Family planning comes to Bangladesh

"Overpopulation" is not the cause of poverty in Bangladesh. The country could easily feed its present population-and more-if the social constraints on agricultural production were removed. Even though population growth is not the main problem, many villagers want access to family planning.

As we learned in Katni, villagers have good reasons for wanting children. Children's labor is a vital part of the household economy, and parents rely on their sons to support them in their old age. Because the infant and child mortality rate is so high in Bangladesh, parents must have many children in order to ensure that at least one son will survive. But once villagers have enough children to meet their needs, they are often very interested in birth control. Women are tired of constant pregnancies, and parents realize that too many children can be a drain on the family's resources.

Soon after our arrival in Katni, we were bombarded with pleas for birth control pills. AID had already given millions of dollars worth of pills to the Bangladesh government to be distributed free of charge, but the only pills the village women had seen were marketed by a travelling merchant woman at a price of eight taka-more than the average daily wage-for a month's cycle. Several daring women had bought them without their husbands' knowledge, but lacking instructions on how to use the pills, they soon became pregnant.

In response to the villagers' pleas, we visited the government family planning office in the nearest town and requested that extension workers come to our village. After their arrival, we learned why the demand for birth control in the villages was not being met. Wearing expensive jewelry and silk saris, the extension workers were educated, middle-class town women, separated from the village women by a gulf of arrogance and indifference. They addressed the villagers in upperclass Bengali and in their presence asked us how we could stand the "inconvenience" of living in a dirty village. After they left, the villagers inquired if they were our sisters from America.

The family planning workers promised to return within three days with a supply of pills, but it was many weeks before the villagers saw them again. They claimed that they could not come because their jeep had broken down, and they were unable to walk the five miles to the village from the town, a distance many villagers covered by foot every day. This explanation did not inspire confidence. Nor did the ensuing discussion. The extension workers told the village women it was immodest not to wear blouses beneath their saris. Unable to afford blouses, the village women sat for a moment in embarrassed silence.

Although the extension workers left behind a carton of pills, the villagers doubted they would ever return to replenish the stock, much less to supervise the women's taking of the pill. As one village woman told us, ''All government officers care about is their salary. They sit in offices and drink tea. What do they care about us?"

Our village's encounter with the family planning service illustrates the failure of Bangladesh's health care system to reach the poor. Over three-fourths of Bangladesh's doctors serve the 10 percent of the people who live in urban centers; in the rural areas there is only one doctor for every 40,000 people.¹ The few health care workers employed in the countryside often share the attitude of the women who visited our village: they look down on the rural poor.

Although the aid donors are now recognizing the limitations of using upper-class government servants for family planning work in the villages, the alternatives they have developed may actually be making matters worse. AID has launched a "contraceptive inundation" program for birth control in Bangladesh. The countryside is literally being flooded with cheap birth control pills, distributed by undertrained field workers or sold through small village shops. In the words of Dr. Ravenholt, the head of AlD's population program: "The principle involved in the household distribution of contraceptives can be demonstrated with Coca Cola... If one distributed an ample, free supply of Coca Cola into each household, would not poor illiterate peasants drink as much Coca Cola as the rich literate residents?"²

But as Stephen Minkin, the former head of UNICEF's nutrition program in Bangladesh, points out, birth control pills are a powerful drug, not a soft drink. Given without adequate supervision, they are potentially harmful to women and children. Pregnant women who take the pill increase the risk of cardiovascular birth defects in their children. Moreover, the use of the pill by nursing mothers may decrease their milk supply, contributing to infant malnutrition.³

In the absence of a health care system designed to meet the needs of the rural poor, aid for family planning, like aid for rural development, more often hurts than helps.