Family planning, choice and health

In the mid-1930s, debates on dispensing family planning advice to the general public were sparked by a press letter discussing birth control, and by a visit by American family planning advocate Margaret Sanger. 1 The colonial government, however, believed the populace was not ready, and there was opposition from within the Legislative Council and Municipal Commission. 2

In 1949, following lectures on birth control organised by the YWCA International Club, some 60 women voted to establish local family planning services. 3 After intense debate in the Municipal Council Chamber, a motion was passed to provide family planning advice once a week in three municipal infant welfare clinics. 4

A group of doctors, nurses, social workers and others found this insufficient, and set up the Family Planning Association of Singapore (FPA) later that year, aiming to set up more dedicated family planning clinics. 5 They ploughed on despite opposition from religious groups as well as a lack of expertise and resources – the Dutch pessary, the only contraceptive available to women, had to be purchased from England. 6 By 1965, the FPA was running 34 clinics in Singapore, the vast majority located in government health institutions. 7

Nevertheless, women still faced resistance from their husbands, and often sought family planning advice in secret. Ms Constance Goh, the first president of FPA, encouraged women to make their husbands think birth control was their idea – a tactic which could afford women more control over their bodies, but reinforced the view that men were entitled to make decisions about women’s bodies. 8

The shift to population control

In 1966, at the FPA’s behest, the government took over family planning services, establishing the Family Planning and Population Board (FPPB). 9 The government was convinced that reducing fertility was necessary for Singapore’s economic survival.

Women’s empowerment through family planning has often been limited by patriarchal norms, but the absorption of these services into the state apparatus brought a competing threat to women’s autonomy: national interests. 10 While the 1965 White Paper on Family Planning stated that its aim was to “liberate our women from the burden of bearing and raising an unnecessarily large number of children”, it added that this was to “increase human happiness for all” through ‘safeguarding’ Singapore’s economic survival. 11

Nevertheless, till 1969, the government did not try to force people to use birth control. Instead, it used strategies like media campaigns, forums and debates to highlight Singapore’s perceived population problem and the necessity for family planning. 12

Mdm Chow Sook Chin remembers the time. 13 She worked as a nurse midwife in the late 1960s, attending to home births as well as in Kandang Kerbau Hospital. She said in an interview for this feature that she preferred home births as they were “more personal”, and she could handle each case from antenatal care all the way to postnatal care.

At this time, a system of government District Midwives was in place. Women were trained in midwifery but not nursing, and worked in centres across the island. Traditional birthing assistants, such as bidans and jiesheng fu 14 also attended to births, although the government actively encouraged women to seek the services of medically trained midwives instead. 15

Government midwives dispensed family planning advice and contraceptives during home visits, 16 and nurses talked to women about the possibility of family planning during their antenatal and postnatal check-ups. According to Mdm Chow, maternal health was quite poor at the time, since women did not have much money with which to take care of themselves, or to buy herbs or vitamins.

Mdm Chow noted that women tended to be more accepting of family planning than their husbands or in-laws were. 17 Unfortunately, though family planning was an issue that intimately affected their bodies, women had less say as to whether to take it up.

Of abortion, sterilisation and stopping at two

With population growth still high as the 1970s began, the state embarked on a more aggressive campaign to limit couples to two children each. There was immense pressure to conform to a new ideal of the nuclear family, including new measures to encourage parents – in practice, mothers – to get sterilised after their second child. However, these policies disproportionately targeted lower-income and less educated people, as well as disabled people.

Increased government intervention in reproduction began with a modification of delivery fees in 1969, from a flat rate for all births to progressively higher fees for subsequent births. 18 Then came the Abortion Act and the Voluntary Sterilisation Act, both enacted in 1970. 19

Abortion was initially criminalised under the British laws Singapore had inherited, except where “abortion was caused in good faith to safeguard the life of the woman concerned”. 20 When reviewing the law, the state was concerned about cases of contraceptive failure, as well as population control. Policymakers also wanted to tackle dangerous “backstreet” abortions. Announcing the government’s intent to legalise abortion in August 1967, then Health Minister Mr Yong Nyuk Lin stated:

With the proposed legalising of abortion, every child born in Singapore would henceforth be a wanted child and our women folk will thus be liberated from the clutches of nefarious people who are unscrupulous enough to exploit and profit in the anomalous situation which regards abortion as being illegal abortion. 21

However, the Abortion Act, as first enacted in 1970, gave women only limited access to abortions. Those seeking abortions needed approval from the Termination of Pregnancy Authorisation Board and, if she was below 18, from her parents or guardian. The Board could grant approval only where there was a serious threat to the life, or mental or physical health of the pregnant woman; where the child might be disabled; where the pregnancy was the result of rape, incest or other unlawful intercourse; and where the socio-economic situation of the woman “justified” terminating the pregnancy. 22

Most approved abortions fell in the last category. In the first ten months after the Act came into force, these cases formed 95 per cent of the abortions approved by the Board. 23 Many women continued to have “backstreet” abortions. 24 It was only in 1974 that abortion was made available on demand. 25

One woman recalled being chided by doctors and nurses, and offered an abortion, when she went for an antenatal check-up while pregnant with her third child.

