Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health

I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH,  to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.

I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)

Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:

i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.

One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.

iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.

Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.

 

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

World’s 7 billionth baby causes journalistic storm

09/11/2011 Comments Off on World’s 7 billionth baby causes journalistic storm

Last week, an opinion piece in the New York Times in response to the birth of the world’s seven billionth baby put forward family planning as the solution to the problem of the still rapidly rising population of the world.

It took pot shots at UN demographers for not being able to predict precisely when the numbers would reach 7 billion. It claimed that family planning, all by itself, could solve problems such as climate change and the destruction of forests, and blamed the absence of family planning for poverty, civil wars and even terrorism, due to an excess of youth in still growing populations! As if youth, and not old men, started wars.

This article is a real throwback to the old days when all the world’s ills were blamed on overpopulation and contraception was put forward as the only solution. Unfortunately, there has been a rash of such articles, one more erroneous than the next. An article in the Guardian quotes none other than Paul Ehrlich, making the same 1968 claims which, as Prof John MacInnes points out in a letter, have been discredited. Then, he claimed that population growth would lead to widespread famine when in fact drought and inequitable global food distribution policies is what causes famine; now he claims that development, which in regard to agriculture prevented famine, will lead to famine.

As MacInnes accurately explains, it is the rapid fall in mortality over the past 100 years, and not, any longer, increases in total fertility rates, that mainly drives population growth. In the past 4-5 decades, total fertility rates around the world have been falling rapidly, and more and more countries have achieved below-replacement fertility levels, such as almost all eastern and western European countries. Fertility levels (number of babies born per woman) are falling rapidly in most other countries as well. Only the poorest and least developed countries are lagging behind.

Unfortunately, below replacement fertility levels have triggered negative reactions in some countries, Russia being the most egregious recent example. [1] Russia has just passed restrictions on legal abortion and introduced pro-natalist policies in which women are offered financial and other incentives to have more babies. Such policies are supported by rightwing conservative religious forces that are opposed to women having any reproductive rights regardless of population trends. The subject is far more complex than it has been presented as being.

Unlike peer-reviewed journals, newspapers and other media do not have (or rather do not make) the time to have anything they publish peer reviewed. Articles about the seven billionth baby have to be published the day that baby is born or at most the day after. Newspaper editors seem to act on the principle that if an article contains false or distorted or contestable information, oh well, there are letters to the editor to correct it. This is a major mistake. The seventh billionth baby is not the same kind of “news” as Berlusconi stepping down or the US being stupid enough to bomb Iran. Articles such as the ones in the NY Times and the Guardian deserve more thought and research not only because they can contribute to misinformation of the public, who do not all have access to the facts, but also because they tie people who do have access to the facts up in knots writing letters to the editor to correct the errors. These letters must use far fewer words than the original article was given, and are placed at the back of the paper, without a big headline, and with the certainty that far fewer people will see the reply than read the original article.

When it comes to science, medicine and health issues – and in this case global demographic trends and the reasons for them – newspapers and the media could and should try harder to ascertain the truth value of what they publish – before they publish it. And they should avoid “prophet of doom” headlines as well. They could so often be an important source of information for the public of valuable health information and scientific understanding of crucial aspects of our lives. And many times they are. But they are also often responsible for purveying false or only partially true, and ultimately distorted, information. Some journalists are unable to interpret or present information contained in peer-reviewed articles accurately or in a more journalistic form, and some choose to rely for their information on people claiming to be experts whose work is itself inaccurate, and who may also have their own axes to grind.

There were two main wrong claims in the NY Times article. The first was the erroneous assertion that family planning is a solution to “many of the global problems that confront us, from climate change to poverty to civil wars”. On its own, family planning is not a solution to either climate change or poverty, though its greater use by those who have an unmet need for “family planning” would be beneficial and contribute to the solutions in both instances. As regards civil wars, I would be interested to learn whether there is any evidence whatsoever that the use of family planning reduces civil wars. I doubt such evidence exists. The claim is absurd. Similarly, I doubt there is evidence that “youth bulges”, that is, a high proportion of a country’s population being young, make countries more prone to conflict or terrorism.

The second wrong claim was support, indeed praise, for anyone who supports the use of contraception but at the same time condemns women’s need for safe, legal, induced abortion. Anyone who does so is not a friend to women, anywhere in the world. Abortion is an essential part of family planning, always has been and always will be, whenever contraception fails or people fail to use it, no matter how high contraceptive prevalence may be.

