Communities of faith and the global family planning movement: friends or foes?

Within the Christian community, diverse views exist on the theological and moral dimensions of family planning, and specifically of contraception. Discussion of these issues frequently focuses on the family planning as a collection of methods and commodities used to space or limit pregnancies.   Often missing from the discussion is the notion of family planning as a social and political movement, and the degree to which this movement’s philosophy and goals are compatible with Christian theology. Nevertheless, faith-based aid organizations, including those with no objection to contraceptive use, must seriously grapple with the moral and practical implications of partnering with the institutions of the global family planning movement.

Within the Christian community, diverse views exist on the theological and moral dimensions of family planning, and specifically of contraception. Discussion of these issues frequently focuses on family planning as a collection of methods and commodities used to space or limit pregnancies. Often missing from the discussion is the notion of family planning as a social and political movement, and the degree to which this movement's philosophy and goals are compatible with Christian theology. Nevertheless, faith-based aid organizations, including those with no objection to contraceptive use, must seriously grapple with the moral and practical implications of partnering with institutions that promote an approach to family planning that is at odds with Christian values.
For purposes of this discussion, the international family planning movement is taken to consist of the network of organizations whose primary purpose is advocacy for and provision of family planning. In contrast to many international aid groups, Christian and otherwise, which seek a variety of solutions to the specific problems of a given country or region, the dominant discourse within this family planning movement has tended to advance one type of solution-contraception, often with abortion as a backup, although the rationale for doing so often changes. Over the last century, the dominant discourse of the family planning movement has shifted multiple times, from a focus on eugenics and population control to a focus on women's rights and empowerment, and then to a public health rationale aiming to reduce maternal and child deaths. 1 More recently, the case for fertility reduction for its own sake has begun to reappear in connection with the global concern about climate change and environmental sustainability. 2 While family planning advocacy invokes a wide range of problems, the proposed solution remains the same.

You shall not kill (Exodus 20:13)
For leading family planning organizations including the International Planned Parenthood Federation and Marie Stopes International, advocacy for abortion as well as contraception is a defining aspect of their work. Nevertheless, according to international consensus among UN member countries, as well as U.S. law, family planning is explicitly defined as excluding abortion. 3,4 This agreed definition made it possible for the delegation of the Holy See to accept the conclusions of the International Conference on Population and Development at Cairo in 1994, albeit with reservations clearly stating their unchanged position on artificial contraceptive methods and the immorality of abortion independent of its legality. 3 This conference, convened by the UN, and its resulting Program of Action which guides the work of the United Nations Population Fund, not only separated the definition of family planning from abortion, but stated that the legality of abortion was a matter for individual governments to determine and not an international human right.
To the extent that family planning is understood to exclude abortion, some Christian aid organizations have been able to justify providing family planning methods, inasmuch as the methods they offer are otherwise deemed morally acceptable. But for Christian groups that oppose abortion, the dominant discourse within the family planning movement may not be tolerant of silent recusal. Philanthropist Melinda Gates drew criticism from many within the movement for "stigmatizing" abortion by not directly supporting it. 5 At the same time, Gates provides support to organizations that also advocate for abortion and was critical of U.S. President Donald Trump for his reinstated and expanded Mexico City Policy which blocks federal funds to abortion-promoting organizations. 6 For those within the Christian community who view abortion as the intentional destruction of innocent human life, Gates' policy of silence on the abortion issue received some praise, but fell short of achieving her aim of "no controversy." When combined with funding of family planning organizations who actively promote abortion, her silence arguably signaled not condemnation, but consent. Again, a clear distinction must be drawn between family planning as methods to prevent pregnancy and the family planning movement as a global advocacy juggernaut with strong ties to abortion. Determining what level of engagement Christian agencies should have with organizations, governments, and multilaterals whose values conflict with Christian values is a complex ethical question that requires in-depth biblical and ethical consideration. In December, 2014, USAID's Advancing Partners and Communities Project (APC) supported a meeting by Christian Connections for International Health (CCIH) titled Faith Matters: International Family Planning from a Christian Perspective. Its concluding report presented CCIH's definition of family planning as excluding abortion. It was perhaps commendable that CCIH was able to articulate such a position and have it included, given the fact that the implementing partners of APC, John Snow International (JSI) and FHI 360, had explicitly promoted abortion, if not as family planning per se, as part of their broader advocacy. 7,8 The existing balance that enables Christian groups to accept government funding-and ensures their eligibility for such grants-is supported by a combination of U.S. laws and policies and international standards that separate family planning from abortion. But these safeguards are under constant assault from many family planning organizations that oppose that separation. JSI, for example, has signed statements calling for both the repeal of the Mexico City Policy and the redefinition of the Helms Amendment to create exceptions in the ban on U.S. funding for overseas abortions. Sneha Barot of the Guttmacher Institute, which advocates for both abortion and family planning, is strongly critical of the Helms Amendment: "Just on its face, the law is extreme and harmful." 9 Elsewhere, Barot acknowledges the "essential safety net" provided by faith-based organizations overseas, and the fact that in some areas, they may be the only providers of essential services. She notes that faith-based groups' eligibility for U.S. family planning funding balances morally-based objections to particular methods against a requirement that they offer referrals to a wider range of services than they might be willing to offer directly 10 If the Guttmacher Institute and its allies successfully advocate Congress to repeal the Helms Amendment, Christian aid organizations might find themselves pressured to refer for abortions as well, or be ineligible for U.S. funding, which could in turn jeopardize much-needed aid in fragile and poor settings.

