26 February 2012

Birth Control & the Muslim World--Misconceptions Abound

Updated, 22 August 2013--see entry for Iran.

During a conversation with [name withheld], she mentioned something about how a woman was stoned in Iran for using contraceptives. I mentioned that this seemed unlikely to me, and indeed, I did not believe it was something that happened anywhere. My friend was flustered and little bit annoyed, but she had to admit she had no idea where she'd heard this. I looked it up and discovered (courtesy of the BBC) that Iran, in particular, had a large contraceptives industry, distributed contraceptives free through its national health system, and had mandatory contraceptive education as a precondition to getting a marriage license.

While reading up, I was (a) surprised at how misinformed I was, or, looking at it another way, how odd it was that I had never looked into the matter, and (b) how easily available the information is.

The main historical force driving birth control, based on my (very brief and inadequate) review of many difference countries and cultures is technology: the medical knowledge required to develop safe and reliable BC emerged around 1910, while the materials science required (elastomer production, for example) took off around 1930. Reliability was achieved for most varieties around the mid-1950's.

Most activists might interrupt me here to object that there had to be a movement demanding BC, which is undeniable, but the technology was definitely developed independently. Elastomers and rubber obviously had a huge number of industrial applications, which paved the way for the development of materials suitable for medical use.

(Here follows a summary of what I found, with links):

In regards to contraceptive availability in Islamic societies, legislation varies by country.

Iran: condoms are a primary form of birth control, but not the only kind available. This article from the BBC  is from 2002, during a period of liberalization in social policy, but it is pretty impressive. "Couples can't get a marriage licence without attending contraception classes..." says a photo caption.

The Keyhan Bod plant is about two hours drive to the west of Tehran, and is the only state-supported condom factory in the Middle East. It produces about 45 million condoms a year, in 30 different shapes, colours and flavours. "About 80% of our production is plain condoms destined for the Health Ministry," says general manager Kamran Hashemi. [Another photo caption mentions that condoms are dispensed for free in health clinics].

In terms of contraceptive education and access, Iran is well ahead of the USA (although the usage rate is slightly higher in the USA). Contraceptive pills are available for sale; the BBC mentions that "no questions are asked." Vasectomies are commonplace as well.

This is the result of a determined and highly successful effort by the authorities to control population growth. In more academic studies performed recently, it appears that the health authorities are constrained mainly by older social norms, including erroneous notions of birth control (link goes to HTML of Ph.D. thesis).

Abortion is also legal in Iran; according to the IES, this reflects a tradition of indifference to the practice.

UPDATE, 22 Aug 2013: Robert Tait, "Iran scraps birth control programme in baby boom bid," Telegraph, UK (2 August 2012).  Iran has recently shifted policies: the Supreme Leader Ayatollah Ali Khameni has announced that the old policies favoring population control and small families were shifting in favor a renewed natalist policy.  This would entail abolishing government subsidies for contraceptives.  More flamboyently, Khameni has re-affirmed support for a future Iranian population of 150 million people. HOWEVER, and this is quite important, by the summer of 2013, the main obstacle for Iranian women seeking birth control in Iran was US sanctions imposed on that country (Iranwire).

Indonesia, Egypt, and Turkey: most forms of contraceptives are readily available; usage is 60-64% (C.f., 76% in USA and 84% in UK). This is in line with usage in non-Muslim countries with comparable average incomes, such as modern Romania (1999). According to the IES entry for Indonesia, there appears to be a general cultural/statutory assumption that contraceptives ought to be confined to married couples; nevertheless, it is not especially difficult or risky for Indonesian couples to flout restrictions on access. In Egypt, access to contraceptives is limited mainly by the impoverished and inefficient nature of the government; conservative objections do not seem to be peculiar to Islam. In Turkey, usage of contraceptives was actively promoted after 1960; main limitation on usage is [misinformed] fear of health risks caused by some methods, or conservative rural mores.

(I forgot to mention that urban legends about the risks of some contraceptive methods are universal, especially in lower-income countries.)

Pakistan: Pakistan and other low-income Muslim countries are confusing to Western observers because their social norms are more influenced by low incomes than by Islam. For example, Austria (mid-1990's) had lower contraceptive usage rates than Egypt. Pakistan, Nepal, India, and Bangladesh represent different religious traditions, but rate of contraceptive usage tends to track urbanization and income levels. India is now substantially wealthier than Pakistan, and this is reflected in social indicators.

This is a chart from the IMF World Economic Outlook database; it has GDP/person in purchasing power parities for 2010 (USD equivalent). Muslim majority countries are in bold.


Pakistan's Ministry of Health has been active in the promotion of family planning; this link (PDF) goes to a report by the Center for Population Studies, an institute affiliated with Oxford University. As you can see, the low rate of contraceptive usage is a byproduct of the extreme poverty of the country (when per capita income was less than a tenth that of modern Mexico). As income has risen, so has contraceptive usage. The authorities have been anxious to promote birth control, and as far as I know, no particular type is prohibited.

In the period 1990-2000, Pakistan apparently accomplished major progress in promoting family planning, although a majority of households apparently still use no modern methods.

Saudi Arabia and other hyperconservative regimes: 
one source of information on contraceptive usage is Saudi Arabia is Qassim University's Journal of Health Sciences (PDF). In recent years, the mean fertility rate in the Kingdom has declined sharply. Contraceptives are not illegal (unless they are illegal in the sense that driving faster than 60 MPH on interstate freeways is illegal in the USA); usage of contraceptives is very common, and the linked study suggests that 45% of women interviewed had used some modern form of contraceptive continuously over the last year.

