Julia Manning: Pills and power: why access to contraception isn’t enough

Julia Manning is Chief Executive of 2020Health. 

On Wednesday, a huge international summit hosted by Melinda Gates and DfiD will take place with the focus on access to contraception. I went to Kenya 2 weeks ago, funded by the Gates Foundation, to look at women's health. Whilst I support this call for access, if we don't address the culture in which teenage girls live in these developing nations we are giving them pills without power. This is the message of the feature below.

Winnie was 13 and had been through the “Healthy Choices” programme supported by the US based Centre for Disease Control satellite that is based in Kisumu County, Kenya. The programme covered the usual health and lifestyle issues with a strong emphasis on teaching girls in their final year of primary school how to resist pressure to have sex, and how ‘bad company’ should be avoided. Winnie said there had been a lot of emphasis on bad company, which is sound stuff, but much harder to put into practice when your relations are the ‘bad company’, or you live without the street lighting that helps you spot it approaching or in a society that still has so many sex-based customs. The global call for access to contraception that will be made on Wednesday is valiant, but it will be an empty promise of power if we don't change the culture.

I was in Kenya 2 weeks ago on a visit with the International Reporting Project, an organisation housed by Johns Hopkins University with this trip funded by the Bill and Melinda Gates Foundation to specifically look at women’s health. The Gate’s Foundation has decided that universal access to free contraception is now a key goal. The Kisumu based CDC team had brought us to this school in Kibuye as part of a two-day whistle-stop tour into which they had packed rural home visits, a hospital tour and patient interviews as well as the primary school call.

Kenya is a country that has a stubbornly high maternal mortality rate – 488 deaths out of every 100,000 live births compared to 8 per 100,000 in the UK. A high child mortality rate and dependence on children in old age has historically driven a high birth rate across Africa. Whilst the average family size has dropped over time to an average of 4.6 children (thought the rural average is 5.2 and the urban 2.9), the country is now growing at an unsustainable rate of 1 million per year. A significant driver of this is teenage pregnancy – by 16 years of age nearly 10% of Kenyan girls have had a baby, by 19 years it’s over 36%. The thorny subjects of population control and abortion have made education around contraceptives harder, but so too have long-standing traditions and a culture that has condoned male superiority, ignored teenage pregnancy and defended gender-based violence.

Melinda Gates put her head above the parapet in April this year when she gave a speech on family planning to a TED conference audience. Urging people that the contraceptive agenda is about “giving women the power to save lives and give their families the best possible future” she highlighted that sub-Saharan Africa is one of only two areas in the world where family size has remained stubbornly large and access to contraception very limited.

Kenya is one such country, although ahead of many of its neighbours. On average, 46% of married Kenyan women (and marriage in Kenya can mean just living with a man) use contraception but the variation is between 3.5% to 67% depending on the region and on average only 6% of teenagers use it. But is access to contraception really the problem? Many young girls remain vulnerable to being coerced into intercourse and customs remain (claiming a home, celebration of harvest etc.) that require young men to find a girl with whom to have sex. Add to this rape, incest, poverty (sex in exchange for food is common), alcoholism and the aforementioned nightly twelve hours of darkness for those in the countryside and slums and contraception begins to look like a sticking plaster solution. Its importance is undeniable, but does nothing to stop the abuse.

On one occasion I specifically asked Marcella and Albert, two village elders, about the many risky customs. They said that they were being discouraged, including many of the sexual traditions. Marcella proudly recounted how a young widowed friend had stayed in her house and refused to be ‘inherited’ by her brother-in-law, traditionally his right. However the subject of teenage pregnancy as a result of abuse or coercion was one that met with near denial. Back at Winnie’s school I had asked three teachers about the girls who became pregnant. “No girl returns who gets pregnant. She usually gets married,” they said. “But these are girls of 13 – usually 12 and under!” I exclaimed, “don’t you ever think they might have been abused?” “You mean raped? Oh we hardly ever have rape in this area,” was the way they ended the conversation.

An unwanted pregnancy is a heart-breaking consequence for a young teenage girl not least as it disqualifies her from education, it raises her chances of maternal mortality and of living in poverty. All of this means that the lack of interest in the culture of accepting young girls get pregnant is also tragic. On one journey I asked two of the male field workers about moves to change Kenyan culture with respect to women. “Very few people study social sciences at University here,” Winston told me, “women don’t expect choice; we don’t expect control”. When malaria can kill you within 24 hours I do see that having ‘control’ is seen as fallacious and with forty-two Kenyan tribes all with their own customs it’s risky to generalise about culture. However gender-inequality is significant in the majority of tribes and its manifestations have become higher profile. As a result, specific attention was given to women in the Kenyan Constitution of 2010 which gave them more rights including to reproductive health and to inherit land, and there have been several programmes in recent years denouncing gender-based violence.

Today Melinda Gates will be in London, co-hosting an international summit on family planning with the aim of raising enough money to offer birth control to all women across the globe. This is a noble cause and access to contraception would undoubtedly transform life opportunities for women and their children world-wide. But the danger is that this will be seen as the strategic solution to the problem of unwanted pregnancies when for many, it will simply mean one less consequence of an abusive culture.  As Peter Druker once said, ‘Culture eats strategy for breakfast’. We cannot ignore the cultural context. In this case, we urgently need to work with countries to address cultures where abuse of pre-teen and teenage girls remains a social norm, because without this, we are giving them pills without power.