Advancing Sexual and Reproductive Health and Rights
 
The Guttmacher Report on Public Policy
December 2001, Volume 4, Number 6
 
Special Analysis

Islam, Women and Family Planning: A Primer

The events of September 11 have focused attention on just how bad things can be for women living under the rule of Islamic extremists. The Taliban's inhumane treatment of women in Afghanistan has led many in the West to conclude that Islam itself defines a subordinate role for women that is incompatible with reproductive choice. In reality, however, Islamic thought is flexible on reproductive matters, and political interpretations of Muslim law are as varied as the countries that make up the Muslim world. By and large, however, Islam is permissive of family planning, and many Muslim countries have active population and family planning programs.
By Heather Boonstra

In his address to a joint session of Congress in the wake of the events of September 11, President George W. Bush went out of his way to acknowledge the vast majority of Muslims throughout the world whose faith is "good and peaceful" in contrast to the radical network of terrorists he described as "traitors of their own faith, trying, in effect, to hijack Islam itself." Behind Bush's remarks is a complexity of thinking about Islam that may not have been commonplace among Western observers. All too often Islam and its believers have been presented as one monolithic culture. Mention the plight of women in the Muslim world and the worst case scenarios come to mind: women strictly isolated within the home, subjected to public floggings and female genital cutting, forcibly given in marriage as a child and condemned to death for presumed adultery.

To be sure, these heinous practices exist, but most Muslim scholars contend they are less a function of religious doctrine than a reflection of history, culture, economics and especially politics. Countries that make up the Muslim world (those with a majority Muslim population) span the globe from Sub-Saharan and Northern Africa through Europe and the Middle East to Southeast Asia (see box). It would be grossly misleading to assert that there is one homogeneous Muslim world. In contrast to the lives of women in Afghanistan under the Taliban, women in many other Muslim countries enjoy the right to work and to participate in public affairs and have far greater control over their reproductive lives. Still, the unmet needs among women in the Muslim world for reproductive health services, and for reproductive and other societal rights, are enormous.

MAJORITY MUSLIM COUNTRIES
Middle East Northern Africa
Iran (99%) Algeria (99%)
Iraq (97%) Egypt (94%)
Jordan (92%) Libya (97%)
Kuwait (85%) Morocco (99%)
Lebanon (70%) Sudan (70%)
Oman (100%) Tunisia (98%)
Saudi Arabia (100%)  
Syria (90%) Central Asia
Turkey (100%) Azerbaijan (93%)
United Arab Emirates (96%) Kyrgyzstan (75%)
Yemen (99%) Tajikistan (85%)
  Turkmenistan (89%)
Sub-Saharan Africa Uzbekistan (88%)
Burkina Faso (50%)  
Chad (50%) South and Southeastern Asia
Eritrea (80%) Afghanistan (99%)
Gambia (90%) Bangladesh (83%)
Mali (90%) Indonesia (88%)
Mauritania (100%) Malaysia (52%)
Niger (80%) Pakistan (97%)
Nigeria (50%)  
Senegal (92%) Europe
Sierra Leone (60%) Albania (70%)
Somalia (100%)  
Sources: Central Intelligence Agency, The World Factbook 2001, Washington, DC, July 2001; and IslamicWeb.com, 1998, <http://www.islamicweb.com/begin/population.htm>, accessed December 4, 2001.

Islamic Doctrine and Country Law

Religious authority in Islam is derived primarily from the Koran (also spelled "Quran"), which Muslims hold as having been divinely revealed to Muhammad in the seventh century. For cases not explicitly addressed in the Koran, Muslims look to other written sources—including the collected examples and sayings of Muhammad (his sunnah)—and follow the direction of religious leaders. The concept of ijtihad, which allows the formulation of independent judgment and interpretation, is also important in Islamic teaching, although various schools of law differ in the extent to which they allow ijtihad. But unlike Catholicism, for example, Islam does not have a central authoritative structure of religious interpretation. Instead, Islam plays out differently across cultures, and various schools of law and religious sects provide diverse understandings about how Islam should be practiced.

