TUC submission to DFID consultation: Choice for women: wanted pregnancies, safe births

Choice for women: wanted pregnancies, safe births

TUC submission to DFID consultation

October 2010

The TUC welcomes the opportunity to put forward its views on DFID's future policy on reproductive, maternal and newborn health in the developing world.

The TUC is the voice of Britain at work, representing some 57 affiliated unions with over 6 million members. The TUC and its affiliated unions have an abiding interest in development in that they seek to bring about sustainable improvements in working and living conditions of workers, their families and communities through the protection and promotion of their economic and social rights. The TUC is part of the global trade union family with 173 million members and works in partnership with trade unions in the developing world to help deliver on its strong commitment to international development through a variety of ways including:

• Contributing to the development of internationally recognized labour standards through the International Labour Organisation and other relevant bodies and to their implementation throughout the world;
• Working in partnership with UK companies to improve labour rights in supply chains, particularly through the Ethical Trading Initiative (ETI);and
• Engaging with, and lobbying, governments and international institutions to promote the ILO Decent Work Agenda.

This Submission draws on the TUC's core areas of expertise in development policy and practice and will detail what actions could improve maternal health through the world of work. The TUC will focus on the ways in which decent work, access to education, workplace initiatives, social protection and access to quality public services can impact positively on maternal health and women's economic empowerment. This submission will also stress the importance of workplace solutions to health challenges including HIV/AIDS and pre and post-natal advice and guidance.

Our ultimate aims are to improve women's control of their reproductive lives and to save mothers' and newborn lives. Within the context of strengthening health systems to deliver for all and recognising that different countries have different needs, what do you think that we should be aiming to achieve?

The International Labour Organisation states that, 'Scaling up efforts to improve maternity protection and health through the workplace is a great need everywhere, to ensure that work does not threaten the health of pregnant or nursing women or their newborns and that maternity and women's reproductive roles do not jeopardise their economic security. Social protection is vital to ensure that health care is within reach of all and that financial barriers do not deter women from accessing the care that they need. Ensuring decent work for health workers is a must for addressing the global crisis facing the health workforce.' The TUC would like to see DFID continue to prioritise gender equality across its work, and specifically to focus on issues around maternity including: access to education (including sexual and reproductive health and reproductive rights) as well as workplace education; access to quality public services with adequate investment in staff; and maternity protection at the workplace.

Education

Education for women and girls and access to information on sexual and reproductive health and reproductive rights can directly affect their decisions about family planning, pregnancy and child birth. Educating women about nutrition, spacing of pregnancy and post natal care can save lives. Workplaces are communities where people come together to share information and learn. There is also a huge cross over into the wider community, where people will spread their learning. For all these reasons, the TUC strongly supports the Education For All campaign, and would urge DFID to make this a key part of its approach to maternal health.

Trade unions are skilled at delivering workplace education; this type of peer to peer education is very effective at challenging taboos and changing behaviour. For example, in Nigeria, following education and training, union officials are educating colleagues on the best ways to prevent HIV/AIDS infection. The protection and promotion of the human and employment rights of workers affected by the disease is on the collective bargaining agenda and are campaigning nationally for anti-discrimination legislation. This model is easily translated to education about other key health issues; DFID should aim to build capacity of developing country trade unions to use the world of work as an entry point for promoting safe maternity.

Public health services

DFID should work with Governments and unions achieve effective access to quality, public health services. Where social protection and government financing of health service is low the financial costs of health care falls to the family. This increases poverty and exacerbates the risks for pregnant women and their babies. Women are often discouraged from seeking the care they need due to the cost. The ILO refers to a global crisis facing the health sector workforce, with severe shortages of workers and uneven distribution of healthcare workers in urban and rural areas. This profoundly hinders efforts to reduce maternal mortality. In many developing countries where there is no universal access to health facilities, workplace health centres already provide some of these services. Support from the UK Government can expand and improve them, as well as supporting the involvement of trade unions.

Health care professionals should be central to any strategy to deliver this. Health care personnel are critical to the delivery of services and are currently facing staff shortages, poor working conditions and lack of training and development. Ensuring these workers achieve decent work will help further professionalise such services, recruit new staff, and retain existing, trained staff.

Due to economic and security issues, some developing countries experience significant emigration where qualified doctors and nurses seek work in developed countries, leaving severe shortages in their countries of origin . It is imperative that pay and working conditions of health professionals are improved. In addition, trade unions and professional bodies often highlight irregularities in making appointments, transfers and promotions. Furthermore, health unions point out that in many countries career prospects are often bleak or non-existent. When working to strengthen health services in the global south DFID must ensure that there is consultation with and participation from health workers, through their unions, through social dialogue and collective bargaining.

