Comments
José Barzelatto, M.D.
Senior Adviser in Reproductive Health and Population,
The Ford Foundation
New York, New York
The International Women's Health Coalition convened this session to discuss three important issues that are of increasing concern to women in general, particularly to those women living in poverty with limited access to adequate health services. Regardless of whether these women live in developing or developed countries, public scientific and ideological debates and alarming press coverage are increasing concern and confusion about reproductive tract infections, genital cancer and contraceptive safety.
The previous presentations have clearly shown that the three problems analyzed are important, that action is required now since there are reasonably affordable means to improve the situation in each case, and in addition, that there is a great need for more research.
As emphasized by the main speakers, their subjects are interrelated in many ways. These interrelations provide a good opportunity to reflect on broader issues that affect women's health in developing countries in general, particularly because these interrelations have frequently been ignored. It is much easier to raise funds and to mobilize political will if you concentrate on a single important issue.
In the past three decades, the world has seen different initiatives that have, and are having, significant and positive impact on reproductive health in the Third World. First it was Family Planning, which is now evolving from distributing and improving contraceptives to a more balanced approach to fertility regulation, including both contraception and infertility, putting more emphasis on investigating beneficial and harmful side affects, and starting to look at motivations for both usage and discontinuation of contraceptive methods. Then came Child Survival, another successful initiative that has found a positive response in all quarters. More recently, we remembered that mothers are also part of the equation. The Safe Motherhood Initiative has produced a positive and generalized response, by trying to improve not only the scandalous maternal mortality figures, but also by starting to look at the magnitude of suffering created by maternal morbidity. As a consequence, and with the help of the universal concern for the HIV pandemic, sexually transmitted diseases, and more broadly, genital tract infections, have also come to be recognized as most important.
What is still lacking is the general acknowledgement that all of these initiatives are different aspects of one problem area: reproductive health. It has yet to be recognized that competition among programs, which at least should be complementary, make little sense to women in the Third World. Unfortunately, these programs sometimes even work to the detriment of each other, because they are not integrated in terms of delivery of services. But recognition of reproductive health is nonetheless growing in many places.
Let me first quote from a World Health Organization (WHO) document. In the context of the definition of health by the Constitution of the World Health Organization as a "state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity," reproductive health means, "a) that people have the ability to reproduce as well as to regulate their fertility" with the fullest possible knowledge of the personal and social consequences of their decisions, and with access to the means of implementing them; "b) that women are able to go through pregnancy and childbirth safely; and c) that the outcome of pregnancy is successful" in terms of maternal and infant survival, and well-being. "In addition, couples should be able to have sexual relationships free of the fear of unwanted pregnancy and of contracting disease."
Women in the Third World are also making demands in this same direction. On June 5 and 6, 1989, the Brazilian Government's National Council for Women's Rights convened in Brasilia a "National Encounter on Women's Health: A Right to be Won." This meeting analyzed the "dramatic" picture of women's health in Brazil, where problems of high maternal mortality, increasing mortality from breast and cervical cancer and from hypertension, "could be substantially reduced with preventive measures." Inadequate prenatal care, and an excessive number of unnecessary caesarean sections were cited as serious problems. The importance of "clandestine abortion" was presented, not only in terms of maternal mortality and morbidity, but also as an expression of the lack of an adequate policy for sexual education and fertility regulation. "This lack, plus the legal prohibition against interrupting pregnancies, shows a disrespect for a basic right of female citizens to decide about their own bodies and to experience motherhood as a choice." The Encounter denounced the lack of implementation in most of Brazil of the Integral Services for Women's Health Program, approved by the Government in 1983 in response to initiatives of concerned health professionals and feminist groups.
They also denounced the lack of Government control over private family planning institutions, which has resulted in almost exclusive use of oral contraceptives as a reversible contraceptive method without adequate medical supervision, as well as in an alarmingly high incidence of tubal sterilization, including among young women. The Encounter made specific demands in relation to each of these and other issues, including decriminalization of abortion. In particular, they stated that "family planning should be the free option of individuals, as part of health actions within the Integral Services for Women's Health Program, and not be used as an instrument of government demographic policies or for population control of ethnic groups." Since the Encounter took place, the National Council has been reorganized and women's health might still be for some time "A Right to be Won," but the women of Brazil have made an eloquent public statement of their demands.
