Vector: Issue 15; Women, Girls, and Gender in Global Health (August 2013)

Editor’s Note Of the myriad issues that pepper the global health landscape the entrenched character of the unequal treatment of women and girls, and the omnipresent and pervasive influence of gender inequality, are among the most challenging problems to redress. While gender specific health outcomes are quantifiable, the mechanisms of power, norms and roles reflected in the practices that govern a country or community can be acutely difficult to identify and remedy. It is true that successive waves of feminism have overturned much of what had previously passed as accepted social dogma, the rights of women and girls have been expanded and declared internationally, and health related services and interventions such as family planning, contraception, maternal care, and HIV/AIDS risk reduction, have shown marked improvements in many places over the last century. Nonetheless, the effective distribution of these outcomes has been notably uneven with many affordable and achievable gender-related health and public policy concerns remaining unremittingly absent in the developing world. While life expectancy is higher for women than men in some countries, the interplay of social and health factors continues to create an unacceptable quality of life for many women and girls, with unequal access to basic primary care, guidance, qualified health practitioners, and safe medical facilities, being commonplace. Of all adults with HIV in subSaharan Africa, 61% are women [1]. Physical and sexual violence continues to be a global problem, and one that is particularly acute in post-conflict environments [2]. Due to a rise in female smoking rates, coupled with the impact of traditional indoor cooking methods, rates of chronic obstructive pulmonary disorder are increasing among women in what was once a male dominated disease. In population terms,

Contents the statistical deficit of women in parts of Asia and North Africa has lasted for decades, and continues to grow in aggregate [3]. Furthermore, essentially all maternal deaths now occur in the developing world. More generally, occupational segregation persists, wage and education gaps endure, and women remain under-represented in political and economic decision making.

From a trekking adventure for Women’s empowerment in Nepal, and new research into measuring the impact of gender on poverty, to a fact sheet on Female Genital Mutilation and an analysis of the power of contraception to shape lives, Vector 15 offers new and interesting perspectives on these long-standing issues… In addition this issue includes Global Health Group happenings, questions of gender identity, MDG 5 progress, views on obstetrics in Sri Lanka, and more.

Andrew Lees, Editor-In-Chief [1] World Health Organisation (WHO). (2011). 10 Facts about Women’s Health. Accessed September 7, 2012, http://www.who.int/gender/documents/10facts_womens_ health_en.pdf.

[2] Elia, L. (2007). Fighting gender-based violence in SouthSudan. Forced Migration Review, 27, 39-40.

[3] Sen, A. (2003) Missing women-revisited: Reduction in female mortality has been counterbalanced by sex selective abortions. British Medical Journal (BMJ), 327, 1297-1298.

Editor’s Note

Andrew Lees (University of Notre Dame Fremantle)

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Trekking Towards Gender Equality in Nepal Stephanie Pender and Merinda Miles (Monash University)

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Engendering Poverty Measurement: Transforming how we define and measure poverty and hardship to make gender disparities visible Jo Crawford (IWDA/ANU)

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The Silver Bullet for Women’s Health: As Simple as a Pill a Day

Laksmi Govindasamy (UNSW)

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Maternal Health Sugapriyan Ravichandran (Deakin University)

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Insight’s Birthing Kit Workshop Johanna Warren ( University of Adelaide)

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Marie Stopes and the Millenium Development Goals Marie Stopes Australia

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Beyond Male and Female Cara Fox and Lance Charisma (Monash University)

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Female Genital Mutilation Factsheet Yu Shan Ting (University of New South Wales)

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Infographic Andrew Lees (University of Notre Dame, Fremantle)

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State of the Nation AMSA Global Health Group Updates

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Vector: The Official Student Publication of the AMSA Global Health Committee AGH Publicity Officer: Bridget Williams (Monash University) Editor-in-Chief: Andrew Lees (Notre Dame Fremantle) Co-Editors: Carly Hayman (Flinders University) and Yushan Ting (University of New South Wales) Design and Layout: Katherine Watson (University of Adelaide) IT Officer: Sugapriyan Ravichandran (Deakin University) Editorial enquiries: vector@agh.amsa.org.au AGH enquiries: publicity@agh.amsa.org.au For past issues of Vector and more information on the AGH visit www.agh.amsa.org.au vector magazine

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trekking guides. Additionally, they provide them with teaching in essential life skills, including reading and writing and also provide small loans in order for them to become established.

A perfect example of what a local organisation can do for a woman, is the transformation of our trekking guide, Amita*, from a neglected daughter to a more confident and proud woman.

In our fourteen days of hiking, we had many long discussions in which we were able to gain an understanding of her life before becoming involved with the 3 Sisters and the social norms of her society.

Trekking Towards Gender Equality in Nepal

Stefanie Pender and Merinda Miles (Monash University)

Gender equality and the empowerment of women have long been recognised as crucial to the development of a country, indeed the United Nations Millennium Development Goal 3 focuses on “promoting gender equality and empowering women” [1]. Promoting gender equality has been demonstrated as an effective mechanism to reducing poverty [2]. The expectation that women are afforded the same basic human rights as men, including access to education and healthcare, should be universal but unfortunately the majority of the world’s women live in societies where gender inequality continues. Promisingly, within the constraints of such societies, more women are standing up for their rights, many helped by local organisations. Evidence has shown that the support of local organisations working towards women’s empowerment is the most effective strategy to improving gender equity [3]. What follows is one example of a women’s organisation that is successfully empowering women in a male dominated society.

The organisation in question is based in Nepal.

Nepal is a low-income developing country that has a population of almost 27 million, of which

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50.3% are female [4,5]. With Nepal’s patriarchal history, its women continue to face widespread discrimination and challenges. Nepalese women have a much lower literacy and employment rate than men [6,7]. Contraceptive use is low (48%) and the majority of pregnant women (66%) do not access any antenatal care [6]. The result is that women have little control over their opportunities for work, little control over their own fertility and are at high risk of negative pregnancy outcomes.

Amita was of similar age to us, reserved and somewhat unsure of herself, however she carried a certain strength and power. It was interesting to uncover the vast differences between our worlds and we were often warmed by her sometimes slightly naive views and her surprise at the things women in our society consider normal, such as having a boyfriend before marriage.

Whilst in her small home village, Amita did not finish primary school, a fact she shares with approximately 30% of young women in Nepal6.

This gave her little hope of leaving her rural life and finding paid employment. Amita, unlike many other girls in her village, was unmarried and as such, felt she was a burden on her poor family.

At 23, she was worried she was now too old to find a husband. She remained working on her parent’s land while her older brothers pursued their education further and, until her involvement with the 3 Sisters, did not expect to ever leave this kind of life.

Many of Amita’s friends, on the other hand, were arranged into marriages as children and soon after, began having their own children. In a Nepali marriage, a woman’s status is typically low, with their lives centred on the traditional roles of menial household chores and long hours of farm work.

This low status contributes to the widespread problems of domestic and sexual abuse. A 1997 analysis reported 93% of women in Nepal were exposed to mental and emotional torture, 82% were beaten, 30% were raped, 28% were forced into prostitution, and 64% reported polygamy [8].

These shocking figures can be in part attributed to widespread social acceptance—in another study 22% of men and 23% of women believed it was acceptable for a man to beat his wife [9].

Unmarried women, on the other hand, are also at high risk of rape, which often goes unreported due to fears of the repercussions.

If an unmarried women has sex, consensual or not, she is stigmatised, and is no longer suitable Women working in a small village on the trek

To gain an understanding beyond statistics, we focus on a recent trip to Nepal made by the authors to appreciate what local women are doing to alleviate their problems.

While choosing a company with whom to go trekking, an integral part of any trip to Nepal, we stumbled upon 3 Sisters Adventure Trekking, a social enterprise which, as the name suggests, was set up by three Nepalese sisters who were determined to make a positive impact to the lives of Nepalese women. The organisation, and its non-profit branch Empowering Women of Nepal, trains young disadvantaged rural women as

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for marriage. Widowed women are similarly stigmatised and in past practices a widow was to be burnt to death on her husband’s funeral pier. All women face exclusion around the time of menstruation when they are cut off from participation in daily life for being considered “unclean”. They are not to touch food, water or other people and are not permitted to take Tikka (a Hindu blessing) or enter a temple. Amita explained her terror at her first period. She thought she was dying and, when comforted by her friend, she spent the rest of the day crying because she did not want to become a woman.

With the help of 3 Sisters, Amita is now learning English, living in a small apartment with another 3 Sisters guide, is self-sufficient and importantly, is growing in self confidence to stand up for herself and control her own destiny. She has also begun teaching the newer guides and as such, will spread this empowerment further. She does still face the stigma of being a woman on the trails and often receives harsh criticism and disgust

from male guides, who believe that the 3 Sisters are interfering in mens business. We witnessed this on occasion and were impressed by Amita’s strength and reserve.

