Reason for Submission

Dr. Jasmine Fledderjohann (hereafter JF) is a social demographer with expertise in health inequalities in Global Majority countries, including inequalities in sexual and reproductive health and rights (SRHR). She has researched infertility, reproductive justice, and the broader context of precarity which shapes sexual and reproductive health risks and access to healthcare resources.

Dr. Swayamshree Mishra (SM) is a social anthropologist with expertise in gender studies. She has worked with women from diverse backgrounds on their experiences with menstruation, reproductive ageing, and infertility. Her research explores how women’s sexual and reproductive choices are embedded in sociocultural contexts governed by caste, class, religion, marriage, and family.

Dr. Ankita Rathi (AR) is social science researcher whose work has focussed on the impact of rapid urbanization in India in engendering precarity and social inequality--particularly intra and inter caste-class, family, and gender. Her current research focusses on investigating the divergent experiences of families facing food precarity, and its racialized and gendered dimensions.

Dr. Charumita Vasudev (CV) is a social anthropologist with experience working with different socio-religious groups on abortion, fertility, sex-selection and access to reproductive healthcare services, including gender-based barriers to access and uptake. She has also worked as a consultant with the International Centre for Research on Women (India).

Our collective background in SRHR and inequalities in Global Majority countries is of direct relevance to the questions posed in the call for evidence.

Introduction

There are four key points we raise for the committee's consideration. First, efforts to improve SRHR in Global Majority countries cannot be divorced from the broader context of precarity in which many people live. Second, infertility remains a neglected but pressing public health issue in Global Majority countries. Third, men (and often their families) are a very important part of reproductive decision-making, but they are frequently left out of sexual and reproductive health programmes. Finally, the preceding points highlight the need for a focus on reproductive justice. Drawing on our previous research findings and on in-depth interviews we conducted in India from 12/2022 to 03/2023, we provide evidence on these points in the sections that follow.

Contextualising Sexual and Reproductive Health Choices

There are stark and persistent inequalities in how reproductive choice is restricted by structural barriers, e.g. socioeconomic status, geography, ethnicity, religion. Greater attention to the social and economic context in which reproductive decision-making occurs is needed to transition to more holistic programme design. Even where sexual and reproductive healthcare is accessible, certain groups face significant barriers to uptake1,2. In the Jammu region of India, CV found abortion stigma is higher for “lower” caste women, forcing them to adopt unsafe, potentially life-threatening methods (e.g. stick method) to abort unwanted pregnancies. Similarly, because of severe religious dictates against abortion, Muslim women in Kashmir reported strong feelings of guilt, regret, and shame for not taking unwanted pregnancies to term, thereby rejecting the ‘nehmat’(God’s gift) of a child3. Abortions are severely tabooed for certain groups, especially in closed communities (e.g. villages). A respondent who aborted a pregnancy due to risk to her life rued “Allah will not forgive me, I was the reason for my child’s death”. Geographical terrain also poses barriers to the availability of healthcare services and practitioners in remote areas1,3.

Precarity can also be a tremendous barrier. JF’s work4 shows, around the globe, food insecurity can leave people—particularly marginalised people—facing “choiceless choices”5. They may, for instance, rely on transactional or commercial sex to acquire food, which can increase power asymmetries and, linked to this, risks of sexually transmitted infections and unintended pregnancy4. Financial strain associated with food insecurity can place people at greater risk of intimate partner violence, make it more difficult to leave a violent situation, and lead people to delay childbearing. Food insecurity can also be a barrier to accessing sexual and reproductive healthcare, particularly where there is a fee for service; however, even where healthcare is free, costs such as transportation and childcare may still prevent people from accessing care. Malnutrition, which has far-reaching implications for maternal and child health and pregnancy outcomes, is also strongly associated with food insecurity. Other forms of precarity (e.g. poor employment opportunities, unsafe and insecure housing) are connected to food insecurity6,7, and are directly linked to SHRH in their own right.

Preliminary results from our team’s fieldwork in India shows the inability to access “hygienic” living arrangements due to economic precarity severely impacts employment opportunities for some women, creating a vicious poverty trap. One participant from a makeshift settlement explained, although she kept herself clean, she was considered “unhygienic” and “unfit to be employed” as a domestic helper in neighbouring households. Families in upper-class neighbourhoods actively looked for domestic help, but they were reluctant to employ women from our participant’s settlement due to their perception of her living conditions. Our participant remarked “they feel we don’t take baths properly and so we will give them diseases. They don’t understand that living here is majboori (desperation) for us.” Her experiences, and those of several other women like her in our study, demonstrate how the inability to access hygienic living conditions can restrict women’s livelihoods.