Although liberalisation of abortion for lower-income women did advance women’s reproductive freedom, the Abortion Act also marked the beginnings of eugenicist policies.

Speaking on the Abortion Bill in 1969, Prime Minister Lee Kuan Yew worried that the legalisation of abortion and voluntary sterilisation would lower the quality of the population. He noted that better-educated parents were more likely to limit the number of children they had, and argued that the laws needed to be applied “intelligently” in order to correct this “distortion” in procreation patterns. 26

Legal abortion was sometimes used in a way that disrespected women’s choices – one woman recalled being chided by doctors and nurses, and offered an abortion, when she went for an antenatal check-up in 1976 while pregnant with her third child. 27

Coming into force at the same time as the Abortion Act, the Voluntary Sterilisation Act led to the establishment of an Eugenics Board to assess applications for voluntary sterilisation. 28 Although this would later cause grief, the law was passed without much comment.

The state soon introduced measures to increase the take-up rate for its sterilisation programme, deeming sterilisation “the best method of family planning”. 29 Priority in Primary One registration – a major concern for many parents – was given to sterilised parents, 30 and delivery fees were waived for Class B and C patients if either parent sterilised themselves following the birth of a child. For Class C patients, ward fees were also waived in such cases. 31 While sterilisation was offered to all, it was often women who got sterilised, though it was then a much more invasive procedure for women than for men. 32

Some women felt pressured to get sterilised despite their religious objections. 33 Husbands sometimes pressured their wives into such procedures due to difficulties with paying hospitalisation and delivery fees. Women were not just subject to state pressures but also class-based financial pressure, and the model of the male breadwinner that gave power to men. 34 Their predicament was made worse by the state’s drive to hospitalise childbirth.

Other measures were also introduced to encourage small families. 35 In 1973, the state amended the Employment Act so that women were no longer eligible for paid maternity leave if they already had two or more surviving children, 36 and lower or no income tax relief was granted from the fourth child onwards. A new rule was introduced whereby those staying in public housing could only sub-let rooms if they had no more than three children.

“If I have a third child, and just because the third child is a third child, and then he’s not given the same priority as the others.”

The denial of priority in Primary One registration to fourth and subsequent children hit the hardest. The specifics changed a number of times during the decade, but generally, priority was only given up to the third child. Fourth and subsequent children would receive priority only if at least one of their parents was sterilised.

Many limited their family size because they did not want their younger children to be disadvantaged. Mdm Chow was one such parent.

“I didn’t want to take the chance, because in those days, a third child, they don’t guarantee you … I was asking myself, if I have a third child, and just because the third child is a third child, and then he’s not given the same priority as the others. It’s very unfair to him,” she said. 37

Abortion and sterilisation legislation were also discriminatory against people with disabilities, including disabled women. The risk of severe impairment was one of the grounds for terminating pregnancy in the 1969 Abortion Act, 38 and both the 1969 and 1974 the Voluntary Sterilisation Acts treated people with disabilities in a eugenicist way that disrespected their right to parenthood. 39

Under these Voluntary Sterilisation Acts, for those “afflicted with any hereditary form of illness that is recurrent, mental illness, mental deficiency [sic] or epilepsy” (mental illness was inserted as a separate category in the 1974 Act), a parent, guardian or spouse could decide whether they should be sterilised, and this would be approved as long as the doctor certified that the treatment was “necessary in the interest of the person… and of society generally.” Consent of the person to be sterilised was not required.

Eugenicist sentiments were apparent in the parliamentary debates on the two acts. Speaking on the Abortion Bill, Minister of Health Chua Sian Chin stated:

I would just like to invite these groups [those who oppose abortion] to visit the Mental Defective Section of the Woodbridge Hospital to see for themselves the mental defectives or "mongols" whom we have to care for. Perhaps then they may begin to think in more rational terms and start to question the very purpose of the Divine creating such mental defectives, the nature of whose existence in this world is just to vegetate. 40

The hospitalisation of childbirth meant that the government now had easier access to women’s bodies to implement their social engineering programmes.

