor health, aggression, overwork, and lack of emotional responsiveness” (Ruxton 2004, p. 10).

It is this type of masculinity that tells men that they should operate in a certain manner and that matters of reproductive health is a ‘woman’s business’. Men’s perspicacity of reproductive health being a matter for females along with the thinking that use of contraceptives will result in women being unfaithful acted as barriers in Uganda to contraceptive use (Atuyambe et al. 2014). Interestingly, in Nepal, the belief that contraception encourages women to be promiscuous resulted in men willingly using male methods of contraception to prevent their partners from using contraception (MOPH Nepal et .al 2012, cited in FHI 360 2012, p.2). Further, studies also show that males believe that protection against pregnancy is the sole responsibility of the woman (Greene et.al 2011). Opposition to the use of condoms is also a deterrent to involving men in FP (FHI 360 2012). For example, males in Bangladesh oppose condoms since they believe that condoms lessen sexual pleasure (Shahjahan and Kabir 2007).

Mula proclaims that women’s reproductive freedom and hegemonic masculinity cannot co-exist and the rights to abortion and contraception threaten this form of masculinity through:

“(1) freeing resources to compete with men for social, legal, and economic power that women might otherwise expend bearing and rear unwanted children; (2) destabilizing production relations by granting women greater ability plan to take on traditionally male-dominated jobs; and (3) destabilizing relations of cathexis by permitting women to explore their sexuality”. (Mula nd)

Essentially, hegemonic masculinity negatively affects the use of FP because it pressures males to openly denigrate the use of contraception based on masculine ideals (Graffty nd).

However, the saying ‘men are not concern about pregnancy prevention’ has been contested. Perveen insists that antithetical to that general belief, men have an interest in FP but in developing countries, they have been excluded from FP programs, other than those of vasectomy or condom distribution (2011). Further, Darrach asserts that some men are willing to accept responsibility for contraception even though pregnancy prevention programs over the last forty years has been virtually centered on women.  He also states that male FP methods presently account for 38% of all reversible contraceptive usage, and 28% of women of childbearing age rely on their partner’s vasectomy as their form of birth control (2000). In a credible study by Ojofeitimi et al confirmed that most men believed that decisions in relation to FP should be made by both spouses rather than by one party contradicts the frequently held notion that men are against FP and governs contraceptive decision-making (2007).

However, the theory of hegemonic masculinity is not without its flaws and there have been several critiques of it (Connell and Messerschmidt 2005). One such critique is that it is based on heteronormativity (Whitehead 2002). Further, it often depicts men as either yielding to dominant gender norms or being excluded by them (Connell and Messerschmidt 2005). While Anderson found that hegemonic masculinity could not justify the social dynamics of the male peer groups that included gay men. He then examined the association between homophobia and the construction of masculinities (Anderson and Mc Cormack 2016) and proposed the inclusive masculinity theory where masculinities exist in a less arranged order of rank and devoid of homohysteria (Anderson and McGuire, 2010).

Moreover, there are many other factors which intersect that leads to the contraception ‘burden’ being placed on women and cannot be fully explained by either masculinities and/or feminist theories. Even, the general ideas of masculinity are peculiar to sociocultural settings and determined by many agents such as sexual orientation, culture, class, and ethnicity (Connell 1995; Kimmel 2000). Therefore, the Intersectionality theory that was created by Crenshaw, which has its origin in black feminism is an appropriate viewpoint which can examine the numerous factors which lends to contraception being gendered. Moreover, Intersectionality transcends the well-known causes of inequality (Crenshaw 1989; Hankivsky 2012) and ‘digs’ deeper for the reasons the weight of pregnancy prevention is placed on the female.

However, hegemonic masculinity was seen to be more fitting to explore the lack of male involvement in FP in Guyana and to subsequently develop an intervention to combat it. Moreover, Blackbeard et. all declares that the theoretical concept of hegemonic masculinity needs to be included in gender interventions and this inclusion can give rise to changes in men’s attitudes, their view of what it means to be a man and their relations with women (2005). Hence, it was chosen as the theory to shape the intervention.

The Planning Framework

The GAM was created by Rani Parker along with development practitioners from a Middle Eastern Non-Governmental Organization in response to an expressed need for an appropriate framework for their grassroots work (March et 2000). It provides a community-based approach to the examination of gender differences which aids in the identification of the potential impacts of the intervention on women and men and it also challenges the community’s preconceptions about gender roles (March et. al 200). However, unlike the Harvard method, which is used by professional planners, it was created to be used in the field (World Bank nd). It carries out analysis at four levels: women, men, household and the community and examines impact on: labour, time, resources and culture (March et al 2000).

Why GAM Was chosen?