Our fieldwork shows how an inability to access steady work with decent wages can put families, particularly women and young children, at grave health risk. Employment precarity and low wages can aggravate gender inequalities, including the early marriage of, and childbearing by, young girls. Ramifications include unintended pregnancies, multiple abortions, and miscarriages. One mother from our fieldwork suggested that, despite knowing her eldest daughter (married at 14) was facing violence in her marital home, she still wanted her daughter to continue with the marriage rather than returning home. She explained, “I have more mouths to feed.” A 20-year-old married woman in a village shared how economic hardship in her family led her to take up domestic and care work at a very young age, often managing it along with schooling. Unlike her siblings, she could not continue her education as she was the eldest and so was married at age ~15. She is now a mother to a two-year-old daughter, and narrated how the family’s economic inability to access prenatal and neonatal healthcare contributed to her five miscarriages and the death of her 12-month-old infant.

The intersection of economic precarity with racial inequality (in India, caste) can push people to migrate to cities to look for a better living. AR’s previous fieldwork8 in an urban area in India, and our team’s recent fieldwork in rural and urban areas, show that migrant workers (who are often daily wage labourers) and their families sometimes live in unsafe, insecure, unsanitary, and temporary housing. They may stay in makeshift houses (made of plastic and sheets), slums, and informal settlements that lack access to basic services, e.g. water, toilets, cooking facilities, and sanitation amenities. Lacking food, adequate housing facilities, and resources to afford healthcare frequently exposed families in our research to seasonal diseases such as dengue, typhoid, jaundice, and malaria—serious illnesses which can result in chronic health conditions, foetal loss, intrauterine growth restriction, premature delivery, and even maternal and child mortality. The burden of health expenditures was often met through informal borrowing; in turn, this can reinforce precarity and put an extensive burden of paid and unpaid labour on children and women to ensure their family’s survival.

To improve SRHR in Global Majority countries, policies must be mindful of the intersecting forces affecting women’s choices about their bodies. These choices are often facilitated and constrained by cultural, economic and political norms and structures.

Broadening the Scope to Include Infertility

There is a disproportionate focus on pregnancy prevention in SRHR programmes, and a lack of attention to infertility. This is reflected in a wide range of FCDO-funded programmes. Infertility is a pressing SRHR concern, and a common experience in many Global Majority countries. Despite popular narratives of infertility as primarily experienced by white, western, middle-class women, some of the highest rates of infertility in the world are found in Global Majority countries, and a roughly equal proportion is attributable to male-factor infertility as female-factor infertility9–12. While 1-in-6 people globally experience infertility13, significant gaps remain in fertility care coverage, particularly in Global Majority countries, highlighting the urgent need for expanded access to care9,13.

Infertility is a potentially distressing and stigmatising experience, with the negative consequences falling primarily on women9,12,14. Through interviews and survey data analysis14,15, JF found women in Ghana who experienced infertility reported loneliness and shame, depression-like symptoms, exclusion from social interactions, social stigma, physical and verbal abuse from husbands and mothers-in-law, and substantial worries about and personal histories of divorce and its social and economic consequences. Additionally, infertility can lead both men and women to seek other sexual relationships, which can result in sexually transmitted infections14,16. The absence of professional fertility care also pushes women to adopt less reliable or even unsafe methods to become pregnant. CV found in Jammu in India2,3 that local babas (religious men) and tantricks (magic men) often physically and financially exploit women, sometimes even endangering their safety, in the name of providing ‘methods’ and ‘cures’ for ensuring the birth of a child, particularly a male child.

JF’s analysis of survey data for women aged 16-24 in Malawi16 has highlighted that even very young women may report experiencing difficulties conceiving and carrying a pregnancy to term. This observation links to a broader literature that suggests people may be more worried about infertility where prevalence is high, and may try to conceive at a younger age and with less space between births to ensure they meet their fertility desires before encountering a reproductive health problem17; this has the potential to lead to larger than desired family sizes across the reproductive lifecourse, particularly if reproductive autonomy is restricted and/or access to contraceptives is limited. In highlighting that worries about infertility can result in larger-than-desired families over the reproductive life course, we are not arguing that this should be the only, nor the primary, reason to provide for comprehensive sexual and reproductive healthcare, including fertility care. However, if the aim is (as it should be) to create an environment which truly enables people to have the families they desire, addressing infertility may be an important way to reduce the risk of women being unable to have children they wish to have, while also reducing internalisation of societal pressure to have children early.

