News & Politics

What's Next for Women's Health (And Rights) in Tunisia and Egypt?

Egypt and Tunisia actually had decent family planning under their dictatorships. Where might they move forward under Democratic government?

It is unsettling, but true: the autocratic regimes of Tunisia and Egypt, now overthrown by democratic revolutions, had, in fact, carried forward what are among the most progressive reproductive rights policies in the region. 

While the idea of offering any public funds at all to the Planned Parenthood Federation of America incites debate in the current U.S. legislature, both Tunisia and Egypt have government-sponsored programs that for decades have offered free or nearly free contraception to citizens—not just condoms, but intra-uterine devices (IUDs) and birth control pills.

Tunisia, which legalized abortion five years before the U.S, also has freely available morning-after pills, Pap smears, and breast exams at both local and mobile clinics. Both North African nations can boast of robust publicly supported education programs in sexual health for adults and youth. Both nations were among the first to sign CEDAW (the treaty of the Committee on the Elimination of Discrimination Against Women) back in 1980; Egypt ratified the declaration a year later and Tunisia, with a few reservations, in 1985. (The U.S. is one of seven nations that have not ratified CEDAW.) The policies and practices for most basic reproductive health services in Tunisia and Egypt has become a social norm, and are unlikely to face contention in the emerging governments. Indeed, they have a significant opportunity to expand. 

Particularly as the U.S. grapples with the intersection of government and reproductive health, it is worth asking the question: how did the dictatorial regimes of Tunisia and Egypt make such advances with family planning--and what were the limits of such care under authoritarian and corrupt governments? What might the rest of the world learn from what these North African nations have and have not accomplished with reproductive rights – and where they might move forward under revolutionized government?

It is Tunisia that has long held the reputation as the Arab and African nation that is particularly “modern” on reproductive health and women’s rights. In 1956, shortly after independence and under the helm of President Habib Bourguiba, Tunisia abolished polygamy, granted equal divorce rights to both women and men, and raised the minimum age for marriage to 17 for consenting women (and age 20 for men). It further granted mothers the right to custody of their children if the father either died or “defaults in his responsibility.” In that same decade, Tunisia was both the first Arab and African country to adopt a specific population policy. As part of its plan, families could only receive government subsidies for the first four children. In 1966, the nation legalized abortion for any reason (although there are gestational limits), without requiring a husband’s approval; it was both the first Arab and first African country to take such a step. (There are still only two other African nations—Cape Verde and South Africa—that broadly permit abortions.) 

Abortions are freely available at Tunisia’s state hospitals. While there were 22 abortions per 1,000 pregnancies in North Africa in 2003, according to the Guttmacher Institute, the only procedures that occurred in safe conditions were those in Tunisia. For wanted pregnancies, working Tunisian women can expect to receive 67 percent of their wages covered during the term of their maternity leave although notably, domestic servants are excluded from maternity leave policy. Tunisia also produced the first female doctor in the Arab world – Tawhida Ben Cheikh, a gynecologist who died two months ago at age 101. She is credited for launching Tunisia’s family planning priorities at a department she founded at Charles Nicolle hospital in 1963.

Since Ben Cheikh opened that family planning department, Tunisia has continued to put a substantive portion of domestic spending toward reproductive health. Over the last decade, under the rule of Zine El Abidine Ben Ali, the government has spent about $10 million each year to educate its 10 million citizens about family planning. With support from the nation’s influential Muslim leaders, local and mobile clinics offer free contraception and cancer screenings. Tunisia’s contraceptive use rate is over 65% and the country now has a fertility rate of 2.1 children per childbearing woman (compared to 7.6 in the 1960s); that is, its rate is at replacement level and one of the lowest on the continent. The decline in Tunisia’s fertility rate, which unfolded more than twice as fast as in developed nations, coincides with an increase in the nation’s per capita income, the growing rate of women attending universities, and the rising age at first marriage. While Tunisia’s life expectancy was 51 years in 1966, it was 74.2 years by 1998, according to the National Union of Tunisian Women.

"Tunisia's integrated approach to reproductive rights can serve to inspire reform and advocacy efforts in other countries," says Leila Hessini from Ipas, an international nonprofit that focuses on reproductive and sexual rights, including access to safe abortions. She points out that Tunisia is the only country in the region to have placed "women's reproductive rights within the general framework of women's rights and gender equality." As a result, Tunisian women benefit from lower maternal mortality rates, greater access to contraceptive methods, and higher levels of female education and employment than other North African countries. 

Meanwhile, Egypt’s capitol city was the epicenter for the world’s thinking on family planning during the 1994 “Cairo Conference,” or the UN International Conference on Population and Development. The resulting “Programme of Action” serves as the steering document for the United Nations Population Fund (UNFPA). Despite numerous points that came under dispute, the Cairo conference reported that consensus goals included “access to reproductive and sexual health services including family planning.” One could consider this the continuation of a long legacy. Hessini, who is director of community engagement for Ipas and board chair of the Global Fund for Women, points out that “Ancient Egyptians wrote extensively about their methods for controlling fertility and reproduction and abortions have been documented as one of the oldest medical practices.”

In kind, former President Hosni Mubarak had been calling on Egyptians to have smaller families since he came to power in 1981. A family planning campaign launched in 2008 by the government’s ministry of health spent $80 million, using the slogan "Two children per family -- a chance for a better life." 

