Dyer et al.’s (2016) analysis offers key insights into religious conservatives’ perceptions of family planning. It also provides the basis for a messaging platform which could help grow support for sexual and reproductive health programming in a highly politicized environment. However, Dyer et al. have put forth a potentially harmful premise in their exclusive focus on “healthy timing and spacing of pregnancies” (HTSP), while ignoring the benefits of making “contraceptives” central to messaging efforts to increase the support of religious conservatives. Not only does the term “contraceptives” elicit the most positive results among those tested, it appeals to reproductive health advocates by avoiding the pitfalls of a singular focus on HTSP, including ignoring the sexual and reproductive needs and rights of those who are unmarried, adolescents and youth, survivors of gender-based violence – and those who simply wish to limit births entirely.  

There are many things to applaud in the paper by Dyer et al. First and foremost, we strongly agree with the need to build greater public support for international family planning assistance – one of the most effective interventions in the history of public health. 

Because the US population assistance program was established in 1965, the world has made remarkable progress. From its earliest days, USAID’s family planning program has been guided by a commitment to voluntarism and informed choice. To that end, the proportion of women in the developing world using modern contraception has increased from <10% to more than half. Maternal mortality rates have dropped from 380 deaths per 100,000 live births in 1993 to 210 deaths in 2013. Child mortality rates around the world have declined by 70%, and many researchers have linked increased survival rates of children to their mother’s ability to access and use contraception (Cleland et al. 2012). US investments in family planning have had – and continue to create – lasting impact. 

It is important to note at the outset that the 1973 Helms amendment restricts the use of US foreign assistance for abortions overseas. Fortunately, there are signs of a growing consensus that at minimum, exceptions for women who are rape survivors or whose pregnancies threaten their lives should be made to this restriction. That said, this commentary intentionally limits our discussion to contraception, regardless of our organization’s fervent support of safe abortion as a necessary public health good and precursor to the realization of women’s human rights. We welcome the invitation to submit a future commentary on this critical issue. 

Today, the US Government is the largest funder and implementer of global health programs worldwide, including family planning and reproductive health programs that serve millions of women in over 45 countries (USAID 2016) and which work to improve the health, safety and dignity of all people. Although US funding for international family planning is above $600 million today, from a needs-based perspective, it is woefully inadequate. If the US were to provide its appropriate share of the total financial resources needed to address the unmet need for contraception of 225 million women in the developing world, this sum would total $1.2 billion annually – double the current investment. 

So, yes, we need more funding for international family planning – and we need more Americans telling the President and their representatives in Congress that this cost-effective intervention deserves our support. 

We argue, however, that Dyer et al. have put forth a potentially harmful premise in their exclusive focus on “healthy timing and spacing of pregnancies” (HTSP), while ignoring the benefits of making “contraceptives” central to messaging efforts to increase the support of religious conservatives on this issue. Not only does the term “contraceptives” elicit the most positive results among those tested, it appeals to reproductive health advocates by avoiding the pitfalls of a singular focus on HTSP, including ignoring the sexual and reproductive needs and rights of those who are unmarried, adolescents and youth, survivors of gender-based violence – and those who simply wish to limit births entirely. 

Whither healthy timing and spacing then? If we wish to grow the movement, our focus should be on contraceptives. 

A Faulty Premise 

The American public chronically misperceives US foreign aid. A 2015 Kaiser Family Foundation poll (DiJulio 2015) showed that Americans think the US spends too much on foreign assistance, largely because they vastly overestimate the US’s investments overseas. Most believe 25% of the federal budget is spent on aid, when, in reality, it represents 0.17% to be exact (OECD 2015). For some context, the OECD’s Development Assistance Committee has set a target of 0.7% of gross national income (GNI) to be spent on foreign aid. Of the 28 OECD members for which data are collected, Sweden ranks first with 1.4% of GNI spent on foreign aid. The US ranks 20th (OECD 2015). The good news is that most think the US should invest more in foreign assistance once they are educated about the actual numbers. This is an incredible opportunity for sexual and reproductive health advocates. Dyer et al.’s analysis is an important attempt to respond to that opportunity. 

There are, however, a number of issues within the paper that deserve at least some clarification and, at most, significant overhaul. Dyer et al. assert that “‘family planning has been at the heart of the US culture wars for the past 45 years.” This is, in fact, not correct. The international family planning assistance program was established over 50 years ago, and for most of its history, family planning has enjoyed bipartisan support (PAI 2016) as a common sense issue and something practiced by the overwhelming majority of American women (>99% of sexually active women between 15 and 44 years old) and couples during their reproductive lives (Guttmacher Institute 2016). Family planning as a practice, and any distaste for the term among political and religious conservatives, is a relatively recent phenomenon. 

A partisan divide has indeed grown and it tracks almost perfectly with the increasing influence of religious conservatives on the Republican Party. Family planning became conflated with abortion in the 1980s during the Reagan administration when harmful abortion-related policy provisions were first attached to international family planning programs and became the subject of congressional debate. Even as late as 1999, Republican votes in the House exceeded 45 on amendments rejecting the Global Gag Rule and supporting a US contribution to the UN Population Fund (UNFPA). On an amendment to zero out all funding for overseas programs in 1999, nearly 80 Republicans voted in opposition. Today, based on recent votes targeting family planning funding for Planned Parenthood, it is hard to see more than a handful of current House Republicans, at best, voting to preserve funding for the international program, and even fewer – no more than three – opposing these harmful policy provisions. 

