China: how can the one-child policy and rights-based family planning be reconciled in the face of recently reported abuses?

23/07/2012 Comments Off on China: how can the one-child policy and rights-based family planning be reconciled in the face of recently reported abuses?

Lisa Hallgarten, RHM social media and communications

Marge Berer, RHM editor

Two recent news stories from China have reawakened concern about overzealous enforcement of China’s one-child policy and the emergence of voices critical of the policy and its implementation. Historically, being a country with 25% of the total world population within its borders, China’s population policy has addressed a unique set of social, demographic and political circumstances, and overall, it appears to have had widespread support from the public. However, these two reports have resonated internally and far beyond its shores.

In the United States, the story of Chen Guangcheng ,the Chinese civil rights activist imprisoned and persecuted for exposing and protesting against abuses of women being forced to have abortions against their will, in the name of Chinese government policies, has been co-opted by anti-abortion US activists. Though he has spoken out mainly against the brutality of forced abortions, not abortion per se, he is being used as a poster boy by the US anti-abortion, anti-contraception movement. Stories of forced abortion, and other human rights abuses associated with the one-child policy, are being presented as the logical conclusion of all and any family planning policies.

In one of two recent stories that hit the press due to US publicity, a mother of one was snatched from her home and forced to have an abortion. The procedure went tragically wrong and just hours later the 38-year-old woman was dead.  In another report, a woman who was seven months pregnant was also forced to have an abortion.  The story and pictures of the woman lying beside the aborted fetus were posted on the internet, generating over a million hits on Chinese social media networks. In response, the officials in the second of these cases lost their jobs and were prosecuted  More recently the women was given financial compensation as well.

At the same time, a flurry of anecdotes from other parts of China have started to emerge about the practice of forced abortions: contradicting the official party line that such practices – especially abortions in late pregnancy – are illegal, rare and not countenanced by the government.

A look at the Population and Family Planning Law of China  is instructive. It aims to maximise contraceptive use and minimise population growth by providing local and district officials with financial and other rewards for meeting family planning targets. The motivation this might create for officials to be overzealous in their implementation of the policy is tempered with tepid instructions not to infringe the rights of women and families and to promote family planning using incentives rather than coercion. In one of the cases above, the woman and her husband were threatened with a huge fee if they wished to continue the pregnancy, which they could not have afforded. This raises questions of which incentives and disincentives, if any, are acceptable to the population, how to prevent coercion, what to do when it happens, and what rights women have to redress and compensation when coercion has been shown to take place. Underlying these questions are broader policy issues – whether it is possible to reconcile the need to limit population growth with its attendant targets for coverage of contraception and even abortion.

The Family Planning Summit in London this month said that the funding associated with the new FP Initiative will explicitly NOT be used to support coercive family planning. It did, however, set ambitious targets for contraceptive coverage, though when criticism was raised, the language was changed to read contraceptive access. Whether it will be possible to achieve a huge increase in contraceptive use without incentives and targets, and how this relates to donor expectations with “results-based financing”, remain on the table for discussion. The consequences for informed choice and the right to use or not to use a method hang in the balance. At the same time, given the many barriers to accessing as well as using contraception successfully in the world’s most underserved communities, there will be enormous pressure to prove that the initiative really can give 120 million more women access to contraception.

The anti-abortion, anti-contraception movement would love to discredit the whole programme, as they have sought to do for years in the United States as regards the Chinese policy. Everyone who supports the right to control fertility needs to be committed to ensuring that any new programmes providing contraception will have women’s rights at their heart in practice. If they don’t, this one-off commitment of money may never be repeated.

Also in the news on this issue:
A group of Chinese scholars have written an open letter calling for revision of the one-child policy. They argue that the policy is bad for human rights and also for sustainable economic development.  Some Chinese demographers have said the one-child policy will damage the country as low fertility rates threaten a shortfall in the productive labour force needed to fund the ageing population.

We have no idea whether these statements are typical of public views. The public debate that has ensued inside China since these reports have come out must be multi-faceted and far from one-sided. We would be happy to receive further reports of the many points of viewbeing expressed in this debate, including by the government, as it unfolds within China.

Race, Reproductive Politics and Reproductive Health Care in the Contemporary United States

20/07/2012 Comments Off on Race, Reproductive Politics and Reproductive Health Care in the Contemporary United States

This editorial from the journal Contraception offers an important analysis of population and family planning policy in the USA, both in the context of current politics and also from history, starting as far back as 100 years ago.

Carole Joffe, Willie J. Parker

From: Contraception [Editorial] July 2012 reprinted as a blog with kind permission of Carole Joffe

To paraphrase Leo Tolstoy, who famously wrote that all unhappy families are unhappy in their own way, we can say that all nations confront the thorny issue of demographics, but each in its own, typically controversial, way. Various European countries, for example, have anxieties about a “demographic winter,” which is a below replacement birth rate of the native population, which has led to corresponding fears about rising birth rates among Muslim immigrants. China, driven by worries about overpopulation, has instituted coercive reproductive policies that many observers find unacceptably harsh. The United States, a country marked by extreme stratification on both racial and economic grounds, is a particularly interesting case to consider from a demographic lens because there has been a history both of targeting the birth rates of people of color and at the same time deep political divisions about the provision of reproductive health services — particularly abortion but increasingly, as the current election season reveals, contraception as well.

