These stark contrasts in health, lives, and policies emerged during a two-day discussion called "Reproductive Health in the Twenty-First Century," a conference on women, gender, and society, at the Radcliffe Institute for Advanced Study at Harvard University on October 14.

The health of women and their families is intimately linked to their economic and political milieu. "If we don’t see biology in a social context, we may not be asking the questions most relevant for understanding health and human disease," said Nancy Krieger, an associate professor in the Department of Society, Human Development, and Health, who chaired a session on the meaning of reproductive health.

Ten years ago, the field of reproductive health gained new visibility at the International Conference on Population and Development in Cairo. There, 179 countries forged an agreement to focus on women’s reproductive health and rights, both as an end in itself and as a key to improving the quality of life for everyone, said panelist Joan Kaufman, founding director of the AIDS Public Policy Training Program at the Kennedy School of Government and HSPH alumna.

The new paradigm distinguished itself in part by asserting the right to a safe and satisfying sex life for consenting men and women who have the freedom to make informed choices, said Kaufman. This requires access to effective and affordable health care services, including voluntary family planning, which suffers from inadequate funding, especially since the withdrawal of U.S. political and financial support in 2001. A "global gag rule" denies funds for international family planning services that include abortion procedures or referrals, and abstinence education cannot adequately address the gender power dynamics inherent in the AIDS epidemic, she said.

At a time when it is difficult to argue against the equality of women, the politics of abortion are a politically expedient way to continue the gender wars, said panelist Gita Sen, adjunct professor at HSPH and Sir Ratan Tata Chair Professor at the Indian Institute of Management in Bangalore, India. Reproductive health is a culmination of a broader social transformation toward gender equity and women’s empowerment. "Reproductive health is caught in the middle of this war," she said. "We will have to fight socially and politically."

The choices about whether or when to reproduce, and how those choices affect decisions to work or become leaders in civic life, are central to the struggles of women’s autonomy, said Jody Heymann, an associate professor in the Department of Society, Human Development, and Health at HSPH, who chaired a session exploring who reproduces and who decides.

In this country, work and family policies constrain the ability of women to earn incomes at the same time as they reproduce, said Heymann, founder and director of the Project on Global Working Families.

Social and environmental factors influence subsequent generations through unknown biological mechanisms, according to another panel that featured Janet Rich-Edwards, assistant professor of medicine at HMS and assistant professor in the Department of Epidemiology at HSPH. A 2003 study of 97,000 women in Chicago led by Rich-Edwards and HSPH colleagues found that black women participants had an increased risk for poor pregnancy outcomes as they aged compared to white women. This racial divergence was explained by social and economic factors, suggesting that the increase in risk of poor pregnancy outcome with age among black women may be a result of cumulative exposures to the grinding stress of poverty. Environmental factors in early childhood, or even in previous generations, can affect women’s pregnancy outcomes, according to other studies.

Science can make a difference in women’s health, said Harvey Fineberg, president of the Institute of Medicine and former HSPH dean, but science must grapple with political and social constraints. One of the key questions is how to balance the efforts to apply existing knowledge to old problems with the investigations to create new knowledge and new opportunities.

--CCM