Health and Poverty
Reproductive health issues are fundamentally
different from almost all other health concerns. Sex and reproduction
are at the core of life, a source of joy, affection and spiritual
RIGHTS DENIED Worry about
their reproductive health is also, particularly for
women, another of the insecurities that mark the experience
of poverty. In the absence of family planning-to which
poor women have less access than the better off-the
risk of unwanted pregnancy can make any sexual encounter
a source of worry; (11)
the possibility of a sexually transmitted infection,
particularly HIV, adds to the insecurity. Pregnancy
can be a hazardous and worrisome time; childbirth can
lead to illness, debilitating injury or death.
Lower fertility, including fewer
unwanted births, leads to better health outcomes for
women and children. Unwanted children are more prone
to respiratory and diarrhoeal infections than wanted
children. Wanted or not, each additional sibling reduces
the chance of a child receiving treatment by 2 to 8
per cent. Where vaccination levels are low, wanted children
receive 50 to 100 per cent more vaccinations than unwanted
ones do (12).
SOCIAL CONSTRAINTS People
in many cultures find it hard to discuss sex and reproduction.
In these circumstances exercising choices-planning for
contraceptive use, for example-can be experienced as
shameful and humiliating. Discussing genderbased violence,
particularly sexual violence, is especially hard for
poor women (13).
There is another crucial difference regarding reproductive
health. Only women bear children. They are exposed to risks that
men cannot fully appreciate. Women are also more exposed to
shared risks, such as sexually transmitted diseases, for reasons both
of biology and of social disadvantage.
Social constraints affect women's
reproductive health care. Men are more likely to use
formal health services, partly because they control
the money needed to pay for them. Women are more likely
to rely on traditional or other alternative services,
because they are cheaper, closer at hand and more familiar
(14). A woman may
be unwilling to travel alone, or not allowed to go to
health services without the approval of her husband
or another man in the family or community.
Women's experience of health care also affects the way they
use it: they are not guaranteed sensitive treatment at the clinic or
hospital. Health workers tend to look down on poor women.
Illiterate women in particular may feel unable to describe their
condition or understand the advice they are given.
The reproductive health needs of the poor, and poor women
in particular, do not command the attention of policy makers, or
even of women themselves. The poor give priority to their many
immediate and pressing needs. Pregnancy and childbirth are taken
for granted-and so are the attendant risks, though they come
from easily preventable causes.
REPRODUCTIVE HEALTH FOR BANGLADESH'S URBAN POOR
Bangladesh's urban population is growing by 6
per cent a year, three times the national growth rate. Growth is
fastest in the slums, where there are some 225,000 persons
per square kilometre. Half of slum inhabitants are poor; 30 per
cent are classifiable as hard-core poor.
Rapid urbanization has produced degrading environmental
and health conditions. Diarrhoea is almost twice as prevalent in
the crowded slums of Dhaka and Chittagong as in rural areas.
Malnutrition, tuberculosis, vaccine-preventable diseases and
sexually transmitted infections are also more prevalent; immunization
rates are lower.
Women in the slums have limited access to reproductive
health information and care because health centres are not
conveniently located. As a result:
- 93 per cent of married teenagers have
- 22 per cent of girls give birth before age 15;
- 63 per cent of women have never used a
modern method of family planning;
- 40 per cent became pregnant unwillingly due
to lack of knowledge of services.
Under the Urban Primary Health Care Project, supported by
UNFPA, the Asian Development Bank and the Norwegian
Agency for Development Cooperation, 14 experienced NGOs
are strengthening reproductive health services and training
staff and managers.
Nine city-run maternity centres in Dhaka and 16 NGO-run
clinics have been upgraded to comprehensive reproductive
health centres. These handle referrals from 190 primary health
care centres, and will eventually provide: pre- and post-natal
care and normal delivery services; emergency obstetric care;
clinical and non-clinical contraceptives; and treatment for
reproductive tract and sexually transmitted infections.
So far, about 200 doctors, paramedics, counsellors and laboratory
technicians have been trained in care and counselling.
Ten centres now provide caesarean section delivery.
Within urban communities, the project provides information
on safe motherhood, breastfeeding, family planning,
sexually transmitted infections and HIV/AIDS.See Sources