A few days after I visited Vishwajeet and Aarti’s program, which trained community health workers who attended home births, I visited a maternal and newborn health program called Sure Start, which encourages mothers to deliver in clinics with trained birth attendants and medical equipment.
When I arrived at the project site, I was invited to watch a group of twenty-five pregnant women playing a quiz game on principles of good health, answering questions about early breastfeeding and first-hour newborn care. Then I met with a women’s group centered on pregnant women and their family members, mainly mothers-in-law and sisters-in-law. I asked the pregnant women if they faced any family resistance for participating in the program. Then I asked the mothers-in-law what changes they’d seen since they’d been pregnant with their own children. One older woman told me that she had given birth to eight children at home, but six had died within a week of delivery. Her daughter-in-law was now pregnant for the first time, and the older woman wanted her to receive the best possible care.
In the afternoon, I was able to visit the home of a mother named Meena who had delivered a baby boy just two weeks before. Meena’s husband worked for daily wages near their home. Their children had all been delivered at home except for the newborn, who was born in a clinic with the support of Sure Start. Meena held her infant in her arms as we talked.
I asked Meena if the program had helped her, and she gave me an enthusiastic yes. She felt delivering in a clinic was safer for her and the baby, and she had started breastfeeding the same day, which made her feel free to bond with her baby immediately, and she loved that. She was very animated, very positive. She clearly felt good about the program, and therefore so did I.
Then I asked her, “Do you want to have any more children?”
She looked as if I’d shouted at her. She cast her eyes down and stayed silent for an awkwardly long time. I was worried that I’d said something rude, or maybe the interpreter had offered a bad translation, because Meena kept staring at the ground. Then she raised her head, looked me in the eyes, and said, “The truth is no, I don’t want to have any more kids. We’re very poor. My husband works hard, but we’re just extremely poor. I don’t know how I’m going to feed this child. I have no hopes for educating him. In fact, I have no hopes for this child’s future at all.”
I was stunned. People tend to tell me the good news, and I often have to ask probing questions to find out the rest. This woman had the courage to tell me the whole painful truth. I didn’t have to ask. And she wasn’t finished.
“The only hope I have for this child’s future,” she said, “is if you’ll take him home with you.” Then she put her hand on the head of the 2-year-old boy at her leg and said, “Please take him, too.”
I was reeling. In a moment, we had gone from a joyous conversation about a healthy birth to a dark confession about a mother’s suffering—suffering so great that the pain of giving her babies away was less than the pain of keeping them.
When a woman shares her grief with me, I see it as a huge honor. I listen intently, offer sympathy, and then try to point out an upside somewhere. But if I had tried in that moment to say something upbeat to Meena, it would have been false and offensive. I asked her a question and she told me the truth; it would have denied her pain to pretend to be positive. And the pain she described was beyond anything I could imagine—she felt the only way to help her children live a good life was to find them another mother.
I told her as gently as I could that I had three children of my own, and that her children loved her and needed her. Then I asked, “Do you know about family planning?” She said, “I do now, but you people didn’t tell me before, and now it’s too late for me.”
This young mother felt like a complete failure, and so did I. We had totally let her down. I was so overwhelmed with emotion, I don’t even recall how we parted or how I said good-bye.
Meena dominated my mind for the rest of the trip. It took me a long time before I could take it all in. Clearly, it was good to help her deliver in a facility, but it wasn’t good enough. We weren’t seeing the whole picture. We had a maternal and newborn health program, and we talked to expecting mothers about their needs in maternal and newborn health. That was the lens we looked through to see the work, but the lenses we should have been looking through were the eyes of Meena.
When I talk to women in low-income countries, I see very little difference in what we women all want for ourselves and our children. We want our kids to be safe, to be healthy, to be happy, to do well in school, to fulfill their potential, to grow up and have families and livelihoods of their own—to love and be loved. And we want to be healthy ourselves and develop our own gifts and share them with the community.
Family planning is important in meeting every one of those needs, no matter where a woman lives. It took a woman with courage to burn this message into me, and her pain became a turning point in my work. When one person tells me a harsh truth, I can be sure that she’s speaking for others who aren’t as bold. It makes me pay better attention, and then I realize that others have been saying the same thing all along, just more softly. I haven’t heard it because I haven’t really been listening.
Shortly after I spoke to Meena, I traveled to Malawi and paid a visit to a health center. The center had a room for vaccinations, a room for sick kids, a room for HIV patients, and a room for family planning. There was a long line of women waiting to visit the family planning room, and I talked to a few of them—asking where they had come from, how many children they had, when they started using contraceptives, what kind of contraceptives they used. My nosiness was matched by the women’s eagerness to talk about their lives. One woman told me that she had come to get her injection but didn’t know if it would be available, and all the other women nodded. They said they would walk ten miles to the health clinic not knowing if the shot would be in stock when they got there, and many times it wasn’t. So they’d be offered some other kind of contraceptive. They might be offered condoms, for example, which clinics tended to have in good supply because of the AIDS epidemic. But condoms are often unhelpful for women trying to avoid pregnancy. Women have told me over and over again, “If I ask my husband to wear a condom, he will beat me up. It’s like I’m accusing him of being unfaithful and getting HIV, or I’m saying that I was unfaithful and got HIV.” So condoms were useless for many women, and yet health clinics would claim they were stocked up on contraceptives when all they had was condoms.