The 1970s was a period of transition when it came to childbirth. Once the Nurses and Midwives Act of 1975 was passed, traditional birthing assistants could no longer practise legally. 41 Instead, the government advised all women to deliver in hospital, citing the risks involved in childbirth. By the end of the decade, hospital births were practically the only option open to women. 42

The hospitalisation of childbirth did not necessarily improve women’s access to reproductive healthcare. Lower-income families found it difficult to afford the more expensive hospital fees, and therefore delayed going to the hospital until the last minute in order to minimise costs. Some ended up delivering their babies on their way to hospital. 43

Many who did deliver in hospital faced medical procedures which were not always necessary, such as routine episiotomies. Labour was sometimes induced in order to fit hospital schedules, and caesarean sections performed when the baby was still not delivered after a set length of time. The process was a top-down one, with many women unable to understand what was going on. 44

“Talent for the future”: overt eugenics

In 1975, Singapore’s total fertility rate dipped under the replacement fertility level of 2.1 children per woman for the first time. 45 Stop at Two had been effective, but the drop in fertility rate was also due to other factors, such as women’s higher educational levels, their increasing participation in the workforce, family nuclearisation and better living conditions. 46

After the 1980 census, the state became concerned that better-educated women were reproducing at lower rates than less-educated women, and that graduate women in particular were remaining single. In his 1983 National Day Rally speech, Prime Minister Lee Kuan Yew worried that the following generation might be “depleted of the talented”. 47 Mr Lee believed that better-educated parents would produce more intelligent, talented offspring, and that it was important to ensure that graduate women had more children.

These comments drew accusations of elitism. 48 Still, the ruling party introduced a slew of eugenicist policies the following year, encouraging graduate women to marry and have more children. 49 It established the Social Development Unit (SDU) in 1984 to encourage matches between graduate women and men in the public service. Under the new Graduate Mothers’ Priority Scheme, children of graduate mothers with at least three children would receive top priority in Primary One registration in a school of their choice. 50 For women with five O Level passes, they would enjoy enhanced child relief that increased from the first to the third child.

On the flip side, the government introduced the Small Family Incentive Scheme to encourage less-educated, low-income parents to limit their family sizes. 51 Where both parents did not have any O Level passes, women could apply to have $10,000 deposited in their CPF if they were under 30, had not more than two children, and agreed to undergo sterilisation. 52 Delivery fees were also revised such that women in Class C wards saw the steepest increase in fees after the second child. 53

These policies angered many citizens; one woman who wrote to the press signed off as “Second-class Citizen”. 54 Even graduates felt it was unfair, as evidenced in the landmark forum in 1984, “Women’s Choices, Women’s Lives”, leading to the formation of the Association of Women for Action and Research (AWARE), whose first position paper was on the issue of population policies. 55

Besides concerns of class-based discrimination, there was also some worry that the government was trying to limit the fertility of Indian and Malay women so as to maintain the ethnic ratio – women from these ethnic groups tended to have less education and more children, and were therefore disproportionately affected by the policies. This belief was bolstered in 1985 when Prime Minister Lee Kuan Yew declared belief that Singapore owed its success to the “practicality” of its Chinese ethnic majority. 56

Indignation over the government’s eugenicist policies was apparent in the election rally speeches in the 1984 General Election, and contributed to the PAP’s significant losses. 57 Even Dr Toh Chin Chye, a founding member of the PAP, condemned the Graduate Mothers’ Priority Scheme, arguing it was unconstitutional and discriminatory. 58 This negativity, and the scheme’s ineffectiveness, prompted the government to scrap the policy less than a year later. 59

Have three or more (if you can afford it)

In 1987, the state announced a new population policy – Have Three or More (If You Can Afford It). By focusing on “affordability” rather than education, it moved away from overtly eugenicist rhetoric, but specific policies and guidelines continued to discriminate against less-educated people. Reproductive policies were still formulated with social engineering in mind.

Sanctions on larger families were lifted, and measures introduced to encourage them. Discrimination against the third child in Primary One registration was removed, 60 and public housing policies were modified so that families with three children and a three-room or larger flat were given priority when upgrading to a larger apartment. These families could also sell their old flats on the open market even if they had not inhabited it for at least five years, allowing them to reap a huge profit. 61 In 2001, the Baby Bonus Scheme began providing cash pay-outs to married parents, based on the birth order of the child. 62

In 1987, the government implemented mandatory pre- and post-abortion counselling to discourage abortion. However, the pre-abortion counselling requirement only applied to women with some secondary education, and aimed to discourage these women from aborting rather than providing them with unbiased information. 63

