in Planning Spain Family

Gradual social and politicalchanges have led the Spanish and to government legalize the use ofcontraceptives to allow of amily planning clinics to be established; liberalization abortionlaw is now beingdebated. Spain's strict

ByJosg Linhard patriarchal of in 1948 to just over 14 by 1981,a 39 percent oftheinfluence thetraditional Spain has longoccupieda rather uniqueposi- reductionin 33 years.The crude deathrate family. planshavebeencarThreedevelopment tionin Europe, even amongthecountries of fell by 31 percentwithinthe same period, since government southern Europe with which it is often and the country'srate of naturalincrease ried out by the Spanish menof grouped. After end ofthe SpanishCivil slowed from the 12.1 per 1,000a yearin 1948to 1964. The first these(1964-1967) in policy only thecondemographic de- tioned became isolatedfrom the 6.5 per 1,000 by 1981. Infintmortality War, the country the aimedat decreasing from75 per 1,000 live textof programs rest of the Continent,remainingneutral clined dramatically rates. The second emigration throughout WorldWar II and subsequently births,a level now seen onlyin less devel- country's and includeda demographic to makinga relatively slow recovery from the oped countries, 15per 1,000,a ratesimilar (1968-1971) the policyaimedat improving geonations. family in economic setbacksof those years. In addi- to thatfound mostindustrialized at distribution the population, of Despite the eventual decline in fertility graphic tion,the strong influence social and culon growth atachievand rates urban of rate slowing turallifeexertedby Franco and the Roman shownin Table 1, withthe totalfertility growth population in Catholic Church insulated Spain fromthe (TFR) declining 20 percent-from av- ingan increase Spain's an by plan development (1972per rates.The third waves of economicand cultural moderniza- erage of 2.5 to fewerthantwo children to tion thatswept through northern west- woman-between 1950 and 1981, Spain's 1975)made no reference anyaspectof and other thantheprotecpolicy ern Europe in the 1950sand 1960s. populationhas continuedto growand will demographic of While therehas been considerable analy- continueto do so, longafter havingreached tion theenvironment. by official disapproval, of fertility levels in 1981. Despitecontinuing sis of the politicaland cultural effects the below-replacement of a Francoregime Spainand itspeople,there Afterthe end of the Spanish Civil War, in the mid-1970s, smallnumber Spanish on had begunto discuss crudedeathratebeganto doctors contraception has been littleand onlyquite recentatten- 1941,thecountry's in and tion paid to the impact of the pronatalist decline steadily a at from highof 15 per 1,000, openly professional meetings even, sercontraceptive populationpolicies adhered to in Spain up resultingin the highestpopulationgrowth some cases, to provide in form pill of prescriptions. mainly the untilhisdeathin 1975.In 1938,whenSpain's ratesthatthe country everknown.Out- vices, had which Society, the Fertility populationwas about 23.5 million,Franco migration became the safety valve that In 1975, Spanish of obstetricians and of declared, "The day will come when our helped to preventthe creation seriousso- is composed respected the to of planned include topic motherland has a populationof 40 million cial and economic problemsas a resultof gynecologists, rates. In the family itself amongthe subjectsdisplanning and willbe able to support withdignity these high populationgrowth held because ofitsgreatresources.1 In 1941,the immediatepost-Civil War period, Spanish cussedat a conference in theCanary at de Pro- emigrantsleft for Latin America. In the Islands. Otherphysicians thatmeeting Ley de Protecci6n la Natalidad (Birth planopposedto family was toward whowerestrongly movement tectionLaw) and the Leyes de Protecci6n 1960s, the migratory a and of las FamiliasNumerosas(Protection Large the economically boomingnations north- ningcalledthepolice,however, those of Families Law) were passed; thesemeasures em Europe, wheremany jobs wereavailable sessionswere banned. One yearlater,a a doctors signed letter groupof Barcelona banned the dissemination family of Spanishserviceworkers. planning forunskilled Prothe of information the distribution use of and and Current projectionssuggestthat by the petitioning repeal the1941Birth conwill tection Law, and in 1977,theannual all contraceptive Spain's population methods,and providedfi- end of thiscentury, successof Society The realdeclinein gress theSpanish Fertility nancial incentivesand special benefits for indeed reach40 million.2 its included as among mafamily planning largefamilies. Even though Birth the Protec- birthrates ofquite recentorigin, Table 1 fully is The massmedia tion Law remainedin effect the next35 also shows. The TFR hoveredbetween2.5 jor conference gave for topics. event great ofcoverage, a deal highlightyears,the pronatalist policiesofthe govern- and 3.0 childrenper woman between 1950 this in of planning menthad verylittlelong-term effect the and 1964 and did not begin a sustainedde- inga statement favor family on mostrecountry's populationgrowth rate,as Table 1 cline until 1972. It is generally agreed that issued by one of the country's who a physician had gynecologists, in decline nowned (page 10)shows.The crudebirthrate Spain the majorfactors to contributing that for influ- been actively opposedto contraception declinedfrom about23 per 1,000population in fertility have been the diminishing the In 30 mod- theprevious years. 1978, Spanish ence ofreligion; economicand cultural a Society organized conferimpactofthe wom- Gynecological ernization;the growing of Jose Linhard is a Professor PoliticalScience at the of to exclusively the subject to as en's movement womenstarted join the ence devoted of Professor Polit of University Barcelonaand an Assistant control. and a lessening birth in laborforce largenumbers; of ical Science at the University Berlin. Background
Volume Number March 9, 1, 1983
9

