Carrying the World on Her Back: Reproductive Health, HIV/AIDS, and Women’s Rights

Karen L Baird. Women and Politics around the World: A Comparative History and Survey. Editor: Joyce Gelb and Marian Lief Palley. Volume 1: Issues. Santa Barbara, CA: ABC-CLIO, 2009.

Many women around the world, but primarily in developing nations, suffer from unwanted, repeated pregnancies. Women endure sexual relations that are undesired and out of their control and bear many of the consequences that follow: sexually transmitted diseases (STDs), unwanted pregnancies, and HIV/AIDS, to name a few. Women, in desperation, seek illegal and unsafe abortions. Others die of AIDS. Women’s health, women’s rights, and women’s lives—all are at great risk in many countries.

In this essay, women’s health will be explored, in particular reproductive health issues, including HIV/AIDS. The common thread running through these issues is the gender inequity women of the world experience. Though the specific form the inequity takes differs from culture to culture and country to country, many women lack control over their bodies and thus their health and their lives. To improve women’s health, society must increase women’s rights, reduce gender inequality, and empower women.

Reproductive Health and Women’s Rights

Reproductive health issues are the leading cause of ill health and death for women worldwide (UNFPA 2005). Maternal mortality, illegal abortions, unsafe pregnancies, and unsafe deliveries all contribute to women’s poor reproductive health. But reproductive health and rights have received increased international focus and political support since the 1994 International Conference on Population and Development in Cairo. At this conference, women’s rights advocates secured a worldwide commitment to improving women’s reproductive health; 179 countries signed the Programme of Action, resulting in “[a] ‘new paradigm’ in population policy—shifting focus from a macro preoccupation with the impact of rapid population growth on economic development to a concern for individual rights in sexuality and reproduction with the benefit of all necessary information, their full consent and free of coercion” (DeJong 2000, 941-942). Support for improving women’s reproductive health was gained and reproductive rights were declared “human rights.”

Some of the agreements coming out of the conference include “[a]dvancing gender equality and equity,” “ensuring women’s ability to control their own fertility,” granting everyone “the right to the enjoyment of the highest attainable standard of physical and mental health,” and “universal access to health-care services, including those related to reproductive health care” (Cairo Programme of Action 1994). Though these goals have yet to be fulfilled, the 1994 Conference was a watershed event in the history of women’s reproductive rights.

Maternal Mortality, Disability, and Unsafe Abortion

Maternal mortality is very high for women in many developing countries. Though most Western and/or developed nations have very low maternal mortality rates, women in poorer nations are dying from unwanted pregnancies, illegal abortions, and repeated births. The World Health Organization (WHO) estimates that worldwide women run a 1 in 74 lifetime risk of maternal death. Put another way, the maternal mortality ratio (MMR) for the world is estimated to be 400 per 100,000 live births (WHO 2004, 1-2). By region, the MMR is the highest in Africa (830), followed by Asia (330), Oceania (240), Latin America and the Caribbean (190), and the developed countries (20) (WHO 2004).

What causes maternal mortality and disability? Technically, the causes are abortion, hemorrhage, obstructed labor, sepsis, and pre-eclampsia/eclampsia (AbouZahr 2003). But why do these conditions or procedures cause death and disability? It is primarily lack of access to quality health care, and with regard to abortion, illegality or unavailability of safe abortion services. For example, severe hemorrhage is estimated to occur in 10 percent of live births (AbouZahr 2003). It rarely occurs in the developed world, where childbirth primarily occurs in hospitals or other medical settings; it occurs principally in developing countries. The vast amount of complications arising from abortion occur from unsafe abortions, which occur when the procedure is performed in nonmedical settings and/or by unskilled personnel (AbouZahr 2003, 9).

