Within the United States, the U.S. Conference of Catholic Bishops has led a vocal and aggressive campaign against access to contraception that might suggest that faith and family planning are incompatible. Yet, among those who have ever had sex, 99% of women overall—including 98% of Catholic women—have used a modern contraceptive method during their reproductive life.1 Moreover, a wide range of faiths, denominations and religious leaders recognize that access to contraceptive services is essential to the ability of women to protect their own health and well-being, and that of their family.
On the global level, many faith-based organizations (FBOs) have had a long tradition of involvement in international development, and in global health in particular. The United Methodist Church,2 Islamic Relief3 and Christian Health Associations in Africa,4,5 among numerous others, consider family planning to be central to their missions to support women, children and families, and integral to their efforts to promote global health. As trusted messengers with deep roots in communities, FBOs can and do play important—sometimes essential—roles in providing contraceptive services, raising awareness and advocating for family planning.
Entry Points for FBOs
Women of every religion and in every region of the world practice contraception. In 2012, of the 867 million women of reproductive age in the developing world who were in need of contraception—because they were sexually active, capable of becoming pregnant and did not want a child within at least the next two years—74% or 645 million were using a modern method.6 * Of those, the vast majority—596 million—were married, 20 million were previously married and 29 million were never married. Still, that leaves 222 million women in the developing world at risk of unintended pregnancy who were using a traditional method (which are more likely to fail than modern methods) or no method and, therefore, had an unmet need for modern contraception. Fulfilling this unmet need would prevent 54 million unintended pregnancies, which otherwise would result in 21 million unplanned births, 26 million abortions (of which 16 million would be unsafe), seven million miscarriages, 79,000 maternal deaths and 1.1 million infant deaths.
Accordingly, because of this established and compelling case for the many health benefits associated with family planning, many FBOs have long supported international efforts to promote access to contraceptive services.7 In fact, FBOs engaging in global health explicitly connect their advocacy for family planning to their maternal and child health projects, based on evidence that birth spacing is critical to lowering numbers of deaths and disabilities. Moreover, some antiabortion faith-based groups advocate for family planning because of their antiabortion positions, in recognition of the key role that contraceptives play in reducing the need for abortion overall—and unsafe abortion in particular, which accounts for 13% of maternal deaths worldwide.8
Some FBOs link their support for family planning to their larger agenda to support global antipoverty, education, health, sanitation and other development programs.7 The Adventist Development and Relief Agency (ADRA), for example, believes that "health is at the very core of much of the world’s poverty and suffering"9 and that family planning is an integral component of alleviating that suffering.10 In addition to the innumerable health benefits, investing in family planning yields many social and economic benefits, by enabling women to determine the timing and spacing of their pregnancies. It means increasing the ability of girls and women to attend and finish school, improve their economic security, better allocate limited resources to their children and families, and contribute to their communities.
FBOs’ long involvement and experience in global health and development actually predates the presence of multilateral development institutions and foreign aid agencies in many developing countries. This history, their commitment to family planning as part of their development work and their broad reach within many low-income countries make FBOs well-positioned—and in some places uniquely positioned—to make significant contributions toward improving family planning access. Faith-affiliated organizations in the health sectors of different countries reach a significant portion of the population, especially in Africa.11 FBOs provide an essential safety net for health services in certain rural, remote, crisis or underserved areas where the government health system is weak or absent altogether—thereby, at times representing the only source of care in that community.12,13
Partnering with the U.S. Government
Recognizing the special influence, experience, and grassroots and national networks that FBOs have in the United States and in other countries, U.S. foreign aid agencies have actively sought partnerships with them. For example, FBOs play a prominent role in the U.S. global AIDS program (PEPFAR), both as advocates in shaping and supporting policy, and as grantees in providing services. Even before the advent of PEPFAR, though, FBOs had been partnering with the U.S. Agency for International Development (USAID) to implement its family planning and reproductive health program overseas. In these programs, faith-based, government and secular partners have found common ground on family planning that is often not acknowledged in the public debate.
FBOs, like secular nongovernmental organizations (NGOs), are philosophically diverse, however. Among FBOs, the fault lines over abortion are often clear, yet the differences over family planning may be more subtle. As Pauline Muchina, a theologian who works at UNAIDS (the Joint United Nations Programme on HIV/AIDS) noted at a recent conference, "Almost everybody believes in family planning, but what we argue about is the method."14 The Roman Catholic Church supports natural family planning, for example, but is staunchly opposed to all modern methods. Given these differences, the U.S. government has established clear rules for partners on family planning that rest on the principles of voluntarism and informed consent (see box).
USAID’s support for faith-based activities on family planning includes a variety of strategies, organizations and assistance. Sometimes, FBOs are directly leading advocacy, communication and education efforts, as well as direct services and provision of supplies, to ensure better access to contraception in communities that are of different faiths or backgrounds than themselves. Other times, USAID funds NGOs—secular and faith-based alike—to engage with local faith-based leaders and to promote behavior change efforts specifically through faith-based messages and messengers. Other activities supported by USAID involve capacity-building and training of religious leaders, FBOs, community organizations and health care workers. Described below are some examples of these different USAID-supported faith-based initiatives or organizations and their value in promoting family planning in low-income countries.
