Reproduction isn’t the point

I changed my mind about where to go with this article at the last minute. Originally, I’d wanted to talk about contraception and pleasure, for a change. How successful would awareness campaigns be if their primary objective were to actually raise awareness, rather than to lecture? What are the real opportunities to start thinking about sex as a practice that makes us feel good, rather than one primarily associated with fear and worry? 

But recent discussion about population growth gives the impression that this is a new crisis we’ve suddenly found ourselves in, and it reduces the issue to whether you’re for or against birth control. It allows no room for the experiences of women, who are the people most responsible for carrying out population control policies. Although I’m critical of our tendency as feminists to assume a defensive posture to protect the limited gains we still have instead of going on the offensive, I’d like to share some observations from the field about women’s experiences in accessing and using contraception and family planning services.

 

Between definitions and slogans

Discussions about family planning are typically limited to statistics, percentages and hard data, but how can we understand/trace the difference between an individual’s right to have children and policies that see us as numbers? I asked Laila, an Algerian feminist who participated in the UN-coordinated International Conference on Population and Development (ICPD) in Cairo in 1994, about the factors that spurred cross-country feminist organizing for the adoption of certain language and terms — like reproductive rights — that feminists fight to preserve today. Though some people may take these rights for granted, states’ recognition of them was a defining moment for the national and international feminist movements and the rights movement more generally. I wanted to understand the conditions in which this term came to be. 

Laila told me that most state delegates at the ICPD came together around reproductive rights because they did not understand the full implications of the term, which she attributes to their lack of familiarity with what was then a relatively new concept. Reaching an agreement on what became known as the Cairo Program of Action required prolonged discussion and negotiations that went far into the night, and this also affected participants’ focus. At some point it became easier to agree than to keep negotiating.

The Cairo Program of Action defines reproductive rights as the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.

I do not cite the Cairo Program of Action because I am fully convinced of its language, but because reproductive rights is an agreed-upon term among states represented at the ICPD. This common language is binding for all states that ratified the Cairo Program of Action, and their obligations and priorities under these terms are regularly reviewed every April during the UN Commission on Population and Developmentin New York. Since Egypt adopted the program, reproductive rights are a local standard of reference, one we can use to frame various points for debate instead of getting sucked into 1990s arguments that blame the poor for their poverty and perceive women’s bodies as vessels for the realization of development objectives.

This is not a moment of déjà vu particular to Egypt. The world is witnessing a right-wing resurgence that is threatened by even the mention of reproductive rights. Though the meaning of reproductive rights was somewhat ambiguous in 1994, it has since come to be nearly synonymous with the right to a safe abortion. Reflections of 1990s feminists from the Global South show that the battle for reproductive rights began as soon as they were inscribed in international conventions and platforms. States realized that reproductive rights were an entryway to personal autonomy, and many rejected the term in international forums that followed the ICPD. Reproductive rights have now become the locus of a heated battle between the global feminist movement on the one hand, and a number of states’ (among them Egypt) anti-abortion, right-wing movements on the other. 

Twenty years after the ICPD — in the same city of the same country — we are still fumbling to integrate the right to have children into family planning and reproductive health services, both at the policy and grassroots level. Development organizations and national drives deliver messages in the form of a lecture. Sometimes, the messages addressing women in door-knocking drives, promotional literature, and media materials are taken straight from the state’s population policy goals. If, for example, the goal is to reduce the fertility rate, you get campaigns like “Two Is Enough!” Other times, the messaging adopts a more liberal tone, pushing the idea that it’s only women who are capable of changing a reality that is, in fact, entirely built on their oppression. Women who do meet the ideal of the responsible woman — that is, a mother of one or maybe two children — are paying the price for their “ignorance” and “failure,” and very often their poverty too. These messages and the services they come with are unstable, wholly dependent on the continuity of funding and institutional partnerships, and they evaporate when those come to an end.

