The Moment of Lift

by Melinda Gates

  That’s a big reason why contraceptives were the number one issue on my mind in 2010 and 2011. And the subject kept coming up everywhere I went. Back in Seattle, in October 2011, Andrew Mitchell, the UK’s secretary of state for international development, was attending a malaria summit hosted by our foundation and approached me with an idea: Would we be interested in hosting another summit the following year, this one on family planning? (This, of course, became the summit I described in chapter 1.)

  The idea of an international family planning summit struck me as both scary and exciting, a huge project. I knew that we would have to emphasize setting goals, improving data, and being more strategic. But I also knew that if we were going to set ambitious goals and reach them, we had to meet a much tougher challenge. We had to change the conversation around family planning. It had become impossible to have a sensible, rational, practical conversation about contraceptives because of the tortured history of birth control. Advocates for family planning had to make it clear that we were not talking about population control. We were not talking about coercion. The summit agenda was not about abortion. It was about meeting the contraceptive needs of women and allowing them to choose for themselves whether and when to have children. We had to change the conversation to include the women I was meeting. We needed to bring in their voices—the voices that had been left out.

  That’s why, just before the summit, I visited Niger, a patriarchal society with one of the highest poverty rates in the world, an extremely low use of contraceptives, an average of more than seven children per woman, marriage laws that allow men to take several wives, and inheritance laws that give half as much to daughters as to sons and nothing to widows who don’t have children. Niger was, according to Save the Children, “the worst place in the world to be a mother.” I went there to listen to the women and meet those mothers.

  I traveled to a small village about an hour and a half northwest of the capital and met with a mother and okra farmer named Sadi Seyni. (I mentioned her in chapter 1, too.) Sadi was married at 19—old for Niger, where nearly 76 percent of all girls under 18 are married. After her first child, Sadi was pregnant again in seven months. She didn’t learn about family planning until after she had her third child and a doctor at her local one-room clinic told her about contraceptives. She then began spacing her births. When I met her, Sadi was 36 years old and had six children.

  We talked in Sadi’s home. She sat opposite me on her bed with two children beside her, another snuggling into her lap, another standing behind her on the bed, and two older children sitting nearby. They were all dressed in colorful fabrics, each a different pattern, and Sadi and the older girls wore headscarves; Sadi’s was a solid purple. The sun was pouring in through the windows, only partially blocked by a sheet they’d put up, and Sadi answered my questions with an energy that showed she was glad to be asked.

  “When you don’t do family planning,” she said, “everybody in the family suffers. I’d have a baby on my back and another in my belly. My husband had to take on debt to cover the basics, but even that wasn’t enough. It’s complete suffering when you don’t do family planning, and I have lived that.”

  I asked her if she wanted another child, and she said, “I don’t plan on having another child until the little one is at least four. If she’s four, she can play with her little brother or sister; she can take him on her back. But now, if I were to bring her a little brother, it would be like punishing her.”

  When I asked her how women find out about contraceptives, she said, “The good thing about being a woman here is that we gather a lot and talk. We talk when we meet under a tree to pound our millet. We talk at feasts after a baby is born, and that is where I talk to others about getting a shot and how much easier it is to use than the pill. I tell them you should take it to give yourself and your children a break.”

  What mother wouldn’t understand that—giving yourself and your children a break?

  The following day I visited the National Center for Reproductive Health in Niamey, the capital. After our tour, five women who were there to get services joined us for conversation. Two young women told us about their lives, and then we heard from an outspoken 42-year-old mother named Adissa. Adissa had been married off at age 14, gave birth to ten children, and lost four. After her tenth pregnancy, she visited the family planning center to get an IUD and has not been pregnant since. That’s caused her husband and sister-in-law to look on her with suspicion and ask why she hasn’t delivered recently. “I’m tired,” she told them.

  When I asked Adissa why she decided to get an IUD, she sat and thought for a moment. “When I had two kids, I could eat,” she said. “Now, I cannot.” She receives from her husband the equivalent of a little over a dollar a day to take care of the entire family.

  I asked Adissa if she had any advice for the younger women who were there, and she said, “When you can’t take care of your children, you’re just training them to steal.”

  A few minutes later we all got up to leave. Adissa walked toward the tray of food that no one had touched, put most of it in her bag, wiped a tear from her eye, and left the room.

  As I took in everything I had just heard, I wanted so badly for everyone to hear Adissa. I wanted a conversation led by the women who’d been left out—women who want contraceptives and need them and whose families are suffering because they can’t get them.

  The Old Conversation—That Left Women Out

  Changing the conversation has been a lot harder than I expected because it’s a very old conversation, grounded in biases that don’t easily go away. The conversation has been in part a response to the work of Margaret Sanger, who has a complex legacy.

