Women and health: How far have we come since Beijing?

Emerging themes and issues: Gender as a social determinant for health
Achievements: The Beijing Platform for Action has been the most comprehensive road map for the achievement of gender equality and women's empowerment for health so far. It has been followed by a number of declarations and goals, the most prominent of which are the Millennium Development Goals adopted in 2000.
Challenges: A few participants raised concern that a gender mainstreaming (GMS) approach in the health system has not been working as it should, or as it does in other sectors. Reasons raised for this included a lack of adequate understanding of GMS and insufficient training on GMS methods and approaches among and for health-care professionals, senior managers of health systems and health related policy-makers. The lack of understanding was thought to contribute to health provider disinterest or apathy when dealing with women as they may perceive this to be the point of gender mainstreaming. Furthermore, they may perceive women-focused services to be unjust.
Gaps: Gender inequality and a lack of respect of human rights for health are evident in every stage of a woman’s lifecycle.
Good practices: A conceptual framework has been proposed by the WHO Department of Gender, Women and Health to guide women and health programming. It is based on four pillars - gender equality, human rights, a life-course approach and engagement of men as partners - and open for discussion.
Recommendations: Health professionals need training to comprehend the concept of gender
mainstreaming and imbibe it into their daily work. In addition, men should be engaged as partners in taking forward the women’s health agenda.

Emerging themes and issues: Making health systems work better for women
Achievements: There has been a paradigm shift from a singular focus on curative medicine to mixed approaches that combine curative and preventive/promotive medicine, including for the health of women.
Challenges: It was highlighted that health systems in most developing countries were not yet geared to face the transition from infectious to noncommunicable diseases.  
Gaps: Health financing and health workforce planning are not based on gender equality and women’s needs. Marginalized women of all types lacked access to health care in most countries.
Good practices: National commitments towards taking forward women’s health seemed to be the single  most important factor for success of women’s health programmes. This would also ensure that a major  portion of a country’s gross domestic product was assigned to women’s health.
Recommendations: Women need to be appointed in positions of power to make decisions about health system reforms to improve women’s health; reform decisions are still controlled by men.
 
                                                                 

                                                       

Emerging themes and issues: Women and humanitarian emergencies

Achievements: The Inter-Agency Standing Committee (IASC) on humanitarian assistance has brought UN and non UN partners together to produce a set of guidelines on mainstreaming gender in emergency situations. Using gender experts in this initiative has shown success. 
Challenges: All kinds of humanitarian crises increase the vulnerability of women, adolescent girls and girl children. Their access to critical health-care services is often reduced and their exposure to sexual and other forms of gender-based violence (SGBV) is increased, often coming from aid workers themselves.
Gaps: Gender analysis and sex-disaggregated data is rarely available during humanitarian emergencies. Hence, the ways the responses are designed and funded seem to suffer.
Good practices: Since 1997, the Minimum Initial Service Package (MISP) has been the standard of care for reproductive health care in emergency settings. Practitioners are educated on how to implement the MISP standard on the ground. 
Recommendations: During humanitarian emergencies, aid workers need to protect women and girls from sexual and gender-based violence and nutritional deprivation by bringing more women and women organizations into the relief work. Attention to mental health and trauma after a humanitarian event is warranted especially for the adolescent girl and girl child.

Emerging themes and issues: Women and climate change

Achievements: The debate on the impact of climate change on human health is taking up global
attention more than before Beijing. In 2008, 193 WHO Member States voted at the World Health Assembly to pass a resolution that called for greater WHO support and stronger engagements by countries in relation to climate change.
Challenges: Common causes of death such as urban pollution, diarrhoea, lack of clean water and poor hygiene all become more unmanageable in higher temperature conditions resulting from climate change. There appears to be a negative correlation between trying to mobilize international political will for climate change and the poorest families becoming the hardest hit. This is because they need more energy to survive and release greenhouse gases.
Gaps: Women often lack basic survival skills such as swimming or climbing trees, and their flowing clothes often restrict mobility. This could have been one of the factors that put women at a disadvantage during disasters resulting from climate change (e.g. Tsunami in 2004).
Good practices: Good practices that could be beneficial include distributing 150 million improved stoves in India. This could reduce black carbon emissions and deaths of women and children caused by indoor air pollution. Two million lives could thus be saved from acute respiratory infections.
Recommendations: Poor women need to be given permission to increase their energy use and
greenhouse gas emissions so that they are not subject to unjust compromises to limit climate change. To understand the implications of climate change, it is advisable to collect and analyse data disaggregated by sex and age, together with other stratifiers