As a result of government-supported efforts, Egypt has one of the highest rates of contraceptive use on the continent, at 59% of the population, according to Dr. Amy Tsui, director of The Bill & Melinda Gates Institute of Population & Reproductive Health. That’s a doubling of the 1980 rate. Nearly all of that contraceptive use (57%) is publicly supported on a sliding scale: free or nearly free birth control for citizens. Tsui added that the great majority of contraceptives used in Egypt are “what we could call modern contraceptives, like IUDS” that have to be obtained from public clinics. IUDs and injectables are replacing the pill as the primary form of birth control in Egypt (they’re also quite popular in Tunisia). Over the years, Egypt’s fertility rate has decreased rapidly, now at about three children per childbearing woman.

Dr. Gamal Serour is the director of the International Islamic Center for Population Studies and Research at Al-Azhar University, and president of the International Federation of Gynecologists and Obstetrics. He has practiced medicine in Egypt for more than fifty years. During his tenure, he says, the most meaningful changes he’s seen, outside of technology, has been a marked drop in maternal mortality and obstetric complications. “We hardly ever see a case of fistula anymore,” Serour said. 

“We often cite North Africa, especially Egypt and Tunisia … as successful family planning programs,” said Tsui. “The Mubarak government has actually been very supportive of family planning and reproductive health.”

But while the family planning efforts yield a significant improvement in the nations’ well-being, it is not all-encompassing. Not quite two-thirds of Tunisia’s population is of working age, according to a 2003 Wall Street Journal report. It was the boom generations born before the fertility decline took full effect that were stifled by high unemployment rates and brutally few opportunities—and that led the revolution to overthrew the government of Ben Ali. Egypt, meanwhile, is the 16th most populous nation in the world, and the most populous Arab nation. It increased its population under Mubarak’s reign from just over 40 million to about 81 million—primarily young people; as Tsui put it, this is a function of fertility rates in the 1980s. And there are many citizens who see large families as a sign of both financial security and status. 

Patriarchal legacies have continued to weigh heavily on the habits of Egyptian women. A Family Health International (FHI) study found that “most women felt the need to seek their husband’s opinion and approval on all matters.” It also found that “women’s subordinate position played a role in family size. Fear of divorce and polygamy lead women to have more children when their husbands wanted them, even if they did not want more children.” Some of the women in the study told researchers that they would advise their daughters to only use family planning practices “after they had given birth and proven their fertility.” 

As well, each nation has notable blind spots in policy. Egypt also has a restrictive abortion law, which Hessini says is based on "an antiquated British code." Tunisia does not consider marital rape to be a crime.

Most potently, and in line with the authoritarian practices of their dictatorial governments, progressive reproductive health policies did not match progressive processes. For one, Tsui noted that in Egypt, there were allegations of government corruption in its family planning programs, with “money siphoned off probably from US aid funds.” But also, the process of determining reproductive health priorities did not have any system in place to listen seriously to those working and living on the ground.

Hessini said, “Tunisia had such a modern image for supporting women’s rights. But at the same time, it was a total police state. There are all these contradictions."Women's organizations and human rights groups, want to be part of defining what the (reproductive rights) policies are," she added. "When policies are generated top-down, civil society doesn't participate in a way that is meaningful.

"Issues that are not part of the government platform—like sexual and gender-based violence, needs of young people, rights of marginalized women—are not given the visibility they deserve," she added.  Particularly given the government crackdown on media, reproductive health priorities that weren’t embraced by the government were unlikely to find space in the public conversation. There was a climate, after all, that saw Mubarak’s administrations take 12 satellite stations off the air ahead of November’s parliamentary elections, and many journalists faced criminal charges for defamation last year, in cases instigated by the government.

Likewise, Tunisia’s Ben Ali administration had a documented history of targeting journalists, including a five-year prison sentence that reporters faced if the communicated with "with agents of a foreign power or a foreign organization with a view to inciting them to harm the vital interests" of Tunisia or its “economic security.” Last March, journalists were ordered by police to not attend a Human Rights Watch press conference on political prisoners, and Tunis hotels told not to host the event. Internet sites were routinely blocked and journalists, both local and foreign, reported to the Committee to Protect Journalists that they had their email and phone calls monitored regularly. 

Relatedly, there were serious limits on even the internal work of non-governmental women’s organizations. A Freedom House report emphasized the danger of the Tunisian government’s restrictions on women’s organizations, particularly those that attempted advocacy. According to the report: “The work of most NGOs is closely monitored by state security agencies, and a 1959 law stipulates that all associations must apply for permission from the Ministry of Interior to hold meetings, conferences, or debates.” 

The suffocation of grassroots process and voices belies the individual autonomy that is purportedly celebrated by what was otherwise progressive reproductive health processes, and it inevitably limits them. 

But as today’s democratic movements reveal, citizens of both Egypt and Tunisia were prepared to collaborate and pushback anyway. Hessini looks back at the Cairo conference as a significant opportunity for NGOs and other organizations to initiate coalitions, realizing the intersection of issues that included FGM, population control, and reproductive rights. This sort of movement-building, founded on the idea of bodily autonomy, privacy, and control of one’s own life as human rights, fed into the power of the 2011 democratic revolution.

In turn, as the newly-forming governments of both Tunisia and Egypt transform the processes that shape them, girded by the value of self-control of one’s own life, the reproductive rights of its citizens have the potential to become truly world-class, to add individual freedoms and an open climate for advocacy and outreach to the mix of an already strong legacy when it comes to family planning.

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Anna Clark is a writer from Detroit who is on a Fulbright fellowship in Kenya in 2011. Her writing has appeared in The American Prospect, Salon, The Nation, The Detroit Free Press, and other publications. She edits the literary and culture website, Isak (