Jocelyn Cook
December 8, 2008
Examining Reproductive Health Among Women in Africa, Refugees and Commercial Sex WorkersABSTRACTIn Africa, one in eight women can expect to die or suffer life altering, debilitating complications due to pregnancy or the birth of a child. In many countries in Africa, men are esteemed as the primary decision maker for the family, thus many women and young girls are denied the choice of contraceptive or timing of having children. With increasing violent conflict in Africa, communities are forced to migrate, creating large populations of refugees and internally displaced persons. Once outside of their communities, women and children more easily fall victim to gender based violence and sexual exploitation, often forced to perform sexual acts in order to obtain basic necessities such as food and clean water. Additionally, as financial disparities continue to widen, women and young girls are finding work as commercial sex workers. Both of these societal changes are affecting the women's reproductive health, as they often are denied access or use of contraceptives of any type, to prevent or postpone pregnancy let alone protect against sexually transmitted infections including HIV/AIDS, denied or prevented access to proper medical care, and denied of prevented access to proper information regarding their health and well-being. The objective of the paper is to take an in-depth look at women's reproductive health as a whole, examining how reproductive health concerns are being addressed in Africa, the refugee and internally displaced community and commercial sex industry.
1.0. INTRODUCTION This research paper will examine Reproductive Health (RH), specifically in Africa paying particular attention to the RH of refugees and internally displaced persons (IDPs), commercial sex workers and the act of survival sex. It will look into the role men play in reproductive health, discuss gender based violence (GBV) and highlight correlations between a lack of RH services and sexually transmitted infections (STIs) including HIV/AIDS.
Reproductive Health is “a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the rights of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth” (Abt, 2005).
In 1994, the International Conference of Population and Development (ICPD) declared reproductive heath “as a basic human right” (Austin, 11). However, research for this paper found that across the African continent, RH services were either lacking in the robustness of the services, accessibility, or existence. The lack of RH services, including access to free or affordable contraceptives unnecessarily increases the risk of disease transmission, including HIV. Furthermore, there is an extremely high prevalence of abortions as a result of unintended or mistimed pregnancies often resulting in death due to complications from pregnancy or unsafe abortions.
Appendix 1 contains data from a sample of African countries and shows the percentage of women who received antenatal (prenatal) care from a health professional, the number of women receiving delivery assistance from a health professional and number of women who received postnatal care within first two days of delivery. Appendix 2 shows a model discussed in a WHO bulletin, illustrates “the key determinants of reproductive health status and indicates where they are affected by components of health sector reform” (Lubben, 2002).
1.1. METHODOLOGY All of the sources of information and statistics used in this paper are secondary in nature. While the original aim was specifically to examine RH as it relates to commercial sex workers (CSWs) and child sex slaves in the refugee and IDP community, the availability of data was insufficient to do so. Additionally, the data available detailing women’s access to RH services was inconsistent. Due to the confines of this assignment, an extensive discussion of the issues related to reproductive health is not practical, but the references contained at the end of the paper offer an exhaustive list of resources utilized, for further study.
2.0. KEY GLOBAL HEALTH CONCERNS OF REPRODUCTIVE HEALTH IN AFRICA A major factor in delivery of effective RH services is the infrastructure within the region. Research shows that there is insufficient access to RH services in Africa due to either an individuals inability to pay for the services and/or a lack of resources and infrastructure to provide and deliver RH services. A 1993 Lancet editorial criticized the absence of RH services in Africa and in 1994, the Women’s Commission for Refugee Women and Children published a report, which thoroughly discussed the weak or failing reproductive health services available, especially to displaced women (Austin, 11).
In 2000, when the Millennium Development Goals were established, criterion were determined for gender equality, child health, and maternal health; however, no clear commitment or goals were developed to address the RH rights of women (Crossette, 71). Traditional responses to emergencies in Africa normally involve delivery of food, water, and basic medical services. The response lacks the acknowledgement and commitment to RH services. One report showed that funding for basic RH services has only increased from 18% to 25% from 1995 to 2008. In comparison, funding for HIV/AIDS has increased from 9% to 56% (Fathalla, 2098-2099).
The lack of emergency RH services, contributes to death that is unnecessary and relatively easy to prevent. The World Health Organization reported that “obstructed labor, sepsis (infection), eclampsia (convulsions) hemorrhage and unsafe abortions accounted for 75% of maternal deaths globally” (WHO, 2). The United Nations Population Fund further stated that 99% of maternal deaths occur in the developing world (2005).
Emergency obstetric care (EmOC) is a vital element of reproductive health services. EmOC “refers to the care of women and newborns during pregnancy, delivery and the time after delivery” (RAISE 2, 2007). A large percentage of maternal deaths occur within the first 48 hours after delivery, thus postnatal care is imperative. Yet, in Swaziland, only 22 percent of women reported receiving care within 2 days of birth, either because of the financial implication of such services, access or education on the importance of postnatal care (NSEO: Swaziland, 07).