Emerging themes and issues: Women and influenza

Achievements: Presently, the different types, classifications and nature of spread of influenza are quite clear. There is now vaccination and treatment for most of the strains including the newly emerging types of influenza H5N1 and H1N1.
Challenges: H1N1 Influenza is a challenge because its complications can lead to death and are affecting the relatively healthy and younger age groups and not necessarily the immunologically weak.
Gaps: There is a big knowledge gap on influenza, sex and gender. Also the differences in incidence, morbidity and mortality between men and women are not yet clear. Data disaggregated by age and sex is lacking. There has been no systematic data collection on treatment outcomes and safety during pregnancy.
Good practices: Norway decided to distribute antiviral medication over the counter for a limited period of time to reduce the burden on primary health care and increase access for patients.
Recommendations: Current recommendations are to treat pregnant women with influenza-like illness with antivirals. It is important to systematically gather knowledge from pregnant women who are taking antivirals during epidemics. This will help further research.
 
                                                                 

                                                       

Emerging themes and issues: The health of adolescent girls

Achievements: At present, sound public health, economic and human rights reasons have been
established for investing in the health and development of adolescent girls. 
Challenges: Early marriage, sexual exploitation, abuse and intimate partner violence still affect
adolescent girls 15 years after Beijing. Maternal mortality remains five times higher among 15-19 year old girls than 20-24 year olds. Death from unsafe abortion remains four times higher among adolescent girls than among adult women in Africa.
Gaps: Adolescent girls (and the especially vulnerable) do not yet have access to both primary and secondary education, including comprehensive skills-based sexuality education and services. Policymakers and parents are still against giving these human rights to adolescent girls for reasons of cultural beliefs. Very little data is available from developing countries on mental health, substance use, diet and physical activity of adolescent girls which lead to chronic health problems.
Good practices: There have been bold local efforts to tackle gender-based violence through community based interventions engaging boys and men in South Africa and Brazil. Small projects, in India and other countries, have demonstrated interesting results tagging income generation with health and sexuality education for adolescent girls.
Recommendations: Policy-makers should be informed about the fact that for a comprehensive agenda for girls it is estimated that a complete set of interventions, with health services, communities and schools, would cost about US$1 per day for each girl in low- and low-middle income countries.

Emerging themes and issues: The health of older women

Achievements: There is enhanced knowledge about the health conditions of older women, and leading causes of death have been identified. Also greater attention is being paid to the abuse of older women as a public health problem.
Challenges: As older women are often the caregivers of their ailing spouses, children or grandchildren, due to economic, social and health burdens, they often suffer from burnout and depression. Older women are also more likely to suffer from dementia, osteoporosis and vision loss compared to men, and diagnosis of certain diseases in women remain a challenge.
Gaps: There are no sex-specific treatment guidelines because of under-representation of women in mixed sex clinical trials. 
Good practices: WHO has developed the Age-Friendly Cities Programme. This is an international effort to help cities prepare for the rapid ageing of populations and increase in urbanization. The programme targets the health and well-being of older adults and assesses the environmental, social and economic factors that influence their health and well-being. Home-based care with minimal intervention has been successful in sub-Saharan African countries with HIV/AIDS populations. 
Recommendations: Older women need to be included in clinical trials to have age- and gender-specific treatment guidelines. Acting on the gender determinants of health throughout the life-course, with a preventive approach, could reduce the long-term treatment costs for health problems of older women


                                                                 

                                                       

