Reproductive Health and Reproductive Rights
• Reproductive Health
Comments from Customer
Use at least 1 of the articles from the Gender and Global Restructuring textbooks in 1 of your answers. You need to state the author’s name (you do not need to cite the year or article title) and tie one of their main points or ideas into your answer. for each of the explain each one in 5-6 pargrahs
• Reproductive Health
- Reproductive Health
Reproductive Health and Reproductive Rights
“… Good health is essential to leading a productive and fulfilling life, and the right of all women to control all aspects of their health, in particular their own fertility, is basic to their empowerment.”
—United Nations Fourth World Conference for Women, Beijing Platform for Action, para. 92
This woman is from Ethiopia, a country in sub-Saharan Africa where women have a life expectancy of age 52, female genital mutilation is prevalent, and maternal mortality and disability are high. Women’s reproductive health and rights are critical issues worldwide although intersectionality and context lead to variation.
he focus of this chapter is women’s reproductive health and reproductive rights.1 Reproductive health includes an array of topics and concerns including family planning, reproductive tract infections such as sexually transmitted diseases and HIV/AIDS, infertility, maternal mortality (pregnancy-related death), maternal morbidity (pregnancy-related illness and disability), unsafe abortion, reproductive tract cancers, and traditional harmful practices such as female genital mutilation/female genital cutting (FGM/FGC). Globally, HIV/AIDS and maternal deaths are the leading cause of death for women of reproductive age (WHO, 2013). Many of these deaths and health conditions are entirely preventable. Reproductive rights refer to the right to reproductive health care and the right to reproductive self-determination (Center for Reproductive Rights, 2006).
At the 1994 International Conference on Population and Development (ICPD), 179 countries agreed that sexual and reproductive health and reproductive rights are fundamental human rights. The ICPD Programme of Action (1994, para 7.3) proclaimed reproductive rights as including the right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion, and violence. Reproductive rights are consistent with basic human rights agreed upon at major international and regional UN conferences by UN member nations and are incorporated into international development agendas, such as the Millennium Development Goals and the Sustainable Development Goals. For instance, Goal 5 of the UN’s Sustainable Development Goals (Achieve Gender Equality and Empower All Women and Girls) includes Target 5.6, “Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action.” Activists often frame women’s reproductive health and choice in terms of human rights agreements and human rights law to bring about legal and policy changes in their countries. Box 3.1 displays twelve human rights that are consistent with reproductive rights.
Reproductive rights mean having reproductive control. According to Jacobson (1992), a woman’s reproductive control can be determined by her answers to the following questions: Can she control when and with whom she will engage in sexual relations? Can she do so without fear of infection or unwanted pregnancy? Can she choose when and how to regulate her fertility, free from unpleasant or dangerous side effects of contraception? Can she go through pregnancy and childbirth safely? Can she obtain a safe abortion on request? Can she easily obtain information on the prevention and treatment of reproductive illnesses?
“When a woman is denied her reproductive rights—when she is denied obstetric care, birth control, the facts about reproductive health, or safe abortion … she is denied the means to direct her own life, protect her health, and exercise her human rights.”
Center for Reproductive Rights
Women’s reproductive rights are a critical global feminist issue because for millions of women worldwide the answer to some or all of the above questions is “no,” andhis affects women’s status, power, economic situation, and health. Women cannot fully realize their human rights without their reproductive rights. Hundreds of thousands of women die or are seriously disabled every year because they lack reproductive control. Without reproductive control, women are at greater risk for sexually transmitted infections, unwanted pregnancy, and unsafe abortion (UN, 2016a). Lacking reproductive control, many women have multiple children in close succession and spend their adult lives in poverty while pregnant, nursing, and caring for their children. Their important maternal responsibilities limit their education and their participation in the paid labor force and in the formal political sphere, thereby contributing to their lower power and to gender inequality. Figure 3.1 shows the factors that constrain women’s reproductive rights and health that are discussed in this chapter.
Although the focus of this chapter is women’s reproductive health and rights, there are many ways in which health risks, experiences, and outcomes are different for women and girls compared to men and boys (WHO, 2007). Some of these gender health disparities are a consequence of gender inequality. For example, gender inequality leads to many health hazards for women, including intimate partner violence, sexual violence, and HIV/AIDS (WHO, 2009). Women suffer from malnutrition at twice the rate as men, and girls are twice as likely to die from malnutrition than are boys (Food and Agriculture Organization, 2016). In the United States, medical practice and research are disproportionately focused on men (Johnson, Fitzgerald, Salganicoff, Wood, & Goldstein, 2014). It is also important to recognize the role of intersectionality in women’s health. Age, class, ethnicity, culture, region, sexual orientation, gender identity, and religion
American women (Center For Reproductive Rights, 2016a).