Another crucial component of reproductive health is the availability and access to contraceptives, and, importantly, the right of a woman to decide to utilize such services. In the Democratic Republic of the Congo, women have the highest maternal mortality in the world (1,837 deaths per 100,000 live births), and as high as 3,000 per 100,000 live births in the eastern DRC (Guy, 25). Women in Sierra Leone, face a 1:6 risk of dying from complications of pregnancy and delivery, while women in Uganda face a 1:3 risk as compared to women in Sweden whose risk is 1:29,800 (Austin, 2008).
Provided that men are the primary family decision makers in many African countries, men play a vital role in the progress that reproductive health services will have in Africa. Much of the research showed that, if given the choice, women would spread out the births of their children or stop having children altogether. With many women facing unintended or mistimed pregnancies due to lack of contraceptives, staggering numbers of women are seeking illegal, thus unsafe, options to terminate their pregnancies.
2.1. UNSAFE ABORTION Unsafe abortion refers to the “termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both” (WHO 1, 2008). Much of the funding to NGOs and other aid agencies is from the United States, and increasingly we are learning of stipulations attached to these aid resources. One such instance, known as the Global Gag Rule, states that any NGO receiving monies from USAID or the US State Department may not “perform abortions in cases other than rape, incest, or a threat to the life of the woman; provide counseling and referral for abortion; or lobby to make abortion legal” (Crane and Dusenberry, 128).
In Kenya, Uganda and Liberia, along with other African countries, abortion is only legal to save a woman’s life, while in Botswana, Ghana, Zambia and Zimbabwe, where abortion is legal, women continue to die because they either cannot afford a legal procedure or did not know where services could be obtained (Ipas, 2008).
One study estimated 5.6 million abortions are performed in Africa annually, with 39 out of 1,000 considered unsafe. The study went on to report that in 1996, deaths from abortion related complications decreased 91% in South Africa after the abortion law was liberalized (Ipas, 2008). If women had access to contraceptives and the ability to make decisions regarding their reproductive health, data supports a mass amount of abortions could be avoided and the lives of unborn child and woman protected.
2.2. REFUGEES AND INTERNALLY DISPLACED PERSONS Individuals are considered refugees when they flee for safety from political upheaval, oppression, and/or persecution across international borders and are considered internally displaced persons (IDPs) when they are displaced within their own country. The UN High Commissioner for Refugees (UNHCR) estimates that 1:170 (32.9 million people) people are displaced refugees or IDPs (Austin, 11), while the Internal Displacement Monitoring Centre estimates that in 2007, there were 12.7 million refugees and IDPs in Africa alone (IDMC, 2007).
The majority of research asserts that RH services are inadequate in refugee settings and often non-existent for the internally displaced. An exhaustive study was executed by the Inter-agency Working Group and UNHCR to evaluated RH services available to refugees and IDPs in Africa. Findings revealed that services for refugees, and IDPs are severely lacking, and that services related to gender based violence (GBV), HIV/AIDS, and emergencies obstetrics (EmOC) must be stronger. The largest hindrance highlighted in the study emphasizes a lack of infrastructure within these regions, namely inadequate amounts of supplies due to poor road conditions, irregular flights, and extreme heat and humidity. In conclusion, the study stated that since 2000 there has been a decline in funding for RH services due largely in part to the theory that RH is not an essential part of emergency response (UNHCR, 2004).
2.3. GENDER: SOCIETAL NORMS AND PERCEPTION A substantial obstacle to overcome is working within the societal perception for cultural norms and gender roles. Many women cannot obtain contraceptive without the approval from their husbands (Guy, 26). Concerted effort must be made to work with the men to educate them of the far reaching benefits of RH. In Swaziland, nearly 63% of men believe that a woman who uses contraception may become promiscuous, while 12% of men consider contraception to be a “woman’s issue” (NSEO: Swaziland, 07). In South Africa, 57% believe that they cannot refuse sex with their partner and state they fear violence as a reason they don’t use condoms for the protection of sexually transmitted STI or pregnancy prevention. Furthermore, in Sub-Saharan Africa, the withdrawal (or threatened withdrawal) of material benefits was threatened if women refused sex or requested the use of contraceptives against their partner’s wishes (Watts and Mayhew, 208).
Engaging men to become part of the solution is essential to improve the overall outcome of reproductive health. EngenderHealth has a Men As Partners (MAP) initiative which “challenges men to confront harmful stereotypes of what it means to be a man” (Engenderealth, 2008).
