The Unfinished Business:Family planning & Maternal Health in a Context of Gender Inequality:

Presented by

Dr Sylvia DeganusGhana

Presentation Outline

• Maternal Health and FP situation in Africa Today• Maternal Health and FP in the context of Gender

Inequality• Cost of Maternal ill-health and Death and FP,• The way forward in addressing Africa’s “unfinished

business” in SRH

MATERNAL MORTALITY WORLDWIDE –WHO 2010

Even though progress has been made (41% ) MMR in SSA still remains dismal162,000 mothers die needlessly because of complications during pregnancy and childbirth. This figure represents a staggering 56% of the global total. Close to 1 million African children are left motherless

In 2010, countries with highest maternal mortality were Chad (1,100), Somalia (1,000), Central African Republic, (890), Sierra Leone (890) and Burundi (800).[11]

Lowest rates included Estonia at 2 per 100,000 and Singapore at 3 per 100,000

These medical causes of maternal deaths tell only part of the full story…….

Deaths associated with HIV infectionform a major proportion of indirectCauses of (other) Maternal deaths

CAUSES OF MATERNAL DEATH IN SUB-SAHARA AFRICA

FERTILITY RATE, 2009 OR LATEST AVAILABLE DATASource: (World Bank 2011)

Sub Saharan Africa has the highest fertility rates in the world, with a TFR averaging 5.5 (range 4.0-7.3

Birth rates in Africa are high in large part due to low use of family planning

29% of African women who are married or in union use contraception, compared with an average of 61% worldwide.

11 African countries have contraceptive prevalence rates of 10% or less, meaning that fewer than 1 in 10 women of childbearing age who are in union use family planning.

CONTRACEPTIVE USE AND NEEDS IN AFRICA

Factors contributing to Maternal Ill-health and Death in Sub-Saharan Africa

• Many factors prevent African women from seeking and receiving care before and during pregnancy and childbirth. These include:– Poor Access to Quality health care services– Ignorance/lack of information– Distance to Facilities– Socio-cultural practices– Poverty

– GENDER

POOR USE OF

HEALTH CARE

SERVICES

& death

Gender Disparity In Africa is a Reality!• Gender inequalities are systematic and occur

at the macro, societal and household levels.• Compared to their male counterparts African

girls and women are:

– Less educated– Poorer– In subordinate positions within the household

context– Economically dependent on men– “Voiceless” in decision making at household,

community and national levels– More exposed to harmful traditional practices– More exposed to unfavorable / harmful sexual and

reproductive health practices.

In sub-Saharan Africa, more than half of girls—54 percent—do not complete even a primary school education ( Bruns et al. 2003).

After primary school, girls’ participation plummets further—only 17 percent of girls in Africa are enrolled in secondary school (UNESCO 2003).

GENDER IN EQUALITY IN EDUCATION STILL PREVAILS….

Gender in Marriage and Childbearing:

• A woman’s identity in society is often associated with her capacity to give birth and the number of children she has.

• 30- 75 per cent of women (20-24 years old) in West and Central Africa were married or in union before they were 18 years old.

• In most of SSA Africa a woman’s has no control over her own sexuality or fertility

• Adolescent pregnancy and motherhood are exceptionally high in West and Central Africa

Women’s Low Economic Status

• Women in SSA constitute 80% of the poor and account for most of the unpaid work.

• Women generally undertake unpaid domestic and agricultural chores that are not recorded in countries’ national accounts– Women continue to care for children, the

sick, and the old, gather fuel and water, and prepare food

• Women’s wages in the formal sectors of employment remain low due to their low level of education and skills.

Gender In-Equality in Leadership

Indicators Total Male Female Participation in Parliament (%, 2007) 100.0 84.4 15.6Participation in Government: Ministerial level (% 2005)

100.0 85.9 14.1

Participation in Government: Sub-ministerial level (% 2004)

100.0 93.1 6.9

Participation in Government : Administrators and managers (% 2004)

100.0 88.5 11.5

Participation in Labor Force (%, 2005) 100.0 59.0 41.0

Source: African Development Bank (2009), Gender, Poverty and Environmental Indicators on African Countries.

•In SSA failure of women to participate in decision making goes beyond the household level to a macro decision-making level.•Gender disparity in SSA Governments promote expenditures that prioritize issues that do not directly benefit women and save them from needless deaths

WOMEN’S SRH AND SURVIVAL IN THE CONTEXT OF GENDER INEQUALITY

• The young African girl and woman enters her reproductive years, in poorer health status and largely ignorant of SRH.

• She is exposed to harmful traditional practices e.g. FGM, early sexual activity and/or marriage.

• She has little control over her sexuality and fertility resulting unsafe sex and unplanned pregnancies with unfavorable consequences (e.g. STI/HIV, Unsafe Abortion).

• During pregnancy her lower social status often means she receives inadequate support and care at household level and from the health care system.

• When complications arise during pregnancy access to care is limited by her subordinate position, her lack of empowerment and economic dependency on her male partner.

• When consequences of poor Maternal health and SRH present (e.g. HIV, Fistula) she bears the blame, is neglected, divorced and further impoverished

Source: Gender inequality, health expenditure and maternal mortality in sub-Saharan Africa: A secondary data analysis: (Frank Chirowa1 Stephen Atwood1 Marc Van der Putte 2013)

RELATIONSHIP BETWEEN GENDER INEQUALITY INDEX (GII) AND MATERNAL MORTALITY

GII, captures disparities between men and women across three dimensions (reproductive health, women empowerment and employment)

Can We Cost a Mother’s Health and Life?

