Adrienne Germain

Population policies reconsidered : health, empowerment, and rights

In this volume, scholars, policy-makers and womens health advocates suggest a new consensus on population policy directions for the 21st century, centred on health, womens empowerment, and human rights. They argue that public policy should assure the rights and well-being of people, rather than simply attempting to limit the ultimate size of the worlds population.

Stalking the elusive "unmet need" for family planning.

The discourse on unmet need in family planning (FP) emphasizes the need to obtain better conceptualizations based on the experiences of southern hemisphere countries. Unmet need has become a concept important for policy decisions, program strategies, budgeting, and resource allocations. The concept varies with the survey questions, with the definitions, and through the exclusion of factors. Conventional means exclude the needs of those not in consensual or marital unions and those who report use of a contraceptive. The exclusion of these women can have a sizeable impact. Unmarried people of reproductive age range from 8% in Mali to 46% in the Dominican Republic. In a study of unmarried women in Paraguay, 6% of single women had an unmet need by their own definition. Contraceptive users may be grouped three ways: 1) those wanting to avoid or postpone a pregnancy and who are using an ineffective method; 2) those who are using a theoretically effective method incorrectly or sporadically; and 3) those who are using an unsafe or unsuitable method. Included in the concept of unmet need are women who has mistimed or unwanted conception. The problems are that the survey questions regarding wantedness are biased and under-reported. Reported unplanned pregnancies and live births do not take into account abortions. The KAP surveys rarely ask for information on abortion; World Fertility Surveys tend to under-report voluntary abortion. There is a need to assess the need for safe, accessible, and affordable methods of pregnancy termination. Projections are that FP demand will rise sharply in most southern countries. national program strategies must be devoted to reducing the level of unmet need for the following women: 1) nonusers who are at risk of an unplanned pregnancy and need contraception; 2) users who need better contraceptive methods; 3) nonusers and users who need a safe, accessible method of pregnancy termination; and 4) nonusers and users who need more comprehensive sexual and reproductive health services. The current conventional method are useful only when limitations are noted clearly. Better measures, which expand the net of unmet need, will show the true extent of women and mens need for family planning formation and services.

Fertility Regulation and Reproductive Health in the Millennium Development Goals: The Search for a Perfect Indicator

Although several key elements of sexual and reproductive health are included in the United Nations Millennium Development Goals, a measure of womens capacity to regulate their fertility safely and effectively is missing. We considered the usefulness of 3 pairs of indicators in monitoring this component of reproductive health: contraceptive prevalence and total fertility; unmet need for contraception and unplanned births; and unsafe abortion and abortion mortality. A single measure of contraceptive use is insufficient. The risks women face from unplanned births and unsafe abortion should also be incorporated into the monitoring process, either directly within the Millennium Development Goals framework or as a parallel effort by reporting governments and other agencies.

