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Family-Planning-KaabongFamily Planning Awareness Event in Karamoja, Uganda. Photo: AWARE Uganda.

By Jennifer Timmons, Safe World Field Partners Manager & Editor. July 2012

“Family planning services are vital in combating the unacceptable maternal mortality rates that persist in Karamoja...

The Karamoja area of Uganda is among the poorest and most underserved in Uganda..  Many thousands of women in the region have not heard of family planning."

Jennifer Timmons reports on family planning, globally, and consulted with Safeworld Field Partners about the availability of family planning facilities at the grassroots level.

July 11, 2012 marks the London Summit on Family Planning, a “groundbreaking summit that will mobilize global policy, financing, commodity, and service delivery commitments to support the rights of an additional 120 million women and girls in the world's poorest countries to use contraceptive information, services and supplies, without coercion or discrimination, by 2020.”

Hosted by UK Government and the Bill & Melinda Gates Foundation with the UNFPA (United Nations Population Fund) and other partners, participants of the London Summit include: national governments, donors, civil society, the private sector, the research and development community, and others from across the world –  who will come together at the London Summit on Family Planning “to support the right of women and girls to decide freely and for themselves, whether, when, and how many children they have.”

Notable names and noble intentions aside, there are many who will be watching and waiting.

Globally, denial of reproductive rights can put women's lives at risk.

Around the globe today, women’s and girls’ lives are at risk because they are denied basic reproductive rights. They are refused information about family planning, they are forced to carry pregnancies, give birth in dangerous circumstances, and in many places, women are still sterilized without their informed consent or even knowledge. The family planning summit should tackle these harsh realities head on. – Liesl Gerntholtz, Women’s Rights Director, Human Rights Watch

Two hundred and twenty-two million is the estimated number of women and girls in developing countries who do not want to get pregnant, but lack access to contraceptives, information, and services – which, for many, will cost them their lives.

In a recent letter jointly signed with Amnesty International and 300 other signatories, to organizers of the London Summit on Family Planning, Human Rights Watch (HRW) said sexual and reproductive health and rights should be at the center of all efforts to meet reproductive health needs, including family planning.

Why?

Women and girls face a wide range of barriers that affect their sexual and reproductive health around the world, including discrimination against marginalized communities in access to care, mistreatment by health workers, denial of HIV and family planning information, and failure to obtain informed consent for services offered, which HRW has documented.

They have also documented the impact of poor monitoring and oversight, including the failure to provide women with effective mechanisms to air their grievances and seek redress for human rights abuses and other barriers that women and girls face in accessing sexual and reproductive healthcare.

The top barriers to sexual and reproductive health in the developing world, according to Pathfinder International, a reproductive health non-governmental organization (NGO), include:

  • Gender inequality: Women often can’t access reproductive health care because of systemic gender inequality. For instance, a woman in desperate need of emergency obstetric care, may have to have her husband’s permission to go to a clinic.
  • Stock outs: For many reasons,including supply chain issues, poor planning, or lack of funding, clinics often run out of contraceptives.
  • Lack of skilled service providers: In many areas, the number of service providers like doctors, nurses, and midwives is limited, and those that exist are often under-trained.
  • Distance to health service point: In rural communities, health centers, clinics, and hospitals can be far away or too difficult to reach.
  • Misinformation in communities: Whether it’s about side effects of contraceptives (like they accumulate in your stomach) or the transmission of HIV, myths and misinformation about reproductive health can take many forms.
  • Opportunity costs: For some women, the time needed to go to a clinic, or travel to a hospital means losing out on other valuable time working in the field, traveling to market, or preparing food for their children.
  • Service provider bias: Just because a nurse is trained in providing a service, does not mean he/she provides it without bias. This can take the form of refusing to discuss contraceptive use with adolescents, for instance, or turning away a woman who is seeking abortion counseling.
  • Legislative and legal barriers: Restrictive laws and policies can have a real—and sometimes devastating—impact on the people. This is particularly challenging in relation to safe abortion services.
  • Cultural norms and traditions: In some cultures women can only seek services from another women; yet, female providers are limited. In others, religious leaders resist the idea of sexual and reproductive health services, such as contraception.
  • Lack of funding: Global reproductive health is significantly underfunded. More than 200 million women want, but lack access to contraceptives. As government budgets become tighter, international funding is even more at risk.

 

Violence against women – or gender-based violence (GBV), linked to gender inquality and cultural norms and traditions,  is also an obstacle; it prevents women and girls from making their own decisions about their own reproductive health care.

And as well, violence against women has increased the possibilities of unplanned and forced pregnancies, unsafe abortions, and sexually transmitted infections including HIV, among other threats to women's reproductive health.

A combination of any of these factors can be lethal.

Reproductive health problems remain the leading cause of ill health and death for women of childbearing age worldwide, reports the  United Nations Population Fund (UNFPA).

Impoverished women –  particularly  those living in developing countries, suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections – including HIV, gender-based violence (GBV),  and other problems related to their reproductive system and sexual behavior. 

Dr. Babatunde Osotimehin, Under-Secretary-General of the United Nations and Executive Director of the UNFPA, says  the right of individuals to determine freely the size of their families was emphasized and expanded by the 1994 International Conference on Population and Development (ICPD), in Cairo. The Conference also put women at the very heart of population programmes.

Yet the reality is that of millions of women – over 200 million, still lack  access to reproductive health care.

A Closer Look

"Women’s rights to health, to life, and to live free from discrimination must be at the center of any discussions regarding family planning—a failure to do so can have serious consequences,"  – Rajat Khosla, Policy Coordinator for Health at Amnesty International.

Reproductive health, defined by the International Conference on Population and Development (ICPD), is a state of complete physical, mental and social well-being –  and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes.

The Millenium Development Goals (MDGs),  set  as a eight interconnected goals as a framework for achieving lasting, sustainable development by 2015 and adopted by 189 world leaders at the Millennium Summit in New York in 2000, includes Goal 5: universal access to reproductive health.

What will be the impact of not focusing on helping women gain their dignity and health so that they have the freedom to decide when and whether to have children, as well as being able to attend to other aspects of their reproductive health?

