A Measure of Equity
-Maternal Death and Disability
-The Feminization of HIV/AIDS
-Reaping the Rewards of Family Planning
"The differences in reproductive health between the rich and the poor-both between and within countries-are larger than in any other area of health care." - UN Millennium Project
Reproductive health problems are the leading cause of women's ill health and death worldwide. When both women and men are taken into account, reproductive health conditions are the second-highest cause of ill health globally, after communicable diseases (see Figure 1). These figures mask huge disparities, both among and within countries. Because reproductive health status depends so heavily on income and gender, addressing this issue becomes a matter of social justice, ethics and equity.
Figure 1: The Global Burden of Sexual and Reproductive Health Conditions
Source: WHO, 2002, cited in Alan Guttmacher Institute/UNFPA, 2003, Adding it Up: The Benefits of Investing in Sexual and Reproductive Healthcare.
Reproductive health and rights are important ends in themselves. They form a foundation for satisfying relationships, harmonious family life and the dream of a better future. Reproductive health and rights are also keystones for meeting the Millennium Development Goals (MDGs): They offer women and young people greater control over their own destinies and afford them opportunities to overcome poverty. Yet poverty and gender discrimination prevent millions of people around the world from exercising their reproductive rights and safeguarding their reproductive health. The costs are highest for impoverished women and adolescent girls. Multiplied across families, communities and countries, these costs are exorbitant.
Universal access to reproductive health care is achievable, could prevent most reproductive health problems and could also spur progress across various areas of social and economic development, as discussed earlier in this report. Some countries, even those with high poverty levels, have demonstrated what political leadership combined with technical knowledge and resources can accomplish. Countries successful in reducing maternal mortality now include Bangladesh, Bolivia, China, Cuba, Egypt, Honduras, Indonesia, Jamaica, Malaysia, Sri Lanka, Thailand and Tunisia, among others.(1) Bangladesh, a least-developed country, has also made exceptional progress in expanding access to family planning.(2) Political leadership combined with broad social mobilization have characterized the few examples of success in reducing the spread of HIV-principally Brazil, Cambodia, Senegal, Thailand and Uganda.
Reproductive health questions and concerns cut across many aspects of social and economic life and are beyond the capacity of the health sector alone to resolve. But many problems and their costly consequences could be averted if reproductive health were routinely addressed within the context of primary health care as a first line of prevention and care. This will require strengthening health systems, building trust among the communities they serve and expanding access to reproductive health programmes that respond to social, cultural, economic and gender factors.
COSTLY CONSEQUENCES FOR POVERTY REDUCTION. A successful fight against poverty requires a healthy population free of reproductive problems. Though almost entirely preventable, reproductive health problems remain widespread in much of the developing world. They ruin lives, burden families, tax health systems and weaken countries. The costs range from the sorrow of a motherless child to the diminished energy and productivity of millions of women. They include maternal deaths, unintended pregnancies, high fertility, abandoned children, unsafe abortions and AIDS, as well as sexually transmitted infections and the cancers, infertility and newborn illnesses associated with them.
At the 1994 International Conference on Population and Development (ICPD), 179 governments pledged to make reproductive health care universally available "as soon as possible and no later than 2015".(3) From that conference emerged the global consensus that reproductive rights are central to human rights, sustainable development, gender equality and women's empowerment. Though the goal of universal reproductive health care was not explicitly included as one of the MDGs, there is widespread international agreement that the MDGs can be met only with a redoubling of efforts and resources for reproductive health and rights. Indeed, the UN Millennium Project concludes that reproductive health is "critical to overall success in economic growth and poverty reduction" and remains one of the "key elements of adequate human capital" essential to achieving the MDGs.(4)
Poverty reduction, gender equality and reproductive health go hand in hand. They are interrelated and mutually reinforcing, and all have positive effects that can last for generations. Social and cultural assumptions about appropriate female and male roles strongly affect decisions regarding reproduction and sexual behaviour, which in turn influence prospects for social and economic development. When restrictive norms and stereotypes are transmitted to children, the cycles of gender discrimination, poor health and poverty are perpetuated. The effects show themselves in direct and indirect ways, most dramatically in the incidence of maternal deaths and injuries, and HIV infections.
12 | LIKE MOTHER, LIKE CHILD
Good reproductive health care and the exercise of women's reproductive rights can help ensure that every infant is wanted, loved and has a chance to thrive. Conversely, a mother's poor reproductive health can undermine the health and well-being of her children.