Emerging themes and issues: Maternal health

Achievements: MDG 5 remains the foremost global advocacy and action objective which has become a constant reminder to expedite the reduction in maternal deaths worldwide. There have been unprecedented commitments by world leaders in recent years - US$5.3 billion for innovative financing mechanisms for global health and stronger health systems for maternal, newborn and child health (MNCH). Dr Margaret Chan, WHO Director-General, has launched the MNCH Consensus to achieve MDGs 4 and 5 - a framework for action and accountability.
It is now known that the most important interventions to save maternal lives are access to skilled birth attendants, timely emergency obstetric care, postnatal care for mothers and babies, and access to reproductive health services. Family planning, safe abortion/post abortion services and all reproductive health services should be adolescent friendly. 
Challenges: The most important causes of maternal death from childbirth are severe bleeding (24%) out of which postpartum haemorrhage (PPH) remains the most crucial, infections (15%), unsafe abortions (13%), eclampsia (12%), obstructed labour (8%), other direct causes (8%) and indirect causes including violence against women (20%). Maternal nutrition, micronutrient supplementation and management of diseases in pregnancy such as HIV, TB, malaria, hypertension/eclampsia, diabetes and postpartum depression need greater attention. Better infrastructure and human resources, both in quality and number, are urgently required.
Gaps: Data on the actual number of maternal deaths and their causes are missing and this is an
important loophole for measuring progress. In countries where MMR has been reduced, there may still not be adequate access to hospital delivery and technology. This is because of an imbalance between abuse of invasive procedures (too many caesareans/episiotomies) in some countries and serious lack of timely care in others (inadequate obstetric surgeons or facilities).
Good practices: Some countries that have started making progress for MDG5 very recently such as India (maternal mortality ratio being down from 327 to 256 in 2009) used additional interventions such as setting up blood storage centres in first referral units (FRUs) and blood banks in district hospitals as well as financial incentives for those below the poverty line to go for institutional delivery. Supported by WHO, they have also started maternal death reviews.
Recommendations: Data on the actual number of maternal deaths and their causes need to be
documented urgently. Furthermore, indirect causes of maternal death such as from gender-based violence need to be included in the statistics. To achieve MDG 5 (and 4) by 2015, it has been estimated that US$30 billion of new investment is required. Greater political leadership, community engagement and mobilization, with accountability at all levels, are required to achieve credible results.

Emerging themes and issues: Unsafe abortion

Achievements: There have been legal reforms in some countries such as Pakistan where, in addition to saving the life of a mother, grounds for abortion now include “necessary treatment”, though this term is yet undefined. Regardless of the legal status of abortion, different activities have been identified in advocacy efforts. WHO’s “Safe abortion: technical and policy guidance for health systems” is an essential guide to provide safe, comprehensive abortion care to the full extent of the law so as to benefit women.
Challenges: Some challenges specific to eliminating unsafe abortion are destigmatization of pregnancy termination; training for health-care providers in safe abortion methods; and supportive health system policies, apart from general challenges of health and related education for women that apply here as well. Other challenges include planning "wanted" pregnancies; preventing unwanted pregnancies; and safely ending those that occur from forced or coerced sex, failed or unavailable contraception or fetal
malformations. Most crucially, legalizing abortion is another challenge, a step which those in positions of influence often evade, even though compelling evidence demanding attention and action exists.
Gaps: The international community limits their advocacy to cautiously recommending that abortion should be safe “when legal”. Technologies for safe abortion (including vacuum aspiration and medical abortion) are often not available, accessible and affordable. 
Good practices: The WHO report “Women and health: today’s evidence tomorrow’s agenda” released in November 2009, highlights the fact that studies have shown that where there are broad legal grounds and access to safe abortion, mortality and morbidity are considerably reduced. A significant modification reported from India is that medical abortion should not be denied irrespective of a woman's decision to initiate postabortion contraception.
Recommendations: Governments, policy-makers and health-care providers must be urged to remove regulatory and other barriers to safe abortion. There is an urgent need to provide safe abortion services globally as evidence is compelling that safe abortion services can save maternal lives.