Likely, the status quo will continue, with aid going only to those women in various places fortunate enough to receive the attention of governmental agencies, NGOs, private donors, or a combination of those.

Others, whose reproductive health care needs remain unmet, will continue to suffer hardships until someone notices them, if at all.

Family Planning at the Grassroots - Africa

Uganda

Grace Loumo, Founder/Executive Director of AWARE Uganda (Action for Women and Awakening in Rural Environment) - a grassroots NGO based in Kaabong in the remote region of Karamoja, in the northeast region of Uganda.

Family-Planning-AWAREAWARE Uganda - Safeworld Field Partner in Karamoja“Contraceptives are not easily available to women due to long distances, and lack of mobile family planning units.  Lack of reproductive rights may be detrimental to community; it may increase land grabbing, lack of food, and poverty”.

The impact of not having reproductive health care services is great:

“The levels of poverty will not be alleviated, population growth, increase in disease, and an increased idle population which may cause crime” Grace says. “Family planning services are vital in combating the high, unmet need for contraception and the unacceptable maternal mortality rates that persist in Karamoja.”

“The Karamoja area of Uganda is among the poorest and most underserved in Uganda; contraceptive prevalence is very low; family planning service provision has been almost non-existent, and on-going violence and insecurity makes providing services difficult. Many thousands of women in the region have not heard of family planning and face huge cultural barriers to controlling their own fertility,” adds Teddy Curran, Technical Director of AWARE.

Last fall, AWARE launched its Reproductive Health and Family Planning project  with the help of Uganda Reproductive Health as well as UNFPA, to teach women about family planning and   prior to that, AWARE opened a Maternity Waiting Hall for pregnant women in critical condition awaiting delivery of their babies. This was so they did not have to walk so far to the hospital.

“I examined a mother who tried giving birth at home but could not. She then decided to walk to the hospital. The woman had started labour at 11:00 p.m. and she had walked for seven hours to get to the main hospital. Her uterus was torn apart”. – A nurse in Kaabong hospital.

Uganda’s maternal mortality rate is 435 deaths per 100,000 live births, while the infant mortality rate is estimated at 76 deaths per 1,000 live births. In Uganda, 16 women die every day in childbirth.

Nigeria

I have 11 children, nine girls and two boys, all of them less than a year apart. I know it is by God’s grace I am alive. My husband threatened to marry a new wife if I refused him more children. I had children to protect my home. Now feeding them is very difficult, and only two of them are able to attend school.” – Mama Dada, Ilishan Community, Ogun State, Nigeria

Adepeju Mabadeje, Founder/Executive Director of Brown Button Foundation (BBF), a grassroots NGO based in Lagos State, south-west Nigeria, says:

Community-hospital-2Community Hospital. Photo: Brown Button Foundation - Safeworld Field Partner in Nigeria“Government should stop paying lip service to women’s health and should face the problem of lack of access to reproductive health head-on. Government should also seek to empower women and create incentive for retaining health service providers in rural areas.” 

“In Nigeria, some rural communities, family planning measures are still unknown. Where they are known, lack of proper advice and the attendant consequences in terms of side effects discourages its use. In most cities, the use of family planning measures are not strange – even though the traditional belief that children –  no matter their number, are a gift from God,sometimes militate against the use of family planning measures.” 

She feels the barriers to reproductive health include:

  • Lack of education on the actual benefits of family planning.
  • Financial dependency on the man also militates against the use of family planning as women are lorded over.
  • The belief that family planning measures are being introduced by the whites to encourage a reduction in their population in order to colonize a second time.

 

Knowledge of reproductive rights save the lives of women around the world. It gives them the freedom to make choices and fuels their determination to lead a more successful and independent life, says Adepeju.
“Not having reproductive health services means more deaths for women, more children who are less likely to live till the age of 5, and loss of economic manpower for the nation.” 

Nigeria has the dubious distinction of having one of the world's highest maternal death rates  which organizations have estimated from between 630 - 840 deaths for every 100,000 live births. As Nigeria does not have a proper and central database, figures vary largely because deaths are greater in the north, than in the west and south.

Zambia

Elsewhere in Africa, Zambian women, like their sisters in Uganda, also must walk far to reach reproductive care. In rural areas, nearly half of families live outside an eight-mile radius of a health facility, according to the Ministry of Health.

Maternal shelters are a relatively recent innovation that the government now offers women who live far from health facilities. The government also drafted a plan last year to increase access to care.

But rural women are still forgoing maternal care or making long walks and waiting in shelters. Funds for transportation and food are a constant challenge as shelters leave it to expectant mothers to provide for themselves, and as well,  staying far away from home for an extended period of time can put a strain on a woman's family – especially if complications from the pregnancy arise.

The maternal mortality rate in Zambia decreased by 19 percent between 2001 and 2007, and currently stands at 591 deaths per 100,000 live births, according to 2011 government statistics.

An International Conference on Population and Development (ICPD) review presented at a meeting of African  ministers revealed that while the conditions for each country vary, the review suggests that each state needs to renew its focus on the following population and development issues:

  • Health and reproductive health, including maternal mortality, family planning and HIV/AIDS.
  • Gender and development.
  • Youth (education, skills development, and productive employment).
  • Resources (human and institutional capacity, and finance, with an emphasis on domestic resource mobilization).

 

African ministers have emphasized their commitment to implement all of the international and continental agreements and initiatives. Perhaps they ought to listen well to the women whom they pledge to support and the organizations working at the grassroots level who work tirelessly to help women in need to gain a clearer understanding of women's reproductive care needs.

Family Planning at the Grassroots - Asia

India

"From Wednesday to Sunday - for five days - we took her from one hospital to another....No one wanted to admit her. In Lucknow, they admitted her and started treatment. They treated her for about an hour, and then she died."  – Suraj S., father of Kavita K. who developed post-partum complications. (Human Rights Watch)

Sixty 60 percent of Indian women have no access to family planning services, giving them little control over their bodies and slowing efforts to boost human development indicators, said  UNFPA Executive Director Babatunde Osotimehin, in a recent interview with Trustlaw.

