Women's Health and Empowerment: A Key to a Better World

12 May 2003

Good evening.  It is wonderful to be here in beautiful Monterey. I would like to thank all of the sponsors of tonight’s programme—the Monterey Institute of International Studies; the Community Hospital of the Monterey Peninsula; my alma mater, Mills College; and the Monterey Chapter of the United Nations Association and its President, Lawrence Levine. Thank you for inviting me to speak tonight.

Ladies and gentlemen,

I want to tell you the story of a Nicaraguan woman named Maria. Maria married young, left school and went to live with her husband on a coffee plantation. She was isolated and alone -- far from her family and friends. Without access to family planning or maternal health care, Maria became pregnant eight times and delivered eight babies alone, cutting the umbilical cords herself. Her husband was never present during the births and no one else lived close by. At one point, she went to her mother and told her that she was afraid of being so isolated, but her mother responded that her place was with her husband, so she returned.

Maria managed to survive eight unassisted births, but thousands more women are not so fortunate. Every minute of every day, one woman dies of complications of pregnancy and childbirth. Ninety-eight per cent of these women live in developing countries -- Africa and Asia in particular. Of all health indicators, maternal health shows the largest gap between rich and poor. In the poorest countries, a woman faces a 1 in 16 chance of dying during pregnancy and childbirth. Here in the United States, the chance is less than 1 in 3,500.

The most common causes for these deaths are haemorrhage, obstructed labour, infection, unsafe abortion and hypertension. This tragic toll amounts to 1,400 maternal deaths each day and over 500,000 deaths each year. The most tragic fact is that nearly all of these women’s lives could be saved if only they had access to four things that we sometimes take for granted in North America: family planning services, prenatal check-ups, skilled attendance at birth and emergency obstetric care.

Just as tragic as the women who die needlessly are the women who survive but are permanently disabled. For every woman who dies from complications of pregnancy and childbirth, there are approximately 15 to 30 other women who suffer from chronic illnesses or disabilities that often last a lifetime. This amounts to some 20 million women each year, who suffer from non-fatal complications of pregnancy, such as anaemia, infertility, pelvic pain and obstetric fistula. When we are talking about 20 million women worldwide whose health is damaged by pregnancy and childbirth, we are not talking about a health issue; we are talking about a global crisis.

Yet, it is a global crisis that receives fairly little attention, at least from the media and relative to its scale. We hear about AIDS, which I will address later, and we hear about SARS. But we hear very little about the millions and millions of women who suffer death and disability not from disease, but from the very process of bringing new life into the world. The fact is that these women suffer because of their nature-assigned physiological duty for the survival of the species, and the tasks related to it. They also suffer because of the social disease of gender discrimination and violence.

Even though women are honoured in all cultures as the givers of life, they are also often dishonoured as human beings. The low status of women continues to prevent policy makers from making women’s survival and well-being a priority. The low status of women also prevents many women themselves from expecting and demanding better treatment. Of course, I am not saying that all women accept maltreatment as normal. No, there are more and more women, and men, demanding that women’s full human rights be respected. In fact, the global movement for women’s rights is one of the strongest social forces, and one of the most successful movements, in recent history. But, despite advances, and there have been many, there continue to be far too many women who accept their second-class status and far too many men who demand it. This is why it is necessary to empower women with education, economic opportunities, health care and legal rights, so that they can demand better treatment and services and, most importantly, so they can meet their full potential as human beings. This is why it is also necessary to work with men so that they can become more sensitive to the needs and rights of women and more fully understand the benefits that result from equitable treatment and respect for women’s human rights.

Ladies and gentlemen,

Women all over the world have a right to safe motherhood. They have a right to life. They have a right to live free of gender discrimination and violence. Yet, millions of women experience violence, which takes a great toll on their health and the health of the family and the community. Globally, the health burden of violence against women is comparable to the burden of other risk factors and diseases, such as HIV/AIDS, tuberculosis, childbirth, cancer and heart disease. That is why it is necessary to address gender-based violence in health and development programmes. Of course, as I said earlier, gender-based violence is also a human rights issue.

Another health and human rights issue is family planning. The right to freely determine the number, timing and spacing of one’s children and to have the means to do so, is an internationally recognized human right. This basic right maximizes choices, and enables women and couples to control fertility and thus to have a larger degree of control over the rest of their lives. Family planning is also critical to health, both for the mother and the child.

