Written by Editor-in-Chief Jodi Jacobson for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

It’s not often that I agree with Michael Gerson, the conservative former speech writer for President George H.W. Bush, advocate for abstinence-only policies in U.S. global AIDS programs, and columnist for the Washington Post. 

Today, however, I am in near-full agreement with him on a piece he published in today’s Post.

Gerson just returned from a trip to the Democratic Republic of Congo sponsored by CARE during which he and others saw firsthand the struggles of women who live in societies in which they have little control of whether, when and whom they marry, and whether, when and how many children they bear.  In these settings, women bear more children than they want and can afford to raise, infant and child mortality rates are high, and complications of both pregnancy and unsafe abortion are the leading cause of deaths among women ages 15 to 49.  Medical care is largely inaccessible.

Reproductive and sexual health and rights advocates have always argued that ensuring that women have unfettered access to family planning information and counseling and consistent contraceptive supplies is a “pro-life” strategy, because voluntary family planning dramatically improves the quality of life and survival rates of both children and their mothers, and by extension, families and societies.

But the anti-choice movement in the United has moved from opposing abortion per se to opposing all forms of birth control, an agenda it was always suspected to have in the first place.  As such, this movement, led largely by male religious leaders, Congressmen or virulently anti-choice male activists opposes support for family planning services and birth control methods both at home and abroad.

Having a “card-carrying” conservative evangelical columnist support family planning as a “pro-life” intervention not only speaks to reality, it is what I hope to be a welcome first step in pushing back against anti-choice positions that cost far more lives–those of women and children–than they ever “save.”

Visiting the village of Bweremana, Gerson writes:

[T]he correlation between the number of children and the absence of some of their mothers becomes clear. Kanyere Sabasaba, 35, has had 10 children, eight of whom have survived. Her last delivery did not go well. “I delivered the baby without any problem, but I was bleeding much,” she told me. The case was too complex for the local health center, so Kanyere had to pay for her transport to another medical facility. After the surgery, the doctor performed a tubal ligation. “If I give birth again, I could die,” she said. “The last child is the one who could really kill me.”

As Gerson rightly notes, for women in this part of Congo, the complications of childbirth are as dangerous as the militias in the countryside.

One woman I met had given birth to 13 children, only six of whom survived. Women sometimes deliver in the fields while working. Medical help can be a few days’ journey away. Each birth raises the odds of a hemorrhage, infection or rupture. Those odds increase dramatically when births come early in life, or late in life, or in rapid succession. In Congo, almost one in five deaths of women during childbearing years is due to maternal causes.

And, he notes, “While both the pill and condoms are generally available in larger cities such as Goma, access is limited in rural districts. Determining the pace of reproduction is often a male prerogative instead of a shared decision. Sexual violence can be as close for a woman as gathering fuel in the woods.”

These are all absolutely true and I appreciate and admire Gerson for acknowledging these realities.

The women of Bweremana, continues Gerson “are attempting to diffuse and minimize their risk. In a program organized by Heal Africa, about 6,000 contribute the equivalent of 20 cents each Sunday to a common fund. When it is their time to give birth, the fund becomes a loan to pay transportation and hospital fees. The women tend a common vegetable garden to help with income and nutrition. And the group encourages family planning.”

But even this is not enough.  It is estimated that 215 million women worldwide want and need access to basic family planning and supplies but do not currently have it.  These women bear more children than they want or can support.  As a result, they also watch more infants and children die, suffer poor health themselves, and are far less likely to achieve their own educational and economic goals.  That is why investments by nations in their own health care systems, including basic reproductive and sexual health care, and international donors in those same systems, are so critical.

But, as Gerson notes:

The very words “family planning” light up the limbic centers of American politics. From a distance, it seems like a culture war showdown. Close up, in places such as Bweremana, family planning is undeniably pro-life. When births are spaced more than 24 months apart, both mothers and children are dramatically more likely to survive. Family planning results not only in fewer births, but in fewer at-risk births, including those early and late in a woman’s fertility. When contraceptive prevalence is low, about 70 percent of all births involve serious risk. When prevalence is high, the figure is 35 percent.

The United States was once the global leader in funding family planning worldwide.  But U.S. funding of international family planning programs has remained essentially flat for the last 10 years, and is hamstrung by an increasing number of medically-unnecessary and ideologically-driven restrictions that end up reducing, rather than expanding access to this urgently-needed health intervention.

