Reproductive Health and Well being: Policy and Methodological Issues A Content Analysis

Research Article By Ishara Mahat

Table of Content

1. Background for the Analysis 2. Alternative Concept on Reproductive Health 3. Plan of research 4. Results and Findings 4.1 Qualitative Analysis 4.2 Quantitative Analysis 5. Conclusion 6. Strategies and recommendations 7. References

1 2 4 6 10 10 12 14 15

1. Background for the Analysis

Reproductive health implies different meaning to the different people especially to the vulnerable groups of the developing world surrounded by the socio-cultural taboos. The common concept of reproductive health initiated at global level focuses on: 1) every sexual act being free of coercion and infection; 2) every pregnancy being intended; and 3) every birth being healthy (Tsui, Wasserheit and Haaga, 1997). However, such concept based on womens rights and objectivity undermines the socio-economic context and the social relations of much of the developing world. In most of the developing society, reproductive health problems are not only determined by social factors and norms, but their social consequences such as stigma and shame, which are heavily influenced by the cultural context. A sex selective abortion in India and China for instance, has incurred large social cost in terms of loss of freedom and practices as well as deteriorating maternal health (Sen, 1999). Thus one hardly worries about the choices in reproduction and furthermore on autonomy as long as children are the sources of their integration into a family unit (Mumtaz and Salway, 2009). Given the stigma and sensitivity associated with the nature of reproductive health problems, the functioning of reproductive health is not that straightforward. Apart from the biological risks, the social arrangements often let women down and constrain their choices on reproductive health (Sen, 1994). These include for instance, multiple social constraints on accessing available care from their spouses or partners, families and communities, to availing and being able to afford transportation even before the health-care system is reached.

2. Alternative Concept on Reproductive Health (Knowledge based approach)

An alternative concept of the reproductive health through a detailed investigation of sociocultural realities is thus inevitable in the context of developing world, which differs from the reproductive health concept based on womens rights. Unlike the global concept on reproductive health as womens rights, this alternative concept (knowledge based) addresses the social bases of reproductive health problems that concerns for the majority in the developing world. Although the global concept on reproductive health is dominant at large due to its authoritative status, I believe that the alternative concept has a wider application for addressing the reproductive health problems based on the following grounds;

Moves beyond Autonomy The global concept on reproductive health highly emphasizes on womens autonomy in making reproduction choices, which is least applicable to the women in developing world. The alternative concept focuses on socio-cultural integration based on the realities on the ground. I believe that this aspect is the most important to sustain the family peace and harmony. As stated earlier, the freedom to give a birth is least important for women as it is their integration into a family regardless of the sex of a child. Women value more of their integration into a family unit with a support from the family members, thus are least concerned on making the reproductive decisions on their own (Mumtaz and Salway,
2009). And such autonomy is less likely to produce family peace and harmony. Women

would rather be involved in joint decisions with their spouses provided that they are equally respected in a family. Such practices help to maintain the familial and societal integration, which ultimately leads to the overall wellbeing of a family.

 Research based problems (knowledge based)

The alternative concept of reproductive health aims to bring up the reproductive health issues that emerge through socio-cultural realities on the ground, which have got least attention at present. As stated earlier, the reproductive health problems in the developing world are largely social base such as deteriorating maternal health due to aborting the female foetus or adding fertility for son preference, inadequate care and nutrition, mobility constraint for accessing health services in absence of spousal support or from the family members and so on (Estelle and Guskin, 2003; Filippi, 1998; Sen, 1999). In addition, the reproductive health problems such as miscarriages, prolapsed uterus, and obstetric fistula leave women with disability to reproduce and thus lead to their disintegration into a family unit, while the causes are often social base such as inadequate care and nutrition, domestic violence, and limited reach to health services (Graham and Campbell, 1992; Estelle and Guskin, 2003). Until and unless such realities are addressed, the problems of maternal mortality are likely to be continued in the developing countries. Hence, the alternative concept focuses on the critical research needs to identify and analyze the social base of reproduction in order to design the reproductive health policies and programs that are reachable to the wider groups of population and least to the vulnerable groups.

