Reflections
Perspectives
Number 1
June 1999
Gender Issues in Reproductive Health:
Let’s Get Serious
by
Dr. Praema Raghavan-Gilbert
Adviser on Gender & Reproductive Health
Introduction
Gender refers to the socially constructed roles
assigned to males and females that define how
men and women should think, act and feel
and are culturally and politically defined.
These roles, which are learned vary widely
within and between cultures, and change over
time, between communities and cultures, as a
result of social, economic and political shifts.
Unlike sex, which is the biological distinction
between males and females, gender refers to
socially learned behaviour and expectations
that distinguish between masculinity and
femininity. Whereas biological sex identity is
determined by chromosomal and anatomical
characteristics, socially learned gender is an
acquired identity. The concept of gender also
includes the expectations held about the
characteristics,
aptitudes
and
likely
behaviours of both men and women.
The Cairo ICPD POA on Gender made a
commitment to the empowerment and
autonomy of women and the improvement of
their political, social, economic and health
status as fundamental to the achievement of
sustainable development.
The POA on
Gender also identified the full participation
and partnership of men and women in
productive and reproductive life including
care and nurturing of children and
maintenance of the household as crucial to the
empowerment of women in reproductive
health, and the implied strengthening of the
family as the centrepiece of the community
for nation building.
Issues in incorporating gender into RH
The complex concept of gender and gender
mainstreaming is not yet well understood by
planners, implementers and providers of
health and other services and is sometimes
rejected as feminist stridency. Much of the
fear and defensiveness about incorporating
gender perspectives into all development
activities will weaken with increased
understanding of the true concept of gender in
reproductive health i.e. to empower women
and strengthen the family bond. A deeper
understanding of how the empowerment of
women is a fundamental pre-requisite of their
own health and the well-being of their family
will evolve over time with increased
awareness and public education about the
gender issues.
Since Cairo, the concept of health has moved
from a narrow biomedical model meaning the
absence of disease focused on childbearing
and child rearing, to health as a right to
emotional, social and physical well-being
within the larger social, political and
economic context. This shift from the medical
model to the rights model challenges the
cultural and economic conditions under which
women in diverse cultures receive RH
services. The narrow medical models in
which the service provider decides what is
best for women clients are more successful in
curative care, seeking relief from pain and
physical distress, than in promotive and
preventive care.
Cultural conditions are mediated by religion,
gender and tradition. Religion may influence
interpretations about use of certain
contraceptives, use of blood or life support
systems in emergency obstetrics, etc. Gender
influences the low level of male responsibility
in use of contraception. Men may also
prevent women from using contraceptives of
the woman’s choice and from limiting family
size. Domestic violence and violence against
women of all ages is an engendered
phenomenon with strong inter-generational
links on the part of both men (the right to hit)
and women (conditioned to suffer in silence).
Gender biased food allocation and a
exaggerated workload causes anaemia,
malnutrition and increased susceptibility to
infectious diseases in girls and women. This
bias is culturally acceptable in many societies.
Cultural pressures may force girls to marry
and bear children at a very young age with
serious reproductive health consequences.
Obstructed labour, ruptured uterus, fistula
formation with leaking urine and faeces for
the rest of her life, are some of the horrendous
consequences of very early child-bearing.
Mental and physical abuse of women blamed
(often unfairly) for infertility, or poor
pregnancy outcomes is a cruel engendered
cultural practice. This may contribute to
depression and suicide or violence against the
woman from the in-laws. There are societies
in which women are not allowed to seek
health care, even for life-threatening
emergency conditions if they are not
chaperoned by a male relative. There are also
traditional practices where there is a
preference to receive care only from female
attendants. And yet, in many of the PICs, the
majority of aide post staff are men, even as
the search for improving rural access
continues.
The economic mediating factors are often
related to poverty, lack of education and the
lack of women’s decision–making power in
the household. At all ages women are more
likely to be poorer than men. Women-headed
households are more likely to be poorer than
those headed by men, irrespective of whether
the data come from rural or urban populations
or from developed or developing nations.
Poor women are likely to live in unsanitary
housing, have poor quality meals, and poverty
further limits access to even free health care.
These economic factors also force women to
tolerate poor quality services, particularly in
the public sector because of their lack of
personal and social status. Poor women
without money for medication or transport are
unable to seek alternative services at a private
sector clinc. The social distance between
providers and poor uneducated women,
because
of
power
and
knowledge
asymmetries, force them to accept low quality
services in which they are treated with little
respect. Minimal technical information is
shared with the client; very limited choice of
FP methods is offered because of the belief
the provider knows best; the services are often
unreliable, causing great inconvenience to the
patients; and women are often treated with
little privacy, confidentiality, respect or
dignity. Quality is also compromised when
unnecessary
administrative
programme
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barriers are placed, e.g. husbands’ consent or
signature to receive certain services. This
affects the woman’s right to receive services
of choice and to space or limit family size.
Women generally are unaware that after Cairo
& Beijing, they have a right to be listened to
and to request and demand access to
appropriate, acceptable and affordable
comprehensive health services of high
standards. This knowledge gap will narrow
with increasing social and economic power
enhanced by awareness, education and
legislation of rights.
The role of men as partners with equal
personal and social responsibility for the
effects of their own sexual behaviour on their
partners’ and children’s health is an issue that
has not been addressed in some of the PICs,
even five years after Cairo.
Men’s
responsibility to practise safe sex has been
addressed
somewhat
through
active
STD/HIV/AIDS programmes.
Men’s
responsibility in fertility management has
seen some successful vasectomy interventions
in Papua New Guinea and Kiribati. The
linkages between STDs in the male and
infertility, pelvic inflammatory disease and
ectopic (tubal) pregnancy in the female has
not been addressed adequately in RH
programmes. The care and nurturing of
children, and the maintenance of the
household as a shared responsibility is a
theme that needs to be strengthened in IEC,
Advocacy and Counselling programmes in the
Pacific.
Programmes have not adequately informed
men about the long-term emotional and
psychological damage to the women and
children in the family when they experience
domestic violence and sexual or physical
abuse. Additionally, most primary health care
providers are not trained to identify,
document and manage victims of domestic
violence. Providers often deny or deflect the
problem. They prefer to believe that the
police or crisis centres are better equipped to
handle these cases and often quote the low
statistics in their communities to support this
view. Statistics reflect only the tip of the iceberg and often represent the endpoint of a
continuum of suffering. The vast majority of
cases of domestic violence prefer to hide from
their friends and family till their scars of
humiliation have faded. They sometimes seek
care from health centres with improbable
stories of repeated accidents that beg a high
index of suspicion.
The true reproductive and health status of
women cannot be measured by the traditional
indicators of maternal mortality and
contraceptive use. A woman’s health status is
determined over her lifetime by the genderbased social, political, cultural and economic
factors that she has experienced. The lack of
access to good nutrition, education and health
care for the girl child often starts from
infancy. The disadvantages inherent in a lack
of educational opportunities and employment
and self esteem increase the risks of
adolescence, particularly teen pregnancy,
sexual exploitation, and STD/HIV and AIDS.
In the Pacific, these factors are beginning to
affect the male child and male adolescents
too. In all countries, this increases their risk
of sexual exploitation and diseases. Later, the
child bearing years are fraught with obstetric
and gynaecological emergencies and diseases
aggravated by pre-existing anemia, and poor
access to FP and health care. The ageing
woman is faced with shrinking financial
resources and personal power (due to the
death or disability of her breadwinner and
head of household husband) and growing
personal health care needs related to
menopause, systemic diseases, disability and
cancers. Throughout her life cycle she may
experience physical, sexual and emotional
abuse. None of these gender-based cultural
and economic experiences are captured in the
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governments’ commitment to the ICPD
POA on Gender.
reproductive health indicators currently in
use.
The Challenges
Many challenges face programmes and
programme managers in mainstreaming
gender.



