Women’s reproductive health as a gender, development and human rights issue: regaining perspective Monique V. Chireau, MD, MPH Assistant Professor, Division of Clinical and Epidemiologic Research Department of Obstetrics and Gynecology Duke University Medical Center Durham, NC, USA

What 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 abortion We 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 family Since 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

Example: 55TH SESSION OF THE COMMISSION ON THE STATUS OF WOMEN (CSW) Convened to address issues regarding the status of women and girls CSW had certain overarching themes, outlined in issues papers and other documents We will briefly examine specific text from these documents as representative of international agendas on the status of women Important to analyze these critically Noble-sounding agendas can have destructive ideology at their core.

55TH 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 girls However 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” appear Page 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”.

Critically examining the association between family planning - education and adolescent pregnancy First, it is important to clarify adolescent pregnancy vs. adolescent birth rate Adolescent 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 pregnancy While 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 counterparts While they are likely to not complete their education, they are less likely to be victimized and to live in generational poverty Data suggest that 50% of women ages 20-24 are married before age 18 in South Asia, 41% in Africa and 25% in Latin America and the Caribbean

UNMARRIED Adolescent pregnancy – gender issues Teen mothers are more likely to not have an involved father or father figure Teen 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)

World Map of Adolescent pregnancy Pale blue is lowest, black is highest. Important distinction to be made between pregnancy in unmarried vs married teens.

Medicalization 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 on These research findings are often used to inform policy However, 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

Example: England, 2000-2010 England has the highest rates of adolescent pregnancy in Western Europe Despite 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 year 50% of teenage pregnancies in Britain end in abortion

Study Findings This 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”.

Teenage pregnancy prevention programs Should emphasize interventions to: Increase abstinence Delay sexual initiation Improve decision-making skills Strengthen families

Teenage pregnancy prevention programs Prevention programs should also address risk factors for adolescent pregnancy Older male partner Dysfunctional family Fatherlessness Inappropriate male-female relationships (rape, sexual abuse, social pressure to have sex) Poor self-esteem Low formal education Early exposure to adult sexuality Poverty

Address Risk factors for adolescent pregnancy How to address the specific known risk factors for adolescent pregnancy? Strengthen families, specifically fathers Involve young men in activities to encourage responsibility Involve young women in activities to encourage chastity Address poverty and social disadvantage Encourage children to stay in school Postpone the onset of sexual activity Prevent teen pregnancy due to rape or child abuse Prevent exploitation of teen girls by older men

Women’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 conditions However, 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 families This paper emphasizes gender equality and the employment of women as key to development It also subtly portrays women’s work in the home as an obstacle to development

Women’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 services However, these associations are not necessarily true.

Maternal mortality for 181 countries, 1980-2008 A systematic analysis of progress towards Millennium Development Goal 5

Global maternal mortality measurement Widespread perception that progress on maternal mortality is lagging behind other key MDG health indicators Complicated by belief that maternal mortality is very difficult to measure Need to assess progress given international commitment to Millennium Development Goal 5 MDG 5 target: reduce the maternal mortality ratio by three-quarters from 1990 to 2015

“Maternal mortality for 181 countries” (hogan et al, Lancet 2010) A landmark study on maternal mortality which fundamentally reset thinking on maternal mortality The Hogan study used innovative statistical techniques to analyze World Health Organization data in order to arrive at a refined estimate of maternal mortality worldwide This study found that contrary to current perceptions, maternal mortality is decreasing In 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

Global 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.

Global 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.

Women’s reproductive health as a development issue Globally, maternal mortality is declining. Why? Increasing education Increasing income Decreasing fertility Fertility dropped from 3.3 children per woman in 1990 to 2.6 in 2008 Improvements in birth care Maternal mortality is not decreasing due to increased access to abortion services, and it is not necessarily higher in countries with more restrictive abortion laws

MMR per 100,000 live births, 2008 Here’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.

Annualized 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 2008. In this case, you can see that dramatic reductions in maternal mortality are occurring in countries in west, central and southern Africa.

Annualized Rate of Decline in MMR, excluding HIV, 1990 to 2008

World 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.

Women’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 mortality Abortion was not noted to be a key driver of maternal mortality in this study This fact may be difficult to accept given the often biased statistics released on abortion-related mortality Rather, known effective interventions, such as increasing access to bed nets, vaccination, vitamin A supplementation, prenatal care and trained birth attendants, should be supported In addition, there are significant demographic consequences as a result of abortion in countries seeking to move through the development continuum

Women’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 mortality Obstructed labor is an important contributor and is associated with fistula

Women’s reproductive health as a human rights issue As noted above, obstetrical fistula is prevalent in rural areas What is obstetrical fistula? A complication of childbirth and obstructed labor After prolonged labor (often lasting for days), the mother’s tissues break down creating a connection between the bladder or rectum and the vagina Fistula affects millions of women per year and is a major cause of maternal and child mortality and morbidity In 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

Women’s reproductive health as a human rights issue Fistula should be a major gender and human rights issue for women However, despite its devastating impact, it has not received broad attention at this conference Family planning (abortion and contraception access) are far more emphasized for 2 reasons There is profit in providing abortion and contraception They are supported by strong ideological agendas Women who suffer fistula have no voice

Women’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 bodies It is practiced in Central Asia, Southeast Asia, the Middle East and Africa Because 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 such Again, 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

Women’s reproductive health as a human rights issue – map of fGM in africa

Women’s reproductive health as a human rights issue – worldwide map of fistula

Global Fertility Rates

What are the long-term consequences of population programs? Decreasing rates of fertility result in long-term decrements in population Birth rates fall below replacement rates This phenomenon is well established in Europe and has economic implications Shrinking populations cannot meet demands for labor and production of capital essential to increasing GDP Systems of social welfare that employ entitlements cannot be sustained under these circumstances without large increases in taxes Eventually, foreign labor becomes essential to maintaining the economy, and economies shrink

What are the long-term consequences of population programs? Example: Rwanda Ministry 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 army This 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 genocide Who will be sterilized, Tutsi or Hutu?

What are the long-term consequences of population programs? Example: China In 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 world There are signals that the one-child policy may be abandoned in 2015 In addition, due to selective abortion of female fetuses, the sex ratio in China is 121-160:100 (the natural ratio has been 104-106/100 worldwide with very little variation for generations) Annually, 32-35 million “excess” boys are born in China Over 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

Other countries where selective abortion of female fetuses has skewed the sex ratio India: 112/100; Azerbaijan: 118/100; Georgia: 120/100 In 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 births Among diaspora populations in the US, similar skewed sex ratios are seen While the full implications of these changes are still unknown, potential consequences could include: Fewer men able to find spouses, with increased sex trafficking/bought brides Fewer family members to support aging parents Labor shortages with economic implications Cultural changes “Demographic winter” A review in the Wall Street Journal of Mara Hvistendahl’s book on this subject: http://online.wsj.com/article/SB10001424052702303657404576361691165631366.html

What 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 21/100 Russian members of Parliament are working with the Orthodox church to reduce abortion Free abortion will be banned at government clinics A week-long waiting period will be required Parental and spousal consent will be required Emergency contraception will be prescription-only Safe havens will be created where women can leave babies less than 6 months old

regaining perspective: summary There is a need to regain perspective on and redefine women’s reproductive health, since perspectives have been skewed by ideology Focus 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 ideology We must consider the long-term implications of international reproductive health policy, both for ourselves and for other countries We must insist on transparency and accountability from NGOs, US government agencies and international partners and governments Ultimately, 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