“Men have a stake in reproductive rights through their multiple roles as sexual partners, husbands, fathers, family and household members, community leaders, and gatekeepers to health information and services.”
Although discussions of reproductive rights tend to focus on women because their health and equality are more affected in comparison to men’s, it’s important to recognize that reproductive rights and choice are not only women’s issues. As sexual partners, husbands, fathers, and family members, women’s reproductive choice and health significantly impact men (United Nations, 2014). Men also need family planning and reproductive health information not only for women’s well-being, but also for their own and their family’s well-being.
Maternal Mortality and Morbidity
Maternal mortality refers to the death of a woman while pregnant or within forty-two days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management. Every year, over 300,000 women die from pregnancy-related causes, about one every two minutes, leaving hundreds of thousands of children motherless and vulnerable (WHO, 2015a). According to the United Nations Population Fund (UNFPA, 2016a), the majority (75 percent) of maternal deaths arise from five direct and preventable causes: (1) hemorrhage (severe bleeding), (2) sepsis (systemic infection), (3) obstructed labor, (4) hypertensive disorders such as preclampsia and eclampsia, and (5) unsafe abortion. However, about 25 percent of maternal deaths are due to indirect causes such as diseases that are more likely to be fatal in combination with pregnancy, such as malaria, anemia, cardiovascular disease, diabetes, and AIDS.
Maternal mortality rates by region are shown in Box 3.2, and rates by country can be found in the Appendix. Maternal mortality ratios (the number of women that don’t survive childbirth compared to the number that do) show that of all health indicators, the greatest gap is between rich and poor countries; 99 percent of maternal deaths occur in developing countries, primarily in sub-Saharan Africa and Southern Asia (UNFPA, 2016a).2 Maternal mortality rates also differ within countries. In the United States, for instance, the rate is 11.8 per 100,000 live births for white women and 41.1 for African American women, and in Texas the rate is 35.8, while in California, it’s 15.1 (Centers for Disease Control and Prevention, 2016; Mcdorman, Declercq, Cabral, & Martin, 2016). These health disparities occur mostly because quantity and quality of reproductive health care available to pregnant women—as well as women’s knowledge of and ability to take advantage of the services that are available—are unequally distributed. For example, in the United States, the state of California has dedicated more resources to improving maternal health, whereas Texas has cut reproductive health care services. In sub-Saharan Africa and Southern Asia, only half of pregnant women receive adequate care during childbirth (United Nations, 2015a). Generally, wealthier nations, urban locations, and social groups with higher incomes and education have lower rates of maternal mortality (Dixon-Mueller, 1993).
The good news is that maternal mortality has dropped 44 percent in the last 25 years. Since 1990, 157 countries have reduced maternal mortality, and only 17 saw an increase (WHO, 2015a). The United States was the only industrialized nation that experienced an increase; from 2000 to 2014, the rate increased by 27 percent (Mcdorman et al., 2016). Nine countries achieved at least a 75 percent reduction (Maldives, Bhutan, Cambodia, Cabo Verde, Iran, Timor-Leste, the Lao Democratic Republic, Rwanda, and Mongolia). The dramatic global reductionin maternal mortality reflects a commitment made by United Nations Member States in 2000 to the Millennium Development Goals (MDGs), the focus of which was to end poverty. These goals included a target of reducing maternal deaths by three-quarters by 2015, which resulted in many national, international, and grassroots programs and initiatives to improve maternal health. In 2015, world leaders committed to the UN’s Agenda for Sustainable Development for 2030, which includes seventeen sustainable development goals (SDGs), each with multiple targets. One of these, Goal 3: Ensure Healthy Lives and Promote Well-Being for All At All Ages, includes a target of reducing the global maternal mortality ratio from the 2015 level of 216 per 100,000 births to less than 70 per 100,000 births by 2030.
Reaching the 2030 target requires both the will and the resources to address the causes of maternal death. Improved access to health care during pregnancy (known as prenatal care or antenatal care), skilled birth attendants, timely access to emergency obstetric care, and postnatal care are key to preventing maternal deaths. Evidence for this can be seen in the 44 percent drop in maternal mortality in developing countries from 1990 to 2015 (World Health Organization, 2015a). During that period, the percentage of women in developing nations receiving antenatal care increased from 64 percent to 83 percent, and the percentage of births attended by skilled health professionals increased from 57 percent to 90 percent (United Nations, 2015a). Reducing child marriage also reduces maternal mortality, since child brides often become pregnant before their pelvises are fully developed
(complications from pregnancy and childbirth are the leading cause of death among girls 15–19 in low- and middle-income countries; United Nations, 2015a). Access to safe, effective, and affordable contraception also reduces maternal death by allowing women to avoid multiple pregnancies in close succession and by reducing the need for women to seek unsafe abortions. Safe and legal abortion also reduces maternal death (this is discussed in more detail later in the chapter).
