A mother’s risk of dying during childbirth is much higher in poorer countries than it is in the developed world. Last year in Nigeria alone, 58,000 women died giving birth, including some who did not choose to be pregnant. Experts say many of the hundreds of thousands of deaths during childbirth each year could be prevented if women had access to family planning. They also believe these figures could be much higher, due to problems of data collection. In addition to improving healthcare in the poorest communities, the NGO EngenderHealth is working to provide women and girls with access to reproductive health services in remote areas.
Ulla Müller, president and chief executive officer of EngenderHealth, said the organization takes a human rights-based approach to tackling women’s health issues. It advocates for policies that provide women with contraceptive choices and calls on men to act against gender-based violence and HIV infection through efforts to promote better health for their families. Müller, who spent 20 years in Africa, spoke to Women and Girls Hub about what she is witnessing in efforts to empower women with knowledge of their reproductive rights.
Women and Girls Hub: EngenderHealth advocates a human rights-based approach to its work. What does that mean in practice?
Ulla Müller: Basically we put the power in the hands of the women, and, to some extent the communities, while recognizing that human rights are individual, not collective. We focus on that empowerment piece, empowering women, putting some context around why they have this choice and what other choices they have. It is not only about women’s choice: husbands have different freedoms to choose. It is a continuum, but it is putting power in the hands of the women.
The challenge is you cannot just walk into a community and say, “Here are your rights.” Rights are not something you give people. It’s a framework that you provide. You can’t just go in and say to women, “You choose!” But you really have to focus on what it means. There is a full spectrum of challenges that affect whether they get what they want from family planning. I’ve seen in Africa very often that women feel they have to choose when we go to them. But then we limit their choice: no children, these methods, or many children. We box it. Engender Health is opening it up, taking it out of the box, explaining that opportunities open up when you make that choice.
Women and Girls Hub: What are your priorities going forward?
Ulla Müller: We have to stop talking about change and accept that change is pretty much a word of the past. We have to just say that’s normal today: constant evolution, embrace it and work with it.
I know that is quite a statement when you look into Africa, where I am right now, because a lot of people will argue that in large parts of the continent there’s no evolution there. But no matter how rural you get, even in Africa, there will be a mobile phone, usually a smart phone. That’s really an indication that actually the world is evolving even in the poorest communities. The sad thing is that we don’t ensure that they can catch up in terms of prosperity even though the world is evolving around them. It is important that we deliver quality reproductive health services in the future, and that we provide women with the freedom to choose. I do think reproductive health, particularly family planning, provides women with a platform and the freedom to freely choose what they do, and empower them to claim their rights.
Women and Girls Hub: You noted the perception that not much changes in Africa. On the issue of maternal mortality, why does there continue to be a substantially disproportionate burden on Africa?
Ulla Müller: A lot of it is born out of the culture where it is a traditional value to have many children. While we were very successful in reducing child mortality in the countdown to MDGs [the Millennium Development Goals] in 2015, along the way we forgot to talk about what that means to families who need surviving children because children died, because they were such an important part of the social safety net for many years. Becoming more focused on women dying where they shouldn’t without talking about why it’s not necessary to have so many children means that culturally we haven’t worked to change that value set. Then we only talk about the health perspective of it, but maternal health goes beyond the health sector. Its impact is broader. In many places, women are sadly just not that important. Women are the last ones to eat in the family. Women very often feel they shouldn’t be spending what little savings the family has on their own health. Government investments go toward infrastructure and logistics to secure trade, which is a smart investment but means that social sectors are neglected. When resources are scarce, women just drop in that list of priorities.
Women and Girls Hub: Why is there still so much unmet need even for women who recognize they need better resources?
Ulla Müller: That comes back to how do we allocate resources in a world of scarce resources? Also, stigma and cultural values are barriers toward the uptake of family planning, going back to the perception that we need to have many children as part of our social security system. If we don’t change that value set, we won’t change it around.
The two key investment areas that I cannot emphasize enough are family planning and education. This is the Catch-22. We know education will drive lower fertility rates. On the other hand, if we get girls into schools, they drop out without access to family planning. Then you often see girls as young as 13 or 14 years becoming pregnant, moving into early marriages, dropping out of school and they never finish. There have to be parallel efforts.
Family planning has to be a priority in investment budgets, but it drops down on the list because a lot of money is spent on training midwives and the capacity of health service providers. It’s important, but the challenge of family planning is that no matter how fast we train midwives, the need outpaces us. We cannot ensure enough safe deliveries, and a key driver of safe delivery is spacing. There is a perception that family planning is expensive, but it isn’t – because the major commodities are donated by USAID [the United States Agency for International Development] and UNFPA [the United Nations Population Fund], and to some extent DFID [the U.K. government’s Department for International Development] is becoming a big actor in this, but family planning is culturally not the norm.
Women and Girls Hub: How did you get involved with women’s health and family planning issues?
Ulla Müller: Quite some years back I met a very young girl in Mozambique who was 16 and had a child, so that means she was pregnant when she was 15. What happened to her is that she gets pregnant, gets kicked out of school – and it is always the girl who is considered immoral, a bad influence on everyone – this happens in Mozambique, but also across the continent, she is forced to marry the young man. Then she has to move into his family home. Because there are two extra mouths to feed, she has to do all the chores because she has to pay back. What this does is it leads to a series of human rights violations. We don’t talk about that. Not only is she deprived of her right to education, deprived of her right to freely choose her spouse – I know we don’t like the wording of what I’m about to say next – but we deprive her of her right to a life free from slavery. What she is doing in her in-laws’ house is a modern form of slavery, it’s unpaid. We deprive her of her full dignity, deprive her of her right to develop her full potential, to go out there and become an economic decision-maker, to make her own decisions about her own life. That is what starts by denying proper family planning to young girls. It’s a cycle and we have to break it. In addition to health outcomes, we would reduce maternal mortality probably by 20-25 percent by just making family planning available, we could stop a series of rights deprivations. It is one of cheapest interventions we can make.