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A Guide fOor Media

II'RIEEDOl'W

ClENTEH FOI( I'll 11'. 01 A.

Uni ~ ed N atlons Pllpu.lati,on Fuml

ilhe fasJ)oflsibUifyfo,r the ,opffinio~s explfi9ssed in,thii5; ipu'b'li:cation ~ests soWe!ly wi~1i'iI theiiralJlhor(:s)olnd doe.s; iI'IIO:~ Qont!ititul~ an endolrsemenfi by the lin/led NoIJcJM POPl.lfalian Fund (UN'P.AJ~

Ptlblished ]996 by the

Cen.te:t' f. M,edi:a.Freedom: &'RelJpOD$ibi1!iq. mlh agtl'mu.f:mm the

UlliitcdNa.tli.ons PO,lilaulJI! hod (U::NFP:A)

Ut'llit4.00 ... Hor.iwn Cond.o:!l'ci1unn1

Mel-ako Ave., City otPas]g_. Metroo ~ 'H' 633-5917, 634-17'73, ,633-94.37

;JJ 633---94±37

'Table of Content,s

I, mtrod'ucf.ion , "." 4:

n , Tracmg poHgr shrills frombmciJ.y phmnmg to repr:odJ.ucbve heaId!. •••••••.............. '7

m. Reprod lilruve health: atpersJloctiv'eOll'td an

a.pp:r.O'a.Ch ,.,.,.",.,.,."............. 13

v,. FundamenW principles 20'

VI. Issues witmnand beyond the pelli'vic zone:

some refiec.tlons , ,., 23

A Framework:.:Eor Understanding Repmductive Health

OD Wo.m.iBll's H·ealth: BeyondllleprodllciioD

by Marilen J. Dafiguilen, M.D.

For sometime now, population dtscussion has resounded with the ·oonn "reprcdnctive healitlh." Obvi.o;usi\y; the tam. can have ooverd meani_ng;s. And its use would depend. on ·th@ irnb1!rpretaoon given by a profession, a politkal perspective or ideology.

It is important for the media. to establish a. framework of -unJi@rsmding mlha.t wID rationiilize im repeatedreference in the pu bIDli.c forum ..

Reproducttve health if; part of women's overall health . .Afl.:er almost five decades of discussion, the illtematriollaJ comm runty has agreed to ad.opt the concept of " reprod.uctive health" as all a.pproa.ch to, the craftitlg of popul!aoon policy. It has provided a saner approach to the solution of popul!a.tiOl1 problems.

4

Tile concept ma.y be Interpreted .in. different ways .. Reproducttve health may be pursued through ddfel'ent progriilllsf depet1!ding on the social and economic conditions prevailing in the country. But there are fUllIdaID ental and ethical prindplesupon which :reprod u.~bive hea1:th. is based. Women, advocates hope ht pohcfes w!i.ll reflect these prwciples,. These principles should be understood to. ckl'ify the basis of conceptual discussion.

The tendeacy to equate "reprodtuctive health" wit.h , .. .lam ily P lartning" :m.le'e,d, s correction. W.hil@ Ule

prfnctples of II reprod uctive hea]llli"' have bam. usedtorevise previous population policy approaches, reproductive health should not be understood as just another name for POptU6l,tiOIli control, It is grounded in reproductrve rights' and H; a basic conditien of "women's em pewerment' (mrUorlunately another misurtderstood md abused term). Womelli'S empowerment is not only about abortion and. fer:l:ilify conn'Ol Rather it is abouttho!re OOl1Id:itiollS which enabl€! men ,md women {'() fulfill their potential, indudmg their sexuality. It is about freedom hom fear of mcest~ rape, the' kWid of Jrarassment, diserim it'Ia.ti:on, expkiitation, and violence that exploit women. bern use tbg-y are WOmen. The empowerment and :ldbeuli.tion is soughtfor men as for women. bemuse these fears hold back both male or female from understanding and appreciating their being .fully and equally hum,ptl:

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But then agam. Ute ability to be (or not to be), or tIle forces that leBid to empowerment, is, really a qu.estion of one's access to a range of opportunities fur jobs, livelihood, property, education, housiing:. health care, ,cre~Ht, as wen as political parlicipMion. These are basic e.l1a.bling coo.ditions tihatt help a peJ!"SOIl enjoy a Culler Iife: b'trild.mg :up one's personal confldence and s~lf-esteem. These oOllliditions allow at woman to choose if and when. to g,et pregnant,. if and when not to. These conditions give one the leverage to "negotiate safe sex;" to say 1iI0' wan oppressive husband and. to seek protection against his abuse. These erutbl€ a man or woman 'to step out of the closet with the truth, of tiheiroo)'''1Hility. These conditions help men and women'ro stand up agednst the stereotypes perpetrated by custom, cultural tradition Of l<eUgiOll tllaGt·ltold {litem down, ,esp@ci1illy in those areas r-elated to se'xuality.

Reprod.uctive health andreproductive rights are c,entrall,o enlpowerm.ent. Development can evelvebasic enabling conditions tl:mt red U.Oe8 poverty levels, sl"f'ength.em, &tiety nets for ll'I,argjrtalized sectors, and focuses on the economic :irl,iiepend,ence for the country and for the individual

R,eprod:u'cti:V@health and Us enabling ,e:onditiolJ.ls ,a'ire ends in themselves, and should be pursued as such, \i\1'hetherornotth€8€ should bring, f'e1'1:illty rates down in ~[he fu ture is no longer the overriding concern. The driving force is, notthe determmasion of how many ehdldren eve1'}1'bod.y should have or what size ,Ell. family should take, The shlft signifiesfhe movement of popn Ia lion concerns from the mim hers count vVhat matters moot is tha_t Wome:n, and men can make mal choices, And tfu1Lt they are a Me to HV'e well with the chotces they make.