“Making motherhood safer is a human rights imperative.”
United Nations Population Fund (UNFPA)
For each woman who dies as a result of pregnancy or childbirth, another twenty to thirty survive but suffer from health conditions or disability arising from pregnancy or childbirth (Firoz et al., 2013). The term for these pregnancy-related health conditions is maternal morbidity. A variety of such health conditions and disabilities negatively impacts women’s well-being. These include uterine prolapse, a condition wherein the supporting pelvic structure of muscles, tissue, and ligaments gives way, and the uterus drops into or even out of the vagina. The condition occurs due to giving birth at a young age, difficult prolonged labor, frequent pregnancies, inadequate obstetric care, and lack of rest and engaging in strenuous work during and soon after pregnancy. Often accompanied by chronic and severe back pain and incontinence, the condition makes daily chores and sex difficult or impossible.
Uterine prolapse is usually a condition suffered by older women, but in regions where early marriage and pregnancy are common, the condition also affects young women. For example, an estimated 1 in 10 Nepalese women experience uterine prolapse, 44 percent of them under 30 (UNFPA, 2009). In Nepal, high levels of gender discrimination mean that many women don’t have the power to delay marriage, deny their husbands sex, control the timing and spacing of their children, seek medical care without their husband’s permission, or rest and reduce their workloads during pregnancy and after giving birth (Amnesty International, 2014). Most women suffer in silence and shame. After a successful lawsuit filed against the government by women’s rights activists, the government began funding surgeries and nonsurgical treatments. However, women’s advocacy groups criticize the government’s efforts as inadequate and too heavily focused on treatment rather than prevention (Das, 2014).
“I gave birth to my first daughter and after six days I went to bring millet from the farm. I was carrying a load of millet and I felt that something was coming out of my vagina.”
Kesar Kala Malla, Mugu District, Nepal
Depression, anemia, and obstetric fistula are also common pregnancy-related disabilities. Obstetric fistula, a childbirth injury, is a current focus of activism and advocacy efforts. It arises from prolonged and obstructed labor, often in young women who are not physically mature or in those who have a small pelvis from nutritional deficits during childhood. Fistula occurs when tissues between the vaginal wall and the bladder or rectum are torn during childbirth, resulting in incontinence, infections, ulceration, and nerve damage (fistula can also arise from rape or other sexual violence). Access to medical care has virtually eliminated fistula in industrialized countries, but an estimated two million women live with fistula in developing countries, with an additional 50,000 to 100,000 new cases occurring annually (UNFPA 2016b). The babies usually die from the obstructed labor, and the women are often ostracized and abandoned because fistula makes personal hygiene difficult to
“Obstetric fistula is one of the most devastating consequences of unequal access to health care during pregnancy and childbirth. Its persistence is a sure signal that health systems in many low-income countries are failing to meet the needs of women.”
Campaign to End Fistula
BOX 3.3 Agaicha’s Obstetric Fistula Experience
Agaicha lives in Mali, a country in sub-Saharan Africa with a high maternal mortality rate (587 per 100,000 births). Over 50 percent of women are married and have their first child before age 18.
“When I was 15, my father arranged my marriage. Soon after I married, I was pregnant. I spent five days laboring in the hands of the village women, battling for my life and battling to give birth. On the sixth day, my uncle took me from the village to the nearest health center, 65 km (about 40 miles) away where an unskilled health provider pulled the baby out by force. My son was dead. The following day, my torment started: I could not control my bladder anymore.
After I came back from the health center, my friends and most of my in-laws family deserted me. At age 16, this rejection and isolation was more painful and destructive than my physical handicap. I thought that if my mother had been alive, she would have taken good care of me. But she had died of a massive hemorrhage while in labor. Things went on like this for two years. Then my father heard on the radio that it’s possible to treat this sickness. He gave up everything he had to take me to Gao and stay with me there for 45 days.
When my husband heard that I was healed, he sent a delegation to pick me up, but I refused and fled. The manager of a nongovernmental organization (NGO) called Greffa took me in. Now, I help this NGO to help other women who are suffering from the same disease. I also raise awareness about this condition in villages.”
Adapted from Fistula Care Plus https://fistulacare.org/stories-from-the-field/survivor-stories/Mali/agaicha/.
maintain. Many are unaware that treatment is possible. Box 3.3 tells the story of Agaicha, a Malian woman who experienced fistula.
