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OCTOBER 20, 2000 VOL. 26 NO. 41 | SEARCH ASIAWEEK
In Indonesia, birth control is no longer just about population control By ANASTASIA VRACHNOS Jakarta ALSO: • Political Storm: The attorney general is not done with Suharto "Vasectomies! Vasectomies!" screams a bright-red poster in the white, shiny waiting room of the Family Clinic. But the words miss their mark. The men at whom they are aimed are outside, waiting for their wives in the parking lot of this small community clinic in the Jakarta neighborhood of Tebet. Inside, married women with squirming babies and young children sit waiting for appointments. Nurses dispense medicine and advice, while the clientele trade tips on contraceptives. Discussions on IUDs (intrauterine devices), birth-control pills and condoms fill the room. Ibu Nurul, 25, the mother of a five-year-old boy, extols the virtues of the IUD. "You don't have to remember to do something every day and you don't get fat like with the pills," she tells the others. A generation ago, such talk would have been unimaginable in this predominantly Muslim society. But contraception in Indonesia, after years of being government policy, is slowly but surely becoming a matter of choice. Call it the fruit of the new democratic era. Indonesia's family-planning program — Keluarga Berencana, or KB as it is commonly called — has long been touted as a model of success. In 1994, then-president Suharto was awarded the United Nations' annual population award for his country's successful efforts in family planning. In the three decades of the program's existence, it has managed to lower Indonesia's birthrate from 5.6 to 2.8 children per couple and engage 55% of women to use contraceptives — numbers that stack up well even against developed nations. But the campaign has been marked by a strong authoritarian streak. Indonesians have started to move away from its influence. The driving force behind Indonesia's population-control measures is the National Family Planning Coordinating Board, whose zeal and well-endowed coffers helped make "IUD" a household word and put the slogan "Dua anak cukup" ("Two children is enough") on the tip of every Indonesian's tongue. But the success came at a price. Stories of forced sterilizations under the Suharto government — "safaris," as they were known, in which the army rounded up men and women for vasectomies and tubectomies — have not faded from many people's minds. There is also a lingering feeling that the limited measure of reproductive control granted to the masses was merely a benign by-product of the government's national-development initiatives. Even the word used to describe the participants in the family-planning program — akseptor, or "accepter" — smacks of the top-down, paternalistic approach taken by the Suharto regime. "In Suharto's time, you didn't have a choice," says Bernardus Budiman, family-planning manager at a non-profit organization that markets contraceptives. "You had to follow family planning. Not enough education was given, and the public didn't understand the pros and cons." Those days are gone, but now Indonesians are facing a new set of challenges. One of the first casualties of the country's economic crisis was social-service programs. The family-planning board lost its budget, and as the rupiah plummeted, so did Indonesia's contraceptive stock. "It was a crisis situation," says Nesim TUmkaya, head of the United Nations Population Fund in Indonesia. "They were running out of contraceptives and not buying any more." With their supplies depleted, health officials worried that poor families who could not afford contraception would drop out of the family-planning program. At the moment, Indonesia's population is set to double to over 400 million in 44 years. Any acceleration of this trend at a time when the country could barely feed its own people would have spelled disaster. Already, 30% of the 3.5 million babies born in the years since the crisis suffer from serious malnutrition. Fortunately, Indonesia was able to meet the $60 million needed annually for contraceptives through a major international donor effort spearheaded by the U.N. And with outside funds came new ideas. "Up to 1998, the Indonesian family-planning program was simply about family planning," says TUmkaya. "But now there is recognition that Indonesia needs to adapt to international standards and show more concern for reproductive choice as a basic human right." According to TUmkaya, this means focusing more on providing "integrated reproductive health services" — the latest jargon for a package of programs including safe motherhood, contraceptive usage and disease prevention. For their part, Indonesians seem to have signed on. There is now more emphasis on education and on understanding the pros and cons of various methods of birth control. Participants are no longer "accepters" but "clients." Contraceptives are becoming branded and competing against one another with names like Andalan ("Reliability") and Sutra ("Silk"). There are comic books on reproductive health, while free T-shirts, calendars and playing cards promote contraceptive use. Even midwives are being given rewards, such as cellular phones with free air time, for promoting certain brands of prophylactics. But like many of the new-found freedoms in post-Suharto Indonesia, this greater measure of reproductive choice is being enjoyed least by the people who need it most — the poor. Ibu Rasidah, 49, is a midwife who runs a local puskesmas, one of thousands of government-sponsored health clinics that have fallen on hard times because of the economic crisis. Rasidah and her staff of seven are responsible for ministering to the health needs of the roughly 22,000 residents in their neighborhood. Unlike clients at the privately run Family Clinic across town, Rasidah's patients cannot afford to pay for services. They take what they can get under a state-supported social safety-net program — and these days it isn't much. Rasidah describes how the "droppings" of supplies from the family-planning board have dwindled to one or two irregular shipments every six months or so. "We used to give out contraceptives for free and no one would come and take them," she says. "Now people come to us, but we don't have enough to give." The only thing she does have plenty of is condoms. Three big boxes gather dust in the back of her clinic. "I can't even give them away as water balloons," jokes Rasidah. Although they are one of the cheapest forms of contraception, condoms are unpopular with both men, who feel they lower sexual sensation, and women, who think they promote promiscuity among their men. One health worker tells of an uproar caused by members of a local officers' wives club when his organization provided condoms to their soldier-husbands in a disease-prevention effort. Another stumbling block to condom use is the widespread notion that responsibility for birth control lies solely with the woman. As Rasidah puts it, her patients believe that "the man's responsibility in contraception extends only to paying for what is necessary." This goes a long way in explaining the 2%-3% male participation in the family-planning program. Health officials acknowledge that this is an area that needs some work. But the weakest area is women's reproductive health — perhaps not surprising given that the family-planning program was designed to meet government targets rather than address the needs of women. Family-planning board head Khofifah Indar Parawansa has acknowledged the problem: "Ironically, the program lacks attention to the reproductive health of women, resulting in a towering maternal mortality rate and abortion cases." The abortion rate is especially alarming. Some 1 to 3 million abortions are believed to be performed every year, with one estimate putting the mortality rate as high as 35%. Why such high numbers in a country where abortion is illegal in most cases and frowned upon by society? Part of the answer lies with unmarried women, who do not have access to contraception because there is no place for them in the family-planning program. The hands of health officials are tied by a law that prohibits contraceptive services for unmarried people and by a strong taboo against acknowledging premarital sex.
Health organizations are now trying to address the issue by reaching out to young Indonesians — through youth centers, radio talk shows and websites. The campaign is sorely needed. Although many youths admit to being sexually active, their knowledge of contraception is often minimal. Health workers talk of teenagers who wanted to know whether kissing for a long time caused pregnancy and those who insisted that jumping up and down after sex flushed away sperm cells. Back in the Family Clinic in Tebet, the women in the waiting room are laughing and swapping tales, including one about a woman who, imitating a health demonstration, put a condom on her thumb. Ibu Ani, 29, a first-timer to birth control, listens attentively. The potential side effects of the IUD are news to her; she says she chose the IUD because her mother told her to. Whether it is Ani's mother-knows-best approach or the father-knows-best policy of the Suharto era, it is clear Indonesia still has some way to go in shedding its old mindset.
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