We, a sociologist and physician, respectively, write here of our dismay about the contemporary state of reproductive politics in the United States and particularly the cynical manipulation of racial themes by the opponents of abortion and birth control. However, we are acutely aware of the mixed legacy of the United States with respect to demographic issues. To name but a few examples, in 1905, President Theodore Roosevelt warned of “race suicide” because of his concern about falling birth rates among white Anglo-Saxon women and the higher rates among immigrants.1 In the 1927 Supreme Court case, Buck v Bell, the Court upheld a statute instituting compulsory sterilization of the unfit, including the mentally retarded, “for the protection and health of the state”.2 In the 1960s, impoverished African-American and Latina women, along with some poor whites, were subjected to coerced sterilizations, often without these women fully understanding to what they had ostensibly agreed.3 When the first federally funded family planning centers were established in the early 1970s, as a result of the passage of Title X, they were disproportionately located in African-American communities, although the language of the legislation did not mention race but rather the income status of the intended recipients.4

Co-existing with these events, however, has been a longstanding reproductive freedom movement in the United States, made up of clinicians and lay activists alike. Starting in the early 20th century, doctors and nurses, along with lay allies, fought for the legalization of first, birth control, and, later, abortion, seeing the particular damage done to the most vulnerable women in the absence of such services. In the 1960s and 1970s, feminist health activists raised an outcry about the sterilization abuses mentioned above; indeed, among the most prominent of the reproductive rights organizations to emerge from the “second wave” feminism of that era was CARASA, the Committee for Abortion Rights and Against Sterilization Abuse, providing a template for the principle that abortion rights should ideally be considered in a broader context that includes the right to have children.5 That generation of feminist activists also severely criticized the then-common practice of testing new contraceptive methods on Third World women. Today, there are numerous reproductive rights/reproductive justice groups hard at work in the United States, a number of them specifically concerned with the situation of women of color.

In short, this very brief recapitulation of reproductive struggles in the United States reveals the truism that the world of sexual and reproductive health services is a complex terrain, always containing both liberatory and coercive possibilities, and always with particular implications for people of color in a white-dominated society. But with respect to present-day conflicts, no figure’s legacy has been more contested than that of Margaret Sanger, the founder of the organization that eventually became Planned Parenthood. Anti-abortion forces for years have accused Sanger of being a racist and a eugenicist. Currently, these groups have pounced upon the high rate of abortion within the African-American community — black women have abortions at nearly four times the rate of white women — and have joined forces with some conservative groups within that community to mount a vigorous campaign against Planned Parenthood in particular and abortion provision more generally. Starting in Atlanta, and spreading to other cities, these groups have sponsored controversial billboards — some proclaiming that “black children are an endangered species” and others comparing abortion to slavery.

As Ellen Chesler, Sanger’s premier biographer, has argued, such accusations are a distortion of Sanger’s record.6 Although Sanger did receive some support from eugenicist organizations (at a time when eugenics was a far more mainstream movement than it is currently), her record cannot be construed as “racist.” Among her supporters were numerous black ministers, leading African-American intellectuals such as W.E.B. Dubois, and prominent community leaders such as Mary McLeod Bethune, founder of the National Council for Negro Women. In 1966, when Dr. Martin Luther King accepted the first Margaret Sanger award from Planned Parenthood, he praised Sanger for “her courage and vision,” comparing her struggle for birth control to the civil rights movement. One of the most effective critiques of the billboard campaign, and against the larger agenda of demonizing Planned Parenthood, has come from Sistersong, a coalition of reproductive justice groups of women of color. As Loretta Ross, the executive director of the group told the New York Times, “The reason we have so many Planned Parenthoods in the black community is because leaders in the black community in the ‘20s and ’30s went to Margaret Sanger and asked for them. Controlling our fertility was part of our uplift out of poverty strategy, and it still works”.7

This manipulation of the history of race and reproduction by those involved in the billboard campaigns and similar efforts obscures the contemporary facts of life faced by the most vulnerable black women. These women experience high rates of unintended pregnancy, low use of the most effective forms of contraception, deep poverty, inadequate educational opportunities, unacceptable levels of intimate partner violence and, very often, lack of support from their churches. It should come as no surprise that these same women would have the highest rates of abortion in this country. Given the conditions, these women need — among many other services — access to comprehensive health care that includes both family planning and abortion. Yet, abortion has long been excluded from most mainstream health care institutions and sources of public funding, and during the current political season, we have watched with dismay the severe attacks on contraceptive coverage as well. The isolation of abortion, in particular, from the rest of health care has contributed to its stigmatization and has helped the development of conspiracy theories, such as we see in the billboard campaign. We decry the inflammatory, false rhetoric of “black genocide” that has been used in this campaign by anti-abortion extremists, and we are hardly the first to point to the hypocrisy of those who oppose contraception and abortion, yet just as fervently oppose any spending for social services.

