International Affairs Forum speaks with Lara M. Knudsen about issues addressed in her book, Reproductive Rights in a Global Context.
International Affairs Forum: How would you define reproductive rights?
Lara M. Knudsen: The definition I like best is from the 1994 International Conference on Population and Development in Cairo. It’s the right for a person to decide freely when and whether to have children and how many; to attain the highest level of sexual and reproductive health possible that includes sex education and having health support to have children. In this country many people tend to equate reproductive rights with abortion and contraception but it’s much broader than that.
IA-Forum: In addition to the United States, your survey took you to South Africa, Uganda, Peru, Denmark, Jordan, and Vietnam. Did you find a prevailing view in any of those countries that their definition conflicted with your definition of reproductive rights?
Ms. Knudsen: Dialogue about reproductive rights in many of these countries is not couched in terms of human rights but more in terms of reproductive health. But there’s a holistic approach to reproductive health in many of these countries. They’re looking at planned motherhood and sex education but it’s usually not coming from a reproductive rights viewpoint. That is, unless you’re talking to people working for women’s rights organizations where people have a broader perspective. If you look at the mainstream feminist movement in the United States, they have focused more on abortion than other issues. That seems to be less the case in countries like Peru and South Africa who have more experience with population control and similar issues.
IA-Forum: Were there any particular surprises you encountered through the survey?
Ms. Knudsen: There were many. For example, in Peru, abortion is illegal unless to save a woman’s life. But in downtown Lima there are signs for abortion everywhere. There’s one block in particular with ten to fifteen little stands that advertise abortion and will set someone up with illegal abortion providers. People on the block bribe the police and there’s little prosecution. This is a touristy neighborhood and they’re right out there in the open with signs everywhere.
In Jordan, I was surprised by the strict policies pertaining to women receiving family planning requiring spousal consent. Even now in 2007 a women can’t get contraception on her own in many clinics and can’t be sterilized without the consent of her husband. Single women are not allowed to get contraception. Even though I knew Jordan was a strict society, I was still surprised by the level of strictness.
IA-Forum: Then there’s the subject of ‘honor killings’ in Jordan discussed in the book…
Ms. Knudsen: Yes. There are even reformation centers set up for women who have been raped or committed adultery that are really like jails. In fact, they are usually housed in connection with jails but separate from the prisoners. The idea is to protect them from their families. If they were released, they would probably be killed.
IA-Forum: Of the countries studied, did one stand out as considerably more progressive than others?
Everyone points to Denmark as being the most liberal when it comes to these issues and in many areas, that’s true. They have the most accepting and pragmatic approach to these issues. They have very comprehensive sex education starting at age nine, contraception is very acceptable and affordable, and there isn’t much of a stigma surrounding sexuality or even abortion, which is free and available on request. But I think it’s also easier for a country like Denmark to have those progressive values because their population is so small and relatively homogenous. It’s only in recent years that there’s been an influx of foreigners from outside of Scandinavia, and that’s causing more tension around these issues. Denmark does have a history of an open view towards sexuality and being very accepting in general. I think that’s impressive but they also haven’t really been challenged like some other countries with significant ethic minorities have been.
South Africa is also one of the more liberal countries, at least at a legislative level. Their recent law liberalizing abortion is probably the most liberal abortion law in the world now. They have laws specifically protecting people from sterilization abuses. Their Constitution is very liberal; it states they can’t discriminate on the basis of sexual orientation. So, on a legal level, they are very progressive but that hasn’t filtered down to the implementation level yet. I don’t think that the average South African has a very liberal view towards these issues.
IA-Forum: Any particular countries that you consider not performing as well?
Ms. Knudsen: I think the United States is in trouble. We have the highest rates of teenage pregnancy and sexually transmitted diseases of any industrialized country. Our sex education programs are extremely variable. We have a full generation of Americans growing up without learning how to protect themselves from sexually transmitted infections and understanding planned pregnancy. On the issue of abortion, many states have made it more difficult with restrictions such as mandatory waiting periods and parental consent, things that cause the pool of women who can get an abortion to shrink even smaller. On the federal level, we’ve slipped on reproductive rights with cuts being made internationally on family planning. I think there are rampant reproductive rights abuses in this country and we’re experiencing a swing back to a more conservative ideology that’s making progress more difficult. As we have such a large and diverse population, it’s a challenge to educate the population about sexual health, how to protect themselves, and maybe even a greater challenge with our health care system to have affordable services for contraception and treatment of STDs.
