More Than One Direction

Beyond the Exclusion of Abortion from Family Planning

The question of abortion should be dealt with separately. But in the United States and around the world the emotional and personal debate about abortion is threatening to get in the way of the lifesaving consensus regarding basic family planning,” said Melinda Gates this June. She then posted on the foundation’s website: “That is why when I get asked about my views on abortion, I say that, like everyone, I struggle with the issue, but I’ve decided not to engage on it publicly—and the Gates Foundation has decided not to fund abortion.” The Gates Foundation, with its outsized leadership role in initiatives to promote contraception in the Global South, sent a strong signal to the reproductive health advocacy community: that there is a wall dividing abortion from family planning, and it should not be disturbed, not even by discussion.

The consensus being promoted by some reproductive health advocates is that family planning is a way to cancel out the need for abortion. Jenny Tonge, chair of the UK All Party-Parliamentary Group on Population and Development, wrote a recent article in the Huffington Post praising the goal of the 2012 London Family Planning Summit, which was to provide contraception to 120 million women and girls in the Global South. Tonge saw this as a way to “avoid 50 million abortions between now and 2020 … 50 million difficult, sad and often tragic circumstances; 50 million moral dilemmas; 50 million costly and testing medical interventions for women that will not need to take place. In light of this, it would be logical to expect that anyone wanting to reduce abortion levels should be celebrating.”

When Gates and Tonge attempt to garner support for family planning initiatives by counterposing them with abortion, they are reiterating a longstanding and problematic perspective that exists in the family planning world. Although contraceptive technologies have changed, this exclusion of abortion remains, with its harmful impact on women’s autonomy, human rights and access to services. Current well-funded international family planning initiatives emphasize provider-controlled methods including LARC—long-acting reversible contraception—like IUDs and implants. Like Tonge, many endorse LARC as abortion prevention. In this article we will review past and current experiences with this approach to explain why advocates for reproductive health, rights and justice should not be celebrating.

A PARTIAL COMMITMENT TO WOMEN’S HEALTH

In the US, the division of abortion from family planning was enshrined in public policy when Congress passed Title X of the Public Health Service Act in 1970. Title X is the only federal program exclusively dedicated to family planning and reproductive health services. It funds much-needed contraceptive services to low income women. However, it does not fund abortion. The 1973 Helms Amendment betrays its origins in the backlash against the Roe v. Wade decision to legalize abortion—Congress passed the measure prohibiting foreign assistance from paying for the “performance of abortion as a method of family planning” or to “motivate or coerce any person to practice abortions.” The 1984 Mexico City Policy, or Global Gag Rule, also made funding for contraception hinge upon rejecting abortion. It prohibited foreign nongovernmental organizations that receive US family planning assistance from using even non-US funding to provide abortion services, information, counseling or referrals and from engaging in advocacy to promote abortion.

The 1994 International Conference on Population and Development held in Cairo is often praised for its success in adopting an approach to family planning based on women’s rights and health. However, this influential decision excluded abortion, and this truncated view of women’s rights has had a ripple effect on international discussions about women’s health up to the present day. The Programme of Action, the consensus document produced by the conference, embraced family planning as a way “to reduce the recourse to abortion through expanded and improved family planning services.” In April 2014, the 47th session of the UN Commission on Population and Development reaffirmed the language of Cairo, adopting a consensus resolution “recognizing that in no case should abortion be promoted as a method of family planning, or in the prevention of sexually transmitted infections, including HIV.”

Insisting that abortion is not a legitimate part of family planning, and that contraception is the way to reduce the number of abortions, undermines women’s repro-ductive health and rights.

To those seeking support for contraception as a proven means of improving women’s health, throwing in a promise to “reduce the need” for abortion may seem like an innocuous way to distance themselves from a volatile issue. For example, the Senate Appropriations Committee decided this June to lift a ban on emergency contraception coverage for Peace Corps volunteers and to permanently repeal restrictions on foreign aid for family planning groups. In arguing for the change, Sen. Jean Shaheen said that eliminating the policy would decrease the number of abortions in Global South countries by increasing access to a greater variety of birth control methods. She was right—expanding safe contraceptive options can improve women’s health. The problem is, these types of calculations ignore the full reproductive needs of real women, who also sometimes need abortions.

