About a third of Rwanda’s hospitals and health clinics are run by the Catholic Church, many of them in remote areas with no government-run alternative. And for decades, that meant their patients could not receive modern birth control. They still can’t – but today, women seeking contraceptives are directed to nearby, government-run “health posts,” set up in the shadow of most Catholic centers. It’s a deal struck over the past decade as Rwanda’s government looked to boost health care in a country where contraception advocates and opponents alike commonly cite faith as their motivation. And in Africa, more than anywhere in the world, sex and public health have collided in ways that force the church into the conversation. “The way we see it, people are responsible for their own health and their own faith,” says Prince-Bosco Kanani, the director of Rwanda Catholic Health Services. “Our spiritual mandate is to let people choose.”

The Roman Catholic health center that hugs the main road here announces its faith plainly.

ARCHDIOCESE OF KIGALI, reads the sign sprawled across the facade of the stout red brick building in this small town just outside Rwanda’s capital. Holographic portraits of Jesus and Mary stare down from the walls of every exam and consultation room, and nuns wander the corridors in full gray habits.

For decades, if you needed health care in this town, this was your option. And that included women looking for birth control – most forms of which the Catholic Church forbids.

“That is our faith. We cannot change what we believe,” says Mary Goretti Nyirabahutu, the nun in charge of the health center.

But now, around the corner, wedged into half of an old municipal office at the end of a long dirt road, a tiny government health center whispers an alternative. Its door is unmarked except for a tiny sign above the doorway reading, “Kuboneza Urubyaro.” Family Planning.

“I’m also a woman of prayer,” says Jackie Buseruka, the nurse who runs the clinic. “But your religion must not interfere with doing what is right.”

Battles over access to birth control and abortion are often cast as a fight between a secular left and a religious right. But in Rwanda, as in much of Africa, people on both sides of the aisle feel God is with them. Both advocates and opponents of modern family planning frequently cite faith as their motivation.

And that has led to strikingly different ideas for how to expand access to birth control to the women who need it most.

When Rwanda’s government was looking for ways to increase the number of women using contraception a decade ago as part of a broader push to improve health care and promote development, they knew they had to include the Catholic Church, since half of Rwandans are members. Long a powerful institution here, the church runs about a third of the country’s hospitals and clinics, according to the Catholic charity Caritas – many of them in remote areas where there is no government-run alternative.

The church, meanwhile, was resolute – it wouldn’t provide artificial birth control. That was against Rome’s doctrine.

But it didn’t make much sense to build new hospitals in those areas. So the church and the government struck a deal.

Ryan Lenora Brown/The Christian Science Monitor A sign directs patients to the secondary health post in Masaka, Rwanda. Secondary health posts have been set up by the government near most of the country's Catholic hospitals in the last decade to offer modern birth control services that they do not provide.

Women who came to Catholic facilities looking for contraceptives would be told their options – all their options – and then pointed down the road to the new mini “health posts” the government was setting up in the shadow of every Catholic hospital. Tiny, bare-bones operations, they had a single purpose: to give out birth control. Today, there are 88 of these, tethered to about 80 percent of the Catholic hospitals and clinics in the country.

“The way we see it, people are responsible for their own health and their own faith,” says Prince-Bosco Kanani, the director of Rwanda Catholic Health Services. “Our spiritual mandate is to let people choose.”

Many Rwandan women have chosen modern birth control. Since 1995, the country’s fertility rate has fallen from six children per woman to under four. Two-thirds of married women and nearly one-third of women total now use contraceptives.

Difficult conversations

Sex is, perhaps, not the first topic the church wants to discuss. But in Africa, more than anywhere in the world, sex and public health have collided in ways that forced the church into the conversation.

“When HIV came to finish us, that’s when we realized we couldn’t keep sex in the dark. We had to begin speaking about it in broad daylight,” says Ronald Kasyaba, the deputy executive secretary at Catholic Medical Bureau in neighboring Uganda. “And the conversation has progressed from there.”

In Rwanda, as in many countries, the prevalence of Catholic health centers means they have been close to the HIV epidemic for decades. (The Vatican has estimated that it provides 25 percent of the care HIV and AIDS patients receive worldwide.) That, in turn, necessitated a tough moral reckoning among many Catholic health officials about the need to talk loudly and clearly to parishioners about protection against sexually transmitted diseases – a subject the church had historically spoken about only in whispers.

Yet it has been reluctant to approve of the use of condoms to prevent HIV, let alone as contraception. But Kigali is also far from Rome, and when church teachings and practical need diverge, many will quietly choose the latter.

“I cannot be limited by my faith when it comes to family planning,” says Adrian Hakorimana, a herdsman in Masaka. “The most important thing to me as a Catholic is to have a family that is a size I can take care of.”

Ryan Lenora Brown/The Christian Science Monitor Nurse Jackie Buseruka runs the government health post situated down the road from Masaka's Catholic hospital. Unlike that institution, her health post offers modern birth control.

'It's a calling'

Inside Ms. Buseruka’s dimly lit government clinic, she spreads out a menu of options for her patients. There are packets of pills and intrauterine devices, silver condom packets, and little vials of injectable contraceptives. “I never turn anyone who comes to this place away,” she says. “If they’re worried about religion, I tell them, God helps those who help themselves.”

Buseruka’s clinic has about 7,000 patients, from shy teenage girls to the wives of local pastors, who often send her text messages asking if they can come by the clinic after hours, when no one will be around to see.

Down the road, at the Catholic health center, Ms. Nyirabahutu leads her own spirited family planning crusade – to interest couples in church-sanctioned forms of “natural family planning.” She clutches a string of beads in her hand like a rosary, explaining that couples can use it to count the days of a woman’s cycle.

But it’s a hard sell. She sees only about 1,000 patients regularly for such services, she says, and only couples. “If you don’t have a husband, what do you need family planning for?” she says, breaking into a wide-brimmed laugh. “You have nothing to plan.”

Still, she says she fully supports the government outpost down the road.

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“Of course they are serving more people than us [at the secondary health posts]. They have more to offer,” she says. But it isn’t a competition. “Health care, for us, it’s a calling. And the most important thing is that women are healthy, that having children is their own choice. They must be free to choose what is right for them.”

Nasra Bishumba contributed reporting to this story. Reporting for this story was also supported in part by a fellowship from the United Nations Foundation.