The causes of death and disability are also more likely to occur in specific circumstances of women’s lives: when pregnancies are repeated and closely spaced, when pregnancies occur in younger women or girls, when pregnancies are unintended, and when women’s health is already compromised by other conditions. In addition

It is most often the poor and illiterate who pay the highest price for inadequate reproductive services; they do so with their lives, broken families, poverty, social isolation and chronic ill health. The human toll exacted from unintended and unwanted pregnancies is typically a hidden one, buried under often age-old social norms governing the roles of women in society. Economic marginalization, poor education, and geographical isolation contribute further to inconsistent reportage, but are by no means the only indicators of high maternal mortality rates. (Global Health Council 2002, 23)

Early marriage, gender inequality, lack of control over sexual decision making, and violence against women also exacerbate these factors.

Abortion, when performed in a safe medical setting by trained personnel, is very safe and women suffer few complications; in fact, in the United States, the procedure carries less risk than carrying a baby to term and giving birth. Sadly, many women live in countries in which abortion is illegal or legal only under certain circumstances. For example, in 69 countries, abortion is prohibited or is only legal to save the life of the woman; this is the law for 29 percent of the world’s population (Center for Reproductive Rights 2007).

If women cannot get a legal and safe abortion, they resort to unsafe ones. One study estimated that from 1995 to 2000, three-fourths of unintended pregnancies were ended by abortion in the world (Global Health Council 2002). Many complications and sometimes death result from unsafe abortions (Ahman and Shah 2004; Global Health Council 2002). Complications include hemorrhage, perforated uterus, blood poisoning, and secondary complications such as gangrene or acute renal failure; long-term complications include chronic pelvic pain, pelvic inflammatory disease, and infertility. For every woman who dies as a result of unsafe abortion, it is estimated that 30 more will suffer chronic disability (Global Health Council 2002, 30). An estimated 14 percent of maternal deaths can be attributed to abortion complications, and these deaths are the highest in Africa and South Asia where services are limited (Global Health Council 2002).

Family planning plays a large role in reproductive health. Singh et al. (2003) report that more than half of women in developing countries are at risk for unintended pregnancy; many of these women are using no method of birth control or are using traditional methods that have very high failure rates. Unmet need for contraception is fairly high in developing countries. Sedgh et al. (2007) and Seltzer (2002) estimate that 17 percent of women of reproductive age have an unmet need for contraception; 24 percent of married women in Sub-Saharan Africa have an unmet need for contraception (Sedgh et al. 2007). The most common reason women have unmet need is difficulty in accessing supplies and services. Included in this are concerns about side effects, health effects, and the inconvenience of specific methods (Sedgh et al. 2007). Meeting this contraceptive need is very cost-effective, increases women’s equality and economic empowerment, and improves their health; in addition, HIV transmission can be reduced. Providing contraception to all who desire it is an easy, inexpensive, and effective way to improve women’s lives.

Reproductive Health Policies, Programs, and Services

Family planning policies are guided by international conferences, organizations, international agreements, and individual countries, and are implemented through international organizations such as the United Nations Population Fund (UNFPA), WHO, the World Bank, and the International Planned Parenthood Federation (IPPF) as well as country governments and nongovernmental organizations (NGOs). The UNFPA works to improve women’s reproductive health, noting the “close links between sustainable development and reproductive health and gender equality” (UNFPA 2007). It supports family planning services and helps countries provide them. IPPF works in 180 countries, has 58,000 member clinics, and operates on the principles that sexual and reproductive rights are human rights, that women should be in control of their reproductive lives, and that choice should be the basis of all services (IPPF 2007).

Family planning programs are fraught with controversy. First, governments often view family planning programs as population control programs. Population growth or control is often viewed in connection to economic development, among other things, and population growth is often seen as a hindrance to economic development. In this perspective, women and the control of their reproduction are viewed as the back upon which a country’s economic, social, and political development rests. But women desire access to family planning so they can freely decide the number and spacing of their children, if any, and they do not want governmental control or pressure. Thus, family planning services are viewed in very different ways by different stakeholders: as health policy, as population control measures, as women’s rights, and so on. Second, contraception has become intertwined with the controversy surrounding abortion. Some see abortion as part of family planning services, and others, such as UNFPA and U.S. Agency for International Development (USAID), hold it as separate. The Catholic Church, pro-life groups, religious fundamentalists, and some Islamic groups are vehemently against abortion; but some support contraception and others do not, such as the Catholic Church (Seltzer 2002). The interplay of abortion and family planning services is exemplified by the “Global Gag Rule.”