Theoretically, interventions working on individual growth and community sustainability are underpinned by more comprehensive approaches in which family planning is just one component. The success of such interventions is not measured solely by women’s uptake of contraception as separate from a high-quality education, or on birth spacing isolated from proper nutrition. Women are not reduced to mere participants in awareness meetings led by a sheikh or doctor, which is largely the case with reproductive health campaigns in Egypt over the past few years. These are just a few examples of the shallowness of community interventions designed to confront what are essentially structural challenges. The contradictory messaging of family planning campaigns in Egypt explains why women might not be responding. The campaigns affirm women’s right to plan their families, but they also hold them to a two-child limit. The slogans also ignore barriers women face in accessing family planning services, which are demonstrated through much published research, according to a 2018 study in PLOS ONE on fertility trends in Egypt.  

 

Barriers and experiences 

Quantitative indicators often do not capture these even when they do provide some clues, particularly since the relevant databases have not been updated since 2014, according to a paper released by the Egyptian Initiative for Personal Rights in 2020. For example, a recent comparative study conducted by the Population Council found that the percentage of Egyptians aged 15–34 who had stopped using family planning methods rose from 27 percent in 2008 to 32 percent in 2014, because of the reported side effects of contraception. 

Here, I will offer some experiences from field research that might help to fill an overall picture of women’s experiences with family planning services.

In late 2016, I could get no satisfactory answer as to why the morning after pill had been unavailable in pharmacies for months. More troubling than the disappearance of the pill itself were the looks I got from pharmacists when I asked for it. Emergency contraception is of two types: the morning after pill and the copper IUD. These are used when more long-term methods fail (when, for example, you forgot to take your daily pill or the condom breaks). 

The starting point for my research project was to understand what alternatives to the morning after pill were available. What sort of solution would the pharmacist offer, even if it were simply a referral to a doctor? Focused on the Dokki area, the study involved in-depth interviews with male and female pharmacists to understand their attitudes toward the availability and access to emergency contraception pills; women were also interviewed and an online survey targeted women in the Greater Cairo area. Based on the preliminary study, I found that pharmacists had a negative attitude toward the morning after pill and the women who requested it. They also typically did not offer additional information, on side effects for example, or refer women to a doctor if the pill was unavailable.

Outside of the pool of pharmacists, the majority of women interviewed in the preliminary study were unmarried. The forms of contraception they used the most, such as the condom and the morning after pill, did not conform with figures in population surveys, because the government health and demographic survey includes only married women in its samples. [1] 

Marital status seems to be a factor influencing women’s preferences regarding contraceptive methods. For example, only 7.1 percent of (married) respondents had knowledge of emergency contraception in the 2014 survey, while 49.7 percent and 99.4 percent were familiar with the condom and IUD respectively. 

A year later, I resumed my digging, this time bringing in class and marital status as an additional research lens. I selected the Cairo areas of Ain Shams and Tora al-Balad as my two sites of research. The turnout for the focus groups was high in comparison with the first study. I was able to hold six focus groups with 39 married women ages 20–43 from April to September 2018. I planned in-depth interviews with 20 pharmacists from the two areas, but I was unable to follow through because my research fellowship program was canceled after the donor was compelled to suspend its activities in Egypt. I was unable to conduct the interviews and complete or publish the study.

Of the 39 women in the focus groups, 26 had had at least one unplanned pregnancy. As they spoke, I was struck by how bothered they were by the looks they received from pharmacists. They worried about their daughters’ reputations if they sent them to buy contraception or sanitary napkins. Because condoms are associated with extramartal sex, they also avoided buying and using them to avoid dirty looks. 

As our discussion moved beyond the availability of the pill, they spoke of violence and harassment from service providers, both doctors and pharmacists. When I asked them who purchased birth control pills for mothers, the mothers talked about protecting their daughters. Most of them were afraid to “open” their daughters’ eyes or let a pharmacist suspect that their daughters were using contraceptive pills. 