The theoretical perspective of hegemonic masculinity underpins the intervention. Hence, a tool that included men was necessary and the GAM was ideal because it is a framework that includes men and could be used in interventions that target them (March et al 200). Further, to ensure the desired synthesis existed between the theoretical perspective informing the intervention and the tool that will use to ensure gender sensitivity the GAM was chosen. moreover, the GAM was selected because it uses ‘bottom-up analysis’ and as a tool it can be used to predict the likely impacts of a given intervention and since it involves analysis of gender issues, it can lead to awareness raising of gender issues within the community which can result in other forms of development (World bank nd).

However, the GAM is not without its shortcomings: It gives almost no detailed data for later analysis; hence a series of meetings are required (World Bank nd). Further, a good facilitator is needed. Also, it can be difficult to define who is a part of the community, vulnerable members may be excluded, it does not perform macro and institutional analysis, and it does not make clear which women and which men are likely to benefit from the impacts of the project (March et.al 2000). However, as Kabeer (1995) rightly declares: “No set of methods are in themselves sensitive to differences and inequalities between men and women; each method is only as good as its practitioner” (cited in March et.al 2000, p.14).

How will GAM be employed in the Intervention?

The GAM is meant to be accompanied by other conventional tools of analysis (March et.al 2000). Therefore, the community leaders will be contacted, and a community needs assessment will be done. Before the commencement of the project, a session will be held with both male and female community members in equal propositions where the GAM matrix will be filled (See https://www.gdrc.org/gender/gender-ests.html). Subsequently, the group will discuss the following questions: “1) Are the effects listed on the GAM desirable? Are they consistent with the programme’s goals? 2) How is the intervention affecting those who do not participate?” (March et. al 2000, p.70)

First, the GAM will be used at the planning stage to ascertain if the possible gender effects are acceptable and in harmony with the goals of the intervention (Parker 1993, cited in March et.al 2000, p.69 ). Further, it will be utilized throughout the intervention since it can be used; “at the design stages where gender considerations may change the design of the project; or during monitoring and evaluation stages, to address broader programme impacts the analysis” (Parker 1993, cited in March et.al 2000, p.69). The GAM will be filled initially once a month for three months, and then once every three months consequently (March et 2000). As a result, the intervention will not be static but one which will change to accommodate the findings from the matrix.

To avoid the ‘project trap’ as described by Kabeer (1994.cited in March et.al 2000, p.14), the practitioner is conscious that “gender equality must be fought for at other levels and by other means” (March et.al 2000, p. 14) other than by using gender analysis tools. In addition, the practitioner will continually bear in mind that while the GAM presents a satisfactory means for data collection, it does not supply the answers (Warren 2007).  Caution will also be taken to ensure that it is not only gender roles that are being examined but also gender relations since Kabeer warns that analyzing gender-roles does not undeviatingly explore how power is distributed (1992) in a community. Moreover, while using the GAM the practitioner will be conscious that frameworks are not fully generalizable (March et. al 2000) and in different cultures can post issues due to them arising from another setting, possibly conflicting with local beliefs (Mukhopadhyay and Appel 1998; Wendoh and Wallace 2006).

The Intervention

This intervention is a pilot project that aims to increase men’s participation in the FP process in Guyana, South America. The focus is on men since it has been noted that the sole responsibility of preventing pregnancy is left on the women. However, it is the man who has the decision-making power and the one who decides if she will be allowed to use contraception. This finding in the country is supported by research that has shown that the male partner has the most important influence on a woman’s decisions about childbearing and contraception, yet FP programs have been solely women focused (Harper and Jezowski 1991). Studies have also depicted that providing men with information can help them to be more supportive of contraceptive use (Adelekan et.al 2014) and in its continued and effective use (Engender health and UNFPA 2017). Michael Kaufman (2003) contends that developmental work has neglected to concentrate on males which have resulted in continued male dominance in gender relations and the marginalization of women and their struggles (Cited in Ruxton 2004, p.11). Moreover, as a family planning advocate, I have realized that it is counterproductive not to include men in FP programs (https://www.globalhealthnow.org/2017-08/shattering-taboos-guyana-qa-patricee-douglas).

To move forward men must be engaged whether feminists agree or not since the reality is that men are the ones who hold the decision-making power both in the private and public sphere (Perveen 2011). Moreover, there have been international commitments to encourage male involvement such as “the landmark International Conference on Population and Development’s (ICPD) Goals and Targets 1994, that called for an understanding of men’s and women’s joint responsibilities, so that they could become equal partners in public and private life, and to encourage and enable men to take responsibility for their sexual and reproductive behaviour” (Perveen  2011).

The intervention will engage men in FP through community outreach and service provision (See https://www.fhi360.org/sites/default/files/media/documents/MaleEngageBrief.pdf) in the form of a male SRH clinic. It borrows best practices from a similar project that was done in Bangladesh (See https://www.fhi360.org/sites/default/files/media/documents/MaleEngageBrief.pdf ). However, it will be adapted to the local context. Moreover, the intervention will be gender transformative with the aim to change men’s perception of FP since “the research work shows that male motivation projects should…convince men that family planning is not only for women but men as well” (Soremekun 2014, p.1).