The U.S. government provides the largest amount of money for international family planning, primarily through USAID (Baird 2004). This is to be applauded, but some of the restrictions the United States attaches to the funds are actually harmful to the provision of family planning services. The Global Gag Rule, or Mexico City Policy, has been instituted by most U.S. presidents since Ronald Reagan. This rule prohibits NGOs that accept U.S. funds from speaking about or supporting abortion as a method of family planning. This applies to all NGOs, no matter if abortion is legal or illegal in the country in which it works. Many organizations refuse to abide by the restrictions and refuse the U.S. funds, which severely curtails their ability to provide services. In Kenya, Marie Stopes International Kenya and the Family Planning Association of Kenya have closed clinics, laid off staff, and raised prices to fill the gap after they refused to accept U.S. funds (Global Gag Rule Impact Project 2007). The United States also cut off payments to the UNFPA, alleging that it was supporting coercive abortion practices in China. Family planning services have been cut in many countries because of the Global Gag Rule, and because many HIV/AIDS services are also provided at family planning clinics, the rule also hinders much needed HIV/AIDS prevention programs.

As outlined by the Global Health Council (2002) , one risk factor for maternal mortality and disability is the lack of government commitment. Many countries do not place priority on family planning, and many even hamper the provision of such services. For example, in Manila, Philippines, in 2000 an executive order was issued to all city health programs to encourage only “natural” family planning: “promot[ing] responsible parenthood and uphold[ing] natural family planning … as a way of self-awareness in promoting the culture of life while discouraging the use of artificial methods of contraception” (Linangan et al. 2007). In 2003, Peru adopted a law that protects the rights of all Peruvians from the moment of conception (Center for Reproductive Rights 2005). Other countries have recently taken progressive steps. In 2002-2003, Benin, Mali, and Colombia adopted laws specifically guaranteeing reproductive rights and reproductive self-determination for all (Center for Reproductive Rights 2005; see Seltzer 2002 for other examples). In conclusion, improving women’s health and thus their lives is a matter of commitment. We have the knowledge, technology, and money to do so; what is lacking in some cases is the dedication and the provision of services.

Women and HIV/AIDS

The Global Fund, the World Bank, UNAIDS (the Joint United Nations Programme on HIV/AIDS), and many other international organizations state that in order to combat HIV/AIDS, the “feminization” of the epidemic must be addressed. The UNAIDS Global Report states that the first major, present challenge is “[t]he female face of the epidemic” (UNAIDS 2004a, 4). Unfortunately, in today’s world, HIV/AIDS is one of the most dire health problems for many women. Though HIV can be transmitted in ways other than sexual contact, the problem of HIV/AIDS is a problem of sex for most women in the world.

Sub-Saharan Africa continues to bear the brunt of the global epidemic. Nearly two-thirds of all people with HIV live in Sub-Saharan Africa, and the largest numbers live in southern Africa. One-third of all people with HIV globally live in southern Africa, and in 2005 34 percent of all deaths due to AIDS occurred there (UNAIDS 2006).

In Sub-Saharan Africa, women are more likely—at least 1.3 times more likely—to be infected with HIV than men. Stated another way, some 55-58 percent of those infected with HIV/AIDS in Sub-Saharan Africa are women (UNAIDS 2004a). The unevenness is the greatest for young women aged 15-24, who are about three times more likely to be infected than young men of the same age. This situation is unlike many other areas or countries that have large HIV/AIDS populations. In locations where heterosexual sex is the dominant mode of transmission, HIV/AIDS statistics are similar to those in Sub-Saharan Africa, and in areas such as North America, Eastern Europe, and Central Asia, women are becoming infected at alarming rates (UNAIDS 2004a). Thus, what are the dynamics of gender and HIV/AIDS? Why are women more vulnerable and why do they have such high HIV/AIDS infection and death rates?

