A Measure of Survival - Calculating Women's Sexual and Reproductive Risk

October 18, 2007

Pregnancy and childbirth are deadly to more than half a million women worldwide every year—a fact that is unacceptable, but not unavoidable. These women are typically poor, uneducated and living in rural areas or urban slums. Despite 20 years of campaigning to improve the reproductive health of women throughout the world, the risk of dying in pregnancy or childbirth shows the largest gap between the rich and poor of all development statistics. The uneven distribution of health services, the concentration of poverty among certain population groups and geographic areas, gender inequity and harmful social norms all contribute to the discrepancy in sexual and reproductive risk globally and locally within countries.

Continuing a Population Action International (PAI) effort begun in 1995, this study is the fourth,^{1 2 3} in a series that assesses the sexual and reproductive health status of nations. The results have been disturbingly static, with low-income countries at highest reproductive risk and high-income ones at lowest risk. Women's sexual and reproductive health are riskiest in sub-Saharan Africa and South Asia, and the need for reproductive health services is greatest among the poorest women and men residing in the world's lowest-income countries. Yet, effective interventions have worked in certain countries and settings, reducing or nearly erasing reproductive risk. For example, Europe and North America reduced their maternal mortality starting 75 years ago by improving the availability of emergency services to treat obstetric complications. In Sri Lanka, maternal mortality was halved between 1930 and 1947 through government efforts to improve overall health and control malaria.⁴ Until the 1990s, Sri Lanka continued to halve maternal deaths at least every 13 years by extending health services to rural areas, training midwives, introducing family planning and advancing obstetric care.⁵ The case of Sri Lanka demonstrates that given the proper investments, maternal health can improve dramatically and rapidly, even in a poor country. (See Box on Sri Lanka, section 8.)

Reducing women's sexual and reproductive risk requires the political will to reduce inequities in reproductive health status and in access to services. It also requires appropriate and sustained funding and programming to take services to those who need them. Harmful policies such as those imposed by the United States—the Global Gag Rule, abstinence-only sex education and the anti-prostitution pledge—undermine access to information and health care, and must be repealed. Weak infrastructure and limited distribution systems in low-income countries complicate access to health services, especially in rural areas, and these issues need long-term solutions.

This study provides a benchmark of where women in 130 countries stand on a range of indicators that were incorporated into the Programme of Action International Conference on Population and Development (ICPD) in 1994, or into the Millennium Development Goals (MDGs) in 2000. Indeed, the World Summit in 2005 affirmed the importance of reproductive health (RH) to achieving the MDGs and human development.⁶

The comprehensive approach of sexual and reproductive health and rights makes it essential to and a component of the attainment of not only the health-related MDGs regarding maternal health and child survival, but all eight MDGs, from poverty reduction to gender equality and women's empowerment. These global commitments are the foundation for action at the country level that values and safeguards the lives of women and girls—from increasing spending on family planning to expanding and enforcing women's legal rights to ensuring quality education for all.

LIFE-CYCLE APPROACH AND PAI'S REPRODUCTIVE RISK INDEX

The study utilizes a framework that takes a woman's life-cycle approach to sexual and reproductive health and emphasizes that every step of reproduction should be healthy (See Methodology). Of course, reproductive risks emerge well before pregnancy and childbirth, and survival certainly cannot be considered an endpoint to reproductive risk. The framework for measuring reproductive risk is constructed according to the basic elements of reproduction—sex, pregnancy, childbirth and survival—as these are among the more direct causes of heightened vulnerability to death and injury for women around the world. Recognizing that reproductive health is influenced by broader issues of inequity in income distribution, in access to social services and in gender relations, this study discusses the linkages between reproductive risk and poverty and gender inequity.

For each country, the study renders a range of RH indicators into a manageable set by combining them into one single measure—the Reproductive Risk Index (RRI). The nine indicators composing the RRI are:

• HIV/AIDS prevalence among adults;
• adolescent fertility;
• percentage of girls married before age 18;
• antenatal care coverage;
• percent of family planning demand met;
• births attended by skilled health personnel;
• grounds on which abortion is permitted;
• maternal mortality ratio (MMR); and
• infant mortality rate (IMR).

As a single measure of reproductive risk overall, the RRI is a guide for advocates engaged in the continued effort toward achieving safe, healthy and informed decisions about reproductive health, especially for the world's poorest women, and for decision-makers and planners in setting their national policy and budgetary priorities. The interventions needed to reduce women's sexual and reproductive risk vary between and within countries and regions, however, and this tool should be used with this in mind.

 

 

	Safe & Healthy	Voluntary
Sex	HIV prevalence among adults age 15+ (%) Adolescent fertility	Girls married before age 18 (%)
Pregnancy	Antenatal care coverage at least 4 visits (%)	FP demand met (%)
Birth	Births attended by skilled health personnel (%)	Abortion policies
Survival	MMR IMR

 

 

Disease Burden of SRH According to the World Health Organization, sexual and reproductive ill health accounts for one-third of the global burden of disease among women of reproductive age (15-44 years old) and close to one-fifth of the overall burden of disease.7 8 Maternal conditions (hemorrhage or sepsis resulting from childbirth, obstructed labor, pregnancy-related hypertensive disorders and unsafe abortion) account for 13 percent of the burden of disease among women of reproductive age and for 2 percent of the overall burden of disease. HIV/AIDS accounts for 14 percent of the burden of disease among women of reproductive age and for 6 percent of the overall burden of disease. Other sexual and reproductive health conditions (STIs other than HIV/AIDS, iron-deficiency anemia among women aged 15-44, breast cancer, ovarian cancer, cervical cancer, uterine cancer and genitourinary disease) account for 5 percent of the burden of disease among women of reproductive age and for 3 percent of the overall burden of disease. Perinatal conditions (low birth weight, birth asphyxia and birth trauma) account for 7 percent of the overall burden of disease.

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