Australian Medical Association

Your voice in the health system of the future

Hearing Amita’s stories was incredibly enriching and between the vast differences, it was most rewarding to appreciate the similarities we found and the connections we formed sharing stories, jokes, songs, packs and a 200km trail through the beautiful Annapurna range.

A project like this makes a real difference to the lives of the women involved, their families and their communities. It allows women access to education and financial independence thereby empowering them with autonomy for their own, and their children’s, lives. Most importantly, it gives women, like Amita, control of their own future. We would strongly recommend our experience and encourage readers to support other sustainable local women’s projects.

STUDENT MEMBERSHIP IS FREE SO JOIN THE AMA TODAY AND ENJOY A LIFETIME OF PROFESSIONAL BENEFITS. The AMA is the only independent, national voice of all doctors in Australia. Your membership ensures all health professionals have a say in the development of the health system you will lead into the future.

*names have been deidentified to protect confidentiality.

1. United Nations. Goal 3: Promote Gender Equality and Empower Women. United Nations. [updated 2010; cited 2012 July 30th ]. Available from: http://www.un.org/millenniumgoals/gender.shtml 2. UNFPA. Linking Population, Poverty and Development. United Nations Population Fund. [updated 2008; cited 2012 July 28th]. Available from: http://www.unfpa.org/pds/poverty.html 3. Hunt, J. Effective strategies for promoting gender equality (OECD DAC Network on Gender Equality Report), [updated 2004; cited 2012 July 28th]. Available from: http://www.oecd.org/social/genderequalityanddevelopment/32126577.pdf 4. United Nations. Population, latest available census and estimates (2010-2011). United Nations. [updated 2012; cited 2012 July 28th]. Available from: http://unstats.un.org/unsd/demographic/products/vitstats/serATab2.pdf 5. WHO, Nepal: Country Cooperation Strategy. World Health Organisation. [updated 2012; cited 2012 July 28th].

Available from: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_npl_en.pdf 6. UNICEF. Nepal Statistics. UNICEF [updated 2003; cited 2012 July 28th] Available from: http://www.unicef.org/ infobycountry/nepal_nepal_statistics.html 7. Silwal D. Status of Women in Nepal, Women’s Global Connection. [updates 2006; cited 2012 July 30]. Available from: http://wgc.womensglobalconnection.org/conf06proceedings/Silwal%20D.--%20Status%20of%20Women%20in%20 Nepal.pdf 8. Deuba A, The Situational Analysis of Violence Against Women and Girls in Nepal, SAATHI/TAF [updated 1997; cited 2012 July 30]. Available from: http://saathi.org.np/images/stories/ResearchPDF/vaw_and_girls_nepal.pdf 9. Ministry of Health and Population Nepal, Nepal Demographic Health Survey 2006. [updated 2007; cited 2012 July 30] available from: http://www.measuredhs.com/pubs/pdf/fr191/fr191.pdf

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Contact Details www.ama.com.au/jointheama Phone: 1300 133 655 Email: memberservices@ama.com.au

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Engendering Poverty Measurement:

Transforming how we define and measure poverty and hardship to make gender disparities visible In June 2012, Jo Crawford, policy and research advisor at International Women’s Development Agency (IWDA), and Research Associate at the Australian National University (ANU) summarised why engendering poverty measurement matters and outlined emerging findings from an international research collaboration to develop a new way to measure poverty that makes gender disparities visible, and is grounded in views of women and men with lived experience of poverty.

Being able to measure poverty at the individual level is essential to understanding who is poor, in what ways, and whether and how this is changing, in response to a crisis or to policies and programs designed to address poverty and inequality. Without such information, it is harder to focus resources where they are most needed, or to track whether policies or initiatives are making a difference (Crawford and Hunt 2012).

Vector thanks IWDA for allowing us to reproduce the article here, in a slightly updated form. You can find out more about IWDA’s work here: http://www.iwda.org. au. There is also a dedicated project website where the emerging findings from the research will be published: http://www.genderpovertymeasure.org/

What does $2 a day really tell us?

Many of you may have seen references to how many people are living below the poverty line of US$1.25 or US$21. Some organisations have made the challenge of living below the poverty line a focus of their awareness and fundraising activities. But think about this for a moment. While $2 might get you enough food to sustain you if you plan well, food is close by and you have utensils to prepare meals, it is not going to be enough to buy you shelter for a night, transport to get to a job or the market to earn your next $2, or secure access to energy or improved sanitation, or health care if you or someone you care for is sick. And what about other things that affect well-being, like security and infrastructure such as roads, or a clean environment? What about those things that money can’t buy but which we know makes a difference to survival and resilience, like a supportive family, or people to help you out when you need it? The idea that $2 a day is all you need to move out of absolute poverty is pretty farcical really.

Another frequent claim is that women and girls comprise the majority of those in poverty. In truth, we can’t be sure because current approaches to poverty measurement don’t tell us accurately who is poor, and in what ways.

Looking inside the household Dominant approaches measure poverty at the household level, which effectively treat all members of the household as either poor or not, ignoring the distribution of resources and assets within households, and the question of whether different deprivations might be experienced by different members of the household. While it may be reasonable to measure shelter at a household level, we know that women and men don’t have equal access to income and productive assets, and that women and girls carry much more of the load of unpaid household and care work, and work more hours overall if both paid and unpaid work are counted (Waring 1988, Young 1992, Tsukada and Silva 2009). Household-level measurement renders these issues invisible (Crawford and Hunt 2012).

1 According to the World Bank, US$1.25 is the average poverty line for the world’s poorest 10 to 20 countries.

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Even if we agree that a multi-dimensional measure of poverty (such as the Multidimensional Poverty Index debuted in the 2010 Human Development Report) is better than a simple income-based poverty line, measuring at the household level means that we can’t know whether multiple dimensions of poverty are spread evenly across household members, or are concentrated in particular individuals. Some household members may also have greater needs than others – for example, men involved in heavy physical work or pregnant or lactating women may have greater nutritional needs than other household members (Crawford and Hunt 2012).

What we measure matters!

The Australia Research Council, with financial support from IWDA and in-kind support from a range of other partners, is funding Assessing Development: designing better indices for poverty and gender equality, a multi-year, multi-country, interdisciplinary research project, housed at the Australian National University. The research is focused on developing a new measure of deprivation that is genuinely gender-sensitive and responsive to the views of poor women and men.

Assessing who is poor and in what ways requires sex-disaggregated data at the individual level, and a metric that uses dimensions and indicators which are responsive to the ways in which gender shapes the deprivations people face. The area of time-use may be the most over-looked dimension in this regard, given women’s responsibility for child care and various services in the home and the impact of this on overall hours worked, return to labour, mobility and other factors relevant to poverty. Security is another area that is of key concern to poor people and gendered. While many men, particularly in conflict zones, face high rates of physical violence, women face higher rates of violence overall although the

nature of the violence they experience is different.

Women face types of violence that are much less commonly experienced by men including rape, trafficking, and intimate partner violence (Crawford and Hunt 2012).

We know that age also matters. Women in particular have different needs, interests and vulnerabilities at different points in their life. For young women, forced early marriage and being taken out of school profoundly shapes their life chances. For older women, having no partner or family to assist, and a lifetime of earning less than men, leaves them highly vulnerable. So the project is also seeking to measure poverty in a way that is sensitive to generation and what matters most to women and men at different life stages.

No single measure can capture the diverse and complex reality of poverty and deprivation but what we do measure matters very much.

Listening to women and men about what defines poverty and hardship Our research is basing its selection of indicators in the perspectives of women and men with experience of poverty and hardship, and in current thinking and research about poverty measurement.

Field work has been conducted across three sites (urban, rural and marginalised) in each of six countries, Angola, Fiji, Indonesia, Malawi, Mozambique, and the Philippines. Phase 1 involved participatory research with groups and individuals to explore conceptions of poverty and related hardships, and the extent to which participants viewed these as varying by age or gender. Phase 2 involved individual surveys (100 per site x 18 sites) with participants asked first to evaluate 25 dimensions of deprivation as ‘essential’, ‘very important’, ‘not very important’, or ‘completely unimportant’ in deciding if a person is living a life free of poverty and hardship, and then to rank the most important dimensions from 1 to 15. Phase 3 will involve testing a new individual-level gender-sensitive measure of multidimensional deprivation.

US$2 a day is the median poverty line for developing countries.

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It is impossible to synthesise the very rich set of reports from Phase 1, and these will have value well beyond their input to developing a new poverty measure. Nonetheless, Phase 1 did provide some clear information about how poor women and men define poverty 2.

