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May 1972 In
recent years Chile has become Latin America's most important center of
demographic and family planning research and practice. Not only is
Santiago the home of CELADE (Centro Latinoamericano de Demografia), the
United Nations subsidiary which has become the main institution for
demographic training and research in this region, but for nearly a decade
now Chile's Servicio Nacional de Salud (SNS), or National Health Service,
has been increasingly committed to programs of family planning, mainly to
curb the alarming spread of abortion and its resultant disasters among
poorer Chilean women. As a result of this public policy and of large-scale
support from foreign (mainly United States) foundation and governmental
sources, the Chilean birthrate has been dramatically reduced since 1964.
However, because of a controversy over what should be the proper role of
this foreign support, these successful family planning programs are
presently in crisis. This Report will focus on the achievements of these
programs and the causes and nature of their present trouble. According
to provisional results of its 1970 census, Chile numbered only 8,840,913
persons, which meant that during the decade of the 1960s this elongated
but compactly settled Pacific Coast republic had dramatically reversed a
constantly ascending rate of population growth that had been rising with
each successive census since 1885. Between 1885 and 1960 the rate of
population increase had grown from 1.14 to 2.43 per cent, with nearly
three - fourths of this rise - from 1.49 to 2.43 per cent - occurring in a
sharp escalation between 1940 and 1960. The abrupt rise of the 1940s and
1950s makes the decline in the rate of increase recorded in the 1970
census - from 2.43 per cent to slightly under 2 per cent - especially
dramatic, a phenomenon which has been almost universally attributed by
demographers to embattled but spreading family planning efforts that
since 1964 have precipitated a sharp drop in the Chilean birthrate. These
developments, potentially of great importance, are being carefully
analyzed by CELADE. The decline of the Chilean birthrate from 37.1 per
thousand inhabitants in 1963 to 26.9 in 1970 has been accompanied by an
even more extraordinary decrease in the Central American republic of Costa
Rica, whose 1960 birthrate of 47.5
- Latin
America's highest
- had
declined to 34.5 by 1969. Like Chile, Costa Rica is a country of high
literacy by Latin American standards, relatively reliable registers of
vital statistics, and the scene of an important birth control effort
during the 1960s, a comparison which seems to confirm the impression of
family planning specialists of the linkage between educational levels,
economic opportunity, and the limitation of family size. In Costa Rica,
literacy and life expectancy increased respectively from 78 to 83 per cent
and from 55 to 62 years during the 1950s, while GNP more than doubled
between 1950 and 1970. In Chile, GNP grew by 38.5 per cent during the
1950s and by nearly 60 per cent during the 1960s, with corresponding
increases in literacy and life expectancy. The
impact of family planning in Chile has been shown not only in declining
general birthrates, but also in a lower percentage of couples who have
children in their first year of marriage and in a rising proportion
- from 41.1 per cent in 1960 to 48.8 per cent in 1968 -
of first - born and second born offspring to the total number of births.
