Of particular interest is Zaitun Mohamed Kasim's contribution on Islamic fundamentalism. His contribution raises many concerning examples of how the differing interpretations of Islamic jurisprudence bear upon a range of reproductive health issues in Malaysia and Indonesia, two Muslim-Dominant countries in Southeast Asia, where 60.4 and 86.1 percent of the population respectively are Islamic. With no central doctrinal authority, fatwahs (religious edicts) serve as the "bridge" between Islamic principles and modern life. With thousands of fatwahs issued every month in Islamic countries around the globe, even religious and political leaders in the Muslim world admit that the number is excessive, causing confusion and potentially reflecting ideology more than learning. 

This divergence in Islamic thought is reflected in the varying levels of acknowledgment and acceptance of abortion. In most Muslim-majority countries, abortion is generally prohibited with exceptions usually made where the health of the mother is at risk. Malaysia's Abortion Act 1967 makes termination of pregnancy illegal, with minor exceptions. A pregnancy may be terminated if two registered medical practitioners are of the opinion, formed in good faith, that continuation of the pregnancy will endanger the mother's life. Termination of pregnancy is also advised to prevent grave permanent injury to the physical and mental health of the mother. ARROW reports that many service providers and members of the public in Malaysia do not know the legal exceptions for abortion, partly due a lack of accurate information and partly because of the low priority accorded by the government to promoting women's reproductive rights. Dr Choong Sim Poey of the Reproductive Rights Advocacy Alliance in Malaysia similarly suggests that whilst abortion services are "widely available" in the private sector, information about public sector abortion services is "hush-hush," with the Ministry of Health refusing to provide abortion services in public hospitals based on the interpretation of the penal code.   

The Indonesian abortion law is based on a national health bill passed in 1992 that has been criticized for its vagueness. The law is generally interpreted as allowing abortion only if the woman provides confirmation from a doctor that her pregnancy is life-threatening, a letter of consent from her husband or a family member, a positive pregnancy test result and a statement guaranteeing that she will practice contraception afterwards. Like in Malaysia, Maria Ufar Ansor, head of the women's section of Indonesia's biggest Islamic Organisation, Nahdlatul Ulama (NU), has stated that dangerous abortion techniques are not uncommon, with the Guttmacher Institute reporting two million induced abortions in Indonesia every year.  

The study conducted by the Guttmacher Institute is particularly interesting for its survey of the attitude to abortion of 105 Muslim, Catholic and other Christian religious leaders in Indonesia. This survey revealed that 82% of the leaders surveyed agreed that abortion is acceptable if a woman's life is in danger, many reasoning that a woman's life should be prioritized over that of the fetus because a woman "is needed to look after the children and family she already has." The survey also concluded that Muslim leaders, though conservative, were more tolerant of abortion than their Christian counterparts, with a higher proportion of Muslim than Christian leaders supporting abortion if the pregnancy would interfere with a woman's schooling or impact her psychological health. 

Importantly, however, the Guttmacher report notes the differences in what is considered an acceptable gestational period according to sect. Followers of Imam Hanafi generally consider an abortion acceptable up to 120 days after conception. However, followers of Syafi'i consider abortion acceptable only within 40 days of conception. Indonesian Matters, an Indonesian website on the theme of culture and Islamization, refers to the head of the Majelis Ulama Indonesia (MUI), Indonesia's Clerics' Council, Ma'ruf Amin, who espouses that the book recalling the words and deeds of Muhammad "says that at the fortieth day of pregnancy the unborn child receives its soul or spirit, and hence abortion after this time is forbidden." For this reason, back in 2004, when 13 Indonesian Muslim scholars proposed that an exception should be created for pregnancy resulting from rape or incest, the MUI rejected the proposal, responding that such an exception would amount to the taking of a life, jinayah or murder.

Interpretations of what is haram (prohibited) or halal (permitted) in Islam similarly impact contraceptive use, attitudes towards family planning services for unmarried couples and people living with HIV/AIDS, which I will discuss in a future posting. Yet, the impact on abortion alone is sufficient to highlight the potential gravity of restrictive interpretations of Islamic tenets, with the World Health Organization reporting that in 2000 unsafe abortion accounted for 19 percent of maternal deaths in Southeast Asia. At the same time, the differences in the abortion laws in the two countries as well as the divergence of opinion within the Islamic religion itself, remind us about the necessity to distinguish between religion and religious fundamentalism. What we see here is the interpretation and application of religious principles in a way that encroaches on reproductive freedoms at the cost of women's lives.

Under the current implementation of the law, government employees who have a third child are denied access to pay rises and promotions. Under the new draft ordinance, the Ministry of Health's General Department of Population and Family Planning is proposing to reprimand Communist Party members and civil servants, as opposed to parents, for their failure to enforce the law. The draft does not explain what punishment will be implemented. Ethnic minorities, however, will be exempt, with couples from ethnic minority groups with populations of less than 10,000 people allowed to have more than two children per family, according to the deputy director of the General Office for Population and Family Planning Duong Quoc Trong. Couples with two children will also be allowed to have a third if one child is disabled. 

A policy of population control seems directly at odds with the government's concerns about the country's growing gender imbalance. Vietnam has far more males  than females. The international ratio at birth is about 105 boys for every 100 girls, but in Vietnam, echoing trends in China and India, the imbalance has grown to 110 boys for every 100 girls and is as high as 120 boys in some provinces. Vietnam has one of the highest abortion rates in Asia, if not one of the highest in the world. Abortion in Vietnam has been legal and available since the early 1960s, for pregnancies up to 12 weeks, and sometimes later, with the average woman having two abortions in her lifetime. Research indicates that couples resort to abortion to achieve their desired family composition. 

