EGH Interview: Ellen Starbird on her 30-year career fighting for women and girls

One of Ellen Starbird's greatest hopes is that family planning won't be controversial anymore. In the future, she has said, she hopes everyone comes to understand that "you don’t make progress without ... making it possible for women to exercise their rights to choose the number, timing, and spacing of their children."

Starbird retired at the end of December as Director of USAID’s Office of Population and Reproductive Health, where she led the agency’s family planning and reproductive health agenda and portfolio, valued at approximately US$600 million per year, and directed the office’s US$100 million program. She leaves behind a legacy of advocating for the rights of women and girls around the world.

We spoke with Starbird about her successes, failures, and lessons learned over a 30-year career.

Reflecting on your career, what were some of your biggest successes and how did they come about?

Starbird: Any successes are not mine alone – they're things that have been achieved by teams and groups of people working together. I think the family planning movement itself is a huge success. The speed with which women were able to take up contraception in the developing world was so much faster than in the developed world. Once you know you can make decisions about your own reproductive health and fertility and have the agency and ability to act on those decisions, it opens all kinds of doors and you realize what else you can do in life.

One of the things I'm really proud of about my career at USAID and in USAID's family planning program is how comprehensive it is. The solution is not just a product solution. There's a lot that goes into it in terms of understanding individuals and figuring out why this is important to them. The social, cultural, political issues that go along with the topic. I think, in the grand scheme of things, we've been pretty effective at dealing with those in the countries where USAID works. I think that's a big success for women and girls in the world as well.

At an event several years ago you said you wanted to help normalize the sharing of failures to help strengthen family planning and reproductive health programs. What were some of your failures and what insights did you gain from them?

Starbird: I think my failures have come in instances where I've not done enough outreach to understand the problem in full. One was around a working group – a piece of it was splitting off from the rest and there was a strong desire among some to keep the group together. I don't feel like I did the outreach to understand the full range of perspectives that might have helped me make a better decision about what to do.

There was another in the mid-2010s, when I was the new office director, and there was a lot of support for taking a very strong private-sector focus. I was quite concerned that we not leave out public sector participation. We took more of a total market approach, which I think worked, but I think we probably could have made faster progress on the private sector side if I had been a little bit more open to a stronger emphasis on the private sector. Again, I think this came about from not fully understanding the issue and maybe making a decision too quickly. Certainly one of the things I’ve learned is the importance of engaging with stakeholders and the beneficiaries in making decisions and how much better decisions are from the very beginning if you do that.

In your view, what are some of the biggest current challenges in family planning – and how should they be addressed?

Starbird: One of the challenges for family planning is that it's been around for a long time. The agency's family planning program began in the 1970s. We have a program that's 50 years old and it can be challenging to help people understand why we're not done. 'You've been at this for 50 years, why haven't you solved this problem?' I think that's a challenge, particularly in the face of pandemics and donor fatigue and other priorities that encourage money to move into other directions, to continue to try and ensure that these rights for women and girls – and really for everybody – to make these choices about their own reproductive lives are not set aside as unrelated.

I think one of the challenges that raises is how do you connect making progress in family planning with improvements in those other areas. How can we have a conversation about climate change and family planning that doesn't devolve into accusations of population control? I think those are two really important areas that the field has to struggle with going forward. They're not necessarily new, but the environment around them is different than it has been in the past. I think we need to have different ways of making those connections and building a broader group of allies to keep family planning very much on the radar.

You’ve said that voluntary family planning is transformational for women, families, communities, and countries. How so for each of these?

Starbird: For families, some of it comes down to being able to, first of all, have the family size that you want, to start having your kids at the right time for you and your partner, have healthy spacing, and to stop when you've had the number that you want. That puts families in a position to make larger investments in the quality of life for each child–their health, their education. To also make investments in the health of the mom and the child. We know that with children who are born too close together, the younger child is more likely to be low birth weight and more likely to be stunted. The older child, if the two are born close together, probably gets less breastfeeding, for example.

At the community level, and again this goes back to the gender connection, when there's a larger value placed on girls' lives as well as boys' lives, we see norms change. Those norm changes are part of what confers some of that additional value for girls, I think, and we really see communities then benefiting from more equitable gender norms. Perhaps women aren't always the ones who are expected to gather the firewood, or the women may have more resources of their own, the ability to work outside the home, and outside the informal economy and bring in resources. We know that women tend to spend those resources on their children, and the community benefits from that.

At the national level, this is where some of the more distal relationships between family planning, and population size, population growth, the economy, and the environment come in. One of the things that family planning enables is slower population growth.

Of course, your family planning program must be grounded in principles of voluntarism and informed choice. Those should be non-negotiable. But those voluntary family planning programs ultimately mean that the population growth rate is slower, and that gives countries time to make investments in schools, roads, hospitals, infrastructure, and again, enables quality investments rather than just trying to keep up with continuous population growth. Countries that have a higher median age are also more likely to have stability and sustainability in those areas.

A lot of the countries where USAID's programming currently is in the family planning space have quite low median age and large youth populations. With those youth populations, there's a huge opportunity. If education can be provided, if work can be provided, there are huge opportunities for really rapid economic growth. The family planning, fertility, reproductive health side of the picture has to be part of the planned policy for that. There's this virtuous circle of benefits at all of those levels.

You’ve also said that investing in family planning is a development ‘best buy' that can hasten progress across the 5 SDG themes of people, planet, prosperity, peace, and partnership. Could you elaborate on these?

Starbird: On the prosperity piece, again, families are more likely to be able to weather shocks with a smaller family size. There's some prosperity that comes from that. These things are intertwined. Certainly, if overall economic growth improves, then the opportunities for girls are going to improve. With education, women, and girls are more likely to use contraception, etc. Family planning programs can also democratize some of this progress in a situation where perhaps you don't have the resources or the education. A publicly provided family planning program can make those available to you and those opportunities can come.

On the planetary side, it's important to think about population resource balance, and certainly populations that depend heavily on natural resources for their livelihoods, whether that's because they're fishermen, or they get what they need from forests, I think recognize how important the continuation of the availability of those resources is, or the sustainability is, to their survival.

On the partnership piece, I think we're all in this together. Obviously, the total fertility rates in higher-income countries are low. In some countries, they're below replacement. They're coming down in low and middle-income countries. This is a planet that we all occupy together, and the solutions to our collective human problems come from partnerships. USAID is, and has been for a long time, the largest donor in the family planning space, but we certainly don't do this alone. It's with partnerships where we've really seen progress come about.

If you were starting your career in family planning and reproductive health now, what advice would you give your younger self?

Starbird: I came into family planning sideways. My degrees are in political science and development economics. I took a class in graduate school where we spent a lot of time on population pyramids and I got excited about population and demography. I went to the RAND Corporation and that's really where I began to get into family planning. I think I had known for a long time that I wanted to work at USAID. I think one of the things I would probably say to myself is there are lots of different paths to get to somewhere. If the first one doesn't pan out, the second, or the third one will.

One of the things that's been spectacular about being in the Office of Population, and Reproductive Health is the range of degrees, and experience that people come with. Lots of people have MPHs. I don't. We have anthropologists, we have biologists, we have supply chain people. I think there are lots of different ways into this field, and lots of opportunities to either learn on the job or decide that you want to go back and get some education in a space that you hadn't thought of originally.