One of us (WP), speaking from my perspective as a member of the African American community and as a women’s health provider, asserts that this attempt to manipulate my community is made possible by our unresolved issues regarding gender roles and sexuality in a modern context. The failure of our community to promote the agency of our mothers, sisters and partners, and to deal forthrightly with sexual matters, leaves us treating abortion and HIV-related issues as “open secrets.” This evasion results in exorbitant rates for both. To truly confront these issues, our community desperately needs medically accurate sexuality education, improved health literacy and a constructive engagement of religious and spiritual leaders, given the central importance of religion in the African-American community. This type of empowerment effort towards shared reproductive health responsibility is the only effective rebuttal to the mischief occurring with race and reproduction in our community. To paraphrase Dr. King, just as individual wealth is always a function of the commonwealth, thus it too holds true that compromising the reproductive health and rights of individual black women results in jeopardizing the collective well-being of black communities.

If to know is to become responsible, my awareness of black women’s unmet reproductive health needs requires me to provide family planning and abortion care to those most in demand for them. Doing so represents a dual sense of responsibility that I feel as both a women’s health provider and as a member of the African-American community. I join with those in my community who have articulated a vision of reproductive justice, defined as creating a society that enables all women and families to have the children they want, the resources needed to raise them, and the ability to prevent or end the pregnancies that they do not want. I call on my fellow health care providers, of all races, to trust women to make the good and tough decisions about when and whether to expand their families. A fundamental respect for fairness necessitates it, and a respect for human rights demands it.

In conclusion, as already noted, we write in a period of unprecedented political attack on women’s health issues — not just abortion, but also contraception and a range of other reproductive health services. Even the seemingly long settled issue of the importance of programs to combat domestic violence is now being resisted by conservative forces.8 This “war on women,” as it has come to be known, has galvanized a countermovement of health activists, both women and men, who have effectively and creatively protested these developments in a variety of ways. We are greatly heartened by this mobilization, although its eventual impact on elections and restrictive measures is unclear at this time. We close by reminding our readers of what is perhaps obvious: the stakes in this “war” are inevitably the highest for the most vulnerable in our society — those poor women of color about whom we have written in this editorial.

Carole Joffe
Advancing New Standards in Reproductive Health
Bixby Center for Global Reproductive Health
University of California, San Francisco
Oakland, CA

Willie J. Parker
Board member
Physicians for Reproductive Choice and Health
New York, NY

  1. Roosevelt T. On American Motherhood. Available at http://www.nationalcenter.org/TRooseveltMotherhood.html (accessed July 20, 2012).
  2. Buck v. Bell, 274 U.S. 200 (1927). Available at http://www.oyez.org/cases/1901-1939/1926/1926_292 (accessed July 20, 2012)
  3. Schoen J. Choice and coercion: birth control, sterilization, and abortion in public health and welfare. Chapel Hill: University of N. Carolina Press; 2005;
  4. Gordon L. In: The moral property of women: a history of birth control politics in America. Urbana, IL: University of Illinois Press; 2002;p. 289–291
  5. Petchesky R. In: Abortion and woman’s choice: the state, sexuality and reproductive freedom. Boston: Northeastern University Press; 1990;p. 392
  6. Chesler E. Was Planned Parenthood’s founder racist?. Salon. 2012;Nov 2. Available at http://www.salon.com/writer/ellen_chesler/(accessed July 20, 2012).
  7. Dewans S. Antiabortion ads split Atlanta. New York Times. 2012;Feb 5. Available at http://www.nytimes.com/2010/02/06/us/06abortion.html?scp=1&sq=Shaila%20Dewan%20Margaret%20Sanger&st=cse (accessed July 20, 2012).
  8. Joffe C. All common ground lost: the right’s opposition to the Violence Against Women Act. Rhrealitycheck.org. Available at http://www.rhrealitycheck.org/article/2012/03/16/all-common-ground-lost-rights-opposition-to-violence-against-women-act (accessed July 20, 2012).

Family planning and safe, legal abortion go hand in hand

19/07/2012 Comments Off on Family planning and safe, legal abortion go hand in hand

Marge Berer

Editor, Reproductive Health Matters

One in three women in the UK will have an abortion in her lifetime, most of whom will have been using contraception of some kind. Yet since as long ago as the late 1930s, there has been a split in the UK between those who insisted on promoting contraception on its own because they thought abortion was too controversial and would hold back acceptance of family planning, and those who insisted that the two go hand in hand. This split exists in many countries, not just the UK, and also within many organisations with a large membership in different countries, such as the International Planned Parenthood Federation (IPPF). It is reflected most recently in a comparison of the list of 600 groups and individuals who have endorsed the International Campaign for Women’s Right to Safe Abortion this year, and the 1300 that signed a letter circulated by the IPPF supporting the Family Planning Initiative – very different groups are on those lists. Yet all of them support the right to control fertility.

