Presentation on theme: "Monique V. Chireau, MD, MPH"— Presentation transcript:
1Women’s reproductive health as a gender, development and human rights issue: regaining perspective Monique V. Chireau, MD, MPHAssistant Professor, Division of Clinical and Epidemiologic ResearchDepartment of Obstetrics and GynecologyDuke University Medical CenterDurham, NC, USA
2What are “reproductive health and rights”? This language has been appropriated as code for health care and education with mandatory inclusion of abortion (often under the guise of “family planning”)As a side note, in discussions of reproductive health it is important to ask specifically if this includes abortionWe can choose to revise this terminology, however, to say that :Reproductive health is a state of freedom from destructive interventions that compromise a woman’s health, well-being and dignity (such as abortion)Reproductive health does include the provision of services and knowledge that promote women’s health, dignity and well being as well as that of her familySince the rights of women are inextricably connected to the rights of their children, the ultimate reproductive right of women is the right to refuse destructive interventions, practices and influences; to be able to protect her children; and to strive for optimal health and well being for herself and her family
3Example: 55TH SESSION OF THE COMMISSION ON THE STATUS OF WOMEN (CSW) Convened to address issues regarding the status of women and girlsCSW had certain overarching themes, outlined in issues papers and other documentsWe will briefly examine specific text from these documents as representative of international agendas on the status of womenImportant to analyze these criticallyNoble-sounding agendas can have destructive ideology at their core.
455TH SESSION OF THE COMMISSION ON THE STATUS OF WOMEN (CSW) Issues paper: “Elimination of discrimination and violence against the girl child”This paper discusses the rights of girlsHowever it is noteworthy that (a) rights of parents are not addressed despite the fact that parents have moral and legal responsibilities to protect and care for their children and (b) nowhere in the document does the word “family” appearPage 3 – “Girls continue to have insufficient access to health services and information, including sexual and reproductive health. There has been some progress in reducing the number of teenage pregnancies, as a result of family planning programmes and education campaigns on the use of contraceptives, but the adolescent birth rate remains high in some regions”.
5Critically examining the association between family planning - education and adolescent pregnancy First, it is important to clarify adolescent pregnancy vs. adolescent birth rateAdolescent pregnancy includes those pregnancies that progress to term and those that do not (i.e. that end in abortion or miscarriage)Second, married adolescent pregnancy differs from unmarried adolescent pregnancyWhile early marriage is a complex and controversial political, social and even religious issue, beyond the scope of this presentation, married adolescents do have very different health and socioeconomic outcomes than their unmarried counterpartsWhile they are likely to not complete their education, they are less likely to be victimized and to live in generational povertyData suggest that 50% of women ages are married before age 18 in South Asia, 41% in Africa and 25% in Latin America and the Caribbean
6UNMARRIED Adolescent pregnancy – gender issues Teen mothers are more likely to not have an involved father or father figureTeen pregnancies may be more likely to be due to rape or child abuse (Harner, 2006)A higher percentages of teen pregnancies are by fathers 3-5 years older than the mother (Darroch et al, Family Planning Perspectives, 1999)
7World Map of Adolescent pregnancy Pale blue is lowest, black is highest. Important distinction to be made between pregnancy in unmarried vs married teens.
8Medicalization of the problem of adolescent pregnancy A focus on medical and public health solutions to teen pregnancy has enabled the development of a large and profitable sector involved in the provision of reproductive health (contraception, abortion, evaluation and planning) services as well as research attempting to support teen reproductive health interventions focusing onThese research findings are often used to inform policyHowever, there is much evidence that countries which have expanded sex education and increased access to contraception and abortion have not seen reductions in rates of adolescent pregnancy
9Example: England,England has the highest rates of adolescent pregnancy in Western EuropeDespite 10 years of intensive efforts using typical prevention strategies including expanding sex education, increasing availability of contraception, and increasing access to abortion (without parental consent) the teen birth rate has continued to rise at 4% per year50% of teenage pregnancies in Britain end in abortion
11Study FindingsThis systematic review of 22 studies found that “…primary prevention strategies do not delay the initiation of sexual intercourse, improve use of birth control among young men and women, or reduce pregnancy rates among young women”.“Four abstinence programs and one school based sex education programme were associated with an increase in number of pregnancies…”“This review shows that we do not yet have a clear solution to the problem of high pregnancy rates in countries such as the United States, the United Kingdom and Canada”.