in Planning Spain Family to wereassumed be febecauseof legal had been sterilized services) de- of contraceptive In the springof 1978, parliamentary about countries, the cund. (In mostdeveloped Despitethesedrawbacks, bates over the repeal of the 1941 law were restrictions. to are of most com- 10percent allwomen believed suffer the of remains single initiated.They heraldedthe start a rapid 1977survey perEighty-five infertility.5) primary and of study fertility contracep-from successionof bills passed by the parliament prehensive thattheyeither cent of womenreported available. The first,the National Family tion that year. had receivedno formal of was Thesurvey basedona sample 5,814 were illiterate, PlanningAct, passed in September,authoonly or the between agesof15 schooling had completed a primary women ever-married rized the opening of 74 government-sponin lived locapercent Forty-eight education. were interviewed. not women the and49. Single clinicsthroughout planning sored family and residents, than50,000 fewer with of was legalatthetime the tions auspices ofthe Preven- Sincedivorce not country.Under the in areas.Sevenlived urban of small proportionever- only16percent a only very of tiveHealth Department theHealthMinis- survey, who of percent thewomen particiwere not ty-seven women(threepercent) con- married these clinicswere intendedto offer try, pracwere they said or is, married-that widowed sepa- patedinthesurvey that In currently setting." traceptiveservicesin a "family said 17 another percent that Catholics; were ticing Six husbands. percent their from Code was amendedto rated Criminal October,the and Catholics the that reported they theywerenonpracticing percent and and use of pregnant two authorize the sale, distribution as themselves nonbelievdefined them remainder that contraceptivesupplies; and a decree that had had an operation prevented relito or percent) belonged another did ers(five The childbearing. survey further expanded from month wentintolaw thefollowing (onepercent). or on forthe not includeanyquestions infertility gion those rightsby issuing regulations in women thesample who The ever-married those except and and advertising sale subfertility, allwomen licensing,manufacture, steriliHowever,surgical of contraceptives. purposesis still ilzation forcontraceptive Increase (CBR),crudedeathrate(CDR), rateof natural crude birthrate Depart- Table 1. Population, the legal in Spain, although Justice rate fertility (TFR),Spain,1948-1981 rate mortality (IMR)and total a prosecuted woman (RNI),Infant menthas neveractually TFR IMR RNI CDR CBR or Population sterilization a Year a for obtaining contraceptive (inOOOs) such a procedure. doctor for performing u 70.0 believe thatthe govemment 1948 12.1 Commentators 11.0 23.2 27,593 ol u fearsthe possible politicalrepercussions 1949 74.6 10.0 11.5 21.5 27,811 has 2.48 such a test case. Abortion also been il- 1950 9.2 69.8 10.9 20.1 28,009 years,and therehave 1951 many legal in Spain for 2.47 68.2 8.5 11.5 20.0 28,236 ol prosecutions 1952 been severalwell-publicized 2.56 60.8 11.0 9.7 20.7 28,474 illegalabor- 1953 doctorsaccused of performing 2.55 58.9 10.8 9.7 20.4 28,713 is tions.The presentgovernment engagedin 1954 2.50 55.2 10.8 9.1 19.9 28,955 anti- 1955 strict the measuresto reform country's 2.58 58.9 11.1 9.4 20.4 29,199 law. abortion 2.61 52.3 10.7 9.8 20.6 29,445 1956 Survey The 1977 Fertility
1957 1958 In a seriesofpublicopinionpollsin the1960s 1959 and 1970s, women were asked theirideal 1960 size and theirattitudetowardfamily 1961 family planning.3These surveysfound that ideal 1962 constant frorm1963 size family remainedrelatively between2.8 and3.5 1964to 1978,fluctuating 1964 of A children family. 1965survey Spanisi per 1965 men showed that only 18 percentfavored 1966 familyplanning,whereas a surveycarriec 1967 ofwom 42-52 percent that out in 1972found 1968 en thought that contraceptive service! 1969 should be made available. The mostrecen 1970 and re patterns surveyto examinefertility behavior ir 1971 productive and contraceptive Survey,car 1972 is the National Fertility Spain ried out in 1977 by the National Statistic 1973 of of Institute the Ministry the Economya 1974 Survey(WFS).' 1975 part of the World Fertility ii The Institutehad considerabledifficulty 1976 because ofrestriction 1977 the completing survey dis 1978 at stillin effect thattimeon gathering, abou 1979 information and seminating publishing use or knowledge.(Therewa 1980 contraceptive also oppositionto the studyon the ground 1981 29,693 29,943 30,195 30,455 30,743 31,066 31,393 31,723 32,056 32,393 32,734 33,079 33,427 33,779 34,134 34,494 34,858 35,225 35,596 35,971 36,351 36,775 37,105 37,380 37,616 21.7 21.7 21.6 21.7 21.2 21.1 21.3 21.9 21.0 20.6 20.7 20.1 19.9 19.4 19.5 19.3 19.1 19.4 18.8 18.4 18.2 17.2 16.1 15.2 14.1 9.9 8.7 8.9 8.8 8.5 8.9 9.0 8.6 8.5 8.5 8.5 8.5 9.0 8.3 8.9 8.1 8.5 8.4 8.4 8.1 7.8 7.9 7.8 7.7 7.6 11.8 13.0 12.7 12.9 12.7 12.2 12.3 13.3 12.5 12.1 12.2 11.6 10.8 11.1 10.6 11.2 10.6 11.0 10.4 10.3 10.4 9.3 8.2 7.4 6.5 53.0 48.1 48.3 43.7 46.2 41.6 40.6 39.2 37.8 36.0 34.0 32.4 29.7 26.5 24.3 21.5 20.1 18.5 18.7 16.4 15.6 15.1 u u u 2.77 2.80 2.79 2.77 2.77 2.81 2.89 3.04 2.92 2.93 2.97 2.91 2.90 2.85 2.88 2.86 2.84 2.89 2.80 2.79 2.66 2.55 2.33 2.16 1.99

oftherespondent thatitinvadedtheprivacy and, by extension,of the Spanish filmily. questions could not h Certain important asked (forexample,questionsabout source
10

