Women’s health has been an area of interest and programmatic development especially since the latter part of the 20th century. International conferences during the last two decades and subsequent support of women’s health programs have raised awareness for the need to encourage the development of an appropriate agenda based on sustainability and equality inclusive of women. In particular, the International Conference on Population and Development (1994), as well as the Fourth International Conference on Women (1995) and the more recent Millennium Development Summit in 2000, have all contributed to the evolution of family planning and population reduction strategies towards a rights-based approach, including reproductive rights.

The focus of this paper is reproductive health and rights within the context of a broader based human rights agenda as related to the emergency situation in the Occupied Palestinian Territory (OPT). It includes breaches of these rights as a result of Israeli policies of closure on towns and expropriation of occupied Palestinian land. Reproductive health is a complex and multi-faceted issue that encompasses a number of components from a human rights perspective. Although ten key human rights have been identified, this paper will focus on four, namely:

The Right to Life, Liberty and Security The Right to Health, Reproductive Health and Family Planning The Right to be Free from Discrimination on Specified Grounds The Right to Not be Subjected to Torture or Other Cruel, Inhuman, or Degrading Treatment or Punishment

This paper will enforce the message that investments in reproductive health and related rights are crucial for progress towards ensuring basic human rights to reduce poverty, improve maternal and child health, prevent the spread of HIV/AIDS, promote gender equality, and ensure sustainable development. However, while the Palestinian Authority is trying to make measurable and tangible development strides in the OPT, the Israeli policy of closure and siege has limited this progress. For example, a significant amount of effort from the PA, supported by the international community has been exerted in the area of legal and structural reform in the health care system aimed at improving equity. Review of primary care programs in health that provide a more comprehensive minimum services package (curative and preventive, clinical and psychosocial care) has been shown to promote better health status. Increased attention and focus has also been on the Millennium Development Goals as a universal basis for the minimum platform of action. It is a signal that the PA is committed to upscaling its developmental efforts. Issues related to the current conflict are key to the right to development and to the rights of women, men and young people in every region to a better quality of life – for the Palestinian population as well as for the Israelis.

Though it is neither within the scope nor intention of this paper to provide a political analysis of the Palestinian-Israeli conflict, it attempts to show that peace is unachievable in isolation of the wider socio-economic context and rights-based approach. It will also show that women may be susceptible to increased vulnerability to a number of adverse health outcomes, whether physical, psychological or emotional as a result of breaches of the rights listed above.

Reproductive Rights Linked to Human Rights Agenda

Since the International Conference on Population and Development in Cairo in 1994, there have been a number of international conventions that support the reproductive rights approach and intimate connection between reproductive health, reproductive rights and human rights and development. As a result, the declarations of human rights and conventions listed below have come to recognize women’s health as a human right including the:

Universal Declaration of Human Rights Civil and Political Rights Covenant Rights of the Child Covenant The Economic, Social and Cultural Rights Covenant Covenant on the Elimination of Discrimination Against Women Global Convention Against Racial Discrimination International Conference on Population Development Program of Action Beijing Fourth World Conference of Women Program of Action Millennium Development Summit These conventions and declarations, made in the last two decades, attest to the fact that human rights have become a high priority issue among nations.

Access to Appropriate Reproductive Health Care, Rights and the Israeli Occupation

Today, poor sexual and reproductive health is a leading cause of death and disability in the developing world. It limits life expectancy, hinders educational attainment and diminishes personal capability and productivity, thus affecting economic growth and poverty reduction. (1)

In most industrialized nations, maternal mortality rates average 5-6/100,000 live births. In less developed countries, the rate may be as high as 1,000 or more maternal deaths for every 100,000 live births. Though the OPT’s official maternal mortality rates are relatively low at 13/100,000 live births (2), it seems highly unlikely when reported rates from the Palestinian Central Bureau of Statistics Health Survey 2000 were estimated at 70-80/100,000. (3) According to WHO, delays in delivery care that are major causes of maternal death include delays in reaching a health facility and delays in receiving care at a health facility. They are two critical potential contributing factors to the exposure to risk of death as a result of checkpoints and other military blockades. Since the beginning of the Intifada in September 2000, a recorded 69 births at the checkpoint have occurred. (4) Checkpoints have exposed women to cruel and inhumane treatment as well as discrimination based on their nationality. More tragic still is the number of women who go unrecorded; those women whose physical and psychological trauma is never counted in the official statistics. These are just statistics which do not convey the full tragedy a family faces when a mother dies during childbirth. This is a double tragedy since these deaths are not only a breach of the right to life, liberty and security, but also, for the mot part, preventable.

The World Bank estimates that ensuring skilled care in delivery and particularly access to emergency obstetric care would reduce maternal deaths by about 74 percent globally. (5)

Benefits of Investing in Reproductive Health and Rights

Good reproductive health enables couples and individuals to lead healthier, more productive lives, and in turn to make greater contributions to their household incomes. The health benefits of these investments are well known, well documented and substantial. They include the prevention of deaths due to HIV/AIDS, certain cancers, complications of childbirth and unsafe abortion; the prevention or reduction of conditions such as obstetric fistula and other sexual and/or reproductive illnesses and disabilities; better nutritional status and decreased risk of anemia for women; and increased survival rates and better health for infants. In such cases, it makes good sense for both the Palestinian Authority and the Israelis to safeguard these rights for protection of their respective societies. When women (and families) prosper, the likelihood of stability, individual, domestic and political, is far more likely.