Family planning has had short shrift in recent years in development policy and funding. Yet contraceptive prevalence rates are also as high as they can get in many countries and rising in most others. To support this trend, family planning deserves more attention and more support in every country of the world. Family planning, and in that I include access to and use of both effective contraception and safe, legal abortion, is essential if women and men are to be able to control their fertility and decide the number and spacing of their children, if indeed they wish to have children.

We don’t need family planning to reduce HIV infection; we need safer sex and needle exchange programmes for that. We don’t need family planning to prevent the earth being devastated by climate change. We need environmental policies to be implemented post haste and a serious change in how we spend our riches and use the earth’s resources. There is no need to tout contraception as a cure-all or a panacea for all the world’s ills. It is valuable enough in itself that there should be no need to pretend it is more than it is.


[1] Russian government seeks to enact laws restricting abortion to increase birthrate. RHM 2011;19(38):219-20

“Human beings have only a 50-50 chance of surviving to the end of the 21st century”

05/06/2011 Comments Off on “Human beings have only a 50-50 chance of surviving to the end of the 21st century”

On 25-26 May, I attended a conference in London, organised by University College London Centre for Global Health, called Population Footprints, on sustainability.

The prediction that we humans have only a 50–50 chance of surviving to the end of the 21st century serves to focus the mind wonderfully. It is based on the seriousness of the environmental problems created by climate change and rising carbon emissions, over-consumption, scarcity of education and employment, population growth, scarcity of resources such as potable water, failure to develop renewable energy, maldistribution of food, the threat of rising sea levels, which could destroy coastal cities and change coastlines worldwide. Health in the context of environmental stress. Urbanisation. Migration. And so on.

Sitting there, I asked myself: What will I do differently starting tomorrow morning, in response to this prediction? In fact, shame on me, I didn’t do anything different. And that’s the problem!

Then I thought: If you were told you had a disease that, only with treatment and only if you changed your behaviour, you would have a 50-50 chance of surviving, would you change your behaviour then? What about 60-40 or 70-30? Not good odds for the whole of humanity, is it? But this is where we stand.

So what’s it got to do with sexual and reproductive health and rights? Some people came to the conference to push for renewed efforts to reduce population growth – a group called Population Matters, for example (no relation to RHM). What was heartwarming, then, was the fact that almost everyone else there had realised that it was a whole string of issues calling for radical change in the direction of sustainability that matter. Including policy on development, trade and health care, and food distribution; access to clean water, education and social welfare; care of the environment and recycling of waste; the role of war; the damage caused by both wealth and poverty; changing economic policy from a 19th century growth model; stabilising population levels, increasing family planning, and seeking demographic balance in population age. But above all, dealing with climate change by capping and reducing carbon emission levels as soon as possible. Family planning  was no longer being presented as the solution on its own. Whew!

We (that is, my generation) who opposed population “control” policies in the 1970s and 80s that abused the right of women and couples to decide the number and spacing of their children, don’t have to go back to square one and start over. But wait – family planning needs to go back on national agendas, with increased funding, with choice of methods and generic production, and popular education about the importance of planning one’s family. The fertility rate is falling almost everywhere but the unmet need for contraception and safe, legal abortion remains enormous; as does the broader need, for reproductive and sexual health.

I started to think about policies in the past that said: one kid or two kids and you’re sterilised. The Chinese have had a one-child policy for 30 years now, and their population has stopped growing. The policy is open to abuse, yes, and it’s incredibly controversial, but it is also widely supported, seen to be a necessity. Could anyone do better, being responsible for a quarter of the whole world’s population? The debate about whether the policy can be relaxed, and when, and how much, is heated, according to the one Chinese participant there. Fantastic! In what other country is population policy the subject of heated public debate?

I’m worried about carbon emissions. We’re already at the stage of not-OK. What happens if we don’t bring down carbon emissions soon enough? Will we get the equivalent of ‘two kids and then you’re sterilised’? For example, you won’t be allowed to fly more than so many miles and once a year. Trains instead of planes. Imagine that! Grounded on a global scale.

Uganda is worried about how they will ever feed, educate, house and find jobs for the 50% of their population who are currently under 15 years of age. Even if things weren’t falling apart there, it would be near impossible.

On the other hand, I was so heartened to hear someone say we have to drop the 19th century model of economic growth and find a 21st century way to organise our economies. Fantastic! Could it lead to the end of production of junk?? A move away from a militarised economy which is expensive and wasteful? Required recycling of all waste? Acknowledgement of wealth and over-consumption as a major source of problems? Limitations on upper income levels? Solar and wind power a must? Less complex technology, more jobs? Yes, yes, yes!

Sustainability. That’s the key. Roll up your sleeves – we have work to do!!

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