Note: u=unavailable. de Nacional Estadistica, Espatla New 1979; Instituto Yearbook, York, Demographic Nations, Sources: United inWestem "Recent Course Fertility of and 1982, 39-58;andC. Calot C. Blayo, pp. Madrid, 1982, Anuaria Estadlstica 36:349,1982. Studis, Population Europe," Perspectives FamilyPlanning International

marTable 2. Percentage fecund, of currently those pregnant) riedwomen(Including who say they wantno morechildren; percentand married womenwho say age of all currently mostrecent theydid notwanttheir pregnanof live cy; bynumber prior births; Spain,1977
No. ofprior livebirths % who want no more (N=5,504) Total 0 1 2 3 4 61.1 3.7 28.5 65.1 77.8 83.0 78.9 % whose most recentpregnancy was unwanted (N=5,641) 27.7 1.5 10.7 24.3 38.9 46.6 53.9

25

Source: See reference Tables 3.2 and 3.4. 4,

reportedan average of 2.5 live births each; thoseovertheage of30 had had an averageof fourchildren.Fertility varied considerably byeducation,withwomenwhodid notknow how to read or writereporting livebirths 3.7 on average, and those who had receiveda university education,only 1.7. In termsof the husband's occupation,fertility ranged from live births 2.2 amongthewivesofclerical employeesto 3.1 amongwomenmarried to agricultural workers.Urbanor ruralresidence and religiosity appeared to have very little effecton fertility. The surveyfound relativelylow levels of infantmortality in Spain, withfour percentofchildren in dying the first yearoflife. Currently married women were asked how manychildren they wanted.The overall average response was 2.8 children,an anto swer similar thatgivenin 1964. The only groupsofwomenwho said thattheywanted morechildren thantheaverage considerably were those who could not read or write, women aged 45-49 and the wivesofagriculturalworkers. The onlypopulation subgroup thatexpresseda desirefor fewer significantly children were womenaged 15-24. As Table 2 shows, 61 percentof fecund, married womensaid thattheydid currently notwantanymorechildren, and 28 percent ofall currently married womensaidthat their mostrecentpregnancy been unwanted. had Both thesepercentages withthe riserapidly number of live births.When women who were pregnant thetimeofthesurvey at were excluded, seven out of 10 fecund,married women said thattheydid not wish to continue childbearing. These women were
*The pill,IUD, diaphragm, condomorspermicides.

askedwhy did they notwant more children. womMorethan percent 50 mentioned economic Table 3. Percentagesof ever-married en* currently using a contraceptive method reasons, percent 25 thought weretoo they and using an efficientt method, seleted by old,20 percent cited health 17 reasons, percharacteristics background (N=5,814) centclaimedthatthey werealready overAny Efficient burdened domestic with and chores, 10per- Characteristic method method centsaid thatthey wanted work to outside 46.1 17.4 thehome.Economic reasons weretheprin- Total for of cipaljustification 35 percent thewom- Ag-group en. (Respondents could checkmorethan 15-24 50.4 26.7 53.9 27.8 one reason.) of Only15percent women who 25-29 56.0 21.2 said theydid notwantanymorechildren 30-34 35-39 51.6 15.6 that in thought somechange their circum- 40-44 41.5 12.0 stances an inthe (mostly improvement family45-49 25.9 4.7 wouldmakethem income) reconsider their Parity decision.Currently married womenwith 0 11.5 7.6 twoormore who children saidthey want 1 did 42.8 18.8 more were asked also their reasons. most 2 The 51.4 18.8 49.7 16.2 common was that loved 3 response simply they 4 50.8 18.0 children. surprisingly proportion A high said 25 40.9 16.8 it was becausethey wanted daughter a (37 withthosewhosaidit Education percent), compared 40.1 10.2 wasbecausethey wanted son(18percent). None a Primary 46.5 17.0 Whenquestioned abouttheir knowledgeSome secondary 52.3 26.9 of contraceptive methods, onlysevenper- Complete secondary 57.7 33.5 centsaidthat 58.5 39.4 knew noway control >Secondary of they to their fertility. Almost two-thirds of those who Residence did notknow were40 or older.Ninety-one <10,000 residents 35.9 8.0 42.8 15.0 of percent allthewomen knew at surveyed of 10,000-50,000 51.0 19.6 least one efficient* contraceptive method. >50,000 Metropolitan areas 55.9 30.9 The most known widely method thepill was to (familiar 89 percent), followed thecon- Religion by 49.8 26.9 dom(68percent). 30 Only percent women Nonbeliever of Catholic Practicing 43.4 13.8 knewabouttheIUD, and 19 percent were Nonpracticing withthe diaphragm. women Catholic familiar The 57.5 30.9 werenotquestioned towhether had Other as they 45.1 19.2 heard contraceptive of sterilization. *Ever-married includes those currently pregnant(5.6 Table3 shows 46 percent allever- percent), those widowed, divorced or separated (3.0 that of reamarried women werepracticing contracep-percent) and those sterilizedfornoncontraceptive of sons (2.1 percent). As a result,only 89.3 percent these women can be considered exposed to the risk of tion thetime their at of interview is,52 (that pregnancy. percent ofwomen exposed the of to risk pregsterilization. tincludingcontraceptive nancyt). However, 17percent only were us- Source: See reference4, Tables 4.14 and 4.16. ingan efficient method. Women aged30-34 had thehighest rates; use those aged15-29 were mostlikely use efficient to methods. overall anduseof efficient use an rise method of Only one-quarterwomen 45-49 were withyearsof education. aged Thus,universityusingany method, and mostof thesede- educated women nearly percent 50 are more pended withdrawal shown). on (not than with to likely women noeducation pracTable3 alsoshows there very that is little ticecontraception arealmost times and four use to the method. contraceptive in Spainbefore first more likely useanefficient (Twobirth. Only12 percent couples of with no thirds all users emwith education of t higher children were usingcontraceptives. How- ploy efficient an method.) the of ever,after birth thefirst use child, Contraceptive practiceis more widerisesrapidly: About half all women of with spread(and moreefficient) women among 24 children they said in some of than rural areas.Ascan practiced kind wholiveinurban fertility control, depending lesseffi- be estimated most on from than two Table3, fewer cientmethods. The tablealso shows and from that outof10users villages small ? towns,
within a certain in no born has marriageswhich child been bethe evidence, Church of number years-probable was consummated. that lieves, themarriage not douche abstinence. and withdrawal, 5Rhythm,
11

