December 2017 Web

Volume 49, Issue 4 ConnectionDecember 2017

MALE CONTRACEPTIVE OPTIONS AND MEN’S ROLE IN FAMILY PLANNING President’s Note

opulation growth is often called the “elephant in the At the time of our founding as Zero Population Growth in 1968, room.” Too many fine people continue to steer a wide there were only four nations on Earth at or below “replacement berth around the topic for fear of being tagged with one rate” — which is just above two children per woman in places Pnegative label or another. with low mortality. Today, there are nearly 100 such nations. With the exception of China and Peru, (and, to a lesser extent, It may be uncomfortable to talk about population growth. But India) which have engaged in widespread, deplorable coercive it’s absolutely essential. In fact, real elephants are endangered practices, it’s been accomplished through voluntary methods. today because of the soaring population and shameful behavior Empowering women works. Smashing all barriers to reproduc- of our own heedless species. tive healthcare works.

A big part of the problem arises because many decent, intel- Yet this mission remains far from accomplished. We’re still add- ligent people don’t quite know how to talk about population. ing a billion people to our already overcrowded planet every And, yes, some do tend to worry a bit too much that they might dozen years. Species are vanishing. And climate chaos is a direct offend someone, somewhere. result of population growth.

Let’s start by acknowledging up front that horrific things have We simply can’t afford not to talk about population growth. Not been done under the false flag of “population control.” Some if we care about our living planet. 70,000 American women were forcibly sterilized over the first seven decades of the 20th century. The spurious pseudoscience The right way to talk population is the rights way: Every person of eugenics was deployed to promote ideas and practices as a everywhere has the inalienable right to determine their own repro- cover for racism. Like some infectious disease, eugenics fever ductive destiny. No exceptions, no conditions. Rights are rights are swept up many otherwise estimable people in the late 19th rights. and early 20th centuries, including Charles Darwin, Teddy Roosevelt, and even Helen Keller. When the population issue was percolating a century ago, we humans lacked the technology to manage our fertility. Times These accomplished, yet imperfect humans were sadly all too change, and we need to change with the times. Women now willing to consign their fellow imperfect humans to fates they have a wide array of effective options — or they would if it did not deserve. weren’t for retrograde politicians. And this magazine issue highlights the vital, unfinished business of male contraception. Now we know better. Social engineering is a blind alley when it comes to that most personal and private of matters — the deci- We need to tell the honest truth that population growth threat- sion about when and whether to bear children. ens our planet. Silence is not an option.

John Seager We’ve now amassed an avalanche of evidence to demonstrate [email protected] incontrovertibly that, when we successfully uphold all individual reproductive rights as an ethical imperative, population challenges evaporate.

Population Connection — December 2017 VolumePopulation 49, Issue 4 Connection December 2017

Features Board Chair Estelle Raboni, MPH 10 A New Push for the Male Board of Directors “Pill” Aaron S. Allen, PhD Andreea Creanga, MD 12 What Do Men Have to Do Amy Dickson with Women’s Reproductive Katie Ferman Padgett Kelly, PhD Rights? Anna Lawson, PhD Nejla Liias 14 Men in Rural Ethiopia Show Sacheen Nathan, MD That Family Planning Is Not Bob Pettapiece, PhD Dara Purvis, JD (Vice Chair) Just a Women’s Issue The Hon. Tom Sawyer (Treasurer) Carol Vlassoff, PhD 16 Can Niger Break Out of Its Kevin Whaley, PhD Cycle of Poverty? Hania Zlotnik, PhD (Secretary) President and CEO 20 In West Africa, Clinics John Seager Confront Suspicion, and [email protected] Husbands, One IUD at a Time Editor Marian Starkey 22 For Nigerian Mothers, Escape [email protected] From Boko Haram Shakes Up Contributing Authors Gary Barker, Abraham Gelaw, Kieran Guilbert, Childbirth Customs Alastair Leithead, Dina Fine Maron, Stacie Murphy, John Seager, Serra Sippel, Marian Starkey, Ike Swetlitz, Rachel Walker, Pamela Departments Wasserman 2 Editor’s Note Proofreader Skye Adams 3 Letters to the Editor Population Connection (ISSN 2331-0529) Population Connection is the national grassroots 4 Pop Facts population organization that educates young people and advocates progressive action to 6 In the News stabilize world population at a level that can be sustained by Earth’s resources. 8 ZPG Society Members Annual membership ($25) includes a one-year subscription to Population Connection magazine. 26 Washington View All contributions, bequests, and gifts are fully tax- deductible in accordance with current laws. 28 Field & Outreach Population Connection 2120 L Street, NW, Suite 500 30 PopEd Washington, DC 20037 (202) 332-2200 • (800) 767-1956 32 Cartoon [email protected] PopulationConnection.org 33 Editorial Excerpts PopulationEducation.org Cover Image: Chum Dam, a 41-year-old Cambodian father, sits in an assessment room prior to his vasectomy procedure. Photo: Marie Stopes International, Courtesy of Photoshare www.popconnect.org December 2017 — Population Connection 1 Editor’s Note

“What about men?” is one of our members’ most frequent refrains when it comes to talk of family planning — and not in the Portlandia sense of the phrase (tinyurl.com/PortlandiaMen).

ight now the chemical burden for contraception deferens — the tubes that get snipped in a vasectomy — relies solely on the female. That’s an unfair balance and blocks sperm from traveling from the testicles to the in the equation,” says Charles Easley, an assistant urethra, thus preventing sperm from leaving a man’s body. “Rprofessor at the University of Georgia, who is involved in the The gel can theoretically be dissolved when a man wants to development of a male pill. resume his fertility. Another version of the gel, RISUG, is expected to launch in India over the next couple of years. I agree with this understatement. I think most people would • Bimek SLV is a valve operated by a switch that is implanted agree that it’s about time there was an effective, reversible in each vas deferens (there are two, corresponding to each method of male birth control besides condoms. Instead, it testicle) and can be manipulated through the skin by seems like we’re always a couple of years away from a pill or the user. The only test subject at this point is its creator, injection that will temporarily suspend male fertility. The drug Clemens Bimek. Obviously. trials continue without producing anything market-ready, and that’s been the case for many years. For now, men are stuck with condoms, vasectomy, and withdrawal, and whatever method of birth control their female A male pill remains elusive for a couple of reasons, Easley says. partners may be using. “I think there’s not much activity in this field because we have an effective solution on the female side.” Others describe the Vasectomy is an excellent option for those who do not want infinitely more difficult job of halting sperm production — biological children or have already had as many as they want. millions are created in the testes every single day — over stop- The Affordable Care Act doesn’t require vasectomy to be cov- ping the release of one egg per month or preventing a fertilized ered by insurance companies, so it’s up to individual insurers egg’s implantation in the uterus. whether to cover it and to what level. (Three states — Illinois, Maryland, and Vermont — have laws requiring vasectomy cov- Here are the reversible methods that have reached the stage of erage at no cost to the insured because their leaders understand clinical trials (but don’t hold your breath — they’re still at least that preventing unintended pregnancy is always the fiscally and a few years away from FDA approval): socially responsible thing to do.)

• An injection to stop spermatogenesis (the creation of And although not a perfect solution for everyone, the effective- new sperm) was very effective in a multi-country trial, ness (when used perfectly) of condoms at preventing pregnancy but caused such unbearable side effects that the study was and sexually transmitted infections cannot be beat. ended early. (To the jeers, it should be noted, of women who have endured the side effects of hormonal contracep- In the meantime, the role of men is primarily to support their tion for over 50 years.) female partners in using whatever method of contraception is • Vasalgel has tested effective on monkeys but has not yet right for them. That’s the majority of what the articles in this been tested on humans. The gel is injected into the vas issue explore. Marian Starkey [email protected] 2 Population Connection — December 2017 Send correspondence to Letters to the Editor [email protected] . Attn: Marian Starkey Letters are also accepted via Population Connection postal mail. Letters may be 2120 L St, NW, Suite 500 edited for clarity and length. Washington, D.C. 20037

Just want you to know how pleased I am with the work you avoids partisan electoral activity, while Population Connection continue to do — sometimes in the face of great opposition. Action Fund engages in that area as a sister organization).

