What’s Wrong with Paying Women to Use Long-Term Birth Control?

As we first blogged a few weeks ago, Project Prevention—an organization that pays female drugs users in the U.S. and UK to be sterilized—has branched out yet again.  Following a lukewarm reception in the UK, it has now turned its attention to Kenya, where it plans to start paying women living with HIV to be inserted with intrauterine devices—a form of long-term contraception.

We put some questions about Project Prevention’s latest move to four reproductive rights experts, two of whom have been leaders in the opposition to Project Prevention in the United States.

The women are:

• Elisa Slattery, Regional Manager and Legal Advisor for Africa for the Center for Reproductive Rights, Nairobi, Kenya
• Betsy Hartmann, Director of the Population and Development Program and Professor of Development Studies at Hampshire College, Amherst, Massachusetts
• Anne Gathumbi, Program Manager of the Health and Rights Unit at the Open Society Initiative for Eastern Africa, and founding member of the Coalition on Violence against Women in Kenya, Nairobi
• Lynn Paltrow, Executive Director of the National Advocates for Pregnant Women, New York City

Can you give us some background on Project Prevention and its founder, Barbara Harris?

Betsy Hartmann: Project Prevention used to be called CRACK—Children Requiring a Caring Kommunity. It was founded in 1997 by Barbara Harris, a homemaker from Stanton, California, with the intent of preventing births to drug-addicted women by offering them cash incentives to be sterilized or use long term contraception. In a logic reminiscent of eugenics, CRACK claimed that the children of these women would be a burden on society, winding up in special education classes, foster care, etc. The original billboards proclaimed: "Don't Let a Pregnancy Ruin Your Drug Habit." There was and is no concern for providing these women with drug treatment.

CRACK spread into a number of U.S. cities where staff targeted poor communities of color, sometimes accompanying police on their neighborhood rounds. What was truly astonishing is how much positive press CRACK, and later Project Prevention, received. Fortunately, however, reproductive rights, public health, and harm reduction groups and agencies started speaking out against the organization and exposed its right-wing funding.

What was your reaction on hearing that Project Prevention is now moving into Kenya?

BH: I am extremely disturbed that Project Prevention is moving into Kenya. Concerned reproductive rights, HIV/AIDS, and public health organizations and activists should do all they can now to make sure the organization does not take root in the country.

Anne Gathumbi: We have many concerns with attempts to use money to coerce women into long-term birth control. Interventions for addressing the needs of women with HIV need to be holistic, integrated, respectful, and responsive to the needs of both women and children, and must be based on evidence. Offering money as an incentive to sign up for birth control is coercive and not based on any evidence that it works. What we need are programs that support prevention of mother-to-child transmission (PMTCT). These programs are available in Kenya, and they have been well documented and proven to be effective.

Elisa Slattery: Project Prevention is part of the problem, not part of the solution. By fueling negative perceptions and sowing misinformation about HIV-positive women as mothers, it only adds to the stigma and discrimination that interfere with HIV-positive women receiving key reproductive health care, including family planning services, services to prevent mother-to-child transmission of HIV, and maternal health care.

Lynn Paltrow: I was appalled, but not shocked, to learn about their latest international endeavor. Project Prevention started by focusing on one set of highly controversial and stigmatized health issues—pregnancy and drug use—and has now expanded to another—pregnancy and HIV.

According to its website, “Project Prevention offers cash incentives to women and men addicted to drugs and/or alcohol to use long term or permanent birth control.” But in Kenya, so far the discussion has focused on IUDs for women living with HIV. Is long-term birth control less problematic than sterilization?

BH: What women living with HIV need are health services that provide safe, voluntary contraceptive options and the kind of prenatal care and antiretroviral regimens that reduce the chances of their babies being born HIV-positive. Giving cash or in-kind incentives for women to undergo sterilization or long-term contraception is a form of coercion and violates reproductive choice and rights.

They push women into making decisions about birth control based on money, rather than which contraceptive is the healthiest and best choice for them. Project Prevention will only further scapegoat and stigmatize HIV-positive women. In truth, the organization's main mission is ideological—eugenics with a 21st-century face.

LP: In addition to the legal, ethical, and moral questions raised by offering money to financially vulnerable women to use certain devices and medications, there are many medical questions that need to be addressed concerning the effects of various methods of long-acting birth control on the targeted women. Depending on a woman’s age and health, long-term contraception may effectively prevent her from ever procreating again.

AG: This is problematic on many levels. First, women living with HIV have specialized health needs. Certain long-term contraceptive devices have been found to result in serious health problems for some women. This is not a decision that should be taken lightly or rushed into for the lure of much-needed cash.

Second, it treats women with HIV as persons lacking capacity to determine the right health choices for themselves and their families. This is a discriminatory attitude that portrays women with HIV as irresponsible and reckless persons. In reality, women living with HIV can and do give birth to healthy babies. Any reasonable woman provided with proper care and factual information will make the right choices regarding her health and that of her baby.

Third, the practice of paying women to accept long-term birth control is not only coercive but also manipulative. Taking advantage of women in resource-poor settings by offering them money is paternalistic, tokenistic, and amounts to blackmail.

Project Prevention’s message focuses primarily on children. Do they offer any support for improving the lives of the mothers (aside from the one-time payment for sterilization or birth control)?

BH: Superficially, at best. Their main concern is to prevent those mothers from having children. If they really cared, they wouldn't be doing what they're doing.