The SRH clinic in the village that claims to be gender neutral but only caters to the needs of females will implement a once per week clinic that caters to the SRH need of men with a special focus on family planning. These sessions will be facilitated by local male nurses and community health workers. The facilitators will be trained in gender and how to involve men in conversations about their SRH. The constructive male engagement framework, which is used to engage men in reproductive health as clients; supportive partners; and change agents (PRB 2018) will be employed in this intervention.

The expected outcomes of the health intervention are that the local men will become:

  • Contraceptive users or partners using methods requiring active cooperation.
  • Engaged in open communication and decision-making about FP and contraceptives.
  • Advocates for gender equality and FP in the community.

The intervention will be evaluated using specific indicators developed for the monitoring and evaluation of programs to increase men’s engagement in FP (See https://www.measureevaluation.org/resources/publications/tr-17-203).

Challenges

As with all projects, there will be challenges and with one of this nature that seeks to challenge the dominant form of masculinities, a few are expected. The writer will present possible challenges that may arise from the literature and what has arisen from work that she has done in the field as it relates to involving men in family planning. Firstly, it is going to be difficult at the beginning of the intervention to get men to access the services since “many men are resistant to changing ideas, beliefs, and behaviours” (Ruxton 2004, p.4). Therefore, it will be essential to have community champions – men from the community that other men respect promoting the cause. Further, clinics operate in Guyana are from 8:00am-4: 00pm and those are the hours men are at work. Moreover, while men’s engagement programs are essential, it is imperative that they are undertaken cautiously as not to serve as a tool to lead to an increase in men’s decision-making power and a decline in women’s bodily autonomy (FHI 360 2012). Therefore, this intervention presents a potential risk of the local men deciding on a contraception method for their partners without it being a shared decision. Hence, it is imperative that gender norms are addressed during the intervention (Engender health and UNFPA 2017).

Written by: Patricee Douglas

Edited by: Terrence Isaacs

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The power and politics perpetuating unsafe abortion.

*This is a piece where the writer challenged her religious and personal beliefs and looked at induced abortion from a public health perspective. 

One in three women in her lifetime will deliberately terminate a pregnancy in the act known as an induced abortion (Marie Stopes Uk 2017). Induced abortions can be classified as either safe or unsafe. The World Health Organization explicates unsafe abortion as the termination of an unwanted pregnancy by either an individual who lacks the medical expertise and/or the procedure being done in an inconducive environment that lacks basic medical standards (2018). Each year between 2010-2014 there were twenty-five million unsafe abortions worldwide, which accounted for 45% of all abortions (Singh et al. 2018). However, unsafe abortions are realistically avoidable (WHO 2018) but they continue to be a highly neglected sexual and reproductive health (SRH) issue (Grimes et al. 2006). This has resulted in unsafe abortions being “a persistent, preventable pandemic” (Grimes et al. 2006).

Further, 97% of all unsafe abortions occur in developing countries (WHO 2017) and 93% of the nations with highly restrictive abortion laws are developing countries (Singh et al. 2018). Grimes et al. confirm that unsafe abortions primarily affect women in developing countries where the abortion laws are highly restrictive or where the laws are liberal, but abortion is not readily attainable. They went on to say that women in these countries who have an unwanted pregnancy normally self-induce or have surreptitious abortions. While, in developed nations, legal abortions have been labeled one of the safest procedures in modern-day medicine, “with minimum morbidity and a negligible risk of death” (2006).

Moreover, sexual and reproductive health was largely ignored because of its “contested” nature in the past. However, in 1994 at the International Conference on Population and Development (ICPD) held in Cairo, Egypt (Natividad 2016) there was a change. ICPD was “unprecedented because it ushered in a major paradigm shift in the field, from its earlier preoccupation with population control to a new conceptualization of reproductive health and rights” (Natividad 2016, p.595). Importantly, the ICPD Programme of Action (POA) brought attention to the dangers of unsafe abortion and beckoned for it to be addressed (United Nations 1994). In 1999, this call to action was strengthened at the five-year evaluation of the ICPD POA, where it was asserted that the health systems of countries where abortion is legal should provide safe and accessible abortions (United Nations 1999).

It is against this backdrop that this piece aims to critically evaluate the power and political relations that perpetuate unsafe abortions. It will commence with an in-depth analysis of the power dynamics that enables unsafe abortions. The Mexico City policy will be assessed to demonstrate how the power and politics of one country can translate into the continuation and/or increase of unsafe abortions in others. Lastly, it will explore the relevance of the public health issue of unsafe abortion to the practice of health and social development.

