3. Women’s physical integrity
This chapter focuses on women’s reproductive autonomy and physical integrity in Africa. Taking a holistic approach, it examines formal and informal laws, social norms and practices to identify the main health challenges facing women in the region, such as unmet needs for family planning, maternal complications and poor birth outcomes as well as gender-based violence. The chapter also highlights persistent forms of discrimination, namely unequal decision-making power and customs that perpetuate harmful practices, including child marriage, violence against women and female genital mutilation (FGM). The analysis considers both the current situation of women and uncovers longstanding underlying factors. Based on this analysis, the chapter provides policy recommendations to improve women’s access to reproductive autonomy and eliminate pervasive gender-based discrimination.
Meeting women’s health care needs is essential for women’s and girls’ empowerment, autonomy and control over their bodies. Furthermore, women’s health influences their well-being and educational attainment as well as their employment opportunities and productivity (AfDB, UNECA, 2020[1]). The Protocol to the African Charter on Human and People’s Rights on the Rights of Women (Maputo Protocol) in Africa recognises the importance of guaranteeing women’s health and access to sexual and reproductive health services (African Union, 2003[2]). With women representing over half of the population and human resources in Africa, improving their health status will contribute greatly to the economic and social development of African countries.
The present chapter is divided into three main sections. The first section looks at women’s health and reproductive indicators and outcomes. It provides a broad overview of the situation of women in Africa, specifically in reference to the unmet need for family planning, maternal complications and poor birth outcomes, as well as gender-based violence, with a particular focus on the consequences of the COVID-19 pandemic on these outcomes. The chapter’s second section explores underlying factors and causes that explain women’s restricted reproductive autonomy, violence against women, female genital mutilation (FGM) and child marriage. The section uncovers the role played by discriminatory social norms, attitudes and practices in explaining women’s poor health status on the continent, the persistence of child marriage, high rates of violence against women and FGM. The third and last section presents some key policy recommendations that could help address discriminatory social institutions that constrain women’s health status in Africa. A table summarising some key indicators for women’s health and reproductive autonomy in Africa can be found at the end of the chapter in Annex 3.A.
Unmet need for family planning remains an area of concern in most African countries
Generally, unmet need for family planning is reflected in gaps in the demand and supply of contraceptive services and is defined as the percentage of sexually active and fecund women who report not desiring any more children or having to postpone their next child but who are not using contraception (WHO, n.d.[3]). Modern contraception methods have a higher efficacy than traditional methods, which are widely used in some places in the region. Modern methods include oral contraceptive pills, implants, injections, contraceptive patches and vaginal rings, intrauterine devices, female and male condoms, female and male sterilisation, emergency contraception pills, and so on (WHO, n.d.[4]). Traditional contraceptive methods include periodic abstinence, withdrawal, and the calendar and cervical mucus methods. In some African countries, traditional methods are also based on the use of traditional medicine and herbs (Rabiu and Rufa’i, 2018[5]).
Regardless, despite the growing use of modern contraception methods in Africa, the vast majority of women and girls still lack secure access to family planning services. The proportion of women of reproductive age (15-49 years) who use modern methods to satisfy their needs for family planning has increased from 36% in 2000 to 56% in 2017 (United Nations Population Division, n.d.[6]). However, the number of women of reproductive age is increasing in Africa, driving a spike in the birth rate. From 1950 to 2015, the number of women of reproductive age has risen from 54 million to approximately 280 million (You, Hug and Anthony, 2015[7]). In 2017, an average of 22% of African women of reproductive age reported having an unmet need for family planning, compared to 12% at the global level. West Africa has the highest rate1 compared to other African sub-regions: in 2018, 27% of women of reproductive age in West Africa reported having an unmet need for family planning. At the national level this figure conceals wide variations, with percentages ranging from 7% in Algeria to 38% in Equatorial Guinea (OECD Development Centre/OECD, 2019[8]). More recently, the COVID-19 pandemic has had a significant impact on health care systems and disrupted women’s access to family planning services and information across the continent (Box 3.1).
Improved access to sexual health and reproductive rights would prevent unwanted pregnancies that lead to unsafe abortions. Africa accounts for 29% of all unsafe abortions and 62% of all unsafe abortion-related deaths at the global level. At the regional level, the World Health Organization (WHO) estimates that approximately half of all abortions occur in the least safe conditions,2 putting women’s health at great risk (WHO, 2020[9]). As a consequence of rapid population growth in Africa, the number of abortions per year in sub-Saharan Africa increased between 1995 and 1999 and from 2015 to 2019, from 4.3 million to approximately 8 million (Guttmacher Institute, 2020[10]).
Pregnancy-related complications can lead to an increase in maternal deaths and compromise infant health and well-being
Maternal deaths remain prevalent in Africa despite significant progress under Millennium Development Goal (MDG) 5 (Improve maternal health). In 2017, there were 481 maternal deaths per 100 000 live births in Africa compared to the global average of 216 maternal deaths per 100 000 live births (World Bank, n.d.[11]). Between 1990 and 2015, sub-Saharan Africa achieved a reduction in maternal mortality rates of 45% (UNDP, 2016[12]). Over the same period, North Africa recorded the largest decrease and achieved the lowest maternal mortality rate of the continent, dropping from 210 to 81 maternal deaths per 100 000 live births between 1990 and 2017, representing a decrease of 61% (World Bank, n.d.[11]). In West Africa, the maternal mortality rate remains high, having declined only marginally, with a maternal mortality ratio of 715 per 100 000 live births in 2017, one of the highest rates at the sub-regional and global level. In Central Africa in the same year, the maternal mortality ratio was 564 per 100 000 encompassing any cause related to or aggravated by pregnancy. Maternal deaths in Southern Africa were lower at 254 per 100 000 live births. At the country level, Sierra Leone records the highest number of maternal deaths with a ratio of 1 150 per 100 000 live births in 2017 (World Bank, n.d.[11]).
