Investing in what the world’s poor really want: a response to Bill and Melinda Gates

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posted on September 22, 2017 by Nadja Wolfe

Investing in what the world’s poor really want: a response to Bill and Melinda Gates

In a recent piece for the Wall Street Journal (paywall), Bill and Melinda Gates wrote about their support for continued health investments as a way to reduce poverty in developing countries. They identified the President’s budget recommendation to stop funding contraception as a major concern, despite Congress’ likely continuation of contraceptive funding. The essay raises awareness about the much-needed aid to some of the poorest countries in the world but misses the mark on what women and families in these countries really need and want.

Bill and Melinda Gates Foundation FEMM Natural Womanhood Fertility Awareness

Senegalese women

Why aren’t more Senegalese women using contraceptives?

The Gates recount efforts to improve contraception access and awareness in Senegal as a success story for foreign aid. The Senegalese government has clearly made contraceptive provision a priority, but it’s not at all clear that Senegalese women agree. According to the article, only 10% of women of reproductive age in Senegal were taking birth control in 2011. Yet, despite a “massive public awareness campaign” and drastically reducing shortages, five years later the number of women using contraceptives is still only around 15% (described in the article as a percentage increase of “more than half”).

The article indicates that women’s choices are limited by cultural factors, and that may be part of it. But there is also good evidence that “culture” isn’t the whole story. A 2016 report published by the Guttmacher Institute, a strong supporter of increasing contraception use, found that most women in the sub-Saharan African countries surveyed knew about contraceptives and could access them (p. 28). The report presented itself as an answer to “unmet need for contraception,” a figure calculated by the number of fertile women who are sexually active, want to delay pregnancy, but aren’t using “modern methods of contraception.” This number is often used to justify increasing funding to improve contraceptive access.

Yet most of the women surveyed had reasons that increasing access won’t address. These included infrequent sex, not having returned to fertility following pregnancy, and sub-fecundity (p. 35). A quarter of married women also cited personal objections to contraceptive use, and of those women, three in five said they personally opposed using contraceptives (id.). Among unmarried women, very few cited cost or lack of awareness for non-use, but over a quarter of unmarried women in the African countries in the study said they were concerned about side effects, health risks, or inconvenience (p. 37). These figures are reflected to a greater or lesser extent in other developing countries, too, where many women discontinue or switch contraceptive methods due to side effects.

Why are we telling women they’re wrong about their choices and priorities?

As the above report discussed, many women in developing countries (like their counterparts in developed nations) have both health and ethical concerns. Many women have experienced side effects due to contraceptive use. Informational campaigns may address those concerns, but full information about how hormonal birth control works may also raise new questions. Moreover, transposing our medicated approach of family planning to countries where basic medical support and options are scarce fails to address the most pressing health needs. Preventing pregnancy is only one aspect of reproductive health care; perfect contraception access is not a substitute for skilled birth attendants, prenatal care, or adequately stocked clinics for childbirth.

Ethical values deserve no less consideration than concerns about side effects; in fact, as rights of conscience are enshrined in international human rights law, they deserve more. When women tell us they aren’t interested in contraceptives, we should find ways to help them achieve their family planning goals and meet their health needs in ways that are acceptable to them, rather than pressure them to conform to certain values and ideologies.

Any campaign to promote a particular health commodity must respect patients’ dignity and autonomy. A bedrock principle of this imperative is informed consent. Knowing that a contraceptive method will prevent pregnancy, an explanation of the side effects and potential health risks, such as blood clots, and instructions to manage or stop treatment are essential to realizing the human right to the highest attainable standard of health. Developed countries often fail to ensure women have the information they need to make an informed choice; we should not export this problem to developing countries.

Bill and Melinda Gates

Bill and Melinda Gates

How can we meet women’s needs?

We have to meet people where they are, cognizant of their values, cultures, priorities, and environment. Culture- and values-sensitive information is the best way to ensure that women and couples make the best choices for themselves. Fertility literacy ensures that women (and men) understand how their bodies work, the health-hormone connection, and how various methods of family planning affect their health and hormonal levels.

Fertility awareness methods of family planning often provide this essential information, have a proven track record of sustainable use in poor countries, and are consistent with the cultural norms of local populations. These programs teach women and couples about their hormonal health and about the ovulatory cycle, what a healthy cycle looks like, when to get medical help for hormonal imbalances, and how to use this knowledge to achieve or avoid pregnancy. Many women and couples find this knowledge empowering and helpful, and whatever decisions they make afterward are truly informed. Media campaigns promoting contraceptive use simply cannot compete with actual patient knowledge and understanding in terms of informed decision-making and better health and education outcomes.

Informed patients not only make informed choices; they get better healthcare because they know when they need it. The birth control pill has been used as a treatment for a wide variety of health concerns, from debilitating pain to persistent acne, without much attention to what is causing the problems. While the pill can manage symptoms, suppressing natural hormonal activity does not treat hormonal imbalances. Diagnosing and treating the specific hormonal imbalances is the only way to actually restore health.

With 14% of American women taking birth control primarily as treatment, and as many as 58% saying that they were managing health symptoms in addition to avoiding pregnancy, perhaps the question we should be asking ourselves isn’t why so few African women are using contraceptives, but why so many American women rely on the pill to manage their symptoms rather than get real healthcare. At the least, we shouldn’t impose our healthcare and family planning solutions onto women through foreign aid. If we fail to respect these differences in culture and values, we risk turning our good intentions into a new form of colonialism.

When we take the focus off the pill and put it onto women, where it belongs, it becomes clear that the real shortage is of knowledge. By educating women and doctors about hormonal health, we can help women improve their health and achieve their fertility goals. That, Mr. and Mrs. Gates, is something worth investing in.

Nadja Wolfe, JD, is the Director of Advocacy for World Youth Alliance and a policy consultant for Fertility Education & Medical Management (FEMM)

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