Contraceptives are freely available to Saudi women over the counter throughout the KSA.

It would appear that some pro forma restrictions on purchases exist—a marriage certificate, perhaps—but pre-marital sex is inherently difficult and dangerous for other reasons, and most people seem to manage to bypass restrictions.

Afghanistan is another case of a country that is so desperately poor that the legal details governing contraceptives are difficult to explain. The current government is notionally supportive of contraceptives and family planning; the Taliban is opposed, for explicitly natalist reasons (IRIN). FWIW, I suspect the realreason the Taliban are opposed to family planning is that they are suspicious of any potential powerbase besides their own, and multilateral health programs anywhere definitely would provide a countervailing force to Taliban influence in the country. To see why I think this, see this study by the WHO.

Sudan is another country with dire poverty and a hyperconservative regime. Yet even it allows NGOs and multilaterals to distribute contraceptives (PDF).

United States: contraceptives effectively outlawed by Comstock Act (1873); eventually overturned by SCOTUS as a result of United States vs. One Package (1936), which included a pessary (an early Japanese form of birth control similar to a diaphragm) sent from Tokyo to a doctor in the USA on the request of Margaret Sanger. SCOTUS ruling ended the force of the Comstock Act. Sanger was tried in the courts before for violation of the Comstock Act, but on at least one occasion the case was scuppered by the death of Anthony Comstock (1915). The Comstock Act was odd because it was in effect a regime of one man over the Post Office—a sort of postal J. Egar Hoover, if you will.

With the Comstack Act defanged, the ABCL immediately became active in promoting birth control in areas that were receptive to NGO assistance. This included then-desperately impoverished Southern states, especially North Carolina. By the 1940's, seven Southern states had incorporated birth control into public health programs (History of the Birth Control Movement).

In subsequent years, many states responded by legalizing birth control information; however, several states had laws restricting information about it. One problem with birth control methods at this time was the low level of reliability. One early (1938) study of condoms reported that only 40% of condoms sold in the USA were fit for use (EBC).

In 1965, the SCOTUS ruled for the appellant in Griswold vs. Connecticut, that certain constitutional rights such as the 4th Amendment cast a "penumbra" that included the right to marital privacy, hence, the police lacked the right to search a married couple's home for evidence of contraceptive use.

In 1972, SCOTUS again struck down a Massachusetts law restricting access to contraceptives to married couples, because it violated the equal protection clause of the 14th Amendment (of single persons).

California was the first US state to legalize abortion (1969, SCOCA overturned), followed by AK, HI, NY, and WA (1970).

Ireland: contraceptives were not legal for sales between 1935 and 1979 in the Irish Free State/Irish Republic (IES). Restrictions on the sale of contraceptives declined after 1980, including bans on information about contraceptives. Abortion is illegal, with exceptions for health (since 1992). Large numbers of Irish women travel to the UK for abortions each year.

Italy: contraceptives were outlawed by the Fascist regime (IES); so was abortion, although abortion was commonplace because of unwanted pregnancies, and the birthrate in modern Italy is among the world's lowest. Contraceptives were formally legalized in an interesting way: the Constitutional Court had hitherto ruled that distribution of literature on contraceptives was an offense against public morality, and in 1971 changed its mind (same deal with SCOTUS in Griswold vs. Connecticut, 1964). This effectively legalized contraceptives in Italy. In 1997, the Italian health ministry began outreach to teenagers with condom distribution.

Nepal: included because it had such an extremely conservative regime for so long and because it is, along with India, one of two majority Hindu countries in the world.
IES: Contraception is available in Nepal, gaining in use and access dramatically since the 1970s, when approximately 3% of couples were estimated to use contraception. More current figures put this at approximately 33%. At the same time, however, access to contraception depends greatly on where a woman or couple lives.
According to the Center for Reproductive Law and Policy, the country’s family planning policies tend to favor the use of the IUD and injectible hormonal methods.
Any reproductive health service that can be accessed in Nepal is most likely to happen in the urban areas, and the rural areas closest to the cities. As one moves farther and farther away, up through the hills and into the mountains, the quality and access to healthcare diminishes dramatically. Problems exist with staffing reproductive or any other health facility in remote areas, as well as with non-appearances of the staff who have been hired.
Nigeria: Nigerian law appears to be quite ordinary, but this particular entry in the IES is one of the most fascinating things I've EVER read.

Hausa society frowns on too-frequent and poorly spaced pregnancies (Kwanika), and nursing mothers who get pregnant before they wean their babies are sometimes derided. There are many traditional methods of contraception among the Hausa, such as rubutu, Qur’anic verses written on a wooden slate (allo) with black ink (tawada), which is washed off with water that is then administered orally. Others include guru, a string of leather, which the woman wears around her waist, and a Qur’anic verse written on a sheet of paper, bound with leather and worn as an amulet. No research has yet been conducted on the efficacy of these contraceptive methods. I believe the IES listed the names of sub-section authors here (and not elsewhere) to distance themselves from outside experts whose knowledge they required.

Nigerian laws on abortion are highly restrictive—comparable to Ireland since 1992.

Canada: legalized all forms of birth control in 1969. This was at the beginning of the Trudeau era, when social legislation in Canada became overwhelmingly more progressive than in the USA.

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