“When women are empowered with such [family planning] information, they can make decisions over their bodies – when they want children, how many and at what intervals, and they have more ability to work and be economically active,” he said.

It sounds ideal, but in fact, there are many barriers and complexities to achieving reproductive health in India.

Beatrice Vanaja, Chief Administratve Officer of New Life, a grassroots NGO based in Tiruchirappalli, southern India, which serves women, encounters many such complexities in her work.

New-Life-2New Life - Safeworld Field Partner in India “Culturally speaking, the women are dependent on men and the decisions on family planning and child birth are taken by or influenced by men. Religious faiths among the minority communities (Muslims and Christians), play a major role in using contraceptives.

Reproductive rights for the women are important as it has an effect on the health of women. Frequent and/or early deliveries or abortions affect their health.

There are myths that the sexual relationship may get affected. Husbands feel that their wives may become fat and ugly, and hence, they don’t want their wives to undergo family planning surgery. Both men and women feel that if the men undergoes a surgery, he can not have sex like before and he will become sexually weak. Children are perceived to be income-earning machines in future. And in poor families, the parents think that having more number of children will help them in future as the children will earn in times or requirements. There is a difference in the  attitude of the people who get the services. The literates understand and accept the services while it is just the opposite among the illiterates and the economically poorer sections.”

 The impact of women not having reproductive health services affects their health. Beatrice says women are affected by cervical cancer, venereal diseases, HIV, and reproductive tract infections. Most of the infections are caught from the husbands, she adds.

“Even though the suppressed women are aware of their husbands’ illness, due to their inability to oppose their husbands they get infected and affected.”

Lack of information is also detrimental to women. Bakyaseeli, who is a mother of seven children, says that the children are gift of God. Beatrice says Bakyaseeli is ready to give birth to any number of children and that mother  says that her health is not spoiled because of the deliveries. She is afraid that her health may get affected  if she undergoes family planning surgery.

On the other hand, if women get family planning information, it can be empowering.

Katheeja, another mother, says that family planning has improved the status of her family. Her health condition will be improved and she can take care of her two daughters well now,  Beatrice says.

Sumathi, a teenager, says that she had many doubts regarding the reproductive health and after she was introduced to reproductive health care, and she is now happy and “feels clean and healthy.”

A random survey of about 1000 young women revealed that  more than half of them did not even have access to basic reproductive hygiene and the knowledge thereof, let alone that of contraception and ideas of having a control over their own bodies.

The survey, conducted by Pankh, a grassroots NGO based in Lucknow –  capital of Uttar Pradesh in northern India, brought home the importance educating women about reproductive health care and rights.

Pankh-7Pankh - Safeworld Field Partner in India“Reproductive rights lay down the basic conditions for an independent existence as far as women go,” says Sheba Rakesh, Founder/Executive Director of Pankh.

“A lack of mutual partnership in deciding upon sexual and reproductive matters can, and does, have adverse repurcussions on the women's psyche.

Culturally, women have been taught to be shy of their bodies and their bodily needs. Poverty, patriarchy, and policy – economic and cultural, have been  the three Ps at the root of this issue. Since bodies are primarily sites of control, women are seldom allowed to use contraceptive methods as more than being anything else; it would an affront to their male counterparts,” she says.

 Other problems that impede women's reproductive health are systemic, as may have been the case with the health care facilities that turned away  and failed Kavita K., mentioned in the quote. Human Rights Watch assessed a program to improve rural health – which focused on maternal health; HRW found shortcomings in the  tools used to monitor the health care system and identify recurring flaws in programs and practice.

Accountability measures, such as monitoring how and why women die or are injured, or how many pregnant women with complications can use the government's emergency obstetric facilities, may seem dry or abstract, but HRW stresses they are critical to intervening in time to make a difference and to saving the lives of women.

India recorded around 57,000 maternal deaths in 2010, which translate into  six every hour –  and one every 10 minutes, according to UN data.

Latin America & the Caribbean

Guatemala

Guatemala-Midwives-Fotos-CTPhoto: Guatamalamidwives blogspot“Midwives in Guatemala attend to women during pregnancy, the birth and the post-partum period. They give the women warmth and support, because they speak the same language and belong to the same culture,” 

– Silvia Xinico,  Network of Organisations of Indigenous Women for Reproductive Health.

However, when midwives must refer expectant mothers to public health services when complications arise, only patients are allowed in, as midwives are indigenous, discriminated against, and scorned by medical staff.

This leaves women vulnerable as the the they do not speak Spanish and  midwives are the only ones available to speak their native language.

A 2008-2009 National Maternal-Infant Health Survey report states that 48 percent of pregnancies in the country were attended in the homes of the expectant mother or the midwife. But in provinces where most of the population is indigenous, the proportion reached almost 80 percent. The worst poverty and lack of public services, healthcare and education are concentrated in indigenous provinces.

Maternal mortality is almost 10 times higher in the predominantly indigenous departments of the highland region than in provinces with the lowest proportion of indigenous populations. Primary education completion rates for girls are 10 percent lower than for boys, and the gap in school enrollment rates between the richest and poorest children is the widest in Latin America, according to the Center for Economic and Social Rights.

Guatemala's historical legacy of armed conflict, political repression, and institutionalized discrimination against indigenous people over centuries may account in part for this state of affairs, the Center suggests.

Further barriers to reproductive care that Indigenous women face  are community and familial pressure to not use family planning: any community members believe that women who use FP methods will be unfaithful to their spouses and are not fulfilling their marital and familial role to bear children. Consequently, indigenous women fear rejection or ostracism by their community, a USAID project reveals.

Moreover, Indigenous culture is also influenced by the opinion of community elders and religious beliefs, limiting the autonomy of women to make decisions about family planning.

Guatemala loses 290 mothers for every 100,000 live births to pregnancy and birth-related causes.  In the rural highlands of Guatemala,where the population is 95% indigenous, the rate is 446 per 100,000.

For Latin American women, class and gender, ethnic identities and the differences between urban and rural lives, and cultural differences can have a great impact on their health. 

Indigenous communities are often disconnected from “modern” approaches to health care not only by geographical factors, but also by a cultural and ethnic divides.  For example, due to ethnic prejudice,  indigenous women confront different challenges than women who claim Spanish descent.