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IT. 'TRACINGPOUCY SHIFf'S FROM FAl!.4ILY .P1LANNING TO REPRODUCTIVE HEALTH

For almostftve dlecades s.IDce the birth of the fuIn.:ily p~a:nn:ing establish:men.t2 r mosegovemments the world over have been irll1Jising enormous Irrvestments and focusing mum of its activllity a.nd. energy into controlling numbers of people, either in their owncountries or elsewhere. The establishment viewed. tihe inc:u:easltThgnum hers - especi.allyfhose in the d€."V"do]ping ccuneries - as a 'liIiIf~a~t tonational we]]1..be:ing and security. The growth in population in {he cl.e've]oping world was ,a.d.esta.hilnizing foro@ that W01l.1dJ. hinder the developed countr:ie:s' susbrined. access to maief.irur.esOt1tlmes. 3

Du.1r:U.ctg the early 50s totJIIe 70s, tIle esmlllisll:unent pushed gOVBlJ.1lllIe:nm of developing countries tomntrol tlheir popnlation growth tatesta.ssisw.,g them. with. :funds illl!d programs to acltreve this,

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Btrth control methods and techniques flooded c·(mntries· of Latin America, AB.la,. and Africa. Popula:tion controllers went to work. India set up :im ster.ilizaoon cam p8 where wemen OO1Jd men weJlesteri.lized. .Ml exchenge for H.. few hund:redIru pees, at sack of w Ileact, or a. transistor radio .. Indonesia staded itasafari campaigns ~ which are still going on up to flt.js day - where the millita11l:r()ru.nd,ed up women lin villages and plunged IUDsitdo' them.

Bu t these aU:empts to control numbers met wiilh.resismn·C'e in most of the d'ev·eiopm.g world. FU'rtlIennore, the estabHslmi,ent also obsewved that fertility levels did no,t go down W d.esn:ed leve1!s.

Thus/in the 70'S, the popula.tiW1l polky comm wnt}l' :sfm'ted to re-think its stra.tegi-.es and shift its foCills hom. populatir.m control or how to reduce numbers immediately at the least cost to population ,plarurlng or how best to reduce numbers by lookuli.ga,t the diffe1rent influencesthat made couples decide to, havechildren,

Population plalWlters became more mrerested JID those factors that monvated people to practice ,family planning. Tbeygave inl portance m research that studied "dete:rnulnants'" of furtiJity and $ulggested governments ,m provide Incentives and. disincenti.'ves to leDOOU~ muples to limit or increase 'the sizes of their f1Ullilies.

The focus was on motivation. Popu:Wa:lion phuUllefS urged govemm!en;i:s to integrate' famJly pwuili'lg mto somebroade» progI:ant lile ~te~.md Child Health 01" Primary Health Care, They believed that such an inieg1aJion would attract mom clients toresurt to birth control methods,

Bu t then again, o\ilfte1t a d ecad e or so of m otivating and ;u'l:tegratiJ1lg. ,lliepapu:ial'ion plru:tners observed. that their a Pl'JlO8JJ':.h. fulled to achieve dramatic results. Gove:mments, they pointed out, were S:lo,w .in integr~.ting funlily plamling iJ:rto broader PJlograms. Motivation and integration, they daim'ed" were tmning out to be velY costly" not (mly for national gcvemments, 1mt for international donor a,gendes M well

8

Throughou t the 80s <1lll1.'~ 90s., the women's gl'OU pS5' began to make theirpres,encef,@lt. The women"Ei, groups pomted on t that the ,establis.hment has blamed women forthe world's teeming poptdalions; thus the fOCUl5 an corrtroffing wmn,en's :fe11ility. Women ad voca tes argued that population, po]!jdes~ w hetherbased On control 01' a. syatem of incentives and. disincentives, have been disrespectful of women's bodies and righm. 'Womi1!'l1. had be come "tar gets" r passive recipients of SOme form of birth eorrtro l method, often without any recognition of tbeir dignity , I ' "" "and their capacity to make

i .. ..tIDnal choices.

WOm'EUl.'S groups have demanded - and continue to demand - from govemment and other il1s.ti~ll lions of soci.e:ly- that smc-e wQmenstand, !in the center Qif popula tion policies, they s,["ould be a ble to pa:m1icipate actively in making ~fu.ose d!ecif'iions that directly a,ftect their JiV€I.s;.

Time and a.gaill; they have insisted that they have needs which .awe not centered solely on the pelvic zone. These needs mclnde food, land, jobs, ,credit, ed uca lion ... houses, health care for their children as well - basics the government should provide. TIley said they also needed to be freed from v:i.o~ent and a busive husbands, from custom ary rules that do not allorw them ro mherit and own property,

9

flflom cultural eonditions that tend to s;h"aitja.eket worn en in. tom. motherhood. role" hom oppressive laws: th:1tt restrict their eHedive access to the means by whidl to control theubodies and, the reprod:uctive function; as well. as; .hom lllSotutioltalliized forms of d.iscrim ination and. sM:lIJrnonsiliatpJlevet'!t them from fuMy ,exp~essmg tf'heit sexuality .

.All these basic needs m. IDife, theyMLid, harve more beaTing 0lI!I. m.,eir health arid their desire and a.bility to ccntrel their fertility fh<U!l. the 111lUl1 hers (If p6 and. IUDs dtstrihu ted. (If the nuen bern of hospitals Ml. their commurtities. These" enabUng co:m)dioons" have to lie fuHilled before they a.m able to achieve repl'oductiveh~altha.l1d befoee they 'Ca:I'I. exercise their reproductive wmgMs.

Popu1ation controNersatnd. pbIU1.em, torwhatever reasons, [urve collaborated w:itb several wQme!l1!!' Si grOllrps6. UNFP A has supported fe:ll1!!irdst cenferences and meetings whlch featull1!e WQmelfl;"SILOtliJOenlS and. it has funded. women's ~O\J1l.pS wOl'ki:ng on healfh prroj:ed.,.The lIPopu1ation Councilhas sponsored meetings 'to work w1lth. femmist lea:d:ers on contraceptive technologyissues, US.AID isstl!eng~'lin,g 1ft; Wom,enin Developmens o1&e:5 w h ic h are fun ding W OIm €!iA.' s projects.

At the N airohi Conference :h'! 1985, for tnstance, popula.tion oontrolli and. plmu1IDg gran ps we:l!e well represeuted. At the Cairo (19941) and. Beijmg (19'95) Confsrenoeapopulatinn oOIDliQ\ollel's and plaruters worked doody witIrl. wom.e11.'S groups. M:.nl_Y feminists arsd womcrr'a g~·oups in these conferences, however, oppoood the contro llera and. p~a~:uilers on ideological gf\ounds (see 'f~ble 1) andhave proposed.a repIlodlldive he<il~h approach ms,read..