What is truth? (John 18:38)
In recent decades, the dominant mostly western-based organizations within the family planning movement have been highly successful in convincing national and international institutions to adopt a range of definitions and measurements designed primarily as tools for family planning
advocacy. The concept of "unmet need" has been characterized as an "invaluable bridge" between demographic and rights-based rationales for promoting family planning. 11 "Unmet need" has been criticized by economists as better suited to advocacy than an actual measure of demand for products or services. 12 Furthermore, "unmet need" is frequently mischaracterized by organizations within the family planning movement as lack of access, despite the fact that far more women described as having a "need" cite personal opposition or concerns about health risks than cost or accessibility issues. 13 As a result of the widespread misuse of "unmet need" by policymakers and advocacy groups alike, there is an illusion of high demand for family planning within developing regions. This in turn leads to costing projections like the 2014 Adding It Up report co-published by the United Nations Population Fund and the Guttmacher Institute, which estimates that an annual $9.4 billion could meet the total "need" for family planning, based on the assumption "that all women with unmet need would use modern contraceptives." 14 This assumption gains little support from the Guttmacher Institute's own analysis, which reveals that most contraceptive nonuse is a matter of personal choice rather than lack of access. 13 Yet modeling programs like the Lives Saved Tool are used to estimate the impact of increased family planning use, for only the cost of providing commodities, in terms of averted deaths of women and children. In some cases, estimates of averted child deaths include children whose hypothetical deaths in infancy might be averted by preventing their conception. In the report Acting on the Call published by USAID, these were referred to as "child lives saved from demographic impact," proposing an innovative way in which a life could be saved without leaving a survivor. 15 It is likewise essential to consider the impact of definitions. While family planning may be considered to exclude abortion, it rarely excludes contraceptive methods that may have abortifacient effects, such as some types of intrauterine devices. Such methods are classified as "contraceptive" if they prevent "pregnancy," as defined as being established at implantation rather than conception. 16 Essentially, this definition not only redefines pregnancy but also entirely fails to consider when human life begins, which is arguably the more important question.
Similarly, while "contraception" and "family planning" are often used interchangeably, fertility awareness-based methods of family planning, the only methods permitted by Catholic teaching, are morally permissible precisely because they are not contraceptive. In other words, they are not intended to render the act of sexual intercourse nonprocreative, or, in the words of the encyclical Humanae Vitae by Pope Paul VI, are not intended to separate "the unitive significance and the procreative significance which are both inherent to the marriage act." 17 While it makes sense on a semantic level to exclude these methods from classification as "modern contraceptive methods," as has been proposed by some within the family planning community, the intent of this proposal is to classify such methods not as "non-contraceptive," but rather as "non-modern." 18 This would have the effect of reducing funding and support for fertility awarenessbased methods of family planning within national and international policy, particularly as the current indicator for family planning within the Sustainable Development Goals specifies that "need" for family planning be satisfied by modern methods.
Christian and other aid organizations would do well to critically examine the measurements and methodologies used by family planning groups, primarily as a means of advocacy, and frequently without internal consistency. For Christian entities, the imperative to speak with honesty must be paramount, and a source of common ground between denominations divided over the contraceptive issue. If the goal is to ensure that women and children have better health outcomes in resource-limited settings, it is counterproductive to use measurements of progress designed to privilege family planning over other interventions. Furthermore, if the goal is to Oas July 2017. Christian Journal for Global Health, 4(2):3-9. ensure that women have access to family planning, better measures of access are needed, preferably originating from entities that do not have a direct stake promoting particular forms of contraception and abortion. Christian organizations might lead the way in this regard, but they may need to part company with many organizations in the family planning establishment, and even actively compete with them to set international norms and standards.