After I heard most of the women tell the same story about walking a long way and not getting the shot, I stepped inside the room and found that, in fact, the clinic did not have the shot everyone had come for. That wasn’t a minor inconvenience for these women. It wasn’t just a matter of driving to the next pharmacy. There was no pharmacy. And they had come miles on foot. And there were no other contraceptives these women could use. I have no idea how many of the women I met that day became pregnant because the health center was out of stock.
An unplanned pregnancy can be devastating for women who can’t afford to feed the children they already have, or who are too old, too young, or too ill to bear children. My visit with Meena opened my eyes to women who didn’t know about contraceptives. My visit to Malawi opened my eyes to women who knew about contraceptives and wanted contraceptives but couldn’t get them.
It hadn’t come as a revelation to me that women want contraceptives. I knew it from my own life, and it was one of the things we supported at the foundation. But after these trips, I began to see it as central, as the first priority for women.
When women can time and space their births, maternal mortality drops, newborn and child mortality drops, the mother and baby are healthier, the parents have more time and energy to care for each child, and families can put more resources toward the nutrition and education of each one. There was no intervention more powerful—and no intervention that had become more neglected.
In 1994, the International Conference on Population and Development in Cairo drew more than 10,000 participants from around the world. It was the largest conference of its kind ever held and a historic early statement on the rights of women and girls. It urged the empowerment of women, set goals for women’s health and education, and declared that access to reproductive health services, including family planning, is a basic human right. But funding for family planning had dropped significantly since Cairo.
That’s a big reason why contraceptives were the number one issue on my mind in 2010 and 2011. And the subject kept coming up everywhere I went. Back in Seattle, in October 2011, Andrew Mitchell, the UK’s secretary of state for international development, was attending a malaria summit hosted by our foundation and approached me with an idea: Would we be interested in hosting another summit the following year, this one on family planning? (This, of course, became the summit I described in chapter 1.)
The idea of an international family planning summit struck me as both scary and exciting, a huge project. I knew that we would have to emphasize setting goals, improving data, and being more strategic. But I also knew that if we were going to set ambitious goals and reach them, we had to meet a much tougher challenge. We had to change the conversation around family planning. It had become impossible to have a sensible, rational, practical conversation about contraceptives because of the tortured history of birth control. Advocates for family planning had to make it clear that we were not talking about population control. We were not talking about coercion. The summit agenda was not about abortion. It was about meeting the contraceptive needs of women and allowing them to choose for themselves whether and when to have children. We had to change the conversation to include the women I was meeting. We needed to bring in their voices—the voices that had been left out.
That’s why, just before the summit, I visited Niger, a patriarchal society with one of the highest poverty rates in the world, an extremely low use of contraceptives, an average of more than seven children per woman, marriage laws that allow men to take several wives, and inheritance laws that give half as much to daughters as to sons and nothing to widows who don’t have children. Niger was, according to Save the Children, “the worst place in the world to be a mother.” I went there to listen to the women and meet those mothers.
I traveled to a small village about an hour and a half northwest of the capital and met with a mother and okra farmer named Sadi Seyni. (I mentioned her in chapter 1, too.) Sadi was married at 19—old for Niger, where nearly 76 percent of all girls under 18 are married. After her first child, Sadi was pregnant again in seven months. She didn’t learn about family planning until after she had her third child and a doctor at her local one-room clinic told her about contraceptives. She then began spacing her births. When I met her, Sadi was 36 years old and had six children.
We talked in Sadi’s home. She sat opposite me on her bed with two children beside her, another snuggling into her lap, another standing behind her on the bed, and two older children sitting nearby. They were all dressed in colorful fabrics, each a different pattern, and Sadi and the older girls wore headscarves; Sadi’s was a solid purple. The sun was pouring in through the windows, only partially blocked by a sheet they’d put up, and Sadi answered my questions with an energy that showed she was glad to be asked.
“When you don’t do family planning,” she said, “everybody in the family suffers. I’d have a baby on my back and another in my belly. My husband had to take on debt to cover the basics, but even that wasn’t enough. It’s complete suffering when you don’t do family planning, and I have lived that.”
I asked her if she wanted another child, and she said, “I don’t plan on having another child until the little one is at least four. If she’s four, she can play with her little brother or sister; she can take him on her back. But now, if I were to bring her a little brother, it would be like punishing her.”
When I asked her how women find out about contraceptives, she said, “The good thing about being a woman here is that we gather a lot and talk. We talk when we meet under a tree to pound our millet. We talk at feasts after a baby is born, and that is where I talk to others about getting a shot and how much easier it is to use than the pill. I tell them you should take it to give yourself and your children a break.”
What mother wouldn’t understand that—giving yourself and your children a break?
The following day I visited the National Center for Reproductive Health in Niamey, the capital. After our tour, five women who were there to get services joined us for conversation. Two young women told us about their lives, and then we heard from an outspoken 42-year-old mother named Adissa. Adissa had been married off at age 14, gave birth to ten children, and lost four. After her tenth pregnancy, she visited the family planning center to get an IUD and has not been pregnant since. That’s caused her husband and sister-in-law to look on her with suspicion and ask why she hasn’t delivered recently. “I’m tired,” she told them.
When I asked Adissa why she decided to get an IUD, she sat and thought for a moment. “When I had two kids, I could eat,” she said. “Now, I cannot.” She receives from her husband the equivalent of a little over a dollar a day to take care of the entire family.