Maternal death is considered a human rights violation with far-reaching consequences for neonatal mortality. It also results in the loss of significant economic resources and amplifies poverty cycles at the household and community levels (Miller and Belizán, 2015[13]). Numerous studies have revealed the links between maternal mortality and the heightened risk of stillbirth and neonatal mortality (WHO, 2014[14]). If the new-born survives after the death of the mother, the infant may face enormous challenges such as nutritional problems due to lack of adequate and early breastfeeding, lack of access to drinkable water and stunting. Older children within the household of the dead mother are more likely to drop out of school and to suffer from interrupted education and difficult living arrangements (Whetten et al., 2011[15]); (Wang et al., 2013[16]). In addition, girls will often assume maternal roles and become more vulnerable to child marriage, adolescent pregnancy and risks of maternal morbidity (Miller and Belizán, 2015[13]). Other findings indicate that maternal mortality is associated with considerable costs to national health systems. In 2013, estimates showed that maternal and neonatal mortality slows economic growth and induces income losses of nearly USD 15 billion each year at the global level (UNFPA, 2013[17]). In Africa, the economic cost linked to poor maternal health care reached USD 45 billion over the 2000-10 period (WHO, 2002[18]). Most recently, the COVID-19 crisis has strained services related to antenatal, delivery and postnatal care with direct consequences for maternal health (Box 3.1).
The health, social and economic implications of the COVID-19 pandemic for the African continent are far-reaching. The crisis is having an uneven effect on women’s health access and outcomes, with long-lasting impacts on their empowerment, threatening to set back progress achieved over the last two decades. On average, more men than women have contracted and died from the virus in Africa, a trend that could heighten the economic vulnerability of women and families, as men are typically the primary earners in households (UN Women, 2020[19]; World Bank, 2020[20]). In addition, lockdown measures, social distancing, school closures and increasing poverty due to lost income negatively affect girls’ and women’s health (UNICEF, 2021[21]). On the positive side, progress has been recorded in the protection of women and girls from gender-based discrimination, ranging from the first-ever marital rape conviction in Eswatini to the criminalisation of FGM in Sudan (Amnesty International, 2020[21]).
The majority of primary formal and informal frontline health care workers are women, who are at higher risk of exposure to COVID-19
As in the rest of the world, women represent the majority of the African health workforce, for example accounting for 65% of the region’s nurses (World Bank, 2020[20]). Combined with their unequal share of unpaid care and domestic work, which involves caring for ill and elderly relatives, women face a higher risk of contracting the virus.
The strain on health care systems has diverted economic and human resources, putting women and girls at risk
Africa’s limited economic and human resources and capacities pre-pandemic, coupled with the current crisis, has increased the risk of care shortages and disruption of services, resulting in a wide range of consequences on women’s and girls’ health. Resources normally used for routine health services, and girls’ and women’s (sexual and reproductive) health care needs, have been diverted to combat the pandemic (African Union, 2020[22]). Among the consequences are:
Increased maternal mortality and adolescent pregnancies. Lockdown measures or fear of contracting the virus prevent pregnant women from accessing prenatal care (World Bank, 2020[20]). This trend is amplified by a rise in adolescent pregnancies, stemming from limited access to contraception and sexual and reproductive health and research (SRH) services, increasing child marriage rates and violence against girls (UNICEF, 2021[23]). For instance, in Kenya, preliminary evidence from the International Rescue Committee aid group in the northern town of Lodwar revealed that teenage pregnancies had tripled among beneficiaries (Smith, 2020[24]).
Unmet family planning needs. African women face additional barriers to access family planning services due to the closure of health facilities, unavailability of medical staff to provide family planning services, and women themselves being hesitant to visit health facilities due to concerns about COVID-19. Recent estimates reveal that for every three months of a lockdown (under high disruption), up to 2 million additional women may be unable to use modern contraceptives at the global level. This will lead to millions of unintended pregnancies, which themselves pose risks to the health of the mother and child (UNFPA, 2020[25]).
The COVID-19 pandemic has prompted a sharp and steady rise in child marriages in African countries
At the global level, the COVID-19 pandemic has impacted the lives of children and families, and has threatened the continuity of programmes and strategies to end child marriage, in particular in developing countries. In Africa, evidence from previous epidemics reveals that teenage girls are disproportionately affected by health crises and emergencies (UNFPA; UNICEF, 2020[26]). In the context of COVID-19, governments have taken measures to stop the spread of the virus and avoid new infections such as closing schools, imposing general lockdowns, and decreasing the availability of social support networks and programmes to alleviate extreme poverty (UNICEF, 2021[23]). These combined measures have medium and long-term consequences for the livelihoods of millions of Africans who rely on informal economic activities. Due to external economic shocks and restricted access to basic services, ranging from access to reproductive health services to child protection, COVID-19 has increased poverty rates, which in turn has enhanced the likelihood of girls being forced into child marriage. Indeed, evidence from an initial assessment conducted in Ethiopia, Mozambique, Uganda and Zambia shows that teenage girls are being disproportionally affected by the pandemic and are experiencing increases in child marriage and adolescent pregnancy (UNFPA; UNICEF, 2020[26]). The interruption of prevention programmes combined with higher levels of poverty is increasing the likelihood of families marrying off their daughters in exchange for a bride price. It is estimated that globally 10 to 13 million child marriages will take place, which otherwise would have been averted (UNICEF, 2021[23]) (UNFPA, 2020[25]).
