One of the frustrating things when working in child maternal health in poor countries is trying to integrate medical aims into the cultural background of the people, without destroying it.

This NYTimes story, about trying to get the Mullahs in Afghanistan to approve of their people using birth control, is a good example of how to tackle  the problem, but only hints on how they could manage to persuade the Mullahs.

The answer is to emphasize the health needs of the mother and the child. A real man protects those whom God has put under his authority, and this means not risking a woman’s mental and physical health with pregnancy after pregnancy. Similarly, people know that women who are too young, too old, or have children too closely together often have children with health problems.

But what about Islam? That religion “hates” women, according to a lot of Islamophobic blogs in the US, who can’t see how the western emphasis sexual promiscuity and abortion on demand has harmed American women who want to raise a family, whereas Islam stresses protection of women by her family so that she can fulfill her calling as a homemaker.

That is why Family Planning is used widely in Iran.

After the Iran-Iraq war, population growth was threatening the economy, and so the Mullahs issued fatwas approving of clinics giving birth control to married women.They justified using family planning for the reasons I stressed above: because it helps the health of the mother and the child.

One result of this is that Iran’s population level is at replacement level, which is either good or bad, depending on who is viewing the statistics. (One is not surprised that the present President wants to scrap the policies, but that’s another story).

Will the Muslim clergy who advise the more conservative tribes in Afghanistan permit family planning?

Afghanistan is not Iran, which has a much more highly  educated population, and tends to be Shiite (which has leaders) rather than Sunni (where leadership is less defined).

Yet for the growing middle class, there is a desire to limit children.

First things first. First you need to get rid of the Taliban bullies and then you can work with the tribes to establish clinics and schools.

Then you work with the tribal chiefs and Mullahs. The best ones to do child maternal health are locals, but the second best choice is Muslim women. Expect lots of money to be lost by theft, bribes, or otherwise diverted, but if you can get long term workers, things can be done to improve the health of the community.

Family planning is not something you go in and give out. It will only work as part of a program that also does basic medical treatment, and works to train birth attendants to lower maternal mortality, give out vaccinations to stop deaths from diseases such as measles and tetanus,  and is able treat children with common illnesses.

Only families who see all their children growing into adulthood will be willing to decrease their family size.

One of the dangers of using outsiders is the ignorant trying to insist “they” want to locals from having too many babies. This was a common objection when I worked in Africa.

The correct answer to this is “what good are having eight sickly babies, half of whom will die before they grow up,  and a wife who is so worn out she can’t take care of them? Isn’t it better to space pregnancies, and have four healthy babies instead?

So can one work with conservative Muslim communities to encourage family planning?

Here in the Philippines, a recent fatwa encouraged spacing of children in marriage.

Pandi says that in truth, the edict is expected to face resistance from Muslims and non-Muslims who have conservative views on family planning. But he says its strength is its clarity and emphasis that ”family planning is birth spacing, not birth control or abortion”. ..

The edict prescribes that, ”all methods of contraception are allowed as long as they are safe, legal, in accordance with the Islamic shariah (courts) and approved by a credible physician, preferably a Muslim, for the benefit of both the mother and the child”. But while it allows contraception, it prohibits the use of vasectomy and ligation, which are considered mutilations of the body – and not accepted by all in the Muslim community.

This idea, to work with the local communities to implement change by building on the positive beliefs and customs, is the most practical way to be successful.

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at HeyDoc Xanga Blog.

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