Feminist groups and health professionals have rarely worked together, and unfortunately, numerous, bitter confrontations over reproductive health issues and lack of mutual trust have characterized much of their relationship. This is not surprising given not only the lack of mutual feedback, but also the different perspectives that historically motivated these two groups.
Governments and health professionals in most countries became involved out of concern for the "population explosion." Governments were concerned about the impact on development, health professionals were concerned about the massive health consequences of population growth. Both saw the need to regulate the number of births. Better and greater variety of contraceptive methods was a commonly perceived need, and making contraceptives available was their initial exclusive policy.
Feminist groups got involved from the perspective of their human rights, including reproductive rights. Women saw the need to improve their status in order to exercise their rights, so they demanded education, equal job opportunities, and adequate health services, and as part of the latter, reproductive health services. Their complaint has been graphically described by the assertion that women are being considered factories for making babies, whose output has to be controlled, rather than as human beings that should be given the means to make and implement responsible decisions about reproduction.
In addition, feminist groups represent the users, while health professionals represent the providers of services. Conflicts between them are almost inevitable, particularly in developing countries given the poor quality of the health services in general. Many recriminations are justified, but some are not. Furthermore, the needed dialogue and collaboration between feminist groups and health professionals in respect to reproductive health, is also affected by ideological, religious and commercial agendas. Nevertheless, and perhaps because both movements have made considerable progress in their thinking and independently achieved remarkable successes, they are coming together almost naturally. They are certainly helped by initiatives like the one that has brought us together today, which follows in the tradition of numerous IWHC activities to bridge this gap. Adrienne Germain and Jane Ordway have described a strategy to review the so-called "population problem": "A 'reproductive health' approach, with women at its center, could considerably strengthen the achievements of existing family planning and health programs, while helping women to attain health, dignity and human rights." In this paper they have rightly concluded that such an approach would also appeal to several other constituencies and they have made several concrete suggestions to further improve the present situation.
To conclude this commentary, I would like to add one contributing idea of value in this field, in my view applicable to public health in general. There is a need to encourage and expand the contribution of anthropologists to public health, as "they alone bring to research in health a holistic approach to understanding daily life."
Most social science research applied to health is due to demands from the medical profession and hence, inevitably serves the medical agenda. What must be encouraged is a marriage among equals to improve health. For example, in improving public health indicators to include quality of services, shouldn't social scientists be telling us how to include the perceptions of the people served by these services? "It is too difficult to quantify" is a frequent excuse. I am not convinced that it cannot be done. Furthermore, can we ignore the non-medical factors influencing the behavior of those we are supposed to help? No one questions the need for a multi-disciplinary approach to solving public health problems, nor the need to rely on quantitative techniques. But in addition, let the anthropologists also do "what they do best: telling stories, that is, providing rich descriptions of how people live and why they act the way they do," to quote Cynthia Myntti, an anthropologist. She suggests that "statistically significant" data may be improved and made more relevant if surveys are followed by anthropological investigation. "Thus, chronologically speaking, anthropology takes over where epidemiology and its sister fields in public health leave off," rather, or in addition to, their initial participation in improving survey instruments.
This is an example of how social sciences may be able to make an even more important contribution to solving health problems in general, and specifically, in reproductive health issues.
References
1) Mahmoud F. Fathalla, "Research Needs in Human Reproduction," in Research in Human Reproduction: Biennial Report 1986-1987, ed. E. Diczfalusy, P.D. Griffin, and J. Khanna (Geneva: World Health Organization, 1988), p. 341.2) Conselho Nacional dos Direitos da Mulher, "Carta das Mulheres em Defensa do seu Direito à Saùde," (Brasìlia: Ministério da Justicia, 1989).
3) Adrienne Germain and Jane Ordway, Population Control and Women's Health: Balancing the Scales, (New York: International Women's Health Coalition, 1989).
4) Cynthia Myntti, "The Anthropologist as Storyteller: Picking up Where Others Leave Off in Public Health Research," presented at the Health Transition Workshop at the Centre for Population Studies,
London School of Hygiene and Tropical Medicine (London: June 7-9, 1989).
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