Studies show that when births are too close together, separated by less than two years, infant mortality rates are 45 per cent higher than when births are two to three years apart. Also, women face risks to their health when births are too early or too late in life. In Bangladesh, for instance, teenage mothers face a rate of dying during pregnancy and childbirth that is twice the national rate.

Babies born to teenage mothers also face tremendous risks. Studies show that they face death rates that are 30 per cent higher than babies born to women who are in their 20s and 30s. This is because teenage mothers are physically immature, which increases their risk of suffering from obstetric complications. Teenage mothers are also more likely to give birth to infants who are premature or have low-birth-weight—conditions that reduce the resilience and stamina babies need to overcome infection or trauma early in life. Also, pregnant teenagers are less likely than older women to receive good prenatal care and skilled medical care at delivery, and to provide adequate care for their babies.

Yet, despite the increased risks, every year, some 82 million 10-to-17 year-old girls and young women get married, many by force. Deprived of education and social opportunities, the young bride enters adulthood with few skills and few opportunities to improve her situation. This reinforces low self-esteem, social isolation and perpetuates a cycle of poverty and ill health.

UNFPA is working around the world to promote the benefits of delaying pregnancy and marriage, and to provide universal access to reproductive health services. We approach this work from a human rights perspective, and we are also pragmatic.

We know that most women who die during childbirth experience one of three delays:

  • The first is a delay in deciding to seek care.
  • The second is a delay in reaching a medical facility.
  • And the third is a delay in obtaining care at the facility.

Maria delivered eight children without complications. She was very fortunate. But women who do experience complications –- and 15 per cent of all pregnant women do -- need to get medical help and it must happen quickly.

Timing is critical in preventing maternal death and disability. Post-partum haemorrhage can kill a woman in under two hours, but for most other complications, a woman has 12 hours or more to get life-saving emergency care. That is why UNFPA is working with a wide range of partners to address these three delays.

Let’s look at the delays a little more closely. The first delay, in deciding to seek care, may occur for several reasons. It may happen due to late recognition that there is a life-threatening problem, fear of a hospital, fear of the cost of care, or just lack of an available decision maker. In many countries, women may need permission from their husband or male relative to visit a hospital.

Nearly half of all births in developing countries take place without a skilled birth attendant -- such as a doctor, nurse or midwife. It is, therefore, easy to understand why problems may only be recognized when it is already too late. Women often have traditional birth attendants -- who do not have medical training -- helping them at the time of delivery. These people are unable to properly diagnose complications. What’s worse, they may even try to propose remedies that further threaten the woman’s health and well-being. One of my colleagues met a woman in Ethiopia who was in obstructed labour for several days and needed an emergency caesarean section. In desperation, the traditional birth attendant tried to suspend her from the ceiling, thinking that gravity would help the baby come out. The woman fell and broke her hip. She also lost her baby. Another woman who was interviewed in Niger was given water to drink after being in obstructed labour for several days. The traditional birth attendant thought it would help expel the baby. As a result, she pushed against a full bladder and suffered an injury that left her incontinent. These tragedies could have been prevented.

The second delay, inability to reach a health care facility, is usually caused by lack of transportation. This is especially common in rural areas. Many villages are either several days walk from the nearest road, have limited public transportation or very poor roads. Even if transportation is available, it is often too costly for poor women and their families. Some communities have developed innovative ways to address this problem, including pre-payment schemes, community transportation funds and radio or telephone contact between midwives and hospitals. In parts of Western Africa, villagers have worked out an agreement with truck drivers’ unions. If a woman is in labour and needs to get to a hospital, villagers simply place a yellow flag on the side of the nearest major road. Passing truck drivers recognize the yellow flag as a sign of a woman being in distress and stop to take her to the nearest hospital. This programme has reportedly saved countless lives.

The third delay, and perhaps the most tragic, is the delay in obtaining care once a woman reaches a hospital or clinic. Often, women will wait for hours because of poor staffing; strict pre-payment policies or difficulties in obtaining blood supplies, equipment, or an operating theatre. This delay is the easiest to correct. UNFPA is working hard to improve the quality of care at existing emergency obstetric centres by helping hospitals to purchase surgical equipment and supplies, by training doctors and nurses, and upgrading facilities.

Ladies and gentlemen,

We know that maternal mortality can be reduced and we know how to do it. In Europe and North America, nearly universal access to skilled attendance at birth and to emergency obstetric care has reduced maternal mortality rates to almost zero. While it would be unrealistic to attempt to replicate this success in exactly the same way in resource-poor countries, it is possible to reduce significantly the number of women who die or become disabled due to childbirth. This can even happen in countries where most women deliver at home, or where education and health systems are collapsing under the stress of poverty and HIV-AIDS.