tradition religion playa rolein the and all $Custom, unwillingness Spanish of couples postpone first to the tIn the WFS, exposed women are definedas currently birth. After weddings, families the most the of bride and married womenwho are fertile (including contracep- thegroom the await announcement the an eagerly that bride tively sterilized) nonpregnant. and is pregnant. somecases,the Church annulled In has Volume 9, Number1, March 1983

in Planning Spain Family

Table 4. Percentagedistribution currently cal and medical of womattitudes than rather to re- rable 5. Percentageofall ever-married married,nonpregnant women, by current encurrently practicing reversible contracepthat It ligious inhibitions.is notable theonly contraceptive practice tion, method, by according ageroup to
Current practice % distribution (N=5,315)

to well levels pillusemay be related politiof

method endorsed specifically contraceptive Age-group absti- Method by the CatholicChurch-periodic method-wasemnence, or the rhythm Total <30 30-39 -40 Uses a method (N= (N= (N= 50.3 ployed only percent allusers. six of by (N= Pill 11.7 5,814) 1,725) 1,957) 2,132) rewidely usedmethod, By farthemost IUD 0.5 users, was Total of lied on by46 percent current 45.7 52.1 53.3 33.6 0.1 Diaphragm 3.2 10.7 19.7 10.9 as- Pill withdrawal. Despite the widespread Condom 4.9 Condom 4.5 5.3 5.2 3.2 extensively menrely sumption Spanish that Sterilization 0.3 17.9 25.4 19.6 0.6 Spermicides of onthecondom, five only percent nonpreg-Withdrawal 20.9 5.7 4.1 Rhythm 7.8 5.1 Rhythm 6.3 used Other that husbands nant wives claimed their 5.2 4.1 2.5 3.9 Withdrawal 23.0 in this method. Condoms still are associated Abstinence 1.5 Source: See reference Tables 4.1 and 4.7. 4, VD Spanish menwith of Otherand unkrfown 1.5 the minds many to protection visits prostitutes. and Uses no method 47.4 limit- wanted more to Table4 alsopoints theextremely no children, were using but not Noncontraceptively was an efficient ed use oftheIUD in 1977.The device 24 contraceptive method; persterilized 2.3 time, hadtobe imported.cent and illegal that at wereusing method all. no at doctors is very fees Thishighlevelofunmet charged high needfor family Total 100.0 What more, to it, (about $100,on average) insert puttingplanning services especially is striking is ifit Source: See reference Table 4.8. 4, of itwellbeyond reach poor the people. with of needobcompared estimates unmet of with levels tainedfrom The twomethods thelowest of Spanish-speaking countries and withaboutfour of 10 urban use werethediaphragm contraceptive developing out the world. Colombia, exIn for compared Again,because of legislationample, comparable was30 percent the level users,employ efficient methods. influ- sterilization. The itis that sterilization, probable some in1976, inCosta in enceofreligious is interesting, banning and Ricaitwas12percent affiliation eswho had in for pecially a country where 90percent ofthewomen saidthey beensteril- the same year.7The explanation the over ol of reasons percent all Spanish (2.1 thepopulation Catholic. is is in in to There to findingthat Spain, contrast appears ized formedical elected thesituation certain had actually women) be little in in difference contraceptive be- ever-married Latin American counuse as for tween nonbelievers, both desired the family andthe size use practicing Catholics surgery thesereasons a wayofgettingtries, for the on around prohibition tuballigation ofefficient and women another of faith. methods Nonpracticing contraceptive (especially is purposes. Vasectomyvirtu- sterilization) low.Itisthis are unique combiCatholics themostlikely use a con- contraceptive are to in it clear nation factors helpsaccount the althoughisnot ally of and that for traceptive method, among nonpractic- unknown Spain, is to levelsofunmet needfor ingCatholics use a method, who contraception more than how muchthisfact attributable igno- high of of to half on themore rely in efficient methods. The rance themethod, theabsence vasec- found Spainin thesurvey year.Dataare services tomachismo. and notavailable further tabledoesnotshow 35 percent Cath- tomy that of to these levels analyze and bythewomen's choice The effects age on method of olicswhoregulate their social demographic and use charfertility thepill, in are thecondom, diaphragm spermicidesoverall it prevalence analyzed Table5. acteristics.they the If or were, ishighly that likely on the reliance theprofile women andanother percent onwithdrawal- The tableshows widespread 49 in of most needof services rely withdrawal women by aged 30-39and the wouldconform that allmethods approved theChurch. not to described sociolby by women under ogists of Table 4 summarizes of Nicohis de Miguel,8 saythat and who patterns curreni popularity thepillamong 30 of under were such womenweretypically use contraceptive among "middle-aged, currently married, 30. One in five all women the a indica- uneducated strildng nonpregnant Spanishwomenby method. using pillin1977, rather from Catholics underpracticing to commitmentfertility strong Thetable confirms more even the of specifically tionoftheir who developed parts thecountry didnot was work the that practice lowlevelsofefficient given fact such contraceptive pre- control, use outside home." the note that also They time. illegal in officially atthat the"situation Spainin 1977 in vailing 1977.Only of one-quarterallusers still very strongly on in relied thepill,theIUD orcontraceptive Table6 summarizes that a number estimatesresembled oftheUnited of States 1960, sterilization. 1976, U.S. National the of women Sur- ofthe relationship between fertility aspira- when only50 percent married (In in Growth a It 13 practice Spain. wereusing birth veyofFamily showed that per- tionsand contraceptive 70 control method. took centofAmerican in women contra- The tableshowsthatsevenout of 10 cur- years theUnited States contraceptive for practicing used one ofthesethree to In whowerenotpreg- prevalence reach70 percent. Spain, women methods.6;rently married ception levelcouldbe attained the with when said interviewed that didnot that they [within same Despitethewidespread familiarity the nant if of were The pill revealedby the surveyfindings want more children. table shows number years] thegovernment to also or any of of establish service inforand knowledge contraceptive family planning methods, only that one-half all fecund,nonpregnant 12percent mation were this centers." using method. sur. womenwere not usingany contraceptive (The out (panel2), and thatfour of 10 thatone-third al method of vey shows,however, Situation women of and The Current ever-married 15-24 usedthe to had exposed therisk pregnancy pill women of it atsometime.) wereunpro- In thecontext thatassessment, is imany children Given uncertain sta. notwanting more the legal to whatstepshave been tusoforalcontraceptives1977,* lom tected in further (panel 3). portant examine the pregnancies against the of the is measure that takentoward achievement universal Probably moststriking
contraceptive servicesin Spain. In 1979, 19 ir Anovial first was introduced shown in panel 5, which indicatesthat44 *When pillformula the women familyplanningcenters were opened, the married Spanish the percentofcurrently it to as 1964, wasregistereda drug be usedto"relax" and firstof the 74 authorizedunder the 1978 were exposed to the riskof pregnancy purposes. ovaries, not contraceptive but for
FamilyPlanning Perspectives International