In every site, common dimensions of poverty include:

Other common dimensions, though not shared everywhere, include:

1. A lack of employment and income opportunities 2. A lack of quality education, for oneself or one’s children 3. A lack of adequate health care, for oneself and one’s household, or frequently falling ill 4. Insufficient or low quality food

• inadequate transportation and roads • begging and other degrading or dangerous work • a lack of support from friends and family • a lack of access to social services or other basic services • an inability to access financial services and productive capital or being heavily indebted • an inability to contribute to others or participate in community functions • a lack of electricity • a lack of voice and recognition in community and government • being displaced • humiliation and shame • being near or having survived armed conflict • being subject to violence • being subject to exploitation • being subject to sexual exploitation • lacking the ability to present oneself in the standard of one’s society (such as not having cosmetics) • lacking a cell phone or other forms of communication • lacking official identification and citizenship • not having secure access to contraception and/ or sanitary pads • a lack of ownership of assets and secure property rights to those assets • being displaced • humiliation and shame

Nearly every participant mentioned these categories. Other very common dimensions included: 5. Inadequate and low quality shelter, with low quality household assets 6. Inadequate clothing, especially by standards of one’s community 7. Inadequate sanitation 8. A lack of adequate, clean, or easily accessible water

2 The following summary is drawn from the draft Phase 1 Fieldwork Summary Report.

The Phase 1 report from Angola was not available when this summary was developed to inform Phase 2 research planning, so while the analysis is based on findings from 5 of 6 countries, it should be regarded as preliminary.

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Many participants associated the word ‘poverty’ with material poverty, which they considered was shared widely, and often evenly, between men and women. But when we asked about hardships faced by men and women, the gender differences were much clearer and they were closely linked to gender roles and responsibilities (Internal Project Document 2012a: 3).

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How do gender and age influence people’s views of what is important?

There was no simple story about how gender, age, and generation influence the distribution of resources within the household, or the dimensions participants consider most important. However, some participants were more likely to mention or prioritise certain dimensions, and these were linked to gender roles and responsibilities and to life experiences. Taking the most commonly cited dimensions, a lack of employment or income was often seen as a problem experienced more by men, whereas a lack of food was seen to affect women more, as they were responsible for providing food and other day to day requirements to the household, including water, sanitation and firewood for example. Women also experience greater hardship than men where there is a lack of, or poor access to, health facilities as they are responsible for their own and other family members’ health and caring for sick family members (Crawford and Hunt 2012: 11).

Overall, ‘men were more likely to identify productive capital (farm implements, ability to borrow), formal employment, and access to electricity as dimensions of deprivation. Female participants were more likely to discuss education, health care, and an inability to care for their families. Female participants were also more likely to identify the lack of small assets, being subject to sexual exploitation, and the lack of children or productive partners as constitutive of poverty. Female participants more commonly identified sanitation, access to sanitary products and adequate contraception as important’ (Internal Project Document 2012: 5).

Sometimes the same deprivation would be identified by men and women, but for different reasons.

For example, bad roads and infrastructure were identified by men as obstacles to market access and productive outputs; women were more likely to highlight the limits to mobility and safety from bad, unlit roads. There were significant differences, too, in the kinds and levels of control men and women have over decisions that affect their lives (Internal Project Document 2012a).

Which dimensions are most important to women and men?

Phase 1 provided rich information on deprivations that women and men consider part of poverty and hardship. In Phase 3, we will pilot a measure of deprivation that includes some but not all of these dimensions. We therefore need a rationale for including or excluding particular dimensions. One part of the rationale will be how important participants think a dimension is to achieving a life free from poverty and hardship. This is what Phase 2 is about.

Local research teams in each country asked participants about their priorities among 25 dimensions mentioned in Phase 1. Researchers briefly described circumstances or issues at or near the ‘top’ and the ‘bottom’ of a dimension, so participants would have a common idea of the range of life circumstances the dimension covered.

We currently have data in from five of six countries so the following analysis is preliminary and will be revised when the remaining country data is received. More detailed analysis of overall differences by gender and age will also be undertaken at this point, and combined with country analysis of gender and age differences. vector magazine

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Table 1 below shows the priority participants accorded particular dimensions for determining whether someone’s life is characterised by poverty and hardship or not. The top cluster shows those areas of life that were highly ranked by both women and men, across all age ranges and should be included in the measure on this basis. Other dimensions that were ranked in their Top 15 by between one-third and two-thirds of all participants also deserve consideration, but only after reflecting on other reasons (such as their ability to reveal gender disparities). Dimensions ranked in the Top 15 by less than onethird of participants do not merit inclusion based on participant response alone, although again there may be other reasons for inclusion (Internal Project Document 2012b: 3) The dimensions for which there were statistically significant differences between the rankings given by women and men, overall, are bolded.

Overall, there were statistically significant differences in the responses of women and men in relation to 10 of 25 dimensions, or 40% of dimensions. Women ranked Cooking fuel, Toilet facilities, Violence, Family planning, Personal care and Shelter, higher than men, whereas men ranked Clothing, Location of services, Participation in community functions, and Property and inheritance rights higher than women did. These dimensions therefore need to be given particular consideration in designing a measure which will be gender-sensitive (Crawford and Hunt 2012: 13).

Table 1: Participants including particular dimensions in their top 15

Positive numbers mean women ranked the dimension more highly than men, negative figures mean men ranked the dimension more highly than women. In calculating average rank and statistical significance, dimensions not ranked in the top 15 were assigned position 20 (i.e. penalised for not being ranked). a

The socially accepted roles and responsibilities of women and men influence the prioritising of dimensions in a number of ways. Those dimensions that are particularly important to women, or men, given current gender roles and responsibilities, are prioritised. For example, significantly more women than men prioritise water, freedom from violence, family relationships and the environment, and significantly more men than women see property, voice in the community, sexual autonomy and clothing as important for determining whether a person experiences poverty and hardship, or not.

The results in relation to sexual autonomy suggest that for women, the constraints associated with gendered expectations may have influenced the extent to which some women could imagine sexual autonomy as a realistic possibility. Researchers anticipated that women may have prioritised this dimension more strongly than men in Phase Two, given the findings in Phase One and the impact of lack of sexual autonomy on women’s life choices and poverty and health status (for example, forced or early marriage, coerced sex, including within marriage, and exposure to HIV/AIDS). However, the picture was not clear cut, with men prioritising sexual autonomy more strongly than women in Indonesia (statistically significant) and Fiji (Crawford and Hunt 2012: 15). vector magazine

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Developing a new gender-sensitive measure of deprivation The research team is currently considering what to include in the final measure. Initial thinking is to include the highly-ranked dimensions, exclude middle-ranked dimensions that can be picked up in other ways, or that are not equally important in rural and urban sites, and include middle-ranked dimensions that are particularly important for revealing gender disparity, such as Freedom from violence, Family planning and Time-use. Once we have agreement on the dimensions, we will go back into the field with a survey to collect data for the trial measure in two or three countries, beginning late 2012 or early 2013.

In March this year, at the Global Human Development Forum in Istanbul, participants adopted the Istanbul Declaration: towards an equitable and sustainable future for all. Among other things, it highlighted the importance and power of measurement. We manage what we measure—and, in turn, what we measure affects what we do. It is therefore vital that we measure progress towards sustainable development in a more comprehensive manner. Measures are required that go beyond GDP to capture a fuller picture of human development, and emphasize sustainable and equitable outcomes. We urge greater support for the work underway around the world, in the United Nations and elsewhere, to design and use more appropriate measures of progress, and for countries and communities to collect data accordingly.

As an organisation contributing to such work, IWDA can only agree! Traditional methods of assessing poverty do not help reveal inequities between women and men nor within the household. Given the gendered nature of poverty, and the widely acknowledged links between gender inequality and poverty, this is a limitation and anomaly that cannot be justified.

As we work towards 2015 and a new global framework and targets for the period beyond, we need to see engendering poverty measurement as central to taking the agenda forward.

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Acknowledgements The research discussed in this article was supported by the Australian Research Councilfunded linkage project Assessing Development: Designing Better Indices of Poverty and Gender Equity (LP: 0989385), made possible by partnerships with the Australian National University, Oxfam Great Britain Southern Africa, International Women’s Development Agency, Philippine Health and Social Science Association, the University of Colorado at Boulder, and Oxfam America.

This article draws heavily on the national and site reports and data from two phases of data collection. We are grateful to all of the research teams involved, particularly to Priya Chattier, Sharon Bagwan Rolls, Ulfah Muhayani, Ilfi Nur, Yuliati Hotifah, Maggie Banda, Peter Mvula, Cristiano Matsinhe, Edite Cumbe, Veronica Sappolo, Fatima Castillo, Caster Palaganas, Nimfa Bracamonte, and Cora Anonuevo.

Much of the thinking and analysis in designing the measure has been done by the core project team. Many thanks to Thomas Pogge, Sharon Bessell, Scott Wisor, Kieran Donaghue, Rosa Terlazzo, Amy Liu, Janet Hunt, Alison Jaggar, Fatima Castillo, Jo Hayter and Alice Banze. We are also grateful to several friends of the project for their assistance, including Elisabetta Aurino, Nicole Rippin, Mandy Yap, Sabina Alkire, Stephan Klasen, and Sylvia Chant.