Bolivia

“We women are more conscious than our male counterparts, They believe that talking about HIV is a joke. In some places you talk about HIV and they confuse it with the IDH [the Direct Hydrocarbons Tax, for its initials in Spanish] that is always on the news. But if that´s how it is, we have to make people talking as much about HIV as they do about IDH.” – Virginia Pereira, leader of the indigenous centre Turubó

Bolivia's indigenous women, like indigenous women in Guatemala, rely on midwives as well, through a culture of rural midwifery known as partera, as midwives speak the local language.

Indigenous women prefer to deliver at home because they do not feel confidence in hospitals, mainly because their customs are ignored or denied in such health services.

In traditional deliveries, women can choose the position. Most of them choose to squat, with their family around, and drink infusions of medicinal plants. Soon after the childbirth, women must keep warm and avoid contact with cold water.

Among indigenous peoples, 78 percent of children are born at home and 53 percent of maternal deaths occurred also at home, reports RH Reality Check.

Many projects supported by international organizations that have been implemented over the past decades have had very low success in terms of maternal mortality decrease. Currently, the government is developing a new strategy based on intercultural reproductive health care approach whereby they are using the aboriginal languages and taking advantage of the regional resources and respecting the habits and traditions

As Bolivia is 95% Roman Catholic, women also face another barrier in prevailing attitudes towards women: “the idea that the pains of labor and birth are a form of retribution for women’s enjoyment or knowledge of sex”  is widely believed and acted upon by doctors,  according to Engender Health, a NGO  working with Bolivian communities to empower local communities with knowledge and availability of reproductive health services.

During labor, doctors have been known to berate women who express pain during labor, and as a result, many women are afraid to visit doctors when they are pregnant or in labor.

Furthermore, women face Inaccessibility of contraception and safe, legal abortions. While contraception is not illegal, only 31 percent of Bolivian women have access to it, leading both to higher fertility rates and higher unwanted pregnancies. Yet another barrier to reducing maternal mortality, says EngenderHealth.

A study on couples in Bolivia has dispelled a myth that indigenous women have higher birthrates simply because they desire larger families than nonindigenous women. The study, done by a researcher at the University of Texas, Austin, reaveals that the difference in the total birthrates of indigenous and nonindigenous women was due almost entirely to a higher rate of unwanted births among indigenous women.

This disparity is likely driven by indigenous women’s poor access to contraceptive services and higher rate of unmet need for contraception.

Rural indigenous women are also highly vulnerable to sexually transmitted infections, reports Latinamerican Press. The women  live marginalized, in poverty, and many lack education and basic services. Few have access to information about health, sexual and reproductive rights, or modern health care for sexually transmitted diseases, such as HIV/AIDS.

“Ten years ago, our communities didn´t even know about HIV/AIDS,” said Eva Melgar Cociabó, one of the leaders of the Chiquitana Indigenous Organization, based in the lowland Santa Cruz department. “But three years ago people started talking about it more. Women who weren´t even leaving their houses in the villages were being infected with this deadly disease. Now, we´re all worried about it.”

HIV/AIDS is increasingly affecting Bolivian women, according to Bolivian indigenous organizations. In the early 1990s for every 10 HIV positive men in Bolivia there was one infected woman. By 2001, women accounted for one in three cases of HIV, and some experts estimate that the disease affects both sexes equally today.

“We´re trying to bring information to the most far-off places and we believe this should be done for all native peoples in the country,” says Eva  Melgar Cociabó.

Lack of official information about the rate of HIV/AIDS among indigenous groups, language differences, concepts of health, gender roles,  and a machismo culture have been barriers to educating women about HIV/AIDs.

“We have so little time to go to the communities, but it´s necessary because in hospitals or health centers that are closer they aren´t told how to protect themselves or what the risks of this illness are,” says Victoria Pereira, leader of the indigenous center Turubó,

 “These women are missing a lot of information that they want to know. Many of them don´t even go to health centers because they´re treated poorly for being indigenous,” she adds.

Bolivia has one of the highest rates of maternal mortality rates at in Latin America, at 229 per 100,000 live births. According to Womankind Worldwide, the ratio for rural Bolivia is 602 out of 100,000.

Haiti

"If you wait all day, you probably won't be seen. So you go back home,deliver, and watch your baby die." – Woman from Port au Prince, Haiti

Even before the January 2010 earthquake, Haiti was the most dangerous place in the  Western Hemisphere, with the lifetime risk of dying in childbirth 1 in 47, according to UNFPA. Haitian women and children were also vulnerable to exploitation, trafficking and physical and sexual abuse. 

Pregnancy rates in the informal camp settlements are three times those in urban areas before the earthquake, reports Amanda Klasing of WomenseNews.  During her visit to Haiti, she observed that women  need better access to contraception, better protection in their camps and communities, job opportunities, affordable medical care for themselves and their children and a safe, dry place to live.

More than two years on, many NGOs such as Oxfam and CARE,  have worked to assist the survivors of Haiti. UNFPA has been working to address maternal health and the growing pregnancy rate in the wake of the earthquake by building maternity clinics, Clinique Sourire or Smile Clinics. The fourth clinic is currently being built, although Haiti still needs 84 more clinics to adequately address the health needs of pregnant women.

UNFPA  Haiti installed 200 durable solar streetlights in 40 of the camps last year, with nearly 200 more to come in 2012. The lights were installed near showers, latrines and water distribution points – places where women may be vulnerable to violence. Sexual violence has been an alarming problem since shortly after the earthquake; rape survivors also suffer from  the stigma of contracting HIV or becoming pregnant as a result.

"We'll never finish with sexually transmitted infections   and HIV/AIDS unless we  address family planning. We need to allow women to have the number of children they want." – Medical doctor and director of a Haitian NGO

Obstetric fistula is also becoming a serious problem in Haiti, says the UNFPA where some women have little or no access to emergency Caesarean sections during prolonged or obstructed labour. That is often the case in crisis situations, says Gillian Slinger, the coordinator of the global Campaign to End Fistula.

Yet for so many efforts, reproductive health is still a challenge for women in girls in Haiti.