12

National Family Planning Act. Several of include women whoaresterile, sexually not Table 6. Selectedmeasuresofunmet needfor thesecenters werequickly or forced closefor active,pregnant seeking to pregnancy. contraception lackoffunds.Government clinics nowbe can Estimatesoftheprevalence illegalaborof foundin Spain's 19 largestcities,*and pri- tion are hard to obtain. Whereas some ob- Measure % vate centershave been opened in Barcelona servers have claimed that as many as (1) Ofcurrently married, nonpregnant (N=5,315) and Valencia.In addition, regions Cat- 300,000-500,000 illegal abortionsare pro- women, whowant more the of % no children 71.4 alonia, the Basque country Madridhave cured everyyearin Spain,12 rangeproband this (2) Ofcurrently married, fecund, (N=5,176) each organizedseparate networks family ablyoverestimates actualnumber. of the There nonpregnant women, not % using planningclinics. Many of the largegovern- is no evidence, forexample,thatthe num- Any method 49.7 method 82.5 menthospitals also provideoutpatient family bers of maternaldeaths thatcould be anti- Anefficient planningservices (approximately hospi- cipated if these projectionswere accurate (3) Ofwomen 36 exposedtotherisk (N=3,157) tals were doing so by November1982),and are, in fact,occurring. 1978, therewere ofpregnancy want more In who no % using some 27 private hospitals providecontracep- 7,927 deaths reportedamongwomen aged children, not method Any 42.9 tiveserviceson a fee-paying basis.9In Barce- 15-49.13It is highly improbable that1,500Anefficient method 78.6 lona, thereare at least 11 publicand private 3,000 of these were due to illegalabortions, % (4) Ofallexposedwomen, who want (N=5,194) family planningclinics and 12 family plan- the range thatwould be likelyifthe lower children arenot and using ninginformation centers.10 abortionestimatewere correct, since inter- nomore method Any 26.1 It is probably for discouraging many wom- nationalabortionstatistics generally showa Anefficient method 47.8 en that because of the huge backlogof pa- mortality rate of about 0.5-1.0 percent.On married women, (N=5,642) tients, waiting the timesin many theexist- theotherhand,reports of from otherEuropean (5) Ofallcurrently % whoareexposedandwant no ing familyplanning clinics are extremely countries show that about 40,000 Spanish more children arenot and using long, creating possible deterrent wider womenobtainabortions a to outsidethecountry Any method 23.9 clinicuse. However,as moreand moreclin- everyyear,half thesein England.'4 Anefficient method of 43.9 ics open, this problemshould gradually be Concerted efforts amend the abortion to Source:See reference Tables3.40,4.7and5.5. 4, resolved. Many of the private-sector family law are currently being made by Spain'ssoplanning centers opening in the largest cialistgovernment,15 whichis relying its on townsand cities are sponsoredby women's parliamentary to majority change the exist- partofthecountry's national health program. groups,political partiesand towncouncils or ing law. The existing provides law longpris- (It is notablethatunderthatsystem, benefineighborhood groups.The pricescharged for on termsforboth women who obtain and ciariesare requiredto pay 40 percentofthe servicesin theseclinicsvary, thegeneral individuals but who provideabortions. The pro- costofall drugprescriptions.) withan addi- posed law would requiretheapproval two rangeis about $1O-15per visit, of It seems clear fromthis analysisthataltionalfivedollarsfor Pap smears.IUD inser- specialists for legal abortionsin the cases thoughenormouspoliticalchangeshave octionscostfrom to $30. EverylargeSpan- of rape, a malformed $25 fetusor risk to the curred in Spain since the death of Franco, ish newspaper carries classifiedadvertise- mother's or healthifthepregnancy life were and althoughbasic attitudestowardfamily ments for the privatelyrun or subsidized continued.The new law has been passed in planninghave alteredradically, is stilltoo it clinics. These centersalso quite frequently the lower house of the Spanish parliament earlyforthese developments have transto offer otherservices,including generalgyne- but there is serious oppositionfromthe lated themselves intomarked changesin the cologiccheckupsand sex counseling. organizedmedical profession, and the gov- reproductive and contraceptive behaviorof Since 1977,therehasbeen noother survey ernmenthas not yet made public how the Spanish couples. Contraceptive servicesare to determinewhethercontraceptive preva- law will be implemented it is finally if rati- still scarce, especiallyoutside of townsand lence has improved with the increased fied. cities(wherethe majority Spaniards of live). of availability services. However, estimates The popularmagazineConsultaSemanalrebased upon unpublished data and theresults Discussion and Conclusions centlyrana majorarticlediscussing famthe and ily planningsituationin Spain, in whichit ofa number marketing of studiessuggest that Spain facesa greatmanysocial,political about 58 percentofSpain's 7.2 million mar- economic problems. These include the claimedthatfour million womenin thecounried womenofreproductive are nowus- threatof ever-rising and unemployment in- tryare stilldenied contraceptive age services or 11 16 the information. The article method. Relianceupon flation,a widespreadfearof terrorism, inga contraceptive wenton to saythat withdrawal is probably still very pro- politicalinsecurity a fledgling of democracy Spain lags behind the restofEurope in this after rule, respect,and thatbecause ofgovernment nounced;an estimated17 percent couples emerging of many yearsofdictatorial neuse this method. However, IMS statisticst problemsover Spain's entry intoNATO and glect,mostwomenare stillobligedto resort point to an increase in pill use; about 15 the Common Market,the problemsof re- to the privatesectorto obtainservices.The for article concludes that "Spain has been exby percentofwomenare now usingthismeth- gionalism(as exemplified thestruggle od. The remainder usersare madeup of12 the independenceofthe Basque provinces), tremely of slowin solving very problem, a old a womenwho relyon the and a seriousproblemofhealthcaredelivery problem which was settled by the rest of percentof married five rhythm whodependon and financing.Consequently,the Spanish Europe morethan30 yearsago." method, percent has condoms,threepercentwhowearIUDs and government been unabletodevotemuch five percent who employ spermicidesand attention family to planning, which,though *Alicante,Badajoz, Barcelona,Estella, Granada,Guadaothermethods.Tubal ligations, officially important, does notrankhighamongitspri- lajara, Logrofio, still Madrid,Malaga, Murcia,Palmade Mabanned in Spain,are probably reliedon byat orities.As a result,the private-sector provi- llorca,Pamplona,Salamanca,Santander, Talavera, Teneand services has become rife,Valencia,Vallad,olid Zaragoza. most two percentof marriedwomen. Esti- sion of contraceptive necessary. Given Spain's curmates of nonuse that can be derivedfrom increasingly Service(IMS) is a private tThe IntemationalMarketing problems,it is highly these data (involvingsome three million rentfinancial unlikely marketing organization thatmonitors drugsales and prewomen) may be exaggeratedbecause they that family planningserviceswill be made scriptions.
Volume9, Number1, March1983 13