Incorporating Family Planning into Child Survival in Liberia
The United Methodist Church has been one of the strongest faith-based supporters of family planning globally, both theologically and in practice. An example is the Ganta United Methodist Hospital in Nimba County, Liberia, which offers community-based primary health care. In 2011, after discovering that misconceptions about family planning and lack of contraceptive access and use were contributing to high maternal and child death rates in the area, Ganta Hospital incorporated family planning into its USAID-supported child survival project. Just over one year later, the project had made remarkable strides in increasing the proportion of women using contraceptives, from 15% to 61%, and decreasing unmet need for contraception, from 68% to 22%, in its catchment area of almost 29,000 women of reproductive age.15 Ganta Hospital achieved these accomplishments through a multifaceted strategy that focused on training community health workers and volunteers to do regular outreach to surrounding communities, including counseling on the types, benefits and effects of contraceptive methods; forging partnerships with key institutions to ensure a secure contraceptive supply; collaborating with government offices; and actively recruiting the involvement of men.
Engaging with Religious Leaders in Afghanistan
Although FBOs are key messengers in reaching out to conservative religious and cultural communities, secular NGOs also frequently and successfully partner with religious leaders. Marie Stopes International (MSI), a London-based NGO and key U.S. partner for family planning and reproductive health, has collaborated with faith-based communities in Mali, Sierra Leone, Yemen, Uganda and other countries to extend family planning services to previously unreached audiences. Particularly noteworthy is its work in Afghanistan, where it has educated over 4,800 mullahs and other religious leaders and their wives on family planning and reproductive health issues since 2009.16 MSI equipped these leaders with information on the medical benefits of family planning, as well as with religious scripts from the Qur’an to bolster their ability to do culturally and religiously sensitive outreach. The wives of mullahs became health education champions in their communities, where they conducted educational sessions with small groups of women and provided referrals to local clinics. Not only did MSI, the mullahs and their wives substantially increase the number of women receiving reproductive health services, the organization was able to make inroads into isolated communities in politically insecure areas that had little to no access to health services of any kind.
Voluntarism and Informed Choice
The guiding principles of USAID’s family planning program are grounded in voluntary consent and informed choice. In practice, this means that individuals must have access to information on a wide range of family planning options, including details about the benefits and health risks of a particular method, and that they must be able to choose from a wide range of methods.
For a variety of reasons, however, not all providers offer all methods. In these cases, providers have a responsibility to ensure that their clients are made aware of their other contraceptive options. Although U.S. law specifically forbids discrimination against organizations in terms of their eligibility for U.S. family planning funding because of their "religious or conscientious commitment" to exclusively offer natural family planning methods, this clause is balanced by the rights and needs of clients seeking health services and information. As a result, under a law known as the DeConcini amendment, funding can be awarded only to organizations that agree to "offer, either directly or through referral" a broad range of family planning methods and services. A similar principle operates under the domestic U.S. Title X family planning program.
This legal and ethical consensus exists under family planning policy to respect the beliefs and needs of faith-based institutions and individual patients alike; however, the same careful balance has been abandoned in HIV/AIDS policy. Under PEPFAR, an organization may refuse to participate in a program or activity, including providing mere referrals, where it has a religious or moral objection. In other words, an organization providing services for the sexual prevention of HIV may withhold information outright about condoms and altogether refuse to refer clients to other programs that supply condoms—no matter that these clients or their partners may be afflicted by or otherwise vulnerable to HIV.
Expanding Family Planning in Nepal
For more than two decades, ADRA has been working on reproductive health in Nepal, a majority Hindu country. One of its most notable family planning successes was a five-year, USAID-funded project in six districts in eastern Nepal, which was launched in 2004.17 ADRA partnered with the Nepal Red Cross Society and other stakeholders to improve maternal and child health by reducing mistimed, unwanted and high-risk pregnancies through increased use of modern contraceptives. The project documented increased community-level knowledge, involvement and interest in family planning; increased access to family planning services through a strengthened public health system; and improved quality and monitoring of services. For instance, quantifiable results included the training of more than 2,600 female community health workers and increases in the contraceptive prevalence rate (from 44% to 53%) and the proportion of providers with good family planning counseling skills (from 27% to 77%). But, equally noteworthy were the widespread changes in attitudes documented by ADRA: Husbands valued girl children as much as boys, men and women both shunned child marriage, couples wanted only two children, and husbands and wives made decisions jointly about the number and spacing of their children.10,17
Promoting Natural Family Planning in Rwanda
Catholic-affiliated groups such as the Institute for Reproductive Health (IRH) at Georgetown University have received significant investments from USAID to develop and support natural family planning methods based on fertility awareness. In Rwanda, where the Catholic Church maintains that it manages 40% of health service delivery points, IRH has partnered with the Ministry of Health and Catholic organizations to expand access to natural family planning methods countrywide in both public-sector and faith-based health facilities. Whereas previously these Catholic health facilities did not participate in the Rwandan government’s family planning program, now these USAID-supported projects facilitate the cooperation of Catholic-managed facilities with Rwanda’s government-run programs and its prioritization of family planning, by expanding the network of service delivery points that offer a range of natural family planning approaches.18 All facilities that only offer natural family planning are required under USAID programs to refer clients for other methods.