Thanks most especially to the participants who shared their lives and experiences.

References

• Crawford, J and Hunt, J. 2012. ‘Engendering multidimensional poverty measurement: why it matters, what’s required, and emerging results from a multi-country research collaboration’. Paper prepared for the Human Development and Capability Association 2012 International Conference, Revisiting Development: Do We Assess it Correctly? Jakarta, 5-7 September 2012 • Tsukada, R and Silva, E. 2009. ‘Age and gender bias in workloads during the lifecycle: Evidence from rural Ghana’, International Policy Centre for Inclusive Growth One Pager, No.88 • Waring, M. 1988, Counting for Nothing: What men value and what women are worth, Allen & Unwin, Wellington.

• Young, K. 1992, ‘Household resource management’ in Ostergaard, L. (ed.), Gender and Development: A Practical Guide, Routledge, London and New York.

• Unpublished papers and reports • Internal Project Document. 2012a. Phase One Fieldwork: Draft Summary Report • Internal Project Document. 2012b. Phase Three of Measuring Poverty and Gender Disparity, draft dated 8 June

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The Silver Bullet for Women’s Health: As simple as a Pill a Day

Laksmi Govindasamy (UNSW)

The Millennium Development Goals (MDGs) specifically target both gender equality and maternal health as key elements of development.

Furthermore, in acknowledgement of the significant gender burden experienced by impoverished women in the developing world, many of the other MDGs have gender-specific targets built within them – universal education is as much about ensuring girls have equal access to education opportunities as it is about funding schools. Sadly, despite this international focus, Maternal Health parameters in the developing world are not on track to reach their targets. The disempowerment of women and the cultural norms that maintain this status quo are such that throughout the developing world women face a disproportionate burden of many health and development problems, often with a compounding impact.

Allow me to paint a picture: it starts at birth – a girl child in many cultures is not as valued as a male; she eats her meals after her father and brothers; she is denied schooling in favour of domestic duties, which reduces her income potential; she is married young and vector magazine

into a relationship within which she is sexually dominated such that soon enough she has children of her own to feed, locking her into a cycle of poverty which is inescapable.

As a feminist comfortably ensconced in a Western paradigm every level of the inequity illustrated above is abhorrent. Equally however, as a liberal thinker, one has to acknowledge several uncomfortable realities. In fact, women are all too often the enforcers of many of these sexist cultural norms. Nor do we as Westerners have an imperialistic right to assert our cultural beliefs on others, not least when there are many remaining unresolved gender equity issues pervasive in our own societies. Indeed, exploring the factors that led to the vast improvement in the lot of Western women over this past century lends a clue to a pathway of change that should be available to women in the developing world.

out of wedlock could be avoided. Married women were no longer relegated to a fate of being permanently barefoot and pregnant in the kitchen. The social and economic opportunities available to women expanded, as they were able to exercise meaningful control over family size and timing. As with so many elements of medicine, prevention is better than cure.

Giving women the means to prevent unplanned pregnancies supports their capacity to achieve in other avenues.

The potential impact that ready access to contraception could have in the developing world is immediately clear. It is well accepted in development lore that women are gatekeepers to family health. Empowering, educating and financing women are sure-fire ways to improve the health of the family unit as a whole because women are the primary care givers. Giving women the means through which they may space and time their children will facilitate a reduction in family size and a consequent increase in the resources available per child.

Ultimately, in the resource poor settings of the developing world, childbirth is a game of Russian roulette. Maternal mortality risk is as high as 1 in 30 in Sub-Saharan Africa and more than 350,000 women die annually from the complications of pregnancy and childbirth [1]. The fate for the

1 million children left motherless each year is equally dark; they are up to 10 times more likely to die prematurely [2]. Access to contraception means that women are not forced to play their hand each and every month, and it is estimated that meeting the need for contraception alone could cut by almost a third the number of maternal deaths [3].

Why such a simple solution is not readily available to our counterparts in the developing world unfortunately yields a complex and multifaceted answer – there are often cultural, social and access barriers that prevent women from accessing contraception. However, this is not to say that women in the developing world do not desire contraception – some 250 million women would prefer to delay or avoid pregnancy but are denied access to safe and effective contraception [4]. Economic barriers are the key factor, not helped by the fact that funding of family planning declined sharply between 2000-2008 such that by 2010 there was less money available for these programmes than there was in 2000 [5].

Without such aid individuals and families in the developing world simply cannot meet their needs.

Contraception is costly – from the commodities (pills, condoms, IUDs) to the health care services, not to mention it is often an ongoing expense [6].

Even the briefest examination of the rise of feminism in the West would be remiss if it did not include the paradigm shift that arose from the introduction of the oral contraceptive pill. All of a sudden, women across the socioeconomic divide could exercise their reproductive rights. The crippling social ostracism that met pregnancy

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This is not to deny that there are very real social and cultural barriers with which to contend. Many women have real or perceived concerns about the health risk of available contraception and perceive themselves to be at low risk of pregnancy, namely those who are postpartum, breastfeeding or rely on periodic abstinence [7]. However, what this situation cries out for is effective counselling, education and a broader range of contraceptive options, all of which rely on funding. The more intractable problem of partner opposition to contraception similarly demands investment in partner support through education. In the meantime though, access to contraception that is controlled by women and not reliant on partner cooperation should be a priority. To that end, recent advances in contraceptive methods such as hormonal implants, injections and intra-uterine devices are safe, highly effective and low maintenance methods that are ideal for developing nation settings [8].

The dark side to this story is that without access to reliable prevention, women have little choice but to resort to unsafe alternatives. Annually, an estimated 19 million abortions are carried out outside the legal system, typically at the hands of unskilled practitioners [9]. The most vulnerable women – the poor and uneducated – are those who are least able to access their reproductive rights. Even within sub-Saharan Africa there is a significant disparity; better-educated women benefit from greater access and more effective use of contraception than their lesser-educated counterparts [10].

Despite the significant environmental, economic and social consequences of unchecked population growth on development and poverty, there are few voices advocating on this issue. A notable exception is Melinda Gates whose inspiring work and advocacy shines a light on an issue many choose to bury in favour of less scandalous and political issues (I refer you to her TED talk) [11].

The opposition of many religious groups to contraception has entangled the issue into one of moral debate. Rather, the focus should be on ensuring that all women can realise their human right to control their reproduction, which, given the very real risks faced by women in the developing world, is literally a matter of life or death. From our comfortable post-feminist perspective in Australia, the onus is on us to ensure that our government agencies and NGOs are pushed to put contraception back on the agenda and into the budget.

References

1.United Nations. (2010). “Fact Sheet: Goal 5 – Improve Maternal Health.” Retrieved online on 12th August 2012 at http://www.un.org/millenniumgoals/ pdf/MDG_FS_5_EN_new.pdf 2. United Nations. (2010). “Fact Sheet: Goal 5 – Improve Maternal Health.” Retrieved online on 12th August 2012 at http://www.un.org/millenniumgoals/ pdf/MDG_FS_5_EN_new.pdf 3. United Nations. (2010). “Fact Sheet: Goal 5 – Improve Maternal Health.” Retrieved online on 12th August 2012 at http://www.un.org/millenniumgoals/ pdf/MDG_FS_5_EN_new.pdf 4. United Nations. (2010). “Fact Sheet: Goal 5 – Improve Maternal Health.” Retrieved online on 12th August 2012 at http://www.un.org/millenniumgoals/ pdf/MDG_FS_5_EN_new.pdf 5. United Nations. (2010). “Fact Sheet: Goal 5 – Improve Maternal Health.” Retrieved online on 12th August 2012 at http://www.un.org/millenniumgoals/ pdf/MDG_FS_5_EN_new.pdf 6. Bongaarts, J. and Sinding, S.W. (2009). “A response to critics of family planning programs.” International Perspectives on Sexual and Reproductive Health. 35(1): 39-44.

7. Cohen, S.A. (2010). “The world at seven billion: Global milestone a reflection of individual needs. Guttmacher Policy Review. 14(3): 2-5.

8. Greene, E. and Stanback, J. (2012). “Old barriers need not apply: opening doors for new contraceptives in the developing world.” Contraception 85: 11-14.

9. Ahman, E.L. and Shah, I.H. (2010). “Contraceptive use, fertility and unsafe abortion in developing countries.” The European Journal of Contraception and Reproductive Health Care, 15(S2): S77-S82.

10. Bongaarts, J. (2010). “The causes of educational differences in fertility in Sub-Saharan Africa.” Vienna Yearbook of Population Research. 8:31-50.