The Chilean demographer Julio Morales recently pointed out in a CILADE
study that the declining birthrates of the 1960s will mean fewer girls
entering childbearing age in the 1980s, thus reinforcing the present
trend. As in other countries where dramatic reductions in the birthrate
have been achieved during the past decade‑namely Taiwan, Malaysia,
and Costa Rica
-
Chip has made substantial progress toward bringing its population growth
under control thanks to an official government program supported by
foreign (mainly United States) private and official contributions of
funds, contraceptives, and advice. About US$ 5 million has been spent in
Chile since the mid
- 1960s
by these agencies-AID, the Population Council, the International Planned
Parenthood Federation, the Pathfinder Fund, the Ford and Rockefeller
Foundations, and the Swedish foundation SIDA
- on
contraceptives, experimental programs, clinical facilities and research in
reproductive biology, birth control technology, and abortion. This
abundant financing has created a busy research community in Santiago, with
interested Chilean public health physicians and demographers joining the
international jet set of population specialists at conferences,
seminars, and congresses financed by these supporting agencies. Unlike
the programs in Taiwan, Malaysia, and Costa Rica, Chile's family planning
programs are not directed specifically at relieving demographic pressures,
but rather at controlling the spread of abortions, which by the early
1960s in Chile had reached epidemic proportions. Abortion traditionally
has born a much more important phenomenon in the countries of the heavily-urbanized
southern cone of South America-Uruguay, Argentina, and Chile
- than
elsewhere in the Western Hemisphere. According to Santiago Gaslonde, a
French public health physician who is conducting a major study for CELADE
on abortion in several Latin American republics, roughly three
- fourths
of all pregnancies in Montevideo and half of those in Buenos Aires end in
abortion, which is practiced much less in countries with a greater rural
population. As Thomas G. Sanders explained in an earlier AUFS Report: While abortions are not this common in Chile, medical doctors, especially those in gynecology and preventive medicine, had become alarmed by the problem in 1960. In 1937 the National Health Service (SNS) registered 8.4 abortions for each 100 births; by 1960 this had increased to 22.3, and the number of women involved had risen from 12,963 to 57,268. These figures represent only those abortions that came under hospital attention because of complications. It is currently estimated that Chile has about 150,000 abortions a year, as compared to 300,000 live births. Abortions cause two - fifths of all maternal deaths, and in 1960 their treatment accounted for 184,000 bed - days and cost over a million dollars. They are responsible for 8.1 per cent of all hospital admissions of SNS, 35 per cent of the surgery in obstetric services, and 26.7 per cent of the blood used in all emergency services. Although
both hospitalizations and maternal deaths caused by abortion have been
reduced greatly since 1964, the ratio of abortions to total pregnancies
seems to have remained constant and may have even risen, according to some
specialists. Most Chilean women face a choice between effective
contraception and an unremitting series of pregnancies, often ending in
abortion and in senseless and sickening tragedies like the following one
recounted to me this year by a plump, pretty 35-year-old seamstress,
unmarried, who lives in a lower middle-class district of Santiago: I have only one child, a five-year-old girl, but the first time I became pregnant was nearly 20 years ago, when I was 16 years old. Around that time I began living, for about five years, with a dentist who had four kids of his own by his wife and didn't want any from me, so from the age of 16 on I had one or two abortions every year. Once, when I was 19 or 20 years old, I had an abortion done in my house in the country town of Talca when I was already six months pregnant. I became very sick when they removed the body of the foetus from the uterus, but somehow the head remained inside. They rushed me to a clinic where my dentist had a doctor friend, and they fixed me up. You know, doctors can do anything among themselves. About ten years ago I began using an intrauterine device, and I have been pregnant only once since then, with the little girl I wanted to have. Chile's
family planning programs have done much to help such women. Not only did
the general birthrate decline by more than one-fourth between 1963 and
1970, but infant mortality has declined by 30 per cent in this period
(1964-1971), maternal deaths caused by abortions were reduced by 44 per
cent (1964-1970) and the hospitalized abortion rate per 1,000 women of
fertile age dropped by more than 20 per cent in the two-year period (1966-1968)
in which Chilean family planning programs swung into high momentum.
Between 1967 and 1969, the number of SNS hospitals and clinics dispensing
contraceptives rose from 103 to 227 and the number of women given them at
SNS establishments increased from 99,239 to 214,124, with a ratio of
roughly four-to-one maintained between IUDs and pills. On a local level,
studies of the pilot family planning program in the Santiago working-class
district of San Gregorio by the staff of Barros Luco Hospital and the
Faculty of Medicine of the University of Chile have shown a 45 per cent
decline in fertility and a 40 per cent drop in hospitalized abortions
between 1964 and 1968. The program's greatest impact was in the 25-29 age
group, which a 1964 survey showed to have the highest induced abortion
rate; by 1968 this rate had dropped by 80 per cent. In the Western Health
Area of Santiago, an intensive campaign for insertion of IUDs-financed by
the Rockefeller Foundation and headed by Dr. Benjamin Viel of the
University of Chile's Public Health Department‑brought about a
reduction of births by one‑fourth, while the districts estimated
population was growing from 408,212 to 521,417 between 1964 and 1968.