The UNFPA’s (United Nations Population Fund) Campaign to End Fistula operates in 50 countries across Africa, Asia, the Arab region, and Latin America and emphasizes a variety of preventative measures, including increasing family planning services, improving access to maternal health care, reducing early marriage, and improving girls’ nutrition. In addition to prevention, the UN and NGOs, including the Fistula Foundation, One by One, WADADIA, Engender Health, and Amref Health Africa, offer and promote programs to repair physical damage through surgery (a simple surgery that costs about $400 can repair most fistulas) and treat emotional damage through counseling.
“In 1948, the Universal Declaration of Human Rights of the United Nations said: ’Everyone has the right to … medical care. Motherhood and childhood are entitled to special care and assistance.’ Therefore, we also see fistula as a basic violation of human rights, a call to action to cry out against this injustice.”
Worldwide Fistula Fund
Female Genital Mutilation/Female Genital Cutting
Another source of reproductive health problems for women is the practice of female genital mutilation (FGM), also known as female genital cutting (FGC) and female genital circumcision (FC). The terminology is a matter of some debate, as some feel the label FGM is culturally insensitive. Others feel that FGC and FC are too mild in their connotations, and that FC suggests that the practice is equivalent to male circumcision when in fact it is far more severe. UNFPA and UNICEF currently use a hybrid term FGM/FGC.
May 23 is the International Day to End Obstetric Fistula (#FistulaDay), which promotes action towards treating and preventing obstetric fistula.
FGM/FGC refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or other nonmedical reasons (UNFPA, 2015a). In most cases, a midwife or practiced village woman performs FGM/FGC using various tools (knives, razors, scissors, rocks, glass) that may or may not be sterilized (UNICEF, 2013). Anesthesia and antibiotics aren’t usually used unless a medical professional performs the procedure (that is more common in Egypt, Sudan, and Kenya than in other countries). Some feel that this medicalization of FGM/FGC is of concern because medical professionals hold power and status, thereby legitimizing the practice and suggesting it’s beneficial for women and girls’ health (UNFPA, 2015b).
“Circumcision makes women clean, promotes virginity and chastity and guards young girls from sexual frustration by deadening their sexual appetite.”
Female defender of FGM in Kenya
There are four types of FGM/FGC (UNICEF, 2013; World Health Organization, 2016):
Type I: Clitoridectomy. Partial or total removal of the clitoris. Sometimes referred to as sunna.
Type II: Excision. Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.
Type III: Infibulation. Narrowing of the vaginal opening through the creation of a covering seal formed by cutting and stitching the labia minora or labia majora, with or without clitoridectomy. The urethra and vaginal opening are almost completely covered.
Type IV: Other forms involving no removal of tissue or alteration of the genitalia, such as pricking, piercing or incising, stretching, burning of the clitoris, scraping of tissue surrounding the vaginal orifice, cutting of the vagina. Sometimes called symbolic circumcision.
“You have one woman holding your mouth so you won’t scream, two holding your chest and the other two holding your legs. After we were infibulated, we had rope tied across our legs so it was like we had to learn to walk again. We had to try to go to the toilet. If you couldn’t pass water in the next 10 days something was wrong.”
Zainab, who was infibulated at age 8In some areas, FGM/FGC is carried out during infancy, but in others it occurs during childhood, at the time of marriage, during a woman’s first pregnancy, or after the birth of her first child. It is usually performed before age 15, and about 50 percent of the time, before age 5 (UNICEF, 2013). An estimated 2 million women alive today have already undergone the practice, and if current trends continue, 15 million more girls will be cut by 2030 (United Nations, 2016b; UNFPA, 2015b). Box 3.4 lists the countries where FGM/FGC is commonly practiced. Most of these are in sub-Saharan Africa, but FGM is also practiced in parts of the Arab countries of Iraq and Yemen, and in Southeast Asia in Indonesia. Due to international migration, the number of girls and women who have undergone FGM/FGC (or are at risk for it) has grown in Western Europe and in the U.S., Canada, Australia, and New Zealand. Although religion is sometimes used to justify FGM/FGC, it is practiced by Muslims, Christians, Ethiopian Jews, and Copts, as well as by followers of certain traditional African religions (UNFPA, 2015b).
“FGM is one of the worst forms of violence against women.”
Zipporah Kittony, Member of Kenya’s Parliament
The negative health consequences of FGM/FGC are often significant, and it offers no medical benefits. Short-term medical consequences include severe pain, hemorrhage, infection, shock, and death. The long-term consequences of narrowing the vaginal opening include urinary retention and infections, difficulty menstruating, and difficulty having and enjoying sex (World Health Organization, 2016). Genital infections, reproductive tract infections, and obstetric fistula are alsolong-term health risks (Berg et al., 2014k). Women who have undergone FGM/FGC are at significantly higher risk for adverse obstetric outcomes such as Caesarean sections, hemorrhaging, prolonged labor, instrumental delivery, obstetric tears, infant trauma and death, and maternal mortality, with the risks especially great for those with more extensive FGM/FGC forms (Berg &Underland, 2013).