“A mother’s life is priceless…..”

• Cost of her death /ill-health extend beyond that quantified in measures, such as DALYs* or Dollars

• Effects of her ill-health and death impact on the well-being of her family, her society and nation affecting even generations unborn both economically and socially.

Courtesy Kat Russell

In 2012, an estimated 162,000 women in Sub-Saharan Africa died from pregnancy- and birth-related causes; 62,000 of these women did not want to become pregnant in the first place.

MATERNAL ILL-HEALTH AND DEATH AND ITS CONSEQUENCES

MATERNAL IL-LHEALTH AND /OR DEATH

SHORT AND LONG TERM CONSEQUENCES

CHILDRENPoor survival

Low educationPoor Growth and

DevelopmentRisk of abusePsychological

challenges

FAMILY AND HOUSEHOLDSocial

Loss of family structureLess social support

Child care challengesChanges in relationships

Violence and neglect

EconomicIncreased povertyProductivity losses

WOMANPhysical

Poor healthAnemia

VVF/IncontinenceUterine prolapse

DyspareuniaHypertension

PsychologicalDepression

Abuse

COMMUNITYProductivity losses

Loss of social cohesionCrime

Adapted From:J Health Popul Nutr. 2012 June; 30(2): 124–130

Beyond 2014-The Way forward

Education

Economic Prosperity

Universal Access to SRH care

Health & survival for

women

A multi-sectorial approach is imperative to improve women’s health and reduce maternal deaths in Africa:

1. Girl child /Women Education 2. Access to quality

Reproductive Health Care, (Maternal, FP)

3. Protecting women’s rights and Economic empowerment

Women with more than seven years of education have on average fewer children in Africa than women with no education (Hobcraft 1993)

1. Female Education Impacts on her Fertility

Education will help achieve reproductive behavioural change in face of challenging socio-cultural, gender and economic circumstances

2. Universal Access (100%) to Sexual and Reproductive Health Care Is Necessary……….

All women must have access to SRH care including FP & skilled care during Pregnancy and childbirth

“Gaps in access to care still exist”

• Prenatal care was 73.47%• Births attended by skilled health attendant was 46.13%,• Contraceptive prevalence (of women ages 15-49) was 21.83%

World Bank Report For Sub-Saharan Africa in 2012

Universal Access To Sexual And Reproductive Health Care

The interventions that save women’s lives are known. What is needed is the commitment to make them a reality:

Evidence-based interventions for major causes of maternal mortality Exist !

Family Planning Saves Lives !

• Fully meeting all need for modern contraceptive methods would prevent 48,000 of the 162,000 maternal deaths ---a 29% decline in maternal mortality.

• If all unmet need were fulfilled, the number of unintended pregnancies in the region would drop by 78%—from 19 million to four million—resulting in 8 million fewer unplanned births, 5 million fewer abortions and 2 million fewer miscarriages.

• Fulfilling unmet need of FP in SSA would also prevent 555,000 infant deaths—255,000 newborn deaths and 300,000 deaths among older infants—which would result in a 22% decline in infant mortality.

Family planning is one of the most basic and essential healthcare services that can promote and ensure reproductive health.

Source: (United Nations Population Division 2011) and (ORC Macro 2011)

CONTRACEPTIVE USE PREVENTS MATERNAL DEATHS

Figure 2. Maternal and child health cost savings if Unmet needs for FP are met add up to $182 million for francophone West Africa, 2010–2020

Source: Policy Initiative/USAID Jan 2011

Figure 1. Social sector savings are three times the costs of meeting unmet need for family planning in francophone West Africa, 2010–2020

Family Planning is Cost saving

RuralUrban

RESIDENCE

NonePrimary

Middle/JSSSecondary +

MOTHER EDUCATION

PoorestSecondMiddleFourthRichest

WEALTH QUINTILE

NATIONAL

.0 20.0 40.0 60.0 80.0 100.0 120.0

53.988.2

54.566.2

79.498.1

40.255.0

70.286.0

98.3

68.4

Women’ s Socio-economic Status Influence Their Use of SRH Care Services

Richer, educated and urban resident Ghanaian women benefit more from skilled deliveries…(MICS 2011)

The Rwanda Success Story:•There are more women in Rwanda's parliament than any other country in the world. •Laws have been passed so they can own land, and wives can legally keep their assets separate from their husbands •Effective strategies and health and financing systems have been established that have improved women’s access to SRH care•Rwanda has done what no other country has done to date – increased its contraceptive prevalence rate (CPR) more than 10-fold in less than a decade.

3. When Empowered economically and socially , Women take charge of their own lives …..

Pictures are courtesy of Women’s health Report, WHO)

Beyond 2014……Africa Must Focus on its Youth

Today…………• The population of youth (15–24 years old) is expected to

reach 200 million in SSA by 2015.

• Their ability to make healthy and informed decisions about sexuality, childbearing and birth spacing now will yield the desired high returns in the region well beyond 2014.

• The 3 strategic approaches of Education, improving access to SRH care (including maternity care, Family Planning, Abortion Care) and Social/ Economic programs must focus on this generation.

THANK YOU FOR YOUR ATTENTION

“The woman is the heart of the house, so if your heart is working well the whole body I think is also to benefit,“. (Dr. Jean Damascene Ntawukuriryayo, a parliamentarian for the Social Democratic Party, RWANDA).