Let them have contraception

Wednesday’s London Summit on Family Planning aims to expand contraception access for women in the developing world.

Over 200 million women worldwide lack access to effective methods of contraception [EPA]

Let them have contraception! After Marie Antoinette exclaimed that starving French citizens should eat cake, it is the turn of the Gates Foundation to cry out for the right of poor women to use contraception. The French Queen never uttered the infamous “let them eat cake”, nor has the Gates Foundation proposed forced contraception. But family planning has a dangerous tendency of coercing poor women into its programmes.

The London Summit on Family Planning is happening today, on July 11. It is an initiative from the Bill and Melinda Gates Foundation and the UK government to build momentum from governments, private sectors and the scientific community around the world to strengthen women’s access to contraception. Organisers estimate that over 200 million women worldwide lack access to effective methods of contraception, resulting in over 75 millions unintended pregnancies each year. The Summit launches an unprecedented global commitment to expand access to contraceptives as an investment for the future.

The focus on contraception is most welcome. Family planning is underfunded, contraceptive needs remain unmet, with obstacles ranging from cultural norms to distribution chains. But family planning requires complex solutions beyond simply increasing the production and distribution of contraceptives.

London Summit

The London Summit wants to increase women’s access to contraception. The goal is to provide contraception to an additional 120 million women and girls in the world’s 69 poorest countries by 2020. The initiative vows to also sustain coverage for 260 million women estimated to be already using contraception. The proposal aims “to serve a total of 380 million women with quality family planning”. This will cost US $10bn in contributions from governments, consumers and external donors over the next eight years.

Securing access to information, services and contraception supplies can immediately improve the lives of women around the world. Contraception can reduce maternal and child mortality. As women live longer and better, their families too become healthier and wealthier. Girls who can delay pregnancies can stay in school longer, thereby expanding their career opportunities and enhancing their agency and achieving greater political participation. As fertility rates drop among more educated women, governments enjoy relief from heavy social expenditure and achieve a more competitive labour force. Letting women decide whether and when to have children simultaneously increases their individual freedom and benefits society.

Yet while the Summit may mark a turning point for sexual and reproductive rights, family planning programmes’ darker history of abuse and coercion lingers on. The Summit’s focus on quantitative efficiency is ringing various alarm bells.
The trauma of forced sterilisation policies

Family planning has often been a tool of eugenic politics, forced sterilisation in selected populations. It is estimated that between 25 to 50 per cent of Native American women in the US were sterilised without their consent between 1970 and 1976. In California, the War on Poverty initiative financed the forced sterilisation of Latina women in the 1970s. Family planning led to coercion in India too, where Indira Gandhi pushed draconian measures to reduce birthrate. The forced sterilisations of Peruvian women in the name of development under Fujimori in the 1990s continue to stir opposition in that country.

Targets and quotas are incentives for physicians and healthcare professionals to coerce women or simply to sterilise them without their knowledge. The 1994 Cairo Conference on Population and Development marked a milestone to reframe policy with women’s human rights at the core of population programmes. Women’s groups from the north and the south worked together to make sure frameworks would remain voluntary and women respected as full participants.

Eventually, paradigms changed. Quotas have largely been abandoned. The US Congress is now vigilant in rejecting quantifiable results of these programmes. But implementation, as usual, is a never-ending saga. Almost two decades later, many abuses continue unabated. For example, Uzbekistan is running a systematic programme to sterilise women, often against their knowledge, underscoring our naïveté in assuming things will be ok.

The business of women’s health

All this to say that whether family planning is a good idea depends on how it is implemented. The Gates initiative raises concerns because of its quantitative goals and the business-like approach to women’s health. Quantitative criteria are embedded in the business plan for producing and selling contraceptives. When the goal to reach 100 million more users by 2020 was announced, women groups became legitimately alarmed that such criteria would revive the system of quotas that encouraged doctors to coerce women for the sake of achieving targets.

The strategy is to massively increase production of contraceptives in order to massively increase access to contraception. Louise Finer, director of Global Advocacy at the Center for Reproductive Rights, worries that the initiative is not concerned with strengthening the health system. If it is necessary to produce more contraceptives to make them available to more women, it is also crucial to see, for instance, how comprehensive sexual education will complement greater access to contraception. Pouring money into production and distribution are part of a much larger equation. Women’s right to choose whether and when to have children encompasses access to contraception as much as it entails long-term investment in the health system that will provide it.

The Gates Foundation is enthusiastic about bringing high-tech to solve our daily problems. We all want efficient contraception. Yet it takes only very low-tech means to prevent the death of women who die from lack of reproductive health services. It is inexpensive to counter millions of deaths from illegal abortions and maternal deaths in emergency rooms. All this is old, decidedly low-tech. To accomplish it only requires political will. Approaching contraception as the one silver bullet is misguided. In healthcare, it is usually not one thing but a broader array of factors, an integrated healthcare system that saves lives.

The louder voices of women

Women’s organisations feel they have not been strongly engaged in the Summit preparation. Francoise Girard, President of the International Women’s Health Coalition, regrets the lack of transparency in the run-up to the Summit. The first draft of the business plan civil society members were given in April had less to do with women rights than with buying contraceptives. The agenda tackled the supply side of the contraceptives market rather than women rights, failing to work within the existing framework of the United Nations Population Fund or UNFPA (an existing institution with the same mission).

Sidelined from the process, civil society mobilised for months. Women’s organisations from the north and the south came together to issue a public statement in June. The document led the UK government to adopt language on non-coercion and non-discrimination. Women’s advocacy groups are now acting as watchdogs, helping shape the policy that comes out of the Summit, making sure services are provided to all women, and reiterating that one type of contraception should not be favoured over others in the distribution chain.

Girard is optimistic with the impact of civil society mobilisation. The latest version of the Summit’s business plan was dramatically improved, including criteria designed to promote the removal of barriers to reproductive care. “We are not here to make them [the Gates Foundation and government organisers] happy but to make them accountable.” The Summit has shown how advocacy networks impact policy frameworks, demonstrating that the broader framework of women rights and contraception is now better understood in government and foundation circles.

Furthermore, civil society networking has proven more efficient than ever. Women’s groups mobilised much faster than before, working across geographies to put together broader political and policy coalitions. As a result, a scandal involving women’s health anywhere will likely quickly become world news. In the process, what is considered a legitimate issue of human rights has evolved considerably. Amnesty International, for instance, would never have got involved with women’s health previously.

The next stage is harder. We need to make sure the promises are fulfilled. If the government of India receives US $40 million from international donors, will women be given a seat at table? Will the funds support the role of women’s watchdog groups to secure accountability or just go to pay the salaries of bureaucrats? Implementation works best when it is a transparent, inclusive and accountable practice.

We know how often good intentions can go wrong. The Summit has great potential. As discussions unfold, however, it is crucial not to lose sight of the complexity of family planning nor exclude women’s voices and experiences.

Manuela Picq has just completed her time as a visiting professor and research fellow at Amherst College.