contraceptives

As most of you know, to some degree a countries development correlates with its fertility rate. A country that is less developed tends to have higher fertility rates compared to fertility rates that are barely above replacement in countries with the highest GDP's. I am fascinated by this phoneme and the simple affect things like education and contraceptives can have on the livelihoods of people struggling in poverty. 

G. Nargund talks about this in his article "Declining birth rate in Developed Countries: A radical policy re-think is required" on the National Center for Biotechnology Information's website. "In developing countries children are needed as a labour force and to provide care for their parents in old age. In these countries, fertility rates are higher due to the lack of access to contraceptives and generally lower levels of female education. The social structure, religious beliefs, economic prosperity and urbanisation within each country are likely to affect birth rates as well as abortion rates. Developed countries tend to have a lower fertility rate due to lifestyle choices associated with economic affluence where mortality rates are low, birth control is easily accessible and children often can become an economic drain caused by housing, education cost and other cost involved in bringing up children. Higher education and professional careers often mean that women have children late in life. This can result in a demographic economic paradox." (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255510/)

In short industrialized and technologically advanced societies do not require huge populations and population growth to advance. Below I made two graphs that compare Fertility rates in some of the highest income countries compared to the fertility rates in some of the lowest income countries. I got all of this information from the CIA's website. (https://www.cia.gov/library/publications/the-world-factbook/fields/2127.html) (https://www.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.html)

If you look to Brazil, you can see how a society can take control of it's fertility rate while simultaneously expanding it's economy and empowering it's women. Brazil has experienced extreme drops in it's fertility rates, and surprisingly, these drops have occurred all over the vast country. In 1960 the fertility rate in Brazil was 6.16 children per woman dropping dramatically to 1.9 in 2011. The Washington Post talks about this rapid drop in rates, "A frenzied migration to the cities, the expansion of the female workforce, better health care and the example of the small, affluent families portrayed on the region’s wildly popular soap operas have contributed to a demographic shift that happened so fast it caught social scientists by surprise.  it's high fertility rate and utilize their population and on a smaller scale, the size of families, to benefit the economic growth that country wants as a whole." You can read more about how their fertility rates dropping parallels their recent economic expansion in The Washington Post article:

https://www.washingtonpost.com/world/fertility-rate-plummets-in-brazil/2011/12/23/gIQAsOXWPP_story.html?noredirect=on&utm_term=.cd5a33ff830e 

Now what does this have to do with Rwanda? I came into Rwanda curious if the country gave women the tools to have control over their fertility rates. These tools being, education, freedom to do with their bodies as they please, and access to contraceptives. I also wanted to understand what social taboos and religious beliefs were surrounding the subject. 