Eliezer T. Margolis, PhD Unfortunately, the Republican party (with sadly rare exceptions) has abandoned its once-strong support for programs Over these past few years of reading your magazine, I’ve come that advance our mission of population stabilization. Presidents to realize that “Population Connection” has moved a long way Nixon and Ford supported key programs, as did the young from its earlier “Zero Population Growth” agenda. Rather than Congressman George H.W. Bush. Even 20 years ago, there supporting ways of reducing population growth and ultimately were about 40 House Republicans who supported family plan- reducing population, the organization seems to have become a ning. Today, there is only one, even on a good day (Rep. Charlie spokesperson for the Democratic platform. Not that I disap- Dent (R-PA/15), and he’s retiring.) We appreciate the two prove of the Democratic platform, but I don’t support either Senate Republicans (Lisa Murkowski and Susan Collins) who party’s platform and will not support either party financially. are great supporters. But the other 50 Republican senators are solidly aligned in opposition. Neither Democrats nor Republicans will ever resolve the population problem. They will argue about the actions that are needed The fact is that, when Obama took office, funding for interna- to deal with the myriad of symptoms (air pollution, water pol- tional family planning was boosted by 40 percent. Now Trump lution, global warming, deforestation, species extinctions, etc.). wants to eliminate all such funding. Further, attempts to tie pet Democratic political positions to population growth is counterproductive and confounding. We just follow the facts where they lead. Nothing would please us more than to see both major parties competing to do more When your organization returns to the population issue and for our cause. As it is, the members of one party (Democratic) that issue alone, I will return, but until that time I’ll continue are mostly supportive, while members of the other (Republican) doing what I can on my own. are almost universally opposed. Steve Albert As Walter Cronkite used to say, “That’s the way it is.” Thanks for your comments. We try hard to stick close to our mission (I might add that Population Connection scrupulously – John Seager

www.popconnect.org December 2017 — Population Connection 3 4 Population Connection — December 2017 Design by Rebecca Dodelin www.popconnect.org December 2017 — Population Connection 5 In the News

Trump Cuts Teen Pregnancy among girls. Only about 50 percent under the 1931 health code. Legislators Prevention Funding of teen mothers receive a high school have been attempting to reverse the ban The Trump administration slashed teen diploma by 22 years of age, whereas since 1991. pregnancy prevention grants by more than approximately 90 percent of women $200 million in July. The second cohort of who do not give birth during adoles- An estimated 70,000 illegal abortions take five-year federal grants under the Teenage cence graduate from high school. place each year in Chile. Until the law Pregnancy Prevention (TPP) Program, • The children of teenage motherschanged, getting caught carried a penalty awarded in 2015, goes to 81 organizations. are more likely to have lower school of five years’ imprisonment. Their grants were supposed to run through achievement and to drop out of high Court Rules Against Anti- 2019, but recipients were informed by school, have more health problems, be Choice Non-Profit the Department of Health and Human incarcerated at some time during ado- Services that the funding would end pre- lescence, give birth as teenagers, and A three-judge panel of the 3rd U.S. Circuit maturely, on June 30, 2018. face unemployment as young adults. Court of Appeals in Philadelphia ruled in Oregon Expands Abortion August that secular employers may not opt The TPP was initiated by President Obama Access out of birth control insurance coverage for in 2010 to find evidence-based solutions employees. The lawsuit was filed by Real to reducing teen pregnancy, with the aim Gov. Kate Brown (D) signed the Alternatives, a Pennsylvania nonprofit of replicating those programs that worked Reproductive Health Equity Act into law whose mission is to “empower women to best in other areas around the country. in August. It requires insurance companies protect their reproductive health, avoid The first cohort of grant recipients, from to cover birth control and abortion with- crisis pregnancies, choose childbirth rather 2010-2014, used either curricula that had out copay and provides funding for the than abortion, receive adoption education, been scientifically proven to reduce teen reproductive health of non-citizens who and improve parenting skills.” pregnancy rates or tested innovative new do not receive Medicaid coverage. programs. This second cohort of grantees Chile Legalizes Abortion in Real Alternatives employs three people, is building on that work. Some Cases who all receive company insurance; their wives and a combined seven children are Without TPP funding, 580,000 students Chile decriminalized abortion in August also insured by the company. will lose their existing medically accurate in cases of rape, when the pregnant wom- 25 Million Unsafe Abortions sex education. an’s life is in danger, and when the fetus is Worldwide Each Year incompatible with life. President Michelle According to the CDC: Bachelet has been urging the lifting of the Safe Abortion Day, observed each year • In 2010, teen pregnancy and child- total abortion ban since 2015, but faced on September 28, highlights the plight birth accounted for at least $9.4 billion serious opposition from the Catholic of women who need abortions and can’t in costs to U.S. taxpayers for increased Church and evangelicals. obtain them safely, often due to restrictive healthcare and foster care, increased laws at the country level. The Guttmacher incarceration rates among children The Chilean Constitutional Tribunal ruled Institute and WHO estimate that of the of teen parents, and lost tax revenue in favor of reversing the ban, 6-4. 55 million abortions each year, 25 mil- because of lower educational attainment lion are unsafe — meaning that they are and income among teen mothers. Until Augusto Pinochet’s military dic- performed by unskilled providers and/ • Pregnancy and birth are significant con- tatorship introduced the ban in 1989, or performed using outdated or unsafe tributors to high school dropout rates abortion had been legal for medical reasons methods.

6 Population Connection — December 2017 The study’s authors found that “In coun- The legislation also overturned a “trigger” abortion ban. The vote occurred on tries where abortion is completely banned law that would have banned abortion in the very same day that one of the bill’s or permitted only to save the woman’s life Illinois if Roe v Wade were overturned. cosponsors — Rep. Tim Murphy (R-PA) or preserve her physical health, only one in HHS Reverses ACA Birth — was publicly outed in the Pittsburgh Post four abortions were safe; whereas, in coun- Control Benefit Gazette for encouraging the woman he tries where abortion is legal on broader was having an extramarital affair with to grounds, nearly nine in ten abortions were In October, the Trump administration get an abortion during a pregnancy scare done safely. Restricting access to abortions released a long-rumored rule gutting the in January. Rep. Murphy has announced does not reduce the number of abortions.” birth control coverage requirement in the that he won’t seek reelection in 2018. House Votes to Allow D.C. Affordable Care Act. While not directly Employers to Discriminate a result of the Real Alternatives case on Rep. Murphy is a member of the House Against Employees for Birth the preceding page, the action will effec- Pro-Life Caucus. He has long cospon- Control Practices tively overturn that decision and allow any sored the so-called “Pain-Capable Unborn employer to opt out of birth control cover- Child Protection Act,” which will go to The U.S. House of Representatives voted age for pretty much any reason whatsoever. the Senate for consideration now that it in September, for the third year in a row, has cleared the House. Trump has said to prohibit the District of Columbia The birth control benefit required employ- that he’ll sign the bill if it reaches him, from using federal funds to enforce the ers to cover all forms of birth control, which is unlikely, since the Senate would Reproductive Health Non-Discrimination without copay, in their employees’ health need 60 votes to pass it. Amendment Act, passed by the D.C. insurance plans. Exceptions existed for Trump’s Awful “Wish List” Council in 2014. houses of worship and closely held private companies (after craft chain Hobby Lobby A Trump administration “wish list,” sub- The law bans employers from discrimi- won a Supreme Court case in 2014), but mitted to the Office of Management and nating against workers based on their use critics insisted that the exceptions didn’t Budget, was obtained by Crooked Media of birth control or whether they’ve had go far enough — they wanted all employ- in October, and it is horrible. It calls for abortions. ers to be able to refuse coverage based on ending UNFPA, Title X, and teen preg- religious or “moral” objections. nancy prevention funding, and requires a Rep. Gary Palmer (R-AL) filed an amend- new focus on fertility awareness methods ment to the House appropriations bill for The rule reversal was instituted by the of family planning (the same methods fiscal year 2018, and the House passed it, Department of Health and Human that have a 24-percent failure rate per the 214-194. It still has to clear the Senate, Services and applies even to publicly chart on page 5). It cuts Healthy Start and which is a long shot, and then get Trump’s traded companies, effective immediately. childhood obesity programs for the same signature, in order to become law. The Center for Reproductive Rights, kids members of the religious right sup- IL Gov. Rauner Expands National Women’s Law Center, and posedly care so much about. Abortion Coverage, Removes ACLU are planning to challenge the rule “Trigger” Law change in court. The atrocious document can be viewed 20-Week Abortion Ban and downloaded on the Crooked Media Illinois Gov. Bruce Rauner (R) signed a Passes House website: tinyurl.com/CrookedWishList. bill into law in September that extends abortion coverage to Medicaid recipients The U.S. House of Representatives voted and state employees. in early October to impose a 20-week www.popconnect.org December 2017 — Population Connection 7 What Will Your Legacy Be? If you aren’t yet a member of the ZPG Society, have you considered becoming one? The simplest way for you to ensure that your dedication to Population Connection’s mission continues well into the future is through a gift — a bequest — in your will. RECOGNIZING MEMBERS You can create a bequest by adding just one sentence to your will. And that sentence OF THE ZPG SOCIETY can make the difference of a lifetime! Contact: Shauna Scherer at [email protected] or 202.974.7730 or Abigail Lunetta at [email protected] or 202.974.7757

Sample Bequest Language: Population Connection’s ZPG Society honors those who have included Population After fulﬁ lling all other provisions, I give, devise, and bequeath ___% of the remainder of my estate [or $___ if a speciﬁ c amount] to Population Connection (Tax ID #94-1703155), a charitable corporation currently located Connection in their estate plans. We are grateful to our ZPG Society members for at 2120 L Street NW, Suite 500, Washington, D.C. 20037. their generosity and far-sightedness. Thank you!

