In the years since the International Conference on Population and Development (ICPD), researchers and policymakers have tried to demonstrate that the reproductive health approach can be translated into program objectives, and that it represents a powerful means to achieve both demographic goals and improvements in individual welfare.1 The task of developing tools to monitor progress in implementation of the different parts of the ICPD agenda has been made especially challenging because traditional indicators are no longer satisfactory due to the expanded scope of population policies. In addition, some observers with long experience in family planning have expressed misgivings about the reproductive health approach, which, in their opinion, takes population policies and programs into uncharted and ill-defined areas, and risks reducing the sense of urgency about population growth, the financial commitment of donors and the effectiveness of family planning programs.2
These factors underscore the need to rapidly define indicators to monitor progress in the implementation of the ICPD agenda, and several systematic reviews of the field have been undertaken. Building on the experience of family planning and sexually transmitted disease (STD) control programs, these reviews have clarified what types of indicators are needed, the levels at which they can be obtained and their link to program performance. A number of useful reports, which summarize what has been learned and provide detailed menus of choices for the selection of indicators, are now available.3
Less attention has been devoted, however, to the conceptual framework that is to guide the formulation of objectives and the selection of indicators to show how well those objectives are being met. In particular, two potentially conflicting goals must be reconciled: development of a uniform set of indicators to monitor progress and to compare program performance, and attentiveness to local conditions.
The reproductive health agenda will have to be applied in diverse settings, and therefore, a cultural perspective that clarifies the link between the global and the local must be developed. Such a perspective would point out that the concept of reproductive health itself is culturally constructed; thus, implementing the reproductive health agenda is as much a question of adoption of a particular set of cultural values in various parts of the globe as it is a question of management and technical know-how.
Inherent in the implementation process is a central tension. On the one hand, the reproductive health approach represents the culmination of a process of consensus-building that brought together activists and thinkers from all over the world. As a result, it has the potential to resonate with the concerns of men and women everywhere. On the other hand, precisely because the notion of reproductive health was so successful in incorporating the concerns of very different constituencies, there are today numerous "others" and multiple perspectives to take into account.
It is important to take a reflexive stance and to recognize that the different sides participating in the implementation of the reproductive health agenda--those who are the targets of policies and those who formulate and implement policies--are in an unequal position. Although many endeavors are motivated by a desire to improve the well-being of others, they take place in a global context often characterized by political strife and disagreement. Furthermore, the determinants and consequences of these endeavors are not necessarily politically neutral.
We may be witnessing a convergence toward a certain set of values, jointly promoted by individuals from both North and South. Yet this process, to a certain extent, is undeniably a function of the power of the United Nations and other international organizations to spread values from societies of the North to those of the South.
The scale of this phenomenon calls for a cultural perspective that would make a special effort to understand the position of "others" in those societies that are usually characterized as Southern, poor or developing. One can go a step further and argue that a cultural perspective also would make it clear that some values dominating international discourse and underpinning international resolutions, when seen from the point of view of those at the receiving end, are also in a sense "other." Hence, they will not be viewed automatically as better, more rational or more desirable.
In sum, the concept of reproductive health developed in part as a result of the coalitions that were built over time among diverse groups--both regional and international--concerned with women's health and its place in population policies. Reproductive health advocates see the approach as representing a universal set of goals, based on ethical principles (such as the right of individuals to control their bodies or the notion of citizenship) that can form a common ground for individuals everywhere.4
The major international encounters that have taken place since the Cairo conference have shown that reproductive health has tremendous potential to bridge gaps between diverse constituencies. But the concept of reproductive health also is a cultural product that emerged as a result of a particular historical, legal and ethical evolution. Implementing it involves not merely the application of principles and the selection of measures, but a process of translation across cultures.
In this article, I offer five observations concerning the challenges that face us as we try to develop indicators that will be useful for measuring and evaluating the implementation of the reproductive health agenda.
Scope, Definition and Translation
First, reproductive health is not defined by strict criteria. The concept extends beyond reproductive ages, reproductive events or reproductive organs, toward a broader perspective on reproduction as situated within a socioeconomic context. As a result, there are no precise guidelines about the exact scope of the concept, nor explicit standards for inclusion or exclusion. Although most people would agree that reproductive health encompasses certain core areas, debates continue about the limits of reproductive health and the appropriateness of including less traditional ones.