11. Gates, M. (2012). “Lets put birth control back on the agenda.” http://www.ted.com/talks/melinda_gates_let_s_put birth_control_back_on_the_ agenda.html

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Maternal Health Although the incidence of post-partum haemorrhage (PPH) may not be higher in Sri Lanka, this complication has a higher severity and mortality rate in Sri Lanka. This is due to the inadequacy of transport facilities for moving patients to tertiary centres. In addition, abortion is illegal in Sri Lanka unless it necessitates maternal survival. Therefore, abortions undertaken by patients are performed illegally leading to injuries or complications that end up not being reported for fear of incarceration. This alone contributes a staggering one fifth of all deaths counted in the maternal mortality ratio, and contributes to higher rates of PPH induced mortality as well. Hence, cultural taboos do play a role in the differences seen in maternal health.

What makes the difference between regional centres in Sri Lanka (Batticaloa) and Australia (Warrnambool) in the eyes of an obstetrician Sugapriyan Ravichandran (Deakin University)

Birth is a wonderful thing. It is how we all came to be here. In developed countries today the impending birth of a baby represents a cause for celebration rather than a risk to fetus and mother. Dying in pregnancy was once a real and dreaded possibility. However, as nations have grown wealthier and medical technology and transport infrastructure has improved, this worry has become almost exclusively a developing world concern.

Would you believe that only 50-60 years ago most countries suffered from maternal mortality rates of over 100 deaths per 100,000 live births? Sri Lanka once had a gross maternal mortality of about 400 deaths per 100 000 live births, a figure which is astounding to think about. Initiatives like Millennium Development Goal 5 (MDG-5) were drawn up to prevent and reduce this horrible statistic and Sri Lanka has since made drastic improvements in its incidence of maternal mortality. This nation, that is still regarded as a ‘developing country’ has proven that a nation’s wealth is not necessarily the primary driver of improved health outcomes.

The following article, which expands upon a series of interview questions posed to obstetrician Dr. Damayanthi, provides an insight into her personal perspectives on the experience of practicing in the eastern Sri Lankan province of Batticaloa, and an exploration of how it compares with her current role in the Australian coastal township of Warrnambool.

On the principle differences between the reproductive health system in Australia and Sri Lanka In our discussion, the first thing that came to Dr. Damayanthi’s mind was the comorbidities seen in pregnant mothers in Australia. There seems to be a higher prevalence of obesity among her patients in Australia compared to Sri Lanka. Obese patients naturally have a predisposition to comorbidities that are associated with it, which increases complications during the antenatal period. In contrast, disease states such as anaemia and rheumatic heart conditions predominated among the gravidas seen in Sri Lanka.

Interestingly, deep- vein thrombosis was rarely seen in Sri Lanka compared to Australia, a fact that may be attributed to higher smoking rates or undiagnosed thrombophilia. vector magazine

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In patients seen by Dr. Damayanthi, the level of general knowledge regarding matters of maternal health was lower in Sri Lanka than Australia. Australian mothers-to-be were more autonomous about their health during pregnancy and are more likely to discuss management plans with their obstetrician. In comparison to this, patients in Sri Lanka placed a lot of trust and responsibility in their obstetrician, and the relationship was far more paternalistic. In our conversations, Dr. Damayanthi showed preference for the patient centred discussions that occur here in Australia, whereas in Sri Lanka she takes it upon herself to decide for the patient about management plans that are in the best interests of the patient. This, again, has a cultural aspect to it and is an expected practice by pregnant mothers. In addition, the workload is much higher in Sri Lanka where Dr. Damayanthi used to see 30 patients in her morning sessions compared to 10 in her current role. Hence, the high workload in Sri Lanka works well in conjunction with the expectations of patients for obstetricians to make executive decisions regarding their care. The patient centred, two-way discussion model of patient communication would be impractical in Sri Lanka due to the 10 – 15 minute consultation limitations that are placed upon the obstetrician.

On the management of antenatal care in Sri Lanka In Dr. Damayanthi’s experience, infrastructure is very different between the public regional centres in Australia and Sri Lanka. In Batticaloa, birthing suites and rooms are unheard of and maternity wards are separated by curtains. Intra-partum monitoring, including fetal-scalp electrodes are also not available unless patients visit tertiary centres. Tests such as trisomy screening are not offered and need to be paid for out of pocket. Where ultrasound morphology scans are performed by obstetricians, abnormalities need to be referred to tertiary centres for further testing.

In Sri Lanka, antenatal care in regional areas is managed by midwives. They represent the front line in looking after pregnant mothers and this model of care has contributed hugely to Sri Lanka’s success in keeping up with the targets of MDG-5. Skilled presence during the antenatal and birthing period has reduced maternal mortality tremendously. Community midwives are informed when a mother is pregnant and all her initial antenatal care and screening is performed by the midwives. The community doctor and the midwives look after the low risk pregnancies. Pregnancies screened as high risk by the midwives are sent to the obstetricians for management throughout their antenatal care. Otherwise, all other gravidas see the obstetrician for their first visit around the 20th week to obtain a morphology scan, then they are seen by the community doctor or midwives every 4 to 6 weeks, depending on the level of care that they need, until birth. High risk patients are seen by obstetricians every 4 weeks and with increasing frequency in times closer to their due date.

Obstetricians also run private clinics outside of their working hours in public hospitals which are not free.

Those who are not near tertiary centres and wish to see an obstetrician still go to these private clinics if they can afford it. vector magazine

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What aspects of the Sri Lankan and Australian maternal health systems could be improved?

The influence of MDG-5 on healthcare objectives in Sri Lanka

In our discussion, Dr. Damayanthi explained that it would be beneficial to introduce the facilities which exist in Australia to Sri Lanka. Technology and infrastructure will naturally provide better maternal health care.

Options for more private birthing suites are a bonus, but this can only coincide with the increasing wealth of a nation or an increased expenditure of GDP towards health care. It is known that Sri Lanka has done well in reducing its maternal mortality rates tremendously (from 340 to 43 deaths per 100,000 live births between the 1960s and 2005) despite having a very low maternal health care expenditure as a proportion of GDP (approximately 4%). Therefore, with increased funding, the potential to further better the system of maternal health care could be huge.

Given that Dr. Damayanthi only worked for a small amount of time in Sri Lanka, it was encouraging to hear that MDG-5 was integrated into the system. Reducing maternal mortality remains one of the primary concerns of the country, and has been clearly expressed in governmental objectives. This has been evident in several areas including: (a) the adoption of a wide network of maternal health services and childcare supported by a cadre of trained Public Health Midwives which has increased the attendance of skilled carers at births; and (b) the introduction of free access to health and family planning services. Furthermore, obstetricians are now required to attend enquiries regarding maternal mortality cases that they were involved in to further investigate the cause of death. Maternal morbidity and mortality meetings occur at the hospital, division and country level to collect data and discuss causes and ways to put in place preventative measures to reduce the rates of death, especially in accordance with Target 5A of MDG-5 (reducing by three-quarters the maternal mortality ratio between 1990 and 2015). Although most obvious causes such as long travel times to city hospitals are put forward every time, these factors take time to be corrected. Fortunately, we have come a long way since the days when we used to have hundreds of deaths per year, and the future only holds more promise as we head towards 2015.

In saying all this, Dr. Damayanthi recognises certain similarities between the two systems such as the nationally funded public health system where maternal health care is provided for free. This enables universal access to antenatal and intra-partum care. There is still, however, a significant population who have to pay to see obstetricians in their private clinics.

Dr Damayanthi’s opinion is that better prevention and reduction of obesity among gravida in Australia would improve the comorbidities seen during pregnancy. Obesity seems to be a growing problem with the potential to cause otherwise avoidable complications such as polyhydramnios, gestational diabetes, and hypertension. Hence, there also needs to be an increased recognition that more aggressive management of weight in advance of pregnancy remains a critical issue here in Australia.

On Maternal Mortality in Sri Lanka and Australia In Dr. Damayanthi’s experience, the major causes of maternal mortality in Sri Lanka were post-partum haemorrhage (PPH), pregnancy-induced-hypertension (PIH) and rheumatic heart disease. However, in Australia her practice showed a very different mortality profile with leading causes of death being amniotic fluid embolism, thromboembolism and hypertension. In Australia, PPHs and PIHs are common problems as well, but they are less fatal because they get managed locally and there is infrastructure present to transport a patient to more equipped centres. In contrast, in Sri Lanka the women do not make it to the hospitals in time simply because there are no air lifts or transport facilities at the regional centres where they have given birth.

On Termination and Maternal Rights When queried on the rights of Sri Lankan woman, Dr Damayanthi explained that when it comes to legal protections the legislation currently in place is “influenced by cultural taboos.” Consequently, a Sri Lankan mother does not have the right to terminate her child for any reason except if it risks her life. She may have the right to know the genetic disposition of her child, but genetic testing is only available in the private sector and is highly expensive. The fact that screening results do not give the choice of termination (as abortion is illegal) places a contradiction at the very heart of the testing process.

