In a 2017 article for the Wall Street Journal (paywall), Bill and Melinda Gates wrote about their support for continued health investments as a way to reduce poverty in developing countries. They identified the President’s budget recommendation to stop funding contraception as a major concern, despite Congress’ likely continuation of contraceptive funding. The essay raises awareness about the much-needed aid to some of the poorest countries in the world but misses the mark on what women and families in these countries really need and want.
Why aren’t more Senegalese women using contraceptives?
The Gates recount efforts to improve contraception access and awareness in Senegal as a success story for foreign aid. The Senegalese government has clearly made contraceptive provision a priority, but it’s not at all clear that Senegalese women agree. According to the article, only 10% of women of reproductive age in Senegal were taking birth control in 2011. Yet, despite a “massive public awareness campaign” and drastically reducing shortages, five years later the number of women using contraceptives is still only around 15% (described in the article as a percentage increase of “more than half”).
The article indicates that women’s choices are limited by cultural factors, and that may be part of it. But there is also good evidence that “culture” isn’t the whole story. A 2016 report published by the Guttmacher Institute, a strong supporter of increasing contraception use, found that most women in the sub-Saharan African countries surveyed knew about contraceptives and could access them (p. 28). The report presented itself as an answer to “unmet need for contraception,” a figure calculated by the number of fertile women who are sexually active, want to delay pregnancy, but aren’t using “modern methods of contraception.” This number is often used to justify increasing funding to improve contraceptive access.
Yet most of the women surveyed had reasons that increasing access won’t address. These included infrequent sex, not having returned to fertility following pregnancy, and sub-fecundity (p. 35). A quarter of married women also cited personal objections to contraceptive use, and of those women, three in five said they personally opposed using contraceptives (id.). Among unmarried women, very few cited cost or lack of awareness for non-use, but over a quarter of unmarried women in the African countries in the study said they were concerned about side effects, health risks, or inconvenience (p. 37). These figures are reflected to a greater or lesser extent in other developing countries, too, where many women discontinue or switch contraceptive methods due to side effects.
Why are we telling women they’re wrong about their choices and priorities?
As the above report discussed, many women in developing countries (like their counterparts in developed nations) have both health and ethical concerns. Many women have experienced side effects due to contraceptive use. Informational campaigns may address those concerns, but full information about how hormonal birth control works may also raise new questions. Moreover, transposing our medicated approach of family planning to countries where basic medical support and options are scarce fails to address the most pressing health needs. Preventing pregnancy is only one aspect of reproductive health care; perfect contraception access is not a substitute for skilled birth attendants, prenatal care, or adequately stocked clinics for childbirth.
Ethical values deserve no less consideration than concerns about side effects; in fact, as rights of conscience are enshrined in international human rights law, they deserve more. When women tell us they aren’t interested in contraceptives, we should find ways to help them achieve their family planning goals and meet their health needs in ways that are acceptable to them, rather than pressure them to conform to certain values and ideologies.
Any campaign to promote a particular health commodity must respect patients’ dignity and autonomy. A bedrock principle of this imperative is informed consent. Knowing that a contraceptive method will prevent pregnancy, an explanation of the side effects and potential health risks, such as blood clots, and instructions to manage or stop treatment are essential to realizing the human right to the highest attainable standard of health. Developed countries often fail to ensure women have the information they need to make an informed choice; we should not export this problem to developing countries.
How can we meet women’s needs?
We have to meet people where they are, cognizant of their values, cultures, priorities, and environment. Culture- and values-sensitive information is the best way to ensure that women and couples make the best choices for themselves. Fertility literacy ensures that women (and men) understand how their bodies work, the health-hormone connection, and how various methods of family planning affect their health and hormonal levels.
Fertility awareness methods of family planning often provide this essential information, have a proven track record of sustainable use in poor countries, and are consistent with the cultural norms of local populations. These programs teach women and couples about their hormonal health and about the ovulatory cycle, what a healthy cycle looks like, when to get medical help for hormonal imbalances, and how to use this knowledge to achieve or avoid pregnancy. Many women and couples find this knowledge empowering and helpful, and whatever decisions they make afterward are truly informed. Media campaigns promoting contraceptive use simply cannot compete with actual patient knowledge and understanding in terms of informed decision-making and better health and education outcomes.
Informed patients not only make informed choices; they get better healthcare because they know when they need it. The birth control pill has been used as a treatment for a wide variety of health concerns, from debilitating pain to persistent acne, without much attention to what is causing the problems. While the pill can manage symptoms, suppressing natural hormonal activity does not treat hormonal imbalances. Diagnosing and treating the specific hormonal imbalances is the only way to actually restore health.