I asked Adissa if she had any advice for the younger women who were there, and she said, “When you can’t take care of your children, you’re just training them to steal.”
A few minutes later we all got up to leave. Adissa walked toward the tray of food that no one had touched, put most of it in her bag, wiped a tear from her eye, and left the room.
As I took in everything I had just heard, I wanted so badly for everyone to hear Adissa. I wanted a conversation led by the women who’d been left out—women who want contraceptives and need them and whose families are suffering because they can’t get them.
Changing the conversation has been a lot harder than I expected because it’s a very old conversation, grounded in biases that don’t easily go away. The conversation has been in part a response to the work of Margaret Sanger, who has a complex legacy.
In 1916, Sanger opened the first clinic in the United States that offered contraceptives. Ten days later, she was arrested. She posted bail, went back to work, and was arrested again. It was illegal to distribute contraceptives. It was also illegal to prescribe them, to advertise them, or to talk about them.
Sanger was born in 1879 to a mother who would eventually have eighteen pregnancies and care for eleven children before dying of tuberculosis and cervical cancer at the age of 50. Her death encouraged Sanger to become a nurse and work in New York City slums with poor immigrant mothers who had no contraceptives.
In a story she told in her speeches, Sanger was once called to the apartment of a 28-year-old woman who was so desperate to avoid another baby that she had performed a self-induced abortion and nearly died. The woman, realizing how close she’d come to killing herself, asked the doctor how she could prevent another pregnancy. The doctor suggested she tell her husband to sleep on the roof.
Three months later, the woman was pregnant again, and after another attempt at abortion, Sanger was again called to the apartment. This time the woman died just after Sanger arrived. As she told it, that prompted Sanger to quit nursing, swearing that she would “never take another case until I had made it possible for working women in America to have the knowledge to control birth.”
Sanger believed women could achieve social change only if they were able to prevent unwanted pregnancy. She also saw family planning as a free speech issue. She gave public talks. She lobbied politicians. She published columns, pamphlets, and a newspaper about contraceptives—all illegal at the time.
Her arrest in 1916 made her famous, and over the next two decades more than a million women wrote to her in desperation, pleading for help in getting contraceptives. One woman wrote, “I would do anything for my two children to help them go through a decent life. I am constantly living in fear of becoming pregnant again so soon. Mother gave birth to twelve children.”
Another wrote, “I have heart trouble and I would like to be here and raise these four than have more and maybe die.”
A southern farm woman wrote, “I have to carry my babies to the field, and I have seen their little faces blistered by the hot sun.… Husband said he intended making our girls plow, and I don’t want more children to be slaves.”
These women’s letters were published in a book called Motherhood in Bondage. Sanger wrote, “They have unburdened their souls to me, a stranger, because in their intuitive faith, they are confident that I might extend help denied them by husbands, priests, physicians, or their neighbors.”
When I read some of these letters, a song came into my head that often comes when I’m engaged in my work—a song I heard constantly in church as a child, attending Mass five times a week at Catholic school. It’s heartbreakingly sad, beautiful and haunting, and its refrain goes, “The Lord hears the cry of the poor.” The nuns taught us that it was the role of the faithful to respond to that cry.
The cries for help in these women’s letters are hard to distinguish from the voices of Meena or Sadi or Adissa or many other women I’ve talked to in health clinics and in their homes. They are far apart in time and place, but alike in their struggle to be heard and in the reluctance of their communities to listen.
Across cultures, the opposition to contraceptives shares an underlying hostility to women. The judge who convicted Margaret Sanger said that women did not have “the right to copulate with a feeling of security that there will be no resulting conception.”
Really? Why?
That judge, who sentenced Sanger to thirty days in a workhouse, was expressing the widespread view that a woman’s sexual activity was immoral if it was separated from her function of bearing children. If a woman acquired contraceptives to avoid bearing children, that was illegal in the United States, thanks to the work of Anthony Comstock.
Comstock, who was born in Connecticut and served for the Union in the Civil War, was the creator, in 1873, of the New York Society for the Suppression of Vice and pushed for the laws, later named for him, that made it illegal—among other things—to send information or advertisements on contraceptives, or contraceptives themselves, through the mail. The Comstock Laws also established the new position of Special Agent of the Post Office, who was authorized to carry handcuffs and a gun and arrest violators of the law—a position created for Comstock, who relished his role. He rented a post office box and sent phony appeals to people he suspected. When he got an answer, he would descend on the sender and make an arrest. Some women caught in his trap committed suicide, preferring death to the shame of a public trial.
Comstock was a creation of his times and his views were amplified by people in power. The member of Congress who introduced the legislation said during the congressional debate, “The good men of this country … will act with determined energy to protect what they hold most precious in life—the holiness and purity of their firesides.”
The bill passed easily, and state legislatures passed their own versions, which were often more stringent. In New York, it was illegal to talk about contraceptives, even for doctors. Of course, no women voted for this legislation, and no women voted for the men who voted for it. Women’s suffrage was decades away. The decision to outlaw contraceptives was made for women by men.
Comstock was open about his motives. He said he was on a personal crusade against “lust—the boon companion of all other crimes.” After he attended a White House reception and saw women in makeup, with powdered hair and “low dresses,” he called them “altogether most extremely disgusting to every lover of pure, noble, modest woman.” “How can we respect them?” he wrote. “They disgrace our land.”
