New mum, baby and midwife at MH

By Liesl Shipard, 2011

It seems like everyone around me is having a baby. At last count I personally knew 16 different women who were pregnant. So naturally the conversation often turns to babies, birth, experiences, advice. And options. So many options. When to have the baby, where to have the baby, how to have the baby, whether to have a natural delivery or use drugs, who to have with them at the birth, when to leave work, when to return to work, to stay at home or use childcare, etc etc.


Options. Such a small yet wonderful word. To have options implies freedom. To be able to exercise choice about a range of options implies power. Setting aside comparisons of GDP or PPP for a moment, it is clear that the Australian women I know are rich and powerful in ways that have nothing to do with money. If only the same were true for women around the world.


In the West we are bombarded with the latest ‘scientific’ discoveries: we’re promised cloned babies, the ability to conceive past menopause, artificial placentas, and other ‘advances’. Yet while all this adds to the ‘lifestyle choice’ that is becoming a mother in the West, millions of women in developing countries (and poor women in developed ones) are denied any sort of choice in the reproductive process that takes place within their own body.


It is taken for granted here in Australia that deciding if and when to have children, and then how many, is a woman’s right. It is her right to have a safe and healthy pregnancy, and a safe and healthy delivery of a healthy child. It is rare that something serious occurs to either mother or infant. Australian women do not need to fear childbirth, other than varying degrees of anxiety about the pain of labour and episiotomies.


Perhaps it is my experience living and working in developing countries, or perhaps it’s working for an organisation that addresses women’s health in western Uganda, but I find myself thinking during all the conversations about babies and births, ‘you should just be grateful that you’ve got a 99% chance of having a safe and non-life-threatening birth. If you weren’t Australian there’d be something to really fear.’


And thinking about maternal mortality in Africa lead me to thinking about the impact of HIV/AIDS and the increasing feminisation of the pandemic, particularly among monogamous, married women. Which got me thinking about the rights of women to access contraception, to say no to unwanted sex or insist on safe sex with an infected partner. Which necessarily led me to thinking about gender and power.


It is impossible to consider issues of women’s sexual and reproductive health and choices without considering the power dynamics and power differentials that shape their lives and their ability to make and implement choices. It is a power thing, it is a rights thing and it is a gender thing.


That it is a gender thing is demonstrated by the comments of a midwife who had worked in the developing world for over 25 years. Her sentiments were that if hundreds of thousands of men were suffering and dying alone and in fear each year, and if millions upon millions of men were being injured and disabled and humiliated, sustaining massive injuries to their genitalia such that they lived in constant pain, infertile and incontinent, and in dread of having sex, then we would have all heard about this issue long ago and something would have been done.


Likewise, if millions of men were being forced into unwanted sexual encounters, being forced to have unprotected sex with an HIV+ partner, denied the right to determine when and how many children to have, and being denied the use of contraceptives or punished physically, emotionally and financially for using contraception, then we would have all heard about this issue long ago and something would have been done.


And yet so much is done, so much time and money is spent by international institutions, governments, NGOs and community groups, researchers and rights groups to increase women’s access to education, to health services, to empowerment. But somehow maternal mortality rates still remain enormously high, still women have little say in their own reproductive processes, still the AIDS pandemic spreads to women who are powerless to prevent it. It is not enough to provide more programs and more health clinics, although these things are definitely needed, if women do not have the ability to benefit from them. This can often be a poverty-related issue, but it is also very much a gendered power and rights issue.


Why power?

Bodies, sexuality and reproduction have always been and continue to be subject to state and religious intervention and control, defining gender, race, class, sexual identity, and establishing hierarchies and inequalities. Everyone knows that women around the world experience a lower status than men, which has negative real world consequences affecting quality and length of life. For many women, reproduction happens in a context in which they have little or no power to make even the most basic day-to-day decisions. A woman’s husband wants another son, so she cannot use contraception, the civic and religious leader has a particular view of foetal life and so outlaws abortion, the doctor and traditional healer believe in the right way to do things, and so she must obey. Common practice, local beliefs, and lack of power dictate how she is born, how she will live and, all too often, how she will die. 


It is impossible to overstate the central role of gendered power in reproductive decisions. Sex and fertility involve negotiations between male and female partners, who often have dissimilar preferences and dissimilar power to implement those preferences. It is well documented that in Africa, particularly in rural areas, a woman’s wishes carry very little weight, if any, in such negotiations. Because of marriage transactions and the prevailing gender power differentials, African men possess authority and enjoy power in sexual and fertility decisions, like the number and timing of children. Pronatalism is a dominant idea in much of Africa, and African men tend to be more pronatalist than women. Having many children not only secures the future but also confers status and a sense of male-pride upon a man. Studies have shown that when it comes to choices regarding fertility and family size, the men’s preferences usually override women’s. African women, particularly in rural areas, say that men are the principal obstacles to their being able to convert their reproductive choices into reality. Differences in spouses’ power-making ability clearly greatly impacts upon women’s ability to control their own reproductive capacity.


How does this relate to sexual and reproductive health, maternal mortality and HIV?

As seen above, power dynamics affect the ability of women to make their own decisions regarding their sexual and reproductive expression and wellbeing. A quick look at the key issues of sexual and reproductive health, maternal mortality and HIV in Africa demonstrate the central importance of addressing gendered power disparities.