As is the case with Judaism and Christianity, however, Islam clearly values procreation within marriage, and fertility is highly prized. Children are a gift of God, the "decoration of life," says the Koran. Some have used this basic position to argue that Islam does not permit contraception or abortion. But on the whole, says Carla Makhlouf Obermeyer, in Power and Decision: the Social Control of Reproduction, the Islamic texts do not present a major obstacle to family planning. Indeed, many Muslim religious thinkers over the past quarter-century have maintained that, notwithstanding Muhammed's exhortation to multiply, family planning is permitted and even encouraged by Islamic law.

A number of Koranic verses, says Obermeyer, emphasize the notion that God does not wish to burden believers, with the implication that the well-being of children overrides concerns for a large family. As a result, contraception has a long history in Islam. Early Muslim doctors recorded the tradition of herbal prescriptions to prevent pregnancy in Islamic books of medicine, which were used for centuries in Europe.

Muhammad, himself, encouraged the practice of al'azl (withdrawal or coitus interruptus). By analogy, the use of other barrier methods, such as the condom and diaphragm, is also allowed. Islamic thought varies on the use of other modern methods, says Nawal Ammar in On Being a Muslim Woman: Laws and Practices. While some religious leaders consider the use of oral contraceptives or implants to be undesirable or even forbidden, most encourage their use as long as these methods do not interfere with a woman's health and well-being.

Tubal ligation and vasectomy pose greater difficulty. Some religious leaders argue that sterilization does permanent harm to a person and is, therefore, unacceptable to Islam. Others argue that to the extent sterilization is reversible, it is permitted.

In keeping with predominate Islamic attitudes toward birth control, the legal status of contraception in Muslim countries (derived primarily from European civil codes) is overwhelmingly permissive. The exception to this rule is sterilization, which is illegal in some countries and remains the subject of ongoing debate within Muslim communities. Iran, Turkey and Tunisia are among those countries that allow both tubal ligation and vasectomy, for example, while Jordan and Egypt do not allow either.

The Koran does not explicitly address abortion, but there is general agreement in Islam that abortion is only permitted for the most serious reasons, such as saving a woman's life. And even then, it is only allowed before "life is breathed" into the fetus, variously regarded as within the first 40, 80 or 120 days. A minority of scholars oppose abortion at any stage of development, based on the belief that the embryo is already on its way to having a soul from the moment of conception.

The legal environment surrounding abortion reflects the prevailing view that abortion is permissible only in the first trimester and only for the most serious reasons. Laws on the books in nearly every Muslim country permit abortion only on narrow grounds. However, a few countries—primarily former Soviet republics—permit abortion without restriction as to reason: Albania, Azerbaijan, Kyrgyzstan, Tajikistan, Tunisia, Turkey, Turkmenistan and Uzbekistan.

Programs and Practice

Within this religious and legal landscape, many national governments in the Muslim world are actively involved in the distribution of contraceptives and the provision of reproductive health services through a variety of government-sponsored family planning programs. Some of these programs have been more successful than others in increasing contraceptive prevalence and reducing birthrates, depending mostly upon the level of government commitment, and interestingly, some have been associated with improving the status and condition of women, while others have not (see box).

Where women do not have ready access to contraceptive services, they often turn to abortion to avoid unwanted births. In Kazakhstan, for example, where contraception has been difficult to obtain from government or private sources, the abortion rate is high: For every 1,000 women of childbearing age, 44 have an abortion each year. In Tunisia, by contrast, the abortion rate is relatively low. There, only nine per 1,000 women of reproductive age turn to abortion, both because a high proportion of women in that country (40%) are using a modern method of contraception and because many still desire relatively large families.