The fundamental premise of Dyer et al. is therefore a faulty one and requires circular logic when viewed in historical context: support for family planning has not waned merely because the term “family planning” has never appealed to religious conservatives. It’s an important point because it shows that messaging is a critical part of our challenge but not the only one. It also requires us to question another premise at the heart of the analysis – that a significant proportion of this constituency is movable primarily through shifts in messaging. 

This is untested. First, there is no evidence of causality presented to indicate that the outreach of the organizations mentioned is responsible for the changes in perceptions about access to contraceptives that Dyer et al. report on page four of their analysis. Second, and most importantly, we have no evidence that these changes in perception translate to changes in voting behavior or in the legislators these individuals help elect – a reality reflected in our current polarized Congress. To some extent, Dyer et al.’s analysis itself validates this. We note that despite changes in the perceptions of religious conservatives about greater access to contraceptives, there is virtually no change in views of contraceptives as positive, negative or neutral (page 9). 

Additionally, almost all respondents reported that their views on international family planning are not in fact linked to the perceived effectiveness of US foreign assistance, or links to women’s empowerment and education, but are almost wholly based on personal morals and beliefs about what is right. Yet puzzlingly, three of the four Dyer-recommended talking points fall outside a moral frame and attempt to link family planning to cost-effectiveness and other arguments. This is confusing. Dyer et al. have done an excellent job of establishing that – for better or worse – family planning as a term is an emotionally charged barrier to religious conservatives’ support of the issue. However, it is simply ineffective from a communications perspective to ask people what motivates them – then to tell them what they should care about instead. If religious conservatives have told us that they are motivated by personal beliefs of what is right, we cannot provide them with impact-based numbers around foreign assistance and think our work is done. If we seek to build common ground, our job as advocates is to provide a values-based frame around contraception that speaks to that sense of what is right. 

Building greater partnerships and crossing political divides requires patience, tenacity and an incredible investment of time and financial resources in an already resource-constrained environment. As we seek to build a bigger tent, we need to be clear that we are keeping the age-old maxim “know your audience” in mind. Awareness and education is the first step to influencing voting behavior, but we must also ensure we are investing our efforts in those audiences who are truly potential converts. 

The Potential Dangers of Using HTSP Terminology 

Does this mean that we should not examine our terminology or appeal to new constituencies? No. We share Dyer et al.’s conviction that this is a worthy effort. However, we must find a balance between messaging that appeals to non-traditional allies, while supporting proven interventions that speak to the lived realities and rights of women and communities. For this reason, we reject the exclusive use of “HTSP” as a replacement for “family planning.” Every legitimate, rights-based rationale for these programs should be used. 

It is important to recall that the Office of Population and Reproductive Health (PRH) at USAID has been actively engaged in HTSP work for some time – one could argue since the inception of the program, although not using the specific terminology of HTSP to describe its longstanding maternal and child health-focused activities. In fact, it is a core component of PRH’s program. However, HTSP is but one of a number of rationales for the existence of the program. 

As mentioned previously, there is a real concern that focusing solely on HTSP messaging could lead to limits on important programming around other critical family planning and reproductive health activities, including programs to prevent child, early and forced marriage; gender-based violence; family planning and HIV integration; female genital mutilation (FGM); and obstetric fistula, to name but a few. 

HTSP programming also should not interfere with or complicate USAID’s ability to provide permanent methods, such as tubal ligation and vasectomy, and long-acting reversible contraceptives. Both types of contraceptives have limiting family size among their principal purposes, not just timing and spacing of pregnancies. 

These concerns are not merely the specters of paranoia. One of Dyer et al.’s recommended talking points mentions the President’s Emergency Plan for AIDS Relief (PEPFAR), which is notable for its bipartisan support. Ironically, PEPFAR’s prevention activities became more effective – from an evidence-based, scientifically rigorous and documented perspective – once they evolved away from a narrow, ideologically driven and irrational set of interventions intended to appeal to religious conservatives. PAI spent many years, for example, documenting the tragic consequences of the abstinence-only policies of PEPFAR under the Bush Administration (PAI 2007). Policies which, by focusing only on sex in the context of marriage (Gorman, 2016), increased the HIV infection rate among young people, men who have sex with men and commercial sex workers – and even among married women who could not abstain from sex (Center for Health and Gender Equity 2010) – and yet also often could not negotiate condom use, 

thereby increasing their risk of acquisition and the risk of mother-to-child transmission of HIV. 

As an umbrella term, HTSP is a non-starter. What to do about family planning then? We agree: the term is opaque and, whatever the original cause, it is now sadly mired in political baggage. Let us use it less, especially when talking to those who are not our natural allies, but let us make the case for contraceptives. Not only is the term simple, clear, descriptively accurate and tested most favorably among those in the Dyer et al. study, but it also resonates with progressives. That seems far more pragmatic than cherry picking ideologically loaded and possibly harmful alternatives because they are comfortable for religious conservatives. 

Conclusion 

Dyer et al.’s analysis provides a clear and compelling rationale for building greater support for international family planning and US global health investments more broadly. The testing conducted offers key insights into religious conservatives’ perceptions of family planning and provides the basis for a messaging platform which could help grow support for sexual and reproductive health programming in a highly politicized environment. Although it is clear that the term “family planning” should be abandoned in outreach to religious conservatives, the surprisingly positive reactions of conservatives to “contraceptives” is good news for reproductive health advocates. The term is simple, descriptive and accurate – and is also supported by core reproductive health supporters. 

There is space for organizations such as both PAI and Hope for Healing Hands in the movement to improve the lives and health of women and girls, but we cannot work at cross purposes. An exclusive focus on healthy timing and spacing will guarantee continued confusion and conflict. We must come together to make the collaborative case for contraceptives, and happily, the stars are aligned in the form of polling and messaging data.  

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