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Seminar on Gender Inequalities and Reproductive Health: changing priorities in an era of social transformation and globalisation

Campos do Jordao, November 16-19, 1998
Co-sponsored by the IUSSP Committee on Reproductive Health
and the Population Studies Center (NEPO) of the university of Campinas (uNICAMP)

Report

The activities of the Committee on Reproductive Health culminated with the organisation of the Seminar on Gender Inequalities and Reproductive Health: changing priorities in an era of social transformation and globalisation in Campos de Jordao, Brazil from November 16-19, 1998. The last in the series of three seminars of the Committee was co-organised by Maria Coleta de Oliveira, Anastasia Gage and Axel Mundigo in collaboration with NEPO, the Population Studies Centre at the university of Campinas (uNICAMP), Brazil. In 1994, the Cairo programme of Action called for a holistic approach to sexual and reproductive health consisting of a package of integrated services that includes family planning, safe motherhood, child survival, and control of sexually transmitted diseases. The reproductive health approach focuses not only on integrating and improving existing health services but also implies a better delivery of services. This seminar marks an important step in advancing our knowledge about the progress and problems of implementing reproductive health policies and services.

The key objective of the seminar was to explore the linkages between reproductive health and gender inequalities in a society at three levels: at the individual and household levels, at the societal level to understand the impact of structural transformations and at the political level to understand how reproductive rights are defined and decisions on service delivery are made. This is particularly important in an era of global economic crisis affecting both donor and recipient countries hence demanding that local communities be sufficiently empowered to develop their own priorities free of external pressures. In the opening ceremony, participants were welcomed by Maria Coleta de Oliveira, Population Studies Center at the university of Campinas, Brazil, Elza Berquo, also of the Population Studies Center at the university of Campinas, Brazil, and Axel Mundigo, co-chair of the Committee on Reproductive Health. The major topics in this seminar covered the global and country perspectives on reproductive health, household dynamics and gender issues, demographic implications, gender ideologies and reproductive health services and structural transformations and health care systems in Africa with respect to reproductive health issues.

Reproductive Health: global and country perspectives

The first session of the seminar introduced the topic of reproductive health with papers outlining a broad global perspective on reproductive health and the change in its interpretation over time. Elza Berquo (Brief Considerations on Population Issues During this Century) detailed the changes in the interpretation of population issues leading to reproductive health in the last 50 years. As early as 1965, many developing countries stressed the need for WHO involvement in population issues. However, its role was confined strictly to the sphere of health. In 1988, it extended the overall concept of health to the area of reproduction, coining the term "reproductive health". However, reproductive health acquired greater social meaning only after the ICPD in Cairo in 1994. Reproductive health then entered the realm of social and behavioural scientists with the increasing importance of such issues as comprehensive contraception in place of predominantly neo-Malthusian views. The role of feminist leaders increased once again with the reintroduction of discussion on empowerment, sexual health and violence and other such issues.

Other papers (From Contraceptive Targets to Reproductive Health Services: evolution of India’s policies and programmes by Leela Visaria; Family Planning and State Ideology: the case of islamic rePUBLIC of Iran by Amir Mehryar and Farzaneh Roudi; and Reproductive Health: does it have a place in a health sector reform agenda by Maha El-Adawy) are case studies of specific countries such as India, Iran and Egypt. While the studies on India and Iran attempt to understand ways in which countries have adapted and changed their policies to include reproductive health, the study on Egypt outlines measures to reform the state defined health agenda to ensure that it included reproductive health. The case study of India explains the evolution of the Indian Family Planning programme from its target approach. In recent years, it has changed to a target free cafeteria approach and later to one more integrated and including reproductive health services. Similarly, data collected in 1997 demonstrates the success of the Iranian Family Planning programme since the decrease in ideological barriers and consequent use of modern contraceptive methods in 1989. In contrast, the paper on Egypt shows that, even today, there is much need to include reproductive health in the agenda of the Ministry of Health in Egypt.

Reproductive Health: household dynamics and gender

The role of individuals, kin groups and relationship between spouses formed the main theme of the papers focussing on the identification and use of reproductive health services at the individual and household level. Each of the papers defines reproductive health outcomes differently: reproductive illness, use of maternal care services, contraceptive use, acceptability and use of condoms and spousal communication with respect to condom use.