“More than a year and half after the earthquake, some women and girls give birth unattended on the muddy floors of tents or trade sex for food without any protection from unwanted pregnancy,” Kenneth Roth, executive director of HRW, said last year. “Despite gains made due to free healthcare services, the government and international donors have not addressed critical gaps in access to health services or addressed conditions that may give rise to maternal and infant deaths.”

In a report, “Nobody Remembers Me”, HRW interviewed more than 100 women and girls ages 14 to 42 in 15 displacement camps who were pregnant or had given birth since the earthquake.

Women described delivering their babies in tents, in the street, or alleys on the way to the hospital, or, in one case, on the street corner after a hospital turned her away for not being able to pay for a Caesarean section.

“I just gave birth on the ground…I had no drugs for pain during delivery,” one woman told HRW.

Haiti had the highest maternal mortality rate in the Western Hemisphere before the earthquake, at 630 per 100,000 live births. The rate after the earthquake is unknown, and there is a lack of effective tracking of maternal or infant deaths in the camps.

Philippines

Irish Gili, 31 is a mother of eight who nearly died while delivering her seventh child, but found herself pregnant again, barely a month after giving birth. She says she never has never had access to family planning advice, much less free contraceptives.

"I have been advised to have a [tubal] ligation already, ... I suppose I need to [have] that now. I have so many mouths to feed, and my body can no longer handle another childbirth."  she told IRIN, a  service of the UN Office for the Coordination of Humanitarian Affairs.

She is likely one of many women in the Philippines who share a similar situation.

The Philippine government recently made the controversial move to  save its “failed” national family planning program and drastically cut maternal deaths by spending 500 million pesos (almost US $12 million) on contraceptives in 2012; this move is bitterly opposed by the influential Roman Catholic Church.

The Department of Health has said it will use the money to purchase "family planning commodities and supplies” - an official euphemism for condoms, intra-uterine devices (IUDs), birth control pills and other contraceptives - and distribute them on a large scale for the first time in largely underfunded community centers across the country.

Twenty-two percent of married women are able to become pregnant, but do not want to have a child in the next two years or at all and are not using any contraceptive method. These women are defined as having an unmet need for contraception, according to a 2010 Guttmacher Institute Study on contraceptive use in the Philippines.

The poorest women – those whose households fall into the lowest wealth quintile –  have about two more children than they want, while those in the richest quintile have only 0.3 more children than they want – evidence of serious health and social inequities. Only 41% of the poorest women use contraceptives, compared with 50% of the wealthiest. Most of this difference is due to lower use of sterilization among poor women. 

  • The most common reasons why women with unmet need in the Philippines do not practice contraception are health concerns about contraceptive methods, including a fear of side effects.
  • The second largest category of reasons why women with unmet need do not use contra-ceptives is that many believe they are unlikely to become pregnant  Their specific reasons include having sex infrequently, experiencing lactational amenorrhea (temporary infertility while nursing), and being less fertile than normal.
  • The cost of contraceptive supplies has become a more common reason for nonuse in recent years.
  • Opposition to family planning by women, their partners or their families is a decreasingly important factor in the Philippines. Personal or religious opposition was reported by 10% of women with unmet need in 2008, down from 18% in 2003. 
  • Only 5% of women with unmet need cited opposition by their partners or families as their reason for not practicing contraception. Still, more poor women than better-off women reported such opposition.

 

Other barriers include – particularly for poor women, lack of awareness of –  or access to, a source of contraceptive care, and lack of awareness of methods.

The study reports  that If all women who wanted to avoid pregnancy used modern methods, there would be 1.6 million fewer pregnancies each year in the Philippines. Unintended births would drop by 800,000, abortions would decline by 500,000 and miscarriages would decline by 200,000.

Expanding modern contraceptive use to all women at risk for unintended pregnancy would prevent 2,100 maternal deaths each year. However, Human Rights Watch reports that contraceptives, including condoms, are restricted in parts of the Philippines, which prohibits and criminally punishes abortion without exception.

And despite vehement opposition from the Catholic Bishops’ Conference of the Philippines, President Benigno Aquino III has remained publicly committed to a reproductive health bill that aims to provide universal access to contraception and maternal health care.

The maternal mortality rate in the Philippines is  221 deaths per 100,000 live births, according to the government’s 2011 Family Health Survey.

Mongolia

“In Mongolia, the sky is a crystalline blue, the land is wide and vast, and when the wind comes, it comes without mercy.” – AmeriCares relief worker delivering medication to disabled teen.

Remoteness, access to emergency, reproductive health care present special challenges in Mongolia, a country of 2.7 million people spread out across 1.5 million square kilometers of steppes, deserts, and mountains, according to UNFPA.

While significant progress has been made in many areas through community worker trainings to raise awareness on reproductive health as well as to provide basic care through “telemedicine” (long-distance diagnosis), maternal death rates remain high in rural areas where insufficient infrastructure and extreme seasonal cold lead to poor maternal care. 

Mongolia’s vast distances make provincial and even district-level health facilities hard to access, making it difficult for women to seek health care.

One nurse described a typical working week, during which she traveled by horse for more than 150 km/93m in bitter winter weather to visit a pregnant woman, encouraged her to attend antenatal clinics, and discussed the health of her older children.

Mongolia's maternal mortality is higher among first-time mothers and among women with low education and many children, according to the World Health Organization. It is also higher among poor herders and the unemployed. 

In addition, due to problems with registration, migrant women in urban areas lack information and tend to be left out of basic health services –  which in turn contribute to increasing maternal mortality among this vulnerable group.

Another factor that may be restricting access to care in rural areas is unequal gender relations and the weaker power of women.  Specifically, the privatization of livestock and the economic crisis have placed a heavy burden on women who face added work responsibilities, reports WHO.

Women's reproductive rights are limited, which also infringe upon women’s physical integrity in Mongolia.  In 1989, the abortion provisions of the the country's Criminal Code were amended. Although abortion is in general still considered a serious offense, the Code was modified to provide that becoming a mother was a matter of a woman’s own decision, according to Social Institutions & Gender Index (SIGI).