Emerging themes and issues: Contraception

Achievements: The contraceptive prevalence rate for modern contraceptives has considerably improved in many countries since Beijing (reported from Pakistan).
Challenges: There is an obvious gender bias when it comes to permanent birth control methods in many countries. The tubal ligation which is performed on women is more popular than the vasectomy for men (reported from India).
Gaps: Information on contraceptive methods and their correct use is still widely unavailable to adolescent girls (and boys) because sexuality education is still a taboo in many developing countries (reported from India and Costa Rica).
Good practices: The United States Congress recently appropriated more than US$648 million in foreign assistance to family planning and reproductive health programmes.
Recommendations: The concern expressed by women for their future fertility preservation should be capitalized upon while developing advocacy messages to improve the appropriate use and uptake of contraception and to adopt healthy sexual and reproductive health behaviours. As in many societies, this is perhaps most applicable within the context of Africa and other developing countries where a woman’s worth is strongly judged by her ability to bear children. Ensuring access to voluntary family planning could reduce maternal deaths by 20 to 35 per cent (and child deaths by 25 per cent) according to UNFPA.

Emerging themes and issues: Infertility

Achievements: Infertility management has made rapid progress globally, especially with the greater acknowledgment of the role of men along with women in this disease of the reproductive system, and the emphasis of the link between infertility and the need for the prevention of sexually transmitted infections.  To give access to underprivileged women/couples in resource poor countries, infertility specialist
societies/communities in partnership with WHO have been discussing good practices in relation to reducing the costs for assisted reproductive technologies. 
Challenges: High cost of advanced infertility management (especially assisted reproductive
technologies), health insurance not covering assisted infertility treatments and public health systems not providing sophisticated treatments remain major barriers to gender equity and universal access to care for the infertile. Monitoring and surveillance of the health and well-being of women prior to and/or when they become pregnant, and also that of the child(ren) born, through assisted reproductive technologies. 
As women age, their ability to reproduce decreases at a more significant rate than in men, yet women are delaying their childbearing,and rates of childlessness are increasing in developed and developing countries. 
Gaps: Education about infertility causes, prevention and forms of interventions is lacking. Infertility can be classified as a social issue which results in women being subjected to stigmatization and divorce. Men often require encouragement to recognize their responsibility in an inability to father a child (infertility is often referred to as a women's problem) and mechanisms are needed to encourage men to adopt healthy sexual and reproductive health-seeking behaviours for fertility preservation. Evidence and guidance are lacking on infertility interventions in resource poor settings. Recognition of the fact that any successful intervention results in pregnancy demonstrates the clear need to link infertility care management with both family planning, as well as maternal and child health care. 
Good practices: In some cases, the HIV-positive discordant couples may now have access to simple and affordable techniques such as sperm washing and other medically assisted reproductive interventions. 
Recommendations: There is a need to make infertility prevention and management available at the primary care level. For this to be successful, it would be appropriate to share infertility management tasks between the doctor, the midwife and the community health worker. Costs of assisted reproduction technologies, without jeopardizing quality of care, have to be drastically reduced to increase access in resource poor settings.


Emerging themes and issues: Harmful practices such as female genital mutilation and forced marriage

Achievements: The international community has accepted that female genital mutilation (FGM) is a violation of a series of human rights, and principles and the silence around it has been broken.
Challenges: FGM, a practice deeply rooted in culture, is still surviving because communities feel it serves some purpose. More than 18 percent of all cases of FGM are performed by health-care professionals.
Gaps: Governments have no system of monitoring the spread and practice of FGM.
Good practices: 17 African countries, including Uganda very recently, have legislated against the practice in their national laws. FGM has been delinked from religion - Islam and Christianity - through workshops organized by IAC and documents published by the Population Council that highlight this point.
Recommendations: Advocate with governments of practising countries to legislate where there is no national law and to implement and enforce where a national law exists. However, legal instruments cannot do it alone. There needs to be some reporting back from medical professionals whenever they come across a girl who has undergone genital mutilation or is at risk. A suggestion was to have medical genital examinations in pre-primary or primary school children to help identify FGM and sexual abuse.
 
