Transcript Deadly Dilemmas in Women's and Girls’ Health: A Model for Advocacy and Positive Change Maureen Kelley, Ph.D. Bioethics Division, Dept of Pediatrics.

Deadly Dilemmas in Women's
and Girls’ Health:
A Model for Advocacy and
Positive Change
Maureen Kelley, Ph.D.
Bioethics Division, Dept of Pediatrics
“Women Hold up Half the Sky”
….and much more
• Empowering women:
Valuable as an end in
itself as a basic human
right.
• And as a powerful
determinant of women’s
health, children’s health,
and the health of families,
and communities.
Integrating Ethics & Global/Community
Health
Three Powerful Ideas:
1. We need both the View from Above & The View from
Below to think beyond isolated health interventions,
toward sustainable solutions.
2. Ethical Dilemmas are a Symptom of Deeper Problems:
Diagnosing dilemmas is part of the Solution
1. Solutions need to be approached with cultural humility,
and rooted in women’s empowerment, grown within
communities and across generations.
The View from Below…
Behind each number is a face and a story.
Every voice is unique and quietly powerful.
The story of Jane
• 16 yr girl admitted to rural district hospital in Eastern
Africa w/ abdominal pain. Plain x-ray shows needle in
pelvic region.
• Pregnancy test (+) // HIV test (+)
• Life threatening attempted self abortion
• Mother does not know, but is eventually told
• She is daughter’s only source of support
• Both daughter and mother fear father/husband
• Fear community reaction
• Mother and daughter choose to keep the attempted
abortion secret, needle is removed and pregnancy still
viable.
• She continues on with pregnancy and will be counseled
on a PMTCT strategy and HIV treatment for herself.
What should be done for Jane and other
girls and women like her?
Moral dilemmas are often a
symptom of deeper problems…
Diagnosing terrible trade-offs is the first step in
identifying barriers to lasting solutions.
Dilemmas Fueled by
Poverty & Gender
Inequalities
Dilemmas of Poverty
& Geography
• A bus ticket to the hospital in
Lusaka or Kampala vs.
Feeding other siblings for the
next five months.
• Among the highest
causes of maternal death
in childbirth could be
prevented with better
access to safe, facility
births, with skilled birth
attendants.
• In Lusaka, most women who
chose to give birth at home did
so because they could hire a
midwife’s services with small
food items. (Hazemba, 2009)
• When complications arise, they
are too far from a facility.
Value trade-offs in reproductive choice
– birth spacing and
contraception
– financial trade-offs for
family and siblings
– nutrition for self vs.
family during pregnancy
– occupational stress vs.
personal health
How do you make decisions at the margins
when the margins are a way of life?
We simply can’t accept the margins….
The View from Above…
• Counting requires being Counted.
Deadly pregnancies
• Approximately 1000 women die
every day due to complications
of pregnancy and child birth
– severe bleeding, infections,
hypertensive disorders, and
unsafe abortions
• For every woman who dies in
childbirth, 20 more will suffer
injury, infection, or disease –
approximately 10 million
Sources: WHO, 2010; Murray et
women each year.
al., 2010
Maternal & Neonatal Deaths –
Why?
Largely
preventable
Goldenberg et al., Stillbirths: The Vision for 2020, Lancet 2011.
Preventable determinants of morbidity
& mortality for women and girls
• Reproductive health problems comprise the leading cause
of death and disability for women globally.
• Skewed prevalence of HIV in girls and young women, even
in countries where rates of HIV have decreased (such as
Brazil).
• Exposure to STDS (e.g., HPV) higher among girls living in
poverty, and ethnic minorities.
• An epidemic of domestic violence: From female feticide, to
genital cutting, trafficking of girls and women, child
marriage, honor killings, physical abuse. (Sources: Shaw,
2006; Nour 2009)
The View from Above…
• The importance of social determinants of
health.
• Looking upstream is critical for identifying root
problems and sustainable solutions
• Example: Girl’s Education
Some sobering facts
• Girls that do not finish secondary education are more
likely to have an earlier age of sexual initiation, engage in
risky sexual behavior, and consequentially be at greater
risk of dying from pregnancy-related causes.
• Girls in school were more likely to have heard of sexually
transmitted diseases or infections than girls not in
school. Girls in school were also more likely than girls not
in school to boil water before drinking
• (Rees et al., Educating for the future: adolescent girls'
