Because of women’s unique biological characteristics and unequal cultural and social status, they are exposed to various reproductive and maternal health problems. In the past decades, the health situation of Sub-Saharan African women has improved significantly but it still lags behind that of other countries. For example, during the period from 2000 to 2017, Sub-Saharan Africa achieved a reduction of 39 percent of maternal mortality (from 870 to 533 maternal deaths per 100,000 live births). However, it still accounts for 68 percent of all maternal deaths per year worldwide (Unicef Data 2020).
Female genital mutilation, which involves partial or total removal of the female external genitalia, still exists in a few countries such as Burkina Faso (13% of FGM prevalence among girls from 0 to 14), Côte d'Ivoire (10%), Djibouti (43%), Ethiopia (16%), Gambia (21%), Mali (83%), Nigeria (13%), and Senegal (14%) (Unicef Data 2020). In addition, 3 in 5 new HIV infections among 10-19-year-olds are among girls, although the percentage of women living with HIV who receive regimens (78%) is about the world average (76%)(Unicef Data 2020). Sub-Saharan Africa remains the region with the highest adolescent birth rate (102.8 births per 1,000 girls aged 15 to 19), while the world’s average is 44 (Unicef Data 2020).
This article will be divided into two parts: sexuality education and healthcare. In each part, I will first consider the agreements, policies, and infrastructure created by the governments to improve women’s health. Then, it will examine the deficiencies in this system in addressing the deep-rooted social, religious, and educational problems, and how projects like Audiopedia can help solve these institutional problems regarding women’s health.
Comprehensive Sexual Education(CSE)
With the help of international organizations, governments across Africa have been implementing sexuality education to better women’s health and well-being. Comprehensive sexual education (CSE) is defined as “a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality” by UNESCO. It gives young people an understanding of sexual health and positive gender norms and empowers them to make better choices regarding their reproductive health. CSE was first brought to attention at the International Conference on Population and Development (ICPD) in Cairo in 1994, where 179 countries adopted a Programme of Action that set goals on sexual and reproductive rights as well as women’s empowerment and gender equality (United Nations 2014).
In 2012, UNESCO and UNFPA published a 10 country review of sexuality education in the school curricula in east and southern Africa, which analyzes the governmental efforts to implement CSE and the gaps in these curriculums. In 2013, countries from ESA committed to scale-up comprehensive rights-based sexuality education starting with primary school level: “We, the Ministers of Education, Health, Gender, and Youth and Senior Government Officials commit ourselves to step up efforts to ensure adolescents’ and young people’s access to good quality CSE and youth-friendly SRH services in the ESA region, and to work in partnership with young people, parents, civil society, and community and religious leaders to achieve the goals set out in the 2013 ESA Commitment” (Young People Today 2019)
The CSE programs have various gaps due to sociocultural factors. Although the curriculum covers such topics as sexually transmitted infections (STIs), safe sex, unwanted pregnancies, and abstinence, which is seen as the main method for contraception, there are problems in the implementation of material. Specifically, the program avoids culturally sensitive topics such as abortion, homosexuality, and contraceptive methods, and takes a fear-based approach on the issue of sexual relationships. Sociocultural attitudes on these taboo topics prevent teachers from teaching CSE effectively, compelling them to conform to traditional cultural beliefs. Parents also pressure teachers to conform to societal norms and convey their own beliefs to children (Wekesah, et al. 2019).
CSE programs are mainly carried out by the appointed government branches, but CSOs, NGOs, UN agencies such as UNESCO, and private organizations have also been involved in the design and implementation of CSE. For example, the organizations in Zambia have been working with government ministries to improve teacher capacity, prepare learning materials, monitor progress, and raise funds. Other than school-based CSE programs, the use of mass and digital media can also be an effective and influential tool in spreading information on sexual and reproductive health. The World Starts With Me (WSWM) is a sexuality education and AIDS prevention program that is implemented in Uganda, Kenya, Ethiopia, Ghana, and Malawi. It consists of a series of 14 online lessons that use virtual peer educators to guide young people. Audiopedia, with its open-source audio resources on women’s health, is also supplementing the school-based sexuality education by adjusting to the need of young people in ESA (Wekesah, et al. 2019).