Internationally, development agencies promote global scaled-up LARC distribution as the most effective way to reduce the need for abortion in the Global South. Pathfinder International claimed in a 2011 report that 26,784 abortions in Ethiopia alone would be averted with the increased international dissemination of the implant, Implanon. Likewise, Global Health Science and Practice Journal, a publication for development practitioners, suggests that if one in five women in sub-Saharan Africa were to switch from their current form of birth control to an implant, it would result in 600,000 fewer abortions in the next five years. Coupled with this is the claim that implants substantially reduce maternal mortality. But what about the other four out of five women, the ones whose situations don’t fit neatly into the international development agencies’ promises that more LARC distribution will equal fewer abortions in the Global South?

WHY DOING REPRODUCTIVE HEALTH HALFWAY HURTS ALL WOMEN

Insisting that abortion is not a legitimate part of family planning, and that contraception is the way to reduce the number of abortions, undermines women’s reproductive health and rights in a number of ways. The following are three of the most damaging consequences.

  1. It leads us away from addressing the root causes of unwanted pregnancy and maternal mortality.
  2. It stigmatizes abortion, women who have abortions and providers of abortion care, while undermining efforts to make abortion more accessible.
  3. It takes us back to the pre-Cairo days when women’s needs and rights, especially those of the most vulnerable, were systematically violated by demographic programs that denied individual agency.

Each of these alone is a compelling reason to break down the wall between family planning and abortion. Together they make an overwhelming case for doing so.

ROOT CAUSES

It is a mistake to think that contraception alone, or any one contraceptive method, is the solution to unintended pregnancy, poverty and health disparities. Contraceptive researcher Jenny Higgins painted a realistic portrait about LARC in an article for the journal Contraception earlier this year: “Alas, contraceptive knowledge and access do not single-handedly determine unintended pregnancy rates—even though we also need to continue fighting for contraceptive services, coverage and education.” The solutions to these larger social problems require institutional and structural change, and, as Higgins noted in the same article, “It would also be unfair to place the burden of such social change on women’s bodies and contraceptive behaviors.”

In order to achieve the important policy goals of reducing unintended pregnancy and maternal mortality, we must address their underlying causes. These include the structural, social and economic inequalities that lead to poor health conditions such as anemia, undernutrition, communicable diseases (including HIV) and inadequate health services—but even if we could wipe away all of these problems, it would never take away the need for abortion. And unsafe abortion is itself one of the main causes of maternal mortality.

Trying to pluck out the single thread of abortion from the web of women’s reproductive health needs will always be a losing battle. But that doesn’t stop many leading advocates, policymakers and donors from being reluctant to even acknowledge the role of unsafe abortion in maternal mortality, much less address it directly. A 2011 article by Sneha Barot in Guttmacher Policy Review plots reproductive health topics along an axis from approachable to untouchable, saying: “promoting family planning as a key intervention in promoting maternal health is acceptable, the discussion of unsafe abortion remains limited, and that of safe abortion, decidedly taboo.” If policymakers are too nervous to even broach the topic of abortion, they certainly can’t commit to promoting access to safe abortion. Abandoning women’s health and autonomy to clandestine procedures is an abdication of the responsibility to provide the people-centered care the World Health Organization demands for policies in the Global South.

THE PROBLEM WITH ‘SAFE, LEGAL AND RARE’

President Bill Clinton, while proclaiming himself a prochoice president, was the first to introduce the idea that abortion should be safe, legal and rare. Pregnancy-prevention programs that include contraception were posed as the way to achieve that goal. Since then, this has become the mantra for politicians and, especially vexing, among some abortion rights supporters. But the promise of prevention creates an adversarial relationship in which contraception is placed on a moral high ground by itself. It is hard to see the good in policies aimed at curtailing abortion access, which disproportionately affect women with the fewest economic resources and exacerbate racial disparities. Further, the idea that there is some right number of abortions effectively stigmatizes all abortions.