Prevention Approach (Education and Awareness)

The global concept of the reproductive health based on rights based approach is

supply oriented and services are structured to meet the health facilities that do not guarantee the equal access at least to the vulnerable groups. For instance, abortion rights of women are highly advocated for preventing unintended pregnancy, however, they are still subject to poor maternal health with frequent abortion practices. It is even worse in the developing countries with poor health facilities in most of the remote regions. In the developing world, the youth pregnancy often is not a choice but through the coercion followed by stigma and the shame. In addition, such abortion is far from being safe even if the health facilities are available for two reasons; a) lack of trained health worker and enough equipments, b) confidentiality of such abortion as it follows the stigma and shame. Thus the priorities should be rather on promoting education and awareness to prevent the violence practices that worsen womens health in many ways to the extent that they become unable to reproduce. So the alternative concept of reproductive health emphasizes the prevention rather than the treatment approach.

3. Plan of research

I wish to study major Canadian newspapers, the Globe and Mail, the Toronto Star and Ottawa Citizen to assess their understandings of reproductive health issues. For this purpose, the two concepts mentioned above have been used as a basis for analysis of the issues. In order to identify the articles to assess their understandings of reproductive health, the key words included are reproductive health policy, maternal health and mortality. The key words helped to locate the articles in a broader context such as

Canadian government policy, maternal health problems in the developing world, adolescent health and some research based information. Most of the time articles have focused on the first concept of reproductive health issues mainly based on rights based approach. The issues for instance, reflected on maternal mortality at large, abortion rights, adolescent health and limited health services. The major emphasis on maternal health funding as G8 initiatives was reflected to improve infrastructure and services with a little knowledge on the availing of such services for the vulnerable population. In addition, information on such subjects was at a very superficial level that provided little space for assessing their understandings on reproductive health issues. There was very little analysis on the alternative concept of reproductive health based on socio-cultural realities. I tried to locate the phrases in articles such as evidence and knowledge based health policies, the socio-cultural research, maternal health problems and social bases of reproduction. A few articles provided detailed information on maternal health problems with some analysis that reflected the socio-cultural realities. Very few articles presented research-base information with elaboration on the research needs for evidence based health programs and policies.

I have categorized the articles for understanding the two concepts based on the following criteria;

a) Reproductive health based on alternative concept If the articles highlight the maternal health problems especially socio-cultural that implies the critical research needs on reproductive health interventions,

If they identify the strategic policies with appropriate delivery mechanism that are reachable to the vulnerable groups in the developing world,

If the focus is on socio-cultural integration and prevention of ill social practices through education and awareness rather than an autonomy of reproduction choices of women,

b) Reproductive health based on the global concept If the articles present information on maternal mortality as a problem of developing world, If the articles overstate on reproductive rights that is least applicable to the vulnerable women in the developing world, and If they highlight reproductive health policies and strategies that are exclusively based on aid and rights based advocacy.

Three years period (2008-2010) has been taken to sample the articles so as to have sufficient coverage to see the pattern on the above content. Altogether, 63 articles (28 from The Globe; 19 from Toronto Star and 16 from Ottawa Citizen) have been sampled to study and analyze the content. Articles were coded and categorized according to the standard criteria to assess their understandings of reproductive health issues on two different concepts. A larger sample from The Globe is justified on the ground that it seems to be filled up with relatively comprehensive information and focused articles as compared to the Toronto Star and Ottawa Citizen.

4. Results and findings:

4.1 Qualitative Analysis

Based on the two concepts explained above, an effort has been made to identify the understanding of the articles on reproductive health problems. Out of the 63 articles, 54 percent of the articles represented their understandings on reproductive health problems based on the global concept. And the remaining 46 percent represented their understanding on the alternative concept. While the first indicated the problems from the rights based perspectives the second indicated the problems from the perspectives on the ground implying the critical research needs. The arguments in favor of global concept were easy to assess as they fairly reflected the reproductive health issues surrounded within the rights based approach. On the other hand, it was not the case with alternative concept, as the arguments were not that explicit in favor of alternative concept. Nevertheless, I analyzed the articles based on the subjectivity associated with the arguments that still represented the socio-cultural realities on reproductive health issues. Among the three newspapers studied Ottawa Citizen reflected a fairly equal proportion in understanding the two concepts. The articles in this paper were mainly centered around the G8 initiatives in funding maternal health to improve the infrastructure and services and to prevent the diseases such as Malaria, Sepsis, and screening and treatment for HIV/AIDS. The following quote for instance,
Canada's G8 initiative will support training for health-care workers; better nutrition and provision of micronutrients; treatment and prevention of diseases such as pneumonia, diarrhea, malaria, and sepsis; screening and treatment for sexually transmitted diseases; proper medication; immunization; clean water and sanitation; and family planning (Ottawa Citizen, Sept. 4 2010).