Sharon Allen Kalya Cotkin Anna Heath Jeff Lesak & Merrily Swoboda Ronald G. Parker Steven R. Stegner Mahmood Anwar Gene & Marilyn C. Cripe Nancy Heck Ellis & Cheryl Levinson Bob Pettapiece Richard Stein Phil Arndt Susan Curry & Gail M. Daniels Dan Heisman & Shelly Hahn Walter Lindell Frank A. & Judy C.M. Pezzanite Judy C. Stevens David Asch Guy E. Dahms Max & Irene Heppner Seymour Lipson Linda M. Plein Steve Stodola & Joyce Thompson Ginger & Fritz Bachem Allan L. & Kendra Daniel Dianne Herman John & Danielle Lochhead Felicity Pool Linda Stokely Christopher Barry Ginny Darvill William W. Hildreth Douglas Longman Denise Powers Guy W. Stoye Robert A. Barry Richard S. & Diane Dennison Regina Holt Dwight E. Lowell II & Kimberly F. Lowell Gladys Powers Lawrence E. Stueck & Kathleen McQuiston Catherine Z. & Richard J. Becker Debbie Dill Agnes Hughes Norman Mandelbaum Penelope Purtzer Lorraine Sumner Sally Beers Raymond H. Dominick John Hutcherson Craig Mandsager Donald W. Rea Charlotte B. Swartz Robert & Gayle Behm Julian & Katharine Donahue Michael Ihlenfeldt Christopher & Catherine Mathews Frederick J. Retzlaff Rowland W. Tabor Keith Berg & Mary Hedblom Fay Dresner Laura L. Jackson T.D. Mathewson Joseph F. Rice Jeffrey Terrill Lynn Bertucci Richard M. Dubiel Rosalie Jacobs David R. & Sandra Matteson Curtis C. Ridling Roland Tozer Rose S. Bethe Lyn DuMoulin Heidi Johnson Elaine McAuliffe Carrie Robertson Gloria D. Valdespino K. J. & Jo Ann Bierman Lee & Tharon Dunn Pierce Johnson Jr. Gary W. McCormick Phil Rockey Claude Vander Veen & Shelly Schaffer Tom Bimmermann Nancy Farrell-Rose Sheri L. Jones Landon B. McDonald Larry & Alice Rodgers Jan van Heurck Barbara Bird Kirsten Fearn Cheryl Jurrus Bernadette McNulty Monica Roy Irene & Robert Wakeland John C. & Dorothy A. Brandt Robert Ford Paul H. Kaser David Miller Nancy G. Ryder William Warburton Darrell Q. Brown Bill Foster Ann Peckham Keenan G. Robert Miller Virginia K. Schilz Robert Wehle Mark C. Brucker Robin R. Friedheim Barbara Keeton Peter Mitchell Hermann F. Schmid David R. Weindorf Leo R. Buckert Doug A. Gardels Carol Ann Kell Russell Moffett Judith Scott Richard W. Weiskopf & Linda DeStefano Leonard N. Butters Don C. Gentry Vicky & Grant Kemp Roberta Moody Jamie Shaw & Christopher Cope Jay R. West Diane Carlin Susan Gerber Douangmala Khounnavongsa Phillip S. Morse Harry & Charity Sherrington Jo Lynne Whiting John Chamberlain Paul L. & Barbara Gerhardt Justine Kirk Eva Moseley Ron & Lucille M. Shissler Steve F. & Elizabeth Willey David B. Chamberlin Armand F. Girard Hunt & Linda Kooiker Mary Moses Leon G. Siegel Alice Wolfson David & Lynne Chelimer Robert M. & Margaret L. Goodwin Mary Koziar Andrew & Linda Mossa Bob Sizoo & Sue Turner William H. Wolverton Harriett Clark Eric Gordon Michael E. Kraft & Sandra K. Simpson-Kraft Barbara Q. Myers Ken & Kathy Smith Wayne Wright Sarah Clark Richard Green James E. Kunz Marcia Newfield John Solso Douglas N. Young Paul G. Clarke James Griffith James Larson James P. O’Callaghan Victor G. Soukup Audrey Clement David Hanna Rebecca Yee Hun Leong Lau* Dorothy Olson Margaret E. Sowerwine * Honorary Member Carl Coleman Ann Harmon Cheryl Lechtanski S Page Bella Starmountain-Sweet Matthew & Dawn Cooper Gary Harrold Dorothy & Andy Leong Mariette & Arthur Parent Bob Starr

8 Population Connection — December 2017 What Will Your Legacy Be? If you aren’t yet a member of the ZPG Society, have you considered becoming one? The simplest way for you to ensure that your dedication to Population Connection’s mission continues well into the future is through a gift — a bequest — in your will. RECOGNIZING MEMBERS You can create a bequest by adding just one sentence to your will. And that sentence OF THE ZPG SOCIETY can make the difference of a lifetime! Contact: Shauna Scherer at [email protected] or 202.974.7730 or Abigail Lunetta at [email protected] or 202.974.7757

www.popconnect.org December 2017 — Population Connection 9 A New Push For The Male “Pill” An international clinical trial will give a contraceptive gel a test drive By Dina Fine Maron | Originally published by Scientific American

he creators of a male birth of “the pill,” a hormonal contraceptive Researchers have been trying for decades control gel designed to inhibit used by women, that would limit sperm to deliver on male hormonal birth con- sperm production — while production. Yet vasectomy requires trol. Theoretically this would inhibit maintainingT healthy testosterone levels surgery and is not always reversible, con- sperm production in men, much as the in the bloodstream — will soon start doms are often used inconsistently, and pill blocks women’s ovaries from releas- recruiting 420 couples from around the withdrawal is unreliable. ing eggs. But in practice it is far more world to enroll in a new clinical trial. complex. In women the pill essentially That’s why the NIH team has turned to tricks the body into acting as though it Male participants will apply the hor- its new experimental gel. It introduces already is pregnant, making it tempo- monal gel to both shoulders once a day. into the bloodstream a combination rarily infertile. Among men a hormonal Then, after lab testing indicates their of the hormones progestin — which contraceptive could inhibit testosterone sperm counts have been suppressed to suppresses sperm creation in the body production in the testes, reducing sperm extremely low levels (which could take — and testosterone. An earlier version levels. It would, however, simultane- two to three months), the couples will be of this approach appeared promising in ously decrease testosterone in the blood tracked for a year while they use the gel a small, six-month pilot trial, in which — which would cause intolerable side as their lone form of contraception. gel application reduced sperm pro- effects that include impeded ejacula- duction while maintaining healthy tion as well as altered libido and muscle The project, led by the U.S. National testosterone levels. In about 89 percent mass. So the biggest hurdle to develop- Institutes of Health (NIH) and the of users, sperm counts were reduced to ing a male contraceptive pill has been Population Council, is expected to begin one million per milliliter or less (a point the difficulty of providing replacement signing up couples in early 2018, along typically considered to indicate success- testosterone in oral form, Blithe says. with collaborating partners at nine loca- ful sperm suppression). “That number The hormone would leave the body too tions in the U.K., Sweden, Italy, Chile, — 89 percent — may sound low, but quickly, rendering such a pill impractical Kenya, and several medical centers in the we suspect that there was some level of because men would have to take it too U.S. Once these sites get institutional noncompliance, since the men in that many times a day. and national review board sign-offs, the pilot trial were not using this for con- study will test whether the latest version traceptive purposes,” says Diana Blithe, Blithe’s contraceptive gel aims to get of a hormonal birth control system for who is leading the gel trial as chief of around those problems by steadily men can overcome the myriad obstacles the contraceptive development program adding testosterone back into the blood- that have sidelined earlier efforts. Just at the NIH’s National Institute of Child stream through the skin — at levels low last year a clinical trial of a hormonal Health and Human Development. By enough to avoid promoting sperm pro- male contraceptive shot was shut down way of comparison, among women the duction in the testes but high enough after some participants suffered concern- typical failure rate for oral contraceptives to prevent problematic side effects. “The ing side effects. hovers around 9 percent due to noncom- amount of testosterone needed for sperm pliance and imperfect use, putting it in production in the testes is believed to be Right now, options for male birth con- striking distance of the male gel sperm- about 50 to 100 times greater than what trol are few — condoms, vasectomy, and suppression numbers. is needed in the blood for other func- withdrawal — and there is no equivalent tions,” she notes.

