Due to their reproductive abilities, women are at risk for health issues that do not affect men. Since women are seen as being of lower class than men and their reproductive capacity is often seen as “different,” these medical issues typically do not receive the attention that they should, on the micro, mezzo, or macro level. This is also true in terms of defining human rights: Many documents do not include reproductive health, an issue that can be a matter of life and death (Agosin, 2001). Many women do not have access to contraceptives, which thus increases the likelihood of an unintended pregnancy. Approximately one in five women in the Global South is estimated to have an “unmet need” for family planning: She would prefer not to become pregnant but is not using any form of contraception (Social Institutions and Gender Index, 2012a). As discussed in Chapter 6, in a number of cultures it is considered inappropriate for a woman to refuse to have intercourse with her husband for any reason; thus, even if she would prefer not to become pregnant, she cannot refuse him.
When women experience an unintended pregnancy, some will opt to have an abortion, whether it is legal or not in their country; such illegal abortions can be fatal. The World Health Organization [WHO] (2012a) found that abortions occur across the world, regardless of abortion laws; however, unsafe abortions are correlated with stricter abortion laws, resulting in higher rates of death and injury. Unsafe abortion is defined by WHO (2012a, p. 1) as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.” Approximately 47,000 women die every year from unsafe abortions, 13% of all pregnancy-related deaths (WHO, 2012a). The incidence varies greatly by region, with the highest rates in South America, as well as Eastern and Middle Africa (WHO, 2012b).
Reducing the maternal mortality rate is one of the Millennium Development Goals (discussed in Chapter 9), and significant progress has been made. Maternal mortality was cut almost in half between 1990 and 2010, with the number of deaths each year decreasing from 543,000 to 287,000; the greatest declines were seen in eastern Asia and northern Africa (UNFPA, UNICEF, WHO, & World Bank, 2012). Substantial progress also has been noted in Egypt, China, Ecuador, and Bolivia (Hogan et al., 2010).
However, this still means that each day, 800 women die due to pregnancy-related reasons (UNFPA, n.d.). The highest rates of mortality are in sub-Saharan Africa and southern Asia (UNFPA, UNICEF, WHO, World Bank, 2012). Half the deaths were concentrated in six countries in 2008: Afghanistan, Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan (Hogan et al., 2010). Even within countries, disparities can be seen. Overall, Nigeria halved its maternal mortality rate between 1990 and 2010, but much of that progress has been in seen in the wealthier southern region of the country, rather than the more rural, poorer northern half (“Bridging the north-south divide,” 2012).
Several factors are noted as important to reducing maternal mortality: reducing the number of births per woman, increased income, increased maternal education, and increased skilled birth attendance (Hogan et al., 2010). Trained midwives are seen as essential in the battle to reduce the number of these deaths. The World Health Organization has called the shortage of trained midwives “deadly” and estimates that their numbers need to more than double to meet the reduction goal set by the Millennium Development Goal (“Shortage of midwives,” 2009). For example, Nepal has cut its maternal mortality rate almost in half, but this reduction is predicted to be unsustainable if the number of midwives does not sharply increase (“Nepal’s maternal mortality,” 2013).
Some countries have used Conditional Cash Transfers to increase mothers’ use of medical facilities, while others work to increase access in other ways. In Bolivia, pregnant women who lack health coverage can register to receive four small stipends through their pregnancy if they receive prenatal check-ups and give birth in a hospital. In addition, they can receive 12 additional payments in the child’s first 2 years if they bring the child in for scheduled check-ups and postnatal care (Moloney, 2009). In Bangladesh, women can receive vouchers for free prenatal care, subsidies for transportation, and cash for utilizing a trained attendant while giving birth (“Demand-side financing,” 2012). In Sierra Leone, Medecins Sans Frontieres provides free emergency obstetric care together with an ambulance service (“Slashing the maternal mortality rate,” 2012), and in Mali, doctors go to rural villages rather than requiring the women to travel to them (Medical house visits,” 2009).
While progress is being made in reducing the mortality rate, even more common, though, are long-lasting infections, injuries, and disabilities resulting from childbirth; 20 times more women suffer from these complications than from maternal death (UNFPA, n.d.). One example of an injury resulting from childbirth that has become extremely rare in the Global North, but is still common in other areas, is a fistula. Typically experienced by young mothers, especially those who are small (as is typical in females who are poor and undernourished throughout their lives), it occurs during extended labor. During contractions, the tissues between the uterus and the bowel, as well as between the uterus and bladder, rub against each other. When labor is protracted, this friction can result in tissue tearing, creating an opening between the two organs. In smaller women, the baby may be too large compared to her body for the birth to proceed easily. Due to the lack of access to medical facilities, the tear is not repaired, and the woman becomes incontinent. The leakage of urine and/or excrement causes a severe rash and a foul odor. As a result, the woman is typically cast off from her husband and her village. If she does not receive surgery to repair the tear, she can die as a result of this societal neglect.
It is estimated that approximately 2 million women are currently living with a fistula and 50,000 to 100,000 new cases occur every year. These numbers are based on women seeking treatment, and thus the actual numbers are likely much higher (UNFPA, n.d.). The problem is concentrated in sub-Saharan Africa due to a combination of reasons: poverty, lack of access to modern health care, the tradition of home birth, and early pregnancy. However, it also occurs in other nations where these factors cluster, such as Afghanistan and Pakistan (UNFPA, 2009).
Maternal mortality and morbidity helps illustrate how discrimination against women in other arenas can lead to permanent injury and death. As mentioned, women who are small are more at risk. Since girls are more likely to be malnourished than their brothers, this creates a risk factor. The stereotype that girls should not be educated but should be married as soon as possible to reduce the cost to their birth family again creates a risk factor, as younger women are more at risk for fistulas. Onolemhemhen (2005) states that to prevent fistulas, long-term solutions must include the education of girls and delaying their marriages until they reach maturity.
The following story helps illustrate the common scenario (adapted from Kristof & WuDunn, 2009):
Mahabouba was 14 when she gave birth. She had escaped from a marriage in which she was abused by her husband and his first wife. Her birth was unassisted by even a midwife, and after 7 days of labor, she lost consciousness and assistance was called. Mahabouba suffered a fistula to both her urethra and rectum and therefore leaked urine and feces. Additionally, she had suffered nerve damage to her pelvis and was unable to stand or walk. She was placed in a hut at the edge of the village, where she fought off hyenas with a stick before crawling for a day to a missionary for assistance. He took her to the Addis Ababa Fistula Hospital, where she was treated.
The surgery to repair fistulas is relatively easy and is typically successful. However, it is typically difficult to obtain because few doctors perform it and the cost, about US$100, is usually beyond the means of the woman. Therefore, UNFPA has launched the Global Campaign to End Fistula and has been working in a number of countries around the world to work on both prevention and treatment of fistulas in several ways. They have been working to help expand the number of people qualified to perform the surgery, as well as reducing the stigma around it. In addition, they have been working to help prevent it by promoting family planning, skilled birth attendance, and emergency obstetric care for those who need it (UNFPA, n.d.). The UNFPA works around the world to try to reduce these numbers of maternal deaths and injuries. However, in 2002, the Bush administration refused to pay the US share of dues, stating that UNFPA supported the one-child policy and forced abortion in China. Data supporting this claim were never found; in fact, the US State Department stated they had investigated and found no evidence to support it. Upon his inauguration in 2009, President Obama resumed the funding.