Vulnerabilities

Poverty
The relationship between poverty and poor SRHR is well established.⁶⁴ A review by Greene and Merrick⁶⁵ concluded that large family size was associated with increased risk of maternal mortality and less investment in children's education. Unwanted pregnancy was positively linked with the health risks of unsafe abortion. Short birth intervals were found to negatively influence child survival, and early pregnancy was associated with lifelong risk of morbidities. On a global scale, women living in low- and middle-income countries experience higher levels of morbidity and mortality attributed to SRHR than women living in wealthier countries.

Low Education
There is a close association between educational attainment and age at marriage, fertility regulation and health-seeking behaviour. Studies from India reveal that while age at marriage among illiterate women is 15 years, age at marriage among girls who have completed high school is significantly higher, at 22 years.⁶⁶ Globally, women with seven or more years of education tend to marry four years later and have 2.2 fewer children than women with no schooling.⁶⁷

Mental Health
Mental health issues may correspond to the decreased ability to make rational choices and increase the probability of risky sexual behaviour. This can lead to more unintended pregnancies, STIs including HIV, and a higher risk of being either the victim or perpetrator of GBV.⁶⁸ Additionally, mental health problems related to SRHR include premenstrual tension syndrome (PMS); mood changes associated with menopause; feelings of loss and guilt after miscarriage, stillbirth or abortion; anxiety over unintended pregnancy; postpartum psychosis; social segregation and low self-esteem; depression or trauma owing to obstetric fistula, infertility, sexual dysfunction and being part of a sexual minority.

Natural Disasters
Research shows that climate change⁶⁹ may prevent people from accessing SRHR services due to natural disasters, migration, urban population growth and pollution. Researchers highlight that climate change generally impacts people’s livelihoods and in turn poverty prevents people from accessing SRHR services. However, the immediate consequences of crisis situations cause SRHR to be neglected as needs for food and clean water become more urgent. Therefore, SRHR needs are important to consider in relief efforts.

For example, the October 2005 earthquake in Pakistan brought a unique agony for women related to SRHR. With the entire health infrastructure demolished and all road links destroyed, women delivered under the open sky, and those with hip injuries or fractures faced additional pain at delivery. In India, lactating rural women who lost their children during the 2004 tsunami suffered from the clotting of milk in their breast.⁷⁰ In most natural disaster situations access to regular contraceptives is reduced, resulting in an increased chance of becoming pregnant when living conditions are less than optimal.

In addition, girls and women living in camps or temporary shelters and housing following natural disasters also may be at a significantly greater risk to sexual abuse and early marriage. Investigations show that Syrian girls in refugee camps in 2012 were at heightened risk of being married off early to older men from other countries. Such realities faced in disaster situations present formidable challenges to the very idea of SRHR.⁷¹

Armed Conflict
Women’s vulnerability to SRHR violations is severely exacerbated during armed conflict. Violence against civilian populations, and acts of GBV against women and girls (including mass rape), are increasingly common features of war and conflict. The psychological consequences for women who have been sexually violated may affect them and their families for long periods. Furthermore, pregnant women are particularly vulnerable where health services are unavailable.

While conflict results in increased SRHR needs, there is typically diminished capacity within the health service community and family to respond to these needs. For example:

• Family and community networks of support and protection may be lost.
• Poverty and loss of livelihood reduce the capacity of individuals and families to protect their SRHR.
• Within a conflict zone, existing health services and structures may have been destroyed, health personnel may have fled or been killed, and international aid may not be able to reach the affected population.
• Emergency obstetric facilities may have been destroyed, or may have become inaccessible.
• Where health services continue to function, the needs of combatants may be given precedence over the needs of non-combatants.
• Girls’ within the conflict may be recruited to participate, experience GBV, low or no access to SRHR services, and, at times, experience forced sterilization and abortion.

Displacement
If mass displacement occurs—whether due to conflict, famine or other causes—displaced populations, including pregnant women, are usually without sufficient health care services. Families may become separated, and adolescent girls may be at risk of GBV from soldiers, border guards, bandits and others. The exodus is usually spontaneous, unplanned and chaotic, particularly if it is due to war or conflict.⁷² Protecting SRHR can then be difficult. The spread of STIs and HIV is fastest in the conditions of poverty, powerlessness and social instability that accompany displacement. In addition, mass migration may bring a population of low STI/HIV prevalence, with little knowledge of these infections or how to protect themselves, into contact with populations of high prevalence.

The overwhelming sense of loss (of home and family) and lack of hope for the future may affect the mental health of women, men and adolescents and can lead to an increase in risk-taking behaviours.⁷³ As the situation stabilises in displacement and post-conflict settings, there may often be pressure on women to give birth to replenish the population. In some cases this may coincide with women's own desire to replace children who have died or disappeared. However, women having several children close together, especially when their own health status is already poor, endangers the health of both the mothers and their babies.⁷⁴

Disability
While persons with disabilities make up 10 percent of the world’s population overall, a disproportionate 20 percent of all persons living in poverty in developing countries are persons with disabilities.⁷⁵  All too often, the SRHR of persons with disabilities has been overlooked by both the disability community and those working with SRHR. This leaves persons with disabilities among the most marginalised groups when it comes to SRHR. Yet persons with disabilities have the same needs for these services as everyone else. In fact, persons with disabilities may actually have greater needs for SRHR than persons without disabilities due to their increased vulnerability to abuse.

The challenges to SRHR faced by persons with disabilities are not necessarily part of having a disability, but instead often reflect lack of social attention, legal protection, understanding and support. Persons with disabilities often cannot obtain even the most basic information about SRHR. Thus they may remain ignorant of basic facts about themselves, their bodies, and their rights to define what they do and do not want. For example, persons with disabilities may have little experience relating to and negotiating with potential partners. As a result, they may be denied the right to establish relationships, or they may be forced into unwanted marriages, where they may be treated more as housekeepers or objects of abuse than as a member of the family. As a group, persons with disabilities fit the common pattern of structural risks for HIV/AIDS and other STIs – e.g. high rates of poverty, high rates of illiteracy, lack of access to health resources, and lack of power when negotiating safer sex.⁷⁶

Stakeholders⁷⁷ in one review identified several barriers to access that need to be addressed to ensure services reach disabled girls and women. They emphasised that access needs to be conceptualised more broadly to go beyond ‘physical access,’ which is usually seen as the main limiting factor. Creating meaningful access to services would mean providing:

• Access to culturally sensitive services
• Access to means of communication
• Access to appropriate education, information, knowledge, and resources.