This week RH Realty Check and UN Dispatch are pleased to host a special series of articles on empowering adolescent girls in the developing world, called Girls Count, which is also the name of a series of reports from the Coalition for Adolescent Girls which seeks to elevate the profile of adolescent girls on the international development agenda and within strategies to fulfill the Millennium Development Goals.
There are more than 60 million child brides in the world today. For girls in the poorest communities, adolescence merges indistinguishably into adulthood. They are forced to marry and bear children while still children themselves. They bear the burden of chores to cook, clean, fetch water and firewood. They work in fields and care for family members. Their labor is the backbone upon which many poor families survive.
Forced child marriage is common in poor and particularly rural communities. In fact, countries with high child marriage rates also have high rates of maternal and child mortality, as well as extreme and persistent poverty. Often because there are few economic alternatives for girls to earn an income and where education cost money, marrying them helps to relieve an economic burden.
However, there are high opportunity costs to child marriage: this practice has deleterious effects on health for girls and economic ramifications for their communities. For example, when girls are taken out of school to get married they lose an opportunity to gain knowledge and confidence. When such a large proportion of the potential work force in a country is married and removed from mainstream society how can economies grow and political systems flourish?
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Severe health consequences also abound. Child brides are at far greater risk of contracting HIV. Often they are married to older, more sexually-experienced men with whom it is difficult to negotiate safe sexual behaviors, especially when under pressure to bear children. The risks of pregnancy are much higher for younger girls. Those under the age of 15 are five times more likely to die in childbirth than women in their twenties and pregnancy is also a leading cause of death worldwide for women ages 15 to 19. Child brides are also more susceptible to domestic violence.
Listening to girls and their aspirations is an obvious but overlooked starting point for addressing the challenges they face. Few policies and programs are directed to adolescent girls or account for the environment in which they live. As a result, many efforts fail.
Fortunately, we can solve this problem and girls themselves hold the solutions as seen in the recent Girls Speak publication by the International Center for Research on Women released today. The publication which draws together girls’ voices provides policymakers and program managers with access to girls’ needs as defined by girls themselves. They understand acutely the obstacles that bar them from opportunities. And they have clear ideas about what needs to change in their lives for them to succeed.
Girls have spoken eloquently about what they want – and now the world should listen and act. They tell us about the best methods to get rid of the barriers that stand in the way of accomplishing their dreams. They have the self-determination required to better their lives.
Girls’ voices echo a growing body of research that shows that positive long-term changes for girls and their families can only be brought about through delay of marriage and childbearing and investment in education, health and creating economic opportunities. When opportunity knocks for the largest generation of girls in history let them heed the call.
Local governments and public officials should look to the reproductive rights and HIV and AIDS movements for insights into the ways in which they can more effectively center the needs of those most marginalized while fighting the Zika virus outbreak.
The Zika virus outbreak and the increase of babies being born with birth defects seemingly linked to the mosquito-transmitted disease have generated a series of prescriptions from governments of the most affected countries about what people need to do and not do. These include asking women to delay pregnancies—until 2018 in El Salvador, for example.
Sadly, these recommendations do not match what is in the realm of possibility for many women living in or near Latin America, the region from which we hail. We propose instead local governments and public officials look to the reproductive rights and HIV and AIDS movements for insights into the ways in which they can more effectively center the needs of those most marginalized while fighting this crisis.
Calls to delay pregnancy in several countries where the Zika virus has spread have revealed gaps in health systems resulting from unfulfilled demands for sexual and reproductive health-care services. While women in Latin America generally have access to contraception—a real demonstration of decades of activism and leadership—in some Central American countries such as Guatemala, over 26 percent of married young women who do not want to become pregnant have an unmet need for birth control, and therefore are at risk of an unintended pregnancy.
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In the regions that have seen a spike in Zika cases, there are also high rates of sexual violence. The World Health Organization reports that one in three women experience violence in her lifetime. Those rates in Peru, where health officials in late January confirmed the nation’s first case of Zika, appear to be higher: A 2005 report found more than half of women in Lima and Cusco experienced physical or sexual violence by a partner some time in their life.
Without access to contraception, many women, including some young girls, will experience unintended pregnancies. And once pregnant, women and girls do not have control over their own reproduction as the laws provide limited options for termination. Incountries that have very restrictive abortion laws, women and girls face an even greater health crisis should they experience an unintended pregnancy, become infected with the Zika virus, and want an abortion.
