If We're Serious About the Millennium Development Goals, Let's Get Serious About Family Planning

January 9, 2010

By: Allen Moore, Distinguished Fellow, The Henry L. Stimson Center

The Millennium Development Goals (MDGs) were adopted unanimously by the United Nations in 2000 to confront the world’s major development challenges. There are eight MDGs with 21 sub-objectives to be achieved by 2015. Every single one is behind schedule—a product of over-reaching and under-achieving.

As international planning experts re-assess what’s doable, there is one area that stands out for its potential to make a positive contribution towards every one of the MDGs—expanding access to voluntary family planning. Family planning has clear potential to:

• Reduce extreme poverty and hunger (MDG 1)
• Improve access to primary education (MDG 2)
• Improve the opportunities and rights of women (MDG 3)
• Reduce child mortality (MDG 4)
• Improve maternal health (MDG 5)
• Reduce the impact of HIV/AIDS and other infectious diseases (MDG 6)
• Improve environmental sustainability (MDG 7)
• Improve economic development (MDG 8)

Fifteen years ago, a very important international conference was held to consider the special needs of women and girls in the developing world. Held in Cairo, the International Conference on Population and Development (ICPD) included 179 nations. Their recommendations became known as the “Cairo Consensus,” and much of the content of their work was incorporated into the MDGs, including a call for universal access to reproductive health.

For most experts, reproductive health services include family planning, but there is no political consensus on what those words mean. So, for the purposes of this discussion, family planning is defined narrowly: education, counseling, and contraception services to enable individuals to make voluntary choices on whether and when to have a child. Ideally, these services are linked in the real world to non-controversial and highly beneficial “reproductive health services,” including pre- and post-natal care, skilled birth attendants, repair of obstetric fistula and female genital mutilation, etc.

“Unmet need” for family planning is estimated to be around 200 million women. These are women who say, in periodic surveys, that they would like to stop having children or want to delay their next pregnancy for at least two years, but aren’t using contraceptives. Their reasons for “unmet need” usually involve one or more of the following: services aren’t available, cultural or religious opposition to contraception, and ignorance.

One sub-objective of MDG 5 (maternal health) is to eliminate the “unmet need” for family planning. It would advance all the MDGs and save millions of lives:

• By allowing mothers and couples to plan for appropriate spacing between children. Babies born within 15 months of a preceding sibling are 50% to 80% more likely to die before age two than are babies born three years apart. Having babies too close together also increases maternal mortality.
• By reducing the demand for abortion. An estimated 76 million women in developing countries have unintended pregnancies each year, and 19 million of those pregnancies will end in unsafe and often illegal abortions…and about 70,000 abortion-related maternal deaths.
• By helping young women to delay a first pregnancy. Complications from pregnancy and child birth are the leading cause of death among teen-aged girls in developing countries, and the babies of teen-agers are twice as likely to die before age five as the babies of mothers at least 20 years old.

Eliminating “unmet need” for family planning would cost $3-4 billion annually, though such estimates are greatly complicated by dramatic differences in local circumstances. And recipient countries have to be willing partners—contributing their own scarce resources and accepting the underlying premise that family planning serves their national interests. That is not a foregone conclusion. Past mistakes have caused poor countries to suspect the motives of outsiders espousing the benefits of “population control.” Focusing on the individual and scrupulously avoiding even a hint of coercion are critically important to gaining acceptance in developing countries. [Except in China, where a highly coercive “one-child policy” disqualifies China from receiving any family planning assistance from the U.S. government.]

The U.S. is the largest funder of international family planning services. Bi-lateral spending of $455 million in FY09 will grow to around $525 million in FY10, up nearly one-third since FY08. Prior to this, spending had been relatively flat in real terms since the mid-1970s, not counting a short-lived spending “spike” in 1995 in response to the ICPD. Prior to FY09, President Bush would regularly seek to cut family planning spending. Congress would re-buff him and eventually restore the proposed reductions. But the annual battles were debilitating and dispiriting.

The argument was less about the money and much more about America’s culture wars over abortion. There is passionate mistrust on both sides, prompting relentless maneuvering to gain political advantage by demonizing the opposition. Both sides have a point. Pro-choice forces really do want to expand abortion rights, reduce unsafe abortions, and reduce what they see as “the need” for abortion through family planning. Those are fighting words for pro-life forces, who really do want to stop almost all abortions. Both sides seem willing to accept stalemate over compromise. Sadly, the stand-off serves the political ends of both camps.

But the collateral damage is real. Flat spending has deadly consequences: more women and babies die; more abortions occur; and more poor families have fewer resources for food, shelter, health and education. It’s difficult to refute the appalling notion that America’s deep divisions over abortion exact a global toll in preventable death and human misery.

Nonetheless, many political and religious leaders won’t touch the issue—a tragic irony in light of the fact that an overwhelming majority of Americans use contraception in their personal lives. Conservatives willing to provide voluntary family planning services in the developing world hesitate even to use the term “family planning” for fear of being called “dupes” by their anti-abortion supporters. Liberals open to providing such services outside the bounds of abortion fear the wrath of pro-choice supporters who insist on using Democratic majorities to “fix” U.S. law once and for all. Political gurus on both sides warn against giving up a “winning” issue. But what about those in need?

The President has publicly deplored the use of international family planning as “a wedge issue (that) has served only to divide us.” He pledged to “initiate a fresh conversation (to seek) common ground to best meet the needs of women and families” around the world. It’s time for that conversation. Common ground exists.

It’s time for the President to invite political, religious, and other leaders to join a call for universal access to voluntary family planning in a manner that clearly fences off abortion from U.S. funding. He should seek to double U.S. spending, and use that prospect both to challenge other donors and to enlist the developing countries with greatest need.

This is not the initiative that everyone wants, especially many in his own party who believe the time is at hand to expand access to safe and legal abortions. But the prize that everyone should support is an opportunity to save millions of lives and improve several times that number. If the President wants to show America’s seriousness about helping achieve the MDGs, this is the way to begin.

photo credit: USAID, http://gemini.info.usaid.gov/photos/displayimage.php?album=810&pos=5

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Allen Moore is a Distinguished Fellow at the Stimson Center. He was Policy Director for then Senate Majority Leader Bill Frist, M.D. (R-TN) when Bush’s global HIV/AIDS program was created in 2003.

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