12Teenage pregnancy prevention programs Should emphasize interventions to:Increase abstinenceDelay sexual initiationImprove decision-making skillsStrengthen families
13Teenage pregnancy prevention programs Prevention programs should also address risk factors for adolescent pregnancyOlder male partnerDysfunctional familyFatherlessnessInappropriate male-female relationships (rape, sexual abuse, social pressure to have sex)Poor self-esteemLow formal educationEarly exposure to adult sexualityPoverty
14Address Risk factors for adolescent pregnancy How to address the specific known risk factors for adolescent pregnancy?Strengthen families, specifically fathersInvolve young men in activities to encourage responsibilityInvolve young women in activities to encourage chastityAddress poverty and social disadvantageEncourage children to stay in schoolPostpone the onset of sexual activityPrevent teen pregnancy due to rape or child abusePrevent exploitation of teen girls by older men
15Women’s reproductive health as a development issue Issues papers: “Gender equality and sustainable development” and “The empowerment of rural women and their role in poverty and hunger eradication, development and current challenges”We might note that economic development can be positive and can result in better living conditionsHowever, this is not always true, since no development can be sustainable where it contributes to the breakdown of the family“Societies are built one family at a time, and they are destroyed the same way”We must be extraordinarily careful about validating any development scheme that does not have at is heart stronger familiesThis paper emphasizes gender equality and the employment of women as key to developmentIt also subtly portrays women’s work in the home as an obstacle to development
16Women’s reproductive health as a development issue “While efforts have been made to broaden the range of health services and quality of care, women living in rural areas still face significant barriers to health care and reproductive health. Fertility rates in rural areas are generally higher than those of urban areas due to rural women’s lower access to education, family planning and healthcare services. Rural areas also have some of the highest rates of maternal mortality and obstetrical fistula”.This statement suggests a relationship between high fertility rates and maternal mortality, and implies that the solution to maternal mortality lies in expanding access to family planning servicesHowever, these associations are not necessarily true.
17Maternal mortality for 181 countries, 1980-2008 A systematic analysis of progress towards Millennium Development Goal 5
18Global maternal mortality measurement Widespread perception that progress on maternal mortality is lagging behind other key MDG health indicatorsComplicated by belief that maternal mortality is very difficult to measureNeed to assess progress given international commitment to Millennium Development Goal 5MDG 5 target: reduce the maternal mortality ratio by three-quarters from 1990 to 2015
19“Maternal mortality for 181 countries” (hogan et al, Lancet 2010) A landmark study on maternal mortality which fundamentally reset thinking on maternal mortalityThe Hogan study used innovative statistical techniques to analyze World Health Organization data in order to arrive at a refined estimate of maternal mortality worldwideThis study found that contrary to current perceptions, maternal mortality is decreasingIn many cases this decrease is occurring most rapidly in countries with high fertility and limited utilization to family planning as well as restrictive abortion laws
20Global births by region This slide shows global births by region from 1990 to 2008 [point out colors]. You can see that the trend is slowly but steadily downwards, with perhaps some leveling toward the end of the decade.
21Global maternal deaths by region This is maternal mortality over the same time period. Note that there are steep declines across all regions, especially in the regions with highest percentages of births.
22Women’s reproductive health as a development issue Globally, maternal mortality is declining. Why?Increasing educationIncreasing incomeDecreasing fertilityFertility dropped from 3.3 children per woman in 1990 to 2.6 in 2008Improvements in birth careMaternal mortality is not decreasing due to increased access to abortion services, and it is not necessarily higher in countries with more restrictive abortion laws
23MMR per 100,000 live births, 2008Here’s another snapshot of maternal mortality, not from the Hogan study. This slide shows maternal mortality per 100,00 live births. Navy blue is lowest rate, red-orange is highest and so on.
24Annualized Rate of Decline in MMR, 1990 to 2008 Here’s another way to look at this data. This slide shows the annual decline in maternal mortality from 1990 to In this case, you can see that dramatic reductions in maternal mortality are occurring in countries in west, central and southern Africa.
25Annualized Rate of Decline in MMR, excluding HIV, 1990 to 2008
26World Map of Abortion Laws Legend: light blue is legal on request up to 12 weeks; green is illegal with exceptions for, maternal life, health, mental health, rape, fetal defects, socioeconomic reasons; brown is same, with no socioeconomic exception; orange is same, with no exception for birth defects; red is same, with no exception for rape; medium blue is illegal, no exception. You will notice that for the most part, some of the most dramatic declines in maternal mortality have occurred in nations with restrictive abortion laws, and often, those countries where contraception is not usually available or utilized.