In light of this situation, how realistic is it to expect the public to delay their pregnancies as they are prescribed to do? Is this top-down approach to tackling a health-care emergency grounded in the realities and needs of women? Are policymakers once again “instrumentalizing” women to solve a threat or a global challenge?
Activists have known for a long time what is needed at a structural level to ensure that women’s health and rights are respected and promoted. Reproductive rights and HIV and AIDS advocates have said it all along.
The response demands long-term commitments to three rights pillars: First, access to information and services. Women need access to information about the virus, including how to prevent transmission. They also have a right, as UN bodies have argued, to access the type of sexual and reproductive health services they need, including a range of contraceptive options. If pregnant, every woman should be able to decide if they will carry to term their pregnancy—and have access to safe abortion or maternal health care and social support services.
Second, governments and stakeholders need to scale up their commitments to protect women’s agency. Women have to be empowered to make choices regarding their own health, and those choices need to be respected. Women living with HIV have shared their painful experiences of being subjected to coercive sterilization or abortion and of having their right to reproductive autonomy erased. Advocates and policymakers need to reinforce the rights and dignity of women and show that respect for their decisions is at the center of any policy and health intervention. As we learned from the AIDS response, this work of fighting a global health crisis must start with the concerns of those most vulnerable and marginalized, and their voices must be heard at all times.
Lastly, in a world where leaders look for magic bullets and advance biomedical approaches as one-size-fits-all solutions to health challenges, governments and different stakeholders need to bolster all efforts aimed at eliminating discrimination and violence against women and girls. These efforts should include removing obstacles to reproductive health services, investing in the empowerment of adolescents, and training health providers to protect and promote women’s sexual and reproductive decision making. These interventions will ensure that when a crisis hits, all persons—whether women or those from other marginalized groups—are enjoying the legal, policy, and cultural conditions that recognize them as full citizens and agents of their health and lives.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of UNAIDS.
“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states a recently published report from the UN Population Fund.
In addition to this growing refugee population, there is an ever-increasing population of internally displaced people: about 38 million in 2014, equaling 30,000 per day. These individuals fleeing conflict within their own country spend an average of 17 years displaced from their home relying on international humanitarian assistance. Although the international community first recognized providing reproductive health services as a human right with widespread economic and social benefits 20 years ago, barriers remain to meeting these needs for the 25 million women and girls living in emergency settings.
“Protecting the sexual and reproductive rights of women and girls in crisis settings is essential and a matter of human rights, but it is also complicated and unsustainable without a change in the way humanitarian assistance is provided and funded,” states the report.
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Two critical ways for the global community to begin making progress include, as the report notes, increasing the international community’s focus on the availability and accessibility of safe abortion and post-abortion care, and cultivating a culture of preparedness and prevention when it comes to providing a full range of such services in communities prior to any crisis.
Access to Safe Abortion as a Human Right
An oft-cited 1999 UNFPA report estimates that 25 to 50 percent of maternal deaths in refugee settings are due to complications of unsafe abortions. (Little research has been done in the past two decades to learn more about this crisis.) This is a startling statistic, yet abortion remains politicized and difficult for non-governmental organizations and leaders to talk about in the international arena, let alone fund.
Few displaced women are in a position to demand access to abortion or organize to advocate for these services. Societal forces are a large part of this disenfranchisement, including pressure from family and the broader community to bring a pregnancy to term to replace lost family or to hide a pregnancy that is a result of rape, which can increase the stigma they are facing. In addition, clinics in most crisis settings are not outfitted with the necessary medical equipment to provide safe abortion care or even to address complications of abortion.Also, many organizations receiving international funding to provide relief to refugees are religiously affiliated and do not offer reproductive health care, including abortion, according to a report about safe abortion for refugees.
As a result, research specifically addressing the state of abortion and post-abortion care in conflict zones often is neglected, creating a gap in information around this specific program area.
Sandra Krause, director of Reproductive Health at the Women’s Refugee Commission, explained to Rewire that, according to a 2012-2014 Global Evaluation from the Inter-Agency Working Group on Reproductive Health in Crises (IAWG), access to post-abortion care in crisis settings has expanded since 2004 but “comprehensive abortion care—in particular, safe abortion care,” is still lacking. The IAWG has since formed a working group to address this gap.
However, the results of that working group are unknown, and much of this work remains unfunded. On a hopeful note, Krause said that she believes the working group will create a sea change in the conversation around funding safe abortion access in humanitarian emergencies. “We did just receive some funding to update the global guidelines for reproductive health and humanitarian settings to better integrate safe abortion care,” she added.