For example, sexual health is a central element in reproductive health formulations, yet the term elicits varied responses in different contexts. While sexual emancipation was a key factor in the struggle for women's equality in Western societies (where, to many feminists, the sexual is political), it is not clear whether (or to what extent) the same formulation applies to settings with a different history. In some parts of the world, where sex is only permissible when it occurs between married partners, public discourse about other expressions of sexuality can appear at best as absurd and at worst as an unjustifiable interference in private matters. Or, such discussion may appear as a politically motivated attempt to undermine cherished values.
The fluidity that characterizes such "border areas" of reproductive health suggests that some degree of flexibility will be important when standards by which performance is to be evaluated are set. Research on sexuality is a relatively recent development,5 and those involved are engaged in debates regarding questions of essentialism (the idea that all cultures share a biologically-based "thing" called sexuality) versus constructionism (the idea that sexuality is entirely socially constructed). Therefore, the task of finding good measures of what would be sexual health or healthy sexuality will depend to some extent on the progress that is made in research that contributes to our understanding of the meaning of sexuality in various cultural contexts.
A second point, which becomes obvious when we consider the implementation of the reproductive health agenda, relates to the very language used to refer to reproductive health and its components. The process of reaching agreement on the Cairo document involved a good deal of negotiation about how concepts that had emerged in the context of the English-speaking world would be translated into the languages of societies that had not gone through similar social and historical developments. Those who observed the process noted the extent to which creative translations were helpful in leading various delegations to endorse tricky passages. But it has been especially difficult to adequately translate some of the key terms of the reproductive health agenda, such as gender, empowerment, sexual health and informed consent.
Expressions found in languages other than English (for example, genre in French and al-naw' in Arabic) have different connotations than those that the word "gender" has in English, and hence are not fully satisfactory. Similarly, santé génésique and al sihha al injabiya may not be especially meaningful outside of a circle of specialists who are already familiar with the concept of reproductive health. And finding a word that conveys the meaning of empowerment has proven nearly impossible in several languages.
The continued use of the terms coined to communicate these new concepts is likely to reduce their clumsiness. Nevertheless, the absence of true equivalents underscores the historical fact that a group of societies are in a position to spread ideas deemed to be important for people everywhere. The process of generalizing these concepts could be greatly enhanced by efforts to learn about the preexisting ideas held by members of particular societies. Although exact translations do not exist, the situations to which the terms refer may have equivalents across social groups because they are universal. Here again, however, our understanding is in its infancy. Initiatives such as the International Reproductive Rights Action Group project, which studied the different ways women in seven countries of Asia, Latin America, Africa and North America think about their reproductive experiences and rights, demonstrate that it is possible to carry out sensitive cross-cultural analyses on the subject.6
A Gender Perspective
A third related set of issues emerges from the importance given to a gender perspective in formulations of reproductive health. Expanding the scope of population policy to include the context in which reproductive decisions are made permits us to assess more realistically the forces that affect reproductive motivations and behavior. In this way, gender and "women's empowerment" issues become key elements in discussions of population and health policy.
Reviews of recent work on the subject,7 however, make it clear that empowerment is by no means captured by such familiar and unidimensional measures as women's education and employment, or by the existence of egalitarian laws. Education and employment often do not correlate with women's ability to make decisions openly (rather than covertly). Neither is it unusual for women to behave in subordinate ways so that their achievements do not appear to threaten the status quo. Education and employment may be associated with behavior, such as high fertility or veiling, that is (sometimes uncritically) taken to indicate a lack of power. This occurs precisely because the implications of these measures are context-dependent.
Research in a number of settings has shown that improved education and employment cannot be assumed to lead to greater empowerment for women. For instance, when male unemployment is high, working to increase female employment may elicit reactions of anger and violence against women. Conversely, practices generally thought to unequivocally hurt women's position can, in some contexts, be empowering. Women may willingly conform to traditional initiation or wedding practices, for example, in order to establish their worth and morality so that they may later be able to negotiate a greater degree of independence.
