Equity and Reproductive Health

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by. Hari Kusnanto

Introduction

The 1994 International Conference on Population and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing declared that women’s empowerment and reproductive rights are essential for the achievement of sexual and reproductive health. Many reproductive health issues among women are not merely rooted in the biology of reproductive organ system. Women often face discrimination and lack of power to decide how and with whom they will have sexual relations, and whether they want to bear the children at the times they prefer. Sexual and reproductive health among women are not only dependent on their own behavior, but especially dependent on their sexual partners, other family members, and health service providers. Pregnancy-related deaths and disability, sexual violence and coercion, adolescence pregnancy, and sexually transmitted diseases have been the main causes of the global burden of diseases, disabilities and deaths among women, during a large part of their productive lives. More than 20% of total years of healthy life lost among women of reproductive age are due to three main groups of reproductive health conditions, namely maternal mortality and morbidity, sexually transmitted diseases (including HIV/AIDS) and reproductive tract cancers.

Many of the adverse conditions affecting women reflect social inequity among nations and people of different gender, race, culture, socioeconomic status and political affiliations. In certain parts of Africa, the risk of pregnancy-related deaths is one in 16, while in most highly develop countries, the risk is only one in 4000. Most maternal deaths in developing countries are preventable. The Government of Indonesia has trained and deployed village midwifes, to serve remote areas all over the country. Quality assurance, such as maternal care audit in hospitals and primary health care, and emergency obstetric system have been attempted to combat the delays in the decision to seek care, in reaching care and in receiving proper care. Little progress in reducing maternal mortality has been made, and the maternal mortality ratio in Indonesia remains the highest in South East Asia.

Violence against women is even a very dark issue, about which very little knowledge can be generated. Part of the problem is that discussions about violence and coercion cannot be done openly at the community level, due to male domination in most societies. Even the limited success to reduce maternal mortality in Indonesia can be attributed to cultural norms, partly related to gender issues.


Reproductive Health Commodities

Several approaches have been used to reduced maternal mortality and improve reproductive health in general. Assuming reproductive health services as commodities, Behrman and Knowles suggested that both supply and demand sides should be improved. The availability of family planning and maternal health care system, supported with the referral system for emergency obstetric care, is a very important factor in the supply side. The establishment of a Unit for Women Care in Panti Rapih Hospital, Yogyakarta, is an example of services specifically directed to the victims of violence and coercion against women. Many women felt that such a commodity is not only a useful emergency measure, but also an entry point to seek a more comprehensive support. Utilization review statistics of the unit indicated a 50% increase in number of women seeking help from 2000 to 2001. Most of the clients are relatively better educated, one third of them obtained tertiary education. Well-informed women will take more responsibility for their own health by obtaining care during pregnancy, delivery, and post-partum period, choosing appropriate contraceptives, and looking for more information and support for their reproductive health problems. There is a need to motivate and empower women to use services provided to them.


Reproductive Health Rights

Maternal mortality can also be viewed as an indicator of how far the reproductive health rights of women have been realized. Equality in a society is closely related to the fulfillment of productive rights of women. In a socially just society, women enjoyed better actualization of their productive rights. Maternal mortality ratio is not only influenced by average income or GNP but also by the distribution of economic gains, such as reflected in the Gini coefficient. Maternal mortality ratio in most countries with Gini coefficient less than 30 is relatively lower compared to those with 30 or above.

It is intriguing to ask whether improving the equity or social justice in the society will improve maternal mortality. The reduction of maternal mortality may take place in a country with significant economic progress, as more resources and options, particularly for reproductive health care, become available for families and especially women. Based on inter country comparisons, life expectancy was found to be positively correlated with GNP, however, this relationship works through the impact of GNP on the income of the poor and public expenditure for health care and education. Sri Lanka is a poorer country than Brazil, however, its maternal mortality ratio is nearly half of Brazil’s. Sen distinguished two types of successes in the rapid reduction of mortality in general, which are called “growth medicated” and “support led” processes. Fast economic growth will successfully reduce maternal mortality, if the enhanced economic prosperity is used to expand health care, education, employment opportunities and social services for women empowerment. On the other hand, the maternal mortalities in Sri Lanka and pre-reformed China are relatively low, although no significant economic growth took place in two countries, but education and health care were prioritized public services. Support led or basic need approach in public health policy is based on the premise that health, including reproductive health, is human right issue. Reproductive health right emphasizes the need to provide specific, women focused health care interventions in order to address the imbalance of need.

The experiences of the Unit for Women Care at Panti Rapih Hospital suggest that the most frequently mentioned reason for seeking care was categorized as sexual violence, 93% of which was due to women’s weaknesses in negotiating power and their vulnerability of being left alone and hurt. The principles of equity in reproductive health should be in line with Rawlsian distributive justice, that resources should be distributed in way that the most disadvantaged persons in the community get the maximum possible amount of gain. Women, especially the poor ones, who live in the most remote areas, who are less educated, should gain most from any public policy.


Conclusion

Basic need or support led approach has been argued as the most appropriate way to improve the reproductive health of women. The implications of this approach are that lawmakers should not only be sensitive to women’s needs, but also be willing to allocate resources in support for empowerment of women, especially with regard to their reproductive rights. Market incentives, legal protection, enhanced community-based capacity to provide reproductive health services should be more focused to disadvantaged women, due to socioeconomic, cultural and political situations.


References

Herz, B., and Measham, A.R. 1987. The safe motherhood initiative: proposal for action. Washington DC : World Bank.

World Bank. 1997. Safe motherhood and the World Bank: lesson from ten years of experience. Washington, DC : World Bank

Behrman, J., and Knowles, J. 1998. Population and reproductive health: an economic framework for policy evaluation. Population and Development Review 24:697-737.

Anand, S., and Ravallion, M. 1993. Human development in poor countries on the role of private incomes and public services. Journal of Economic Perspectives 7:133-150.

Sen, A. 1999. Health in development. Bulletin WHO 77:619-623.

Standing, H. 1997. Gender and equity sector reform programmes: a review. Health Policy and Planning 12:1-18.

Gwatkin, D.R. 2002. Health inequalities and the health of the poor: What do we know? What can we do?. Bulletin WHO 78:3-18.