Economic Case for Funding Reproductive Care Services
In addition to recognizing these services as a human right, the UNFPA report points to obstetric care, safe abortion and post-abortion care, and services for those who experience gender-based violence as keys to achieving sustainable development. There are measurable economic impacts from denying these services to women and girls.
“It prevents girls from being able to go to school, it prevents girls and women from accessing education more generally, and seeking higher education. It pulls women out of the workforce and makes them unable to provide for their families and for themselves,” Katherine Mayall, a global advocacy adviser at the Center for Reproductive Rights, told Rewire.
“There is a strong economic case to be made for meeting the reproductive health needs of a country’s population in humanitarian emergencies,” added Kade Finnoff, an economics professor at the University of Massachusetts. “In lower-income countries where many humanitarian emergencies occur, we now have empirical studies that document the economic impact to individuals and local economies.”
One study ofGhana and Bangladesh about the impact of increased access to reproductive health services found that improved access to family planning services led to “improved birth spacing” and an increase in women’s earnings and participation in paid employment. Further, children of women with access to family planning were better educated than those without these services. Another study of Nigeria found, “reproductive health is a panacea towards reversing the stalled socio-economic growth of Nigeria as evident from the linkage between reproductive health and development.”
A long-term strategic focus on providing sexual and reproductive health services could also allow non-governmental organizations to increase their support for prevention and preparedness before a humanitarian emergency.
As the UNFPA report notes, “Humanitarian funding is mainly directed towards the response to crisis, with relatively little directed to prevention and preparedness.” This lack of preparation often exacerbates already devastating situations, as we’re seeing now in countries affected by the Zika virus. Some government leaders in these affected nations are advising their citizens not to get pregnant for fear that their fetuses will develop a life-threatening anomaly. But many of these same countries don’t have the health-care systems in place to assist the women in need of contraception or abortion care, because of restrictive anti-choice laws.
Ultimately, meeting the needs of every community requires a holistic approach that includes support for prevention and preparedness as well as emergency services.
Cultivating a Local Response
IAWG encourages all communities to implement the Minimum Initial Service Package (MISP) for reproductive health, which is a “life-saving” set of guidelines “to be implemented at the onset of every humanitarian crisis,” the website reads. “It forms the starting point for reproductive health programming and should be sustained and built upon with comprehensive reproductive health services throughout protracted crises and recovery.” For example, a MISP checklist includes a form with sections on how to gather information about the demographics of a humanitarian setting, how to prevent sexual violence and respond to the need of survivors, how to reduce the transmission of HIV, and how to prevent excess maternal and newborn morbidity and mortality. And a yes/no checklist fosters the development of a weekly monitoring initiative at the onset of a response and then tapers down to a monthly review of the status of reproductive health-care services in the humanitarian setting.
“We know in every crisis women and girls are going to have these priority needs, even if it’s in New York City,” said Krause. “Pregnant women are going to need emergency obstetric care because of the breakdown in civil society in cities. There is always an increase in risk for sexual violence and so women are going to need access to care. A certain percentage of women who are pregnant are going to have emergency complications. Newborn care is essential.”
Some local communities are already focusing on prevention and preparedness. “There are some wonderful efforts—led by displaced communities themselves—to address these issues, such as the Adolescent Reproductive Health Network (ARHN) on the Thai-Burma border and Association for Refugees with Disabilities in Uganda,” noted IAWG researcher Sarah Chynoweth. Both organizations work on issues often overlooked in emergency situations.
Rewirereported on the work of ARHN to meet the needs of adolescent refugees, such as providing condoms, peer sex education, and birth control pills. The UN Human Rights Council has recognized the Association for Refugees with Disabilities in Uganda as an example of good practices for allowing refugees living with disabilities to advocate on their own behalf.
Chynoweth emphasized the importance of focusing on those who are particularly marginalized when preparing for emergency response and outreach. “Displaced adolescents, people with disabilities, LGBTQ individuals, and sex workers are particularly vulnerable to sexual violence and exploitation, and they also have specific [sexual and reproductive health] needs. We can’t just keep ‘doing business as usual’—targeted outreach must be conducted to engage these groups, something which humanitarian agencies often neglect.”
As the UNFPA report and other researchers have shown, the best way to provide for immediate and long-term support for sexual and reproductive health services is to fund both global and local initiatives aimed at spurring sweeping improvements in the lives of women and girls.