10 Population Connection — December 2017 Her team’s effort comes on the heels of every eight weeks and then decreased in to impede egg fertilization have yet to a troubled, high-profile male contra- the body at varying rates until the next reach the same level of testing in men. ceptive trial. Last year a study headed injection, likely contributing to the neg- Animal tests have been performed with by the World Health Organization and ative side effects. a couple of products including a com- a reproductive health institute called pound called H2-gamendazole, which CONRAD reported a hormone injec- Colvard, who is not involved with the keeps sperm from reaching maturity tion suppressing sperm production in gel effort, says it seems promising. “We so they are not fully developed when men was about 96 percent effective. (The don’t know for a fact that the fluctuating they are ejaculated — causing men to NIH had no role in that project.) The hormones in [our] study were the only essentially “shoot blanks.” Another non- shot — which men needed to receive cause of the side effects that occurred, hormonal product, called Vasalgel, is a every two months — included testoster- but it’s plausible, given that behavioral polymer hydrogel that physically blocks one and progestin. Despite the injection’s changes occur during different hormonal sperm in the vas deferens so they can- effectiveness, the study was halted early cycles in men — like when teenagers not reach an egg. Researchers published when male volunteers experienced side hit puberty,” he says. For now his group promising results with Vasalgel in rab- effects including depression, acne, and is analyzing links between some of bits and monkeys earlier this year but its mood swings. Twenty of the 320 par- the mood swings seen in its study and maker says it has no timeline for human ticipants in that trial dropped out citing hormonal fluctuations in the weeks fol- clinical trials. Yet another product, problems such as mood changes, erectile lowing the injections, he says. Gendarussa, was created by researchers dysfunction, or pain. One participant’s at Airlangga University in Indonesia. It sperm levels had not returned to normal Aaron Hamlin, executive director of prevents sperm from fertilizing an egg four years after an injection and remain the Male Contraception Initiative — a via a mechanism that remains unclear at levels considered subfertile, says nonprofit organization that funds and — and the Indonesian team has not Douglas Colvard, a reproductive expert advocates for nonhormonal male birth published results from its phase I human at CONRAD and one of the lead inves- control — says a gel that continuously trials — so it is hard for outsiders to tigators of the hormonal shot effort. delivers a hormone makes sense. “If you assess the product’s success or science, are able to spread the dosage out over Blithe and Colvard say. Gendarussa has, Yet even with those side effects there more time, intuitively it seems like a however, received clearance from the was still a lot of interest in the product. better approach than having spikes that Indonesian equivalent of the U.S. Food The remaining trial participants mostly occur every so often, like with the shot,” and Drug Administration to proceed praised the injections and said they were he says. But he cautions that reversible with phase II trials, says Paul Feldblum, still interested in continuing to use them, nonhormonal methods — those that a senior epidemiologist in global health even after the scientists brought the test block sperm from fertilizing eggs with- research at FHI 360, a human develop- to a halt. out introducing hormones into the body ment organization that helped develop — would still be preferable, because any some protocols for the trial’s next phase. Blithe and her team expect their hormone-based intervention would be Gendarussa’s creators did not respond to approach to be largely free of the side subject to months-long delays between a request for comment. effects seen with the injection, because when a man starts using it and when the daily gel applications would release his sperm production is sufficiently Despite their different methods, all these the hormones more consistently. The suppressed. The body, Hamlin notes, products have one thing in common: most common side effect would likely must also clear a reserve of sperm that They are designed to fill the massive be acne, according to Blithe. In the pilot existed before the treatment began. He need for more contraceptive options. work a small number of men reported is also concerned about the side effects In 2012, 40 percent of all pregnancies acne, increased appetite, decreased libido, of hormonal birth control, and the con- worldwide were unintended, according mood swings, headaches, or insomnia — sideration that it may not adequately to the Guttmacher Institute. New forms side effects also seen among women who suppress sperm count in all men. of birth control, reproductive specialists take oral contraception. Unlike the gel, hope, could help slash those numbers. Blithe notes, the shots contained large Yet nonhormonal methods (beyond levels of hormones that were introduced vasectomies and condoms) that seek www.popconnect.org December 2017 — Population Connection 11 What Do Men Have To Do With Women’s Reproductive Rights? By Gary Barker, President and CEO of Promundo-US, and Serra Sippel, President of CHANGE | Originally published by Girls’ Globe

n his third day in office, President Trump solution for many couples, they have the added pro- signed the new and worse Global Gag Rule, tection of STI and HIV prevention. Oa restriction on international organizations that receive U.S. global health assistance that There are other male contraceptive methods in vari- blocks them from using their own, non-U.S. funds ous stages of development. The most recent trial of to provide or refer women to abortion services. a male hormonal contraceptive method was halted And lest we forget: He signed that presidential in 2016 due to negative side effects. Some wom- memorandum with seven men and zero women en’s health advocates pointed out that the decision standing behind him. represented a double standard, given that trials for women’s hormonal contraceptives have continued The disturbing image of a group of men literally despite multiple side effects experienced by women. blocking women’s access to abortion conveys the narrative of centuries of men controlling women’s Here’s the other reason we need men on board: bodies and lives. So, to the question, “What do men Millions of women report not using contracep- have to do with women’s reproductive rights?” the tives because of their husbands. In 2012, the UN obvious answer in these political times seems to be: Population Fund (UNFPA), the Gates Foundation, Stay out. It might be that we want men to have little and the UK government, among others, created or nothing to do with women’s sexual and reproduc- Family Planning 2020 (FP2020), with the goal of tive health and rights. reaching 120 million of the world’s poorest women with contraception. At their meeting in London But would women be better off? Excluding all men in July, coordinators of the Family Planning 2020 from discussions around sexual and reproductive partnership acknowledged they had only achieved rights is a disservice to women. It keeps the bur- about a quarter of their target and that a key obstacle den for contraception on women. It halts efforts that was men’s attitudes toward women’s usage of fam- encourage men to support the reproductive choices ily planning. Currently, the FP2020 initiative has of their female partners, and perpetuates a culture in no target for increasing men’s use of contraceptives. which no man is perceived to be, or engaged to be, Given the realities of sex and reproduction, we may an ally in ensuring reproductive rights of all people. never achieve a truly equal sharing of the contraceptive burden — but we can do better. Clearly, men matter in this discussion. There is the obvious point that, in the context of heterosexual At the very least, donors, governments, and public relationships, men are half of the human reproduc- health agencies need to talk to men about support- tive process. However, they represent only about ing women’s reproductive health. Studies from many one-quarter of total contraceptive use, including of the world’s poorest countries show that many withdrawal, vasectomy, and male condoms. That men want more children than their female partners, proportion has remained virtually unchanged since while in other countries, many men support their the 1980s, despite the fact that vasectomy is cheaper wives’ decisions to have fewer children. We cannot and safer than female sterilization. And, while rest until that becomes all men. condoms may not be the long-term contraceptive

12 Population Connection — December 2017 What Do Men Have To Do With Women’s Reproductive Rights? By Gary Barker, President and CEO of Promundo-US, and Serra Sippel, President of CHANGE | Originally published by Girls’ Globe

What about access to safe and legal abortion? Shouldn’t abortion stay in the realm of exclusively women’s decision-making? The answer is a defini- tive yes. Her body, her decision. In practice, though, many women confide in male partners on this issue. Household surveys coordinated by Promundo in several countries found that between 40 percent and 90 percent of women said that they involved a male partner in a decision to have an abortion. We can’t assume this is always a positive involvement on the part of male partners. But we can work to make men’s involvement respectful and supportive. Women and men, boys and girls, of all ages should be educated about contraception and abortion, and why both are critical components of comprehensive health services and rights. In addition, surveys in the U.S. show that men are as likely as women to support keeping abortion legal. Maybe it’s time for those men to speak up.