explains the intervention strategies and an integrated approach to address maternal health problems and thus supports the alternative concept of reproductive health. On the other hand, the arguments in favor of the global concept are surrounded by the critiques on G8 initiatives for not funding the abortion. For instance, almost half of the articles made a critique for Harpers policy on G8 initiatives for not including the abortion facility as reproductive rights for women. Such analysis is based on the fact that the reproductive rights including abortion is taken for granted in

western society and women in the developing countries should not be excluded. Here I quote the relevant arguments in favor of global concept:
Providing safe and legal access to abortion is an important component of reproductive rights. Providing such access addresses a key cause of maternal mortality. And it ensures consistency between Canadian laws, which respect the right of women to choose abortion, and Canada's international policies. Should women outside of Canada be treated any differently? (Ottawa Citizen, April 30 2010). The Canadian initiative, as it stands, will not be fully effective or sustainable. Each G8 country undertaking different interventions will dilute the strength of the initiative, duplicate effort and further burden developing countries. Disallowing funding for abortion and failing to focus on health systems ignores public health evidence of what works (Ottawa Citizen, April 30 2010).

While I do agree that conflicting interest in abortion funding can deteriorate and even place burden on the developing countries, I do not believe that abortion funding will help to solve the reproductive health problems in the most of the developing society, where abortion is often followed by stigma and shame and more so leading to poor maternal health due to unsafe abortion practices. 64 percent of the articles in the Globe Mail is in favor of the global concept in which, the reproductive health issues were explained mainly highlighting maternal mortality problems at large without a detailed analysis of maternal health problems, rights based advocacy such as abortion rights and use of contraceptives for adolescent health, and funding initiatives for maternal health but without right delivery approaches to reach to the vulnerable groups. For instance, here are few quotes from Globe and Mail;
With Mother's Day just past, we cannot ignore the upwards of 60,000 pregnant women who die annually, mainly in
eastern and southern Africa, of HIV/AIDS. Nor can we ignore the decision of the Harper government to exclude access to abortion in the initiative on maternal health at the upcoming G8 and G20 meetings. This decision puts Canada at odds with the global community and fails to recognize maternal health in a comprehensive strategy to address the issue of maternal mortality (Globe Mail, May 20, 2010).

"You cannot have maternal health without reproductive health," Ms. Clinton said at a news conference after a meeting of G8 foreign ministers in Gatineau, Que. "And reproductive health includes contraception and family planning and access to legal, safe abortion. (Globe Mail, March 31 2010)

While these statements highlight maternal mortality and abortion rights as reproductive health problems, this is very plain without any analysis of the realities on the ground that are most relevant for understanding reproductive health problems. However, some of the articles (36%) in this paper also reflected their proximity to the alternative concept highlighting on maternal health problems on the ground. Here are few quotes from the articles from Globe and Mail;
Traditional cultural practices and social inequalities - from early marriage and early pregnancy to female genital mutilation and domestic violence - are among the biggest factors in maternal mortality. These are among the toughest obstacles to overcome. (Jan, 1 2010) In a perfect world, access to safe and legal abortions would exist for women everywhere. The reality is that abortion is illegal or severely restricted in the very countries where the most basic maternal health programs are needed. No amount of foreign aid money will change that (June, 09 2010). You can imagine a 13-year-old girl trying to negotiate with her husband or her family to take her to a hospital," Ms. Capoor says. "She is working almost 20 hours a day, she is malnourished, and everyone is exploiting her. We need to delay marriages, but it's hard in many regions where it is the cultural norm. The younger the girl, the easier it is to get her married. Maternal deaths are part of a spectrum of violence against women," Mr. Anderson says. "The violence they experience throughout their lives is accentuated through pregnancy and childbirth, when they are most vulnerable (June 30, 2010)

