The Ethics of Supervising Family Planning in Developing Nations

Abstract

Western-style medicine based on specialists and hospitals is called inappropriate for developing countries and even inappropriate for the poor in the U.S. This physician-dominated health care is beginning to develop roles for auxiliary medical personnel in both curative and preventive care roles which might be applied in developing countries. Some have even called the Western system highly immoral because it focuses resources on the diseases which involve the elite and fails to attack the problems which affect the masses. The Chinese system with trained farmers functioning as barefoot doctors is cited as a possible model. It is false to assume that only physicians can dispense contraceptives. A report from Bangladesh shows that local women trained to work in the operating room were eventually able to perform a minilap procedure with performance comparable to physicians. Several studies have shown that trained persons can insert IUDs well and a program in Thailand using a checklist of contraindications has enabled nurse-midwives to prescribe oral contraceptives with no appreciable increase in complications. It is assumed that a physician can do a pelvic examination and as a result doctors often receive only cursory training in IUD insertion. By comparison paramedical personnel receive thorough training. This is why they often have rates better than doctors in some areas. Tables show that the mortality rate due to thromboembolic disease among pill users in developed countries is 1-3/100000 no greater than the postpartum incidence of thromboembolism and far greater than the maternal mortality rates in developing countries (250-1000/100000 live births). On a strictly risk/benefit ratio it is unethical to deny care for the majority of the population by insisting that contraception be dispensed only with medical supervision.