There are two basic issues: physiological, but more importantly, social/cultural issues. Physiologically, women are at a greater risk than men of becoming infected during sexual contact. The large area and thinner lining of the vagina make women more vulnerable. In infected men, semen and ejaculate contain a high concentration of HIV, and semen is more effective at transmitting HIV than vaginal fluids. The presence of other sexually transmitted diseases (STDs) also puts women at greater risk; STDs that cause ulcerations in the vagina (genital herpes, syphilis) open pathways for the entry of HIV.

The more important factors are cultural or social ones, namely the inequality of women. In most countries, women have less access to power and are viewed as unequal—socially, culturally, and legally—in the public world and in private relationships. The inequality of women has long existed with many severe consequences. With the HIV/AIDS epidemic, this inequality often costs women their lives. There are many factors in this story—unfortunately, the inequality of women is vast, pervasive, complex, and multifaceted.

Some of the important factors of vulnerability for women include violence, coerced sex, transactional sex, rape, economic dependence, lack of sexual decision making, lower education levels, marriage (especially early marriage), polygamy, lack of inheritance rights, and overall cultural norms of gender inequity; a few of these issues will be examined here. World AIDS Day 2004 was devoted to women and girls; “Have you heard me today?” was the slogan, which was used to highlight “the way women’s inequality helps fuel the transmission of HIV and increases the impact of AIDS” (UNAIDS 2004a).

In sexual relationships of any kind—in marriage, out of marriage, and so on—women and girls often lack the power to abstain from sex or to insist on condom use. In Zambia, for example, only 11 percent of women surveyed believed they had the right to ask their husband to use a condom, and in Mumbai, India, many women believed the economic consequences of losing a long-term relationship far outweighed the potential health consequences of staying in the relationship (Gupta 2002). Other studies have shown that women feel obliged to provide sex to their husbands “on demand.” These are the conditions in which HIV thrives. Because many women are married at fairly young ages in developing countries, special attention must be paid to preventing HIV infection within marriages.

Marriage has been noted as a risk factor for women with regard to HIV/AIDS. More than four-fifths of new HIV infections in women result from sex with their husband or primary partners (UNFPA 2005). In Sub-Saharan Africa, an estimated 60 to 80 percent of HIV-positive women were infected by their husband (UNFPA 2005). Married couples are likely to engage in unprotected sex, especially if children are desired. For younger women, husbands tend to be much older, more sexually experienced, and thus more likely to be HIV infected and transmit it to their new wives. Additionally, the cervix of younger women is not fully formed and more susceptible to infection. Given these circumstances, marriage can be quite hazardous for many women. In the face of such findings, programmatic efforts to encourage “abstinence until marriage” are ineffective for many women because women are most at risk of contracting HIV/AIDS after marriage.

Violence against women is also highly correlated with HIV/AIDS. Women who are in abusive relationships often do not have decision-making power with regard to sexual relations. Instances of rape and coercive sex are also situations in which women cannot demand condom use. In many countries, especially South Africa, rape and coercive sex are more common than consensual sex for young women (Fox 2003; Human Rights Watch 2001, 2003a; UNAIDS 2004a). Couple these factors with ignorance about HIV, “cultures of silence” (Gupta 2000), and stigma—stigma related to sex and HIV/AIDS that keeps young women from becoming informed—women are becoming infected with HIV/AIDS at alarming rates in many countries.