“I will circumcise my daughter because I don’t want people to say that my girl is empty, I want her to be beautiful and her thing [to be] shiny like a mirror.”
Efforts are underway to eradicate FGM/FGC. The first campaigns were health risk approaches focused on educating about the harmful medical consequences of FGM/FGC. These campaigns had a limited effect and contributed to medicalization of the practice (UNICEF, 2013). Human rights approaches emphasize that FGM/FGC violates major international human rights such as the right to be free from all forms of gender discrimination, the right to be free from torture, the right to health and to bodily integrity, and children’s right to special protections. FGM/FGC was first recognized as a human rights violation at the 1993 World Conference on Human Rights in Vienna where it was identified as a form of violence against women (UNICEF, 2013). In 2012, the United Nations General Assembly agreed on a resolution (67/146) urging UN Member States to pursue a comprehensive, culturally sensitive approach to eliminating FGM/FGC based on human rights and gender equality principles. Goal 5 of the UN’s
“It is what my grandmother called the three feminine sorrows: the day of circumcision, the wedding night, and the birth of a baby.”
From “The Three Feminine Sorrows,” a Somali poem
Sustainable Development Goals, “Achieve gender equality and empower all women and girls,” includes the target, “Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation by 2030” (United Nations, 2016a). Human rights approaches have stimulated UN and government action.
“Eradicating FGM does not take one single individual or organization; it’s a collective effort by civil society, government, and young people. It’s time we stood up for every girl. A world where women are not free is not a just world.”
Amie BojangSissoho, GAMCOTRAP, Gambia
Legislative approaches focus on the passing of laws criminalizing or restricting the practice. Since the early 1990s, 24 of the 29 countries where FGM/FGC is commonly practiced have enacted laws, many resulting from grassroots and international activism. The laws vary, with penalties ranging from fines to life in prison. Thirty-three countries that receive immigrants from countries where FGM/FGC is practiced have also passed laws (UNICEF, 2013). For example, a 1996 U.S. law made it illegal to perform FGM/FGC. Activist JahaDukureh, a FGM/FGC survivor living in Atlanta (in the American state of Georgia) was instrumental in getting the law amended in 2012 to make it illegal to knowingly transport a girl outside of the United States for the procedure in what is known as “vacation cutting.” For the most part though, police and judges fail to arrest and punish perpetrators, and families and practitioners conspire to keep their actions secret. In Egypt, for example, where 81 percent of women have undergone FGM/FGC, FGM/FGC was banned in 2008, but the first case to be prosecuted was in 2013 (Michaelson, 2016).
February 6 is the International Day of Zero Tolerance for Female Genital Mutilation #EndFGM
While health, human rights, and legal approaches are important for reducing FGM/FGC, they are increasingly acknowledged as incomplete because FGM/FGC occurs in a broader social context that influences its occurrence (UNICEF, 2013). For example, while laws are important, they alone can’t change the social norms and traditional customs that support the practice. Cultural and social norms approaches acknowledge that FGM/FGC are entrenched cultural practices that are best understood and changed by the people in those cultures. These approaches consider FGM/FGC to be a social norm in the communities in which it’s practiced. Like other social norms, people conform because they fear social rejection and want to be accepted members of their communities (and their children to be accepted as well). People also conform because they accept their community’s beliefs about the desirability of a practice—In the case of FGM/FGC, people often believe myths that perpetuate the practice, for example, that it’s necessary for hygiene, beauty, to control women’s sexuality, or to preserve virginity, or that it’s a religious requirement.
Social norms approaches target the social norms underlying the practice by mobilizing influential community members and groups to express their belief that the practice should change. Research finds that in most countries where FGM/FGC is practiced, a majority of girls and women, men and boys believe it should end, though there are educational and ethnic differences in attitudes towards FGM/FGC (UNICEF, 2013). People where FGM/FGC is practiced often believe it is more socially accepted and expected than it is and so don’t share their own desires for change. They conform because they anticipate negative social consequences for their daughters and family such as ridicule, shame, or exclusion. Social norms approaches are intended to correct these social misperceptions that lead to pluralistic ignorance. Individuals and groups within aculture are encouraged to be catalysts for change by using their social networks to correct misconceptions about FGM/FGC and express support for its abandonment.
