Cross-examination of a human right
One in ten women around the world doesn’t use the contraceptives she needs. We analyse how women exercise this right and how side effects, misogyny, beliefs, and outsiders interfere with it.
Family planning is not a privilege, but a right. That’s what Babatunde Osotimehin said when he was executive director of the United Nations Population Fund (UNFPA), in 2012. It not only helps eradicate poverty, he said, but is also “one of the most effective means of empowering women”. He died last July. International organisations, including the United Nations, have been declaring for decades that choosing if you want to have children and when and how to do it is a fundamental human right.
But it’s a right that is undermined whenever a girl becomes pregnant, whenever a woman is accused of being promiscuous, or being a prostitute, for using some form of birth control. It is undermined every time she is forced to have unwanted children, every time she is forced to have abortions in unsafe conditions, every time someone tells her what she must do or what she cannot do with her body, even when she is the one who, in many countries, bears the consequences of those decisions. It is undermined every time a new birth puts a woman’s health at risk or kills her. These are not made-up examples. They are true stories gathered in this investigation of how people exercise this universal right and the barriers women must overcome to do so.
Fanta Jatta knows more than most about these cases. She talks about it at the headquarters of Action Aid International, in Banjul, The Gambia, where she directs the program on women’s rights. For her, in addition to the health problems–for mothers and children–caused by a lack of access to contraceptives, there is something more fundamental: who decides and how. “We need to understand how our bodies work and make our own choices,” she says.
“We need to understand how our bodies work and make our own choices”.
Worldwide, the most common contraceptive methods are emale sterilisation (30%), intrauterine devices (IUD, 22%) and the pill (14%).
But contraceptive use is not homogeneous between countries or across social classes. The economic situation, cultural context, availability of pharmacies and public policies determine the most popular method in each country.
Some facts about the use of contraceptive methods
- Female sterilisation is the most common contraceptive method in India (67%); it is also common in Mexico and in many Central American countries such as the Dominican Republic (59%), Puerto Rico and El Salvador.
- Male sterilisation is a lot less common. It’s used by 30% of couples in Canada and 25% of couples in the United Kingdom.
- The IUD dominates in Asian countries. It is used by 95% of women on birth control in North Korea.
- In China, 48% of women on birth control today use the IUD. At the time of the one-child policy, the government forced women to use the IUDs after giving birth to their first child. Now, the government is offering to remove IUDs for free. In other countries, its use is almost negligible. Some doctors refuse to insert it due to false beliefs about its safety in women who have not yet had children
- The pill is the leader in other places, such as North Africa and much of Western Europe, but not Spain.
- The male condom is one of the most common methods in countries as different as Botswana (79%) and Greece (49%), and in other countries where unmarried women do not have access to longer-lasting methods. It is the leading contraceptive method in Spain (38%).
- The injectable hormone method is popular in Africa. For many women it is the perfect solution if they decide to use contraceptives without their husband’s knowledge. Many men would be against it. But injections are easy to administer: a quick shot every one, three or five months, and they leave no trace.
- Traditional methods range from tracking the menstrual cycle to local practices tied to religion or magic. These methods, which are unreliable at best, are the leading method in the Balkans. In Albania, for example, the pull-out method is the main form of birth control for 84% of women.
In The Gambia, many women use variations of a traditional method that goes by different names. They share the same, unscientific, principle: the women tie a cord or a branch with or without words from the Koran on a slip of paper to their waists to try to prevent pregnancy. Of course, it does not work.
So far we have discussed women that use some form of birth control. Of married or in-union women from 15 to 49 years of age, 64% practise some form of birth control. Another 24% wish to continue having children and so are not practising birth control. The remaining 12% are women who wish to delay or prevent maternity but are not using birth control. These are the women with unmet needs. And is is a problem.
They may want to space their pregnancies for health reasons or to stagger their child care or organise their own lives a certain way. Jarra Joof, a 42-year-old member of her community’s Mothers’ Club in Banjul, The Gambia, wanted to wait a while after her first child was born. But, “only seven months later I was pregnant again. Then I had my second baby. However, I did not want to find myself in the same situation for my third pregnancy,” she says.