Bringing Men and their Families into the Discussion

Men, and in many cases their families—particularly, but not exclusively, their mothers—are an important part of reproductive decision-making. Marital families can sometimes override the preferences and desires of women themselves18. Yet their involvement in reproduction is frequently overlooked in sexual and reproductive health programmes12. Because power imbalances are rooted in social structures (such as gender norms), programmes which fail to acknowledge the range of actors involved in reproductive decision-making are unlikely to be effective.

In AR’s in-depth interviews19 with upper-caste women in a small town in Punjab, India, while women expressed the important role families played in providing social support during and after childbirth, they also highlighted the social pressures associated with familial involvement. For instance, a 28-year-old spoke about how birth-related complications, inability to give birth, and familial and social pressure led her to undertake painful and intrusive medical tests like in-vitro fertilisation. As CV’s work 2,3 shows in Jammu, India shows, marital norms that dislocate young women from their communities to reside with their marital families can limit their mobility and bargaining power and, consequently, also limit their access to reproductive health services.

Indian women can face immense pressure to prove their fertility early in a marriage to establish legitimacy in the household. Social hierarchies position husbands as key decision makers with respect to sexual and reproductive health. However, mothers-in-law play the role of custodians of social norms for the family, and reproductive decisions are heavily influenced by the opinions of family elders. A participant in SM’s work in Odisha, India20 shared how, after giving birth to four daughters, she was worried about another pregnancy. Her mother-in-law wanted the couple to “keep trying” until they had a son. However, since the family faced extreme economic hardship, she decided to try oral contraceptives. When her (marital) family found out, she was brutally beaten and told that she did not have the right to make decisions about the number of children the family would have. It is imperative to involve men and their families in SRHR programmes because women not only face structural barriers in accessing information, but can also have limited bargaining power to utilise information.

Additionally, programmes which focus narrowly on women can do active harm by reinforcing the problematic notion that women are primarily (or exclusively) responsible for reproduction11,12,21. This places a hypervigilant gaze on women’s bodies, particularly where state policies and sexual and reproductive health programmes (problematically) aim to restrict fertility. It also compounds women’s experiences of stigma and shame if they are not able to have children, as women typically bear the brunt of the blame for having “too few” children12,14. As a participant in JF’s qualitative study of infertility in Ghana said14, “Mostly do they know it’s the man? They think it’s the woman. Even if the medical report says the man is impotent, their woman won’t tell anyone.” SM found similar evidence in India20,22 where, although infertility is a distressing experience for both partners, it is primarily considered a “woman’s problem.” It is particularly distressing for women since it adversely impacts their gendered and moral identities that mandate motherhood. 14One participant in SM’s study20,22 was blamed for the absence of children in her marriage even before she and her husband saw a doctor or conducted tests. JF similarly found some young women in Ghana sought infertility care within months of getting married due to the immense pressure placed on women and their bodies14.

Nor are gendered messages of reproductive responsibility limited to the context of marriage. SM’s recent work in a rural village of India 20,22shows young girls were ostracized for using tampons because, unlike a sanitary napkin or a cloth, a tampon had to be inserted into the vagina. This was perceived to threaten girls’ virginity. Similarly, consuming contraceptive pills to medically treat polycystic ovary syndrome (PCOS) was seen with suspicion, despite girls having medical prescriptions. Both choices—using tampons and consuming contraceptive pills—went against norms and were perceived as violations of the cultural construction of a “good respectable daughter” and her “honourable and asexual” image—labels girls are often expected to adhere to. CV also found2,3 that families’ honour is linked to the chastity of young daughters. This can result in marriage at a young age to “protect” girls from falling into “unwanted traps” of self-choice marriages and against threats of sexual harassment. In turn, low age at marriage is linked to maternal and child morbidity and mortality and other SRHR issues, including broader concerns about autonomy and well-being. The hypervigilant focus on girls’ and women’s bodies from a very young age teaches them that their bodies are not purely their own, subjecting them to stigma and social control. Sexual and reproductive health programmes which focus narrowly on girls and women reinforce these harmful messages.