Power and politics as forces driving unsafe abortions

The radical feminist saying, “the personal is political” (Connelly et al. 2000, p.124) proves to be true in the heavily debated matter of abortion. Conversely, liberal feminists proclaim that there should be a separation between the private and public sphere (Connelly et al. 2000). However, the latter philosophy does not hold true in the context of abortion – where the ‘private’ literally becomes a matter of public contention. Further, “the increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health” (Glasier et al. 2006, p.1595). Moreover, there are multiple power dynamics that propel the unsafe abortion ‘pandemic’. As a result, a framework adapted from Braam and Hessini (2004) will be employed to critically explore how power dynamics perpetuates unsafe abortions which have detrimental health and socioeconomic consequences.

The power of Patriarchy

Patriarchy – “the systematic, structural, unjustified domination of women by men” is essentially the reason abortion is a “contested and political issue” (Braam and Hessini 2004, p. 45). “The ideology of male superiority denies abortion as an important issue of status and frames the morality, legality and socio-cultural attitudes towards abortion” (Bram and Hessini 2004, p.43). This ideology fuels inequality in gender power relations and threatens women’s bodily autonomy (Bram and Hessini 2004). For instance, the termination of pregnancy up to 10 gestational weeks upon request was permitted in Turkey, in 1983 (Berer 2017). However, married women who wished to have an abortion needed their husband’s consent (Berer 2017).

The Power of Laws and Legal Systems

Singh et al. (2018) state that abortion laws are a continuum ranging from complete repudiation to permitting abortion without limitations. Further, evidence has shown that there is a connection between unsafe abortion and restrictive abortion laws (Haddad and Nour 2009). For instance, the “more restrictive the legal setting, the higher the proportion of abortions that are least safe, ranging from less than 1% in the least-restrictive countries to 31% in the most-restrictive countries” (Singh et al. 2018).

Further, Singh et al. claim that the abortion rate is analogous irrespective whether countries have restrictive or liberal abortion laws (2018). “Abortions occur as frequently in the two most-restrictive categories of countries (banned outright or allowed only to save the woman’s life) as in the least-restrictive category (allowed without restriction as to reason)—37 and 34 per 1,000 women, respectively” (Singh et al. 2018). However, the difference is in the matter of the safety of the abortion (Bosoley 2016). For instance, Berer states that in some Latin American countries where abortion laws are highly restrictive “women have begun to take matters into their own hands”(2017). Misoprostol which was created to treat gastric ulcers has been used by an undocumented number of women to self-induce abortion (Berer 2017).

Further, Haddad and Nour proclaim that there is an association between abortion-related deaths and a countries’ abortion laws. They used Romania to demonstrate this association. Abortion was available upon request until 1966 in Romania. In 1960 their abortion mortality ratio was 20/100,000. In 1966 the abortion laws became restrictive, and by 1989 the abortion mortality rate was 148 deaths/100,000. Because of this increase, the restrictions were removed and within a year the ratio declined to 68/100,000. By 2002 it was as low as 9/100,000 (2009). Similarly, South Africa made abortions legally available on request in 1997. This resulted in a 52% reduction in abortion-related infection, and a 91% reduction in the abortion mortality ratio between 1998 – 2001 as compared to that in 1994 (Haddad and Nour 2009).

Further, laws may limit women’s access to safe abortion services even in “progressive” countries. Singh et al confirm that some countries with extremely liberal abortion laws have frequently attached constraints that “chip away” at easy access to safe abortions; the United States and several nations in the former Soviet Bloc or zone of influence are examples of such countries (2018). Additionally, although most of the countries with restrictive abortion laws are developing nations there are developed nations that still have highly restrictive laws. For instance, abortion has historically been a schismatic matter in Ireland, where a complete ban was removed in 2013 allowing terminations only if the mother’s life is at stake (Rahman 2018). However, on May 25, 2018, a plebiscite on Ireland’s stringent constitutional stance on abortion will be held (Rahman 2018). This will give citizens the first opportunity in 35 years to liquidate one of the world’s austere abortion laws (Rahman 2018).

Also, Hemminki et al. report that originally, the Chinese government instituted a strong pro-birth policy promoting child-bearing through the use child subsidies and by banning contraceptives and abortions. However, in 1953 this policy was slackened, and under specific conditions contraceptives and abortions were permissible. Subsequently, in 1957, abortion became easily accessible because of the country’s first birth control campaign. In addition, abortions increased rapidly after the implementation of the 1979 one-child policy (2005). During that time women were forced to have abortions, arrested when they declined and imprisoned (PRI 2012). Those who still refused were physically hauled into medical clinics, where they were constrained, and the abortion procedure was performed (PRI 2012).