The wider constituencies brought together by the reproductive health agenda may hold quite different positions regarding gender, and it cannot be assumed that a consensus is possible (or even necessarily desirable). Program managers and policymakers whose experience was predominantly gained in the context of traditional fertility control or maternal and child health programs may now find themselves charged with implementing directives towards which they have a degree of ambivalence. They may perceive the egalitarian concepts that support the directives to be foreign or vague or to be a threat to the established order--which is often favorable to men.
Alternatively, women themselves may find that the struggle for empowerment is too onerous. For the time being, they may be willing to defer to the existing social order. How such dilemmas are resolved depends in part on the ability of those who support a reproductive health agenda with a gender perspective to demonstrate that its implementation is beneficial for both men and women in the long run, and to develop a vision of gender equality that can liberate both sexes from the constraints of traditional unequal arrangements.
My fourth observation is that incorporating the socioeconomic context into formulations of reproductive health draws attention to women's general living conditions and the important link with development. This in turn raises questions regarding how to set priorities for reproductive health in relation to development. While several observers have noted that the success of the reproductive health approach at ICPD somewhat overshadowed debates about development, the question raised here is on another level: To what extent do the issues currently considered to be key components of a reproductive health approach represent priorities in societies where women and men must struggle to gain access to such fundamental human needs as food, shelter, security and basic amenities?
The issue of female genital surgeries provides a dramatic illustration of the complexity of the priority-setting process. Researchers with firsthand experience in the countries where these practices are found have repeatedly pointed out that the international fascination with them deflects attention from what may be greater problems for the people involved. In fact, in many of the societies where such practices are performed, people live in disastrous conditions of poverty and socio- economic deprivation.
We actually have little experience with the process of eliciting priorities from groups of people whose voices have traditionally been muted. We do, however, know that in many parts of the world women may willingly or under pressure negotiate with their bodies and make sacrifices--such as wearing a veil, undergoing certain practices or going into commercial sex work--precisely in order to achieve better socioeconomic conditions for themselves and their families.
However we interpret such evidence and regardless of whether we take it to support or call into question the strategy of using reproductive health to achieve empowerment or development, we must be mindful that interventions may have outcomes other than those we intended. Indicators inevitably oversimplify a complex reality; therefore, we have to exercise caution when we use them as measures of success or failure, especially with respect to domains of life that are fraught with contradictions.
Reproductive Health and Well-Being
Finally, discrepancies have repeatedly been found between women's perceptions and expressions of their needs and biomedical assessments of their health.8 Careful validation studies of obstetric and gynecologic morbidity--in contexts as diverse as Bangladesh, Egypt, India, Indonesia and the Philippines--have shown that women's ability to recognize medical conditions and their potential complications and to seek the appropriate services is limited. As a result, indicators that are based on women's own reports will not be sufficiently accurate.
Improved diagnostic methods and cheaper laboratory tests for field studies of reproductive tract infections, as well as closer attention to the pain, discomfort, impairment and anxiety that accompany reproductive morbidity, are providing us with innovative approaches to the measurement of reproductive health. Such progress, however, does not entirely dispose of the issue of the discrepancy between women's reports and biomedical measures. Even as we improve such measures and develop indicators that approach a "gold standard," we cannot dismiss women's complaints as being merely inaccurate, "psychological" or "in their heads" when they diverge from "objective" measures.
Historical studies of changing definitions of female illnesses have shown a close connection between unfavorable social conditions and various female complaints and disorders. Women cannot always recognize symptoms, put a name to a malaise or seek appropriate health care for reproductive conditions. Yet a growing body of evidence shows that they can, if one listens carefully, assess pretty well whether their reproductive health overall is satisfactory.
One theme that recurs in studies of reproductive morbidity is the sense of fatigue, exhaustion or deterioration of reproductive organs, variously expressed in the local languages by women in places as diverse as Argentina, Egypt, India, Mexico and South Africa. Such findings are impressive not just because they appear in varied settings, but also because they suggest that what may at first seem to be culture-bound syndromes are closely related to poverty, and do, in fact, correlate fairly well with anemia, poor nutritional status, untreated reproductive tract infections and poor sexual life.9
Such evidence shows that it is possible to find equivalents between the biomedical model that guides our evaluation of health and local expressions of well-being or ill-health. These indicators may not have the rigor of statistical or medical measures, but they make it possible to establish a dialogue between those who have authoritative knowledge and those they seek to help.