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Tabl e 1 ~ Comlpa!'ti!H)n of IPOpulldi'on co ntrol and Ireprodu eliive heallh POIP'ul c:di 0 n poUdes7

Area

Popu~i.on CO!l:1Ltl"O]

I Goals

Reduction of growtb r.at'€,fI!'Id

Improve women's artd children's heaH'h and fa:mily welfare.

Chft!ng~ socio-ecenoraic oo<nditi~n$;

Improve won~en's and m.en's oV1Elr;8Jll an d ~!!pro,d!i1~H\!"~ health,

Increase women's contro! over their bodies and lives.

Eth~t::(11 Prii'ldplel~

Ul1lde!'lying ASSIJ m pti o n s

P~OGftAM OPERAnONS

Demographic goab are IBodU~ h:'1t@~"Hy;. pflI"Sonhood;

crucial. Hqu.a:lity; DIVersify

Popukr.l:ion si!2.e/ gr~wth mmn deteTmjn~t of poverty, uocle-td,evelopmentt ~rtd. e:nvirco.nmenml sustamaibHity;

Populral:ion eonb'>oliB ablero reduce fertility.

'Poverty l'S due-to eco:n.onlic growth model; need to meet: be.9~c need.s;

Impro vm ill women' ~·e.t~\lJ:U:l and q uabty reprod ucdve herut.h programs will wduc@f@i'tijil:y.

Obi eetives

Ta.rget oriented wl,th m.cei'iltive.s !!!rId die.U"Icentives

Ag'G of wom 91'1 (lli'1ld Imolrilo I $tQtU.5

Contrll:(Jepl:i,01'l; matem~j ~d cnnd heaith.

Me:rried wom.en of reprod ilJJctivea_ge

11

ContTaeeption; miflll~maJ. health; STDa, lRTIEt, mv I AiDS; violence agfli:i:1Lst womflfi; eance'f sc:reenHlg.-in the! context of gender relaticma

Wom~ Of an a:g@sthroughout their hi'e qde; rna,rded or W1il'f!,a.n'ted;

Serv i ce del iYery S:!{l i'1 de fch

QL!lall1ly uf care not 'em p.hasitzed

Women's

em pewerment

No component on w,Q;m.'~filrS s!:.fl,tu.sj dgilts

mcre~s!!d .tI.rsOi!!ss and. contro:l; ~\i'om en':s ~m.p owermem 11 u iJ:t ~l:'iIlto a!l~1 serviee des~gn 1M.'Ildi impleDlen'm.'tion..

Effort's atsllrllctu.raJ reform. off society (e.g. leg .. l ~efu'fmp" poJieYl'e[Ql1lIlIs, e'b;: _ to' e1:iID irrllhEe d L!iC r~m illilElinClflElm'lii V10~!I?l:'ilCe OliWl'm:Slt 'I'" omen) OiJItsjd@ th~ pro'g ram at\es,u.p ported.

C(I'I'l ~f(] COl pl'i", .. methods

Focus on pen:l1l~.nent, ]ong-!:I.Ctitl,g ~oil'lt~!!IC~r'thrE!~

I"8rt l!I irn1tg n:tecll k~ intE!'l'vl!ntion (!! ,g. sl:errili2a,tion, iIrrjecfotb~e5, i:m p]anti); pro wd er prefe~eTl.ce5 d.omWaEi!!.

~D1Iph~~i~ (In ~O'Ifui e:fl!i!!('I:!lVI!- and] fi.ff[}:roab~.f! M@thods whkh WOrn en (:lOnbroI;

BHod-s, are to .iln.C'~ea&e m.ale rl'!spons,i.b.i.lity, research .into ,!U1d use of ITl!JJe 1T1I<!!thods.

PROGItAM MANAGEMENT

User',.. leed bo ck B,ul'eagcl'a.ti.c; lli.Wle Ili'Itetestllfl !llse!'s' pe~sp,e~ti\l'es

RJIOlMorehl evo I uc1i O~

D<em oS:t!'lphic

q Uatltrimtiv@ r,(!!s!!aKh 1:\f!1EI.~~dtofi!!rrl]tl.y control

f\l!Qon research W if!:} .bigb d egn!e of partiC'ipat,tion

I nd h::[]lofS

Q!lltlnl:iitathfe' and q,uflilldtaI:1iVll' starn:di,Mds €.mp harsUiiir\g users' saHs:i!l!:l-non, w,e'U.[lem:g, q Ulftlity of 'Calle, and em pow eml.errt

Pklnlrling and deds10nm(!king

Tnp-dowm m iiu:in'I al p,atl::idpliQOil of SE!:~viee provkl,er(l, ~i:: £II ]evehL

Com:m. unity hlgJ.~y invo! ved iln, cont::i!!pm aH2:aJj[OI~. and 1"0!'view of d esig;n and of f!l'art:ilons; users we.J:I_'rif!rl-esen~diil'll d.E!ciSd,cH"'1,· vnaking bod ias,

12

m. IbJrRODUCIIVE HEALTH: A l'ERSPOC1'IVE AND AN APfROlACH

Reprodudive health is concerned with the heaJH:h of both men and women. BU.t smce women's reproductive roleis moee marked titan men's, I'efll'Oductiv,e health. becomes more nnportant to women. (Women.in this Cotl:tllitly and in other less developed countries die more from pregnancy-related <ll1!d. gyneCiologicaleauses than from any othe':t:' cause Iike caraccidents 0'1::" suicides. The Phifippsnes' maternal morbility rate is 209' per 100 .. 000 lli:v,@: b.irtl1S .. )

Two poinm .need to be empha_s~ed here,

One, while :i1'eprod. uctivehealfh 1ieie:lrSto the physiological process of lie prod. uction, it is im portaJ:tt to li!U1Idersbmd ·that it is part of a woman's overall health" and should never 'be taketil m isola.tion Oi' separate from it.

