“I want to stop giving birth… because of the difficulties I encounter each time…”
Hadiza Damina received a contraceptive jab in a rural part of Jigawa state, Nigeria. Damina, who has had three children and six miscarriages, falls into two categories of women.
She is one of the millions of women contributing to Nigeria’s rapidly growing population — it is projected that the country’s population could reach 400 million by 2050 — and part of a trend that has prompted the Nigerian government to mull over birth control legislation. On the other hand, she is the subject of renewed international focus — one of the over 200 million women in poor countries who, according to the recently convened London Summit on Family Planning, jointly organised by the Bill and Melinda Gates Foundation and the UK government, lack access to family planning and contraceptives and are thus at risk of pregnancy-related deaths.
Bringing family planning back on to the global agenda will ensure that deserved attention is given to socially and economically marginalised groups of women. However, the suggested international approach also carries substantial risks: top-down, prescriptive policy may provide short-term gains but at the same time obscure wider structural deficits in domestic health and education sectors.
A “family planning cures all” approach
Nigerian women are some of the 200 million women in poor countries who lack access to contraceptives. These are the women that the London Summit seeks to aid in this regard by mobilising “global policy, financing … and service delivery commitments to support … an additional 120 million women and girls in the world’s poorest countries to use contraceptive information, services and supplies by 2020”.
Birth control is advocated as both a solution to developing countries’ rapidly growing populations, and as a means of improving reproductive health. According to Melinda Gates, this is the route to empowering these voiceless women.
Conveners of the London Summit posit that women’s access to contraceptives could result in over 200,000 fewer women and girls dying in pregnancy and childbirth and nearly 3 million fewer infants dying in their first year of life. According to this logic, making contraceptives widely available to women in developing countries would improve maternal and child health, reduce female school drop-out rates, improve literacy, reduce poverty and hunger, and save governments revenue on public services.
Addressing the symptoms without considering the causes
However, the focus on family-planning as a solution to reproductive health challenges downplays the underlying governance issues which are the root causes: public sector corruption, mediocrity, waste and mismanagement. For instance, in Nigeria these problems helped to establish an inefficient healthcare system where surgeries are sometimes performed by flashlight or lantern, with decaying infrastructure and lack of basic medical equipment and supplies.
Yet the Summit convenors regard the wide availability of birth control pills or the Depo-Provera injection, as the panacea that would drastically reduce Nigeria’s maternal mortality rate of 630 deaths per 100,000 live births due to pregnancy-related complications, and ensure young women stay in school, allowing the government to redirect freed-up funds to the provision of other public goods.
This approach leaves the needs of other groups of women completely unaddressed. As Wendy Wright of the Catholic Family and Human Rights Institute rightfully noted, contraception “does little to address the true needs of (already) pregnant women… or newborn children”. To address maternal and child mortality, discussions need to be had about building affordable medical centres, paying skilled birth attendants, providing emergency obstetric and other basic medical care, building better roads to clinics, particularly in rural areas.
The Summit fails to consider how developing countries’ deplorable health care systems, still grappling with treating malaria, typhoid and post-partum bleeding, would manage the side effects of long-term usage of hormonal contraceptives such as the birth control pill and especially the contraceptive injection on a large scale. It’s difficult to imagine how rural women, at the bottom rung of the socio-economic ladder, would deal with possible harmful side effects to their hormonal balance — these have been known to include thinning of bones, an increased risk of osteoporosis, an increased risk of STDs, breast and cervical cancer. The many who will require follow up treatment will be left unattended — especially if governments divert funds from a sector they view as being fixed.
Top-down and prescriptive
This “big push” to bring family planning back onto the global agenda is prescriptive and ignores the dynamics of different societies. It carries with it an overtone of cultural neo-imperialism.
The Gates Foundation have proclaimed that “more than 200 million women and girls in developing countries want to delay, space or avoid becoming pregnant” but do not have access to contraceptives, “resulting in over 75 million unintended pregnancies every year”. However, not every pregnancy in advanced economies is intended. By outwardly seeking to empower women, are they indeed robbing these women of their agency? How faithfully have the views of women in developing countries been represented?
Should the Contraception Prevalence Rates in Nigeria (15%) be equal to France’s 71% or the United Kingdom’s 84%, given the disparity in the levels of development? Do Nigerian women, with an average birth rate of six births, want to have two children given the dynamics of such societies where polygamy and large families are the norm among the urban middle classes or the rural poor? The risk of curtailing a country’s cultural norms looms large.
International examples have not been encouraging. Top-down family planning approaches have led to the coercion of many vulnerable and poor people by governments eager to meet targets of population control in China, Namibia, Peru and India. Setting numeric targets, such as giving 380 million women access to contraceptives by 2020, risks tampering with people’s legitimate reproductive rights. The approach fails to address the genuine concerns raised by those sceptical of the family planning agenda for religious or cultural reasons or for fear of a coercive population control agenda. These groups have genuine reasons to be concerned given the length some governments have gone to achieve targets in reducing population — such as the on-going forced sterilisation in India (an initiative part of a programme funded by the UK’s Department for International Development).
Polarising and contradictory language
So how have these risks been glossed over? At the level of semantics, the language employed by birth control discourse presupposes its benefit. By subsuming women’s rights and human rights within its purview, it polarises the debate: pro-family planning advocates are seen as moral champion of women’s rights, other groups with legitimate cultural oppositions — religious and otherwise — are seen as out of touch with them.
Family planning has been framed within a human rights narrative as giving the world “a moral obligation to help ensure that everyone, equally, has the right to access family planning”. At the outset, religious leaders are shown to oppose family planning, without giving the organisations an opportunity to defend their work in development. It is worth noting that well-known abortion providers such as the International Planned Parenthood Federation and Marie Stopes International were partners of the London Summit.
The concern is that the London Summit approach to family planning will mask wider structural change. Sub-Saharan African women need access to affordable and quality education, better health care services and economic opportunities. As Ms. Theo Sowa, CEO of Africa’s Development Fund noted at the London Summit "Education is one of the best family planning techniques we have, so let's educate and empower our women". A study by the United Nations Population Fund in Nigeria shows that the contraceptive prevalence rate increases with education, literacy and wealth. Thus, a government’s socio-economic policies are a precondition for women voluntarily deciding to have more manageable family sizes.
There are no shortcuts to economic and social development. Political leaders should not be given reasons to excuse their governance failures towards citizens — education and health care, employment and economic opportunities — by blaming population growth or a lack of contraceptives. Service delivery rests with reform-minded leaders implementing transformational economic and social policies, not with birth control policies.