Bitter pill for Muslim women

In May, "The Pill" celebrated its 50th anniversary and counted up enormous accomplishments in terms of improved women's health, falling birth mortality and improved professional and personal status for women, not to mention sexual satisfaction.

But in the 50 years since it was approved by the US Food and Drug Administration in the United States and swept much of the planet, the lack of birth control methods in the Muslim world – and a misconception that birth control is forbidden by Islam -- have prevented many women from controlling their family size.

Although Islam has endorsed conception for 1,400 years, many Muslim countries across the planet have the lowest rates of birth control, according to the United Nations Population Fund, despite the fact that Muslim women want fewer children and know about contraception. There is an apparent discrepancy between Islamic theological opinion and the real lives of Muslim women.

It is the marginal status of women in Muslim countries, not Islamic law, that prevents women from obtaining contraception, according to Khadijah Knight of Amana, a London-based Islamic education organization: "Birth control is often presented as a religious question, as a way of subjugating women."

Islamic family planning is quite rudimentary. Theoretically premarital relations are forbidden. Sex before and outside of marriage are viewed harshly. Sexual relations between a wife and husband form the ideal expression of love, not just procreation.

Nonetheless, either with the pill or without it, many Muslim countries have slashed their fertility rates dramatically, Indonesia and Pakistan among them. Pakistan has reduced its fertility rate from six or seven children per woman to 2.48 per woman. And ddespite the problems that Muslim women face in many other countries, Indonesia, the world's fourth most populous nation, has been making considerable gains in family planning.

Some 88 percent of Indonesia's 320 million population are Muslim. The country's National Family Planning Coordinating Board coordinates all of its family planning needs under the Ministry of Health.

Indonesia's contraceptive usage tripled in 27 years (1976, 19 percent; 2003, 60.3 percent). Total fertility decreased by more than 50 percent in 35 years (1968, 5.6 births per woman; 2003, 2.4). In 2003, 60.3 percent of married women used contraception and 13.2 percent were on the pill. In 2007, the NFPCB drafted a handbook for the ulemas to further disseminate its family planning program. In a Family Health International (FHI) study conducted in Indonesia, women with only one or two children reported feeling greater satisfaction than those with more than two children. They also felt more attractive, with more free time to devote to family, work or other interests.

Malaysia ironically had a strong family planning program in the 1960s, with the main method of contraception being the pill. By 1967, the Family Planning Board had reached 90 percent of its target. One of the pioneers instrumental in driving the family planning message was Dr. Siti Hasmah, the wife of former Prime Minister Mahathir Mohamad, also a physician.

But in the Second Malaysia Plan of 1971-1975, the New Economic Policy was introduced to tackle the problem of Malay poverty. Efforts to promote family planning were hampered by government neglect and inadequate facilities and personnel. The government considered family planning a "sensitive topic" and so ignored it.

Then in 1984, Mahathir reversed the National Population Policy completely, setting a target of 70 million Malaysians by 2100 at a time when the country's population stood 12.6 million. His aim, to make Malaysia a fully industrialized and developed nation by 2020, required Malaysians to contribute to the economy by increasing both their production and their reproduction, an economic theory that most planners found to be irrational.

The result was that the birth-rate among the rural and poorer Malay women increased, while their Contraceptive Prevalence Rate dropped sharply, according to the Malaysian Population and Family Survey of 1984-85. Today, birth control is hit-and-miss, carried out largely and often surreptitiously by women who do not want any more children. Abortion pills like RU486 are widely available, known colloquially in Malaysia as pil cuci benih.

"Norma," a 29 year-old housewife who lives in a Kuala Lumpur suburb with her husband and their four children, is a product of this change in policy. She is of slight build and looks old for her age. Her husband works as a bus-driver and she is aware that if she doesn't budget carefully, she would have to pawn more of her jewelry to feed her children.

When she discovered she was pregnant, she feared telling her husband and confided in her friend that she didn't want any more children. She was told to go to the gynecologist and say that she missed her period. She would be given pil cuci-benih, which cost a few ringgit and are cheap, compared with an illegal abortion, which costs RM870 (US$267).

Norma says, "I have no choice. I am forced to do this. I'd rather not have an abortion or take these anti-abortion pills, but we cannot afford another child." She regrets that her husband's refusal to share the responsibility means that she now uses abortion as a form of family planning.

In a 2008 Malaysian Population and Family Survey, 24 percent of married women who said they didn't want any more children were not using any kind of contraception. Despite Malaysia's economic growth and an increase in women's education, it has a low contraceptive prevalence rate compared with Asian countries with a lower socio-economic status like Thailand, Vietnam or China. In Malaysia only 32 percent of women use a modern method in 2004 compared with 30 percent in 1994 and 34 percent in 1998. In 2004, the rate was lowest in Kelantan (16 percent) and the highest was Negri Sembilan (63 percent).

Part of the problem relates to Islamic beliefs, compounded by a rise in fundamentalism, which has led to lower levels of contraceptive use. Birth-control is perceived to be infanticide, and family planning programs are considered a western conspiracy to reduce the number of Muslims, and thus diminish their power.

Women allow their daughters to take the pill to regulate their periods when on a religious holiday but strongly oppose its use for contraception. "It is permitted when we are on the haj or umrah because a menstruating woman cannot pray or enter the mosque," said one mother."But she cannot take the pill ordinarily, unless she marries. It will lead to free sex."

Even married women do not find the same liberating experience with the pill as their western counterparts. There is no separation of sexual pleasure from child-bearing. In Islam, sexual relations between a wife and husband are mainly for procreation. Having children is encouraged because children will bring rezeki (gifts or blessing from God). The pressure to bear children is enormous, as is the pressure to have boys.

However, among Malaysian youth, there is desire to increase sexual awareness with 59 percent saying they would like to consult someone in confidence, 57 percent wanting better sex education in school, and 50 percent needing access to more educational literature. A secondary schoolgirl, Sita, said in an interview, "When Whisper (a sanitary-towel company), came to the school to talk about condoms and sex, that was the first time we learnt about our bodies. Even our teachers are embarrassed to talk about human sexual organs, during biology lessons."

Mala, a marketing executive in a multi-national company and who is in her early thirties said, "I learned all that I needed to know about sex from the internet." She comes from a typically modern Malay family, but even her mother considers sex a taboo subject. Mala was briefly on the pill until she found that it made her put on weight; 10 kilograms in two months. "The pill gave me a better complexion, but my friends said that I would have thrombosis and other health problems, so I stopped. If it had not made me fatter, I might have continued."

Two elderly women said that in the 60s, they took the pill. One who lived in the kampong (village) said that in those days, she had easy access to a bidan or midwife. Just as today, husbands left the choice of contraception to the wives, but they did participate. According to the other 77 year-old: "After dinner, my husband and I would sit down in front of the television, have coffee and I would take my pill. It was the same ritual every night."

Today, Family Planning clinics charge minimal fees and provide a good, confidential service. Unmarried girls are encouraged to visit and may qualify for free contraceptive services.

Without easy access, women cannot enjoy the benefits of family planning. If money is scarce, a woman's priorities are her family, food and schooling. Not on transport to clinics, even if the Pill is cheap or free.