27Women’s reproductive health as a development issue – CONCLUSIONS FROM THE HOGAN STUDY A strong connection cannot be made between abortion and contraception access and maternal mortality, or even between increased fertility and maternal mortalityAbortion was not noted to be a key driver of maternal mortality in this studyThis fact may be difficult to accept given the often biased statistics released on abortion-related mortalityRather, known effective interventions, such as increasing access to bed nets, vaccination, vitamin A supplementation, prenatal care and trained birth attendants, should be supportedIn addition, there are significant demographic consequences as a result of abortion in countries seeking to move through the development continuum
28Women’s reproductive health as a human rights and development issue Despite these data, the issues paper on “Eliminating preventable maternal mortality and morbidity and the empowerment of women” states that “the major direct causes of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor.”HIV is not mentioned, although it is an extremely important contributor to maternal mortalityObstructed labor is an important contributor and is associated with fistula
29Women’s reproductive health as a human rights issue As noted above, obstetrical fistula is prevalent in rural areasWhat is obstetrical fistula?A complication of childbirth and obstructed laborAfter prolonged labor (often lasting for days), the mother’s tissues break down creating a connection between the bladder or rectum and the vaginaFistula affects millions of women per year and is a major cause of maternal and child mortality and morbidityIn addition to prolonged illness and death from complications, it results in women being unable to care for themselves or their families and often being driven out of their communities
30Women’s reproductive health as a human rights issue Fistula should be a major gender and human rights issue for womenHowever, despite its devastating impact, it has not received broad attention at this conferenceFamily planning (abortion and contraception access) are far more emphasized for 2 reasonsThere is profit in providing abortion and contraceptionThey are supported by strong ideological agendasWomen who suffer fistula have no voice
31Women’s reproductive health as a human rights issue Fistula is also more common in people groups who practice female genital mutilation (FGM)FGM consists of cutting, suturing or otherwise surgically removing or altering the genital parts of women’s bodiesIt is practiced in Central Asia, Southeast Asia, the Middle East and AfricaBecause women who have undergone FGM have difficulty with childbirth, it contributes significantly to obstructed labor, hemorrhage following birth, fistula and maternal and neonatal mortality.The association between FGM and fistula again is not emphasized, is a human rights issue of major proportion, and should be prioritized as suchAgain, however, because there is no profitable product or service nor ideological agenda, these entities are not addressed as gender issues; rather, the issue of fistula has been medicalized
32Women’s reproductive health as a human rights issue – map of fGM in africa
33Women’s reproductive health as a human rights issue – worldwide map of fistula
35What are the long-term consequences of population programs? Decreasing rates of fertility result in long-term decrements in populationBirth rates fall below replacement ratesThis phenomenon is well established in Europe and has economic implicationsShrinking populations cannot meet demands for labor and production of capital essential to increasing GDPSystems of social welfare that employ entitlements cannot be sustained under these circumstances without large increases in taxesEventually, foreign labor becomes essential to maintaining the economy, and economies shrink
36What are the long-term consequences of population programs? Example: RwandaMinistry of Health-sponsored program, to circumcise and sterilize 700,00 young men over the next 5 years to control spread of HIV and reduce population growth; the program targets young men in the armyThis program is supported by USAID through US NGOs IntraHealth (http://www.intrahealth.org/page/assessment-of-vasectomy-client-satisfaction- conducted-in-rwanda) and Family Health International (http://www.fhi.org/en/Research/Projects/Progress/Countries/Rwanda.htm)Since the male population in Rwanda totals 5 million, considering the age distribution of the population, this amounts to sterilization of slightly less than ½ of the males of reproductive age, with the potential for drastic population decline in a nation recovering from genocideWho will be sterilized, Tutsi or Hutu?
37What are the long-term consequences of population programs? Example: ChinaIn China, it is estimated that more than 400 million abortions have been performed over the last 20 years (mostly females)As a result, the Chinese population is aging faster than that of any other nation in the worldThere are signals that the one-child policy may be abandoned in 2015In addition, due to selective abortion of female fetuses, the sex ratio in China is :100 (the natural ratio has been /100 worldwide with very little variation for generations)Annually, million “excess” boys are born in ChinaOver a 10 year period, this will mean approximately 300 million more men than women, in addition to the estimated 111 million Chinese men who currently cannot find wives
38Other countries where selective abortion of female fetuses has skewed the sex ratio India: 112/100; Azerbaijan: 118/100; Georgia: 120/100In South Korea, a study of sex ratios suggests severe skewing of sex ratios in couples with a firstborn girl: 113/100 for second births, 185/100 for third births, 209/100 for fourth birthsAmong diaspora populations in the US, similar skewed sex ratios are seenWhile the full implications of these changes are still unknown, potential consequences could include:Fewer men able to find spouses, with increased sex trafficking/bought bridesFewer family members to support aging parentsLabor shortages with economic implicationsCultural changes“Demographic winter”A review in the Wall Street Journal of Mara Hvistendahl’s book on this subject:
39What are the long-term consequences of population programs? Example: Russia’s impending “demographic winter”Russia’s abortion rate is 53.7/100 women, while the birth rate is 21/100Russian members of Parliament are working with the Orthodox church to reduce abortionFree abortion will be banned at government clinicsA week-long waiting period will be requiredParental and spousal consent will be requiredEmergency contraception will be prescription-onlySafe havens will be created where women can leave babies less than 6 months old
40regaining perspective: summary There is a need to regain perspective on and redefine women’s reproductive health, since perspectives have been skewed by ideologyFocus should move toward improving the status of women and increasing access to health care, not “reproductive health” as it is currently defined with a narrow focus on “family planning” (abortion and contraception).Policy and discourse should be informed by accurate data, not driven by ideologyWe must consider the long-term implications of international reproductive health policy, both for ourselves and for other countriesWe must insist on transparency and accountability from NGOs, US government agencies and international partners and governmentsUltimately, our perspectives on women’s reproductive health, need to be not only informed by data, but illuminated by moral values and an ethical framework that is consistent with the value and dignity of women and the family