In 1994, the ICPD Programme of Action, a consensus document on the integration of sexual and reproductive health and rights, was only able to be passed if it included a “compromise” clause that called for abortion to be safe only if it was legal. This compromise was and remains a violation of public health principles and women’s human rights. ICPD failed to condemn the often 19th century, often colonial laws on abortion still in place in the criminal code in many countries. However, the Programme of Action did recognise that unsafe abortion was a major public health problem, one which to this day still affects some 22 million women every year, among whom 5 million end up in hospital with complications annually and tens of thousands die (WHO, Guttmacher). And young women, whom everyone wants to be  seen to be supporting these days, are in fact most at risk of unsafe abortion and also have the least access to contraception (Shah & Åhman, RHM, May 2012).

The answer is not to promote contraception in order to reduce unsafe abortion, as the FP Summit did. The answer is to promote contraception to reduce unwanted pregnancy and provide safe abortion to every woman who finds herself with an unwanted pregnancy. That is the way to make unsafe abortion history. Abortion will not go away unless men and women stop having sex with each other or everyone is sterilised. So forget it! The growing number of countries in both the north and south, east and west, where there is 60-80% contraceptive prevalence proves that. Research shows that women and men take up contraception in large numbers if they feel they have the right to control their fertility and have access to the means to do so. There is a huge need for information, because every new generation of young women and men will know nothing about contraception or abortion unless they have access to this information. But there is no need for “demand creation”, a retrograde concept which implies lack of interest. The steadily falling fertility rate globally, falling since the 1970s, proves that, and in every country, abortion is in there, safe or unsafe, reducing the number of births. Forty-four million abortions globally and hundreds of millions of people using contraception and sterilisation prove the huge demand for the means of fertility control. “Unmet need” is more than just lack of knowledge or interest on the part of the women and men who aren’t using contraception, or using it erratically or unsuccessfully.

Women seek an abortion if they have an unwanted pregnancy, legal and safe or not, because it’s too late for contraception. There is no split between contraception and abortion from women’s perspective, they are two sides of the same coin. Even so, many of the biggest supporters of “family planning” refuse to support women’s need for safe, legal abortion. Even worse, they always talk about abortion in negative terms. They mention it along with STIs, as if it were a disease, or treat it as an annoying problem that they wish would go away, and consider it inferior to use of contraception. They even claim that use of contraception will (or should) make it go away. But this is about the realities of people’s sex lives and how sex happens, not just about well-thought-out, planned-in-advance decisions about family formation. Many pregnancies are started without any forethought at all, and all too often as one of the consequences of sexual pressure and coercion.

Campaigns for women’s right to safe, legal abortion have been going on for at least 100 years. Many of us involved in these campaigns are still seen as annoying by people who are supposed to be our colleagues. We’re told it’s sensitive, controversial, difficult, it can’t be put on the agenda, including in the FP Summit. At the same time, many of us who are fighting for abortion rights stopped supporting “family planning” years ago, because of what happened in the past, when coercive programmes put many people off “family planning” and gave it a bad name. Some family planning supporters have blamed ICPD for the neglect of family planning, because it placed family planning in a wider context. But as Gita Sen said at the Summit, ICPD in fact sought to rehabilitate family planning and restore its good name, while the barriers to safe abortion were left in place.

Today’s supporters of family planning would like everyone to forget the coercive programmes of the past, which were target-based. But they may yet become target-based again because of “results-based financing”. So let’s not confuse opposition to coercive family planning policies with being anti-family planning. Yet, it is absolutely true that provision of contraception has been neglected in recent years – and yes, this neglect must stop. At the same time, neglect also characterises how women’s unmet need for safe abortion is treated. What needs to change is that both forms of unmet need should be taken into account – together – starting with donor and national government policies.

For example, although DFID’s development aid policy has long been to fund both family planning services and abortion services, in their roll-out of these policies, funding for family planning is (I am told) separated from funding for safe abortion. That is, it is managed by different people and in different programmes within DFID and in the recipient countries, and these different people may not work closely together or know what each other are doing. Yet DFID did not see a problem in agreeing to a family planning initiative in which funding for abortion is excluded. They fund abortions anyway, they say, so what’s the problem? The problem is that separating abortion from family planning at the programmatic level allows some countries to keep abortion legally restricted and not take responsibility for unsafe abortion.

Then there’s the US, where support for family planning by USAID has been the highest in the world for many years now, while safe abortion services are not funded by them at all. Since ICPD, however, the US has funded post-abortion care, which was invented at ICPD as a way to save women’s lives who had had an unsafe abortion. Unfortunately, the evidence that post-abortion care has in fact saved many women’s lives since ICPD is sparse and not compelling. Yes, the number of deaths from complications of unsafe abortion has fallen a lot, but this may be due to self-medication with misoprostol replacing life-threatening methods.