In sum, programmes which omit men and their families risk being ineffective, and even reinforcing harm, because they ignore the familial context in which reproductive decision-making occurs. One way forward may be to work with existing programmes that rely on local, decentralised community contacts and groups for service delivery. For example, India's Janani Suraksha Yojana (JSY) programme relies on female community-based health workers (ASHAs) to improve pregnancy and birth outcomes through a combination of building relationships with local families and a targeted cash incentive programme. Community health workers who understand the local context and can work over an extended period to build relationships with the family can be particularly effective at bringing men and their families is into the discussion18. This can overcome misinformation and create attitudinal change that can ultimately foster empowerment and improved SRHR for women.

However, sociocultural and community norms limit the interactions female health workers can have with men unrelated to them; a female-only cadre of ASHAs inherently puts the onus of reproduction on women and side lines men from these interactions. The Ujjwal programme (2013-2016), funded by UK Aid, takes a step to involve men in the discussions of family planning through community-based entrepreneurs called Ujjwal sathis, who provide need-based reproductive services. However, the programme limits the involvement of men, replicating the narrow focus contraception seen in programmes focused on women. Men need to be involved in all aspects of truly holistic sexual and reproductive programmes so that reproduction stops being considered solely a woman’s domain.

Focusing on Reproductive Justice

Linked to the above considerations, a focus on reproductive justice is needed. Reproductive justice highlights that SRHR is about more than preventing unwanted pregnancy. It is both an activist movement and a theoretical framework which asserts that all people have the right to have a child, to not have a child, and to parent children with dignity in safe and healthy environments5. Around the world, marginalised people have faced the greatest reproductive coercion, with people who experience multiple forms of marginalisation facing the greatest structural barriers to reproductive justice.

Reproductive justice highlights how historically rooted social and political systems can result in reproductive coercion. While this certainly includes restricted access to contraception and abortion (barriers to the right to not have a child), for marginalised people reproductive coercion has also frequently involved forced sterilisation, child removals and family separation, restricted access to fertility care, inaccessibility of housing and employment, and many other structural barriers to the rights to have a child and parent with dignity in safe and healthy environments.

As the evidence we have provided in previous sections highlights, programmes which focus primarily on the right to not have a child, and which fail to take a holistic approach to meeting the full set of rights outlined by the reproductive justice framework, are unlikely to be successful. This is because they neglect the broader context in which reproductive decision-making occurs, and systematically fail to meet the full set of SRHR needs of the people they aim to serve. Reproductive justice provides a powerful roadmap for meeting internationally recognised sexual and reproductive rights in a way that recognises the historical and structural roots of reproductive oppression and inequities and prioritises the needs of marginalised people, thereby redefining success.

The immense value of the reproductive justice framework is increasingly being acknowledged in the international discourse on improving family planning programmes. For example, in a report23 of the High-Level Commission on the Nairobi Summit, reproductive justice is argued to be ‘fundamental to realizing the 12 global commitments of the Nairobi Summit’. Nonetheless, the report highlights serious gaps in the realisation of reproductive justice globally, which in part reflects the recency of discussions about this framework and its limited implementation in policy discourses and SRHR programmes. Among other urgently needed transformations, a commitment to reproductive justice from funders and a restructuring of programmes on the ground to reflect this commitment is needed.

Conclusion

The above is not an argument against programmes which seek to facilitate access to contraception and improve maternal and neonatal health outcomes. Rather, we highlight that a narrow focus on these aims has resulted in the neglect of other very important reproductive health matters. FCDO efforts in the area of SRHR would be strengthened by a revision of programmes and funding to:

Take a broader view of the context in which sexual reproductive decision-making occurs;
Expand programmes to provide counselling and healthcare to address infertility;
Recognise and address the role men and their families play in reproductive decision-making;
And, building directly from these recommendations, to define institutional aims and measure programmatic success through the lens of reproductive justice.

There are difficulties in commenting precisely on the efficacy of FCDO’s efforts in this area because much of FCDO’s work operates by funding third sector work, and so it is difficult to trace precise expenditures in different SRHR domains. We note, however, that the points we raise above also apply to varying degrees to a range of actors across the sector. Earmarking funds specifically for the issues raised above could help to ensure these important issues appear on the agenda across the sector.