Two papers (Individuals, Households and Kin Groups as Determinants of Access to Reproductive Health Services: the case of Jordan by Jon Pederson; and Women’s Social Networks and Pregnancy Outcomes in Mali by Alayne Adams, Sangeetha Madhavan and Dominique Simon) deal with kin/network influences on women’s reproductive outcomes – an area of research with little empirical evidence. Both papers show that kin networks are important in some but not all contexts. While women with networks are more likely to use ante-natal care services in Jordan, network influences are important in preventing still births among the Bamana and child deaths among the Fulbe, the two groups under study in Mali.

Yet, some questions regarding the household gender dynamics and the specific type of network, whether comprising of women or men, of members of the household or outsiders are important to answer as well. In terms of policy implications, these papers raise questions on the specific role of women’s labour force participation in empowering women to utilise reproductive health services. It is highly possible that women’s employment could place constraints on women’s time to use such services. Secondly, the papers show that better networks and support systems do decrease negative consequences for children. However, its influence on use of maternal health services and reproductive health services is yet unclear.

The focus on the household brings in issues such as gender inequality, inter-spousal communication, bargaining power and decision-making power of women in the household. The paper by K G Santhya and G L Dasvarma (Spousal Communication on Reproductive Illness: a case study of rural women in southern India) conceptualises spousal communication as an intervening variable in the relationship between gender inequality and the treatment of reproductive illness. The cultural context in India provides a good venue for the silence about reproductive tract infections. With limited choices in sexual decisions, and the inability to abstain from sexual intercourse, women are forced to endure domination by their husbands in marital relationships. Furthermore, the cultural context also poses many negative connotations surrounding women’s reproductive tract infections as opposed to men’s. The issue of women’s sexual rights is also raised in the paper – given that men have greater rights to sexual gratification irrespective of women’s consent or dissent.

Moving away from the cultural context, the paper by Kathleen Beegle, Elizabeth Frankenberg and Duncan Thomas (Bargaining Power within Couples and Reproductive Health Care use in Indonesia) focuses on three measures of power based on asset ownership, parental status at time of marriage and household decision-making power of partners in households. They demonstrate the impact of these measures of power on the use of reproductive health services such as contraception, use of prenatal care and choice of a location and attendant for delivery. Data on Indonesia show that despite a large increase in contraceptive use in the last two decades (from 27% in 1980 to 55% in 1994) and gains in the use of prenatal care, high maternal mortality rates persist. The main reason for this phenomenon lies in the decision-making process within households. Their analysis shows that each of their measures of power influences different aspects of reproductive health.

Along the lines of the paper on Indonesia, Brent Wolff and Ann Blanc (The Role of Gender Balance in Decision-making on Condom use in High and Low Risk Settings in uganda) also focus on decision-making using two scales of decision-making power which measure – i) women’s relative decision-making authority over sex and ii) perceived decision-making power in the area of fertility regulation. The paper shows that a smaller age difference between partners and similar education levels of both partners diminishes the gender imbalance in power encouraging men and women to discuss the use of condoms. However, both women’s and men’s sense of their own empowerment has a positive impact on the acceptability and use of condoms.

The papers presented in this session outline several methodological issues as reproductive health enters the demography arena. Quite often, endogeneity and difficulty in establishing causality between the explanatory and outcome variables or in establishing the temporal ordering of events e.g. between spousal communication and reproductive illness and treatment in India or the temporal ordering of contraceptive use decision-making and pre natal care in Indonesia create problems in research. Secondly, the concept of gender inequality is also often difficult to measure with data from large surveys. The paper on Indonesia mainly uses economic power as a measure of gender inequality while the paper on uganda uses decision-making power on sex and fertility regulation.Third, the paper by Wolff and Blanc highlights an important methodological dilemma: of whether to report and analyse the husband’s or wife’s report of the same event, such as contraceptive use when conducting and analysing data from large surveys. The issue is especially important given the high incidence of divergent responses to the same question addressed to both partners. The typical use of the wife’s response needs to be understood in the context of poor spousal communication and high levels of spousal misinterpretation of each other’s attitudes.