Violence against women and girls increased in all countries affected by the pandemic, with progress towards ending gender-based violence by 2030 reduced by one-third.
Recent research from six Sahel countries1 found a 12-percentage point increase in reported domestic violence cases, due to confinement measures. In these cases, women were isolated at home and without access to people and resources that could help them (African Union et al., 2020[27]). Additionally, in East Africa, there was a 48% increase in reported cases of gender-based violence (African Union et al., 2020[27]).
← 1. The six countries are Chad, Senegal, Mali, Burkina Faso, Mauritania and Niger. Domestic violence cases increased from 40.6% prior to the pandemic to 52% during the pandemic.
Skilled birth attendance has been recognised as a key element for maternal and new-born survival. Postnatal care services for mothers and new-borns prevent, detect and treat health complications after delivery including infections and post-partum depression, yet many women in Africa continue to lack access to these services. In 2016, in sub-Saharan Africa, 82% of pregnant women received prenatal care compared to 87% of women at the global level (World Bank, n.d.[11]). Nonetheless, only 62% of births are attended by skilled health personnel in the region, ranging from 89% in North Africa to 52% in East Africa (World Bank, n.d.[11]). When women are not able to give birth in a health facility or do not have access to primary neonatal services, they may call on local midwives and nurses in their area to ensure that skilled personnel can address health complications during labour. Yet, the number of nurses and midwives (per 1 000 people) in Africa was 1.1 in 2018 compared to 2.8 at the global level (WHO, n.d.[28]).
In cases of adolescent pregnancy, there is a heightened risk of spontaneous abortion, complications during labour, postpartum haemorrhaging, HIV infection, malaria and obstetric fistula, which can take place when a mother delivers children before her body is physically ready to do so. Adolescent pregnancy is thus accompanied by a higher risk of maternal mortality. For instance, in Mali, the maternal mortality rate for girls aged 15-19 years is 178 per 100 000 live births compared to only 32 maternal deaths per 100 000 live births for women aged 20-34 years (Nour, 2006[29]). In addition, the children of adolescent mothers face higher rates of under-nutrition and mortality (UNDP, 2016[12]). The infant mortality rates are higher for young mothers due to their limited access to information and adequate health services. For instance, at the global level, new-born mortality rates are 73 higher for mothers under the age of 20, a correlation that also applies to the five African sub-regions (UNDP, 2016[12]).
Gender-based violence against women can cause long-term physical and mental health problems
Restrictions on physical integrity prevent women from pursuing their goals in the private and public spheres, such as education, employment and participation in public life. The spectrum of violence affecting women and girls includes intimate partner violence, rape, FGM and sexual violence. Moreover, gender-based violence decreases women's reproductive options and increases rates of maternal mortality and HIV/AIDS infection (UNDP, 2016[12]).
On average, approximately 33% of African women have experienced intimate partner violence or sexual violence in their lifetime compared to 31% at the global level. At the sub-regional level, Central Africa has the highest prevalence of domestic violence (45%) followed closely by East Africa (36%) and North Africa (28%). Compared to the prevalence rates of these regions, intimate partner violence appears to be less pervasive in North, West and Southern Africa, where it affects, respectively, 28%, 27% and 22% of women at some point in their lives (OECD, 2019[30]). At the national level, there is wide variation in domestic violence rates ranging from 6% in Comoros to 80% in Guinea. However, prevalence rates of recent episodes of intimate partner violence are decreasing slightly. In 2019, 19% of women were the victims of assault by their partner in the past year, compared to 26% in 2014 (OECD Development Centre, 2014[31]; OECD Development Centre/OECD, 2019[8]). Since the COVID-19 outbreak began, initial estimates and reports have revealed that all types of violence against women and girls have increased in countries affected by the pandemic. Gender based-violence is exacerbated particularly under lockdown measures, restrictions on movement and school closures (Box 3.1). For instance, administrative data from the South African Police Services reveal that within the first week of a level 5 lockdown in 2019, cases of gender-based violence reported to the police increased 37% compared to the weekly average (African Union et al., 2020[27]). Similarly, in Nigeria, data from 24 states show that the number of reported cases of domestic violence increased by 56% throughout the first two weeks of April following the imposition of lockdown measures on 31 March (African Union et al., 2020[27])
Domestic violence is linked to negative health outcomes for women, ranging from poor mental health to adverse reproductive health consequences such as poor birth outcomes. Results from various studies in Africa indicate that women who have experienced physical abuse and violence are more likely to have body injuries ranging from contusions to broken bones (Emenike, Lawoko and Dalal, 2008[32]). In sub-Saharan countries, women present numerous emotional and mental disorders in response to intimate partner violence (Ahinkorah, Dickson and Seidu, 2018[33]). In addition, recent evidence reveals a strong relationship between intimate partner violence and poor pregnancy outcomes (Salazar and San Sebastian, 2014[34]). Women who reported experiencing either physical or sexual violence by their husbands are more likely to suffer from unwanted pregnancies. Furthermore, intimate partner violence has been connected to health complications during pregnancy and delivery, spontaneous abortions and termination of pregnancy (Emenike, Lawoko and Dalal, 2008[32]). In addition, women who have experienced intimate partner violence are more likely to contract sexually transmitted infections and diseases, which in African countries carry importance as latent gateways3 to HIV/AIDS infection (Seth et al., 2010[35]).
