A Discussion with Henry Mosley, Professor Emeritus at Johns Hopkins Bloomberg School of Public Health

With: Henry Mosley Berkley Center Profile

September 16, 2013

Background: Dr. Mosley brings to the topic of family planning, and public health issues more broadly, long field experience, which began with research on cholera in Bangladesh in 1965. His interest and research in population studies are colored by keen interest in the intersections of religion, culture, politics, and health. He argues that religion and religious leaders can play important roles in promoting or discouraging the use of contraception, though formal religious teachings are often less significant in private decisions than is assumed. In some countries, such as Iran, Muslim religious leaders have been instrumental in decreasing fertility rates while in places like the Philippines, the Catholic Church has influenced the government to prohibit family planning legislation. Mosley argues that it is not usually religion itself but the culture and politics that surround religion that can present barriers to family planning uptake. Above all he makes the case that information and public discussion of evidence and issues are what can make the most difference. This discussion with Katherine Marshall, Lynn Aylward, and Nava Friedman on September 16, 2013 was part of a WFDD review of the family planning work of faith-inspired organizations, undertaken for the United Nations Foundation.

How did you first enter the international family planning field, and what were some early formative experiences?

I was first introduced to population studies (through a course on demography) in my master of public health (MPH) program at Johns Hopkins University in 1964-65. Immediately afterwards I went to Bangladesh (then East Pakistan) to do research on cholera. There I saw the effects of rapid population growth and had the opportunity to learn about some of the factors involved in family choices about child-bearing.

During the course of my research in Bangladesh (East Pakistan at the time), my task was to conduct large scale vaccine field trials. In doing this, I needed to gather statistics about the behavior of a large rural population. There were large gaps in information, and our survey work offered a chance to gain some better understanding. At the time, I knew very little about fertility studies and I realized that almost nothing was known about it in that population. Since the cholera vaccine studies required a visit to every house every single day, I designed a census and vital registration system to check on how the treatment was going. After setting up this survey, I had some questions in my mind, and, notably, wanted to figure out why, even though people were not practicing family planning, households were only having about 6 children instead of many more. We found out that very prolonged breast feeding was being used as a means of birth spacing because it inhibited ovulation through lactational ammenhorea. But it was also hurting the health of children as it contributed to malnutrition.

At that time, USAID gave a very large grant to Pakistan (including the area that is currently Bangladesh) to implement a national family planning program based largely on giving IUDs to women to prevent pregnancies. However, the program was not working in my region because of the conservative culture. The program’s goals were ambitious: to reduce fertility by 20 percent in five years, but it did not take into account the cultural realities of the society. By 1968, I had data that showed that the birth rate hadn’t changed at all in two years. I was observing a family planning program (that of USAID) that wasn’t working. My reports got me in serious trouble with USAID because they did not like my data.

Around this time, the national government collapsed and a main issue behind this collapse was the family planning program that, at the local level, people did not like. They accused the program of sterilizing men without their knowledge. My experience in Bangladesh was thus something of a trial by fire, one that took me closer and closer to a focus on and study of child health, birth spacing, and the dynamics of family planning in the area, as well as the political dimensions of the issue.

In 1970, I was invited back to Johns Hopkins to chair a new department of Population Dynamics and continued with family planning work. But I had gotten my first real taste of the issues by observing those early stages of a national family planning program in Bangladesh that totally collapsed because of poor management and flawed design by the donor community. It is important to remember that at that time no one really knew what successful family planning policies looked like; they had no experience with successes or failures.

In the years that followed, I witnessed similar ill-fated programs. The government of India collapsed in 1976 because Indira Gandhi tried to introduce a coercive family planning program. The Congress party lost the election for the first time since independence in 1948 because of that.

In contrast, from the early 1970s to the 1990s in Indonesia under Suharto, there was a heavy-handed family planning policy that was working. The government had a ministry of religious affairs, and was able to bring religious leaders together, and did so often. They were part of the family planning program. But the government there was too heavy-handed in all affairs and tried to stay in power too long and was eventually kicked out.