Healthcare: Infrastructure, Services, and Policies
In terms of health infrastructure, services, and policies, African governments have also been recognizing the deficiencies in the current system and collaborating with various partners to improve women’s health outcomes. Back in 2001, the African Union countries set a target of allocating 15% of annual budgets in the Abuja Declaration to improve the health sector, although this number was only around 10% ten years after. Committing themselves to further enhancing maternal and child health, the governments have adopted a series of strategies. These include the road map to accelerate the attainment of the MDGs related to maternal and newborn health in 2014, which called for the provision of skilled attendance and strengthening of the capacity of individuals, families, and communities to improve maternal and newborn health. In addition, the Sexual and Reproductive Health Maputo Plan of Action of the African Union 2007-2015 and the newest 2016-2030 plan seek to help the continent progress towards the goal of universal access to comprehensive sexual and reproductive health services in building on 9 areas (Maputo Plan of Action 2008). The African countries have increased the number of health experts and personnel, scaled up the prevention of mother-to-child transmission (PMTCT) and pediatric HIV care, and started recognizing the importance of family planning (United Nations).
However, health systems are affected by gender norms and sociocultural contexts. Specifically, these norms can influence the healthcare workforce, policies, and healthcare access across ESA. For example, research shows that the involvement of males, the general decision-makers in terms of health-related choices in the families, influences women’s access to health services. In Nigeria, for example, women’s access to prevention of mother-to-child transmission (PMTCT) services is limited by the lack of male involvement. Few men accompany their wives to antenatal care or educational sessions on HIV. Time and financial constraints, the expectation that maternal health services are “women-only” spaces, as well as the flawed health system that requires long transportation and separate appointments for the couple all contribute to this lack of involvement.
Numerous reviews have also shown that interventions that address these gender norms, such as empowerment projects for women, are effective at increasing women’s access to healthcare (Morgan 2017). Moreover, these social norms can determine male and female employment in the healthcare workforce. A Zimbabwe case study found that the career development and opportunities of health workers are influenced by their gender. Men usually have more financial resources and fewer family obligations to pursue training. In contrast, women often follow their husbands during relocations, which prevents them from advancing professionally (Morgan, et al. 2018).
All of the aforementioned findings show that policy-makers need to integrate gender into their practice (Morgan, et al. 2018). One Tanzanian study analyzed five PMTCT policy documents and found that gender-related factors were mentioned in all, yet none of them were gender-transformative or intended to transform the harmful gender inequality that prevents women from accessing care. Consideration of gender was, to a large extent, confined to the promotion of couple voluntary counseling and testing (CVCT), but attempts at reducing harmful gender norms - such as the promotion of couple counseling and testing for HIV, women’s economic dependence, lack of decision-making power in sexual and reproductive health, masculine norms that encourage male dominance, and gender-based violence - were lacking (Nyamhanga et al. 2017).
International organizations such as WHO, UNICEF, and the World Bank have been working with African governments to create plans and strategies, but local NGOs have also been making positive contributions to the health personnel, services, and information resources. For example, African Medical and Research Foundation (AMREF), the largest NGO in health development in Africa, intends to increase health access to local communities in seven African countries through solutions in human resources for health, health services delivery, and investments in health. Other than the NGOs that work directly with the government and local communities, there are some that use the media to spread knowledge about sexual and reproductive health (Amref Health Africa). Journalists Against AIDS (JAAIDS) Nigeria, a media-based NGO HIV/AIDS advocacy organization in Nigeria, has been organizing media activism, community participation in stigma reduction, and publications and roundtables on the topics of AIDS. Similarly, Audiopedia provides resources to individual women across sub-Saharan Africa, touching on topics of health, nutrition, family planning, child care, work, and more.
“The State of the World's Children 2017 Statistical Tables.” UNICEF DATA, 5 May 2020, data.unicef.org/resources/state-worlds-children-2017-statistical-tables/
Morgan, Rosemary, et al. “Gender Dynamics Affecting Maternal Health and Health Care Access and Use in Uganda.” Health Policy and Planning, vol. 32, no. suppl_5, 2017, pp. v13–v21., doi:10.1093/heapol/czx011
Morgan, Rosemary, et al. “Gendered Health Systems: Evidence from Low- and Middle-Income Countries.” Health Research Policy and Systems, vol. 16, no. 1, 2018, doi:10.1186/s12961-018-0338-5
Nyamhanga, Tumaini, et al. “Prevention of Mother to Child Transmission of HIV in Tanzania: Assessing Gender Mainstreaming on Paper and in Practice.” Health Policy and Planning, vol. 32, no. suppl_5, 2017, pp. v22–v30., doi:10.1093/heapol/czx080