Reproductive Health and Gender: demographic implications

The main focus of the papers in this session is on specific demographic outcomes such as infertility, pregnancy and other reproductive behaviour. Rebecca upton (Gender Inequalities and Perception of Health in Northern Botswana: some implications for the study of fertility in Southern Africa) focuses on infertility, a topic of little interest to policy makers in a context where decreasing fertility rates are deemed more desirable. The paper examines how gender inequalities in reproductive health, specifically with issues of infertility, affect status and the social construction of health in Botswana. This issue is examined with respect to two kinds of transformation in the region - in terms of migration and the advent of a severe AIDS epidemic. Increasing male absence, economic support and the AIDS epidemic are external factors that help determine why infertility may occur.

In his paper titled Impact of Credit-plus Programme of Development on Gender Inequality, Women’s Empowerment and Reproductive Behaviour in Rural Bangladesh, Firoz Mahboob Kamal focuses on reproductive decision-making as the outcome of interest. Critiquing other conceptual models of empowerment that use household power dynamics as the key outcome variable, this paper conceptualises the use of empowerment not as a determinant but a process variable representing a control over resources and ideology. By contrasting the development models followed by Grameen Bank, the well known micro-credit programme and BRAC (termed the credit-plus programme), the paper outlines policy implications including the need for value-free perspective of researchers, the use of better measurement tools and an evaluation of the process variable, empowerment.

In contrast to the other two papers in this session, Indralal De Silva’s paper (Biomedical Facts and Social Constructs: the relative attention paid to pregnancy and postpartum periods in Sri Lanka) investigates the level of care that mothers receive during their last fertile pregnancy and postpartum period as well as identify which mothers receive inadequate care during these two important parts of motherhood. The study demonstrates the high level of pre-natal care in Sri Lanka, more so among women who desire the last pregnancy. This has a great positive impact on the health and survival of both the mother and her child. However, there is still need to improve post-natal care at the community level to reduce the burden of ill health. Hence, the study recommends the need to change focus from pre-natal to better post-natal care based on the health status of the mother and child.

Gender Ideologies and Reproductive Health Services

Moving from research on reproductive health at the individual and household levels, the next session of the seminar focused on gender ideologies and reproductive health services at the macro level. Papers presented in this session outline the changing views of individuals that often interfere with the role of the state hence demanding a change in the state health sector agenda.

Zhao Jie (uneasy to Take Reproductive Health for Women) uses data from rural women in Yunan, a mountainous border province in China to study the complex relationship between reproductive health and gender. She attempts to better understand how reproductive health based gender discrimination occurs and whether solving this problem will empower women in the long run. Solving reproductive health problems are essential policy goals but are not possible without the active participation of social scientists and feminists in conjunction with the medical establishment. The paper recommends detailed research and the active participation of the women involved by breaking the prevailing culture of silence.

Along the lines of the above paper, Iwo Dwisetyani utomo’s case study on Indonesia (State Ideologies and Provision of Reproductive Health Education and Services: a case study of Indonesian youth) portrays the changing attitudes of individuals, particularly youth in Indonesia. The state is unwilling to accept this situation and hence does not provide the necessary reproductive health services including contraception to this group of unmarried persons. Consequently there is an increase in the threat of AIDS and other STDs, premarital pregnancy and abortion, early marriage and maternal and child health problems. As youth become more liberal with PUBLIC expression of sexual feelings with the onset of globalisation and Westernisation, this parochial attitude of the state continues to have disastrous consequences. using the framework of Indonesian "idealised morality", ongoing modernisation and mixing between the sexes, the paper demonstrates the negative consequences of this conflict between state and individual ideologies.

Moral worldviews for the interpretation, description, explanation and regulation of everyday life are another influence on sexual and reproductive behaviour of individuals (Attribution of Control and the Abortion Controversy: different sides, the same struggle by Carlos A Lista). This paper focuses on the debate underlying the decriminalisation of abortion in Argentina, a dominantly Catholic country where this practice is illegal. Results from the quantitative and qualitative analysis show that the anti-abortionist position treating the woman who aborts as a selfish and irrational person prevails regardless of the social position of the individual. Despite the more permissive worldview based on a secular ethos, Catholicism is the main reason for this attitude in Argentina.