                                                                 

                                                       

Emerging themes and issues: women and cancers

Achievements: In many developing countries and especially in African countries, there is more national commitment to combat breast and cervical cancer than before Beijing. Breast Cancer Day is regularly observed to encourage women and girls to go for screening/checkups while there is widespread information, education and communication about cervical and breast cancer. 
Challenges: Cancer continues to kill women in high numbers; yet talking about it is still a taboo in many countries such as the United Arab Emirates. Human Papillomavirus (HPV) vaccination is too expensive for most families to access it (e.g. reported from Kenya where cervical cancer is a big killer).
Gaps: Screening tests such as Pap smear (for cervical cancer) or mammography (for breast cancer) are not accessible to most women. In some countries such as the United Arab Emirates there is no centralized cancer registry and so it is difficult to get up-to-date information or perform evidence-based services or awareness campaigns about cancer.
Good practices: Friends of Cancer Patients (FOCP) Society in the United Arab Emirates includes
women living with cancer or who have cured their cancer (thanks to advocacy and education efforts), which gives hope and boosts the morale of others in a positive way. Hospice, an NGO in Uganda, provides free services to women with terminal diseases like cancer and ensures that they die with dignity and less suffering.
Recommendations: In the absence of mammography and Pap smear tests, breast self-examination and visual inspection with acetic acid (VIA) should be available and accessible methods for detecting breast and cervical cancer (reported from India). 

Emerging themes and issues: Women and diabetes

Achievements: Various initiatives are raising the profile of women and diabetes as a priority issue on the global health agenda. The International Diabetes Federation’s (IDF) new women and diabetes programme is part of this movement, which builds awareness, the evidence base, capacity and political commitment towards women and diabetes.
Challenges: Neglecting the vicious cycle of poverty, food insecurity and malnutrition in girls and young women can cost heavily by their giving birth to low birth weight babies later in life, who will be at higher risk of developing type 2 diabetes in their lifetime.
Gaps: There is a lack of consensus around diagnostic criteria for gestational diabetes mellitus (GDM) causing a controversy around screening protocols. Despite GDM being a public health issue of great importance, at present there is a paucity of GDM prevalence data. Awareness about the complications associated with diabetes in pregnancy and the necessity of planning for it beforehand is poor.
Good practices: The International Diabetes Federation (IDF) recently launched the first Global
guidelines on pregnancy and diabetes. This is the first time there has been worldwide consensus about the identification, treatment and management of the pregnant woman with diabetes.
Recommendations: Investing in the nutrition of the girl child could improve the health of millions of infants by breaking the vicious cycle of giving birth to low birth weight babies who are at higher risk of developing type 2 diabetes.
There needs to be an agreed set of diagnostic criteria for GDM so that its prevalence can be accurately assessed. Offering women services for diabetes during family planning and reproductive health care (including antenatal care) is a missed opportunity. It would, however, help reduce mortality from diabetes in the mother and the child