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Insight’s Birthing Kit Workshops Johanna Warren (University of Adelaide)

According to the World Health Organisation, 385,000 women die each year from childbirth and more than 20 times that number suffer infection or lasting injury as a complication of delivery. Sadly, over 99% of these women live in developing areas without access to quality healthcare. In 2007 the leaders of Insight, the University of Adelaide’s global health group, recognised that students wanted to do something to help improve these appalling maternal health statistics, but struggled to know where to begin. Fortunately, they stumbled across an incredible project run by the Birthing Kit Foundation Australia (BKFA). Over the past five years, Insight has worked alongside the BKFA, providing an opportunity for University of Adelaide students to make tangible difference through distributing simple, sterile birthing kits to women in developing countries.

Kits are equipped with six basic items (Figure 1): • A sterile scalpel blade – for a clean cut of the umbilical cord; • Two gloves – to help reduce risk of infection during delivery; • A plastic sheet – for the mother to lie on, to prevent her or the baby coming into contact with the floor or ground; • Soap – for clean hands and stump; • Five gauze squares – to wipe secretions from the baby’s eyes and mother’s perineum, which helps to prevent infections such as trachoma; • Three cords of string – to tie off the umbilical cord and prevent bleeding from the cord of the mother or baby.

What is a birthing kit?

The contents of a birthing kit have been carefully crafted by members of the BKFA in order to satisfy the “7 cleans” required for a safe delivery (Table 1).

Table 1: The “7 cleans” required for a safe delivery.

1. Clean birth site 2. Clean hands 3. Clean ties 4. Clean cut 5. Clean eyes 6. Clean umbilical cord 7. Clean perineum

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Figure 1: The six simple items that are packaged into each birthing kit

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How did the Birthing Kits Project come about?

Thirteen years ago Dr Joy O’Hazy, a member of the Zonta International Club in the Adelaide Hills, designed a basic birthing kit, which was small, cheap and able to be easily distributed to women around the world. The club members then began planning and implementing mass packaging and distribution of these $1 kits. The project grew and grew under the organisation Zonta International with support from AusAid, and achieved great success with 97% of kits arriving at their often very remote destinations.

In 2006 a new organisation, the BKFA, was established and expanded the project to work with local health authorities at the kit destinations. They implemented 5-day birth attendant training programs to complement the supply of clean kits. The ultimate goals were to achieve self-sustainable kit production in targeted countries and for the training programs to be locally funded. This has been partly achieved in Vietnam, with kits now under production in the Ha Giang province. As of 2011, over 8,000 birthing attendants had been trained around the globe and in 2012 the BKFA celebrated the packing and distribution of their millionth birthing kit!

medical, dentistry, nursing, health sciences and development studies students worked alongside Faculty of Health Sciences staff to achieve the ambitious goal. It was exciting to see students from so many different courses coming together to make such a simple and effective difference to the health of women overseas. The day included eye-opening speeches from Dr Joy O’Hazy, a founder of the BKFA, and obstetrician Dr Rosalie Grivell on their experiences of maternal health in the developing world. At the end of a long day’s packing, the 2,200 birthing kits were packed and promptly dispatched to the BKFA ready for distribution to women in an area of need.

Holding a Birthing Kits Workshop event provides a highly effective, practical opportunity for students to improve the medical care of mothers and infants in developing countries. I encourage you to consider running one of these inspirational, hands on Assembly Days at your own university or workplace.

For more information about the BKFA and how to organise an Assembly Day of your own, please visit http://www.birthingkitfoundation.org.au or email info@birthingkitfoundation.org.au.

How has Insight been involved?

Through Insight’s annual Birthing Kits Workshops, University of Adelaide students have packed and distributed 13,600 birthing kits since 2007, with destinations including Papua New Guinea, Ethiopia and Vietnam. At the 2012 Birthing Kits Workshop event on Sunday 25th March, over 130 University students gathered on campus to pack 2,200 birthing kits. Materials were purchased from the BKFA at $3 per kit, using funds raised from Insight events and sponsorship. Throughout the day vector magazine

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Marie Stopes and the Millenium Development Goals

Australian General Practice Training

Marie Stopes Australia

In the year 2000, the United Nations’ member countries convened and agreed to the United Nations Millennium Declaration - the United Nations Millennium Development Goals. This is a set of eight goals that aim to address global poverty by 2015. The goals range from halving extreme poverty to halting HIV/AIDS, and providing universal education. Australia is a signatory to the Millennium Development Goals and they are used as a guiding framework for the activities of many development agencies, including Marie Stopes.

Marie Stopes directly contributes to the achievement of the Millennium Development Goals through the work they do in their international programs. Marie Stopes’ work addresses, in particular, Millennium Development Goal Five: Improve Maternal Health. This goal has two targets: (1) reduce by three quarters the maternal mortality ratio; and (2) achieve by 2015 universal access to reproductive health.

Improving access to sexual and reproductive health can have a catalytic impact on saving mothers’ lives and is vital to reducing the shocking maternal mortality rates that the United Nations member countries have committed to reduce.

Worldwide, over 350,000 women die from pregnancy and childbirth related causes every year and over 68,000 of these deaths are caused by unsafe abortion practices. Over 215 million women want to use contraceptives but are unable to access them, and the majority of the deaths relating to unwanted pregnancy could be prevented by family planning, contraceptive access and safe abortion services.

Marie Stopes provides all of these services through its international programs, but as a recent report from the Guttmacher Institute clearly explained, without a global doubling in aid funding specifically for maternal health and family planning services, the goal of improving maternal health is unlikely to be achieved. If aid funding was doubled and if the need for maternal vector magazine

and family planning services was fulfilled then maternal deaths could be reduced by 70%, the deaths of over 1.6 million newborns could be averted and unsafe abortion would be reduced by 73%, thereby reducing the number of women needing life-saving medical care for unsafe abortion complications.

Global commitment to the Millennium Development Goals is vital and none more so than Goal Five, as maternal health cannot continue to be seen as a development issue separate from hunger, poverty or economic burdens. Goal Five will only be achieved if the value and importance of women is placed where it rightfully belongs – at the heart of all the other challenges surrounding it.

Marie Stopes is an independent global provider of sexual and reproductive healthcare operating in 40 countries through more than 610 health centres. The organization offers services and support for women, men and their families in key areas such as family planning, abortion and pregnancy termination, vasectomy, contraception, and STI screening. Marie Stopes International Australia supports seven country partner programs in the Asia Pacific including Aboriginal and Torres Strait Islander programs in Australia. More information regarding the impact of Marie Stopes’ work on MDG 5 can be found at their Goal Five campaign website: www.fivebyfifteen.org

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Looking for a rewarding career in general practice?

For information on training opportunities visit www.agpt.com.au or talk to the GPSN Ambassador athealth yourcommittee university today! vector magazine amsa global page 25

Beyond Male and Female Cara Fox and Lance Charisma (Monash) When exploring gender in health it is easy to focus on the inequalities faced by females when compared to males. However, it is important to recognise that the categories of male and female do not describe all people, and that individuals who are sex and gender diverse face unique challenges related to their health.

It is important to have a basic understand of what the words ‘sex’ and ‘gender’ mean and how exactly they differ. A simple definition from the WHO is that ‘sex’ refers to the “biological and physiological characteristics that define men and women” and ‘gender’ refers to the “socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women” [1]. Gender identity is an individual’s inner sense of being male, female or another gender.

Both sex and gender should be viewed as a spectrum. The term intersex describes people whose biological sex cannot be classified as ‘male’ or ‘female’ due to chromosomal, hormonal or anatomical developmental variations – this includes conditions such as Klinefelter’s syndrome, congenital adrenal hyperplasia and androgen insensitivity syndrome. Trans* can be used to describe people whose gender identity is different from their assigned sex, or crosses the social norms of ‘male’ and ‘female’. This includes people who may identify as transgender, transsexual, female-to-male (FTM), trans man, male-to-female (MTF), trans woman or genderqueer (there are many other identities that have not been listed here). The term ‘Sex and Gender Diverse’ (SGD) can be used to include all trans* and intersex people, as well as anyone else who may not fit into the binary characterization of ‘male’ and ‘female’.

Of course, in medicine, our time is short and we need motivation beyond idealism to divert time and other resources towards fixing a problem.

However, there is ample justification for making ourselves aware of the issues faced by the vector magazine

community and becoming part of the solution.

These issues are believed to be linked to the discrimination that SGD individuals often face within our society. Literature identifies extremely

So, you just found out your patient is SGD...

It is most important to treat a SGD patient with the same consideration and respect that you would give to any patient. Below are a few specific things that you may also want to keep in mind when you do come across SGD individuals: - If someone asks you to use a particular name and/or pronouns, make an effort to use them.

- If you are not sure what pronouns to use for someone, it is respectful to ask.

- Many trans* people live in stealth. Disclosure of their trans* status may make them uncomfortable and may even put them in danger. Do not disclose their status without their consent. If there is a situation where you believe you need to disclose a patient’s trans* status (e.g. in a referral letter), discuss it with them first.

- Be aware that trans* people do not all wish to transition in the same way – don’t assume that someone has had or wants surgery or hormones.