With 14% of American women taking birth control primarily as treatment, and as many as 58% saying that they were managing health symptoms in addition to avoiding pregnancy, perhaps the question we should be asking ourselves isn’t why so few African women are using contraceptives, but why so many American women rely on the pill to manage their symptoms rather than get real healthcare. At the least, we shouldn’t impose our healthcare and family planning solutions onto women through foreign aid. If we fail to respect these differences in culture and values, we risk turning our good intentions into a new form of colonialism.
When we take the focus off the pill and put it onto women, where it belongs, it becomes clear that the real shortage is of knowledge. By educating women and doctors about hormonal health, we can help women improve their health and achieve their fertility goals. That, Mr. and Mrs. Gates, is something worth investing in.
photo credit: Wikimedia Commons https://commons.wikimedia.org/wiki/File:Femmes_senegalaises.jpg
There is so much wrong with this statement it’s hard to know where to start.
The absolutely last thing Africa needs is more Africans. Africa, where women give birth on average to 4.7 children and the population is rising nearly three times faster than in the rest of the planet.
You are advocating that ignorance is bliss, that there is danger in educating people in a region already dealing with unsustainable populations. Overbreeding is the single number one reason for rampant poverty in Africa, with corruption and mismanagement closely behind.
By 2100 Africa’s population could be three billion to 6.1 billion, up sharply from 1.6 billion today, if birth rates remain stubbornly high. This unexpected rise will stress already fragile resources in Africa and around the world.
A significant fertility decline can be achieved only if women are empowered educationally, economically, socially and politically. They must also be given easy and affordable access to contraceptives. Following this integrated strategy, Mauritius has lowered its fertility rate from six to 1.5 children; Tunisia’s rate dropped from seven to two.
Men also have to relinquish sole control over the decision to have children and refrain from abusing wives or partners who seek birth control. Because in most African societies men dictate when they wish to have sex with their women regardless of the woman’s desire to do so. Spousal rape is not even a concept in most of Africa. ONLY by allowing women unfettered access to regular contraceptives can control over childbearing decisions can be passed onto the women.
For such efforts to succeed ultimately, government leaders must encourage public and policy conversations about slower population growth. When there is no leadership in this area, foreign NGOs must step in to help and prevent the population ticking time bomb.
Africa is already mired in ignorance about birth control and taught by Christian missionaries and particularly of the Catholic ilk that contraception is immoral. In fact the previous Pope Benedict XVI (the quitter) , once said that condoms can “increase the problem” of HIV and AIDS. A blatant lie.
So endemic is the Catholic brainwashing that according to a Pew Poll Research poll in Nigeria and Ghana, roughly half or more of each population said that contraceptive use is “morally unacceptable” (54% and 52%, respectively). Out of the 40 countries surveyed, only Pakistan (65%) had a higher rate of opposition.
There is less moral objection to contraception in the other sub-Saharan African nations in the survey, but significant shares in Uganda (38%), Kenya (33%) and Senegal (28%) said contraceptive use is morally wrong. The comparable figure for the U.S. is 7%.
Your suggestion that African women should just use the rhythm method (aka The Vatican Roulette) is archaic, absurd and scientifically proven to be no more effective than expecting the man to “pull out” in time.
If you actually care about your fellow humans in Africa, please stop spreading misinformation about the issue.
Your extremism is showing.
Maybe many African women *want* four children each. They might not want westerners to “enlighten” them. Why not let them soak for themselves instead of “educating” them.
Your assertions about fertility awareness being the “rhythm method” are not accurate. You actually used “thermometer” and “archaic” in the same sentence. All those ancient basal body thermometers out there, huh? Modern fertility awareness is actually pretty scientific (it’s biology).
The only thing I agree with is that yes, in cases where men are abusive to their wives in Africa, something needs to be done to help them. Giving them contraception so their husbands can continue raping them consequence-free doesn’t do *anything* to actually stop the bad behavior though.
If you would address the actual words and concepts in this article, then your comments would be taken more seriously instead of appearing to be an ideological rant.
Yeah, who knows, maybe they really do want a life of poverty and suffering also. Different strokes for different folks right? Let’s not educate they about anything and they just let them fend for themselves. Survival of the fittest. We can just loan them more money that they can never pay back so that they are indebted slaves until the end of time.
Btw, “Fertility awareness” IS the rhythm method and it IS as archaic as it is ineffective.
Its promotion as an actual “tool” of birth control is equivalent to treating illness with a placebo medicine like homeopathy.