Moreover, it should be noted that access to safe abortions can be restricted without altering the law itself but by the subversion of laws and policies (Berer 2017). Alternatively, safe abortions can be restricted through policies compelling females to have more “children, public denunciation of abortion by political and religious leaders, or restricting access to services” (Berer 2017). Therefore, the availability of safe abortion is not only reliant on governing laws but on a “permissive environment, political support, and the ability and willingness of health services and health professionals to make abortion available” (Berer 2017).

The Political Power of Institutionalised Gender Inequality

Braam and Hessini assert that the field of politics is frequently “male-dominated, and men’s needs and experiences establish political agendas” (2004,p.45). Therefore, if the men in power do not think that women should have the right to terminate an unwanted pregnancy it will have no place on their agenda. Further, because it is perceived as a sensitive issue that could jeopardize electoral support many political leaders have studiously neglected abortion (Braam and Hessini 2004).

The Power of Economic Inequality

Braam and Hessini state that poverty is a pivotal determinant of unsafe abortion. They further claimed that several women prefer to terminate pregnancies as a result of economic strain and the resultant inability to sustain a child (2004). Therefore, they resort to unsafe methods to get rid of an unwanted pregnancy. Additionally, there are cases where abortion laws can be liberal but due to the cost to secure safe abortion poor women are forced to have an unsafe abortion. This demonstrates that merely having less restrictive abortion laws do not guarantee safe abortions for all (Haddad and Nour 2009). For instance, in the United States of America (USA) some states have Targeted Regulation of Abortion Providers (TRAP) laws which restricts public funding of safe abortions (Gorm 2016). This leaves “lower income women not being able to pay fees as high as $1,500 (£1,190.81) to terminate their pregnancies” (Gorm 2016).

The Power of religion and Culture

Religion has long been implicated in opposing women’s right to bodily autonomy (Braam and Hessini 2004). However, the issue is not religion in itself, but religion becomes problematic when it influences laws and policies. For example, “when politicians vote according to a religiously informed conscience or when churches and their members lobby politicians to effect changes to legislation” (Parker and Skeene 2002, p.215). Further, even as abortion becomes more prevalent, it is often denounced in the setting of “religiously conservative and pronatalist cultural belief systems” (Braam and Hessini 2004). For example, the Catholic church continues to embed itself into governments in Latin America lending to abortion being “broadly legal” in just six countries (Sanchez 2013). Hence, many women in the region go to “traditional practitioners” to abort, or they administer abortion-inducing drugs on their own (Sanchez 2013). Similarly, the Catholic Church’s influence on politics has been implicated as a significant agent repressing political action towards the overhauling of restrictive abortion laws in many countries on the African continent (Braam and Hessini 2004).

Personal Power and Power in the Sphere of Relationships

Societal perceptions of womanhood play an integral role in forming individual women’s understanding of self and their capacity to employ personal control of their SRH (Braam and Hessini 2004). In most cultures, motherhood is oftentimes viewed as the core of womanhood, on the other hand, abortions are regarded as a decisive interruption of this process (Braam and Hessini 2004). Further Oyefara found that there are four typologies of gender and power relations namely: male-female power relations, parent-child power relations, significant other and power relations among peers, and lecturer-student power relations that promote the deleterious practice of unsafe abortion amongst young undergraduate students in Nigeria (Oyefara 2017).

Concurrently, Chikovore found in his study that the fear of violent responses from parents and of rejection by male partners leave girls with few options but to have an unsafe abortion when they get pregnant (2004). Similarly, Braam and Hessini claim a woman’s decision to have an unsafe abortion is often due to the retort of “her male partner to her pregnancy, the extent of her financial dependency on him, and her concerns about the survival of other children”. They further went on to say that in some circumstances, unsafe abortion despite its dangers to a woman’s well-being and life may emerge into the lone medium by which she reclaims her decision making power (2004).

The Power of Discourse

The broadly conservative approach to abortion can be significantly attributed to the language utilized in discussions about it (Braam and Hessini 2004).  The pro-life campaign uses words such as “life, babies, families, all of which tend to put those who advocate for women’s rights to control their bodies and access to safe abortion services morally on the defensive” (Braam and Hessini 2004, p.47). While, the discourse surrounding a woman’s right to terminate a pregnancy is focused on “death, blood, and infertility” (Braam and Hessini 2004, p.47). Hence, further preventing reformation of abortion laws in nations that have highly restrictive abortion laws (Braam and Hessini 2004).

A case study of Power and Politics in International Funding for Reproductive Health: the Mexico City policy

The Mexico City policy is an example of an anti-abortion philosophy that was translated into a foreign policy (Guttmacher Institute 2017). This policy generally known as the “global gag rule” by its antagonists was initially implemented in 1984 and it denies U.S government funding from non-U.S organization that renders or even speaks about abortion (Marie Stopes International 2018). “The politics of the Gag Rule have been rooted in domestic political struggles over abortion, played out between anti-abortion and pro-choice factions of the Republican Party, between Republicans and Democrats, and between the Executive branch and Congress” (Crane and Dusenberry 2004, p.129). President Trumps’ administration restored and extended the Mexico City policy to hinder U.S support to all international organizations that employ their own funding to provide abortion-related services (Guttmacher Institute 2017).