Most of the respondents also avoided discussing menstruation with their daughters, waiting for it to surprise them. Often they did not discuss sex with their daughters, even if they were on the cusp of marriage and even though the lack of knowledge about sex had had an adverse impact on most of the participants themselves. “I was blindsided on my wedding night,” one participant said. “I felt like crap, I was totally shocked.”

After listening to them, I realized how similar my research question was to community interventions that treat reproduction or female circumcision as an isolated problem, as though they can be disentangled from all other aspects of our lives and solved on their own. 

 

Violence and harassment in health services

Participants in the focus groups had experienced mistreatment by nurses or doctors during childbirth. Sometimes it was an inappropriate remark: “You’re still wearing your underwear? Strip!” One participant said that when she was in the delivery room at a general hospital, a doctor gestured to her and said, “If we’d been sewing up a mattress we’d be done by now.” Another woman expressed discomfort with the questions the male pharmacist asked when she would send her son to buy sanitary napkins. “He might ask questions, playing naïve,” she said. “Like if I sent my son to get some Always, the pharmacist asks, ‘What size? For a fat woman or a short one?’” All the participants at one focus group in Ain Shams said they had been harassed by a certain doctor, after one of them mentioned that she was afraid of him.

 

Medical consultation

One participant said that she did not use family planning services from the health unit because she was angry about the female doctor’s manner at the clinic. Commenting on the woman’s pregnancy, the doctor had said derisively, “Stop screwing!” Although this is more an indication of the doctor’s unprofessionalism and hostility than the quality of service at the health unit, it offers another window into the conclusions of the Population Council’s report, which found that the proportion of family planning consultations that involved discussion of contraceptive options, side effects, and side effect management had dropped substantially, from 42 percent in 2008 to 32 percent in 2014. 

 

Reproductive decisions

Many participants were upset with the pressure they faced from family or their husbands to have a certain number of children. “Have them one after the other, then you can relax,” one said she had heard. Another complained that her husband goes out to work and comes home to sleep, while she’s the one taking care of the children all day. According to the 2014 demographic and health survey, more than one-fifth of married women think that their husbands want more children than they do.

 

Policies without women

The decline in the quality of family planning services is not due to a dearth of resources. USAID resumed its cooperation with Egypt on its reproductive health program in 2018 after Egypt sought its help to confront population growth. The five-year partnership, supported by $19 million in assistance, provides for the implementation of activities aimed at improving reproductive health services, increasing contraceptive use, and reducing the fertility rate in nine governorates. The same year, the EU also extended a five-year, 27 million euro grant to Egypt, again at the behest of the Egyptian government, to be used to support a review of the national population strategy, increase the voluntary use of family planning services, support population governance, improve the quality of health services provided at family planning clinics and health units and to draft a strategy for the security of basic family planning goods. At the same time, the Support Fund for Civil Associations and Institutions at the Social Solidarity Ministry, in partnership with the UNFPA, is promoting the “Two Is Enough” program. As part of the LE90 million initiative (LE10 million of which is contributed by the UNFPA), the Health Ministry is providing contraception at more than 60 Two Is Enough clinics in disadvantaged areas of the target governorates.

Rereading the input of participants in my research, I think about some of the recent references made online to the success of Iran in reducing the birth rate from 5.6 to 2 between 1985 and 2000. Much of this discourse is wholly decontextualized and often accompanied by implicit and sometimes official threats warning that Egypt has thus far avoided violence in dealing with population growth “like they did in Iran.” But the success of the Iranian experience is attributable to numerous factors. National campaigns urged men to use condoms, get sterilized, and practice the traditional contraceptive method of withdrawal. Contraceptive use among married couples reached more than 70 percent and the use of male contraceptive methods (condom, withdrawal, sterilization) reached 36 percent. In contrast, in Egypt only 1.2 percent of couples use condoms or withdrawal (Roudi-Fahimi and El-Adawy, 2005). In Iran, the rate of male sterilization reached 5 percent, and a population and health survey in 2000 found that 97 percent of men were satisfied with their decision. In Egypt, male sterilization is not considered a form of contraception; only 15.7 percent of the population is aware of it, compared to 74.9 percent who have knowledge of female sterilization, according to the 2000 demographic and health survey. And despite growing interest in contraceptive use in Egypt in recent years, certain methods like condoms are still perceived as a threat to masculinity or even a joke worthy of punishment.