Maternal and infant mortality are closely linked. When a mother dies giving birth, her infant often dies as well. Motherless newborns are three to ten times more likely to die than those with mothers who survive. Surviving children also suffer: Mothers are usually the primary guardians of the health, education and nutrition of their children, and in many cases, also a contributing or main breadwinner. Every year up to two million children lose their mothers for lack of services that are readily available in wealthier nations.
Birth spacing significantly reduces infant mortality. A twoto three-year interval between births reduces the chances of premature birth and low infant birth weight. Birth spacing is credited with reducing child mortality by close to 20 per cent in India, and 10 per cent in Nigeria. Unwanted children in general are more vulnerable than others to illness and premature death.
Routine screening of pregnant mothers for sexually transmitted infections can boost child survival as well, because these infections can cause miscarriages, stillbirth, premature birth, low infant birth weight, blindness, and pneumonia. Syphilis leads to illness or death in 40 per cent of infants afflicted. Voluntary testing for sexually transmitted infections and HIV can lead future mothers to treatments that can protect them and their children. See Sources
"Better health and education, and
freedom to plan their family's
future, will widen women's
economic choices; but it will also
liberate their minds and spirits."
- Nafis Sadik, Secretary-General of the ICPD
Maternal Death and Disability
Maternal death and injury rates throw into sharp relief the impact of poverty and gender inequity on reproductive health. Every minute one woman dies needlessly of pregnancy-related causes. This adds up to more than a half million mothers lost each year-a figure that has hardly improved over the past few decades.(5) Another eight million or more suffer life-long health consequences from the complications of pregnancy.(6) Every woman, rich or poor, faces a 15 per cent risk of complications around the time of delivery, but maternal death is practically nonexistent in developed regions.(7) The lack of progress in reducing maternal mortality in many countries highlights the low value placed on the lives of women and testifies to their limited voice in setting public priorities. The lives of many women in developing countries could be saved with reproductive health interventions that people in rich countries take for granted.
POVERTY, DISCRIMINATION AND MOTHERS' SURVIVAL. Poverty increases the risks inherent in childbearing, and maternal mortality and morbidity deepen poverty. In sub-Saharan Africa, where high fertility multiplies the dangers mothers face over a lifetime, 1 in 16 women is likely to die as a consequence of pregnancy; in some of the poorest parts, as many as 1 in 6 face this risk. By comparison, in industrialized countries the lifetime risk is only 1 in 2,800.(8) Ninety-nine per cent of maternal deaths occur in developing countries, almost all-95 per cent-in Africa and Asia.(9) Wealth matters: Two thirds of maternal deaths in 2000 occurred in 13 of the world's poorest countries, and one quarter of these were in India alone.(10) Within countries, the wealthiest women have much better access to skilled obstetric care than the poor (see Figure 2).
Figure 2: Births Attended by Skilled Personnel* Among the Poorest and Richest Women
Source: World Bank, 2004, Round II Country Reports on Health, Nutrition, and Population Conditions Among the Poor and the Better-Off in 56 Countries.
Poverty and gender discrimination exacerbate reproductive health problems throughout the life cycle. The foundation for good reproductive health begins early in life. For instance, stunted growth in underfed girls increases the risks of obstructed labour later in life. Malnourished mothers and their babies are vulnerable to premature death and chronic disability. Anaemia, which can lead to post-partum haemorrhage, afflicts 50 to 70 per cent of pregnant women in developing countries.(11)
Gender discrimination related to education, health care and lack of control over economic resources and reproductive decisions further increase pregnancyrelated risks. High levels of maternal mortality are associated with gender inequality.(12) Although using contraceptives can prevent 20 to 35 per cent of maternal deaths,(13) limited family planning supplies and services, as well as social norms, often bar women from using them. Inadequate education often leaves women with little or no understanding of childbearing risks and other health matters, including how to navigate the health system or negotiate timely lifesaving care within the family. Informing women about their right to free care (where it exists) can be critical. High service costs can push families into poverty and deepen impoverishment. Fees may thus deter families from seeking services, especially when the quality of care provided is considered no better than that of trusted traditional birth attendants.