Emerging themes and issues: Women and mental health/substance abuse

Achievements: In recent years more attention has been paid to the human rights aspects of women’s mental health.. Efforts have been made to prevent the risk factors and make mental health services more available and accessible to women at the global level. However, universally accepted principles need to be applied at the country level with due consideration of the local culture. Launching of WHO's mhGAP action programme in 2008 by the WHO Director-General provided an opportunity for scaling up mental health services, and this would provide better access for women as well.Increased attention to smoking patterns among women across ages has yielded important information that can be used in health promotion and illness prevention campaigns.
Challenges: WHO assessment instruments show that women have greater needs for services in middle-and low-income countries yet have far less access to them than men.
Smoking increases the danger of cancer of the lungs, chronic obstructive pulmonary disease (COPD) and heart disease in women and reduces the birth weight of the newborn, if continued during pregnancy.
Gaps: Women are disproportionately hit by Alzheimer's disease and dementia. Yet services are underresourced in high-income countries and almost absent in low- and middle-income countries. Violence against women and rape and its subsequent lack of attention from the authorities is a major cause of depression among women in some countries in Africa (reported from Uganda). In many countries (including in high-income countries) mental health services are less accessible to marginalized populations. On top of that, linguistic and cultural barriers remain for ethnic minorities. 
Good practices: WHO has started its "maternal mental health" pilot programme in Eritrea and completed needs assessment for the same in Nigeria and Ethiopia. Suicide prevention pilot programmes have also started in Asia targeting control of pesticides (facilitating suicide) among rural women. In all abovementioned programmes (including mhGAP), women have been involved at different phases from planning to implementation. Alzheimer's Disease International (ADI) is campaigning for more awareness, recognition and local solutions for better services in every country.
Recommendations: More attention needs to be paid to women-specific conditions such as postpartum depression.   Women who are not thinking of quitting smoking should be made aware of and educated about the pros and cons of quitting versus continuing smoking. In addition, those who quit would require ongoing support so as not to restart smoking.

Emerging themes and issues: women and disabilities

Achievements: After considerable advocacy, disability is now being considered as a condition and not a disease (even though it may occur as a consequence of a disease).
Challenges: Measuring progress remains a challenge as there is hardly any documentation about women with disability (WWD) and girls with disability (GWD) at the country level.
Gaps: State or NGO reports seldom mention WWD/GWD. WWD have much less access to assistants, sign language interpreters, information, buildings and facilities, guides or other support services compared to men with disabilities. There are gaps between human rights obligations towards WWD and the reality of many legal systems.
Good practices: Struti Disability Rights Centre, an NGO in Kolkata, India is strongly advocating to the local authority to document and act on the cases of violence against disabled women.
Recommendations: All governments that have ratified the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) and the Convention on the Rights of Persons with Disabilities (CRPD) should address the needs of WWD and GWD in their national policies and programmes. In particular, they should meet their needs concerning health care, both primary and advanced care, and secure informed consent from WWD/GWD before any treatment.

                                                                 

                                                       

Emerging themes and issues:

The participants thought that the discussion was useful and most of them would use the knowledge that they gathered in their daily work. About 50% preferred the daily digest and the other 50% preferred immediate e-mails as mode of communication. All except two participants thought that the technical content and the way the discussion was conducted were the best possible. Two participants thought it could have been better if the discussion had been announced much earlier. There would have been many more participants. Participants would also have preferred to being asked in the beginning about their expectations. But they understood that time was short compared to the vast scope of discussions.

Early on in the process, one of the participants sent out the weekly summary to relevant directors of her region (Asia) and these responded promptly by instructing their departments to include gender analysis in all programmes.

There was a strong demand from the participants of the discussion community for a progressive world order for the health of women. They denounced the negative attitudes of male decision-makers that halted progress and made the agenda move backwards. They thought there was a dual standard when it came to issues that concerned only women such as unsafe abortion, maternal health or contraception.

Health service providers needed to be sensitive to the needs of women across their life-course, including older women, women with disability, adolescent girls, most-at-risk groups of women, HIV-positive women, migrants, refugees, IDPs and widows.

With the global gag rule not in operation, it was time to move forward with legalization of abortion where possible, or alternatively, at least decriminalization of abortion.

The national governments and their development partners had to exercise leadership to end harmful traditional practices such as FGM, child marriage, female foeticide/infanticide and sexual and gender based violence against women as all of these were causing harm to the physical and mental health of girls and women.

Natural disasters, climate change and influenza epidemics needed to be brought into the health paradigm.

National policy-makers and health planners needed to mobilize communities and hold all stakeholders accountable. If gender was mainstreamed into their accounting and data collection, analysis and reporting, evidence-based decision-making would allow to give women and girls their human right to health.

There were sound political, social and economic reasons to invest in the health of a woman over her lifecourse, i.e. the girl child, the adolescent girl, the adult woman and the older woman. The financial loss from not doing anything today was far larger than the economic loss in spending a tiny part of that amount today.