“Transactional sex,” or sexual relationships in exchange for gifts, is a survival strategy used by some young women. Many women and girls find themselves using sex as a commodity in exchange for goods, services, money, accommodation, or other basic necessities; quite often this involves younger women with older men and is hence called “cross-generational” sex (Halperin and Epstein 2004). Such sexual transactions commonly involve multiple partners and older male partners, reflecting men’s superior economic position and access to resources and women’s difficulties in meeting basic needs. Some research in parts of Africa, for example, has found that older men often help girls’ families meet essential needs such as school fees, transport costs, and groceries (Baylies and Bujra 2000; Kaufman and Stavrou 2002). Though such relationships have always been risky, in the era of AIDS they can mean death. Older men are much more likely to be HIV positive and to infect the younger women. The older men choose younger women for many reasons, one being that they are much less likely to have HIV. The younger women find it difficult to insist on condoms and potentially lose the relationship and income.

HIV/AIDS Policies, International Programs, and Prevention Efforts

International organizations, governments, and private donors devote billions of dollars to fighting HIV/AIDS in low- and middle-income countries (UNAIDS 2006). International funding has steadily increased over the years, but it is inadequate: UNAIDS estimates that over $22 billion will be needed in 2008 to fight HIV/AIDS (UNAIDS 2006). One of the latest programs is the U.S. President’s Emergency Plan for AIDS Relief, which has recently committed $15 billion to fight HIV/AIDS (Kanabus 2005).

Unfortunately, many prevention and education programs do not take gender and women’s issues into account. Programs such as “ABC”—“abstain, be faithful, or use a condom”—do not speak to the reality of women’s lives. Choosing to abstain from sex or to use a condom are the very issues over which many women have little control. “Many HIV strategies assume an idealized world in which everyone is equal and free to make empowered choices, and can opt to abstain from sex, stay faithful to one’s partner or use condoms consistently” (UNAIDS 2004a). Gupta (2005) discusses an “ABC PLUS” approach that adds women’s concerns to the framework, but few programs have adopted such a model (UNAIDS 2004b).

Microbicides are one hope for women and their fight against HIV/AIDS. A microbicide is a gel or foam that a woman inserts into her vagina before sex that will prevent her from becoming infected. Microbicide research has been progressing and, as of 2007, the Global Campaign for Microbicides (2007) reports that 10 clinical trials are underway. The campaign estimates that a microbicide could be available by the end of the decade but this may be overly optimistic. Microbicides are very important because women control their use, which is, more effective than relying on a man to put on a condom. The only other female-controlled prevention method, the female condom, has proven to be unpopular. Microbicides have the potential to be undetectable to a male sex partner.

Putting Women at the Center of the Response

If it can be said, as it can, that by the year 2020, the number of deaths from AIDS in Africa will approximate the number of deaths, military and civilian combined, in both world wars of the 20th century, then it should also be said that a pronounced majority of those deaths will be women and girls. The toll on women and girls is beyond human imagining; it presents Africa and the world with a practical and moral challenge which places gender at the centre of the human condition. The practice of ignoring a gender analysis has turned out to be lethal…. For the African continent, it means economic and social survival. For the women and girls of Africa, it’s a matter of life or death.

—Stephen Lewis, United Nations secretary-general’s special envoy on HIV/AIDS in Africa, July 2002 (as quoted in Human Rights Watch 2003b).