PAYING THE PRICE: UNINTENDED PREGNANCY AND UNSAFE ABORTION. Unsafe abortions are a leading cause of maternal mortality and can result in permanent injuries. Lack of access to family planning results in some 76 million unintended pregnancies every year in the developing world alone.(14) Each year, 19 million abortions are carried out under unsanitary or medically unsound conditions. These result in some 68,000 deaths.(15) Many women who seek abortions are married. They are usually poor and struggling to provide for children they already have.(16) Research suggests that 1 in 10 pregnancies will end in an unsafe abortion, with Asia, Africa and Latin America accounting for the highest numbers.(17)
Unsafe abortion is one of the main reasons women and girls seek emergency care: In sub-Saharan Africa, post-abortion care takes up one fifth to half of all gynaecological beds.(18) Fearing exposure and judgmental attitudes from providers, many women delay seeking life-saving treatment until it is too late. The many costs of unsafe abortions far outweigh the price of the contraceptives that could prevent such suffering.
Recognizing the impact of unsafe abortion as "a major public health concern", the ICPD Programme of Action urges governments to spare no effort in preventing unwanted pregnancies and reducing "the recourse to abortion through expanded and improved family planning services".(19) The efficacy of this strategy is proven: Access to safe and effective contraception decreases the incidence of induced abortion.(20) In several countries of Central and Eastern Europe, abortion rates declined rapidly with the establishment of family planning information and services, increased supplies of contraceptives and the active involvement of civil society and religious groups.(21) The most dramatic decrease was reported in Romania, where abortion rates dropped from 52 to 11 per 1,000 in women aged 15 to 44 between 1995 and 1999.(22)
MEN AND PREGNANCY. Where pregnancy is defined as a "women's issue", the participation of men in the decisions and responsibilities it entails may be limited. Yet helping men and communities appreciate the risks of pregnancy can improve a woman's chance of obtaining life-saving care.(23) In Uganda, educating fathers about safer childbirth discouraged unsafe home deliveries.(24) In India, training physicians to involve men in maternity care resulted in more husbands accompanying their wives to antenatal clinics.(25) In rural China, a survey found that where husbands shared domestic chores and parenting responsibilities, women were more likely to receive prenatal care, to reduce their workloads before giving birth and to deliver under more sanitary conditions.(26) The Mother Friendly Movement in Indonesia-along with the Alert Husband programme-has helped communities recognize the need for maternal support and establish emergency transport for women in labour.(27)
SAVING WOMEN'S LIVES. Though safe motherhood has been high on the international agenda for nearly two decades, progress has been uneven, and in some countries maternal mortality rates are considered to be rising.(28) More is known about which strategies are most effective in averting maternal death and injury. They are: family planning to reduce unintended pregnancies, skilled attendance at all births, and appropriate and timely emergency obstetric care for all women who develop complications.(29) Weak health systems, limited transportation in remote and rural areas, shortage of skilled health providers, and the limited availability of contraceptives are among the major challenges. Gender discrimination can make it difficult to muster the political will and resources needed to implement change.
A leading initiative is the Averting Maternal Death and Disability programme to improve emergency obstetric care in developing countries. UNFPA, WHO, UNICEF and many non-governmental organizations have partnered with governments across the developing world to restructure health systems and build capacity. UNFPA supports programmes to expand access to skilled attendance at birth and emergency obstetric care for women in poor and rural areas, including health-provider training now being undertaken in 76 countries. (30) Uganda is tackling several of the challenges commonly faced in reducing maternal deaths, including equipping and staffing health centres with doctors and nurses, and establishing referrals and transportation to handle emergencies. A radio communication system ('RESCUER') and ambulance services have been introduced in some areas.(31) In three regions of Nicaragua, the proportion of women who received emergency obstetric care climbed from 37 in 2000 to 50 per cent in 2003.(32) In Senegal, 100 rural women were saved within a year of UNFPA support to a local health centre.(33) In Yemen, the number of female providers has been increased, with 12,000 community midwives trained.(34)
Some countries are dealing with their acute shortage of doctors by delegating obstetric care to other skilled medical practitioners. For example, nurses in Mozambique have been trained to perform Caesarean sections.(35) In Nepal and Afghanistan-a country with one of the world's highest maternal death rates- midwives are being trained to provide skilled attendance at birth.(36)
Communities play a key role in reducing maternal mortality. Trusted local health workers can refer women to the formal health system and encourage them to deliver in safe settings. In poor countries, communities can pool resources to arrange emergency transport for women with complications, for example, by working with taxi, bus or truck drivers and their unions. In Honduras, community-based efforts helped cut maternal mortality by 37 per cent between 1990 and 1997 and increased skilled attendance at delivery by 33 per cent in rural areas.(37) In Senegal, imams have been enlisted to promote safe motherhood.(38)