health and education in West Bengal, India. Int J Adolesc
Med Health. 2012)
Domestic Violence
• The higher the education
level of the women the
less the likelihood of
experiencing physical
intimate partner violence.
• (Tumwesigye et al. Problem
drinking and physical intimate
partner violence against women.
BMC Public Health 2012, 12:399
from the Women’s dataset in the
Uganda Demographic and Health
Survey of 2006)
Empowered Women are Healthier
Mothers
• Social and political
marginalization impacts
demand for prenatal and
antenatal interventions.
• Literacy, education, and
empowerment known to
improve access to
prenatal, delivery and
postnatal care.
Wise P. Transforming preconceptional,
prenatal, and interconceptional care into a
comprehensive commitment to women’s
health. Womens Health Issues 2008.
Connected Outcomes
Require an Interdisciplinary Approach
Maternal
Child
Prematurity
and
stillbirth
Newborn
Fetal
Women’s Education and Child Survival
• Increase in the education of
women has been shown to
decrease child deaths under
five.
•
(Gakidou E, Cowling K, Lozano R, Murray CJL.
Increased educational attainment and its impact on
child mortality in 175 countries between 1970 and
2009: a systematic analysis. Lancet 2010.)
• Two decades of research
shows that children benefit
when their mother’s status is
raised.
•
(Chen & Li, 2009; Apodaca,2008; Heaton, Forste,
Hoffmann, & Flake, 2005; Gokhale et al., 2004;
Caldwell & Caldwell, 1991; Cleland &
Ginneken,1988; Hobcraft, 1993; Caldwell &
McDonald, 1982.)
Under 5 Deaths, Where?
Worldmapper, Age of Death. WHO Global Burden of
Disease (GBD).
Illiterate women – where?
•
•
Source: Worldmapper, United Nations. 2005. The
Millennium Development Goals Report, 2005 . New York:
United Nations.
In South American
and Western
European territories
men and women
have very similar
levels of literacy.
Elsewhere,
particularly in India,
China, Pakistan and
the Islamic Republic
of Iran, there are
much larger numbers
of women who cannot
read or write
compared to men.
Girls not in Primary School
•
•
•
•
Largest absolute gap between the enrollment of girls and boys in primary
education is India.
In India there are about 8 million fewer girls than boys enrolled in the first five
years of education, ten times the number in any other territory.
Other territories with significant gaps: Yemen, Chad, Benin and Niger.
Source: Worldmapper, United Nations. 2005. The Millennium Development Goals
Report, 2005 . New York: United Nations.
How do we help achieve sustainable
solutions?
1. Building Women’s Social Capital
• Social capital - high levels of participation in local
community groups - is thought to be an important
determinant of health
• Example:
Social Capital and Women's Reduced
Vulnerability to HIV infection in Rural Zimbabwe
(1998-2003)
• Individual women in community groups had lower
HIV incidence and more extensive behavior
change, even after controlling for confounding
factors.
•
(Gregson et al. Popul Dev Rev. 2011).
2. Helping women to organize
themselves…
3. The power of local movements
4. The power of women across
generations
5. Educating boys and men:
6. Political Empowerment
What is our role?
To Bear Witness
and Effect Change through Partnerships
What’s upstream?
• Social
determinants:
 Illiteracy
 Poverty
 Lack of political
power
 Lack of autonomy
in reproductive
health
What’s downstream?
•




Unintended Effects:
Stigma or abandonment
Physical harm
Reluctance to seek care
Increased risk of
mortality/disability
 Breach of trust
 Patient
 Hospital
 Community
Cultural Humility & Local
Empowerment
Solutions need to be approached with cultural
humility, and rooted in women’s
empowerment, grown within communities and
across generations.
Navigating cultural and social
norms without legal protections can
also be hazardous to women’s
health.
• Empowering women
can also expose them
to personal and social
risk.
Example of well-meaning, harmful impact:
• Reporting pregnancy
complications and STDs
carry significant costs for
women.
• Example: Partner disclosure
of HIV status and PMTCT in
ANC setting (Hardon et al)
• Women “Captured” in ANC.
Unintended consequence:
false discordance.
• can lead to stigma, abuse by
husband, and abandonment.
Photo Credit: Richard Lord
YOU ARE HERE

Upstream
What can I
do now?
Downstream
• Determinants of What
Healthis your sphere
• Impact
of influence to effect
• This patient’s story
• Mitigating impact for this
lasting change?
patient
• Social, cultural, and
political context How can you partner
• Opportunities for more
with others to systematic change
expand it?
Helping girls believe on the inside…