We need men around the world, from the heads of foreign assistance, to health policymakers, to male partners and husbands to join women and show in their voting, their voices, and their decisions that they stand up every day for women’s reproductive rights. We need fathers and mothers around the world to talk to their children, from early on, in open and feminist ways, about sex, sexuality, gender identity and expression, choice, rights, and contraception. We need men and women to vote for school board members who support comprehensive sexuality education, and speak out against violence against women. Moses, a member of the Village Health Team in Until every woman in the world has access to Nakasongola, Uganda, uses a flipchart to educate his modern contraceptives, safe abortion, and bodily peers about family planning. Photo: Lucian Alexe/ Reproductive Health Supplies Coalition, Courtesy of autonomy, we all must talk about family planning. Photoshare At home, in the classroom, and in the halls of power.

www.popconnect.org December 2017 — Population Connection 13 Men In Rural Ethiopia Show That Family Planning Is Not Just A Women’s Issue By Abraham Gelaw | Originally published by UNFPA

ileshi Deguale was busy working Improving Access to Family alongside his family, preparing Planning their land for planting season, but Ethiopia is working to improve access She paused to recall how difficult the work to modern, reliable forms of contracep- was last year. His wife had been too ill tives. In recent years, the country’s health to help with the farming. It was around extension program has brought family that time he made the biggest decision planning services to people’s doorsteps. of his life, a choice that would help his wife regain her health by protecting her UNFPA is supporting these efforts by from unplanned pregnancies — he got a training healthcare workers — including vasectomy. physicians, nurses, midwives, and health extension workers — to provide sensi- Vasectomies are a relatively common tive counselling about contraceptives. All form of contraception in places like family planning decisions must be fully Australia, South Korea, and the United informed and voluntarily. Kingdom, according to recent UN statis- tics. But the procedure is less popular in UNFPA also supplies Ethiopia with a other parts of the world, and in Ethiopia, variety of modern contraceptives, aim- vasectomies are rare. Perceptions about ing to increase the family planning masculinity prevent many men from options available. Around one-third of considering it as a contraceptive option. the required reproductive health com- added over two million new users of modities and life-saving reproductive modern contraception. Still, Mr. Sileshi says he is confident he health medicines in Ethiopia are being made the right decision. provided through the UNFPA program Family planning saves lives by decreasing known as UNFPA Supplies. the incidence of pregnancy complica- He and his wife already have six children. tions and unsafe abortions. The increased He did not want to burden her with sole These efforts are showing results. contraceptive use in Ethiopia is esti- responsibility for their family planning. mated to have averted two million unsafe The use of modern family plan- abortions and 20,000 maternal deaths. “My wife tried both short- and long- ning methods among married women term family planning methods for some increased from 8 percent in 2000 to 36 Still, the country has a long way to go. time, but they did not go well with her percent in 2016, according to a recent health,” he remembered. survey. And since 2012, the country has Currently, over one in five Ethiopian women has an unmet demand for

14 Population Connection — December 2017 Sileshi Deguale recounts his story, explaining why family planning was the right choice for himself and his wife. © UNFPA Ethiopia family planning, according to the recent was eager to listen. And when the con- community continue to ridicule me,” Mr. national survey, and this figure is much traceptive methods were explained, he Sileshi said. higher in rural areas. knew immediately what he wanted to do. His wife’s health has improved, and with A Trailblazer He conferred with his wife, and then it, the welfare of their family, he said. Most users of contraceptives are women, headed to the nearby Yeduha District and in many communities, family plan- Hospital to get the vasectomy. He now advises other men in his com- ning is considered a women’s issue. munity to consider this method of family He is one of three men in his sub-district planning. Mr. Sileshi saw things differently. In this who have undergone the procedure. way, he has been a trailblazer. “I have no regrets for the decision I unfpa.org/news/men-rural-ethiopia-show- When community health workers visited took, despite the fact that people in the family-planning-not-just-womens-issue his area to talk about family planning, he www.popconnect.org December 2017 — Population Connection 15 CAN NIGER BREAK OUT OF ITS CYCLE OF POVERTY? By Alastair Leithead | Originally published by BBC News

frica’s population is expected this window of opportunity to make the to double by 2050, but in the most of this youth dividend.” Acountry with the highest birth rate in the world it’s on track to triple. Most of the economy is in agriculture — subsistence agriculture — and barring a In Niger, women have an average of 7.6 dramatic transformation it’s an opportu- children each — and in rural Zinder the nity that may not be taken. rate is even higher. And so in the village of Angoual Gao Not surprisingly, it’s more than just a they’re getting plenty of outside help to statistic in almost every village you visit try to encourage better family planning. — there are kids everywhere. Tucked away amid the thick mud-walled Even the children have children — more compounds a group of young women are than half the girls are married before the sitting having very frank conversations age of 15. about contraception, forced marriage, or the problems of marrying young and As economies grow and both countries having children early. and their people get richer, the number of babies being born naturally begins to It’s what the aid workers call “a safe fall, but Niger is also one of the world’s space” for girls — and some of them are poorest countries. as young as 10.

“In Niger, we have a national character- Saratou Kanana, 27, is one of three older istic which is pro-birth, where having girls trained to lead the conversation. children is considered a traditional sign of wealth and power,” said Dr. Hassane She’s had four children, but despite all Atamo, head of the government’s family the talk of “spacing” births — leaving it planning division. longer between each child — she won’t say how many more kids she wants. “The immediate consequences of having such a high birth rate is that it’s impossi- “It all depends on Allah,” she said. But ble to feed, educate, and care for all these it is a little more complicated than that. children in the short term. After dodging a question asked a few “In the long term, the very survival of different ways, the translator finally the country is threatened unless we take explained.

16 Population Connection — December 2017 As a woman, she has no say. It depends on her husband. If her husband decides to stop having children, then she can go to the health center and stop. “But here it all depends on the husband. The last word is from the husband.”

www.popconnect.org December 2017 — Population Connection 17 Article Title Article Author

Nurse Salamatou Zahadi examines a child in the village of Dan Mazadou in southeastern Niger. Armed only with a medical bag and her determination, she battles heat and fatigue to look after pregnant and nursing women in Maradi, one of Niger’s poorest areas. The large, semi-desert country has the worst infant mortality rate in Africa at 127 deaths per 1,000 births. Previous page: Women with their children wait for a consultation in a health center in Madarounfa. Both photos: BOUREIMA HAMA/ AFP/Getty Images

As a woman, she has no say. It depends Smaller Families Health, education, and talk of the millet on her husband. If her husband decides And so on the other side of town the harvest is interspersed with chats about to stop having children, then she can go men are sitting cross-legged under a tree breastfeeding and spacing children. to the health center and stop. “But here and chatting about similar things — they it all depends on the husband. The last call it husband school. Although Musa Malamharu, 47, is lead- word is from the husband.” ing the conversation, he has two wives

18 Population Connection — December 2017 If there’s more certainty in life people “My husband is an educated person. He’s don’t need as many children, but it’s get- actually the one who’s encouraging me to ting over the “national characteristic.” go to the health center for family planning,” she said. Mudaha Musa, 27, seems persuaded that five or six children — two or three more But even if many people are persuaded, than he has at the moment — are prob- the dramatic growth of population in ably sufficient. Niger will take a long time to slow down.

“Truly there is a problem here with hav- Its population of 21 million people is ing too many children,” he admitted, predicted to exceed 68 million in the “but with husband school we’ve begun to next 30 years. see the benefits.” “Yes the culture is changing. Because Education appears to be the key to it’s women themselves who understand reducing the number of babies born. that having many children is a problem for themselves,” said midwife Furera At a mobile clinic well off the main Umarou. road a small open room is packed full of women and small children. She believes those couples who are persuaded may have four or five children The nurses are handing out different rather than eight or nine — it’s a start. contraceptive methods for the crowd to inspect. There’s much talk of a “demographic dividend” — the ability of a young and There are condoms, femidoms [female active workforce to catapult economies condoms], pills, IUDs, and even a dis- out of poverty as fertility and mortality cussion about birth control implants. decline, but that needs investment and jobs for them to fill. That’s when Nana Aisha, 28, stepped up and said that’s what she’s agreed — “If we don’t capture the benefits of the despite fears about the pain and the demographic dividend, we will be thrown dangers — to have a three-year implant into a total state of disequilibrium,” said injected in front of everybody. Dr. Hassane Atamo.

