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Introduction
Sexual and reproductive health (SRH) is a human right, essential to human development and the achievement of the Millennium Development Goals. SRH issues include death and disability related to pregnancy, abortion and childbirth, sexually transmitted infections, HIV and AIDS, and reproductive tract cancers. SRH accounts for at least 20 per cent of the burden of global ill health for women of reproductive age, and 14 per cent for men.
Sexual and reproductive rights are essential for a variety of reasons. Access to safe, affordable and effective methods of contraception provides women with the opportunity to make informed decisions about their lives. Family planning information and services can contribute to improvements in maternal and infant health by helping prevent unintended or closely spaced pregnancies among women. Adolescent girls are particularly at risk of complications during pregnancies. Sexual and reproductive rights can also help prevent HIV and AIDS.
In developing countries, high fertility rates, early age at birth of first child, and high birth rates among adolescents are closely associated with the risk of HIV infection and cervical cancer. It is also estimated that close to 70,000 maternal deaths annually (13 per cent) are due to unsafe abortions.
In 1994, the International Conference on Population and Development (ICPD) agreed the goal of reproductive health for all by 2015. Although countries have turned ICPD commitments into policies and action, increased access to a range of family planning options, and in some countries reduced maternal deaths, further and faster progress is needed. In 2007, the target of universal access to reproductive health was added to MDG5.
Worldwide, more than 140 million women aged 15 to 49 who are married or in a union have an unmet need for family planning (UN, 2013). The unmet need for contraceptives remains particularly high in sub-Saharan Africa, where SRH programmes have developed slowly and failed to reach enough disadvantaged women and adolescent girls, who are more vulnerable to poor health outcomes. Where country policies, budgets and programmes have reflected the ICPD goals, there has been progress (UNFPA, 2008).
UNFPA. (2008). ‘Making Reproductive Rights and Sexual and Reproductive Health A Reality for All’, United Nations Population Fund (UNFPA)
This paper outlines UNFPA’s SRH framework and strategic plan 2008-2011. UNFPA will invest in four priority areas: (a) support for the provision of a basic package of SRH services; (b) the integration of HIV prevention, management and care in SRH services; (c) gender sensitive life-skills based SRH education for adolescents and youth; and (d) SRH services in emergencies and humanitarian crises
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Maternal health
Improving maternal health is one of the Millennium Development Goals (MDG5). Globally, maternal mortality has declined by 47 per cent since 1990, to 287,000 deaths in 2010. Eastern Asia, Northern Africa and Southern Asia have reduced maternal mortality by two-thirds (UN, 2013).
Most maternal deaths are caused by major complications, including: severe bleeding (mostly bleeding after childbirth); infections (usually after childbirth); high blood pressure during pregnancy (pre-eclampsia and eclampsia); obstructed labour; and unsafe abortion. Antenatal health problems such as poor nutrition, hypertension, anaemia and malaria also contribute significantly to the risk of neonatal death. Studies have shown that the likelihood of maternal death increases among women who have many children, are poorly educated, are either very young or old, and who are subjected to gender discrimination.
A large proportion of maternal deaths are preventable with access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth. High maternal mortality rates can be attributed to failing health systems, the low status of women, and the systematic violation of their basic human rights (Hawkins and Newman, 2005). In developing regions, antenatal care increased from 63 per cent in 1990 to 81 per cent in 2011, but only half of women receive the recommended amount of health care (UN, 2013).
Hawkins, K. and Newman, K. (2005). ‘Developing a Human Rights-Based Approach to Addressing Maternal Mortality – Desk Review’, DFID Health Resource Centre, London
Can a rights-based approach reduce maternal mortality? Can its focus on equity improve health outcomes for poor women? This review argues that rights-based approaches can add impetus to reducing maternal mortality. It argues that policy actors in government and civil society should find ways of addressing the economic, social, cultural and political forces that prevent poor women from asserting their right to maternal health.
United Nations Secretary General. (2010). ‘Global Strategy for Women’s and Children’s Health’, The Partnership for Maternal, Newborn and Child Health
The strategy sets out the key areas where action is urgently required, including: support for country-led health plans; integrated delivery of health services and life-saving interventions; stronger health systems, with sufficient skilled health workers at their core; innovative approaches to financing, product development and the efficient delivery of health services; and improved monitoring and evaluation to ensure the accountability of all actors for results.