  In 1916, Sanger opened the first clinic in the United States that offered contraceptives. Ten days later, she was arrested. She posted bail, went back to work, and was arrested again. It was illegal to distribute contraceptives. It was also illegal to prescribe them, to advertise them, or to talk about them.

  Sanger was born in 1879 to a mother who would eventually have eighteen pregnancies and care for eleven children before dying of tuberculosis and cervical cancer at the age of 50. Her death encouraged Sanger to become a nurse and work in New York City slums with poor immigrant mothers who had no contraceptives.

  In a story she told in her speeches, Sanger was once called to the apartment of a 28-year-old woman who was so desperate to avoid another baby that she had performed a self-induced abortion and nearly died. The woman, realizing how close she’d come to killing herself, asked the doctor how she could prevent another pregnancy. The doctor suggested she tell her husband to sleep on the roof.

  Three months later, the woman was pregnant again, and after another attempt at abortion, Sanger was again called to the apartment. This time the woman died just after Sanger arrived. As she told it, that prompted Sanger to quit nursing, swearing that she would “never take another case until I had made it possible for working women in America to have the knowledge to control birth.”

  Sanger believed women could achieve social change only if they were able to prevent unwanted pregnancy. She also saw family planning as a free speech issue. She gave public talks. She lobbied politicians. She published columns, pamphlets, and a newspaper about contraceptives—all illegal at the time.

  Her arrest in 1916 made her famous, and over the next two decades more than a million women wrote to her in desperation, pleading for help in getting contraceptives. One woman wrote, “I would do anything for my two children to help them go through a decent life. I am constantly living in fear of becoming pregnant again so soon. Mother gave birth to twelve children.”

  Another wrote, “I have heart trouble and I would like to be here and raise these four than have more and maybe die.”

  A southern farm woman wrote, “I have to carry my babies to the field, and I have seen their little faces blistered by the hot sun.… Husband said he intended making our girls plow, and I don’t want more children to be slaves.”
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br />   These women’s letters were published in a book called Motherhood in Bondage. Sanger wrote, “They have unburdened their souls to me, a stranger, because in their intuitive faith, they are confident that I might extend help denied them by husbands, priests, physicians, or their neighbors.”

  When I read some of these letters, a song came into my head that often comes when I’m engaged in my work—a song I heard constantly in church as a child, attending Mass five times a week at Catholic school. It’s heartbreakingly sad, beautiful and haunting, and its refrain goes, “The Lord hears the cry of the poor.” The nuns taught us that it was the role of the faithful to respond to that cry.

  The cries for help in these women’s letters are hard to distinguish from the voices of Meena or Sadi or Adissa or many other women I’ve talked to in health clinics and in their homes. They are far apart in time and place, but alike in their struggle to be heard and in the reluctance of their communities to listen.

  Across cultures, the opposition to contraceptives shares an underlying hostility to women. The judge who convicted Margaret Sanger said that women did not have “the right to copulate with a feeling of security that there will be no resulting conception.”

  Really? Why?

  That judge, who sentenced Sanger to thirty days in a workhouse, was expressing the widespread view that a woman’s sexual activity was immoral if it was separated from her function of bearing children. If a woman acquired contraceptives to avoid bearing children, that was illegal in the United States, thanks to the work of Anthony Comstock.

  Comstock, who was born in Connecticut and served for the Union in the Civil War, was the creator, in 1873, of the New York Society for the Suppression of Vice and pushed for the laws, later named for him, that made it illegal—among other things—to send information or advertisements on contraceptives, or contraceptives themselves, through the mail. The Comstock Laws also established the new position of Special Agent of the Post Office, who was authorized to carry handcuffs and a gun and arrest violators of the law—a position created for Comstock, who relished his role. He rented a post office box and sent phony appeals to people he suspected. When he got an answer, he would descend on the sender and make an arrest. Some women caught in his trap committed suicide, preferring death to the shame of a public trial.

  Comstock was a creation of his times and his views were amplified by people in power. The member of Congress who introduced the legislation said during the congressional debate, “The good men of this country … will act with determined energy to protect what they hold most precious in life—the holiness and purity of their firesides.”

  The bill passed easily, and state legislatures passed their own versions, which were often more stringent. In New York, it was illegal to talk about contraceptives, even for doctors. Of course, no women voted for this legislation, and no women voted for the men who voted for it. Women’s suffrage was decades away. The decision to outlaw contraceptives was made for women by men.

  Comstock was open about his motives. He said he was on a personal crusade against “lust—the boon companion of all other crimes.” After he attended a White House reception and saw women in makeup, with powdered hair and “low dresses,” he called them “altogether most extremely disgusting to every lover of pure, noble, modest woman.” “How can we respect them?” he wrote. “They disgrace our land.”