“I’m just going to show to the other “That could threaten the survival of the ladies, because there are some false country and encourage different things and 15 children, and is expecting to have rumors that it might be something that like terrorism and emigration.” at least two or three more. can get stuck inside of muscles,” she said, and it was over in an instant. A vast pool of jobless young people could It’s part of the same program — Project be set on the migrant trail to Europe, or Sawki they call it — and the aim is to Some of the women gathered round to into the hands of Islamist extremists like reduce the number of women dying in prod and poke at her arm — the implant Boko Haram. childbirth and children dying before the clearly visible beneath her skin. age of five — as well as trying to encour- Massive population growth is everyone’s age smaller families. She has three children, but will put off problem. having any more for at least the next three years. www.popconnect.org December 2017 — Population Connection 19 In West Africa, Clinics

Confront Suspicion, and

Husbands, One IUD at a Time By Ike Swetlitz; Kate Sheridan contributed reporting | Originally published by STAT

t was after dark when a woman and Pathfinder received two grants total- contraception, including IUDs, are safe to her husband arrived. They crossed ing about $10 million from the Bill and use while the woman is still breastfeeding. the dirt road and entered the cement Melinda Gates Foundation, based in part Ibuilding in a western neighborhood of on the work they’ve done in Burkina Faso, “If she comes in with her child, we can this sprawling West African capital. to study how to help women get access to use that opportunity to chat with her contraception. about contraceptive methods before she He had a demand: Remove the metal gets pregnant again,” Nassa said through rods you’ve put in my wife’s arm. He’d For instance, Nassa’s clinic is one of 84 in heard rumors that the strange technolog- Burkina Faso that have received the tools ical device was going to give her cancer, to insert an intrauterine device, or IUD, and it needed to go. from Pathfinder, according to Dr. Bruno Ki, the organization’s technical director in The nurse on duty at the health clinic, the country. Before that, the clinic didn’t Bernadette Nassa, was insistent. She even have the basic specula and tongs explained that the tiny rods were there for used in gynecological exams. Since May, a reason: They provided the woman’s body Nassa estimates, the clinic has performed with a hormone to keep her from having 30 or 40 IUD insertions a month, and the children. She needed to give her body devices remain effective for up to 12 years. rest before becoming pregnant again. Eventually, the husband relented. Counseling New Mothers Each morning, a hundred women crowd But, Nassa said, there’s not always a into Nassa’s small waiting room and spill happy ending. She’s seen women whose out into the courtyard; she and her staff, husbands insist on a divorce if their wives just under a dozen, can’t take care of all use contraception. of them. Her cement clinic only has four rooms for patients, so one doubles as a Such encounters underscore the difficulty birthing suite and a family planning con- of providing contraceptive services and sultation room. women’s healthcare in [Burkina Faso] — and in other developing countries — Demand for the clinic’s services has where reproductive health education is soared since the government started sub- limited and husbands make many deci- sidizing healthcare for new mothers and sions for their wives. young children in April. Now, healthcare is free for women for six weeks after they But since May, the clinic has had a give birth. new partner: Pathfinder International, a nonprofit geared toward increas- That makes for a crucial juncture for ing global access to reproductive health Nassa to intervene. Back-to-back births services. And soon many more clinics carry higher risks for both mother and could receive their help. In November baby, and non-hormonal methods of

20 Population Connection — December 2017 a translator. She tells the women about all Meanwhile, the organization is working As a result, many women try to induce kinds of contraceptive methods, includ- at a national level to change the country’s an abortion, with horrifying results. Ki ing IUDs. laws on abortion. has heard stories about women who stuck bleach pills into their vaginas or drank Pathfinder is also funding improvements “[The] abortion law is very restrictive in soup laced with ground glass. at other health clinics around the city. It is Burkina Faso,” Ki said. “In 2012, we [had] building a cement incinerator for medical more than 105,000 unsafe abortions in If the new statute is adopted, women waste at a health clinic in Bangpooré, a Burkina Faso.” would be able to receive an abortion if poor neighborhood by the railroad tracks their mental health or social well-being to Abidjan, where the current incinerator Currently, abortions are only legal if is at risk. The legislature was supposed to was nothing more than a brick fire pit in ordered by a judge, and only in four cases: vote on the changes in October, but never which a stack of papers smoldered next to rape, incest, if the [woman’s] health is at did, Ki said, and he’s not sure when they a jumble of aluminum and a can of insec- risk, or if there is a high probability the will pick it up in the future. ticide that had not yet exploded. child will be born with an incurable con- genital disorder.

Nurse Bernadette Nassa stands in the courtyard of a health clinic in Zagtouli, a western neighborhood of the capital of Burkina Faso. Photo: Ike Swetlitz/STAT

www.popconnect.org December 2017 — Population Connection 21 For Nigerian Mothers, Escape From Boko Haram Shakes Up Childbirth Customs

By Kieran Guilbert | Originally published by the Thomson Reuters Foundation

estled among dozens of pregnant women huddled eventually improve the sexual and reproductive health of together on benches in the clinic’s antenatal ward, countless women across the region, health workers and experts their children clad in jumpers, jackets, and woolly say. Nhats against the morning chill, Fatima Abdulai is glad to have the company. Some 1.4 million of the displaced are now residing in camps and communities in Borno state, where aid agencies are offer- Having fled her home in northeast Nigeria when Boko Haram ing free health services in camp clinics and state health centers. militants struck in 2015, Abdulai is preparing for the birth of her eighth child — her first since arriving in Maiduguri, the For many women uprooted by Boko Haram, like Abdulai, this capital of Borno state. But this time, she won’t be alone. is the first time they have set foot in a health facility, or heard about antenatal care, birth control, and family planning. “I gave birth to the others on the floor at home, alone,” she told the Thomson Reuters Foundation at the Maimusari health “We can challenge the norm of giving birth at home ... and center in Borno, the heart of Boko Haram’s seven-year-long have more conversations about women’s health,” said John campaign to carve out an Islamic caliphate in the northeast. Agbor, Nigeria chief of health for the UN children’s agency (UNICEF). “There was no hospital in my village, so I had no choice,” said Abdulai, who now lives in a rented apartment, rather than a Family Planning Fears camp for the displaced. “But some women in Maiduguri told Many of the women arriving at health centers for the first time me to come here ... now I know the risks of having a baby at are fearful that using contraception may leave them perma- home.” nently infertile, betray their Muslim faith, or spark a violent reaction from their husbands, several midwives said. In Nigeria, where many women deliver without medical care, around one in 125 die during or just after childbirth, making “Concerned about a cultural and religious backlash, we chose to it the world’s fourth most dangerous country in which to give raise awareness about the services by using local volunteers in birth, according to the World Health Organization (WHO). camps and host communities,” said Shehu Dasigit, reproductive health manager at the International Rescue Committee Many women in the northeast do not have a health facility (IRC). nearby, cannot afford the transport or healthcare costs, or are compelled to deliver at home by their husbands and families. Yet the fact that more than two-thirds of the displaced in Borno live among communities rather than in camps makes it But the destruction wrought by Boko Haram in the north- harder to reach and encourage women to seek health services, east, which has uprooted more than two million people, may Dasigit said.

22 Population Connection — December 2017 Women sit in the waiting area of the International Rescue Committee (IRC) health clinic in Bakassi Internally Displaced People (IDP) Camp in Maiduguri in northeast Nigeria. The camp provides vital healthcare services, including medication, family planning counseling, and skills training for girls and women affected by the Boko Haram insurgency. Photo: STEFAN HEUNIS/AFP/Getty Images

However, in health centers and camp clinics across Maiduguri, “My husband knows my check-up schedule, and even reminds dozens of women queued patiently in the heat, saying that they me when I have my next visit,” said Ali, who had not been able would happily wait three or four hours to be seen. to afford antenatal care for her first four pregnancies in Gwoza, the first town Boko Haram fighters claimed control of in 2014. While some of the women in Bakassi camp had decided to come without telling their husbands, 25-year-old Zuwaira Ali could Many like Ali are considering family planning for the first time not stop smiling as she attended her latest antenatal check-up. in a country where only around one in 20 married women use contraception, according to the Population Reference Bureau.

www.popconnect.org December 2017 — Population Connection 23 “Being displaced and living in a camp is not the perfect situa- tion for children,” said Ali, who is due next month. A woman gets her blood pressure checked during a consultation at the IRC health clinic in Bakassi IDP Camp in “After this child is born, we will use family planning to wait Maiduguri. Photo: STEFAN HEUNIS/AFP/Getty Images before having any more,” she added, sitting next to a pinboard covered with condoms, contraceptive pills, and posters.

Taking On Tradition Not all women have such understanding husbands and families, according to Clara Afolyana, a nurse who works in Bakassi camp.

Men in the camps are often against birth control because they believe having many children will lead to more humanitarian aid, or prosperity in the future, several health workers said.