The question that arises in this topic of discussion is whether issues relating to reproductive health are within the domain of the private or the PUBLIC sector. While there is no such debate on the provision of health services, it is a totally different picture in the case of reproductive health issues. State provision of water facilities and immunisation is not questioned by individuals whereas state interest in contraceptive use and sexual lives of individuals is.

Reproductive Health: structural transformation and health care systems in Africa

In keeping with the final objective of focusing on the impact of globalisation, the seminar concluded with a session examining the role of structural transformations and health care systems in Africa. The range of papers in this session generally focused on reproductive health issues given the changing socio-economic context in Africa.

The onset of structural adjustment programmes in Nigeria in 1986, as in many other African countries has resulted in the introduction of "user fees". An increase in cost of services hence accompanied the declining income of individuals. Data analysis of the 1992-93 Nigerian Health Transition Study (Women’s Health Treatment under Adjustment in Nigeria by I. O. Orubuloye) show that structural adjustment programmes accompanied by an increase in household expenditure and the simultaneous deterioration of quality in government provided services have increased women’s health burden across regions. Based on these research findings, the paper proposes the re-examination of the user fees policy of the government due to its negative impact particularly on women and children.

Joseph-Pierre Timnou (Atteindre les Objectifs de la Santé de la Reproduction: un défi difficile pour les pays africains: analyse du contexte camerounais) also addresses a similar issue specifically focusing on the consequences of poor implementation of reproductive health services in Cameroon. using data from the Demographic and Health Surveys, Wave II, the paper shows the declining reach of health services to mothers and children in 1991 with increasing instances of diarrhoea and child mortality. With liberalisation and the deteriorating economic situation, reproductive health services also stand to lose. While reproductive health is of little interest to the private sector, the poor quality of services offered by the PUBLIC sector and mismanagement of PUBLIC funds in conjunction with individual payment for services has had negative consequences.

Agnes Adjamagbo (Gender Inequality and Reproductive Health in the Changing Context of Rural Africa: qualitative evidence from Cote d’Ivoire) adds the aspect of gender inequality to the issues examined in the other papers in this session. The economic crisis and growth of the cash crop economy has resulted in increasing gender inequality. Gender relations traditionally biased against women worsened further with the economic crisis, the decrease in cocoa and coffee prices and increasing land pressure. Analysis of data collected in 1994-95 from married males and females as well as health centre workers show the negative implications of male control of economic resources and decision-making on women’s use of health and reproductive health services.

The growth in membership in spirit associations is seen as an outcome of the globalisation process, poverty and the poor provision of health services in the Kigoma region of Tanzania (Women’s Reproductive Health Strategies During the Era of Structural Adjustment: a case study of adapting medical systems in Kigoma, Tanzania by Sheryl McCurdy). With currency devaluation and poverty during the post-structural adjustment period, growth of immigrants and refugees following independence and increase in religious fundamentalism, spirit possession cults form an effective survival strategy for large numbers of women. Analysis of data from individual interviews and a reproductive history survey show that spirit possession associations act as an effective social support system in Kigoma in an era of economic change. Particularly those Muslim women over 35 years of age and those who have experienced a reproductive tragedy such as infant mortality, a miscarriage, still birth or infertility are more likely to join these associations.

All the papers in this session demonstrate the association between the introduction of structural adjustment programmes and the deterioration in the use of health and reproductive health services by women in Africa. While this is true, some questions arise. Is the deterioration in quality and use of services a result of the introduction of structural adjustment programmes in Africa? And if this is the case, how can the actual level of impact be measured? Secondly, what are specific individual responses to the introduction of structural adjustment programmes?

In general, the seminar was a good opportunity to discuss reproductive health issues and to understand interlinkages between macro level processes and negotiations among individuals within the household e.g. the influence of state policies and economic changes such as structural adjustment programmes on family planning and reproductive health. Moreover, examining the role of household level decision-making processes on individual use of reproductive services is also important. The seminar recognised the need for greater empirical evidence and research in this field. Particularly while examining household level decision-making and power, many methodological issues including appropriately defining decision-making power of individuals and establishing causality between variables arise. This issue of establishing causality also comes up when studying the impact of structural adjustment programmes in Africa.

Soumya Alva

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