In Comstock’s eyes, and the eyes of his allies, women were entitled to very few roles in life: to marry and serve a man, and bear and take care of his children. Any detour from these duties brought disrepute—because a woman was not a human being entitled to act in the world for her own sake, not for educational advancement or professional accomplishment, and certainly not for her own pleasure. A woman’s pleasure, especially her sexual pleasure, was terrifying to the keepers of the social order. If women were free to pursue their own pleasure, it would strike at the core of the unspoken male code, “You exist for my pleasure!” And men felt they needed to control the source of their pleasure. So Comstock and others did their best to weaponize stigma and use it to keep women stuck where they were, their value derived only from their service to men and children.
The need of men to regulate women’s sexual behavior persisted in the US even after the Second Circuit court in 1936 ruled that physicians could advise their patients on birth control methods and prescribe contraceptives. In spite of this advance, many restrictions on contraceptives stayed in place nationally, and in 1965, when the Supreme Court ruled in Griswold v. Connecticut that contraceptive restrictions were an intrusion into marital privacy, the Court lifted restrictions for married people only! It didn’t mention the rights of the unmarried, so single women were still denied contraceptives in many states. This is not so long ago. Women in their seventies still come up to me at events and tell me, “I had to trick my doctor into thinking I was married or I couldn’t get contraceptives.” Unmarried women weren’t given the legal right to contraceptives until Eisenstadt v. Baird in 1972.
This strand of the conversation on family planning is grounded in society’s discomfort with women’s sexuality, and this line of conversation absolutely endures today. If a woman speaks up in public for the value of contraceptives in a health plan, some misogynistic male voices will try to shame her, saying, “I’m not going to subsidize some woman’s sex life.”
Shaming women for their sexuality is a standard tactic for drowning out the voices of women who want to decide whether and when to have children. But that is not the only discussion that has diminished the voices of women. Many interests have tried to control women’s births in ways that make it hard to have a focused conversation on contraceptives today.
In an effort to control their populations, both China and India adopted family planning programs in the 1970s. China created a one-child policy, and India turned to policies that included sterilization. In the 1960s and ’70s, population control was embraced in US foreign policy based on predictions that overpopulation would lead to mass famine and starvation and possibly to large-scale migration because of a lack of food.
Earlier in the twentieth century, birth control advocates in the United States had also pressed their case, many of them hoping to help the poor avoid having unwanted children. Some of these advocates were eugenicists who wanted to eliminate “the unfit” and urged certain groups to have fewer children, or none at all.
Sanger herself supported some eugenicist positions. Eugenics is morally nauseating, as well as discredited by science. Yet this history is being used to confuse the conversation on contraceptives today. Opponents of contraception try to discredit modern contraceptives by bringing up the history of eugenics, arguing that because contraceptives have been used for certain immoral purposes, they should not be used for any purpose, even allowing a mother to wait before having another child.
There is another issue that has blocked a clear and focused conversation on contraceptives, and that issue is abortion. In the United States and around the world, the emotional and personal debate about abortion can obscure the facts about the life-saving power of contraception.
Contraceptives save the lives of mothers and newborns. Contraceptives also reduce abortion. As a result of contraceptive use, there were 26 million fewer unsafe abortions in the world’s poorest countries in just one year, according to the most recent data.
Instead of acknowledging the role of contraceptives in reducing abortion, some opponents of contraception conflate it with abortion. The simple appeal of letting women choose whether or when to have children is so threatening that opponents strain to make it about something else. And trying to make the contraceptive debate about abortion is very effective in sabotaging the conversation. The abortion debate is so hot that people on different sides of the issue often won’t talk to each other about women’s health. You can’t have a conversation if people won’t talk to you.
The Catholic Church’s powerful opposition to contraceptives has also affected the conversation on family planning. Outside of governments, the Church is the largest provider of education and medical services in the world, and this gives it great presence and impact in the lives of the poor. That is helpful in so many ways, but not when the Church discourages women from getting the contraceptives they need to move their families out of poverty.
Those are some of the conversations that have been heard in the world over the previous hundred years or more. Each conversation helped drown out the voices and the needs of women, girls, and mothers. And that gave us a crucial purpose for holding the first summit in 2012: to create a new conversation led by the women who’d been left out—women who wanted to make their own decisions about having children without the interference of policymakers, planners, or theologians whose views would force women to have more, or fewer, children than they wanted.
I gave the opening address that day in London and asked the delegates: “Are we making it easier for women to get access to the contraceptives they need when they need them?” I talked about the trip I had made a few years before to the poor Nairobi neighborhood of Korogocho, which means “shoulder to shoulder.” I was discussing contraceptives there with a group of women, and one young mother named Marianne said, “Do you want to know why I use contraceptives?” Then she held up her baby and said, “Because I want to bring every good thing to this child before I have another.” That desire is universal, but access to family planning is not. I reminded everyone at the conference that this was why we were all here.
Then, to make the point that the summit was all about having women own the conversation, I stepped aside and invited another woman to come to the stage and complete my talk.
The speaker was Jane Otai, who had served as my translator when I spoke to Marianne. After growing up in Korogocho in a family of seven children, Jane had left to earn a university degree, and then returned to help girls who faced the same challenges she had.
Jane talked to the conference about growing up poor and said, “My mother told me, ‘You can become what you want to become. All you have to do is study very hard—and wait. Don’t have children as early as I did.’” Jane closed by saying, “Because someone told me about family planning very early, I was able to space my children and delay my first pregnancy. That is why I am here. If not for family planning, I would be like any other child in Korogocho.”