In fact, once ICPD was over, this so-called post-abortion care should have been rejected as unethical, because it allows harm to be done unchallenged and forces health care providers to clean up the mess without the support of the law. Under US aid policy, even countries where abortion is legal who tried to use USAID funds for safe abortions as well as for contraception and sterilisation, in integrated programmes, had their “family planning” funding stopped. Research has now shown that this leads to higher rates of unwanted pregnancies and abortions in those very same countries, proving how illogical such a policy is/was. Will that evidence, published only recently, lead to a change in USAID policy? Unlikely. Too sensitive. And meanwhile, a violent and fanatical anti-abortion movement flourishes in the US, where some of the most punitive and misogynistic barriers to safe abortion are being implemented with near impunity, in one state after another.

The anti-abortion movement is also anti-family planning. For years, they were very circumspect about this as they feared, quite rightly, that it would lose them support. But the current Vatican has helped to bring anti-abortion opposition to contraception and assisted conception out in the open again. This is evidenced in campaigns to ban emergency contraception and assert conscientious objection to providing contraceptives, e.g. by pharmacists. But still, many in the family planning movement do not support the right to safe abortion.

In light of the Family Planning Summit, it is a good time for abortion rights activists who have ignored family planning to link up with the family planning movement, and help to ensure that services have a rights-based approach. It is also a good time for all family planning colleagues to support the right to safe, legal abortion alongside the right to access contraception and sterilisation – and talk about abortion as a legitimate part of fertility control, a solution to unwanted pregnancy, a public health necessity for women, and a legitimate health care service. All of us should acknowledge the huge unmet need for safe, legal abortion services as well as for contraception and sterilisation services, and ensure that they are provided – and funded – together.

Many effective contraceptive methods, condoms, two types of emergency contraceptive pill and two very safe methods of early abortion – all on the WHO essential medicines list – can and should be provided at primary health care level. This includes medical abortion pills and manual vacuum aspiration for abortions up to 9-10 weeks. Some of these can even be provided during home visits by community-based health workers – the pill, condoms, injectables, emergency contraceptive pills and medical abortion pills for early abortions – as long as there are nurses, nurse-midwives or other mid-level providers who have been trained to do so. The evidence is there– this is all safe and effective. Moreover, the legitimate sort of post-abortion care, i.e. the kind that happens after safe abortions, needs to include information about and provision of contraception, just as post-partum care ought to do. So, even programmatically and clinically, the integration of family planning and abortion makes more sense than ever.

The morning after: the beginnings of an assessment of the FP Summit

16/07/2012 Comments Off on The morning after: the beginnings of an assessment of the FP Summit

Marge Berer
Editor, Reproductive Health Matters

13 July 2012

From a communications point of view, the FP Summit was a raving success. Newspapers, TV and radio all over the world covered it. Around the globe everyone reached by the media heard how wonderful family planning is and how neglected it has been, the Lancet launched a special edition , Guttmacher and others released facts and figures showing the extent of unmet need. Across the women’s health movement the listserves, Facebook and Twitter were full of it. All in all, the day – and many of the messages it gave birth to – had enthusiastic, even missionary, overtones.

On the absolutely fabulous side, Melinda Gates’ challenge to the Pope to acknowledge that contraception is ‘not controversial’ even amongst Catholic women, is likely to rock the foundations of the Vatican’s whole policy on abstinence, condoms and contraception from the grassroots of the Catholic church up. It was God’s gift to Catholics for Choice, who will be promoting Condoms-for-Life and safer sex at the upcoming AIDS conference later this month.

Also on the plus side, there were representatives of governments and many, many others who are making progressive change happen in their countries, and who spoke out about it. These are people who can make a big difference when they get home who did support comprehensive sexual and reproductive health and rights from the podium and the floor of the meeting, and who insisted that family planning services can only be provided within that wider remit. There were people who needed to learn what it was all about, some of whom were too young to have lived the history, but who came with strong pro-choice views.

The media exposure of the value of family planning has a huge potential for good, because it will have reached people who didn’t know family planning existed or whether it’s good for them and safe, and others who have never had a chance to talk about these matters with others. It will also have put fertility control as a public good on the map around the world. And hopefully it will spur those with expertise in sexuality and reproduction to start talking about what they know, and what is and is not true amongst all the hoopla – and to assert that the power of money must not be allowed to take precedence over public health values and human rights principles, or the values of knowledge and truth.

On the oh-God-help-us-no-no-no side, though, Melinda Gates anointed herself as the new saviour of women’s and children’s health, and the press ate it up in both pictures and words. Some of the best people in the field of sexual and reproductive health, were unexpectedly uncritical, singing the praises of this wonderful opportunity. Perhaps not surprising given the historical shortfall in funding for family planning.