FamilyPlanning Spain in
CongresoNacionalde Planimadeto Someserious attempts being are In addition, someelements Spain's of po- Familiaren Espafia,"Primer Familiar,Gij6n,Nov. 1982. remedythis situation. Duringthe 1980 litical right wing havebegun express to anxi- ficaci6n Congress held ety overthe country's WorldFertility Sterility and declining birthrate.10. Ajuntament Barcelona,Guia de Centresd;lnforde i discussed the Recentarticles in Madrid, specialsession a in appearing Catholic and macioPlanificacioTerapiaSexual,Areade Joventut, associ- right-wing formation Spanish of a family planning journals have attempted ex- 1982. to in the that work conjunction the plain country's with slowed population growth 11. Estimates made by the authoron the basis of unation could Servicedata. Marketing Federa- in terms theeconomic Intemnational PlannedParenthood of pressures fami- publishedInternational on en tion. The main purpose suchan organiza-lies, the declinein religious of practice, and 12. S. del Campo, "La PoliticaDemografica Espafia," del Supremo, EDICUSA, on tionwouldbe to exert pressure thegov- increased foreign influence.17 none Memorial Fiscaldel Tribunal While of Madrid, 1974; and "Se Ha Elegido el Sistemadel Aborto of ernment advance provision univer- thearticles directly to the has attacked family plan- Libre Durante los Primeros NoventaDfas,"El Pais, May In or commen- 16, 1980,p. 12. services. ning theuse ofcontraceptives, sallyavailable family planning in of type undoubtedly has of contributed fact, early1981,the Ministry Labor, tary this de 13. Ministerio Economfay Comercio,AnuarioEstaan of Healthand SocialServices expressed in- tothelack political support family for plan- disticode Espafia 1981,Instituto Nacionalde Estadfstica, However, in existing ningservices. Spanish demogra-Madrid, 1982,p. 55. terest reorganizing country's the was phersand socialscientists awarethat 14. C. Tietze, network clinics. panelofexperts of A are Abortion:World A Induced Review, 1981, and assembled discussthe situation to Spain's to birthrate began fall a time to at when fourth The PopulationCouncil,New York,1981. ed., the pronatalist makerecommendations. However, out- strongly policieswere in full 15. "Spanish Bishops Fight AbortionLaw Changes," in lethal form sway,well before of break May1981ofa highly contraceptive programsNew YorkTimes,Feb. 8, 1983. available. is generally It agreed 16. "Consulta Medica: Contracepci6n,Espafna, and hadbecome pneumonia,* which caused381 deaths Furg6n regulation technique most de Cola," ConsultaSemanal,May2, 1980,pp. 12-13. over19,000 forced thatthefertility casesofserious sickness, for low has from theministry divert attention this responsible continued fertility 17. Confederaci6n to its Espanola de Cajas de Ahorro,"Esin im- beenthewidespread initiative order focus themore to on practice coitus of inter- tructura Social de Espana, Elaboradoporla Direcci6nde amongSpanish couples.The exact Estudios Sociales," ComentarioSociol6gico,Vol. 1, Nos. mediate problems caused theepidemic. ruptus by 33-34, Jan.-June, 1981. is, unknown. Even though initiative was roleofabortion ofcourse, thatnational of temporarily halted, Ministry Culture In conclusion, the form whatever thecontraResumen interest offer-ceptive in hasrecently shown renewed in revolution assumes Spain throughen Espana de planning. Al- out the nextdecade,it can confidently Hastala muerte Franco, 1975, ingtraining courses family in be pronatalista laws level has stated though progress the national at that repressive the pronatalist of era un paisfundamentalmente de faIn bodieshave the1940s 1950s a thing the of past. en el que las actividades planificaci6n been slow,local government are and Sin oficialmente. miliar estabanproscritas more in beensomewhat successful establish-stepwith rest itsEuropean the of neighbors, y pese a esas actitudes politicas of ingclinic programs. Examples suchlocal Spain is gradually a developing socialand embargo, de la organized political efforts be seenintheprogram can that oficiales, tasade