A giant step forward on contraception -- but we can't lose sight of abortion

The London Family Planning Summit on July 11 drew an impressive amount of global attention -- and money -- to the vital cause of improving access to contraception in developing countries. While there's much to celebrate in this bold initiative, some troubling concerns need to be addressed if the global community truly hopes to cut the high death toll from pregnancy, most of which is completely avoidable with basic reproductive health care and a little political will.

An estimated 222 million women, mostly in developing countries, want to delay or stop childbearing but lack the ability to do so because they can't access effective contraception. After witnessing the desperate need firsthand in her global travels, billionaire philanthropist Melinda Gates (and husband Bill) co-hosted the London summit, together with British Prime Minister David Cameron and the United Nations Population Fund (UNPFA). It was the first large international meeting on family planning since the 1994 United Nations conference in Cairo, signalling a possible sea change in global attitudes towards birth control.

At the one-day summit, donor countries, NGOs, and the private sector pledged $2.6 billion to provide voluntary planning services to 120 million more women and girls in the developing world -- with the Bill & Melinda Gates Foundation alone pledging $560 million. In addition, over 20 developing countries promised to increase public spending on family planning and improve the status of women in their countries.

Family planning is a proven and cost-effective health intervention that saves lives. If the summit initiative succeeds in its goal to reach 120 million women by 2020, it will result in 200,000 fewer women dying in pregnancy and childbirth, 110 million fewer unintended pregnancies, 50 million fewer abortions, and 3 million fewer babies dying in their first year of life.

How exactly does reducing unintended pregnancies save lives? Here are some key health and social benefits of using contraception:

• Spacing pregnancies at least 2 years apart is better for women's and babies' health. When pregnancies occur too close together, women are more likely to have unhealthy pregnancies and to die in childbirth. Their newborns are more likely to be premature or have a low birth weight, and more likely to die before age 5.

• Delaying or preventing pregnancy protects the health and lives of certain groups of women. Adolescent women face an increased risk of health problems and death from early childbearing. Older women also face increased risks, as do women with additional health issues.

• Pregnancy and childbirth always carry some health risks. Fewer pregnancies (in the world overall, and per woman) will translate to lower rates of maternal mortality and morbidity.

• Choosing to limit the size of one's family is a basic human right. When a woman has more children than she wants or can care for, it not only poses health risks to the entire family, it may result in hardship, a lesser quality of life, and loss of freedom and independence.

• Families and entire communities benefit through reductions in poverty and an improved quality of life. Melinda Gates calls this the "virtuous economic cycle." She cites a decades-long study on the effects of offering family-planning information and contraception to women in Bangladesh. Compared to a similar group that did not have such access, contraceptive use increased, fewer women died in childbirth, child mortality decreased, and families became wealthier. This in turn led to higher levels of education, better access to water, better quality housing, improved health, and greater financial security.

As Gates rightly insists, there is "no controversy" in providing access to contraception to women who want it and need it, because the overwhelming evidence that it saves lives cannot be denied. This puts anti-choice "moral" opposition to birth control on very tenuous footing indeed. We can see a desperate backlash playing out in the United States, where the Republican Party is waging an all-out war on contraception, even though it's been legal for decades and used by virtually all American women, and even though this "War on Women" has created a gaping gender gap that could easily cost the Republicans the election in November. Here in Canada, the Conservative government's distaste for contraception meant it had to be shamed into including funding for family planning in its G8 maternal health initiative -- but only 2 per cent of the total money allocated so far has been spent on family planning.

Apart from the problem of right-wing dinosaurs like the Conservatives and the Republicans, what are the other concerns about this commendable global drive to provide voluntary family planning to every woman that wants it? The past spectre of coercive population programs has raised its head, with concerns expressed over some of the donor countries wanting to reach contraceptive "targets" and "compete" with other countries, rather than espousing a human rights-based approach that would ensure that women voluntarily choose birth control without any pressure.

Second, the driving force behind the London Summit and one of the largest donors is a private citizen whose largesse is comparable to a medium-sized country donor like Australia or Belgium. While Melinda Gates is well-intentioned, courageous and committed, providing basic reproductive health-care services to hundreds of millions of women around the globe should not be the responsibility of a private citizen. As Marge Berer points out: "This golden moment ... had to happen mainly because so many governments have failed to take responsibility for the public health needs of their citizens..."