Rural Mongolian women continue to face reproductive health needs that WHO, UNFPA, and others have identified and continually strive to meet, in part to reduce the country's maternal mortality rate to meet MDG goals.

  • Provision of Quality, Accessible Care in Rural Areas.
  • Transport and Referral Systems.
  • Promotion of Reproductive Health and Family Planning for High Risk Groups.
  • Creation of an enabling environment for the provision of emergency obstetrics care.
  • Increasing Awareness of Maternal Health among population, especially vulnerable groups and teenagers.
  • Building Partnerships with Communities.

 

Mongolia's maternal mortality rate is 81.4 deaths per 100,000 live births.

The Costs to Women – and Society

Contraceptives are one of the best investments a country can make in its future. Each U.S. dollar spent on family planning can save governments up to 6 dollars on health, housing, water, and other public services. – London Summit on Family Planning website

The London Summit on Family Planning organizers state they will call  for partners to work closely together across a range of areas, such as:

  • Increasing the demand and support for family planning
  • Improving supply chains, systems and service delivery models
  • Procuring the additional commodities countries need to reach their goals
  • Fostering innovative approaches to family planning challenges
  • Promoting accountability through improved monitoring and evaluation

 

With the call for funds comes a host of criticisms and concerns, as is the nature of family planning initiatives, whether regional or global. Governments,  policymakers, international human rights groups, health experts, and many others all have their say when such initiatives are proposed.

Concerns about family planning initiatives involve economic development, the need for contraception, program effectiveness, population explosion or implosion, narrow technological focus, health benefits, abortion and contraceptive use, quality of care, human rights concerns, and cultural and religious concerns.

The Philippine government's recent decision to save its “failed” national family planning program and drastically cut maternal deaths by spending 500 million pesos on contraceptives in 2012 – which is bitterly opposed by the Roman Catholic Church, is an example of  the spark of opposition that can occur with a family planning initiative – and the relief and hope it brings to countless women and their supporters.

Perhaps of greater concern, regarding the London Summit on Family Planning, Human Rights Watch stresses that autonomy, accountability, and monitoring of funding should be central to the Summit's success.

“The expected injection of more money and attention to family planning presents a great opportunity to improve the lives of women and girls, but with it comes great responsibility.. Without accountability and a focus on rights, the money may not reach those who need it the most – and could even inadvertently cause harm.”  – Liesl Gerntholtz, Women’s Rights Director, Human Rights Watch

Controversies aside, women's reproductive health remains the core issue, for better or for worse, as an issue lost in politics or the focus of reproductive health research policy institutes. The Guttmacher Institute, which recently published a new study, “Adding It Up: Costs and Benefits of Contraceptive Services, Estimates for 2012" made several key points:

  • In 2012, an estimated 645 million women in the developing world were using modern  methods--42 million more than in 2008. About half of this increase was due to population growth.
  • The proportion of married women using modern contraceptives in the developing world as a whole barely changed between 2008 (56%) and 2012 (57%). Larger-than-average increases were seen in Eastern Africa and Southeast Asia, but there was no increase in Western Africa and Middle Africa.
  • The number of women who have an unmet need for modern contraception in 2012 is 222 million. This number declined slightly between 2008 and 2012 in the developing world overall, but increased in some sub-regions, as well as in the 69 poorest countries.
  • Contraceptive care in 2012 will cost $4.0 billion in the developing world. To fully meet the existing need for modern contraceptive methods of all women in the developing world would cost 8.1 billion per year.
  • Current contraceptive use will prevent 218 million unintended pregnancies in developing countries in 2012, and, in turn, will avert 55 million unplanned births, 138 million abortions (of which 40 million are unsafe), 25 million miscarriages and 118,000 maternal deaths.
  • Serving all women in developing countries who currently have an unmet need for modern methods would prevent an additional 54 million unintended pregnancies, including 21 million unplanned births, 26 million abortions (of which 16 million would be unsafe) and seven million miscarriages; this would also prevent 79,000 maternal deaths and 1.1 million infant deaths.
  • Special attention is needed to ensure that the contraceptive needs of vulnerable groups such as unmarried young women, poor women and rural women are met and that inequities in knowledge and access are reduced.
  • Improving services for current users and adequately meeting the needs of all women who currently need, but are not using modern contraceptives, will require increased financial commitment from governments and other stakeholders, as well as changes to a range of laws, policies, factors related to service provision and practices that significantly impede access to and use of contraceptive services.

 

On a more local level, small grassroots organizations and activists who work tirelessly to assist the women  in their communities – often on shoestring budgets (compared to large governmental bodies, NGO's or corporations), do have their concerns as well. 

When asked what they might like to say to governments and donors about addressing women's reproductive health care, they had no hesitation in replying.

Nigeria

“In the light of the fact that government has consistently tried and failed to deal with the issue of access and provision of reproductive right choices to women, donors should encourage organisations working to ensure that the needs of women around the world are met, especially in the rural areas where the problem is at its peak.”  – Adepeju Mabadeje, Founder/Executive Director, Brown Button Foundation (BBF)

India

“The government should give incentives for smaller families. Early marriages to be stopped. The women need to be made aware of their reproductive rights. They should also be given empowerment to exercise their powers.” – Beatrice Vanaja, Chief Administrative Officer, New Life

Uganda

[Women need] Access to family planning units, reproductive health commodities, and mobile family units. Also, a program in place to educate women and men to ensure that every pregnancy is wanted, and every birth is safe and free of diseases especially HIV/AIDs.

“If world leaders and donors do not act on their commitment to help women get better access to reproductive care, the population will be put under pressure because the officials will no longer be able to cope with everybody and all services in education, health, society, environment, work – and there will be an increase in the spread of diseases,  especially HIV/AIDs.” – Grace Loumo, Founder/Executive Director, and Teddy Curran, Technical Director, AWARE Uganda

Brazil

Fernanda-AmaralFernanda Amaral - Gender Researcher for Safeworld“The most important issue in Brazil regarding reproductive rights is the right to safe abortion, because  rich women can do it  by travelling to countries in which this is fine to do – or they go to particular clinics that does this kind of service illegally.