If women suffer from hormonal contraceptives and poor quality medical consultation services, which are often unsafe and at times are unavailable or inaccessible, why can’t the condom be the focus of future awareness campaigns? Such campaigns should aim to erase the stigma of condom use, raise awareness of them as contraception and protection against STDs, and ensure that high quality condoms are widely available.

With the alarm bells warning of population growth, condoms offer a political opportunity for a societal discussion of masculinity and extramarital relationships. They are also a practical way to destigmatize STDs and are 98 percent effective at preventing unwanted pregnancies, meaning that they offer a way to achieve the goals of population policies in the short term while also impacting family dynamics in the long term. More importantly, they offer many women a well-deserved respite from side effects, which population policies do not take seriously. Modern contraceptives constitute a hormonal burden on women, and pharmaceutical firms have historically lacked the will to invest in male contraception, despite women’s recurring complaints. Once again, women bear full responsibility for preventing and planning pregnancy.

It has been common for population policies to ignore women as primary partners in shaping and achieving their objectives. Hard numbers and quantitative logic are more familiar and “objective”, a 2020 literature review found, and development is more important than the complaints and fears of women or making their experiences central to any public policy that affects them. More accurately, development is more important than reproductive rights.

The political leadership’s concerns about population date back to the 1930s. The ministerial committee formed in 1954 to study family structure and ideal family size, observe patterns of reproductive behavior among various Egyptian communities, and assess the acceptability of contraception marked the first clear shift toward the nuclear family model and coincided with ambitious government programs to change women’s productive and reproductive role, according to the same literature review. Once a personal matter, reproduction was now an issue of public concern. This later led to the appointment of more women in the government sector, as the family itself became a locus for planning and a subject to be shaped.

The organizational framework for population growth evolved structurally from 1965 to 2011 in its remit, staffing and administration, due to reasons of nationalism or patriotism, war, or the divergent outlooks of decision makers. In 1965, the Supreme Council for Family Planning was formed, headed by the prime minister. Following the economic conference of 1982 and the national population conference of 1984, held to assess national population policy from 1972 to 1982, the National Population Council was created in 1985. The council was headed alternately by the president, prime minister and other ministers, until the Ministry of Family and Population was absorbed into the Ministry of Health and Population in 2011 and the council became subordinate to the ministry. With a changed leadership and its coordinating role much reduced in recent years, the actual role of the National Population Council has become unclear, EIPR found. In 2015, the council released two national strategies: the National Population Strategy and the National Reproductive Health Strategy. The council leadership seemed untroubled by the fact that the first is grounded in birth control while the second uses the framework of reproductive rights, taking the Cairo Program of Action as a reference. These are two irreconcilable approaches: Free, non-coercive reproductive rights are not compatible with policies that decide how many children individuals should have or give incentives for “ideally sized” families and terrorize others into compliance by withdrawing state support.

In developing the concept of contraceptive autonomy, Leigh Senderowicz defines it as a set of necessary factors that enable us to understand what we need from contraception and then make decisions on that basis. Contraceptive autonomy is of three types: informed choice, full choice and free choice. Informed choice is a decision based on sufficient, unbiased information about a range of family planning and contraception options, including benefits and risks of both use and non-use. Full choice represents the ability to decide with access to a diverse range of family planning methods from which to choose. Finally, free choice is a decision to use or not use contraception, made without barriers or coercion, Senderowicz argues.