crecimiento la poblaclimate favorable theconcept to del a a Ma- all couples Madrid should abletodetermine how cioncomenzo desacelerarsemediados by themunicipal government. be de drid'shealth department plansto set up a manychildren theywillhave,and should decenio 1960.La tasaglobaldefecundi1948 de por clinics resi- haveavailable them means achieve dad descendio 2,5hijos mujeren for number family of planning the to to de dents thecity itsenvirons. of and Likewise, their to Whatremains be seenis a menos dospara1981. intention. leyes las quese por thehealth of the departmentBarcelona, cap- howrapidtheprogress be toward will mak- En 1978se aprobaron a las relativas la of italofCatalonia, wellinadvance therest ingthat is so the levels revocaban prohibiciones goala reality, that high de y ofthecountry providing services ofunmet in clinic to servicesventa,distribucionempleo productos need for family planning de clinicas yse whowish plantheir to families. couples in can identifiedthe1977 survey bereduced. anticonceptivos establecieron patrocinadas el por familiar planificacion of Even the formation a private family De la modos, disponibilidad gobierno. todos is prob- References planning organization notwithout es ya anticonceptivosdesigual with life lems.Spanish public isrife factional- Palabrasdel Caudilo: 19 abril,1937-13 1. diciembre,de servicios sobretodoen las ciudades que se concentra is arena noex- 1938, Editorial Barcelona, Fe, 1939. ism,andthefamily planning del y will be There undoubtedly a consid- 2. Instituto ception. Nacional Estadistica, de Boletin Esta- grandes en regiones paisen las que se de especialespor han desplegadoesfuerzos and erable amountof infighting rivalry&istica INE, Sept.-Oct. del 1980. anLa abrirclinicas. esterilizac6on confines commu- 3. J. Diez Nicolas J.M. de Miguel, the among various political parties, and Control la de es ticonceptivos ilegal,pero el nuevogoinan Natalidad Espafa,Fontanella, and nity groups feminist organizations, en Barcelona, 1981. de bierno estd socialista tratando enmender of an 4. Instituto the to attempt dominate ideology such de Nacional Estadistica, de Ministerio Ecose a In the of organizationproviders. fact, overtlynomia, Encuesta Fecundidad 1977): Meto- la leysobreel aborto finde que e'ste de (Dicitebre pueda Uevara cabo en casos en que hay 1978. y Madrid, cast openedin the dologia Resultados, political ofsomeclinics del en de to haveserved scare 1970smay away poten- 5. K. S. Moghissi T. N. Evans,"Infertlity,"D. riesgo malformac6onfeto, que ha in and o la violacion, cuando vidao la salud some tial clients-somuch that ed., and Harper neighbor-Danforth, Obstetrics Gynecology, and habido so, Md., p. estd de la madre enpeligro. to are nowopening at pains es- Row,Hagerstown, 1977, 812. hoodclinics En una encuesta realizada 1977como en are the that tablish fact they notassociated 6. K. Ford,"Contraceptive in theUnited Use States, Mundial Fecundide 1978. partede la Encuesta 1973-1976," Family Planning Perspectives, 10:264, or with political ideological group. any de dad, se encontro el 61 porciento las que 7. J.W. Brackett, "Family Planning Availability inFour espafnolas casadasen la actualidad *Theepidemic found be caused theconsump- Latin was to by American Use Countries-Knowledge, andUnmet mujeres tion an industrial made of from seed,which was Need,"International oil, rape Family Planning Perspectives no queriatener and mds solo hijos.Sinembargo, distributed soldatlowcost cooking Digest, and for being widely 4:116,1978. el 57 por ciento las mujeres expuestas al de olive purposes,as a substitute thefarmoreexpensive for 8. J.Diez Nicolas J.M. de Miguel, and 1981, cit.(see riesgo embarazo que no querian op. y tener del oil thatis a stapleofSpanishcooking. The disease mainly reference 3). mds un antiestaba practicando matodo hijos slumareas, attacked people living thecountry's in poorest thoseleastable to aff;ord regular cooking oils. 9. F. G. Lam,"Organizaci6n estaba conceptivo, solo el 21 por ciento y Futura la Planificaci6n de