There is need and scope for increasing the institutional capacity for training health professionals, not only doctors and nurses and other professionals allied to medicine, but also other health staff. In many developing countries, though not in all, there are students who have completed secondary education in sufficient numbers, some of whom can be trained to become health professionals with technical and financial support from developed countries.

Maternity protection

DFID should aim to achieve social protection for women during and post pregnancy. Maternity protection is central to achieving DFID's aims and would help to ensure the economic security of women and their families everywhere. Firstly, it helps to preserve the health of mothers and their babies and secondly, it serves to provide a measure of job security. This means adequate protection from dismissal and discrimination, the right to resume work after birth and maintenance of wages and benefits during maternity. DFID can begin to achieve this through working with the international trade union movement and the International Labour Organisation (ILO).

Without access to decent work women in developing countries often fall outside of legal or social protections that safeguard against vulnerability and provide access to health care. Working during pregnancy is not in and of itself a risk. But women around the world continue to face maternity related threats to their health and economic security. Women continue to face dismissal and discrimination in pregnancy, workplace environments can be hazardous and long or irregular working hours can have negative effects on maternal health. Often, women are not covered by any maternity protection and are forced to leave work for the birth too late and return to work too early. Some vulnerable workers, particularly those working as migrants or in the informal economy, may not be able to access public services or social protection because the state does not formally recognise them as workers with a legitimate entitlement.

The International Labour Organisation addresses the challenges of maternal morbidity and mortality through its Decent Work Agenda: jobs, rights, social protection and dialogue. Working with 183 member states the ILO seeks to ensure that labour standards are respected in practice as well as in principle. Through three specific conventions the ILO's member states have adopted three Conventions on maternity protection (No.3, 1919; No. 103, 1952; No. 183, 2000). These Conventions have progressively expanded the scope and entitlements of maternity protection at work and provided guidance on implementing national policy and action.

The Social Protection Convention, 1952 (No. 102) sets minimum requirements for the provision of health care during pregnancy and maternity cash benefits for replacing lost income. Other relevant conventions are the Nursing Personnel Convention, 1977 (No. 149) and the Medical Care and Sickness Benefits Convention, 1969 (No. 130) which set standards for working conditions of medical professionals and access to healthcare.

Only 19 countries have ratified the Maternity Protection Convention, 2000 (No. 183), but 62 countries have ratified at least one of the three conventions on maternity protection. There remains a lot of scope to improve legal protections for maternity, particularly in the global south. DFID should continue to support the work of the ILO in order that countries can benefit from training and technical assistance in the implementation of maternity protection. DFID should ensure countries are financially able to make maternity protection sustainable. This should be done by supporting countries to implement progressive tax policy.

As well as renewed efforts to ensure that the relevant ILO conventions are ratified, the International Trade Union Confederation has called on trade unions to engage in social dialogue with employers and governments on this important issue. DFID's in country offices should work with the trade union movement to enhance work to win maternity protection for women workers. Trade unions are key to realising decent work: they organise workers in order to secure better pay and working conditions and social protection, including maternity protection. DFID should ensure that trade unions in the south, working with trade unions in the north, play a vital part in the strategy to end maternal mortality.

Where should we focus our efforts along the continuum of care (pre-pregnancy, during pregnancy and birth and after delivery) and why, in order to have an impact on MDG 5 by 2015? What do you think is most important to tackle in order of time priority?

The TUC believes that strengthening public health care systems in order to provide the full continuum of care must be the focus of DFID's efforts. We believe such stronger health systems should be DFID's priority, rather than choosing to intervene at a particular stage in the process of pregnancy and childbirth.

How should we address inequality?

Vast numbers of women across the world lack access to decent work that enables them to lift themselves and their families out of poverty. Many will not have access to legal or social protection that will protect them or enable them to access health care. A new drive on achieving decent work (including the crucial element of equal pay) for workers in developing countries is key to addressing poverty and inequality.

As organised representatives of working people, trade unions have a key responsibility to challenge discrimination and ensure that everyone can earn a living wage and access Decent Work. Working with union partners across the global south, TUC activities have particularly focused on gender equality and the workplace rights of people affected by HIV/AIDS. We have supported unions to deliver empowerment training to enable workers to find their voice, to provide specific services to key groups and to run educational workshops. In Nigeria, trade unions were struggling to address the concerns of women workers over the discrimination they faced at work and in wider society. The TUC contributed both funding and technical expertise to a project to enhance the unions' ability to tackle gender inequality.