The summit was hailed as a success, with unprecedented pledges of financial support and partnership from organizations and governments around the globe, but I learned pretty quickly that changing the conversation would still be difficult.
Immediately after the summit, I was singled out for criticism in a front-page story in L’Osservatore Romano, the official Vatican newspaper. I had “gone astray,” it said, and was “confused by misinformation.” It went on to say that every foundation is free to donate to whatever cause it wants, but not “to persist in disinformation and present things in a false way.” The article charged that I was dismissing or distorting the value of natural family planning, and suggested that I was being manipulated by corporations who stood to gain from selling contraceptives. The movement we had launched at the summit to expand access to contraceptives was based on “an unfounded and second-rate understanding,” it said. I did notice that the article focused on me, and corporations, and Church teaching, but not the needs of women.
Forbes later said the story showed that I “could take a punch.” I expected the punch—I also expected the online comments that referred to me as “former Catholic Melinda Gates” or “so-called Catholic Melinda Gates”—but it stung anyway. My first reaction was “I can’t believe they would say that!” (That’s probably a typical response for a beginner in public life!) After a couple of days, though, I had calmed down, and I got why the Church said what it said. I didn’t agree, but I understood.
I have met with high-ranking officials of the Church since the conference, but our meetings didn’t focus on doctrine or differences. We talked about what we could do together for the poor. They know that I understand the basis of the Church’s opposition to contraceptives, even though I don’t agree. They also know we share some similar concerns. We are both opposed to any effort to coerce women to limit the size of their families, and we are both opposed to wealthy countries imposing their cultural preference for small families on traditional societies. If a woman does not want to use contraceptives because of her faith or values, I respect that. I have no interest in telling women what size families to have, and no desire to stigmatize large families. Our work in family planning leaves the initiative to the women we serve. That’s why I believe in voluntary family planning and support a wide range of methods, including natural fertility awareness methods for any woman who prefers them.
Obviously, though, I’ve felt the need to express my differences with the Church. Contraceptives save the lives of millions of women and children. That’s a medical fact. And that’s why I believe all women everywhere, and of any faith, should have information on the healthy timing and spacing of pregnancies, and access to contraceptives if they want them.
But there is a big difference between believing in family planning and taking a lead advocacy role for a cause that goes against a teaching of my church. That is not something I was eager to do. When I was trying to decide if I should go ahead, I talked it over with my parents, with priests and nuns I’ve known since childhood, with some Catholic scholars, and with Bill and the kids. One of my questions was “Can you take actions in conflict with a teaching of the Church and still be part of the Church?” That depends, I was told, on whether you are true to your conscience, and whether your conscience is informed by the Church.
In my case, the teachings of the Catholic Church helped form my conscience and led me into this work in the first place. Faith in action to me means going to the margins of society, seeking out those who are isolated, and bringing them back in. I was putting my faith into action when I went into the field and met the women who asked me about contraceptives.
So, yes, there is a Church teaching against contraceptives—but there is another Church teaching, which is love of neighbor. When a woman who wants her children to thrive asks me for contraceptives, her plea puts these two Church teachings into conflict, and my conscience tells me to support the woman’s desire to keep her children alive. To me, that aligns with Christ’s teaching to love my neighbor.
Over the past decade or so, I’ve tried to get inside the mind of some of the Church’s most committed opponents of contraceptives, and I have wished they could see inside mine. I believe that if they faced an appeal from a 37-year-old mother with six children who didn’t have the health to bear and care for another child, they would find a way in their hearts to make an exception. That’s what listening does. It opens you up. It draws out your love—and love is more urgent than doctrine.
So I don’t see my actions as putting me at odds with the Church; I feel I am following the higher teaching of the Church. I have felt strong support in this from priests, nuns, and laypeople who’ve told me that I am on solid moral ground when I speak up for women in the developing world who need contraceptives to save their children’s lives. I welcome their guidance, and it’s reassuring to me that a huge majority of Catholic women use contraceptives and believe it’s morally acceptable to do so. I also know that ultimately moral questions are personal questions. Majorities don’t matter on issues of conscience. No matter what views others may have, I am the one who has to answer for my actions, and this is my answer.
As I mentioned before, as we began planning the summit we were determined that it be focused on goals and strategy, and we ended the summit determined to make contraceptives available to 120 million more women in the sixty-nine poorest countries in the world by 2020, on the way to universal access by 2030. Those were the goals. Four years later, at the midpoint of our campaign, our data showed there were 30 million additional users of contraceptives; that meant that 300 million women overall were using modern contraceptives. The round number sounded nice, but it was 19 million below what we’d hoped.
We had learned two important lessons by 2016. First, we needed better data. It was crucial to help us predict demand, see what was successful, and help pharmaceutical companies design products that have fewer side effects and are easier to use and cheaper to buy.
Second, we learned again that women do not make decisions in a vacuum; they are hemmed in by the views of their husbands and mothers-in-law—and those traditions do not change easily. So along with gathering more data, we had to learn more about how our partners work in communities that might be hostile to contraceptives, and how they address the sensitive question of making contraceptives available to unmarried youth.
To understand some of the biggest successes in these areas, I traveled to East Africa in the summer of 2016. Kenya was well ahead of its goals, and I wanted to see why.