I want to introduce Rwanda's birth rates and contraceptive use by sharing an excerpt from a book I just finished, "A Thousand Hills, Rwanda's Rebirth and the Man Who Dreamed It" by Stephen Kinzer. He talks about the overarching issue of population size, economic growth, and contraception in Rwanda, "I love Rwandans, but I don't want too many of them. There are enough already. President Habyarimana might have been exaggerating when he said in the early 1990s that Rwanda was full, but not by much. It was and is one of the world's most densely populated countries. If its population continues to grow at current rates, it is doomed. For more than a decade after the genocide, few Rwandans wanted to admit this harsh fact. With so many dead, it seemed almost sacrilegious to suggest that overpopulation could ever again become a problem. Yet Rwanda has long had more people than its meager resources and small area can support. The first Rwandan census, taken in 1911, found that the country had about two million inhabitants. The population grew steadily over the next half-century. By 1969, it was 3.6 million, which may be the limit of what an agricultural country of this size can support with traditional farming techniques. Then the growth rate began rising more sharply. At the time of the 1994 genocide there were nearly seven million Rwandans. In the years that followed, those born far exceeded the number who had been killed. By the end of 2007 the population was approaching 10 million. The average Rwandan woman has six children, At this rate, there will be thirteen million Rwandans in 2020. That will make any substantial social or economic progress impossible. It will deeply destabilize Rwandan life. Some believe it could also lead to another outbreak of mass murder. "Rwandans in general view the genocide as related to overpopulation," De. Cassing Hammond, a professor of obstetrics and gynecology at Northwestern University Medical School, told me after returning from a research tour. "As we get population back to pregenocide levels- and Rwanda is once again the most densely populated country in Africa- if they don't control population, not only will there be a serious effect on infant and maternal mortality, but they may face another war. This was driven home to me time and time again." President Kagame was among the Rwandans who closed their eyes to this looming crisis. That allowed cabinet ministers and members of Parliament to do the same. Few of my experiences in Rwanda were as maddening as hearing senior officials blithely insist that Rwanda can hold a limitless number of people as long as they are educated, or that a large population is beneficial because it creates a market for local products. Those officials were reflecting social beliefs and conventions that are deeply rooted in Rwandan society. They make Jeannette Mukabalisa's job hard. She is a young health promoter who travels among villages in south-central Rwanda trying to persuade women to have fewer children. "They say we're not Christian," Jeannette lamented when I visited her base in the town of Mayange. (An excerpt from Mukabalisa) "The say, 'You're town people, we're traditional.' Children bring these families prestige. For them, children come from God. So it's difficult, very difficult... We have to show them precisely the bad side of having many children. The first example we use is land among many children, the parcels will be too small. Dividing in two, maybe, but if you have ten, what will you do? The second things we talk about is education: 'You're going to have to pay for the education of each child.' The same goes for medical care; everyone needs it. And there's food security; if there are many children, there won't be enough to eat. We're working on it. We have good policies and good planner, but not enough resources are being put into implementation. The role of government is to change traditional beliefs. This is something they have to change." It was changing even as we spoke. A handful of outspoken women- of whom there is no shortage in Rwanda- were demanding that the government make population control a priority. One of the most dynamic among them, Senator Odette Nyiramilimo, went as fare as to introduce a bill in Parliament that would limit families to three children, with harsh punishments for violators. 'It was coercive,' she told me without hesitation when I visited her office soon after she introduced her bill. Diplomats and aid administrators quietly explained to Senator Odette that the outside world frowns on coercive population control. Nonetheless she had forced the issue onto the national agenda. When I asked President Kagame about it, I was surprised to find him not only eager to act, but apologetic about his failure to do so sooner. 'We realize we are late on this,' he admitted. In 2007 Rwanda launched a population-control program that will, if it is fully realized, be the most sweeping in African history. Under its provisions, everyone of childbearing age who visits a clinic and offered a choice of methods. Health workers give women Jadel, a small silicone pin that is inserted beneath the skin and is effective for up to five years. Sex education classes are being introduced in schools. President Kagame has begun promoting the program, which makes it effectively impossible for anyone to oppose it. Nor is the Catholic Church resisting; it was so shamefully compromised by its collaboration with the genocide that it no longer dares to enter public debates. What led to the government's change of heart? Part of the answer lies in a PowerPoint presentation that the ministry of health made at the government's annual retreat in early 2007. Slides made clear that if Rwanda could achieve "zero population growth," everyone would be more prosperous. Most persuasive was a slide that displayed data from Thailand. It showed between 1975 and 1990,, the fertility rate there dropped by half and average income more than doubled. The headline over this slide proclaimed, 'Thailand Emerged as a Middle-Income Country in a Single Generation!' For the visionaries who run Rwanda, that was unbearably tantalizing. Soon after that government retreat, messages exhorting patriotic Rwandans to limit size of their families began filling the airwaves... Responses to these calls was more positive than anyone had imagine. That created unexpected problems. Health clinics were overwhelmed, and demand for contraceptive devices, especially Jadel implants, far outstripped supply. Government officials realized that their financial resources did not come close to matching their newfound passion for poputlation control. They began quietly casting about for an "angel"from abroad who would agree to underwrite the entire effort." (P. 248 - 251)