LP: Project Prevention's strategies whether in the U.S. or UK regarding pregnant women and drug use, or in Kenya regarding pregnant women and HIV, have one major thing in common: their framework. The considerable public relations they do to promote Project Prevention all make it appear that the biggest threat to children's health is their own mothers. This model ensures that blame for medical and social ills will be placed on mothers, distracting attention from male responsibility and the public health, political, and economic conditions that profoundly effect the lives and health of children regardless of what their mothers do. Such an approach undermines public will to fund and support effective public health and development models that Project Prevention suggests, falsely, would be unnecessary if only certain women would stop procreating.

AG: This project takes a very demeaning and stigmatizing approach to women with HIV. It is a gross violation of women’s rights to coerce them into long term procedures that deny them the opportunity to make informed choices about their reproductive health and options. The project must be stopped before it takes root in Kenya.

Project Prevention put out a press release claiming that getting HIV-positive women on long-term birth control is the only way to “prevent the conception of a child who will only be born to die.” What is your response to this?

LP: Project Prevention is making claims that lack support in evidence-based research. Clearly the U.S. has extensive experience with preventing perinatal transmission of HIV—reducing it to two percent. So obviously targeting certain women and seeking to prevent them from procreating is not the “only” way to prevent children from acquiring HIV.  If we value the women of Kenya as much as we value women in the U.S., we should be promoting those same interventions to pregnant women and new mothers in Kenya as well.

BH: Project Prevention seems to assume that HIV-positive women will necessarily have HIV-positive children. This flies in the face of medical research and scientific evidence. And it ignores the fact that HIV is a chronic condition, not an automatic death sentence. With access to health care and the appropriate medicine, people with HIV—both adults and children—are living much longer lives than in the past.

AG: Project Prevention’s claims are way off the mark. Overwhelming evidence shows that transmission of HIV can be stopped by giving mothers the medicine Nevirapine before delivery. Project Prevention should direct its energies and resources to the already existing successful programs that reduce transmission of HIV from mothers to their babies. The Treatment Monitoring and Advocacy Project, for example, advocates for a four-pronged approach to caring for women and children in the context of HIV:

• HIV prevention in women of childbearing age;
• Preventing unintended pregnancies;
• Preventing vertical transmission (mother to child transmission of HIV);
• Treatment, care, and support for women, children, and families.

How do you feel about Project Prevention’s choice of target population: women who use drugs in the U.S., and HIV-positive women in Kenya. These are seemingly very different populations. Are there any links or commonalities?

BH: Definitely. For one, Project Prevention mainly targets women of color in the U.S., and now it is targeting African women. This is no accident. Project Prevention's racism is very thinly disguised. Essentially, while it targets specific vulnerable populations, it is trying to build support for eugenic and population control measures more broadly. I find this extremely worrying. There is a long history of population control organizations using incentives and disincentives to pressure poor people to be sterilized. These were roundly rejected at the 1994 UN population conference in Cairo, but they persist, for example in China and India. USAID unfortunately is talking about introducing incentives again into family planning programs despite their terrible history of coercion and abuse.

Africa has also become the main focus of population agencies given that in some countries birth rates remain high. Project Prevention is helping spread the message that African women don't deserve freedom of choice and quality of care in reproductive health programs. Also, there have been increasing reports of coercive sterilization of HIV-positive women in other African countries. This is a dangerous trend.

AG: The groups selected share similar characteristics: they are on the margins of society, ostracized, and suffer double marginalization. They are blamed for infecting their partners and children with HIV. There is a false assumption that they are weak and lack capacity to decide what is good and bad for themselves. This kind of targeting and labeling women further drives them away from coming forward to access services.

ES: In 2008, the Center for Reproductive Rights and the Federation of Women Lawyers-Kenya issued a factfinding report, At Risk: Rights Violations of HIV-Positive Women in Kenyan Health Facilities, which found that HIV-positive women are consistently discriminated against in the health sector when they try to exercise their reproductive choices. They are often denied comprehensive family planning information because of beliefs that HIV-positive women should not be sexually active and should not have children. And pregnant women living with HIV are often abused or neglected when they go to give birth in health care facilities, which threatens their health and undermines efforts to prevent transmission during delivery.

Project Prevention is asking people to donate $47 for the Kenya effort—$40 to pay to the woman, and $7 to pay the doctor. What is your message to people considering supporting this project?

BH: Don't do it. There are plenty of good reproductive health and HIV/AIDS treatment programs that need support. Fund them instead.

AG: Don’t. There are other interventions that are based on evidence and are respectful of the rights of women to exercise the choices that are available.

LP: People supporting Project Prevention will be giving money to a program that serves a political ideology over the needs of women, children, and families. Project Prevention suggests that there is a particular portion of the population that should not be, or that is not worthy of, reproducing the human race. The risk is that this will be easily interpreted to mean that this group is unworthy of being regarded as fully human and deprived of the rights, health, and support to which all human beings are entitled.

At the very least, no one should support this program without knowing much, much more about it. For example, in light of barriers to reproductive health care in Kenya, what health risks do various long-acting birth control measures pose to older women? Will Project Prevention work with programs distributing condoms, encouraging men to use them, and empowering women to ask men to use them? Does the project support HIV prevention and education efforts overall?

ES: The real solution to safeguard the lives and health of women and their children is to ensure that all women, regardless of HIV status, be allowed to exercise their reproductive choices and to obtain the necessary information and services to do so.