On my first stop, in Nairobi, I went to visit the women who gather the data. We call them resident enumerators, or REs for short. They go door-to-door in their communities, interviewing women and entering the data into their cell phones. They are trained to ask very personal questions: “When is the last time you had sexual intercourse? Do you use contraceptives? What kind? How many times have you given birth?” Most of the time, the women they interview are eager to answer. There’s something empowering about being asked. It sends a message that your life matters.
The resident enumerators learn a lot about the lives of the respondents that they don’t really know how to turn into data. One RE told me she went to a house where a woman lived with her husband and twelve children. The woman’s husband was opposed to family planning and turned the RE away at the door. But the mother ran into the RE later—REs live in the communities they serve—and asked her to come talk to her nine daughters when her husband wasn’t around. Unfortunately, we don’t yet know how to make the data capture the story of the controlling husband who sent the RE away.
I saw this data challenge myself when I went to a local household with Christine, one of the REs. When she was halfway done with her survey, she handed me a mobile phone and told me to finish up. I asked the mother how many children she had, and she said two daughters. When I asked how many times she had given birth, she said three—and started to cry. She told me about her son, who died the day he was born, and then told me a painful story of her husband turning violent, beating her, and destroying all the chairs and supplies in the hair salon she had built. She took her daughter and moved in with her mother. Then she had a second daughter with another man, but she never made a reliable income, so she had trouble paying school fees and medical expenses for her daughters, and sometimes couldn’t afford to feed them.
I was listening to this heartbreaking story, trying to enter the information in the phone, and I became frustrated that her story overwhelmed the system set up to capture the facts of her life. How did her abusive marriage affect her income? How did her income affect her use of contraceptives and the health of her children? Even if I had asked the questions, I had no place to put the answers.
What would it take to get a more complete picture of her life? You can’t meet a need you don’t know about. I brought this question up later when I talked to the women who had gone door-to-door with me. They all nodded their heads. Every one of them had more questions they wanted to ask—about clean water, children’s health, education, domestic violence. Christine said to me, “If we could ask about domestic violence, we would be signaling to the woman that this is unacceptable behavior.” She’s exactly right, and this is an ongoing project of ours—improving data systems so we can ask more questions, gather more information, and capture the texture of women’s stories. There will never be a system that captures everything, so there will never be a substitute for hearing women’s stories. But we have to keep working to get better data so we can understand the lives of the people we serve.
I was also eager to visit Kenya to see a program called Tupange, a slang term for “Let’s plan.” Tupange had done a terrific job boosting contraceptive use in three of Kenya’s largest cities, and I could see why. My hosts took me to a community outreach event that had the feel of a fairground. Tupange representatives sang and danced outside to help attract foot traffic to the fair, and inside, volunteers walked around wearing giant aprons festooned with contraceptives—the most effective methods hanging at the top, the least effective methods on the bottom. There were stands offering counseling on HIV, HPV, family planning, and nutrition. It was a great way to make healthcare and family planning easy to get and stigma-free. There was a striking openness in the atmosphere and conversations—an amazing accomplishment when promoting a subject that is still in many ways taboo. Tupange has many initiatives, but each of them, in one way or another, challenges stigma and social norms. That is the key to their success.
One of the first Tupange leaders I talked to was Rose Misati, who as a little kid was filled with dread every time her mom became pregnant. Each new baby meant more childcare duties for Rose, more chores in the home, and less time to study. She began staying home from school and falling behind her classmates. When Rose was 10, just after her mom had given birth to her eighth child, a healthcare worker came to the house, and every day after, Rose remembers her mom asking her to bring her a glass of water and one of her pills. There were no more little brothers and sisters for Rose to take care of.
Sometimes the best thing a mother can do for her children is not have another child.
Rose got back up to speed at school, did well on her exams, and gained entrance to the University of Nairobi. She is now a pharmacist, and she says she owes it to her mom’s family planning. So when the Tupange program asked her to help, she jumped at the chance, and became a big voice for sending community health workers door-to-door. “I know this works,” she said. “This is how they found my mom.”
Rose knocks down stigma by the way she talks about contraceptives. When she opens meetings, she says her name, her title, and the method of family planning she uses. Then she asks others to do the same. The first time she tried it, people were shocked. Now people embrace it, and the stigma is weakening. I’ve come to learn that stigma is always an effort to suppress someone’s voice. It forces people to hide in shame. The best way to fight back is to speak up—to say openly the very thing that others stigmatize. It’s a direct attack on the self-censorship that stigma needs to survive.
Rose weakens another stigma by reaching out to men to talk about “a women’s issue.” “When you get men on board,” she says, “their wives’ use of contraceptives is nearly universal.” She tells the men family planning will make their children healthier, stronger, and more intelligent—and because fathers see intelligent children as proof of their own intelligence, they’re open to this argument.
Male allies are essential. It’s especially beneficial to have male allies who are religious leaders, like pastor David Opoti Inzofu. David grew up in Western Kenya with conservative parents who didn’t use family planning or discuss it. As a young man, he thought family planning was a population control conspiracy. But he started listening after he met Tupange workers who said that timing and spacing pregnancies could improve the health of the mother and child and allow families to have only as many children as they could take care of. That convinced him. Not only do he and his wife use contraceptives, but he uses his pulpit to share the message with his congregation. He points to the Bible verse 1 Timothy 5:8: “And whoever does not provide for relatives and especially family members has denied the faith and is worse than an unbeliever.”
