UNFPA/Government of FIJI

Gender Issues in Reproductive Health:

Let’s Get Serious

Dr. Praema Raghavan-Gilbert

Adviser on Gender & Reproductive Health

Introduction

Gender refers to the socially constructed roles assigned to males and females that define how men and women should think, act and feel and are culturally and politically defined. These roles, which are learned vary widely within and between cultures, and change over time, between communities and cultures, as a result of social, economic and political shifts. Unlike sex, which is the biological distinction between males and females, gender refers to socially learned behaviour and expectations that distinguish between masculinity and femininity. Whereas biological sex identity is determined by chromosomal and anatomical characteristics, socially learned gender is an acquired identity. The concept of gender also includes the expectations held about the characteristics, aptitudes and likely behaviours of both men and women.

The Cairo ICPD POA on Gender made a commitment to the empowerment and autonomy of women and the improvement of their political, social, economic and health status as fundamental to the achievement of sustainable development. The POA on Gender also identified the full participation and partnership of men and women in productive and reproductive life including care and nurturing of children and maintenance of the household as crucial to the empowerment of women in reproductive health, and the implied strengthening of the family as the centrepiece of the community for nation building.

Issues in incorporating gender into RH

The complex concept of gender and gender mainstreaming is not yet well understood by planners, implementers and providers of health and other services and is sometimes rejected as feminist stridency. Much of the fear and defensiveness about incorporating gender perspectives into all development activities will weaken with increased understanding of the true concept of gender in reproductive health i.e. to empower women and strengthen the family bond. A deeper understanding of how the empowerment of women is a fundamental pre-requisite of their own health and the well-being of their family will evolve over time with increased awareness and public education about the gender issues.

Since Cairo, the concept of health has moved from a narrow biomedical model meaning the absence of disease focused on childbearing and child rearing, to health as a right to emotional, social and physical well-being within the larger social, political and economic context. This shift from the medical model to the rights model challenges the cultural and economic conditions under which women in diverse cultures receive RH services. The narrow medical models in which the service provider decides what is best for women clients are more successful in curative care, seeking relief from pain and physical distress, than in promotive and preventive care.

Cultural conditions are mediated by religion, gender and tradition. Religion may influence interpretations about use of certain contraceptives, use of blood or life support systems in emergency obstetrics, etc. Gender influences the low level of male responsibility in use of contraception. Men may also prevent women from using contraceptives of the woman’s choice and from limiting family size. Domestic violence and violence against women of all ages is an engendered phenomenon with strong inter-generational links on the part of both men (the right to hit) and women (conditioned to suffer in silence). Gender biased food allocation and a exaggerated workload causes anaemia, malnutrition and increased susceptibility to infectious diseases in girls and women. This bias is culturally acceptable in many societies. Cultural pressures may force girls to marry and bear children at a very young age with serious reproductive health consequences. Obstructed labour, ruptured uterus, fistula formation with leaking urine and faeces for the rest of her life, are some of the horrendous consequences of very early child-bearing.

Mental and physical abuse of women blamed (often unfairly) for infertility, or poor pregnancy outcomes is a cruel engendered cultural practice. This may contribute to depression and suicide or violence against the woman from the in-laws. There are societies in which women are not allowed to seek health care, even for life-threatening emergency conditions if they are not chaperoned by a male relative. There are also traditional practices where there is a preference to receive care only from female attendants. And yet, in many of the PICs, the majority of aide post staff are men, even as the search for improving rural access continues.

The economic mediating factors are often related to poverty, lack of education and the lack of women’s decision–making power in the household. At all ages women are more likely to be poorer than men. Women-headed households are more likely to be poorer than those headed by men, irrespective of whether the data come from rural or urban populations or from developed or developing nations. Poor women are likely to live in unsanitary housing, have poor quality meals, and poverty further limits access to even free health care.

These economic factors also force women to tolerate poor quality services, particularly in the public sector because of their lack of personal and social status. Poor women without money for medication or transport are unable to seek alternative services at a private sector clinc. The social distance between providers and poor uneducated women, because of power and knowledge asymmetries, force them to accept low quality services in which they are treated with little respect. Minimal technical information is shared with the client; very limited choice of FP methods is offered because of the belief the provider knows best; the services are often unreliable, causing great inconvenience to the patients; and women are often treated with little privacy, confidentiality, respect or dignity. Quality is also compromised when unnecessary administrative programme barriers are placed, e.g. husbands’ consent or signature to receive certain services. This affects the woman’s right to receive services of choice and to space or limit family size.