  In Comstock’s eyes, and the eyes of his allies, women were entitled to very few roles in life: to marry and serve a man, and bear and take care of his children. Any detour from these duties brought disrepute—because a woman was not a human being entitled to act in the world for her own sake, not for educational advancement or professional accomplishment, and certainly not for her own pleasure. A woman’s pleasure, especially her sexual pleasure, was terrifying to the keepers of the social order. If women were free to pursue their own pleasure, it would strike at the core of the unspoken male code, “You exist for my pleasure!” And men felt they needed to control the source of their pleasure. So Comstock and others did their best to weaponize stigma and use it to keep women stuck where they were, their value derived only from their service to men and children.

  The need of men to regulate women’s sexual behavior persisted in the US even after the Second Circuit court in 1936 ruled that physicians could advise their patients on birth control methods and prescribe contraceptives. In spite of this advance, many restrictions on contraceptives stayed in place nationally, and in 1965, when the Supreme Court ruled in Griswold v. Connecticut that contraceptive restrictions were an intrusion into marital privacy, the Court lifted restrictions for married people only! It didn’t mention the rights of the unmarried, so single women were still denied contraceptives in many states. This is not so long ago. Women in their seventies still come up to me at events and tell me, “I had to trick my doctor into thinking I was married or I couldn’t get contraceptives.” Unmarried women weren’t given the legal right to contraceptives until Eisenstadt v. Baird in 1972.

  This strand of the conversation on family planning is grounded in society’s discomfort with women’s sexuality, and this line of conversation absolutely endures today. If a woman speaks up in public for the value of contraceptives in a health plan, some misogynistic male voices will try to shame her, saying, “I’m not going to subsidize some woman’s sex life.”

  Shaming women for their sexuality is a standard tactic for drowning out the voices of women who want to decide whether and when to have children. But that is not the only discussion that has diminished the voices of women. Many interests have tried to control women’s births in ways that make it hard to have a focused conversation on contraceptives today.

  In an effort to control their populations, both China and India adopted family planning programs in the 1970s. China created a one-child policy, and India turned to policies that included sterilization. In the 1960s and ’70s, population control was embraced in US foreign policy based on predictions that overpopulation would lead to mass famine and starvation and possibly to large-scale migration because of a lack of food.

  Earlier in the twentieth century, birth control advocates in the United States had also pressed their case, many of them hoping to help the poor avoid having unwanted children. Some of these advocates were eugenicists who wanted to eliminate “the unfit” and urged certain groups to have fewer children, or none at all.

  Sanger herself supported some eugenicist positions. Eugenics is morally nauseating, as well as discredited by science. Yet this history is being used to confuse the conversation on contraceptives today. Opponents of contraception try to discredit modern contraceptives by bringing up the history of eugenics, arguing that because contraceptives have been used for certain immoral purposes, they should not be used for any purpose, even allowing a mother to wait before having another child.

  There is another issue that has blocked a clear and focused conversation on contraceptives, and that issue is abortion. In the United States and around the world, the emotional and personal debate about abortion can obscure the facts about the life-saving power of contraception.

  Contraceptives save the lives of mothers and newborns. Contraceptives also reduce abortion. As a result of contraceptive use, there were 26 million fewer unsafe abortions in the world’s poorest countries in just one year, according to the most recent data.

  Instead of acknowledging the role of contraceptives in reducing abortion, some opponents of contraception conflate it with abortion. The simple appeal of letting women choose whether or when to have children is so threatening that opponents strain to make it about something else. And trying to make the contraceptive debate about abortion is very effective in sabotaging the conversation. The abortion debate is so hot that people on different sides of the issue often won’t talk to each other about women’s health. You can’t have a conversation if people won’t talk to you.

  The Catholic Church’s powerful opposition to contraceptives has also affected the conversation on family pla
nning. Outside of governments, the Church is the largest provider of education and medical services in the world, and this gives it great presence and impact in the lives of the poor. That is helpful in so many ways, but not when the Church discourages women from getting the contraceptives they need to move their families out of poverty.

  * * *

  Those are some of the conversations that have been heard in the world over the previous hundred years or more. Each conversation helped drown out the voices and the needs of women, girls, and mothers. And that gave us a crucial purpose for holding the first summit in 2012: to create a new conversation led by the women who’d been left out—women who wanted to make their own decisions about having children without the interference of policymakers, planners, or theologians whose views would force women to have more, or fewer, children than they wanted.

  I gave the opening address that day in London and asked the delegates: “Are we making it easier for women to get access to the contraceptives they need when they need them?” I talked about the trip I had made a few years before to the poor Nairobi neighborhood of Korogocho, which means “shoulder to shoulder.” I was discussing contraceptives there with a group of women, and one young mother named Marianne said, “Do you want to know why I use contraceptives?” Then she held up her baby and said, “Because I want to bring every good thing to this child before I have another.” That desire is universal, but access to family planning is not. I reminded everyone at the conference that this was why we were all here.

  Then, to make the point that the summit was all about having women own the conversation, I stepped aside and invited another woman to come to the stage and complete my talk.