“Some men divorce, beat, and even rape their wives if they merely bring up the idea of family planning,” said Afolyana, who provides victims of such violence with counseling, anti- HIV medication, and emergency contraceptive pills.

With many of the displaced contemplating a return home soon as Nigeria’s army secures areas previously held by Boko Haram, several women said they hoped to challenge traditional beliefs about reproductive health in their home communities.

“The influence of grandmothers — who themselves gave birth at home and often every year — is strong across the northeast,” said Fatima Kolo Lawan, a 23-year-old midwife at Maimusari who provides antenatal care to up to 100 pregnant women each day.

“We want those women giving birth now, the next generation of grandmothers, to deliver a different message to their daughters,” she said, beckoning yet another woman into her room.

The state government is repairing some 500 health centers damaged or destroyed by Boko Haram, two-thirds of facilities in Borno, and aims to offer maternal and child health services in all of them, said Muhammad Ghuluze, director of emergency medical response in the state health ministry.

While such an approach would benefit women like Abdulai, she laughs heartily at the prospect of having a ninth child.

“For now, I‘m just happy to be having this baby at a health center,” she said. “It feels good to be here.”

24 Population Connection — December 2017 www.popconnect.org December 2017 — Population Connection 25 iew As the Year Winds Down, No Sign V Attacks Will End By Stacie Murphy, Policy Director a shington W

or family planning supporters, every day is a new (and mostly “The Global Gag Rule is a dangerous and ill- unpleasant) adventure under conceived policy that blocks millions of women Donald Trump. Here’s what the last F and their families from receiving critical aid and quarter of the year brought us. assistance. . . I’m very pleased that this amendment Budget Outcome Remains was approved on a bipartisan basis and hope that Unsettled Congress can continue to make progress to repeal In our last issue, I wrote about the House this disastrous policy.” version of the State Department/Foreign – Sen. Jeanne Shaheen Operations Appropriations bill. To recap: It was really, really bad. It limited funding for international family planning to not more than $461 million and codi- fied Trump’s expanded Global Gag Rule and the ban on funding for the United UNFPA. The amendment passed 16-15, House Passes 20-Week Nations Population Fund (UNFPA). with Sens. Susan Collins (R-ME) and Abortion Ban Democrats offered amendments to fix Lisa Murkowski (R-AK) voting for the In early October, the House passed a these problems, but they were defeated changes, along with all Democrats except bill to ban abortion nationwide after 23-29, with only retiring Rep. Charlie for West Virginia’s Sen. Joe Manchin. 20 weeks of pregnancy. The justification Dent (R-PA) crossing party lines to vote for the measure, which passed 237- with the Democrats. The disparities between the two bills will 189, was the medically dubious theory have to be worked out before there can that a fetus can feel pain by that point The Senate Appropriations Committee be any vote on a final funding package. in a pregnancy. The bill contains excep- met in early September to consider tions for pregnancies caused by rape their version of the bill. Initially, it Because it was believed to be unlikely and incest, and for those that are life- wasn’t any better than the House bill. that both chambers would get all their endangering to the pregnant woman. However, the outcome in committee funding bills done by the end of the It does not, however, allow for abortion was quite a bit better. During markup, fiscal year (September 30), Congress in cases where there is a fetal anomaly. Sen. Jeanne Shaheen (D-NH) offered had already passed a three-month Although Donald Trump has vowed an amendment to increase funding to Continuing Resolution, which will fund to sign it if it reaches his desk, the bill $585 million, remove the Gag Rule the government at current levels through currently remains mostly a symbolic ges- and insert the language of the Global December 8. ture, since passage in the Senate would HER Act, and allocate $37.5 million for require 60 votes.

26 Population Connection — December 2017 Trump Administration Rolls to notify anyone but their employees, … and Undercuts the ACA Back Birth Control Benefit … and insurers don’t have to do anything Removing the birth control ben- Only days after the passage of the House in response to offer the coverage to efit wasn’t the only attack on the ACA. abortion bill, the Trump administration enrollees. Congress failed to repeal the health- added its own attack on reproductive care bill, but the administration is doing rights: the rollback of the Affordable Part of the administration’s stated ratio- everything in its power to make sure it Care Act’s birth control benefit. nale for the change? Access to birth doesn’t work anymore. They had already control might promote “risky sexual refused to allow states to make requested At least 55 million women have gained behavior” among teens and young adults. fixes to their marketplaces. They cut the access to birth control without a copay advertising budget so people wouldn’t since the benefit was first introduced. And as with so many of the actions taken know they needed to sign up, and lim- In 2013 alone, birth control pill users by this administration, they’re not even ited the open enrollment period to create saved $1.4 billion in out-of-pocket pretending to follow the normal process less opportunity. And then, shortly after costs. Upfront costs for IUDs — one for making changes like this. Most regu- the birth control rule change, Trump of the most effective long-acting latory changes go through what’s called announced that he would not make the methods — fell to $0 for most women a “notice and comment” period before cost-sharing payments required by law with insurance. they take effect. It’s done so groups or — payments that help prevent premiums individuals affected by the changes have from skyrocketing for some customers. The new rule specifically says that the an opportunity to have their objections ACA does not require that birth control heard. Not so with this change — the Soon after that decision, a bipartisan be covered. And it dramatically expands new rules were final as soon as they were group of senators, led by Lamar the religious and “moral” exemptions issued. Alexander (R-TN) and Patty Murray that were the result of the Hobby Lobby (D-WA) announced that they had case in 2014. Previously, entities that In response, Senate Democrats, led by arrived at an agreement that would make objected to covering birth control had to Patty Murray (D-WA) released a bill the payments and stabilize the market- notify the government that they would designed to undo the rollback. A group places. As of our deadline, Trump had not comply. Insurers were then required of Democratic women in the House have spent several days waffling on whether he to offer separate birth control cover- indicated that they will release com- would support the measure, and Speaker age at no additional cost to the affected panion legislation soon. Additionally, Paul Ryan had made no comment. employees. The new rules do away with multiple advocacy groups and the attor- all of that. They let any employer, large neys general for several states have or small, religious or secular, assert a reli- already either filed suit against the gious or moral objection to birth control administration, or announced that they and refuse to cover it. They don’t have plan to do so. www.popconnect.org December 2017 — Population Connection 27 ch The Resistance Begins with You! By Rachel Walker, PhD, Advocacy Fellow utre a & O ield F

ach demonstration, each event — big and small — that our activists host or participate in is an important effort Etoward resisting Trump’s deadly agenda and promoting the health, empowerment, and rights of people all around the world. Join us in the resistance by texting FIGHT to 52886, visiting IWillFight4HER.org, and following our sister organization, Population Connection Action Fund, on Twitter (twitter.com/popconnect) and Facebook (facebook.com/PopConnectAction). We need your support to push our movement forward!

World Contraception Day, September 26 SisterSong’s “Let’s Talk About We joined Planned Parenthood Generation Action and NARAL Pro-Choice Sex” Conference in New Orleans North Carolina to co-host the “Defending Access at Home and Abroad” panel at Our Deputy Field Director, Tanisha Duke University. The event featured local, national, and international perspectives Humphrey, along with Field on reproductive health from human rights activist Lisa Shannon, NARAL-NC Coordinator Lauren Salmiery and Field student advocate Anna Katz, and Gender Studies Professor Kimberly Lamm. Organizer Lindsay Apperson, presented Population Connection Field Coordinator Lauren Salmiery moderated. the workshop “Advocacy in Action: Defending Global Reproductive Rights in the Face of 45.” The conference welcomed over 1,000 attendees who gathered together to talk about ways to strengthen the voices of women of color in reproductive justice.

Our sister organization, Population Connection Action Fund, co-sponsored a Twitter chat with CHANGE and columnist and non-fiction author Jennifer Wright. The chat prompted 320 people to tweet or retweet 870 posts using #TrumpGlobalGag, potentially reaching over 1.6 million Twitter users. Several notable influencers engaged in our chat, including author and actress Mara Wilson (Matilda, Mrs. Doubtfire).

Pride Festivals in Colorado and North Carolina We tabled at pride festivals in Aurora, CO, and Charlotte, NC, to support LGBTQ rights and highlight how Trump’s Global Gag Rule will harm access to healthcare for LGBTQ people all around the world. At Aurora Pride we collected over 100 #Fight4HER petition signatures, and 45 people sent photo petitions featuring our cardboard cutout of Sen. Cory Gardner directly to him via Twitter. We collected several hundred #Fight4HER petition signatures at Charlotte Pride.