Programs targeting social norms can take a variety of forms, including enlisting the support of religious leaders, training midwives to educate women so they will choose not to cut their daughters, and public service announcements. The Girl Generation: Together to End FGM, supported by international NGO Equality Now, includes a social media campaign designed to highlight support for ending FGM/FGC. In Ethiopia, a UN program fostered the development of anti-FGM/FGC committees in six districts comprised of a village elder, the local clan leader, the community’s religious leader, and a former FGM/FGC practitioner. These groups were successful in gaining community commitment to abandon the practice; 7,000 girls have been spared so far (UNICEF, 2014).
“Together we will end the cutting of young girls!”
Tweeted by MaimounaYade (age 25) President of AfriYAN Girl to more than 3,800 women in Senegal
Chapter 1 said it is important to avoid ethnocentricity and cultural superiority when studying global women. Cultural sensitivity is clearly important when it comes to FGM/FGC. African feminists often feel that Western feminists (feminists from Western Europe and the United States) are arrogant and demeaning in their study of and attitudes toward those who practice FGM/FGC. They remind us that although it is tempting to see cultures where FGC is practiced as barbaric and woman-hating, the practice is not intended to harm girls and women. It occurs because parents love their daughters and want them to be socially accepted so that they can have a good future and because parents believe that it is good for their daughters (Muteshi& Sass, 2005).
The Agents That Control Women’s Reproductive Choice and Health
Male partners, governments, corporations, and religious organizations are major influences on women’s reproductive lives. In the public sphere, corporations and governments sometimes make women’s health concerns a low priority in the marketing and availability of contraception. Governments concerned with population control and corporations concerned with profit sometimes endanger women’s health or, at the very least, restrict women’s options. Powerful religious groups may also influence reproductive choice. Meanwhile, in the private sphere, male partners often restrict women’s reproductive choices. However, women are also agents of reproductive rights and health, and advocacy and activism for reproductive rights are common globally.
Because sex education is typically government funded, governments often determine reproductive knowledge. Governments pass and enforce abortion laws and policies and affect reproductive choice by approving and regulating contraceptives. For example, in the 1960s, Japan banned hormonal contraceptives, saying that they were unhealthy and promoted promiscuity. This finally changed in 1999 after 30 years of lobbying by women’s activists.
Through public funding of family planning and health care services, governments affect women’s maternal and reproductive health and reproductive control. The limited contraceptives and services offered by government family planning programs often create racial and class disparities in reproductive health and choice. In the United States, the Title X national family planning program passed by Congress in 1970 is intended to fund Medicaid family planning services so that poor women have greater access to contraception. However, the 1977 Hyde amendment bans Medicaid funding for abortion; this makes abortion less available to poor women and women of color, who are more likely to rely on Medicaid insurance (Boonstra, 2016). Funding also varies depending on congressional and presidential administration. By the end of President George W. Bush’s eight-year term, funding for low-cost, confidential family planning services was 61 percent lower in constant dollars than it was in 1980. President Obama’s first budget in 2009 increased funding by $7.5 million (Jacobson, 2009).
China’s one-child family policy, first instituted in the 1970s and ended in 2015, provides one of the more extreme examples of coercive antinatalism. In its early incarnation, parents were issued permits to have children, and those who had additional children could be fined; lose their jobs, land, or homes; or be demoted (Chow & Chen, 1994; Fang, 2003; Hartmann, 1995). There were also reports of forced abortion, and women could be fitted with an IUD after their first child and sterilized after their second (Pan, 2002). Governments usually claim that coercive antinatalism is necessary to reduce poverty and promote economic development, but there are other ways to achieve these goals. When women have higher status, when child mortality is low, and when women have access to information and a variety of ways to control their fertility, they have fewer children (Dixon-Mueller, 1993; Hartmann, 1995).
Many countries have a history of selective coercive antinatalism where the government targets groups of lower-income women or women from an ethnic group deemed undesirable by government officials. For instance, in 1976 it was revealed that the U.S. government had sterilized 3,000 Native American women in a four-year period without obtaining adequate consent (Hartmann, 1995).
The involuntary sterilization of Mexican immigrant women, African American women, and Puerto Rican women also occurred through the 1970s in the United States (Davis, 1990; Guitterez, 2008). In the Czech Republic, Romany (Gypsy) women were sterilized without their consent as late as 2004 to limit the Roma population, a growing and unpopular minority (Amnesty International, 2008). From 1994 to 2000, the Peruvian government forced the sterilization of over 200,000 indigenous women; survivors still seek justice (Collyns, 2016; Kearns, 2009).