During this period the number of IUD users in the district rose from 4.073
to 36,418, while the number of hospitalized abortions declined by 31 per
cent. As
a result of the intense and well-financed family planning proselytism of
the late 1960s, the SNS brought into its program of contraceptive practice
roughly 11 per cent of its female patients of childbearing age, who are
the poorest 70 per cent of all fertile women in Chile. Among the
remaining, wealthier 30 per cent, birth control devices are far more
commonly used, though statistically unregistered. Using statistics of
distribution of contraceptives by private health plans and over-the-counter
sales at pharmacies, professional estimates have been made that slightly
more than 300,000 Chilean women regularly use contraceptives, or roughly
13 per cent of all females of child-bearing age. The pregnancy rate among
users of contraceptives is roughly two pregnancies per 100 woman-years of
use both for IUDs and pills. Doctors blame most of these pregnancies on
irregularities of women in taking pills and going for their periodic
checkups, which would find and correct in time dislocations of their IUDs.
According to these doctors, women tend to blame headaches and other minor
ailments on the contraceptive devices. The women themselves complain that
they sometimes miss their periodic checkups because of a sickness or other
family emergency that prevents them from going on time to the birth
control clinic or from waiting there several hours for their turn. If they
miss their clinic appointment, they often must wait two months for another
checkup. Despite
their unquestionable achievements, Chile's family planning programs
presently are in trouble because of a controversy over the role of foreign
assistance in these efforts. As a result of this controversy, the IUD
program of the Rockefeller Foundation-by far the largest private
contributor to IUD contraception-was terminated in 1970. Many SNS
officials and representatives of private agencies feel that the
termination of the Rockefeller program has been a major factor in causing
a slight rise in the Chilean birthrate in 1971, the first such rise in 10
years, interrupting the decline that gained momentum during the late
1960s. In terms of the future of family planning efforts in Chile, this
rise in the birthrate from 26.9 in 1970 to 27.3 in 1971 may mean much more
than the additional 10,000 births officially registered. This
damaging controversy has focused on the channeling of private foundation
money to family planning efforts through the teaching hospitals of the
University of Chile's Faculty of Medicine as well as directly to
provincial SNS doctors and hospitals instead of through the central SNS
bureaucracy in Santiago. The lightning rod in this dispute was Dr.
Benjamin Viel, a professor of public health administering a $450,000
Rockefeller grant, who theoretically was conducting a pilot contraceptive
program in the Western Health Area of Santiago, but who also traveled up
and down the length of Chile contracting SNS personnel for additional
"experimental" family planning work. The main question in the
public controversy that followed was what might be called the "Taiwan
method"' of economic incentives to SNS clinic staff members
participating in the Viel-Rockefeller family planning program, as well as
in parallel efforts by the International Planned Parenthood Association's
affiliate, APROFA (Asociación Chilena do Prontección de la Familia).