 

The main goal

“I like the strawberry ones,” said one of the focus group participants, talking about condoms. Her comment brought me up short and confounded us all for a second before we laughed. Remembering that moment now, I think I just wasn’t used to such forthright, unvarnished comments in my field research. Field interactions with “targeted” women are typically rigid, and often I get the impression that women are reciting what they think of as the correct answers for researchers, having been coached by rural leaders or local coordinators in order to ensure a good research sample. That moment of candor made me question the value of evaluating women’s — and everyone’s — familiarity with contraception if determining what they liked was not a core part of the exploration.

That moment relates to a paper published in 2016 by the Women and Memory Forum examining sexuality in the feminist movement’s activities, which explored opportunities lost because the feminist movement in Egypt is always on the defensive rather than proactive. Historically, the feminist movement relied on statements from moderate Islamists to improve the status of women in the family without challenging the concept of the traditional family itself, focusing instead on preventing men from arbitrarily exercising the rights and power granted them inside the family. This had a long-term impact on how we have organized and where we have ranked sexuality and sexual rights in the priorities of the feminist movement. One example is the way the discourse against female circumcision has tended not to frame the practice as an infringement of the sexual rights of women and girls but rather a violation of bodily integrity. How, then, do we feminists avoid negotiating down our rights? How is it that we haven’t noticed the ineffectiveness of the well-worn tactics of seeking the permission of policymakers, sheikhs, priests and doctors? 

The idea of contraception and pleasure first struck me while attending an international conference on maternal health and family planning in 2016, listening to a speaker discuss the Pleasure Project, an initiative uses pleasure as an avenue into discussions of contraception, to encourage young men and women to use it and practice safe sex. (Amid embarrassed jokes from some audience members, she pulled out a female condom and pressed on with her presentation).  Today, there are campaigns about pleasure in Arabic in online platforms, and lately we’ve all noticed the strong feminist presence on Instagram and Facebook addressing gaps in sexual knowledge in a fluid, simple and playful way. But the gap between online campaigns about pleasure and the instructional door-knocking campaigns remains vast.

How might the experiences of women in my study have been different if a visit to the doctor was safe, if the body was not so strongly associated with shame, or if the knowledge of what flavors we like was more important than the looks we got from the pharmacist? What if pregnancy and childbirth were not a boogeyman, but experiences we could choose to have or not have without intimidation or fear? What woul population policies look like if those who read and analyze were convinced that the main goal of most of the sex that happens between people was not reproduction?

Bibliography

Afifi, Wisal and Bahgat, Hossam. 2016. The Feminist Movement and the Sexual Rights of Egyptian Women. Cairo: Women and Memory Forum. (Arabic)

Abuelsoud, Nana; Azab, Ahmed; and Galal, Farah. 2020. Missing Data and Incompetent Coordination: The National Population and Reproductive Health Strategies in Five Years. Egyptian Initiative for Personal Rights.

Abdelaal, Doaa and Abuelsoud, Nana. 2017. Women’s Access to Emergency Contraceptives in Egypt. Mawanie.

Abdel-Tawab, Nahla, Attia, Shadia; Bader, Nourhan; Roushdy, Rania; El-Nakib, Shatha; and Oraby, Doaa. 2020. Fertility Preferences and Behaviors among Younger Cohorts in Egypt: Recent Trends, Correlates, and Prospects for Change. The Evidence Project.

Radovich, Emma; El-Shitany, Atef; Sholkamy, Hania; and Benova, Lenka. 2018. Rising UP: Fertility Trends in Egypt before and after the Revolution. PLOS ONE 13 (1) (January): 11.

Roudi-Fahimi, F., & El-Adawy, M. 2005. Men and family planning in Iran. The XXVth IUSSP International Population Conference. Tours.

Samir, Marina. 2020. Desk Review: Cairo 94. Ikhtyar African Feminist Collective.

Sayed, Hussein A. 2011. Egypt’s Population Policies and Organizational Framework. Social Research Center of the American University in Cairo.

Senderowicz, Leigh. 2020. Contraceptive Autonomy: Conceptions and Measurement of a Novel Family Planning Indicator. Studies in Family Planning 51 (2) (May): 165–166.