Towards a sexual ethics of rights and responsibilities

Abstract Sexual rights as human rights encompass individual freedoms and social entitlements. Both depend for their realisation on equally important social responsibilities on the part of individuals, couples, families, other social institutions, and the State. The principle that all persons must understand their own sexual rights and responsibilities and respect the equal rights of others — particularly those of their sexual partners — informs our interpretation of the ethical basis of sexual behaviours. We propose a conceptual framework for defining a sexual ethics of equal rights and responsibilities pertaining to five dimensions of sexual behaviour: 1) sexual relationships and the right to choose one’s partner; 2) sexual expression and the right to seek pleasure; 3) sexual consequences and the right to cooperation from one’s partner; 4) sexual harm and the right to protection; and 5) sexual health and the right to information, education and health services. We suggest that the ethical principles presented here pertaining to sexual partnerships should be incorporated into sexuality education, sexual and reproductive health services, and social policies aimed at promoting the health and rights of all persons regardless of gender, marital status, sexual orientation, religion, ethnicity and other personal or group identities. Résumé Les droits sexuels en tant que droits de l’homme englobent les libertés individuelles et les prestations sociales. La réalisation de ces deux types de droits dépend de responsabilités sociales aussi importantes de la part des individus, des couples, des familles, d’autres institutions sociales et de l’État. Notre interprétation du fondement éthique des comportements sexuels est basée sur le principe selon lequel tous les individus doivent comprendre leurs responsabilités et leurs droits sexuels, et respecter l’égalité des droits de l’autre, en particulier leurs partenaires sexuels. Nous proposons un cadre conceptuel pour définir une éthique sexuelle d’égalité des droits et des responsabilités touchant cinq dimensions du comportement sexuel : 1) les relations sexuelles et le droit de choisir son partenaire ; 2) l’expression sexuelle et le droit de rechercher le plaisir ; 3) les conséquences sexuelles et le droit à la coopération du partenaire ; 4) les atteintes sexuelles et le droit à la protection ; et 5) la santé sexuelle et le droit à des services d’information, d’éducation et de santé. Nous recommandons que les principes éthiques présentés ici sur les partenariats sexuels soient intégrés dans l’éducation sexuelle, les services de santé génésique et les politiques sociales de promotion de la santé et des droits de toutes les personnes, quels que soient leur sexe, leur état civil, leur orientation sexuelle, leur religion, leur origine ethnique et autres identités personnelles ou collectives. Resumen Los derechos sexuales como derechos humanos abarcan libertades individuales y derechos sociales. La realización de ambos depende de responsabilidades sociales de igual importancia por parte de particulares, parejas, familias, otras instituciones sociales y el Estado. El principio de que todas las personas deben comprender sus propios derechos y responsabilidades sexuales y respetar la igualdad de derechos de los demás, particularmente de las parejas sexuales, influye en nuestra interpretación de la base ética de los comportamientos sexuales. Proponemos un marco conceptual para definir la ética sexual de la igualdad de derechos y responsabilidades concernientes a cinco dimensiones del comportamiento sexual: 1) relaciones sexuales y el derecho de escoger su pareja; 2) expresión sexual y el derecho de buscar placer; 3) consecuencias sexuales y el derecho a la cooperación de la pareja; 4) daño sexual y el derecho a la protección; y 5) salud sexual y el derecho a la información, educación y servicios de salud. Sugerimos que los principios éticos aquí presentados concernientes a las parejas sexuales se incorporen en la educación sexual, los servicios de salud sexual y reproductiva y las políticas sociales destinadas a promover la salud y los derechos de cada persona independientemente de su sexo, estado civil, orientación sexual, religión, etnia y otras identidades personales o de grupo.

Status and Roles of Women as Factors in Fertility Behavior: A Policy Analysis

Family planning programs in the Third World were developed on the assumption that subsidized provision of contraceptive education information and services would increase contraceptive use help reduce national fertility and encourage economic and social development. But family planning programs at best have had a marginal impact on societal fertility. This paper explores the hypothesis that the traditional definitions of womens roles as well as the treatment of women in the modernization process have been factors that have retarded progress toward reduced fertility national development and achievement of social justice. The paper is based on the premise that a fuller understanding of both the socioeconomic determinants of population trends and the consequences of these demographic trends for development requires recognition of the relationship between womens status and population trends as well as understanding of the current and potential roles of women in national development. (excerpt)

Reproductive health and human rights

One of the greatest disparities between rich and poor countries and often rich and poor people is in maternal mortality. The risk of dying from maternal causes in sub-Saharan Africa is 1 in 16. In Western Europe it is 1 in 4000. 70% of maternal deaths occur in only 13 countries. Why do more than 500 000 girls and women die every year—99% in developing countries—from preventable conditions and injuries related to pregnancy and childbirth? Why do 3·9 million newborns die every year in their first 28 days of life? Why are more women than men at younger ages living with HIV/AIDS? 62% of all young people (aged 15–24 years) infected with HIV-1 are female; in sub- Saharan Africa this proportion is 67%. (excerpt)

Integrating gender into HIV/AIDS programmes in the health sector: tool to improve responsiveness to women's needs

