Global perspectives on women's sexual and reproductive health across the lifecourse

436 Pages·2018·6.74 MB·English

by  Choudhury

Shonali Choudhury
Jennifer Toller Erausquin
Mellissa Withers E ditors
Global Perspectives on
Women’s Sexual and
Reproductive Health
Across the Lifecourse
Global Perspectives on Women's Sexual
and Reproductive Health Across the Lifecourse
Shonali Choudhury • Jennifer Toller Erausquin
Mellissa Withers
Editors
Global Perspectives
on Women's Sexual
and Reproductive Health
Across the Lifecourse
Editors
Shonali Choudhury (deceased) Jennifer Toller Erausquin
Department of Public Health Education
Mellissa Withers
University of North Carolina Greensboro
University of Southern California
Greensboro, NC, USA
Los Angeles, CA, USA
ISBN 978-3-319-60416-9 ISBN 978-3-319-60417-6 (eBook)
DOI 10.1007/978-3-319-60417-6
Library of Congress Control Number: 2017949355
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Foreword
This volume comes at an opportune time, bringing together the right mix of issues
and perspectives that, if given proper attention, could truly make a difference to the
sexual and reproductive health of women across the globe. The countries of the
world are at very different stages in their efforts to improve women’s sexual and
reproductive health. Some have decades of experience, while others are only just
beginning to put the mechanisms in place to strengthen such efforts. That said, simi-
lar challenges have long existed in resource-rich and resource-poor countries alike.
The extent to which the health services that are made available are actually respon-
sive to what women need is of course of paramount concern. There is also a host of
distinct but related challenges posed to women of all ages, and in all parts of the
world, ranging from inhospitable legal environments to family and community
structures which conspire to ensure that true sexual and reproductive health—a state
of complete physical, mental, and social well-being—is still not fully attainable. As
is made clear in this volume, these challenges must all be addressed. To that end, in
all places even incremental changes in policy, processes, and systems can lead to
big-picture changes with positive and lasting effects. This is as true in places with a
long history of doing the right thing as in places where such efforts are only just
beginning. In this context, it is worth remembering that all nations have made legal
and political commitments to protect the health of all people, including their sexual
and reproductive health, through the application of human right norms and
standards.
A particular feature of a human rights orientation is the explicit attention it
requires to the participation of affected people and/or communities. A rights-based
approach to sexual and reproductive health has to enable all people, especially those
from vulnerable and disadvantaged groups, to exercise their rights to information
and services free of discrimination, coercion, and violence. Who is vulnerable or
disadvantaged clearly will vary between countries and within countries, but explic-
itly bringing human rights norms and standards into research and into programming
can assure not only that human rights concerns are explicitly assessed and addressed
but that better health outcomes are achieved. Human rights may be brought into
both programming and monitoring of sexual and reproductive health efforts with a
v
vi Foreword
wide range of primary concerns: to improve the delivery of services; to reduce
inequalities in access and use of services by certain populations; to identify any
violations that may be occurring because of program design and/or implementation;
to directly impact health outcomes; or to orient a program to bring attention to
broader human rights issues that may impact the populations being addressed by the
program. Human rights norms and standards have implications for programming,
for monitoring mechanisms employed, for data collection, for disaggregation—the
list goes on. There are today many large- and small-scale processes occurring within
countries and at the global level to engage and monitor human rights within the
context of sexual and reproductive health programming, but they remain inade-
quately documented, reported, funded, or replicated. Even with the best of intent,
health information systems and other relevant mechanisms are largely inadequate to
report data from population subgroups—let alone describe the extent to which
human rights formed part of how an intervention was put in place or implemented,
or whether the extent to which human rights were promoted or violated in the inter-
vention contributed to the health outcomes of concern or to human rights realization
more generally.
Whether the action taken is big or small, the strength, capacity, and commitment
of governments are of prime importance, including their convening and coordinat-
ing role to engage national stakeholders. The engagement of civil society is key as
well, not only to name the issues of concern but also for the capacity and ability to
organize. Although the strength of civil society varies greatly between countries,
civil society institutions are critical to attaining visibility and a platform from which
to engage in everything from advocacy to the delivery of services in ways that speak
most clearly to the women who need them. Getting the right interventions right,
including getting the right combination of people actively engaged and energized, is
central to supporting the sexual and reproductive health of women everywhere and
throughout their lives. A purposeful mix of key stakeholders is important for conti-
nuity, visibility, and building relationships, and ultimately useful for simultaneously
engaging bottom-up and top-down approaches—as each type of stakeholder has
access to and credibility in different national, regional, and international spaces.