Marie Stopes International and International Planned Parenthood Foundation (IPPF) are two organizations that have been directly affected by this policy. Marie Stopes International is a London based organization that works in 37 countries to provide abortion and contraception services (Quackenbush 2018). They claim that “unless we are able to close that funding gap of US$80m (£60m), we estimate that more than 2 million women will no longer have access to contraception services…2.5 million unintended pregnancies, 870,000 unsafe abortions, 6,900 avoidable maternal deaths (and) £107m increase in direct healthcare costs” (Marie Stopes International 2018). While IPPF that works in over 150 countries, is confronted with setbacks in their contraceptive, HIV/AIDS, and tuberculosis programmes. They declare that for “$100 million in lost funding, the organization could have prevented 20,000 maternal deaths in 29 countries” (Quackenbush 2018).

The Mexico City policy has seriously affected the safety of abortion, as there is a direct association between unregulated abortions and unsafe abortions (Bangs 2017). Restricting access to safe abortion forces women to undergo unsafe procedures, including the induction of their own abortions (Bangs 2017). Hence, in contrast to what its defenders claim, the gag rule just as other restrictive abortion policies do not prevent women from having abortions (Guttmacher Institute 2017). For example, in Romania, where legal abortion has been the primary means of fertility control for numerous women, the Gag Rule led to the division of contraceptive services from abortion-related services (Crane and Dusenberry 2004). This action dramatically diminished the chance to promote post-abortion contraception services, plausibly leading to more rather than fewer abortions (Crane and Dusenberry 2004). Moreover, this ideologically motivated policy is “harming the health of people in poor countries, violating medical ethics and trampling on democratic values” (Guttmacher 2017). All of which undermines the very objects of the U.S. foreign aid programs (Guttmacher 2017).

Unsafe Abortion Relevance to the practice of health and social development

Unsafe abortions have many detrimental consequences not only for the woman but to the health systems of countries and the society at large.

Health Consequences

The outcomes of unsafe abortion include complications such as “sepsis, hemorrhage, genital trauma and even death” (Arnaldo 2018). Five million women are hospitalized each year for management of abortion-related complications and 220,000 children are left without mothers due abortion-related deaths globally (Haddad and Nour 2009). Data on the longstanding health consequences of unsafe abortion is limited but the known ones are: “poor wound healing, infertility, internal organ injury (urinary and stool incontinence from vesicovaginal or rectovaginal fistulas), and bowel resections” (Haddad and Nour 2009). Further, Unsafe abortion could increase the “risk of ectopic pregnancy, premature delivery, and spontaneous abortion in subsequent pregnancies” (Grimes et al. 2006).

Moreover, the mortality and morbidity from unsafe abortion lead to the loss of approximately 5 million DALYs per year by women of reproductive age (Grimes et al 2006). It is estimated that yearly 68 000 women perish due to complications arising from unsafe abortions globally —that is eight women per hour (Grimes et al. 2016). That translates into a case-fatality rate (367/100 000) which is hundreds of times greater than that for legal abortion in developed nations (Grimes et al 2016). Additionally, yearly 4.7% – 13.2% of all maternal deaths can be connected to unsafe abortion (Say et al. 2014, cited in WHO 2018).

Health Systems consequences

The consequences of unsafe abortion are not only felt by the women and families directly affected but also a strain is placed on the public health system (Haddad and Nour 2009). Managing the side effects of unsafe abortions devastates disadvantaged health systems and side-tracks already inadequate resources from other critical health-care programmes (Grimes et al. 2016). Further, in some low and middle-income nations, up to a staggering 50% of hospital budgets for the obstetrics and gynecology (OBGYN) department are consumed in managing complications of unsafe abortion (Grimes et al. 2016). According to Vlassoff et al. (2008), approximately US$553 is the yearly cost of managing the significant complications from unsafe abortion (as cited in WHO 2018).

Socio-economic consequences of abortions

In addition to the above-mentioned, there are several other detrimental consequences of unsafe abortions such as “the economic consequences – the costs of medical care for longer-term health consequences, lost productivity to the country, the impact on families and the community, and the social consequences” such as stigma (Singh 2010). Further, the damaging effect on children’s health and education when their mother dies cannot be ignored (Grimes et al. 2016).