2.4. GENDER BASED VIOLENCE Rape, sexual assault, domestic violence, coercive and exploitative sex, sex trafficking, and forced pregnancy or sterilization are all forms of gender based violence (GBV) (RAISE 5, 2007). In many African conflict countries (and post-conflict), a large population of women fall victim to GBV. As has been seen in many conflict settings, rape is increasingly used as a weapon of war and a method of ethnic cleansing (forced pregnancy of children of specific ethnic groups) (RAISE 5, 2007). Preventing GBV must become a key component of RH as GBV has vast implications for women’s rights and reproductive health.
A 2004 study in Malawi showed that 39% of women reported they were physically or sexually violated once or twice in the last 12 months preceding the survey, 21% three to five times, and 10% more than five times (NSO: Malawi, 2005). GBV has profound negative implications on socio-economic, psychological, and physical health related issues, and carries with it a number of gynecological and reproductive health problems, including sexually transmitted infections (STIs), unwanted pregnancy, vaginal bleeding or infection, genital irritation, urinary tract infections and fistula (uncontrollable leakage of urine or feces or both through the vagina) to name a few (Watts and Mayhew, 207).
2.5. COMMERCIAL SEX WORKERS AND SURVIVAL SEX Unfortunately, while women and girls are generally not the perpetrators of violence, they often suffer the grave consequence. When women and children flee their communities, they require a new source of income to purchase basic life necessities. Collective research has shown some girls leave school to go into commercial sex work, while others participate in survival sex (sex for necessities such as food and housing). A 1999 survey conducted in Sierra Leone, found that 37% of prostitutes were under the age of 15, 80% of who had been displaced by war (Austin, 15).
Reproductive health services are no more readily available to this population of women, yet their participation in high risk activities creates more urgency for policy makers to examine the need for readily available contraception and education. Additionally, policy makers and NGO’s need to evaluate what women are doing to earn income and procure life necessities, addressing the problem using needs based solutions.
2.6. SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV/AIDS Populations affected by conflict are substantially at a greater risk of Sexually Transmitted Infections (STIs) due largely in part to increased risky behavior such as sexual acts as a comfort or rape as a weapon. Additionally, refugees and IDPs are in migration, crossing paths with many individuals who have most likely been in contact with many other individuals (McGinn, 179).
RH education and resources, including clear information on HIV/AIDS and other STIs, are core components of a solution. However, these components are in desperate need of improvement. A study from 2006-2007 in Swaziland showed men and women believe HIV is transmitted by mosquito bites and did not know that mother-to-child transmission of HIV is possible through breastfeeding or that drugs are available to prevent the transmission (NSEO: Swaziland, 07). Basic knowledge related to disease transmission and prevention can lead to dramatic improvements in the health and welfare of displaced people. Fear of ostracism and violence in the home was reported as a determining factor for why pregnant women refuse an HIV test or do not return for their results (Watts and Mayhew, 208).
Globally, unsafe sex is estimated to account for 80 million unwanted pregnancies, 340 million treatable STIs and 2 million new HIV infections (Lusti-Narasimhan and Van Look), continuing to prove that education on STIs is imperative for decreased incidence. Additionally, it “is estimated that if every girl and boy received a complete primary education at least seven million new cases of HIV could be prevented in a decade” (Family, 2005).
3.0. WHAT IS BEING DONE TO ADDRESS THESE CHALLENGES AND BY WHOM In 1999, Inter-Agency Working Group on Reproductive Health in Crisis (IAWG) produced the first ever field manual addressing the issue of RH. The nearly 200 page manual contains issues such as GBV, STIs and safe motherhood. The IAWG is comprised of nearly 40 governmental and non-governmental organizations, with the objective to “increase access to good quality RH services for displaced people” (Austin, 11).
One key notable advancement in RH services is the development and implementation of the Minimum Initial Service Package (MISP). The MISP is a set of procedures which address RH needs in the earliest phases of emergencies, including coordination of staff and procedures for addressing GBV, STIs, and ensuring accessibility of condoms and other contraceptives. Another goal of the MISPs is to ensure clean delivery kits and develop a referral system of qualified medical providers (Austin, 11-12; RAISE 3, 2007).
The Sphere Minimum Standards, developed by NGOs following the Rwandan genocide, was an effort to establish clear guidance for humanitarian responders in all sectors (Austin, 12). The Reproductive Health Response in Conflict Consortium (RHRC) supports increased access to RH care through collaborative advocacy, development of technical resources and field support and is comprised of seven coalition members (Austin, 11).
The RAISE Initiative (Reproductive Health Access, Information and Services in Emergencies) is designed to “equip and renovate health facilities, provide supplies, and recruit and build the capacity of health staff to improve reproductive health throughout this region” (Austin, 14). Partners of the RAISE initiative include the American Refugee Committee, CARE, the International Rescue Committee, JSI Research and Training Institute, Marie Stopes International partners, Profamilia Colombia, Save the Children UNFPA and the Women’s Commission for Refugee Women and Children (Austin, 17).