What roles do you believe that faith has played in promoting (or blocking) family planning?

I would start with asking how faith groups have influenced government, and what comes to mind is how far it really depends on the country and faith group. One example is with the Christian Health Associations (CHAs) in Africa that work directly with the government in providing health care, including family planning services. Because a lot of these countries are predominantly Christian, like Kenya, Uganda, and Ghana, Christian Health Associations have been very influential in primary health care and providing guidance with respect to intervention and policy. In fact, in the early 1980s they were taking the lead in early family planning services.

In the Islamic world, when I was working with Al-Azhar University in Egypt, important academic studies were produced that showed that Islam supported family planning (though not sterilization nor abortion) and many religious leaders supported the idea that birth spacing and only having children you can support fit well with the ideas of the Qur'an. Shifting forward in time to three or four years ago, there was a significant international meeting in Pakistan where Islamic leaders published a largely supportive document on family planning and Islam.

We can thus see that religious leaders have been quite influential in some of these countries with respect to leaders from a dominant religion in a country, working with their politicians to improve the perception and acceptance of family planning.

Can you think of examples where religious institutions or ideas have influenced national policy against family planning?

The Philippines and Peru are indeed cases where religious authorities have been very opposed to family planning. The Catholic Church has been very influential there in the politics and resistance to family planning. The Church there has tended to be very conservative, with significant Opus Dei influence.

If we go back in history to the start of the family planning movement in the 1960s and early 1970s, we see other examples of governments not supporting family planning and the impact of this. But we also see more complex interactions. Chile is an interesting example. In the 1960s, Chile was having a huge epidemic of abortions that were overwhelming health services and blood transfusion needs due to abortion complication surgeries. Abortion, illegal as it was, was being used as a means of dealing with unwanted pregnancy. The government introduced family planning in spite of the resistance of the Catholic Church as a preventative measure, as the alternative was much worse for the population.

Why, in contrast, has the Catholic Church not launched strong anti-family planning movements in some countries, especially in Africa?

It is important to keep in mind that most of these countries have, historically, already been pro-natalist. Polygamy was common, with men taking on more wives with the purpose of producing more children. And certainly, while birth spacing was intrinsic to the culture, birth control was not. But I can’t tell you exactly why the Church did not try to vocalize resistance to family planning movements that arose. If you look at the case of HIV, however, you can see the Church’s influence in how long it took to address the issue—particularly the reluctance to allow the use of condoms to prevent disease. It took a long time to gain acceptance.

Maybe one difference is that countries like the Philippines and Peru were colonized by Catholics from Catholic Spain. Perhaps that historical experience helps to explain the difference; while there were Catholic missionaries in Africa, these countries were not extensively colonized by Catholic colonists.

In many African countries where contraception use is low, to what extent is religion influencing individual families’ use of contraception? How important a factor is religion in these private decisions?

Honestly, I don’t think the religious influence is the most important factor when it comes to the individual level. Many factors are at work, including traditions and politics. In my experience with family planning programs in African countries, for example in Uganda, which has very high fertility, the government at the national level has made clear efforts to promote family planning. One difficulty I learned of during a meeting there is that while national leaders were trying to promote family planning, leaders at the local level, were telling people to have more kids because they needed a larger voter base to receive more government allocations. Underlying this is the fact that the country is divided by tribal differences. As such, no district or province wanted to see its population reduced. At the meeting one national leader stated, “Our provincial leaders tell people to have lots of kids, otherwise they will be outnumbered by another tribe.” So it seems that politics and culture are the driving force behind high fertility there.

To take another example, in Nigeria there is higher fertility in the Islamic north than in the south. But it’s not really because Islam is in some way against family planning. Islamic cultural values are preventing women from getting education and having any role in life other than marrying early and bearing children. This is not directly because of Islam as a religion being against birth control. It is rather that the specific Islamic culture in that area has been depriving women of opportunities for education and work and movement outside their traditional roles in these societies.

Thus, in my experience, it has been ethnic and cultural values—and often these values being goaded along by political leaders—that has maintained higher fertility, not religious association per se.