From the above, it is clear that Sexual and Reproductive Health is a locus for contestation, particularly regarding abortion rights. Further, power dynamics have a critical role in perpetuating unsafe abortions which ultimately affects peoples’ SRH. Although the moral deliberation over abortion will persist, the public-health stance that safe and legal abortion on request advances wellbeing is indisputable (Grimes et al. 2006). While the health of women degenerates when safe abortion is not easily accessible or is illegal (Haddad and Nour 2009). The solutions to combat unsafe abortions are accessible and inexpensive but governments in developing countries often do not have the “political will” to do what is required (Grimes et al. 2006). However, if we are going to make the world a safer place for women and girls, then highly restrictive abortions laws must be abandoned. The reality is “there is no such thing as no abortion – there is only safe and unsafe abortion” and politics and power relations dictates which one will take precedence in a country. Fundamentally, politics should never impinge on women’s reproductive right to end an undesired pregnancy.

Written by: Patricee Douglas

Edited by: Terrence Isaacs

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A collection of “the first time I got my period” stories.

“Menstruation is one of the most natural functions in the world. It is a mark of femininity and fertility, and a huge part of life for most women. Yet, for some reason, women are frequently made to feel ashamed or embarrassed simply because they bleed” New York Post 2018.

On the 21st of May 2018 SRHR Adventures, a grassroots organization that seeks to promote sexual and reproductive health and rights with a special focus on family planning/contraception in Guyana issued a call for “the first time I got my period” stories on their Facebook page. The call was made to encourage open discussions around periods since its oftentimes shrouded in shame and secrecy. 

The following are a few of “the first time I got my period” stories that were collected:

God saw you playing you big and decided to humble your ass!

“I was 13 so I had to wait a little while longer than the other girls in my class😒 I remember that I had an argument with my mother 3 days before cause she asked me to drink a vitamin tablet and I refused to because of the taste and when she pressured me I decided to play Rihanna and started singing “Just live your life 🎧” cause apparently those premenstrual hormones were getting to ya girl 🤦🏽‍♀. Now I’m normally the girl that does exactly what mother says so when this happened all my sibling pulled up a chair to see how this ish was gonna go down. Needless to say, I got lashes and three days later on my 13th birthday, I got my first period. I knew exactly what was happening because I grew up surrounded by females. My sister was like that’s punishment for giving your mom sass. God saw you playing you big and decided to humble your ass!!”

There were days you actually wished for menopause.

“I was fortunate enough that my parents allowed me to read…they just ensured that I had reliable sources: encyclopedias and science books. So when I got my first period at 12 I knew what it was….but you know….I still made a big deal about it, pretended as if I didn’t know what was going on then ran to my mother. She just showed me how to use a pad and told me to calm down. But the irregularity of those cycles for the first few years was annoying and led to a few embarrassing moments…..there were days you actually wished for menopause 😒.”

I asked my mother…who killed a pig in the toilet.

“When I first found out about periods, my cousin who usually goes through a lot of pain when she’s on hers used the toilet and when she was finished my mom was going to clean it for her. Before my mom could get to the toilet I went in and saw the blood and the question I asked my mother was who killed a pig in the toilet.

A year later when I was in grade 4 in primary school my period came. I remember going to the toilet, seeing the blood and being super excited. It wasn’t painful like my cousin’s; I remember the same day she was on her period crying in her room and I went to ask her for a pad until my grandmother bought mine. I didn’t get a boiled egg, nobody didn’t make a big deal of it, I was the one on the phone calling my aunts and telling them about my period. When my second period came, then the pain kicked in and that’s when I realized aunt flow was just being nice to me the first time, but the second time she meant business.”

It was after that talk I realized this wasn’t my fault and every girl go through this “ordeal”. I stopped hiding and throwing my panties away.

“My first period! It lasted for about 4 months – not in a literal sense but it sure felt like a long time.

It was a midday one Saturday, I remember it as though it was yesterday even though it was many moons ago. I went to the toilet – back in the days toilet if you know what I mean! About to do one of the many bodily functions when I noticed the bottom of my underwear didn’t look the way it usually looks.

I started to investigate and discovered it was blood. I was horrified because I thought something was wrong. I thought I did something bad to my body. I thought this meant trouble. I began thinking lord what my father will say.

You see I never read about a woman’s period before nor did I hear anyone talk about it. I was clueless, afraid and I felt weird and distant. So, I hatched up this plan. I wasn’t going to tell a soul what happened or what I intend to do. I hid my panty. I threw some away. I figured that if I didn’t wear any me nor anyone else won’t see the blood and I won’t have to worry. That didn’t stop the bleeding though. This continued for days. Every day felt worse than the one before. The pain wasn’t easy to bear but to keep my secret I endured it, daily. In addition to concealing the pain, I continued throwing away, hiding or quickly washing the panties so that no one will find out.