Advocating from a Faith Perspective
Within the United States, an array of faith-based actors advocate for U.S. support for a robust global family planning effort. Such support, however, should not mask the real limitations and challenges posed by diverse faith-based approaches to family planning. Some of these rifts include disagreements over "acceptable" contraceptive methods, clients and partnerships: For example, some faith-based actors consider the IUD or emergency contraception to be equivalent to abortion, others may object to partnering with groups that provide or support abortion services, and yet others may oppose outreach or services to adolescents or unmarried individuals.
Despite these differences, certain groups in the United States are striving to find common ground where possible, including by way of greater engagement in public advocacy. Through this advocacy, both within and outside faith-based communities, groups have opened up important dialogues and urged support for improved U.S. policy and increased funding for international family planning programs. These faith-based advocates represent both progressive and conservative religious traditions, and have led a number of pro–family planning initiatives.
The Religious Institute, a progressive multifaith organization whose staff provide technical assistance to clergy and denominational bodies on the intersection of sexuality and religion, released its Open Letter on Family Planning in February 2013 with over 1,000 original endorsements of religious leaders.19 The letter affirms their commitment to safe, affordable, accessible and comprehensive family planning services as a moral imperative and advocates for increased U.S. assistance for domestic and international family planning programs. It asserts that the "denial of family planning services effectively translates into coercive childbearing and is an insult to human dignity."
Also well-known for its strong embrace of family planning is the United Methodist Church, the largest mainline protestant denomination in the United States with more than eight million members domestically, which implements family planning programs through its affiliated institutions. Several church-based texts affirm its support for comprehensive family planning, including its most recent 2012 maternal health resolution, which calls upon its congregations to advocate to policymakers to increase access to family planning to improve maternal health.2 Consequently, the church’s followers have been actively reaching out to members of Congress to raise awareness of faith-based support of international family planning.
In 2012, the New Evangelical Partnership for the Common Good—an evangelical organization that seeks public engagement to fight social injustice—issued a call to Christians to find common ground on family planning as necessary to protect maternal and child health, strengthen families and reduce abortion.20 Speaking to both evangelicals and policymakers, this initiative put forth a "loving challenge to pro-life Christians" through this appeal: "Please do not block family planning efforts, globally or domestically, because of your opposition to groups that provide both contraception and abortion. Instead, consider how a deeply pro-life moral commitment, focusing on the flourishing of all human beings made in God’s image, actually ought to lead to support for family planning."
Christian Connections for International Health (CCIH), an association of over 200 organizational members and 300 individual members with a range of perspectives on sexual and reproductive health, promotes global health and wholeness from a Christian perspective.21 It has played a leading role in efforts to educate both the faith-based community and U.S. policymakers on the importance of international family planning assistance. CCIH unequivocally explains supporting family planning because of its relationship with other health issues and its role in the prevention of abortions. CCIH has also worked at the global level in bringing different faiths together to advance support for family planning. In 2011, CCIH, DSW (a German secular NGO) and Muhammadiyah (an Indonesian Muslim NGO) hosted an interfaith meeting of Christian, Muslim, Hindu and Buddhist FBOs to discuss family planning and reproductive health. The participants agreed to a consensus declaration that stated, "we commit to leveraging our networks to support family health by providing education and services that enable families to plan the timing and spacing of their pregnancies consistent with their faith."5 The declaration committed participants to influencing government and donor policies to this end through the newly established Faith to Action Network, which will advocate at the local, national and global levels.
FBOs that support family planning are fully aware of how important it is for them to be more vocal, because they are cognizant—more than most—of the many misperceptions and misunderstandings that arise when the politics of religion and reproductive health mix. Policymakers need to catch up with the fact that a large swath of this community actively supports a robust U.S. family planning program overseas, because of the real differences it is making in people’s lives. Michael Gerson—an evangelical Christian, conservative columnist and former speechwriter for President George W. Bush—knows this because he has seen it in rural villages in Congo, where he travelled under the auspices of CARE—a major U.S.-based health and development NGO and a key partner in promoting family planning and reproductive health care. As Gerson opined earlier this year at CARE’s national conference: "[Family planning] is often a controversial topic here in D.C., but it shouldn’t be. When births are spaced more than 24 months apart, both mothers and children are dramatically more likely to survive. In cases like this, family planning is a pro-life cause, and everyone should support it."22
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16. Misunas C, Marie Stopes International, Washington, DC, personal communication, Nov. 4, 2013.
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