I was thrilled to see Tupange giving so much attention to the role men play in family planning. Men shouldn’t want to have more children than they can care for. They shouldn’t oppose women’s desire to space the births of their children. Men’s and women’s interests should be aligned, and the men who see this are the ones we want leading family planning discussions with other men.
I met another male ally who became an advocate after an unplanned pregnancy nearly ruined his life. Shawn Wambua was only 20 years old when Damaris, his girlfriend, got pregnant. His church was on the verge of excommunicating him, his girlfriend’s family was furious with him, and he had no one to turn to—both his parents had died.
Shawn visited a health center and learned about contraceptives. Then he asked Damaris to marry him, and she got an IUD to delay the next child until they were sure they could provide for two. Shawn then became connected with Tupange and created a group called Ndugus for Dadas (“brothers for sisters”). Every week, he leads a group of about twenty young men who talk about contraceptives and other issues they’re facing. Shawn is also taking his advocacy to the church that nearly threw him out. When church leaders spoke out against a reproductive health bill, saying that sex education would encourage promiscuity, he publicly challenged them. He believes the church is wrong to think that young people aren’t having sex or that contraceptives will give young people ideas they didn’t have before. “We share the same room with our parents,” he said. “We know what they are doing.”
Remarkably, the church elders now allow Shawn to talk to young members of the congregation about reproductive health, as long as it’s not on church grounds. This, I think, is a perfect metaphor for the split convictions that the keepers of the old order often have. They know there is a truth on the other side that they’re not acknowledging, and while they can’t bring themselves to express that truth personally, they realize they can allow the message to be spread by others. It’s a special experience to see when that happens, and to meet the people whose stories are so compelling that they lead the elders to soften their views.
When social norms help everyone prosper, they have natural support because they’re in people’s self-interest. But when norms protect the power of certain groups or forbid or deny things that are a natural part of human experience, the norms can’t stand on their own; they have to be enforced by some sanction or stigma.
Stigma is one of the biggest barriers to women’s health, and people in Tupange figured out that sometimes the best way to weaken a stigma is to defy it openly. This can be a risky strategy when the time isn’t ripe. But Tupange workers knew the culture, and they knew that their courage and defiance would force a public discussion that would expose the flaws and unfairness of the stigma. As more people challenged the stigma, there was a shift, the stigma softened, and the culture changed. This can work whether the stigma is a social norm or a national law.
Tupange shows the power of group action, but it takes individuals to bring a group into being.
Pia Cayetano is one of those individuals. When she was elected to the Philippine Senate in 2004, there was no national law guaranteeing access to contraceptives. Local jurisdictions could do anything they wanted. Some required a prescription to get a condom. Some required pharmacies to keep a record of every contraceptive purchase. Others banned contraceptives outright. Legislators had drafted a bill to legalize contraceptives across the country, but the Catholic Church was opposed, and the bill sat idle for more than a decade.
As a result, the maternal death rate was rising in the Philippines—even as it declined around the world. By 2012, fifteen Filipino women were dying every day in childbirth. Unlike most of her colleagues, Pia knew the wonders and dangers of childbirth. When she was pregnant with her son, Gabriel, she learned from an ultrasound that he had chromosomal abnormalities. She carried Gabriel to term and cared for him for nine months until he died in her arms. Her loss allowed her to hear with special compassion the stories of Filipino women who couldn’t get contraceptives. There was Maria, who suffered from hypertension, had three unplanned pregnancies in a row, and died during the third. There was Lourdes, who was unable to care for her eight children and had three of them taken away and given to others to raise.
When a sympathetic president, Benigno Aquino III, took office in 2010, Pia decided to push for the bill in the Senate, highlighting the tragedy of maternal death and saying, “No woman should die giving life.” She was told it was hopeless, that her colleagues would amend the bill till she didn’t recognize it, and she’d never get the votes to pass it anyway. Other senators heaped doubt on her statistics about mothers dying and downplayed the significance of the mothers’ deaths, saying that more men die at work, so women shouldn’t complain. Not one of her male colleagues would support her until one senator stood with her—her younger brother, Alan Cayetano.
When Alan joined the debate on the side of his sister, men began to acknowledge the hardship the current law created for the poor. As the bill gained momentum, the Catholic bishops intensified their opposition, and Pia and other supporters were targeted in personal ways.
One Catholic congregation hung a banner outside its church with the names of the legislators who voted for the reproductive health bill. The banner was headlined TEAM DEATH. In sermons, priests would mention Pia’s name on the list of people going to hell. She stopped taking her family to Mass so her children wouldn’t have to hear it.
At the same time, Pia told me, some Catholic leaders reached out to her, offering political guidance and building a bridge of quiet cooperation around common goals of supporting the poor and reducing the deaths of mothers and infants. With a lot of effort and delicate diplomacy, the bill passed—and was immediately challenged in court.
A year later, in May of 2013, I met Pia at the Women Deliver conference in Malaysia. She told me she had to put off a long-planned visit to the United States so she could be in the Philippines to make oral arguments at the Supreme Court. The following spring I saw Pia’s name in my inbox with a joyous message and a link to this news article:
MANILA, Philippines (UPDATED)—After earning the ire and ridicule of some male colleagues for defending the controversial reproductive health law, a beaming Senator Pia Cayetano hailed the Supreme Court decision upholding the legality of its key provisions.
“This is the first time I can honestly say I love my job!” she said.
“Many women who have questioned this, even men, are people who have access [to reproductive health], so this is for the poor, especially poor women, who do not have the ability to access their own information and services.”
