Sexual and reproductive health rights and poverty

Presentation held by Gudrun Haupter at the congress panel on women’s human rights, gender equality and the post-2015 development goals, Congress of the International Alliance of Women, London, September 2013

For a long time WHO used to speak of sexual and reproductive health but not of “rights”. Progress has been made mainly by action of the Human Rights Council and NGO pressure. Due to the reform process, WHO now has a Gender, Equity and Human Rights Team. In the words of Director-General Margaret Chan in May 2012, the goal is “to achieve a WHO in which each staff member has the core value of gender, equity and human right in his/her DNA.”

The Cairo Conference on Population and Development in 1994, better known as ICPD, has been a milestone for individual SRHR. Some texts, including that on abortion, have been copied into the Beijing Platform for Action and remain the internationally valid reference. CEDAW had paved the way for changes in marriage and family matters. The findings of the WHO Commission on Social determinants of Health raised awareness about health inequities and asked for ways in which to tackle the inequitable distribution of power, money and resources between men and women. From here it is easy to establish the linkages between SRHR and poverty.

At the global level we have come a long way toward equal rights for the enjoyment of SRHR. What about the national and community levels?

Governments used their right to make reservations, particularly on the CEDAW Art.16, which deals with marriage and family matters. Moreover, in many countries traditional norms prevail at community levels in spite of legislation harmonized with international treaties and standards. Traditional barriers are often reinforced by moral and religious rigidity. Thus, if you happen to be poor and uneducated and live in a village, you have few, if any, choices!

This situation is a big threat to women’s and girls’ sexual and reproductive rights, all the more so if they happen to be poor.

I’ll devote my speaking time to going through the main sections of sexual and reproductive rights and try to clarify what the burden of poverty or lacking resources mean to women’s enjoyment of these rights. As to men, they are not expressly mentioned but are, of course, included where appropriate.

Information on and access to family planning
I belong to those who consider family planning to be the bottom line for women’s empowerment as well as for poverty alleviation. I simply cannot imagine how, with a daily income of 1 or even 2 US $, large families can send all their children to school or pay for the health care they need. And free education and health care are not around the corner! As long as a country’s women, and particularly its poor women, continue to have many children because of lack of empowerment and access to family planning, development problems cannot be solved, and women’s hardship persists.

In the film Empty handed, Population Action International deals with the frustration of women in sub-Saharan Africa who are faced with shortcomings in the supply chain for contraceptives. “Men mostly consider family planning to be women’s responsibility and none of their business,” an intern in our rural FGM project answered to a question passed by the Project Committee of my German organization, Deutscher Frauenring.

Urban women are more likely to be near a reliable source for contraceptives of their choice. A UNICEF report of March 2013 says the unmet need for family planning is higher amongst rural, poor and uneducated women in Africa. And in some countries in Latin America the poorest 20 percent of women are twice as likely to have an unmet need compared to the wealthiest 20 percent. Currently an estimated 220 million do not wish to become pregnant now – or to have any more children.
Six years ago IAW adopted in New Delhi a resolution on the unmet need. My draft said “unmet need of married women” which was the term used by UNFPA and others. However, IAW women insisted that “married” be scratched. The restriction now seems out-dated. The discussion runs rather about health services that need to become more youth friendly.
This clearly means helping adolescents to prevent sexually-transmitted infections including HIV and untimely pregnancies, as well as to obtain safe abortion where legal. In addition, care and curative measures which include mother and child care should be provided.

IAW has actively participated in the recent discussions at the UN level on maternal mortality and morbidity as human rights issues. According to the 2006 UN Special Rapporteur’s report on health, for every woman who dies from obstetric complications, approximately 30 more suffer injuries, infection and disabilities.
Over 90 % of maternal deaths occur in developing countries where public health systems tend to be weak, a high percentage of girls and women are poor and lack the right to terminate an unwanted pregnancy in a safe way – while well-off women often have access to both abortion and emergency contraception.
According to research of the Guttmacher Institute, maternal deaths for all causes could be slashed by 70 % and abortion substantially reduced if investment in family planning and maternal and child health services was doubled.

Child marriage
“Let girls be girls not brides” is the slogan UNICEF has chosen to campaign against the harmful tradition. Online research for the resolution on Child Marriage, and for a French article in International Women’s News, revealed that the connection between child marriage and poverty could not be clearer. This data is from the UNICEF country survey though by far not all countries where child marriage is practiced, responded.
Guess where the empty lines are! A number of countries indicated only the national prevalence. Others added figures on the frequency of child marriage in urban and in rural settings. These show that in all countries rural girls are much worse off. Family wealth levels play a crucial role. The poorer a family is, the higher the risk that their girls are married away early.

To illustrate this I have examples from several continents, however they are awkward to read out.

Female Genital Mutilation is another harmful cultural practice which, in the past, got far more publicity than early marriage.

The brutal ritual continues to be practiced in 29 countries. The latest UNICEF report reveals that compared with the generation of their mothers the percentage of genitally mutilated girls is significantly lower for the present generation. However, we have to be distrustful of percentages, as they do not necessarily mean a reduction in absolute figures in countries with a high number of live births per women. All the more so if child bearing starts early as programmed by child marriages.

With FGM the poverty link is not quite as evident. Well-off families take their girls to be “operated on” by skilled people, under anesthesia and hygienic conditions.

This does not make it any more acceptable to FGM activists and the international community! Affluence may not guard against FGM but, as a rule, the physical consequences will be less severe. And: girls and boys who have been sensitized at school, will probably not have their own girls mutilated, particularly in urban settings where the extended family’s influence is less strong. From our project in rural Burkina Faso we know that despite poverty and illiteracy among women, anti-FGM activities can be successful.

HIV / AIDS and poverty
– In most countries poverty prevents the infected victims from accessing Antiretroviral medicine. WHO has made the prevention of mother-to-child transmission a priority. However, in poor countries with a high incidence, progress is far from satisfactory.

– Sexualized violence including rape hits poor segments of a population particularly hard and often puts women at an increased risk of HIV/AIDS.

– Prostitutes in low and middle income countries are no doubt the largest risk group for getting infected.
I read the story of a 34-year old divorced mother of three who worked as hard as she could as a prostitute in a seedy quarter of Djakarta. Every few months she returns to her village with the small net profit of what she earned. Otherwise her children and her mother could not survive. An NGO pays for the condoms included in the package price, but most lovers refuse to use them. She was lucky in that she did not test HIV positive till now. Soon she’ll be too old for the trade so she tries to scrape together as much as she can.

I could go on pointing out situations and settings where poverty and social status decide whether or not a woman can avail herself of her sexual and/or reproductive health rights or not. Dividing countries into rich and poor ones does not really work. Even in affluent countries poverty exists and is aggravated if there are no adequate social systems. Out-of-pocket payments for reproductive or sexual health (and of course for other health conditions) can turn well-off citizens into poor ones.