To combat HIV/AIDS, programs are needed that will empower women, reduce violence and rape, and change the culture of gender inequality. These are hefty goals and to achieve them will take fierce commitment and dedication on the part of all involved. Of course, goals such as eradicating gender inequality are fairly large and long term in nature; long- and short-term objectives (to immediately stop transmission) are often difficult to address. Some analysis is available of women’s collective efforts to address these gender dimensions (see Baylies and Bujra 2000; Booth 2004; Campbell 2003; Fox 2003; Chavkin and Chesler 2005; UNFPA 2005; UNIFEM 2006). One example is the United Nations Development Fund for Women’s (UNIFEM) recent community-led initiatives, one in India and another in Zimbabwe, in which they developed gender equality zones (UNIFEM 2006). In Mutoko, Zimbabwe, UNIFEM first conducted a needs assessment of women in the village, and then initiated an “integrated programming approach to address gender, social, political, and economic empowerment needs” (UNIFEM 2006, 6). The program trained a group of men and women on gender, human rights, and safe sex negotiations so they could become peer counselors. They educated and assisted women to begin income-generating activities. They also raised awareness on the gender dimensions of home-based care, which was provided by Padare, a men’s organization. Community leaders, primarily male, were involved in the early stages of the project’s development, which increased their support. They found that the term “gender equality” was imbued with negative overtones in the community, implying women wanting to challenge men, so they presented a consistent message that gender equality was “a means of promoting harmonious relationships” that would equally benefit women and men. Women and men were trained as gender trainers and then worked with members of their respective genders, helping them understand how women’s inequality makes them vulnerable to HIV/AIDS and showing them how to use condoms and avoid risky behavior. All members of the community were involved—community leaders, men, women, and youth—and they marketed the messages in culturally appropriate manners, thus helping to spur its success (UNIFEM 2006).

Successful programs need to address many factors. One is to challenge the construction of sexuality and its gendered dimensions (Baylies and Bujra 2000). Women’s needs are often subordinated in intimate relations and this forms the backdrop for HIV/AIDS. Masculine norms regarding sexuality have to be confronted but in sensitive manners so as to not instigate alienation. Gendered power relations regarding women’s economic dependence also have to be addressed, as women need to have a sense of social and economic empowerment to be able to confront their intimate partners—risking the loss of home, money, and children is too daunting for many women who have no other recourse. And the connection of these factors—sexuality, economics, and women’s inequality—is crucial for addressing and preventing HIV/AIDS for women (Baylies and Bujra 2000).

Geeta Rao Gupta (2005) states, “[W]e knew at least a decade ago that gender inequality would place girls and women at special risk and that their vulnerability would fuel the AIDS epidemic…. What went wrong?” (1). Many people are asking such questions (see Epstein 2007 for a review of various answers). We can only hope to continue to learn from and to build on successful programs.

Women’s Health, Women’s Rights, and Women’s Lives

The most invigorating and promising hope for women is the application of human rights to women—women’s rights as human rights. To improve women’s health, we must improve women’s lives. To improve women’s lives, we must end inequality and fully implement women’s rights. In the area of health, reproductive rights and women’s right to health were articulated in the 1994 Cairo Programme of Action, as discussed earlier. According to the 1995 Beijing Platform of Action:

The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationships between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent, and shared responsibility for sexual behavior and its consequences.

In 2000, the United Nations created eight Millennium Development Goals, including promoting gender equality and empowering women, improving maternal health and mortality, and combating HIV/AIDS (United Nations 2007). International agreements, programs, covenants, and goals to end gender inequality and implement women’s rights abound, but the day-to-day lives of many women have changed very little.

Challenging a very long and complex history of women’s subordination is extremely difficult, but a few things are clear. Women’s health cannot solely be viewed in medical or behavioral perspectives; sociocultural, political, and economic constraints have much greater effects. Such constraints affect everyone, but with gender inequality, the constraints are particularly harmful to women. When instituting programs, all stakeholders of the community need to be involved, and they need to be involved from the initial program design stages. Men and women have to be involved for change to happen; neither group can be successful on its own. All efforts have to be grounded in a culturally appropriate and culturally sensitive manner, but what does this constitute? Determining how to create and implement a culturally sensitive program can often be very difficult. One has to challenge the culture of gender inequality while remaining “culturally appropriate.” Real tensions exist between culture, religion, and rights (Chavkin and Chesler 2005). And change has to happen at all levels—at the top level in terms of government, laws, and court systems, and at the bottom level of the rural village and the day-to-day lives of the men and women who inhabit them. “Human rights begin in small places close to home” (Chavkin and Chesler 2005, 270, quoting Eleanor Roosevelt). We must improve women’s rights to improve their lives and thus their health.