Saturday, April 18, 2015

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Family Planning is No Substitute for Development

Zainab Usman argues that new family planning strategies could obscure wider deficiencies in governance.
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Melinda Gates speaking at the London Summit on Family Planning. Photo by Russell Watkins (DFID)

“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 ChinaNamibiaPeru 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.

Going forward

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.

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Do reasonable, compassionate and responsible human beings have a “duty to warn” of looming threats to future human well being and environmental health, and then to sensibly help one another respond ably to the challenges? Or are we to pose as if we are blind, deaf and dumb to the human-driven global predicament looming before all of us and thereby let the least fortunate, most poorly situated and simply unaware among us suffer the consequences, come what may?
What we know thanks to well-established scientific knowledge about evolutionary biology, humankind and the finite physical world we inhabit would lead sensible people to conclude that there is precious little that can be done to change the ‘trajectory’ of human civilization. So powerful is the force of evolution that we will “do what comes naturally” by continuing to overpopulate the planet and await the next phase of the evolutionary process. So colossal, reckless and relentless, too, is the unbridled expansion of the global political economy now overspreading the surface of Earth and polluting its frangible environment. Even so, hope still resides within that somehow humankind will make use of its singular intelligence and other unique attributes so as to escape the fate that appears ‘as if through a glass darkly’ in the offing, the seemingly certain fate evolution appears to have in store for us. In the face of all that we can see now and hear, I continue to believe and to hope that we find adequate ways of consciously, deliberately and effectively doing the right things, according the lights and knowledge we possess, the things which serve to confront and overcome the ‘evolutionary trend’ which seems so irresistible.
Somehow we have to grasp much more adequately the sum and substance of our distinctly human nature, with special attention given to improving our ‘reality orientation’ with regard to such vital issues as human population dynamics. Although relatively small in number, evolutionary biologists and scientists in other fields of research understand what the best available science indicates to us about the skyrocketing growth of absolute global human population numbers in our time. Research of outstanding scientists indicate that the population dynamics of the human species is essentially similar to, not different from, the population dynamics of other species. We have uncontested, apparently unforeseen and unfortunately unwelcome scientific evidence regarding the ‘placement’ of the human species within the order of living things that is everywhere denied; whereas, preternatural theories (eg., Demographic Transition Theory), political ideologies (eg., Conservatism and Liberalism) and economic theologies (eg., neoclassical economics) are deceitfully and ubiquitously presented as supported by science. To elect to extol the virtue of ideas that have been refuted by scientific research cannot be construed as the right thing to do. Even though ‘political correctness’ is predominant and accepted everywhere as what is real and ‘all that really matters’, when theory, ideology and theology are directly contradicted by science, then the best available science must be widely shared and consensually validated. Scientific knowledge must come to prevail over spurious theory, self-serving ideology and specious theology.
There are several things we can at least begin to think about: learn how to live without fossil fuels; adapt to the end of economic growth; substitute a steady-state economy for the endless growth economy we have now; stabilize human population numbers worldwide; and deal with the relentless dissipation of Earth’s limited resources, the reckless degradation of its environs, the wanton extirpation of its biodiversity as well as confront other human-induced threats to our planetary home as a fit place for human habitation. In any event, I trust most of us can agree that stealing the birthright of children everywhere, mortgaging their future, and exposing them and life as we know it to foreseeable danger cannot somehow be construed as the right things to be doing. We have to think clearly and keep our wits about us as we move courageously away from outrageous overconsumption, unconscionable hoarding and big-business-as-usual activities to a way of life that embraces true sustainability. Perhaps necessary and positive changes toward more sustainable lifestyles and right-sized corporate enterprises are in the offing.
Steven Earl Salmony
AWAREness Campaign on The Human Population, established 2001
Chapel Hill, NC

Well written article. Negetive population growth and its long term effects as consequence of family planning which is presently being confronted by Europe and the Americas will have a devastating impact on African countries in their present economic state.

Instead of Nigeria reaching a point where there is a population explosion, the government should make a policy where a couple is allowed to give birth to a maximum of 3 children.

In this era of political correctness,no doubt,factions will still argue over Africa's unrequired need of family planing as a developmental policy. But the idea that some things are too sensitive and or too little to be acted upon are what is keeping them shrouded in silence. For me,family planing has never and will never be a top geared health insurance policy toward addressing developmental and reproductive health issues,two phenomena that has engulfed the fabric of almost every African society. What the London summit suggested or rather focused on is more like assembling a car without an engine.The basic structural component upon which the target population should use in understanding the rationale behind such policy is completely absurd and dysfunctional. Cultural and societal norms adds to the complexities of making such policy feasible in an society faced with socio-economic deficiencies,political instability and security challenges as reflected in the recent societal breakdowns. Another unattended issue is decongesting the already overloaded theoretical framework without many meaningful impacts on the targeted countries. A situation that need massive redressing if the issue of reproductive health is to be made relevant in averting maternal child deaths. Overall,the consequences of adopting family planning upon a society driven by illiteracy,hunger,poverty,insecurity and a deficient health system are too compounded to be curtailed by the initial simple,otherwise one directional idea of the policy. The elementary necessities of life must be made basic - albeit empowering women in all capacities of life. By so doing, 90% of the caprices would have been solved and the women will automatically,in response to their literate consciousness,deploy various mechanisms and strategies to fit into the developmental system without havng to be bothered with family planing policy and it likes.

I think the revival of focus on contraception and population control in Africa is long overdue. Providing birth control solutions to African women is actually empowering them. Long gone are the traditional beliefs that a woman has to have six plus children! Even my illiterate grandmother in the village would be utterly surprised at such an attitude. Who can afford it? The new African woman (including the one in rural areas) has a slightly different mindset. Given the choice, she would use bc anyday because she has other obligations and ambitions besides bearing children. This applies to both the literate and illiterate. Even if you point out the other problems of governance and poverty in Africa as the main challenges to healthcare, you cannot turn a blind eye to the essence of population control in developmental matters. Our resources are scarce, misused and depleted as it is. Governments are actually struggling to sustain the current populations! What will happen if we add more people to the already unbalanced equation? Not every Western initiative is unpalatable. The Melinda Gates initiative might reduce some of the problems. After all, Rome was not built in a day.