(October 2002) A young woman bleeding profusely after a difficult birth in remote western Kenya urgently needs medical care, but the provincial hospital is many unpaved miles away. By the time her husband finds a car to transport mother and child, both are dead.

At a family planning clinic in Benin, a 30-year-old woman with six children comes in for contraceptives. She wants an implant that she had heard is safe and easy. But the clinic sends her home because she does not have her husband’s written permission. In Jamaica, a clinic worker refuses to give condoms to a 15-year-old girl because, the worker says, she should not be having sex.

These experiences are common in the developing world where health care is limited or inaccessible, contraceptives are unavailable or not used for social or cultural reasons, and girls may be forced to marry before their bodies can safely handle pregnancy. Preventable deaths and injuries continue, despite a global clamor for reproductive health and rights.

Reproductive health came to the fore in the 1990s, principally through promises made at the International Conference on Population and Development (ICPD) in Cairo in 1994 and the Fourth World Conference on Women in Beijing in 1995. The five-year reviews of the Cairo and Beijing conferences strengthened those commitments and put reproductive health and rights firmly on the map.

Reproductive health implies the ability to have a “satisfying and safe sex life” as well as the freedom to “decide if, when, and how often” to have children and to have access to effective and affordable methods of family planning, according to the ICPD Programme of Action. It also says health care services should be available to enable women “to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.”

But translating rights into reality has been a challenge.

Each year in less developed countries, more than a half million women die from pregnancy-related causes, and as many as 20 million sustain serious injury from pregnancy and childbirth, according to the World Health Organization. An estimated 28.5 million people in sub-Saharan Africa — more than half of them women — are infected with HIV, but only 30,000 in the region are receiving life-prolonging antiretroviral drugs, according to the Joint United Nations Programme on HIV/AIDS.

Limited Access to Care

While contraceptive use has risen to 60 percent among married couples in developing countries overall, the rate in sub-Saharan Africa is only 18 percent, the Population Reference Bureau reports. Each year, 75 million pregnancies are unplanned, and each day registers 1 million new cases of sexually transmitted infections, according to the International Planned Parenthood Federation (IPPF).

The low status of women compounds health care delivery problems in much of the less developed world. With little power to negotiate with men, women often have no say in when they will have sex and whether contraceptives will be used, leaving them vulnerable to sexually transmitted infections, including HIV/AIDS, and unwanted pregnancies.

In many parts of the world, parents force their daughters into arranged marriages when the girls begin menstruating. With pressure to prove fertility, the girls often become pregnant quickly, though their underdeveloped bodies are more prone to obstructed labor and other complications that can result in serious injury or death.

Laws in some countries prohibit women from visiting health clinics without their husbands’ permission; in some countries, unmarried women cannot get contraceptives. In societies that frown on unmarried women having sex, women say they are reluctant to visit reproductive health providers for any reason, fearing that it implies they are sexually active.

Many poor women cannot afford health services. Even where clinics provide free services, some women, especially the young and unmarried, will not take advantage of them because they sense a condescending attitude from health care workers. Health care workers complain, in turn, that they are overworked, underpaid, and have never been trained on how to counsel clients.

Raising the status of women is the key to overcoming many of the obstacles, says Dr. Pramilla Senanayake, IPPF assistant director general. “The bottom line is for women to be empowered,” she says.

Sometimes village women must travel — often by foot — many miles over unmaintained roads to reach a health facility, and when medical emergencies arise they cannot get there in time. But just getting to a health care clinic does not assure that trained personnel will be on hand or that required medical supplies or equipment will be available.

Financial resource allocation — whether to pave roads or build a clinic, train health workers or provide contraceptives — cannot be ignored. A lack of money need not limit progress toward reproductive health, however. Projects, large and small, in resource-poor settings around the world have found ways to improve health.

One Project for Rural Poor

A community-based health care program for the rural poor in India’s Maharashtra state has dramatically improved health care and the overall health of about 350,000 people, according to Dr. Shobha Arole, associate director of the project. Launched 30 years ago by Dr. Arole’s parents, Drs. Raj and Mabelle Arole, the Comprehensive Rural Health Project trains local villagers in the basics of maternity, child, and other health care and to recognize problems that require a higher level of care. It also works with villagers to provide clean water, adopt good agricultural practices, empower women, and make other improvements that “are more cost effective than hospital care,” Dr. Arole says.

The village health workers are the main providers of health care and information that prevents health problems, while mobile teams of medical workers visit villages regularly. A hospital is available for problems that cannot be handled in the village. It keeps costs low by relying on donated equipment and dispensing generic medications instead of expensive brand name ones. “We don’t have the five-star amenities some hospitals have, but we give good care,” says Dr. Arole.

The project’s holistic approach, integrating health and socio-economic development, drastically reduced major health problems that are common in less developed regions. More than 98 percent of the children are immunized, and malnutrition has plummeted. Nearly all women get prenatal care, which has reduced maternal and infant mortality to levels comparable to those of developed countries, according to Dr. Arole.

The key, Dr. Arole says, is to empower and enable people with the information and tools they need to protect their health. “Health isn’t the responsibility of doctors and nurses,” she says. “It’s the responsibility — and the right — of every human being.”

Deborah Mesce is senior media coordinator of international programs at PRB.