Are there any particular challenges you have encountered or observed in terms of working with family planning in a faith context?

Not really. I know the Catholic Church at the official level teaches against what they call artificial contraception. In the U.S., however, you notice that Catholics do the same thing as non-Catholics in terms of using birth control; most Catholics practice modern contraception despite Papal doctrine. But when I was working overseas, I found that a lot of local Catholic leaders were not actually against artificial contraception, when you talked to the people at the grassroots level. So it might be more the hierarchy which is in place and teaching resistance to family planning measures than these local leaders. In the Philippines, the hierarchy might be keeping politicians from passing laws on family planning, but people on the ground might still be interested in learning more about it. Catholic families here in the United States are not necessarily against the services. So the issue is not individual Catholics, but a hierarchy that is providing a barrier at the political level. And a hierarchy that is out of tune with what people at the family and community level actually think and do.

Can you point to any particular faith-related initiatives that have been influential with family planning, and how were they successful?

A major example is the transformation of Iran. The country used to be extremely pro-natalist. However, Iranian economists did studies on the negative effects of high fertility and there were open dialogues and debates, with issues put out in front of the public. People were able to express different views from economic, political, and religious standpoints. In my view, a best practice they showcased was to provide space for such open debate, through radio shows, television and press, about the advantages and disadvantages of bigger and smaller families for economic, social, and cultural and a whole host of reasons, rather than keeping it under wraps.

This dialogue is particularly important because more people are open-minded about family planning, in my experience, than you might think. Even in conservative societies this can be the case. The late Carl Taylor, a professor at Johns Hopkins University, was working in villages in Afghanistan, talking to women there. They expressed to him a clear interest in birth spacing and reducing fertility so their children would have more opportunities. And I myself have encountered this in Ugandan villages. Thus, in my opinion, a best practice is certainly to have more open dialogue about the issues, allowing families themselves to discuss them and listen to these issues.

In your time working in the field, have you seen major changes in attitudes toward family planning from lower-income governments, communities, or churches?

When I first worked in Bangladesh in 1965, it was a very conservative Islamic society. In Dhaka, women barely went out in public and when they did they were always covered up in burkas. In rural villages, when you were walking through the village bazaar you would see only men. The only women were widows and gypsies selling things.

In the country at that time, there were 60 million people but only 3 percent of people were recorded as practicing family planning. When they conducted a survey, they found that the women who did practice family planning would not talk about it or admit to it. Another study about family planning found that two thirds of women who went to clinics and got an IUD would deny having received services if they were interviewed. So while it was still low, the rate was actually closer to 7 percent of women who practiced family planning.

Prospects of change seemed unlikely then because the culture had been that way for hundreds of years. But when you go to Bangladesh now, 65 percent of women practice family planning, and fertility has gone down significantly, from 6.5 children per woman to 2.2. There are millions of women coming every day to the textile mills in Dhaka City wearing their bright saris. The social transformation is unbelievable for what was considered such a conservative society.

What is striking to me is that Bangladesh was part of Pakistan. But today, when you go to Pakistan (which used to be West Pakistan), unless you go to the elite areas of the major cities, things have hardly changed in the last 50 years. The remarkable transformation that has occurred in Bangladesh has not happened in Pakistan. Many things have gone into that difference. Bangladesh gained independence and experienced famine and flooding, but also huge amounts of development. Women’s education was a big factor in Bangladesh. In Pakistan, these social development movements have been slow, except for some movements in the elite. Government policies and services increased significantly in Bangladesh, whereas in Pakistan, there have been very few services. Thus, fertility is still very high. The government has not supported education in Pakistan, and while there’s been occasional progress on family planning services, that hasn’t changed the fundamentals of the culture in terms of ensuring access to family planning and education for women.

You refer both to birth spacing and birth limiting. CCIH emphasizes the importance of language and its effects on comfort with family planning initiatives in a faith context. Does a difference in language have a large impact on the effect of family planning initiatives?