I think that gives you a good overview of the reproduction/population situation in Rwanda but also gives you an understanding of how this growth, and on a smaller scale, family size can be intertwined with the economics of a country and the prosperity of people. The difference with Rwanda is that in 2000, Rwanda's President Paul Kagame adopted Vision 2020 which was a government development programs with it's main objective to accomplish different goals in reducing poverty, improving health, and unity by 2020. Kagame's desire to rapidly grow his country through this program made it easy for him to pair with "Family Planning 2020" which according to it's website is a, "global movement that supports the rights of women and girls to decide- freely and for themselves- whether, when, and how many children they want to have". Family Planning 2020 partners with "governments, civil society, multilateral organizations, donors, the private sector, and the research and development community to enable 120 million more women and girls to use contraceptives by 2020." (http://www.familyplanning2020.org/microsite/about-us). You can see Rwanda's commitment to this goal of providing women with contraceptives by 2020 in partnership with Family Planning 2020 below.

All of the information below is lifted from The Family Planning 2020 website. The acronym "mCPR" stands for, modern contraceptive prevalence. "MW" stands for married women and "AW" stands for all women.

According to this information, approximately 30% of all women are using "modern contraceptives". This is all data the government is giving to the third party group, Family Planning 2020, so I looked to the newspapers and see if they were saying something else.

The East African newspaper, in 2016 talked about how, "more Rwandan women opt for birth control" with 1.2% of women choosing to get permanent birth control (tubal ligation). While according to Rwanda Demographic Health Survey (DHS), "growing trends in use of contraceptives indicating an increase in uptake of modern methods from 10 per cent in 2005 to 48 per cent in 2014/5". This article can be found at:

http://www.theeastafrican.co.ke/rwanda/News/More-Rwandan-women-opt-for-birth-control-/1433218-3254362-7uy9mnz/index.html

The New Times, Rwanda's leading Daily newspaper had a different view of the status of contraceptives. One of their articles from 2016 titled, "Family Planning: Why are women shunning contraceptives" talks about the trials women face in regards to contraception. The different issues they highlight are, misconceptions about contraceptives, fear of side effects, fear of becoming barren, lack of education on the subject, friends or families sharing false information with women, or pressure from husbands or families to have a child. Dr. Rachna Pande, a specialist in internal medicine at Butaro Hospital talks about the issue, “It is a social problem. Pressure by the husband or the family to have a child early or other children makes it hard for a woman to accept contraception. Other women may be ignorant about contraception and hesitate to come forward and discuss it with a health care provider….. Then there is a fear of adverse effects or worse still infertility caused by contraceptives. She may have used some contraceptive for a short time, then given it up because of some side effects,” (http://www.newtimes.co.rw/section/read/203854)

There is another article in The New Times from 2012 that highlights some issues that are still relevant. The article has information from the UNFPA Resident Representative, Victoria Akyeampong, the article writes, “She also pointed out lack of decision-making power of women about the use of Family Planning and insufficient support and involvement of their male partners is another barrier. Another challenge she highlighted is that of insufficient human resource for health, especially Midwives, gynecologists and neonatologists.”

While the article talked to Pastor Banard Buchana, of Christian Life Association that spoke about the socio-cultural and religious beliefs that women were facing when thinking about using contraceptives. The pastor “observed that religious leaders are not against Family Planning but instead they are against abortion.” He is quoted saying, “We are only against killing which is through abortion. Family planning is birth control and doesn’t stop the progress of a pregnancy. The religious leaders who are against family planning speak for themselves and not on behalf of all clerics."

One of the views that is most interesting to me came from a pharmacist, Lambert Ingabrice, who said that “the challenge is mostly with unmarried girls and women who are faced with societal stigma therefore making it hard for them to access contraceptives and family planning methods.” He went on to say, “Some of these women are shy, afraid and go as far as sending kids to help them buy the contraceptives yet in most cases we need the user so we can advise them on how to use these contraceptives.”

I have been asking a few of my young girl friends here about this subject and their responses are equally interesting so I am going to interview a few of them on the subject.