Joof used birth control to space her next four pregnancies. Now she is back to using birth control full time. “Seven children are enough,” Joof says.
Some women may not want to have any more children, like Joof, or they may not want children at all. Though their reasons may vary, women with unmet birth control needs have at least one thing in common: they don’t want to get pregnant and they are not doing anything about it.
The problem of unmet needs is bigger in some countries than in others. It hardly exists in China, while in Angola it exceeds 36%.
But if we compare by their Gross National Income (GNI), in rich countries, such as the United States, Germany or Spain, the percentage of women with unmet needs is less than 15%. In the least developed countries the percentage is over 30%. Japan and Saudi Arabia, despite their wealth, have unmet needs on par with much poorer countries.
Percentage of women with unmet needs
So the percentage of women with unmet needs in the least developed countries (21.4%) is almost double that of the global mean (11.5%), according to the UN.
Let’s focus on countries with the most difficult situations. What are the barriers for women to access contraceptives? According to the Guttmacher Institute’s report Unmet need for contraception in developing countries: examining women’s reasons for not using a method, which analysed 52 countries, the principal barriers are side effects, infrequent sex and resistance by the woman or others.
Women with unmet needs not using contraceptives for health reasons
The majority of respondents not on birth control for health reasons have used it at some point, according to the study. That is, they know what they are talking about: excess or reduced bleeding, nausea, changes in the body–weight gain or hair growth–loss of libido, mood changes… the long list of side effects for hormonal contraceptives does not help.
“As far as the side effects are concerned, there needs to be a lot more progress and research made. This is just simply not sufficient, mainly because most of the contraceptive methods focus today solely on women, whereas for men there are very few opportunities to be active”, says Mirjam Beck, a 27-year-old in Berlin, Germany. A 2016 trial of an experimental male contraceptive was stopped due to its side effects, which are very similar to those suffered by women today.
“I really had the feeling that any form of hormonal contraception burdened me both psychologically and physically.”
And there are also reasons not based on scientific evidence, such as the claim that certain contraceptives might harm a woman’s ovaries, cause infertility, or even harm a man’s penis.
In Pout, Senegal, one hour from Dakar, dozens of women, most with children in their arms, wait with their feet in the sand under an awning that shades them from the sun. Lively rhythmic music starts the show. The imam is also present.
They prepare the condoms and everyone takes their place. The DJ turns down the music and Coumba Dieng, of Marie Stopes International in Pout, begins her class on how to use contraceptives.
She explains and demonstrates the methods one by one with the enthusiasm and banter of an experienced master of ceremonies.
The main barrier to convincing them to use birth control are “mostly rumours,” she says.
The key, according to Alieu Jammeh, Reproductive Health Commodity Security Coordinator at UNFPA in Banjul, The Gambia, is the availability of variety, that their effects are well-explained to avoid bad unjustified bad reputations, and that each woman can decide which is best for her. This is the most important thing across all the analysed countries.
Many women claim that they don’t use contraceptives because they do not have sex on a regular basis. But sometimes they reply in the very same survey that they have had sexual encounters in the preceding month. In some countries, single women may not report their sexual activity to avoid being singled out. For many of them, at least in public, sex and contraceptives don’t exist.
Women with unmet needs not using contraceptives for opposition
This refers to cultural reasons, in contrast to women’s health-related barriers, such as the side effects of some hormonal contraceptives. Most of the respondents who say this is their principal barrier have never used any method of birth control, according to the Guttmacher study. Somebody, whether it’s the woman herself, her husband or others, is against her using birth control. But whom and why?
In most such cases, the woman being interviewed says she is against birth control. Keeping in mind that we are only analysing the responses of those women whose necessities are unmet–that is, they do not want more children but are not using birth control–their response reflect outside influences, from cultural to social to religious.
Although the percentages are lower, religion can also affect opposition in the above cases. And that goes for all the major religions. In the most orthodox cases, it’s the imam, priest, or rabbi who decides who uses, or doesn’t use, birth control and what type.