Paternity leave and supporting the role of the father can help to address inequalities. By emphasising the shared responsibility of care, societal attitudes may start to shift and instigate the development of more gender-balanced approaches.

Inequalities in terms of accessing health and public services should be a priority for DFID to address. This would involve avoiding charging for or privatising health services.

And, similarly, universal access to primary and secondary education is important: DFID should continue to support Education For All. Trade unions, primarily through education unions, the global education union (Education International) and through the Global Campaign for Education are strong advocates for universal access to education. The National Union of Teachers is working with the Sierra Leone Teachers' Union on a specific project which seeks to empower girls and women through education. Girls in Sierra Leone face significant barriers to staying in education post primary, such as early pregnancy, domestic chore burdens and even sexual harassment from male teachers. With a successful funding application, the project will seek to increase the progression rate of girls into secondary education through ensuring the career progression and empowerment of women teachers. A lack of women teachers in secondary school compounds many of the barriers that female pupils face.

How can we improve the realisation of women's rights and women's and girls' empowerment?

The underlying cause of such high rates of maternal and neonatal mortality cannot be ignored in any strategy. The gender disparities that contribute greatly to the state of women's health and economic empowerment must continue to be tackled. Half a million preventable deaths per year are a symptom of the systematic discrimination against women and girls throughout their lives. The low status and lack of economic independence of women and girls results in a lack of control over their bodies whether it be family planning, pregnancy care or the birth itself. In order for any strategy on maternal mortality to be successful and sustainable DFID must continue to prioritise women's empowerment. For this reason, the TUC welcomes the publication of the structural reform plan which made the role of women and the promotion of gender equality a priority.

Trade unions are an engine through which societal attitudes and prejudices can be challenged and broken down in a safe, workplace environment. Through workplace education and women's empowerment programmes within unions, trade unions can make a significant impact in challenging the social norms, attitudes and practices that drive oppression of women and girls. DFID should support programmes in the global south which seek to empower women in the workplace and educate men about the equality agenda. In the way that trade unions in Britain succeeded in winning an Equal Pay Act and other legislative reforms, so trade unions in developing countries also advocate for progressive change.

Women's economic empowerment through the realisation of decent work and social protection - as set out above - is central to winning gender equality, as is universal access to education, also covered above.

How can we deliver better results through multilateral aid?

The TUC has recently made a submission to DFID on the Multilateral Aid review and supports the Bond submission on behalf of the development community in the UK. In the TUC's submission, in view of the multiplicity of the multilateral institutions under the current review and the complexity and range of issues concerning them, the TUC focused on the need for continued and potentially increased financial support for the International Labour Organisation. This funding would allow continued targeted funding for Decent Work country programmes and technical co-operation work in line with DFID priority areas including improving maternal health. The submission emphasised the relevance of ILO work to development with a focus on the achievement of Millennium Development Goals (MDGs) and to the broad thrust of DFID policies and strategies.

What are optimal models of service delivery for delivering reproductive, maternal and newborn health outcomes?

Quality public health and education services, accessible in rural and urban areas are the optimal model of service delivery to ensure the good health of mothers and their babies.

How should we work in fragile and conflict affected states? Are there particular interventions and issues we should be focusing on?

Working through non-state actors to deliver reproductive, maternal and newborn health services, information and supplies can be a short term solution. In fragile states governments need to work closely, where possible and appropriate, with trade unions and other civil society organisations that have the capacity to provide health care through their structures, institutions and networks. For instance a number of health unions in Sri Lanka were actively involved in the provision of health care for Tsunami victims and many of them are still carrying on some of the work they initiated in January 2005.

When working bilaterally to strengthen national health systems in fragile states, it is crucial that the trade unions are consulted on and are involved in the process.

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The Ethical Trading Initiative is a leading multi-stakeholder body of companies, trade unions and NGOs, working collaboratively to improve working conditions in global supply chains. For more information see www.ethicaltrade.org

Decent work is an International Labour Organisation strategy aimed at fulfilling the aspirations of people in their working lives. Decent Work involves opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organise and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men

Safe Maternity and the world of work, ILO, 2007

An introductory guide to international migration in the health sector, PSI www.world-psi.org

www.ilo.org

Safe Maternity and the World of Work, ILO, 2007