UNFPA currently has programmes in over 100 countries aimed at reducing maternal mortality and improving the status of women. We focus on three main areas that are intended to address the three delays I just outlined:

  1. UNFPA works to increase access to comprehensive family planning services to help women and couples plan their pregnancies to avoid pregnancies at too young or too old an age and to properly space births. Yet, many couples still lack access to contraception. Today, it is estimated that 120 million couples would be using modern methods of family planning if they had access to such services. Meeting the existing demand for family planning services alone would reduce maternal deaths by more than 20 per cent. These services should respect individual choice and offer a wide range of contraceptive options, including the male and female condom. They should also include voluntary testing and counselling for sexually transmitted infections, particularly HIV/AIDS.
  2. UNFPA works to ensure that all pregnant women deliver their babies with help from a skilled birth attendant. This can be a doctor, nurse or midwife, who can manage a normal labour, quickly recognize complications, start treatment and supervise referral to emergency obstetric care if necessary. Most complications occur at the time of labour and delivery. Having skilled attendants present to refer the 15 per cent of complicated births to hospitals will significantly reduce maternal mortality. UNFPA has programmes to train midwives and seeks to place them in areas with the greatest need. Incentives, such as free housing, distance learning programmes and rotation systems, are often used to keep midwives and doctors in rural and semi-rural areas.
  3. UNFPA works to ensure that women who experience complications have timely access to emergency obstetric care. This refers to facilities that can perform caesarean sections and manual removal of the placenta, provide safe blood transfusions and administer antibiotics. As a general rule, caesarean sections should account for about 5 per cent of all births, but not more than 15 per cent. It is also estimated that for every 500,000 people, there should be at least one hospital that offers emergency obstetric care. This should be well-equipped and staffed 24 hours a day, seven days a week. These services are not that costly to set up in terms of equipment and supplies, but require trained, committed personnel.

Although UNFPA is actively involved in all three areas, our main focus right now in the area of safe motherhood is on the provision of emergency obstetric care. Let me give you some examples.

  • In Uganda and Angola, UNFPA bought ambulances and radios to improve transportation and communication between villages and hospitals.
  • In Nigeria, it worked with the Ministry of Health to distribute pre-packed supply kits for caesarean sections to hospitals. The Fund also helped to hire anaesthesiologists and provide on-site accommodation for doctors and nurses so that they could maintain 24-hour care.
  • In Bolivia, UNFPA trained health-care workers to monitor high-risk cases and increase referrals for emergency obstetric care. As a result, maternal mortality declined sharply in one municipality.
  • In Timor-Leste, UNFPA is supporting the only emergency obstetric care facility in the country. We are also distributing solar lamps to midwives, so that they don’t have to deliver by candlelight.

Another major focus of our work is to prevent and treat obstetric fistula, which is the most devastating of all pregnancy-related diseases and affects about 50,000-100,000 women each year. Prevalence is highest in impoverished communities in Africa and Asia. Obstetric fistula usually occurs when a young, poor woman has an obstructed labour and cannot get a Caesarean section when needed. The woman is often in labour for five days or more without medical help. The baby usually dies and, if the mother survives, she is left with extensive tissue damage to her birth canal that renders her incontinent.

Fortunately, obstetric fistulas are both preventable and treatable. They can be prevented by delaying pregnancy, having skilled attendants at birth and giving women access to emergency obstetric care. They can also be treated with reconstructive surgery. If done properly, the surgery has a 90 per cent success rate and costs about $350. Women can usually have more children.

Fistula was once common throughout the world, but has been virtually eradicated in Europe and North America through improved obstetric care. UNFPA recently launched a campaign to fight fistula in sub-Saharan Africa. We are working to equip hospitals, train doctors and nurses, improve transportation and referral systems, and provide counselling and support for survivors of fistula.

UNFPA also works to address women’s health needs in emergency situations, such as natural disasters and war. We want women to be a priority from the moment a crisis begins. To protect the health of pregnant women in Iraq, UNFPA has deployed life-saving equipment -- including mobile surgery units, ambulances and ultrasound scanners -- as well as antibiotics, clean delivery kits, sanitary supplies and contraceptives to Iraq and neighbouring countries. Around the world, about one in five women of childbearing age who arrives at a refugee camp is pregnant. These women are at heightened risk of miscarriage, premature delivery and complications. Making childbirth safe for them is a top priority for UNFPA.