These quotes are supportive of the alternative concept that highlights the socio-cultural realities on the ground emphasizing on maternal health problems (e.g., unsafe abortion, violence related problems, risk with young age pregnancy, and importance of maternal health) that demand for further research on these areas and to make the strategic interventions. The Toronto Star is another paper that I studied to assess their understandings on reproductive health issues. 47% of the articles represented their support to the global concept on reproductive health that focuses on rights-based approach. Interestingly, this paper got higher (53%) support for alternative concept on reproductive health. The arguments in favor of the alternative concept included contextual information highlighting maternal health problems due to gender stereotype in the developing countries, research- based information on reproductive

health such as unsafe abortions, need-based interventions and strategies for providing basic health care. Here I quote some of the arguments that reflect the above ideas;
Daughters are a drain, too often not worth educating, not worth keeping around as they grow older, unless they can contribute to the family's income - valued for whatever bridal price they can attract, a formality traditional throughout Africa and Asia. Then they start to breed - children having children, pubescent girls wracked by labor and infants dead out of the womb. (Toronto Star, July 28 2010) The needs are many, but foremost among them is the presence of more skilled health workers capable of delivering critical obstetric care and reducing the number of maternal deaths caused by hemorrhage, obstructed labor and other complications. Even today, fewer than half of all births in sub-Saharan Africa are attended by trained health personnel of any kind. (Toronto Star, May 2 2010) While many other health problems in the world are witnessing remarkable breakthroughs, maternal mortality remains persistently high in some parts of the world, notably sub-Saharan Africa and South Asia. The reasons are many HIV infection, lack of access to life-saving C-sections, post-delivery bacterial infections, the side effects of prior - usually illegal - botched abortions, lack of prenatal care, inferior nutrition, child marriage resulting in teen pregnancy, and simply too many pregnancies. (Toronot Star, August 6, 2008)

Whereas the arguments on global concept included rights based advocacy including abortion rights, aid based funding initiatives, and mortality problems at large. Most of the articles presented the contemporary debate on G8 initiatives for funding maternal health with a critique of Harpers strategy for excluding abortion and family planning.

4.2 Quantitative Analysis

In order to have a birds eye view on the understandings of reproductive health issues, the information were also analyzed using some statistical methods such as distribution of frequency and are presented them in graphic form as below.

Reprductive Health Issues

Ottawa Citizen 25% Toronto Star 31%

Globe & Mail 44%

As presented in the diagram above, out of the total articles studied for understanding reproductive health issues, 44% constituted from the Globe and Mail, 31% from Toronto Star and 25 % from the Ottawa Citizen respectively. The chart below presents the understanding of each newspaper on reproductive health issues based on two different concepts explained above.

Understanding of Reproductive Health

70
Percentage of articles

60 50 40 30 20 10 0 Globe & Mail Toronto Star Ottawa Citizen Alternative Global

As presented in the graph, 64% of the articles in Globe and Mail presented an understanding of reproductive health issues based on the global concept mainly focusing on the maternal mortality as a problems of developing world, funding initiatives for improving infrastructure and services, womens rights on reproductive health including sexuality and abortion rights. 36% of the articles in Globe and Mail presented the argument in favor of alternative concept revealing the maternal health problems (such as unsafe abortion, early marriage and pregnancy due to cultural context, inaccessible health services and need based interventions etc.) in the developing countries. In the Toronto Star, 58 % of the articles represented the support for the alternative concept as compared to 42% for the global concept indicating larger understanding of reproductive health issues based on the socio-cultural realities. As indicated above, Ottawa Citizen has equal proportion of articles for representing their understanding for reproductive health issues based on global concept as well as the alternative concept.

5. Conclusion

Overall, the three newspapers seem to have a fair understanding of reproductive health issues centered around the global concept and relatively less understanding of the alternative concept. A common understanding on global concept of reproductive health focused mainly on maternal mortality, funding initiatives, reproductive rights including use of the contraceptives and abortion. However, the information were presented at very surface level without a clear understanding of use and implications of the information. Such information represented more of advocacy for promoting the northern values and beliefs on reproductive rights. The debate on abortion rights presented most of the critiques for not including abortion and ignoring the reproductive rights of women in the third world. The argument in favor of the global concept is

