Urgent Need for Education on Safe Family Planning in Sri Lanka

By Bhagya Wijayawardane

Although access to family planning is considered a millennium development goal according to the United Nations, and a human right, the shortage of family planning commodities in Sri Lanka still persists. As a result of the lack of awareness for long- term methods of family planning, women often turn towards abortion as a form of birth control.

The law governing abortion in Sri Lanka is exceedingly restrictive, while permitting exceptions for cases where pregnancy/child birth is life-threatening to the mother. In a year, a country with a population of 19 million performs between 150,000 and 175,000 unsafe abortions at over 3,000 abortion centers (according to the Family Planning Association (FPA) Resource Centre). Women below the age of 18 and over 30 are among the majority of women who confront such illegal abortions, especially in countries that restrict abortions, like Sri Lanka.

30-year-old Meenakshi’s home is located in a beautiful town of Weliweriya, a 100-kilometer drive from the capital city, Colombo. She married when she was 18 and today is the mother of three children. Her husband, Ramanan, works as a laborer at an estate, and they carry out a hand-to-mouth existence with his poor earnings. Though desiring a small family, Meenakshi has been through three pregnancies.

When Meenakshi was pregnant with her fourth child, she learned about family planning one day during a talk at her local health clinic. It was a talk Meenakshi wished she had heard years earlier. Before her current pregnancy, Meenakshi had been pregnant numerous other times, but she and her husband could barely afford to feed the three children they already had, so they terminated the pregnancies.

Abortions were costly and the couple struggled to pay for them. Once, they had to wait until the fourth month of a pregnancy until they were able to come up with the money for one. A good abortion would cost 10,000-15,000 Sri Lankan rupees, while a local clinic would cost only about 3,000 rupees (FPA resource centre). Women like Meenakshi face induced unsafe abortions, usually when resorting to clandestine circumstances. “There were times I was afraid of doing it,” Meenakshi says, referring to her abortions. She is right in being afraid. These abortions are operated secretively by non-licensed, minimally trained individuals in exceptionally unhygienic conditions, under the guise of “medical clinics”.

Meenakshi had tried a particular family planning method after her second child, which she decided to use to cut down the expenses on clinical abortions. She had sought assistance from her friends of her area to ensure that she followed the procedure carefully. Meenakshi knew the risk she was taking when she used a traditional herb to induce abortion. She believed that it was safe, had no harmful side effects, and was said to be foolproof. However, something went wrong and she conceived an unanticipated third child.

When Meenakshi and Ramanan were finally ready for a fourth child, she knew she didn’t want to face the other unwanted pregnancies that would inevitably come after she gave birth and became fertile again. Six weeks after the arrival of their fourth child, both of them were directed by a neighbor at the estate to a health clinic adjacent to the community they live in, where they received in-depth family planning counseling. Meenakshi chose to have an IUD worn for five years, and in 2007 had a second one reinserted.

Despite not being able to control the unwanted pregnancies earlier in her life, Meenakshi’s IUD allowed her control her future pregnancies. Many women in Sri Lanka have an unmet demand for family planning. The main reasons for the unmet need are high up-front costs, lack of trained providers and lack of supplies and a lack of accurate knowledge about how the family planning devices work, according to the FPA Resource Centre. In coming years however, the need and demand for family planning is only expected to develop as more people than ever enter their reproductive years in Sri Lanka, and urbanization – a force helping to drive the desire for family planning – continues its rise across the Island.

For Meenakshi, family planning has enabled her to improve her life and that of her family. Money is now spent on food and school supplies instead of terminating unwanted pregnancies.

Meenakshi no longer has to worry that an unwanted pregnancy might lead to her death, and she has spread the word. Since she first attended the talk on family planning, Meenakshi has encouraged her friends and neighbors to attend consultation programs at the family planning centre as well.

What remains unsaid in Meenakshi’s story is that she had not properly understood the family planning methods and the purpose and use of the device. Contraceptive use in Sri Lanka is relatively high and popular. However, due to myths, misconceptions, cultural and religious taboos, a significant number of women end up being pregnant, providing a stable wave of business to the large number of illegal abortion clinics that have escalated in cities around the country.

Meenakshi’s case is a good example. She chose the particular method because she believed there was a more easy-to-use method than any of the regular family planning methods. “Condoms are an additional expense and I did not want to allocate money to buy them,” Meenakshi says. When women are unaware of the free availability of condoms at many family planning clinics, the price of these important items are many times overshadowed by the need for other family necessities.

What emerges in Meenakshi’s case, is the need for Family Planning awareness programs and for consultations and guidance to be conducted in the local language, so that misunderstandings can be avoided and so that women can reap the proper benefits from the program.