It’s easy for me to connect very deeply with people doing this work, and I’ve always found it exciting to watch and applaud the success of people I admire, even when I have to do it from a distance. But I especially appreciate the chance to show my love and respect in person. When Pia came to the US for a conference in Seattle in 2014, I was able to give her a big hug, and it reminded me how much all of us in this work need one another. We give energy to one another. We lift each other up.
The work of Pia and others in the Philippines was a huge success. In another success, Great Britain has cut its teen pregnancy rate—once the highest in Western Europe—in half over the last two decades. The experts say success came from connecting young people to high-quality, nonjudgmental counseling.
The United States has also been successful in bringing down teen pregnancy rates. The country is at a historic low for teen pregnancy and a thirty-year low for unintended pregnancy. Progress is due largely to expanded use of contraceptives, which accelerated thanks to two initiatives begun in the prior administration—first, the Teen Pregnancy Prevention Program, which spends $100 million a year to reach low-income teens in communities across the United States; and second, the birth control benefit in the Affordable Care Act, which allows women to get contraceptives without paying for them out of pocket.
Unfortunately, that progress is in jeopardy—both the drop in unwanted pregnancies and the policies that helped make it happen. The current administration is working to dismantle programs that provide family planning and reproductive health services.
In 2018, the administration put out new guidelines for Title X, the national family planning program, which serves 4 million low-income women a year. The guidelines basically state which kinds of programs the government will fund, and this version does not mention any of the modern contraceptive methods approved by the Food and Drug Administration. Instead, it named only natural family planning, or the rhythm method, even though less than 1 percent of the low-income women who rely on this federal program use that method.
The administration also proposed eliminating the Teen Pregnancy Prevention Program, which would end a crucial supply of contraceptives for teens who need them. We’re talking about young people living in poor areas who have few options, like teens from the Choctaw Nation in Oklahoma and teens in foster care in Texas. In place of these services, the administration wants to offer abstinence-only programs.
Overall, its goal seems to be replacing programs proven to work with programs proven not to work, which, in effect, means that poor women in the US will have less access to effective contraceptives, and many poor women will have more children than they want to just because they’re poor.
Another dire threat to family planning in the United States comes in a policy the current administration has proposed but not yet finalized—one that would stop federal funds from going to healthcare providers that perform, or even refer for, abortions. This is similar to laws already enacted in Texas and Iowa, where the effect on women has been devastating. If this policy takes effect nationally, more than a million low-income women who now rely on Title X funding to get contraceptive services or cancer screenings or annual exams from Planned Parenthood will lose their healthcare provider. A half million women or more could be left with no provider at all; there are simply not enough community health clinics to serve the women who will be cut off by this policy. If you’re a woman with no economic means, you may have nowhere to go.
For women outside the United States, the administration has proposed cutting its contribution for international family planning in half and cutting its contributions to the UN Population Fund to zero—even though there are still more than 200 million women in the developing world who want contraceptives but can’t get them. Congress has so far stood up for poor women and largely maintained previous levels of international family planning funding. But the world needs the US administration to be a leader for women’s rights, not an opponent of them.
The administration’s new policies are not trying to help women meet their needs. There isn’t any reliable research that says women benefit when they have children they don’t feel ready to raise. The evidence says the opposite. When women can decide whether and when to have children, it saves lives, promotes health, expands education, and creates prosperity—no matter what country in the world you’re talking about.
The US is doing the opposite of what the Philippines and the UK did. It is using policy to shrink the conversation, suppress voices, and allow the powerful to impose their will on the poor.
Most of the work I do lifts me up, some of it breaks my heart, but this just makes me angry. These policies pick on poor women. Mothers struggling in poverty need the time, money, and energy to take care of each child. They need to be able to delay their pregnancies, time and space their births, and earn an income as they raise their children. Each one of these steps is advanced by contraceptives, and each one is jeopardized by these policies.
Women who are well off won’t be harmed, and women with a stable income have options. But poor women are trapped. They will suffer the most from these changes and can do the least to stop them. When politicians target people who can’t fight back, that’s bullying.
It’s especially galling that some of the people who want to cut funding for contraceptives cite morality. In my view, there is no morality without empathy, and there is certainly no empathy in this policy. Morality is loving your neighbor as yourself, which comes from seeing your neighbor as yourself, which means trying to ease your neighbor’s burdens—not add to them.
The people who push these policies often try to use the Church’s teaching on family planning for moral cover, but they have none of the Church’s compassion or commitment to the poor. Instead, many push to block access to contraceptives and cut funds for the poor. They bring to mind the words of Christ in the Gospel of Luke: “And you experts in the law, woe to you, because you load people down with burdens they can hardly carry, and you yourselves will not lift one finger to help them.”
It’s the mark of a backward society—or a society moving backward—when decisions are made for women by men. That’s what’s happening right now in the US. These are not policies that would be in place if women were making decisions for themselves. That’s why it’s heartening to see the surge of women activists across the country who are spending their time knocking on doors, supporting family planning, and changing their lives by running for office.
Perhaps a big push for women’s rights has been triggered by these recent efforts to take rights away. I hope that’s what’s happening now, and that the fire that drives this defense of family planning fuels a campaign to advance all rights of women, all around the world—so that in the future, in country after country, more and more women will be in the room, sitting at the table, leading the conversation when the policies that affect our lives are made.