Nor has affirming the separation stopped the antiabortion movement’s efforts to blur the boundaries between abortion and contraception in order to undermine access to both. For example, claims by opponents of abortion that emergency contraception (EC) is an abortifacient marked the beginning of a new strategy whereby pharmacists refused to fill prescriptions for EC. Protections for so-called conscience claims have now been extended and enshrined in law in the recent US Supreme Court decision, Burwell v. Hobby Lobby. In that case a craft supply chain claimed that Plan B, Ella, and two types of IUDs were abortifacients that violated the owners’ religious principles. The court accepted this argument and exempted many corporations from required compliance with providing contraceptive coverage under the Affordable Care Act.

THE BAD OLD DAYS OF POPULATION CONTROL

Thirdly, the focus on contraception and LARC promotion in order to avoid abortion comes with a troubling emphasis on population reduction. Influential players, like the World Health Organization and the Gates Foundation, suggest that family planning is a necessary tool to curtail population growth, which they blame for stalled economic development and environmental degradation, the spread of disease and even conflict. A USAID toolkit for LARC and sterilization suggests specifically promoting LARC as a way for countries to meet their national fertility reduction goals.

When population reduction has been the main goal of family planning, it has come steeped in a history of coercion. This has created skepticism and distrust about family planning, especially from vulnerable populations in the US and internationally, including people of color, people with disabilities and those living in poverty.

Systematic human rights abuses have been documented in service provision, including coercive sterilization among HIV positive women in some countries; the failure to inform women about safety concerns and side effects of contraceptives; and the denial of a full range of contraceptive options.

Advocates working in the US and globally are finely attuned to this history. Their communities have experienced the harms caused by a population control mania that undermined women’s freedom to have children. And coercive contraception or sterilization still occurs whenever a woman’s needs are subjugated to a population plan. Reproductive health advocates and researchers Anu Gomez, Liza Fuentes and Amy Allina cautioned against family planning outreach campaigns that target particular groups of women “without consideration of [each woman’s] unique history, preferences and priorities.” They were responding to LARC promotion in the US aimed at women who are deemed most “at risk” for unintended pregnancy, namely young African American, Latina and poor women. The programs were conceived in the name of addressing health disparities and breaking down barriers to access, but since the impetus came from outside these communities, the campaigns were met with suspicion.

Similarly, international family planning campaigns promote LARC to those women and girls who are considered the most “at-risk” for unintended pregnancy. Here, too, the target population is the poorest women and girls living in less developed countries. This includes countries in Africa, particularly in sub-Saharan Africa, where HIV is hyper-endemic. Although LARC does not provide protection against HIV transmission, in South Africa women report being required to obtain a stamp showing they have obtained contraception, preferably LARC, before they can have access to HIV medication.

Resisting reproductive coercion and fighting for the right to decide whether and when to be pregnant are at the heart of the reproductive rights and justice agenda. Unfortunately, the inseparable elements of abortion and contraception have often been left out of the strategies pursued by both reproductive choice and family planning advocates, creating political divisions that weakened both arms of the reproductive health and rights movement. Cairo appeared to create a new consensus, replacing population control and contraceptive targets with a focus on women’s rights and reproductive health. However, it seems that the consensus has broken down.

No doubt this is, in part, a reaction to the relentless efforts of the antiabortion movement to limit access to abortion and all or some methods of family planning, often by employing a “guilt by association” model meant to discourage any endorsement of reproductive choice. Not even Melinda Gates is immune from their attacks. In response to her recent statements quoted above, opponents of abortion condemned the Gates Foundation for supporting the “abortion industry” by channeling family planning money through the International Planned Parenthood Federation and Marie Stopes International.

