Globally, an estimated 200 million women have an unmet need for modern contraception and 25 million women have unsafe abortions each year (Horton 2019). Arguably, these estimates are likely to under estimate the actual number of women seeking care, due to the shrouded nature of such an emotive and often very personal issue. In addition, women suffer a high burden of sexual and reproductive ill-health due to sexual transmitted infections, most notably in countries that fail to address the sexual and reproductive health rights of women and girls. More than 300,000 women die from complications before, during and after childbirth, and more than 300 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections (Glasier et al 2006). There is compelling evidence that countries and governments that do not prioritise sexual and reproductive health rights have disproportionately poor health indicators (Adewole et al 2018).
Similarly, the global burden of unsafe abortion is most significant in countries with restrictive abortion laws. Unplanned pregnancy may lead to unsafe abortion, which accounts for up to 13% of all maternal deaths (Say et al 2014). Restricting the access women have to family planning denies their right to dignity, undermines the control they have over their lives and poses a greater risk of unplanned and unsafe pregnancy. For adolescent girls, the implications can be grave, with death during childbirth being a leading cause of death in this group (WHO 2017). There are clear links between poor sexual and reproductive ill-health, high preventable maternal mortality, and, systematic failures to effectuate the rights of women to the highest attainable standard of health. There is also a clear correlation between preventable mortality, and, whether a woman experiences her right to privacy, decision-making free from coercion, information and education, water, shelter and sanitation, freedom from torture and violence (Parker 2007).
Gender inequity limits opportunities
If we also consider that unintended pregnancy retrenches the opportunities women have for education and participation in society and economic advancement, then a woman’s access to family planning services is intrinsic not just to her reproductive health, but also to her social and economic equality and growth (UNFPA 2017). Arguably across the globe, women face a plethora of unequal opportunities and unrealised rights. Although the detrimental effects of denied access to family planning and contraception may be experienced by women in all settings, women living in low- and middle-income settings, who may already experience especially social and health inequalities, face serious consequences of this denial. Unsafe sex was proposed as the second most significant risk factor for disability and death in the world’s most deprived communities and the ninth most significant in high-income countries (Glasier et al 2006).
A woman’s right to healthcare, including access to safe abortion was outlined in the 1948 Universal Declaration of Human Rights, followed by countless international treaties (United Nations,1948). Yet, to the present-day, women and girls continue to have a disproportionate burden of sexual and reproductive ill-health (UNFPA 2017). Many women face an inaccessible, unnavigable and disjointed landscape of health and there is a vast quantity of evidence linking gender inequity and poor health (Guttmacher Institute, 2017). Staggeringly, sexual and reproductive health was omitted from a seminal global health agenda, proposing the Millennium Development Goals (Glasier et al 2006). However, the current era of the Sustainable Development Goals has a renewed focus and the mandate is clear. These goals are focussed on achieving healthy lives for all and, more specifically, achieving gender equality and empowerment of all women and girls, including a target to achieve universal access to sexual and reproductive health and rights (United Nations, 2015). Only when these goals are achieved will humanity reach an equilibrium where each individual experiences dignity and equality.
International strategies must focus on women’s rights
Opinions about sexual and reproductive health care are often still contentious, deep-rooted and emotive. In 2017, an extension of the global gag rule was enforced by the president of the United States of America, prohibiting foreign-aid funding of abortion services, counselling, or referrals, or any form of advocacy for abortion laws. Conservative strategies such as these have been criticised for their broader effects on contraceptive, antenatal, vaccination and HIV prevention services (Starrs, A,M 2017).
Availability, accessibility and quality of family planning services can empower women and girls to control their futures by timing, spacing or preventing pregnancy. Every woman, everywhere, deserves the right to decide whether, when and with whom she has a baby, as a fundamental human right (WHO 2019). As the often-neglected issue of sexual and reproductive health is spotlighted, there is increased recognition that to address a complex and multidimensional issue such as maternal mortality, a focus on human rights is required, as well as the traditional focus on development.
Midwives as essential advocates
Midwives have a key role in exercising and advocating for the rights of women and girls. It is this ‘right to health’ approach, that can be used as a tool to improve maternal mortality. A colleague of the Centre for Maternal and Newborn Health, working a large referral hospital in Zanzibar recently shared her innovative ideas for how a ‘rights-based’ approach could be achieved. This passionate midwife had displayed posters in her clinical setting, outlining the human rights of women, as a vital first step to empowering both women and midwives with information. For the sexual and reproductive rights of women to be realised, they must first be understood.
The ICM states that ‘midwives are skilled to provide the vast majority (> 85%) of pregnancy-related services, making them the ideal healthcare provider to support women through the maternity continuum of care’ (ICM, 2017). Midwives are ideally placed to promote women’s and girls' agency and empowerment. Midwives are usually an integral part of the community and they are positioned to tackle gender and social norms; engaging communities and local leaders meaningfully. Midwives are very much involved in the collection and use of data, research and evidence, enabling them to influence the global agenda to realise the sexual and reproductive rights of every women, everywhere.