Husband or partner opposition
“Many women do not make independent decisions. They are made for them,” says Fanta Jatta, of Action Aid International. She has known cases of women whose husbands began abusing them upon discovering they were taking the pill and others forced to carry pregnancies to term even when it was a health risk. Momodou Njie of the Family Planning Association in Banjul tells stories of women who visit the clinic incognito and leave their paperwork there for fear of being discovered. “The majority of the decisions are made by men, but in some instances the woman makes the decision, not because they don’t want to do what the husband says, but they want to save their lives,” he says.
In Albania, where the pull-out method is most common, opposition from husbands is also the main barrier to access to birth control. It is followed by East Timor, Mali, Senegal and Afghanistan.
The key is who makes the decision. For Alieu Jammeh, of the United Nations, it’s important to include men in the decision to “minimise the friction in the household, but beyond that, if the woman wants it, even if the man doesn’t want it, we give it to the woman.”
“They continue imposing their personal morals when it comes time to serve customers”
Mothers-in-law, fathers, or even medical or pharmaceutical services, among others, may intervene in a woman’s birth control decisions. The Network for Sexual and Reproductive Rights in Mexico (DDESER) did a study of contraceptive distribution under two different governments. They interviewed managers, doctors, civil servants, and users. They even sent mystery shoppers posing as customers. They found health centres that refused to give condoms to youth, where the condoms piled up until they expired, or where they don’t give the pill to married women, to give just two examples.
It’s increasingly rare for women not to know about birth control, to lack access, or not to be able to afford it. But in West and Central Africa, those reasons, were mentioned by more than ten percent of respondents in the Guttmacher study. In Mexico, Patricia Ortega of DDSER says that some university students, “don’t even know how to use a condom.” When asked about how many times a condom can be used, 15.5% of respondents to the Mexican National Health and Nutrition Survey responded incorrectly.
“Poverty is not just the lack of money, or material, it’s also the inability to make choices.”.
In The Gambia, television ads promoting contraceptive use were a social revolution a few years ago, and did not lack for critics in the Catholic community.
In Europe promotional campaigns for contraceptives have been rare for a while, with the exception of those paid for by Durex, and there is more and more public investment in promoting child-bearing. The Polish government ran a campaign encouraging its citizens to have sex and there is an annual campaign in the Spanish autonomous community of Galicia that appeals to the “necessary shared responsibility” of bringing more children into the world.
What does it mean for there to be unmet needs? That a woman cannot exercise her right to plan her own reproduction. According to the WHO, family planning reduces abortions, especially dangerous ones, reinforces the right to determine the number and timing of children and prevents the deaths of both mothers and children.
In 2012, 85 million pregnancies worldwide were unintended. This is 40% of the total and many of them end in abortion, whether natural or voluntary. An estimated 25 million unsafe abortions are performed annually, most of them in developing countries.
Some 830 women die every day due to pregnancy- and childbirth-related causes. Almost all are in developing countries. In fact, the WHO estimates that in 2015 more than a third of those deaths occurred in Nigeria and India. Another way to put it is: if you live in a developed region your odds of dying in childbirth are 1 in 4,900. If you live in a developing country, they are 1 in 150.
It’s a question of public health, but above all of rights. Women have the right to freely choose if they want children, and how, and when.
See it their way
Explore the data and discover how access to birth control differs for women all over the world.
Eva Belmonte, Miguel Ángel Gavilanes, María Álvarez del Vayo & Verónica Ramírez
This article has been produced as part of a data journalism initiative called ‘Medicamentalia – Contraceptives‘ brought to you by the Civio Foundation.
This project is funded by Journalism Grants, which is financed by the Bill and Melinda Gates Foundation. As with previous publications, neither organisation has influenced in any way our reporting nor the content of this project. Nor have they had advance review of the project.
The database and all materials produced by the project (i.e. not including photographies provided by third parties) are Creative Commons (CC BY). You may use anything that you need or that interests you on one condition: you must attribute and link to Medicamentalia. We also ask that you tell us about it! We would love to hear from you.
Featured image credit: Malyka Diagana
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