Daniele Belanger, Canadian research chair and director of the Population Studies Centre at the University of Western Ontario, highlights the detrimental impact of sex-selective practices on women in the long-term. Belanger notes the current trends of men in China, South Korea and Taiwan to seek wives through the "bride trade." Other researchers similarly report that a scarcity of women will be matched with increased pressure to marry, higher risks of gender-based violence, rising demands for sex work and the development of trafficking networks. Even the Vietnamese Deputy Minister of Health Nguyen Ba Thuy, has warned that the sex ratio would be 125 boys per 100 girls by 2020, with more than 4 million Vietnamese men unable to find wives by 2030 unless this gender balance is address. 

Authorities in Vietnam defend the need to vigorously enforce the two-child policy by arguing the need to avoid placing a strain on public services in the country of 86 million people. However, the UNFPA recently responded that the Government of Vietnam should reconsider this decision as it will be difficult to increase the population in a few decades. According to UNFPA, Vietnam currently has a population growth rate of 1.3%, which has remained largely unchanged for the past few years. Vietnam will therefore face an aging population and the consequences of an insufficient labor force if it enforces the policy.  

Editor's Note: In the coming weeks, RH Reality Check's Global Perspectives writers will examine the impact the outcome of the US presidential election could have on women's health and rights in their regions. This piece is the first in that series.

With PEPFAR (President's Emergency Plan for AIDS Relief) reauthorized until 2013, the upcoming US election presents a vital opportunity to reflect upon the program's shortcomings. Vietnam was, controversially, the only country in Asia selected to be one of 15 focus countries, (the remaining from Africa and the Caribbean), beating other Asian countries like India in its designation as one of the worlds most severely affected nations. Since its inception, many of the requirements of PEPFAR have proved to be similarly controversial in hindering efforts to combat the spread of HIV/AIDS in Vietnam.

Given the prevalence of HIV in Vietnam among sex workers, a major flaw with PEPFAR is the requirement that grantees pledge opposition to prostitution. In Vietnam, pledging opposition to commercial sex exacerbates the already prevalent marginalization of women and men in prostitution, some of whom have been trafficked. The requirement has proved to be a major obstacle to those groups trying to provide legal, social and health services to those Vietnamese engaged in commercial sex. Whether one supports or opposes the commercial sex industry, the prostitution pledge requirement has so far undermined services ranging from aiding Vietnamese to move out of commercial sex altogether, to inhibiting programs designed to empower sex workers in their demands for universal condom use. Given the pressing need to reach one of the groups must vulnerable to HIV infection, their marginalization through PEPFAR's prostitution pledge reflects a fundamental shortcoming. It is in fact very telling that in 2005 Brazil rejected $40 million in U.S. Global AIDS funding, the Brazilian Government recognizing that the anti-prostitution requirement would undermine the very programs that have proved the most successful amongst Brazil's efforts to reduce the spread of HIV.

A second major flaw with the implementation of PEPFAR in Vietnam has been the classification of "most-at-risk" populations, a classification that has not only ignored the reproductive health reality facing Vietnamese youth, but also that of  women in general. One recent study shows that whilst a significant proportion of HIV positive Vietnamese women are infected through sharing needles and syringes with infected drug users or by having unsafe sex with clients, the majority of new infections result from pre-marital sex with young male injecting drug users. Despite studies like these, a perception persists that the epidemic predominantly exists amongst young Vietnamese males.

According to Vietnam's Ministry of Health, about 263,000 people are living with HIV/AIDS in Vietnam, though only 103,000 cases have been reported. How many of those unreported cases are women who should otherwise be a central target group for curbing the spread of HIV/AIDS? Since the majority of PEPFAR's prevention funding for condom promotion in Vietnam is reserved for most-at-risk populations, the failure to perceive women who engage in pre-marital sex in the most-at-risk category reflects misdirected funding. In light of the abstinece-until-marriage focus, if PEPFAR remains narrow-minded and ideological in its approach, Vietnamese women engaging in pre-marital sex will continue to be ignored by awareness-raising efforts and HIV prevention programs. Clearly, the very likely continued support of abstinence-until-marriage spending requirements by Republican candidates McCain and Palin will continue to impede access to family planning information and services for these at-risk women and girls.

Obviously, a further failing is the approach of targeting HIV alone, without coordinating with family planning programs, despite the fact that unintended pregnancy and the need for family planning remains high in PEPFAR focus countries. Population Action International reports that funding for HIV programs in these countries completely dwarfs the amount allocated for family planning and reproductive health.  In Vietnam, funding for HIV/AIDS from international donors, including PEPFAR, has significantly exceeded government funding. Yet the opposite situation exists for family planning, with government funding always higher than international funding since the mid-1990s.

Health advocates can only hope that candidates for the upcoming US election commit to rectifying  PEPFAR's flaws evidenced over the last 5 years. If we hope to enhance sustainable development and encourage rights-based approaches to HIV/AIDS and family planning policies in focus countries like Vietnam, we cannot suffer another 5 years of similarly narrow and restrictive PEPFAR funding.

Policies designed to target the HIV pandemic obviously must work to combat stigma and to ensure health care exists to address the needs of those infected and all men and women vulnerable to infection, including those engaged in sex work and women having pre-marital sex. Instead, the shortcomings of PEPFAR wastes funds that could otherwise be successful in reducing the spread of HIV amongst the general population of Vietnam. Moreover, support by candidates of such ideological and restrictive policies reflects a willingness to jeopardize reproductive health, the empowerment of women and girls and sustainable development in general in PEPFAR's focus countries.