Two, it :is WI po.id:ant to stress that reprod uctive heallflhgoe5 well beyond llJiomed.mci1d definitions WIld categories, extends fa.r beyO!i:l!d genital areas, and way ba-Y(IUd the eJlogenous zones, though all th,I1'lS@ are ,all part of it., Reprodud1ive health isinfluenood as ill uch by viruses, b.ilI!diel'ia,p'rotozoa, 'of other germs as ii is 'by c'11ltM.ra.l. practices, cnsiomary norms, legA1l structures, poverty levels, ed.ucafioruU. sy:;;de:ms, gender JOOla:tionsr an,d eco;nJ)'mk POOO@51 ,e'Vell ..

Reprodu,dive health oonstitutes a p~spectivef a, way ofIooking at the rep1"od.uction a:ndsexuallity of women and men, as they live day-by-day m. the i5odo-culm:ii'aJ. political, i'U!1d economic mntexta of \thei]i tim.,e-,.

At thesame fun,e, it is, an apcproachr a w~y of ,de.aling with and :respondmgto the' actnali needs of women and men through the srnp~g of po1lici.es and the d,esign of services,

Reprodlndive healt:h, as it is presented here, is not a fixed concept and is d!efinitely not engraved In stone. It is, flexible and it changes, a.cc'ord.mgto w.hat women <Ul!d men need, and. a.CCOJ:1rng to w hat their (:iJirctmu;tan~e& <mJl. condillions are.

As a Pe:rsp@cti:ve

GiventhJs~ :repro ductive .herutib, ~ a, per.s.pedive', recognizes the roles ofwo:nu~iIDI. and men .. ~ expecta,tions a.rising hum. fhese roles, dle sta·ws aororded to these roiesl and how s:u![h roles anA statu,s afie.ct their state of well-being and health.

Reprod u£tive health is to a.1!arge ,extent a reflection of women's status rutd. :relative pOlwer. Hashands or partners who ,abuse and sexuallly assault their wiv'es or partners Or who forbid them to take the pill or use tile' IUD illustra~te the dynamics of power whlch. have adverse oonsequences for women'a reproduetive and ov,e:ram health,

Men and women have specific roles whidlBOdety tradino.ruilly has ascribed to them. (e.g., man. fhe primaJy breadwinner~ tile head of

the household.; Wom,aJ.1.r tlhe :mot11.er" the wife iiI!.nd. hOllseleeper; ffind. if she needs orris allowed. to be, the secondarv b,l!ead winner), These roles

._

are mdHcative cdf the ~1ative positrons of men. and WOmen m.s<ociety. TI1.ey also give m:.mseto the differe!l:'ltexpecmtiotl!!s whidl men andl women helve to fulfill. llfllill:'thel', su.d't toies geJ.l!era.t€ needs w melil. policies (),1' lPoog;rarD'1S maylocUl5 'on, tothe exclusion of orlhel' equally vital needs.

For ex:atl!!(l:p~e'r :nuhiti..on p'Il!ogams Mve largeilly been directed k:lwa.rds ,th.€' ~cts of mahrunmtion ort WOmeJElt s a.lbili:ty mgive birt:ll:J. to healthler iHfanrts, to 'breastfeed, and to care for their growfu~g child.ren.

Sttch. ,efforts are obviou.sly imp(:J.JI:'tant

to mfrur1l:ts and cWldren. but ma[llllesta

1benignneg;I:ruge:m:lloa towards whose :heaW.th4 pe'( set is Apar't {worn this" su c h blind. to the 06ter aspects ·of pernrntTha arndl1fi!he dwff~t ,at womQ' 5 life. Assuming women's only role is motherhood, m:hey 1500 arum of meeds as r~1ated. to this role position in mife. Hut as can seeywomen are not ,81iJ'li~ llia.cta ting the w hole sometimes, they never do.

W 0 men :iimpodant. dh:n:ts are

,

women s

'l!\r om e n" 15 and a.nybody

To achieve repreductiveheadfh, therefore, it isimportaillt that WOmen and men, but p!Mticubrly womBji~, s~lo'Ul~d OHlU free hom. the stereotypes, .For i!;lstaJ;l,ce,- womeruthe stereotype goes, jfullfill their potential and aJre at their best when they are lITIloth.ew:s; that tll.e.iJr reason for being ismotlherhood; tha,tthey engage m. flex fur the 801e purpose of g~ffing pilYegn.al1lit; thatthey have little or nom-e'ristent llii'bidos. Their enjoyment (~f sex Js deJ[llied... Female o~ga5m isseduced only to phanmsm.

Reprcd 1i!lctiv,~ ImaJth is ,3tNII the allmty of women ai!I.lId menlo [rtatv,e sexual reit\ool1!s w hony illlld. freely, witnoll t eeercien, W:itlltOlUt rear of mll.wantedl pre~cy; lV1iJnOiL!l, t :®ea.r of disease.

15

It is moreover the aWlity to oonuoI one/s t:erlility, by wha:hwer method Of tech_nique one chooses, to avcid or milnin:U!Zie adverse sideeffects and OCI'l1.Seq_l1Ilence'S:r be tlieH physical. e'llll,oti_,Q(t'Md,~ or social.

It.:is: being,able to live oat one's sexual orientation with,01!Jlsu~g discrimm.!lI.ti.on, stigma. or other vfuillent:i:llllre.llm $0 one's peTS<O'n.

Reprodudive 'health is, likewise the ability of women togo &rough pregnm1.cies, safely and, togellier.w:Wl! 6.1arh.usbands and parbners, raise' healthy children in .a manner tl1at is free front getllder d h;cri:mkrlation and stereotyping.

U also 'refers to menmumg and. <tSS'tm:!:w_g I'e~po;nsib!lit:y not 0'111y in the control of fEirlility and 'birth but: also :in men being able to desb'Qy opp'l:'e8siir,e, a.ge~old stereotypes a.ndi, praetices tba.t are harmful an.,d disrespectful to' women,

As an ,approach, reprcductive hea11dh deals lvith the needs an problems of each stage in ilie lue cycle of an individua], Each stage in '6le J:ife cycle of a. humanbeing tt()lO mfan,(y to ,eld,.erThY - ulIvohres special needs and different problems (see Table 2) and these dll"ectl~7 and wdirectly affect reprod uctfve health.