A golden moment, the kind that big money and a Tory government are at home in, stage-managed by a slick public relations company called McKinsey (who describe themselves as “the trusted advisor and counsellor to many of the world’s most influential businesses and institutions”). With big pharma, having abandoned contraceptives for many years, talking about the opportunity (“70% of this market is under-served”) to make a profit from family planning needs and then give some of it back to women – as a charitable gift. Patting each other on the back for being so wonderful as to finally have recognised that women have health needs they can exploit. A truly Hollywood event, except this is not entertainment. This is women’s lives.

This golden moment, which had to happen mainly because so many governments have failed to take responsibility for the public health needs of their citizens, for maternal health, family planning, abortion, sexual health, in the only equitable manner that works – by providing publicly funded, well-resourced services.

It was a day that showed the world it was possible for one very well-meaning woman, backed by the power and money of her husband, to direct global policy and claim ownership of the provision of family planning to 120 million women and at the same time, to disparage and stigmatise women’s need for abortion to the entire world – and get away with it without being challenged. She had the courage to challenge the Pope. It is a shame that a summit attended by many of the world’s experts on these subjects could not emulate her bravery and challenge her in return.

She was not the only one who got away with it. The Summit also gave the podium to and applauded politicians from countries where millions of women have the very unmet need for contraception in whose name this Summit was called: women who are still dying from unsafe abortions because their governments are too cowardly to make abortion legal and safe; and women who are dying from complications of pregnancies because they have no access to life-saving maternity care. Countries that since the 1960s have received hundreds of millions if not billions of US dollars for family planning, which have as good as disappeared, or been squandered and misspent.

It included representatives of the very same private sectors whose services and prices for contraceptive methods and safe abortions remain inaccessible to and unaffordable for many in the world’s population who need them, especially young women and men. And not only in low- and middle-income countries, but also in the United States, a country whose health industry has made life hell for Barack Obama for trying to make health care even a little bit more affordable, excluding abortion of course, for millions of disenfranchised people. The United States – a country that has the biggest and most violent and aggressive anti-abortion movement on earth, second only to the Vatican, and some of the highest unintended pregnancy rates in the developed world, especially among poor women.

It was addressed by the Prime Minister of the UK, the Right Honourable David Cameron, who got a standing ovation for a speech about the importance of empowering women, a speech that stank of hypocrisy. A Prime Minister who is responsible for indefensible, swingeing spending cuts that are adversely affecting women, young people and children above all, including cuts in family planning, sexual health services and welfare, at a time when it has never before cost so much to raise a family. Whose Secretary of State for Health is selling off our National Health Service piece by piece, who has wasted public time and at least £1 million in public money harassing some of the real heroes of women’s rights, that is, abortion service providers, for no credible reason. Whose Minister for Public Health put an anti-abortion group on the government’s sexual health advisory group “for the sake of balance” and to propitiate anti-abortion fanatics in Parliament – a Minister who described abortion as a “sensitive” issue, after 45 years of safe, legal abortions (except for women in Northern Ireland, of course).

And now it’s the morning after. How to go on from here and engage in what will happen? It’s a pity about Melinda Gates’ prejudices against abortion. I hope she will reconsider them because it would make her a far more credible ambassador for this cause which, after all, does not belong to her.

Making change happen is in the air

13/07/2012 Comments Off on Making change happen is in the air

Marge Berer

Editor, Reproductive Health Matters

Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.

Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…

The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…

Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).

In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).

full editorial

All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

11/07/2012 Comments Off on All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

Marge Berer, Editor, Reproductive Health Matters

I was among the first generation of women in the 1960s to experience the miracle of the pill just at the age when I was wanting to start having sex. All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant if I didn’t want to, and it worked! But oh, if only it had all turned out to be that easy! Like one in three women in the UK today, a country where contraceptive prevalence is almost as high as it can get, I needed an abortion several years later. Again, I was lucky, the 1967 Abortion Act meant I was able to get a legal abortion. The lesson is simple – while contraception continues to be a miracle, because it helps people not to have children if and when they don’t want to, it is not enough on its own and it never has been.

Family planning has been out of the news for a long time, and suddenly it’s back. Welcome!! Bring out the red carpet, and I mean it!! Women and men need contraception now as much as they have ever done, and young women and men who are beginning to explore their sexuality together need contraception and condoms more than anyone. But there has been a lot of water under the bridge since family planning was promoted as the cure-all for the world’s ills in the 1960s when the pill came out, and everyone needs to study that history anew so that the same mistakes, of which there have been many, and the same narrow vision, are not repeated.