Half of all people living with HIV/AIDS worldwide are female and in sub-Saharan Africa it is far more than half, especially among those aged 15–24. Women living with or widowed by HIV/AIDS are commonly spurned by their families, beaten, lose their property, forced to marry a brother-in-law or cast out of their communities. They are the caretakers in the household and held solely responsible for getting pregnant and protecting the babies they bear. Girls’ and women’s vulnerability to HIV is fuelled by endemic sexual coercion and violence; early and forced marriage to much older men; and lack of access to HIV information, sexuality education and reproductive health services. Over a period of six years, WHO’s Department of Gender, Women and Health invested in field tests in five countries and painstaking reviews by diverse practitioners to produce this manual. As a result, HIV/AIDS programme managers and service providers now have a jargon-free guide, focused on action, with enough information on inequalities between women and men to persuade readers to act. Four sections for health-care providers focus on selected services that are not addressed in the other 187 resources listed in the excellent reference section: HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and care, and home-based care and support. An opening section explains the role that gender inequalities play in women’s vulnerability to HIV, in limiting women’s access to and effective utilization of HIV/AIDS services, and the steps required to deliver and monitor programmes that will reduce these problems. Each section of the manual, even the preface, is a gem, a terrific exposition of the investments that should be, but rarely are, made to produce a user-friendly tool. Although the authors suggest that the first section, on gender equality concepts, is most suitable for programme managers, service providers would also benefit from this clear and succinct clarification of “core” concepts. Each of the four service sections has examples of how to address the particular barriers, fears and challenges that women clients and patients are likely to face: at home, in the community and from health services. Examples from real life and materials from programmes provide additional energy to the already clear language and succinct presentations. Two of the best parts of the manual are presented as annexes but no reader should miss these. Each is constructed as a checklist for managers and service providers, respectively, to assess their progress. These lists are an additional way of presenting and reinforcing the actions needed, broken into useful subactions and presented in sequence. Sprinkled throughout the manual are special jewels, such as a clear and compelling list of reproductive rights interpreted for the HIV/AIDS context. There are also several pages on violence against women, its relationship to HIV exposure, its role in deterring effective HIV prevention, testing, disclosure and treatment, and examples of interventions specific to the health sector. This is also a compelling role-play for negotiating safer sex. Annex 3 invites users of the manual to submit suggestions for the expected revision of the manual in five years. This reviewer has a few suggestions, without which HIV/AIDS will persist, especially for girls and women. First, each section needs action steps to assist readers to integrate into their work ways to help women cope with stigma and discrimination outside the health system. Second, each section should emphasize supervision and other means to hold managers and providers accountable for improved performance. Third, the section on prevention of mother-to-child transmission does not include treatment for the woman herself. The reference in the treatment section is brief and phrased in negative terms rather than with the strong affirmation it deserves. Further, while addressing family planning, this section does not address women’s need and right to access safe, legal abortion should they want it. Fourth, references are inadequate on the importance of identifying and providing the comprehensive services women need, and to “linkages” between sexual and reproductive health services and HIV/AIDS programmes. All women need comprehensive reproductive health services. This has been agreed many times by governments since 1994 to include, at a minimum: family planning, safe abortion where legal, maternity care and diagnosis and treatment of sexually transmitted infections including HIV. Especially for women and young people, a paradigm shift is needed in HIV/AIDS programming to address HIV as a sexual and reproductive rights and health concern, including the services listed above as well as comprehensive sexuality education. This manual should be widely introduced, not simply disseminated, by WHO and all others engaged in the delivery and funding of HIV/AIDS services in the health sector. ■

Population policy and feminist political action in three developing countries.

This paper reviews the impact of womens political action on population family planning and health policies during the 1980s in Brazil Nigeria and the Philippines. These cases share similar processes of democratization and economic crises but differ in region population policies demographic processes and levels of womens political mobilization. The countries studied have all undergone a process of democratization which allows the examination of womens political action under evolving conditions of popular participation. The case studies reveal different configurations of feminist political activism. An active and explicitly feminist movement is in place in Brazil which capitalizes upon its political support for the democratic coalition which defeated the military regime. Nigerian women are organized into multiple associations but lack a coherent womens movement. They have been largely reactive to the new national population policy but with little effect. Finally the nascent womens movement in the Philippines is effectively protecting womens access to family planning services from conservative forces.

Mobilising support to sustain political will is the key to progress in reproductive health.

In May 2004 the 57th World Health Assembly endorsed WHO’s first strategy to accelerate progress toward reproductive health. All countries except the USA joined the consensus on the strategy noting that achieving reproductive health for all is essential to meet the Millennium Development Goals (MDGs). The strategy recommends action in five key areas: strengthening health-system capacity; improving information for setting priorities; mobilising political will; creating supportive legislative and regulatory frameworks; and strengthening monitoring evaluation and accountability. Although action on all five fronts is needed we believe mobilising political will including organising broad constituencies to support agendas for action and to hold governments accountable is the prerequisite for success in the other four areas. (excerpt)

HIV testing: the mutual rights and responsibilities of partners

Important questions about implementation of the new guidance by WHO and UNAIDS on provider-initiated HIV testing and counselling were raised by Daniel Tarantola and Sofia Gruskin. Their comments and those by other critics centre on individuals rights to confidentiality to refuse testing and to not disclose their status if they fear negative consequences. We are concerned that a singular focus on the individuals rights of refusal overlooks the rights of the individuals sexual partners to protect themselves from HIV. Human rights and public health will be best served by an ethical framework which recognises that both persons in a sexual relationship or exchange have equal rights and responsibilities for their mutual pleasure and protection. Further these individual rights are meaningless unless each partner respects the rights of the other. Protection of the human rights of both partners needs more commitment from health systems and from societies than simply ensuring informed consent and confidentiality. (excerpt)