Fears about providing fuel to antiabortion fires have inhibited conversation among advocates of abortion and contraception. This has caused political divisions even among advocates for women’s health and rights, with critical voices being relegated to the margins of policy debates, or worse, sometimes painted them with the antiabortion brush.

At this time, when a numbers-driven family planning agenda is once again being openly expressed; when the opponents of abortion are successfully curtailing both abortion and contraception; and where maternal mortality and unwanted pregnancy remain pressing concerns, it is crucial that we transcend the fear of talking about abortion. We need to take these threats to women’s health seriously when advocating for both family planning and abortion. We have a significant political opportunity not to repeat the mistakes of the past.

A NEW APPROACH: ‘TO DECIDE FREELY’

In order to address the reality of all women’s lives and reproductive needs, we must break down this wall between contraception and abortion. We need to take a holistic approach and stay focused on our ultimate goal, as expressed by the Call to Action for the International Day of Action for Women’s Health: “to promote, protect, and respect our sexual rights and reproductive rights to decide freely upon all aspects of our body, our sexuality and our lives, free from coercion, discrimination and violence.”

Within this broad perspective, contraception and abortion represent points on the same continuum of tools enabling people to make their own decisions about their reproductive health and lives. A comprehensive approach to sexual and reproductive health and rights should include a full range of contraceptive methods with information on their effective use and adverse effects. It should include safe and legal abortion, free from stigma, as well as education and counseling on sexuality, gender and healthy relationships; appropriate services for people living with HIV; other STI prevention and treatment; and prenatal and maternal care in the context of overall health services.

While we oppose strategies that promote contraception at the expense of abortion, we certainly support increasing women’s access to safe contraception, including LARC. Like abortion, these are essential aspects of a reproductive health policy that will enable people to exercise their reproductive autonomy and human rights. We know all too well from settings where access is prohibited or highly restricted that the costs in terms of maternal health and mortality are high. Abortion and contraception are necessary public health interventions that save women’s lives and preserve their health.

Abortion should not be seen as a failure of individual or social responsibility. There are many reasons why women need abortions. But what holds true in all situations is that a woman will do whatever she must in order not to carry the pregnancy to term. She may wish that she had not become pregnant in the first place, although this is not always the case. For example, at the National Network of Abortion Funds (NNAF), after Hurricane Katrina we heard from many women whose pregnancies had been planned and desired, but whose lives had radically changed. Nor does it require a hurricane to turn a wanted pregnancy into one that is no longer welcomed. When a woman decides, for whatever reason, that she cannot continue a pregnancy, access to safe abortion is a blessing, as the Reverend Katherine Ragsdale said in 2007 speech delivered before an abortion clinic under siege from protestors.

If we continue to leave abortion out of the reproductive rights and health toolkit, we misunderstand the battle for women’s healthcare, become distracted from our agenda and cede the upper hand to our opponents. Dr. George Tiller, unwavering in his support for abortion rights and women’s autonomy, and ultimately murdered for his work by an antiabortion zealot, had great clarity about this point, saying, “Make no mistake, this battle is about self-determination by women of the direction and course of their lives and their family’s lives. Abortion is about women’s hopes and dreams. Abortion is a matter of survival for women.” Tiller’s public avowal of abortion rights as essential to women’s autonomy is an eloquent reminder of what we must do now.

Contrary to Melinda Gates, debate about abortion is essential to achieving a consensus that women should be the ones with the power to make their own reproductive decisions.

It is past time for women’s health advocates to boldly affirm that safe, accessible and voluntary abortion is both a social and individual good and an essential aspect of basic human rights. The wall between abortion and contraception stands in our way. Let’s bring it down.

Marlene Gerber Fried is professor of philosophy and faculty director of the Civil Liberties and Public Policy Program at Hampshire College. She is also a longtime reproductive rights activist and was the founding president of the National Network of Abortion Funds and the Abortion Rights Fund of Western Massachusetts.

Anne Hendrixson is the director of the Population and Development Program at Hampshire College, which is a feminist center on population, peace and the environment. Anne is a reproductive health advocate, writer and speaker.

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