Family planning is not a privilege, but a right. That’s what Babatunde Osotimehin said when he was executive director of the United Nations Population Fund (UNFPA), in 2012. It not only helps eradicate poverty, he said, but is also “one of the most effective means of empowering women”. He died last July. International organisations, including the United Nations, have been declaring for decades that choosing if you want to have children and when and how to do it is a fundamental human right.

But it’s a right that is undermined whenever a girl becomes pregnant, whenever a woman is accused of being promiscuous, or being a prostitute, for using some form of birth control. It is undermined every time she is forced to have unwanted children, every time she is forced to have abortions in unsafe conditions, every time someone tells her what she must do or what she cannot do with her body, even when she is the one who, in many countries, bears the consequences of those decisions. It is undermined every time a new birth puts a woman’s health at risk or kills her. These are not made-up examples. They are true stories gathered in this investigation of how people exercise this universal right and the barriers women must overcome to do so. Fanta Jatta knows more than most about these cases. She talks about it at the headquarters of Action Aid International, in Banjul, The Gambia, where she directs the program on women’s rights. For her, in addition to the health problems–for mothers and children–caused by a lack of access to contraceptives, there is something more fundamental: who decides and how. “We need to understand how our bodies work and make our own choices,” she says.

We need to understand how our bodies work and make our own choices.

Uses

But contraceptive use is not homogeneous between countries or across social classes. The economic situation, cultural context, availability of pharmacies and public policies determine the most popular method in each country.

In The Gambia, many women use variations of a traditional method that goes by different names. They share the same, unscientific, principle: the women tie a cord or a branch with or without words from the Koran on a slip of paper to their waists to try to prevent pregnancy. Of course, it does not work.

They may want to space their pregnancies for health reasons or to stagger their child care or organise their own lives a certain way. Jarra Joof, a 42-year-old member of her community’s Mothers’ Club in Banjul, The Gambia, wanted to wait a while after her first child was born. But, “only seven months later I was pregnant again. Then I had my second baby. However, I did not want to find myself in the same situation for my third pregnancy,” she says.

Joof used birth control to space her next four pregnancies. Now she is back to using birth control full time. “Seven children are enough,” Joof says.

Some women may not want to have any more children, like Joof, or they may not want children at all. Though their reasons may vary, women with unmet birth control needs have at least one thing in common: they don’t want to get pregnant and they are not doing anything about it.

The key, according to Alieu Jammeh, Reproductive Health Commodity Security Coordinator at UNFPA in Banjul, The Gambia, is the availability of variety, that their effects are well-explained to avoid bad unjustified bad reputations, and that each woman can decide which is best for her. This is the most important thing across all the analysed countries.

Many women claim that they don’t use contraceptives because they do not have sex on a regular basis. But sometimes they reply in the very same survey that they have had sexual encounters in the preceding month. In some countries, single women may not report their sexual activity to avoid being singled out. For many of them, at least in public, sex and contraceptives don’t exist.

This refers to cultural reasons, in contrast to women’s health-related barriers, such as the side effects of some hormonal contraceptives. Most of the respondents who say this is their principal barrier have never used any method of birth control, according to the Guttmacher study. Somebody, whether it’s the woman herself, her husband or others, is against her using birth control. But whom and why?

In most such cases, the woman being interviewed says she is against birth control. Keeping in mind that we are only analysing the responses of those women whose necessities are unmet–that is, they do not want more children but are not using birth control–their response reflect outside influences, from cultural to social to religious.

Although the percentages are lower, religion can also affect opposition in the above cases. And that goes for all the major religions. In the most orthodox cases, it’s the imam, priest, or rabbi who decides who uses, or doesn’t use, birth control and what type.

They continue imposing their personal morals when it comes time to serve customers

Mothers-in-law, fathers, or even medical or pharmaceutical services, among others, may intervene in a woman’s birth control decisions. The Network for Sexual and Reproductive Rights in Mexico (DDESER) did a study of contraceptive distribution under two different governments. They interviewed managers, doctors, civil servants, and users. They even sent mystery shoppers posing as customers. They found health centres that refused to give condoms to youth, where the condoms piled up until they expired, or where they don’t give the pill to married women, to give just two examples.

It’s increasingly rare for women not to know about birth control, to lack access, or not to be able to afford it. But in West and Central Africa, those reasons, were mentioned by more than ten percent of respondents in the Guttmacher study. In Mexico, Patricia Ortega of DDSER says that some university students, “don’t even know how to use a condom.” When asked about how many times a condom can be used, 15.5% of respondents to the Mexican National Health and Nutrition Survey responded incorrectly.

Poverty is not just the lack of money, or material, it's also the inability to make choices.

In The Gambia, television ads promoting contraceptive use were a social revolution a few years ago, and did not lack for critics in the Catholic community.

In Europe promotional campaigns for contraceptives have been rare for a while, with the exception of those paid for by Durex, and there is more and more public investment in promoting child-bearing. The Polish government ran a campaign encouraging its citizens to have sex and there is an annual campaign in the Spanish autonomous community of Galicia that appeals to the “necessary shared responsibility” of bringing more children into the world.

What does it mean for there to be unmet needs? That a woman cannot exercise her right to plan her own reproduction. According to the WHO, family planning reduces abortions, especially dangerous ones, reinforces the right to determine the number and timing of children and prevents the deaths of both mothers and children.

In 2012, 85 million pregnancies worldwide were unintended. This is 40% of the total and many of them end in abortion, whether natural or voluntary. An estimated 25 million unsafe abortions are performed annually, most of them in developing countries.

Some 830 women die every day due to pregnancy- and childbirth-related causes. Almost all are in developing countries. In fact, the WHO estimates that in 2015 more than a third of those deaths occurred in Nigeria and India. Another way to put it is: if you live in a developed region your odds of dying in childbirth are 1 in 4,900. If you live in a developing country, they are 1 in 150.

It’s a question of public health, but above all of rights. Women have the right to freely choose if they want children, and how, and when.

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