Another acute form of violence against women is the harmful practice of FGM. On average, in 27 countries with available data, 42% of women and girls aged 15-49 years have undergone FGM, compared with 46% in 2014 (OECD Development Centre, 2014[31]) (OECD, 2019[30]). The pace of decline has been uneven and is dependent on country contexts. At the sub-regional level, the highest prevalence of FGM is found in North Africa where 43% of women have been cut. The practice is also predominant in East and West Africa where, respectively, 38% and 28% of women and girls have undergone this procedure, which constitutes in itself a severe form of discrimination. Conversely, only 5% of women and girls have been cut in Central Africa and no cases have been reported or measured in Southern African countries (OECD, 2019[30]). At the national level, the prevalence of FGM varies greatly across countries where data are available, ranging from 2% of women in Cameroon to over 90% of women in Sierra Leone, Djibouti, Guinea and Somalia. In the latter countries, over nine in ten women aged 15-49 years have been subjected to FGM.
Female genital mutilation/cutting can be classified into four distinct categories (OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO., 2008[36]):
Type I: Excision of the prepuce and part or the entire clitoris
Type II: Excision of the prepuce and clitoris together with partial or total excision of the labia minora
Type III: Infibulation. Excision of part or all of the external genitalia and stitching together of the two cut sides, to varying degrees
Type IV: Pricking, piercing, incision, stretching, scraping or other procedures harming the clitoris or labia, or both.
With the exception of Eritrea, the largest percentage of women who had been circumcised reported having some flesh removed as opposed to being infibulated (Figure 3.1). Extensive research has proven that the first three types of FGM/C have long-lasting and severe health implications. The most critical health problems comprise shock, severe haemorrhage, infections and psychological consequences. In the long term, women and girls who have been cut will experience throughout their lives prolonged pain, infections, potential infertility and birth complications. Although the first two types of FGM/C are perceived by people as harmless and relatively safe procedures, they too may provoke a series of health complications including haemorrhage, urogenital complications and in some cases sexual dysfunction (Kaplan et al., 2011[37]).
Note: This figure presents three types of female genital cutting, including the percentage of circumcised women who were cut but no flesh was removed; the percentage of circumcised women who were cut and had flesh removed; and the percentage of circumcised women who were sewn closed.
Source: (IFC, 2015[38]). The DHS Program STATcompiler. www.statcompiler.com.
Discriminatory social institutions represent a significant structural obstacle for women and girls to access empowerment opportunities on an equal basis to men and boys, perpetuating health-related gender inequalities. Deeply entrenched social institutions that comprise legal frameworks particularly affect girls’ and women’s rights and discriminate against women’s physical integrity and well-being (see Chapter 2). In addition to laws and regulations, social institutions include norms, attitudes, stereotypes based on customs, traditions and beliefs that restrict girls’ and women’s rights in the family, private and public spheres and undermine their ability to exercise agency. These discriminatory social institutions often overlap and have long-lasting impacts throughout the lifecycle of women and girls. This section highlights the role played by these discriminatory social institutions in explaining the persistence of harmful practices including violence against women, FGM and child marriage.
Deep-rooted discriminatory social norms result in unequal power relations within the private sphere which may result in poorer health outcomes
Gender power imbalances constrain women’s full control over decisions related to their health. Women’s ability to seek appropriate health services and attend health care facilities relies on their decision-making autonomy. Yet, African women’s status within society significantly constrains their decision-making power regarding their own lives. Prevailing cultural beliefs, traditions and customs determine gender roles, thereby establishing the conditions under which women can exercise autonomy in making decisions regarding their own health care (Woldemicael and Tenkorang, 2009[39]). Despite variations across countries, data suggest that men’s control over women’s access to health care is widespread. Moreover, men may not have adequate knowledge about the female body and therefore cannot make reliable and legitimate choices. Furthermore, men might refuse women’s access to health care and treatment if they disagree with certain practices derived from discriminatory social norms, including examinations or medical treatment by male doctors and nurses (OECD, 2021[40]).In at least half of the 40 countries for which data are available for 2002-18, the husband was the main decision-maker regarding women’s health care. In contrast, men are more likely to have decision-making authority over their own health care than their female counterparts (Figure 3.2).
The domination of male partners over women’s health also affects their reproductive health choices and autonomy. Numerous research studies in developing countries reveal that partners exert a considerable influence over the decision of women to use contraceptives (Bankole and Singh, 1998[41]). Moreover, well-educated women who intend to use contraceptive methods may fail to do so because of their partners’ reluctance to adopt family planning measures. For instance, a study conducted in Ghana found that a husband’s attitude toward family planning was an important contributing factor to his wife’s attitude toward contraception (Bankole, 1995[42]). In Africa, women confronted with decisions on family planning are more likely to base their decision on their partner’s fertility preferences and attitudes toward family planning. Only 45% of women, on average, can make their own informed decisions regarding sexual relations, contraceptive use and reproductive health.4 This proportion ranges from 58% in Southern Africa to 33% in Central Africa (World Bank, n.d.[11]).