My generation of women’s health activists, along with a whole generation of researchers, service providers and policymakers who brought their knowledge together at the International Conference on Population and Development in 1994, got the world to recognise that the need for the means to control fertility, which is as old as history itself, was part of a much broader set of needs related to reproduction and sexuality, and that these were inextricably connected. These include: being able to have sex without fear of negative outcomes, being able to have sex if and only if we want to and only with whom we want to, being able to have the children we want, being able to get pregnant at all, being able not only to survive pregnancy but also still be in good health, being able to have a safe abortion without fear of death or condemnation when an unwanted pregnancy occurs, being able to protect ourselves from sexually transmitted diseases, and being able to get treatment for all the many causes of reproductive and sexual ill-health, which start with menstruation and menstrual problems, and continue into old age with things like breast and prostate cancer and uterine prolapse.

There is indeed a huge unmet need in today’s world, but the unmet need for contraception is only a fraction of the unmet need for sexual and reproductive health, and for sexual and reproductive rights. The results we should be working for encompass every aspect of the issues I have just named, and those in turn must be seen in the even wider context of the right to health, social justice and an end to poverty and violence – which were the real point of the Millennium Development Goals – not the measurable targets.

I will be blogging about these issues in the light of the FP Summit over the next weeks – watch this space!

Can we ever say a woman can’t choose?: a response to Frances Kissling

14/01/2011 Comments Off on Can we ever say a woman can’t choose?: a response to Frances Kissling

Can we ever say a woman can’t choose? It’s hard for pro-choicers to admit sometimes a woman shouldn’t be allowed to choose abortion – but we have to
by Frances Kissling Salon, 21 June 2009.

This article, which I’ve only recently discovered, was posted on the Salon website last year. Salon long ago closed the discussion, but alongside Ann Furedi,[1] I feel compelled to respond, because I want to exclude myself from the group she has placed herself in, one she wants to call pro-choice but now believes has the right to refuse women a late abortion.

Frances would not be the first person to move from being pro-choice on abortion to being against some aspects of it, if not becoming completely against it. This article appears to be indicative of such a shift on her part. Yet the Frances I know has been a formidable force in challenging official Catholic  doctrine on abortion. As a board member and later first president of Catholics for a Free Choice she became the face of an organization that brought together Catholics from all over the world to take a public stand against a profoundly anti-women doctrine, all of them people who refused to give up their identity as Catholics. She argued then that according to Catholic theology, acting upon one’s own conscience was the most profoundly ethical stance on abortion that a person can take.

So what has moved Frances from there to here, where she calls for refusing some women an abortion?

The case that she says first moved her to rethink her views, which she was asked to respond to on an ethics panel, was the kind of case an anti-abortionist would come up with, of a woman with a seemingly “frivolous” reason for wanting an abortion . There were few details offered, only that the couple didn’t want a second boy (“oh, it’s just that we wanted a girl”, presented as if it were equal to “oh, but I wanted the blue dress, not the red one”). There was no apparent gender discrimination mentioned, as there mostly is when fetal sex is given as a reason for abortion. The couple are one-dimensional; they have no history, no background. Their “case” for abortion is easy to reject. And of course there are always some women and couples who have “lightweight” reasons for seeking an abortion, and many more who could and should have prevented the pregnancy, but should they become the basis for compromising the whole ethos of women’s choice on abortion? You can’t be involved in abortion issues, read the literature or work in an abortion clinic without knowing that people with trivial reasons for abortion form a small minority of abortion seekers and that those who have to confront an unwanted pregnancy do learn (the hard way) about taking responsibility. Mostly they learn well because they never come back. So why didn’t Frances reject the example given and ask for a serious case to exercise her judgement on?

Instead of asking whether the couple should have been refused an abortion, perhaps the meeting should have asked: 1) whether a woman should ever have to justify or give reasons for her need for an abortion to the abortion provider at all, and 2) whether the provider should have the power to refuse a woman a procedure the outcome of which, one way or another, will have a major bearing on the rest of her life. The pro-choice answer to both these questions is no.

In making her case for refusing the woman an abortion, Frances fails to focus on the woman and the woman’s life, or what will happen if she has the baby, and instead decides she has to punish the woman and bring the baby into the world because the request comes late in pregnancy. A baby for which Frances has no duty of care and for whose life she will take absolutely no responsibility. But it is in fact the absence of responsibility for what happens to the woman and the baby, if the pregnancy is carried to term against the woman’s will, that explains why an abortion provider must never pass judgement on the validity of a woman’s need for an abortion. In my opinion, it is only possible to be anti-abortion if you will never be the one left holding the baby, nor be around to see or take responsibility for what happens to those who are.

And yes, for me that means that abortion providers should act as technicians with a clinical skill to offer, as all other medical professionals do, not as judges. Health professionals are not forced to provide abortions, and abortion providers who are only willing to do abortions up to a certain number of weeks of pregnancy should make this clear to everyone who seeks their help, and refer women to someone who can and will help them. The fact that there are so few doctors willing to provide late abortions in the United States is surely due as much to the fear of aggressive and oppressive anti-abortion harassment, violence and the very real threat of assassination as anything else. No morality in that.