These direct payments by private agencies to SNS personnel led to charges
that doctors and nurses were being induced by these economic incentives
into devoting excessive amounts of their regular clinic time to inserting
IUDs while shirking other functions normally performed in maternal-child
care clinics. In a recent article in a leading Chilean medical magazine,
Viel wrote that 100,653 or 44 per cent of the IUDs inserted in Chile
through December 31, 1969, were done so under the Rockefeller grant. Viel
quoted an unpublished report on the impact of family planning in Chile,
which was jointly sponsored by AID and SNS, to assert that
"Rockefeller Foundation funds were used to pay 37 per cent of the
specialized physicians doing contraceptive work, 46 per cent of the
general practitioners, 38 per cent of the midwife-nurses, 52 per cent of
auxiliary personnel and 50 per cent of administrative and auxiliary
personnel." Payments were made either per "medical hour"
engaged in contraceptive clinical work or per IUD insertion. However, it
is widely conceded in birth control circles in Chile that medical
personnel often were paid for extra "medical hours" by
Rockefeller and/or APROFA without actually performing any additional hours
of clinical work. In some cases clinical personnel reportedly were paid by
three sources-Rockefeller, APROFA, and SNS-for the same contraceptive
procedures. It
may be significant that the heads of SNS during the Christian Democratic
administration of President Eduardo Frei (1964-1970) and during the
present Unidad Popular regime of Socialist President Salvador
Allende (1970-1976) have condemned the practice of offering economic
incentives for birth control procedures. The most common explanation for
the 1971 rise in the Chilean birthrate given by both government health
officials and representatives of private agencies, is that the sudden
withdrawal of the windfall extra income received for birth control
activities created great resentment among clinic personnel and led to a
sudden, unprogrammed downgrading of contraceptive procedures soon after
the Rockefeller program was terminated in mid-1970. A sign of this is the
one‑third drop in the number of IUD acceptors, from 62,301 in 1970
to 41,385 in 1971, reported by APROFA, which pays between 20 and 30 per
cent of the income received by clinic personnel for family planning
programs and which donates nearly all of the contraceptives distributed by
the SNS as well as by SERMENA, the health plan for private sector white-collar
employees. One high SNS official told me: Chile believes in family planning as a right of every woman to save herself from the tragedies issuing from abortion and from giving birth to children that are not wanted and that cannot be given adequate support. Birth control already has reached such proportions here that it cannot be stopped even if we wanted to do so; if all contraceptives were suddenly withdrawn from all SNS clinics, there would simply be a massive and brutal rise in the number of abortions practiced by working-class women to the proportions that abortions are practiced today in Uruguay and Argentina. Rather than reduce birth control practices, we are planning to double our SNS contraceptive coverage from 11 per cent of our patients to about 22 per cent, knowing that this will be an expensive proposition. What we insist is that any family planning program-and any foreign assistance supplied for birth control-be an integral part of an overall program of maternal-child care, with no foreign funds specifically marked for contraceptive procedures. The sudden flood of outside money in the late 1960s theoretically was to pay clinic personnel for extra hours of birth control work, but what really happened was that many if not most doctors and midwife-nurses performed extra contraceptive activities in their regular SNS schedule and did not work the extra hours, thus shunting aside their normal prenatal and postpartum clinic obligations. Now that all this extra money has been turned off, many doctors are refusing to devote themselves to birth control practices. They refuse to recognize that family planning was part of the SNS program before Rockefeller began to pay them extra money, and that this is a job that can be easily performed within their normal work schedule. Unfortunately, the foreign agencies supplying this money seem to be interested only in birthrates and IUD insertions, while we are interested in improving many other procedures to better the health and welfare of Chilean women. Family planning cannot be the only form of maternal-child care that grows and prospers in Chile, the only practice that enjoys deluxe financing and facilities. We are seeking outside support for an overall improvement of maternal-child care services that would significantly expand our contraceptive coverage. But we can only accept money for the overall program. The
Chilean SNS presently is concluding negotiations for United Nations
support for its maternal-child program that will include provisions for
family planning activities. Nevertheless, the fact remains that, while
Chile has become Latin America's leading center of contraceptive and
demographic research and practice because of its relatively developed
public health delivery system and its pool of skilled and interested
professionals, it has encountered great difficulty in persuading foreign
donors to its family planning programs that its main problem is abortions
more than demographic control. Along with Argentina, Uruguay, and Cuba,
Chile is one of the four Latin American republics with relatively modest
population growth. The success of its contraceptive programs in recent
years is more a function of Chile's pre-existing installed capacity to
rationally use foreign donations rather than the degree of its need
compared with poorer countries like, say, the Dominican Republic, where
population growth is out of control and where there is no public health
infrastructure for large-scale delivery of contraceptives. Indeed,
Chile's main economic problems have less to do with overpopulation than
with achieving greater productivity from its abundant agricultural and
mineral resources. Subsequent Fieldstaff Reports will examine Chile's productivity
problems in its newly nationalized copper mines and in the sweeping land
reform of President Salvador Allende's Unidad Popular regime in the
context of demographic pressures and increasing personal consumption in a
nation trying to emerge from the upper reaches of underdevelopment.
