Family planning is a controversial frontier in the maternal health field. Almost everyone can get behind saving mothers and babies from preventable death–be it from hemorrhages, anemia, preeclampsia, or logistical barriers to doctors and health care.
But granting women control of their reproductive choices is as controversial in the developing world as in the US.
Save the Children put out a report (pdf) last week in preparation for an upcoming summit on Family Planning in London in July. The report, like most shiny development documents, is in many ways a sales pitch to convince funders, public and private, to prioritize investment in family planning.
Shocking statistics open the document, followed by high contrast, beautifully saturated portraits of women who need contraception.
Spacing births is well known to improve health outcomes. Children born less than two years after their preceding sibling are “more than twice as likely to die as a child who is born after a three-year gap.” Mothers who rush from birth to pregnancy to birth to pregnancy suffer higher odds of dying from complications. Their nutritional stores deplete with each pregnancy and are never given time to replenish, so women grow progressively weaker as pregnancies pile on.
The report highlights the logistical barrier to getting contraception to far-flung mountains and deserts, and of course, like all sales pitches, the numbers are tucked far below the emotional testimonies. 4.1 billion dollars are needed to get contraception to the 215 million women who want it but can’t get it (“unmet need” in development jargon).
But buried even below that ungodly number is the real challenge: “Even when contraception is provided free of charge at a reliable nearby clinic, many women are still unable to use family planning due to discrimination and lack of empowerment.”
Which is to say, culture and society place barriers as serious as the easier to grasp issues of money, infrastructure, and logistics.
Senegal is a case in point. Twenty-one percent of menopausal women had given birth to 10 children or more in 2005. Nineteen percent of births occurred less than two years after the preceding birth (that is delivery to delivery, so these women have at most 15 months not pregnant in between).
Only 10.3 percent of Senegalese women use modern contraception. The ministry of health pointed to “sociocultural and religious convictions”, “negative image of family planning” and “absence of marital and community support” among other influencing factors for the low rate.
Last year Senegal hosted the 2011 International Conference on Family Planning, which put then President Wade in the hot seat. He had to walk a tightrope between the sometimes-conflicting gazes of the visiting international health elite and the local imams.
Senegal is 95% Muslim and spiritual leaders hold significant sway in the court of public opinion. Wade is quoted as saying at the conference, “As believers, we can only give explanations to make it understood that it is useless to bring 10 or 15 children into the world without having means to support them.”
His suggestions continued in a line of fitting family planning into cultural and religious beliefs: “I will not say to the youth to have fewer spouses, but to have fewer children. Couples should voluntarily accept to reduce births.”
The country’s shallow reach of contraceptive access points in part to a trust in faith over medicine to deliver health outcomes.
But let’s not “otherize” African Muslims for ideologically based health behavior. One of the major hurdles to contraceptive access has been lack of support from international donors. President George W. Bus pushed massive increases in HIV funding but mostly focused on treatment, not prevention. Those policies “took the sex out of AIDS,” Johns Hopkins Professor Duff Gillespie told The Guardian, and allowed conservatives to deal with AIDS while letting reproductive health and contraception fall to the back burner.
Currently, the US, one of the largest family planning funders, dispenses $648.5 million for international family planning, which is down $100 million from 1995, according to the Center for Gender Health and Equity.
With insufficient funding, insufficient demand, insufficient access, and widespread suspicion of contraceptives, there are still many knots left to untangle before women control when and how often they have children. This month’s London Conference will try to unwind some of those issues, at least rhetorically. But the cultural chasm between health policy makers and African mothers remains significant and often overlooked.