This article makes the assumption that a person can be pro-choice sometimes and not at other times. How is this possible? “Pro-choice” is short for “supporting a woman’s choice on abortion”. It’s an unfortunate terminology, because it assumes that women really do have a choice and have more than one viable option to choose from. But this does not reflect the reality of most women’s lives or what women themselves say. Women risk their lives, if they have to, to end an unwanted pregnancy. It is not a matter of choice for them, but of overwhelming need. Nevertheless, even accepting the terminology, if the decision is not the woman’s, then the “choice” has either been denied altogether or it has been transferred to someone else – and that could as easily include George W Bush or the Pope as well as Frances. In my moral universe, anyone who thinks they have the right to refuse even one woman an abortion can’t continue to claim they are pro-choice. It’s a contradiction in terms.

As it progressed, I began to feel offended by this article because it says things such as “These things should make us pause and think hard.” (The “things” being some of the reasons women have given for seeking an abortion.) As if Frances is the only person in the pro-choice movement who has ever paused and thought hard about these things. By this point in her paper, the “we” and “us” who she claims to speak for begins to shift, however, because she separates herself from those of “us” who are pro-choice by such statements as: “I realize that expressing pro-life values, when you’re pro-choice, is much more complicated.” “Pro-life” is it now?

And then comes the final blow to any lingering concept of “choice” when she says: “But I have come to believe that women’s autonomy does not require that all efforts be made to protect women from pain or from hearing the word ‘no’.” Thus does she reject her own historic respect for women acting on their conscience and reduces them to the moral equivalent of spoilt children whose only problem is that they might feel pain or be refused something. In 1993, Frances encouraged me to publish “An open letter to a Diocesan priest”,[2] a personal statement about the lifelong pain of having to give up a baby for adoption as an alternative to having an abortion. Why does Frances no longer acknowledge this level of pain when she talks about “choice”? What really has made the person who put Catholics for a Free Choice on the map trivialise both much unwanted pregnancy and the women who experience it?

She goes on to say: “I think it’s important for us to be able to say: When a fetus reaches the point where it could survive outside the uterus, is healthy, and the woman is healthy, and she has had five months to make up her mind, we should say no to abortion”. Who exactly are the “we” that she now considers herself to be part of?

But wait a minute. If the actual subject of this inquisition is only women with unwanted pregnancies at 26 or more completed weeks of pregnancy, which is the point at which scientists agree the independent survival of a fetus outside a woman’s body begins to be feasible, she is actually talking about refusing abortions to only a handful of women. In Great Britain in 2009, for example, the number of women who had an abortion at 24+ weeks of pregnancy was 136 out of a total of 189,100 abortions. All 136 were on the ground that there was “a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped”.[3] None of these women had had five months to make up their minds.

Does this demolish her argument? No, I assume she would point to the 2,036 women that year who had abortions at 20+ weeks of pregnancy, on grounds of “risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”. Those are the women, I think, whom she accuses of having had five months to think about it and should have acted sooner. The fact that a third of them were less than 20 years of age, and none of them had had their abortions when the fetus was capable of independent survival may not alter her stance either.

Still, why has she singled these women out and stigmatised them and their circumstances as unworthy of the respect that legal abortion provision expresses? And if she would indeed force them to carry an unwanted pregnancy to term, why does she think they would want her compassion, let alone her help. Help? What help can she, would she, give them, year in and year out?

Anti-abortion sentiment like this is creating a climate of rejection of second trimester abortions, including those that take place well before “viability”, in countries across the developed world where the abortion law has (more or less) supported women’s choice on abortion for decades.

Everyone who is pro-choice would prefer for women not to need late abortions, just as everyone would prefer, in the best of all possible worlds, for there not to be any unintended pregnancies. But there are millions of unintended pregnancies globally every year, because we are imperfect, make mistakes, and are less in control of our lives and behaviour than we would like to be. The pro-choice answer is not and can never be to refuse women abortions. The pro-choice answer is to remove all the obstacles to getting an abortion as early as possible, provide young women and men with the education on abortion from an early age that would enable them to prevent pregnancy, recognise they are pregnant early on, obtain non-directive counselling and support if they need it , and if the pregnancy is unwanted, ensure there is timely access to abortion services. That combination of education, support and service delivery would allow almost all abortions to take place before 24 or even 20 weeks of pregnancy. Countries like Sweden, where women have the right to choose up to 18 weeks but abortion is legal until 24 weeks, have proved it is possible. But there will always be a handful of women who fall outside the net, even in the best of conditions. The moral thing, the compassionate thing, the pro-choice thing to do is to support them and do the abortions anyway.

Frances, come back!

This article was first posted on the RH Reality Check website on 2nd January 2011.


[1] A moral defence of late abortion. 20 December 2010. At: <http://www.spiked-online.com/index.php/site/article/10015/&gt;. Reprinted with kind permission at: <www.rhmjournal.org.uk>.

[2] Wolch Marsh MJ. Reproductive Health Matters 1993;1(2):87-91.

[3] Department of Health. Abortion Statistics, England and Wales: 2009. London: DoH, 2010.

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