Alarmingly, Berer notes that many developing countries who made promises and pledges at the summit are the same countries with abysmal records on women's rights -- countries in which governments are "too cowardly to make abortion legal and safe," where women "are dying from complications of pregnancies because they have no access to life-saving maternity care," and nations that have received "hundreds of millions if not billions of U.S. dollars for family planning, which have as good as disappeared, or been squandered and misspent." How confident can we be that much of the newly pledged $2.6 billion won't be similarly "disappeared," with little or nothing to show for it?

Melinda Gates is Catholic, and while she strongly supports access to birth control, she has deliberately excluded provision of safe abortion from her foundation's work. But 13 per cent of maternal deaths in developing countries are still due to unsafe abortion, making it impossible to effectively address maternal mortality without addressing the terrible scourge of unsafe abortion. Even with reasonable access to contraception, there will always be a need for safe abortion because contraceptive use is imperfect and no method is completely effective.

Nevertheless, this major new investment in contraception is groundbreaking, and has the real potential to save millions of lives in years to come. Is it possible to celebrate it even while it leaves aside the necessity of safe abortion? Certainly, but it means that abortion providers and advocates must fill the void and lead the way in furthering access to safe and legal abortion. As reproductive health expert Dr. Malcolm Potts (Professor at the Bixby Center for Population, Health, and Sustainability, School of Public Health, University of California at Berkeley), states:

"Politics is the art of the possible and compromises need to be made. I think Melinda could not have established the leadership she showed at the London Family Planning Summit if she had not set the abortion controversy aside. I am passionately committed to safe abortion, but with medical abortion you don't need great subsidy (in India, mifepristone/misoprostol is US$2.00 wholesale). We do need money for family planning. I think we should welcome what has happened, which is a giant step forward for women. It is up to us [abortion providers and advocates] to get the info about medical abortion around -- it is the ultimate game changer. I can teach 30 people in an afternoon to use mife/miso or miso alone and I don't need billions of dollars to do that." (personal communication, July 25).

Nothing exemplifies this better than the excellent work of Women on Waves, which on a small budget, has established a growing global network of safe abortion hotlines, including in Kenya, Pakistan, Indonesia, Chile, Ecuador, Peru, Argentina, and Venezuela. The hotlines give women information on how to safely abort by ordering mifepristone pills through the mail or purchasing misoprostol at a local pharmacy. Self-use of misoprostol by women is a cost-effective and promising way to reduce abortion-related complications and deaths because of its accessibility, low price, and its relative safety over other traditional clandestine methods. Use of misoprostol has spread rapidly throughout Latin America, where it appears to be significantly reducing the maternal mortality rate from unsafe abortion, despite strict laws against abortion in most countries. For example, evidence suggests that serious complications from unsafe abortion have been reduced by 75 per cent in the Dominican Republic, where misoprostol was introduced in 1986.

Of course, medical abortions that are safer but still illegal are no substitute for repealing criminal laws against abortion, which are blatant tools of discrimination against women. The present danger is that the singular focus on contraception might politicize and marginalize abortion care even more than now. It could make it harder to lobby for legal reform and repeal of anti-abortion laws by intimidating people from speaking out about it. As a condition of receiving family-planning funding, aid groups might not be able to help women who need abortion services and health-care workers could be prevented from providing care.

In developing countries, most women resorting to abortion are already mothers who are just trying to survive and support their families, while some are young women trying to build a future for themselves without the serious stigma and challenges of single motherhood. They should not be forced to risk their health and lives with unsafe, illegal abortion. Not only is safe and legal abortion a basic human right, it is an essential, life-saving component of reproductive health programs, alongside family planning and safe childbirth services. We must never let the world forget that.

Joyce Arthur is the founder and Executive Director of Canada's national pro-choice group, the Abortion Rights Coalition of Canada (ARCC), which protects the legal right to abortion on request and works to improve access to quality abortion services.

Photo: Russell Watkins/Department for International Development/Flickr

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