Tahle 2: lis,ts sam e of fb,e health problems ~that occur in it, worn aD' is ijlfe cycle. This list.is notinclusiv@'. But it illuma.t:es. bow each stage' builds en the' P'I!"eVWtl s stage, how the health and survivru. of an mdant, for instance, is influenced byth.e mother's smm of health d u· .. :iug conception and pregnancy" or how ilie b.eaJtll! of a.D. adolescent m~y heaffected by Illness d 1I.lr.ing mrlm~cy <U1I.d ChiJdllOO d.

Certain problems, however, ron IthrO:u.gbout the .e,llme life' cycle and these are ,eall.ed, Hfetime' ptobol,ems. Violence a.ga:irnst WOill@J11l. is ODe pF(lblem - as a chlld, adoID.eocent, a young ad uU,. and a:n elderly woman, she may be the object of sexual abuse, rape, and incest, It is at critical problem and urgent issue as it erodes the.gams whim government programs l\ike CIU1d ,Su.n.rival! and Safe Motherhood have achieved.

labile 2. Hleollrth Problems AH,ecflng 'Women During 'the Ute CYd'e

I nfcmcy and Ch i lid h a ad (U·9 yea rs]

D ifferenfia I ~ed i n 9 and d i scri rni nata ry nutrition

D" ""' h lth

_ rscrrrranctory hec 'n care

Adolescence p 0-1 '9 years) Emily childbearing Abortion

SIDs, :Reprodudive frad Inredioaf1s (R];s~j' and HIV IAIDS Undernutrifion and micron ut'rient deficiency

Ris i 11109 tren din cig,Q r,elife srno kingl 'and sou bsto nee 0 b use

Reproductive years 1(20-44) Un planned pregnancy STD's, Rlilsj and IHIIV/ AIDS Abortion

Pnag n a n,t:y comp I icenions

Malnu~r~tionr especially ~mn deficiency I ni,ertility

Pos1'-repr'odvctirve yean (45 + ye,ors)

Cancers, induding breast and gynecological cancers Osteo porosis

Carrd i ovo seul or diseases Osteoor! h rif s

Diahetes

Ufetime heclth problems

Violence .again5lr women (balten n9, sexual ossa ul~ r rape, incest) Certuin occopotionol and environmental heojth hozords Mentall illness, depression

17

IV Wm ItEPRODUC'TIVE HEALTH?

For three' ma:joi'lI€!a:s:orm, a. reprod uetive health perspective MIld approach is needed, if the status of women is m be raised and the quality of their lives im proved.

Firsf, declmes in maternal mortality requsre more than family plmmi__l'\g or birth control.methods done. Indonesia, for example, MS at matemalmm:i:alttyrah'l of 450 pel' J1.00rOOO Jive births, despite 50 pel' cent of married 'Women using a oontsaceptive method. The same argumerrt goes for China.. Its matemedmortality rate is 115 per 1(0)))0 we births buteontracepttve use' among the Chinese women is as high as 72 per cent.

In countries with im proved ~i(V:ing standards, and W hose gov,emments Mve provided women with a comprehensivehealth

18

package, materrtal rnortality rates have declined dl'ama:tically. Sweden's matemal morlalityrate, for mstanc..e, dropped frOID levels of around 1,000 m about fiv@per 100,;000 ltve births over a period ef 250 Ye81nl,. &~d this d,ecmte occurred be'fol'El any kind of modern conzraeeptien was, a.vailable. Malaysia has a mate:nudmortalily rate' of 26 per 1:00,000 live lmtlm but contraceptive use is o,nlly 51 per cent.

These cases indicate that family plu1Ding alone is not enough 'to prevent maternal deaths. Effident he,aUh ~are is more effecti'l.;e than fertility regulation in preventing maternal mortality .

Se,oona" .fum:iy planning alone ",rWI not improve 'tVOW@I1'S health.

Most governments resostto fmnilly pliamUng to reduce ferlJilijfry levels and. popuIDatwn growUI. rams, not toim prove women' 8 overall health and well-being.

A reproducttve health approach, properly carried out and mind.tul of its fundamental and ethical principles, offers much more to women not only m.teml. s of 'q'uality and rang.e of services that respond 'to the needs of women throughout thetr Iifebut witb regard to erihancfng 'WoO m en' s autonomy and. seUd.etenn:wation.

o

19

Third,r,epro d uc rive health is based on certain fundamental and ethical principles wMdt respect women's and men's dignify and aut.o:n01ll y. As such. it :is carried out in a manner ftlat is not coercive, that d (I,eS not d is regard women's €Iud men's needs, and that does not: violate women's and men's, basic

lights,.

V. FUNDAMLENT AL PRrNC'IPLES

On the level of goven:1mI1umts and inSOnl tiQWl\s"these p'i.~cip1e& should serve as guide in policy :rom1ultlon, progaIll planning and implementatlon.,8

The pdndpIe of self-I'elia,n,ce refers to e.x;ercising effective control and fun use of the country' s reSO'Illi'CeS- human and material - so that its government can provide for thepeople' sbasic needs.

The pdndple of sell-reliance can and should be applied in the context of reprod ud'ive health.

For tile long-term, govenuneut should rely on its scie1;lItific and tedmologjcatl resources to undertake research &at will give wise' to 'blleaktlurough tecM\o1ogy in health as wei as in illndustry. Ushould

20

rely on its own knowledge pool to develop omdpwd ucecontraeeptives and other forms ot fertility control a.ppraroprilll.te m people's needs,

For the short-fL!e:ll:lmt w.ethodls of fe1"tilify control tha:trely on WOI11.en's capa.city to d:ecid.€: and care fur themselves andnot on the m!edicaJI. esta.b.lishment alone should. be e.m.1!i.oOl:~I.1!fage\d. and promoted.