Fortunately, coercive antinatalism and coercive pronatalism are far less common than they once were. Research, along with women’s and human rights activism, has led most governments to reject coercive antinatalist and coercive pronatalist policies. However, exceptions remain. The Islamic State (the fledgling government of ISIS) has both coercive pronatalism and coercive antinatalist policies. In 2014, to boost their population and set down roots in their conquered territory, they banned contraception and shut down family planning services in Monsul, their stronghold in Northern Iraq (Sridhara, 2014). Meanwhile, they sexually enslaved women from the Yazidi religious minority, forced them to take contraceptives, raped them daily, and sold them to other men. According to ISIS’s interpretation of ancient Islamic law, sexual slavery is allowed, but the owner of a female slave can have sex with her only if he is sure she is not pregnant (Callamachi, 2016).
Politics and political administration changes also significantly affect the reproductive choices available to women. Policies affecting women’s reproductive rights are often made at the executive level, without legislative approval, and this means that when government leaders change, policies often change as well. The U.S. approval of Mifepristone, a chemical alternative to aspiration abortion used in early pregnancy, is a good example (the use of medicine to induce abortion is called medical abortion). Because surgical facilities are not needed for medical abortion, it can help make abortion more available and lower in cost. The drug became available in France in 1988, but activists opposed to abortion threatened to boycott its manufacturer Roussel Uclaf should it be marketed in the United States. By 1991, President George H.W. Bush put the pill on a list of medications banned by the United States. In 1993, newly elected President Clinton called on the FDA to test the drug. Roussel Uclaf gave the rights to the drug to a nonprofit group, the Population Council. This group had to raise millions of dollars to conduct clinical trials of the drug, because none of the major pharmaceutical companies was interested due to the controversial nature of abortion in the United States. Seven years later, the drug was approved for use in the United States, largely due to the efforts of activists who felt strongly that Mifepristone should be available to American women (Bernstein, 2000).
Where family planning programs receive foreign aid to fund family planning programs, the policies of the government of one country may affect the reproductive choices of women in other countries. A good example is the Mexico City policy, also known as the Global Gag Rule. First instituted by U.S. President Ronald Reagan in 1984, this federal policy prevents foreign nongovernmental
organizations (NGOs) that receive USAID family planning funds from providing legal abortion services, lobbying their own governments for abortion law reform, and providing accurate medical counseling or referrals regarding abortion. This dramatically reduces funding for family planning and women’s health services and reduces contraceptive availability, which increases unplanned pregnancies and abortions.
Since 1984, the pattern is for Democratic presidents to repeal the global gag rule and restore funding and for Republican presidents to reinstate the rule and deny funding to the UNFPA. In his first act as President of the United States in 2001, George W. Bush reinstated the policy. The administration also attached abstinence-only program requirements to U.S. funding for international family planning and AIDS relief despite evidence that these programs are ineffective (Elders, 2008). As a result, the U.S. Agency for International Development (USAID) could no longer ship contraceptives to sixteen countries in sub-Saharan Africa, Asia, and the Middle East. In 2009, one of President Obama’s first actions was to rescind the rule and promise increased funding for international family planning. On his first full day in office, President Donald Trump reinstated the rule and expanded it to include not just family planning agencies and programs but any organization that receives U.S. aid (at this writing, the impact of this and reduced funding for international aid was unknown but expected to affect millions of people globally). One of the saddest things is that the policy is counterproductive: Research indicates that during the years the rule is in effect, abortion rates increase (Barot& Cohen, 2015).
Where men are considered the head of household and have higher status and power in their relationships with women, they are more likely to control sexual decision-making, including contraceptive use and abortion. As the family decision-makers in patriarchal cultures, men often decide the number and spacing of the children (Kabagenyi et al., 2014). In some cultures, men prefer large families, fear that birth control will result in infertility or costly side effects, or believe a woman who uses contraception will have sexual affairs (Mosha, Ruben, &Kakoko, 2013; Kabagenyi et al., 2014). On average, 9 percent of women from fifty-two African countries who weren’t using contraception cited their male partner’s opposition as the reason (Sedgh, Ashford, & Hussain, 2016). In Timor-Leste and Mali, almost a quarter of women cited this reason, in Krykyrgyzstan, 15 percent did, and in Nigeria, 36 percent of women provided this reason for contraceptive non-use (Lawani, Iyoke, &Ezeonu, 2014; Sedgh, Ashford, & Hussain, 2016). About 12 percent of American women cited males’ unwillingness to use birth control as the reason for not using contraception (Mosher et al., 2015).