According to Dr. Ratnam (a private practitioner and experienced social worker in tea plantations), arrangements should be made to provide more opportunities facilitating family planning counseling for couples. There is a widespread, mistaken notion about family planning devices that suggest that they cause ailments and side-effects, which is untrue.

“There can be small discomforts and uneasiness if one is new to certain contraceptive devises, however the discomfort is only for a short time”, she says. Thus she calls upon teaching couples about the proper use of contraceptives and the symptoms following the treatment during the initial period.

Ratnam also believes that there are unseen reasons as to why women consider home remedies as an option; young women should be able to make an informed choice to have a child or not, and be supported to do so. But all too often their choice to not have sex, or to not have a child, is violated.

Ratnam believes that the responsibility to help most women seek education about family planning rests with the mother-in-law and husband, as they would be the individuals to escort the woman to health centers. Women are rarely financially stable, which further restricts their ability to use medical services, Ratnam explains. Women also lack timely transportation to the nearest hospital, which aggravates the problem. She also believes that it is important to raise the standard of family planning services in rural areas, especially in the plantation areas.

Gone are the days when large families of six to seven children were deemed the rule. Due to economic, health and social reasons, modern couples prefer to limit their families to one to two children, and often use contraceptives to ensure no unwanted pregnancies take place. This has been the trend for the past 10 years.

According to the FPA Resource Center, the Demographic and Health Survey of 2000, showed that the percentage of family planning use in Sri Lanka was 70%, and use of new methods was 50%. The wealthy individuals in Sri Lanka approach reasonably well-staffed and well-equipped clinics, while the poor are left with two options: local clinics that operate under unhygienic conditions or home remedies such as the herb Meenakshi used.

Shalaka Nishan Wannipurage, a police officer based at the Mount Lavinia Police Crime Department says that a substantial number of unmarried, adolescent and even underage girls are caught at abortion clinics that are raided. “These young girls get sexually involved without knowing the consequences. None of them has any concept of protective sex. Though most women may not resort to suicide, many girls suffer at the hands of unskilled doctors, nurses and even quacks when they go for abortions. Unfortunately most cases are not reported,” Nishan says.

The Chief Nurse at the Family Planning Association, Elizabeth Mottanj, says that FPA has been conducting seminars and discussions, media awareness campaigns, mobile health clinics and distributing hand bills to generate awareness to guide the general public in selecting the right family planning method. “Condoms, IUD’s (loops), depoprovera, oral contraceptive pills, vasectomy and LRT (mastectomy), are some of the methods introduced to couples. Besides, we have a resource library that students and professionals can access,” she says.

According to Dr. Hemantha Wickramatillake, former Medical Director of the FPA, there is a great need for couples and the younger generation to be educated about regular use of family planning methods, appropriate timing and other necessary information. The assumption has been that parents in Sri Lankan families do not talk about sexual and reproductive health with their children.

Mottanj also points out that knowledge about safe sex and the importance of using condoms or other birth control measures as well as access to services empowers young people to make choices about their bodies and their sex lives. He believes that comprehensive sexuality education, in and out of school, can change gender stereotypes and the traditional attitudes that disempower young girls and boys.

Dr. Wickramatillake believes that expanding family planning services is a huge task and it cannot solely be a responsibility of the government. The private sector and NGO’s should join hands with the Government in expanding the family planning services to areas where it is currently not available. The private sector and NGO’s should formulate their own programs to cater to the needs of the people for high-quality family planning services. Such participation by the private sector and NGOs will undoubtedly contribute towards the extension of quality services to a large number of families in different parts of the country.

Mottanj, the Chief Nurse at the FPA, says that when a smaller proportion of women use family planning services, the money that is spent on the complications of abortions are much larger than that required for providing family planning methods.

Dr. Wickramatillake points out that the lack of adequate funding and shortage of skilled health personnel is a major problem in the successful implementation of family planning programs, while those who are already working in this service are deprived of adequate professional training and knowledge. “The language barrier is also an important issue when opening up of the north and the east of Sri Lanka,” Wickramatillake says.

Ratnam, the doctor and social worker, says that when women and youth are protected from sexual exploitation in their reproductive age and have the opportunity to access the services and the freedom to make decisions about the most intimate aspects of their lives, they will generally make positive, healthy choices.

According to Nishan, the police officer, making abortion illegal and raiding abortion centers does not stop women from having abortions. Clinics exist because there is a need for abortion.

“What needs to be done is not to raid and arrest those who operate them, but to increase sex awareness and extend family planning services and improve contraceptive usage that would ultimately drop down the percentage of unwanted and unplanned pregnancies,” he suggests.