Will World Population Day Open the Gates to Coercive Contraception?

On July 11, World Population Day, the British government and the Bill & Melinda Gates Foundation are hosting an international Family Planning Summit in London to launch an ambitious $4 billion contraceptive program initiated by Melinda Gates. Its aim is to get 120 million poor women, mainly in Africa and South Asia, access to modern contraception as well as to stimulate research into new birth control methods.

On the surface it all sounds good, wrapped in the language of saving and empowering women. But many reproductive health and human rights activists worry that the summit represents a serious backslide to the bad old days of population control when contraception was deployed as a technical fix to reduce birthrates. Indeed, the Gates Foundation's family planning strategy blames population growth for exacerbating all matter of social ills, from stressing government budgets to contributing significantly to "the global burden of disease, environmental degradation, poverty and conflict." It as if the fertility of poor women causes these problems, and not the exploitative policies and practices of the rich and powerful.

A recent critical statement issued by the Center for Reproductive Rights, Amnesty International, and three international women's networks calls for human rights to be at the center of the forthcoming summit. Signed by over 320 women's groups and activists from around the globe, the statement points to the danger of a return to coercive contraception and forced sterilization. "The Family Planning Summit must ensure that the clocks are not put back on women's human rights: women's autonomy and agency to decide freely on matters related to sexual and reproductive health without any discrimination, coercion or violence must be protected under all circumstances."

These fears are justified. The Gates initiative focuses on India, for example, where the government's family planning program, supported by international donors including the U.K. government, is forcibly sterilizing poor women from disadvantaged communities, especially in the states of Bihar and Madhya Pradesh. An April 15 expose in the London Observer describes cases of pregnant women being sterilized and bleeding to death after miscarrying. While donors are not directly implicated in these practices, their failure to adequately monitor how their funds are used contributes to the abuse.

A certain political blindness is at work in the Gates initiative. The assumption is that you can just pour in money and contraceptives to health and family programs that already discriminate against the poor and miraculously they will turn around and help women. Add to this the imperative to drive down birthrates and you get a recipe for coercion.

But coercion is not the only problem. Another serious concern is which contraceptives Gates and its associates are pushing, and why. Even when population programs don't employ force, they often limit contraceptive choice to long-acting methods like injectables and implants that are viewed as more effective in preventing pregnancy and hence reducing population growth. What is the safest and most appropriate method for the individual woman is simply not the priority.

The hormonal injectable Depo Provera is a case in point. For over a decade now, studies have pointed to a possible link between Depo Provera use and increased risk of acquiring HIV, the virus that leads to AIDS. In October 2011 the British medical journal, The Lancet, published the results of a study which found that Depo may double the risk of women and their male partners acquiring HIV. The study sent shock waves through the international population community, since Depo Provera is their method of choice for Africa.

Precaution would dictate that Depo be phased out in populations at high risk of AIDS, but instead the World Health Organization has thrown caution to the wind. At a meeting in February the WHO decided to continue its "no restrictions" policy on the use of hormonal contraception, only adding the stipulation that women on injectables like Depo also use condoms to prevent HIV infection. Present at the meeting was only one HIV-positive woman from Africa.

At a time when Depo Provera should be under intense scrutiny, the Gates initiative is vigorously promoting it, along with a Chinese hormonal implant, as the two main contraceptive technical fixes for sub-Saharan Africa and South Asia. The foundation is enthusiastic about a new version of Depo that can be injected under the skin instead of intramuscularly. This will allow it to be delivered by nonmedical providers and maybe even by women themselves. In other words, little or no health screening and counseling, or concern for a possible heightened risk of acquiring HIV.

There is no doubt that women and girls should have the right to safe and affordable contraception and abortion as part of, not a substitute for, broader programs that address the full range of their reproductive and sexual health needs. That broader agenda is what feminists fought so hard to achieve at the UN's 1994 population in Cairo. Women's health activists have also fought long and hard to direct contraceptive development away from dangerous methods like high-dose estrogen pills and the Dalkon Shield IUD and to ensure that health and safety, not corporate profits and population control, motivate research in the field. All these gains are now under threat as a dark cloud hangs over World Population Day.