- Be mindful that certain consultations may be triggering (e.g. Pap smears for trans men) - Ask how they would like their genitalia referred to.

high rates of assault, violence, rape, harassment, sex work, economic discrimination, domestic violence, unemployment and poverty suffered by members of the SGD community. In the Australian “Private Lives Report” 73.5% and 69.7% of trans-men and trans-women SGD respectively reported verbal abuse, 29.4% and 46.9% had been threatened with violence, 11.8% overt and 18.2% experienced physical abuse or violence, and 14.7% and 12.1% had objects thrown at them [2]. These are just a few of the ways in which society makes life difficult for many SGD individuals. As a result depression is 5 times more prevalent within the SGD population than the general population [3] and suicide attempts are 25 times as prevalent [4].

And while we would like to think that doctors would be helping SGD people overcome these obstacles in many cases they are just another source of discrimination. The National Transgender Discrimination Survey Report on Health and Health Care reported some sobering statistics about what SGD people face when accessing health care. 28% of SGD individuals postponed medical care when sick or injured due to discrimination, 50% had to teach their medical providers about SGD care, 28% were subjected to harassment in medical settings, 19% were refused care due to their SGD status and 2% were victims of violence in doctor’s offices [4].

This issue is compounded by the fact many SGD individuals will require greater care from the medical community due to their identity. For many SGD people, gender affirmation therapy (whether hormones or surgery) is a life changing and life saving intervention. Doctors act as a gatekeeper to this therapy and the medical system, societal consideration and financial constraints make it difficult enough to access without having to face bewilderment, discrimination or straight up abuse from doctors.

There is much more to be said about SGD health than we could ever hope to cover here. When it comes down to it though, what you need to remember is this: SGD people do exist, they are people just like you, and they deserve the same respect and care that any other human being does.

- Be aware that an individual’s gender identity does not determine their sexual orientation.

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References 1. World Health Organization. (2012). What do we mean by “sex” and “gender”. World Health Organization, 2012 [cited 2012 July 29].

2. Pitts M., Smith A., Mitchell A., & Patel S. (2005). Private Lives Report: Australian Research Centre in Sex, Health & Society.

3. Pitts MK., Couch M., Mulcare H., Crow S., & Mitchell A. (2009).

Transgender people in Australia and New Zealand: health, well-being and access to health services. Feminism & Psychology, 19(4), 475-95.

4. Grant JM., Mottet LA., Tanis J., Herman JL., Harrison J., & Keisling M. (2010) National Transgender Discrimination Survey Report on Health and Health Care 2010.

Glossary of Useful Terms Trans* - An umbrella term to describe anyone whose gender identity is different from their assigned gender. May encompass transgender, transsexual, genderqueer, etc.

Cisgender - A term to describe anyone who identifies as the gender/sex they were assigned at birth.

Trans men - A trans* person who identifies as male. Sometimes referred to as FTM (femaleto-male).

Trans woman - A trans* person who identifies as female. Sometimes referred to as MTF (male-to-female).

Genderqueer - A term for gender identities other than male and female. This may include people who identify as both male and female, neither male nor female, people moving between genders, or other-gendered.

Gender Dysphoria - The feeling of mismatch between gender identity and biological sex/ assigned gender. This term is likely to replace the “Gender Identity Disorder” category in the DSM-V. Crossdresser - Someone who wears clothing associated with the opposite gender, but does not desire to live as that gender. The term transvestite should be used with caution, as it can be used as a slur.

Drag King or Drag Queen - Someone who dresses as the opposite gender for the sake of performance.

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Female Genital Mutilation Factsheet What does FGM mean for Australian Practitioners?

Female genital mutilation (FGM), also known as female genital cutting or female circumcision, is defined by the World Health Organisation (WHO) as “procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.” It is a practice that has been experienced by between 100-140 million females currently living, and has been reported worldwide, though is concentrated in some African and Asian nations [1]. Eleven African nations have rates of FGM in reproductive age females of 70-98% - namely Somalia, Egypt, Guinea, Sierra Leone, Djibouti, Sudan, Eritrea, Gambia, Ethiopia, Burkina Faso and Mauritania [2].

There are considered to be four forms of FGM, which may be administered separately or in combination [3]. As shown in Figure 1, they are: • Type I: Clitoridectomy. In very rare cases only the prepuce is removed; • Type II: Excision. Partial or total removal of the clitoris and labia minora, with or without removal of labia majora; • Type III: Infibulation. Narrowing of the vaginal opening through the creation of a covering seal, formed by repositioning and cutting the inner or outer labia (with or without clitoridectomy); and • Type IV: Other. Involves all other harmful procedures to the female genitalia for non-medical purposes.

According to the WHO, many cultural, religious and social reasons in families and communities underlie these FGM practices, and that is why it is often so difficult to curb them. Common motivations include:

Yu Shan Ting (UNSW) “FGM is considered a social convention and a necessary part of raising a girl properly and preparing her for adulthood and marriage, associated with cultural ideas of femininity and modesty”.

• FGM is considered a social convention and a necessary part of raising a girl properly and preparing her for adulthood and marriage, associated with cultural ideas of femininity and modesty.

• FGM is in many communities believed to reduce female libido and help her resist ‘illicit’ sexual acts.

• Religious leaders take different stances towards FGM: some promote it, some are against it and some consider it irrelevant to religion.

The medico-legal context governing FGM in Australia is relatively well defined. Notably, in the scenario of FGM common law is overruled by legislative regulation, which prohibits any person in Australia from performing any type of FGM [10]. Consequently, even if by common law young adults aged over 18 (or 16 in South Australia) consent to the procedure, the medical practitioner administering the FGM would still have committed an offence [11].

Seeing as most of these practices occur in overseas communities, you may ask, why is it relevant to Australian medical practitioners and allied health staff? Analysis of immigration data shows that from 1999-2009, Australia received 38299 people as settlers from 4 of the aforementioned 11 African nations – namely Sudan, Egypt, Ethiopia and Somalia (5). In particular there has been a high rate of increase in settlement of people from Sudan [6]. This has led to an increase in FGM prevalence, presenting both health and ethical dilemmas to Australian doctors [7].

Many Australian institutions have released resources for further practitioner learning in this subject, such as those listed below:

It important to understand the health repercussions of the FGM procedure. Depending on the degree of circumcision involved, there can be immediate complications of severe pain, shock, haemorrhage, tetanus and sepsis involved; or longer term complications of recurrent bladder and urinary tract infections, infertility, and increased risk of childbirth complications [8]. The procedure is also often repeated especially in the context of Type III FGM because the vaginal opening has to be cut open to allow for sexual intercourse or childbirth. Each time this occurs the woman is re-exposed to the aforementioned risks. In addition to this, myriad psychological consequences may occur such as post traumatic stress disorder, depression, anxiety and fear of sexual relations [9].

• Melbourne Royal Women’s Hospital guide on different types of FGMs and how to carry out deinfibulation procedures in elective and labour situations (http://www.thewomens.org.au/ FemaleGenitalMutilationFGMClinicalManagement) • South Australian Department of Health guidelines on pre-pregnancy counselling and antenatal, intrapartum and post-natal considerations (http://www.health.sa.gov.au/PPG/Default.aspx?P ageContentID=908&tabid=211) However, despite these sound guidelines and well laid out legislation, practitioners may still find themselves facing practical challenges in response to FGM demands. It is imperative when faced with these situations, doctors should not only decline to carry out these practices but also play the role of educator through sensitive discussion with the child and all family members involved. After all, education and discussion have been shown to contribute hugely to successful FGM eradication strategies in certain parts of Africa, specifically: • Involving men and community leaders in educational and awareness raising efforts; • Cooperation between government and nongovernment agencies, health experts, societal opinion leaders and religious leaders in public education; and

Figure 1: Forms of female genital mutilation [4]

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• Education focusing on young girls, since mothers play a major role in the FGM of daughters.

Finally, it is widely agreed in the medical community that more research is required in order to further shed light upon the true incidence of FGM in Australia, different community attitudes towards FGM, and the need for treatment and support for those already experiencing its implications. It is expected that Australian FGM guidelines will continue to be modified as the evidence base is further consolidated, which will help refine practitioner attitudes and approaches towards FGM.

References

[1] Barstow, D. (1999). Female genital mutilation: the penultimate gender abuse. Child Abuse & Neglect , 501510.

[2] Office of the High Commissioner For Human Rights, J. U. (2008). Eliminating female genital mutilation: an interagency statement. Geneva: World Health Organisation .

[3] WHO. (2012, February). Female Genital Mutilation.

Retrieved August 16, 2012, from WHO l Female Genital Mutilation: http://www.who.int/mediacentre/factsheets/ fs241/en/ [4] Female circumcision. (2011, September 30). Retrieved August 10 , 2012, from http://www.intactipedia.org/index. php?title=Female_circumcision [5] Australian Government Department of Immigration and Citizenship. (2009). Settler arrivals 1998–99 to 2008–09, Australia, states and territories. . Canberra: Australian Government Department of Immigration and Citizenship.

