The Right to Choose Without Coercion
Every year 585,000 women-one every minute-die from causes related to pregnancy or childbirth. About 200,000 maternal deaths each year result from the lack or failure of contraceptive services. Compounded by widespread discrimination and violence against women, this situation constitutes a serious violation of women's human rights.
At the third International Conference on Population and Development, held in Cairo in 1994, the world's governments first validated sexual and reproductive rights, recognizing the right of women to make their own decisions on issues of sexuality and reproduction, as well as the right to have information about and access to contraceptive services.
This year, in the context of the 50th anniversary of the Universal Declaration of Human Rights, which also forms the basis for the United Nations campaign to eliminate violence against women, these commitments are crucial for understanding the link between gender-based violence and women's human rights.
Cairo's Programme of Action is very explicit about this connection when it states that "advancing gender equality and equity and the empowerment of women, and the elimination of all kinds of violence against women, and ensuring women's ability to control their own fertility, are cornerstones of population and development-related programmes"(ICPD Programme of Action, Principle 4).
The exercise of sexual and reproductive rights is clearly described in the Cairo agreement as "the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence..."(ICPD Programme of Action, Chapter 7.3).
The Platform of Action from the 4th World Conference on Women (Beijing 1995) echoed these principals in Paragraph 96, stating that "sexual rights include the human right of women to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence."
Coercion limits women's ability to exercise their right to control their health and sexuality. Coercion is, above all, a form of violence. Many pregnancies result from the lack of information about and access to contraceptive methods. Pregnancies resulting from rape are not uncommon and may end in illegal abortion performed in unsanitary conditions which endanger women's lives and health.
Women are also exposed to other forms of coercion, such as the practice of unnecessary cesarean deliveries, sterilization without consent and the distribution of contraceptive methods without sufficient information. Sometimes women are poorly treated in the health care services. They may not receive truthful and understandable information in a timely manner. Women are often humiliated and made to feel guilty, and they may even be verbally abused in the hospital delivery room.
While considerable gains have been made in the field of health, structural adjustment programs have dramatically reduced the resources assigned per capita for primary health care. In many countries of the region, this has resulted in a reduction of quality health care services. As always, the effects of structural adjustments have particularly impacted populations with limited resources, especially women and children. The public sector has been accused of compounding this situation through inefficiency and corruption.
Without a doubt, truly comprehensive health care services imply improving coverage to satisfy the demand for contraceptive services, and these services must include prevention and education, in addition to purely clinical aspects. The fact that a considerable number of women resort to induced abortion in the case of unwanted pregnancy clearly reveals the lack of effectiveness and coverage of current contraceptive services. According to some surveys, a high percentage of these women would have preferred to have used a contraceptive method. The simple conclusion: providing improved contraceptive services will reduce the number of abortions.
At the same time, the number of emergency obstetric care centers must be increased to care for complications in pregnancy and childbirth in order to reduce maternal mortality rates and achieve the goals set by the international community. The maternal morality rate for 1990 should be cut in half by the year 2000, and halved again by 2015.
According the calculations of the United Nations Population Fund (UNFPA), by the year 2000 better reproductive health care services for the entire world will cost $17 billion annually. This sum is less than one week of world expenditure on armaments. However, UNFPA also warns that, while many governments have increased their allocations for population programmes since 1994, annual global expenditures are still well below the $17 billion goal.
The ICPD Programme of Action was a great step forward in the conceptualization of the close relationship between women's health and gender-based violence. The Cairo agreement recognized that "the human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights," and from this perspective, the document denounces the effects of human rights abuses as an endless number of injuries, infections, illnesses and death linked to violent actions committed specifically against women.
High rates of fertility are also related to the various expressions of gender-based violence, and consequently this violence contributes to maternal morbidity and mortality, as do high rates of abortion and vulnerability to sexually transmitted diseases. The rise in prenatal and infant mortality rates, growing numbers of adolescent pregnancies, increased maternal mortality rates among young mothers and the increased number of women with HIV/AIDS are all phenomenon linked to the various expressions of gender-based violence.
