Melinda Gates and I both feel strongly about healthcare availability to poor women, and we see family planning as key to women’s healthcare. However, we have a key difference: she has chosen to provide contraceptives; I have chosen to provide NFP education.

Contraceptives will not advance the health of women and families or contribute to a “virtuous cycle” in developing nations, for two main reasons. First, contraceptives aren’t an accurate or sensitive panacea to existing international needs; second, they are not the farsighted support to advance women’s health or equity.

International Policy

In her TEDx talk, Gates states that “birth control has almost completely and totally disappeared from the global health agenda.” But birth control has been on the international agenda continuously since the 1994 Report of the International Conference on Population and Development and the 1995 Fourth World Conference on Women. In 2006, the Convention on the Elimination of All Forms of Descrimination Against Women reprimanded Ghana for inadequate healthcare availability for women and recommended contraceptivesSimilar remarks were made between 2006 and 1997 to Uruguay, Khazakhstan, Mongolia, Nicaragua, Vietnam, the Democratic Republic of the Congo, Chile, and Antigua and Barbuda. Obviously, contraception has been a near-constant theme in the work of treaty-monitoring bodies (TMBs) and non-governmental organizations (NGOs).

Last month, I met Obadias Ndaba, president of the World Youth Alliance (WYA), a global coalition of young people dedicated to human dignity and solidarity among nations. He is often required to reemphasize to States Parties, NGOs, TMBs, and other bodies that there is no international human right to any particular form of family planning method.

Ndaba called approaches like Gates’ a “one-size-fits-all strategy,” that is, “let’s just dump [contraception] on Africa,” as if it is one country with one culture, and as if poverty and undevelopment come from large family size. In fact, Ndaba said, poverty comes from corrupt regimes, polygamy, and unmet basic needs for water, food, and familial and national peace. Gates’ approach is a bandaid solution for nations’ underdevelopment. I prefer to treat the cause of a problem.

Women’s Health

Gates’ approach is also a bandaid solution to women’s health and social advancement. It makes assumptions about women’s desires, and proposes artificial contraceptives that are simply suboptimal.

Gates comes from a culture where contraception is almost as normal as vitamins. However, not all cultures are like that. The WYA puts out a white paper on family planning in international law. It explains (emphasis added),

The number of unintended pregnancies in the world is high, but the idea of a global unmet need  for contraception is misguided. Although there may be 215 million women who want to delay or avoid pregnancy and are not using contraception, that does not mean that all of these women want to use contraception. 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 [because of concerns] about health and other side effects of artificial contraception, incompatibility with religious and ethical beliefs, and the financial cost of contraception. Unmet need for family  planning should not be equated with an unmet need for contraception.

Besides this cultural assumption, Gates also prefers artificial birth control (especially the injectable medoxyprogesterone acetate or MPA, a.k.a. Depo Provera) without considering that this method is not medically superior for anyone, especially the nations she desires to help. The highlights of the prescribing information MPA draw attention to the frightening loss of bone density, especially in adolescents taking this drug (a 5.4% decline after two years of use). While other teenagers gain 2.19% bone mineral density (BMD) over two years, adolescents taking MPA lose 5.40% of their BMD during the same time. Melinda Gates hopes to provide Depo-Provera to regions like sub-Saharan Africa, but the ten countries with the highest adolescent birth rates (153-199 of every 1000 teenagers pregnant) are all in sub-Sarahan Africa. Check the UN-DESA puts out period fertility indicators.  Because of this negative bone density effect, Depo-Provera is recommended for a maximum of two years of use; not only is this shot dangerous, but it’s unsustainable.

But there is more than bone density at stake for the 200+ million women Gates wishes to aid. Gates noted that the preferred method of contraception for many women “is an injectable…[since] they can hide it from their husbands, who sometimes want a lot of children.” I doubt that promoting the lack of communication between couples is a good idea for women, especially in cultures where women and men don’t have equal decision-making authority in family planning. Gates is inadvertently enabling gender inequity.

Contrast all those effects of contraception with the goals for Safe Passages, a comprehensive program designed to reduce maternal morbidity, improve child health, prevent the spread of HIV, and positively affect marriages:

[NFP] is a shared method which involves the active participation of both husband and wife. Fertility literacy empowers couples with  knowledge and respect for their fertility and sexuality, fostering values and behaviors of chastity, self-control, spousal communication, and respect for women.  Fertility literacy teaches and supports breast feeding, healthy child spacing, and proper nutrition and care during pregnancy. Finally, fertility literacy provides a stepping stone to gender equity, reordering a value system that often places the worth of a domestic animal above the well-being of a woman.

Safe Passages was begun by George Mulcaire-Jones, M.D., an OB/GYN. I met Dr. Mulcaire-Jones last February, when he discussed his work at Maternal Life International. In Mulcaire-Jones’ experience (as in Ndaba’s), the problem Gates identifies is not rooted in family size but cultural sexual mores. If Mulcaire-Jones is right, Gates will hurt more than help by enabling poor spousal communication to continue.

Unfortunately, Gates does not seem to consider NFP as a viable alternative to artificial contraceptive. Granted, she mentions “the rhythm method” in her talk and shows “cycle beads” in her display of methods. But she must not have realized that rhythm and fertility-awareness methods are very different. Rhythm is a rigid, calendar-based method; fertility awareness methods are tailored to each woman and each month. In programs like Mulcaire-Jones’, beads are provided as practical equivalents to the charts and apps that western NFP users enjoy. Gates’ oversight here is an unfortunate one: a closer look at NFP might have inclined Gates, who is so well-intentioned, to a more effective aid to those most in need.

In short…

Melinda Gates wants to eliminate controversy over contraception in international relations. But as long as there are people who care about cultural sensitivity, women’s health, and gender equity, there will be controversy.