Donors were asked to stick to their promises and pool together US$30 billion that could help meet the goals of MDGs 4 and 5. It was thought that 15 years after Beijing, all policies that stood in the way of saving a woman’s life should be discarded and a new social order welcomed. This would be a grassroots movement where every woman would stand up for her rights to change the health of women for the better.

However, the agenda above could not be accomplished unless men and boys were engaged as partners. Only then would women indeed enjoy community norms and health systems that are gender-sensitive, culturally sensitive and based on human righ

                                                                 

                                                       

As the end of these two weeks approaches, we would like to address Fertility Awareness-Based Methods (FAM) in general. Are there any questions that as participants, you would like to see answered?

Full text daily digest
                                                                 

                                                       

1. Women's rights and the need for empowerment

• "It is a tragedy that women living with HIV and their allies still must advocate for their rights to bear children. Fortunately, attention to violations of this right has increased over the past years. Advocacy regarding the rights of HIV-positive women to not have unwanted pregnancies still lags behind, partly due to stigma and partly due to the reluctance of agencies to advocate for law reform in this area. It is striking that many organizations will advocate for law reform concerning issues that affect both men and women (e.g. regarding sexual orientation and gender identity, harm-reduction strategies, sex work) but not for an issue that only affects women—the right to prevent (emergency contraception) and end an unwanted pregnancy. It seems that a gender-based double standard is at work here."
• "While the girls are scared to death facing their pregnancy, no certain assistance empowers them to survive in antenatal care, labour and delivery, nor to [escape] having someone shouting loudly about the dangers of abortion. Being powerless, lonely and desperate, these girls easily fall prey to unsafe abortions. Most of the time we forget to treat them to fulfill their rights to grow as children, to protect them from mistakes, to respect them to [make] their choices and preferences differently from the parents; and we forget that the world of girls now is not the same as our world two decades ago…."  
• Regarding Canada: "There is an enduring myth that Aboriginal women are "easy"—meaning that they are continually confronted by sexualized violence that is rationalized by men in their own culture and within the wider society. This increases the likelihood of sexual assault/rape, which has repercussions for the higher rates of HIV/AIDS infection among these women. Some female patients I have cared for in a professional capacity have expressed feelings of shame when dealing with care providers who believe that it is the woman's fault that she was diagnosed with this illness. Aboriginal girls and women remain powerless members of their society. Without access to power within the household, and within their communities, they have no way to address the inequalities they must face every day of their lives."  
• "Less educated women, lesser economic [status] women, and lesser social status of the women—these lead to less bargaining power of women with men; including within marriage, when they are giving birth to the new generation. They don't have power to make decisions for the future child, for their own rights to health. Many women are afraid of being divorced if having no child; and many of them don't know their rights to health within gender equality and women's empowerment."  

2. Vulnerabilities in crisis situations

• "Anecdotal data point to several factors that contribute to the increased risk of women in emergency situations. From a general perspective, the breakdown of social networks and institutions resulting from forced population movements in conflicts reduce community cohesion and may disrupt important protection mechanisms for women and girls. Moreover, in the context of food insecurity and extreme poverty, women are also more likely to engage in transactional sex for food or protection, thus being vulnerable to increased risks of HIV and STI exposure, as well as unwanted pregnancies. They may also be subjected to sexual exploitation and abuse by those providing assistance."
• "Natural disasters deepen and intensify pre-existing gender inequalities, making it one of the many factors in the disaster vulnerability of women and girls. Lack of food, goods or cash due to a lack of access or socio-cultural constraints may force women/girls into prostitution, making them vulnerable to infection with HIV/AIDS or other sexually transmitted diseases. Gender norms that govern women’s/girl’s sexual behaviour may work to increase the spread of HIV/AIDS. Lack of shelter, due to ineffective analysis or planning post-disaster, impacts the safety and security of women/girls, increasing their risk of sexual/physical violence and having negative impacts on their mental and physical well-being. The unequal gender roles and responsibilities of women and girls are significantly taxed in disaster and conflict situations, straining the coping strategies and capacities of female survivors. Unwanted pregnancies, unsafe and complicated abortions, abandoned babies, rejection by family and community can potentially lead to increased suicide attempts. Lack of food and clean water, due to access issues or poor disaster management, also unfairly impacts the nutrition of women and their families, putting them at greater risk for malnutrition and disease (especially communicable diseases post-crisis). Lack of property or access to financial resources forces both women and girls to be dependent on men for support; without these resources they are subject to any number of physical, sexual and mental abuses. Lack of access to land, cash or other income-generating endeavours due to the invisibility of women’s/girl’s work also reinforces the poverty in which many of them live, putting them at even greater risk for disease or even death."  