Note: Decision making over own health care refers to the percentage of respondents who acted as the principal decision maker for their own health care. No data were available for men in Congo, Egypt, Eritrea, Eswatini, Gabon, Madagascar, Morocco, Sao Tome and Principe, and Yemen.
Source: (IFC, 2015[38]) The DHS Program STATcompiler. www.statcompiler.com.
In Africa, women and young girls are more vulnerable to HIV due to gender power imbalances (Box 3.2) with consequences for their ability to negotiate safe sex. It has been well documented that women's household decision making in relation to the negotiation of sex, and ultimately safe sex, constitutes a crucial determinant of their likelihood of and vulnerability to contracting HIV infections. Married women’s HIV infection is associated with various factors, including their inability to ask their partners to use condoms or to refuse sexual intercourse even in risky situations. For instance, in Yemen (Seidu et al., 2021[43]), only 50% of women aged 15-49 years consider that a woman is justified asking a men to use a condom if she knows that her husband has a sexually transmitted infection (DHS, n.d.[44]). In other contexts, young girls begin their sexual activities with older men who are more likely to be infected with HIV and have greater decision-making power over young girls, which in turn, determine their reproductive health choices and contraception methods. Data on this area are lacking at the regional level, but various demographic and health surveys carried out among a group of 27 African countries found that infection rates increase significantly among women in the 20-24 age group in comparison with women in the 15-19 age range (Seidu et al., 2021[43])
The links between women’s ability to make decisions about their health care and HIV testing may be explained by the Theory of Gender and Power (Connell, 2013[45]). This theory hypothesizes that power dynamics between women and men are expressed in three major crucial structures: sexual division of labour, sexual division of power, and the structure of social exposure and affective attachment. These various structures determine the power relationships between women and men and illustrate the dynamics at play in the ways men control women (Connell, 2013[45]). Women’s decision to visit a health care facility and take a test therefore depends strongly on whether they enjoy equal status in the home. A recent study using data from the DHS in 28 Africa countries revealed that women’s decision-making abilities and capacities play a fundamental role in their uptake of HIV testing (Seidu et al., 2020[46]).
HIV is considered to be one of the main causes of illness and death for women aged 15-49 years, accounting for 19% of all deaths among women globally. Sub-Saharan Africa is the region with the most prominent HIV/AIDS epidemic at the global level, with women disproportionally affected by this infectious disease. In 2018, women accounted for around 59% of new HIV infections among individuals aged 15 and older. This proportion has remained stable over the last two decades (UNAIDS, 2020[47]) Recent figures show that East and Southern Africa are the most impacted sub-regions with approximately 12 million women living with HIV (UNAIDS, 2020[47]). In Southern Africa, in particular, an estimated 13% of adults aged 15-49 years are living with HIV compared to 0.7% at the global level in 2019. Countries with prevalence rates over 20% are Eswatini (27%), Lesotho (23%) and Botswana (21%) (World Bank, n.d.[11]).
Women who are HIV positive experience and suffer various forms of discrimination in the family sphere, limited access to inheritance and property rights, marginalisation and exclusion from the community or kinship, and divorce or denial of rights related to the guardianship of their children (Paudel and Baral, 2015[48]). In addition, women who were already excluded and marginalised, including sex workers, can lose their main source of income and suffer from social stigma and discrimination, which may aggravate their socio-economic condition and increase their vulnerability (WHO, 2012[49]). Finally, in 2020, measures taken by governments to combat the COVID-19 crisis and pandemic exacerbated difficulties and barriers for women living with HIV/AIDS to access treatment, services and information.
Discriminatory social institutions increase women’s and girls’ vulnerability to multiple forms of violence during their lifetime
Gender-based violence remains an area of concern in Africa given, among other factors, present weaknesses in legislation. The absence of legal provisions criminalising domestic violence in 20 countries leaves women and girls without any legal protection from the perpetrators of violence against them and without any recourse to justice. Moreover, efforts to guarantee women’s legal protection from various forms of gender-based violence have been inconsistent and slow. The majority of countries still fail to recognise marital rape and 21 countries lack criminal laws acknowledging FGM as a harmful practice (see Chapter 2).
Violence against women remains socially accepted across African countries. On average, 47% of women and girls consider that a husband may be justified in hitting or beating his wife under certain circumstances – if she burns the food, argues with him, goes out without telling him, neglects the children or refuses to engage in sexual relations. Over the last ten years, domestic violence has become less tolerated and accepted among women. For instance, between 2012 and 2018, acceptance of spousal violence decreased by nine percentage points among women (i.e. from 56% to 47%). At the sub-regional level, North Africa shows the lowest level of acceptance of domestic violence among women (34%), followed by Southern (40%) and West Africa (42%). Conversely, female acceptance of spousal violence is much higher in East (54%) and Central Africa (66%). At the country level, this figure ranges from 16% in Malawi to 92% in Guinea. These attitudes combined with restrictive norms of masculinities5 explain in part the persistently high rates of domestic violence in Africa. SIGI data reveal a correlation between countries where intimate partner violence is condoned by an important proportion of the population and high rates of domestic violence (Figure 3.3 3.3).