In recent years, although it remains insufficient, support for the sexual and repro-
ductive health and rights of women across the globe has been unprecedented. This
book is of crucial importance, sharing the work of academic and practice-oriented
experts who are advancing theory, empirical research, and interventions for and
with women around the globe. It is my strong belief that what exists must be sup-
ported and sustained, but with a watchful eye towards global, regional, and national
political realities. The fact that the subject of women’s sexual and reproductive
health is in and of itself deeply political—and politicized—affects how such work
is best advanced. Even in the best of times and with the most sensitive and appropri-
ate approaches, setbacks are inevitable as political momentum shifts. Of particular
concern to women’s sexual and reproductive health in all parts of the world, how-
ever, are the retrogressive shifts in the larger global political economy occurring in
the last few years. The recent election in the United States of America only adds to
this concern, bringing into question the survival of relevant US government-funded
Foreword vii
family planning programs in the USA and outside. As the implications for the con-
tinuing support of national governments to women’s sexual and reproductive health
are unknown, so too are the potential impacts—not only for the institutions engaged
in relevant service delivery and advocacy, but also for the lives of women and girls
more generally.
There is a very real concern that the field of sexual and reproductive health, as
tenuous as gains have been, will substantively regress, something as true within the
borders of the USA as outside. More constrained national spaces, let alone the larger
geopolitical space, may lead (either deliberately or inadvertently) to reductionist
approaches to sexual and reproductive health. Truly important issues, many of
which are discussed in this book, will be dropped or de-emphasized, alongside a
loss of attention and support for ensuring the sexual and reproductive health of the
most difficult to reach and most marginalized populations in each of our societies.
There is a very real risk that sexual and reproductive health will be reduced to sim-
ply ensuring that X many millions of women and girls use contraceptives, without a
strong focus on free and informed choice and all of the various aspects of our sexual
and reproductive health and rights that are necessary not only for services to work
but for us to fully live our lives. We may end up back where we were decades ago
with target-driven programs that will reduce choice and restrict rights—with almost
no attention to understanding the specifics of the populations who most need contra-
ception and other sexual and reproductive services nor what it takes to support
people’s ability to use them. Contraceptive services are clearly necessary but not
sufficient to reduce the unmet need for family planning and for sexual and reproduc-
tive health services more broadly. As stated in 1994 by the governments of the world
in the International Conference on Population and Development Program of Action,
and recognized in research and policy and programmatic efforts many times since,
contraception is most effectively delivered as a key element of a package of mutu-
ally reinforcing sexual and reproductive health services which includes attention to
human rights.
We need vigilance to ensure that political winds do not take us backwards into
something vague, undefined, and ultimately harmful to women’s lives. It is precisely
at the intersection of human rights and the public health evidence brought together
here, and with the support of key stakeholders, that we can build the inclusive and
collaborative intellectual and political leadership needed to ensure that the sexual and
reproductive health of women of all ages will be fulfilled without discrimination.
Department of Preventive Medicine and Gould School of Law Sofia Gruskin
University of Southern California Program
on Global Health & Human Rights,
Los Angeles, CA, USA
[email protected]
Preface
Global Perspectives on Women’s Sexual and Reproductive Health Across the
Lifecourse was conceived by Shonali M. Choudhury, Ph.D., a women’s health
scholar and advocate. Shonali believed passionately in women’s rights, and she
championed research and practice that centers the experiences of marginalized
women. When she conceptualized this compiled volume of work, Shonali was a
faculty member in the School of Nursing and Health Studies at the University of
Miami. She had already completed a qualitative study of establishment-based
female sex workers in Tijuana, Mexico, and was beginning new collaborations in
Miami to better understand Latina women and HIV. She envisioned this book as a
way of bringing together diverse, global perspectives on current issues in sexual and
reproductive health. She felt strongly that the book should give voice to women
whose perspectives and experiences are often discounted or ignored: young women,
old women, those who seek abortion, and survivors of violence, among others.
Shonali also wanted to highlight the work of new investigators, who are rising in the
field of sexual and reproductive health and have new insights to share.
At the age of 31, Shonali was diagnosed with a brain tumor. Over the next three
years, Shonali would work, struggle, and resist. With the unparalleled support of her
parents, Parimal Choudhury and Barbara Southard Choudhury, she worked through
surgeries, chemotherapy, and radiation—teaching, writing, planning projects,
designing data collection, dictating manuscript edits. Shonali continued to pour her-
self into her work as she was fighting for her own survival because she saw women
all over the globe, of all ages, engaging in their own fights for survival and she
wanted to tell their stories and better their lives.
The three of us—Shonali, Jennifer, and Mellissa—first met as graduate students
in Public Health at the University of California, Los Angeles. Our experiences in the
Department of Community Health Sciences shaped our shared values and goals,
and helped us to forge warm personal and professional ties. So when Shonali’s
health was declining and it became clear that adding co-editors would ensure that
the book would come to fruition, she turned to us. The book was still in its initial
stages of planning, with several chapters solicited, and some edited, but no pub-
lisher. Motivated by friendship, intersecting professional interests, and the weight of
ix
x Preface
Shonali’s legacy, Jennifer and Mellissa have brought the book to its completion.