Status of Women in Palestinian Society

Palestinian women of all ages and social classes represent half of the Palestinian population - 1,425,177 women of a total 2,895,683 residents in the West Bank and Gaza Strip. They have challenged their socially-defined gender roles through their political participation, including involvement in marches and demonstrations (at times even serious confrontation with the Israeli army) and in grassroots organization to fill the gaps in social services in the West Bank and Gaza whether under the rule of Egypt, Jordan, Israel or the Palestinian Authority.

Selected socio-demographic indicators illustrating the status of women’s health in Palestine:

Literacy Rate 1 87.4 % Participation Rate of Women > 15 Years in Labor Force 2 12.8 % Average age of marriage 3 18.7 years Received Antenatal Care 3 80 % Life Expectancy 3 73.8 years Fertility Rate 3 3.89 Marriage Rate 3 6.5 per 1,000 population Mothers who completed elementary school 3 5 % Mothers who completed the preparatory school 3 16.4 % Mothers who completed secondary school 3 66.5 % Mothers who completed university 3 11.5 %

Palestinian Census Bureau of Statistics, 2003. Palestinian Census Bureau Labor Force Survey Results (January – March, 2005). Health Status in Palestine – Ministry of Health Annual Report 2003.

Moreover, health concerns such as sexually transmitted disease, especially HIV/AIDS that transcend borders and political barriers, which are risks to both populations should warrant rigorous and collaborative motivation to curb the spread of infection. However, the OPT and Israel both have relatively low prevalence rates (there are only 69 reported cases of HIV/AIDS in the West Bank and Gaza according to Ministry of Health data from December 2004). (6)

The issue of domestic and gender-based violence (GBV) is also critical to the status of women’s health. Although domestic violence and GBV exist in every society, there is little documented evidence on the incidence in the OPT. However, health service providers have noted anecdotally that the incidence among the Palestinian and Israeli populations is rising. It would be far-fetched and irresponsible to blame such a complex issue solely on the violence perpetuated by the occupation. However, recent research in the OPT has found that “exposure of children and their parents to political violence is the strongest predictor of violence in the family – between spouses, against the children and among siblings.” (7)

Including family planning and other reproductive services in a minimal services package at the primary care level has been shown to be a cost-effective method of promoting better health status in general. These investments result in more relevant and cost-effective programs with greater impact. By using the same services, the same health workers and the same infrastructure—and investing in training, and upgrading facilities and equipment—we can scale up responses that are so urgently needed to improve maternal health, decrease child mortality, prevent HIV infection and provide HIV counseling, treatment and care.

A study in Mexico found that for every peso the Mexican social security system spent on family planning services between 1972 and 1984, it saved nine pesos in expenses for treating complications of unsafe abortion and providing maternal and infant care. In Thailand, every dollar invested in family planning programs saved the government more than US $16. Even more dramatically, an analysis in Egypt found that every dollar invested in family planning saved the government $31. This projection included government spending on education, food, health, housing, and water and sewage services. (8)

But as striking as these numbers are, the personal, social and economic benefits of reproductive health services may be even more important. These benefits are extremely important for human welfare and economic development. They include improvements in women’s status and greater equality between women and men, as well as benefits at the individual, household and societal levels.

Where mortality is high, parents are likely to have more children, but invest less in each child’s health and education. It is also known that chronic disease, poor health and low productivity discourage foreign direct investment in business and infrastructure. It is also true that reproductive health investments, in particular family planning, can produce what is called a demographic bonus. This is spurred by lower rates of fertility and mortality, and a large healthier working population with relatively fewer dependents to support. If jobs are generated for the working population, this bonus results in higher productivity, savings and economic growth.

What Can Be Done?

It is important to invest in sexual and reproductive health, as part of an overall effort to strengthen health systems and improve public health free from discrimination and based on the right to life for all people. We need to further strengthen the partnerships, especially among professionals and member of the international and Palestinian and Israeli civil society to ensure that information and services are expanded and scaled up to reach all people, especially those with the greatest need.

We must work to see how we can better support women and girls and couples to fulfill their aspirations, to avoid unintended pregnancies, to prevent HIV infection, to combat gender-based violence and to ensure healthy pregnancies and safe deliveries by upholding universal human rights and speaking out on injustices no matter who the perpetrator. In working together side-by-side, such universal aspirations will hopefully be adopted to galvanize increased political commitment and resources for a more prosperous society.

Laila Baker has been working for the last 14 years throughout the Middle East and North Africa. She has been with the United Nations Population Fund in Jerusalem for the past five years. Laila earned her BSc. in BioChemistry from Bir Zeit University in Ramallah, Palestine and received her Master's in Public Health from Cardiff in the UK.

References:

1  UNFPA. State of the World Population Report. September, 2004.

2) State of Palestine Ministry of Health, Health Information Center (PHIC). Health Status in Palestine: Ministry of Health Annual Report, 2003.

3) Palestinian Central Bureau of Statistics (PCBS). Health Survey, 2000.

4) OCHA Update. April, 2005.

5) Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AM, Rosenfield A. Transforming health systems to improve the lives of women and children. Lancet, 2005 Mar 12;365 (9463):997-1000.

6) UNFPA. Country Office Annual Report. December, 2004.

7) Sinai R. (2003, December 1). Humiliation can scar a boy for life. Ha’aretz.

8) UNFPA Intranet. Statement of the Executive Director. April, 2004.