Jordan, out of all these countries, is probably the strictest in terms of having a dialogue about these issues. They need to get on board and start talking about these issues, but that needs to come from within. People working for reproductive rights in Amman, for example, say that they are confronted with accusations of being Western imperialists and imposing American ideology on them. If you look at the roots of Jordanian culture and Islam, there are a lot of reproductive rights-centered beliefs so it’s just a matter of people within Jordan educating fellow citizens. They have a lot of work to do in these areas and it will probably take decades given where they are right now to make considerable progress.
IA-Forum: Were there particular commonalities across these countries?
Ms. Knudsen: One of the commonalities is, when there’s the situation of a woman who has an unplanned pregnancy - either trying to get an abortion illegally or continuing the pregnancy to term without the resources to support that child – it is often the end result of a long road in which many steps have broken down. These steps range from sex education and having control over choosing one’s sexual partner, to accessing contraception and health services in general. In any of these countries, when you hear individual women’s stories, that pattern is often repeated. In all of these countries, there are pregnant women who don’t want to be pregnant and when you explore their personal stories, you’ll find at least one or more gaps where society, the government, or the health care system has failed that person. It’s not just a matter of having access to contraception but people don’t know how one gets pregnant in the first place. So we have to start from the beginning and make sure each of those steps are in place in order to avoid unplanned pregnancies and sexually transmitted infections.
Additionally, the existence of reproductive rights movements across these countries was interesting. I went to these countries not expecting to find organizations like Planned Parenthood in the United States or the National Abortion Rights Action League but there are many organizations in these countries working for reproductive freedom, personal autonomy and control over one’s fertility and reproductive health. These issues are greater than our individual cultures, they’re found in every country, even though they may be dealt with in many different ways
IA-Forum: How effective has international aid been?
Ms. Knudsen: It’s a mixed bag. Certainly millions of women have been helped by the international community with family planning, and maternity and infant mortality rates have declined. But areas of international aid have been problematic in the past, in particular with population control and family planning.
I think that’s shifting though. The Cairo Conference helped donor agencies gain a broader perspective on reproductive health, not just family planning but basic safe motherhood services and integrated reproductive services. However, there is still a disproportionate focus on contraceptives rather than health care infrastructure. From a donor’s perspective, it’s not as exciting to channel funds into paying electric bills for a hospital and maintaining infrastructure; there’s more emphasis on building new clinics and projects that have visible results. Groups also shouldn’t focus all their attention on family planning when people aren’t going to consider having fewer children. If more money were put into education and job development, people will seek to have smaller families. I think that’s a more appropriate way to address this than flooding the market with contraceptive pills.
IA-Forum: How well have international groups been able to work with localized NGOs?
Ms. Knudsen: That varies from country to country and the agency’s approach. In Jordan, if an international donor agency collaborates with local groups, they’re more prone to accusations of trying to impose American culture on them. But in a lot of these countries international groups collaborated with local agencies and tried to funnel their supplies and funding through local organizations and governmental bodies. For example, in Uganda, aid is funneled through their Ministry of Health and policies are supported by USAID. But I don’t see a lot of support for the small, local, community-based organizations getting funding from international donors. There are a lot of feminist organizations that do get some funding from international donors but community-based groups don’t receive much of that – they’re not large enough to have a grant writer on their staff and the Global Gag Rule has certainly limited their ability to collaborate with one another and with USAID.
IA-Forum: What did you find to be the state of access to good health care facilities in these countries?
Ms. Knudsen: Again, it varies. In Jordan most of the population lives in urban areas so physical distance from health clinics is not much of an issue. But in more developing countries like Uganda and Vietnam, the rural population has little access to health clinics. A lot of people rely on traditional birth attendants (TBAs) or traditional healers to address their needs. Another difficulty is that many donor agencies have not embraced the traditional health care system. In Peru, a lot of people in rural areas use natural family planning – rhythm, withdrawal methods – and there are ways those traditional methods can be incorporated with modern methods and health clinics to maximize their efficacy. Teach women that it they want to use the rhythm method, here’s the most effective way of doing it – here’s how to take your temperature every day at the same time, how to chart it. For the most part, that sort of thing doesn’t happen. Women tend to think if they don’t subscribe to Western family planning they shouldn’t go to clinics but to traditional birth attendants or local midwives. I think that’s a huge missed opportunity because you could integrate them and bring the traditional birth attendants to learn more about modern methods.