The priLn.citples ,of aumnomy .m.d scl:f~d.eterminaitioril!. should. be articudated, These J1efew !o m._,e counery r m. genel'al,. and' to the worn en, in particnlar,

Po,lli:y - lie itreprod tu:tive health 01' papulation - should. be shaped. by llioca] issues and factors and not depend. blindly on fOl'effign. direction. Foreign. funds which OlLttadt ce:mfain ,cond.itions goes ag~st the p~:indpill,es of autonomy and seU-detennination. Similady,any reprod uctive health initiaifive ShoUi1d. recognise andhaveas its starifug point women' 5 autonomy and. self-,dce'l:ennmation in all areas of their lives, pMticu:lariy their]\eprod uctive choices, The 0 bservamce of these ~fti!:,m,d:rille5 will help prevent both p:ta.ctll;E and orientatimll. wmell. regam Women. M 'klob to I'SId. uce population growth rates,

The principle (!If pb.uralis:m should. uphold the diverse sociocu]tu1lf'al characte:mtics of ID.oci±ilities and regiens m.llie entire OOW!lrITy.

As Stl!C~ no one grOin PI iru;,tim tion, or sector ~ ~Oc.al()if foreign. relliigious Or sectarian - should 1m po~ its beIefs and 1i1Il)raJs On the e.l1IIrnre country. The d iVeF8!e pluralism of the COUlil1!tty should be aecommedated, 1Ilpheld1"and respected; WomEm.'s gr01lllpSy be they gTassroClts or urbanims§ should then have as much poli,tical spare as the Ca:tholk: CI1.Urm' s p~Q-1Hem,.

The prrincirp,le ofparlidpa:lory dem(!l(";!)"acy meanstbat people are ahle to pa~didpate In political prooe!soos wmch.hemp shape t1w polieies .md programs tl:tat ll(lay affect their li:v'es. As such, their ideas are reflectedin policies and. programsand fum need:s are addressed. by them.

The prindpl.es of' responsibility amd.aITrn:mtabiHty i5hou~dbe moogruzed inany:r.ep:rod1.!Jctivle heallltt initiative. En~na1ag~cies wmch push popalation pFogra1ll5 and goventments slhou.ldbe accoontable amd respmlSibme fO'r observingfue prindl'les Qf autonomy amd 5eH-deie:rmin1lltion.in their programs.

They should. 'be held :responsibJl!e and aecountable fur the, adverse effects (If reprnd'lld:ive ·t;eclmologles tl1l!af p'R.!lt women/s and men's health atrisk, They aJle'respom:s~bm JorcfuID.::a.l trials and experimIH~nts tha,t they conduct; 'They Blust provrude sufficient itdonm.ation arul wi:lliouttJ.leiir <:(IDsel~t;.an.d when they dliJ.mp uI'lSd~md mefiective <contraceptives :kIr .th.rit use.

,......,---~ ...

22 <,

VI. ISSUES WITHDJ AND B:EYONU 1'HEPELVIC ZONE::

SOl!v[E REFLECnONS

l&eprodluctive heidth CCI'V'€1'l!i a lot of issues th~tneedt'Q' be talked abcu t as o<penly as iPos5~ble. 'Th.eseis'1'Ou.es have to be debab~ d, resea rehed, d iseessed Wi the publicfoifll!lm. Evenkl.allY theyha.ve to b€ ,!li!dldressed by gov,emmHntatn~ NGOs alike.

The med~a, p.]ay t~.e critical mle of brmgrng these: issues out.in the open. BsSMtially" ·thesfil ~ues revolve M'Oltnd !

a) Medi(M., These incllud€ clImicru.tri_a]s and S1I.!l ell as clinical. m.ds Mld ,experimentation among the poor wumen in developing countries H~e ours; reprcd Ulctive ®eclmolog;ies 19M1Cfl as the vaoc:nme ,a_gainst 1P1'egrum.g.r, RU41b86 or t'heallortion pill and. what ·'these mean for wome1'l,;theincitea.s~g rusmbers of wnmenwho h~ve unde:I',gone ~essHY caesareanseebena; the eflec-m '0.£ pesticides ru:1I pregnM1twomen workers in .hug plantations reflected in the ineressing

13

b) Sudal.These.indude ~di5 such as flmdamelll.taJism on the rise and its effects 00 WOIDefI!} the rolle of o~gruUzed reE.gions Uke the Catho<Iic Chmtch. on teptoductive health poHcyma.kmgand im plementation ef programs; the megit:i:m.acy of 5e'xuail. orienta.tionand .lrufusty1es and. the smW S 1ieOOgmdtion of these as crudall. tothe removal otf discrimmanon <I!Ild :&fi~a,tiztttWn; se;x1iJalvioJ.en>c:elike rllLpe,nmest and wife-ibaJttering; and.

c) Poli'Iica1. These include the impaJct ot mtrematiol'lal agendes which pmvid.e 1~ and aids on na,tion.aJandl ~al policies~ ot pti.ority setting not in tune 'With tIle needs of ,c.tIizel18 M'l.d conmtu~; the in1 pact O'f mlentational fundmg on NGO tlt.Ctivities, musrog stiff 00II:\:pet:i.ti'm for access to fundswmdt shape and d.irect thtlli' p:rognuns mil thei1c a.ctivit!i.es.

'The MR is long. And. these Me just some of the Issues which .need. to be coaxed rnJ, t 'of the closet. Their CUfi-ent low vislWlify 1m tI1!e p1!I.lllk f~m, and the pu bilic agenda. does not reflect theiir importa.Jrn.te and. sigmficanoe in. the oonducl ofpe.hlic affaritrs and the dmrediml of naoonal d.evelopID.ent.

hi itboca;use they have Derome so 1000unonplace? Is it because theseare m~exdtmg;. lespedallyif one comparee.these to the ambu.sh of at colonel in. at busy st:reet on <IL hot :E>mIl1!ner .monnng!' A:m1:m.S]lIe5, afmr·.an" are not damly OCCU1:reti'loes. And. repJ:loilluctive health msS1Iles mOl]{ no;l: be as dramili.a.tic as am.bltsile:!! .

