Every woman in the world should be able to space or limit her births. At a minimum, that means every woman should have access to the contraceptive method of her choice, whether it's a female condom, birth control pills, an IUD, sterilization or a long-acting injectable. But physical access to contraception does not guarantee reproductive freedom. For many women in the developing world the real barrier to the exercise of reproductive choice is male opposition, religious teachings, social norms, or misinformation about contraceptive options.
There has always been some truth to the idea that supply creates its own demand: make modern contraceptives more available and more women will want to use them. But in male-dominated societies where religious teachings or social norms promote large families, there are practical limits to how far supply will drive demand. And that's particularly true in areas where child marriage is still prevalent. When a girl is married at an early age, and her husband demands a large family, the mere availability of contraceptives does not guarantee that she can exercise reproductive choice. In societies where violence against women is widespread the exercise of reproductive freedom can even result in physical violence or even death.
The problem is, and it's a significant one, is that countries with the highest fertility rates and the lowest rates of contraceptive use tend to be male-dominated societies where gender inequality prevails and religious teachings or social norms dictate larger families. Add to that ignorance or misinformation about contraceptive options, and women, in practice, may have little or no reproductive choice... even if modern methods of contraception are available. Girl brides, in particular, seldom exercise any real degree of reproductive freedom; any decision about childbearing is effectively out of their control.
Demographic and Health Surveys (DHS),commissioned by USAID, underscore the scale of the problem. In Ethiopia, where women still have nearly five children on average, the 2005 DHS reported that less than 1 percent of young married women (ages 15-24) not using contraception cited lack of access to a contraceptive method as their reason for non-use. In fact, nearly one out of four said they wanted to have as many children as possible. 7.1 percent cited male opposition to contraception as a reason for non-use; 14.3 percent cited religious opposition. 12.8 percent reported health concerns or fear of side effects as their reason for non-use, and 16.9 percent indicated lack of knowledge.
Similar results are found throughout sub-Saharan Africa. The 2008-09 DHS in Kenya found that only 1.2 percent of married women (age 15-49) reported cost or lack of access as a reason for non-use of contraceptives. More than three out of ten cited health concerns (14.9 percent) or fear of side effects (15.8 percent) as their reason for non-use, while 9.0 percent cited religious prohibition and 6.0 percent attributed their non-use to their husband's opposition.
In Sierra Leone, where women on average have five children, the 2008-9 DHS found that only 1.6 percent of married women (ages 15-49) attributed their non-use of contraceptives to cost or lack of access. One out of seven (14.4 percent) reported male opposition as their reason for non-use, while 9.3 percent cited religious prohibition. In Mauritania the most recent DHS survey indicated that one out of four women not using contraceptives were deterred by religious prohibitions. In Liberia, Ghana, and Uganda, a fear of side effects stops one out of four non-users from using contraception.
These findings do not diminish the importance of ensuring that women in developing countries have access to a wide array of contraceptives. As contraceptives become more widely available and women become more informed as to the benefits of spacing births, more women will opt to use a contraceptive method. But in many countries the cultural or informational barriers to contraceptive use loom much larger.
The United Nations has declared that access to reproductive health services is a universal right and, as part of the Millennium Development Goals (MDG5b), it set 2015 as the target year for achieving universal access. The target will not be met. While the MDGs have achieved great success in many areas, progress with respect maternal and reproductive health has been disappointing. Any hope of achieving universal access to reproductive health care anytime soon will require much greater investments on the part of donor countries.
But it will take more than expanded access to contraceptive services to ensure that all women are capable of spacing or limiting their pregnancies. So long as a woman's reproductive freedom is constrained by her husband's opposition, religious prohibitions, or misinformation, she will not be fully capable of exercising that freedom. And because reproductive choice is so important to a woman, her family, and her community, the empowerment of girls and women -- a high priority in its own right -- takes on added importance.
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