IA-Forum: Getting back to the Cairo Conference, what effect did that have on these countries’ health policies? Has it been effective?
Ms. Knudsen: For the most part, Cairo had a significant influence on countries but more at a policy level than in implementation. A lot of countries went to the Cairo Conference and revised their population policies or their family planning policies to adopt a more holistic approach toward reproductive health. Often those changes are limited to the policy level and changes in language. In Tanzania, the Family Planning Division changed its name to the Reproductive Health Division. So it’s now politically correct to talk about reproductive health rather than population control and family planning. But at the local clinics, the services they provide haven’t changed much. Policy is the first step though, things can’t be changed at the implementation level without changing policy language first. Cairo was a very important conference but it’s not going to change individuals working in small clinics overnight. While it’s important that the national government speaks about reproductive health, it’s going to take time for that to filter down to clinicians.
IA-Forum: One of the criticisms of international health aid has been that corrupt governmental officials prevent that aid from actually getting to those needing the aid. Did you witness or hear of any such practices?
Ms. Knudsen: That didn’t come up as much as you’d expect. The closest was in Uganda but it wasn’t at a federal level, more with individual physicians. If one works in the public health service in Uganda as a doctor, there’s barely enough money to get by. There’s a study about doctors who have resorted to doing everything from selling pancakes to prostitution in order to have enough money. It’s very common in that situation that doctors will steal supplies – gloves, contraceptives, antibiotics - from the public hospitals and take them to their private practice. So on that level, there’s corruption. For a donor agency that supplies x amount of contraceptives, maybe only half of them are actually available at a clinic free of cost to the population. Even though Uganda has a bad reputation about corruption, I didn’t hear about it occurring at a higher level.
IA-Forum: What’s your prescription for the United States to get things back onto a more progressive track?
Ms. Knudsen: The most important issue to start with is education. Both government and NGOs need to become more involved in that area. If you have a population that has comprehensive, solid sex education – how the human body works, how people get pregnant, how to prevent it, if they know the whole range of contraceptive methods, how they work, how effective they are, about abortion – if the population is that well informed, then there would be an effect on services because patients would be more empowered to demand all of their options. If they understand new contraceptive methods that have come out in the past few years and go to a clinic that only offers three options – they might say ‘what about this other one? I want this.’
I would like to see the federal government taking a stronger role in shaping sex education in a positive way. The government has directly supported abstinence only programs by funding those associated organizations with hundreds of millions of dollars. If that money were instead directed toward comprehensive sex education programs, it would make a huge difference not just with people’s awareness of these issues but economically when you think of the cost of sexually transmitted infections and the cost of unplanned pregnancies whether they are carried to term or end in abortions. Funneling those monies into comprehensive policies would be much more cost effective.
Individual organizations have a role in promoting that education as do individual health workers. Medical schools should provide more education on how to talk to patients about their sexual and reproductive health. In daily encounters, there should be more of an emphasis on that, particularly in a primary care setting when a person may be there for diabetes and might not even be asked questions about their sexual health. If they’re not using contraception is it because they want to get pregnant or because they have insufficient information? Health care workers should do a lot more regarding education on an individual level with patients in addition to the government instituting more formal education in schools.
IA-Forum: How do you see the trend of reproductive rights progressing?
Ms. Knudsen: The overall trend is positive if you look at the direction of things over the last hundred years. There have been a number of temporary backslides. In Peru the government is very conservative about these issues and even in Denmark, the current government is quite xenophobic and is not addressing the reproductive rights of immigrants adequately. But the overall trend is towards more reproductive freedom and rights, empowering women to make decisions about their bodies. The conference in Cairo is an example of that shift in ideology and countries are slowly liberalizing abortion laws, there’s more awareness of sterilization abuses such as in South Africa during apartheid and more recently in Peru, and more awareness in general about these issues.
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