References

1. Vasudev, C. & Kaur, R. Gender regimes, reproductive strategies and child sex preferences: A comparative study of villages in Jammu and Leh. Asian J. Womens Stud. 28, 111–130 (2022).

2. Kaur, R. & Vasudev, C. Son preference and daughter aversion in two villages of Jammu. Econ. Polit. Wkly. 54, 13–16 (2019).

3. Vasudev, C. Gender regimes, reproductive strategies, and gender preferences for children: A cross-cultural comparison of villages in Jammu, Kashmir, and Leh. (Indian Institute of Technology, Delhi, 2023).

4. Fledderjohann, J., Patterson, S. & Owino, M. Food insecurity: A barrier to Reproductive Justice globally. Int. J. Sex. Health (Forthcoming) doi:10.1080/19317611.2023.2201841.

5. Ross, L. & Solinger, R. Reproductive justice: An introduction. (Univ of California Press, 2017).

6. Clair, A., Fledderjohann, J. & Knowles, B. A Watershed Moment for Social Policy and Human Rights?: Where Next for the UK Post-COVID. (Policy Press, 2021).

7. Clair, A., Fledderjohann, J., Lalor, D. & Loopstra, R. The housing situations of food bank users in Great Britain. Soc. Policy Soc. 1–19 (2019).

8. Rathi, A. Seeing the Urban from the Agrarian: Emerging Forms of Agrarian Urbanization in India. South Asia Multidiscip. Acad. J. (2021) doi:10.4000/samaj.7306.

9. Thoma, M., Fledderjohann, J., Cox, C. & Adageba, R. K. Biological and social aspects of human infertility: A global perspective. Oxf. Res. Encycl. Glob. Public Health (2021) doi:10.1093/acrefore/9780190632366.013.184.

10. Mascarenhas, M. N., Flaxman, S. R., Boerma, T., Vanderpoel, S. & Stevens, G. A. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 9, e1001356 (2012).

11. Fledderjohann, J. & Barnes, L. W. Reimagining infertility: a critical examination of fertility norms, geopolitics and survey bias. Health Policy Plan. 33, 34–40 (2018).

12. Fledderjohann, J. & Roberts, C. Missing men, missing infertility: The enactment of sex/gender in surveys in low-and middle-income countries. Popul. Horiz. 15, 15–36 (2018).

13. WHO. 1 in 6 people globally affected by infertility: WHO. World Health Organisation https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility (2023).

14. Fledderjohann, J. ‘Zero is not good for me’: implications of infertility in Ghana. Hum. Reprod. 27, 1383–1390 (2012).

15. Fledderjohann, J. Difficulties Conceiving and Relationship Stability in Sub-Saharan Africa: The Case of Ghana. Eur. J. Popul. 33, 129–152 (2017).

16. Fledderjohann, J. Self-reported fertility impairments and help-seeking strategies among young women in Malawi. Glob. Public Health 17, 2139–2155 (2022).

17. Sundby, J. Infertility and health care in countries with less resources: case studies from sub-Saharan Africa. in Infertility around the globe: new thinking on childlessness, gender, and reproductive technologies (eds. Inhorn, M. C. & Van Balen, F.) 247–260 (University of California Press, 2002).

18. Vellakkal, S. et al. A qualitative study of factors impacting accessing of institutional delivery care in the context of India’s cash incentive program. Soc. Sci. Med. 178, 55–65 (2017).

19. Rathi, A. Transition from Village to Town: A Study of Two Settlements in Punjab. (2021).

20. Mishra, S. Contemporary Meanings of Menstruation: Gendered Identities, Anxieties, and Lived Experiences of Rural and Urban Odia Women. (Indian Institute of Technology, Delhi, 2023).

21. Barnes, L. & Fledderjohann, J. Reproductive justice for the invisible infertile: A critical examination of reproductive surveillance and stratification. Sociol. Compass 14, e12745 (2020).

22. Mishra, S. & Kaur, R. “If I cannot give birth to a child, why would anyone accept me?”: Menstrual anxieties, late marriage, and reproductive aging. Asian J. Womens Stud. 27, 535–554 (2021).

23. McGovern, T., Maier, M., Naylor, N., Neff, A. & McNerney, C. Sexual and reproductive justice as the vehicle to deliver the Nairobi Summit commitments. 1–201 https://www.nairobisummiticpd.org/publication/sexual-and-reproductive-justice (2022).

Fledderjohann, Mishra, Rathi, & Vasudev, 8