4.0. HOW MAY TECHNOLOGY, IN PARTICULAR BIOTECHNOLOGY, PLAY A ROLE IN REPRODUCTIVE HEALTH IN AFRICA While data is not readily available drawing a correlation between the use of biotechnology and RH, there was a lot of research on the use of contraceptives as a technology, and the challenges of obtaining and correctly using contraceptives. In 2007, Population Services International estimated 2.6 million unintended pregnancies and 3,000 maternal deaths due to complications related to pregnancy and child birth were avoided because of increased education and use of modern contraceptives (PSI, 2008).
In Eritrea, almost nine in ten women know of at least one contraceptive method; however, use of such contraceptives in Eritrea show no increase since 1995 because of accessibility or restrictions on the woman’s choice of methods (NSEO: Eritrea, 2003). One study highlighted a drawback to considering modern contraceptive methods is a shortage in supply; “women are unable to depend on a steady supply of their chosen contraceptive” (Guy, 26).
In Swaziland, the three most widely used methods are injectables (17%), male condoms (12%), and oral pills (10%). Sexually active, unmarried women reported 65% use of any method (NSEO: Swaziland, 07). Still with all this knowledge of the vast benefits contraception methods have in RH, “RH services seem increasingly difficult to place on the health agenda” (Gakidou and Vayena, 387).
5.0. WHY ARE ETHICS AND HUMAN RIGHTS PERTINENT IN THE FUTURE OF GLOBAL MEDICINE “Poverty is not just about lack of money, but even more about lack of choice” (Family, 2005). With that lack of choice, many women and children are denied fundamental human rights. In the future of global medicine, policy makers and NGOs must recognize the grave implications of the lack of access and choice.
When considering human rights attention must be given to income generating opportunities for women and greater emphasis on education of women in Africa. Research shows that women denied control over their own reproductive rights, add economic strain on their families and communities due to decreased productivity from complications related to pregnancy or illness related to STIs (Krause, 2002). Studies conclusively confirm, when the woman’s rights are protected and supported, she will have a smaller family, space her children further apart and “invest more in nutrition, health, and education for each member of the household” (Family, 2005).
6.0. CONCLUDING THOUGHTS: SUGGESTION FOR IMPROVED REPRODUCTIVE HEALTH SERVICES For RH services to increase in effectiveness, findings conclude that the health infrastructure must be further developed and supported ensuring access and consistent availability of services by trained health care providers to both women in the general population as well as refugees and IDPs in Africa. Men must become involved in working to ensure the health of women in Africa is preserved by fighting social stigma, allowing women the choice to utilize modern contraceptives to protect against pregnancy and STIs, and allowing women to have control over their own reproductive health. Greater support for victims, and awareness of GBV, must be implemented. Resources and education tools need to be translated into local languages, and disseminated through areas of most access, such as markets or shops where people who cannot afford medical treatment can still have the opportunity to learn about RH services, where services are available and the reason for use.
We must explore and develop alternative income generation activities to prevent the increase in commercial sex and increase peer educator opportunities, making sexuality and reproductive health education a mandatory part of school curricula. Without access to good quality RH services, people living in emergencies are at risk of dying from reversible and treatable conditions and diseases.
Appendix 1
The following charts were created with retrospective data collected from nine individual Demographic and Health Surveys in Africa preformed through from 2002 - 2007. Many more countries had DHS reports published; however, the reports were not translated into English. A full listing of Demographic and Health Surveys may be found at http://www.measuredhs.com/aboutsurveys/dhs/start.cfm. For surveys included in this Appendix, specific situations are noted in the works cited page.
Women in each of the nine countries were asked to report on their utilization of antenatal (prenatal) services from a qualified health professional (doctor, nurse, midwife), use of delivery assistance from a qualified health professional, and utilization of post natal care within the first 48 hours of delivery. The responses were sorted based on women’s empowerment. The empowerment indicator was the woman’s response to the below three questions:
1) Number of decisions the married woman makes regarding her health care, making major household purchases, making purchases for daily household needs, and visits to her family or relatives.
2) Number of reasons for which wife beating is justified. Reasons are: burns the food, argues with him, goes out with telling him, neglects the children, and refuses to have sexual intercourse with him.
3) Number of reasons given for refusing to have sexual intercourse with husband. Reasons are: knows husband has a sexually transmitted disease, knows husband has intercourse with other women, and is tired or not in the mood.
Appendix 2
The model below from a WHO bulletin, illustrates “the key determinants of reproductive health status and indicates where they are affected by components of health sector reform. The following points should be noted. First, reproductive health should lie at the heart of all health-related activities. It is therefore at the centre of the model. However, in many countries there is a tendency to focus on reproductive health services as the goal rather than on reproductive health status and its importance as an approach” (Lubben, 2002).
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