At its root, gender-based violence stems from restrictive norms of masculinities that perpetuate male dominance in the private sphere and acceptance and entitlement to perpetrate physical, sexual, psychological and economic violence (OECD, 2021[40]). Following these restrictive norms of masculinities, women are expected to be “obedient, silent and good” and should accept the violence inflicted by men and in some cases by other women. For example, FGM is associated not only with expected behaviours for woman in the community, but also with notions of masculinity. In communities where FGM is widely practised, a man should marry a woman who has been excised or cut. In Burkina Faso, for instance, a staggering 50% of men would prefer to marry a woman who has undergone FGM. (OECD Development Centre, 2018[50]). Women also often uphold social norms that limit their empowerment and opportunities. Incidences of violence towards daughters-in-law perpetrated by mothers-in-law and the role played by elder women and grandmothers in perpetuating mutilation of their own daughters' and granddaughters’ genitals have both been largely documented (UNDP, 2016[12]).
Note: Attitude towards domestic violence is defined by the percentage of women aged 15-49 years who consider a husband to be justified in hitting or beating his wife for at least one of the specified reasons: if his wife burns food, argues with him, goes out without telling him, neglects the children or refuses to engage in sexual intercourse with him. The lifetime prevalence of domestic violence is the percentage of women who have suffered intimate partner physical and/or sexual violence during their lifetime.
Source: (OECD Development Centre/OECD, 2019[8]), Gender, Institutions and Development Database, https://doi.org/10.1787/ba5dbd30-en.
Similarly, discriminatory social norms contribute to condoning or tolerating harmful practices such as FGM. This practice is largely considered a rite of passage for young girls transitioning into adulthood and determines their eligibility for marriage. However, the teenage girl rarely decides herself whether she should undertake the procedure or not (UNICEF, 2013[51]). Instead, decisions concerning FGM are often determined based on pressure from elder people, extended families, relatives, neighbours and customary, local or traditional leaders (UNICEF, 2013[51]). Acceptance of this harmful practice appears to be declining, however, in particular among younger generations. However, acceptance remains high in sub-regions where FGM is commonly practised. In 2018, on average, 16% of African women of reproductive age were of the opinion that FGM should continue. At the sub-regional level, these rates vary from 15% in East Africa to 27% in North Africa (OECD, 2019[30]).
The practice of child marriage engenders significant health risks for young girls and women
Decreasing the prevalence of child marriage is essential for securing girls’ rights and wellbeing and helping them to take full advantage of opportunities for empowerment. In concrete terms, the later a girl marries, the higher her level of education, which increases her employment opportunities. In addition, eliminating child marriage would provide other positive gains, ranging from better health outcomes to greater autonomy in sexual and reproductive decision making, as well as additional development and economic benefits (Harper et al., 2014[52]). In Niger, for instance, the annual economic benefit from eliminating child marriage could reach USD 1.7 billion by 2030 (Wodon et al., 2017[53]).
A staggering 23% of African girls marry before their 18th birthday compared to just 3% of boys. Africa is also home to 15 of the 20 countries with the highest number of child brides globally. Whereas the prevalence of child marriage remains relatively low in North Africa (11%), it represents a major cause for concern in Central (26%) and West Africa (29%). Child marriage rates range from around 1% in Libya to 62% in Niger, the highest level in the world, together with the Central African Republic (61%) and Mali (44%) (OECD, 2019[30]). If current rates of child marriage remain unchanged, and the present trajectory of population growth continues, child marriage will double by 2050 (OECD, 2019[54]).
Child marriage is closely associated with adverse impacts on girls’ and women’s physical and psychological health and well-being. In particular, SIGI data show that child marriage prevalence rates are correlated with high rates of adolescent pregnancy in Africa (see Figure 3.4). In addition, a 2016 study in nine West and Central African countries established strong links between child marriage, lower use of modern contraception and higher fertility rates (ICRW; UNICEF, 2016[55]). In sub-Saharan Africa, there were 100 births per 1 000 adolescent girls aged 15-19 years in 2019. This is well above the world average of 42 (World Bank, n.d.[11]).
Note: Girl child marriage is calculated as the share of women aged 15-19 years who have been or are still married, divorced, widowed or in an informal union. The adolescent fertility rate is calculated as the number of births per 1 000 women aged 15-19 years. (SDG indicator 3.7.2)
Source: (OECD Development Centre/OECD, 2019[8]), Gender, Institutions and Development Database, https://doi.org/10.1787/ba5dbd30-en; and (United Nations Population Division, n.d.[56]), United Nations Population Division https://population.un.org/wpp/Download/Standard/Fertility
At the global level, social norms reinforce marriage systems, which play a critical role in the development of social institutions. A marriage system is defined as the set of rules that regulate reproduction in a given society (Fortunato, 2015[57]). In the majority of African countries, the normative structure of the institution of marriage is based on a patriarchal system and organisation of power that allows individuals to permit and tolerate the practice of girl child marriage. The normative structure covers norms, beliefs and ideologies related to girls’ transition from childhood to adulthood, the community’s compliance with elders’ customs and beliefs, and the predominant role of marriage in the development of girls’ lives. For instance, in some African countries, girls reaching the last stage of puberty are expected to take on gender roles linked to womanhood and reproduction, including entering a marriage and becoming a mother (Deane, 2021[58]). In addition, within the African context, families may be afraid of facing stigmatisation from their community if they do not marry their daughters at a young age in conformity with traditional social expectations coupled with the considerable concern of dishonour from pregnancy outside of marriage (Gemignani and Wodon, 2015[59]).