Poor women always try to use abortive pills, like Misoprostol, or put objects and products insides themselves (inside their vagina), or go to corrupt clinics that perform abortions illegally and without security –  because is less expensive that the one the rich women can go to. Poor people do not have access to information on how to use better the contraceptives, especially the pills.   They have access to pills free from the  government, but sometimes they don't know how to use it properly.

The government needs to use education to help such people. Planning a family must be done with knowledge. Also, it is important to mention that the female condom is not used –  just the male condom; working to create a better female condom could be very interesting to reproductive rights.

Another important contraceptive  method to have access to is sterilization, for women and men who have more than three children, or just want to have the surgery.  Some doctors –  when a poor woman is having a baby, ask her that is better for her that she sterilizes herself at that moment.” – Fernanda P. Amaral, Safe World Gender Researcher

India

“A greater allowance for transparency in dealings in health  issues is  required in India. Women need to be reached out to. Funds being siphoned  off in the name of work need to be checked through a greater public  participation. And most importantly, all of the donor parties –  including the government, needs to be 'really' sensitive to the issue of health, hygiene, and women's  healthy existence.

The London Summit, marks an important step towards the above mentioned goals.  A step retarded would mean retarding the progress of women quite  substantially. Although each work has its own time frame, the importance of the work being done –  and needed to be done is the first realisation towards an active and charged progression.” – Sheba Rakesh, Founder/Executive Director, Pankh

USA: Women at Risk, too

Student activists care about women –  it's clear the struggle for reproductive rights isn't going anywhere, and we arent's going anywhere either! We are here today and will be at the polls in November to stand up for reproductive justice and women's rights everywhere.” – Tess Koenigsmark, Campus Action Intern, at Unite Women rally in Connecticut

Reproductive health and rights concerns reach beyond the domain of women in developing countries; they are also an important concern of women in wealthier nations, including the USA.

In rural areas of the US, women have a particular difficulties in accessing reproductive health care:

  • A higher rate of uninsured and underinsured populations than in urban areas.
  • Access to transportation barriers, such as geographical isolation, lack of public transportation, and lack of funds for individuals to pay for their own mode of transportation. This can disproportionately affect single women with children responsible for transporting their families.
  • Lack of providers, particularly obstetric providers due to the recruitment and retention problems in rural areas in addition to malpractice suits, which make obstetric care particularly expensive and risky for providers.

 

The Rural Assistance Center (RAC), an online resource for rural Americans, states that studies show women in rural areas also face challenges related to childbirth:

  • More non-metropolitan than suburban women receiving delayed or no prenatal care, and rural women receiving less adequate care when it is available. This is a major concern in rural areas as risk factors for infant death include delayed or no prenatal care, contributing to a higher rate of infant mortality in rural areas.
  • More mothers under age 20 or over age 40. Teen pregnancy rates are often higher in rural areas, and the population is aging at a disproportional rate in rural areas as compared to the rest of the United States.
  • Low educational attainment of mother, which is correlated with poverty. Rural poverty rates have consistently been higher than urban poverty rates, particularly in persistent poverty areas such as Appalachia, the Northern Plains states, the Delta region, the Southern Border Region, the Four Corners area, and Alaska.
  • Maternal smoking during pregnancy, which is higher in rural areas.
  • More than three previous births, which is also related to poverty.

 

Morever, rising malpractice insurance rates, relatively impoverished populations, lack of facilities, and too few physicians for back-up arrangements may make obstetrical practice in rural places unattractive.

Lack of local care means that many women must seek prenatal care and delivery outside of their county of residence. There is some evidence that an increase in distance and travel time to prenatal care decreases the utilization of such care, leading to relatively poor outcomes, according to RAC.

Though barriers to accessing basic reproductive health care are arguably more challenging for women in developing countries, American women have met resistance to accessing reproductive health care through numerous laws enacted throughout the nation, most especially in the last couple of years.

In the first quarter of 2012, legislators introduced 944 provisions related to reproductive health and rights in 45 of the 46 legislatures that have convened so far. (Legislatures in Montana, Nevada, North Dakota and Texas do not meet in 2012.) Fully half of these provisions would restrict abortion, according the Guttmacher Institute. They add that aside from abortion, legislators in several states—mirroring the debate at the national level, are considering allowing employers to refuse to provide insurance coverage of contraception.

Reasons behind the proposal  of these restrictive  laws vary, but two frequent and prominent arguments are budget cuts and declarations by politicians and religious entities that contraceptives and abortion – which is legal in the USA, are abhorrent to their consciences or religious beliefs, and more so if public funds are involved.

The state of Texas is an example of what happens when a state announces budget cuts, whereby social services are often the first items to receive fewer funds: women’s clinics around Texas were being forced to greatly reduce services or shut their doors entirely.

When women legislators speak up in opposition to measures that would be detrimental to the health of many women in the communities they serve, they are ridiculed or silenced by their male counterparts who are offended by any use of medically accurate anatomical terms, when speaking about a restrictive reproductive health bill in question. This was the case of Michigan State Legislator Lisa Brown, who made national headlines last month for using the word “vagina”. 

Men who oppose measures to restrict women's access to contraceptives or laws which make it more difficult to obtain an abortion – even in cases of rape or when a mother's life is at risk, are also ridiculed or silenced in state legislatures. Advocates for women's reproductive health have publicly condemned these “silences” and said that the legislators' First Amendment rights to free speech were violated.

Deadly Delivery: The Maternal Health Care Crisis in the USA, a 2010 study by Amnesty international (AI)  revealed that maternal care in the USA has many challenges.

AI reported that the USA spends more than any other country on health care, and more on maternal health than any other type of hospital care. Despite this, women in the USA have a higher risk of dying of pregnancy-related complications than those in 49 other countries, including Kuwait, Bulgaria, and South Korea. A total of 1.7 million women a year, one-third of all pregnant women in the country, suffer from pregnancy-related complications, the report says.

Minorities, those living in poverty, Native American and immigrant women, and those who speak little or no English are particularly affected.

African-American women are nearly four times more likely to die of pregnancy-related complications than white women. These rates and disparities have not improved in more than 20 years, states AI. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.