Where abortion is illegal, many women go to extreme measures to obtain one anyway. This often means an abortion that it not only clandestine but also one that is performed under unsanitary conditions and by an unskilled practitioner. Unsafe abortion puts women at serious risk of impaired health and, sometimes, of dying. In Egypt, for example, some 216,000 women were hospitalized in 1996 for treatment of abortion-related complications, according to a study of postabortion caseloads published in 1998 in International Family Planning Perspectives.

Successes and Challenges

In short, the notion of family planning is overwhelmingly sanctioned as compatible with the teachings of Islam. The extent and manner of reproductive health service provision, however, varies across the Muslim world according to the cultural and political context in which women's rights are defined.

Successes abound, and so do the challenges. Few know this as well as do the two Muslim women who most recently have led the United Nations Population Fund (UNFPA), Thoraya Ahmed Obaid of Saudi Arabia, the current executive director, and her predecessor, Nafis Sadik of Pakistan. Obaid describes herself as a product of Islam interpreted as a religion of moderation. This, she says, allowed her to rise to the level of Under-Secretary General of the United Nations: "[In the context in which I was brought up,] I was able to pursue my education to the highest level, to choose my specialization, choose my husband, plan my family, work and pursue a professional career of the highest quality." But Obaid is painfully aware that not all women in Muslim countries—or women in other countries for that matter—are afforded the same level of opportunity. She not only advocates for women's access to reproductive health services but also makes the case that all women should be able to exercise their right to "development as individuals." "Supporting women to have choices in their lives [need] not threaten the social fabric," Obaid contends. "Ensuring that people enjoy the full measure of their rights strengthens the community. And by way of shared values, it extends the sense of community, even to the global level."

Government Family Planning Programs in Four Muslim Countries: A Study in Similarities and Contrasts

Iran. Under the leadership of the Shah and a secular government, Iran established a formal population policy and birth control program in 1967. Although largely limited to urban areas and to middle class couples, it was accompanied by other reforms for improving the status of women. In the 1970s, the government limited polygamy and entitled women to child support and custody rights, for example.

Following the 1979 Islamic revolution, although the Ministry of Health and Education continued to provide some family planning services through government clinics, the new regime criticized the program as an imperialist plot to reduce Muslim populations and overturned many of the reforms that gave women greater autonomy. By 1986, the population had reached nearly 50 million, an increase of approximately 14 million in one decade.

At the end of the Iran-Iraq war in the late 1980s, the Iranian government renewed its interest in family planning amidst deteriorating economic conditions. The country's National Birth Control Policy issued in 1989 had the endorsement of the country's highest Islamic authorities, and religious leaders joined with health and policy experts in a campaign to persuade the public of the need for family planning through newspaper reports, television spots and Friday prayer speeches.

Iran's family planning program today is considered a model for developing nations and other Muslim countries. Infant, child and maternal mortality all have declined, and contraceptive use has risen from 37% of married women in 1976 to 73% in 1997. An explicit goal of the program is the improvement of women's position within the family and society, and, indeed, there is evidence that women's status has improved. Between 1976 and 1996, the literacy rate for all women six years and older almost doubled to 74%. And more women are working outside the home with the support of their parents and husbands.

Pakistan. Like Iran, Pakistan is an Islamic republic, but Pakistan's family planning program, in sharp contrast to Iran's, has suffered long years of neglect and frequent policy changes that accompanied political upheaval. Until recently, there has been no consistent government policy and limited involvement on the part of nongovernmental organizations and international donors.

Although many Pakistani women report being aware of contraceptives, their contact with family planning workers is limited. An extremely conservative view of Islam prevails in most parts of the country, and many women live in purdah, a custom that restricts them to their homes unless accompanied by a chaperone. Levels of literacy and school attainment remain very low among women, and men are given disproportionate power in decision-making. It is estimated that the government's family planning program currently serves only about 15-20% of the population; nongovernmental organizations reach another 5%.