Following its announcement in 1993, the Small Family Incentive Scheme from the eugenics era was modified and reintroduced as the Small Family Improvement Scheme in 1994. The sterilisation requirement was removed; instead, parents had to agree not to have more than two children. 64 In 2004, benefits were enhanced and the scheme was renamed the Home Ownership Plus Education (HOPE) Scheme, and continues to advocate that less-educated, low-income parents keep their families small. 65

The state also had other forms of social engineering in mind. Wanting to uphold the image of the ‘traditional’ nuclear family as the social norm, it insisted on childbearing only within the context of heteronormative marriage. 66 This impinged on the reproductive rights of anyone who did not fit this norm. Up till today, unwed single mothers are not entitled to the Baby Bonus scheme or government -paid maternity leave or benefits. 67

Recent developments

Recent developments hint at a shift away from overt eugenicist policies and towards greater respect for autonomy and human rights.

In March 2013, the Ministry of Health commenced a review of Singapore’s pre-abortion counselling guidelines. 68 Recognising that the criteria were “no longer relevant with the shift in Singapore’s demographic and social landscape,” 69 it embarked on a public consultation exercise in 2014, which culminated with the MOH making pre-abortion counselling mandatory for all women in April 2015, regardless of their nationality, educational level or number of children. Moreover, the counselling was presented as intended to support women in making informed choices, rather than discouraging abortion. 70

Another emergent trend is heated and robust debate on matters of sexual and reproductive autonomy not between citizens and state, but between various factions in society, signalling a new era of public engagement.

In 2012 Minister for Health Gan Kim Yong similarly declared his ministry’s intention to amend the Voluntary Sterilisation Act, as there had been “many changes in Singapore since [1974], both in the healthcare landscape as well as in society generally”. 71 Once again this was carried out with public consultation, incorporating input from groups such as AWARE. It resulted in better protections for disabled people and allowed more autonomy in deciding on sterilisation. It also introduced more safeguards for minors seeking sterilisation. 72 Significantly, Singapore reviewed the act in part because it sought to be a party to the United Nations Convention on the Rights of Persons with Disabilities. 73

Despite these shifts, the state’s pro-natalist policies continue to include strong class-based components. Many of its incentives for parenthood – such as co-savings schemes or income tax relief 74 – inherently favour parents with higher incomes.

Another emergent trend is heated and robust debate on matters of sexual and reproductive autonomy not between citizens and state, but between various factions in society, signalling a new era of public engagement. The changes to mandatory pre-abortion counselling in 2015, for instance, were preceded and surrounded by lengthy debates in the press on the appropriate role of regulation in governing abortion access.

Sexuality education has also sparked controversy. In 2006, AWARE—alarmed by the steep climb in sexually transmitted infections amongst teenage girls and data that over a hundred girls below age 20 had undergone abortions in 2006 alone 75 —developed a comprehensive sexuality (CSE) programme for teenagers. The course aimed to empower youth to make informed choices. 76

However, in 2009, the programme came under attack by Christian activists for its neutral approach to homosexuality. 77 Subsequently, the Ministry of Education centralised the vetting of external sex education providers 78 in local schools, and required the “heterosexual married family” to be presented as “the basic unit of society”. 79

Returning choice and empowerment to pregnant mothers

People have also started to challenge medical authority over childbirth, 80 as evidenced in the small but growing interest in natural childbirth. This school of thought sees childbirth as a natural process rather than a medical issue, and holds that control over the birthing process should be returned to pregnant women. Natural births involve significantly less medical intervention, including lower rates of episiotomies and caesarean sections. With the help of pain management techniques, the need for pain medication, including epidural anaesthesia, is also reduced. 81

Meanwhile, the medical profession has started giving women more reproductive health choices.

People who choose natural birth often opt to deliver in more familiar settings. Although it is still rare, growing numbers of parents are delivering at home. 82 Advocates point out that most planned home births following uncomplicated pregnancies in healthy mothers are completed safely, especially for women who have had safe deliveries previously. 83 Many doctors, however, warn against the risks of childbirth and advise against home birth. 84

Meanwhile, the medical profession has started giving women more reproductive health choices. For instance, they may assist women in creating birth plans, and offer the choice of a water birth. 85 The National University Hospital also provides one-on-one nurse midwife support services, similar to doula services, though delivery itself still has to happen in the hospital. 86 Not all hospitals offer these options: some contend that there is insufficient evidence in support of natural birth techniques, such as water birth. 87 Regardless, such services are available only to the higher socio-economic classes as they cost much more.

As the state grapples with evolving demographics and family structures, and faultlines over societal values emerge in a society whose pluralism and diversity grows daily more apparent, voices for women’s and girl’s autonomy will no doubt become ever more vital to ensure the protection of reproductive rights.