. \!VJ:We theoo issaes .m.ay not rate the same :scope and mttention in ~e plJlillicarena, they a~ intllma.tely related. to, furldlam.enm.il. aspects of both pe1'Sonal ~d.pmblli.c me. Reprod. ucHve h.ea.lth liss1.U!Jes may be maq,>in.aHzed beca.llIIse wome11l. have yet to establish. tl1.e.iN don t as ,politicali actions: who d_etennme the eourse of pu.h.Iic aifai:rs"

·n_._~ .~. • LL!'_ "L ..:.11~& ...... 11,. ,iLd £ '1' 11 te DU.~ 1i:~ m mtrus al\eaq~al!. m.e ~es5.l!.~ape· an_ roem. 10 're'lega, ..

reprod tu;tive health to the periphery of policyI' lliegislalion and political agt'!nda creates anlimbalan.oe ht affects the mtewity <Uld .oomlldaticm ef'haman mIfe. '0

24

NOTES

ll. .Paragrapb 7.3 of thehittemaJlional Co1ll1er;enceol'l POPil1ffithCllllfUld Developm~d; Programme of Action {1994'1 rere.n. in reproductive rights as tJbe t'ecogrul::io:n o.£tbe ballie right of all oo'Mples and mwvid.1I)l,ah; to decide freely an:d.1rOOpansilily fue munber, spac:l!ng.and .~ of 61'BU ch:ildl'~m Bi!.1:d, to have themoo:rnu:!.tion and means 00 do soand HIe ri.e;b:r to alrdin. the hlgpe!ll stan_AOU'ds of~aJ a..n.d rep.wdu.ctive ~llh .( uttder&r.JGrin.g provided.).

2 The family plruuringestaiblisluuent is. a,tliallSl1t.atioua]. coalition of 11ia<_tiOnal. goverrume:rl£s (mtUnly US, Japan, UK, Gell"IDa£!ll!Y, Canada, Fr.ru;l!Ce, Bi.1mio:ngothers ),mUitila$erru iru:;·limtLolru;. (UN agencies, pa:rl:kula:rly UNFPA, Worlld, BMlili,.. and ilie llVlF),bill'tte:ralmstihd:t01lS (USMD, CIDA, ]ileA), private popu1a,tion oJ'giUliza:ti01W (IPPF, 'Population Council. Populanen Crisis Commitlee., Rockefeller, Feld, MacAl:iiT:ru.x), envitm1m.ellt and comervoocmgrou.:ps whkhs()lttru'€ly Marne mcreasmg ropulation gl:owllirates fDJ' elwirionmental Gg:;h''!ilctW:n (Sierra. Leotll€,wnong .others), and. m09Uy US-based A.c;ruien:t!i:c fustimno;ns (East-West;. University of Chic~o., University of N orth CaJlolma).'I"his. esm:bhs~E!nt,. as I c~ them" has: lUlJdia, b~melldolU6 impact on how gevemmenss, esrecmIly :Illl00e of poorer and tess d.ev.eloped. oounmes"have shaped their popnbtion policies. It has. greatly i1:illuenced roo the current thinking on poptilloo011l that continues: to PJrevaiJ[ lin eountnes llike fuePWlippfu.1ES.

In ~ .paper, whenever I writE!: "f:lul~stab&h:mmt"! E :reru to the family plamting eswhl!:ismnent asI have defined ill here,

,3 Jim. 1952, the US govel1~nt estahlish.ed. the Presidene's Nfu.teri&lfulky Cemmssten wmch rerCl':rI:ed.lliat U8 c:ou,kl "~1lStain i~ civ.iliz!lCtio:n" ol';ly if it coeld depend u po.n the. raw maren.1.lililo·f the poor ccunrraes, [he very eounhaes which had "FOPuNttio~growths tftat pressed. hardest on avalliible ruthttal resources",

4: Dereruillcuulls are those fu.ctors thatfrn:fitll€l'lce decffiion -malmg rr'Ocesse:9. or behac,via" - in this case, ferl:!iJljty. For llrustM!ce,.researclt S'w"dtes have shown H:'La,t a. WQ:lll;a11'S ed:u;cation is a major fertility d,derm:inant 'I'his means ttIata WCm.1.ffill who :is .. eaucab;!dis ]1l10l'~ b1bi~ly

to conLTul her ferbh~ fuJ.'ough SQ]j[l~ :!l1e:th,oas she chooses,

25

5 It's very difficmt ~o t:aJk abo'ut women' sgroups because t111.ey are so diverseend the personal ,Elind. polltti.ca1 dym.mics among tftese gt'Oilpsi areso ,complex and so romplicab~d it:is dilllcuJt to keep track of them. But Jor darity's sake and for purposes of simplifying things, when I say women' s groups", I refer, in Ibis paper, I!:o women's group,oompooed of women in developmgcountnea working fm women's health .. hlthe Philippines, Woma:I1lHealth was the rust women'sgroup whlc.h. advocflJWd.furwome1'll.'srigI1beliJ."Id worked on women's health. I,E'IIlso refer to tbe 'US4)ased. and other W@si;@m-bt'lSed women's ,groups worllting for l-vom@1l.'S health and women's rights Iikethe h,mmalimW Women's Health CoAlition,. the Boston Women's Health Collective, rumong oUle'!:'S.. Wom.en's &'Oups ll'ldiji!'Velopit1!g C01lllDtrres ru:td.d.eveloped COltnm:€s mayor may not work togethe:r, D1..a.y o~ may not belong to the sm:nenetworks. But,. in their orwn. ways, ,ti~y allstrive to putwomen fIl.1.d. their heaJth in their government' 5 hst of priorities O'r in the el;g~dlll ofin.CiemabonE11X conferences Of' provide women aconstellatinn of services.

6 lvIa.uyw,omen's groups - here (e.g .. Gabriela) and abroad (e.g. Finn"l'a.g~ in Bal~,l.adesh) -l'ehtse lbo, hav.€ anything k) do with international donors. whidt have longbeen into popuJ!afun control p'rograms. Others have d.ec~dw work wiLlhmstirutians .Jhi1.e the· UNFP Ar World HMJth OrgarrizalioI\. Foro Foundation,.. Mac JUfhur Foundation.., but Mv;e been critically oollaborating Vliith them.

7 This was developed by Asfa-Pfl.cilic R~sQ1iliJiCe and. Resew:rn. on Women, an NGOhased m Ma1a:ysia w01"kingwifu womell's reproductive health, booed on 'the work of ferrt&rrlsts hkeRooalind Petchesky t1Jr1d Sonia Correa (see Petchesky and Correa: "Reproduetrve and Sexua] Rigbts; afenlinist pempective", 1994)1 ..