The practice of bride price – which is generally paid by the groom’s family to the bride’s family – is commonly found across sub-Saharan Africa. It is widely accepted that bride price payments can exceed or even reach seven or eight times the annual households’ income (Lowes and Nunn, 2018[60]). In many African countries, the bride price can be paid in kind (livestock) or in cash. For example, among the Zulu and Xhosa of Southern Africa, the bride price varies from 10 cows to a maximum of 60. (Forkuor et al., 2018[61]). In sub-Saharan Africa, bride price payments stem primarily from customs and traditions and are practised irrespective of religious considerations (Mbaye and Wagner, 2016[62]). Bride price also generates a strong incentive for parents living in poor households to marry off their daughters in exchange for the payments, which in turn results in high rates of child marriage and adolescent pregnancies (Lowes and Nunn, 2018[60]). In some cases, under extreme poverty, girls may be considered an economic burden and a potential source of wealth through this custom. In areas where bride price is a common practice, loss of household earnings increases the likelihood of marriage by 3% (Voena and Corno, 2016[63])
The bride price practice is both a source and a symptom of male dominance over women and girls. It curtails girls’ education and compels women to remain in abusive relationships if they or their family do not have the financial resources to repay the bride price (Brown, 2012[64]). In Uganda, 78% of people consider it to be a common practice. Furthermore, 92% of people consider that the practice is required and gives status to a girl (93%), while bestowing ownership on the husband (72%) (OECD Development Centre, 2015[65]).
In Africa, as in the rest of the world, unequal power relationships are intrinsic to child marriages. Growing evidence shows that young girls are more likely than adult women to be married to substantially older men. The apparent age gap between child brides and their adult husbands results in limited agency, autonomy and low decision-making power within the household. Because of this imbalance of power in child marriages, a substantial number of girls are unable to negotiate contraceptive methods with their partners, which in turn results in early pregnancies. Furthermore, as men are perceived and considered to be the head of the household in many African countries, they remain the main and/or sole decision makers regarding girls’ futures and opportunities.
Improve women’s access to family planning
In line with Article 14 of the Maputo Protocol, governments should lift mandatory authorisations from parents or husbands of married teenage girls for them to access family planning services.
Strengthen the supply chain of contraceptive methods through the adoption of innovative logistic models.
The Ministry of Health and Social Action of Senegal together with the National Pharmacy and other partners formed a public-private partnership to reduce contraceptive shortages within the country. The government implemented the Informed Push Model aimed at reinvesting profits from users’ contraceptives purchases back into the public contraceptive supply system to guarantee the availability of modern methods of contraception to everyone. With the application of this approach, the shortages have been practically eliminated (Gueye et al., 2017[66]).
Carry out awareness-raising campaigns and activities in schools, universities and youth groups on family planning and contraception methods.
Expand information on family planning and HIV prevention by sharing key family planning messages via motorised caravans and radio spots.
A 2.5 year randomised controlled trial was conducted in 16 areas of Burkina Faso to broadcast brief spots on family planning on eight radio stations across the country and in six languages. The broadcasts covered a wide range of topics on modern contraception including myths about side effects of using modern contraception methods and birth spacing. The national wide campaign led to a 20% increment in the use of modern contraception methods among women. The radio broadcasts also transformed general knowledge about family planning and attitudes towards the use of contraception (DMI, n.d.[67]).
Reduce maternal mortality rates
Train more midwives to provide skilled birth attendance to women (poor women, women living in rural areas, migrant women) and comprehensive family planning counselling.
Employ new technologies to deliver important information on maternal, new-born and child health.
Zero Mothers Die is a global programme aimed at decreasing maternal and new-born mortality rates through the utilisation of mobile technologies as well as information and communications technology. In Nigeria, for instance, the initiative targets pregnant women who are victims of risky practices. The programme shares instant phone messages with crucial information on pregnancy and on the potential risks of harmful practices to save women's lives during labour (Zero Mothers Die, n.d.[68]).
From 2006-2008, the government of Rwanda provided presents to pregnant women in exchange for receiving antenatal and postnatal health care, as well as for delivering in health care centres. The results of the randomised control trial conducted in 19 districts and four sectors revealed that pregnant women who started antenatal care within the first four months of their pregnancy increased by 8 per cent. In addition, women who received postnatal care in the 10 days after childbirth incremented by 9 per cent (Shapira et al., 2017[69]).
Prevent and eliminate child marriage
In line with Article 6 (c) of the Maputo Protocol, governments should establish 18 years as the minimum legal age for marriage for girls and boys, without any legal exceptions, in compliance with international and regional legal frameworks aimed at eliminating the harmful practice of child marriage.
Eradicate violence against women and protect them from all forms of gender-based violence
Provide all women with legal protection from all forms of gender-based violence at work and in public places and educational institutions.
In 2019, The Domestic Violence Bill became law and criminalises domestic violence, which includes physical, mental, and sexual abuse, neglect and exploitation (Government of Liberia, 2019[71]).