The high risk inherent in being a woman is clearly revealed in the number of rape cases involving girls and adolescent women between 11 and 16 years of age. One specific example is found in Peru where a national survey of schoolchildren between 11 and 19 years old revealed that, of the students of both sexes who reported having had sexual relations, 9.5 per cent had been forced in their first sexual relation, and the proportion of girls was much higher than boys.
In Nicaragua, from 1993 to 1995, Hospital Berta Calderón treated 224 adolescent girls who had been raped (31.2 per cent of the total) (UNFPA, Salud Sexual y Reproductiva de los Adolescentes. Un Compromiso con el Futuro. Resumen de los Informes Nacionales de los países de América Latina. New York, 1998).
In response to this reality, the ICPD agreement encourages the governments to develop policies against gender-based violence by following the principles set forth in the Declaration on the Elimination of Violence Against Women (DEVAW) and the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW).
The Cairo Conference first recognized the existence of a broad sector of society whose sexual and health care demands and needs are ignored and, therefore, require special attention. This sector is made up of young women and men.
Traditionally, most health care services have turned a blind eye to this reality, and in particular, that of girls and adolescent women who are most vulnerable to the various forms of violence. The ICPD Programme of Action explains that, in general, youths of both sexes are poorly informed about the different forms of protection against unwanted pregnancy and sexually transmitted diseases. They need adequate information, as well as access to contraceptive services, but they also have the right to privacy.
It is well known that adolescent mothers run a higher risk of dying in pregnancy or childbirth and that their children suffer higher levels of morbidity and mortality, but early marriage and
early childbearing are also obstacles that hinder young women's access to opportunities for education and employment, The Cairo agreement stresses that educating girls is a fundamental step towards improving the health of the family, reducing infant mortality and changing reproductive behavior.
High rates of pregnancy, childbirth and abortions performed in unsanitary conditions are also related to the lack of educational and economic opportunities and are a violation of women's human rights, and therefore an expression of gender-based violence. Adolescent women and girls, particularly those from low-income sectors, are frequently victims of sexual abuse, and many are forced into prostitution.
Studies carried out by the Pan American Health Organization (PAHO) reveal that adolescent mothers have seven times fewer opportunities to continue their education than any other young woman of the same age that is not a mother. Their possibilities of escaping poverty decrease 30-fold in relation to other poor women of the same age who do not have children. According to the United Nations Childrens Fund (UNICEF), another problem of early pregnancies is that they tend to trap girls in a cycle of having children by different fathers as they move from one source of temporary support to another.
Because of this, one of the priority objectives of the ICPD Programme of Action is to increase women's access to education, especially as young girls. This means going against cultural and social codes, religions, laws and traditional customs that reinforce discrimination based on gender. But gains have been made: in the past few decades women's literacy rates have been increasing, by at least 75 per cent in most countries in Latin America and the Caribbean.
However, opportunities for girls are still restricted by social, cultural and economic barriers. Faced with this situation, Nafis Sadik, Executive Director of the United Nations Population Fund upholds the need to achieve real commitments from the governments regarding the rights of girls to education and to be free from violence of any sort. This goal requires giving priority to spending in education as well as reproductive health.
Isis International Documentation and Information Center
According to UNICEF, of the 31 million births registered each year in Latin America and the Caribbean, 2 million - 15 per cent of the totalare to adolescents.
The World Health Organization (WHO) estimates that if girls receive the same care as boys, their chance of surviving during the first five years of life is 1.01 in their favor.
In Guatemala, one fourth of all women give birth before age 18. In Brazil, one out of every 12 adolescents between 15 and 19 years old is already a mother. In Ecuador, 20 per cent of rural women under 18 years of age have at least one child, as in Peru, where 100,000 girls between 12 and 14 years old are mothers.
In Bolivia, 17.4 per cent of all births are to women under 20 years of age, and 20 per cent of all abortions in this country are performed on women under age 18.
El Salvador is the country in the region with the most pregnant teenagers with 138 per 1000, while the lowest rate is in Barbados, 60 per 1000.
In the Dominican Republic, 85 per cent of sexually active adolescents become pregnant, even though 99 per cent of them know of at least one form of modern contraceptive.
Poor families in Costa Rica and Guatemala have a total fertility rate 60 per cent higher than those families with better economic resources.
In Chile, 40,000 children are born to adolescent mothers each year. At least 80 per cent of these births are unplanned and unwanted.