8 I do not know if these prinriples are being observed by govemments n1!b:!n'll'It!i:onail. IDs'titu;ti.ODS, .like til'l'l Esmblashment. But, I suggested these, and if we're talking reprodlu::tive healeh-repsoductrve riglds as key to ~PQwerment, !hen these principles .Iiltn! appr-oprif1.te.

26

i\ibdlillaih. R.asmdah.Bro:adenif1:g F amUy Plannir1g PfDgrll:rnm~$: A Won~nCmtef.l'!:d. Rcprod14 chve Henlth Frwnew-ork. Paper preseJ.itred atthe Pnannmg M,e@ting on El1Ihw1Cing Gel"ld.er-c5e:msitiVllty and Gend.€r~ Responsrveness of Fflimily Pw1'llUQg mtd Pepalation Programmes. 6t]]- 8th. October 1994, Tagaytay City r Philippines, lnwnmt:ional Council on IvEanagement ofPbpWalionProWamn;les.,

Abd.ulliah,. Rasludah and Rita Raj-Ha&hiln Mafemal Hrnl tfl. Paper presoo,ted atESCAP Asia PaGifJ.c NG05yu1!posiumo!ll Women:in Developme:rllt;. November 1994" Ivfu:ru1a,

Eergl'trom, smJ"farn, {{Myths and Realities in Pcpulation MJstance and.

MatemalHealEh Care" in Su:cce.sses a'nd Failures in Popula.tian Policies lind Programs: RepDwt .From a Confenmce {n Os.lo" 25th :l'vfay ]: 994:.

N onvegian Forum.:fuJ!' Environment and Development and. Cen:I::!J:e For [:nremlililiomalWomen':s, Issues.

Correa, Sol'l:ia.Mld. Ros.ilind. PeocJlesky., "Reprod.1I1Ctiv~ and SeX'U.a]' Righl5: A Feminist Perspective"u'L (eds, Se.net all) Popul,~M(m Polide$ RecOO5ideri3d: H ~Uhf Empowerment, arid Rights. Harvard Center far Populataon and Develbpn1eutStudies and In~-emati.onal Women' So Healllh. Ccalition. ~]'~ge, MA: Haxvard Un:iversftyPress, 1994, pp" ]O!7 -126.

Dailg1lliilan,. MatriillenJ PoUcymaking.Across Borders,; How the So~'th mas Won.,.

Paper pres.e1'llt.ed:a.t :fu'he Pkna_ry Panel 001 "PopullMion,. Development 8l1i1. Women' is Health: N orlh-Sornth lRe1>.t:i.ml&t Resp')J:1Sib.iliJies, oo(] RigJ;iis-" January 25, 1994 at iI:I"le [ffiP"RODUClTiJE HBALm i\ND JUSTICE: Intenla.tirn:w Wom.en'sHetdfu COlliference fur Cai1'o'94.Januru:y2-4-28, 11,994, Rio de Jarte'lro.

_______ To:a:rard"s ag.end(!r~5En$iti!le (md reproductiv.r: heaJt/~ population policy. Lecture delivered at th~ Wowel1i-m- Deve.liopm.e1"1t for Family Welfare Trainmg, POPCOM-jICA, Ta;gacytayCity, Ja.xl.\utry 29· Peb~ry 18, 1995.

_______ A cdtiqueof~he Philippine Population POliCYf Philippine PopulatioJ'l Program Plan, 1993-1998, and Nle Calm try Rep01't fo:r N~e.

27

h:liemaliorml Conference. on Populnl:ion a~d De.v,rdCipmcmt. rOf'C:OM. 1994.

FfuMe, JL and. BE: Crt'Ul.e. "The [pOlitics of Intem~01Il!:lllPopu1atiou J'olic~l' .ful. lrJter'Mnon.al TrMlsmi6Sioil'~ ofPopu{aticm Policy Experience. New York Ull:ited Na~, 1900_pp.167-182

Harrington, J u.rufu, "-Brnl'eraL Popuhdion Assista'J.1'ce"ill.PopulatiG~ Polide:; and iPmgr'1I1tJJne5, New York: Uniied. Nal::i.oots, 1993. pr. 16!5-18tJ-

Jacqu.el"te, J S e.nd. K A Sta1Ll!d.t "Po:l:itics" f'Qpuhtiou, and A FeIll:'l!i!riuist A:!.l1aly5:is of US Popu!atio:!,li Poliky inI:heTImd.WOirld." photocopy.

1ak1, Anrudh and Judith Bruce. N A Reprod.iI.4H.::ti:v,e Health Appmadhto Ute Objocliv,es and A..ssessmen.t of :Family f'lm..CI].iliIg ProgrttllIflS" m. (eds. Sen et al) PGP~IatiQn Policies .Reconsidered: HeI2HIl, Empowerment, flnd RigJds;, Hervasd Genre]' fur' Fopubtio:n aad DeveAopnlfi!l1!t Sh]rnes, and I:n:te:matiotwl WOmetll'S H:e,aJ!th Coalition CBOl.bridge,.MA Hervard University PJ:lESS. 1994, Fp. 193-210.

Kas1.!l!;tl, Jacq_m;1!lbl..e. The War Ag.a-ins.f. Populatiolt;: Th,e Economics and Ideology of PopuhzHon Contr'OL San.F:iI"'l'Ullc:mco, USA :K.g:natiw;J?rws,l%ll.

Maguire, Ellmbetfl. S. "The Evolution of United, $ta,ms Agency lor' InternatiQual Development and Oth@J(' Dc}nor i\ssistaa1.ce in Popula:oon Policy" in New- Ym,k UlI'Iited Nati.001"lS, 1990, :Pl'. 4£0-56.

M8h.ll"lUJd, 5iIDE!lE!u."Mobilization ofResoll1'Ces: The Special Problems of the Least Developed C()imtrnes" in Population P'olicifrs and :Pmgmm~NetV' York Urrlbad Nations, 1998. pp.14&-15:2,

gEn., Gtm; Gen:rtrlame, Adtieru1e; Chen, Lmeoln c. Popu latim: P'()li ties Reconsidered: Health., EU1pO'I.Verment, atld Righ t5. Cambridge, MA Harvard University Press, 1:994.

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2:8