Another top priority is the prevention of HIV/AIDS. Today, there are 42 million people living with the infection, and there are more than 14 million AIDS orphans. Sadly, half of all new infections are in women. In sub-Saharan Africa, where AIDS has hit the hardest, women comprise 58 per cent of those infected. In some places, teenage girls are five to six times more likely to be HIV-positive than boys their age.

While all young people are particularly vulnerable to HIV infection because they lack access to sexual and reproductive health information, education and services, young women are at the greatest risk. This is due to gender inequalities and practices like early marriage, sexual violence and the search by older men for younger “HIV-free” partners. Roughly 47 per cent of the 14,000 new infections each day are in women of childbearing age. Women are biologically more vulnerable to HIV infection and often socially disenfranchised. Therefore, they often lack the means and power to say “no” to unwanted or unsafe sexual relations.

The pandemic is, therefore, taking a severe toll on women and children. Historically, efforts -- including collaboration among United Nations agencies -- have largely concentrated on the prevention of HIV transmission from mother to child. While this is a necessary intervention, it is also necessary to prevent HIV infection in mothers in the first place. UNFPA is focusing on the mothers in “mother-to-child-transmission plus” because we have found that very few examples of interventions exist that focus on pregnant women in their own right.

While, in a few countries, alarming infection rates exist among pregnant women, in most others the great majority of pregnant women are HIV-negative. An estimated 200 million women become pregnant each year, of which about 1.8 million are HIV-positive. Thus, 99 per cent of pregnant women worldwide are HIV-negative. UNFPA is working with partners worldwide to ensure they remain so.

By preventing HIV infection in pregnant women, preventing transmission to children is assured. Concentrating efforts on the majority -- that is uninfected women and young people -- in the face of limited resources has been the rationale for UNFPA’s strategic focus.

Pregnancy is known to be one of the few occasions where women go to clinics and hospitals. Therefore, it is a natural entry point and opportunity to provide information on HIV prevention to help ensure that HIV-negative women remain free of infection. It is also an opportunity to provide HIV-positive women with the support and care they need to ensure a better chance of safe pregnancy and delivery.

Since there is no vaccine for HIV/AIDS, prevention remains key to any response. An effective strategy has been demonstrated in Uganda, which has been able to slow the spread of AIDS. The strategy is called the ABC approach: abstain, be faithful and condom use. UNFPA funds programmes that focus on all three messages, which taken together, form a comprehensive and effective approach.

All over the world, women and girls in many countries need increased support to meet their basic needs and protect their basic rights. Access to education and health care, including reproductive health care, is absolutely critical. Also important are legal rights, and increased access to resources, economic opportunities and greater participation in decision-making.

The support of individual men and women like you can make an invaluable contribution. Here in the United States, two women have made a great difference. After the United States withdrew its funding from UNFPA last year, Lois Abraham of New Mexico and Jane Roberts of California started a grass-roots campaign to replace the missing funds. The 34 Million Friends Campaign started out as a trickle of support over six months ago and has now turned into a steady stream. A little over a week ago, the Campaign announced its first million dollars.

Some UNA chapters in the United States have taken the challenge and the Monterey Chapter is one of them. For this, we are truly grateful. UNFPA receives hundreds of letters each day filled with heartfelt messages. One family decided to have a scaled down Christmas last year and donated the money they would have spent on a Christmas tree. Another woman wrote us from a domestic violence centre and said she understood how important our programmes were. She sent a dollar for herself and a dollar for a woman who might not have one.

This spontaneous show of support from Americans has been very encouraging. It shows that people want to make a difference for women in developing countries. The money will be spent to prevent unwanted pregnancies and HIV infection, and to ensure safe motherhood.

Of course, we very much hope that the United States Administration will decide to resume funding UNFPA. The United States was instrumental in the founding of UNFPA in 1969 and has been a key supporter over the years, and I encourage all of you to voice your support for UNFPA.

In closing, I would like to stress that, although the challenges we face may seem daunting, we have made much progress together. And together, we will make even more. Women are the backbone of families, communities and nations. Women should be at the centre of development efforts. When women are healthy and educated, all of society benefits. Studies show that nations that invest in girls’ education and reproductive health, including family planning, register slower population growth, higher productivity and faster economic growth. Investing in girls and women is one of the smartest investments we can make.

Thank you.

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