28 Population Connection — December 2017 International Safe Abortion Day, September 28 We teamed up with the Population Advocates in Nevada and Pennsylvania Institute, Reproaction, Advocates for created a coat hanger display to remind Youth, and Physicians for Reproductive viewers what happens when abortion is Health to make some noise for safe illegal and/or inaccessible. abortion access at our own cacerolazo (English translation: casserole — a type of very noisy protest popular in Latin America). We gathered outside the White House with pots, pans, wooden spoons, cowbells, and almost anything that could make racket to let Donald Trump know that supporters of safe abortion are watching. Activists in New Hampshire also held a mini-cacerolazo with about twenty students. Supporters in Ohio and Colorado held International Day of the Girl photo petitions so constituents could Child, October 11 tell their members of Congress to repeal Nearly fifty students, volunteers, Trump’s Global Gag Rule and keep abor- and activists at the University of tion safe, legal, and accessible. Denver in Colorado highlighted the challenges faced by girls around the world. They shared their support for the health and empowerment of girls everywhere by writing messages on paper dolls to create a moving visual display.

www.popconnect.org December 2017 — Population Connection 29 People and the Planet PopEd Launches New Edition of Middle School Curriculum By Pamela Wasserman, Senior Vice President for Education d E op P

n time for the 2017-18 school year, introduces teachers to the seven units: standards including Common Core, PopEd launched an ambitious new The History of Population Growth, Next Generation Science Standards curriculum. Aimed at teaching Population Concepts, Land Resources, (NGSS), and the National Curriculum Imiddle school students about population Water Resources, Air Pollution and Standards for Social Studies. Both the trends, their impacts, and our paths Solid Waste, Our Global Family, and units and individual activities can be to a sustainable future, People and the Sustainable Future. Each unit includes a integrated across subject areas to allow Planet develops students’ understanding background reading and lesson plans — for interdisciplinary learning and easy of the interdependence of people, the 41 in all. There are also short case studies incorporation into existing curricula. environment, and our connections as featuring specific stories of challenges a global family. This fourth edition of and crises (like the Deepwater Horizon oil Each unit in People and the Planet People and the Planet not only updates spill and overfishing of Bluefin tuna) but includes a summative assessment. These already popular lesson plans, but includes also inspiring projects like the Nashua are project-based and designed to many new ones that reflect current River clean-up and Malala’s work to pro- measure student learning on key unit environmental and social issues relating mote girls’ education. concepts, while building skills such as to population. The curriculum addresses writing, designing, policy analysis, and the latest content standards across a The content and teaching techniques advocacy. Some of the assessment proj- range of disciplines and incorporates employed in People and the Planet ects reinforce concepts learned (like innovative ways for teachers to measure activities make them relevant in today’s creating a trivia game to test each other’s students’ grasp of the concepts. classroom and representative of best command of demographic terms and practice instruction. To keep students trends). Others challenge students to As citizens growing up in the 21st cen- engaged, lessons use a mix of memorable, design ads, comic strips, eco-friendly tury, students face innumerable global hands-on strategies including inquiry, products, and community service action challenges: climate change, global wealth games, role-playing, debate, small group plans. To enhance the lessons, People and gaps, water scarcity, deforestation and problem solving, science labs, and more. the Planet provides teachers with over 30 biodiversity loss, gender inequality, and The activities also require students infographics on unit topics and dozens more. But as tomorrow’s leaders, vot- to use higher order thinking skills to of suggested resources (books, websites, ers, and policy makers, they are also in tackle complex real-world problems. videos, and articles). a position to steer our planet toward a This encourages learning to be applied sustainable future. outside of the classroom and prepares People and the Planet is password pro- students to make informed decisions as tected. Teachers have the option of While People and the Planet originally global citizens in the years ahead. accessing the entire curricula online debuted in 1996, this is the first edi- or downloading individual units. tion to be produced online. The online The blend of real-world content and More information is available at format has many new features and a higher order thinking make People populationeducation.org/store/people- number of activities that were not avail- and the Planet activities an ideal match and-planet-lessons-sustainable-future. able in previous editions. The home page for addressing current educational

30 Population Connection — December 2017 The new People and the Planet includes 22 of the teaching activities from previous editions. The other 17 activities are new to the curriculum. Here’s a sampling of some of those new activities.

Almighty Aquifers: Aquifer deple- grazing and a third of cropland goes to students compare the life cycle stages tion is threatening water resources produce food for livestock. Meanwhile, of four everyday products (jeans, ear- around the globe. As the human popu- we need to grow more food for our buds, sneakers, and a lamp) in order to lation grows, so does the demand for human population. In this activity, stu- hypothesize which item has the lowest groundwater. In this board game, students graph global meat consumption, environmental footprint. They then pick dents play the roles of different states use bingo chips to explore the environ- one product and brainstorm improve- drawing from the Ogallala Aquifer mental impact of four different types of ments that could be made along the underneath the High Plains. Each round protein, and discuss the pros and cons of product’s life to minimize its eco-impact. of play represents a decade (1950-2000) a shifting global diet. and the amount of water withdrawn Lessons for Life: There is a strong mirrors the demand from each state dur- Population Future: According to link between education and fertility; the ing that time period. the UN, 11 billion people are projected more education women have, the more to be on the planet by 2100. Much of likely they are to have small families. Fracked or Fiction: Students ana- that growth will be in sub-Saharan Raising the status of women and mak- lyze a dozen different pieces of data Africa. In this graphing activity, students ing education equally available to girls on fracking, including articles, graphs, draw gridded bars to represent the popu- and boys is key to breaking the com- charts, and maps from a variety of sources lation sizes of world regions in 1980, plex cycle of poverty that traps so many (government agencies, energy industries, 2015, 2050, and 2100. They also analyze women around the world. In this activ- environmental advocacy groups, and fertility and mortality trends for the past, ity, students read the story of two girls in mainstream news outlets) to determine present, and future. an Ethiopian village with different edu- bias, gather information, and, ultimately, cational opportunities. They also view form their own opinions about fracking. The Secret Life of Stuff: As popu- photo essays of girls around the world lation and affluence grow around the describing their day-to-day routines and Meat of the Matter: A quarter of the globe, so does the demand for more their hopes for the future. planet’s ice-free land is used for livestock “stuff.” In this STEM-based activity, www.popconnect.org December 2017 — Population Connection 31 Cartoon

32 Population Connection — December 2017 Editorial Excerpts

Under the new U.S. Department of Health and Human For more than a century, some conservatives have tried to Services rule, any employer with a “sincerely held” religious or prevent American couples from using birth control. Planned moral objection to contraception can stop covering the cost Parenthood pioneer Margaret Sanger was jailed eight times of birth control. The federal government doesn’t have to vet under puritanical Comstock Laws for teaching contraception. those objections for sincerity; companies can halt coverage just because they don’t feel like paying for it. Several hidebound states banned birth control until 1965, when the U.S. Supreme Court ruled that married couples have What’s more, companies that have opted out are no longer a right to use contraception in the privacy of their bedrooms required to allow workers to access copay-free birth control — and 1972, when a follow-up ruling extended the right to coverage directly from insurance companies. So millions of unwed couples. American women who get employer-sponsored insurance may lose all coverage of contraception — forcing them to either pay Now President Donald Trump has signed a directive saying all out of pocket or forgo the well-known benefits to their health employers with strong religious beliefs may block their com- and financial stability they get from being able to plan their pany health plans from covering birth control. pregnancies. Why is it “religious freedom” to try to block contraception and Aside from the religious objections, the Trump DHHS — cause some women to have babies they don’t want? Why is which is packed full of believers in misinformation about religious freedom only for bosses? Why don’t female employees birth control — also presents a weak health-based case, saying have religious freedom to choose birth control if they want it? that the rollback will help keep access to contraception from encouraging “risky sexual activity” among teens and young We think birth control should be a human right for every couple adults. (The fact that far fewer teens are having sex or giving and every female in the world. With the population explosion birth today than in the 1980s would seem to lead to the oppo- still soaring out of control, all people everywhere should have a site conclusion.) right to choose whether they want more children. No outsider, such as a boss, should have “religious freedom” to interfere with But it’s obvious that this isn’t about the facts. It’s about (again) that choice. catering to the president’s base. And it would be almost laugh- able if the implications for women’s lives and health weren’t so Birth control is a secure part of the modern safety net. serious. Politicians shouldn’t try to gain votes by damaging it.

– October 11, 2017 – October 19, 2017

www.popconnect.org December 2017 — Population Connection 33 Population Connection 2120 L Street NW, Suite 500 NON PROFIT ORG US POSTAGE PAID Washington, DC 20037 POPULATION CONNECTION

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