The difficulty of acquiring and analyzing
disaggregated data without trained gender
focal points in all Ministries and
organizations.
Disaggregated data by
gender must be made available by
legislation and training in all sectors. This
is central for national planners to use in
education, employment, nutrition and
health care to work towards narrowing
gender disparity.
Currently, there is no mechanism for
women’s groups and Ministries of Health
and Women and NGOs to meet regularly
for tactical planning and feedback.
Strategic partnerships must be formed and
led with government ministries, women’s
NGOs and international and private
organizations to create a platform for
coherent
programmes
in
gender
sensitization and gender mainstreaming.
There is a need to extend services to reach
out to men, adolescents, and ageing
women within the existing health
structures. The need already exists for the
health care system to enable the
identification of domestic violence,
physical and sexual abuse, and rape.
Health service procedures, and the
provision of support services and training
must address these inadequacies as part of

IEC and Advocacy strategies must be
modified to promote male responsibility
and to increase community education on
women’s rights and issues as an integral
part of family health development.

The ratio of male/female RH service
providers must be re-examined to respond
with appropriate gender sensitivity and a
long-term view to increase RH service
utilization and quality.

Quality of Care supervision must be
enabled through training and tools
particularly in the areas of informed
choice and consent, interpersonal process,
reliability of services, confidentiality and
privacy,
while
strengthening
all
management systems.

The implementation of more gender and
adolescent friendly RH services through
legislation, policy, and institutional
changes may need to be instituted within
the existing health care structures.

Researchers may wish to collect and
analyse data on women’s health in the
Pacific from the perspective of women.
This is because diseases affect men and
women differently, may be unique to
women, may have different risk and
exposure factors and may require different
interventions. All of which have longterm health planning implications. ■
Reflections will be published periodically by the UNFPA Country Support Team for the South Pacific. Views
expressed do not necessarily reflect the opinions or policy of the United Nations Population Fund. Correspondence
should be addressed to: The Director, UNFPA Country Support Team, GPO Box 441, Suva, Fiji. Phone: (679) 312-865
Fax: (679) 304-877 Internet email: Registry@unfpacst.org.fj
Homepage: http://www.undp.org./popin/regional/asiapac/fiji/fijihome.htm
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