Men’s sexual decision-making power over women is sometimes enshrined in law. Eleven countries (Syria, the United Arab Emirates, Republic of Korea, Equatorial Guinea, Kuwait, Maldives, Morocco, Saudi Arabia, Japan, Taiwan, Turkey) require married women to have their spouses’ consent for an abortion (Center for Reproductive Rights, 2016b). Nine states in the United States have laws requiring
spousal consent or notification, but these are unenforceable as a result of the 1994 Supreme Court decision Planned Parenthood v. Casey. In the next chapter, men’s control of women’s sexuality is linked to HIV/AIDS in women
Corporations play a large role in the reproductive technologies available to women, and they are motivated primarily by profit, not by concerns about women’s reproductive choice or health. For instance, in the United States, the Today Sponge (250 million of which were sold from 1983 to 1995) was taken off the market when pharmaceutical giant Wyeth didn’t want to pay for plant upgrades. The popular product was unavailable to American women until a small company bought the rights to it in 2003. It reappeared in 2005 under new ownership before being sold to another company that declared bankruptcy in late 2007, taking the Today Sponge out of production until a new company began selling it again in 2009 (Singer, 2009).
Pharmaceutical companies also have a long history of emphasizing benefits and downplaying contraceptive side effects and risks. One recent case is Mirena, an IUD made by the Bayer Corporation, which has made the company billions of dollars. In 2009, the U.S. Food and Drug Administration sent a warning letter to Bayer claiming that Bayer overstated the benefits and safety of the device and made false and misleading advertising statements. Over 45,000 “adverse events,” including uterine perforation, pelvic inflammatory disease, ectopic pregnancy, and device migration, have been reported to the FDA. Bayer is currently being sued by thousands of women (Sequeira, 2016). Merck, another pharmaceutical corporation, paid out more than 100 million dollars in damages due to their NuvaRing product (used by women in 50 countries). Apparently, the company downplayed evidence that the device comes with an increased risk of blood clots and pulmonary embolism (Karlsson & Brenner, 2013). Unfortunately, the billions of dollars paid due to lawsuits since the 1970s have made corporations increasingly wary of investing in contraceptive development. This has slowed the development of new and improved contraceptive methods, and in the process, reduced reproductive choice (Schwartz, 2014).
Religious institutions, religious leaders, faith-affiliated and faith-inspired health services and workers, faith-based advocates, and international faith-inspired organizations may all affect women’s reproductive health and reproductive choice. For instance, in the United States, Catholics and evangelical Christians act to create abortion restrictions and abstinence-only sex education and to decrease funding for family planning services that offer abortions or abortion information. Religion often influences reproductive law and services and shapes attitudes about contraception, abortion, and men’s control of sexual decision-making. Some religions have beliefs about conception and when life begins that form the basis for opposition to contraception and abortion.
Human rights documents and agreements make clear that the freedom to practice religion is an important human right. However, international human
rights law limits this right when it infringes on public safety, health, or the fundamental rights and freedoms of others (UNFPA, 2016c). Women’s and human rights advocates are concerned that despite this, the freedom of religion sometimes comes at the expense of reproductive rights and women’s health. One example of this is the conscientious objection of health care providers and organizations. Due to their religious and moral beliefs, conscientious objectors refuse to provide reproductive health care services such as prescribing contraceptives and providing emergency contraception or performing sterilizations or abortions (even in cases of rape and incest, or when medically indicated).
According to international human rights agreements, conscientious objection to reproductive health services should be limited when another person’s rights to personal integrity, autonomy, and health depend on the timely provision of a particular service (Center for Reproductive Rights, 2013). But conscientious objection to providing reproductive services is on the rise worldwide (Zampas&Andion-Ibaniez, 2012). For example, in Europe, 10 percent of UK OB-GYNs refuse to provide abortions, and in Italy, almost 70 percent of gynecologists are registered as conscientious objectors to abortion (Chavkin, Leitman, &Polin, 2013). A 2014 U.S. Supreme Court decision (Burwell v. Hobby Lobby) allows companies to refuse health insurance coverage for contraceptive methods that violate the owner’s religious beliefs. Health providers may refuse to provide abortion services in forty-three U.S. states and contraceptive services in twelve states; and in eighteen states, they can refuse sterilization (Guttmacher Institute, 2016c).
Not all religions pose barriers to reproductive rights and health, but some, like Catholicism, have exerted a considerable, negative global influence. With the exception of the calendar or rhythm method, the Catholic Church is officially opposed to the use of contraception and is strongly opposed to abortion. The Philippines, a largely Catholic country (80 percent), has one of the highest birth rates in Asia, and as many as 600,000 women have illegal abortions each year, with some 90,000 going to the hospital due to complications (Hundley, 2013). The Church opposes access to modern contraception and until recently, successfully reduced contraceptive access by influencing government policy (contraception was even banned in the country’s most populous city, Manila). Finally, in 2014, after a fourteen-year battle between women’s rights activists and the Catholic Church, the Philippines Supreme Court upheld a reproductive health law passed in 2012. The law, which was supported by 70 percent of citizens, funds universal and free access to contraception, requires hospitals to treat post-abortion complications, and mandates family planning and sexuality education in schools.