Women generally are unaware that after Cairo & Beijing, they have a right to be listened to and to request and demand access to appropriate, acceptable and affordable comprehensive health services of high standards. This knowledge gap will narrow with increasing social and economic power enhanced by awareness, education and legislation of rights.

The role of men as partners with equal personal and social responsibility for the effects of their own sexual behaviour on their partners’ and children’s health is an issue that has not been addressed in some of the PICs, even five years after Cairo. Men’s responsibility to practise safe sex has been addressed somewhat through active STD/HIV/AIDS programmes. Men’s responsibility in fertility management has seen some successful vasectomy interventions in Papua New Guinea and Kiribati. The linkages between STDs in the male and infertility, pelvic inflammatory disease and ectopic (tubal) pregnancy in the female has not been addressed adequately in RH programmes. The care and nurturing of children, and the maintenance of the household as a shared responsibility is a theme that needs to be strengthened in IEC, Advocacy and Counselling programmes in the Pacific.

Programmes have not adequately informed men about the long-term emotional and psychological damage to the women and children in the family when they experience domestic violence and sexual or physical abuse. Additionally, most primary health care providers are not trained to identify, document and manage victims of domestic violence. Providers often deny or deflect the problem. They prefer to believe that the police or crisis centres are better equipped to handle these cases and often quote the low statistics in their communities to support this view. Statistics reflect only the tip of the ice-berg and often represent the endpoint of a continuum of suffering. The vast majority of cases of domestic violence prefer to hide from their friends and family till their scars of humiliation have faded. They sometimes seek care from health centres with improbable stories of repeated accidents that beg a high index of suspicion.

The true reproductive and health status of women cannot be measured by the traditional indicators of maternal mortality and contraceptive use. A woman’s health status is determined over her lifetime by the gender-based social, political, cultural and economic factors that she has experienced. The lack of access to good nutrition, education and health care for the girl child often starts from infancy. The disadvantages inherent in a lack of educational opportunities and employment and self esteem increase the risks of adolescence, particularly teen pregnancy, sexual exploitation, and STD/HIV and AIDS. In the Pacific, these factors are beginning to affect the male child and male adolescents too. In all countries, this increases their risk of sexual exploitation and diseases. Later, the child bearing years are fraught with obstetric and gynaecological emergencies and diseases aggravated by pre-existing anemia, and poor access to FP and health care. The ageing woman is faced with shrinking financial resources and personal power (due to the death or disability of her breadwinner and head of household husband) and growing personal health care needs related to menopause, systemic diseases, disability and cancers. Throughout her life cycle she may experience physical, sexual and emotional abuse. None of these gender-based cultural and economic experiences are captured in the reproductive health indicators currently in use.

The Challenges

Many challenges face programmes and programme managers in mainstreaming gender.

The difficulty of acquiring and analyzing disaggregated data without trained gender focal points in all Ministries and organizations. Disaggregated data by gender must be made available by legislation and training in all sectors. This is central for national planners to use in education, employment, nutrition and health care to work towards narrowing gender disparity.

Currently, there is no mechanism for women’s groups and Ministries of Health and Women and NGOs to meet regularly for tactical planning and feedback. Strategic partnerships must be formed and led with government ministries, women’s NGOs and international and private organizations to create a platform for coherent programmes in gender sensitization and gender mainstreaming.

There is a need to extend services to reach out to men, adolescents, and ageing women within the existing health structures. The need already exists for the health care system to enable the identification of domestic violence, physical and sexual abuse, and rape. Health service procedures, and the provision of support services and training must address these inadequacies as part of governments’ commitment to the ICPD POA on Gender.

IEC and Advocacy strategies must be modified to promote male responsibility and to increase community education on women’s rights and issues as an integral part of family health development.

The ratio of male/female RH service providers must be re-examined to respond with appropriate gender sensitivity and a long-term view to increase RH service utilization and quality.

Quality of Care supervision must be enabled through training and tools particularly in the areas of informed choice and consent, interpersonal process, reliability of services, confidentiality and privacy, while strengthening all management systems.

The implementation of more gender and adolescent friendly RH services through legislation, policy, and institutional changes may need to be instituted within the existing health care structures.

Researchers may wish to collect and analyse data on women’s health in the Pacific from the perspective of women. This is because diseases affect men and women differently, may be unique to women, may have different risk and exposure factors and may require different interventions. All of which have long-term health planning implications. ■

Reflections will be published periodically by the UNFPA Country Support Team for the South Pacific. Views expressed do not necessarily reflect the opinions or policy of the United Nations Population Fund. Correspondence should be addressed to: The Director, UNFPA Country Support Team, GPO Box 441, Suva, Fiji. Phone: (679) 312-865 Fax: (679) 304-877 Internet email:

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