Gerson argues that support for family planning and contraceptive supplies shouldn’t be the ideological lightening rod it has become because:

“[e]ven in the most stringent Catholic teaching, the prevention of conception is not the moral equivalent of ending a life. And conservative Protestants have little standing to object to contraception, given the fact that they make liberal use of it. According to a 2009 Gallup poll, more than 90 percent of American evangelicals believe that hormonal and barrier methods of contraception are morally acceptable for adults. Children are gifts from God, but this does not require the collection of as many gifts as biologically possible.

In fact, more than 80 percent of the U.S. public writ large strongly supports women’s rights to determine the number and spacing of children they have.

So far we strongly agree: It’s a strategy that saves lives, it makes economic sense, and because this is about public health, it should be free from ideology.  If you don’t like contraception, don’t use it. But don’t use religion or ideology to deny it to others, especially when the overwhelming majority of women of all religious persuasions in fact use birth control.

Where I diverge with from Gerson in regard to these issues is on abortion. 

Gerson points to “[s]ome liberal advocates” who think these are intrinsically related.  In regard to self-determination, human rights, and public health, the linkage between a woman’s ability to prevent pregnancy and her ability to safely and legally terminate an unintended and untenable pregnancy are intrinsically linked and women know this. It only becomes ideological when religion and politics intervenes in these basic rights and tries to undermine them.

It is true, as he notes, that “support for contraception does not imply or require support for abortion.”  You can, personally, be a supporter of contraception but decide you would not choose abortion were you to become pregnant, which obviously men can’t.  Where we’ve become lost, however is in politicizing abortion care in much the same way as family planning services and ignoring, for ideological convenience, the same public health and medical evidence on safe abortion services that supports access to family planning.  Safe abortion care makes sense because it saves women’s lives, and ultimately the lives of their current and future children borne through wanted pregnancies.

Notwithstanding religious and ideological beliefs, access to safe abortion is also a well-recognized critical public health intervention.  Moreover, without it, ultimately women can not truly be in charge of their reproductive destinies–and hence can not truly exercise self-determination. Access to safe abortion services is a necessary back up to any unintended and untenable pregnancy, from any cause, including contraceptive failure, interrupted access to contraceptives, and pregnancies resulting from intimate partner violence and rape, rape as a tool of war, stranger rape, or incest.  Access to contraception can dramatically reduce the number of unintended pregnancies and hence the need for abortion, but it can never completely eliminate abortion. So the need for access to safe abortion care is a fact-based medical and public health position, not an ideological one. And by suggesting it is an ideological position, we continue to miss the point.

What Gerson doesn’t clarify is that for the purpose of U.S. policy, contraception and abortion are already kept separate.  U.S. international family planning assistance goes solely to family planning information and supplies; it does not support access to safe abortion care.  Under the Helms Amendment, funding for abortion care is only allowable in cases of rape, incest or the health and life of the mother.  In reality, because of politics, U.S. funding is rarely if ever used even for these “allowable” conditions.  The issue of abortion would come into play if we were talking about repealing the Helms Amendment, an effort I wholeheartedly support, but which has nothing to do with current discussions around the scope of U.S. international funding for family planning, unless you are a Congressperson trying to deflect attention from the fact that you don’t want to support family planning and want to ignore the evidence that it saves the lives of women and their children.

So when we talk about ideological fights around family planning, it really comes down to a majority male GOP Congressional leadership that vociferously opposes access to basic services that would enable women to choose the number and spacing of children they want by using basic family planning services.  Abortion is a red herring here, because it is not in the equation.  Gerson himself would have been more forceful if he had clarified that, and he also would have been more honest if in this piece he had reversed his own earlier position supporting the prohibition of integration of family planning into U.S. global AIDS programs, a position adopted by the Bush Administration and, unfortunately, continued by the Obama Administration that dramatically diminishes access to contraceptive supplies to HIV-positive women who desire not to have any more children.

So I agree with Gerson that family planning is pro-life, as all people who are pro-choice and by definition therefore “pro-life” understand those concepts.  I also agree with Gerson that “women in Congo have enough home-grown problems without importing irrelevant, Western controversies.”  And finally, I completely agree that access to contraceptives do not solve every problem and that women in Bweremana want access to voluntary family planning for the same reasons as women elsewhere: to avoid high-risk pregnancies, to deliver healthy children and to better care for the children they have.”  They want the same happy, healthy families we all strive to have.

This is the best understanding of why the pro-choice movement, based as it is on public health and medical evidence is indeed “pro-life,” and why U.S. support for voluntary international family planning services is one of the single most effective investments we can make.  Let’s keep the funding politics separate from abortion right now, while recognizing that on the ground, in the hut, for the woman, these two things are rarely in neat little boxes.