APPENDIX The
following are excerpts from taped interviews done by this writer with two
women who were respondents in a recent CELADE study of abortion practices
in two poor neighborhoods of Santiago. Norma is a middle-class housewife
living in stable surroundings, while Cristina lives in a shack in an area
that was invaded by squatters. While the question and answer repartee of
the original interviews has been eliminated, these women tell their story
in their own words. The CELADE study of 675 women between the ages of 26
and 40 in the Santiago communes or barrios of Renca and Conchalí
was directed by Dr. Maria Luisa García. It attempted to compare the
results obtained by "retrospective" and
"prospective" interviewing; that is, between obtaining a case
history in a single visit with the interviewee and making monthly visits
during 1970 to each woman to record each pregnancy and trace its
development. According to preliminary and unpublished results of this
survey provided by the CELADE staff, the "retrospective" or
single case history method yielded a pattern of roughly one-third of all
pregnancies ending in abortion, which is similar to the results of earlier
abortion studies, while the "prospective" or monthly follow-up
method of closer case supervision led researchers to estimate that
between 50 and 60 per cent of all pregnancies were ending in abortion. The
author is grateful to Dr. García and Señora Marta Rodriguez for the
cooperation that enabled him to carry out these interviews. Norma Thirty-five
years old, five children between ages seven and 17, with a history of
"between 10 and 15 abortions." My
husband has a taxi, all his own, of the latest model. He has no fixed
income, but he earns seven or eight thousand escudos each month. Next
month (April 1972) he will be working in the UNCTAD conference and will be
earning 700 escudos daily. Besides this, he has an older taxi that a
brother of his drives, splitting the income, so, you see, I have no
economic problems. The food shortages in Santiago don't affect us too
much. We drink lots of milk, because my husband goes every other day to a
farm here in Conchalí, on the other side of the terminal, and brings us
10 quarts of milk straight from the cow. I have a frigidaire, and I put
them there, so my children consume plenty of milk and eggs. On weekends my
husband goes into the valley and brings us cheese, fruit, and a pig. So I
would be ungrateful to complain of shortages the way other women do. Some
women have their frigidaires full, but nevertheless join the street
demonstrations against the government, the so‑called Marches of the
Empty Pots, banging empty pots in the streets to protest against the
shortages. The ages of my children are 17, 16, 13, 12, and seven, and in the years between the birth of the youngest and the oldest I had at least one abortion each year that I didn't bear a child. I must have had between 10 and 15 abortions in all. My first abortion came after giving birth to my second child, who was born almost exactly a year after the first. I became pregnant again 40 days after giving birth the second time, so I provoked an abortion, and for the next three years I kept on having abortions. I didn't take care of myself, so then I gave birth to the 13-year-old boy, and then to my youngest son who now is 12 years old. After that I kept having abortions until I had the little girl who is now seven. My
last abortion was only a few months ago. I went to a private clinic, and I
stayed there overnight. They anesthetized me from the waist down, so I
didn't feel anything. It cost 2,000 escudos, but it was safe and there
were no complications. In the seven years since my little girl was born, I
had taken pills until I got sick recently and they suspended the pills. I
hadn't taken pills until I gave birth to my daughter. My friends said the
pills made you sick and were bad for the nerves, and I became terribly
sick in the nerves. I never had taken any medicine for my nerves because I
don't have marital or economic problems, thank God. My only reason for
nervousness is my 17-year-old boy, who is very rebellious. He has gone to
live with my mother because he says we don't understand him. He says the
house is crowded and the younger children bother him. My mother adores him
because he's her oldest grandson, and she spoils him shamelessly. Most
of my friends have abortions because of the number of children they have,
because they have children against their will and all their life is spent
raising children. I am very Catholic, but I had no problems of conscience
about taking the pills. When I wanted to have an operation so as to have
no more children, I went to the clinic at the Catholic University. The
doctor told me that he couldn't do such a thing because he is Catholic and
both of us would be excommunicated. Then I thought that if the operation
were a problem of conscience, what about the pills? But the only problem
of conscience I really have is when I have an abortion. The recuperation
is hard and I get very nervous, very irritable. So does my husband. When I
have an abortion I go through a lot of nervousness and anguish, because I
am very Catholic and I feel that I am killing something that already
lives. Frankly,
I never knew about the pills until my seven-year-old daughter was born. It
was either ignorance or not asking a doctor. I have a chronic cervicitis
that prevents me from using an IUD, but my abortions have always been less
risky than those of other women I know. For example, my sister was
critically ill for three months because she provoked an abortion with the sonda.