found to be very vocal without seeking its practical implications. On the other hand, all three newspapers represented some understandings of the alternative conception of reproductive health, the information was often hidden and the assessment of such understanding was made based on the qualitative criteria identified above. The information such as child marriage, youth pregnancy, domestic violence and unsafe abortions revealed the reproductive health problems on the ground indicating the critical research needs for strategic interventions. Some other articles depicted the understanding based on the reproductive health rights associated with limited health services, needs based interventions (e.g. training health workers for effective delivery etc.) and the G8 funding initiatives that emphasized purely maternal health rather than abortion. These reflected the support for alternative concept. As indicated above, the newspapers have a clear understanding on reproductive health issues mainly based on the global concept and there is a limited understanding of alternative concept although the trend is not that visible in terms of size of the articles but with the quality of arguments inside the article. In any case, it is essential to develop the understanding of reproductive health issues based on the ground realities, which is mainly social base that caters the needs of majority of the developing countries. Despite a critical emphasis on reproductive health based on womens rights for years, the maternal mortality rate in the developing world has been continued to increase. A real challenge remains in framing enabling health services that has a wider reach at least to the vulnerable groups of the developing world. The health policies and interventions without considering the social realities of the developing world are unlikely to be successful in addressing the problems of maternal health and thereby the maternal mortality.

6. Strategies and Recommendations

Research in understanding social base reproductive health problems It is very urgent that the reproductive health issues are appropriately identified at the grassroots that accommodate the maternal health needs for the majority of the population in the developing countries. Beyond the limitation of health services and facilities, much needs to be done in addressing maternal health problems that have been a barrier for improving reproductive capacity of women. As mentioned earlier, the reproductive health issues are largely social base in the developing world and they have to be identified with in-depth research and analysis so as to initiate the strategic interventions on reproductive health.

Promotion of Awareness and Education The reproductive health problems that are social base can largely be addressed with promoting awareness and education among the community members, families and societies. It is more about educating people for socio-cultural integration through reducing gender inequalities, minimizing power relations that lead to barriers in improving maternal health. For instance, once the society, family and community understand the importance of mothers health that relate to child health (regardless of sex) and of their future generation, there will be less restrictions on mobility for attending health clinic, less concern for child marriage, less priority for son, and less fear of risky abortion and so on. Hence, awareness and education should be a top priority that does not only helps to ensure socio-cultural integration but also encourages preventive approach through creating awareness on violence practices as well as on sexual health.

Appropriate Interventions in health Services In order to have enabling health services to address the reproductive health problems, structure of basic health services are not sufficient. The health services are to be equipped with trained health workers as well as adequate medical supplies. In the remote regions of the developing world, health facilities are often located at urban centers, and if they are located at rural centre, they are without enough supplies and insufficient health workers. Such health centers only fulfill the lip services than real. At any cost, the reproductive health workers should be very mobile and be able to attend the delivery cases as needed. For this purpose there should be incentives for health workers to remain in the remote regions or to train the local community members to attend to such health problems. The other alternative would be to run the mobile clinic for basic medication such as providing vitamin A and Folic acid for pregnant women, immunization services, and for regular check ups during and after pregnancy.

Monitoring and Evaluation In order to check the efficiency and effectiveness of health services located in the developing world, there should be a regular monitoring system at local and regional level. This can be done in partnership with different stakeholders such as local community organizations, schools, development organizations and the government institutions. Such monitoring and evaluation practices help to identify the problems and issues, document the best practices and make corrections for continuous improvement in addressing the reproductive health issues.

References

Earth, B. and Sthapit, S. (2002) Uterine Prolapsed in Rural Nepal: Gender and Human Rights Implications, A Mandate for Development Vol.4 (3), pg. 281-296. Estelle, S. A. Gruskin, S. (2003) Vulnerability to HIV/STIs among Rural Women from Migrant Communities in Nepal: A Health and Human Rights Framework, Reproductive Health Matters 11(22) pg.142151. Graham, W.J. and Campbell, O.M. (1992) Maternal Health and the Measurement Trap Social Science and Medicine, 5(8) pg. 967-77. Filippi, V. (1998) Near Misses: Maternal Morbidity and Mortality Lancet 351(10). pg. 145146. Mumtaz, Z. and S. Salway, S. (2009) Understanding Gendered Influences on Womens Reproductive Health in Pakistan: Moving beyond the Autonomy Paradigm, Social Science & Medicine 68 (7) pg. 13491356. Sen, A.K. (1999) Development as Freedom (Oxford: Oxford University Press) Sen, A.K. (1994) Population: Delusion and Reality, New York Times Review of Books, 41 (15) pg. 62-71. Tsui, A., Waserheit, J.N., and Jaaga, J.G. (Eds) (1997) Reproductive Health in Developing Countries (Washington, D.C.: National Academy Press).