There are many things Margaret Simon lacks in her job as a health professional. First, there's no running water at the hospital where she works in Tanzania. She could also use a proper light in the exam room, so minor procedures could be done there rather than having to squeeze into the operating theatre between surgeries.
But she also needs a more reliable supply of contraceptives. Specifically, Depo Provera, which she says her patients prefer because they can take it even if their husbands don't approve of birth control.
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"They come for vaccinations for their children. They use that opportunity to be given injections so their husbands do not know that there is family planning," said Simon, a coordinator for reproductive and child health in Tanzania's Iramba district, through a translator.
The United Nations Population Fund (UNFPA) estimates the unmet need for contraceptives at 220 million women — that is, reproductive-age women who don't have access to condoms, birth control pills or other methods of family planning. While the number of women in sub-Saharan Africa using contraception more than tripled to 34 million in 2012 from 10 million in 1990, one quarter of women in the region still can't access it.
For many of those women, that increases the risk to their health. They get pregnant at a younger age, some in child marriages, which puts them at greater risk of complications. They can't space out their pregnancies enough to fully recover in between, putting their children's health at risk. And those who turn to unsafe abortions risk dying from badly performed procedures.
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This unmet need for birth control is complicated, with a range of causes, including poor access to health professionals who can prescribe certain kinds of contraception, ordering problems and corruption in health departments, and reluctance on the part of finance departments to follow through on funding commitments made by their health counterparts.
Lack of support — even outright opposition to family planning — by husbands is an additional barrier.
But the world isn't spending enough to pay for the contraception that women want and need, and Canada is part of that problem.
When Prime Minister Stephen Harper announced Canada's commitment to maternal, newborn and child health five years ago, one of the first questions to him and then-international development minister Bev Oda was whether that would include family planning and abortion. It took Oda months to confirm that Canada would indeed allow its $2.85 billion in funding to be used for contraceptives. Abortion, however, was out of the question.
But in practice, only 1.4 per cent of Canada's funding under the Muskoka Initiative — the name attached to the five-year plan to provide more money to save the lives of women and children — has gone to birth control. That works out to about four per cent of overall international aid provided by Canada.
Both Harper and International Development Minister Christian Paradis turned down multiple requests for interviews for this story.
Rester Boniface spent the past three years coordinating a World Vision Canada project in Singida, the region of Tanzania where Margaret Simon works. It's one of the poorest regions in the country, the roadsides full of unemployed people standing idle amid the red dust and charcoal-scented air.
Boniface says money is needed to help women have fewer children.
"Family planning contributes to the reduction of maternal and under-five mortality rate," she said.
"So when we increase the funding for family planning, it means by doing child spacing, women will have time for themselves and their children, and we reduce unwanted pregnancies."
Unsafe abortions account for a full 13 per cent of the 289,000 maternal deaths every year, according to the World Health Organization.
Education, equality also stand in the way
Direct funding for contraceptives, though, is far from the only answer. Even health professionals can't agree on the biggest barrier to getting families to plan the number of children they'll have.
Some say it's lack of education, others say funding won't help as long as supply chains are weak, still others point to the difficulty many women have in convincing their husbands they should plan to limit their number of children.
"I think women need education. Lack of education and awareness results in poor understanding of what family planning and child health is," said Jane Makiya, the top nursing official in Nzega, Tabora, a neighbouring region of Tanzania.
"There are still women who have up to 10 children, which is not healthy for the kids and mother too," she said.
Ngemera Mwemezi is the director of health systems and management at Marie Stopes Tanzania, an organization Canada funded until 2011. Marie Stopes International provides contraception and post-abortion care around the world, and abortion services in countries where the practice is legal.
Mwemezi says there's a huge gap between the number of women who use family planning methods and those who want them but don't have access.
"You cannot close [the gap] if you don't have adequate funding, if you don't have proper utilization of the funding, if you don't have proper community mobilization, if you don't have proper infrastructure, if you don't have good, trained staff everywhere in the country," he said.
'Powerful contribution' to reducing poverty
A 2006 study published in the Lancet Sexual and Reproductive Health Series notes family planning would make "a powerful contribution to poverty reduction," while the UNFPA estimates the cost of pregnancy-related care is reduced by $1.47 (U.S.) for every additional dollar invested in contraception.
Giving women the ability to decide how many children they have is vital to improving economic development since parents put more money into their children when they have fewer of them.
All of which raises the question why Canada seems reluctant to provide funding for contraception, even in programs listed as reproductive health projects.
Until more of those 220 million women around the world get the contraceptives they need, it's hard to see how the world will significantly reduce the number of maternal deaths.
Boniface, the World Vision coordinator, says she's a firm believer that abortion is wrong — to her, she said, it's killing.
But on contraceptives she's equally clear.
"That is the only option we have."
- Tomorrow: The trouble with Haiti
The CBC's Laura Payton is this year's R. James Travers Fellow. The Travers Fellowship provided $25,000 in funding for her pitch to look at whether Canada's maternal, newborn and child health program was working. Read more about the project here.