CCIH did do a survey among its member organizations, led by Dr. Doug Huber (a reproductive health specialist). It found that these organizations were not against family planning altogether, but were against abortions.

What CCIH does, therefore, is focus in its presentations on pregnancy prevention. If you talk about family planning, people think you could mean birth control, and that could mean abortion. Thus CCIH shies away from “birth prevention” and states “pregnancy prevention” because the institution can’t take stands on topics like abortion and other sensitive issues because of the sensitivities of some of the membership base. Other organizations talk about “birth spacing” and not “birth limitations.” However, this wording is chosen in relation to the sensitivities not of the recipients, but of donors and politicians.

When working in a country, we talk to the women in a community and we find out that they are not just interested in birth spacing but also in terminating childbearing (aka birth limiting) because they recognize the investment involved in providing for the children they already have. They want to focus on providing opportunities and ensuring the welfare of these children. But if we are working in this area, we can’t talk about birth limiting. We talk instead about birth spacing, but that is largely because of the politics and sensitivity of the issue at the political level.

Just to clarify my own view, as a public health professional, I do not promote abortion as a means of family planning but I recognize that it is a reality. And as health professionals, we need to prevent deaths of women and thus, in that context, need to make safe abortion accessible to those who want it to prevent risky, back-alley procedures.

Is this just a semantic issue or does it influence the work itself at all?

I don’t know any organization that only focuses on birth spacing versus birth limiting. They may talk about spacing, but when interacting with women of communities, both issues come up. To me, it’s a more semantic issue because of people’s perspective. But with women, you’re dealing with both issues.

Another sensitive issues when discussing family planning is adolescent use of contraception outside of marriage, which clearly bumps up against various religious views. What is your experience here?

I made a presentation to an Evangelical audience a few weeks ago about lifesaving interventions, namely family planning, to prevent deaths of both women and children. The audience kept raising issues that suggested that they saw family planning as encouraging sex among adolescents.

In such situations, the key is providing scientific data on giving adolescents contraception. It is well documented that young people will postpone having sex if better informed, and also will have 90 percent fewer pregnancies and abortions. The idea that if you tell kids about contraception, it increases sexual activity is simply not true; there is no evidence to support this view. However, if you don’t provide them with information, they will have sex and also have more pregnancies and then more abortions. There is a lot of data that makes this clear. Sex is often about hormones, so adolescents need to be provided with the means to have safer sex. You can’t really change sexual behavior by keeping kids misinformed. To me this is a sad commentary on our own society, where we have evidence that informing young people does not encourage them to have sex sooner, but these misconceptions are still widespread.

Can you identify thoughtful religious leaders at the forefront of this aspect of family planning with adolescents?

I say that the data is there, yet I’m not sure that I have encountered any religious leader who has gone into the scientific information to address this issue. When I’ve talked to people, I’ve had to send them a lot of publications to show them what the scientific data says and that they were wrong about their attitudes and impressions. So I don’t know about a religious leader who has taken this on.

What should be the next steps to engage faith leaders and organizations in the family planning field?

You need to have dialogue, we need to have more leaders on board, but more than that, you need common people to be involved. For example in Pakistan, (as I mentioned earlier) an important international conference of Islamic leaders came out with a declaration that was published supporting family planning. However, this did not engage any of the local religious leaders or the people directly. In Pakistan, there is no religious hierarchy in the Islamic tradition. A document like that won’t have much effect. People sometimes don’t even know these reports exist. What you need to have is ongoing discussion through the press and community leaders. So this is something to consider in other Islamic countries. Every local Muslim leader has his own view. Unless there is some way to get these local religious leaders together, and get them into a dialogue to talk about how the Qur'an can be argued as pro-family planning, the conferences won’t have too much effect.

Things worked out very differently in Iran because this dialogue was possible with the Shiite hierarchy, which released guidelines for all the mosques. But this kind of hierarchy does not exist in Pakistan, and you can see how that has affected the country. What is most important is broad-based public discussions including religious leaders and all voices about what family planning means for individual families and society at large.

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