The religious milieu has undoubtedly undermined public support for family planning. The organized religious party in Pakistan officially opposes family planning as "un-Islamic," and couples commonly cite religious concerns as their reason for not practicing contraception. At the same time, many local religious authorities are supportive of family planning efforts. And in villages and communities where service providers are unwelcome, family planning workers have initiated discussions about birth control with religious leaders as a means of improving the health of mothers and children.

As a result of the ineffectiveness of Pakistan's family planning program and the social, religious and economic environment, contraceptive prevalence is only 18%. This does not mean that women in Pakistan do not want to control their childbearing, however: Nearly 40% of women report that they do not want to have another child but are not using any method of contraception. To many experts, Pakistan is ripe for change. During the 1990s, women increasingly reported wanting smaller families, contraceptive use increased somewhat and fertility began a gradual decline.

Bangladesh. In many respects, Bangladesh is very much like Pakistan. The two countries were one nation for 24 years, until 1971 when East Pakistan seceded to become a separate country. Both countries are poor and overcrowded. But in Bangladesh, unlike Pakistan, the government is secular and has consistently supported family planning over the past 30 years.

Bangladesh's family planning program was designed to comport with conservative Islamic tradition, in particular the practice of purdah. Field-workers delivered contraceptives door-to-door, allowing women to stay within their homes. This system was successful on its own terms: Between 1975 and 1997, contraceptive prevalence among married women rose from 7% to 43%. However, the program was criticized for diverting attention from meeting the full range of women's health and development needs. Indeed, women's status in Bangladesh remains low. Although the government recently raised the legal age of marriage for women to 18 and is encouraging women's education and workforce participation, only 8% of the workforce is female, and women have little independence.

Following the 1994 International Conference on Population and Development in Cairo (see related story), Bangladesh revised its strategy. Service delivery is moving from a doorstep delivery system to a more client-centered package of services offered at fixed clinic sites. Nongovernmental organizations and donor agencies also play a large role in providing services and have encouraged women's economic development through micro-credit programs and other opportunities to work outside the home.

Some observers contend that the revised program faces rising religious opposition, however. Early in the program's history, there were concerted efforts by family planning advocates to educate Muslim clerics about the health benefits accruing from women's ability to space and limit births. However, according to Sajeda Amin of the Population Council in The Continuing Demographic Transition, religious political groups are far less accepting of the increased role of women in public life. Amin goes so far as to speculate that whatever support for family planning there is among Islamic leaders "may wane when the connections between family planning and women's changing roles become more evident."

Turkey. Located at the crossroads of Europe, Asia and the Middle East, Turkey is a Muslim country with hopes of joining the European Union. The country instituted a secular government soon after it was created in 1923, and it has a history of progressive policies and legislation designed to improve maternal and child health. In 1982, Turkey guaranteed the right to reproductive health in its constitution, ensuring the provision of "family planning education and application"; the legalization of sterilization and abortion up to 10 weeks followed a year later.

Throughout the 1990s, Turkey's family planning program focused on promoting more, and more effective, contraceptive use by improving the training of providers, clients' knowledge and the overall quality of services. In 1998, an estimated 38% of married women of reproductive age were using a modern method. Still, withdrawal remains the most commonly practiced means of contraception; it was used by 24% of currently married women in 1998.

Turkish women typically report that they want only two children. But because withdrawal has a high failure rate, unintended pregnancy and abortion are relatively common, and there is a very high incidence of repeat abortion. In an effort to reverse this trend, the Turkish family planning program, supported by the U.S. Agency for International Development (USAID), initiated a postabortion family planning program in the early 1990s by formally linking abortion services with family planning services. A recent analysis of abortion trends in Turkey by Pinar Senlet, published in Studies in Family Planning in March 2001, shows that the rate of abortion has declined significantly over the last decade, with a shift from traditional to modern method use being an important factor. In the wake of this success, USAID and the government of Turkey have been laying the foundation for a self-sustaining program, and USAID is preparing to phase-out its financial assistance.