"This country's extraordinary record of medical advancement makes its haphazard approach to maternal care all the more scandalous and disgraceful,” said Larry Cox, executive director of Amnesty International USA.

Amnesty International’s analysis also shows that the health care reform bill –  passed by Congress since the report's publication, does not address the crisis of maternal health care.

"Mothers die not because the United States can't provide good care, but because it lacks the political will to make sure good care is available to all women," Cox added.

The United States had 21 maternal deaths per 100,000 live births, a total of 880 maternal deaths in 2010, says the UN, in a new report released in May 2012. U.S. maternal deaths rose an average of 2.5 percent a year from 1990 to 2010.

Girls: What Future Do They Face?

“Knowledge of reproductive rights saves the lives of women around the world. It gives them the freedom to make choices and fuels their determination to lead a more successful and independent life” – Adepeju Mabadeje, Founder/Executive Director, Brown Button Foundation (BBF), Nigeria

Girls: they have dreams, they have energy! But around the world, because they do not have access to basic reproductive health care, there are many who cannot dream about a bright future with possibilities and instead, may be burdened by pregnancy complications, childcare, sexually transmitted diseases (STDs), and any number of health problems.

The reality of young women in developing countries around the globe is stark. According to the Guttmacher Institute:

  • In every developing country, early marriage and early childbearing are most common among poor women and those with little education, two factors that are themselves intricately related.
  • Whether they are single or married, most adolescent women are poor or without monetary resources of their own—some because they are still in school, others because they are married with little or no control over household income, they are not working or they earn very low wages.
  • Inadequate knowledge about contraception and how to obtain health services, high risk of sexual violence and little independence in deciding on the timing of births or use of contraception are other reasons why many adolescent women in developing countries are especially vulnerable.
  • In addition, in most parts of the developing world, unmarried adolescents often face societal disapproval and condemnation if they are sexually active.

 

The need for reproductive health education on family planning is great. Yet for many funders such as multi-national corporations, girls' education seems to be more popular than their sexuality and providing funding for access to contraception, safe and legal abortion, and broad  about their reproductive health and rights, says Kavita N. Ramdas, former executive director and CEO of Global Fund for Women.

Reproductive health and rights—which was a significant emphasis of global philanthropy in the 1980s and 1990s—has now dwindled in popularity, she writes, in the Stanford Social Innovation Review.

Educating girls in schools has long-term benefits, such increasing the likelihood of girls marrying later, bearing fewer children, educating their own children, and being less vulnerable to sexual abuse and coerced sex (and therefore less likely to be infected by sexually transmitted diseases), and these outcomes have important positive implications for the poorest developing countries that are still struggling to expand their economies and provide basic services to their citizens.

However, it is not the magic bullet, says Kavita.

“Girls and young women need basic information about their bodies and programs to build confidence and self-esteem. The value of sex education in schools has been studied and recommended for decades, and sex ed has been incorporated into the UN Convention on the Rights of the Child. Yet this remains one of two important documents—the other is the UN Convention on the Elimination of All Forms of Discrimination Against Women—that the United States has refused to ratify because of internal political resistance from conservative forces, which believe the best way to deal with sexuality is to suppress it and encourage abstinence.”

Those in positions of authority and wealth apparently hold such influence that even well-meaning supporters of reproductive health shortchange the very girls (and women) they aim to help by not discussing sex. Why?

Kavita says reproductive health and rights are topics that most environmental and women’s rights activists are wary of broaching. “The environmentalists shy away from talking about family planning for fear of being labeled racists; the women’s rights activists resist openly discussing contraception or abortions for fear of losing support among US conservatives.”

Meanwhile, countless girls around the globe continue to suffer from lack of reproductive health rights.

Save the Children, a global NGO, recently published a report on family planning. They state:

  • Worldwide, complications in pregnancy are the number one  killer of girls and young women aged 15- 19. Every year 50,000 teenage girls and young women die during pregnancy or childbirth, in many cases because their bodies are not ready to bear children.
  • Babies born to young mothers are also at far greater risk than those whose mothers are older. Each year around 1 million babies born to adolescent girls die before their first birthday.
  • In developing countries, if a mother is under 18, her baby's chance of dying in the first year of life is 60% higher than that of a baby born to a mother older than 19.
  • Many adolescent girls know little or nothing about family planning, let alone where to get it.  Their low status within their families, communities and societies mean they lack the power to make their own decisions about whether or when to have a baby.

 

While countless, small grassroots organizations from Bolivia to Mongolia travel great distances to reach women and girls in remote areas so that women have some means of reliable reproductive care, what will it take for those in positions of power and influence to recognize the  reproductive health and rights of girls. Our future?

The number one killer of girls aged 15-19 is pregnancy and childbirth; it's the cause of 50,000 deaths of teenage girls every year, according to Save the Children, a global NGO.

Will Leaders Deliver on Their Commitments?

Last month, world leaders ignored the importance of women's reproductive health and rights to sustainable development at the UN's Rio+20 conference in Rio de Janeiro, Brazil, much to the anger and disappointment of  the reproductive health rights activists community.

At best, the conference's outcome document re-affirmed its various existing agreements in stated a general intent to address the needs of women by providing information on – and access to, sexual and reproductive health services, including safe, effective, affordable, and effective methods of family planning.

But there was no reference to reproductive rights nor recognition of women’s rights being at the center of development.

The London Summit on Family Planning declares on its website that it will call for unprecedented global political commitments and resources that will enable 120 million more women and girls to use contraceptives by 2020.”

Will its participants deliver on their commitments to the millions of women and girls they aim to support?

Women and girls around the world are waiting.

“Denying women the power and means to control the number and spacing of their children, would deny them of their human rights to health, life, and equal opportunity. The 21st century must enter history as ending that. Each one of us should help speed up that progress”. – Dr. Babatunde Osotimehin, UN Under-Secretary-General and Executive Director of UNFPA


Many thanks to Grace Loumo and Teddy Curran (AWARE - Uganda), Adepeju Mabadeje (BBF - Nigeria), Sheba Rakesh (Pankh - India), and Beatrice Vanaja (New Life - India) for your generous contributions to this article. Your input is greatly valued.

Sources