We share Shonali’s passion and hope. We believe that the interventions and research
presented here can help to shape the next generation of advocates, healthcare pro-
viders, and researchers striving to improve quality and equity in women’s sexual
and reproductive health.
The Importance of the Lifecourse Perspective in Sexual
and Reproductive Health
This book emphasizes a lifecourse perspective in understanding women’s sexual and
reproductive health. This perspective takes into account critical periods in a woman’s
development and recognizes that experiences are shaped by the wider social,
economic, and cultural contexts in which they take place. It also emphasizes that pres-
ent experiences are shaped by the past and will, in turn, affect future experiences.
While this perspective stresses the importance of all ages and stages of life, it allows
us to consider the long-term consequences of both biological and sociocultural experi-
ences that take place early in women’s lives. For example, several chapters in this
book highlight the pervasiveness of gender-based violence and demonstrate that vic-
timization of girls and women often begins very early. Because gender norms and
beliefs are so deeply rooted in many societies, many forms of violence against women
can be perceived as normal or even sanctioned by society, thereby going unrecog-
nized. This book brings attention to the multitude of harmful gender norms and
vulnerabilities that affect women at different stages in their lives, including early mar-
riage, unwanted or mistimed pregnancies, sexually transmitted infections, economic
disempowerment, and physical and sexual abuse. It also recognizes the ways in which
women in a variety of contexts resist, survive, and overcome.
As shown in this book, gender inequities affect girls and women at every stage of
their lives, placing them at a disadvantage to boys and men, and often influencing
their life trajectories. Although women may experience heightened vulnerability for
exploitation or violence during key milestones in their lives, such as sexual debut,
marriage, or pregnancy, we should not examine each milestone in isolation. Rather,
we wish to acknowledge the importance of considering the intersection of biologi-
cal, sociocultural, and behavioral factors that influence women’s health status and
how these may accumulate over a woman’s lifetime, shaping health outcomes over
the long term.
In taking a lifecourse perspective, we also reject the emphasis that is often placed
on women (and women’s health research) solely in terms of reproductive capabilities.
This limited perspective minimizes the experiences of older women, as well as women
who choose not to have children. In addition to looking at women at all stages of life,
in this book we examine a range of sexual and reproductive health experiences, not
only marriage, contraception, and childbearing, but also sexual pleasure and sexual
partnerships, health issues not directly related to reproduction.
Preface xi
Finally, in this book we hope to highlight the opportunities to improve women’s
sexual and reproductive health and to achieve socioeconomic and racial/ethnic
equity at various points in women’s life courses. We should aspire to the best pos-
sible health outcomes at every age and must examine how to best support women to
achieve this. Improving sexual and reproductive health for all women will require a
close examination of the opportunities and challenges for change across the life-
course—for individual women and for the institutions with which women interact
beginning even prior to their birth.
Women’s achievement of optimal sexual and reproductive health rests on the
realization of a wide range of human rights. Women must have the freedom and
autonomy to make decisions throughout their lives, whether choosing a marital
partner, determining if and when to have children, or deciding to work outside the
home. Women across the world are denied the ability to exercise these rights on a
daily basis. We subscribe to the notion of sexual and reproductive rights as funda-
mental to women’s health, well-being, and participation in society. Ensuring wom-
en’s sexual and reproductive rights across the lifecourse must be at the forefront of
our efforts to improve the health of women across the globe.
Organization of This Volume
The book is organized into five parts, each with its own substantive focus. The book
begins with a part on childhood and emerging adulthood. The chapter by Anita Raj
and colleagues lays a foundation for understanding the risks and challenges of child
marriage for girls and women. Next, Marie Brault and colleagues examine the role
of individual agency in delaying marriage and first pregnancy in India. Eunice
Muthengi and Karen Austrian present an integrated, multisectoral model to prevent
child marriage and early childbearing in Kenya. The last chapter in this part, by
Brittany Chambers and Jennifer Toller Erausquin, focuses on the US setting and the
stigma surrounding teenage motherhood.
The second part of the book focuses on childbearing, with three chapters touch-
ing on different topics. The chapter by Kara Francisco and Morgan Sanchez exam-
ines the perceived autonomy of black women in the USA in choosing vaginal births
after previous cesarean sections. The chapter by Charlotte Warren and colleagues
relates the experiences of women living with obstetric fistula in Kenya. Finally,
Aparajita Gogoi and colleagues explore access to and quality of maternal health
care in India through an innovative mobile phone program.
The third part explores reproductive control: fertility, contraception, and abortion.
Mellissa Withers and colleagues examine cultural influences on fertility preferences
in Bali, Indonesia. Then, the chapter by Deborah Mindry and colleagues presents
strategies to promote safer contraception among HIV-positive women in sub-Saharan
Africa. The final two chapters of this part relate to abortion: Natalie Whaley and Jenn
Brandt examine abortion in the USA through the lens of media (both mainstream and