In the western cape, community workers tried to implement contraceptives in squatter settlements. They found over and over that women were prevented from using them by their male partners. Men refused to wear condoms, even when their wife/partner knew that he had other girlfriends. Women were threatened with abandonment and violence when they tried to insist on condom and other contraceptive use. Similarly, efforts to empower women to negotiate over sex in Kenya resulted in gender-based violence. Researchers concluded that this was because the initiative failed to address the social norms and expectations about women and men in sexual relationships. As seen above, women’s ability to make decisions regarding fertility, spacing of children, the use of contraceptives and abortion, and access to reproductive health services is often determined by the preferences of their husband/male partner. Gender-based power differentials are thus crucial factors affecting women’s ability to make decisions regarding their sexual and reproductive health and welfare, impacting the likelihood of their dying from pregnancy-related causes and their susceptibility to HIV infection.


Each year half a million, or 1 in 48 women, die from pregnancy-related causes. 99% of these women are from developing countries, and 50% are from Africa. 70-80% of maternal deaths in Africa are from direct obstetric causes – complications during pregnancy, labour, delivery or in the postpartum period. What’s more, for every woman who dies a pregnancy-related death there are as many as 30 women who will suffer some form of serious, often permanent injury – over 15 million women per year. And many, many of these deaths are completely preventable, as the negligible maternal mortality rates of a country like Australia demonstrate. While there is a clear link between adverse maternal health outcomes and poverty – access to health services, transport, malnutrition, youth, increased risk of HIV, etc. – there is also a gendered-power link. Access to services and transport often depends on the willingness of male partners to relinquish income for the time it takes to attend clinics. In western Uganda, it is often not a man’s priority to see that his wife, who is economically dependent upon him, gets adequate care during pregnancy and labour. It is not uncommon for women to walk alone to the nearest (underequipped) clinic while in labour, or for boda (motorcycle taxi) drivers to end up delivering babies en route, increasing the likelihood of infant and maternal mortality and morbidity. Furthermore, that women receive less food to eat than men, even during pregnancy, is another factor relating to power and adverse maternal outcomes. A malnourished women gives birth to a malnourished child, and if that child is a girl she will likely remain malnourished for the rest of her life and continue the cycle, if she lives. Etc.


The link between adverse maternal outcomes and HIV infection is strong. Each day over 8,000 people become infected with HIV, and half of them are women. An HIV+ woman is 1.5-2 time more likely to die from pregnancy-related causes than an HIV- woman. In southern Africa, AIDS has become the leading cause of maternal death.


In every region of the world, rates of HIV infection among women and girls are on the rise. Women’s heightened risk to HIV lies in women’s lower status and decision-making power worldwide. Women are by and large economically dependent upon men, which leaves them vulnerable to violence and sexual coercion. Without economic autonomy, and even sometimes with it, women lack power to negotiate over safe sex with their male partners. The increasing feminisation of the pandemic can be attributed to, among other things, discrimination and violations of women’s human rights, which result in women’s powerlessness to insist upon safe sex practices and consensual sex. Many HIV prevention programs do not recognise these realities of women’s lives, and as such fail to adequately reduce women’s infection rates.


On a positive note, however, studies in Kenya comparing rural and urban preferences for and use of contraception showed that urban women were as able to exercise their preferences as urban men. Education of young people around sexual and reproductive health and rights, safe sex practices and HIV prevention, and women’s human rights is resulting in change in social and cultural attitudes to women and sexual and reproductive rights.


So what about rights?

Most African countries are signatories of the African Charter on Human and People’s Rights (African Charter) and thus at least formally recognise the importance of human rights. A basic principle of human rights is that they are inalienable and applicable to each human being all of the time. A woman is thus entitled to exactly the same protections as men when they suffer the same abuses. However, traditional human rights discourse is inadequate to protect women for women-specific abuses. There are many things that women suffer as women that men do not. Men do not get pregnant and have babies. Nor are men’s lives shaped in the same way by their biological capacity for reproduction. Thus women’s movements and rights groups have campaigned to bring women’s sexual and reproductive rights onto the international agenda.


All of the issues discussed above are also rights issues. A woman’s right to choose what enters and what emerges from her body. A woman’s right to choose when, how and with whom to have sex. A woman’s right to say no. A woman’s right to determine if, when and how many children to have. A woman’s right to have safe sex and not be infected with STIs or HIV. A woman’s right to safe pregnancy and childbirth.


The Protocol on Women’s Rights in Africa was adopted in 2005 to redress the failing of the African Charter to adequately protect women. Yet while many countries have signed the protocols, there remains a huge gap between law and policy and reality. That the 2 women-focused MDGs and the MDG pertaining to HIV are the three goals experiencing least progress is understood in a UN report as representing a failure to protect and promote women’s human rights. The obstacles to making sexual and reproductive health rights a reality are multiple, encompassing sociocultural norms, gender inequalities, resource and capacity constraints and unfavourable legal environments. Furthermore, women’s reproductive and sexual health rights are challenged by some on the basis of tradition and culture, such as when these challenge traditional and customary law that favours men (male violence, marriage rape etc.) and in this way restricted by governments.


Understood in the context of human rights, the ongoing power deficit experienced by women in Africa and around the world with regards to their sexual and reproductive health is one of the grossest human rights abuses ever seen. And yet, because the power dynamics behind such appalling abuses are entrenched in the structures of many developing nations, they are being overlooked and ignored. It is much easier and less politically threatening to provide programs, interventions, clinics that address the symptoms of the problems than to challenge the gendered-power differentials that are the cause. But until such changes are made, at national, community and individual levels, all the money and programs in the world will not be sufficient to ensure that women enjoy the same levels of health and wellbeing with regards to their sexuality and reproduction as men.


I look forward to the day when my friends in Uganda, in India, in Cambodia spend their months of pregnancy fretting over baby names and which cot to buy, rather than whether or not they will die in childbirth, or whether or not they will pass on HIV to their unborn child.


Liesl Shipard is the Project Coordinator for Maranatha Health Australia 


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