[6] Statistics, A. B. (2010). Migration, Australia, 2008–09.

Canberra: Australian Bureau of Statistics.

[7] Jenkins, G. J. (2007 ). Understanding female genital mutilation . Medical Journal of Australia , 186.

[8] Ladjali, M., Rattray, T., & Walder, R. (1993). Female genital mutilation. British Medical Journal , 460.

[9] Bishai, D., Bonnenfant, Y. T., Darwish, M., Adam, T., Bathija, H., Johansen, E., et al. (2010). Estimating the obstetric costs of female genital mutilation in six African countries. Bulletin of the World Health Organisation , 281288.

[10] Mathews, B. (2011). Female genital mutilation: Australian law, policy and practical challenges for doctors. Medical Journal of Australia , 139-141.

[11] Mathews, B. (2010). Children and consent to medical treatment. Sydney: Thomson Reuters.

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State of the Nation

Describe the most notable or amusing happening for your GHG this year?

• Insight has formed an exciting new partnership with the Health Workforce Australia (HWA). This will support 2 projects which combine clinical training and Indigenous healthcare. HWA will fund Indigenous Ophthalmology trips to remote communities in Central Australia for sixteen students and the 6th year Katherine Psychiatry Elective for two.

• New “Ideas fund” which allow students to bring their initiatives to Insight and receive some funding in order to get the project off the ground and running.

AMSA GHG Updates ASPIRE (University of New England) Maddie Gramlick, AGH Representative

What major activities and events have you run this year?

This year we have run two inaugural events: Birthing Kit Morning Tea in partnership with the Armidale Zonta Club, and an International Health Speaker Night featuring passionate doctors and professors who have worked in Papua New Guinea, Nepal and throughout Africa. We are also fundraising for Maternity Africa, a charity working to improve maternal health in Ethiopia.

What is new or upcoming for your GHG during the remainder of 2012?

Our largest event for 2012 is ASPIRE’s second Red Party, which is set to be bigger and better than last year! And of course there will be fundraising and celebrations for the annual 40 Hour Famine in August. We are also running the inaugural Maternal and Child Health Skills Day, designed to equip third year students with basic skills in obstetrics and neonatal resuscitation before they embark on final placements (many of which are in developing countries) and on to their clinical years.

Describe the most notable or amusing happening for your GHG this year?

2012 has been a huge year of growth and progress for ASPIRE! We are very proud to have introduced three new events to UNE: International Health Speaker Night, Birthing Kit Morning Tea, and Maternal and Child Health Skills Day. There has also been a huge increase in support from fellow students, local clinicians and the wider Armidale community.

Insight (University of Adelaide)

Rebecca Zhao and Deeva Vather, AGH Representatives What major activities and events have you run this year?

• Insight Welcome BBQ – Recruiting new members and promoting Insight’s Event calendar • Insight Movie Night • Insight Birthing Kit Workshop – Over 130 Students from various faculties got involved and we managed to pack 2,200 birthing kits.

• Insight Photo Exhibition – 102 student photos exhibited from Elective trips around the world displayed in the Carclew Youth Arts Centre. Guest speaker, Dr Joseph Masika, gave a talk highlighting the gap between developing and developed world

MAD (Bond University)

Nathan Yii, AGH Representative What major activities and events have you run this year?

We hit the ground running this year with a focus on a number of awareness days including World Cancer Day and World Water Day. Fortnightly we had volunteer trips to the RBCH Wonder Factory, giving students a chance to make a difference in a very “hands-on” way. The biggest event we ran was a Global Health Seminar in July which included speakers from the likes of MSF, World Vision and the Hamlin Fistula Clinic.

What is new or upcoming for your GHG during the remainder of 2012?

MAD has a number of projects on the table, the biggest of which is Bond’s inaugural Red Party. Planned for the upcoming semester, we hope to bring the success that Red Party has been nationally to the Gold Coast. Other projects include birthing kit packing and volunteering with a local soup kitchen charity HAVAFEED. Describe the most notable or amusing happening for your GHG this year?

This year, MAD is having its largest delegation attending GHC to date! We are all excited to learn more about global health and to be challenged and equipped to make a bigger impact in our university and beyond. We are also keen get together and meet like minded people from around Australia and participate in the greater global health community.

What is new or upcoming for your GHG during the remainder of 2012?

• Quiz and Talent Night – Major fundraiser for our sustainable projects • Global Health Seminar “Crash Course in Global Health” – Round table discussions, focusing on cultural awareness, social determinants of health and a discussion of field experiences from MSF Buganda Medical Centre – New organisation we are supporting this year, to raise money to develop an educational video on birth fistula and how to manage it for Tanzanian women.

• Development Fund Dinner • New Insight Magazine – “InVision”!

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MUHI (University of Melbourne) Kristijan Jovanoski, President

What major activities and events have you run this year?

We kicked off the year with a guest lecture by neurosurgeon Kate Drummond with Specialists Without Borders, followed soon after by a launch barbecue and a panel session on alternative medicines.

We also launched the Melbourne branch of the Global Health Mentoring Program as well as the first issue of our Bulletin, which showcases student analysis of health issues. We have also run a movie fundraiser and an educational seminar together with Ignite and UHAD. What is new or upcoming for your GHG during the remainder of 2012?

In addition to another two issues of our Bulletin, we are currently organising a charity gig coming up very soon followed by a health art exhibition along with a couple of public lectures. Meanwhile, our flagship material aid program is making progress towards developing a global health elective for the medical course while a new Kenyan village-based educators program is currently recruiting volunteers with the aim of sending them to Kenya in early January.

Describe the most notable or amusing happening for your GHG this year?

We are now one year old! As a very young group, we’ve been glad to become incorporated and we’re patiently awaiting the outcome of our application for charity status. Also, we invited a homeopath and two sceptics to our panel on complementary and alternative medicines ... they had an informative, robust, and entertaining debate!

SANTE (James Cook University) Andrew Dawson-Smith, SANTE GHN Representative and Vice President What major activities and events have you run this year?

2012 has been a highly successful year for SANTE. We began the year with a movie and guest speaker night, showcasing Dr. Ajay Rane’s internationally acclaimed film, ‘Riwayat’, which raises awareness of the sensitive issue of female infanticide in India. This event allowed us to sign on many new members, we raised $352 for Dr. Ajay Rane’s research and 140 attendees were treated to a very educational and enjoyable night. Our next big event was Red Party. SANTE has held a Red Party for several years now and so we aimed to make this year’s Red Party bigger and better. It was a truly special night and we managed to raise $5,320 in support of HIV/AIDS orphans in Zambia (En Gedi Project). vector magazine

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What is new or upcoming for your GHG during the remainder of 2012?

Another big annual event of ours, ‘Run to the Water’, will be held on August 19th. This is a community fun run, raising money for Water for Ghana, a charity started by one of our own, Nicole Buttner in Med 4. Although only being in existence for a few years, Water for Ghana has now provided over 20 rainwater tanks to rural villages and schools all over Ghana, training locals to both build and maintain these tanks. SANTE is really proud to support this charity going forward and would love to take this opportunity to promote it. (Google it!!)

Vision MSAND (University of Notre Dame, Fremantle) Steve Pannell, Chair

What major activities and events have you run this year?

Raising awareness of the issues related to Climate Change and Health.

We organized a talk from the chair of Doctors for the Environment Australia (DEA), Professor Kingsley Faulkner, about the impacts that climate change will have on health care and what we can do as health care professionals to address these challenges. We invited our partner Global Health Group, Interhealth from UWA and also the Physio and Nursing students from Notre Dame University. We provided food and refreshments before the talk and had a question time at the end of the 1 hour presentation.

Highlights: A great talk by Professor Faulkner, inspiring and informative. Good networking amongst Nursing, Physio and Medical students. Good to have a DEA presence there, Professor Kingsley Faulkner brought some flyers for DEA and some connections were made between him and Katherine O’Shea, the WA DEA rep, to get Notre Dame, Fremantle more involved with DEA. What is new or upcoming for your GHG during the remainder of 2012?

Planning a talk from MSF, inviting all health disciplines from Notre Dame Fremantle and working in partnership with another independent interest group, Vision Vietnam. Scheduled for early September, our speaker, Erin Calabrese, who has completed four missions with Médecins Sans Frontières since working with them in 2010. Erin has worked with the following missions: • Kyrgyzstan in 2010, working with IDPs and refugees affected by ethnic conflict; • Libya in 2011, during the height of the conflict; • Ethiopia in 2011, in response to the (Horn of Africa) nutritional emergency; • and most recently South Sudan, where refugees have crossed the border from Sudan into camps including one in Maban, and face catastrophic health conditions (see more at http://www.msf.org.au/from-the-field/field-news/fieldnews/ticle/what-we-are-facing-is-an-extremely-serious-situation.html) vector magazine

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