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UN. (2011). ‘The Millennium Development Goals Report 2011’, United Nations, New York
This annual report provides updates on progress towards the MDGs. In 2011, most countries showed a decline in maternal mortality rates, but this is one of the goals with least progress. Maternal deaths are concentrated in sub-Saharan Africa and Southern Asia. Adolescent births declined in the 1990s but progress stalled during the 2000s.
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UN. (2013).The Millennium Development Goals Report 2013. United Nations, New York
Maternal mortality has declined by nearly half since 1990, but is not close to meeting the MDG target of a reduction of three-quarters. Only half of pregnant women in developing regions receive the recommended minimum of four antenatal care visits. The urban-rural gap in skilled birth attendance still persists. Some 140 million women worldwide who are married or in union say they would like to delay or avoid pregnancy, but are not using contraception. However, 62 per cent of married women in developing regions do use contraception.
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Williamson, N. (2013). State of World Population 2013 – Motherhood in Childhood: Facing the challenge of adolescent pregnancy. Information and External Relations Division of UNFPA
This paper proposes that a change in views is needed. Instead of viewing the girl as the problem and changing her behaviour as the solution, governments, communities, families and schools should see poverty, gender inequality, discrimination, lack of access to services, and negative views about girls and women as the real challenges, and the pursuit of social justice, equitable development and the empowerment of girls as the true pathway to fewer adolescent pregnancies. It also suggests that girls aged 14 and younger are the most at risk and neglected, and that they should be the priority.
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Gender and HIV/AIDS
Women account for half of all people living with HIV worldwide. In sub-Saharan Africa, nearly 60 per cent of people living with HIV are women, and three out of four infected young people are female (UNFPA, 2009). Gender inequalities and norms relating to masculinity are a key driver of the HIV/AIDS epidemic, for example contributing to higher infection rates among young women by encouraging men to have more sexual partners and older men to have sexual relations with much younger women. Masculinity norms may also discourage men from using contraception and from seeking HIV services due to a fear of being perceived as ‘unmanly’.
Gender-based violence also increases vulnerability to HIV transmission in several ways. Women (and men) who fear violence may be less able to refuse unprotected sex. Forced sex involving tears and lacerations can also increase the risk of HIV transmission. In addition, fear of experiencing genderbased violence in response to being found HIV positive can be a deterrent to testing. Confidentiality of results can be essential.
Transactional sexual relationships, involving exchanges of material gifts or services for sex, have also been linked with an increased risk of HIV infection. Transactional sex typically involves multiple partners and large age differences (usually between older men and younger women or girls). Younger women (and men) generally have lower negotiating power to insist on condom use.
Crichton, J., Nyamu Musembi, C. and Ngugi, A. (2008). ‘Painful Tradeoffs: Intimate-partner Violence and Sexual and Reproductive Health Rights in Kenya’, IDS Working Paper no 312, Institute of Development Studies, Brighton
This paper explores links between intimate-partner violence and sexual and reproductive health (SRH) rights in Nairobi. Significant gaps exist between formal legal rights and the realities experienced by individuals. Legal reform, improved services for affected women and better coordination among service providers are required.
UNFPA. (2009). ‘Fact Sheet: Poverty and AIDS’, UNFPA
This brief fact sheet provides an overview of how poverty and HIV/AIDs are linked. It highlights that the burden of care for the sick falls disproportionately on women and girls. Women from disadvantaged groups are more likely to contract HIV.
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Boesten, J. & Poku, N.K. (2013). Gender and HIV/AIDS: Critical Perspectives from the Developing World. Ashgate Publishing, Ltd
This book provides a comprehensive overview of the relationship between gender, inequality and vulnerability to HIV/AIDS. It examines current thinking on the core topics and on interventions. It stresses the complexity of this relationship, and that accounting for gender will increase our understanding. A focus on women might, however, reinforce stigma and blame towards women.
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Further resources
- Haider, H., 2011, ‘Early Marriage and Sexual and Reproductive Health’, GSDRC Helpdesk Research Report, Governance and Social Development Resource Centre, Birmingham
- Ipas and Guttmacher Institute websites on access to safe abortion and right to choose
- Population Council on adolescent girls and SRHR issues
- AIDS Alliance and Eldis on HIV and AIDS and gender
- Centre for Reproductive Rights
- White Ribbon Alliance on safe motherhood
- International Women’s Health Coalition
- Maternal Health Task Force