One stop-centres providing comprehensive health care, information and legal advice to victims of gender-based violence have been implemented in South Africa, Kenya, Malawi, Uganda, Somalia and South Sudan. In Somalia, for instance, the one stop-centre is located next to a health care facility and provides health treatment, counselling services and legal support to victims of rape or domestic violence (UNFPA, 2020[72]).
End the harmful practice of female genital mutilation
Criminalise the practice and establish penalties for all perpetrators, including parents and medical practitioners. Add an extraterritorial jurisdiction clause extending penalties to citizens who commit the crime outside of the country.
In Kenya, the Prohibition of Female Genital Mutilation Act penalises its citizens who practice FGM, even when they are beyond its national borders (Government of Kenya, 2011[73]). In 2021, the High Court of Kenya upheld that the country’s Prohibition on Female Genital Mutilation Act was constitutional after a legal challenge was brought by a medical doctor (High Court of Kenya, 2021[74]).
Ensure the effective enforcement of the law by prosecuting perpetrators and providing guidance on prevention, protection, support and follow-up assistance services for survivors.
Involve customary chiefs, religious and local leaders in the formulation and adoption of national programmes, policies and strategies aimed at eradicating harmful practices and discriminatory attitudes towards women’s health and physical integrity.
In 2019, the Council of Traditional Leaders was created to shift and eliminate harmful practices, including, child marriage and female genital mutilation. In Malawi, thanks to a collaboration between traditional chiefs and police and child services, they were able to dissolve over 1 800 child marriages across the country. Furthermore, in Liberia, customary chiefs of the 11 countries where FGM is widely practised, endorsed a Seven County Policy prohibiting this harmful practice (UN Women, 2021[75]).
Mobilise public opinion against the practice through tailored awareness-raising interventions within local communities on the short- and long-term negative consequences of FGM on women’s and girls’ physical and mental well-being.
Include FGM modules in national surveys on a systematic basis to monitor its appearance.
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1. State Parties shall ensure that the right to health of women, including sexual and reproductive health is respected and promoted. This includes:
b the right to decide whether to have children, the number of children and the spacing of children
d the right to self-protection and to be protected against sexually transmitted infections, including HIV/ AIDS
e the right to be informed on one's health status and on the health status of one's partner, particularly if affected with sexually transmitted infections, including HIV/AIDS, in accordance with internationally recognised standards and best practices
a provide adequate, affordable and accessible health services, including information, education and communication programmes to women especially those in rural areas
b establish and strengthen existing pre-natal, delivery and post-natal health and nutritional services for women during pregnancy and while they are breast-feeding
c protect the reproductive rights of women by authorising medical abortion in cases of sexual assault, rape, incest and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus.
States Parties shall, by 2015, in line with the SADC Protocol and other regional and international commitments by Member States on issues relating to health, adopt and implement legislative frameworks, policies, programmes and services to enhance gender sensitive, appropriate and affordable quality health care, in particular, to:
b develop and implement policies and programmes to address the mental, sexual and reproductive health needs of women and men
c ensure the provision of hygiene and sanitary facilities and nutritional needs of women, including women in prison.
1. States Parties shall take every step necessary to adopt and implement gender sensitive policies and programmes, and enact legislation that will address prevention, treatment, care and support in accordance with, but not limited to, the Maseru Declaration on HIV and AIDS.
2. States Parties shall ensure that the policies and programmes referred to in sub-Article 1 take account of the unequal status of women, the particular vulnerability of the girl child as well as harmful practices and biological factors that result in women constituting the majority of those infected and affected by HIV and AIDS.
3. State Parties shall, by 2015:
a develop gender-sensitive strategies to prevent new infections
b ensure universal access to HIV and AIDS treatment for infected women, men, girls and boys
c develop and implement policies and programmes to ensure appropriate recognition of the work carried out by caregivers, the majority of whom are women, the allocation of resources and the psychological support for caregivers as well as promote the involvement of men in the care and support of people living with HIV and AIDS.
Article 23: Prohibition and Support for Victims
a adopt laws prohibiting all forms of gender-based violence, and ensure their enforcement
b ensure that the perpetrators of gender-based violence, including domestic violence, sexual harassment, female genital mutilation and all other forms of gender-based violence are brought before a court of competent jurisdiction and punished accordingly.
2. Member States shall adopt laws on gender-based violence that provide for testing, treatment and care of victims of sexual offenses. Victims of sexual offences shall have access, in particular, to:
b post-exposure treatment/prophylaxis in all health centres so as to reduce any risk of contracting HIV and other opportunistic infections.
Notes
← 1. Unmet need levels of 25% or more are considered very high and values of 5% or less are regarded as very low.
← 2. Abortions are dangerous or least safe when they involve the ingestion of caustic substances, or when untrained persons use dangerous methods such as the insertion of foreign bodies or the use of traditional concoctions.
← 3. Sexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship.
← 4. This proportion of women were aged 15-49 years (married or in union) and are able to make their own decisions on three selected areas: to refuse sexual intercourse with their husband or partner; to make decision regarding the use of contraception; and to make decisions regarding their own health care. Only women who answered “yes” answer to all three areas were considered to make their “own decisions regarding sexual and reproductive health”.
← 5. “Restrictive masculinities” describes masculinities that confine men to their traditional role as the dominant gender group, undermining women’s empowerment and gender equality.