14

Perspectives FamilyPlanning International

plus pratiun de ou' de eficaz.El uso de la nataliste lesactivite's planificationla qui ne voulaient avoird'enfants utilizando metodo et baja pildoraera todaviarelativamente en famulleetaient officiellement contraceptive, 21 interdites.quaientune methode une malgre attitudes politiques pour centutilisaient methode ces efficace. de et 1977(el 11 porciento todaslas mujeres), Toutefois, relativede e'tait encore dele en tanto el doblede esa proporcion officielles, tauxde croissance que d'mogra- L'utilisation la pilule en peu pour des cent El au del (el t des ment repandue 1977(11 pendia retiro 21porciento). empleo phiquea commenceralentir milieu tandis qu'uneproportion presque anticon-annees1960.La somme naissances confines delDIU yla esterilizaci6n des re- femmes), sur foispluselevee comptait la retrait en desconocidos duites tombee 2,5 enfants femme deux est eran de ceptivos prdcticamente par inL'utilisation dispositifs de se en 1948tmoinsde2en1981. Espafia cuando hizola encuesta. (21 pourcent). et de des e'taient praLa cotnprobacs6n principal la encuesta En 1978, loisont Mte promulguees por- tra-ute'rins la ste'rilisation inconnues Espagne lrepoque en t de fueque lafrecuencia usode anticoncepti- abrogation l'interdictionla vente, tiquement tant de de enqugte. de vos era mdsbaja entre mujeres mds de la distribution de l'utilisation pro- de cette las et de A La principale conclusion cette de enqugte en et edad y las que vivian zonasrurales. duits contraceptifs e'tablissant clides de que de e'tait influencia la iglesia niques de planification la famille pesarde la acentuada de par- 6tait l'utilisation contraceptifs la plus et par religiosa rainees l'Etat.Toutefois, lafourniture plusfaibleparmilesfemmes dge'es de cat6licaen Espafia,la afiliacto6n dans les zonesrurales. o tuvo muypoco efectoen la incidencia tipo services contraceptifs inegale, se con- parmicellesvivant est et La de cathode me'todoanticonceptivo. mujer espa- centre dans villes Malgrela forteinfluence l'eglise principalement lesgrandes religieuse para avait fiola a raravezrecurre anticonceptivos et dans les regions paysouW effortsliqueenEspagne, du des l'affiliation peu sur ou de del partodespues matri- particuliers et consacres ouvrir aplazarsu primer ont i des tres d'effets l'incidence le type Les utilisent con trWs aumente rapi- cliniques. stWrilisationilldgale, le contraception. Espagnoles monio, perola utilizacion La est et une contraceptive pour nouveaugouvernement dezal incrementarse la paridez. socialiste s'efforcerarement me'thode naissance maritale, a los El autordescribe problemas que se d'amender loirelative avortements reculerleur premiere la aux de utilisation augmente rapidement en que encarael gobierno espafiol susesfuerzosmaniere l'avortement autorise soit lors- maiscette d'enfants. los mds porfacilitar ampliamente servcios qu'il y a risquede malformationfoetus, avecle nombre du les L'auteur dgcrit problhNnes auxquels se que las mujeres apresviol sila sante'ou viedela mere ou y predice anticonceptivos, la est dansses heurte gouvernement le espagnol de del continuardn dependiendo lasfuentes enperil. pour l'usage services des conUneetude al en y executee 1977dansle cadre efforts elargir sector privado comercialestiempo su que II que continueel de sur adquiere ritmo de l'EnqueteMondiale la Fecondite' traceptifs.predit lesfemmes prdctica anticonceptiva a sur et privg les europeos. de paises la mayoria losotros permis constater 61 pourcentdes rontde compter le secteur de que femmesespagnolesactueUement i mesure leurremari6es sources commerciales que d4claraient i qu'ellesne voulaient avoir cours desm6thodes plus contraceptives R6sum6 rattrape de 57 seulementceluide la plupart voisins des Toutefois, pourcent Jusqu'tila mort de Franco, en 1975, d'enfants. europeens au de et un exposees risque grossesse l'Espagne. essentiellementpayspro- desfemmes l'Espagne etait

VaginalSpermicides, Chromosomal Defects Abnormalities Limb and Reduction

ByJos6 Cordero Peter Layde F. and M. Summary
thatspermicides teratogenic. infants tiondefects for are For and hypospadias abnor(an used spermicides thetime malplacement the at Each year, 300,000-60,OOO U. S. women whose mothers of opening the of urethra). become pregnantwhile usingvaginalsper- of conception, the relative risk of having Women whousespermicides alsobeen have micides. Two recent reportshypothesized Down syndrome was 1.2 and thatforothei reported havean increased ofspontato risk abnormalities also 1.2. The neously was thatoffspring from these pregnancies at chromosomal aborting, these and are fetuses more are defects among likelyto have chromosomal increasedrisk certain of birth defects, partic- relativeriskoflimbreduction defects than and suchchro- infantsexposed to spermicidesin the firsi those exposed spermicides.2 ularlylimbreduction defects not to is was Otherinvestigators, datafrom mosomalabnormalities Down syndrome. trimester 1.0. None oftheserisks sta. as the using In a case-control significant. Collaborative analysisof data fromthe tistically Perinatal found eviStudy, no dence thatspermicide during first Metropolitan Atlanta Congenital Defects use the four Program(MACDP), we studiedthe terato- Introduction lunar months pregnancy of increases the of genicityof spermicidesby comparing 3 Two congenital their Two published reportshave suggestedthai risk major malformations use aroundthe timeofconception moth- thereis an increasedriskofcertain congeni. by ers of infants in withchromosomal of abnormali- tal malformations the offspring womer Birth F. Epidemiologist, Defects is nearthetimeo: Jose Cordero Medical ties and limb reduction defectsto theiruse who use vaginalspermicides M. Diseases Division, Peter Layde and Branch, Chronic by mothers infants withbirth of defects that conception.1The investigators observedar is Deputy Studies Branch, Chief, Epidemiologic Division have notbeen linkedto spermicides. increased riskforsuch chromosomal abnor. ofReproductive for both theCenters Disease of Health, The resultsdo notsupport hypothesis malitiesas Down syndrome, limbreduc- Control, Atlanta. the for
Volume9, Number1, March1983 15