I did that for about 4 months. You see I was in primary 4/grade 6 when the “period” came. All my focus was on not getting into trouble, go to school and do well. That I did. It wasn’t until the last few weeks for my primary schooling which meant it was play time. Ms. Washington wasn’t having it though. She decided to talk with us girls who she called young ladies. She told us about menses. She described it. She told us what to expect. She told us how keep clean and what to use during that time. She made it fun. She told us it made us “women”. We all laughed because that wasn’t true, we still needed boobs.

It was after that talk I realized this wasn’t my fault and every girl go through this “ordeal”. I stopped hiding and throwing my panties away. I told my dad and stepmom what happened. I wasn’t afraid anymore.

That’s my first-period story!”

I was on a dancing trip in Jamaica.

“I was anticipating my period since everyone around my age was getting it. I expected it to flow anytime soon. I was on a dancing trip in Jamaica. I was practicing with my fellow dancers when I felt my belly hurting. I ran to the bathroom quickly because I knew what it was. I found out I got my period I told my big cousin. I was scared to tell my mom, so she ran and told my mom.”

She was not prepared, and her uniform was stained with blood.

“I was 10 years old and I clearly remember when one of my friends saw her first period.

She was not prepared, and her uniform was stained with blood. There were mixed emotions from my classmates. Some laughed, others were a bit concerned while a guy who I was very close with and had a crush on secretly, started to like my friend.

In my mind, I felt sorry for her because she was not prepared, and I wondered if she knew what she had to do or what was happening to her. Did her mom ever speak with her the way my mom did with me?

Nevertheless, that day I realized that once you turn a “young-lady” boys will like you. Who will not like that? 🤣 However, if you know my mother, you will also know that thought was crushed.

Nevertheless, I remembered the day I first saw my period in the year 2001. I was traveling home on a bus from school and felt something “flowing out of my vagina” on to my liners and I wondered if it was my period. I quickly rushed to the washroom when I reached home and there it was – blood on my liner. Even though I knew it was my period I needed confirmation from my mom. So, I called her and told her what I saw and asked her if it’s my period and she said yes and directed me to enter her room and take a sanitary napkin. Even though she told me several times before how to use the sanitary napkin, mom reminded me once again.

I was happy to be a young lady and that was the beginning of my endless reminder of what it means to be a young lady (feelings for the opposite sex, consequences of sex etc).”

You must tell Mommy and I kept looking at her then back at the underwear then I said to her with fear “don’t tell Mom”.

“We were about to take our usual afternoon swim before bath. Myself and my sister who’s 10 months younger than I, I was 11 at the time. We were both changing into our swimwear when I noticed it, actually, my sister noticed before me because I wasn’t looking at my underwear when I took it off but there was a dark stain on it. I panicked when she asked me, girl, what is that? Something is wrong with you! You must tell Mommy and I kept looking at her then back at the underwear then I said to her with fear “don’t tell Mom”.

I used to see Mom using sanitary napkins, but I never really got in-depth as to why. (We were quite isolated from society hence we were not exposed to certain information, we were home-schooled for most of our early years). So, after our brief hesitation and moments of figuring out what to do my sister grabbed her towel around herself and ran up to the house shouting for mom and she told her.

My mother then came down to the pool and told me to go shower quickly and come upstairs which I did. Upstairs in my room now mom had my own pack of sanitary napkin which she gave to me and showed me how to use it and told me that since I’m now starting to menstruate it’s easier for me to get pregnant if I have sex. (Think she just told me that to scare me) anyways I used the pad which was the most uncomfortable thing I’ve done in my life up until then. My sister kept laughing at me I was so upset with her.

That night I experienced what I imagined to be hell. The pain was so much I was literally rolling on the floor and crying. It lasted for hours until I fell asleep.

A few cycles after that I was a ‘PERIOD PRO’. #mystory.”

… but why was I feeling wet…down there???

“I expected when I woke up to have a normal day as usual, but mother nature had different plans…I woke but why was I feeling wet…down there??? I checked and saw it was blood and knew it’s significance because I was what you can say ‘a bright girl’ always inquisitive! I called out to mama and showed her, she told me go clean up which I did, then she placed a stayfree on my panty and sat me down for ‘the talk’.

As I said I was a smart girl (still is) so I wasn’t fooled with that baby comes in airplane theory which I was told when I was younger, however this time mom told me “Well you’re a young lady now and that means if you sex you gon get pregnant, so don’t think about that now wait until yo marry to your husband, continue to take in your education. Don’t let nobody touch you inappropriately ok. You will need pads now every month and always ensure yo clean yourself properly and wash yo panty clean good.”

Not sure if she called up anyone after that caz I had to go prepare to go VBS (Vacation Bible School). The change in my body made me uncomfortable especially the pains but a day like today I’m grateful that I am a woman who menstruates!”

“Why you are a badass: because you can bleed for a week straight without dying. Periods prove how strong women really are!” Anonymous. 

By Patricee Douglas