3. Access to services

• "At the heart of this is the limited access to required heath care for the health problems that women often face. This limitation of access relates to the cost of health services, as women are more likely to be poor, unemployed, or engaged in part-time work or work in the informal sector, which often does not offer health benefits. Limited access also relates to autonomy, which is often restricted for women because of gender norms which shape a broader context of social inequality. Another health system issue relates to the way health services are organized and provided. Sometimes health services do not engender the trust to encourage women to make the first "toe in", and at other times issues relating to privacy, confidentiality and respect discourage women who have dared to utilize available services."  
• "It is unfortunate indeed that Costa Rica, a country that is widely respected for its contributions to international peace and environmental sustainability, continues to deny adolescents the right to receive comprehensive sexuality education and to deny women the right to control their fertility safely and effectively and to receive the highest attainable standard of sexual and reproductive health care."  
• "How come we are not focusing enough on working with the duty bearers who have the means and responsibility to ensure universal access to "any and everything" but continue to "flog" the women…the victims (and winners) in all of this? I don’t have all the answers but want to end by asking—Can we tell each other the truth really and freely? …Has that time come yet?"  

4. Violence against women

• "First, there are differences in men's and women's security and protection needs that need to be addressed. Women and girls are at higher risk for sexual and gender-based violence, exploitation and human trafficking. Domestic violence also tends to increase post-disaster. Protection initiatives should ensure that vulnerable populations have access to material assistance, comply with international law and deal with physical or safety and security issues."  
• "I can understand that so many people in many countries have been practicing FGM [female genital mutilation] or FGC [female genital cutting], even [though] there must be dangerous [associated] with this practice. Two days ago, when I was facilitating a communication training for women from the grassroots about this practice, they said that they had practiced FGC or FGM since very long ago. I asked them if there is a risk with this practice; they then answered there is no problem with us. I was then silent to hear that. So, I just continued and said that, based on health, it is dangerous? It makes me ask myself, what about the daughter? What about the Muslim community, who still also practice this?"  
• "Therefore, to nullify such "blind" socio-cultural arguments, it is important for the international community to continue to advance arguments specifically related to the negative implications of FGM on the health of women, girls and their unborn children. Unlike other forms of VAW/G such as rape, labeling FGM as "misopedic" will only elicit a defensive postures from the practicing communities including their national governments."  

5. Policy-making

• "And, as you note, we have all the answers, and have had them for a long time. We also know that both all men and women can only benefit from a rational approach to women's health.... Worse, things are regressing on these issues, with many countries now claiming at the UNHRC that human rights (and women's rights, of course) are not universal but need to be contextualized based on 'cultural values'. Yes, it's a nasty political game."
• "How is it that the same policy-makers (mostly men) who do not want their wives or daughters to die from the consequences of unsafe abortion (for obvious reasons, including cultural taboos about men who lose their wives) are the same ones that will not include policies relating to sexuality education and access to post-abortion services? How come we have not found innovative ways to engage men in the discourse around these issues? How come 15 years after Beijing we are recycling a lot of information on what is wrong , sometimes why it is wrong, , and we do not share as much about HOW to effectively remedy the situation. We have many documents now analysing the issues, many guidelines, many reports from civil society organizations, governments, special panels, even the UN….but still the women and girls are dying and being maimed."