"This is a rubber tube with a bulb at one end through which water is
squeezed or sometimes a piece of wire is inserted in the uterus to provoke
an abortion. The water and the tube often are dirty, and this infects the
blood and very frequently leads to a septicemia (blood poisoning) and
hemorrhaging. My sister was turning purple when they took her to the
hospital because the dead foetus was still inside of her. They had to
operate on her and she nearly died. She always had been kind of reckless,
but never more. She had two children from her first marriage and one by
her second husband, but now she is using an IUD. Cristina Thirty‑one
years old, four children, seven abortions, lives in a shack in Barrio E1
Salto, Commune of Conchalí, Santiago. I
found out about this woman through a friend, one of these friends who are
never lacking. She told me you can have an abortion in such-and-such a
place, and I went around in the street to find the right house. A girl
came up to me in the street and asked who I was looking for. I said,
"Look, I'm looking for such-and-such a person who does such-and-such
a thing." The girl said, "My sister does this," and I went
to talk with her. This woman came to my house to do it; I didn't have to
go to hers. She charged something like 50 or 100 escudos, which in those
days (1964) was real money. She
dissolved some pills in lukewarm water in a lavatory, and then poured the
water through the sonda into my womb. My impression is that this is
supposed to dissolve the foetus inside the mother's womb. I always have
had my abortions between one and two months of pregnancy. Never after
that. After the woman put the tube inside me I almost exploded. A friend
came to my house and said, "You're shivering with cold." I said,
"Throw a blanket over me because I'm dying of cold." Then my
friend said, "Look, Cristina, I'm going to take you to the hospital
because otherwise you're going to die here." I told her, "Let me
stay here because by now I've had enough of this business, so many kids
and so many problems that I don't know what to do." So she took me to
the J. J. Aguirre Hospital. My womb was so infected that the doctors
couldn't touch me. One doctor wanted to treat me and the other didn't. One
said to the other, "If you send her back home she'll die on the
way." So they operated on me, scraping my womb clean, almost without
anesthesia as a kind of punishment. They scraped and scraped as if they
were cleaning the inside of a watermelon. Then they asked me who did this
to me and I could tell them nothing. One must not talk in these
situations, and I really wasn't lying because I didn't know where this
woman lived nor did I ever see her again. This woman had no license, but I
was desperate to find someone because my pregnancies never have brought me
happiness. My problems about having babies started very early, because I became pregnant very young, when I was 17 years old. Both my mother and father got mad, and the people on my block called me a whore. From then on I've always felt a lot of anxiety about having a baby, even today when I have a good husband and a good marriage. In those days I was worried about having to stop working, since I was studying dress design at night and working in a textile factory by day. After that terrible abortion I took care of myself as other women advised me, washing myself with soap and water or lemon and water, that kind of stupid trick so as not to have more children. Then I heard about an Israelite Clinic, where they treated people free, and they gave me an IUD spiral. A woman full of children doesn't have time even to look up. The most beautiful thing in the world is for a woman to have the number of children that she wants. According to us Catholics we should have the number of children that God sends us, but there are times when one cannot anymore although God keeps sending them. My husband is a hard worker who doesn't rest day or night. He sells bread from house to house and works from eight to 16 hours each day, and the doctors tell him that he'll end up very sick in the hospital if he doesn't get some rest. So what do I get from having seven or eight kids if I can't give them eggs, cheese, or milk for breakfast?
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