Be fruitful and multiply (Genesis 35:11)
Central to the "sexual revolution" is the principle that the sexual act must be uncoupled from the potential for procreation. This goal, promoted by the development of modern contraceptives, has proven extremely difficult to accomplish, even with them. Despite the fact that approximately 40% of pregnancies worldwide are designated as "unintended," the international family planning movement continues to rely on definitions of pregnancy as "unintended," "unwanted," "mistimed," and "unplanned," all of which "assume that pregnancy is a conscious decision." 19,20 Advances in global development and medicine have driven down maternal and child mortality, but gaps remain, linked to poverty and resource inequity. Although Africa is the global region with the highest rates of maternal and child mortality as compared with the number of live births (defined by the UN as the maternal mortality ratio and the under-5 mortality rate), it is also the region with the lowest percentage of pregnancies classified as unintended (35%). 21,22,19 It is important to note that the terminology of "intendedness" (and, similarly, of "wantedness") originates from fertility surveys designed and intended to promote contraception and abortion, and which have no interest in promoting the acceptance of children whose conceptions were not "planned." Perhaps the best illustration of this point is the frequency with which attempts to measure "unintended" births refer to the problem of "retroactive rationalization"-that is, parents who not only come to accept their unexpected child, but deny having ever wished to avoid or postpone the pregnancy. 23 This is typically regarded as an unfortunate flaw in the data that masks the true scale of the problem of unintended pregnancies, rather than evidence that the problem is, to an extent, selfsolving. Furthermore, decades of studies seeking to demonstrate that "unintended" or "unwanted" children fare worse than their counter-parts have produced inconsistent and under-whelming findings, once confounding variables are accounted for. The third edition of the World Bank's Disease Control Priorities stated in summary that "[i]nsufficient data exist to indicate whether unintended pregnancies carried to term are disadvantaged in health or schooling, compared with intended births." 24 Within the international family planning movement, there is little acknowledgment that unplanned pregnancies or abortions might be addressed by any intervention apart from contraceptives. In a 2015 article in Demography authors Kathryn Kost and Laura Lindberg, both of the Guttmacher Institute, clearly articulate this position: "[T]he public health goal is not to help mothers change their attitudes so that those unintended births become intended ones; the goal is to delay those pregnancies until women move into a life stage when they do want to have a baby . . . Similarly, the negative consequences for an unwanted birth can be alleviated not by convincing mothers to want the births, but by preventing the unwanted pregnancies." 25 Christian aid organizations, who are often a front line of assistance for women with crisis pregnancies both at home and abroad, have a duty to ensure that their message is one of hope and resilience for both mother and child. This mission is not only outside the agenda of many organizations in the international family planning movement, but it also starkly refutes many of their core principles.

Bad company corrupts good morals (1 Corinthians 15:33)
Many leading family planning organizations have made great strides in reaching out to the Christian community to form partnerships, particularly around the goal of ending preventable deaths and reducing poverty. To the extent that religious leaders within local communities are seen as powerful gatekeepers, this may be a sensible strategic move. But whether Christian organizations providing aid at the local, national, or international level stand to benefit from such partnerships-or can justify them at a moral and ethical level-remains to be seen. For all its attempts at outreach to faith groups, most organizations within the family planning movement have remained stubbornly committed to promoting abortion, whether they regard it officially as a method of family planning or not. 26 They continue to push for institutional acceptance of definitions and measurements better suited to promoting the interests of their own organizations than the general public good. In recent years, the dominant discourse within the family planning movement has moved to favor "sexual and reproductive health and rights," a construct that remains highly controversial within international institutions, and is typically defined as encompassing a set of norms that are on a direct collision course with a traditional Christian concept of the dignity of the human person, sexual morality, and the nature of the family. 27 Christian organizations engaged in international family planning work face a choice with important moral implications: navigate their own course in parallel to or sometimes in competition with organizations in the family planning movement, or engage to speak prophetically and help guide the movement away from abortion as a solution and amoral principles which are antithetical to Christian morality.
However, this approach risks inviting organizations into their much-needed and faith-inspired efforts, which could dilute or challenge their moral beliefs. Whatever choices Christian groups ultimately make in this regard, they should be fully aware of the baggage the global family planning movement carries with itand shows no indication of letting go.