A June 26 press release from Save the Children, an international humanitarian organization, begins ominously: “Pregnancy is the biggest killer of teenage girls worldwide, with one million dying or suffering serious injury, infection or disease due to pregnancy or childbirth every year.”
One million is a big number, and a friend who sent the press release insisted that his jaw dropped when he read that, in his words, “teen pregnancy is responsible for over 1 million deaths a year in the developing world.”
There is a subtle, but important, discrepancy here. The report says one million teenage girls die or suffer serious injury, infection or disease due to pregnancy, the operative word being the conjunction. What our friend read was that one million teenage girls die annually due to pregnancy, full stop. When we read the email, before reading the press release, we were confused. According to the World Health Organization, in 2010, 287,000 women died of pregnancy-related causes. Could Save the Children be so brazen as to claim that the number of teenagers dying in childbirth was nearly three and a half times the total number of pregnancy-related deaths worldwide? We were intrigued.
It turns out that the actual report, Every Woman's Right: How family planning saves children's lives, states that only 50,000 women ages 15 to 19 die every year of pregnancy-related causes. Now that’s different. Although this figure is terribly tragic, it represents only 5% of the one million that the press release implies in its first line, “biggest killer…, with one million.” Our friend can be excused for misunderstanding.
The Save the Children report was released as part of an effort to draw attention to the Family Planning Summit organized by Melinda Gates in London this month, which has now concluded with an enormous amount of money—some $4.6 billion—secured to meet the supposedly unmet need for contraception. The blustery rhetoric with which Save the Children and other groups worked to prime the pump for the Summit is a sure sign that we should be wary of the claim of nearly universal consensus that more funding for contraception in the Third World is the answer to the maternal mortality problem.
So do we need more money for family planning? USAID has budgeted fully $547 million for family planning in 2012, and the Gates Foundation spent $437 million in 2009. With EU nations included, we are easily over one billion dollars in family planning funds annually. That’s a lot of money. We need more? Every dollar spent on family planning is a dollar not spent on other urgent needs, like education, basic health care, and infrastructure.
There is no question that it is a tragedy when anyone dies of a pregnancy-related cause, and it is particularly tragic when adolescents do. But the vast majority of these maternal deaths are preventable. Let’s look at how $4.6 billion could be used to reduce maternal mortality.
First, the provision of skilled birth attendants is particularly critical to combat maternal mortality. According to UNFPA, providing skilled birth attendants to all women would reduce maternal mortality by 75 percent. Skilled attendance at birth has been shown to correlate with lower maternal mortality ratios. A survey of 58 countries where 91 percent of maternal deaths occur shows that less than 17 percent of the world’s midwives are available in those countries. The provision of midwives worked in Sweden in the 1800s, and it has worked recently in countries such as Sri Lanka, Malaysia, Thailand, and Egypt. A large scale birth attendant training program would be a straightforward, highly measurable, and long lasting intervention that would significantly decrease the maternal mortality ratio. Gates’s $4.6 billion will not be spent on such a program.
In addition, access to education should be a major concern in efforts to decrease teenage pregnancy and the maternal mortality ratio. More educated women delay and space their pregnancies, which allows them to maintain their health, and education empowers women to determine for themselves how best to control their fertility.
The educational level of women is also highly correlated to the maternal mortality ratio. The education a woman has represents both the opportunities she has had and the opportunities she will have in the future; it also “promotes increasing autonomy, awareness, responsibility and knowledge for self-care, healthy lifestyles and behaviours.” An educated woman therefore will access the appropriate maternal and reproductive health services, including skilled birth attendants, greatly reducing her likelihood of maternal death. This affirms the central role of education in combating maternal mortality. Also, because women’s educational attainment means access to information about appropriate prenatal and postnatal care and childbirth, it follows that the maternal mortality ratio can decrease in areas where women typically do not have a high educational attainment, so long as they are provided with information about best practices related to their pregnancies. Gates’s $4.6 billion will not be spent on primary and secondary education for girls, either.
Adolescent girls and women also need access to basic and maternal health care. When governments focus intensively on maternal and child health, introducing health measures such as low-cost basic health care, including prenatal, postnatal, and obstetric health care, and social protection for the extreme poor, the maternal mortality ratio decreases drastically. 4.6 billion dollars could also help improve the poor medical infrastructures in countries with the highest maternal mortality ratios.
The push for contraception as a solution to maternal mortality is also problematic because many women won’t use it. The claim that 222 million women lack access to contraception is misleading. First, it is not necessarily a matter of access. Many women have access to contraception and choose not to use it. Social scientists and public policy experts identify women as having an unmet need for contraception even when those women have not expressed a desire to use contraception. The idea of unmet need for contraception ignores the reasons for unmet need that women express, such as concern about health and other side effects of artificial contraception, and incompatibility with religious and ethical beliefs. The fact that a woman is not using contraception is not the same as an unmet need for contraception. The more relevant datum would be the number of women who want contraception and cannot get it. That number is much less than 222 million. Another helpful figure would be the number of women who do not want to use contraception and do not have access to other methods of family planning, such as knowledge-based fertility education programs.
But even if we assume that it is true that 222 million women want contraception and can’t get it, do we really need $4.6 billion more in funding for contraception? That’s twenty dollars for each woman. A woman whose education has not been improved; whose access to essential healthcare has not been improved; whose very real and legitimate desire for children has not been met; whose economic opportunities have not been improved a whit. For this woman, Melinda Gates has one message: “Here’s twenty bucks; don’t have babies.”
Even worse, the promise of more aid from the Gates Foundation incentivizes local government officials and family planning authorities to start pushing contraception on women even if they don’t want to use it. This can lead to undue influence or coercion, eerily reminiscent of the population control movement.
There is no question that there are vastly different ideas of the value of human life at work here. The folks at Save the Children and their friends at the Gates Foundation think human persons are better off never existing than being born into poverty and dying before reaching their full potential. There are also very different ideas of how population relates to economic development that are quite germane to this controversy. Let that be. As a practical matter, it seems unlikely that Gates and friends will be able to have substantially greater success than decades of similar effort have had. It is a tragedy that they won’t spend their enormous resources trying to empower women who want to bring children into this world to do so safely and with the support of the medical resources they need.
Those of us who value all human life, from conception to natural death, should regret this terrible misallocation of resources, but we should also work to defend and protect, and indeed empower, those women whom Melinda Gates wishes to subject to her idea that contraception is their single most important unmet need. Let’s not forget that this idea is the same idea that underlies the population control movement, which has promoted contraception for decades in an attempt to reduce the population. The Family Planning Summit, which coincided with World Population Day, may not have used this rhetoric, but the simple fact is that women and men ultimately want to bring children into the world. Not all the contraception on earth will change that. Rather than try to prevent them from doing so, we should work to ensure they can do so safely.
Addendum: The authors wish to clarify that of the $4.6 billion pledged at the Family Planning Summit, only approximately $560 million came from the Gates Foundation. $2 billion in commitments came from the governments of developing countries, and $2.6 billion from developed countries and donors. Every dollar that these governments of developing countries in particular commit to contraception is a dollar they are not spending on education, basic health care, and other basic unmet needs of their populations.