In sum, in light of the major advances that have been made in initiating a reproductive health agenda, it is useful to think about reproductive health indicators as falling on a continuum. At one end are indicators that can be developed generically and are readily applicable to any given setting. These are usually quantifiable measures--such as percentages, proportions or durations related to reproductive events, vital statistics, medical conditions or services provided--that can be refined through largely technical advances in medical research, data collection and data processing.
At the other end of the continuum are indicators that seek to capture progress along those dimensions that set reproductive health apart from earlier approaches to population policy. These include socioeconomic conditions, changes in awareness, measures of satisfaction or well-being, and empowerment. Such measures are often proxies rather than direct equivalents, and are to a great extent qualitative and multidimensional. In addition, they require a process of cultural translation in order to be applied to a given situation and necessitate, in order to be valid, an understanding of context.
Progress in selecting from the second type of indicators those that are most appropriate within a given context requires a process that fosters reflection and negotiation among the different parties involved in defining the parameters of the reproductive health agenda. Such a process is needed, both within organizations and between policymakers and their constituencies, to delineate the various categories and components of reproductive health, to identify the changes to be monitored, to clarify how they are to be defined in the local context and to select the appropriate combinations of qualitative and quantitative measures to capture them.
It is not possible (or even desirable) to resolve ongoing debates about the scope and measurement of reproductive health before selecting a set of indicators. Some flexibility needs to be incorporated into guidelines for the specification of indicators, because ultimately the choice of these types of indicators must be context- and program-specific. The current conceptualization of reproductive health reflects a greater awareness of its multiple aspects--demographic, medical, social and political--and hence demands a better grasp of several disciplinary areas. Further advances will depend on the extent to which progress can be made in carrying out research that integrates multidisciplinary perspectives, and in designing multidimensional interventions.
1. Tsui A, Wasserheit J and Haaga J, eds., Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions, Washington, DC: National Academy Press, 1997.
2. Harvey P, Let's not get carried away with reproductive health, Studies in Family Planning, 1996, 27(5):283–284.
3. Koblinsky M et al., eds., Indicators for reproductive health program evaluation: final report of the subcommittee on safe pregnancy, Evaluation Project, Chapel Hill, NC, USA: University of North Carolina Chapel Hill: Carolina Population Center, 1995; and Dallabetta G and Hassig S, eds., Indicators for reproductive health program evaluation: final report of the subcommittee on STD/HIV, Evaluation Project, Chapel Hill, NC, USA: University of North Carolina Chapel Hill: Carolina Population Center, 1995.
4. Correa S and Petchesky R, Reproductive and sexual rights: a feminist perspective, in Sen G, Germain A and Chen L, eds., Population Policies Reconsidered: Health, Empowerment and Rights, Cambridge, MA, USA: Harvard Center for Population and Development Studies; and New York: International Women's Health Coalition, 1994.
5. Vance C, Anthropology rediscovers sexuality, Social Science and Medicine, 1991, 33(8):875–884.
6. Petchesky R and Judd K, eds., Negotiating Reproductive Rights: Women's Perspectives Across Countries and Cultures, International Reproductive Rights Action Group, London: Zed Press, 1998.
7. International Union for the Scientific Study of Population (IUSSP), Female empowerment and demographic processes: moving beyond Cairo, proceedings of an IUSSP seminar, Lund, Sweden, April 21–24, 1997.
8. Zurayk H, Younis N and Khattab H, Rethinking family planning programs in light of reproductive health research, in Obermeyer CM, ed., Family Gender and Population in the Middle East: Policies in Context, Cairo: American University in Cairo Press, 1995.
9. Obermeyer CM, ed., Cross-Cultural Perspectives on Reproductive Health, proceedings of an International Union for the Scientific Study of Population Seminar, Kwa Maritane, South Africa, June 1997 (forthcoming).